User:Cajetan.Ndukwe/Cajetan Ndukwe

Cyber medicine and medical ethics: towards a moral justification

Ndukwe Cajetan Okechukwu

Abstract

In this paper, the morality of cyber medicine in the forms of the consultation sites, the e-pharmacy sites and the information giving sites is viewed via the ethical principles. I argue that for now the three forms of cyber medicine cannot be morally justified unless some checks and balances are put in place. Moreover, it is doubted if the ethical principles of autonomy, responsibility, privacy, trust and caring and a morally appropriate doctor-patient relationship are realizable in cyber medicine. However, cyber medicine has the potentials

of improving the modern healthcare given its technologised nature. Therefore, cyber medicine remains relevant.

Keywords: Cyber medicine, medical ethics, autonomy, responsibility, privacy, trust.

Introduction

Information technology has changed the modern healthcare. According to Bemmel, J.B. in Collste G. (Ed), (2000), healthcare today can no longer be practised without computers and electronic transportations. I argue that the idea is that cyber medicine remains a unique achievement of information technology and should be seen as such. At the same time, cyber medicine creates some moral problems that need to be addressed before it gets off hand. The ethical issues connected with cyber medicine become more disturbing when one realizes the amount of individuals seeking medical information via the net.Goran Collste in Ten Have A.M.J. (ed) (2002) maintained that there are about 15000 to 100000 health related sites in Great Britain and they have been visited by approximately 30 million people (Parker and Gray 2000). A Swedish survey showed that about 20% of all who viewed the internet had been looking for health related information (Garpenby and Husberg, 2000).

There are a number of reasons that may lead patients to the use of the internet in search of medical care. It acts as a second opinion or second doctor for desperate patients. Also, it gives insight into patient problems, as well as the drugs that could cure them. (Collste, G.2002).

But, I contend that medication via the internet raises a number of ethical problems. It is these ethical problems that I addressed in this paper. The paper is in these parts, the definition and classification of cyber medicine, the analysis of cyber medicine with a focus on ethical principles and other important relationship in health care, arguments for and against cyber medicine based on a number of ethical principles, and the conditions necessary for a morally acceptable cyber medicine, with critical evaluation and concluding remarks.

Cyber Medicine: Meaning and Types

For the purpose of this paper, I am going to define cyber medicine as all medications via the internet, whether in the form of doctor’s consultation or in the form of seeking medical information via an internet web site or the buying of drugs via an internet pharmacy. Hence, the consultation sites, the information giving sites and the e-pharmacy sites are the three different kinds of cyber medicine websites that elicit different ethical problems.

The consultation sites

These are sites that offer medical advice by the use of a doctor or a pharmacist. This is what Goran Collste (2002) called” the internet doctor”.

The Pharmacy Sites or Drug shops

These are sites that engage in the sale of Drugs. According to Mills, D. (www.grove.ufl.edu.:20/05/05), they are of two types, those that will only dispense medicine to consumers that have first obtained prescriptions from a doctor and submitted to them online and those that do not require a prescription from a doctor before they sell drugs to patients.

The Information Giving Sites

These are websites that give medical information about some sickness or drugs which patients log in and read up. These information giving sites may contain variety of information concerning various sicknesses and the ways of treating them. It may also contain healing claims.

Cyber medicine and ethical Principles

Beauchamp and Childress in their book Principles of Biomedical Ethics (5th edition,2001) outlined four ethical principles (pillars of contemporary biomedical ethics) namely: the principle of nonmaleficence, which is a norm of avoiding the causation of harm, the principle of beneficence which is a group of norms for providing benefits and balancing benefits against risks and costs, the principle of justice which is a group of norms for distributing benefits, risks and costs fairly, and the principle of respect for autonomy which is a norm of respecting the decision-making capacities of autonomous persons.

I will apply these ethical principles in my discussion with emphasis on respect for autonomy, responsibility, privacy, and trust and caring. I will also view the doctor-patient relationship as an important value in healthcare that aids the healing of patients.

Cyber medicine and Autonomy

Cyber medicine enhances the autonomy of patients because patients influence their cure. Interestingly, there are strong basic requirements that need to be fulfilled for the realization of the principle of autonomy. These include access to necessary information, alternatives from which the individual chooses from, and then the person in question must be competent.

