The term info-ethics is used to describe the application of ethical principles in information and telecommunication technologies. However, in eHealth applications, the application of ethics needs to take in account cultural factors in account as well. Because one of the reasons for implementing eHealth is to improve healthcare delivery in rural areas and underdeveloped countries, cultural differences and socioeconomic factors may impact the communication with patients and the application of those technologies.
In a project designed to implement telemedicine in Botswana, Quinley (2010) discusses the implications of cervical cancer diagnostics using mobile-Health (mHealth) technology. With the implementation of ClickDiagnositics mHealth solutions, which are designed to bring telemedicine in areas without internet accessibility, the project focused on screening women for cervical cancer. The women were educated to perform a self-assessment by applying vinegar to the cervix with a cotton swab. After a minute, they took a picture with their mobile phone and sent it to the healthcare providers, who were responsible for evaluating the diagnoses and prescribing treatments.
Although, the project was successful in delivering care to a remote area, it is not possible to generalize the success and consider it possible to implement on a national level. According to the World Health Organization (WHO, 2010), using telemedicine improves care delivery and treatment outcomes, but from an ethical perspective, the development of those systems may become a burden to local healthcare systems that struggle with scarce resources. For example, personnel requirements, ensuring a sufficient amount of bandwidth for frequent updates and uninterrupted communication, and electricity costs may impact the economy of the developing country and reduce their quality of life (Sarhan, 2009; WHO, 2010).
Furthermore, while several nations have already developed ethical frameworks that define several important principles in telemedicine, including control, possession, access, and ownership of data, those regulations are not universal (WHO, 2010). In a different social and cultural context, such as in Botswana, views on privacy, informed consent, and the role of spiritual dimensions in traditional societies should be considered when translating those frameworks to avoid ethical imperialism.
Another danger of implementing care in developing countries is the possibility of care marginalization (WHO, 2010). When developing a telemedicine system at a national level, it is important to consider how equality among patients will be emphasized, which is especially important for international collaboration when diversity and cultural differences need to be respected. Otherwise, there is a danger of violating the dignity of all people and supporting discrimination based on age, gender, education level, or language.
For example, when describing the telemedicine project in Botswana, Quinley (2010) does mention that several difficulties existed because of differences in language. However, it is possible to overcome that issue by introducing translators and negotiators, who need to be familiar with ethical values and cultural customs of both groups involved in the project. That way, the dignity of both cultures is preserved.
Another example of marginalization is the requirements for a certain degree of technical literacy. While the project described by Quinley (2010) was successful, it is important to consider that the technology used for that particular diagnosis was developed with consideration to make it simplistic and available to people of all education levels. However, other disorders may require complex procedures for diagnosis, so simple solutions may not be an option. Before implementing a national telemedicine system, technical and health literacy need to be assessed and suitable solutions, such as patient education need to be implemented.
It is also important to consider that, based on cultural differences, both physicians and patients may refuse to adapt a model that implements information technology in healthcare (WHO, 2010). While developing a national framework, the cultural factors of traditional practices and possible differences among individual patients’ cultural values need to be considered and implemented to achieve a balance between improved care delivery benefits and the satisfaction of patients whose cultural background will be considered.
Besides telemedicine ethical policy developments in national and international settings, physicians remain accountable for maintaining their ethical practice when working remotely with patients. While several technological safeguards need to be implemented to avoid data breaches, confidentiality remains a serious issue because the access to patient records is granted to several healthcare providers who are involved in treatments and could be shared over international borders (Sarhan, 2009). Establishing confidentiality regulations in institutions is necessary to prevent instances of malpractice or information abuse, and patients should be informed that their data will be shared with other healthcare professionals involved in the treatment.
Overall, the core principles of biomedical ethics, which include beneficence, justice, non-maleficence, and respect for autonomy (Ewashen, McInnis-Perry, & Murphy, 2013), are universal and should be included in daily practices of all healthcare providers who work with telemedicine technologies in different cultural settings. By following those principles, the healthcare providers will improve their collaboration with colleagues and quality of care when working in cross-cultural settings and overcome ethical issues because local patients and healthcare providers will feel respected and acknowledged as human beings.
References
Ewashen, C., McInnis-Perry, G., & Murphy, N. (2013). Interprofessional collaboration-in-practice: The contested place of ethics. Nursing Ethics, 20(3): 325-335. doi:10.1177/0969733012462048
Quinley, K. (2010). Telemedicine and its novel use in cervical cancer screening in Botswana [Video file]. Retreived from http://www.youtube.com/watch?v=L3-gr_JKuUk
Sarhan, F. (2009). Telemedicine in healthcare 2: The legal and ethical aspects of using new technology. Nursing times, 105(43), 18-20.
World Health Organization. (2010). Telemedicine: Opportunities and developments in Member States. Retrieved from http://www.who.int/goe/publications/goe_telemedicine_2010.pdf
