Like skilled assassins, many diseases seem to know exactly what types of cells to attack. While decimating one cadre of cells, diseases will inexplicably spare a seemingly identical group of neighbors. What makes cells vulnerable or not depends largely on the kinds and amounts of proteins they produce - their “translational profile,” in the lingo
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We have in our hands a provocative study which will almost surely lead to great controversies: A “cyberdoctor” who prescribed sildenafil online (Viagra) compared the collected data and outcomes of his online patients with those from a traditional clinic. His conclusions were based on more than 2,000 online encounters: “the Internet-based prescribing physicians has more, not less, clinically relevant and useful information than was typically obtained and utilized in a specific hospital clinic setting”, and there is no evidence to believe that patients could have been harmed in any way.
However — to avoid any misunderstandings — we must stress right up front that this particular study is subject to considerable limitations, and there was no way that a prospective and active follow up of the “clients” could be performed, and the outcomes of the patients who didn’t volunteer any follow-up information are of course unknown. Larger prospective studies with a more rigorous design, such as cohort studies, are urgently needed. Still, we believe that the study is groundbreaking, in a sense that this is the first study providing any sort of data about online prescribing.
We must mention that today, in many areas of the world, online prescribing of drugs without a prior personal doctor-patient relationship is still considered unethical or, in some cases, even unlawful. The accompanying article outlines how is the current situation and debate in the US. The FDA is “concerned about the proliferation of sites that substitute a simple online questionnaire for a face-to-face examination and patient supervision by a health care practitioner” and is actually believing that “the risk of negative outcomes such as harmful drug interactions, contraindications, allergic reactions or improper dosing is greatly magnified.”
However, we should not forget that ethics and law-making have to be based on evidence, just as medical practice itself is; some may argue that the current paradigm and restrictive legislation is not evidence-based, but in fact overly paternalistic and an anachronism.
Paternalism (when we allude to a child-parent relationship) has been defined as (1) being primarily intended to benefit the recipient, and (2) the recipient’s consent or dissent is not a relevant consideration for the initiator. To try to justify a paternalistic medical practice and legislation, which to a certain degree affects patients’ autonomy and in many cases their right to decide, we have to ask ourselves whether these actions really accomplish the benefit of the recipient, and whether — in the age of openness and free information — the free will of patients (to make an informed choice not to see a doctor in person but to order pharmaceuticals after an online assessment) is something which can be ignored.
This is the bottom line: Currently, we just do not have enough evidence whether, and under which conditions, online prescribing of relatively safe and simple drugs such as the impotence drug Viagra (sildenafil citrate) actually creates more harm than benefit, or vice versa. More and urgent research is needed to address questions such as which drugs can be prescribed safely and to which kinds of patients, and which safeguards we can install to monitor and prevent adverse events.
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