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HEA0010.1177/1363459319891213HealthBotrugno

Article

Health

Information technologies 1­–19

© The Author(s) 2019

in healthcare: Enhancing or
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DOI: 10.1177/1363459319891213
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dehumanising doctor–patient journals.sagepub.com/home/hea

interaction?

Carlo Botrugno
University of Florence, Italy

Abstract
Since the very emergence of the information technologies in healthcare, a major concern
has been raised about the potential of remote services to undermine the intimacy,
immediacy and humanity intrinsic to conventional, face-to-face medical practice. By
contrast, notable literature reports the benefits of information technology–mediated
services and their potential to improve efficiency and economic convenience of healthcare
systems. This article aims to shed light on this ambivalence by retracing the evolution
of doctor–patient interaction in relation to the main technological advancements
in healthcare, and in particular, to services mediated by information technologies.
Consequently, the reduction of cues and clues associated with the use of these services
is framed into the reductionism of the biomedical paradigm, which provides a key to
interpret the nature, scope and features of this process of technological innovation,
along with its potential and limits.

Keywords
dehumanisation, doctor–patient interaction, information technologies, reductionism,
technological innovation in healthcare

Introduction
From the Hippocratic foundation up to modern times, a myriad of factors contributed to
shape the features, the techniques and even the aesthetics of medical practice – in par-
ticular, the forms and rituals of doctor–patient interaction. As further illustrated below,

Corresponding author:
Carlo Botrugno, Research Unit on Everyday Bioethics and Ethics of Science, L’Altro Diritto Interuniversity
Research Centre, Department of Legal Sciences, University of Florence, via delle Pandette 35, 50127
Firenze, Italy.
Email: carlo.botrugno@unifi.it
2 Health 00(0)

the complex, goal-oriented and bureaucratic organisation of contemporary healthcare

systems has progressively led to the shift of this interaction from an enduring and inti-
mate personal relationship to more brief and impersonal forms of interaction (Clark and
Mishler, 1992; Ha and Longnecker, 2010). In this metamorphosis, a primary role has
been played by technological innovation. Within the wider landscape of technological
innovation in healthcare, the latest significant stage is currently represented by the advent
of information technologies (ITs). ITs are increasingly permeating medical practice, not
only to ease communication tasks (as they can for email exchanges) but also to carry out
highly complex medical procedures at distance, like in the case of telesurgery.
The spread of ITs is contributing to a significant extent to virtualise patients’ bodies
while reshaping the valence of touching and physical examination, which for many cen-
turies has represented the primary tool at the disposal of physicians. Moreover, most of
these IT-mediated healthcare services envisage that the physical presence of doctors
themselves will soon become unnecessary, which has brought a number of scholars to
express concern about the overall impact that ITs will have on doctor–patient interaction
and the quality standards of healthcare-delivery (Fleming et al., 2009; Kaplan and
Litewka, 2008; Kluge, 2011; Lateef, 2011; Schermer, 2009). However, while the available
literature usually identifies the most relevant ethical issues to deal with when considering
the use of remote services, it often does not clearly address those issues nor does it provide
a sort of guidance to inform clinical practice. In this context, this article aims at exploring
the relationship between the most recent evolution of doctor–patient interaction and the
latest technological advancements, in particular, with reference to the spread of
IT-mediated healthcare. This work may shed some light on the main ambivalence sur-
rounding the use of ITs in medical practice, that is, their potential to ‘dehumanise’ doctor–
patient interaction, as well as to enhance it by means of virtuality. As a matter of fact, the
lack of physical presence reduces the number of cues for the evaluation of physicians.
This unavoidably leads to wonder whether – and to what extent – technologies intersect
and/or overlap the ‘reductionism’ of medicine in the terms defined below (par. 7).
The article starts by retracing some of the major technological advancements in
healthcare, in which the advent of the ITs in healthcare is then framed (par. 2). After this,
other factors are briefly recalled that, in correlation with technological innovation, have
contributed to redesigning healthcare practice towards a modern system, which progres-
sively turned the doctor–patient relationship into a provider–user interaction (par. 3).
Afterwards, the psychotherapeutic function that a good doctor–patient interaction may
achieve is remarked upon (par. 4), and thus the importance of physicians developing
excellent communication skills to exhibit in the ever-briefer encounter with patients. In
the following paragraph (par. 5) the spread of ITs in healthcare is linked to the emergence
of a new forma mentis, which resonates both in a notable literature (Eysennbach, 2001;
Floridi, 2018) as well as at a political level (European Commission, 2012, 2017, 2018).
After that, the debate on the potential effects of implementing ITs in healthcare is retraced
(par. 6), with a view to provide a better understanding about the effective benefits they
bring to medical practice as well as their potential drawbacks. In the end, the reduction
of cues and clues brought by ITs is linked to the innermost features of the biomedical
paradigm (par. 7), which may help to understand further the intrinsic nature of this pro-
cess of technological innovation, along with its potential and limits.
Botrugno 3

