Copyright 1999 The New York Times Company
The New
York Times
September 5, 1999, Sunday, Late Edition -
Final
NAME: C. Everett Koop
SECTION: Section 1; Page 1; Column 1; National Desk
LENGTH: 2794 words
HEADLINE:
E-MEDICINE -- A special report.;
Hailed as a Surgeon General, Koop Is
Faulted on Web Ethics
BYLINE: By HOLCOMB B. NOBLE
BODY:
During the eight years he held the post of
United States Surgeon General, Dr. C. Everett Koop became one of the country's
most authoritative and recognizable public figures on the subject of health.
But more than a decade after leaving office, Dr. Koop, now 82, is facing
criticism, from medical ethicists, including two representatives of the American
Medical Association, consumer advocates and others.
Among the complaints
are that his hugely popular health information Web site, DrKoop.com, has
frequently blurred the line between its objective information and its
advertising or promotional content, and that his ties to business have not been
properly disclosed.
Until recent days, for example, the Web site did not
give notice of an arrangement that entitled the company and Dr. Koop himself to
a commission on products and services sold because of the Web site. Dr. Koop
gave up those commissions on Aug. 27.
Web sites devoted to health and
medicine -- some providing information and advice, others selling medications --
have been among the hottest Internet properties this year, and DrKoop.com is one
of the most heavily trafficked.
Indeed, with the explosion of
E-commerce, the distinction between objective information and advertising has
blurred across much of the Web, as newspapers and newer types of information
providers struggle to capitalize on the information they gather, and as other
businesses try to use the new technology to connect with new customers. Many
sites, for example, receive a commission for referring their users to on-line
merchants, and what would be called advertisers in other media are often labeled
"partners."
But Dr. Koop's site and his role in it have come under
particular scrutiny not only because of his stature but also because what is
involved is the public's health. There is, too, the matter of the traditionally
strict regulation of medical practices and advertising -- an issue that the
profession and the Federal Government have yet to fully address in cyberspace.
The critics of the former Surgeon General say that he has done nothing
illegal but that he has -- knowingly or not -- engaged in activities that amount
to a conflict of interest, or the appearance of one. Some say Dr. Koop, who
became a role model to young physicians with his campaigns to deter cigarette
smoking and to raise AIDS awareness, has in effect traded on his respected name
to his financial gain, and to the gain of the new health-information
corporation, DrKoop.com.
"He's certainly a very honorable man," said Dr.
Robert M. Tenery Jr., a former chairman of the A.M.A.'s council on ethics and
judicial affairs, when asked to comment on the criticisms. "But to claim that
you're the nation's family doctor, well, perhaps he's not tainted, but the
picture is colored somewhat by his relations to vested interests."
In
interviews over the last few weeks, Dr. Koop said he would be making changes in
his financial arrangements and on the Web site; some of those changes have
already taken effect. In response to his critics, Dr. Koop said that he had done
nothing wrong and that he remained devoted to educating the public about health
issues. He cannot help it, he said, that some people are bothered by the idea of
a former public servant's making money.
"I have never been bought," he
said. "I cannot be bought. I am an icon, and I have a reputation for honesty and
integrity, and let the chips fall where they may."
The Web Site
Building on Power Of a Trusted Name
Dr. Koop and other investors
started the Web site in 1998 and took it public with an initial offering of
stock in June, quickly joining the ranks of Internet multimillionaires. Dr. Koop
is chairman of DrKoop.com and a major shareholder in the company. On paper, the
stock he held at the time of the initial offering is worth more than $47 million
today. As chairman, he draws an annual salary of $135,000 plus other payments
like speaking fees.
On its 80,000 electronic pages, DrKoop.com offers
information on medical conditions like heart disease and anorexia, features an
Ask the Expert column and includes advice on topics like buying health insurance
and participating in clinical trials of new drugs.
As
chairman, Dr. Koop says he takes overall responsibility for DrKoop.com. But the
day-to-day operations are managed by executives and staff members at the
company's headquarters in Austin, Tex. Dr. Koop lives in Hanover, N.H., where he
runs the Koop Institute, a research center connected with the Dartmouth Medical
School.
The power of Dr. Koop's name and his ranking in opinion polls as
the nation's most trusted health authority appear to have been very much on the
minds of the former Surgeon General and his business advisers in founding
DrKoop.com. In a prospectus filed June 8 with the Securities and Exchange
Commission, the company said its goal was to "establish the DrKoop.com brand so
that consumers associate the trustworthiness and credibility of Dr. C. Everett
Koop with our company."
The prospectus states that the Web site is
permitted to use Dr. Koop's "image, name and likeness in connection with
health-related services and products," subject to his prior approval of the
products. In return, Dr. Koop was entitled to receive 2 percent of DrKoop.com
revenues "derived from sales of our current products and up to 4 percent of our
revenues derived from sales of new products." The prospectus says the site deals
in a wide variety of such health products and services, including prescription
drugs, nonprescription drugs, vitamins,
nutritional supplements and health insurance offered by outside parties.
