Ethical aspects of telemedicine
Gonzalo Herranz, department de Humanities Biomedicas, University of Navarra.
University Secretary of the Central Commission of Deontology of the Organización Médica Colegial.
discussion paper at the VII National congress on Health Law.
Ilustre high school Oficial de Médicos de Madrid.
Madrid, 19, 20 and 21 October 2000.
2. The Code of Medical Ethics and Deontology
a. CEDM messages to telemedicine
Two paths can be followed to deal with the ethics of telemedicine. One is that of the analytical and problematic considerations of bioethicists. The other is that of medical ethics and deontology, which is more empirical and resolutive.
I think that, in a health law congress , it is better to follow this second path, despite its limitations, and to consider the guidelines that medical professional bodies have promulgated on subject: these rules are, by their very nature and despite their limitations, closer to health law than the reflections of bioethicists.
In my speech, I will present and comment on the doctrine and recommendations contained in the documents of international organisations of which the Spanish Medical Association is a member. I will then comment on what our Code of Medical Ethics and Deontology contains that is applicable to subject.
The Ethical Guidelines for Telemedicine of the committee Standing Committee of European Doctors (1997) and the Declaration on Ethical Responsibilities and Ethical Guidelines in the Use of Telemedicine of the association World Medical Association (1999)1, have common ethical principles and overlapping, sometimes literally identical, content2.
Guidelines and Declaration tell us about the ethical-professional requirements (accreditation, authorisation and skill) of the doctor whose scope of work, thanks to telemedical technology, goes beyond the limits of provinces and regions, states and even continents; about the special characteristics that the relationship between doctor and patient takes on when distance separates them; the ways in which technical quality, security and confidentiality must be maintained in the telemedical context, where technical collaborators are often numerous and can play a very active role; teleconsultation between doctors and how their respective responsibilities must be shared, assigned and recorded; how the relationship between doctor and patient and between doctors and the decisions they have taken must be documented; how this documentation must be preserved; and, finally, the economic implications of internship telemedicine.
The most basic idea underlying both documents is that telemedicine is another way of practising medicine, justified both by its ability to reach certain otherwise inaccessible patients with the doctor's attendance and by its power to improve the quality of medical care. Consequently, the general principles of professional ethics are fully applicable to telemedicine3 . The fact that the information that circulates between doctor and patient, or between doctors, is not transmitted in their immediate presence or within the walls of the same building, but uses telecommunication systems, does not nullify, but rather intensifies the power of that rules and regulations4.
But within this common ethic, telemedicine has some special features to which the Guidelines and the Declaration pay attention.
requirements professional-ethics
In fairness and justice, and by virtue of the potential benefits of telemedicine, all doctors with the necessary qualifications and skill, should be allowed to use telemedicine, provided that they comply with the rules of professional ethics5.
The ability of telemedicine to leap over territorial boundaries does not abrogate the physician's statutory and ethical obligation to be licensed to practice medicine both at the location from which he or she works and at the location of residency program of the patient for whom he or she provides services.
The obligation to obtain the necessary authorisation in the places of residency program and practice means that the internship of telemedicine is fully subject to the ethical rules in force in the respective territories. Telemedicine that is disconnected from the deontological communities of origin and destination, or at least from international regulation, is unacceptable.
It is understood that the obligation of double or multiple membership is not a mere administrative formality or a mere functional advantage. It is a resource which protects professional ethical values, since, if on the one hand it is desirable to promote the freedom to provide services, on the other hand it is necessary to guarantee the moral and technical quality of the services provided, by clearly defining ethical responsibilities.
The doctor/patient relationship when distance gets in the way
Ideally, telemedicine techniques should help to optimise medical care for the general community; they should foster, not destroy, the trusting relationship between doctor and patient. They should enhance everyone's sense of responsibility and impose the internship of respect for the individual, which underpins patient autonomy and physician independence.
In telemedical care, patient and doctor are persons, with names and identities: hence the essential requirement to identify each other personally in each of their contacts and for each of them the doctor must obtain the patient's authorisation apply for . Obviously, in situations of extreme urgency, some of these requirements must be sacrificed in order to serve the priority purpose of preserving life.
The responsibility of the doctor
In the uses and applications of telemedicine, physicians take full responsibility for the treatments and decisions they pass on to their patients. They will not forget that their patients are above the technique and that their rights must be taken into account when designing new telemedicine applications or modifying existing ones.
