AMA Journal of Ethics^®

Abstract

Broad dissemination and consumption of false or misleading health information, amplified by the internet, poses risks to public health and problems for both the health care enterprise and the government. In this article, we review government power for, and constitutional limits on, regulating health-related speech, particularly on the internet. We suggest that government regulation can only partially address false or misleading health information dissemination. Drawing on the American Medical Association’s Code of Medical Ethics, we argue that health care professionals have responsibilities to convey truthful information to patients, peers, and communities. Finally, we suggest that all health care professionals have essential roles in helping patients and fellow citizens obtain reliable, evidence-based health information.

The Growing Problem of False Health Information on the Internet

Over the course of the past century, causes of disease and social conceptions of health have evolved from an infectious-agent theory of disease, to a behavioral theory of disease, to a social-ecological model.^1,2The social-ecological model recognizes that social and environmental conditions, including the information environment and health-related speech, affect health outcomes for both individuals and populations.^3,4

A problem our society currently faces is the pervasive availability and consumption of false health information,^5,6 which can cause individual and social harm by nurturing false beliefs about medicine, disease, and prevention.⁷ One major source of health-related information is the internet.^8-11 The internet has democratized health information, but, as a result, health care professionals are no longer perceived as authorities with exclusive knowledge about health-related content.¹² Search engines like Google allow anyone to easily find information about anything. Social media sites like Twitter, Reddit, and Facebook provide forums for private citizens to freely express their views, including about medicine and health care. Yet the content disseminated through websites and online communities is largely unregulated. Thus, it is largely up to consumers to determine the quality and reliability of the information.

The question this raises is whether the proliferation of health-related information on the internet should be regulated and, if so, by whom. An argument might be made for government oversight because the wide circulation of false health information can lead to real injuries and harms. After all, a well-established role of the government in a democratic society is to “promote the general welfare” of its citizenry.¹³ Yet, in the United States, the government also has an obligation to protect private citizens’ right to free speech. Thus, there exists a tension between the government’s commitment to general welfare and its duty to affirm individuals’ right to free speech.

This article will explore this tension. First, we review our society’s commitment to protecting the free speech of private citizens in the public sphere, although the content of private speech might be false and even harmful. Second, we briefly describe commercial and professional speechas a specific category of speech that can be regulated by the government for the purposes of public health and welfare. Finally, in recognizing the Constitutional boundaries on free speech in society, we discuss the professional and ethical obligations of health care professionals to provide truthful and accurate health information both in clinical practice and in the community. We suggest that all engaged in the biomedical and scientific enterprise have an ethical and social responsibility to share truthful information about health and to correct falsehoods when possible.

Free Speech and the Internet

The First Amendment states, “Congress shall make no law … abridging the freedom of speech.”¹⁴ Supreme Court jurisprudence interpreting the First Amendment has affirmed that private citizens have a constitutionally protected right to articulate personal views and beliefs in public spaces without unnecessary government regulation or censorship, including public spaces on the internet. The right to free speech prevents the government from suppressing speech even if the content is false or offensive, including when the content is health related.¹⁵ Examples of constitutionally protected false, health-related speech in both physical and virtual public spaces include advocacy groups’ assertions that vaccines are ineffective and cause autism¹⁶ and prolife advocacy groups’ assertions that abortions cause breast cancer.¹⁷ In the context of online but not health-related information, the Supreme Court ruled in Reno v ACLU that government-instituted, content-based restrictions on nonobscene speech were unconstitutional.¹⁸As such, it is unlikely that any health-related internet speech that is not obscene can be regulated by the government. Moreover, given the unpredictability of internet expansion and changes in consumer preferences, whether the government can develop long lasting and enforceable solutions to the problem of false health information remains a difficult and unresolved challenge.¹⁹

Commercial and Professional Speech

There are, however, 2 categories of speech for which the government might have authority to constrain or compel speech to promote the health and welfare of the community: commercial speech and professional speech. Commercial speech is a category of speech defined as speech that (1) identifies a product for sale, (2) is a form of advertising, and (3) confers economic benefits.³ Courts can uphold regulation of commercial speech based on a 4-part test articulated in Central Hudson Gas and Electric Corporation v Public Service Commission of New York.²⁰ Historically, examples of the regulation of commercial speech include advertisements for tobacco, alcohol, and gambling.¹ However, since Central Hudson, courts have demonstrated increasing reluctance to regulate commercial speech, emphasizing the rights of speakers rather than the state’s interests in the health and welfare of community members.⁴ We believe this places an increased burden on physicians to correct inaccurate or false health-related information that can be found in commercial sources, including on the internet.

