Advertising Ban on Doctors

ADVERTISING BAN ON DOCTORS

The "Regulation on Promotional and Informational Activities in Medical Services" prepared by the Ministry of Health came into force after being published in the Official Gazette dated 29.07.2023 and numbered 32263.

An Overview of Advertising Bans

Due to the increasing amount of time that people spend on social media, many businesses and companies have recently moved their advertising and promotional activities from conventional media such as newspapers, magazines and television to digital media, especially social media, and have started to carry out a large part of their advertising and promotional activities through social media.

Not only commercial businesses, but also many freelancers and self-employed persons have made efforts to increase their recognition through social media. Except for a few freelance activities, it is possible for almost all self-employed persons to become more known, more recognised and more popular and increase their business volume by using social media and advertising on social media. Being able to promote and advertise through social media has become extremely attractive for small businesses and freelancers owing to its low cost and the ability to easily reach very large audiences. For example, there is no legal obstacle for an air conditioner repairman, tailor, carpenter, pastry chef, painter, blacksmith, body shop worker or plumber to provide information and promote themselves, to promote their products and work which they do on social media, or even to advertise on social media.

However, in our country, some freelance professions such as medicine, dentistry, veterinary medicine, law, and financial consultancy are subject to advertising bans. The legislation largely prevents these highly educated, white-collar professionals from sharing information about themselves and their work, introducing themselves and their professional activities, and mentioning about their work.

However, freedom of science and art is guaranteed under Article 27 of our Constitution. Pursuant to Article 27 of our Constitution: "Everyone has the right to freely learn and teach science and arts, to explain and disseminate them, and to conduct all kinds of research in these fields." As can be seen, advertising activity, which is defined as the activity of announcing and promoting a product or service, an institution, a person or an idea to large masses through mass media, is within the scope of the right to "explanation and dissemination" included in the Constitution, therefore, there is no unconstitutionality in advertising and promotion. It is an indisputable fact that advertising and promotional activities increase competition in the relevant field and this is in favour of all actors in the market.

Furthermore, the above-mentioned professions such as medicine, dentistry, veterinary medicine, law, and financial consultancy, are subject to similar economic conditions as professionals in other sectors that make up the service sector, and they pay a large amount of taxes. Moreover, in case of a dispute arising out of the service provided by these professionals, consumer courts have jurisdiction. On the one hand, these highly educated and white-collar professionals are strangely considered by the legislation as if not performing any economic activity. On the other hand, members of this profession are prohibited from working without pay. It is a great contradiction that all kinds of promotional activities carried out by this group of professionals, who are prohibited from working for free, in order to develop their customer portfolio and increase their business volume with the intention of earning a wage, are subject to an advertising ban and sanctions are imposed on the members of the profession accordingly.

The question of the unconstitutionality of the relevant legislation is a separate topic of discussion, and we leave this issue aside for now and will examine advertising and promotional activities in the field of medicine in terms of current legislation.

A Detailed Overview of Current Legislation

The law that determines the principles of medical practice in our country is the Law on the Proper Practice of Medicine and Medical Arts dated 11.04.1928 and numbered 1219 (Hereinafter referred to as the "Medical Law".). The ban on advertising to doctors derives its legal basis from this Medical Law, which was enacted 95 years ago. According to this law, doctors can notify about the address of their offices, examination hours and areas of expertise, but they are strictly prohibited from engaging in promotional activities such as making announcements, advertisements, etc. other than what have been mentioned above.

The ban on advertising for doctors was also included in the Medical Deontology Statute (Hereinafter referred to as the "Statute".), which was published in the Official Gazette dated 19.02.1960 and numbered 10463 and entered into force on 19.04.1960. In accordance with the Statute, it is forbidden to give a commercial aspect to the professions of medicine and dentistry, and members of these professions are prohibited from advertising themselves in any way. In addition, doctors and dentists are prohibited from printing thank-you announcements in the form of advertisements in newspapers and similar printed media.

A similar regulation is stipulated in the Rules of Medical Professional Ethics, which were accepted at the 47th Grand Congress of the Turkish Medical Association held on 10-11 October 1998, published on 01.02.1999, and to which all medical doctors are obliged to comply. It has also been stipulated that doctors cannot advertise while practicing their profession, cannot be an intermediary for commercial advertisements, cannot give a commercial appearance to their work, and cannot engage in behaviour that may misguide people, cause panic, mislead people, or cause unfair competition among colleagues. It is stated that doctors can only state their field of specialisation, working days and hours in their announcements via broadcasting tools.

