Guidelines for advertising on health web sites

The Internet is a promising and popular tool for the global dissemination of health information to the public. According to one estimate, “health sites draw two thirds of all online users at least once.”¹ Unfortunately, the power of the Internet to facilitate quick, inexpensive, and worldwide publication is also a weakness when it comes to information about health. Distinctions between trained medical professionals and quacks, tested drugs and untested compounds, and advertisements and content are difficult to make. Furthermore, the global nature of the Internet defies most current nation-specific laws regulating the practice of medicine or sales of health-related products based on unverified health claims.²

The use of the Internet has encouraged the blurring of distinctions between content areas and advertising. Criticism of the well-traveled health information web site, drkoop. com, started by the former US Surgeon General C Everett Koop,³ however, illustrates why such ambiguity is a problem for health care professionals and why the criticisms bring to mind images of foxes and henhouses.

Summary points

• Health care professionals who provide health and medical information on the Internet have a professional duty to ensure its quality and integrity, just as they would if the information were in print

• Advertising to support health web sites can create a conflict of interest for the creators of the site

• If advertising supports such web sites, great care should be taken not to undermine the integrity of the educational information

• One way to militate against conflicts of interest is to clearly label and separate editorial content from advertising and promotional activities

• Public trust in physicians will be eroded if educational activities on the Internet are seen as being used to further professionals' financial interests through promotional activities

CRITICISMS OF DRKOOP.COM

The main criticisms of Koop's web site have been his failing to disclose his financial relationships with advertisers and to clearly distinguish between editorial content and advertisements. For example, a prospectus filed with the Securities and Exchange Commission, but not listed on the web site, states that Koop could receive a percentage of revenues derived from sales of health-related services and products that are presented on the web site.⁴ As another example, the site lists hospitals and health centers as “the most innovative and advanced health care institutions across the country” but does not state that the hospitals on the list have paid a fee to be included.³ In defense of his web site, Koop has asserted, “I cannot be bought” and that he cannot help it if some people are bothered by the idea of a former public servant making money, particularly because physicians have always been paid for their services.

CONFLICTING INTERESTS FOR HEALTH CARE PROFESSIONALS

The ethical issues raised by advertising on drkoop.com are clearly those of conflicts of interest. Contrary to popular belief, stating that a conflict of interest exists is not an accusation of moral lapse, but rather is pointing out that a primary duty may be in conflict with a secondary (possibly competing) duty to or interest in another party.^5,6

Contrary to Koop's assertion, if he stands to gain personally from sales of products advertised on his web site, he has a conflict of interest. When patients pay physicians for services, a conflict of interest is built in. A distinction must be made, however, between conflicts that are unavoidable and known to the patient or public and those that are not. Furthermore, a conflict of interest must be acknowledged as a problem precisely because often it is impossible to know or prove that one has or has not been influenced by a competing interest. Ample evidence suggests that physicians are affected by the potential for personal financial gain, perhaps unwittingly and despite the best intentions.^7,8,9

Likewise, if promotional information is not disclosed as such and is portrayed as educational or as endorsements based on appropriate evaluation criteria, a conflict exists between the interests of the readers or patients and those of the advertisers or the company. If an organization provides health care information with the aim of educating the public, the organization must bear the same responsibilities that health care professionals have in ensuring the quality and integrity of the information. Any organization whose mission includes disseminating health care information, and any person receiving this information, should be concerned with the following questions:

• Is it appropriate to support the educational mission with advertising?

• If there is advertising in conjunction with the educational information, has the content of the information been influenced by the advertiser?

• Is the promotion of the advertised products appropriate to the aims of the educational mission? Or does the advertising detract?

ADVERTISEMENT POLICIES IN ANALOGOUS SITUATIONS

The publication of synthesized health news and information on a web site for public and professional use is analogous to several other situations in the health professions with respect to conflicts of interest, including the publication of medical journals and the endorsement of products by medical professional organizations.

Publication of medical literature

The primary function of most medical journals is to provide clinical and research information for professional and lay audiences. This function is diminished if journals are seen as contributing to the unwarranted promotion of specific advertised products (for example, by publishing misleading or inaccurate ads¹⁰ or implying endorsement of a product by ad placement). The accuracy of advertisements is regulated by federal laws. However, selection and placement of ads within medical journals is determined by the editors of journals.

The American Medical Association (AMA) and the journals of the American College of Physicians and other medical publications have published guidelines for the selection and publication of advertisements. These, like many other medical publications, generally limit the advertising they allow in their journals to commercially available products or services related to medical practice, education, or health care delivery.^{11, 12}

Medical journals also face a conflict of interest when publishing work that has been financially supported by companies whose products are related to the published material. Journals have developed extensive guidelines on competing interests of authors.¹³ These guidelines usually ask that authors disclose their financial interests, but at least one journal has decided not to publish commentaries or review articles by authors with conflicting financial interests.¹⁴

Endorsement of products by medical professional organizations

Several medical professional or health-related organizations endorse products, and some have developed policies about endorsements. These policies are relevant to medical web sites because there is evidence that the linkage of names of trusted organizations to products is, not surprisingly, construed as implicit endorsement of the advertised products, companies, or industries (State Attorney General Report). What's in a nonprofit's name? Public trust, profit and the potential for public deception. A preliminary multi state report on commercial/nonprofit product marketing. April 1999).