Technological innovation and the ‘virtualisation’ of

healthcare practice
Since the time of Hippocrates, doctors have commonly used their sensory perception –
the so-called five senses – to perform a physical examination on patients’ bodies (Bynum
and Porter, 1993; Ha and Longnecker, 2010), together with the central role of the patient’s
description about their experience of illness (Clark and Mishler, 1992; Hunter, 1991).
The results of this in-depth scrutiny would have later converged into a rational interpreta-
tion, prior to the formulation of a diagnosis. As has been argued,

Before the late twentieth century, most doctors relied heavily on physical exam, observations
and intuition, where they listened to patients’ complaints and performed a sort of laying on of
hands to diagnose, and sometimes treat, illnesses. The doctor touched each tool he used –
scalpel, speculum, stethoscope – which in turn touched the patient. Each tool was a physical
extension of his hand, eyes, or ears. The patient was integral to the exam, the diagnosis and the
treatment, at least in terms of a physical presence. (Koller, 2011: 19)

Doctors’ modus operandi has significantly changed due to a series of technological

advancements that have shifted the diagnostic process towards the paradigm of virtuali-
sation and representation of the patient’s body. Among these advancements is the discov-
ery of X-rays by the German physicist Wilhelm Conrad Röntgen, in 1895. Although at
first it was conceived as a mere diagnostic tool, the subsequent development of medical
imaging would progressively turn into one of the most important diagnostic methods
known to date (Da Gama, 2001). The availability of tools such as magnetic resonance
scans, nuclear medicine and computed tomography – among many others – provided
physicians with ‘a window into the body that shows objective evidence of disease and
decreases their reliance on the patient’s subjective complaints’ (Koller, 2011: 3).
Considering the relevance assumed by medical imaging in routine healthcare practice, it
has been underscored that these technologies

are changing the way that we look at our bodies and our doctors. We can see our bodies as they
are and as they are not. [. . .] We do recognize the power of medical technology over our lives,
in that it can seek and destroy disease and lengthen our lives. (Koller, 2011: 14)

The availability of radiological images has significantly lessened the need for physicians
to rely on patient descriptions, while it has increased their reliance on the formal organi-
sation of healthcare (Berger, 1999). In addition, these technological advancements

added a highly persuasive rhetoric to the authority of medicine. They also made it possible to
move part of the diagnostic process behind the scenes and away from the patient where several
physicians could have simultaneous access to the evidence. (Berger, 1999: 5)

Another step towards the virtualisation of healthcare is the spread of electronic health
records (EHRs) as a standard for the documentation of patient-related data. As known,
EHRs are an integral part of the digitalisation process recently fostered by the increasing
availability of ITs. Though the introduction of medical records is usually attributed to
4 Health 00(0)

Hippocrates, traces of novel forms of organising the knowledge related to patients’ condi-
tions include a myriad of advancements, from the Egyptian papyrus (Al-Awqati, 2006) to
the case histories of the medieval period (Alvarez, 1999). However, a systematic use of
keeping records on note books was first reported in the middle of the 16th century, in
particular, in Italy (Kassell, 2016: 121). Today, EHRs are spreading in medical practice at
a fast pace, with several healthcare systems in western countries adopting strategies of
massive digitalisation of patients’ health data (among which includes the United Kingdom
and Australia).1 Undoubtedly, EHRs represent an inestimable tool for improving the qual-
ity and the efficiency of the modern organisation of healthcare (Shortliffe, 1999; Van
Bemmel and McCray, 2016). However, concerns have been raised on the risk that an
excessive affordance to EHRs may undermine the quality of doctor–patient relationship:

physicians must not allow technology to devalue the doctor-patient relationship and a continuity
of care in which the patient as person maintains a place in the memory of a clinician, not merely
a computer. The electronic health record/electronic medical record must enable this relationship,
not interfere with it as when the physician faces a computer screen with back towards the
patient. (Gillum, 2013: 856)

The modern organisation of healthcare systems

Along with technological innovation, other factors have contributed to the recent meta-
morphosis of doctor–patient interaction towards a provider–user perspective. Among
these factors is what has been referred to as the ‘modification of the main object of medi-
cine’ (Da Gama, 2001), that is, from treating patients’ disease to optimising the popula-
tion’s health. Here it is worth remembering that this shift has attracted the attention of
several scholars from the most diverse disciplines, which have diversely interpreted the
effects correlated with the emergence of the modern clinic, in particular, around the 18th
century – for example, the Disappearance of the Sick Man by Nicholas Jewson (1976),
the Birth of the Clinic by Michel Foucault (1973) or the Division of the Clinical Work by
Paul Atkinson (1995). For the purposes of this article, however, it is sufficient to consider
that such a transformation has significantly contributed to the physical distancing
between doctors and patients. Indeed, since doctors have been progressively attracted
into a system, they became – or were induced to become – public officers, charged to
pursue a public interest, and thus called to deal with numbers more than with people. In
this regard, the Italian sociologist Paolo Donati has described how doctor–patient rela-
tionship was becoming:

ever more impersonal, rushed and superficial, one in which each knows ever less of the other.
The technologies and the procedures that mediate this relation also change. Thus both doctors
and patients increasingly rely on technical tools (gadgets, devices, laboratories, etc.) that
distance their subjectivity. (Donati, 1984: 555; translated from the original in Italian)