According to the Regulation on Job and Task Descriptions of Healthcare Professionals and Other Professionals Working in Medical Services, which came into force after being published in the Official Gazette dated 22.05.2014 and numbered 29007, it is stated that healthcare professionals and other professionals working in medical services are prohibited from making misleading, demand-increasing and self-praising promotions, organising campaigns and advertising. They are only permitted to introduce their name, title, branch and address.

Prohibitions and restrictions on advertising and promotional activities in the field of medicine are binding not only for medical doctors and other healthcare professionals, but also for medical institutions and organisations. According to the Private Hospitals Regulation, which came into force after being published in the Official Gazette dated 27.03.2002 and numbered 24708, private hospitals cannot engage in behaviour that is contrary to the rules of medical deontology and professional ethics, that misguides people, misleads people and aims to create demand, creates the impression that it accepts and treats patients other than the specialisations written in its license, and creates unfair competition against other hospitals, and they cannot make promotions of this nature. All kinds of medical information on the websites created by private hospitals must be provided by healthcare professionals who have knowledge and experience in their field. No information regarding therapeutic medical services can be provided through these sites. The date of last update of the information provided on the websites shall be clearly stated.

In the Regulation on Private Medical Institutions Which Provide Outpatient Diagnosis and Treatment, which came into force after being published in the Official Gazette dated 15.02.2008 and numbered 26788, it is clearly regulated that medical institutions cannot make any advertising. Accordingly, medical institutions cannot make any promotions based upon practices that are contrary to the rules of medical deontology and professional ethics, that misguide people, mislead people, aim to create demand, are not scientifically proven or have not become an established medical method, and cannot engage in behaviours that create unfair competition against other medical institutions. Medical institutions can provide information that protects and promotes health. Provided that it is not contrary to the provisions specified herein, they may promote and publish announcements in order to inform the public about their opening, service areas and services offered. However, misleading, exaggerated, scientifically unproven information and statements intended to create demand cannot be included within the scope of informational and promotional activities.

In addition, acting as an intermediary between doctors and patients and using intermediaries in the provision of medical services are among the prohibited activities. According to the Rules of Medical Professional Ethics, a doctor cannot send patients to other doctors or examination-treatment institutions in exchange for financial gain. The doctor cannot benefit from intermediaries to provide patients.

In fact, in the Turkish Medical Association Law numbered 6023 dated 23.01.1953, a more severe sanction has been foreseen in this regard, and it has been regulated that those who bring business to doctors in return for a fee or any benefit shall be sentenced to imprisonment from 3 months to 1 year. Besides, according to this Law, "preventing advertising through cinema, radio, messengers or other written and oral means" is listed among the duties of the board of directors of the Turkish Medical Association.

At the 67th Grand Congress of the Turkish Medical Association held on 12.06.2016, the "Guideline on the Sharing of Doctors and Medical Institutions and Organisations in Electronic Environments" (Hereinafter referred to as the "Guideline.") was accepted. In this context, a number of principles and rules have been determined for the use of the internet environment by all doctors and medical institutions and organisations, taking into account the nature of the medical service and the respectability of the healthcare profession. According to the Guideline, under the title of "personal information" on their websites, doctors can include information about the education they have received, their international qualifications and titles in the field of specialisation specified in the Medical Law, their scientific publications, their speeches at scientific meetings, the meetings they organise, their awards, their memberships to local and foreign specialist associations, their administrative and consultancy duties, and they may share content that protects and promotes health and informs the public. However, information whose accuracy has not been scientifically proven cannot be included; the source of the information given and its last update date must be stated. At the bottom of each information page, the phrase of "Page content is for informational purposes only, be sure to consult your doctor for diagnosis and treatment." must appear in at least the same font size as the other text and in an easily recognisable manner. According to the Guideline, information that is contrary to the knowledge accepted by the scientific community today, that is incorrect or whose accuracy has not been scientifically proven cannot be included, and elements containing information regarding therapeutic medical services (statements, articles, photographs, videos, interviews, news, etc.) cannot be included in any way. One of the most important provisions in the Guideline is that images or statements of patients before and/or after treatment cannot be included in any way. In parallel with this, redirection cannot be made by providing links to publications of this nature. Similarly, it is prohibited to include images of healthcare professionals with patients and their relatives before, during and after treatment. Patients' evaluations, opinions, and thank-you announcements about the doctor or the medical institution and organisation and the healthcare personnel working there cannot be included. Statements and images related to the physical environment and medical devices or equipment of clinics and other medical institutions and organisations cannot be used. In addition, all rules in this Guideline also apply to the views of the website in foreign languages. However, in case of violation of these rules, the authority authorised to impose sanctions has been the Turkish Medical Association.

