HEALTH CARE MISINFORMATION: A MOVING TARGET FOR REGULATORY OVERSIGHT
GERALD GIANUTSOS, PhD, JD
Gerald Gianutsos, PhD, JD, is an Emeritus Associate Professor of Pharmaceutical Sciences at the University of Connecticut School of Pharmacy, Storrs, Connecticut.
Topic Overview
Misinformation and disinformation about health care is an age-old problem that took on new significance during the COVID-19 pandemic. Public health officials, professional organizations, and credentialing bodies issued warnings to health care personnel and attempted to counteract what they identified as information that endangers patients’ health. State authorities also took action, but their response was varied. Some state medical boards sought to sanction physicians for disseminating information perceived as untrustworthy. In other states, authorities sought to protect health care workers from sanctions for expressing “unconventional” viewpoints. Both approaches raised legal dilemmas. This activity will review these phenomena.
Accreditation Statement
RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.
Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is
Pharmacist 0669-0000-23-163-H03-P
Pharmacy Technician 0669-0000-23-164-H03-T
Credits: 2 hours of continuing education credit
Type of Activity: Knowledge
Media: Internet/Home study Fee Information: $6.99
Estimated time to complete activity: 2 hours, including Course Test and course evaluation
Release Date: September 25, 2023 Expiration Date: September 25, 2026
Target Audience: This educational activity is for pharmacists.
How to Earn Credit: From September 25, 2023, through September 25, 2026, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “educational activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
Credit for this course will be uploaded to CPE Monitor®.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Discuss the characteristics of health misinformation and its effect on public health
Describe the role of regulatory bodies in disciplinary actions for misinformation
Characterize the different approaches taken by states in addressing the dissemination of health care information
Disclosures
The following individuals were involved in developing this activity: Gerald Gianutsos, PhD, JD, and Pamela Sardo, PharmD, BS. Pamela Sardo was an employee of Rhythm Pharmaceuticals until March 2022 and has no conflicts of interest or relationships regarding the subject matter discussed. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.
© RxCe.com LLC 2023: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Introduction
A vibrant, effective health care system relies partly on disseminating accurate health information to the public. Information may come from governmental entities, national or state medical organizations, medical professionals, or individual citizens and community members. But what happens if health information is incorrect, misleading, or false? What should the societal response be to overcome misinformation and disinformation? These questions rose to new prominence with the COVID-19 pandemic. Federal governmental entities, states, and national or state medical organizations have grappled with controlling COVID-19 misinformation and disinformation while at the same time not chilling the development of COVID- 19 science or the free speech of medical professionals and laypersons. This activity will review misinformation and disinformation and some of the attempts to deal with it.
Health Information
An apple a day keeps the doctor away. Eating food within five seconds of dropping it on the floor is safe. Sugar and chocolates are aphrodisiacs.1 No doubt all health professionals have encountered situations where patients seeking care have experienced misconceptions derived from searching for medical and health information, especially on the internet.
False, misleading, and unsubstantiated health misinformation is a serious public health concern, made worse by its proliferation on social media and other online sites, where it spreads with exceptional speed and scope.2 The speed and scope have been so dramatic that Dictionary.com chose misinformation as its word of the year in 2018.3
The potential harm from misinformation is unsettling, and the highest levels of the government’s public health infrastructure have expressed alarm. The Surgeon General of the United States, Dr. Vivek Murthy, declared that “Health misinformation is a serious threat to public health. It can cause confusion, sow mistrust, harm people’s health, and undermine public health
efforts.”2 This leads to public skepticism about the health establishment, with patients becoming less willing to follow public health guidance. Governmental and professional organizations have tried to reign in misinformation, but these efforts have generated their own controversies.
Defining Misinformation
Misinformation has been defined in many ways. Chou, et al., (2020) defined “health misinformation” as “any health-related claim of fact that is false based on current scientific consensus.”4 Other scholars see misinformation as information that conflicts with the “best available evidence.”5
The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment considered these definitions and chose to define misinformation as information that is false, inaccurate, or misleading according to the best available evidence at the time.2 This definition sidesteps the need for “scientific consensus”: “This Advisory prefers the ‘best available evidence’ benchmark since claims can be highly misleading and harmful even if the science on an issue isn’t yet settled.”2 It also suggests that misinformation is fluid and can change as new evidence emerges and techniques and methods improve, making misinformation more difficult to evaluate and counteract.2,6
The U.S. Surgeon General’s Advisory acknowledges that governance of misinformation needs to be done carefully. The Advisory asked, “How do we curb the spread of harmful misinformation while safeguarding user privacy and free expression?”2 The Advisory wants to assure that governing authorities do not conflate controversial or unorthodox claims with misinformation.2 Not only would excessive restrictions on misinformation impact free expression but it could also dampen or impede new discoveries and treatments for the target disease. This is especially concerning when the target is a novel disease that is in the early months or years of study.
What is missing from this definition is a definition of misinformation or disinformation when governmental entities or professional associations (non- governmental medical organizations) do not agree on what the “best available evidence” says. Examples of this issue could be seen throughout the COVID-
19 pandemic response in the testing, vaccination, and treatment of the disease.
For example, the Centers for Disease Control and Prevention (CDC) began promoting the polymerase chain reaction (PCR) test to detect the SARS-CoV-2 virus.7 The American Medical Association followed this view.8 On the other hand, the Association of American Physicians and Surgeons questioned the usefulness of the PCR test to detect the SARS-CoV-2 virus.9 The CDC states today that the PCR test is the “gold standard” for COVID-19 testing.10 The CDC’s clear statement establishes the “best available evidence,” but the lack of full consensus from within the medical profession can undermine the message.
The same issue arose for the COVID-19 mRNA vaccinations when the Florida State Surgeon General, Dr. Joseph A. Ladapo, issued guidance questioning their safety and efficacy.11 The CDC and the Food and Drug Administration (FDA) disagreed with the State of Florida on the safety and efficacy of COVID-19 vaccinations.12 Does this mean that in the State of Florida, saying that the COVID-19 vaccinations are safe and effective is misinformation but in other states, it is not? Or do the CDC and FDA take precedence over Florida State law and the Florida Surgeon General because they are federal (national) organizations?
