Expert systems may significantly help medical personnel to fulfil their obligation of providing the best possible care for their patients. However, in spite of this there is a high level of resistance from some medical personnel towards using these computer systems. This paper will examine the ethical issues uncovered in a case study conducted amongst a group of clinicians routinely using expert systems in their day-to-day work.
A group of clinicians working in a progressive teaching hospital in Vienna, Austria have access to four “expert systems” that have been routinely used in that facility for over five years. These systems range in function, from making “judgements” regarding when the patient is ready to be weaned from artificial ventilation, to examining blood test results in order to diagnose the presence of Hepatitis A and B, to aiding Primary Care Physicians in making diagnoses of unusual Rheumatological cases, to monitoring the spread of hospital-caught infections within that hospital.
It was recognised by the developers of these expert systems that if the systems were to cause any reduction in the quality of the provision of healthcare, these systems would be immediately (and rightly so) rejected by clinicians. These systems have therefore been tested extensively and have been proven to work at least as effectively, and often more effectively, than can the medical personnel. Medical personnel have a duty to treat and care for their patients to the best of their abilities (the Principle of Beneficence) and to cause no harm to those patients (the Principle of Non-Malfeasance). These duties can be fulfilled more effectively by utilising expert systems; resistance against using these systems may be indicative of a failure on the part of medical personnel to meet these duties.
Resistance by clinicians
Interviews conducted with 6 clinicians (see King et al, 2002 for a more in-depth description of this case study) revealed that although all the expert systems worked as well as, if not better than, the healthcare workers, some clinicians were reluctant to use these systems. Broadly speaking, older clinicians were perceived as less likely to be receptive towards the introduction of expert systems into the workplace than their younger colleagues. This may be due to a lack of familiarity of, and suspicion towards, computer systems in general. Significantly, it was found that all clinicians that were interviewed, regardless of age, even when that particular clinician had been instrumental in the creation of one or more expert systems, did not fully trust the advice or results given by those systems and treated the systems more as an academic exercise rather than a useful tool to enhance patient treatment.
The actions, or inaction, of the clinicians interviewed were analysed by comparing their behaviour against a list of fundamental ethical principles provided by a professionally recognised Health Informatics body. These principles included the Principle of Non-Malfeasance, the Principle of Beneficence and the Principle of Autonomy, all of which will be examined below. The principles of Equality and Justice, Impossibility, and Integrity will also be examined fully in the final paper.
Non-Malfeasance: All persons have a duty to prevent harm to other persons insofar as it lies within their power to do so without undue harm to themselves All clinicians interviewed stressed their commitment towards caring for their patients. Their behaviour noted above may in some part be explained by a misguided belief that the reluctance to use these systems is actually upholding the principle of Non-Malfeasance. However, genuine concerns were also raised. These included concerns such as the use and/or maintenance of the systems being time-consuming, which may allow less time for direct patient interaction and so may be malfeasant towards the patients. Much time has also been spent by the group ensuring that the medical knowledge is both correct, and up-to-date, to ensure that the systems do no harm.
Beneficence: All persons have a duty to advance the good of others where the nature of this good is in keeping with the fundamental values of the affected party If, has been claimed, the use of these systems provides the best possible care for patients, it is clear that the clinicians have a duty to use them in order to uphold this principle. As described above in the ‘Resistance by clinicians’ section, levels of usage of these systems varies greatly. Some (principally the older) clinicians are not using these systems at all. Other clinicians are not using them to their fullest extent. Both kinds of inaction indicate that the clinicians are not fulfilling the principle of Beneficence towards their patients.
Autonomy: All persons have a fundamental right to self-determination Clinicians in Vienna are asserting their right to be autonomous in the methods in which they work. This right is supported by their hospital and work culture. This assertion may at times clash with other principles, particularly the Principle of Beneficence where it applies to the advancement of the good of the clinicians’ patients. This may be due to a lack of awareness of the potential of the expert systems.
Patient autonomy may be actually bringing forward the introduction of expert systems as patients become more knowledgeable and more willing to challenge clinicians’ diagnosis, perhaps due to the Internet; and market forces driven by insurance companies require more elaborate and rigorous tests which may only be satisfied by the use of expert systems.
Many factors need to be taken into consideration when assessing how clinicians ought to use Expert Systems. Clinicians’ primary concerns are protecting their patients’ welfare but this may be leading to an unwarranted reluctance to use the best tools possible for the job.
King, H., Garibaldi, J. & Rogerson, S. (2002) Intelligent Medical Systems: Partner or Tool? Proc. ETHICOMP conference Lisbon, Portugal 2002.