The growth of the Internet over the last 10 years as a medium of information and as a communication technology has, not unsurprisingly, provided a foundation for the growth of direct-to-the-public online sales. Amongst the many commercial activities that are now flourishing in this environment are Internet Pharmacies, providing a variety of products (e.g. health and beauty products) as well as prescription drugs. Some pharmacies only dispense drugs with a valid prescription, some provide online consultations for prescribing and dispensing medicines, and some dispense medications without a prescription.
This paper reports on how technology has facilitated the practice of medicine online, and discusses the benefits to consumers in terms of access and convenience, together with the problems that have arisen as a result of remote consultations and lack of professionalism. It is this latter aspect that provides the focus of the paper.
We explore the ethical issues that emerge within the context of remote/online medical consultations and prescribing. We refer to current United States and United Kingdom practitioner guidelines to aid our discussions. For example, members of medical boards of all US states (The Federation of State Medical Boards) published, in 2002, ‘Model Guidelines for the appropriate use of the Internet in Medical Practice’1. Two of the guidelines specifically address the issues of remote prescription practices, referring to “documented patient evaluation” (including a patient history and physical evaluation) and stating that “Issuing a prescription based solely on an online questionnaire or consultation does not constitute an acceptable standard of care”. Further, guidelines issued by the American Medical Association in 2003 regarding the prescribing of medicines to patients via the Internet state that a physician who prescribes medications via the internet must establish or have an established a valid patient-physician relationship2. This includes among other things obtaining a reliable medical history and performing a physical examination of the patient. In 2004 the General Medical Council (GMC) in the United Kingdom issued new practice guidelines which has similar regulatory goals to the US position but some noticeable differences. The GMC details conditions to be met for remote prescribing in situations where a practitioner is either: continuing to care for a patient; deputising for another doctor responsible for the patient; or has prior knowledge and understanding of the patient’s condition and medical history and has access to the patient’s medical records. In the absence of these situations, however, the GMC does not expressly forbid remote prescribing but gives additional conditions to be satisfied if remote prescribing is to be used.
The above guidelines indicate the concern of regulatory bodies regarding Internet pharmacies and the prescribing of drugs. These concerns are particularly genuine in light of the increasing use and availability of the Internet for healthcare. We argue that online medical services have become a global market, due to widespread availability of online consultations and prescriptions irrespective of geographic location. We discuss among other issues whether current regulatory guidelines in the UK and US provide sufficient safeguards at present for society, organisations and individuals. We also discuss their impact on the future growth on online medicine.
In exploring ethical issues surrounding current online medical practices we refer to instances of prosecutions for online consultation both in the United States and United Kingdom. Such cases include Dr Richard Franklin who was found guilty of serious professional misconduct and suspended by the GMC in January 2002 after prescribing drugs online1, and Dr Shreelal Shindore, of Florida who in 2004 was forced to relinquish his license for violating standards of care when prescribing drugs over the Internet2. Using these cases we further highlight ethical issues of concern and provide concrete examples of what can go wrong. We also assess where problem areas may arise, and provide guidance on formulating recommendations for the future.
We conclude with an overview of the social and ethical issues of concern regarding online medical consultation and prescribing. We highlight how these present concerns are relevant to looking forward into the future. We also discuss how advances in technology can impact on online healthcare, both in terms of providing solutions to present difficulties and in creating further ethical concerns. Finally we provide some ethical guidance on how online medical practice can be safeguarded as a genuine consumer alternative.
C.Radatz, Internet Pharmacies, Wisconson Briefs, Brief 04-5, March 2004. http://www.legis.state.wi.us/lrb/pubs/wb/04wb5.pdf
Model Guidelines for the Appropriate use of the Internet in Medical Practice. Accessed via the FSMB homepage: http://www.fsmb.org/
H-120.949 Guidance for Physicians on Internet Prescribing: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-120.949.HTM