Professional speech is a category of speech that scholars have defined as speech “uttered in the course of professional practice.”²¹ The Supreme Court indicated in Planned Parenthood of Southeastern Pennsylvania v Casey in 1992 that physicians’ First Amendment rights not to speak are implicated, but only as part of the practice of medicine, subject to reasonable licensing and regulation by the state.²² While this case involved the constitutionality of a law requiring, among other things, that at least 24 hours before performing an abortion (except in an emergency) physicians inform the woman of the nature of the procedure, the health risks of the abortion and of childbirth, and the “probable gestational age of the unborn child,” it set the stage for state regulation of professional speech between physicians and their patients. Since then, courts have struggled to articulate a consistent approach to defining the scope and limitations of a state’s power to regulate health care professional speech on a range of issues, including physician speech regarding firearm ownership and sexual orientation change efforts.²³

While the government has some powers to regulate health-related speech, those powers are very limited and are not comprehensive or consistent. Recognizing the constitutional limits on the government’s powers to regulate private citizens’ free speech in the public sphere, we suggest that government regulation cannot be expected to resolve the problem of false and harmful health-related information that is perpetuated on the internet by private citizens who are speaking with their private citizen rather than their professional “hat” on. Furthermore, the government cannot be relied upon to be the sole speaker of truthful and accurate health information. As recently demonstrated by politically motivated prohibitions of certain words in official documents, the government can publish biased or incomplete statements or refrain altogether from saying anything at all.^24,25 Since the government cannot be relied upon to resolve the problem of false health information found on the internet, it is important for anyone involved in the biomedical enterprise to participate in public discourse. Furthermore, we suggest that physicians, as part of their professional code, have an ethical duty not only not to share bad or false information but also to actively participate in conversations about health and help correct false or harmful information that can be found on the internet.

Implications for Health Care Professionals

Medical professionals have a unique responsibility to confront false or misleading beliefs by virtue of their specialized knowledge and professional obligations. First, medical professionals are members of a community that possesses specialized knowledge about and training in health. Second, licensed professionals are the only people in our society who are allowed to practice medicine. The professional obligation to confront false health beliefs and information is more straightforward within a clinical setting: when patients express false or misinformed beliefs, it is professionally and ethically appropriate to attempt to correct and redirect the patients so that they can hopefully use evidence-based information to make an informed decision about their care. But outside an individual patient-clinician relationship, what is the obligation of a health care professional to the broader community to confront false beliefs and information?

We would suggest that health care professionals have an ethical obligation to correct false or misleading health information, share truthful health information, and direct people to reliable sources of health information within their communities and spheres of influence. After all, health and well-being are values shared by almost everyone. Principle V of the AMA Principles of Ethics states: “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated” (italics added).²⁶ And Principle VII states: “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health” (italics added).²⁶ Taken together, these principles articulate an ethical obligation to make relevant information available to the public to improve community and public health. In the modern information age, wherein the unconstrained and largely unregulated proliferation of false health information is enabled by the internet and medical knowledge is no longer privileged, these 2 principles have a special weight and relevance.

To withdraw or refrain from public discourse in an environment where false and harmful health information is pervasively disseminated would be an abdication of the ethical obligation to make “relevant information” (or accurate information) available to improve community and public health, as medical and public health professionals possess reliable and truthful information about the nature of health and the causes of disease. For example, educated professionals can embrace invitations to speak at local groups about a particular health-related topic or respond to a blog posting. Another venue is Twitter; some use Twitter in their professional capacity to share news releases and articles and to participate in organized, moderated Twitter chats. Even in their own social circles, health care professionals can have a positive impact by directing people to accurate sources of information and correcting misperceptions when possible. We recognize that this obligation of health care professionals extends outside the clinical setting and into the sphere of their lives. However, as the causes of death and disability extend beyond the boundaries of the clinic, so do the obligations of health care professionals. This is an obligation they take on when they choose the profession of medicine.