Hence, doctors progressively lose the traditional spirit that inspired doctor–patient inter-
action since the time of Hippocrates, growing distant from that privileged relationship
between two people: one seeking help that can be found in the other’s main vocation.
Botrugno 5

Surprisingly, this metamorphosis has been also linked to the progressive inclusion of
the right to health among the fundamental entitlements guaranteed by the constitutional
legal orders in western countries (Da Gama, 2001). Accordingly, the emergence of such
a right has represented a first cause of conflict between doctors and patients:

This notion of right implicitly covers that of duty or obligation – the non-satisfaction of a right
being source of frustration and claiming – and represents one of the possible factors that
produce tension, suspicion and conflicting spirit that have instilled in doctor-patient relationship.
(Da Gama, 2001: 287; translation from the original in French)

A further factor that has contributed to reshape the innermost features of medical
practice is the powerful lobbying of medical corporations, which have slyly permeated
all the relevant sectors of public healthcare organisation – for example, professional
education, research funding and adoption of new drugs and devices. This has had a nox-
ious impact on doctor–patient interaction, as proven by the mounting trends of consum-
erism and commoditisation in healthcare:

Physician employers, pharmaceutical companies, and insurance companies have abruptly

entered the once private relationship between physicians and patients, changing a true
relationship into a simple encounter. The substitution of the generic terms physician and patient
for provider and client mirrors the increased impersonality of the encounter based on the
commercialization of medicine. (Osorio, 2011: 400)

Accordingly, the interaction between doctors and patients has progressively lost the
semblance of a relationship and has rather turned into a mere encounter – or a series of
encounters – within which doctors hurriedly collect the information they need and use it
in an impersonal way, that is, objectively. Thus, given that doctor–patient interaction is
no longer necessarily based on an intimate and personal relationship, its main core shifts
from the level of sensory perception and emotional proximity towards that of verbal
communication, thus conferring a special importance on doctors’ communicative skills.

Communi-care: doctors’ skills and the second death of

Hippocrates
To understand the potential impact that good communication between doctors and patients
may have on the therapeutic course, the famous quote by the Hungarian psychoanalyst
Michael Balint should be recalled: the doctor herself/himself is the most frequently pre-
scribed medication, which illustrates the well-known approach applied in the field of
group psychotherapy (Balint, 1957). Moving from this acknowledgement, the importance
of the emotional connections usually implicit in a good doctor–patient relationship has
been stressed also in medical practice (e.g. Hodgkin, 1996; Hunter, 1991; Silverman,
1987). In this way it has been argued that when going to the doctor, implicitly or explic-
itly, patients seek for a kind of interaction that may be somewhat affective: ‘expressing
verbally his/her own troubles enables the patient to unburden the tension accumulated
because of doubt, imagination, concerns and fear related to the disease. This contributes
6 Health 00(0)

to demonstrate the psychotherapeutic function that a good conversation achieves’

(Cazzullo and Poterzio, 2007: 18; translated from the original in Italian).
However, the progressive attenuation of physical and emotional closeness between
doctors and patients has made the establishment of an affective relationship ever more
arduous. In this regard, it must be acknowledged that in medical practice,

usually, there is little room for an exchange of words between patient and physician. Erroneously,
it is considered as a waste of time. Often, the communication is reduced to a mere exchange of
objects such as copies of documents, reports, prescriptions, radiographies. The interaction ends
up becoming an interrogation: the brief investigation is limited to the scientific field of the
supposed disease and to the specialist domain of the physician. (Cazzullo and Poterzio, 2007:
18; translated from the original in Italian)

The interposition of a series of data and information obtained with the support of new
technologies has contributed to weakening the physical and emotional intensity that was
intrinsic of a good-quality doctor–patient relationship, leading some scholars to talk
metaphorically of a second death of Hippocrates (Da Gama, 2001).
Thus, in absence of that kind of mutual knowledge that proceeds from an intimate
relationship – one consolidated over the time – the establishment of a good feeling
between doctor and patient can only be achieved if the first is able to adopt certain behav-
iours and styles of interaction:

the way in which doctors and patients behave during a consultation may influence a patient’s
subsequent state of health. More control by patients, more expression of emotion, and more
information sought and provided have all been shown to be associated with better health on
follow-up [. . .] Doctors with ‘integrated’ styles, characterized by patient and goal orientated
approaches, appeared to enable patients to feel more healthy and have a more realistic
expectations of professional help, than doctors with ‘interventionist’ or ‘minimal diagnostic’
styles. (Dowrick, 1997: 12)