On the consultation sites, I submit that the cyber doctor might be a quack, and the credentials might not be verifiable. Also pharmaceutical companies may sponsor some of the e-pharmacy sites for commercial purposes though they may be of high standard. A patient who based medical decisions on this information from the website may be deceived, resulting in more harm which counters the principle of nonmaleficience.

Responsibility in cyber medicine

According to Goran Collste (2002), a person P is responsible for the outcome O of an action  A when  P has intentionally caused  A in order to achieve O."P" who is responsible must be able to answer questions like; why did you do ‘‘A’’? Why did you want '' O’’? As a result of being responsible, if ‘‘O" is a bad outcome,  P can be blamed or punished. Responsibility can be moral, legal or professional.

Generally speaking there may not be enough information given on the net about a patients' sickness- in terms of up-to-date medical history, extensive information on physical examination, etc. Again, internet doctors are not sure that patients will follow adequately the recommendations that were given by them, which is expected to be for seen by the doctor, hence, the doctor’s responsibility for negative outcome. In cases of compensation, my argument is that the insurance company in a particular country the site is launched should pay because the laws of such country must have been followed by the site in question.

Then is it feasible to apply the professional responsibility to the cyber doctor? Of course, professional responsibility could be applied to the cyber doctor if he or she belongs to the World Medical Association but the problem I for see is how to determine the real identity of the cyber doctor and if he or she is a real medical practitioner or just a quack whose motive is just to make money and deceive people. There is an urgent need to fashion out ways of detecting the identities of the launchers and operators of cyber medicine websites. When this is done, it will go along way in solving the problem of responsibility in cyber medicine.

Privacy in cyber medicine

Privacy which is freedom from unsanctioned intrusion has been a nagging moral issue in information technology as well as its application to healthcare in particular. The underlying moral question is what amount of information about oneself can one reveal to others and with what condition and under what safe guards? There is no guarantee to patient's privacy especially with the consultation sites and e-pharmacy sites where the patients are required to fill in some questionnaire for medication to be giving.

Even on personal computers one's privacy is in no way secure especially from the prying eyes of the technician called to fix a personal computer, who is not under any professional rules in respect to confidentiality. Also there is no contract binding the cyber doctor not to reveal the medical data of patients. Privacy invasion and hacking have shown that information can be distorted on the net. To guard against misuse of medical data of patients with regard to privacy, various regulations have been put in place, e.g. the use of smart-like cards by patients. But it has been noticed that both the restrictive and the permissive styles of data protection are problematic. There can be denial of vital information to doctors when needed, and tendency of confidentiality breaching. Another danger is that the stored medical records of the patients may be changed by computer wizards (Barroso, P.in Collste, G. (Ed) 2000).

But cyber medicine has great potentials of improving health care generally provided more

checks and balances are put in place so as to protect the privacy of patients. This is a

challenge to computer engineers and all stakeholders in the information technology industry.

Trust and caring in cyber medicine

The World Medical Association Declaration of Helsinki number two states that it is the duty of the physician to promote and safeguard the health of the people and that his or her knowledge and conscience are dedicated to the fulfilment of this duty. On this lies the basis for the principle of trust and caring in healthcare which could also be seen as implying the principles of beneficence and nonmaleficence. Physicians owe it as a duty by this declaration to care for patients and on this basis patients have trust on medical personnel. This trust presupposes that the medical personnel are reliable given the facts at hand. There must of necessity be an encounter between doctors and patients.

I doubt if the cyber doctor will be breaching the principle of care when he or she fails to perform in the same manner that a reasonable and careful physician would in the similar situation. Most importantly, there are no criteria for determining a breach to this principle

of trust and caring .Also there are no body and sanctions to prosecute those cyber doctors who will go against this principle of care and trust.

However, cyber medicine seems to have potentials of improving on the principle of care and trust in healthcare. I argue this way because  the sophisticated nature of the internet often times make patients to presume that cyber doctors are more competent than conventional medical doctors; that the information gotten from the information giving sites are more reliable than the one gotten from ordinary hospital because the launchers of the internet are experts; that the drugs bought from the e-pharmacy sites are more reliable than the one bought from ordinary pharmacy because the e-pharmacy are more sophisticated than the ordinary pharmacy. Patients presume because in this jet age it is believed that the more technologised a thing is the more reliable it is.