The sanctions that the Turkish Medical Association can impose based on the Turkish Medical Association Law No. 6023 dated 23.01.1953 are as follows:

• Written notice,

• A fine of not less than 3 times and not more than 5 times the highest annual membership fee of that year,

• Temporary prohibition from engaging in professional activities for a period of 15 days to 6 months,

• To prohibit those who have been banned from engaging in professional activities in a region 3 times from working in that region,

Courts of honour exercise their wide discretion in imposing these penalties, regardless of order.

In accordance with the provisions of the Turkish Medical Association Law and the Turkish Medical Association Disciplinary Regulation, the Turkish Medical Association has the authority to conduct examinations, initiate investigations, conduct disciplinary proceedings and impose disciplinary penalties, upon notification or complaint made to the medical chambers or ex officio.

Regulation on Promotional and Informational Activities in Medical Services

This was the legislation before the Regulation on Promotional and Informational Activities in Medical Services (Hereinafter referred to as the "New Regulation".), which was prepared by the Ministry of Health and entered into force after being published in the Official Gazette dated 29.07.2023 and numbered 32263.

In brief, in all legislation with regard to the field of medicine, doctors and medical institutions have been already prohibited from advertising under any circumstances, informational and promotional activities have been significantly restricted by being subject to certain rules, and providing information regarding treatment has been prohibited. In other words, there has been already a ban on advertising to doctors. However, in case of violation of this ban, the only authority authorised to impose sanctions was the Turkish Medical Association, which is the national umbrella organisation of medical professional chambers.

However, with the New Regulation, the Provincial Evaluation Commission for Medical Promotional and Informational Activities (Hereinafter referred to as the "Commission".), which shall be established within the Ministry of Health, shall also be able to impose administrative sanctions. In order to detect cases of non-compliance with the New Regulation, the Commission, which shall be established with the approval of the governorship, shall evaluate the compliance of promotional and informational activities within the provinces in accordance with the provisions of the New Regulation and other relevant legislation. The Commission shall evaluate and decide on its review of the promotional and informational activities that are found to be inconsistent, within 30 days at the latest as from the date on which the relevant file is forwarded to the Commission.

Although the New Regulation is parallel to the regulations in force in the previous period, it also includes more detailed and up-to-date provisions and introduces some innovations. The New Regulation contains regulations parallel to the provisions in the Guideline in many respects, but the importance of the New Regulation lies as follows. Now, in addition to the Turkish Medical Association, a new institution, the Commission, has been established to impose sanctions in case of violations.

New Regulation covers healthcare professionals, promotional and informational activities, made by all medical institutions, organisations, corporations and international medical tourism intermediary organisations which belong to real persons and private law legal entities that provide medical services and operate with the permission, certificate of conformity or license issued by the Ministry of Health in accordance with the relevant legislation, as well as promotional and informational activities carried out by persons, institutions and organisations which do not have authority, permission or license in the field of medical service provision.

According to the New Regulation, advertising is defined as “announcements in the nature of commercial marketing communications made through written, visual, audio and similar means in any medium in connection with private healthcare facilities in the field of medicine, medical service provision or medical professions, in order to create or increase demand for a product or service and to persuade people". According to the New Regulation, promotional and informational activities are defined as “activities that are not misleading and deceptive, do not endanger human health, do not create demand and unfair competition, and do not fall within the scope of advertising; regarding private healthcare facilities, which contain information about the specialisation fields where patients are admitted and treated, address and contact information, health-protective and health-promoting information about the medical field in which the medical service is provided; and regarding doctors, which include their professional and academic title, major and sub-branch specialisation specified in the Medical Law, examination days and hours, information on the time and place they accept patients, and health-protective and health-promoting information about the medical services they are authorised to provide”.