Answering these questions becomes more unclear as states pass laws conflicting with the CDC and FDA on COVID-19 response. For example, The CDC and FDA have not recommended or approved ivermectin to treat COVID-
19.13,14 The FDA page shows a picture of a horse with a veterinarian standing beside it. This could imply that ivermectin is for horses, not humans, but this is not what the FDA says on its page. Ivermectin is also a human drug with applications to treat parasites and several infectious diseases, but it is not recommended by the FDA for COVID-19.13 However, in states like Tennessee and Kansas, the opposite is believed to be true, and these states have passed laws to make ivermectin more available to its populations.15,16 Does this mean that in Tennessee and Kansas, saying that ivermectin should not be an optional treatment for COVID-19 is misinformation, but in other states, it is not? Or, again, do the CDC and FDA take precedence over these state laws, even within those states, because they are federal (national) organizations? These questions are not simple to answer.
A Historical Look at Misinformation and Disinformation
Misinformation is frequently used as a catch-all term for related concepts such as disinformation, ignorance, rumor, and conspiracy theories and has sometimes resulted in an expansive use of the term and imprecise characterization.17 Misinformation is often distinguished from disinformation based on intent. In this context, misinformation is used to describe unintentionally erroneous information (e.g., mistakenly or due to ignorance). At the same time, disinformation is information that is deliberately intended to mislead or deceive (e.g., malicious or fraudulent information or information used for propaganda).17
While misinformation and disinformation gained new prominence during the COVID-19 pandemic, health misinformation and disinformation are not a recent phenomenon, occurring in one form or another since at least the Middle Ages with misconceptions about communicable and other diseases being promoted.18 In more recent history is the notorious example of misinformation and disinformation that occurred from the 1930s to 1950s when advertising promoted misleading industry-sponsored research on the safety of tobacco
products.18-21 Cigarette companies used advertising featuring physicians’ endorsements of their products, claiming that their brand produced less throat irritation than their competitors. However, they failed to mention that the physicians surveyed were asked leading questions or were recruited by the company.9 As late as 1994, tobacco company executives testified before Congress that cigarettes were not addictive and that evidence that tobacco may cause lung cancer, heart disease, and other health problems was not conclusive.22
In another example, the manufacturers of the mouthwash Listerine falsely claimed for more than five decades that their product cured the common cold until the Federal Trade Commission ordered them to issue “corrective advertising” in 1972 to prevent the manufacturer from continuing to profit from false or misleading advertising.19,20 The manufacturer was forced to admit that although the product is anti-bacterial, it could not kill viruses. This example foreshadowed the more recent controversies about the risks of vaccines that preceded COVID-19 by many years.2,18 In 2014, Ebola clinics in Liberia were attacked because of a rumor-fueled, unverified claim that the virus was part of a government conspiracy, resulting in delays in achieving care for patients stricken by Ebola.20
Misinformation and Disinformation Affecting Health Care
If misinformation and disinformation were simply distractions, it would not demand much consideration, but the U.S. Surgeon General Advisory stated that misinformation can cause confusion and lead people to reject public health measures and use unproven treatments.2 Dr. Garth Graham, head of YouTube Health, remarked in an interview, “Health care does not begin when someone walks in the door of their doctor’s office, but when they search online for videos and articles and then act on that information — whether good or bad.”23 Moreover, patients are no longer passively exposed to health advice but actively seek and evaluate available health information.6 While there are benefits to people having the freedom to research their health conditions, most laypeople are not health experts, and there is a risk of reliance on misleading or incorrect interpretations of available evidence.6,24
Research suggests that as the scientific quality of social media posts decreases, engagement (such as views and likes) increases.6
In addition to confusing patients, negative consequences of health misinformation and disinformation include misallocation of health resources, fraud, increased reliance on unreliable cures, a negative impact on mental health, and an increased hesitancy to seek medical care.18,24 Beyond physical health, misinformation breeds distrust in medicine and science and increases divisiveness in society.2,18,24
A study investigating the prevalence of current health misinformation and disinformation topics on different social media platforms found that they are most commonly linked to six main topic areas: (1) vaccines, (2) diets and eating disorders, (3) drugs and new tobacco products, (4) pandemics and communicable diseases, (5) non-communicable diseases, and (6) medical treatments and health interventions (especially for cancer).25
Health care providers are also impacted by misinformation and disinformation. A public health policy organization conducted a poll of physicians in 2022 and found that almost ¾ of the physicians responding said that medical misinformation has hindered their ability to treat COVID-19 patients and harmed patient outcomes.26 Nearly 50% of the physicians estimated that more than half the COVID-19 information communicated to them by patients is misinformation or disinformation. Physicians also noted that misinformation is not limited to COVID-19. More than 2/3 of the physicians in the poll said that it is also a problem with many vaccines and in the areas of weight loss, dietary supplements, mental health, cancer, and diabetes.26 Physicians also believe that patient trust in them has decreased, although only 21% of the public surveyed in the same poll said their trust has decreased.26
Significantly, 77% of physicians supported medical board disciplinary action against health care workers who intentionally spread false information (i.e., disinformation).26 Some medical boards have done so, as discussed below. A strong majority of physicians and members of the public in the survey
believed that a physician’s responsibility to share credible information with their patients outweighs their right to free speech.26 Although medical misinformation and disinformation have a greater profile now because of the COVID-19 pandemic, physicians saw it as a problem even before the pandemic.
How Federal and International Public Health Agencies are Dealing with Perceived Misinformation and Disinformation
Misinformation and disinformation are perceived to have significant public policy implications,2,23 and consequently, public health officials have taken steps to address the situation where false information may influence medical decisions. The most common approaches are to issue warnings, monitor social media, and attempt to provide educational resources to correct perceived misinformation.
