No, says the Deontologist.
Yes, says the Utilitarian.
Consider the following question:
We know that bariatric surgery offers significant benefits to patients with diabetes and obesity. These benefits include a 68% lower cardiovascular mortality. (Ref: Association Between Bariatric Surgery and Major Adverse Diabetes Outcomes in Patients With Diabetes and Obesity).
Is it ethical to use the EHR to flag these patients on their next visit with their Primary Care Provider?
I think the majority of people will say yes. The EHR is generating a simple reminder for the physician (not that dissimilar to reminding the patient of a need for a colonoscopy).
Here, however, is the more difficult question: Is it ethical for a healthcare organization to search their entire patient population EHR data set, identify patients with concurrent elevated BMIs and diabetes diagnoses, and then send them targeted information—not specifically requested—about the benefits of bariatric surgery?
In other words, is it ethical for an organization to use EHR population data set to generate new business, even if this business does medical benefit the patients?
Here, I think the answer is not clear-cut, and it depends on what ethical system the healthcare organization is using.
If the organization is applying a Utilitarian Ethics—roughly, doing the most good for the most people—then it is probably OK.
However, if the organization is applying a Deontological Ethics—roughly, treating every patient as an end in themselves—then it’s unethical.
Why?
Because it is unlikely that every time a patient stands on a scale they are also giving explicit informed consent that this data will help target people for new business development.
Put another way, patients are a means to an end, rather than an end in themselves.
One counterargument is that when patients first registered for their EHR, they gave implicit consent for this type of data usage.
Really?
Did the receptionist who handed a new patient a HIPPA form also say, “Hey, just so you know, we are going to keep all of your patient data forever, and we are going to continually filter it and search it for new business opportunities indefinitely. And, if you don’t sign this, you can’t be seen for your medical problem today.”
Of course not!
What I believe happens in practice is this. Healthcare organizations publicly speak the language of Deontology: “The Patient Always Comes First!”
But, behind the scenes, they are using Utilitarian Ethics: “Doing this search on 250,000 EHR patient data sets is OK because we are going to be able to help reduce the mortality of 1000 patients over the next 5 years.
It’s not so much that an organization using Utilitarian Ethics using Big Data (in the context of EHR searches) is wrong—it’s just that it will necessarily require them to be Deontologically unethical.
Utilitarian Ethics and Deontological Ethics are mutually exclusive in the healthcare domain.
And that is something worth pondering.