In the New Regulation, it is regulated that it is prohibited to make or receive implicit or explicit advertising in the provision of medical services, and the limited scope of information that doctors can share is drawn, as well as introductory information such as "academic title, examination days and hours, information about the time and place of admission to patients", as well as. information on specialisation branches is limited to the "major and sub-branch specialisation" determined by the Medical Law. It is forbidden to use any expression other than the areas of expertise specified in the referred Medical Law. For example, since a field of expertise such as "aesthetician" is not included in the legislation, the term that must be used is "Plastic, Reconstructive and Aesthetic Surgery Specialist", and instead of "Neurosurgery Specialist", "Brain and Nerve Surgery Specialist" ought to be used. Information that protects and promotes health should also be limited to the medical field served. For instance, it is prohibited for an internal diseases specialist to share information about hernia disorders which falls within the scope of orthopaedic and brain and nerve surgery branches.

One of the prohibitions in the New Regulation is that no activities can be carried out that would create the impression that patients are expressing gratitude for the medical service. From now on, patients who are satisfied with the doctors' treatments are not even allowed to thank the doctor via social media or other methods. Therefore, doctors' posts on social media should now be closed to comments, as there is a clear provision on this issue. There is currently no obstacle for patients who are satisfied with the treatment provided by the doctor to recommend that doctor to their friends in their conversations among themselves. One of the requirements of the New Regulation is that in the informational letters shared by doctors on their websites, "clearly stating the last update date of the information and the contact information through which the website editor can be reached".

According to the New Regulation, it is prohibited for healthcare professionals and healthcare facilities to include "before and/or after images that compare the effects of the treatment and create demand" in their promotions and information about the medical services they provide. This provision stands out as one of the most remarkable provisions of the New Regulation. From now on, doctors will be able to provide visuals of the pre-treatment and/or post-treatment conditions of the patients they have operated on or cured by applying another treatment, only if these images are not comparable to the effects of the treatment or do not create a demand. Aside from presenting comparative before/after photos, sharing the pre-treatment photo alone or the post-treatment photo alone is only possible if these images are not comparative of the effects of the treatment or create a demand. The Commission shall evaluate whether the images shared by doctors are comparable to the effects of the treatment or create a demand.

Although all these bans seem to be for doctors at first glance, the scope of the New Regulation is quite wide. According to the New Regulation: in addition to the professions of "doctor, dentist, pharmacist, nurse, midwife and optician", professions such as “Clinical psychologist, physiotherapist, audiologist, dietician, language and speech therapist, podologist; healthcare physicist; anaesthesiologist / anaesthesia technician; medical laboratory and pathology technician, medical imaging technician/mechanist, oral and dental healthcare technician, dental prosthesis technician, medical prosthesis and orthosis technician/mechanist, operating room technician, forensic medicine technician, audiometry technician, dialysis technician, physiotherapy technician, perfusionist, radiotherapy technician pharmacy technician; occupational therapist (ergotherapist); occupational technician (occupational ergotherapy technician), electroneurophysiology technician, mammography technician, emergency medicine technician, nurse assistant, midwife assistant, healthcare technician” are also obliged to comply with the prohibitions set out in this New Regulation.

Hence, pursuant to the New Regulation, it is absolutely prohibited for a dietician to shares the before-after images of a client, who has lost weight as a result of his/her activities, provided that these images are "comparative of the effects of the treatment or create a demand". Time will show how and on what basis the Commission, which shall evaluate whether an image "comparative of the effects of treatment or creates a demand", will determine its decision. The jurisprudence that will be formed through the precedent decisions that will emerge over time will enable us to gain an idea about the Commission's perspective and interpretation criteria.

Another prohibition in the New Regulation is as follows: Patient comments regarding visual content or expressions that constitute a declaration of gratitude cannot be shared, even if they are made in other media. It is mandatory for posts of visual content to be completely closed to comments. This provision has been prepared considering the possibility that positive comments and expressions of gratitude made by the patient under the patient images shared on social media platforms such as Instagram may increase demand among social media users, and it is obligatory for the images to be closed for comments.