According to José Henry Osorio (2011), building a good feeling in the few minutes avail-
able with a patient often previously unknown requires doctors to deploy two kinds of
communicative skills: instrumental communicative skills, through which patients are
provided with necessary information and their doubts are addressed; and emotional com-
municative skills, which allow them to act with empathy and show to patients the com-
mitment and effort they put in addressing their cases (p. 402). In this perspective, a good
doctor–patient interaction is the one characterised by a kind of affective interaction or a
good equilibrium between instrumental and emotional communication. Of course, this
equilibrium is not to be presumed, nor is a constant, but instead varies according to the
situations, needs and concerns expressed by each patient. However, its achievement has
been intended as a primary function of contemporary medical practice:

Good doctor-patient communication has the potential to help regulate patients’ emotions,
facilitate comprehension of medical information, and allow for better identification of patients’
needs, perceptions and expectations. Patients reporting good communication with their doctor
are more likely to be satisfied with their care, and especially to share pertinent information for
Botrugno 7

accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment. (Ha
and Longnecker, 2010: 38)

Patients indeed look to doctors as the most reliable resource available and view them as
a source of psychological support and empathy. These elements are fundamental for
patients, insofar as they allow them to reduce and control sensations, such as isolation
and frustration, and thus contribute to making sense of their own conditions. Nevertheless,
this equilibrium cannot be achieved if doctors deny their patients the opportunity and the
time to discuss available treatments and their possible alternatives. Thus, doctors are
expected to guide their patients in the process of choice and to share with them the
responsibility for any decisions taken (Goldim, 2006: 90). This entails a specific negotia-
tion with patients, one in which personal situations and conditions are assessed, and
possible treatments are suggested and tailored on the basis of individual cases more than
on standardised protocols.

The spread of the ITs in healthcare: from bedside to

webside
The introduction of ITs in healthcare is shifting conventional medical practice, allowing
health professionals to interact remotely with patients (telemedicine or telehealth), to
monitor patients’ conditions by means of wearable or implantable sensors and devices
(telemonitoring or telecare), to integrate healthcare-delivery by means of virtual services
(virtual and/or augmented reality) or even to obtain an automated diagnostic response
by means of algorithms and data mining applications (artificial intelligence systems).
Among the main implications of the digitalisation process is that patients’ bodies are
not only increasingly virtualised but also datafied, stored and accessed over the wire
(Atkinson, 1995; Cartwright, 1995; Lun, 2018). At a closer look, this is consistent with
the idea that IT-mediated services in healthcare are contributing to the emergence of a
new forma mentis (Eysennbach, 2001) on the basis of which it is assumed that health
professionals are significantly advantaged by the availability of a larger amount of health
data – most of which is remotely collected – and that patients are finally given the oppor-
tunity to be more autonomous and more engaged in the control of their own health condi-
tions. This idea not only resonates among notable literature (e.g. Lear, 2018; Noel et al.,
2018; Rubeis et al., 2018; Sirintrapun and Lopez, 2018) but has also been endorsed at a
political level, as shown by the orientations adopted over the last two decades by the
European Commission within the wider framework of the Digital Single Market (e.g.
European Commission, 2012, 2017, 2018). However, for the purposes of this article,
it must be acknowledged that, despite the undeniable advantages associated with digitali-
sation, concerns have been raised on the economic convenience and the efficiency of
IT-mediated healthcare services. In particular, the Whole System Demonstrator
Programme (WSDP) must be mentioned, which currently results as the biggest trial ever
conducted in the field of telehealth/telemonitoring. The WSDP had a total length of
approximately 4 years and it has been financed by the UK Department of Health at a total
cost of 29 billion pounds. Its main purpose was to collect robust evidence of the benefits
of remote healthcare with a view to launch a massive implementation of remote services
8 Health 00(0)

in the UK National Health Service (NHS). Despite the enthusiastic declarations released
by the Department of Health on the benefits of remote services,2 the researchers at work
on the trial have been cautious when interpreting collected findings:

this study has shown that a smaller proportion of telehealth users than controls were admitted
to hospital during a 12-month follow-up. However, the magnitude of the group difference in
admission proportion was relatively small [. . .] raising questions about the clinical relevance
of the results. (Steventon et al., 2012: 5)

In addition, it has been underscored that most of the evidence available in the field is
inadequate as it relies on small-scale and poorly designed studies, which make it difficult
to generalise findings as well as to translate them in medical practice: ‘The current find-
ings underline the importance of using data from adequately powered, high quality trials
to make decisions about telehealth implementation and caution against reliance on meta-
analyses based on small, poor quality studies’ (Cartwright et al., 2013: 7).
Nevertheless, notable literature remarks on the potential of ITs to improve the quality
and increase the efficiency of healthcare. For instance, with regard to the follow-up after
hospital discharge, it has been stated that ITs provide

an important opportunity for telehealth intervention allowing for daily surveillance of vitals,
weekly virtual visits and review of all available electronic data. This practice of telemedicine
may potentially reduce dangerous adverse events through improved patient-provider
communication, medicine reconciliation, patient education, and assurance of patient
hemodynamic stability. (Noel et al., 2018: 9)

