This paper discusses ethical aspects of different models of evaluation based upon different concepts of telehealth. The term telehealth is often used alongside or interchangeably with telemedicine and telecare. These terms refer to health and care services that can be provided at a distance over various telecommunications networks. Telemedicine facilitates remote patient care in an institutional setting, for example, linking hospitals with remote surgeries and enabling remote diagnosis. Telecare refers to services that provide care for people away from institutions, typically in their own homes, for example monitoring elderly people as they lead their normal lives. Telehealth is perhaps more encompassing, and includes opportunities for health promotion among a wide range of people including the young and healthy.
We take telehealth as covering a number of heterogeneous technologies and services that cut across boundaries between different professions, including medicine, health promotion, health administration, social services and information systems. We could envisage finding a conception of telehealth in a variety of contexts:
- a ‘drug’ or a therapeutic agent in a medicine/health context
- an information system – embedded in an institutional/organisational context
- an information service – in a social/community context.
These different ways of conceptualising telehealth highlight different issues and suggest different approaches to evaluation and different ethical concerns.
Ethical concerns have a particularly strong position within the medical tradition. The primary ethical concern regarding the evaluation of a drug is ‘to do no harm’. However the ethics of drug prescription, medical treatments and technologies reflect a complex model that increasingly incorporates a variety of concerns, including humanity and acceptability, accessibility, health outcomes, quality of life, and in the case of health projects the impact on related socio-economic development as well as effectiveness and efficiency. Thus there is tension between a scientific approach, the search for the gold standard and a more qualitative approach to evaluation.
Efficiency as an ethical system is much more prominent in the information systems tradition. In contrast to the medical setting, efficiency is not seen as a need for a better use of scarce resources but as a legitimate goal of increasing profitability and organisational effectiveness. Thus, efficiency could be seen as a primary interest, although different concerns, e.g. the quality of working life and job satisfaction are also (but to a lesser extent) present in information systems literature.
Perhaps the overriding ethical concern behind the concept of information services is the idea of information as a right, i.e. citizens/humans have the right to information. Information is seen as a tool for self-empowerment. At the same time there is tension between the idea of universal access and the trend towards commodification of information. The literature on information society and the role of information and communication technologies (ICTs) delivers its own set of ethical concerns. Telehealth can be evaluated in terms of empowering patients and communities, contributing to social cohesion, and democratising health care structures and service delivery versus intensifying social exclusion (information rich and poor), alienation and de-personalisation of health services (providing treatment not care), and the emphasis on standardisation and control.
This conceptualisation of different traditions is simplistic and crude and merits more sophisticated analysis in a full size paper. But this simplification has also a purpose – to emphasise the conflicting ethical underpinning of varied concepts of appropriate evaluation approaches for telehealth.
As telehealth crosses the boundaries of different disciplines, its evaluation must draw on a variety of traditions. Certainly, treating telehealth as a drug and concentrating on randomised controlled trials is very limited and, in many cases, of doubtful benefits. Tension between the different traditions of diverse disciplines highlights the complexity of evaluating telehealth. This can also be taken as an illustration of the struggle to define the ethical underpinning of the evaluation of ICTs in the context of information society.