Like other commercial Web sites, DrKoop.com accepts advertising. But
because Dr. Koop's name carries so much weight with the public, his critics
argue, he has a special responsibility to keep the distinction between
advertising and education clear.
"Based on his reputation," said Dr.
Herbert Rakatansky, chairman of the A.M.A.'s ethics council, "he should disclose
any financial interest or tie to those providing a medical service or treatment
he or his Web site is recommending, or it is a betrayal of trust. He has to
remain independent."
On Tuesday, an official at the Web site said Dr.
Koop's contract had been changed to eliminate the provision under which he
received a percentage of sales of health services or products generated by the
site.
Financial Ties
Health Information Or Advertising?
The issue of compensation aside, critics say it has not always been
clear whether information about health products or services on the DrKoop.com
site are company promotions or advertising, or balanced medical and health
information.
In one example, Dr. Joshua Hauser, a medical ethicist at
the University of Chicago, said that when he visited the site two months ago he
discovered a DrKoop.com Community Partners Program. It contained a list of
hospitals and health centers described as "the most innovative and advanced
health care institutions across the country." In fact, the list was an
advertisement for 14 hospitals, each of which had paid a fee of about $40,000 to
be included.
Troubled by the brevity and accuracy of the list, Dr.
Hauser said he made repeated telephone calls and sent numerous E-mails to the
DrKoop.com headquarters in Austin, asking whether what he read was advertising
or editorial content. Finally, he said, he received an E-mail from a company
official, who told him that the Community Partners were advertisers and assured
him that this fact would be made clear on the site. But when he checked later,
no such steps had been taken.
"On a site whose slogan was 'Your Trusted
Health Network,' " Dr. Hauser said, he found "this blurring of the line between
editorial content and advertising to be a problematic conflict of interest."
"Web sites like DrKoop.com have the potential to lead to better and
faster information," he said. "But not if companies can buy their way onto
sites."
Daniel W. Hackett, chief executive of DrKoop.com, said in an
interview that he did not know why the changes had not been made. About 10 days
ago, after the interview, the site was changed to say that the hospitals
"represent prominent health care institutions across the country." A newly
worded flag inviting visitors to "Find a health care provider near you" was
labeled as an advertisement. And a notation was posted on the hospital listings
saying that the institutions had paid a fee to be included.
Similarly,
critics say, the Web site was slow to disclose financial ties with Quintiles
Transnational Corporation, a Durham, N.C., company that manages clinical trials
of new drugs for pharmaceutical companies and is using the Web
site to recruit volunteers for the trials.
The Web site originally gave
Quintiles space to declare itself "the world's leading clinical organization,"
but contained no mention of a financial agreement. But in separate interviews
last Sunday and Monday, officials of DrKoop.com and Quintiles acknowledged that
the Web site was entitled to receive a payment from Quintiles for each person
enrolled in a trial through the site.
On Tuesday, DrKoop.com added to
the Quintiles description a sentence saying that Quintiles "has entered into a
relationship with DrKoop.com in which DrKoop.com is compensated for successfully
recruiting qualified participants into clinical trials."
Though the Food
and Drug Administration regards postings of future clinical
trials to be advertising, the notices of trials are not labeled as such on
DrKoop.com.
Even with the disclosure about the Quintiles arrangement,
visitors to the Web site are not informed that the inspector general of the
United States Department of Health and Human Services is conducting an inquiry
into whether the newly evolving business of commercially run clinical trials of
drugs properly protects the interests of patients and other
potential test subjects.
Mr. Hackett said that in his view the Web site
already carried a more than adequate description of risks associated with
clinical trials.
The arrangement with Quintiles was one of the issues
that has exposed Dr. Koop to criticism from medical association officials. Under
the Web site's original operating plan, Dr. Koop would have been entitled to 2
percent of payments from Quintiles, Mr. Hackett said. Under A.M.A. rules,
"payment by or to a physician solely for the referral of a patient is
fee-splitting and is unethical."
When asked about a possible ethics
violation, Dr. Koop said that he had received not "one dollar" from Quintiles
because no referrals had yet resulted from the site, and that visitors to the
Web site were not his "patients."
But Dr. Rakatansky said the ethics
principle would apply if people visited the site and signed up because of their
trust in Dr. Koop, and his connection with the company running the trials was
not disclosed.
At Dr. Koop's request, his arrangement with the Web site
has been altered, and his contract no longer calls for a percentage of revenues
from all services or products, including those from Quintiles, Mr. Hackett said.
Industry Ties
Drawing Criticism In Political Arena
It is not just Dr. Koop's financial arrangements that have come
under fire. He has also drawn criticism for forming a partnership with the
American Council on Science and Health in May.