Likewise, mobile health applications and services appear to be promising, which have
been deemed to represent

a critical tool for cancer care from prevention to palliation. Recognizing that patients with
cancer seek to stay well while staying closer to home and limit time in the outpatient and
inpatient medical settings, mHealth’s goal is to help patients stay well while staying closer to
home and living their lives. (Sirintrapun and Lopez, 2018: 542)

A more specific field within the wider landscape of ITs is currently represented by
virtual reality (VR), whose benefits have been estimated to embrace an increasing
range of specialties and interventions. Just to mention a few: the virtual postopera-
tive follow-up, which is credited to enable economic savings and improve quality of
care: ‘The real promise of virtual postoperative care is to move beyond remote iden-
tification of early complications and support real-time recovery that aims to identify
and treat early phase complication aggressively’ (Cornejo-Palma and Urbach, 2018:
2); the virtual simulation of magnetic resonance imaging, which allows the ‘desen-
sitisation’ of future patients thus avoiding claustrophobia: ‘There clearly is an oppor-
tunity to improve care by making our patients aware of what to expect during the
procedure in advance of actually having the scan’ (Brown et al., 2018: 97); or virtual
rehabilitation:
Botrugno 9

combining the accessibility of telerehabilitation and motivation aspects of VR seems convenient.

[. . .] The functional improvements tend to be equal compared to a similar intervention with
therapist-supervision in the clinic, suggesting that for efficient rehabilitation parts of therapy
could be transferred to the homes. (Schröder et al., 2019: 81)

The virtual means is deemed to be a valid alternative also for cardiac rehabilitation (CR):
‘various home-based CR programs have been developed. A review of these studies found
no appreciable difference to hospital-based CR with respect to total mortality, cardiac
events, and reduction in [cardiovascular] risk’ (Lear, 2018: S279). As, perceivable, the
spread of ITs is leading to a significant proliferation of new services and forms of remote
intervention. This makes it difficult to provide a general evaluation of the innovative
services as well as to trace any major distinction between success in diagnosis versus
treatment. Indeed, given the multiplicity of technologies and services available, together
with the medical specialties involved, the quality of each IT-mediated service – along
with its conformity to medical ethics’ standards – should be evaluated through a case-by-
case approach. In this way, it would be possible to assess all the conditions that surround
and support the implementation and functioning of the service (e.g. number of profes-
sionals involved, adequate training prior to interact with patients remotely; adequacy of
the locales, maintenance of the technological devices). Given the complexity of these
tasks, as well as the progressive relevance of ITs in clinical practice, it is of no surprise
that a new medical specialty has recently been suggested, namely the medical virtualist
(Nochomovitz and Sharma, 2017). This new kind of specialist would identify a profes-
sional who ‘will spend the majority or all of their time caring for patients using a virtual
medium’ (Nochomovitz and Sharma, 2017: e1). The medical virtualist would thus need
specific training to successfully master techniques and skills required in a webside man-
ner (Nochomovitz and Sharma, 2017), and, in particular, to ensure quality of healthcare-
delivery despite the technological mediation of the ITs. As a matter of fact, medical
virtualists might be soon requested to work for the emerging virtual clinics. Among the
latter, is the virtual nephrology clinic, which aims ‘to provide and ensure a robust moni-
toring system for patients with [chronic kidney disease] using non-face-to-face com-
puter-based decision support with the intention of improving recognition of patients with
deteriorating [chronic kidney disease]’ (Harnett et al., 2018: 357). As well, the feasibility
of a virtual laboratory for neuroscientists has been tested, aiming to provide them with
‘access to a wide range of clinical and neuroimaging datasets, algorithm applications,
computational resources, services, and information support. This virtual laboratory has
been mainly developed for neuroscientists but is also applicable and adaptable to other
user communities’ (Munir et al., 2015: 245).

Information technologies enhance or dehumanise doctor–

patient relationship?
Despite the fact that several scholars have made reference to the risk that using ITs may
‘dehumanise’ doctor–patient relationships (e.g. Bartolo, 2010; Bauer, 2001; Fleming
et al., 2009; Shortliffe, 1999; Zwijsen et al., 2011), a definition of this term is still missing:
10 Health 00(0)

‘telemedicine may dissocialize and dehumanize the original and genuine purpose of a
doctor-patient interaction to the extent that telemedicine may have a negative impact
on the doctor-patient communication’ (Roback and Herzog, 2003; Matusitz and Breen,
2007: 14). Even physicians involved in empirical research have been found to refer to this
notion, though in absence of a specific definition:

I can’t think how it would help therapy in that the person is being asked to talk to a machine.
[. . .] I think if people are in a state of distress, then to ask them to speak to a video camera is
dehumanizing. (A psychiatrist interviewed in May et al., 2001: 1897)