Technical quality and safety
A physician will choose to use telemedicine when he or she believes that, in the circumstances of the case, this is the best option available. In such a decision, the ethics of medical indication must be very strongly present.
requirements Physicians must be seriously concerned about the quality and condition of the technical instruments they use: not only must they meet the quality and performance requirements of the current professional state of the art, but they must also undergo frequent function and calibration checks to assess the accuracy and quality of the information received and transmitted. A physician may not give opinions or make recommendations when he/she cannot rely on the quality and quantity of the information he/she uses.
The doctor shall surround himself with the necessary technical staff to ensure the regular functioning of the equipment. He/she shall draw up a protocol indicating the measures that he/she and his/her collaborators shall take in the event of malfunction or breakdown.
Documentation of telemedicine care: creation and preservation
In telemedicine, the doctor who treats the patient directly, as well as doctors who are consulted by colleagues, must keep their patients' medical records up to date, recording each of their actions and incorporating the relevant auxiliary documentation. The method of patient identification cannot be omitted. Every procedure performed by the physician or his or her staff must be authenticated and therefore bear the name of the person who performed the procedure, signature .
Every effort should be made to ensure the durability and accuracy of stored information, including special measures to protect data stored in electronic form from accidental loss, intrusion by outsiders, theft or deliberate destruction.
Confidentiality and consent in the telematic context
Telemedicine takes place in a human context that is as complex and problematic as its technical context. This requires special attention to be paid to the common rules of confidentiality and confidentiality with feeling. The patient must know that the information concerning him or her may be known to people who collaborate with or are consulted by the doctor, and he or she must consent to this. The patient must be informed that everyone (doctors and nurses, physicists, engineers and technicians, computer specialists, telecommunication network managers) is bound to secrecy.
It is a strong duty to establish appropriate systems to control access to stored information, through individual and secret passwords assigned to each person.
Similarly, because of the risk, inherent in certain types of tele-transmission of data, of information being stolen or leaked to other destinations, the physician has an obligation to protect, through encryption or other security procedures, the confidentiality of the information he or she transmits.
The data transmitted should be all, and only, those strictly relevant to the problem at hand.
Teleconsultation between doctors and the allocation of responsibilities
The possibility to apply for an expert opinion to a distant colleague to whom clinical data or images (electrophysiological tracings, X-rays or other diagnostic images, histological preparations, skin lesions, etc.) are transmitted is among the most important applications of telemedicine. Teleconsultation can be done either at application of the patient or on the initiative of the physician with the patient's permission.
The physician consulted is free to accept or not to accept enquiry, and retains the right to determine whether or not the information conveyed is sufficient to provide an informed opinion. The physician who seeks the opinion of another colleague retains responsibility for treatment, and it is up to the physician to determine, with the patient's consent, the use he or she makes of the consulted colleague's opinions or recommendations.
The doctor consulted should be informed of the patient's progress, so that he/she can assess the quality of his/her own performance in the case.
Economic implications of telemedicine
The problems posed by telemedicine in the economic field are not small. First of all, there is the need to legitimise telemedicine on the grounds of its superior efficiency compared to traditional procedures. Much remains to be done in this area research.
Secondly, telemedicine creates problems regarding the regulation of fees to be paid to doctors, Departments or hospitals cooperating in the care of a patient. A transparent and rational system of fee allocation should be agreed, to avoid that telemedicine may lead to prescription abuses or dichotomous practices.
It is important to clearly separate what is merely generic information from what constitutes a enquiry on a specific patient. In the deontological tradition, information is always free of charge, whereas enquiry must be remunerated. The former does not carry a qualified responsibility and has as its final recipient the colleague who asks; the latter has as its final recipient the patient, in whose care the doctor consulted is committed, and, although it must be mediated by the doctor who enquiry, it is intentionally charged with responsibility towards the patient.
2. The Code of Medical Ethics and Deontology 
The 1999 Code of Medical Ethics and Deontology of the Spanish Medical Association (CEDM) does not deal specifically with telemedicine, a further indirect test that the general code of ethics rules and regulations applies to telemedicine. For this reason, it will suffice, on the one hand, to briefly allude to the messages that the articles of the CEDM send to telemedicine6 ; and, on the other, to deal in detail with the only article of the CEDM, 22.1, which directly touches on the subject that concerns us.
a. CEDM messages to telemedicine7
General principles
In telemedicine, respect for the dignity of the individual imposes the duty to give precedence to the patient over technology. The latter must be at the service of the individual, whose health must be protected above all other interests. A basic ethical requirement of the dignity of the individual is to take due precautions to verify his or her identity, especially in the first telemedical contacts (Art. 4.1).
