The Ethical Implications of Telemedicine

The Ethical Implications of Telemedicine
June 26, 2020 No Comments Brave New World Apara Sharma

From the Bedside to the Web-Side: Is Telemedicine Infringing on the Doctor-Patient Relationship?

By Georgia Post-Lipnick

Telemedicine concept. Doctor with a stethoscope on the computer laptop screen (Photo by JYPIX )

Have you ever had a virtual doctor’s appointment? Whether you knew it or not, you took part in using telemedicine, remote healthcare by means of technology. Telemedicine is making healthcare more accessible, affordable, and convenient for both the patients and the providers. But, telemedicine is also drastically altering the doctor-patient relationship. Now more than ever, telemedicine is taking over our healthcare systems in the United States. This prompts us to take a step back and ask ourselves whether the use of telemedicine is ethical. This paper will examine telemedicine through an ethical lense using the framework of utilitarianism to discuss the increase of accessibility to healthcare and the change in the traditional doctor-patient relationship. 

Table of Contents


Introduction

As technology continues to advance at a rapid pace, change is inevitable. Today, we cannot imagine our lives without a car, a dishwasher, a washing machine, and a phone to carry around. A more recent addition of technology into our society is telemedicine, remote healthcare by means of technology. Created to make a patient’s experience more accessible, convenient, and affordable, telemedicine has been implemented in more than half of all U.S. hospitals. As I will discuss throughout this paper, there is no question that telemedicine is improving accessibility to healthcare while reducing costs, but at what expense? Empathy and effectiveness can be lost when doctors are treating patients remotely. Doctors are diagnosing patients without ever physically examining them and it is likely a patient will be talking to a different doctor every single time they have an appointment. The fundamental physical exam and the “laying on of the hands” is no longer present with the use of telemedicine. These major differences bring up questions about whether the use of telemedicine is ethical and challenge our traditional model of the doctor-patient relationship. 

During the coronavirus pandemic, there has been a dramatic increase in the use of telemedicine. All of a sudden, we have been able to see the clear benefits and advantages of telemedicine. Doctors have been able to see their patients without the risk of catching or spreading the virus and vise versa. Doctors have also been able to track a patient’s symptoms remotely to try and limit a trip to the hospital. 

 “Telehealth can be a force multiplier that helps protect health workers and extends their reach, and should absolutely be seized upon.”

– Eric Perakslis, a Rubenstein Fellow at Duke University, told STAT News. 

Even though most people have heard of the term telemedicine, strong supporters of telemedicine view its use in the United States as surprisingly low. It is evident that the industry has much more potential. Advocates of telemedicine have started to wonder whether this surge in telemedicine is what it will take for this advancement to finally reach its full potential. However, this growth in telemedicine also pushes us to examine this advancement from an ethical perspective and consider all the ramifications before it gets beyond our control. 

This paper will examine the use of telemedicine through the utilitarianism framework analyzing if the increased access justifies the change in the doctor-patient relationship. I will use the values of accessibility and empathy to consider the ethical issues at hand. Does the increase in accessibility outweigh the loss of the in-person doctor-patient interaction? Ultimately, to what extent is telemedicine an ethical approach to healthcare?


Background Information

First, it is essential to understand what telemedicine is. Most technically, telemedicine translates to “at a distance medicine” (Craig). Broadly it can be defined as, “The delivery of health and the exchange of health-care information across distances” (Craig). 

“Telemedicine is the remote delivery of health care services and clinical information using telecommunications technology.”

-The American Telemedicine Association

There are other terms related to telemedicine that are important to distinguish between. While some organizations have differentiated the terms telemedicine and telehealth, the American Telemedicine Association uses them interchangeably on their website. Frequently however, telehealth refers to a broader scope of remote healthcare with the aid of technology. Terms like telecare or telemonitoring refer to more specific branches of telehealth. 

Telemedicine began to take shape in 1960, when the Nebraska Psychiatric Institute in Omaha and the Norfolk State Hospital implemented the first ever video link that could provide medical care between the two hospitals (112 miles away from each other).  Also emerging in the 1960s was NASA’s telemedicine program, where doctors at NASA worked on ways to provide healthcare to astronauts in space. While steps like these took place, general technology was advancing. Television was being broadcast in color, and the first form of video chatting technology (the picturephone) was invented.

