In April 2018, I wrote about the ethics of e-health. E-health is a term that encompasses various technological methods and platforms used for health purposes. One type of e-health is telemedicine, which when a clinician is at least one of the parties involved in a healthcare interaction occurring through technology. A related type of care is that of telepractice, which, according to the College of Nurses of Ontario, is “the delivery, management and coordination of care and services provided via information and telecommunication technologies”, presumably by clinicians and other members of a healthcare team.
At the time of the column’s publication (i.e., in 2018), telepractice services were on the rise, but they were far from the norm in terms of how care was being offered. In response to the COVID-19 pandemic, however, the tables abruptly turned. As we are all aware, the immediate response to the pandemic was for everyone to remain at home and to follow public health guidelines when outside of one’s residence. In the healthcare domain, many treatments and procedures were cancelled, but some appointments and interventions became available via telepractice. Ultimately, the pandemic forced our society to expedite the process of developing reliable telepractice options since many people were not allowed to and/or were unable to attend appointments in-person. And since it is likely that this method of care provision will be encouraged for the foreseeable future, it is important for us to explore the ethical benefits and to unpack potential harms in order to ensure that our society’s healthcare needs are being met effectively.
Some benefits of telemedicine (including telepractice) are noted in the 2018 column. For instance, being able to provide access to care for people who live in remote and/or rural locations is one upside of telepractice. Prior to the pandemic, it would have been the case that some people would receive in-person support whereas others would be cared for through telepractice depending on their location. As a consequence, some people may have been disadvantaged insofar as telepractice options were rare and/or less ideal than receiving in-person care (although perhaps still better than no care at all). Because almost everyone is receiving care via telepractice in the current context, however, it may be the case that more equal care is provided across groups since everyone is given the same options irrespective of location.
Although more equal care may be provided amongst populations who can access telepractice, one of the challenges is that some of the most vulnerable and marginalized people in our society are plausibly the ones who may be unable to do so, thereby leading to increased inequity. While most people may be able to attend telepractice appointments, a person who is marginally housed may not. Relatedly, people who do not have a reliable internet connection and/or who cannot afford a necessary device (e.g. a computer) and/or who are unable to navigate the technical complexities because of a cognitive impairment may be unable to benefit from this type of care.
The individuals in this position, i.e., those who may be unable to access and/or benefit from telepractice services because of socioeconomic, housing, and/or other factors, may be those who are experiencing health consequences from the social determinants of health (SDH). The World Health Organization defines the SDH as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” The idea behind the SDH is that a person’s place in society (e.g. their socioeconomic status, housing, education, employment, etc.) will inevitably influence their health. It is important to highlight that people suffering from the SDH may make up a large portion of individuals who cannot effectively utilize telepractice and who may be more likely to require care.
Insofar as some of society’s most vulnerable individuals may require but be unable to access care, we ought to explore alternative options available. Can and/or should we provide people with devices (e.g. computers, phones)? Can and/or should we alter our provision of care such that we see specific members of our society in-person, outside, etc.? Can and/or should we prioritize addressing and spending resources on the SDH? If the answer to any of the above questions is “yes”, then implementing changes to our care provision in the current context may be worth considering.
Balancing the duty to provide effective individual care with that of public safety during a pandemic is difficult and complex. In performing this balancing act, however, it is important to be mindful of the most vulnerable individuals and to try to decrease inequities in addition to inequalities when it comes to care access. We may be able to do this in the current context by offering telepractice support and alternative care options. Ultimately, our society’s response to COVID-19 ought to take into account the whole of society and make efforts to accommodate the most vulnerable and in need.
Andria Bianchi, PhD is a Bioethicist at University Health Network and an Assistant Professor (status-only) at the Dalla Lana School of Public Health – University of Toronto.