During the COVID-19 pandemic, the World Health Organization (WHO), in conjunction with the United Nations, established information centers that were charged with working with social media outlets and others to challenge and disprove myths and false information.27
The U.S. Surgeon General issued an advisory in 2021 urging Americans to help slow the spread of health misinformation.2 The advisory contained recommendations encompassing educational, policy, technological, legal, and regulatory measures to curb the spread of harmful misinformation while safeguarding privacy and free expression.
In 2023, a bill was introduced in Congress, the Promoting Public Health Information Act, which would create a panel of experts from various fields reporting directly to the Secretary of Health and Human Services to help establish a set of best practices that public health agencies across the country can use to most effectively disseminate timely and accurate information to the public during a public health crisis. The panel would also be tasked with establishing procedures that public health agencies should take to address misinformation that is spread unintentionally and disinformation that is spread intentionally during such a crisis.28
Non-governmental medical organizations in the U.S., also cautioned against the spread of misinformation. In 2023, 50 health-related national organizations, including representation from pharmacy, formed a coalition with the aim of correcting and countering misinformation and disinformation that decreases trust in healthcare and has the potential to harm the public’s health.29
The American Medical Association adopted a policy in 2022 that states in part that “physicians have an ethical and professional responsibility to share truthful information, correct misleading and inaccurate information, and direct people to reliable sources of health information.”30 The policy also encourages licensing boards to have the authority to take disciplinary action against health professionals for spreading health-related disinformation and affirms that “all speech in which a health professional is utilizing their credentials is professional conduct and can be scrutinized by their licensing entity,” discussed in the next section.30
Credentialing boards also adopted similar policies. A joint statement from the American Board of Family Medicine (ABFM), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP) declared that providing misinformation about the COVID-19 vaccine contradicts physicians' ethical and professional responsibilities and warned physicians that such conduct may prompt a Board to take action that could put their certification at risk.31
Rules exist governing inappropriate acts committed by pharmacists.32 For example, one area of unprofessional conduct in the Model Pharmacy Act developed by the National Association of Boards of Pharmacy (NABP) is “engaging in conduct likely to deceive, defraud, or harm the public, or demonstrating a willful or careless disregard for the health, welfare, or safety of a patient, or engaging in conduct which substantially departs from the Standards of Care ordinarily exercised by a Pharmacist, with proof of actual injury not having to be established.”32
How States Have Dealt with Perceived Misinformation
State boards have more aggressively confronted the issue of the dissemination of health care information, but their solutions have taken conflicting approaches. The general approach by most states is to invoke standards of unprofessional conduct. The definition of unprofessional conduct and appropriate sanctions for non-compliance are described in a state’s Medical Practice Act and differ from state to state.33 Most well-known examples of unprofessional conduct that can lead to penalties are unrelated to mis- or disinformation and include conviction of a felony, fraud, alcohol, and substance abuse, sexual misconduct, failure to meet the acceptable standard of care, prescribing drugs in excess or without legitimate reason, and professional dishonesty.33
Traditionally, some state medical boards have initiated disciplinary actions against physicians for making false or misleading statements in situations such as serving as an expert witness in malpractice cases.34 Some state laws explicitly authorize disciplinary action against physicians who make false, deceptive, or misleading statements to the public. In most cases, these statutes apply to statements made in connection with advertising, especially in the solicitation of patients. However, some are worded broadly enough to cover other forms of misrepresentation.34,35 For example, Minnesota authorizes disciplinary action against physicians who engage in “conduct likely to deceive or defraud the public.”36
In 2021, the Federation of State Medical Boards (FSMB) issued a warning that physicians generating and spreading COVID-19 misinformation or disinformation risk disciplinary action by state medical boards, including the suspension or revocation of their medical license.37 The FSMB felt that this was warranted because “physicians possess a high degree of public trust” due to their specialized knowledge and training and “therefore have a powerful platform in society, whether they recognize it or not.”37 Moreover, they have an ethical and professional responsibility “to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded and consensus-driven for the betterment of public health.”37 The FSMB also stated that a physician’s ethical and professional responsibility is contradicted by spreading inaccurate information and that such action “threatens to further erode public trust in the medical profession and puts all patients at risk.”37
Some states have endorsed this sentiment. Since the FSMB statement, state medical boards in at least 10 states have disciplined physicians for spreading misinformation related to the COVID-19 pandemic, including supporting anti-masking, spreading vaccine misinformation, promoting ivermectin as a therapy, and issuing inappropriate vaccine exemption letters.38,39 Penalties include suspension or revocation of a license or board certification.24,28,40
These actions have generated repercussions, including lawsuits and disruptive acts against state officials by the affected health care workers.32,41 The physicians being investigated countered by citing their scientific expertise and claimed in their defense that regulators are censoring opposing information.39 The physicians received penalties ranging from fines to suspension or revocation of their licenses.38,39 The effectiveness of the measures has been questioned: few physicians face disciplinary actions, reported fines have been relatively low ($500 in one case), and physicians who lose their licenses may choose to continue promoting misinformation on social media using their MD titles.38,42
Many factors hinder action from being taken. The licensing system for health professionals is fragmented with state-to-state variability and licensing boards comprise a mix of health care practitioners, lawyers, and laypeople.42 The boards focus on medical malpractice, usually responding only to complaints against individual physicians, and lack the financial and personnel resources to monitor the internet.42 Disciplinary proceedings can be lengthy and challenging for all involved.35 In many states, the legal framework for discipline, which was developed in the 20th century, may narrowly apply to actions or speech related directly to patients under the physician’s care and not to broader circumstances like social media.39
Boards and employers can face legal challenges from the health care workers who have disputed disciplinary proceedings.39 Political opposition from legislators in some states can also impede a board’s actions.39
