Proceedings of the 8th WSEAS Int. Conf.

on ARTIFICIAL INTELLIGENCE, KNOWLEDGE ENGINEERING & DATA BASES (AIKED '09)

Telemedicine and ethical dilemmas

LILIANA ROGOZEA,
LUCIANA CRISTEA,
MIHAELA BARITZ,
VICTORIA BURTEA
Transilvania University of Brasov
ROMANIA
r_liliana@unitbv.ro

Abstract: Telemedicine is still under development and the main goal is to deliver medical care at distance. The
application of telemedicine and telecommunication – telematics – in the healthcare system is the privilege of the rich
countries, where reliable and secure satellite connections are available at high speed transfer rate, and its use is limited
by the necessity to exist the highly sophisticated equipment. To facilitate telemedicine applications for all countries is
one of the goals for the next years. In the same time, educational programs in the field and ethical analyzes are not only
a trend for the next years but a real necessity. In this respect, in this paper, we will consecutively pay attention to the
ethical aspects of telemedicine correlate with patients, health care services, communication or biomedical literature.

Key Words: ethics, telemedicine, health care

1. Introduction European citizens are getting older and life expectancy

In this paper we reflect the phenomena of telemedicine,
its implication and the common problems develop by
this new way in medicine.
Telemedicine can improve the lives of European
citizens, both patients and healthy people, and also
integrate at a higher level the activities of health
professionals, while tackling the challenges of
healthcare systems. [1] (fig.1.) According to WHO
statement made in Geneva in December 1997:
“Telemedicine is the delivery of health-care services,
where distance is a critical factor, by health-care
professionals using information and communication
technologies for the exchange of valid information far
diagnosis, treatment and prevention of disease and
injuries, and for the continuing education of health-care
providers as well as research and evaluation, all in the
interests of advancing the health of individuals and their
communities.” [10]
Figure 1.
is greater because we are developing better and new
treatments and we can use better and better drugs. In that
context there are a greater number of people living with
chronic diseases. Their health condition often requires
enhanced medical attention. Medical support may not be
available in remote areas as easily or as frequently as
their health condition would require.
"Telemedicine can radically improve chronically ill
patients' quality of life and give people access to top
medical expertise. It is our duty to make sure patients
and health professionals can benefit from it," said
Viviane Reding, EU Commissioner for Information
Society and Media. "At the same time, the provision of
remote healthcare services through ICT can optimize the
use of scarce human and financial resources in the
medical field." [10]
2. Changes in Health care environment?
Introducing telemedicine could help doctors and
patients access health care from distance, but there are
also many considerable problems that must be solved in
order to successfully implement telemedicine in medical
systems (fig.2).
There are a number of challenges generated by
changes done in the health-care environment like: [2, 4,
and 5]
ƒ population mobility and continuity of care,
ƒ increasing the number of female who work,
ƒ conflict between home care and care in special
units,

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 Proceedings of the 8th WSEAS Int. Conf. on ARTIFICIAL INTELLIGENCE, KNOWLEDGE ENGINEERING & DATA BASES (AIKED '09)

ƒ necessity of distant monitoring of health status,
including between hospital and home,
ƒ the grievance of political and economical to reduce
the expenditure in health sector
ƒ increasing the role of bioinformatics and electronic
evidence
ƒ developing new concept of e-Health and evidence
based medicine
ƒ to use advanced diagnostic and therapeutically
technologies (CT, MRI, etc.) for a large number of
patients/citizens
ƒ to develop a health promotion system
ICT and Telemedicine can contribute to win these
challenges by improving the level of health maintenance
and reducing costs. (fig.3)

Figure 3.