In 1967, the first telehealth station was created. It connected a medical station of paraprofessionals at the Boston Logan Airport to physicians at the Massachusetts General Hospital 2.7 miles away.

Throughout the 1970s, telemedicine expanded in the US through funding and research. Notably, the programs worked to improve healthcare in rural areas. The invention of the internet helped move things along and the American Telemedicine Association was established in 1993. Insurers began paying for telemedicine for patients who lived in rural areas. Video chatting applications like Skype became more popular, making it even easier for people to connect remotely. In 2010, as hospitals looked for ways to reduce cost and improve care, telemedicine continued to expand at a fast rate (eVisit).

Telemedicine can take many different forms and therefore can be classified into several categories. There are two criteria to be addressed when classifying telemedicine. First, we must think about the type of interaction between the client and the expert. Is it asynchronous or synchronous? An asynchronous interaction is utilizing a branch of telemedicine called store-and-forward. This consists of pre-recorded information from a client being sent to the expert. Most commonly this is through a system like email (Craig). A frequent example of this is in the field of teleradiology, where scans are sent from a patient to their remote doctor to analyze and come up with the best steps for treatment. A synchronous interaction is a real time conversation usually through a video conference (Craig). This is the type of telemedicine I will be focusing on because it affects the doctor-patient interaction most prominently. 

Secondly, we must identify the type of information being transmitted. Data, text, and images fall into one category. This is because charts, writing, and pictures are usually sent asynchronously without a live interaction or conversation needed. Video and audio fall into the second category because they lend themselves to a synchronous connection. To summarize, all telemedicine can be categorized if we think about the type of interaction as well as the type of information being transmitted. 


Telemedicine Today

In 2017, 76% of US hospitals were using telemedicine in some shape or form (AHA Fact Sheet). This varies from telemedicine in emergency trauma centers to check ups with a dermatologist. In addition to the variety of reasons for using telemedicine, each instance of telemedicine brings up different ethical implications and considerations. 

Situated in Sioux Falls, South Dakota, lies an unusual sort of “emergency room” where remote doctors sit in front of huge screens and direct nurses and physician assistants who are treating their in-person patients. This remote emergency room reaches about 180 hospitals across the country. Doctors are able to view the patient as well as several monitors that show the patient’s heart rate, oxygen level, etc. Additionally, these remote doctors are able to see different parts of the patient’s body, even down a patient’s throat (for instructing procedures such as an intubation). As the gap widens between healthcare in rural and urban hospitals, a remote emergency room such as this one reaching rural hospitals all over the country, is definitely in high demand.

This “virtual hospital” helps with an average of 300 cardiac episodes, 200 tramatic injuries, 80 overdoses, and 25 burns each month!

Doctors are able to help patients in an extremely timely manner as each new call comes in through a monitor. This is important because in an emergency room, time is everything and could be the difference between life and death (Saslow).

But, there are some points that call into question whether the use of telemedicine is the best solution to accessing better health care in this situation. For example, Dr. Skow, a remote doctor working in this emergency room recalls struggling to lead a group of nurses on his screen through an intubation of a patient. He notes that performing an intubation like that one, was a procedure he could do in his sleep. In contrast, not one of these nurses could effectively perform the procedure even with all his help and instructions. (Saslow). In addition, when a doctor is giving instructions remotely to a clinician at the bedside of a patient, questions arise around responsibility. Who is responsible for the patient? If something were to go wrong, is the remote doctor responsible or are the in-person nurses responsibile? Furthermore, hospitals are having nurses and physician assistants carry out tasks that they do not generally perform, such as intubations. Are we putting an unfair burden on these professionals by expecting them to successfully perform procedures without adequate training?  

This raises questions about whether rural hospitals should be incentivizing more qualified doctors to work for them, instead of turning to telemedicine. Should we continue to utilize this remote emergency room helping hundreds of patients each month, or should we take a different route to help close the gap between healthcare in urban and rural areas? 

Another example of telemedicine is a machine called the RP-Vita that roams around hospital hallways and into patients’ rooms as if it is a doctor. This robot is a pole-like figure with wheels on the bottom and a screen on the top showing a doctor’s face on a live video camera. As it makes its way around to visit patients, in-person nurses can enhance its function by using its connected stethoscope and other medical devices with the patient. The information collected from the devices is relayed back to the doctor on the screen who can then interact with the patient remotely. 

