Virtue Ethics in a Value-driven World: Ethical Telemedicine

When considering ethics, extreme examples generally are not useful, as the outliers tend to obscure the underlying issues and potential learning opportunities. A recent New York Times article [7], for example, highlighted the clear insensitivity associated with healthcare providers utilizing telemedicine for communicating end-of-life treatment to their patients. The piece described hospital workers rolling a television atop a tall machine with wheels into a patient’s hospital room unexpectedly, confusing both the patient and his family. Moments later, a doctor the family did not recognize appeared on the video screen, informed the patient that he had incurable lung disease, and stated that there was nothing more doctors could do other than making the patient comfortable with morphine. The video feed’s connection cut in and out, forcing the patient’s daughter to repeat the devastating news to her father, who did not initially hear the doctor’s grim diagnosis. “It should have been a human,” the patient’s daughter said in the piece. “It should’ve been a doctor who came up to his bedside” [7]. The former president of the American Medical Association (AMA) agreed, saying that delivery of bad news electronically should be a doctor’s “last choice” [7]. The clear ethical error, in my view, was in the hospital ultimately choosing efficiency over compassion. But telemedicine—with its potential to revolutionize access of care—is not going away [6], and so we need to ask ourselves some tough questions. Imagine a patient receiving care in an outlying area, where specialty care may not be available. If that patient is near death, would informing him promptly using telemedicine be more ethical than waiting an indeterminate period for a bedside consult? While it might be appealing to have another care provider—such as a nurse—communicate the information in person should a physician not be available to do so, this may not be possible. Nursing’s scope of practice provisions and code of ethics [1, 10] do not allow the communication of medical diagnoses to patients. Perhaps in some situations, delivering hard, end-of-life news via telemedicine (either through an interpreter, following peer-to-peer consultations, or through direct patient care) would be appropriate. Still, ethical dilemmas abound (Table 1) .Table 1.: Models of telemedicine: Clinical opportunities and ethical dilemmasAlthough it seems unethical to me, focusing on the scenario in the New York Times may be instructive. In my view, the providers in that story fell short of upholding one of the four principles of medical ethics [3], beneficence, as the patient’s welfare was subjugated to efficiency or convenience. Face-to-face care should have been possible; the patient was in a busy hospital in the Fremont region of San Francisco, CA, USA. A physician should have made time to speak to the patient face-to-face about his terminal diagnosis. In medical school, I recall our professor advising us to always sit down when communicating bad news to emphasize our presence with the patient at that moment, as well as to signal our availability to the patient as (s)he processed the news. As a minimal standard, I would propose that any conversation that might be “chair worthy” should not occur via telemedicine, unless there is no other reasonable way to communicate with the patient. The AMA recommends telemedicine be used as a supplement to, rather than a substitute for, in-person medicine [5]. But what are the mechanics of this supplementation? At the present time, I think the best uses of telemedicine involve convenience care for “low-stakes” health issues. For example, a friend recently texted me a photo of his son’s clavicle, bruised with an obvious deformity, asking if he needed to go straight to the emergency room on a Friday evening. We spoke, and the child had full range of motion and sensation, with point tenderness over the deformity. I advised they go to an urgent care rather than a hospital emergency department, where a radiograph later confirmed a clavicle fracture. The child was given a sling for comfort and followed up with my partner on Monday. For patients who don’t have an orthopaedic surgeon on speed dial, an immediate telemedicine consultation would both be more convenient for the patients (by preventing unnecessary emergency room trips) and more efficient for the healthcare system. I’d call examples like that “low-stakes” medicine: The history and visual inspection of the patient are straightforward, and the possibility of major harm is low. Additionally, the consultation primarily functions as a point of triage rather than definitive care, and it fits within the supplement to standard care as advocated by the AMA [5]. Would it be possible to expand telemedicine in orthopaedics beyond such low-stakes evaluations? Although there are commentaries on this issue [9], I could not find academic research on direct orthopaedic care via telemedicine in the United States. But in Norway, nurses in rural areas receive training in physical examination and casting, and then consult physicians through video to determine definitive care [4]. The presence of a medical professional for physical examination mitigates the risk of harm, which is essential to an orthopaedic encounter, and what ultimately makes the use of telemedicine ethical in this scenario. In contrast, psychiatric telemedicine, which has a limited need for a physical examination beyond a video screen, is more widely adopted for direct patient care [2]. While a psychiatrist may have the ability to differentiate anxiety from depression via video screen, an orthopaedic surgeon would not be able to apply the Ottawa Criteria for an ankle sprain [11] or differentiate normal post-operative swelling from swelling suspicious for a deep vein thrombosis. The ethical practice of orthopaedic medicine would seem to require some ability for physical contact—whether by a physician or a trained healthcare professional—in order to ensure the principle of non-maleficence is maintained. There are certain circumstances whereby upholding another principle of medical ethics, non-maleficence, might require avoiding telemedicine. For example, I would argue that telemedicine should be avoided in young children, particularly non-ambulatory children, where there is an increased need to screen for child abuse [8]. The logistics of coordinating such care via video screen are difficult to contemplate, given the importance of child protective services and specialized support only accessible in the hospital environment. Concerns about the potential great harm should outweigh any potential benefit in this scenario. Yet, telemedicine may be appropriate for other types of acute care. For example, I can imagine walking a nurse practitioner through the Ottawa Criteria for an acute ankle injury. Importantly, I do not think most orthopaedic care can occur without an in-person provider, who is able to perform a physical examination as well as basic orthopaedic care, such as dressings and splinting. The limits of telemedicine in acute injury care should be carefully considered; with current resources, I believe it should be limited to a triage service. For all the ethical pitfalls of telemedicine, there are ethical arguments in favor of telemedicine use. The principle of justice requires fairness and equity in the delivery of healthcare, creating an obligation to serve the underserved. Telemedicine would permit patients in rural, underserved areas access to orthopaedic care otherwise difficult to attain [6]. It is easy to imagine a rural telemedicine service, with trained healthcare professionals assisting with the physical exam for an orthopaedic surgeon in another location. The opening example demonstrated the harms of telemedicine’s efficiency and convenience. Yet, it is this same efficiency and convenience that, when ethically applied, would result in expanded access to orthopaedic care.

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