Ethical Challenges in Digital Public Health
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Digital public health involves the integration of digital technologies into public health to achieve public health goals, suggesting that this integration can potentially improve outcomes and efficiency of services. The past two decades have been characterized by rapid proliferation and application of digital technologies in various domains of public health. A wide range of these digital technologies, including mobile apps, social media, wearables, artificial intelligence, and big data, have been deployed with promises of increased speed, efficiency, and cost-effectiveness of public health services.
Recognition of the importance of digital technologies in public health services is emphasized by the increasingly common use of the term digital public health within public health discourse. Digital public health is a reimagination of public health, blending established public health wisdom with new digital concepts and tools. It may be described as the exploration of new models of public health using technology while introducing flexibility and resilience to allow the adaptation of public health practice to improve health outcomes.
Digital public health is referred to not as a discipline per se but as an asset that the public health community can use to fulfill its aims and mission to ensure quality, accessibility, efficiency, and equity of health care. Digitization may be described as a technical process of converting analog (including paper-based) health records to digital formats that may then be available for use electronically. Whereas, digitalization is the integration of technology in the production of services. The technological integration allows health services to be organized and delivered in new ways. It is the establishment and ongoing maintenance of basic infrastructure, including but not limited to hospital information systems, electronic medical records, mobile health, and public health surveillance.
The digital transformation is the fundamental change in the culture and model of delivery of health services. Digital transformation is both health-specific and driven by the broader changes in society, including the widespread availability of smartphones and the increased awareness and tracking of health and lifestyle data, as well as storage and processing of large amounts of heterogeneous data that may not be directly related to health but are relevant in understanding health and health outcomes in populations.[1]
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Digitization in Public Health
Digitization of existing paper-based immunization records may allow the data to be linked to other databases to evaluate health prevention programs. An example of digitalization is the use of computer systems and electronic health records at a sexually transmitted infection clinic that allows for the generation of health data during the process of service delivery, ensuring that such data may be used to inform disease prevention, surveillance, and health care quality improvement. Nevertheless, it must be acknowledged that digitization and digitalization have been used interchangeably, with digitization used in this context to refer to processes that are more consistent with digitalization. Regarding digital transformation, for example, in sexually transmitted infection testing services, digital transformation may be envisioned as the creation of web-based testing portals, self-testing models, health education, and promotion of services through mobile apps and clinic-based referral systems that are all interconnected in a technological ecosystem built around the needs of the public to ensure that health is equitable and of high quality.[2]
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Digital Health As A Medical Device
Today, digital health is a cornerstone of developed health systems all over the world. Without question, digital health uses (latest) information and communication technologies to develop a faster, more efficient and cost-reducing healthcare practice. Some medical devices help many people to be connected to apps on smartphones and are referred to as digital health devices. These devices are used by millions of people every day. All medical devices are regulated by the FDA. The Digital Health market consists of three markets: Digital Fitness & Well-Being, Digital Treatment & Care and Online Doctor Consultations. The worldwide revenue of US$170.25 billion in 2023 is expected to increase to US$274.93 billion by 2028.[3]
Advantages and Disadvantages of Digital Technology
The advantages and disadvantages of Digital Technology are multifaceted. It is undeniable that digital technology has revolutionized the way people interact, communicate, and do business. However, it is essential to consider both the pros and cons when making decisions about how to incorporate this technology into individual’s lives. On one hand, digital technology offers powerful tools for creating connections with people across distances and cultures as well as providing access to vast amounts of invaluable information. On the other hand, digital technology can also be used in ways that may infringe upon people’s privacy or lead to undesired social consequences like cyberbullying or online fraud. Therefore, it is important for the users to thoughtfully evaluate its potential implications before fully embracing it in one’s everyday life.
With digital technology, from the comfort of one’s own home, people can now access information about almost any topic at a moment’s notice, but this increased connectivity has also brought with it an element of vulnerability. People can now communicate across long distances more quickly than ever before thanks to email, messaging platforms, and video calling applications like Skype.[4]
Advantages
· Connectivity: It is the ability to interact, communicate and collaborate with each other regardless of physical location or time; it creates a virtual bridge between people located at different places. The digital age allows for numerous opportunities, communication across networks, simultaneous sharing of data, increased access to information and resources, and more, allowing users to transcend physical boundaries.
· Access to Information: As digital technology is more accessible and becomes more prevalent, the advantages of digital technology have revolutionized the way people access information. Nowadays, individuals can easily access vast amounts of data with ease and convenience due to the advancements in technology. The advantages of utilizing this digital technology are manifold; from being able to reach an extensive global audience in moments to be able to switch between devices seamlessly. The speed at which communication can be achieved is one of the most noteworthy benefits offered by digital technology. This means people can collaborate on projects without ever meeting face-to-face while still maintaining high levels of productivity and efficiency.