For a third example, Memorial Sloan Kettering Cancer Center has implemented telemedicine into their clinics throughout New York and New Jersey, as this technology allows worried cancer patients to quickly schedule preoperative and postoperative appointments. In speaking with Dr. Shah, an interventional radiologist who oversees MSKCC’s telemedicine program, he explained to me the ins and outs of their program. When patients want to be seen quickly, MSKCC is able to match the patient demand with available doctors, even if they are located far away. Newly diagnosed patients with cancer are especially anxious to schedule a preliminary  appointment so they can proceed with their treatment as expeditiously as possible. Patients are always given the choice whether to have an in-person visit or one through a live video call, knowing that telemedicine could be a quicker alternative to booking a traditional appointment. 

The visit itself looks like this. Patients will enter the “telemed” room when coming for an appointment and a secretary will run the machine to connect with the remote doctor. From there, the doctor is able to take the necessary measures to review a patient’s charts and examine the patient through the screen. In most cases, patients can be cleared for their operation and/or have their questions and concerns answered. 

This system at MSKCC made me think about whether telemedicine is suitable for cancer patients. Unlike many other reasons for using telemedicine, cancer is a serious one. On one hand, some cancer patients are fragile, and need all the in-person support they can get. On the other hand, some cancer patients want to go on with their lives, or some might be immunocompromised. Telemedicine can be a beneficial tool in order to make their appointments more safe, convenient, or timely. But as I will soon discuss, is it ethical to treat vulnerable patients in a way that might be overlooking how serious their sickness is?

Telemedicine encompasses a large spectrum. The interaction could be between a doctor and a nurse, a nurse and a patient, a doctor and a patient, and several other combinations. Cases range in severity and countless forms of technology are used. Though many people might picture patients lounging on their couch on a video call with their doctor through their smartphone, telemedicine stretches far beyond just that. With each situation, there are new questions and components to consider. How do doctors and patients feel about telemedicine? Are there financial implications to consider when using telemedicine? Are there regulations in the United States that might hold us back from using telemedicine? The roles of these stakeholders and organizations must be considered.


Current Attitudes and Legal Policies Concerning Telemedicine

Shown by statistics, it is clear that telemedicine shortens travel time, appointment time spent waiting, and saves money. These positive changes affect many stakeholders, but also pull into question all the possible consequences. The average telemedicine visit takes between 13-15 minutes (American Well), whereas an in-person visit takes an average of 2 hours (AJMC). This seems like a huge difference and you might be questioning if a 13-15 minute visit is long enough, but if you think about how much time you spend in person actually being examined by your doctor, it most likely ends up being closer to that duration. Furthermore, the average wait for a new patient’s physician appointment is 24 days while a telemedicine’s average wait time is 20 minutes (Merrit Hawkins).

Telemedicine has the potential to be cost effective for the patient and the provider. For the patient, the average estimated cost of a telemedicine appointment is $40 to $50 whereas an in-person visit for acute care was estimated between $136 and $176 (Yamamoto). For hospitals, the US national average of savings with the use of telemedicine is estimated at $20,841 per medical facility (Urac). Generally, telemedicine is profitable because it offers better care at lower costs, as well as limiting unnecessary hospital admissions. 

 “Creating the best possible experience for patients, in terms of both price and convenience, ensures that they remain loyal to your organization and return for any subsequent healthcare needs.”  

-URAC Staff Member

Even though telemedicine is a less expensive option, there are some additional hospital expenses that come with the use of telemedicine. First of all, the technology itself (monitors, cameras, etc.) serves as an upfront cost. For example, the RP-Vita is priced at about $6000 per month. Secondly, money is invested in training purposes. Doctors, nurses, support staff, insurers, and lawyers all have to be taught how to properly use telemedicine (as it will come into play in all their jobs). Lastly, a team of employees to oversee and regulate the project is also necessary.