It is clear that the term is used to evoke the risk that ITs detract from the features of
humanity (intimacy, immediacy and physical proximity) that characterises a good doc-
tor–patient interaction (Fleming et al., 2009: 798). However, a similar effect is also
described in terms of ‘depersonalisation’ (Miller, 2003; Spiegel, 2017; Van Wynsberghe
and Gastmans, 2009). Such a term is prevalently used to refer to the lack of in-person
contact typical of remote services: ‘the doctor-patient relationship has become more
impersonal as physicians increasingly rely on high-tech instruments during their encoun-
ters with patients. Since telemedicine relies on advanced communication technologies, it
would seem to continue the trend towards greater depersonalization in healthcare’
(Miller, 2003: 2). Thus, ITs are seen as a kind of interference for the development of a
‘personal’ doctor–patient relationship, due to the ‘impersonal nature of the service’.
Here, regardless of the different terms used in the literature, the dehumanisation and/or
depersonalisation will be referred to interchangeably to describe the negative impact that
IT-mediated healthcare services may have on the quality of doctor–patient relationships,
and thus on the healing process. Therefore, when considering such an impact, conclu-
sions drawn from empirical studies and reviews can lead to very divergent conclusions.
A paradigmatic case is represented by ‘telepsychiatry’ or ‘telemental health’, in which
technological mediation might play a very ambivalent role. For instance, recalling the
tradition of personalism in bioethics, some scholars have argued that the lack of in-per-
son contact is morally challenging and inevitably leads to depersonalisation (Van
Wynsberghe and Gastmans, 2009: 471). In particular, it has been emphasised that human
beings stand ‘in an open relation with reality’ and, correlatively, that good care rests upon
the preservation of human dignity:

Humans are sensible beings, able to perceive their world according to touch, smell, sound,
vision and speech. The loss of one or more of these capabilities leaves us in a vulnerable state
and threatens to diminish our trust of the situation. (Van Wynsberghe and Gastmans, 2009: 473)

By contrast, others (Aragon, 2003; Tachakra and Rajani, 2002) have been inspired by a
well-known psychosocial perspective, which was aimed at assessing the effects of tech-
nological mediation on features of human communication (Short et al., 1976). Among
the core concepts of this perspective is the notion of social presence, which has been
described as ‘the actions, understanding and confirmation that appear to result from
being there, that is, being present and having available a number of modalities and clues
that influence communication’ (Tachakra and Rajani, 2002: 226), or otherwise as the
Botrugno 11

‘degree of salience’ through which each participant perceives the other during the virtual
interaction (Aragon, 2003: 59). Therefore, rejecting the hypothesis of dehumanisation/
depersonalisation, several scholars have stated that IT-mediated services enable the
establishment of a social presence, empowering patients and encouraging them to reduce
the sense of discomfort typical of conventional, psychiatric consultations (Mahmoud and
Vogt, 2018; Tachakra and Rajani, 2002). Finally, it has also been alleged that remote
interaction provides a unique means to observe a patient’s home environment (Chan
et al., 2015).
Looking at ITs from the patient’s perspective, a number of studies have shown that
patients are usually enthusiastic when it comes to using new healthcare technologies
(Chakrabarti, 2015: 296; Chan et al., 2015; Pflugeisen and Mou, 2017: 1544; Toledo
et al., 2012). This is first due to the fact that innovative services are designed to be
‘seductive’ and to call the attention of their users, for example, by integrating anthropo-
morphised interfaces. Second, it must be taken into account that patients have been con-
vinced of the usefulness of these services as they are often presented – and marketed – as
something that can have a significant impact on a diagnosis or therapeutic course, despite
available evidence which shows uncertainty on their effectiveness (as in the case of the
WSDP mentioned above). In a recent study (Voruganti et al., 2018) aimed at exploring
the opinions and beliefs of patients regarding the use of a web-based tool for supporting
cancer care, it has been suggested that: ‘the introduction of technologies must take into
account the potential perceptions of disruption to the patient-physician bond, even when
a new tool is not intended to replace face-to-face meetings’ (Voruganti et al., 2018: e8).
From a different standpoint, despite acknowledging the potential of this innovative tool
as a facilitator for the communication between professionals (i.e. team members) and
patients, it has also been highlighted that the:

introduction of the tool alone cannot broaden communication opportunities between patients
and the team without negotiating the undercurrents of the relationship, existing care practices,
and patient preferences. However, through facilitated implementation entailing discussion
about expectations of use, the tool can present an opportunity to realign the goals and
expectations of the patient-physician relationship. (Voruganti et al., 2018)

From this perspective, it appears clear that technological innovation cannot ‘automati-
cally’ bring benefits, but rather its success in clinical practice is strictly bound to the
efforts made by healthcare and IT professionals to sustain its implementation and ensure
its working.
From a different viewpoint, it must also be considered that the availability of remote
services is blurring the distinction between traditional provision of care and well-being
activities, allowing patients to be more engaged and autonomous, which, as seen earlier,
is a clear objective of the latest EU orientations. However, it has been reported that the
vision inspiring this kind of empowerment might result as inadequate, as it presumes
patient as

being independent and self-sufficient and views relationships as secondary, fashioning these
relationships in more or less contractual terms where people act as equal citizens within a
12 Health 00(0)

public realm. [. . .] The specific ethical realm of (care) relationships, however, is characterised
by asymmetry, vulnerability and dependency. (Zwijsen et al., 2011: 425)