The obligation to treat everyone without discrimination and with the same diligence and application is the ethical driving force behind telemedicine, which precisely seeks to treat those who are far away or who cannot get close to a doctor. Telepatients" can never receive an inferior quality attention : they enjoy the same rights that, from ethics and law, protect all patients (Art. 4.2).
The duty to do no harm is fully applicable to telemedicine. Thanks to its ability to bridge distances and to speed up the speech between doctor and patient, telemedicine carries within itself the possibility of reducing the delay in the attendance to the patient (Art. 4.4).
Telemedicine, once the technical hurdles have been overcome, is set to play a decisive role in the provision of financial aid medical care in urgent and catastrophic situations (Art. 5.1 and 5.2).
Telemedical technologies should be subject to a cost and performance analysis prior to deployment and, once in use, should be audited to determine their fair use and to prevent misuse (Art. 6.1).
Physicians' relationships with their patients
Neither distance nor the interposition of instruments can affect the full relationship of trust that should exist between doctor and patient, nor blur the interpersonal nature of their relationship. In this relationship, the patient's freedom to accept or reject, to initiate or fail, telemedicine care is a priority, a freedom that must be respected both in systems run by private organisations and in those managed by public services. There is no place, in telemedicine, for monopolies or promotional practices that might diminish the patient's freedom to choose the doctor and services of his or her choice. The ethical and legal rules on the patient's freedom of choice of doctor therefore apply to telemedicine in a qualified way. It is necessary not to lose sight of the human dimensions of telemedicine and to investigate frequently the Degree satisfaction that patients express about telemedicine (Art. 9)8.
At internship telemedicine, the rules of polite propriety and respect for the patient's privacy apply. Thus, for example, the installation of video conferencing equipment in the patient's room does not authorise snooping into the patient's private life. The patient must authorise when and for what purpose the transmission is connected and who can watch it9.
In distance medicine, the typical and unique features of the doctor-patient relationship must be maintained, such as the continuity of services, the negotiation of their suspension, the way to manage the change of doctor and the procedure transmission of (tele-)information about the patient to the new doctor (Art. 9.1)10.
Apart from the prior and general information to be given to the patient or his/her relatives about the telemedical interventions that may be convenient for him/her, it is required, before starting the telemedical care, to offer specific information, which shall not differ in clarity, sensitivity, content and guarantees from that given in the ordinary medical internship , in order to obtain the specific consent. This presupposes respect for the patient's right to refuse in whole or in part any of the proposed interventions (Art. 9.2). The doctor may refuse to provide telecare if he is forced to work under unsuitable or unacceptable conditions, for example, if neither the patient nor his relatives are competent in the correct use of the telematic equipment (9.3).
Telemedicine incorporates a very wide capacity of speech between doctor and patient. It can facilitate the exchange of information and help to record it immediately, both on magnetic media and on paper (Art. 10.1).
Distance need not depersonalise the clinical meeting , nor create strangeness between doctor and patient. In some cases it may even reduce or eliminate it. By means of visual, auditory or written messages, doctor and patient can maintain a direct and frequent clinical dialogue in real time. The technical possibilities do not dilute, but rather reinforce, the obligation to authenticate the relationship, to let the patient know on each occasion which doctor is treating him or her at any given moment and which doctor assumes final responsibility for his or her attendance (Art. 10.2, 10.3).
Informed consent is a key part of telemedicine, with requirements added to those of conventional medicine). Before obtaining consent, the physician must ascertain the ability of the patient or, as the case may be, those close to the patient to operate the equipment to be used, and their skill ability to authenticate, obtain, encrypt, transmit, receive, document and interpret the information they send and receive via the telecommunication system. This requires, in addition to technical skill , a dose B of psychological disposition and ethical adherence11. In telemedicine, consent does not only refer to what may occur during the examination or treatment, but must include the use that may be made of the text or image records of a teleconsultation (Art. 10.4).