As telemedicine becomes increasingly more popular, it has also proven to be effective and patient satisfaction is high. 79% of patients said telemedicine was more convienient in terms of scheduling, 83% found that the care was either as good or better than an in-person visit, and 66% felt a personal connection with their telemedicine doctor (Massachusetts General Hospital). While this number is the majority, it calls into question whether the number of patients that feel a personal connection should or could be higher. While we may not have a specific percentage for how many patients feel a personal connection with their in-person doctor to compare with 66%, I feel that seeing a doctor in person would only increase one’s connection. Later in my paper, I will expand upon what factors contribute to the altered doctor-patient relationship and in what ways these factors enhance and/or hurt the bond between a patient and their doctor. Another point to consider is, in what ways is patient satisfaction being measured? A patient might have gotten their questions answered and their medications prescribed, but how can we measure the connection they felt with their doctor? How can a patient sense if they would have felt more fulfilled talking to an in-person doctor? Is it ethical to encourage people to use telemedicine when we do not truly know the effects on the patient? It might be worth looking into the emotional effects of a telemedicine appointment compared with an in-person one. In conclusion, even though percentages show that patients are happy with telemedicine, it is difficult to understand if psychologically patients would be better off with an in-person connection.

Another very important stakeholder is the doctor. Most doctors have expressed willingness to use telemedicine and have found it to be useful and beneficial for them as well (eVisit). I will elaborate on a few doctor’s perspectives later on in my paper, explaining that they experience comfort from working at home or enjoying exotic vacations with their families while always adjusting their hours as needed. This is important because doctors notoriously work long and late hours with little time off. They face sleep deprivation and little time at home with their families. Telemedicine has the potential to help to alleviate these problems. 

On the other hand, telemedicine is redefining what it means to be a doctor. Some people want to become doctors because of the hands-on connection with their patients, but others likely struggle from the emotional toll it will take on them. When doctors see their patients in pain, struggling, getting worse, or pass away, this can be hard to witness. On the other hand, doctors also see their patient’s symptoms alleviated, get better, or go home from the hospital. Telemedicine has the power to desensitize many of these emotions that doctors feel in their daily work life. At the end of the day, each doctor will have a different opinion towards telemedicine, but it is necessary that we value each of them as an important stakeholder and hear their perspectives. 

Once a patient or doctor has decided that they would like to use telemedicine, how easy is it to get insurance coverage for a telemedicine appointment? In a recent study, 96% of large insurance companies said they provided telehealth insurance in states where it was allowed (NGBH). A study conducted by America’s Health Insurance Plans, found that telemedicine is actually quite attractive for insurance companies to pay for. The report was summarized with this statement.

“Telehealth has already proven effective to help patients with chronic care needs, rural patients, patients with mobility issues, and more. These tools have been documented to reduce hospital readmissions and help with population health management initiatives. These are all reasons why insurance providers are offering virtual healthcare to their insured patients and why the AHIP expects this trend will continue and increase in the future.” 

-Griewe

To name just one example of telemedicine benefitting insurance companies, a $50 telemedicine visit to diagnose an ear infection is much cheaper than a $600 trip to an emergency department (Herman). But some companies have yet to join this upward trend, possibly restricting their customers from telemedicine. Insurance in rural areas is actually more accessible. Because there is a greater need for telemedicine, insurance companies are quicker to adapt to telemedicine in areas where it is more of a necessity than a want. Telemedicine companies hope for greater insurance coverage in areas that are not necessarily rural. 

Dr. Shah noted that for his program, most insurance companies will not cover telemedicine visits from home. For his team of doctors, they are conducted on an experimental basis. This is most likely the case because it is harder to monitor what goes on during a video call from someone’s home as opposed to a healthcare facility. Overall, insurance is not the largest barrier to telemedicine, but it could definitely stand in the way of the telemedicine industry expanding.

Another problem that arises with telemedicine is the difference in state regulations (Kaplan). In order for a doctor to make a video call to another state, the doctor needs to be licensed to practice in that state. This rule restricts the use of telemedicine all over the US. States also require license renewal, which is hard to complete for physicians practicing in many states. Through the Interstate Medical Licensure Compact Commission, physicians have been allowed permission to practice in several states. But as of today, only 29 states have adopted the compact. Going forward, doctors may advocate for more flexible rules or a national license to ensure telemedicine can reach its full potential.

All of these examples, statistics, and regulations concerning telemedicine, raise several ethical questions. Is telemedicine a suitable solution for a lack of proper health care? When a patient is using telemedicine, who is really responsible for that patient? Should patients always have the autonomy to choose from telemedicine or an in-person visit? Should insurance coverage for telemedicine always be available no matter what the circumstances are? Is it ethical for state line regulations to prohibit the use of telemedicine across state lines? How is telemedicine redefining what it means to be a doctor? In thinking about all these questions, we have to take a step back and consider all the ethical implications of telemedicine. 