Another prohibition introduced within the scope of the New Regulation is that patient images cannot be shared during surgery or medical intervention and in the operating room. This provision is extremely important. Today, on social media platforms such as Instagram and YouTube, there are extremely useful videos and photographs that inform patients, medical students, and the scientific world about how various and challenging surgeries are performed. The prohibition introduced in this Article no longer allows this. Because there is no regulation that allows the contrary in case of the patient's permission, that is, even if the patient allows his/her image to be shared in the operating room, this is not possible, and it does not change anything whether the patient's identity can be identified or not. Even the image of the patient in a position where the patient's identity cannot be identified, for example, only the waist area is seen in a herniated disc surgery, cannot be shared in accordance with this provision.

Another provision of the New Regulation that is open to interpretation and debate is as follow: "visual contents of private parts of the body cannot be shared in a way that would violate general moral rules." How and in what way subjective and controversial criteria such as public morality and privacy can be evaluated by whom in an objective field such as medicine and health science is a separate matter of discussion.

Another important regulation included in the New Regulation is as follows: Visuals regarding the region, place, medical device, equipment, tools, equipment or personnel or any similar element cannot be shared in order to give the impression that the healthcare professional or medical institution is superior or better than other healthcare professionals or medical institutions. Accordingly, the above-mentioned professionals and medical institutions operating in the medical field cannot share images of their clinics, hospitals and the tools and equipment they own, if their purpose of sharing these images is "to give the impression that they are superior or better than other healthcare professionals or medical institutions”. So, how and on what basis will the Commission determine the existence of an intention to give this impression? This is also a subjective regulation and will bring about a lot of comments and discussions.

Another innovation in the New Regulation is the supervision of promotional and informational activities carried out in the field of health on radio and television channels. Healthcare professionals who participate in promotional and informational programs and make speeches and statements on radio and television channels broadcasting via cable, satellite, terrestrial and similar transmission media must sign, before the program, a letter of undertaking containing commitments in line with the provisions regarding promotional and informational activities in this New Regulation and the relevant legislation.

The New Regulation also sets out what sanctions shall be applied in case of detection and decision of non-conformity with the regulations in the New Regulation. In the new Regulation, reference is made to the Medical Law and it is stated that an administrative fine shall be imposed in case of violation. In addition, notification is made to the professional organisations to which the relevant persons are affiliated. Thus, in addition to administrative fines, the professional organizations to which they are affiliated may also impose other sanctions. Therefore, in case of violation, both administrative fines and warnings, reprimands, etc. from the Turkish Medical Association can be imposed. It is possible to receive penalties.

The sanctions to be applied to the healthcare facility in case of violation are also specified in the New Regulation. The healthcare facility that is found to be carrying out promotional and informational activities in violation of the provisions of the New Regulation shall be warned twice. If it is determined that promotional and informational activities contrary to the provisions of the New Regulation have been carried out for the third time within 1 year, the activities of the unit in the relevant medical or specialisation branch shall be suspended for 3 days.

In case it is determined that the persons, institutions and organisations whose promotional and informational activities are carried out are providing medical services without authorisation, permission or license, in violation of the relevant legislation and Ministry regulations, in accordance with the New Regulation, the activities of places providing unauthorised medical services shall be immediately stopped and a criminal complaint shall be filed before the Public Prosecutor's Office, against those concerned pursuant to the provisions of the Medical Law and the Medical Services Basic Law numbered 3359.

According to the New Regulation, self-employed healthcare professionals other than doctors and dentists, and other professionals working in medical services can provide promotion and information only under the following conditions:

Promotion and information must not contain a health declaration.
Promotion and information cannot be oriented towards diagnosis and treatment.
Promotion and information should be within the scope of professional expertise field of the person performing it.

If the promotional and informational activities carried out by these people do not comply with all 3 conditions mentioned above, they will be considered as unauthorised medical service provision and a criminal complaint shall be filed before the Public Prosecutor's Office against the relevant people in accordance with the provisions of the Medical Law and the Medical Services Fundamental Law.

Therefore, if the promotional and informational activities carried out by a self-employed healthcare professional other than a doctor or dentist include a health declaration or are aimed at diagnosis and treatment, or are not within the professional expertise field of the person providing the promotion and information, after the indictment is prepared against the relevant person by the Public Prosecutor's Office, if the person concerned is found guilty as a consequence of the trial to be held in the criminal court, he/she may be sentenced to prison.

