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The Ethical Tradeoffs of Medical Surveillance: Tracking, Compassion, and Moral Formation

photograph of medical staff holding patients hand

Our ability to track doctors – their movements, their location, and everything they accomplish while on the job – is increasing at a rapid pace. Using RFID tags, hospitals are able to not only track patients and medical equipment, but hospital staff as well, allowing administrators to monitor the exact amount of time that physicians spend in exam rooms or at lunch. On top of that, electronic health record systems (EHRs) require doctors to meticulously record the time they spend with patients, demanding that doctors spend multiple hours a day charting. And more could be on the way. Researchers are now working on technology that would track physician eye movement, allowing surveillance of how long a doctor looks at a patient’s chart or test results before making a diagnosis.

There are undeniable benefits to all of this tracking. Along with providing patients and their families with detailed examination notes, such detailed surveillance ensures that doctors are held to a meaningful standard of care even when they are tired or stressed. And workplace accountability is nothing new. Employers have used everything from punch clocks, supervisors, and drug tests to make sure that their staff is performing while on the job.

Yet as the surveillance of physicians becomes ever more ubiquitous, the number of moral concerns increases as well. While tracking typically does improve behavior, it can also stunt our moral growth. Take, for example, plagiarism detectors. If they are 100% accurate at detecting academic dishonesty, then they drastically reduce the incentive to cheat, making it clearly counterproductive for those who want to pass their classes. This will cause most students to avoid plagiarism simply out of sheer self-interest. At the same time though, it robs students of an opportunity to develop their moral characters, relieving them of the need to practice doing the right thing even when they might not get caught.

On the other hand, while school might be an important place to build the virtues, hospitals clearly are not. We want our doctors to be consistently attentive and careful in how they diagnose and treat their patients, and if increased surveillance can ensure that, then that seems like a worthwhile trade off. Sure, physicians might miss out on a few opportunities for moral growth and formation, but this loss can be outweighed by not leaving it up to chance whether any patients fall through the cracks. If more surveillance means that more patients get what they need, then so be it.

The problem, however, is that surveillance may not mean that hospitals are always getting more quality care, but simply getting more of what they measure. As doctors become more focused on efficient visit times and necessary record-keeping, there is evidence piling up that suggests that technological innovations like EHRs actually decrease the amount of time that physicians spend with their patients. Physicians now spend over 4 hours a day updating EHRs, including over 15 minutes each time they are in an exam room with a patient. Many doctors must also continue charting until late into the night, laboring after hours to stay on top of their work and burning out at ever increasing rates. So, while patient records might be more complete than ever before, time with and for patients has dwindled.

All of this becomes particularly concerning in light of the connection between physician compassion and patient health. Research has shown that when healthcare providers have the time to show their patients compassion, medical outcomes not only improve, but unnecessary costs are reduced as well. At the same time, compassion also helps curtail physician burnout, as connecting with patients makes doctors happier and more fulfilled.

So maybe the moral formation of doctors is not irrelevant after all. If there is a strong link between positive clinical outcomes and doctors who have cultivated a character of compassion (doctors who are also less likely to burn out), then how hospitals and clinics form their physicians is of the utmost importance.

This, of course, raises the question about what this means for how we track doctors. The most straightforward conclusion is that we shouldn’t give physicians so much to do that they don’t have any time for empathy. Driven by an emphasis on efficiency, 56% of doctors already say that they do not have enough time for compassion in their clinical routines. If compassion plays a significant role in providing quality healthcare, then that obviously needs to change.

But an emphasis on compassion and the moral characters of doctors raises even deeper questions about whether medical surveillance is in need of serious reform. It is extremely difficult to measure how compassionate doctors are being with their patients. Simply tracking a certain period of time, or particular eye movements, or even a doctor’s tone of voice might not truly reflect whether doctors are being empathetic and compassionate towards their patients, making it unclear whether more in-depth surveillance could ever ensure the kinds of personal interactions that are best for both doctors and their patients. And as we have seen, whatever metrics hospitals attempt to track, those measures are the ones that doctors will prioritize when organizing their time.