Ethical Implications Concerning Accessibility and Empathy

Telemedicine helps the greater good by offering health care to those who might not otherwise have access, therefore supporting the utilitarianism ideals of helping the greatest number of people. But at the same time, doctors swear to “First, do no harm.” So even though telemedicine might be helping the greater good, does telemedicine actually cause harm to individual patients by taking away a degree of empathy and respect between the patient and doctor? Ultimately, is it ethical to prioritize the health of the greater good even if it means a patient’s individual needs might be overlooked? Through the value of accessibility I will explore the ways in which telemedicine is helping the greater good. Through the value of empathy I will discuss how telemedicine changes the doctor-patient relationship and if it challenges the notion to do no harm.

Accessibility

First and foremost, it can be recognized that telemedicine is grounded in the fact that it widely increases access to healthcare. Healthcare becomes more accessible in several communities. Rural areas where hospitals and doctor’s offices are sparse become the first obvious place where there is a need for telemedicine services. Many patients simply have to travel too far in order to visit the doctor they need to see. Additionally, often patients at rural hospitals have to be transferred to bigger hospitals where they can receive the care they need.

 “Avoiding patient transfers when care can be provided locally is critical for both small hospital and provider viability in rural areas.”

-Rural Health Information Hub

Elderly people, disabled people, patients in need of an uncommon specialist, and people with a low economic status are all communities that could benefit from the accessibility of telemedicine. Accessibility also increases for the doctor themselves as they are able to see more patients without necessarily having to travel. Dr. Mia Finkelston tells American Wells, the telemedicine company she works for, her positive experience using telemedicine. 

“I work in my basement, flanked by 2 senior dogs. If I travel, I take my computer with me, as needed. As long as I have a private location to work in, a cable outlet or good Wi-Fi, I can work. I have seen 3 children through high school and college. I have been available for them in ways that traditional office-based medicine could not. American Wells’ service is 24/7, so that allows me to adjust my schedule as personally needed.”

Dr. Mia Finkelston, MD, Family Doctor at American Wells

At the most extreme end, another doctor, Claire Young, writes on KevinMD.com. 

“I am sitting writing this article from the hot, tropical lowlands of Colombia, on the site of Pablo Escobar’s Hacienda where, in a few hours, I will run my next 3-hour telemedicine clinic seeing patients back in British Columbia, Canada. […] I run my clinics from inside my camper, in every sort of geographical location possible — beaches, deserts, jungles, indigenous Mayan villages, and even at over 14,000 feet up snow-capped mountains.”

Claire Young, physician practicing telemedicine 

It is evident from these quotes that telemedicine can dramatically change a doctor’s day to day work. Many argue for the better, and many argue for the opposite. Telemedicine also gives doctors the ability to be on-call for more hours (especially at night) if they are working at home. Often patients make uneccessary visits to emergency rooms at night, because they have no other options. If patients are able to call their doctor at night instead, this could lead to less ER visits and comfort in hearing from your doctor, either letting you know that either everything is okay, or you should go to the ER. 

This wider spread of care also has the potential to result in negative consequences. Wider access could result in lower quality of care. Will the dramatic spread of telemedicine result in care that is not as high as it was set out to be? As telemedicine grows, will it become harder to regulate/oversee? For example, if a chef makes a homemade dish for 10 people at his restaurant, it is very likely that all 10 servings will be carefully thought out and executed. But what happens if he shares his recipe with 100 other restaurants serving 50 people each night. The quality of one of those 5,000 dishes might not be as delicious as the original 10. Why is this? Well, the chef will not be able to regulate 100 restaurants each night just like it is hard to regulate telemedicine at thousands of hospitals all over the country. Next, there is no way for the chef to guarantee that the restaurants he passed the recipe onto are using the right tools and ingredients. Telemedicine companies aim to use safe and reliable technology, but as the demand grows, will they be able to keep up with it and continue to be careful and safe? This brings into question, who exactly will be in charge of regulating telemedicine? The companies themselves, or an outside body? A strong figurehead is needed to keep telemedicine safe and effective. 