In addition, while health care professionals have ethical and professional obligations, it is not clear that they have any legal obligation to promote public health since they are not government officials.35 Finally, disciplinary actions due to statements about health-related matters may encounter issues of constitutional protection of free speech and there are concerns that restrictions on providing information could inhibit physicians from raising legitimate questions about existing standards of care.34 Physicians facing disciplinary actions have used these defenses,
Some states have specifically addressed misinformation/disinformation with new laws. In September 2022, California passed a bill stating, “It shall constitute unprofessional conduct for a physician ... to disseminate misinformation or disinformation related to COVID-19.”43 This includes “false or misleading information regarding the nature and risks of the virus, its prevention and treatment; and the development, safety, and effectiveness of COVID-19 vaccines.”43 Misinformation is defined in the statute as false information that is “contradicted by contemporary scientific consensus contrary to the standard of care” and is delivered with "malicious intent or an intent to mislead"44 This definition has created legal uncertainty (see below). The misinformation or disinformation must be conveyed “[by] the licensee to
a patient under the licensee's care in the form of treatment or advice.”44 It excludes speech outside a direct physician relationship, such as social media postings.44 California Governor Newsom also indicated that he is “confident that discussing emerging ideas or treatments including the subsequent risks and benefits does not constitute misinformation or disinformation under this bill's criteria."44
The Medical Board of California could punish violators by imposing a fine or a suspension or revocation of their license to practice in the state.45 The governor and the sponsor of the bill (who is a pediatrician) indicated that the law was intended to address “the most egregious cases” of deliberately misleading patients.45
The law has been challenged by physicians and the American Civil Liberties Union (ACLU), claiming unconstitutional infringement of free speech and violation of the 14th Amendment.46 McDonald v. Lawson (2022) was filed first, followed by Høeg v. Newsom (2023).47,48 The physicians bringing the challenges had previously commented on government restrictions and recommendations by experts during the pandemic and warned that the law’s definition of misinformation as false information that is “contradicted by contemporary scientific consensus” would suppress the ability of physicians to advise patients about the pros and cons of COVID-19 treatment and practices.47,48
McDonald v. Lawson was filed in the United States District Court for the Central District of California. The judge found that the law was not unconstitutionally vague.47 Essentially, he ruled that the clause that the conduct contravenes the applicable “standard of care,” long familiar to health care personnel in the context of malpractice, provided sufficient clarity to define the prohibited acts. He also noted that the law does not prevent medical professionals from “publicly advocating for their views regarding the prevailing scientific consensus in any respect.”47
Høeg v. Newsom was filed after McDonald in the United States District Court for the Eastern District of California. The Federal judge temporarily blocked the implementation of the law (by issuing an injunction), on the basis that the definitions of misinformation were “unconstitutionally vague” and that the plaintiffs would likely prevail on their constitutional challenge to the law.48 The Court noted that the phrase defining the unlawful conduct as contradicting “contemporary scientific consensus” lacked any established meaning within the medical community and was not clarified further in the statute.48 He went on to say that it “fails to provide sufficiently objective standards to focus the statute’s reach.”48 The judge found this particularly problematic in the context of the pandemic since the scientific understanding of the virus had repeatedly changed, negating a true consensus.48 One of the plaintiffs commenting on the decision was, Aaron Kheriaty, a professor of psychiatry and human behavior at the University of California, Irvine, medical school and the school’s director of the medical ethics program. He said, “Today’s quote-unquote misinformation is tomorrow’s standard of care.”46 This split in authority may necessitate a decision from an appellate court.46
As the controversy escalates in California, the state legislature is expected to rescind the law. However, the California board believes that they already had the authority to punish physicians for spreading false information even before the law was passed and will continue in its efforts.49
Missouri has also enacted statutes dealing with the dissemination of health information, but the approach is quite different from California.50 A law passed in 2022 prohibits the state boards overseeing medicine and pharmacy from disciplining a registered practitioner for “lawfully” prescribing or dispensing ivermectin or hydroxychloroquine for human use.50
In addition, the law prohibits a pharmacist from contacting the prescribing physician or the patient to dispute the efficacy of ivermectin or hydroxychloroquine unless the physician or patient asks the pharmacist about the drug’s efficacy.50 The Missouri Pharmacy Association issued a clarification indicating that pharmacies are not required to dispense nor stock the drugs, nor does it prevent a pharmacist from counseling a patient who should not
take these drugs due to certain health conditions or interactions.51 A bill sponsor indicated that these actions were necessary because “certain pharmacists wanted to begin acting like physicians and denying the filling of the prescriptions. This reestablishes the professional equilibrium between doctors and pharmacists.”52
The law, like the California measure, has been challenged on First Amendment grounds by a pharmacist.53 The suit alleges that “all pharmacists in Missouri now face the impossible—and constitutionally impermissible— conundrum of deciding whether to endanger their livelihood when choosing whether to speak in a manner that is both vital to their professional duties to patients and protected by the First Amendment.”53
Ohio is considering a law which would prevent a medical board from suppressing the access to or promotion of “alternative,” non-FDA approved medications for COVID-19.54 The bill specifically covers four drugs: ivermectin, hydroxychloroquine, azithromycin, and budesonide. It would also prevent a board from reprimanding, threatening, or penalizing a health care professional for prescribing, administering, or promoting one of the drugs.54 The sponsor of the bill stated that it would achieve the goal of “respecting the authority and judgment of Ohio’s medical community by limiting unnecessary state interference in the doctor-patient relationship.”55 He contends that these therapies have been shown to be clinically effective yet remain “unavailable to patients who may benefit from them because of unnecessary government intervention and red tape.”39 The legislature in North Dakota passed a bill preventing physicians, nurses, and pharmacists from being disciplined for prescribing or dispensing ivermectin to treat COVID-19. 56,57
Controversies have also erupted in other states when seeking to limit or promote unconventional approaches to treating COVID-19. In Tennessee, the state’s Board of Medical Examiners unanimously declared that a physician spreading false information about COVID-19 would be putting their license in jeopardy.58 Soon afterward, state legislators charged that the board had overstepped its authority and demanded that the statement be deleted from the state’s website and threatened to disband the board.57,58
