Ethics In HTM: Part IV - The Challenges of Megatrends

Change has always been integral to HTM delivery. The advent of electronic health records, telemedicine, and remote patient monitoring have long evidenced a substantive growth curve impacting the industry. The Internet of Medical Things (IoMT), connecting medical devices, wearables, and other sensors to garner and process real-time data for monitoring and treatment, hosts valuable new opportunities in health outcomes but comes at the cost of cybersecurity challenges and new skillsets that need to be developed. The increasingly prevalent integration of Artificial Intelligence (AI) in healthcare is already on a definitively hyperbolic growth curve. All of which begs the question: can ethics keep pace?

Ever more complex, integrated technologies supported by the IoMT is a daily reality to which the industry must adapt. Despite the presence of malicious actors attempting to exploit cybersecurity vulnerabilities in healthcare—as evidenced by the recent cyberattack on Ascension Health, the fourth-largest hospital network in the nation—the ethical imperative remains to safeguard sensitive data. This necessity becomes even more critical as integration and digitalization in the industry continue to advance rapidly.

Regulatory authorities hold jurisdiction to enforce industry security norms. However, the field is more decentralized than any banking system, which exacerbates the challenge. This is particularly evident as the World Health Forum continues to rank healthcare as a particularly vulnerable industry, trailing behind education/research and government/military entities, but significantly ahead of other industries. The post-Pandemic myriad new or hastened drivers of change – empowered consumerism, digital health proliferation, increased home and community care, personalization, and preventative care priorities – bring further concerns even as they add to health opportunities. As Morten Rand-Hendrickson has succinctly stated on the three recent B.C. health authority attacks: “Ransomware is one of the biggest threats to our modern society. It’s only a matter of time before attackers take down critical infrastructure and cause loss of life.” The development of and training on new skillsets is necessarily urgent and critical as, with apologies to the late Donald Rumsfeld, such ethical exigencies are currently known unknowns.

Developments in artificial intelligence (AI), on the other hand, bring in their coattails an unignorable number of unknown unknowns. ChatGPT, if fed by the right resources, could easily provide a 3,000 word-plus summary of breakthroughs in the field every day of the week, and healthcare newsfeeds already give us a daily diet of novel solutions for, say, implant-addressed obesity, autism, depression, and schizophrenia or the latest superbug countered by an effective antibiotic identified by means of machine learning.

The dramatically improved accuracy of diagnosis rates, drug discovery, and AI clinical decision-making, or even surgical support, may seem beyond many of our expertise levels. However, the corresponding impact on HTM is substantial. Healthcare delivery, administration, and patient care are influenced by predictive maintenance, enhanced medical imaging, optimized resource allocation, and AI-driven solutions, which will continue to exponentially transform the industry. All aspects of the medical device lifecycle, from design, utilization, and use to maintenance and repair will be impacted by developments in advanced diagnostics, real time monitoring and alerts, data driven insights, and automated regulatory compliance processes.

That such rapid advances can easily outpace standards for application is an evident ethical concern. That AI may work least objectionably by identifying patterns in and analyzing large amounts of accurate data, with the emphasis on accuracy, seems incontestable, but reminds us that AI is not quite intelligence, per se, as much as a series of predictive algorithms that need unbiased data to function as hoped by human beings innately bereft of easy manipulation of such algorithms but key players in their development. Technology’s genius depends to a large and, no doubt, welcome extent on human research and input. Until, of course, it doesn’t.

We must remain vigilant regarding the technology’s functionality as intended, take ownership of responsibilities if the technology fails and consider its impact on health equity. We must examine whether the human traits essential to healthcare – such as communication skills, empathy, bedside manner, and non-discrimination – are threatened, as feared by studies involving patients. There is the added threat of de-skilling healthcare workers through over-dependence on technology.

Of primary concern is the apparent inability of ethical considerations to keep pace with such paradigm shifts. That technology is leading ethics, as in a race, always one pace ahead, has long been a concern, but rarely has that fact been so stark as in the context of its current impact on healthcare.

We have long recognized the concept of technical debt, which can sometimes be beneficial. For instance, in the case of “best to market” goods such as cell phones produced by companies which, when releasing new technologies, have update costs built into their business plans. However, often, technical debt tends to be negative. This occurs when deadlines are tight, knowledge is lacking, and research and resource needs are unrealistic or inadequately addressed.

?Ethical debt, on the other hand, is always negative, and typically results from ethically questionable decision-making resulting from the absence of a culture of ethical awareness and prioritizing short-term gains over long-term values. No good or adequate financial business planning is going to accommodate either type of debt in healthcare, but, absent Lazarus solutions, ethical debt should obviously be non-negotiable.

We must effectively incorporate ethical considerations into our daily decision-making and prioritize the implementation of appropriate systems to manage them. To do so in an age or transformative change is no small charge and all the more critical for that reason.