To continue thinking about the negative consequences, telemedicine might further the divide between people who can afford regular healthcare and those who cannot, creating issues around justice. As of today, telemedicine serves as a way to promote justice, distributing health care so everyone has access to the care they need. But, as telemedicine continues to serve as a less expensive alternative, will an in-person visit slowly become more expensive or for the “elite”? More importantly, will telemedicine widen the gap between those who have the money for “better” in-person care and those who have no choice but to use telemedicine? If someone who wants to access in-person care is not able to because of the financial burden, leaving them no choice but to use telemedicine, that would be a clear sign that telemedicine is creating issues around justice. The opposite of this situation could also take place. In a survey conducted by Deloitte, 23% of patients said they did not have the technology to support virtual care. As we saw during the coronavirus pandemic, many students lost access to education because they did not have the technology necessary to attend class or complete assignments. Will telemedicine create a similar inequality? People who have the resources (insurance, technology) may be able to access telemedicine while those who cannot afford technology might be left with no care at all, or maybe a doctor who does not suit their needs. Currently, telemedicine serves as a more accessible option, but it is important to think about whether it might create obstacles to equal access to healthcare in the future. 

Empathy and the Doctor-Patient Relationship

Medicine is not black and white, and an essential part of receiving health care lies in the relationship a patient holds with their doctor. Empathy is subjective, and the answer to the question of whether telemedicine preserves empathy between the patient and the provider can differ from person to person. The American Medical Association (AMA) provides guidelines for patients as to what a patient can expect and demand from their doctor in the course of their medical care. I will examine whether these rights are violated or altered by telemedicine. 

“The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives.”

-AMA  

A live video call gives the patient and the physician the opportunity to have conversations about all possible treatment plans, so I do not think telemedicine gets in the way of this guideline. However, if a patient is not seeing the same doctor consistently, these kinds of conversations could get lost in translation. Are we implementing an organized system of documentation that will make its way from one doctor to another? Will both the patient and the doctor be able to easily view these documents if needed?

“The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment.”

-AMA

Although telemedicine allows patients to receive recommended treatment plans from their remote physician, how might one accept a medical treatment if they do not have means to achieve it? For example, if a patient walks into a regular emergency room with a swollen ankle from a fall, if recommended, they will shortly get an x-ray and next steps. But, if a doctor recommends a patient via telemedicine to come in and get an x-ray of their swollen ankle, that might be easier said than done. What happens if the closest doctor’s office is 30 miles away or if they don’t have the proper insurance plan for an x-ray?  Even though patients can easily accept or refuse a treatment plan, there are ways in which it might be hard to implement the recommendations.

“The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs.”

-AMA

Although telemedicine certainly supports “timely attention” to one’s needs, “courtesy, respect, and dignity” could be lost with the use of telemedicine. For example, a 78 year old man named Ernest Quintana, was told he had little time left to live through a telemedicine monitor that unexpectedly rolled into his hospital room. His family was outraged about how this news was relayed. To make matters worse, Mr. Quintana had never spoken previously with the doctor who delivered this hard news to him. He also had a hard time hearing the doctor on the screen and was not able to properly discuss his options for end of life care. Ideally, an in-person doctor would have come to Mr. Quintana’s beside at a time when his whole family was present, to reveal his prognosis and discuss how he would like to live as he nears the end of his life. Proper courtesy was not given in this case and Mr. Quintana deserved to have more respect and dignity (Jacobs). This is an extreme example, and it is possible to deliver hard news in a respectful way using telemedicine. The doctor needs to make sure they have met the patient before in previous appointments, and they might ask the patient if they would like their family present before discussing. Even when seen in person, some patients have felt a lack of respect by healthcare workers. It is already difficult for a doctor to deliver hard news. Telemedicine can amplify these challenges and further impersonalize the experience for patients. 

More generally we must ask, is telemedicine contributing to a loss of respect for a human life? By using telemedicine instead of taking other measures to deliver healthcare, are we discounting a person’s sickness by settling on talking to patients in a distant way through a small phone or computer screen? Does society’s desire for extreme convenience actually make patients feel disrespected? A few of the driving factors of telemedicine are efficiency and convenience. Will this hurt the patient if they think they are just being treated in the most efficient way possible rather than in a way that is the most respectful? We as a society do have the potential to extend health care in different ways, and the fact that telemedicine is being chosen as the solution definitely sends messages about our values, both good and bad.