For this reason, it might be that extensive tracking will always subtly undermine the outcomes that we want, and that creating more compassionate healthcare requires a more nuanced approach to tracking physician performance. It may be possible to still have metrics that ensure all patients get a certain baseline of care, but doctors might also need more time and freedom to connect with patients in ways that can never be fully quantified in an EHR.

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The Quandary of Contact-Tracing Tech

image of iphone indicating nearby infections

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

All over the country, states are re-opening their economies. This is happening in defiance of recommendations from experts in infectious disease, which suggest that states only re-open after they have seen a fourteen-day decline in cases, have capacities to contact trace, have sufficient personal protective equipment for healthcare workers, and have sufficient testing capabilities to identify hotspots and deal with problems when they arise.

Experts do not insist that things need to be shut down until the virus disappears. Instead, we need to change our practices; we need to open only when it is safe to do so and we need to employ common sense practices like social distancing, mask-wearing, and hand-washing and sanitizing when we take that step. The ability to identify people who either have or might have coronavirus and to contact those with whom they might have come into contact could play a significant role in this process. Instead of isolating everyone, we could isolate those we have good reason to believe may have become infected.

Different countries have approached this challenge differently. Many have made use of technology to track outbreaks of the virus. Without a doubt, these approaches involve balancing the value of public safety against concerns about personal privacy and undue governmental intrusion into the lives of private citizens.

Many in the West were surprised to hear that Shanghai Disney was scheduled to re-open, which it did on May 11th. Visitors to the park won’t have the Disney experience that they would have had last summer. First, unsurprisingly, Disney is restricting the number of people it will allow into the park at any one time to 24,000 people a day. This is down from its typical 80,000 daily guests. When guests arrive, they must have their temperatures taken, must use hand sanitizer, and must wear masks. Crucially, they must open an app on their phone at the gate that demonstrates to the attendant that their risk level is green.

Since the COVID-19 outbreak, people in China have been required to participate in a system that they call the “Alipay Health Code.” To participate, people download an app on their phones which makes use of geolocation to track the whereabouts of everyone who has it. People are not required to have a COVID-19 test in order to comply with the demands of the app. Instead, the app tracks how close people have come to others who have confirmed cases of the virus. The app assigns a person a QR code depending on their risk level. People with a green designation are low risk and can travel through the country and can go to places like restaurants, shopping malls, and amusement parks with no restrictions. Those with a yellow designation must self-quarantine for nine days. If a person has a red designation, they must enter mandatory government quarantine.

At first glance, this app appears to be a reasonable way of finding balance between preventing the spread of disease on one hand, and opening up the economy and freeing people from isolation on the other. China isn’t simply accepting the inevitable—opening up the economy and disregarding its obligation to vulnerable populations. Instead, it is trying to maximize the well-being of society at large.

Things are more complicated than they might originally appear. First, the process is not transparent to citizens. The standards for reassignment from one color designation to another are not made public. Some people are stuck in mandatory government quarantine without knowing why they are there or how long they might expect to be detained.

There are also concerns about regional discrimination. It appears that a person can be designated a particular threat level simply because they are from or have recently visited a particular region. Citizens have no control over how this process is implemented, and the concern is that decision-making metrics might be discriminatory and might serve to reinforce oppressive social conditions that existed before COVID-19 was an issue. We know that COVID-19 disproportionately affects people living in poverty who are forced to work in unsafe conditions. This kind of tracking may make life for these populations even worse.

There are also significant concerns about the introduction of a heightened degree of governmental surveillance. Before COVID-19 hit, the Chinese government had already slowly begun to implement a social credit system that assigns points to people based on their social behaviors. These points then dictate the quality of services for which the people might be eligible. The Alipay Health Code increases governmental surveillance and encroachment. When people download the Alipay app, the program that is launched includes a command labeled “reportInfoAndLocationToPolice” that sends information about that person to a secure server. It is unclear for what purpose that information will be used in the future. It is also unclear how long it will be mandatory for people in China to have this app on their phones.

But China is not the only country that is using tracking technology to manage the spread of COVID-19. Other countries doing this include South Korea, Singapore, Taiwan, Austria, Poland, the U.K., and the United States. There are advantages and disadvantages to each system. Each system reflects a different balance of important societal values.