· Automation: It eliminates much of the manual. This saves time and money while increasing accuracy by removing potential human error. Automation can quickly adjust their processes without having to add staff or retrain existing personnel. It provides scalability that traditional methods cannot match.
· Technology Scalability : It refers to the ability of a technology, system, or software to handle an increasing amount of work, users, or data without a significant decrease in performance or a need for major modifications.
· Transportation: In recent times, technological advancement has been a driving force in the furtherance of transportation services. Digital technology enables users to access more convenient travel arrangements thanks to improved mapping capabilities and real-time traffic updates. This can help people save time by selecting alternative routes or avoiding congested areas automatically. Furthermore, passengers now have access to information about their chosen mode of transport such as fare prices before making a decision on how they want to move around. Ultimately this helps individuals make more informed decisions when it comes time for them to select a form of transportation that meets their needs best.
Disadvantages
Although digital technology has made our lives simpler in many ways, there are some notable drawbacks to consider. From strained eyesight due to spending too much time glued to screens, to security risks associated with online banking, digital technology has its fair share of detriments that should be heeded. It can also lead to feelings of isolation as a result of relying on tech for communication rather than face-to-face conversations. Additionally, an over-reliance on gadgets can rob people of the chance of honing their problem-solving skills and foster a culture of instant gratification where patience is no longer valued.[4]
· Data Security: The rising use of digital technologies has left people’s sensitive information vulnerable to hackers, malware, and other malicious attacks. Even with advanced firewalls and encryption protocols in place, there is always the risk that nefarious individuals could breach these defenses and gain access to confidential information. In addition to this threat, digital systems often rely on complex software programs with their own set of vulnerabilities; if one component fails or malfunctions then entire databases may become compromised. Furthermore, physical devices such as hard drives are prone to accidental damage or theft which can lead to data loss or leakage.
· Digital Media Manipulation: It involves the alteration of visual and audio content, with the intention of creating something that did not exist before. The most significant problem posed by digital media manipulation is ethical in nature. Manipulating existing images or recordings can be considered deceitful if it is used to convey a false sense of reality or to alter an individual’s reputation without their consent or knowledge. Furthermore, excessive use may lead to miseducation on certain topics if key details are omitted from manipulated stories or experiences are portrayed as factual when they are actually fictitious. The second major issue is related to accuracy and reliability. Digital media can be easily copied and altered undetected; thus, biasing results when using them for data analysis or research purposes.
· Work Overload: Work overload can manifest itself in various ways; from physical stress due to long hours at a desk or computer station to mental fatigue caused by too many tasks or constant decision-making. Additionally, it can also lead people down a path of unhealthy lifestyle choices such as poor diet or lack of exercise.
· Shrinking Job Opportunities: As automation and artificial intelligence become more prevalent in business operations, many jobs that were once necessary are now becoming obsolete. Not only does this make it increasingly difficult to find employment opportunities; but even when one is found, wages tend to remain stagnant due to the competitive nature of the labor market.
· Social Isolation: People’s reliance on digital technology has led to a situation in which people are becoming increasingly isolated from one another and the environment around them. The disadvantages of this new way of life can be seen in its effects on mental health, interpersonal relationships, and overall quality of life. The intense immersion into the digital realm has resulted in a decrease of face-to-face interaction between individuals. Additionally, it impacts positively enjoyed activities such as sports or leisurely outings with friends and family that promote healthy lifestyle habits.
Ethical Challenges In Digital Health[5]
· Privacy And Security: As more data sources become available and advanced analytics can be applied for various purposes, protecting privacy is undoubtedly a complex challenge. What contributes to this complexity is that standard mechanisms of protection such as anonymization, notice and consent are excessively stretched in this environment of new capabilities. Consent for data uses can hardly include the exhaustive list of all possible future data uses. In turn, anonymization technologies, even if robust, still leave re-identification in the realm of possibility if enough resources were to be devoted to it. Data security has also been a challenge, with cyber-attacks, hacking of databases and data kidnapping being reported frequently. Incidents of data breaches and “kidnapping” (data held by hackers for ransom) are on the rise. Against this background, the public needs to be reassured that robust security measures are mandated and enforced through clearly articulated policies. Concerns can be addressed with the adoption of appropriate technologies, monitoring and evaluation of security systems, transparency and accountability mechanisms such as legal remedies and compensation for privacy harms resulting from security breaches.