For patients who think in this way, cyber medicine is more caring than conventional medicine. But this potentiality of improving the principle of trust and care in healthcare urges us urgently to set up a body and the criteria for validating the various cyber medicine website.

The doctor-patient relationship

The doctor-patient relationship though not an ethical principle, is an important relation in healthcare that goes a long way in helping the healing of patients. There are doubts if doctor-patient relationship exists in cyber medicine. For Warner

V.Slack, (2001) this new doctor-patient relationship which exists in cyber medicine is for good.

As Collste, G (2000) noted, there are four different kinds of clinical interaction that exist

between the patient and the doctor in a typical clinical experience, namely: the engineering

model, the healing relationship, the trust or fidelity relationship, and the contract model.

It is doubted whether these can be established in cyber medicine in its various forms. In reality, the medical advise, information and drugs are collected from a distance. Even though there may be interactions, it could not be equated, or better than face-to-face encounter. It is because of this that the American Medical Association (www.ama-assn.org,04/06/05) stated emphatically that it is doubted if any reasonable doctor-patient relationship do exist on the net.

Stakeholders in healthcare know that doctor-patient relationship presupposes a contract between the doctor and the patient. I doubt for now whether this type of contract could exist between the patient and the various forms of cyber medicine sites. As a result of this, the doctor – patient relationship is not easily constructible in cyber medicine. Hence, cyber medicine should be viewed as a potential threat to the moral integrity of the physician – patient relationship and the most basic goal of medicine- the advancement of patient health

and wellbeing. It interferes with the development of physician compassion and patient trust (Bauer, K.2004). The nature and quality of doctor-patient relationship existing in cyber medicine is questionable.

Arguments for and against cyber medicine

Various arguments have been developed for and against cyber medicine. They include:

Bridging of gap in healthcare

One argument to appreciate cyber medicine is that it bridges the gap in healthcare between the highly developed countries with adequate healthcare facilities and the developing countries with inadequate healthcare facilities. Recall that the ethical principle of justice states that healthcare resources should be allocated according to a just standard for the benefit of all. (Beauchamp and Childress, 2001). For instance, with cyber medicine a patient in Umuduru Mbieri, Imo state, Nigeria can read up medical information from a web site that was launched in Tolentino, Italy. The patient can also seek a medical advice with a cyber doctor in Texas, USA as well as buy a drug from an e-pharmacy that is based in Sweden. The case in Africa is that burgeoning population and a chronic shortage of doctors and nurses are throwing healthcare into crisis… (African Business, 2004).

However, the attendant problems include, low access to internet by both patients and doctors; information monitoring and application isn’t possible, correction of mistakes is not easy, etc. According to a report monitored in a Nigerian teaching hospital and Tanzanian medical school, more than half of the students are not computer literate (Ajuwon,A.G; Mirian S. et al. in www.pubmedcentral.gov.: 30/04/05)

Following from this report, mistake by patients is beyond argument if they decide to seek medical information via the net, hence the likelihood of worsened sickness. It is not morally sound by the ethical principle of beneficence that a patient went for healing but instead the sickness worsened. Therefore, it is doubted for now if the argument of bridging the gap in healthcare holds water rather, emphasis should be put on improving computer literacy in the developing nations.

Convenience

Focusing primarily on convenience, proponents of cyber medicine are of the opinion that there are some limitations of orthodox medicine which cyber medicine has the potentials of solving. These limitations are; proximity problem between patients and doctors, difficulties in reaching out to doctors at odd hours, queuing to see doctors, doctor’s unavailability round the clock etc. Cyber medicine takes care of these limitations by providing answers to health problems at any hour, direct communication with a doctor in any part of the globe, buying drugs online with varying delivery options and so on.

Despite being more convenient than conventional medicine, when the question of morality comes in which is the basis of my argument, conventional medicine is preferred than cyber medicine because some cyber medical sites are anonymous.

