Support for the empowerment of patients, including their ability to seek health care abroad and to receive advertising direct from the pharmaceutical industry, has come from Dr Anders Milton, chairman of the World Medical Association.

Addressing a meeting organised by the governments of the Nordic countries, Dr Milton said that patients today were no longer prepared to wait for treatment as they did in the past and accept treatment without questioning. The patients of the future would not accept being treated like second class citizens and were becoming more assertive.

Patients had a right to information, a right to decide and a right to a second opinion and, said Dr Milton, as a result of a recent European Court judgement patients might have a right to seek professional health care outside their own country.

'If the decision of the court is implemented, all our patients within the European Union will have a right to seek health care wherever they want to, if they are not treated within a reasonable time in their own home area'.

This would give the patient enormous power and could change the system of financing health care.

Dr Milton said that when it came to advertising drugs, the Internet crossed national boundaries. He said the pharmaceutical industry now wanted to advertise directly to the consumer. If this happened, he said the information should be truthful and patient safety must be paramount. The information should also be sent to doctors.

He said it was important that direct advertising to the consumer did not entice patients into overconsumption. But he said doctors should welcome having well informed patients, although it would require doctors themselves keeping better up to date.

Note: A copy of Dr Milton's speech is attached.

For further information please contact:
Nigel Duncan: (+44) 0171 383 6113 (office),
0181 997 3653 (home),
07990 542 026 (mobile)
nduncan@bma.org.uk (e-mail)

Dr Delon Human, WMA Secretary General:
(+33) 450 407575 (office),
33 607 164177 (mobile)

The New Role of Doctors when Information is Distributed Directly to the Patient Anders Milton

The World Medical Association was founded in 1947 as a reaction to what had happened during the Second World War, when some physicians had used their knowledge, not to help and to heal, but to harm and inflict pain. They had participated in torture and other inhuman treatment of prisoners or civilians. A number of medical associations - all the Nordic associations and twenty others - met after the war and founded the World Medical Association, in order to ensure that doctors would never again participate in cruel or inhuman treatment of human beings.

There are now some 80 democratic and independent member associations from the same number of countries, representing about 8 million physicians around the world.

Medicines on the Internet and the role of doctors

In the Nordic countries, as in all the industrialized countries, patients have become empowered in recent years and acquired a much stronger role than in the past. The patients of yesteryear waited on the telephone and in waiting rooms, they waited for operations and in queues, they accepted what was done to them without questioning, they took for granted what they had been told and what they had been ordered to do, and they were grateful for the outcome.

Those patients do not exist any more. The older generation still have that sort of relationship to the professional health care sector, but younger patients and the patients of the future will not accept being treated like second-class citizens, just because they want to see a doctor or a nurse. Instead, more and more patients are becoming assertive. They are becoming demanding, in terms of service and quality, and they want to have a say in what is being done to them.

Patients have a right to information, and to decide on the procedures they are subjected to. It is not like in the past, when they were told, 'We have to do this or that to you.' They have a right to decide, within reasonable financial limits, and they can choose the method they want to be treated by, provided of course that it is a method recognized by the health care provider. They have a right to a second opinion, meaning that if they are not happy with the decision or device their doctor gives them, they can turn to somebody else without the doctor having any hard feelings about it.

Furthermore, the Court of Justice of the European Communities in Luxembourg has decided that, at least when it comes to teeth and spectacles, citizens might have a right, depending on how the decision of the Court is implemented, to seek professional health care outside their own country. In the cases of the Nordic countries, that would probably mean outside the county council area where you live. If the decision of the court is implemented, all our patients within the European Union will have a right to seek health care wherever they want to, if they are not treated within a reasonable time in their own home area.

This gives the patient enormous power, and if this is what actually happens, it will also change the system whereby professional health care is financed. It will probably mean that money will have to follow the patient, because if patients have the right to choose where they want to be treated, then the institutions treating them will have to be paid. If this happens, we will have to move away from the old budget approach we have had so far in our countries.

Nowadays, patients are the subjects and not the objects of our care. They are the subjects in the relationship, for several reasons.

There is now a higher general level of knowledge in the population, and a better general education. The difference in knowledge between health care professionals and the public has diminished. Society is less hierarchical, due to the higher level of knowledge and the fact that our economic situation brings everybody in society up, and we have not really left many people behind. Patients are empowered and have a greater interest in health care and health-related issues than in the past. In any newspaper or magazine you will find articles on health care and health-related or lifestyle issues. The interest in what is called parallel or alternative medicine is increasing. Nowadays this sector is economically much more important, and the amount of money consumers spend on it is increasing rapidly.

Health care has been one of the strongest growing sectors of the economy in the last couple of decades. As primary needs are met, and as science develops, we will see greater investments being made in health care and health-related activities. So far in our countries information about therapeutic procedures has not normally been provided to the end consumer. Normally we do not in the Nordic countries see hospitals or health centres advertising to the general public about the procedures they perform. In the sector where costs are met out of taxes or through insurance, you really do not see companies advertising their specific therapeutic procedures to the end consumer.