Pursuant to the Medical Services Fundamental Law, those who provide medical services without a license or have medical services provided by unauthorised persons are punished with imprisonment from 1 to 3 years and a judicial fine of up to 20,000 days.

In accordance with the Medical Law, those who do a job that is within the authority of healthcare professionals defined in the legislation or have the title thereof, without having a diploma or professional certificate, shall be punished with imprisonment from 1 to 3 years and a judicial fine from 200 days to 500 days.

International Medical Tourism

Although these are the innovations introduced within the scope of the New Regulation, there is an area that is excluded from all these bans and sanctions: international medical tourism.

According to the New Regulation, promotional and informational activities within the scope of international medical tourism shall be carried out in accordance with the provisions of the Regulation on International Medical Tourism and Tourist Health (Hereinafter referred as to “Medical Tourism Regulation”.), which came into force after being published in the Official Gazette dated 13.07.2017 and numbered 30123. Therefore, if the promotional and informational activities fall within the scope of international medical tourism, it is possible to exclude the harsh provisions of the New Regulation.

In the Medical Tourism Regulation, after regulating who are within the scope of the Medical Tourism Regulation and under what circumstances, it has been stated that among the persons mentioned within the relevant provision, those who wish can also receive services within the scope of the Medical Tourism Regulation "if they voluntarily undertake to pay a fee within the scope of international medical tourism". Within the relevant provision of the Medical Tourism Regulation, since the citizens of the Republic of Türkiye are also mentioned, provided that a Turkish citizen is treated by a Turkish doctor in a medical institution in Turkey and undertakes to pay a fee within the scope of international medical tourism, this activity will fall within the scope of the Medical Tourism Regulation. However, the authorised institution to determine the fee to be paid within the scope of international medical tourism is the Ministry of Health. Pursuant to the Medical Tourism Regulation, the cost of the medical services provided within the scope of international medical tourism to be provided within the scope of this Regulation is determined by the Ministry by taking the opinion of the Medical Tourism Coordination Board. International medical tourism healthcare facilities are obliged to comply with the procedures and principles specified in the medical tourism fee tariff determined by the Ministry.

So, what is required to operate within the scope of international medical tourism? In order to operate within the scope of international medical tourism, it is mandatory for the healthcare facility and the intermediary organisation to obtain an international medical tourism authorisation certificate. International medical tourism activities of those who do not receive an authorisation certificate are stopped by the Ministry.

Other requirements to obtain an authorisation certificate are regulated in detail in the Medical Tourism Regulation. Informational and promotional activities to be carried out within the scope of international medical tourism can only be carried out by healthcare facilities and intermediary organisations authorised within the framework of the Medical Tourism Regulation. Although the provisions regarding informational and promotional activities included in the Medical Tourism Regulation are generally parallel to the provisions in the New Regulation, extremely strict provisions in the New Regulation, such as not being able to share before/after images and sharing posts without comments, are not included in the Medical Tourism Regulation. However, in accordance with the Medical Tourism Regulation, promotions cannot be made in Turkish language and in a way that will create demand within the borders of Turkey. Promotions can be made in the languages of the countries where promotion will be made and/or in English.

As can be seen, in case of promotion and information in any language other than Turkish, sharing of the patient's pre-operative and post-operative photographs, receiving comments in the form of thanks and praise from the patient, all of these are possible on condition of "not being made in Turkish and in a way that creates demand within the borders of Turkey". There is no legal obstacle for the promotion and information within the scope of the Medical Tourism Regulation to contain a health declaration, be oriented towards diagnosis and treatment, and be encouraging to other people. Because it is thought that the aims, target audiences and the masses that the Medical Tourism Regulation and the New Regulation want to protect are different.

However, it is extremely important that sharing only in a foreign language without providing a service within the scope of international medical tourism, in other words, without having the necessary authorisation document specified in the Medical Tourism Regulation and without applying the specified fee tariff, is not sufficient to remain outside the scope of application of the sanctions in the New Regulation.

Att. Exp.Mdt. Emre Senar BOZKURT, LL.M.

For detailed information on the subject, you can contact us at info@emresenarbozkurt.av.tr.

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