· Trust: Essentially what is at stake is the creation of a culture of trust that will enable all stakeholders in the big data ecosystem to benefit from the development of digital health. In particular, public trust in health data uses is of paramount importance. But trustworthy digital health activities require more than privacy protection. Elements of trust include transparency, accountability, benefit sharing and certainly more clarity about data ownership and data control. What is important here is the realization that trust cannot only be built through achieving just one element, but rather through a concerted effort to promote all of its elements.
· Accountability: With automated data mining for decisions of clinical or public health relevance becoming one of the most promising features of digital health, accountability is of critical importance. In particular, the adoption of these new tools requires relevant adaptations in existing accountability standards. For instance, in the field of digital epidemiology, data mining can be used to analyze free, unstructured text from social networks in order to make predictions about the spread of infectious diseases. Moreover, mobile technologies can be used to target specific populations with health-related information that can help contain the spread of infectious diseases. These new approaches can increase the speed and accuracy of health dynamics monitoring, leading to more targeted and effective interventions. Similarly, it is anticipated that medical practice will increasingly be aided by AI algorithms for diagnosis, treatment decisions and surgical procedures. Progress in such areas is expected to greatly improve the quality of healthcare provision for individual patients. Such tools can range from simply providing assistance to practitioners, to possibly one day being fully autonomous from human supervision. Indeed, increasing sophistication could lead to more accuracy. However, as more AI-guided tools become autonomous, fewer human operators are able to override their decisions. Hence, AI-guided medical devices have the potential to jeopardise current norms of professional accountability in clinical practice, making it more complicated to trace responsibility back to individual practitioners.[5]
Ethical and Privacy Considerations in Digital Health
As digital technology continues to shape the healthcare landscape, it is crucial to prioritize ethical and privacy considerations. Protecting individuals’ privacy, ensuring informed consent, promoting equity, and maintaining data accuracy and security are essential for the responsible and ethical use of digital health technologies. Ethical and privacy considerations in digital health are of utmost importance as digital technology continues to transform the healthcare landscape.[6]
The use of digital health technologies, such as wearable devices and health apps, involves the collection and storage of personal health data. It is crucial to ensure that individuals’ privacy is protected and that their data is handled securely Unauthorized access or misuse of personal health data can lead to ethical concerns and breaches of privacy. Strong regulations and safeguards should be in place to protect individuals’ privacy rights. Some key points to consider:[6]
· Informed Consent: In the context of digital health, obtaining informed consent from individuals is essential. Users should have a clear understanding of how their data will be collected, used, and shared. Transparent communication about data practices and giving individuals control over their data can help build trust and ensure the ethical use of digital health technologies.
· Equity and Non-Discrimination: Digital health technologies should be leveraged to advance the right to health in an equitable and nondiscriminatory manner. It is important to ensure that these technologies are accessible to all individuals, regardless of their socioeconomic status, race, or other factors. Ethical considerations should be taken into account to prevent exacerbating existing health disparities.
· Data Accuracy and Reliability: Digital health technologies, including artificial intelligence and machine learning algorithms, have the potential to support healthcare decision-making. However, it is crucial to ensure that these technologies are rigorously tested and validated. Ethical considerations include the need for transparency in algorithm development, accountability for algorithmic biases, and ongoing monitoring of the technology’s performance.
· Confidentiality and Security: Maintaining the confidentiality and security of health data is paramount in digital health. Robust measures should be in place to protect data from unauthorized access, breaches, and cyber threats. This includes implementing encryption, secure data storage, and regular security audits.
· Ethical Research Practices: Digital health research should adhere to ethical principles and guidelines. This includes obtaining informed consent from research participants, ensuring privacy and confidentiality, and conducting research with integrity. Ethical considerations should be taken into account when conducting research in conflict or humanitarian settings, where vulnerable populations may be involved.
· Ethical Issues In Digital Communication And Cyberspace: The main ethical issues in cyber communication are: personal privacy, access rights, and harmful actions. Personal privacy is threatened by the large-scale exchange of individual data online, risking disclosure and privacy violations. Ensuring data accuracy and protection is important. The five major ethical dilemmas currently faced by emerging technologies are (i) data privacy, (ii) risks associated with Artificial Intelligence, (iii) developing sustainable environments, (iv) health implications due to technology use, and (v) infodemic and data weaponization issues. One of the primary ethical concerns with wearable digital health technology is data collection and storage. As these devices track and monitor personal health data, such as heart rate, activity levels, and sleep patterns, they collect a significant amount of personal data. The main themes of Digital Ethics are the relationship between man and machine and the standards of a society shaped by digital technology. Regarding artificial intelligence (AI), digital ethics asks, for example, to what extent decisions made by AI are traceable and to what extent humans can and should trust these decisions.[7]
Physical and Psychological Well-Being in a Digital Technology World
In today’s digital technology world, both physical and psychological well-being can be influenced by people’s interactions with digital devices and platforms. It is important to strike a balance between the benefits and potential risks of digital technology in order to maintain both physical and psychological well-being. Being mindful of one’s digital habits, setting boundaries, and seeking support when needed can contribute to a healthier relationship with technology.[7]
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Physical Well-being
· Digital Wellness: Digital wellness refers to the use of technology to promote and maintain physical health. For example, using fitness tracking apps or wearable devices to monitor physical activity and encourage exercise.
