E-Health Ethics: A Yet to be Recognized Issue in Medicine and Medical Ethics

- Hans-Martin Sass, PhD
Senior Research Scholar, Kennedy Institute of Ethics, Georgetown University, Washington DC, USA; Zentrum fuer Medizinische Ethik, Bochum, Germany
Email: Sasshm@aol.com

- Xiaomei Zhai, PhD
Director, Research Centrer for Bioethics, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing
Email: xmzhai@hotmail.com

Eubios Journal of Asian and International Bioethics 14 (2004), 147-8.


Health education and the promotion of health competence have not become a prime focus in medical ethics yet, but increasing numbers of millions of people travel to Internet health-sites daily. Over 20 million people go to webmd.com, a well known e-health site, weekly; daily more people surf the internet for health advice than go to a doctor or hospital in the US. At the crossroads of emerging knowledge in predictive and preventive medicine and public health and of internet based technologies and networks e-health has developed as powerful medium, not yet regulated, widely traveled, full of beneficial information and advise, but also presenting new uncertainties and risk of false or deceptive information, certainly also a modification of traditional physician-patient relationships and in part a de-professionalization of medical expert knowledge.
E-health, according to Gunther Eysenbach, editor of the Journal of Medical Internet Research, is 'an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the internet, and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health locally, regionally, and worldwide by using information and communication technology'. Information and advice, easy to use, available 24 hours, 7 days a week, has all the capabilities to change attitudes towards one's own concept of health and disease, can promote protection of health and avoidance of health risk, might even give rise to wards a new culture of health enhancement.
Huang Di Nei Jing of the Western Han Dynasty once hold that 'if one waits until sickness is there and uses medicine to cure it, that is not different from waiting until one is thirsty and then starting to dig a well'. Most e-health sites provide information and advice on medical as well as non-medical means to stay healthy, become healthier, to cope with stress, improve lifestyle and promote 'wellness'. Some sites offer interactive rooms for communication, exchange of ideas, experiences, and advice; new cyberspace based health communities are formed, develop their own cultures, customs, even new forms of friendship and closeness.
E-Health has all the properties to empower lay people to become health-literate and health-responsible, i.e. to make their own informed and educated choices about lifestyle and quality of life, a vision of Immanuel Kant and other European educators and philosophers of the Age of Reason. But e-health will also change the established local systems of health care and caring for patients. Health care surfers, e-health providers and local medical and nursing experts will need to review and to reconfirm or modify traditional customs and ethics of providers and customers of health care services.
Gong Tingxian, a 15th century Confucian scholar and physician, once introduced action guides and health care rules for providers and consumers of medical care and health care advice. He had laid emphasis on the integration and interaction of medical advice and health compliance within wider framework of concepts of life and health, of lifestyle and of trust-based communication and cooperation between local doctors and patients. We have used Dr. Gong Tingxian's health care rules as guidance for drafting a set of interactive action guides for cyberspace health care communication and communities. These action guides address [1] the interaction of medical and non-medical factors for good health and the need for a personal commitment, [2] the risk of fraud and the need for highest personal and professional standards in providing e-health services, [3] courtesy and cultivated neighborly forms of communication and support in cyberspace communities, [4] the limits of e-health as very useful and needed source of health care additional to but not replacing the doctor in the neighborhood.
We present the following interactive Action Guides for discussion. We invite critical reviews and remarks, as we will discuss the ethics of e-health in one of the concurrent sessions at the Seventh International Congress of Bioethics in Sidney in November 2004. We welcome your e-mail response which we will - with your consent - put on the site www.health-literacy.org / 'IAB Session E-Health'; there you will find more material, links, and bibliographies on e-health in preparation of the session.

Action Guide for Health Care Surfers
1. Wellness as well-being and well-feeling depend among causes on good self-care information and advice, medical and non-medical, also on a personal commitment to deal responsibly with medical and non-medical risks to health, wellness, quality and life and length of life.
2. Be a critical consumer of cyberspace based communication on the protection and promotion of health and on dealing with diseases and disorders. Trust, but be critical and verify by using more than one source of information and advice. Do not trust those who promise everlasting health, wonder drugs and sensational cures and remedies.
3. Be a courteous and civilized partner, helpful and understanding neighbor and a trustworthy friend in cyberspace health care communities; protect your privacy and meet close friends in private outside of community rooms.
4. E-health communication never can replace health care provided in your local neighborhood; use private consultation rooms in cyberspace, but keep in personal contact with health care experts and local institutions of your trust in your neighborhood.

Action Guide for E-Health Providers
1. Provide easy to understand and scientifically sound, proven and evidence based information and education on non-medical and medical advice for a healthy and enjoyable life, for wellbeing and well-feeling; encourage health care surfers to responsibly deal with their individual risk to health and wellness, help them to develop their own concept of quality of life and to live accordingly.
2. Do never promise what you cannot deliver responsibly; respond to trusting clients in a trustworthy and fair manner; to provide health care is not just a profit oriented business, neither in local nor in cyberspace communities. Seek certification and professional oversight of your services; employ only persons of highest personal and professional standing.
3. Provide and promote rooms for health care communities; allow those communities to develop and to create their own culture in sharing information and emotion, in supporting each other, and in building networks and communities; never allow uncivilized or offensive behavior in your rooms.
4. Advise health care surfers to seek medical diagnosis and personal advice from experts in their neighborhood outside of cyberspace and to keep in personal contact with a trusted health care expert; provide rooms for private consultation and guarantee privacy and quality service in your private as well as in public services.

References
1. Eysenbach G. 2001. What is e-Health? J Medical Internet Res 3(2):e20 [www.jmir.org]
2. www.health-literacy.org

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