In parallel, critics have alleged that the use of ITs in routine healthcare entails a shift of
tasks and responsibility from health professionals to patients, which, especially in some
telemonitoring services, may assume ‘oppressive contours’ (Chiapperino et al., 2012;
Nagel and Remmers, 2012). Also, it has been remarked that this shift must be framed into
strategies and policies whose primary goal is containing costs rather than increasing
quality of healthcare (Lupton, 2013; Mort et al., 2013).
As a matter of fact, the risk that ITs may dehumanise healthcare practice has induced
national health authorities and international ethical boards to restrict the use of innova-
tive services to specific situations, such as emergencies or cases, in which a physical
examination was carried out prior of the use of remote services (European Commission,
Information Society, 2011).3 Among the others, this position has been endorsed by the
World Medical Association (WMA) within the Statement on the Ethics of Telemedicine,
which warns:

The patient-physician relationship should be based on a personal examination and sufficient

knowledge of the patient’s medical history. Telemedicine should be employed primarily in
situations in which a physician cannot be physically present within a safe and acceptable time
period. It could also be used in management of chronic conditions or follow-up after initial
treatment where it has been proven to be safe and effective. (WMA, 2018: Art. 1)

Therefore, despite confirming that face-to-face medical practice must be considered the
‘gold standard’, the WMA Statement expresses a reasonable orientation, suggesting an
integration of remote care with conventional consultations. This position seems to be
compliant with evidence from empirical studies on remote doctor–patient interaction in
which patients have shown to benefit from such an integration: ‘This study demon-
strates high levels of satisfaction for Virtual-care and Traditional-care patients, with
significantly higher overall and domain patients monitored with a mix of videoconfer-
ence and in-clinic visits’ (Pflugeisen and Mou, 2017: 1544). In this regard, it has been
widely acknowledged that virtual interaction should not replace conventional health-
care-delivery, but rather integrate with it, that is, it should represent a plus: ‘This should
not be interpreted as substituting current practice of therapeutic interventions, but to
allow a more efficient use of human resources and achieve more time actively exercis-
ing’ (Schröder et al., 2019: 81). In addition, to ensure that such remote healthcare-
delivery is adequately performed, the need for specific professional training has been
underscored:

Because few practicing physicians are familiar with telemedicine technology, training is
essential. A teleconsultation is not simply FaceTime with a patient. Training with the
telemedicine technology is essential to facilitate rapport, maximize engagement, and conduct
an accurate virtual exam. With the appropriate attachments, the only limitation to the virtual
exam is palpation. (Sirintrapun and Lopez, 2018: 543)

And also,
Botrugno 13

Medical virtualists will need specific core competencies and curricula that are beginning to
develop at some institutions. In addition to the medical training for a specific discipline, the
curriculum for certification should include knowledge of legal and clinical limitations of virtual
care, competencies in virtual examination using the patient or families, ‘virtual visit presence
training’, inclusion of on-site clinical measurements, as well as continuing education.
(Nochomovitz and Sharma, 2017: e2)

Technological innovation and reductionism

The progressive digitalisation of healthcare practice, along with the virtualisation of
patients’ bodies must be framed into a wider shift from mechanical medicine to informa-
tional medicine (Lupton, 2013, 2016; Nettleton, 2004; Pickstone, 2000). This shift calls
on: ‘less of a reliance on the haptic (touch) and the concept of medicine as an “art” to a
focus on generating and using data on the human body, on the part of both medical prac-
titioners and of patients’ (Lupton, 2013: 260). Digitalisation – and thus the advent of
informational medicine – is redesigning healthcare practice, including the role of the
patient. Indeed, just a few years ago, the patient was seen as an ‘acquiescent contributor’
(Koller, 2011: 18), with his or her role being limited to contributing to the collection of
symptoms by doctors. Nowadays, patients are expected to be increasingly active or ‘digi-
tally engaged’, which means contributing actively to the production and collection of
data that will then be used for elaborating a diagnosis.
Thus, insofar as clinical cases are increasingly scrutinised elsewhere, the patient’s
presence may become progressively redundant, while that of the doctor cannot be taken
for granted anymore. In this context, it should be acknowledged that, while from one side
IT-mediated healthcare services open impressive opportunities, from the other they also
reduce the number of clues and cues available, compared to conventional, face-to-face
practice. In this regard, it has been stated that the spread of ITs threatens the centuries-old
tradition of doctor–patient relationship based on sensorial perception, empathy and
mutual comprehension, compromising to a significant extent ‘the richness and complex-
ity of eye contact, look, posture, facial expressions, body positioning, that is, clues that
could change the meaning of verbal expressions’ (Barbosa and Silva, 2017: 929).
Nevertheless, as seen throughout the historical excursus outlined before, it must be
acknowledged that much of that richness and complexity seems to have already vanished
in the irreversible transition of medical practice from the Hippocratic teachings towards
the goal-oriented, business-like and managerial organisation of modern healthcare sys-
tems. Such a transition has paved the way for the metamorphosis of the doctor–patient
relationship towards a provider–user interaction. As described earlier, within this transi-
tion a relevant role has been played by technological advancements, which, among other
positive effects, have contributed to increase the objectivity and certainty in medical
practice, for example, providing material evidence (images of the body). This has
increased the reliance of professionals on processes of numerical quantification in health-
care, which has in turn drastically reduced their affordance on patients’ symptoms and
their descriptions. In this regard, it has been reported that most of the physicians ‘were
taught about and tend to adopt a mental model of the human body as a machine and
14 Health 00(0)