3. Telemedicine – medical aspects

Figure 2. Telemedicine (fig.4.) use ICT, in situations where the
health professional and the patient are not in the same
In spite of some difficulties and barriers which can
location. Also it can be used when a doctor like to
appear, telemedicine could be a good opportunity for
receive an advise from other colleagues. In that context,
helping people, especially because in the last decade we telemedicine encompasses a wide variety of services,
remark a lot of challenges in medicine, like: [7, 9] like: telemonitoring, telepathology, teleconsultation, and
ƒ increase the number of elderly people telesurgery. [9]
ƒ increase the morbidity by chronicle or
cardiovascular diseases, cancer, neuropathologies,
genetic diseases
ƒ change the spectrum of infectious diseases
ƒ developing international programs for diseases
prevention (epidemiology)
ƒ developing rehabilitation centers and home care
assistance.
Citizens/patients ask for more information and in future
also will increase the facilities to give to citizens
accurate, easy to understand and up to date information
about health, preventive disease and also about the
health system.
The health system records challenges of healthcare
providers (public and/or private) structures based on the
new philosophy of development this sector. The
directions are:
ƒ to improve quality and treatment for each person
ƒ to develop standards of care for patients and of life
for the citizens
ƒ to reduce costs Figure 4.

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 Proceedings of the 8th WSEAS Int. Conf. on ARTIFICIAL INTELLIGENCE, KNOWLEDGE ENGINEERING & DATA BASES (AIKED '09)
The effects of using telemedicine could be:
ƒ re-organization and re-deployment of healthcare
resources
ƒ increase quality of care for patients
ƒ a coherent partnership between patients, health
professionals, healthcare providers
ƒ optimize the patient's monitoring and treatment
protocols
4. Ethics and telemedicine.
Telemedicine and its branches put a number of ethical
problems, which must be solved for giving a high level
of trust in these methods.
Virtual consultation, virtual libraries, telepharmachy,
teleradiology and of course, security issues are only few
elements connected with ethical dilemmas. [3, 9]
Figure 5.
The most important problems (fig.5) develop in the
telemedicine ethical fields are:
ƒ how is certificate the competence of medical doctors
involved in telemedicine
ƒ how is assure the confidence in telemedicine
ƒ how is achieved the confidence and acceptance of
telemedicine solutions by health professionals,
patients and health authorities
ƒ how is assessed the efficiency of telemedicine
ƒ how are respected the rights and fundamental
freedoms
ƒ how is influence the health professional – patients
relationship
ƒ how safety are the patients records
ƒ remote real-time examination, remote real-time
assistance, remote robotic surgery
ISSN: 1790-5109
Telemedicine means to practice medicine at the distance,
but not at distance of competences. Foe example, in
order to certificate the quality of medical sites it
becomes obvious that it must be found a way to
certificate the competences of people who use
telemedicine services, and also to certify the quality of
connection. [8]
Telemedicine consultation is one of the high
challenges for medicine today; the doctors must have
very good abilities, adequate knowledge and to accept
the virtual community. Tele-monitoring could be very
useful for people who live in inaccessible areas, but
generating this process could be unwholesome.
Even if some computer scientists think that is possible
to have a maximum security of data used in e-Health,
unfortunately, our experience show that even most
secure systems can be broke. But, of course using
electronic data means to allow doctors to have access to
medical records and databases and, of course, to assure
the updating process of patients’ data.
Also are very important to development the
telemedicine into benefit patients and society, make
telemedicine information available to others, encourage
development the doctors specialist in telemedicine,
provide telemedicine services with a high accessibility
or use telemedical resources to acquire new knowledge,
to learn new skills, and maintain their levels of expertise
Recognized standard of telemedical care is an important
step for developing the future medicine. [6]
5. Ethics and telemedicine – few
dilemmas in students view
In order to see how telemedicine is perceived by our
medical students we have design a survey based on a
questionnaire. The study group comprises 174 students
which have a minimum of 18 and a maximum of 47
years. The study was realised in December 2008-
January 2009, in Transilvania University of Brasov and
University of Iuliu Haţieganu Cluj.
One of the questions addressed to medical students
was: In what scope we can use telemedicine? (fig. 6)
They have the possibility to choose one or more
answers:
a. deliver the data between patients and doctors
b. for the isolate regions, for regions affected by war
c. for developing mobile applications useful in
ambulance services
d. for developing the application which permit
consultation at home, facilitating the doctors access
and reducing the time until the consultation is
possible
e. to reduce the expenditure of medical offices.
43 ISBN: 978-960-474-051-2
 Proceedings of the 8th WSEAS Int. Conf. on ARTIFICIAL INTELLIGENCE, KNOWLEDGE ENGINEERING & DATA BASES (AIKED '09)

