A sensible use of the various telemedical resources to enhance the common welfare implies a sound philosophical consideration with regard to the ethical consequences of the new technological developments in health care. Dr. Koen Raes, professor at the University of Ghent, highlighted the most critical and moral aspects in telesurgery and telediagnostics at the International Symposium on Telemedicine, last October in Brussels. His final conclusions can be summarised in the general creed: patients before technology. A not so commonplace statement as one perhaps might be inclined to think...
Telemedicine has to be seen as an exercise in medicine rather than in electronics, as Professor Raes points out. In fact, there are two main moral categories, health care providers who apply telesurgery and telediagnostics, should take in account. First, physicians have to strive for a just system of health care delivery and second, the quality of care for particular patients should form their highest ambition. A righteous approach towards care taking includes that the future telemedical society should contribute to factors such as cost-effectiveness; efficiency and quality as well as accessibility. As for the quality of care, this applies to both the technical issues of teleguided surgical intervention and the physical, psychological and moral comfort of the patient.
Extreme caution towards security trespassing is no luxury if we consider the possibilities for fraud, malfeasance and abuse, the new technologies might encounter. An equally serious danger constitutes the so-called MASH-syndrome. Raes here alludes to the potential for negligence, detachment, dehumanisation and cynicism. The more telemedicine contributes to a greater health security for soldiers in combat for instance, the lesser the inhibition may become to expose them to greater risks. The cool arrogance which assumes to have everything under control might end up in a permanent attitude of moral hazard.
One of the main aspects in telemedicine is the technological reduction of geographical distance. Remote diagnostics and telesurgery are aiming at the highest level of preciseness and accuracy but can this really be achieved? On top of this, Raes calls attention to the issue of how to attribute moral responsibility to the various parties involved: the distant physician, the local health provider, the designer of the telemedical resource and the patient. In any case, the patient's rights including the requirement of informed consent, should by all means be respected. Yet, why should telemedicine not be capable of precisely strengthening for example the rights to a second opinion or to the most effective technological treatment?
Transmission of medical information constitutes another defiant challenge concerning the protection of the patient's privacy, the confidentiality of data and the professional secret of physicians. Raes not in the least doubts the tremendous advantages of a computerised patient medical data-file and welcomes the introduction of electronic medical expert and communication systems. It enables the physician while in real contact with the patient, to feel at ease since he is supported by a well organised database but he can in no way be obliged to effectively consult these files. To what extend, on the contrary, are patients and third parties allowed to have access to the files? Legislation urgently has to be adapted to these new developments to protect delicate information from falling into wrong hands.
Problems like the concentration and scarcity of medical experts are met by the introduction of the telemedical society but Raes warns against the possibility that physicians might even become more scarce and less available in the long run under the influence of integrated managed care systems. Far from rejecting the obvious benefits, Koen Raes finally has to admit the difficulty to assess the future consequences of telediagnostics and telesurgery. Nevertheless, the contact between patient and physician, based on mutual trust, confidence and understanding should always be kept in mind as the highest ethical value in medicine. Telemedicine therefore has to fully concentrate on improving the communication between them, even though the distances divide them. For further details on the ethical aspects of telemedicine, we refer to the Symposium web site.