The head of a legislative panel, who had earlier threatened to defund the Health Department when it promoted COVID-19 vaccines to teens, charged that the board had overstepped its statutory authority and had obstructed the rights of physicians and patients through intimidation and threat.58 He demanded that they justify their action.59
In other states, licensing board activities have been disrupted. In North Dakota and Mississippi, the state Department of Health turned off comments on its social media accounts to stop the spread of misinformation.60 An ND agency spokesperson indicated this was necessary because the statements initially were about COVID-19 but spread to other guidance, including precautions for Sudden Infant Death Syndrome, and were “discrediting information about everything we posted.”60 In Maine, the state Medical Board suspended the license of a physician after one of her patients who had been prescribed ivermectin for COVID-19 was admitted to a hospital with respiratory complaints. Her administrative hearing was live-streamed on the internet, and anti-vaccination groups supported her. She claimed to have turned the state investigation into a "'spectacle.”61
The efforts of the federal and state governments to protect the public from misinformation and disinformation is necessary; however, they are ultimately set against the backdrop of the United States Constitution, specifically the First Amendment that protects free speech.62 The government may restrict limited subcategories of false speech without violating the First Amendment. For example, defamation, fraud, political advertisements, and broadcast speech are subject to special considerations.34 However, while some false statements may be stopped, the United States Supreme Court has left
open the door to challenge government action against misinformation and disinformation on First Amendment, free speech grounds.62,63 While false statements may be of little value in public discourse, censoring such speech may “chill” more valuable speech and run afoul of the First Amendment.62
Dealing with Misinformation in the Pharmacy Setting
Pharmacists and pharmacy technicians can be leaders in confronting and controlling misinformation and disinformation.64 Pharmacists communicate with patients and dispel medication misinformation daily. Patients frequently report myths and misinformation about various medications, such as influenza vaccines or dietary supplements.64 It is the community pharmacist that responds to these reports and provides patients with evidence-based guidance.64 Pharmacy technicians may refer patients to the pharmacist or other appropriate clinician for counseling when they see possible misinformation and disinformation.
Combating misinformation also involves the pharmacist working collaboratively with interdisciplinary colleagues. This applies to the COVID-19 pandemic and future public health crises. Marwitz (2021) stated that combating misinformation as a pharmacist is a professional responsibility.64
Pharmacy teams practice with evidence-based medicine in mind. The scientific community has an approach that ‘one article is interesting,’ but two articles provide evidence of reproducibility and the ability to replicate the process and achieve the same results. Reproducibility is obtaining consistent
results using the same input data, methods, and conditions. This helps address misinformation. Pharmacists and pharmacy technicians should also remember that although the First Amendment protects free speech, the government may restrict defamatory or fraudulent speech, and political advertisements and broadcast speech.34
Summary
Health care misinformation and disinformation grew during the COVID- 19 pandemic, especially through social media. Efforts to control them on social media are complicated due to their rapid spread and persistence. Conflicting information on mitigation measures and therapies results in patient confusion, misuse of remedies, and skepticism about the health establishment, with patients becoming less willing to follow public health guidance.
Efforts to restrain misinformation have proven to be difficult. Misinformation and disinformation are imprecise and, unfortunately, politically charged terms. Defining them when governmental entities or professional medical organizations disagree on what the “best available evidence” says confuses the discussion even more. As such, national public health officials have generally taken a low-key approach, focusing on identifying and attempting to clarify information seen as dubious. At the state level, boards overseeing health professions and some legislatures have embraced a more hard-line approach, adopting laws and policies that seek to discipline individuals for spreading potentially harmful questionable information. Penalties include suspension or revocation of a license or board certification. These actions have generated repercussions, including lawsuits and disruptive acts against state officials by the affected health care workers.
In other states, there has been additional backlash against this approach, with legislative opponents arguing that efforts to suppress differing viewpoints constitute government overreach and raise constitutional issues related to limiting the flow of health information. The turmoil is further complicated by the recognition that misinformation is nuanced and shifting. It is truly a dilemma for regulators and clinicians.
Pharmacists and pharmacy technicians can be leaders in confronting and controlling misinformation and disinformation. Pharmacists communicate with patients and dispel medication misinformation daily. Pharmacy technicians may refer patients to the pharmacist or other appropriate clinician for counseling when they see misinformation and disinformation.
Course Test
The U.S. Surgeon General Advisory issued a statement about misinformation
that set a lower standard of proof of information reliability during a public health crisis.
claiming it causes people to reject public health measures and use unproven treatments.
Identifying government guidelines as “best guesses” that do not need to be followed by licensed physicians.
applied only to physicians in federal facilities.
The U.S. Surgeon General Advisory uses as the benchmark for judging whether medical information is misinformation or disinformation.
current “scientific consensus”
“best available evidence”
public polling
federal rulemaking
Disinformation is unlike misinformation because it
is information that is deliberately intended to mislead or deceive.
lacks “scientific consensus.”
is due to ignorance.
it can lead to harm.
What is the position of the Federation of State Medical Boards (FSMB) on health misinformation?
Physicians may use unauthorized treatments in a pandemic without fear of reprisal.
State medical boards should not monitor health care workers’ medical information.
Physicians risk suspension or revocation of their medical licenses if they disseminate misinformation.
State medical boards do not have the legal authority to interfere with medical discussions between doctors and patients.
Laws recently passed in California and Missouri regarding the dissemination of controversial health information were challenged in court because
the laws interfered with the practice of medicine.
the legislatures did not have the legal authority to pass the laws.
the laws violated the rights of patients to seek treatment.
the laws violated the First Amendment.
A judge in California issued an injunction against California’s law on misinformation. What was the basis of his decision?
The description of the prohibited acts was unconstitutionally vague.
The law impermissibly interfered with the doctor-patient relationship.
The state could not demonstrate any harm resulting from the information.
The state did not follow the correct procedures in passing the law.