A press release said the
partnership was intended to provide consumers with "an unbiased, scientific
analysis of the latest trends in health and medicine, as well as clarifications
of health misinformation found in the mainstream press." Information from the
council, which identifies itself as a nonprofit consumer advocacy organization
and receives financing both from industry and from private foundations, is
published on the Web site.
But other consumer advocates say the council
is hardly unbiased. Rather, they say, the group consistently takes industry's
side in disputes over product safety. The council, said Philip E. Clapp,
president of the National Environmental Trust, "has never met a pesticide it
didn't like."
An official of the council said those accusations were
false, adding that the group's mission is to offer balanced, scientifically
based analysis of health news. He said the council provided the information to
the Web site free to carry out that mission.
Dr. Koop dismissed
criticism of the council, saying it "takes positions based on science, not
political correctness." He said it "often undertakes research on issues that the
media have already decided are resolved," adding: "When they go against the
popular story narrative, the media and activists get upset. Curiously, the media
and activist groups don't bat an eye when a lurid allegation is made about a
product's hazards by an unqualified source."
Some of Dr. Koop's
activities in the political arena have also come under scrutiny.
In
March Dr. Koop testified at a Congressional hearing about the contention that
some latex gloves are causing life-threatening allergies. He said the claims
were highly exaggerated and called them "borderline hysteria." Dr. Koop based
his conclusions, he said, on a study by the Centers for Disease Control and
Prevention, in Atlanta.
But Dr. Michele Pearson, the chief investigator
of the C.D.C.'s latex-allergy inquiry, said that while the agency had collected
raw data from blood samples, Dr. Koop's statement went beyond what the centers'
data could show. Research paid for by the Allegiance Healthcare Corporation, a
leading manufacturer of the latex gloves in question, reached identical
conclusions to those cited by Dr. Koop, however.
Dr. Koop said that he
was misled about the nature of the latex gloves study and was not aware of a
connection between his comments and the analysis paid for by Allegiance.
In April, the former Surgeon General circulated a letter in Congress on
behalf of legislation that could enable the Schering-Plough Corporation of
Madison, N.J., the company that manufacturers the allergy drug
Claritin, to extend its patent on the medicine by five years,
an extension that could generate an estimated $6 billion in
sales. The following month, Dr. Koop also met with members of the House Commerce
Committee to defend the company's position on legislation involving another
drug, used to treat hepatitis C.
The Star-Ledger of
Newark reported in June, however, that Dr. Koop did not disclose that his
nonprofit organization, the Koop Foundation, had earlier in the year received a
$1 million grant from Schering-Plough. A spokesman for the drug
company said there was no connection between the grant and Dr. Koop's efforts on
Capitol Hill.
Dr. Koop acknowledged that his foundation had received the
grant from Schering-Plough, but he said the company's money did not influence
his public positions.
"I never disclosed the grant because I did not
think it was an issue," he said. "I'm not a lobbyist, de facto or otherwise. I
did not receive any payment for my work. Most foundations accept grants from
private sources. There was no quid pro quo."
Dr. Koop said that he did
not believe he had been involved in any conflicts of interest at all. "I didn't
go into DrKoop.com to make money," he said. "I did it to change the way that
medicine is practiced, to bring important information to patients faster and get
them more involved in decisions about their health."
"It is true," he
went on, "there are people in my situation who could not receive a
million-dollar grant and stay objective. But I do. I was approached by people
who asked me if I would represent the side of tobacco in the tobacco settlement
and I refused. I can tell you it would have been very worth my while."
He said, too, that as chairman of DrKoop.com he was deeply committed to
making it clear that he was not practicing medicine on the Web site and to
keeping the lines between advertising and balanced content clear. "But I guess
we have to redouble our efforts," he said.
Such statements, though, do
not erase the sense many of his critics have that America's family doctor, as
Dr. Koop referred to himself in a 1991 memoir, has put his credibility at risk.
Some of those most critical were once Dr. Koop's most ardent admirers.
"Dr. Koop was much revered by the people he trained," said a Public
Health Service doctor who spoke on condition of anonymity. "He inspired me to
become a doctor in the first place. But many of these people believe now that
the way he is acting is a big departure from what we saw in him as a public
health leader -- and he was one of the great ones."
Dr. Koop, told of
the physician's comment, offered a suggestion to his detractor. "He or she ought
to come and talk to me about it," he said.
http://www.nytimes.com
GRAPHIC: Photos: Dr. C.
Everett Koop faces questions about DrKoop.com. (Associated Press)(pg. 1);
Critics say the DrKoop.com Web site blurs the line between information and
promotion. Dr. C. Everett Koop, the former Surgeon General, is chairman of
DrKoop.com, but he does not handle day-to-day operations. (pg. 20)
LOAD-DATE: September 5, 1999 