The truthfulness with which certify is to be used to report on the care provided is particularly important in telemedicine, whose technological component can lend itself to fraud: it is not difficult for those with the necessary technical knowledge to manipulate images and data, in order to create fictitious evidence or to change the issue or economic value of the medical acts that are billed to insurers. The possibility of manipulating records and reports makes them unreliable. It has been reported that certain experts have offered their services to subject documentation to cosmetic treatment to remove compromising data and to correct errors and omissions (Art. 11.1)12.
Telemedicine moves, in a kind of electronic transport, from the patient's home to the doctor's office, which is the ethical and legal place where telemedicine is practised13 . Consequently, the requirements quality standards required of the ordinary doctor's office apply directly to telemedicine installations and equipment. This gives rise to obligations to calibrate and periodically check instruments, to repair malfunctions, to produce protocols to avoid errors and to implement safety measures to prevent accidents. This is a decisive point: the clearer and more precise these protocols are, the easier it will be to distinguish between human error, fortuitous accident, lax or negligent conduct, and wilful misconduct (Art. 12).
The medical record must be scrupulously documented. As mentioned above, data, interventions and incidents can be immediately recorded in the electronic record. The digitised images should be archived so that they can be easily reviewed when appropriate. test Given the added risk of medical litigation that telemedicine may experience in the first years of its implementation, extreme care must be taken in the keeping of medical records, both as a record of clinical observations and judgements and as a testimonial record of consents and interventions (Art. 13.1).
It should not be forgotten that the file of data and magnetic-based images is of limited duration. It has been argued that keeping information only in electronic text is tantamount to self-inflicted dementia, as data is entrusted to a fragile, unstable and irretrievable report 14. Therefore, the obligation to keep records and diagnostic aids raises the problem of periodically recopying them to prevent deterioration. In contrast to the long life of printed word and image on paper, "magnetic media begin to lose integrity between 5 and 10 years, a tenth of the time that printed on acidic paper remains readable; that optically recorded on a compact disc (CD-ROM) lasts only 5 to 15 years, even with moderate use. Worse still, digital files do not degrade gradually, as does a tape. When they fail, they fail completely: they cannot be opened (Art. 13.2)15.
Professional secrecy of the doctor
The obligation of confidentiality has broad and intensive consequences in telemedicine, to which the concept that medical confidentiality is inherent to the practice of the profession applies with particular force (Art. 14).
All employees of the physician should be aware that they are obliged to maintain strict secrecy about personal data that they have come to know, and that if they breach this obligation they will suffer employment and criminal consequences commensurate with their misconduct (Art. 15.1).
Only the doctor manager of the case is authorised to transmit clinical information to others, which requires a rigid discipline between all components, medical and technical, of the telemedical service (Art. 15.2).
Of particular importance here is the protection of electronic information, whether stored in files or transmitted via network, against loss, leakage, theft or adulteration. The information transmitted must be only that which is relevant to the problem in question: the principle of parsimony must be applied here, which makes it necessary to be very selective in the recording of data and in its transmission to others (Art. 17.2)16.
The diligent use of information technology makes it easy to apply the ethical rules of maintaining a strict separation between clinical data and administrative data (Art. 17.2); of regulating the procedure encryption and access to stored information, so that the file can be considered as not connected to the network (Art. 17.4); of anonymising documentation to be used in scientific audits or management (Art. 17.5).
It is not possible to relax the internship of the deontological rule which establishes that the ultimate manager of the protection of the stored data must be a doctor: it is up to him to determine the system of delegation of functions to his collaborators, with the clear awareness that he bears the ultimate responsibility for the integrity of the secrecy (Art. 17.3).
Quality of medical care
Telemedicine, although still on a learning curve, is linked to a commitment to quality. Much research is still needed to clearly define its problems and promises, its advantages and weaknesses17. The implementation of telemedicine is not without its difficulties for many doctors, who are no longer young, some of them victims of an understandable but not justifiable technophobia18 . Today, the implementation of telemedicine is voluntary, supererogatory, and inhibition or refusal must be tolerated19. But it is conceivable that, in time, telemedicine could become, at least in certain circumstances, an obligatory part of the state of the art, resource of obligatory use for the correct care of certain patients (Art. 18.1).
Telemedicine offers doctors excellent opportunities to consult more competent colleagues. Once the technical difficulties of reliable transmission of digitised images have been overcome, diagnostic radiology, histopathology, dermatology and the more "visual" medical specialties have been regularly using enquiry remotely for years (Art. 19.1, 32.3)20.