How does the Missouri law on the dissemination of health information affect Missouri pharmacists?
It prevents pharmacists from dispensing ivermectin or hydroxychloroquine for COVID-19.
It mandates counseling for all prescriptions for ivermectin or hydroxychloroquine.
It prohibits pharmacists from contacting the prescribing physician or the patient to dispute the efficacy of ivermectin or hydroxychloroquine.
It made ivermectin an OTC drug in the state.
The Tennessee State Board of Medical Examiners issued a statement that a physician spreading false information about COVID-19 would be putting their license in jeopardy. What did the state’s legislature do in response?
Overwhelmingly endorsed this position.
Threatened to disband the board.
Enacted a law to include other areas beyond COVID-19.
Passed a resolution that established fines for misinformation but prohibited loss of licensure.
What did the North Dakota Department of Health do when faced with opposition to its misinformation policy?
It excluded the public from further hearings about the policy.
It suspended the license of a clinic that opposed the policy.
It turned off comments on its social media accounts to stop the spread of misinformation.
It replaced the Commissioner by order of the Governor.
Pharmacists can be leaders in confronting and controlling misinformation and disinformation by
telling the patient not to participate on social media.
telling the patient to find another pharmacy.
providing the patient with literature showing how off-label uses of drugs are inappropriate.
providing patients with evidence-based guidance.
References
Mosher D. 49 Health 'Facts' You've Been Told All Your Life That Are Totally Wrong. Business Insider. August 3, 2016. https://www.businessinsider.com/worst-science-health-body-myths- 2016-8#myth-milk-does-a-body-good-1. Accessed August 21, 2023.
Office of the Surgeon General (OSG). Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment [Internet]. Washington (DC): US Department of Health and Human Services; 2021. References. https://www.ncbi.nlm.nih.gov/books/NBK572167/. Accessed September 24, 2023.
Italie L. Dictionary.com Chooses ‘misinformation’ as Word of the Year. AP News. November 26, 2018. https://apnews.com/article/entertainment-north-america-ap-top-news- religion-fake-news-e4b3b7b395644d019d1a0a0ed5868b10. Accessed August 21, 2023.
Sylvia Chou WY, Gaysynsky A, Cappella JN. Where We Go From Here: Health Misinformation on Social Media. Am J Public Health. 2020;110(S3):S273-S275. doi:10.2105/AJPH.2020.305905
Sell, T.K., Hosangadi, D., Smith, E., Trotochaud, P.V., Gronvall, G.K., Rivera, Y., Sutton, J., Ruiz, A., & Cicero, A. National priorities to combat misinformation and disinformation for COVID-19 and future public health threats: A call for a national strategy. Johns Hopkins Center for Health Security. 2021. https://centerforhealthsecurity.org/sites/default/files/2023-02/210322- misinformation.pdf. Accessed September 24, 2023.
Swire-Thompson B, Lazer D. Public Health and Online Misinformation: Challenges and Recommendations. Annu Rev Public Health. 2020;41:433-451. doi:10.1146/annurev-publhealth-040119-094127
Centers for Disease Control and Prevention. Museum COVID-19 Timeline. CDC. 2023. https://www.cdc.gov/museum/timeline/covid19.html. Accessed September 24, 2023.
American Medical Association. Considerations for physicians ordering SARS-CoV-2 PCR diagnostic testing. AMA. 2020. https://www.ama- assn.org/delivering-care/public-health/considerations-physicians- ordering-sars-cov-2-pcr-diagnostic-testing. Accessed September 24, 2023.
Association of American Physicians and Surgeons. COVID-19: What Does a Positive PCR Test Mean? AAPS. 2020. https://aapsonline.org/covid-19-what-does-a-positive-pcr-test-mean/. Accessed September 24, 2023.
Centers for Disease Control and Prevention. COVID-19 Testing: What You Need to Know. CDC. 2023. https://www.cdc.gov/coronavirus/2019- ncov/symptoms- testing/testing.html#:~:text=PCR%20tests%20are%20the%20%E2%8 0%9Cgold,the%20virus%20than%20antigen%20tests. Accessed September 24, 2023.
State Surgeon General Dr. Joseph A. Ladapo Issues New Mrna COVID- 19 Vaccine Guidance. Florida Health. 2022. https://www.floridahealth.gov/newsroom/2022/10/20220512-guidance- mrna-covid19-vaccine.pr.html. Accessed September 24, 2023.
Centers for Disease Control and Prevention. FDA and CDC Response to the Florida Surgeon General. CDC. 2023. https://www.cdc.gov/media/releases/2023/p0313-letter.html. Accessed September 22, 2023.
Food and Drug Administration. Why You Should Not Use Ivermectin to Treat or Prevent COVID-19. FDA. 2021. https://www.fda.gov/consumers/consumer-updates/why-you-should- not-use-ivermectin-treat-or-prevent-covid-19. Accessed September 24, 2023.
Centers for Disease Control and Prevention. Rapid Increase in Ivermectin Prescriptions and Reports of Severe Illness Associated with Use of Products Containing Ivermectin to Prevent or Treat COVID-19. CDC. 2021.
https://emergency.cdc.gov/han/2021/han00449.asp?ACSTrackingID=U SCDC_1052-
DM74752&ACSTrackingLabel=Ivermectin%20Products%20are%20Not% 20Approved%20by%20FDA%20to%20Prevent%20or%20Treat%20COV ID-19&deliveryName=USCDC_1052-DM74752. Accessed September 24, 2023.
Tennessee Senate passes bill to allow over-the-counter sales of ivermectin. The Hill. 2022. https://thehill.com/news/state- watch/3261642-tennessee-senate-passes-bill-to-allow-over-the- counter-sales-of-ivermectin/?rl=1. Accessed September 24, 2023.
Ivermectin, hydroxychloroquine off-label prescription bill passes Kansas Senate in late-night vote. The Topeka Capital - Journal. 2022. https://www.cjonline.com/story/news/politics/2022/03/24/kansas- senate-passes-ivermectin-hydroxychloroquine-off-label-covid- treatment-pharmacists-bill/7150014001/. Accessed September 24, 2023.
