Understanding technology has become an ethical responsibility

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With its extension to the private health sector, the recent ehealth laws have led to a focus on legal and regulatory issues. This commenced with the Privacy Act (1988) and was followed with a quantity of legislation, regulations and guidelines, writes Professor Colin Thomson. 

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The complexity reflects two aims: that health professionals have relevant patient medical information and that patients’ privacy is protected. These aims reflect ethical principles and obligations that continue to inform professional practice. 
Essential principles of medical ethics 
Conventionally, three essential principles have emerged in the last four decades: respect for autonomy, beneficence and justice. Reflection on the way that these can be expressed in working with electronic health records is likely to help guide conforming conduct.
Respect for autonomy
Respect for autonomy  is expressed when patients are given clear opportunities to make choices about their health care options. Those choices need to be informed so that the principle is also expressed by ensuring that patients have sufficient information to make choices. The principle also respects a patient’s choice in providing information on which advice or treatment will be based.
One likely advantage of the ehealth environment is that all relevant medical information about a patient can be available to a treating health professional. As a result, the information that can be provided to the patient may be more comprehensive than before. However, this likely advantage is balanced by respecting, as the ehealth environment does, a patient’s right to decide how much of the medical information will be available and to whom.
The ehealth environment changes the manner in which other familiar aspects of respect for autonomy will be fulfilled. Health professionals will need to know how to discover the extent and maintain this level of access. No longer will risks result from accidentally leaving paper files opened where they can be read, but rather risk will result from not fully understanding the computer technology through which the records are made available.
Beneficence 
This principle essentially means to do good; to promote a patient’s welfare. Without the balance of the principle of respect for autonomy, beneficence would permit a paternalistic provision of health care: doctor knows best. The recognition of respect for autonomy means that what is good for a patient emerges from her preferences and her doctor’s advice.
Doing good for patients requires good information about their medical history.  Patients are encouraged to provide maximum information to health professionals because of the professional duty to keep that information confidential. The advent of an ehealth system will enable a patient to make their full information available by authorising a health professional to have access. Also, an ehealth system will permit a patient to allow all of that information to be available to any health professional independently.
Some health professionals have experienced difficulty in understanding whether their disclosure of patient’s health information to someone else infringes a patient’s privacy, even when they believe that it falls within conventional understandings of confidentiality. One advantage of an ehealth system is that it may obviate the need for a health professional to convey information to another: rather, a health professional will add diagnostic or treatment information to a patient’s electronic health record and the patient can then decide whether another health professional can have access to that information. As a result, a patient’s welfare may be maximised.
Justice
Where health information is recorded inaccurately, it can lead to unfair judgements about suitability for the allocation of treatment or health care resources. Such an outcome would be regarded as unfair or unjust: for example, if the degree of a patient’s need for transplantation was misrepresented, he may wait longer and suffer more.
The accuracy with which information is added to a patient’s personally controlled electronic health record will be more important than ever.The record will become accessible, if a patient so chooses, to other health professionals whose advice or treatment the patient seeks. Risks of unfair and inadequate treatment may emerge in such a system if there is less inter-professional communication.
Accordingly, the principle of justice may require greater care recording accurately diagnostic or treatment information in a patient’s record.
Summary 
Ethical principles of respect for autonomy, beneficence and justice remain as applicable to the decisions and conduct of health professionals as ever. The advent of an ehealth system merely changes the manner in which professionals demonstrate fulfilment: does not reduce the obligations. What such a system does introduce is the obligation to understand the technology, how to know what information and to which health care providers the patient has granted access to their information.
Colin Thomson
BA, LLB, LLM (Sydney)
www.ehealthinfo.gov.au
Colin Thomson is a Professor in the Graduate School of Medicine at the University of Wollongong and is Academic Leader for Health Law and Ethics. He is also Associate Editor of the Journal of Bioethical Inquiry and is a joint author of Good Medical Practice:Professionalism, ethics and law, 2010, Cambridge University Press.