· Healthy Use of Technology: Excessive use of digital devices, such as smartphones or computers, can have negative effects on physical well-being. It can lead to sedentary behavior, eye strain, poor posture, and disrupted sleep patterns. Practicing mindful and balanced use of technology can help mitigate these risks.
· Ergonomics: Paying attention to ergonomics while using digital devices is important for physical well-being. This includes maintaining proper posture, using ergonomic furniture and accessories, and taking regular breaks to stretch and move around.
Psychological Well-being:
· Digital Well-being: Digital well-being also encompasses mental health and emotional well-being. It involves using technology in a way that supports mental well-being and reduces stress and anxiety. For example, using meditation or mindfulness apps to manage stress.
· Impact on Mental Health: Research has shown that excessive use of digital technology, particularly social media, can contribute to feelings of loneliness, depression, and anxiety. It is important to be mindful of one’s digital consumption and take breaks when needed.
· Digital Detox: In the case of a digital detox, it refers to a set period of time for an individual to stay away from the devices and social media sites that have become such an integral part of life -- smartphones, computers, tablets, televisions. Taking regular breaks from digital devices and engaging in offline activities can help improve psychological well-being. This can include spending time in nature, pursuing hobbies, or engaging in face-to-face social interactions.
· Digital Literacy and Education: Building digital literacy skills and promoting digital education can empower individuals to navigate the digital world more effectively and make informed choices that support their psychological well-being.
Future Directions[8]
The defining feature of digital health, however, has to do with data rather than technology. What is distinctive about digital health in this respect, is that – typically through wearable, portable, ingestible or otherwise implantable devices – it generates a seamless flow of critical medical data between patients, their families and their physicians. The ambition of digital health is therefore aptly described as generating a circulation of data from patients (patient-generated data), to devices and/or health professionals (who analyse and make sense of the data), and then back to devices that eventually provide the patient with information regarding their health status and how to manage it. Digital health thus inhabits what has been recently labelled an evolving health data ecosystem, a space that also includes data gathered by healthcare services, such as electronic health records, genetic or genomic data, diagnostic data, claims data and the like. This expanded set of health-relevant data is expected to occasion huge progress in medicine, for example by helping people monitor their health status, assisting patients in coping with their conditions, inferring health-related issues earlier on, personalising treatment to individual patients’ characteristics, improving outcomes, reducing costs and inefficiencies, and also boosting medical discovery and accelerating drug development. Admittedly, there are significant expectations of digital health and there is strong interest on the part of numerous stakeholders in promoting it and seeing it flourish. At the same time, for digital health to materialise several ethical and policy challenges need to be overcome.[9]
Innovation in digital health faces several ethical and policy challenges. For digital health products and applications to produce tangible innovation and health impacts, be it at the individual or at the population level, few conditions need to be met. First, data are of paramount importance for digital health: access to sufficient amounts of data is thus a primary condition for the development of innovative diagnostic, therapeutic and monitoring tools is this area. Second, alignment with existing legal provisions regarding data protection, data security and privacy are key to digital health innovation. Legal frameworks can thus have a major impact in facilitating or hindering progress in this field. Nonetheless, legal provisions do not address the full range of ethical issues in data processing. Nor do they cover the full spectrum of legitimate concerns of data subjects. Third, robust and transparent accountability mechanisms should ensure the precise identification of responsibility for data uses and their consequences on individuals, families and communities. Mechanisms have to be set for communicating health relevant information to data subjects. Fourth, evidence of safety and efficacy is a significant condition for the success of digital health. Reliable preferably licensed digital health products and applications will have to go through extensive assessment processes and will have to meet cost-effectiveness requirement before they can be reimbursed by insurers and public healthcare systems. Fulfilling these requirements will foster the fifth condition for digital health innovation, that is, trust in both developers and regulators, which in turn will facilitate the uptake of digital health by healthcare providers and lead to fair benefit sharing of digital health innovation.
References
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