The American Dental Association (ADA) has a long-standing policy of endorsing dental products used by the public or dental professionals. Endorsement is limited to products related to dental care and requires that products satisfy a series of safety and efficacy tests. Advertisement content is also evaluated by the ADA to ensure accuracy and balance. Payment by manufacturers covers testing costs only. In contrast, the American Heart Association and the AMA have been criticized for endorsing products without independent certification.¹⁵,¹⁶ Such arrangements potentially mislead consumers and may impair the ability of the organizations to later criticize products that they now endorse.

The AMA has devised new guidelines for sponsorship and endorsements that are in keeping with its mission “to promote the art and science of medicine and the betterment of public health.” Guidelines now include a restriction on accepting grants from tobacco or alcohol companies, and the product certification program limits fees to the costs of conducting the program.

SPECIFIC GUIDELINES FOR ADVERTISING ON HEALTH WEB SITES

To maintain credibility, organizations posting health web sites need to avoid conflicts of interest and the appearance of conflicts. Both not-for-profit and for-profit organizations need to examine carefully the extent to which advertising is necessary to support their web sites. Existing guidelines for medical and health web sites are either broad¹¹ or restrict advertisement to health-related products and companies. Such restrictions, however, may actually pose more of a conflict of interest for health organizations⁹ and unnecessarily limit sources of revenue.

The following guidelines have been developed for health organizations that are contemplating advertising on their web sites or digital publications. They are currently being used by the California Center for Health Improvement (CCHI), a nonprofit organization whose mission includes dissemination of health policy information for a policy and general audience through paper publications and a web site (www.policymatters.org). Like many other non-profit health organizations, CCHI is funded by grants from private foundations and private clients and is considering allowing advertising on their web site to generate additional revenue.

IDENTIFYING CONFLICTS OF INTEREST IN SELECTING ADVERTISERS

The organization should determine the sources of funding of companies that wish to advertise on or sponsor web pages. The primary source of funding for foundations, support groups, or other organizations is not always obvious. For example, a smoker-rights group states that it is supported by membership fees, although most of its funding comes from the tobacco industry. Sometimes the prospective advertiser hires an advertising agency to create the ad copy and to find potential advertising sites. Organizations should communicate directly with the advertiser or sponsor rather than intermediaries. The organization should maintain the right to remove an advertisement if it finds that an advertiser or sponsor has misrepresented itself.

If the primary mission of the advertiser or the health effects of the product are in direct conflict with the mission of the organization or with public health goals generally, the advertisement should be rejected. For example, companies that sell tobacco fall into this category because tobacco is known to pose serious threats to public health that outweigh its benefits. Some products, however, such as alcoholic beverages, may decrease the risk of some diseases while increasing the risk of others. Thus, benefits should be weighed against possible dangers.

If the primary mission is completely unrelated to the organization's or public health goals and the products do not have health effects that conflict with these goals, consideration should be given to accepting advertising but maintaining control over some aspects of it. Products or companies, however, that may not seem health related or have no apparent health effects may at a later date be determined to have such effects. Advertisements should be reevaluated periodically for such changes.

If the primary mission is related to the organization's or public health goals, but not necessarily in direct conflict, and the health effects of the product are not in conflict, consideration should be given to accepting advertising but maintaining control and rights of disclosure. Health care-related companies, such as drug companies or managed care networks, are not necessarily inappropriate advertisers on a web site. Special care must be taken, however, to militate against conflicts of interest when considering advertisers that could be affected by policies published on the web site.

General selection and management strategies

Once an organization has decided that an advertiser is acceptable for its web site, the organization has many options for deciding how to control the content and placement of ads. Some (non-mutually exclusive) possibilities for limitations are to limit advertisements to a specific size relative to the web page; limit the use of “pop-up” windows linked to advertisements; limit the number of advertisements per web page and per advertiser; separate ads from text by location in the area of each web page dedicated to advertisements, borders, and/or color or other visual aids; clearly label advertisements as being such; prohibit advertisements on certain key pages, such as the home page or table of contents page; prohibit direct links from advertisements to external commercial sites; and limit the total revenue that is accepted annually from any one advertiser.

Limits specific to advertisement or web pages

If an advertiser's product, company, or industry is related to the content of a web page—for example, a company that manufactures nutritional supplements wants to place an ad for a folic acid supplement on a web page summarizing policies about the prevention of birth defects—the organization has a number of (non-mutually exclusive) options to decrease the conflict of interest:

• Restrict the placement of ads (such an ad should not appear where it may be mistaken as an endorsed treatment);

• Restrict the type of advertisement—show the company logo only, as opposed to an ad for a specific product; and

• Opt for sponsorship by an organization (with disclosure on the sponsored web page), rather than advertisement of a specific product.

Disclosure

The web site should disclose information that might not already be evident if it poses a conflict of interest. For example, if the logo of a drug company that manufactures a vaccine is displayed on a page about immunization policies, it could be explained that the vaccine mentioned in the policy is or is not manufactured by the company whose logo appears on the web page.