Digital Health: An Ethical Minefield? #2
Part 2 of 3. The Cost Paradox
Even as recently as a decade ago, mail-order genomic tests and homes that monitor your health weren’t on the general public’s radar. But technological advancements have integrated both into our lives, already changing medical care, and our future health. The public’s understanding and acceptance of these technologies also has grown, making their impact even greater as patients request specific genetic tests or download smart medicine apps to track their health.
Previously, we discussed the issue of confidentiality and data protection.
Just as important as privacy is the issue of cost.
The Cost Paradox
Technology increases accessibility and cuts costs (to the tune of $300 billion, according to Goldman Sachs projections), but will digital health’s most life-changing tools be accessible only to the most powerful and wealthy, further widening the divide between the haves and the have-nots?
The answer comes down to potential. Digital health holds an immense amount of promise for our health care system. Picture an ideal world in which nanotechnology brings medical care to rural communities in a sustainable way. Mobile monitoring ensures that people take their medication. Telemedicine helps eliminate unnecessary hospital visits and improves overall health care system function.
Investors see that potential. In 2017, they infused nearly $6 billion into digital health companies, which are aiming to foster greater connectivity, patient engagement and coordination with providers. But the companies have primarily failed to show they can make a difference to high-cost populations. A 2019 study in Health Affairs examined the 20 top-funded private U.S.-based digital health companies.
The researchers found that less than one-third of the companies’ studies focused on high-cost, high-burden populations, and few measured their impact on outcomes, cost or access.
Digital health companies tend to sell directly to consumers, promoting health among healthy populations.
Precision medicine, for example, is a form of digital health — and so far its costs are skyrocketing. Targeted treatment for breast cancer can cost thousands of dollars per month, while gene therapy to cure haemophilia comes with a $1.5 million price tag. The availability of such treatments speaks to how far we’ve come technologically, but it also raises the question of who gets access to them.
Essentially, we’re awash in technology with great promise, but we still don’t know how effective it is among those who might benefit from it the most.
Is Policy the Answer?
All policy language around health care presently reinforces the centrality of digital solutions but there is only sporadic attention given by authorities to matters of variation in the impact or benefit of digital health technologies for different social groups, including those who are marginalised and underprivileged. Yet, understanding this variance — or not assuming that digital solutions diminish health inequalities — has yet to be fully acknowledged as a key area of concern for policymakers.
Evidence suggests that equality is improved only in circumstances where participants have high levels of digital literacy.
Where this does not exist, then, the drive towards digital health solutions may exacerbate social inequalities due to the displacement of any other solution by digital solutions.
Equity is assembled through discourses of efficiency and empowerment, democracy and autonomy. There is a need for policymakers to engage with the social, cultural, geographical, political contexts that mediate and provide opportunity for access and engagement with digital health technologies and the data they generate.
Health care costs are a frustrating challenge, despite the technology’s great potential. Nevertheless, optimising digital health to make medical care affordable to everyone across society will benefit all of us in the long run. We have to cut through the debates and ensure that people’s needs are truly being met in an economically sustainable way.
About the author
Clara Chen is a first year medical student at the University of Cambridge, with a particular interest in the application of digital technology to empower healthcare provision. In the future, she hopes to combine medical practice with clinical academia, alongside improving quality of care with accessible and personalised digital medicine. Aside from her studies, Clara enjoys spending her free time playing music, reading, running, and cooking!
References
- Aicardi, Christine et al. “Emerging ethical issues regarding digital health data. On the World Medical Association Draft Declaration on Ethical Considerations Regarding Health Databases and Biobanks” Croat Med J. 57(2): 207–213. April 2016.
- Nebeker, C., Torous, J. & Bartlett Ellis, R.J. “Building the case for actionable ethics in digital health research supported by artificial intelligence.” BMC Med 17, 137. 17 July 2019
- Caroline Brall, Peter Schröder-Bäck, Els Maeckelberghe. “Ethical aspects of digital health from a justice point of view” European Journal of Public Health, 29:3(18–22) October 2019
- Caiani E. “Ethics of digital health tools” European Society of Cardiology, e-Journal of Cardiology Practice 18:27. 8 July 2020
- Rich, E., Miah, A. and Lewis, S. (2019), Is digital health care more equitable? The framing of health inequalities within England’s digital health policy 2010–2017. Sociol Health Illn, 41: 31–49. https://doi-org.ezp.lib.cam.ac.uk/10.1111/1467-9566.12980