Greater access to information

This argument supports cyber medicine based on the fact that patients have quicker access to information about their diseases and sicknesses, how to cure them, preventive measures and the most recent drugs that are produced about them. Even though similar information could be gotten in health centres it isn’t in the same degree and precision.

The danger is that patients use these information for self-medication, which is contrary to nonmaleficence because it can aggravate patient’s condition. However, I am of the opinion that these information gathered from the web sites should act as a means of enhancing the personal interaction with one’s doctor.

Confidentiality

Sufferers of some diseases and sicknesses like Acquired Immune Deficiency Syndrome (AIDS) in the developing countries do not feel free to approach a conventional doctor to receive treatment. This may be as a result of shame. Some of these patients feel that when they report to the government hospitals or to conventional doctors that a terminal injection will be giving to them and they will die gradually. They prefer dying in silence than visiting a conventional doctor. But the same patients feel free to approach cyber doctors via the internet because the cyber doctors do not know their identity.

With this confidentiality, proponents of this argument maintain that in cyber medicine more information and anonymity of a patient is guaranteed. (Calabretta, N.:15/05/05).In spite of this argument, cyber medicine lacks doctor’s physical and experimental examinations, cross questioning and touching, adequate medical history and psychological healing of face-to-face patient-doctor interaction.

In medicine, some drugs go with age and certain situations of sickness require certain drugs. It is only a trained and qualified medical doctor that can dictate these situations and the appropriate drugs to be dispensed. Even, there are times that certain patients will be allergic to some drugs. Doctors get to know their patients' problems by cross-questioning, physical and experimental examinations. But all these are not possible with cyber medicine.

With all these I doubt for now if cyber medicine will give adequate and the required healing to patients who make use of it though it is more confidential than conventional medicine. Hence it goes against the ethical principles of trust and caring, beneficence and nonmaleficence. Furthermore, there is also confidentiality in conventional medicine because medical doctors take oath of secrecy not to reveal medical information about their patients.

Quality of healthcare

According to the American Medical Association (www.ama-assn.org,04/06/05), the quality of healthcare that is giving in the cyber space is below standard. For the fact that there is a distance between the doctor and the patient, the information seekers and the information, the patient and the e-pharmacy, there may be over diagnoses or under diagnoses. Given all these, I doubt the quality of the medication given over the net.

On the contrary, this argument could be opposed because with the amount of information on healthcare that is on the net and the easy accessibility; healthcare will improve via the net than in conventional medicine, take for example the association of patients suffering from the same sicknesses using chat rooms. Here the patients advise and encourage themselves on the possibility of their healing, leading to psychological healing and information on the best doctor to approach. Also, doctors can update their knowledge about recent drugs and cure about a particular disease via the net thereby improving the quality of healthcare given to their patients. However, I submit that, cyber medicine is more effective for patients that have formerly seen a doctor and are aware of their sickness.

Potentiality of fraud

Due to the anonymous nature of the internet, there can be the potentiality of fraud in cyber medicine. The fraud can be two sides; on the side of the patients and on the side of the internet website. The fraud is heightened because of the following; patients and drug addicts could buy controlled substances via e-pharmacy, cyber doctor’s professional competence is not assured, inability to discern a cyber doctor or healthcare website that is just a money spinning machine rather than offering genuine service to patients, no assurance about cyber doctor’s certificate and school attended, and no evidence of license from a medical association to practice. All these go a long way in showing that there is a great potentiality of fraud in cyber medicine, which is absolutely against the ethical principle of beneficence and nonmaleficence.Therefore; cyber medicine moral justification is based on the check of fraud.

The illegal drug sales

The e-pharmacy sites are criticised because of the sales of drugs without control over the net. There are policies guiding sales of drugs in various countries. In Sweden, for example certain drugs cannot be given to a person unless on doctors prescription. In Nigeria, drugs have to reach certain (NAFDAC) standards before the government agrees that it should be sold to the public. There are also policies guiding the establishment of pharmaceutical shops. For instance people with no formal knowledge of medicine are not allowed to operate pharmaceutical shops.

