1)     Is personal electronic mail private?

Dr. Brown: Personal electronic mail should be as private as regular mail correspondence. I do not have expertise in the area of electronic mail but I would imagine that even password protected does not preclude invasion of that privacy.

Dr. Goodman: Generally not, though this is actually an empirical question — such that I believe the answer is “generally not.” The question whether it should be private is another matter.

Dr. Husted: Yes.  The ethical right to privacy avoids conflict and, like all rights, promotes harmony.  And here we take harmony to be the standards of ethical judgment.

2)     Are ethical issues involving computers different from other ethical situations?

Dr. Brown: Ethical dilemmas (I prefer to use the term dilemmas instead of issues because an "issue" is noncontextual) involving computers can be guided by Symphonology just as any other situation.

Dr. Goodman: Some are and some are not. The need for confidentiality was perhaps first articulated by Hippocrates, so if anything is different it is in the ways it can be violated. It might be that the use of computers for clinical decision support and data mining in research raise new ethical issues.

Dr. Husted: Not fundamentally, or the term “ethics” becomes ambiguous.

3)     As medical informatics quickens the pace of what's possible, will bioinformaticethics help us decide what's right?

Dr. Brown: Bioinformaticethics, especially if one is utilizing Symphonology as the decision- making framework, can very well help us to decide what is right. It must be understood that ethics does not promise ballistic accuracy in any decision. The goal of any ethical system should be that a rational, justifiable decision was reached.

Dr. Goodman: Ethics is always there to help us decide what is right. Indeed, the measure of an adequate ethical system or theory or approach is in part its ability to be useful in novel contexts. A comprehensive, robust theory of ethics should be up to the task of addressing a broad variety of new applications and challenges at the intersection of informatics and health care.

Dr. Husted: Since information concerning an ethical dilemma, to be useful, must be kept in the context of the dilemma, if the idea that the resolution of dilemmas can be had at the “push of a button” bioinformatics might deflect one from deciding what is right.  If bioinformatics would gather, manipulate, classify, and retrieve information, effective reasoning that has been applied to various sorts of ethical dilemmas, it would be useful in helping us to decide what is right in a given context. 

4)     Does a patient have the right not to be entered into the electronic healthcare database of her/his provider?

Dr. Brown: I think the question can be answered by asking, does a patient have a right to not have a medical record? I think not. The confidentiality applied to the electronic database should be the same as that which is applied to the paper medical record.

Dr. Goodman: For a number of reasons —not least that they improve patient care — health providers are generally duty bound to store patient information in electronic databases. But there are perhaps some special circumstances in which, at least temporarily, a patient might be able to withhold information from the record. This is true of paper records, too, however, and the general rule there is that patient records must be comprehensive and accurate. However, providers are also increasingly required to disclose the existence of such databases and, beyond patient care, patients do have some rights to prevent the use of their information (e.g., certain kinds of research).

Dr. Husted: If a patient lacks this right, then it is a right he has been denied arbitrarily.  According to any system that treats individual rights as arbitrary, this would be acceptable. But if rights are grounded in some non-arbitrary manner, it surely would not. 

5)     Should an individual's genetic data be shared with pharmaceutical companies and other organizations? Who will guard the privacy of this data for those individual's from whom it is collected?

Dr. Brown: Genetic information should only be shared with other organizations if the individual gives consent. The privacy of this data should be protected by the collecting agency.

Dr. Goodman: Information of any sort should not be shared with any person or entity without patient consent. So the answer here is, “Sure — if patient consent is obtained.” This requires that the patient be told of the uses to which the information will be put. Once information is shared, it is up to the new custodians to safeguard its privacy as if it were theirs alone.

Dr. Husted: Certainly not without the individual’s permission.  The second question is beyond the scope of our expertise. 

6)     Is the Internet free? Should we provide Internet-based information to our patients?

Dr. Brown: The Internet is not free. Not only must a person have access to the appropriate hardware but they must also have an Internet provider. Internet-based information for our patients is wonderful as long as we are sure about the accuracy of the information and the patient is able to access the Internet. We must be prepared to provide patients with health information in a form that is appropriate to their capabilities.

Dr. Goodman: To the extent that public libraries or other organizations provide Internet access, yes. The question whether to share on-line information with patients should be answered the same as regarding any other medium: Is it reliable and accurate? Peer reviewed? Is it collected, maintained and presented by those with a conflict of interest (or the appearance of a conflict of interest)? Does it provide advice best or more appropriately provided by a clinician? A nurse, psychologist, physical therapist or physician must be familiar with the information before commending it to patients.

Dr. Husted: We should provide all the information possible to our patients. 

7)     Should healthcare professionals be required to take ethics courses in their basic education curriculums?

Dr. Brown: Yes, healthcare professionals should be required to take an ethics course during their basic education.  The needs and conditions of the people who enter into the health care context do not allow for purposeless and/or arbitrary decisions. Patients are vulnerable and the threat to their values is very real. Without an ethical background, biomedical professionals may be tempted to take actions that can be justified only through rationalization. An ethical decision-making model such as Symphonology motivates and guides ethical actions; actions that pursue vital and fundamental goals and involve the rights of others.

Dr. Goodman: They should be required to take interesting, high-quality ethics courses. Alas, much ethics as it is taught in nursing and medicine curricula is made to be boring, punitive or over simplistic. Ethics is exciting, and competent practitioners need to know about ethical issues and solutions in their professions.

Dr. Husted: This entirely depends upon the course and the teacher.  An ethicist has been defined, with tongue in cheek, as “an expert in the arbitrary and ungrounded opinions of other people.”  Odds are they would be taking courses in the arbitrary and ungrounded opinions of other people.  Study after study has shown that 6 months after taking an ethics course, what professionals have learned has no influence on their professional interactions. 

8)     Should healthcare professionals be required to have informatics competence? Who should decide what they should be competent in?

Dr. Brown: Informatics competence should be required as it pertains to the healthcare professional's academic work and "job skills" therefore informatics competence should be the responsibility of the professional.

Dr. Goodman: They should be competent to use the tools needed to hew or exceed the standard of care in their profession. To the extent that information technology is reshaping healthcare practices, or promises to improve patient care, then healthcare professionals must be trained and be competent in the use of these tools. This competency needs to be evaluated by instruments developed by professional groups or societies; this will help (though not guarantee) consistency and quality

Dr. Husted: Only if this would strengthen health care professional/patient interaction in ways that are most efficient or that could not be achieved otherwise.  Anyone who can objectively prove the case – should.  Not who – what – their ethical responsibilities are. 

9)     Should healthcare professionals be required to understand information science and the impact of information technology on healthcare?

Dr. Brown:  In order for the healthcare professional to be a patient advocate it is necessary for the professional understand how information technology impacts the patient and the subsequent delivery of care.

Dr. Goodman: Information science and its effect on healthcare are interesting and important … it follows that IT and its ethical, social and legal implications (ESLI) should be incorporated into professional and post-professional (continuing education) training. 

Dr. Husted: This would depend on the success of informatic science at objectively proving its value. 

Dr. Goodman's References

Gert B.  Morality: A New Justification of the Moral Rules.. New York, Oxford, 1989.

Gert B, Culver CM, Clouser KD. Bioethics: A Return to Fundamentals. New York, Oxford, 1997.