Doctor, You've Got E-mail—Reply

In Reply: Jurisdiction in most countries probably agrees that if a physician replies to an unsolicited patient e-mail, this can be considered to establish a patient-physician relationship, with all its legal and liability implications. However, a much more complicated question than whether physicians can establish a patient-physician relationship online is whether they should do so, to what extent, and under what circumstances.

Most current ethical guidelines for telemedicine would, applied to the fictitious patient described in our study, explicitly discourage giving any concrete advice under such circumstances of limited information. For example, ethical guidelines for telemedicine adopted by the Standing Committee of European Doctors demand that "Where a direct telemedicine consultation is sought by the patient, it should normally only take place when the doctor has an existing professional relationship with the patient, or has adequate knowledge of the presenting problem."¹ Moreover, it says that "Preferably, all patients seeking medical advice should see a doctor in a face to face consultation, and telemedicine should be restricted to situations in which a doctor can not be physically present within acceptable time," which is rarely the case on the Internet, as most patients could also see a physician in person.² German physicians who give individual advice to patients by mail or e-mail would clearly violate their professional code, which explicitly provides that no physician may give "individual medical treatment, including medical advice, neither exclusively by mail . . . nor exclusively over communication media or computer communication networks."³ Similar codes exist in other countries. Physician associations show little intention to change this—a spokesperson from a German physician association recently insisted that "any medical advice must be given face-to-face. This has been always like this, and it will remain like this."⁴