illness as due to malfunction of its parts’ (Wilson and Holt, 2001: 688). This recalls the
mathematic vision of the human body developed by René Descartes (Cosmacini and
Rugarli, 2007; Powell, 1970) upon which, Ivan Illich commented:

His description effectively turned the human body into clockworks and placed a new distance,
not only between soul and body, but also between the patient’s complaint and the physician’s
eye. Within this mechanized framework, pain turned into a red light and sickness into
mechanical trouble. (Illich, 1976: 58)

Therefore, at a closer look, it must be acknowledged that the intrinsic vocation of

IT-mediated healthcare to reduce the number of cues and clues available in doctor–
patient relationship builds upon the reductionism of the biomedical paradigm. This does
not mean that ITs have a neutral impact. In contrast, technological innovations in
healthcare

represent transformations in how bodies are conceptualised, touched, managed and visually
displayed. Rather than simply neutrally mirroring key aspects of a pre-given natural body,
technologies as they operate in medicine and healthcare configure and reconfigure the body in
certain ways, enacting how they are understood and treated. (Lupton, 2013: 257)

Hence, the emergence and spread of IT-mediated healthcare services taps into the reduc-
tionist groove of biomedicine, not only enhancing its scope and possibilities but also
exacerbating its limits and pitfalls, which is a constant in the endless evolution of medi-
cal practice. As described above (see p. 9), this confers a renewed relevance to the psy-
chological, social and environmental factors in medical practice, especially regarding the
use of IT-mediated services. In this case, it is worth to recall that the above mentioned
WSDP dedicated an entire section of the trial to investigating the psychosocial outcomes
of using the remote healthcare services (Cartwright et al., 2013). Thus, given the impor-
tance of these factors, the rise of a figure, such as the medical virtualist, could play a
fundamental role in tackling the reduction of cues and clues intrinsic to IT-mediated
healthcare. The education of medical virtualists could therefore be designed to assist
these professionals in being able to develop skills, competencies and strategies to over-
come the negative effects played by technological mediation and consequently to act
with the view of ensuring high-quality healthcare and conformity to medical ethics
standards.

Conclusion
This work shows that the IT-mediated services in healthcare overlap the reductionism of
the biomedical paradigm and thus reflect its main ambivalence, which derives from the
vocation to select, filter and thus to reduce the potential sources of knowledge available
for doctors in carrying out a diagnosis and elaborating a therapy. The digitalisation of
healthcare runs alongside the proliferation of health data, which inevitably leads to lessen
the human valences typical of conventional, face-to-face relationships between patients
and doctors. However, the (physical) presence of doctors – their sensorial abilities, and
Botrugno 15

the intimacy and immediacy characterising physical encounters – must be seen as still
fundamental for patients making sense about technical details, such as symptoms and
medical prescriptions, which in turn is fundamental for establishing an effective thera-
peutic alliance.
Therefore, the implementation of ITs in routine healthcare needs to be scrupulously
guided to balance effective advantages with potential drawbacks and, thus, to keep the
standards of quality of medical practice high.

Declaration of conflicting interests

The author(s) declares no potential conflicts of interest with respect to the research, authorship
and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship and/or publication of this
article.

ORCID iD
Carlo Botrugno https://orcid.org/0000-0002-6082-6205

Notes
1. For the United Kingdom, see https://digital.nhs.uk/services/national-data-opt-out-programme
(accessed 13 February 2019). For Australia, see https://www.myhealthrecord.gov.au/for-you-
your-family/opt-out-my-health-record (accessed 14 February 2019).
2 See WSDP Headline Findings at https://assets.publishing.service.gov.uk/government/
uploads/system/uploads/attachment_data/file/215264/dh_131689.pdf (accessed 14 February
2019).
3. As documented by a report of the European Commission, Information Society (2011). See
also Article 94 of the Portuguese Deontological Code for Medical Practice and the Brazilian
Deontological Code for Medical Practice adopted by Federal Council of Medicine with
Resolution no. 1931/2009.

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Author biography
Carlo Botrugno is research fellow at the Department of Legal Sciences, University of Florence,
and coordinator of the Research Unit on Everyday Bioethics and Ethics of Science (RUEBES) at
L’Altro Diritto inter-university research centre on Detention, Deviance, Marginality and Migration
Management.