South Korea’s system keeps its residents informed of the movement of people who have tested positive for COVID-19. The government sends out texts informing people of places these individuals have been so that others who have also been to those places know whether they might be at risk. This information also lets people know which places might be hotspots so they know to avoid those places. All of this information is useful to prevent the spread of the virus. That said, there are serious challenges here too. Information about the location of individuals at particular times leads to speculation about their behaviors that might lead to discrimination and harassment. The information is anonymous in principle; COVID-19 patients are assigned numbers that are used in reports. In practice, however, it is often fairly easy to deduce who the people are.

Some countries, like the U.K., Singapore, and the United States have “opt-in” tracking programs. Participation in these programs is voluntary and there tend to be regional differences in what they do and how they operate. Singapore uses a system called “TraceTogether.” Users of the app turn on Bluetooth capabilities for their devices. Each device is associated with an anonymous code. Devices communicate with one another and store each other’s anonymous codes. Then, if a person has interacted with someone who later tests positive, they are informed that they are at risk. They can then take action; they may be tested or may self-quarantine. This system appears to have established a comfortable balance between competing interests.

One problem, however, is that its voluntary nature results in low participation numbers—only 1.5 of Singapore’s 5.7 million people are using the app. What follows from this is that a person has the peace of mind of knowing that if they have been in contact with another app user who contracts COVID-19, they’ll know about it. However, this kind of system doesn’t achieve that much-desired balance between concerns for public safety and concerns for a healthy functioning economy. If a person knows only about some, but not all, of the people they’ve encountered who have tested positive for COVID-19, they’re no safer out in the world as a consumer in a newly-opened economy. This app also does nothing to prevent the spread of the virus by asymptomatic people who may never feel the need to get tested because they feel fine.

There are other, less straightforward ways of collecting and using data about the spread of the virus. Government agencies are attaining geo-tracking information from corporations like Google and Facebook. Most users don’t pay much attention when an app asks if it can track the user’s location. People tend to provide a morally meaningless level of consent—they click “okay” without even glancing at terms and conditions. Corporations use this information for all sorts of purposes. For example, police agencies have accessed this information to help them solve crimes through a process of “digital dragnet.” Because these apps track people’s movements, they can help the government to see who was present at sites later identified as hotspots and can identify where people at those sites at the time in question went next. This can help governments direct their attention to where it might do the most good.

Again, in many ways, this seems like a good thing. We don’t want to waste valuable time searching for information where there isn’t any to be found. It’s best instead to find the clues and follow them. On the other hand, this method of attaining information highlights something troubling about trust and privacy in the United States. A Pew poll from November, 2019 suggests that citizens view themselves as having very little control over who is collecting data about them and very little knowledge about what data is being collected or the purposes for which it is being used. Even so, people tend to pay very little attention to the fact that they are being tracked. They simply accept the notion that, if they want to use an app, they have to accept the terms and conditions.

People concerned about personal liberties are front and center on the public stage right now as their protests make for attention-catching headlines. People are unlikely to want to be forced by the government to use a tracking app. Their fears are not entirely unfounded—China’s program seems to open the door for human rights violations and a troubling amount of governmental surveillance of private citizens. Ironically, though, these people give that same information without any fuss to corporations through the use of apps. This may be even worse. At least in principle, governments exist for the good of the people, while the raison d’être of corporations is to make a profit.

The case of tracking poses a genuine moral dilemma. There are very good public health reasons to use technology to track and control the spread of the virus. There are also very good reasons to be concerned about privacy and human rights violations. Around 3,000 people died in the tragic terrorist attacks that took place on September 11th, 2001. As a result, Congress passed The Patriot Act, which significantly limited privacy rights of the people. Its effect on the way respect for individual privacy changed at airports is also noteworthy. How much privacy should we be willing to give up in exchange for safety? If we were willing to give up privacy for safety in response to 911, how much more willing should we be to do so when the death count is so much higher?

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Rural Health Disparities and Telemedicine

photograph of surgery performed with help of teleprescence robot

Rural America has been struggling from a lack of hospitals and physicians at an alarming rate. In the past decade, ER patients in rural communities have increased by 60% and hospitals in those locations have decreased by 15%. A potential solution to the lack of health care providers is to consider telemedicine as an option for these rural locations. Telemedicine is a remote care center which provides hospitals, clinics, or even individuals with direct access to a physician. One such company that provides this service is Avera eCARE. At Avera eCARE, doctors work out of high-tech cubicles, dressed in scrubs to look the part, but never actually physically touching or seeing their patients. Instead, they use a high-resolution camera and microphone to work with their patients and nurses or healthcare professionals at remote locations.

