Are You suprised ?

The last few years have witnessed the rapid proliferation of websites offering online medical advice and selling prescription drugs over the Internet. These new class of Online Pharmacies originated as an innate part of the booming e-economy, wherein all real world services were rendered online.

The inherent anarchic structure of Internet lets anybody sell virtually anything over the Internet, without bothering to obey the law of any single country. Moreover the cross-border practice possible over the Internet lets it impractical to monitor the activities of these websites. This poses a severe public-health threat and an ethical catastrophe.

The concerns regarding Cyber-pharmacies have been growing steadily probably with the report in early 2000 on some cyber pharmacies [which advertised of facilities that were in existent] settling US Federal trade commission charges [1], and the publishing of the E Health Ethics Initiative code of conduct. [2]

Interesting Research on Cyber-pharmacies

Eysenbach [3] studied Websites selling Viagra Online by posing to be a patient for whom the drug was clearly contraindicated, and found that 3 of the 22 websites delivered the drug in spite of being contraindicated. He also found that only on two websites a physician reviewed the order. He also found that in a majority of cases, even a proper history was not taken.

Bonakdar [4] studied websites offering cancer cure and concluded that a number of websites offered cancer cure through herbal medication with little regard for current regulations.

Scaria [5] studied websites offering sale of Viagra and analysed the information regarding contraindications provided to potential consumers and found that though most of the websites provided information on contraindications, majority was incomplete

Consumers have the right to reliable and trustworthy information about something he is going to buy. Studies [5] show that most of such information is incomplete. Often the Information is fraudulent or inconclusive [see Fig1]. Inconclusive or fraudulent information bound in a cloak of professional design and presentation is an important concern.

Figure [1] A Screenshot from a website that claims to enlarge male genital organs in 30 days. The website claims it to be Medically proven, but does not provide any evidence/details regarding research.

Honesty, Disclosure and Candor

The consumer has the right to know who is behind a website, and what his/her affiliations are- since they are of direct importance to his health. It would also enable the consumer to make informed decisions, and to think of probable avenues of malpractice. The fact is that most of the websites selling drugs are really gateway websites, which redirect/link to bigger firms by virtue of some affiliate program. These websites [serving as middlemen] are little concerned about the quality of information they provide or responsibility to consumers. In other words, these websites are interested in nothing but profit.

Consumers also have the right to honest analysis of research findings. Many websites advertise of 'Medically Proven' products, but hardly provide any information regarding the setting in which the study [if any] was conducted, and when and where [a scholarly journal] it was published. Stephen Barrett [7] says Herbal medications, could not possibly be sold profitably on the Internet without deception, which includes (a) lack of full disclosure of relevant facts, (b) promotion or sale of products that lack a rational use, and/or (c) failure to provide advice indicating who should not use the products. Given the number of websites selling such 'Herbal" medications, anyone could just imagine how ethical the marketing practices on the Internet are.

Informed Consent and Responsibility

Informed consent is a key pillar of trust and relationship in real world. Over the Internet, consumers are potentially under-informed or worst un-informed. This raises the integrity of the consent provided by potential consumers. Most of the websites offer a disclaimer notice, according to which all liability is restricted to refund of money.

Trust and Relationships:

Physician-patient or Customer relationships virtually never exist in the online world. The maximum liability in any case is minimized to refund of money. Thus lack of relationship in the virtual world, with the potential of Internet to maintain anonymity of concerned individuals leads to the deterioration of ethical conduct and quality of services.

Anonymity

Internet has created a situation wherein anybody could operate in total anonymity. This is perhaps the prime source for concern. Over the Internet, anybody could express anything, sell anything and mislead anyone, under the cloak of a professional website and a flashy Domain name and E-Mail ID. Anonymity means the concerned individuals are potentially free of any responsibilities to the customers and thus not obliged to perform according to ethical norms.

Quality Assurance, Accountability and Consumer Protection

One could easily see that anybody could promote virtually anything over the Internet. Only a good web host and a flashy website is all what is needed. Since most of these websites operate in anonymity, and potentially out of the reach of law of any single country, patients who have been deceived are less likely to get protection/compensation from consumer reprisal forums.

Privacy and Confidentiality

Privacy and Confidentiality are part of ethical conduct in a real world physician-patient relationship. Over the Internet, there is hardly anything private/confidential. Anybody from a Webmaster to a hacker could have access to your personal information. Most of the websites do not have a privacy policy or reliable framework to prevent people from peeking into their consumers' personal information. Though regulatory frameworks [6] are emerging, there is hardly any compulsory system to oversee the implementation of such frameworks over a time-bound period.

Cross Border Activity and Legal implications.

Legal frameworks are highly variable. What might amount to an unlawful conduct in one country/region may not be the same elsewhere. Similarly one drug that may be available with prescription in one country/region may be available elsewhere without one. Moreover different countries have different standards for production and marketing of drugs. This would also serve as potential areas of conflict between two parties. Moreover, due to the lack of a Universal code of conduct, the consumers hardly have any avenues to have their complaints redressed.

Experiences with the E-Health Adversities Research Database [E-HARD]

The E-HARD [8] was set up in January 2003 to collect evidence related to E-Health adversities. To date three cases of fraud involving cyber pharmacies have been submitted, and currently under evaluation. These websites were involved in marketing so-called 'herbal preparations' for diseases as varied as Cancer and AIDS. One website even claimed to cure AIDS with their six week therapy.

It is also amazing to note that these websites also significantly contribute to the menace of Unsolicited Commercial E-Mail [UCMs] or SPAM. Some of our unpublished research shows Health related spam contribute to something around 10-12% of all Unsolicited commercial E-Mails.

Internet is slowly evolving into a new 'Virtual World' or the 'Second World' and is leaving its impact in our lives too. The emerging E-Economy is also making its presence felt in all domains. The virtualization of Healthcare is also underway- with the Emergence of CyberMedicine and Telemedicine as emerging technologies. Cyber-Pharmacies- a virtual extension of real world pharmacies also forms a significant part of the new economy. The ethical concerns regarding marketing of medications online are myriad- most of them emerging from the anonymity and anarchy offered by the Internet. A regulatory approach to this problem is not possible due to the uncontrolled and anarchic structure of Internet.

The possible way out is perhaps trustmarks/seals like the HON code of conduct seal [9] and consumer Education. Coaxing more websites to join such accreditation programs would significantly improve the state of E-Health. Moreover setting up of websites that systematically collect evidence on misconduct over the Internet is necessary. A host of such websites, with interconnectivity would enable planning and implementation of strategies aimed at improving the state of affairs.

3] Eysenbach G.Online Prescribing of Sildanefil (Viagra(r)) on the World Wide Web. Journal of Medical Internet Research 1999;1(2):e10 http://www.jmir.org/1999/2/e10/

4]Bonakdar RA. Herbal cancer cures on the Web: noncompliance with The Dietary Supplement Health and Education Act. Fam Med 2002 Jul-Aug;34(7):522-7

5] Scaria.V. Buying Sildenafil Citrate Online: are prospective buyers informed of contraindications [in process of publication] [Preliminary Draft]

7] Barett S.How to Spot a "Quacky" Web Site

Competing Interests: The author maintains the E-Health Adversities Research Database [E-HARD]. He is also the author of the research paper [4] on cyber pharmacies cited in this paper.

Introduction