Online direct-to-consumer pharmaceutical companies can give rise to distinct ethical challenges including potential conflicts of interest for prescribing physicians. Although these companies aim to provide easier and more cost-effective access to medications, the lack of direct contact between patients and physicians may be harmful. These concerns highlight a potential need to further regulate and oversee online direct-to-consumer pharmaceutical companies, authors of a recent paper published in the Journal of Medical Ethics argue.

The online direct-to-consumer pharmaceutical market offers medications for a variety of purposes, including erectile dysfunction, smoking cessation, skin care, and oral care. In this model, prospective customers complete an online, self-reported medical evaluation, which is then reviewed by a physician hired by the company. The company’s medical team then evaluates whether the patient would benefit from treatment with medication. If the patient passes this vetting process, a prescription is filled and shipped directly to the customer.

Such a business model is vulnerable to financial conflicts of interest, the authors wrote. The primary purpose of direct-to-consumer pharmaceutical companies is to fill and sell prescriptions, rather than treat and diagnose. In this way, medical professionals employed by these companies may be unduly influenced by financial profit. Although online pharmaceutical companies do not pay their physicians by commission, their existence is still predicated on sales. Consider a hospital, the authors wrote, for which revenue is generated simply by admitting patients, even in the absence of treatment. In the case of online pharmaceutical companies, however, no profit is generated without prescription sales. As such, the core business model of these companies prioritizes sales rather than patient welfare.

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Without an in-person evaluation, the online prescribing model may also fail to consider certain contraindications or differential diagnoses. Erectile dysfunction, for example, may be a result of underlying cardiovascular, neurological, or psychiatric disorders. An online, self-report survey is insufficient in evaluating these myriad factors. In standard practice, vital signs are measured at regular visits, through which hypertension and similar conditions may be identified. Without observation from a medical professional, patients may unknowingly begin using a medication for which they are contraindicated. In-person evaluations also offer the patient an opportunity to broadly discuss their health concerns beyond a specific issue, a process that is not possible through an online survey alone.

Because of these ethical dilemmas, the authors advocated for stricter regulation of the online direct-to-consumer pharmaceutical business model. Although telemedicine itself presents no inherent issues, according to the authors, online pharmaceutical companies have a vested interest in profit, rather than patient care. In addition, the lack of direct physician-to-patient interaction may lead to uninformed prescribing. “At most,” the authors wrote, “these companies should be allowed to distribute prescription medication[s],” but not simultaneously prescribe them.


Curtis H, Milner J. Ethical concerns with online direct-to-consumer pharmaceutical companies [published online November 28, 2019]. J Med Ethics. doi:10.1136/medethics-2019-105776