There are similar bodies to NAFDAC in various countries of the world; the existence of cyber medicine makes it difficult for such bodies to control the sales of sub-standard and unapproved drugs over the net. The drug shops keep doctors aside when drugs are dispensed, whereas, doctors by qualification are entitled to give prescription and dosage. The conflict is that some patients may want a particular drug due to some reasons, for instance sleeping drugs but the drugs may not be good for their health. These patients satisfy their desires via internet pharmacy, contrary to ethical principles of beneficence and nonmaleficence. Therefore, I argue that the drug shops and cyber medicine generally are potential threats to healthcare. But, cyber medicine has made it possible for people to buy certain drugs that are not available in their own country or state from other countries or states. However, the worry is that drugs bought on the net can lead to drug abuse.

Conditions for a morally acceptable cyber medicine

Cyber medicine is a moral problem because of the various ethical problems that have surrounded it. One option will be to outlaw cyber medicine because of the ethical implications that follow its practice. A second option will be to allow cyber medicine to operate without any regulation since it’s a unique achievement of information technology. But allowing cyber medicine to develop without any regulation will lead to so many complications in healthcare. But a third accepted opinion (to me) will be to accept cyber medicine with some regulations to checkmate its excesses.

Various medical and health associations have developed some conditions for a morally justified cyber medicine. I limit myself to the one provided by Health on the Net Foundation (HON) as a guide because it is non governmental and non profit oriented organization. Again, giving the integrity and status of the people that came together to form it, the information contained in their website is reliable. The conditions are:

Authority

According to HON Foundation authority as a principle for the acceptability of cyber medicine maintains that any medical or healthcare information hosted on the net must be given by medically trained and qualified healthcare professionals. If there is any need for organizations that are not in the healthcare arena to launch a website on cyber medicine, there must be a clear cut statement to indicate this. This is very necessary and practicable.

Complementarity

Complementarity as noted by HON Foundation says that all website must provide information that should act as help or improvement towards the existing relationship between a patient and the doctor hence should be complementary to orthodox medicine. (www.hon.ch.:06/06/05).One way of doing this is by distinguishing the true and false websites and using a seal to mark them. Though this may be difficult as a result of the sophisticated nature of the internet, but it is better started than never.

Confidentiality

For HON Foundation confidentiality maintains that all medical data relating to a patient or visitors to a cyber medicine website must be treated with utmost secrecy. This principle is made to solve the problem of privacy. The website launchers are bound to obey the legal requirements of medical information privacy that is obtainable in the country and state that the website is located. Every website must of necessity describe in details how it treats the medical data that visitors to the website present. This principle is necessary due to the anonymous nature of the internet but the problem is how to enforce this and the agencies that are going to do this.

Attribution

Attribution as a condition for an acceptable cyber medicine according to HON Foundation says that the information contained in the cyber medicine websites should contain date of publication, the origin of the quotations, and the update of all the information. In the case of clinical pages, the dates of creation and the last modification should of necessity be included in the information that should be given (www.hon.ch.:06/06/05). But one may ask of the feasibility of this, given the nature of the cyber space. I argue that this is possible. Moreover, stakeholders in medicine and healthcare generally should have a way of ensuring that reputable websites are only allowed on the internet. One way of doing this is by having an editorial board and having a seal to distinguish the approved and non approved cyber medicine websites.

Justifiability

For HON Foundation, justifiability implies that all information in the cyber medicine websites will be given with all necessary precaution that were laid down in the principle of attribution. (Ibid). Hence, any claims relating to the benefits or performance of a specific treatment, commercial product or service must of necessity be supported by appropriate, balanced evidence. This is because some websites make unproven claims which can deceive visitors to the website. This principle will reduce the potentiality of fraud in cyber medicine. With much caution this could be achieved.

Transparency of Authorship

Transparency of authorship according to HON Foundation simply means that cyber medicine in its three different forms should give these information; contact address, valid phone number and e-mail address, in a way that is very clear because most websites prefer being anonymous. (www.hon.ch.:06/06/05). One way of ensuring the transparency of authorship is for the world medical association to provide a website in which people will know that the information are accurate and valid. One may argue that this will eradicate the false claims and other ethical problems that occur in cyber medicine but in reality this is not the case. In this age of information technology, it is possible for quacks to launch internet websites with the names of renowned organisations. I argue that healthcare associations developing their own websites will go along way in checking the abuses that are in cyber medicine provided there are ways of distinguishing the correct and incorrect websites.

