Message from the Editor

Virtual Medicine and Ethics

The impressive advances made by informatics and telecommunications in the last years are leading to serious tensions on medical ethics and professional practice. With Internet and telemedicine, there is for the first time the real possibility of diagnosing and treating patients remotely, using computer networks. There are many studies proving that the cost/benefit ratio provided by telemedicine can be very favourable in many situations (for example, when a single specialized physician can deliver medical attention to several geographycally remote places which are medically underserved, with no need to travel.)

Problems begin to appear when we imagine that the entire legal and ethical framework of traditional medicine (which, in Brazil, like in many countries, is under the supervision of some country-level appointed medical council or association) does not comtemplate, with very few exceptions, the advances brought about by telemedicine. Legally, in the USA as in Brazil, no physician is allowed to practice outside the state boundaries where he/she has received official license. Telemedicine makes this an easy thing to to, regardless of the distance; or even across country borders. Furthermore, it is clear that due legal process in cases of malpractice, violation of medical ethics, protection of patient confidentiality, etc., is very difficult to be carried out when physicians and patients, and different legal systems of two countries are involved !

Danger is looming: for countries like Brazil, there is a real possibility (already happening !), that European and American physicians start to use these loopholes, omissions and difficulties of medical regulations and laws to gain access to huge worldwide markets of medical services, by means of telemedicine, avoiding any legal responsibilities or accountability. Many institutions abroad, hard-pressed by the economic crisis of the health care sector, are on the lookout for alternative markets. Recently, one of the largest medical insurance companies in Brazil, owned by a big bank, began to study the possibility of offering medical second opinion services for their customers in the highest paid coverage plans. They are considering using telemedicine technology to connect to prestigious universities and hospitals in the USA for that purpose. In case the patient has doubts about the diagnosis or treatment recommended by Brazilian physicians accredited by this insurance company, they will have the right to hold a telemedical consultation with American specialists, sending x-rays, ECGs, full medical history, etc.; using Internet.

The medical establishment feels that it is unacceptable that physicians from other countries are allowed to practice in this country without licensure; but, at the same time, it is clear that this is going to be a remarkably hard obstacle for the progress of international telemedicine and the benefits which it may bring to patients and to the local health care situation. Medical knowledge is borderless in nature, and many patients who are able to pay would like to have free access to it. Sometimes is easier to pay for a telemedical consultation than to pay for airfare and stay of a patient to be sent to Cleveland or NewYork, a bill which may easily run into the tens of thousands of dollars.

In addition, there is also a need of caution when remote diagnosis and treatment is done without a face-to-face encounter and examination of the patient.

As it often happens, economical issues are going to steer the entire process, and all relevant issues must be carefully taken in consideration by the involved professionals, medical associations, lawmakers, etc., before it's too late.
 

Published by:     Center for Biomedical Informatics  State University of Campinas, Brazil   © 1997 Renato M.E. Sabbatini

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