It would be wrong and unfair to place telemedicine on the list of unvalidated medical practices. But it must be acknowledged that certain programmes have been adopted on internship telemedicine without having been subjected to the clinical trials necessary to prove their performance and benefits. Physicians should not be uncritically taken in by the technological fallacy (Art. 21.2)21.
Doctors' relationships with each other and with other health professionals
A major ethical problem in telemedicine is the question of how to deal with the ethical postulate that "ethical responsibility does not disappear or become diluted by the fact of working in a team". The possibilities of partnership opened up by telemedicine have not yet been fully explored. In telemedicine, work in a team requires the establishment of very precise rules for delegation to medical or non-medical collaborators, highly structured decision-making algorithms, and the establishment of a hierarchical chain of responsibility. How is responsibility shared in a telesurgery operation mediated by an "intelligent" robot? Is it ethical to install in them decision-making programmes that may contradict an order that deviates from the paradigm established by the designer? (Art. 33.2, 34).
Fees
The common fee rules apply to telemedicine to the full extent, both in the case of a direct doctor-patient relationship and in the case of a teleconsultation requested from an expert. Invoices passed on to the patient must clearly state which doctor's share of the total is due (Art. 40.3).
b. A specific message: the unethical nature of practising medicine exclusively by letter, telephone, radio, press or Internet.
There is, in the Code, only one indication on telemedicine, contained in the chapter on the quality of medical care. article 22.1 states that it is unethical to practise medicine by means of consultations exclusively by letter, telephone, radio, press or internet.
Our Code states that an ethical doctor/patient relationship is not possible if it relies exclusively on telemedical resources. Telemedical resources are a supplement to, not a substitute for, the necessary direct, face-to-face meeting between physician and patient. Professional ethics demands that, at some point in the professional relationship between doctor and patient - the sooner the better - an immediate contact , staff, should be established to enable the obligatory medical history and the corresponding physical examination to be carried out.
This is required by clinical tradition, never contradicted by the regulations of more recent times. The Code of the Spanish Medical Association is echoed, for example, by the Code of German physicians22 and that of the American Medical Association association 23. Their doctrine is endorsed by the Declaration of the association World Medical Association and by the Guidelines of the committee Permanent of European Doctors, which state, in almost identical words, that it is the norm for all patients seeking the doctor's committee to see him/her in a face-to-face enquiry ; and that, ideally, the doctor should only have access to a "direct telemedicalenquiry if he/she has had a previous professional relationship with the patient and can thus gain an adequate understanding of the problem at hand and form a correct and justifiable clinical opinion".
In a Charter adopted in April 2000, the Order of Doctors of France is even more explicit: "The Order is fully aware of the formidable opportunities offered by the development of the network at subject for health and patient follow-up. But this does not mean that the information or the telemedical committee can dispense the doctor or the patient from a real enquiry, with its anamnesis and clinical examination, leading to a diagnosis and a prescription24. Symbolically, some regulations for telemedical home care stipulate that the first and last medical act cannot be "video-visits", but rather visits by the doctor in person to the patient's home25.
In special situations, e.g. in psychiatric practice, the need for such a face-to-face relationship can take on special nuances. There is still no reliable programs of study as to how telematics can influence the dynamic aspects of the speech between psychiatrist and patient, and whether or not it can modify transference and countertransference. There is anecdotal evidence from data that some patients find it easier to communicate at a distance from the doctor than in the doctor's presence. It is even claimed that the interposition of telemedical instruments puts doctor and patient on an equal footing and diminishes the asymmetry of power that occurs in the ordinary enquiry . But the view still dominates that the telepsychiatric relationship cannot be the only contact between doctor and patient, but only a way of fill in the regular visit .
Even the language of telemedicine service offerings is fundamentally cautious in appealing to contact face-to-face. These services proclaim that telemedicine can solve many problems for patients in medically underserved areas, that it can provide real-time advice in emergencies, or that, through advice or treatment from test, it can alleviate anxiety for those who notice new symptoms. But they do not neglect to tell their clients that they will need to see a doctor in person in time, as they claim that telemedical services are in no way a substitute for regular medical care27.
It can be concluded that, for the time being, telemedicine can be guided by existing ethics, with the help of the necessary adaptations required by some of its specific features.
