Contributors.

In the advent of the 21st century there can be no doubt that we have entered uncharted territory as we continue to employ diverse information and communication technologies (ICT) within healthcare. This is simply a matter of fact, at least for the Western world. But, as a question of value, what are the ethical and social ramifications of this healthcare trek? What assessments can we render on this murky, barely explored topography? A utopian answer is that ICT would deliver us to a technologic garden of healthcare delights. Here, health-related information and services abound and healthcare professionals and patients, under the protection of an electronic, global umbrella, operate in perfect harmony for the good of patients.

The intersection of ethics, computing, and genetics plots a space not yet adequately mapped, despite its importance, indeed, its rapidly growing importance. Its subdomains are well-enough known: “Genethics,” or the study of ethical issues in genetics and genomics, is part of core curricula everywhere. Ethics and computing is an established subfield. Computing and genetics—bioinformatics—has in little more than a decade progressed from subsubspecialty to the sine qua non of contemporary biomedical research, and it bids fair to transform clinical practice. We must prepare for the complete digitization of the genomes of individual patients and the storage of millions of these genomes in very large databases.

We have all heard a refrain much like this one over the last decade, increasingly so, as the cost of genetic sequencing has been drastically reduced with improvements in associated techniques and technologies. Already, discoveries are being made in laboratories that can help doctors determine from which drug a particular patient will receive the most efficacious treatment. The working presumption is that, eventually, individuals’ genetic sequence information will be included in each of their personal medical records.

According to a 2001 market report, titled “The Cure Is in Hand,” handheld computers, or personal digital assistants (PDAs), will “dramatically change the way that physicians practice medicine.” Such enthusiasm has resulted in an extraordinarily rapid diffusion of PDAs into a wide range of clinical settings. One report states that 47% of internists use PDAs once a day with rates of daily usage reaching 70% for resident physicians. Another study found clinical usage as high as 85% in teaching hospitals. The rapidly expanding employment of PDAs, however, has been uneven. Some clinicians have explored the devices’ benefits more thoroughly than their colleagues. Similarly, a number of potentially valuable uses of the handheld computer have been ignored or remain insufficiently developed by the medical community and the health delivery system at large.

As healthcare institutions expand and vertically integrate, healthcare delivery is less constrained by geography, nationality, or even by institutional boundaries. As part of this trend, some aspects of the healthcare process are shifted from medical centers back into the home and communities. Telehealth applications intended for health promotion, social services, and other activities—for the healthy as well as for the ill—provide services outside clinical settings in homes, schools, libraries, and other governmental and community sites. Such developments include health information web sites, on-line support groups, automated telephone counseling, interactive health promotion programs, and electronic mail exchanges. Concomitant with these developments is the growth of consumer health informatics, in which individuals seeking medical care or information are able to find various health information resources that take advantage of new information technologies.

The potential public and individual health consequences of unequal access to digital technologies have been recognized in the United States for at least a decade. Unequal access to the Internet and related technologies has been characterized as a “digital divide”; naturalistic trends toward broader access across the population and targeted intervention to increase access are described as progress toward “digital inclusion.” The problem of the digital divide has been characterized as one of healthcare justice. The idea that everyone should have access to the telecommunications grid—telephone and computer—is a central tenet of the U.S. universal service policy. With the diffusion of broadband technologies, the issue of digital access includes not only access to the Internet but also access to new levels of service, such as broadband, to support a wide range of emerging applications.

As we move toward the creation of a networked health information environment, the potential of privacy intrusions increases, with potentially devastating impact on quality and access to healthcare. This paper describes the risks we face and proposes a framework to minimize those risks. In particular, it proposes nine principles to protect privacy in an information age.

The privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 emphasize taking steps for protecting protected health information from unauthorized access and modification. Nonetheless, even organizations highly skilled in data security that comply with regulations and all good practices will suffer and must respond to breaches. This paper reports on a case study in responding to an important breach of the confidentiality and integrity of identifiable patient information of the Kaiser Internet Patient Portal known as “Kaiser Permanente Online” (KP Online). From the perspective of theories about highly reliable organizations, effective health information security programs must respond resiliently to as well as prospectively anticipate security breaches.

From computerized medical records to databases of pharmacological interactions and automated provisional EKG readings, the emergence of information technology has significantly altered the practice of medicine. Information technology has been widely used to enhance diagnosis and treatment and to improve communication between providers. The advent of the Internet also brings far-reaching implications for patient–physician communication, challenging physicians, patients, and policymakers to consider its impact on the delivery of medical care and the therapeutic relationship. A new set of practices by patients and physicians is unfolding in cyberspace, ranging from the use of e-mail to communicate between physicians and patients in an existing relationship to one-to-one consultations with an anonymous physician and ongoing online treatment, such as psychotherapy. These practices are emerging in both the for-profit and not-for-profit spheres.

These CQ Sources were compiled by Bette Anton.

It is still remarkably difficult for public health officials charged with developing and implementing pandemic influenza preparedness plans at the community level—where care is delivered—to obtain clear, concrete, and consistent guidance on how to construct plans that are both ethical and actionable. As of mid-2007, most of the federal and state pandemic plans filed with the Centers for Disease Control and Prevention, describing how public health officials will coordinate public agencies and private entities in the event of an outbreak, failed to include ethical guidance for first responders responsible for providing essential services and making fair decisions during a public health emergency.

The Principle of Double Effect has been with us since the Middle Ages and has sanctified actions that might otherwise be viewed as morally wrong. What I wish to show in this brief perspective is that an overlooked element in the discussions of this principle raises a serious question about its applicability.

Readers are invited to contact Greg S. Loeben in writing at Midwestern University, Glendale Campus, Bioethics Program, 19555 N. 59th Ave., Glendale, AZ 85308 regarding books they would like to see reviewed or books they are interested in reviewing.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.