Cacciatore MA. Misinformation and public opinion of science and health: Approaches, findings, and future directions. Proc Natl Acad Sci U S A. 2021;118(15):e1912437117. doi:10.1073/pnas.1912437117
Keslar L. The Rise of Fake medical News. Proto. Mass General Hospital. June 18, 2018. https://protomag.com/policy/rise-fake-medical-news/.
Accessed August 21, 2023.
F.T.C. Upheld on Listerine's Ads as Supreme Court Bars a Review. NY Times. April 4, 1978. https://www.nytimes.com/1978/04/04/archives/ftc-upheld-on- listerines-ads-as-supreme-court-bars-a-review- 93.html#:~:text=The%20appeals%20court%20confirmed%20F.T.C.,wi dely%20held%20mistaken%20beliefs.%20.%20. Accessed August 21, 2023.
van der Linden S. Misinformation: susceptibility, spread, and interventions to immunize the public. Nat Med. 2022;28(3):460-467. doi:10.1038/s41591-022-01713-6
Little B. When Cigarette Companies Used Doctors to Push Smoking. History. September 13, 2018 (Updated March 28, 2023). https://www.history.com/news/cigarette-ads-doctors-smoking- endorsement. Accessed August 21, 2023.
say-cigarettes-aren-t-addictive.html. Accessed August 21, 2023.
Graham G., Lee TH. What’s Up with Health Misinformation? NEJM Catalyst. January 31, 2023. https://catalyst.nejm.org/doi/full/10.1056/CAT.23.0039. Accessed August 21, 2023.
Borges do Nascimento IJ, Pizarro AB, Almeida JM, et al. Infodemics and health misinformation: a systematic review of reviews. Bull World Health Organ. 2022;100(9):544-561. doi:10.2471/BLT.21.287654
Suarez-Lledo V, Alvarez-Galvez J. Prevalence of Health Misinformation on Social Media: Systematic Review. J Med Internet Res. 2021 Jan 20;23(1):e17187. doi: 10.2196/17187
U.S. Physicians: Medical Misinformation Is Harming Patients’ Health. Findings From a National Poll of Physicians & The Public. De Beaumont Foundation. 2022. https://debeaumont.org/wp- content/uploads/2023/03/misinformation-poll-brief-FINAL.pdf. Accessed August 21, 2023.
Zarocostas J. How to Fight an Infodemic. Lancet. 2020;395(10225):676.
congress/house-bill/1004?s=1&r=4. Accessed August 21, 2023.
joins-leading-national-organizations-curb-infodemic-health-and-science- misinformation. Accessed August 21, 2023.
American Medical Association. AMA Adopts New Policy Aimed at Addressing Public Health Disinformation. AMA. 2022. https://www.ama- assn.org/press-center/press-releases/ama-adopts-new-policy-aimed- addressing-public-health-disinformation. Accessed August 21, 2023.
American Board of Internal Medicine. Standing Up for the Profession, Protecting the Public: Why ABIM Is Combatting Medical Misinformation. May 18, 2022. https://blog.abim.org/standing-up-for-the-profession- and-public-why-abim-is-combatting-medical-misinformation/.Accessed August 21, 2023.
National Association of Boards of Pharmacy. Model Pharmacy Act/Rules.
NABP. 2022. https://nabp.pharmacy/members/board-resources/model-
pharmacy-act-rules/. Accessed August 21, 2023.
Federation of State Medical Boards. About Physician Discipline. https://www.fsmb.org/u.s.-medical-regulatory-trends-and- actions/guide-to-medical-regulation-in-the-united-states/about- physician-discipline/. Accessed August 21, 2023.
Coleman CH. Physicians Who Disseminate Medical Misinformation: Testing the Constitutional Limits of Professional Disciplinary Action. First Amend. L. Rev. 2022;20:113-146.
Yang YT, Schaffer DeRoo S. Disciplining Physicians Who Spread Medical Misinformation. J Public Health Manag Pract. 2022;28(6):595-598. doi:10.1097/PHH.0000000000001616
2022 Minnesota Statutes. Section 147.091(g)(1). https://www.revisor.mn.gov/statutes/cite/147.091. Accessed August 21, 2023.
Federation of State Medical Boards. FSMB: Spreading Covid-19 Vaccine Misinformation May Put Medical License at Risk. Federation of State Medical Boards. July 29, 2021. https://www.fsmb.org/advocacy/news- releases/fsmb-spreading-covid-19-vaccine-misinformation-may-put- medical-license-at-risk/. Accessed August 21, 2023.
Morris J. Doctors Who Knowingly Spread Covid-19 Lies Should Be Held Accountable. Stat. September 27, 2022. https://www.statnews.com/2022/09/27/hold-accountable-doctors-who- knowingly-spread-covid-19-lies/. Accessed August 21, 2023.
Tahir D. Medical Boards Get Pushback as They Try To Punish Doctors For Covid Misinformation. Politico. February 1, 2022. https://www.politico.com/news/2022/02/01/covid-misinfo-docs- vaccines-00003383. Accessed August 21, 2023.
DePeau-Wilson M. Two Doctors Will Lose ABIM Certification for Allegedly Spreading False Information. MedPage Today. August 10, 2023. https://www.medpagetoday.com/special- reports/exclusives/105835?xid=nl_medpageexclusive_2023-08-
10&eun=g1359385d0r&utm_source=Sailthru&utm_medium=email&utm
_campaign=MPTExclusives_081023&utm_term=NL_Gen_Int_Medpage_ Exclusives_Active. Accessed August 21, 2023.
Turner v. Washington Medical Commission. Complaint for Injunctive and Declaratory Relief. Wash Sup Ct. Filed July 12, 2023. https://www.documentcloud.org/documents/23903002-complaint- physicians-v-wmc?responsive=1&title=1. Accessed August 21, 2023.
