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Abstract
As the telemedicine projects develop among the countries, the ethical and legal problems of
telemedicine and telecare come into more attention. Here, in this article, we address the ethical and
legal issues associated with telemedicine. These issues include duty and standards of care,
confidentiality and security, rights of access, malpractice, physician licensure and reimbursement,
intellectual property rights, and the ethical and legal aspects of healthcare advice and provision on
the Internet.
Keywords: Telemedicine, Medical Ethics, E-Health, Telecare
∗
Student of Medicine
assurances about confidentiality patients may be reluctant to give doctors the information they
need in order to provide good care.
The GMC Guidelines make no distinction between conventional face-to-face medicine and telemedicine
consultations. The duty of confidence applies to all information given to a teleconsulting doctor by a third party.
If this party is a healthcare professional then they will be aware of the patient-doctor relationship and
acknowledge they are under the same obligation of confidentiality. What, however, if the third party is remote
from the patient, possibly in another country, or is not a healthcare professional at all but perhaps a technician
working with clinical staff to ensure the quality of a radiological image and its error-free transmission?
Consent to Treatment
Every competent adult has a right to refuse or consent to available medical treatment or healthcare and the
clinicians in charge of this care must obtain a patient’s consent before proceeding with the treatment. Any
clinician who proceeds without this consent runs the risk of prosecution for tort of battery or negligence. Courts
will only accept consent as a valid declaration if patients are made fully aware of the options available to them.
Consent may be implicit (e.g. offering an arm for a blood pressure measurement) or explicit (e.g. signing a form
of consent before a surgical operation). The GMC guidelines on the duties of a doctor state the position clearly
by requiring doctors to [3]:
Give patients the information they ask for or need about their condition, its treatment and
prognosis; give information to patients in a way they can understand; [and] respect the
rights of patients to be fully involved in discussions about care.
As we have noted already, the ethical aspects of telemedicine are similar in many respects to conventional
medicine but telemedical practice sometimes leads to more testing situations.
A second difficulty, highly relevant to telemedicine, is the point at which a patient should be asked to give
consent. A company might provide telemedical cover for their employees who have to travel to remote areas on
company business. Neither the company nor its employees can foresee all of the circumstances in which consent
would be required and it is always possible that an employee might want to change their decision.
A third and final problem noted here arises when a patient refuses treatment. For example, a patient may be
willing to receive treatment but only by conventional means and not by telemedicine. Alternatively, and
reflecting the global nature of modern medicine, telemedical treatment may be acceptable but not by certain
practitioners, e.g. an Albanian patient might not wish to be treated by a Serbian doctor. Yet again, a patient may
refuse treatment on moral or religious grounds. In these situations, patients with the capacity to do so are
required to sign a written record stating the fact of their refusal and accepting its medical consequences.
Clinician Reimbursement
We will end this article on the jurisdictional issues with a very quick look at physician reimbursement.
In the USA, physicians are reimbursed for the medical services they provide directly by patients, or indirectly
by managed care organizations under insurance arrangements, or from the government’s Medicare and Medicaid
schemes. The schedule of what is allowable and what is not under the indirect schemes is therefore of
considerable interest to doctors. The established practice before telemedicine arrived on the scene was to
reimburse doctors only for face-to-face consultations. That is now changing. Teleradiology is reimbursed
nationally and Medicaid reimbursement for telemedical consultations is provided in Arkansas, Georgia, Montana
and West Virginia. Non-videoconferencing applications such as remote cardiac and fetal monitoring,
telepathology and teleradiology have been nationally reimbursed by Medicare, for some time. From January
1999, Medicare reimbursement is also available for telemedicine services in rural counties.
As noted, the US General Accounting Office found no evidence to support the Health Care Financing
Administration's assertion that offering fee-for-service reimbursement of telemedicine services to Medicare
patients would vastly increase expenditure in the USA [13].
REFERENCES
[1] Stanberry B A, The Legal and Ethical Aspects of Telemedicine, Royal Society of Medicine, London, 1998,
Chapter 1
[2] British Medical Association, Medical Ethics Today: Its Practice and Philosophy,BMJ Publishing Group,
London, 1993
[3] General Medical Council, Duties of a Doctor-Confidentiality: Guidance from the General Medical Council,
General Medical Council, London, 1995
[4] Stanberry B A, The Legal and Ethical Aspects of Telemedicine, Royal Society of Medicine, London, 1998,
Chapter 3
[5] NHS Executive, NHS-wide Networking Program Security Project, Department of Health, London, 1995
[6] Howard G S, Introduction to Internet Security, Prima Publishing, Roseville, CA, 1995
[7] Health Internet Ethics web site, Ethical Principles for Offering Internet Health Services to Customers. See
web site at http://www.hiethics.org/Principles/index.asp
[8] Stanberry B A, The Legal and Ethical Aspects of Telemedicine, Royal Society of Medicine, London, 1998,
Chapter 5
[9] Stanberry B A, The Legal and Ethical Aspects of Telemedicine, Royal Society of Medicine, London, 1998,
Chapter 7
[10] Craig J O M C, Litigation concerning clinical radiology, in Powers M J and Harris N H (eds) Medical
Negligence, 2nd edn, Butterworths, London, 1994, Chapter 41
[11] Stanberry B A, The Legal and Ethical Aspects of Telemedicine, Royal Society of Medicine, London, 1998,
Chapter 9
[12] American Medical Association, CME Resource Guide: Chapter 7, Section 4: The Physician Licensure
Debate on Telernedicine: An Update, US Medical Licensure Statistics and Current Licensure Requirements,
1997.
[13] Dakins D R, ASTP focuses on telemedicine business strategies, Telernedicine and Telehealth Networks, 3
(6), 19-21, 1997