The pharmaceutical industry now wants to advertise a specific agent or several specific agents directly to the end consumer, while they are still being paid for out of taxpayers' money, as it were.

This approach is different and new, and in this environment we have empowered patients, a greater interest in and more money being spent on health care, and an interest on the part of the industry in advertising and promoting its products to the end consumer.

In this environment we also now have the Internet. The Internet gives patients a means of obtaining information, of informing themselves. It offers the possibility of expanding the health care sector, and it certainly gives the industry a means of reaching the end consumer, the patient, with information, including information on prescription drugs, which they have really not had before. The Internet allows boundaries to be crossed; national frontiers are no longer relevant.

The information available in one country is available in all countries. All the products, all the prescription drugs that are legal somewhere will be found on the Net. None of our governments can really change that.

The younger generation, who have a better knowledge of English and access to the Internet, have the right and the opportunity to obtain information on diseases and on diagnostic and therapeutic procedures. This includes medicines, and they have the possibility of using both interactive and non-active sites to find this information. On the other hand, the older section of our population, with a more limited knowledge of English and less access to the Internet, will not have this information.

By chance and through technological advances, we have ended up with a situation of inequality between age and socio-economic groups in terms of access to information. In the Nordic countries, our politicians do not usually readily accept inequalities. We will most probably see a change in the legal system, and I think we will see it in one or a few years' time.

We will see a change which will make information on health care, and also on prescription drugs, legally available in our countries.

What will patients find when they access the Internet?

Patients will find information: beginning with their symptoms, they will find information all the way down to the particular drug or drugs or other forms of treatment they can use to relieve their symptoms. They will find information on different diagnoses, and on companies and their products. This will probably lead, in the case of the pharmaceutical industry, to the patient being able to choose a particular proprietary medicinal product. This enhances patients' knowledge, which means that when they go to see their doctor, they will know more than they did before. In some cases they will know more than the doctor, because they will have studied this particular subject especially closely. Our position is that this is good: it is always better to have a well-informed patient than somebody who is totally illiterate. However, if you have very good information, but in a very narrow sector, then your overall view might be distorted and you might come to the wrong conclusions, because you do not take into consideration all the other aspects of your disease. It is important that information is not seen by the patient as too black and white.

The industry will reach patients with information concerning their products via all these different sites and all these different possibilities. Furthermore, I believe that the industry will use advertisements of different kinds on active or interactive sites connected with health-related issues in general, or indeed on any sites that attract a lot of people.

Health care is a growing sector of the economy - not so much in our countries, where it is paid for by taxes and where we have had difficulties in the last ten years, but in the rest of the world it is growing at an enormous rate. I think that we will see the pharmaceutical industry trying to reach end consumers to influence them. Via the Internet, all patients or a very large majority of them will have the possibility of access. They will also find promotion, advertising, that influences their wishes regarding with what and how they should be treated.

What do we as doctors demand, then, when it comes to the information provided by the pharmaceutical industry?

The information should be truthful and not misleading. Information might be truthful as far as the drug in question is concerned, but it might be misleading in that it does not mention all the other possibilities or the other aspects of treating the particular disease or condition.

The industry should remember that, at present, it is to some extent isolated from the public, or from the courts which the public might drag them into. When you go directly to the end consumer, you yourself are responsible for how you inform him or her. I think the industry must be aware of this when it makes claims in advertisements, and it must remember that patients' safety must be paramount.

The second thing we think is important is that the information which companies sell or provide on the Internet should also be sent to doctors. Doctors should use the same sites, and they certainly will.

It is important that doctors know and are informed about what patients have been told on the Internet, about a particular drug or how to treat a particular illness, if the information comes from a pharmaceutical company. They should know, otherwise they will not understand the context in which the patient is speaking. If you have to send your information to doctors, too, that could to some extent provide a check on quality. It is important that information does not entice patients into overconsumption; it should not give them the idea that drugs are the sole solution to their problems. It should not be misleading.

The doctor will become more of a counsellor and less of an authority. Our role vis-à-vis the patient will change, because, as I have said, the patient will be better informed; he or she will come to us with information acquired via the Net and, of course, by other means too. We believe that this is good; we would rather have a well-informed patient than somebody who is less informed. It will also require the medical profession to keep better up to date about developments in the pharmaceutical industry and the development of the industry's products. And it will mean that we need more time for continuous professional development (CPD).

I believe that, with this general knowledge, the introduction of new medicinal products will perhaps be more rapid, because the Nordic public will know what is happening in other countries. They will have the possibility of using the same drugs. There will be a need for the medical profession to participate, including in the creation and upkeep of interactive sites, to ensure that information to patients is reliable.

There will also be a need for us as doctors to communicate with our patients via the Net.

All in all, I would say that, for the medical profession, the Internet and all the information and communication it entails is very good. We believe that empowerment of the patient is intrinsically good, and that the patient who is better equipped, and who is more a subject than an object, is a patient for us. The patient will always need a caring counsellor and an empathic doctor who is knowledgeable and well placed to take care of his or her patients.