Given the importance and interest involved with bioethics on the national and international arena, it is essential to conduct a narrative review to elucidate the main bioethical issues currently faced by dermatology. The present review will focus on aspects such as the management of vulnerable groups, clinical dermatology, cosmetic dermatology, aesthetic dermatology, bioethics training, dermatological photography, the pharmaceutical industry, AI, SM, and teledermatology to improve the management of bioethical conflicts in everyday practice.

Research questions were:

• 1.

  Which bioethical issues can arise in regular dermatologic or aesthetic dermatologic consultations?

• 2.

  What solutions do the authors of scientific articles propose?

• 3.

  Do the codes of ethics for doctors and dermatologists address these issues?

Searches were conducted across PubMed (MEDLINE), Web Of Science (WOS), and Scopus from March 1st to March 5th, 2023. Results were limited to the period that goes from 2000 through 2023. The terms, boolean operators, and fields used are shown in Table 1.

The selection of articles was conducted in full compliance with the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews” (PRISMA-ScR) methodology.18 Inclusion criteria were scientific opinion articles, letters to the editor, reviews, and case reports on bioethics. Clinical trials and protocols were not included as they focused on obtaining informed consent (IC) for participant involvement in research.

Exclusion criteria were full text not available, articles not written in Spanish or English, responses to articles, book chapters, historical articles, those addressing broadly applicable issues to all specialties such as participation in clinical trials, and dermatopathology articles. Grey literature was also reviewed, particularly the Spanish Medical Code of Ethics (CDM-E)17 and that of the American Medical Association (CDM-AMA),16 the AEDV Ethical and Good Governance Code (CE-AEDV),15 and the Standards of Professionalism and Ethics for dermatologists of the American Academy of Dermatology (EPE-AAD).19

The search found a total of 562 articles, 159 of which were duplicates, leaving 403 articles total. After evaluating title and abstract, 194 were selected for full reading, and, eventually, a total of 77 articles were selected to become part of this narrative review (Fig. 1).

Figure 1.

Article flow based on PRISMA methodology.

(0.35MB).

Bioethical issues were categorized as vulnerable groups (issues related to minority ethnic groups or LGBTQ+), clinical dermatology (related to common skin diseases and conditions), cosmetic dermatology (related to cosmetic products), aesthetic dermatology (related to the practice of aesthetic techniques such as botox, fillers, lasers, and hair transplants), Bioethics training (training for residents and specialists), dermatological photography (issues related to taking photographs of patients), the pharmaceutical industry (problems arising from industry collaboration), AI (related to the use of AI systems in dermatology), SM (related to the use of e-mails, instant messaging services, and SM), and teledermatology (issues related to the use of teledermatology).

Bioethical issues have been identified in association with the doctor-patient relationship due to ethnicity, religion, and gender change. Most conflicts focus on the lack of training on how to treat these patients, which can undermine the clinical relationship. To avoid this, training programs during residency should include these aspects.23–25 The CDM-E, CDM-AMA, and EPE-AAD advocate for treating all patients with the same diligence, without discrimination of any kind.16,17,19 Conflicts and proposed solutions are shown in Table 3.

Bioethical problems have been identified in association with the prescription of isotretinoin27 and free melanoma screening in the United States. 28Issues also arose with the funding of axillary hyperhidrosis therapy with botulinum toxin,30 excision of nevi for aesthetic reasons in pediatrics,31 search for biomarkers in inflammatory diseases,32 and the management of skin cancers in patients with guarded prognosis.29 Problems and proposed solutions are available in Table 4.

Although the sale of cosmetic products in private clinics is a common practice, this creates conflicts of interest. This can be done by non-medical personnel and be accompanied by financial incentives.13,33,34,38 Sometimes, product packaging includes “Dr. X” or the logo of a university/public institution to promote sales.37,38

Selling cosmetic products could be morally acceptable if conflicts of interest are declared, the cosmetic product is backed by scientific evidence, the risk-benefit ratio of its use has been explained, and other alternatives are suggested. Additionally, magistral formulas not available on the market could be suggested too.13,33,34,36,38 Some authors say that academic institutions and dermatology services should be particularly cautious in their relationship with the industry.35 The recommendation of cosmetic products could be delegated to trained personnel.13

The CDM-E, CDM-AMA, EPE-AAD, and CE-AEDV emphasize the importance of declaring the conflicts of interest, while the EPE-AAD and CE-AEDV prohibit the use of their logos on cosmetic products.15–17,19 The CDM-E does not allow doctors to sell drugs or other products for therapeutic purposes to patients.17

Problems have been identified on whether it is appropriate for dermatologists to perform aesthetic procedures,41–44 especially for patients seeking treatment for other disease,39,45 and whether these procedures can be performed by nurses and assistants.37,40,42,44 Problems and detected solutions are available in Table 5.