But we must not forget that telemedicine has only just begun. The problems will amplify as the use of telemedicine becomes more widespread and new capabilities become available at development . Telemedicine will surprise us with unexpected problems. It could, in the not too distant future, become the preferred way for many patients to interact with their doctors. It is not a very risky prediction to predict a telemedical invasion of the professional internship 28.
It is necessary to wait. For the time being, the CEDM has the light to illuminate the problems of telemedicine today. This link to deontology cannot be an obstacle to the expansion of telemedicine, but rather a channel to save it from possible aberrations.
In a few years (ten, twenty) things will be different: we will see how far telemedicine has come in its long-distance applications and to what extent it has infiltrated the internship suburban . In all likelihood, a new chapter in the Code will have to be opened for it.
bibliography and notes
(1) The following documents in particular are concerned: association World Medical Association. Declaration on Responsibilities and Ethical Guidelines in the Use of Telemedicine. Adopted by the 51st General Assembly, Tel Aviv, Israel, October 1999. (currently here). Hereinafter referred to as the Declaration. Standing Committee of European Doctors (CP). Ethical guidelines in telemedicine. Adopted, April 1997 (CP 97/033). Handbook of Policy Statements 1959-2000. Brussels, committee Permanent des Médecins Européens (CP) 2000:36-37. Hereafter referred to as Guidelines.
(2) This is not surprising: the Guidelines were offered to the Permanent committee by Dr. Fiárimaa of the Finnish Medical Association association ; and the Declaration resulted from the consolidation of documents contributed by the Finnish, French and American Medical Associations. association World Medical Association. project for a Declaration on Ethical Responsibilities and Ethical Guidelines in the Use of Telemedicine. Document from work 17.36/C, for discussion at the 153rd session of committee, Santiago, Chile, April 1999.
(3) In an analysis of the ethical discussion that preceded the adoption of the Guidelines, the following principles could be identified: Principle of responsibility, derived from the fact that telemedicine, insofar as it responds to a request for medical care, is to be considered without dispute as a medical act. Principle of security, which requires that data be properly protected when it is transmitted, reproduced and stored. Principle of confidentiality, which emphasises the importance of confidentiality in the remote doctor-patient relationship. subject The precautionary principle, which imposes, given the sensitive nature of data, particular care to protect the data handled from any computer crime by encrypting transmitted messages and archived documents. Principle of transparency, which obliges the doctor to give the patient the necessary and correct information to obtain his informed consent to the uses and applications of the data concerning him. Principle of non-maleficence, which implies abstention from any ethically unjustified and unauthorised operation. Haehnel P. L'impact de la télémedecine sur la deontologie medical en Europe. Colloque "Deontologie medicale et télémedicíne", du 6 mai 1996. Available here.
(4) The Guidelines state: "The principles of medical ethics binding on the profession must be followed at internship telemedicine. The Declaration states: "Regardless of the telemedicine system used by the physician, the principles of medical ethics to which the medical profession is globally bound must never be compromised. This is a universal, unanimous view. Two testimonies from very different institutional and geographical origins suffice. One, from the Order of Physicians of France: "The speech opportunities offered by the development of new resources, and in particular by the Internet, do not exempt the doctors who use them from any of their legal and ethical obligations and responsibilities. The rules set out in the Code of Medical Ethics apply to it in all their rigour, because it is a question of protecting the patient and acting in his or her best interests. Conseil National de l'Ordre des Médecins. Quality and ethics on the Internet. Charte adoptée lors de la session d'avril 2000. The other, from an Australian parliamentary committee : "Most experts were of the opinion that the existing codes of ethics that have been applied to the traditional way of practising medicine are fully relevant in the new technological environment. [...) The current ethical internship needs to be applied to the privacy, medical records and stranger presence issues of telemedicine" (Parliament of the Commonwealth of Australia, House of Representatives. Standing Committee on Family and Community Affairs. Health on line. Report into health information management and telemedicine. October 1997).
(5) "The possibilities offered by telemedicine should be open to all physicians across geographical boundaries," say the Guidelines. It is echoed in the Declaration: "Telemedicine [...] should be open to all physicians, including across national borders.
(6) In France, Dusserre and Chassort have made the interesting work of rereading the problems raised by telemedicine and the use of Internet in the light of the Code: Dusserre L. La prise en compte des nouvelles technologies de l'information par le code de déontologie de 1995. In: Colloque "Déontologie médicale et télémédecine", du 6 mai 1996. Chassort A. Exercise de la médecine et Internet. (currently here).