Brumfiel G. This Doctor Spread False Information About COVID. She Still Kept Her Medical License. NPR. September 14, 2021. https://www.npr.org/sections/health- shots/2021/09/14/1035915598/doctors-covid-misinformation-medical- license. Accessed August 21, 2023.
California State Legislature. AB-2098 Physicians and surgeons: unprofessional conduct. 2022. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202 120220AB2098. Accessed August 21, 2023.
Clark C. California Bill Barring Docs from Telling COVID Lies Signed into Law. MedPage Today. October 1, 2022. https://www.medpagetoday.com/special- reports/exclusives/101008?xid=nl_medpageexclusive_2022-10- 03&eun=g1359385d0r&utm_source=Sailthru&utm_medium=email&utm
_campaign=MPTExclusives_100322&utm_term=NL_Gen_Int_Medpage_ Exclusives_Active. Accessed August 21, 2023.
Myers SL. Is Spreading Medical Misinformation a Doctor’s Free Speech Right? NY Times. November 30, 2022.https://www.nytimes.com/2022/11/30/technology/medical- misinformation-covid-free-speech.html. Accessed August 21, 2023.
Myers SL. A Federal Court Blocks California’s New Medical Misinformation Law. NY Times. January 26, 2023. https://www.nytimes.com/2023/01/26/technology/federal-court-blocks- california-medical-misinformation-law.html. Accessed August 21, 2023.
McDonald v Lawson F.Supp.3d (2022).
Høeg v. Newsom, F.Supp.3d (2023).
Clark C. California Misinfo Law Is Destined for the Dustbin. 2023. https://www.medpagetoday.com/special-reports/features/106316. Accessed September 24, 2023.
General Assembly of the state of Missouri. House Bill 2149. 101st General Assembly. 2022. https://documents.house.mo.gov/billtracking/bills221/hlrbillspdf/4028H
.06T.pdf. Accessed September 24, 2023.
Latner AW. Missouri Law Prevents Pharmacists from Disputing Ivermectin Efficacy with Physicians. Pharmacy Learning Network. July 5, 2022.
https://www.hmpgloballearningnetwork.com/site/pln/commentary/miss
ouri-law-prevents-pharmacists-disputing-ivermectin-efficacy-physicians. Accessed September 24, 2023.
Weinberg T. Missouri Governor Signs Law Shielding Doctors Prescribing Ivermectin, Hydroxychloroquine. Missouri Independent. June 7, 2022. https://missouriindependent.com/briefs/missouri-governor-signs-law- shielding-doctors-prescribing-ivermectin-hydroxychloroquine/. Accessed September 24, 2023.
Stock v. Gray. Plaintiff Ashley Stock’s Verified Complaint for Declaratory and Injunctive Relief. Dist. Ct. W. Mo. https://hlli.org/wp- content/uploads/2022/07/Stock.1.Complaint.pdf. Accessed September 24, 2023.
Ohio Legislature. Enact COVID-19 Health Care Prof-Patient Relationship Protect. HB 631. 135th General Assembly. 2022. https://www.legislature.ohio.gov/legislation/134/hb631. Accessed September 24, 2023.
Walsh M. Ohio Bill Permitting Ivermectin, Alternative COVID-19 Drugs Gets Hearing. NBC4. November 22, 2022. https://www.nbc4i.com/news/local-news/ohio-bill-to-promote-use-of- ivermectin-alternative-covid-19-drugs-gets-first-hearing/. Accessed September 24, 2023.
Ollove M. States Weigh Shielding Doctors’ COVID Misinformation, Unproven Remedies. Stateline. April 6, 2022. https://stateline.org/2022/04/06/states-weigh-shielding-doctors-covid- misinformation-unproven-remedies/. Accessed September 24, 2023.
ND Senate passes bill shielding medical professionals who dispense ivermectin from career consequences. KX News. November 12, 2021. https://www.kxnet.com/news/state-news/nd-senate-passes-bill- shielding-medical-professionals-who-dispense-ivermectin-from-career- consequences/. Accessed September 24, 2023.
Farmer B. Medical Boards Pressured to Let It Slide When Doctors Spread Covid Misinformation. KFF Health News. February 15, 2022. https://kffhealthnews.org/news/article/medical-boards-pressured-to- let-it-slide-when-doctors-spread-covid-misinformation/. Accessed September 24, 2023.
Information for the Joint Government Operations Committee. House of Representatives, State of Tennessee. November 30, 2021. https://wpln.org/wp-content/uploads/sites/7/2022/02/21-11-30-TN- Board-of-Medical-Examiners-Information-Request.pdf. Accessed September 24, 2023.
MacPherson J. Citing Misinfo, North Dakota Health Agency Cuts Out Comments. AP News. October 26, 2021. https://apnews.com/article/coronavirus-pandemic-media-social-media- health-north-dakota-018dfb2f115ae4ee012a905f4e5aaf15. Accessed September 24, 2023.
Bader E. Maine Physician Who Prescribed Discredited COVID-19 Treatments Wanted to Make A ‘Spectacle’ Of A State Investigation. 18 Months Later, She Said She’s Succeeded. Maine Monitor. July 30, 2023. https://themainemonitor.org/maine-physician-who-prescribed- discredited-covid-19-treatments-wanted-to-make-a-spectacle-of-a- state-investigation-18-months-later-she-said-shes-succeeded/.Accessed September 24, 2023.
Brannon V. False Speech and the First Amendment: Constitutional Limits on Regulating Misinformation. Congressional Research Service. August 1, 2022. https://crsreports.congress.gov/product/pdf/IF/IF12180. Accessed August 21, 2023.
Marwitz KK. The pharmacist's active role in combating COVID-19 medication misinformation. J Am Pharm Assoc (2003). 2021;61(2):e71- e74. doi:10.1016/j.japh.2020.10.022
DISCLAIMER
The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.
Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.
Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.
Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course, or course material.
© RxCe.com LLC 2023: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.