abcde 4 100% 16
abde 2 90% 39 44 39 36
29
abcd 14 80%
27
70% 24 36
bce 1 36 46
60%
bcd 1 43
50% 43
64 35 29
ade 11 40%

acd 9 30% 21 25 25 39

abd 2 20%
41 35 34 35 29
10%
abe 8
0%
abc 13 1 2 3 4 5
e 16 39 44 39 36
de 8
d 29 36 36 46 27
ce 1 c 24 43 35 29 43

cd 3 b 64 21 25 25 39
a 41 35 34 35 29
be 9
bd 4 Figure 7.
bc 9
ae 5 Another problem discuss was: Confidentiality in
4
ad telemedicine is in connection with ….? (fig.7)
ac 2
a. to respect the patients rights so that the information
ab 17
4
about the patient is to be known only by the
e
7
doctors or nurses involved in her/his treatment;
d
c 6 b. to assure the security of the information that is
b 21 transmitted;
a 9 c. to respect the confidentiality rules not only by the
medical professional group, but also by the
0 5 10 15 20
specialist in telemedicine involved in medical
activity.
Figure 6.
The majority of the students think that the greatest
problem in respect to confidentiality is to ensure that
The students think that is very important to use confidentiality rules are respected not only by the
telemedicine especially for the isolate regions medical professional group but also by the other
(geographical or political) this result being in specialists in telemedicine which could be involved in
according with the idea of medical doctors that this process. (60%)
telemedicine could change the communication process Also, 17% of them think that confidentiality is in
between medical staff and patients and that it is better connection with more than one problem, being a
to be used only if it is necessary. complex process.
One of the problem discuss with the student was: What The lowest percentage was obtained by answer b), to
are the principal ethical problems developed by assure the security of the way how is transmitted the
telemedicine? The students were request (fig.7) to put information. (fig. 8)
in order the next affirmation, from 1 to 5 (5 being the
problem with biggest importance):
a. not knowing the competence of the person who uses 80
80
this facility 70
b. the change in the relation doctor-patients
60
c. confidentiality, reliability and security
d. possibility to obtain incomplete information, 50

according with the level of education of patients or 40

the people from their entourage 37
30
e. the manner of store and transfer of the information 27 15
regarding the patients 20
6 6
As it could be seen in the next graphic the biggest 10
3

problem is sought to be the risk of loosing

0
confidentiality. Only on the second place is the a b c a+b a+c b+ c a+b+c
possibility to modify the relation between patient and
doctors. (fig.6) Figure 8.

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 Proceedings of the 8th WSEAS Int. Conf. on ARTIFICIAL INTELLIGENCE, KNOWLEDGE ENGINEERING & DATA BASES (AIKED '09)
8. Conclusion
Telemedicine is for the e-patients, for the real ones or
for both?
Sharing the uneasiness is a good way for avoiding the
ethical problems and to use in a safe mode the
computers and electronic facilities.
Telemedicine needs abilities in medicine, telecommu-
nication and information technologies sectors, which
could be assure only in a multidisciplinary team
In the same time, the team who analyzes the ethical
problems must be also interdisciplinary. Telemedicine
applications have to be developed by the doctors,
engineering and computers scientist together. [2] That
means that telemedicine must evolve as a stand alone
speciality, not only a medical competence. Even if the
team is interdisciplinary, the physician must understand
technical problems and the computer scientist must
understand medical terminology.
The survey conducted among medical students, shows
that they have a good opinion about telemedicine, but
very few experience and real knowledge. The low
percentage of interest obtained by the transmission
security issue is an indicator of the need to find a way
for students to assist to telemedicine experiments.
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