(7) For the sake of simplicity of the references to the text of the CEDM (1999 edition), the issue of the article referred to in each case will be indicated in brackets.
(8) Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000:320:1517-1520.
(9) Anderson RJ. Security in clinical information systems. London: British Medical Association, 1996.
(10) Spielberg AR. On call and online: Sociohistorical, legal, and ethical implications of E-mail for the patient-physician relationship. JAMA 1998:280:1353-1359.
(11) Stanberry B. Telemedicine: barriers and opportunities in the 21' century. J Intern Med 2000;247:615-628.
(12) Anderson R. NHS-wide networking and patient confidentiality. BMJ 1995;311:5-6.
(13) Besses GS. Telemedicine: legal issues. In: Sanbar SS, Gibosfky A, Firestone MH, LeBlang TR. Legal Medicine. 41 ed. St. Louis; Mosby, 1998:610-615.
(14) Davidoff F. Suppose there were no printers. Ann Intern Med 2000;133:57-58.
(15) Brand S. Ending the digital dark age. In: The clock of the long now. Time and responsibility. New York: Basic Books; 2000:82-92.
(16) Herranz G. Medical requirements in data protection. In: Commission of the European Communities DG XIII/FAIM. Data protection and confidentiality in health informatics. Handling health data in Europe in the future. Amsterdam; IOS Press, 1991:71-79.
(17) Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promises. Ann Intern Med 1998;129:495-500.
(18) Drezner JL. Understanding adoption of new technologies by physicians.
(19) Nutig MH. Second opinion: Understanding physician resistance proves key to overcoming it. Telemedicine Magazine, June 1998.
(20) Goodman KW. Ethics, computing and medicine. Informatics in the transformation of health care. Cambridge: Cambridge University Press, 1998:13.
(21) Wyatt JC. Commentary: Telemedicine trials - clinical pull or technology push? BMJ 1996;313:1380-1381.
(22) Bundesarztekammer. (Muster) Berufsordnung für die deutschen Arztinnen und Arzte. Deutsche Arzteblatt 1997;94:A2354-A2363. Paragraph 7 (3) of the Code states: "A physician may not perform individual medical interventions, including in particular the giving of advice, exclusively through newspapers or magazines, nor exclusively through the media of speech or computer networks speech ".
(23) American Medical Association. Council on Ethical and Judicial Affairs. Code of Medical Ethics. Current Opinions. 1996-1997 edition. Chicago: American Medical Association, 1997. Opinion 5.025 states: "Any telecommunications service should apply certain safeguards to prevent abuse. For example, a physician responding to a call should not make a clinical diagnosis, since diagnosis by telecommunication would be made without the essential financial aid physical examination and face-to-face meeting with the caller. The doctor could then be missing data decisive information. Physicians responding to calls should act within the limits of telecommunication services and ensure that callers understand the limitations of such services. Under no circumstances should they prescribe medication.
(24) Chassort A. Qualité et déontologie sur Internet. (currently here).
(25) American Telemedicine Association. Telehomecare clinical guidelines.
(26) American Psychiatric Association. APA resource document on telepsychiatry via videoconferencing (approved by APA Board of Trustees 7/98). (current version here)
(27) Thus, for example, the US-based tele-medical services organisation CyberDocs requires that "All patients it serves must be seen promptly by a physician in person. CyberDocs believes that it is providing a valuable service to its patients by providing access to an online, real-time medical enquiry , but recognises that telemedical consultations suffer from clear limitations, chief among which is the inability (at present) to perform physical examinations over the Internet [...] We must emphasise that we are NOT in any way a substitute for conventional medical care, which the patient does in person with a physician of his or her choice. Treatment may be indicated to prevent your health from acutely deteriorating while you are waiting for an examination in the conventional health care system (doctor's office, outpatient clinic, hospital emergency department), but such follow-up IS vitally necessary and will be ordered for you if you use our services". Cyberdocs. Why do I need medical follow-up? In: Frequently asked questions.
(28) B. Glorion, President of the Order of Physicians of France, has stated, not without rhetoric, that the implementation of telemedicine is an inexorable and imminent event: "I often quote Sauvy's phrase that 'progress condemns us to perpetuity, i.e. we cannot refuse progress, we cannot refuse telemedicine [...] telemedicine will invade medicine in the years to come'". Glorion B. Conclusion. Colloque "Déontologie médicale et télé médecine", du 6 mai 1996.