Transparency of sponsorship

According to HON Foundation, this principle maintains that, the sponsors of a particular website must be vividly shown. (Ibid). This is because some medical companies or groups sponsor some cyber medicine websites just for the promotion of their products (some are below standards) and for their own personal aggrandisement. The various cyber medicine websites should of necessity include statements showing their sources of funding. This will help to know the people that are behind the various cyber medicine websites and the various agenda that they have in mind.

But how can we know when the cyber medicine websites are telling us the truth about their source of funding? However, I argue that cyber medicine websites indicating their sources of funding will go a long way in bringing a morally acceptable cyber medicine, provided the HON Foundation will have a way of detecting when the launchers of the cyber medicine websites are telling the truth or lies about their sources of funds.

Honesty in advertising and editorial policy

This principle according to HON Foundation states that, it should be clearly stated at the website whether advertising is the source of funding of a particular website or not. (www.hon.ch.:06/06/05). All cyber medicine websites should of necessity display in their home pages the advertisement policy that they adopt. Also, cyber medicine websites that do not display advertisements should make a direct statement indicating source of funding. This is practicable though difficult.

Conclusion

I have argued that, cyber medicine in the forms of the information giving sites, the consultation sites and the e-pharmacy sites cannot be morally justified for now because of the ethical problems that have surrounded it. However, cyber medicine remains a prospect for the healthcare industry in the future. There is need to consider critically the ethical principles in the use of cyber medicine.Moreover,the reality of cyber medicine is a challenge to the World Medical Association and other bodies in the healthcare arena to urgently fashion out ways of distinguishing the authentic and quack cyber medicine websites. The criteria established by HON Foundation are worthy of note. Above all, there is the need for proper orientation (i.e. sensitization and education) of the internet launchers and visitors about the end purpose of every medicine, which is the healing of the patient. So, for its moral implications lets all be involved.

Acknowledgements

I thank Professor Goran Collste, Emmanuel Animasaun and colleagues in the master’s programme in applied ethics, 2004/05, Linköpings University Sweden, for some critical comments that led to the realization of this paper.

References

Ajuwon. A., Computer and Internet Use by first year Clinical and Nursing Students in a Nigerian Teaching Hospital, in: www.pubmedcentral.gov.accessed 30.04.2005.

Bauer, K., 2004. Cyber medicine and the moral integrity of the Physician – Patient relation, in: Ethics and Information Technology, 6, Kluwer Academic Publishers.

Beauchamp, T.L. and Childress, J. F., 2001. Principles of Biomedical Ethics (5th Ed), N.Y: Oxford University Press.

Calabretta, N., Consumer-driven patient Centred healthcare, in: www.pubmedcentral.

Gov accessed 01.05.2005.

Collste, G., (Ed). 2000, Ethics in the Age of Information Technology. Studies in Applied Ethics series, vol. 7. Linköpings: bpt- TRYCK AB.

Collste, G., 2002.The Internet Doctor and Medical Ethics, in: Ten Have A.M.J (Ed),

Medicine, Healthcare and Philosophy vol 5, Kluwer Academic Publishers

Cyber medicine, in: www.ama-assn.org, accessed 04.06.2005.

Mills, D., Cyber Medicine: The Benefits and Risks of Purchasing Drugs Over

the Internet, in: http// www.ufl.edu, accessed 20.05.2005

Owen, J. D., ET. Al., Information-Seeking Behaviour, in: www.pubmedcentral.gov, accessed 15.03.2005.

Paris, J.J., 2001. Ethical Issues in Cyber medicine in: online America magazine, Vol. 184, No.4. accessed 08.06.2005.

Slack, V. W., 2001.Cyber medicine: How Computing Empowers Doctors and Patients for Better Healthcare, (revised and updated edition), Boston: John Wiley and Sons Inc.

Ten Have A.M.J., 2002. Editorial in Medicine, Healthcare and Philosophy vol 5,

Kluwer Academic Publishers.

www.hon.ch/Honcode/guidelines/guidelines.html accessed 06.06.2005.

Www. web dictionary .Com. accessed 30.04.2005.