Just what the limitations of healthcare Web sites should be is difficult to define. No one officially polices online content, although organizations such as Health on the Net suggest policies for voluntary self-governance (http://www.hon.ch/HONcode/Conduct.html). So each Web site essentially sets its own parameters. The result is a wide variation in what is considered acceptable online.

Bill Stallknecht, RPh, co-owner of The Pillbox Pharmacy site (http://www.thepillbox.com) and The Medical Center (http://www.medicalcenter.net), fills prescriptions written via online consultations. But he said he will only provide three drugs—Viagra, Propecia, and Claritin—via the cyber-prescriptions. He draws the line at those three because he considers them history-based drugs, that is, medications that can be safely prescribed on the basis of reviewing a patient’s medical history. "I think there are possibilities for other history-based drugs," Stallknecht said. "I don’t know what they are yet. Time will tell."

Another point of view

Other pharmacies draw the line more conservatively. "We’re not interested in cyberspace doctors, so to speak," said Brenda Corbett, RPh, vice president of pharmacy operations for Soma Corp., an online pharmacy, which launched an online pharmacy in January at http://www.soma.com. Though the site will process new prescriptions and refill existing ones, it will not provide online medical consultations to obtain the prescriptions themselves, Corbett said.

"Individuals need to have a relationship with a physician," she said. "It’s not filling out a form." Corbett said that Soma would launch an intense marketing campaign to distance itself from instant prescription sites, which she does not deem ethical.

The Internet has many appropriate uses in health care, but cyber-prescriptions written solely on the basis of a form submitted by the consumer isn’t one of them, said Donald Palmisano, MD, JD, member of the American Medical Association board of trustees. "I think this is an example of one of the dangers of the Internet, but it doesn’t mean that the Internet is bad. The Internet can be a treasure-trove of information."

But that treasure-trove can easily become Pandora’s box. Easy availability of drugs through some Internet sites has given some people the idea that drugs are obtainable at every medical Web site, said oncology nurse Maggie Hampshire, RN, managing editor of OncoLink (http://www.oncolink.com), a preeminent cancer information site operated by the University of Pennsylvania. She said that although the site frequently gets requests for medications, physicians at OncoLink would never prescribe drugs via the Web site. "That would never happen, because we don’t feel that would be ethical at all," Hampshire said. "I don’t see how any physician or nurse practitioner could prescribe a medication without seeing the person in person."

Health professionals do not answer queries directly at OncoLink, but instead post general information about drugs and treatment at the frequently asked questions page. A disclaimer on every page states that the information provided is for educational purposes only and should not be used for diagnosis or treatment. Instead, the readers are directed to consult their own healthcare providers. "We don’t know the patient. We haven’t seen the patient in person. We don’t know if it’s just someone who’s making this up," Hampshire said.

Internal debate vs external regulation

Although that line was easy to draw for their Web site, the staff frequently debates what information to include on OncoLink, she said. "We battle with that [what’s appropriate] ourselves within OncoLink as we try to decide which articles would go online, especially when it comes to alternative medicine treatments," she said.

Corbett doesn’t think any more lines need to be drawn by legislators. Existing regulations are already in place that can be applied to Internet pharmacies, she said. "An Internet pharmacy is basically no different than a retail pharmacy or a mail order pharmacy," she said. "The Internet is just another way of receiving information." Corbett said that Soma is already licensed in Ohio and is in contact with all the other state boards of pharmacy to determine what other state licenses they need to obtain.

Stallknecht said that The Pillbox Pharmacy is licensed in Texas and a dozen other states, with several pending as well. "I’m licensed in every one [state] that wants one so far," he said.

Despite her doubts about the ethics of other sites, Hampshire would like to keep the process of deciding what’s acceptable on the Web an internal battle and not one subject to external regulation. She added, the Internet is the last bastion of free speech.