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The ethics of online health
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November 1, 1999: 4:34 p.m. ET
Digital medical industry faces tough issues of ethics, access
By Staff Writer Martha Slud
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NEW YORK (CNNfn) - Does someone "treated" in a cyberspace chat room have grounds to sue for malpractice? Who regulates online doctors? And how secure is a medical record that can be accessed through the Internet?
As health care goes digital, legal experts say the medical industry is diving into uncharted waters that the law is ill-equipped to handle.
"There are bound to be more injuries as a result," said Prof. Linda Fentiman, director of the Health Law and Policy Program at Pace University. "Some injured patient is going to find a lawyer that then will sue."
Already, the health care industry is in a tailspin amid litigation stemming from managed care organizations, says Nicolas Terry, a professor at the Saint Louis University School of Law. Lawyers are gearing up to challenge a decades-old federal law that has protected health maintenance organizations from lawsuits, charging that HMOs have based coverage decisions on cost issues instead of medical need.
"As the legal system tries to come to grips with managed care, now we're adding this additional gloss of the Information Age," Terry said. "I think that there's a serious disconnect between our health law rules and the new business models that are appearing."
One issue that will be closely tracked is the advent of disease management Web sites that help patients keep track of their conditions. Many doctors are in favor of these types of supplemental services, but others are more cautious, saying that unless a patient's doctor is an integral part of the program then the patient may be getting conflicting advice.
A question of ethics?
Dr. George Lundberg, editor-in-chief of Medscape.com, thinks it's unethical for doctors and patients to communicate via e-mail unless a face-to-face relationship already has been established. Fentiman also says she fears that many people won't be entirely truthful over the Internet, making even the most well-meaning online doctor unable to correctly diagnose a patient.
Another issue is cyber doctors who have been prescribing lifestyle drugs such as impotence remedy Viagra or baldness treatment Propecia to people they've never actually met in person. State attorneys general are looking into how to regulate this growing phenomenon.
Meanwhile, another issue challenging the medical community is that of electronic medical records. More HMOs are moving toward requiring doctors to submit reimbursement claims electronically, raising questions about privacy and security.
President Clinton recently introduced a federal proposal to protect electronic records, saying that personal privacy is being jeopardized by some employers and marketing firms who have access to sensitive patient files. Congress has debated the issue, but missed an August deadline to come up with protections for patients.
Besides these issues, observers also are concerned that while the Web can offer ease and efficiencies, many people without Internet access may be left behind.
Terry thinks it's inevitable that many services of managed care will ultimately move exclusively to the Internet. He said that as online drugstores proliferate, insurers likely will give patients discounts if they order prescription drugs online, creating imbalances for people without Internet access who already have trouble paying for costly medications.
Fentiman said that while the Internet could be a good source of medical information for the estimated 45 million Americans who have no health insurance, these people are also the least likely to have Internet access. Web access is rapidly extending to public libraries and other outlets, but she said that's not practical in many cases.
"If you're a mother with two sick children you're not going to go to the public library to log on," she said.
Jose Gonzales, the head of the 28,000-member Southern California-based Latino Health Care network, also says that while the Internet is awash with health-oriented Web sites, there is little quality information available in Spanish. He also fears that there are many Web quacks and charlatans looking to prey on the sick and vulnerable.
But Gonzales said it is crucial that minority groups get wired. His network is launching a Web-based service for its health care personnel that will be available to patients over the next year, allowing people to access a secure electronic database from home.
"We're going to have a whole group of adults who in their mind are too old to learn, but they will have the kids there to be their link to the Internet," he said.
While access clearly is an issue, the Internet also has the potential to reach elderly and rural people who often are cut off from health care information, said Dr. Richard Corlin, speaker of the American Medical Association's House of Delegates. For many older people, the Internet has presented a way to connect and reduce their sense of isolation, he said.
Some Web proponents also argue that the Internet sometimes can serve as a tool for people who are wary of in-person interaction with doctors.
"If anything, the Internet is narrowing the gap rather than broadening it," said Dr. Richard Rockefeller, president of the Portland, Maine-based Health Commons Institute, which promotes the use of computerized tools in health care.
Tough issues ahead
Industry observers say that the burgeoning e-health industry must take steps to ensure that it's above-board ethically in order for these Web sites to gain patients' trust. But already, the industry has been hit by some negative publicity. This past summer, former Surgeon General C. Everett Koop, partial owner of the popular drkoop.com health information site, came under fire for receiving commissions for health-related products sold on his Web site. Dr. Koop has since stopped the practice.
Last week, The Wall Street Journal reported on another potential conflict of interest. The newspaper disclosed that a prominent official of the Massachusetts Medical Society, which owns the New England Journal of Medicine, holds a major stake in Web company HealthGate Data Corp., which has reached an exclusive deal to carry articles from the medical journal. HealthGate has filed to hold an IPO, although the offering has been delayed.
The industry is working together to come up with ethics guidelines, hoping to hammer out a policy on online medical content, patient privacy and sponsorship. Lundberg, who was fired from his long-time post as editor of the Journal of the American Medical Association earlier this year after publishing a controversial article on oral sex that coincided with the presidential impeachment hearings, said it's important for the industry to conform to existing publishing standards but the industry also wants to demonstrate that it can regulate itself.
Meanwhile, despite the tough issues ahead, some e-health proponents say that the advent of the Internet is serving to reinvigorate a profession in need of a shake-up.
The Internet has the potential to be "a platform for the redesign of the health delivery system," Ian Morrison, a senior fellow at the Health Futures Institute, recently declared at Intel Corp.'s annual online healthcare forum. The Web, he said, can transform an industry "that's pretty much brain dead."
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