Economics and Net Medical Ethics
Dr. Koop: Meet Dr. Napster
Glenn McGee, Ph.D. / SPECIAL TO MSNBC 23jun00

Internet health is going to be big business and there have to be ethics codes. But the transparently corporate codes we have seen so far don’t get the job done. “Breaking Bioethics” columnist Glenn McGee, Ph.D., explains why.
            You would never think of getting an annual medical exam over the Internet. Your clinician has to poke and prod you, take your blood and look you over before your checkup is complete. Some kinds of medicine just don’t translate into HTML.
       But if you are visiting your doc about a problem, and you know how to use the Internet, odds are that you will show up with Web search results and even detailed studies about your health problems. Your doctor may not like it, but you may know more about the state of research on your condition than he or she does. And because that is true, these days you may join a growing group who skip their checkup and order their drug of choice online from a Web drug vendor in Mexico.
       Where sensitive issues are concerned, like sex and sexually transmitted diseases, lots of patients would just as soon skip the part where they have to tell Dr. Condemnation about what they did last weekend. For this and many other reasons, Internet health sites are beginning to look like a pretty profitable venture.
The big boys of the Internet health world — WebMD, DrKoop.com and OnHealth — may not be reporting big corporate earnings yet (one, DrKoop.com, looks like it is well on the way to bankruptcy), but millions of dollars are poured into these sites by advertisers hoping that when you search for Web pages about herpes you will find not only medical information but also a clickable link to their company; maybe even a coupon you can use to try to leverage a prescription when you see your doctor.

BLURRED BOUNDARIES
       American physicians have made it perfectly clear that where the Internet and patients are concerned, docs better be cautious about self-educated Web-headed patients. “A little [Web] information is a dangerous thing,” said one prominent editor of a major medical journal.
      Most physicians know about and have used the Internet in some way, but that doesn’t mean that HMOs, hospitals, medical associations or consumer groups have developed good rules for how to guide clinicians whose patients show up with laser-printed medical articles framed by ads for drugs.
       The onslaught of direct-to-consumer advertising that has come along with the gold rush in Internet health has everyone confused. It has blurred the boundaries between advertising and journalism, between science and malarkey and between profiteering and fair business practice. Already all of the major health sites on the Internet have been subject to severe scrutiny for their financial relationships, ranging from simple conflict of interest (can a Web site really endorse hospitals who pay a fee?) to complex collusion (when is a medical Web site really medical, really corporate or really free?) and violations of privacy (does your browser cookie from Joe’s Internet Health Shop really need to store information about which drug ads you click?).
      No one has really studied the impact of the Internet on patient care. What has happened though is a rush to write and push “codes of ethics” for Internet health care. In response to pressure from patients and physicians alike to enforce codes of conduct for Internet medical sites, three codes of ethics have been produced in the past year, both sponsored by insiders in the Internet health industry.
       The first code was written by the DrKoop.com company, just a couple of months after Koop and his company were flogged in the media for engaging in an egregious conflict of interest by endorsing hospitals who had paid fees to the site. You probably haven’t heard much about the other two codes of ethics, each written by a brand new health coalition, because despite the high profile of those who wrote the codes of ethics and their ethicist consultants, neither code applied to anyone who wanted to ignore it.

THE NAPSTER EFFECT
       What we need to help patients and doctors deal with the Internet is a code of ethics for medical Web sites. Right? Wrong. Ironically, the most dangerous thing in Internet health care may be simple codes of ethics. Why? If the failure of a code of ethics to save DrKoop.com from implosion doesn’t convince you, just look at the rest of the Internet, and it becomes clear that systematic, bureaucratic rule-making for the Web is dead, dead, dead.
       The best example of why simple-minded Internet codes of ethics won’t work is Napster, the now world-famous music exchange program that has swept the Internet and sent shock waves through the recording industry. Like a big Internet health site, Napster lets you download and exchange lots of very expensive information, in this case music. Instead of buying a CD, Napster lets you download it from some anonymous guy with the handle “BigBoy3321” in Wyoming or Malaysia.
       Napster is the seepage of the Internet. While recording executives rage about the ethics of downloading copyrighted material and call for a very expensive site that preserves the music business as they know it, the Internet version of music ethics is about free information. No matter who makes the rules, the Internet has always been a place for individual users to ignore them and create alternative systems of making and distributing information.
       In the case of health care, Internet health sites promise to take a lot of the money out of hospitals, specialist clinical care and medical publishing by replacing time spent with physicians with time spent on the Internet.
       Just like Napster, lots of little sites in Mexico and Poland are selling drugs to anyone who can answer a questionnaire, despite the obvious rules against such conduct out in the great unwired world of medicine. There are some problems with that behavior, ethical and otherwise. But the big boys in Internet health have another big incentive to come up with a code of ethics that shuts out these little players, and fast: money. Little sites that don’t follow rules can grab tons of traffic and make it less profitable to sell ads to big medical companies at the big sites. Not surprisingly, then, both of these new codes of ethics read like a business plan for world domination, calling for every Internet medical site to have an impossibly expensive set of privacy protocols, a huge staff of clinical evaluators, and other bells and whistles no small Internet health site could afford. Neither does a good job defining the important ethical issues that have plagued DrKoop and other big players, like the difference between an endorsement, an advertisement and a “sponsored article,” or the responsibility of Web sites for hazards caused by products they discuss or promote. And the effect of the codes of ethics that have been proposed would be devastating for non-U.S. health sites and for alternative medicine, who could never meet the technical standards.
     Internet health is going to be big business and there have to be rules, sanctions and rewards for good practice. But a real code of ethics for health information on the Internet can’t be produced until someone actually studies the effect of Web sites on health. Once we have data, we need conversation and the little players have to have a voice too.
       A code of ethics from the big players is really just a Trojan horse: It looks like a great idea right up until the point where you see that the authors have designed a world in which only two or three medical Web sites can survive, and each amounts to little more than a shill for drug advertising. Or perhaps the lesson of Napster is that no matter how hard you try to keep the old business plan together in the Internet world, information has a way of poking its way through, until the leaks collapse the dam.

       MSNBC Columnist Glenn McGee is a bioethicist at the University of Pennsylvania. His latest book is “Pragmatic Bioethics.”