AMA ethical guidance now available for e-mail, web

E-mail only in established relationships

As new information technologies continue to make person-to-person communications easier and more varied, they also are transforming the way that health care can be provided. Patients frequently make appointments and receive information via e-mail, and some even get second opinions from on-line web sites. While these advances have enormous potential to improve access to care, it’s important that medical professionals address potential ethical and legal complications new technologies pose.

Last month, the American Medical Association’s (AMA) Council on Ethical and Judicial Affairs (CEJA) in Chicago published two reports offering guidance on the appropriate use of e-mail and health-related on-line sites.1,2 (See CEJA’s Internet use guidelines.)

"These are the first in a series of reports that we are planning that address ethical uses of emerging technologies," explains Michael S. Goldrich, MD, chair of the CEJA and a practicing otolaryngologist in Highland Park, NJ. "We wanted to address the increasing potential for medical care to be delivered at a distance. Primarily, we are beginning to look at the practice of telemedicine, but we also realized that there was some groundwork that needed to be done first." There are a number of communication technologies that have become more frequently used in health care settings — fax, e-mail, interactive web sites — that need closer examination, he says.

The CEJA wanted to examine how different communication methods are being used and how these uses may affect the physician-patient relationship. In their research, they discovered a wide variety of practices:

  • Some practitioners use e-mail to recruit new patients and communicate a variety of clinical and diagnostic information this way, while others use e-mail exclusively as a method to reserve appointments or communicate routine, nonsensitive information.
  • Institutions sponsor or participate in interactive web sites to provide a wide variety of health information to patients and the public. Some web sites provide general information, but some provide — or attempt to provide — detailed, individual medical advice.

"The quality of the sites varies a great deal. Some are maintained by physician’s groups or other institutions to offer information to patients, while others were started by various e-business ventures," Goldrich says. "Some provide information tailored for specific patients, while others offer more general medical information, but that sometimes crosses the line and gets into more what we would consider to be patient care and advice."

The guidelines developed by the CEJA are meant to give guidance about how these information technologies can be used ethically and to enhance relationships with patients. In general, the CEJA recommends that e-mail between practitioners and patients be limited to correspondence with an already established patient, and that the provider — in a face-to-face meeting with the patient — explain the limitations and vulnerabilities of e-mail communications and determine whether e-mail might be an appropriate means of communicating with that patient.

The provider and patient also should determine what kinds of information can be communicated via e-mail, whether the patient’s e-mail address is secure, and what personnel on the practice’s end will have access to the patient’s e-mail messages. For example, a patient who uses an e-mail account at his place of employment might need to understand that his employer might have access to messages he receives at work and, thus, any medical information contained in them.

Several on-line sites now are offering medical advice on-line — both to established patients and to nonaffiliated members of the public, Goldrich notes. For example, individuals can seek on-line consultations at Johns Hopkins Radiosurgery (, or inquire about a second opinion at the Cleveland Clinic’s site, e-Cleveland Clinic ( At e-Cleveland, people may upload medical records and diagnostic test results for a second opinion. This involves entering a secure site and filling out an on-line questionnaire that documents patients’ medical conditions.

Provided appropriate measures are put in place, these methods of patient encounters are not necessarily as problematic as they might appear, Goldrich adds. "These are examples of technologies developed that are appropriate to the existing practices of the institution."

At a major center such as Johns Hopkins or the Cleveland Clinic, a patient’s medical information may be sent to someone in a specialty area, such as radiology, or reviewed by the chairman of the department of medicine in order to confirm a diagnosis or get another opinion about a treatment option. This is not so different from a patient seeking similar input through the on-line site.

"Some patients travel an entire day’s journey for a consultation at such a center, while this method might allow them to get the same information without a long journey," he says. As long as appropriate procedures have been established, both methods should be equally sound, Goldrich notes. It’s important for providers to consider the specific benefits and limitations of each kind of technology and develop policies and procedures concerning their use that reflect that understanding, he says.

Emerging technologies have the potential to facilitate and ease communication between patients and providers, and eliminate access barriers to those in remote areas for whom traveling is difficult or impossible. But it is the responsibility of the AMA and other medical societies to determine the ethical issues that individual technologies may present and educate their members about how to address the issues, Goldrich says.


1. Bovi AM. Ethical guidelines for use of electronic mail between patients and physicians. Am J Bioethics 2003; 3(3) InFocus:1-8. Accessed on-line at Also, go to:

2. Bovi AM. Use of health-related on-line sites. Am J Bioethics 2003; 3(3):InFocus. Accessed on-line at Also, go to:

Need more information?

  • Michael S. Goldrich, MD, Chair, Council on Ethical and Judicial Affairs, American Medical Association, 515 N. State St., Chicago, IL 60610.