Dr. Brian Skow is an example of a physician who works from one of the Avera eCARE centers that provides remote emergency care for 179 hospitals across the nation. Skow was called in when a comatose, unresponsive patient came into the emergency room in rural Montana with only nurses on staff. Skow remotely instructed the nurse how to incubate the patient – inserting a tube into the patient’s throat in order to get her onto a ventilator. Without his help, this patient would have most likely died from lack of oxygen.

“If anything defines the growing health gap between rural and urban America,” The Washington Post claims, “it’s the rise of emergency telemedicine in the poorest, sickest, and most remote parts of the country, where the choice is increasingly to have a doctor on screen or no doctor at all.” And Dr. Skow’s situation is a perfect example. He watched as 5 people performed the procedure, all with careful instruction and encouragement from his remote location. To compare this to his hospital at Sioux Falls, he has to compete with an emergency physician, trauma surgeon, cardiologist, anesthesiologist, a team of 20 residents, ER nurses, and paramedics to be at the bedside. This has meant that each month telemedicine can help cardiac episodes, traumatic injuries, overdoses, and burns at a rate that is much higher than before.

There are a number of benefits generated by the move to such a system. Telemedicine helps hospitals retain doctors and recruit them because it allows for time off- and on-site support. Many critical-access hospitals are struggling to find even a single doctor or can’t keep physicians long. This technology offers the option for the nurses and physician assistants to call in for immediate health care suggestions. Another benefit is that hospitals are able to treat more patients with more intense conditions than before, as the technology allows hospitals to treat patients without needing to immediately transfer them. These transfers increase the time in which the patient suffers, and for most of these cases, every second counts. Apart from pain and outcome, transferring also greatly increase billing charges for patients. Even hospitals benefit by treating more cases and thus generating more profit.

Despite these advantages, there are still many limitations. Telemedicine costs approximately $70,000 monthly and $170,000 to install. Hospitals have to face a difficult decision in choosing between installing this technology or investing money on other life-saving machines like MRI and CAT scans.

Critics also worry that telemedicine takes the humanity out of patient-physician relationship. Instead of physically being with the patient, that crucial interaction is separated by a screen and thousands of miles. This reality can affect treatment in ways that are unexpected. Especially in remote communities, it is very common for the nursing staff to know the patient personally, but for the virtual doctor, the patient can become “less human.” Doctor Kelly Rhone, describes this phenomenon as she watched nurses from North Dakota perform CPR on a patient for over 10 minutes. One of the worst things that the remote doctor can do, Rhone argues, is withdraw care too quickly. Even when a patient has passed, it’s important for the medical staff in the room to acknowledge the situation in their own time. This obligation may even extend to being present with grieving family members.

It is important to consider then, if remote care is an adequate substitute and can offer sufficient support for the human element to medicine. Perception can play a major role in diagnosis, and if doctors aren’t seeing their patients in the same way, they will treat them differently. It may be more likely for doctors to withdraw care or save resources, compared to situations where they are with them in person.

There are also some challenges when it comes to telemedicine being used directly in people’s homes. There are apps which can help patients connect with a doctor via Facetime, text messages, and phone calls. There are some benefits to this option. For busy parents and working folk, this is a quick and easy solution to getting better fast. Some people live an hour or more from the nearest health clinic, and so to be able to describe their symptoms over the phone and get their medicine prescribed within minutes is a great benefit. However, there is also the increased risk of misdiagnosis. It can be easy to miss symptoms of larger health problems – when chest discomfort isn’t just a strained muscle, but an early sign of a heart attack, for example. In this way, reliance on telemedicine can increase risk to patients.

There is a clear injustice in our health care services in the United States for rural areas and urban locations. Telemedicine is one option for those who are suffering from lack of adequate healthcare. It increases virtual staff and gives current staff direct access to help for their situations. With the rising trend toward virtual telemedicine, we must consider what cost to patient health we are willing to accept for increased efficiency.