A new ethical guidance from the American Medical Association focuses on how the physician’s fundamental responsibilities play out differently with the use of telemedicine. Some considerations include the following:
- Telemedicine changes the way patients and clinicians communicate.
- Some telemedicine physicians don’t ever meet the patient in person.
- Others ‘off-camera’ may be able to hear or observe the interaction.
A patient asks her physician, whom she’s never seen previously, a particularly sensitive medical question. How does this interaction differ if the patient is at home, viewing the doctor’s response on a computer screen?
“Telemedicine services can change communication and power relationships between clinicians, between patients and clinicians, and between family members,” says Bonnie Kaplan, PhD, FACMI, Yale Interdisciplinary Bioethics Center Scholar and faculty in the Yale Center for Medical Informatics at the School of Medicine at Yale University in New Haven, CT.1
A telemedicine physician may never meet the patient or others involved in caring for that person. “So physicians may not get to know the patient’s situation, and that can affect care,” Kaplan says.
New ethical guidance from the American Medical Association (AMA) aims to help physicians understand how their fundamental responsibilities may play out differently when patient interactions occur through telemedicine instead of in-person.2
BJ Crigger, PhD, the AMA’s director of ethics policy and secretary for the AMA’s Council on Ethical and Judicial Affairs (CEJA), explains, “As the public becomes increasingly fluent in utilizing novel technologies in all aspects of daily life, evolving applications in healthcare are altering the contours of when, where, and how patients and physicians engage with one another.”
Crigger describes the practice of medicine as “inherently a moral activity.” This is founded in a covenant of trust between patient and physician. “No matter what the model for care, physicians’ fundamental ethical responsibilities do not change,” she says.
The ability to maintain privacy and confidentiality is one oft-cited ethical concern with telemedicine. “Others ‘off-camera’ at the patient site and unknown to the physician may be able to hear or observe the interaction taking place,” says David A. Fleming, MD, MA, MACP, director of University of Missouri’s Center for Health Ethics in Columbia.
Fleming names the following three issues as other central ethical concerns:
- preventing harm to the patient by ensuring standards of care equal to in-person visits,
- avoiding the entrepreneurial temptation of deploying telehealth primarily in the interest of profit, or in situations where it’s inappropriate, and
- ensuring the technology being used does not serve as a barrier to maintaining the trust and integrity of the physician-patient relationship.
Kaplan says that ethical policies for the use of telemedicine should include the following:
- Familiarize everyone involved with a realistic assessment of its benefits and limitations, and current ethical and practice guidelines.
- Train people for the change in their roles and responsibilities.
- Address the burgeoning area of commercially available smartphone apps.
- Develop guidelines for incorporating telehealth data into patient records.
- Involve patients in designing telehealth and telemedicine services.
- Promote shared decision-making for each patient’s use of telemedicine services.
- Set up policies for patient consent when possible consequences are unknown, because the technology or services are so new.
- Prevent assumptions built into computer software algorithms, hardware, or telemedicine from replacing clinical judgment, patient autonomy, and human values.
- Evaluate telemedicine services to make them better, improve health and well-being, support patients, caregivers, and clinicians.
- Weigh this use of resources against better or more cost-effective ways to improve health.
- Ensure that patients’ decisions are freely made. “Patients should not be pushed into unwanted monitoring or other forms of remote care by their well-meaning children, clinicians, or caregivers,” says Kaplan.
Fleming says that bioethicists can offer education for providers who will be using telehealth about its potential ethical pitfalls. Bioethicists can also make themselves available if questions arise during clinical encounters, or if there are questions about appropriate telehealth utilization.
“The ethics team can provide an invaluable service to systems that are establishing telehealth services,” says Fleming.
- Kaplan B, Litewka S. Ethical challenges of telemedicine and telehealth. Cambridge Quarterly of Healthcare Ethics, 2008; 17(4):401-416.
- Opinion 1.2.12 Ethical Practice in Telemedicine, AMA Code of Medical Ethics, 2016. Available at: http://bit.ly/PrZ0Uy.
- David A. Fleming, MD, MA, MACP, Director, Center for Health Ethics, School of Medicine, University of Missouri, Columbia. Phone: (573) 884-2013. Fax: (573) 884-1996. Email: firstname.lastname@example.org.
- Bonnie Kaplan, PhD, FACMI, Yale Interdisciplinary Center for Bioethics, New Haven, CT. Phone: (203) 436-9085. Fax: (203) 436-8310. Email: email@example.com.