In the routine clinical practice, we face bioethical problems such as interaction with the industry and minors, off-label drug prescriptions... However, training in this area is often insufficient during residency.46,48,52 Resident tutors need to be further involved, as they are the role models for residents. Suggested activities include seminars, article discussions, and case-based learning. Teaching should include the declaration of potential conflicts of interest, relationships with the pharmaceutical industry, establishing boundaries with other health care workers and patients, and responsible use of social media.46,49,51 The AEDV and other institutions emphasize the need for training in “dermoethics” and deontology during residency and for specialists with a focus on everyday problems.15–17,19

Photography is part of the health record, and it is necessary to request informed consent (IC), which should include the purposes and destinations of the image (such as publication or use in conferences); otherwise, the patient's autonomy could be violated or damaged. Some authors believe that even when the photograph cannot be identified, the corresponding IC should be requested since nearby anatomical areas, scars, tattoos, or piercings make the image identifiable to third parties.53,54,56,57 It is recommended to use storage systems provided by the hospital and avoid using mobile phones, which may pose a security breach.54,56,57 The currently available various codes of ethics emphasize the importance of obtaining IC for patient images and their use for different purposes, such as medical care, publication of scientific articles, or teaching.15–17,19

Industry contact with professionals is increasingly early, affecting residents and medical students, and intends to influence their decision-making and prescribing habits.12,58,59,61,62,66 Identified problems and proposed solutions are collected in Table 6.

Some studies have already demonstrated that AI can match or surpass a group of dermatologists, reduce costs, and increase health care coverage. However, there are still doubts on its safety, efficacy, confidentiality, and equitable access.9,68–71 Large image databases are required for AI to work properly because if these databases only contain lesions from Asian and European patients, they could make more diagnostic errors or promote less follow-up for African ethnicities.9,70,71 IC should be obtained before using images for this purpose.70,71 On the other hand, the financial cost associated with software, cameras, and infrastructure could reduce implementation in less resourceful areas, thus increasing inter-regional disparities. Additionally, the IT system must be secure to prevent photographs from being used with other purposes.9,70

The CDM-E allows the use of AI, as long as it has been designed and develop for the benefit of society, and ensures validity, safety, and traceability while always preserving patient privacy and confidentiality.17

Although patients seek information on SM, most content is created by people outside the dermatology setting. Therefore, the participation of dermatologists is advisable to inform patients, doctors, and residents.73,74 SM can also be used for advertising and marketing private clinics, provided it is done respectfully and professionally, avoiding unrealistic results and expectations.11,76,78 Therefore, using “before and after” photos of an aesthetic procedure after obtaining the corresponding valid IC, explaining the associated risks and benefits and the possibility of revocation is required.11,76,78 Another use is advertising cosmetic products, which creates conflicts of interest and can be controversial,74,75 or receiving teleconsultations, which is ill-advised as there are other regulated modalities of teledermatology.72,77,79 The CDM-E and CDM-AMA allow the use of SM for assistance, education, research, and marketing, provided ethical standards are respected.16,17

The use of teledermatology can benefit patients by shortening wait times, reducing costs, and increasing dermatological coverage for immobilized patients or those in hard-to-reach areas.80,82–89 Additionally, it can also prevent damage to patients, such as COVID-19 infection, and serve as training for dermatology or family medicine residents.85–87,89 However, the use of teledermatology raises questions related to patient safety and confidentiality. It is important to inform patients of the limitations associated with teledermatology (no total body surface examination or image quality).10,80,83,85–88,90 Prescribing drugs is contentious since it is often impossible to identify the patient, inform them, or explain therapeutic alternatives.81

The CDM-E, CDM-AMA, and EPE-AAD include sections on telemedicine, where its use is permitted, provided ethical standards such as obtaining IC, preserving confidentiality, and declaring conflicts of interest are maintained.16,17,19 The CDM-AMA allows prescriptions if patient identity is ensured16, while the EPE-AAD requires an initial in-person visit before prescribing via teleconsultation.19