Medscape and the History of Internet Medical Ethics

Back in August 1995, in the nascent days of the World Wide Web, I helped launch the websites of the American Medical Association (AMA) and the Journal of the American Medical Association (JAMA) along with Robert Musacchio and Bill Silberg. At the time, Robert was senior vice president of publishing for the AMA, Bill was the editorial director of news and new media at JAMA, and I was JAMA's editor-in-chief. We thought we were pretty early with our internet presence, and we were, but Medscape was already there.

Peter Frishauf had founded Medscape in May 1995. As part of this 25th-year Medscape celebration, I wanted to call attention to activities Medscape either invented or facilitated as an early pioneer, including the ethics of the medical internet.

The Wild West

By around 1997, the very new "medical internet" was acting like an American Wild West show — unruly, unregulated, and full of misinformation, including unfettered commercialization of medical products and services.

The US Food and Drug Administration (FDA) was very concerned about advertising, promotion, and sale of pharmaceuticals. A group of us from AMA publishing went to see Dr David Kessler, the FDA Commissioner, and he brought in Dr Stuart Nightingale, then FDA's associate commissioner for health affairs. We reached an agreement that the ethical standards established by the International Committee of Medical Journal Editors applied to our internet sites as well and would suffice for then.

However, some European governments (especially the Netherlands) were so worried that they wanted to ban advertising, promotion, and sale of drugs on the internet. So, the World Health Organization convened a meeting of government representatives and medical organizations to discuss the proposed ban. Dr Nightingale and I went to Geneva for the meeting. We argued that the internet provided the greatest opportunity for useful, effective medical communication since the printing press, and it should be encouraged, not repressed.

We were able to convince the assembled group that the proposed ban was both futile and unnecessary and that self-regulation by publishers, medical organizations, and existing government agencies was a better plan. That thinking prevailed.

New Ethical Standards

I joined Medscape as its editor-in-chief in 1999, and it was immediately apparent that Medscape needed a formal advertising policy that was both ethical and would foster significant revenue. Medscape was set up to be free to readers who registered on the site, but it was organized as a for-profit company.

Using an editorial published in JAMA as a basis, I decided to draw from four domains to inform the total package of ethics for the medical internet.

The ethics of medicine in its core form, which includes the nine AMA Principles of Medical Ethics, several of which are directly applicable.
The ethics of journalism: Truth and accuracy; independence; fairness and impartiality; humanity; accountability.
The ethics of business: Honesty; integrity; promise-keeping and trustworthiness; loyalty; fairness; concern for others; respect for others; law abiding.
The ethics of medical journals: Proper behavior of authors, editors, publishers, sponsors, advertisers, and the medical public media.

I gave many lectures around the country about this process and the evolving products, soliciting criticism and support, and in September 1999, Medscape published its advertising policy in Medscape General Medicine, the first open-access general medical journal (more on that later). The reference full text is also available at PubMed Central.

I believe it was the world's first such internet advertising policy.

Two organizations of online medical publishers and editors were fundamental to the success of the field. One was the Internet Healthcare Coalition , founded in 1997 and headed by John Mack. Its product, the eHealth Code of Ethics, was published in 2000. This code emphasized the professionalism of self-governance and was also intended to prevent governments from feeling a need to create new laws and regulations.

A competing initiative called Health Internet Ethics (Hi-Ethics) was founded in November 1999, led by the late former Surgeon General C. Everett Koop. Some believe that one motivation was to move beyond the widely publicized ethical scandal of the now-defunct site DrKoop.com over mixing editorial with advertising and failing to disclose financial support.

Meanwhile, Medscape was acquired in 2000 by MedicaLogic. That June, the chairman of the board, Mark Leavitt, MD, PhD, and I testified about these initiatives and other professional considerations to the Joint Economic Committee of the US Congress, which was considering legislation to regulate the medical internet.

It did not.

The next 25 years were not always smooth, but a solid foundation had been laid.

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