With the value of respect comes a patient’s right to autonomy. We could argue that telemedicine is actually increasing respect extended to patients because it is increasing patient autonomy. Telemedicine puts more trust in the patient by relying on the patient to communicate to their provider all their symptoms/concerns. Telemedicine gives a patient autonomy to decide what they need to address with their doctor and some patients may feel more at ease asking an embarrassing question behind the safety of a screen. But, giving patients this increased autonomy is not necessarily a good thing. Sometimes it is important a doctor decides what to access, instead of a patient telling their doctor what needs to be examined. It is very possible that a patient would not tell their doctor the truth about their symptoms, and in many cases telemedicine makes it impossible for the doctor to know the truth. Also, the physician is not always able to pick-up on subtle body language or other nuances when they are not in the same room as the patient. 

In the realm of autonomy, the choice whether or not to use telemedicine services needs to be preserved as well. Technically, offices are always giving patients the choice, but that does not  stop patients from being coerced into it by their family members, caregivers, advertisements, or physicians (Kaplan). It is important to notice society’s tone on telemedicine. Even though an 80-year-old patient might not feel comfortable using telemedicine, the constant smiley advertisements and discussions with their younger family members might influence and pressure the patient to use it. 

“The patient has the right to confidentiality. The physician should not reveal confidential communications or information without the consent of the patient.”

-AMA

At the moment, most live video calls are not recorded and notes are taken by the doctor in the same way an in-person doctor would take notes. But, there are definitely possible ways that conversations can be wrongly recorded, copied, or saved through telemedicine technology. Just as many feared medical records going from paper to electronic, now the appointment itself is electronic. It is important that patients feel that their environment is private, so they can tell their doctors everything there is to know, in order for doctors to properly treat them. Many patients simply might not have faith in technology, especially elderly patients who do not have much practice using it. Ultimately, is a secure computer system or a closed off room more reliable in terms of confidentiality? Even though hospitals strive to use as safe and secure technology as possible, will patients feel more comfortable talking behind a closed door rather than through a computer system?

“The patient has the right to continuity of health care. The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care.”

-AMA

As much as doctors are trying to keep consistency with their patients via telemedicine, this could certainly become a problem. In some telemedicine programs, a patient sees a different doctor every time they have an appointment. This is not really a problem if the patient is just dealing with a cold or a rash, but if they are diagnosed with a serious condition, most would want to have a consistent doctor who is aware of their case and is keeping track of developments and progress. Although a doctor has chart notes to inform them about a patient, they also use their memory of the patient’s previous appointments to help them deliver the best care. When this component is lost, will the quality of care decrease? Again, some telemedicine programs do have continuity with the same doctors and regularity in their appointments but telemedicine holds major differences that make it more difficult to ensure consistency. For example, the patient is no longer checking out with a receptionist to schedule the next appointment with their doctor as they leave. Although it is challenging, there are ways in which we can try to replicate these systems into telemedicine programs therefore creating continuity of care.

If a physician cannot treat a patient because they are remote, how will doctors go about referring their patients to someone who can treat them locally? Unlike doctors working in the same hospital, it is possible that these doctors are not familiar with providers who practice in the same communities where their patients live. This goes back to the second guideline highlighting a patient’s right to accept or refuse treatment. If a patient wants to pursue the recommended treatment, there needs to be enough continuity and logistics in place to make that feasible.

“The patient has a basic right to have available adequate health care. […] Fulfillment of this right is dependent on society providing resources so that no patient is deprived of necessary care because of an inability to pay for the care. Physicians should continue their traditional assumption of a part of the responsibility for the medical care of those who cannot afford essential health care.”

-AMA

This guideline both supports and attacks telemedicine. It comes down to the question, does telemedicine effectively deliver “essential health care” as stated in the rule above, regardless of the patient’s ability to pay. Currently if a patient walks into an emergency room in the US, they will never be denied care even if they do not have the means to pay for it. Contrary to this, in most instances a telemedicine appointment can only be obtained through proof of insurance or an advanced payment. Just like standard in-person healthcare, patients should be able to access essential emergency care via telemedicine regardless of whether they can pay for it. 

Richard Wooton, Director of the Institute of Telemedicine and Telecare at Queen’s University in Belfast, and Adam Darkins, Medical Director at Riverside Community HealthCare Trust in London, examined telemedicine in an interesting way. They examined how telemedicine either helps or hurts the “art of medicine” and the “science of medicine”. The “art of medicine” refers to a doctor’s ability to understand a patient in an empathetic way, while devising their best treatment plan. The “science of medicine” refers to all the medical technical knowledge a doctor should hold. 

