Dr. Koop isn't the only online medic getting thrown for a loop.
Two weeks after Web site
got a dose of unwelcome publicity for its ethically suspect compensation arrangements with the former surgeon general, a second Web site carrying consumer health information has been caught in a bioethical dilemma.
The company that's raising the eyebrows of medical ethics experts is
Women First HealthCare
. Women First, which netted $51 million in a July IPO, posts articles discussing health issues of interest to menopausal and postmenopausal women, such as the benefits of cholesterol-lowering drugs and hormone-replacement therapy.
But you have to click "About Us" on the site, look for press releases and then start combing through them before you learn that Women First has cut deals with several drug companies to either sell or promote to medical professionals brand-name versions of certain drugs -- the same drugs that it discusses extensively, using their generic names, elsewhere.
That reticence about its financial interest in specific brands of certain drugs troubles several medical ethicists, who point out that when doctors publish or discuss research, they regularly make disclosures about any financial ties they might have to drug companies.
"It's an obvious potential conflict of interest," says Stuart Youngner, interim director of the
Center for Biomedical Ethics at Case Western Reserve University
in Cleveland. "I think you have to reveal conflicts of interest and I think there is one here."
But the pharmaceutical deals aren't the only bits of information Web surfers might want to know about.
- An anticholesterol drug Women First praises by its generic name, pravastatin, on its site, is available in the U.S. only as
Bristol-Myers Squibb's (BMY) - Get ReportPravachol -- a drug that Women First has an agreement to co-promote to medical professionals, in an arrangement that links its compensation to increased sales.
Although the company discusses on its site the value of estrogen supplements for menopausal women, it doesn't say that more than 58% of its revenue in the first half of the year came from the sales of the
Ortho-Est oral estrogen product for women -- nor that the company has committed to buying $40.5 million worth of the product over nine years for resale.
Nor does Women First mention that
Johnson & Johnson (JNJ) - Get Report, manufacturer of both Ortho-Est and
Ortho Tri-Cyclen, which Women First co-promotes, is the second-largest shareholder in the company, with at least an 11% stake. A J&J executive has served as a director of Women First, but gave up that seat before Women First went public in June.
And though Women First President and CEO David Hale said in an interview with
TheStreet.com that a member of the company's health advisory board owns stock in Women First, the company doesn't disclose that. The advisory board, a credential-heavy team of doctors which reviews medical information the company publishes and bolsters the site's credibility, includes
Deepak Chopra, a doctor who has popularized holistic medicine. (Hale wouldn't identify which board member owned stock.)
"We are certainly looking at whether we should disclose our interest in the products that we have, and what would be the most appropriate way to do that. We're actively doing that right now," Hale says.
A Johnson & Johnson spokesman referred questions about disclosure requirements and policies to Women First.
Women First's situation points to the business and ethical quandaries faced by health care Web sites like drkoop.com,
. Like many Internet companies unrelated to health care, they're trying to blend e-commerce with editorial content. But unlike other sites where potential obstacles to objectivity may be obvious or unimportant, on health care sites they can be subtle -- yet essential for consumers to know.
Herbert Rakatansky, chairman of the
American Medical Association's
council on ethical and judicial affairs, says Women First's failure to explain its drug-promotion arrangements isn't as problematic as Everett Koop's arrangement with the drkoop.com site, recently reported in
The New York Times
. In that deal, now discontinued, Koop could receive a percentage of sales of products and services generated by the site. Rakatansky says the difference is that on the Women First site, where medical information appears in unsigned articles, information doesn't appear to be endorsed by a particular physician.
But, says Rakatansky, "If I were a consumer reading
the site, I would like to know what the incentives are for them to publish different data," he says. "It's not a medical ethics issue, it's a business ethics issue."
Hale says there's nothing wrong with the educational material published by Women First, which also runs on a health site run by the women's Internet content company
. He cites Women First's footnoted references to medical studies, and its coverage of products that it doesn't sell. "We haven't had any complaints that any information on our site is not medically correct," he says.
And the estrogen therapies that the company touts are commonplace. "That is the mainstream," says Susan Lark, a California physician who has written
The Estrogen Decision
and eight other books on women's health. "That's what most doctors in the United States prescribe. ... There's nothing controversial other than a lot of women aren't interested in taking prescription hormones."
Eugene Grochowski, associate professor in the
Johns Hopkins University Bioethics Institute
-- one of five bioethics specialists contacted by
-- doesn't object to the material on the Women First site. He notes, for example, that the company mentions the benefits of cholesterol-lowering statins other than pravastatin.
But others say that good information isn't enough. Says Arthur Caplan, director of the
Center for Bioethics
University of Pennsylvania Medical Center
, "The ethical rule to follow is disclose, disclose, disclose."