“Patients expect a consultation that encompasses art and science from their doctor, both of which require the trust of the patient. If doctors are unable to assure patients of their technical (scientific) knowledge, this undermines the magic of the art of medicine.”

-Adam Darkins, Richard Wooton

Does an isolated doctor living and working in rural America in primary care have the wealth of knowledge needed to treat someone who most likely is in need of a specialist? The answer is probably not. In a situation like that, telemedicine helps the “science of medicine.” For most people at first glance, distancing a doctor and patient through telemedicine surely devalues the “art of medicine”. It could be interpreted that the message being sent is we doctors don’t care enough to sit in the same room with the patient anymore. But, from a more rational point of view, we can clearly see that doctors hold empathetic intentions behind using telemedicine. Ultimately, it will be up to one’s personal opinion whether telemedicine upholds the “art of medicine” between the patient and their doctor.


Conclusion

Throughout this paper I have examined telemedicine, considered its many ethical implications, and discussed its future concerns and risks. Telemedicine makes health care more accessible, but it comes with the risk of losing empathy from patient to provider. Telemedicine allocates health care to populations in need, promoting justice for access to quality health care. Furthermore, telemedicine supports the utilitarianism framework, while potentially taking aspects of a patient’s individual needs away.

Based on my ethical analysis of telemedicine, I think telemedicine should be used in low stake circumstances. This means in situations where a patient is battling a life threatening disease or a serious condition, telemedicine should not be used as a substitute for all in-person visits. This is a suggestion that is not currently being widely accepted anywhere, likely because it is so hard to draw a line between those who should have access to telemedicine and those who should not. To me, there is no question that we should have qualified doctors in every hospital in the United States. Although telemedicine can be an option, every patient should have the choice whether to take advantage of it or not. If one is home and has an undiagnosed skin rash, a video call from their couch is an effective and convenient plan to make sure the rash is nothing that needs to be examined in person. But, if one has just undergone radiation treatment to treat cancer, I believe these patients should be connecting with their doctor in person. Even though telemedicine presents benefits to those with serious illnesses, a life-threatening sickness is an emotional journey just as much as a physical one. I hope to continue to think about how we can classify who is eligible for telemedicine with this approach.

In going forward, we need to consider all the possible paths telemedicine can take as well as consider the possible risks. From my conversation with Dr. Shah, he hopes that telemedicine appointments from home will increase. 

“To survive and compete in this new environment you need to add services that patients will enjoy.”

-Dr. Shah, interventional radiologist who oversees MSKCC’s telemedicine program

In thinking about this, as telemedicine progresses, will it take over or coincide with in-person visits?

What are some potential risks? Getting inappropriate access to medication becomes easier. It is certainly easier to fake a diagnosis via telemedicine than it is in person. This could lead to dangerous prescriptions put into the wrong person’s hands. As the US suffers from over prescribing and drug addictions, this is an extremely important potential harm. As I talked about earlier, there is a risk of hackers getting access to private medical information that is stored in this technology. Could insurers gain access to patient data? Finally, as telemedicine continues to grow, in what ways will the industry be regulated? How will the government both support and protect telemedicine? What measures can we take to make sure the quality of care delivered through telemedicine remains as high as it should be when it was first implemented?

In 2016, the AMA adopted new guidance for physicians in telemedicine encounters.

 “While new technologies and new models of care will continue to emerge, physicians’ fundamental ethical responsibilities do not change.” 

-AMA 

Author Bonnie Kaplan worries we aren’t doing enough. 

“These measures are not enough. More attention to legal and ethical issues is needed.”

-Dr. Bonnie Kaplan, PhD, research psychologist

When ethicist, Arthur Caplan, was recently asked if it was ethical to go to your doctor for a non-urgent problem during the pandemic, he answered with this. 

“No. Call your doctor; you may also be able to have a visit via WebEx or Skype. I think that’s going to linger on after the epidemic; there’s going to be a lot more telemedicine in the future.”

-Ethicist Arthur Caplan

These are revolutionary views when it comes to telemedicine. Ten years ago, even five, we could have never imagined telemedicine playing such a prominent role in our healthcare systems as it is today. 



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