Smart Healthcare and Ethical Issues
Victor Chang
1
, Yi Cao
1
, Taiyu Li
1
, Yujie Shi
1
and Patricia Baudier
2
1
Internatinal Business School Suzhou, Xi’an Jiaotong-Liverpool University, Suzhou, China
2
Ecole de Management Normandie, France
Keywords: Smart Healthcare, IoT, Ethical Issues, Privacy, Data Leaking.
Abstract: With the development of Internet of Things (IoT) technologies, the medical field has begun to use this
technology to better cover society’s needs. The users’ data can be accurately collected and analyzed, and
people can get quite the same level of quality of medical services without shuttling back and forth between
hospitals and their homes. Smart healthcare not only reduces the social burden, but it also lowers the financial
burden on end users. However, the collection and upload of massive data still have concerning data security
risk, which may lead to various ethical problems and endanger the users’ interests. The analysis of ethical
issues, can help us to provide users or developers with suggestions and demonstrate the central role played by
governments. How to balance the user experiences and ethical security is always a hot topic. The aim of this
paper is to review existing literature to present recommendations to balance both the use of IoT technologies
or smart healthcare and ethics to deliver accurate smart medical services.
1 INTRODUCTION
Many countries have faced social problems such as
population expansion, population aging, chronic
diseases or epidemics, and poor living conditions.
Although people's basic needs have been met, they
have started to seek the improvement of medical
services (Marmot, 2005). Nevertheless, people still
need to queue up for medical treatment. Those
patients with chronic diseases need to go to the
hospital for controls and for prescription using the
existing medical service system (Darkins et al, 2008).
Due to the population growth and urbanization
process, the demands of high-quality medical
treatment will become more and more urgent
(Farahani et al, 2018). With the help of IoT
technology, patients can monitor their health using
wearable devices, but also some devices part of the
smart home concept to ensure security at home
(Baudier et al., 2018).
However, the application of this technology may
impose a variety of ethical issues directly or
indirectly. Ethics is defined as the discipline of
“dealing with good and evil”, moral responsibility
and obligation. Healthcare ethics include some
specific ethical issues which are related with disease
prevention, lifelong extension or public behaviors of
mental and physical health, and those medical ethical
issues mainly focus on the relationship between
patients and physicians. Healthcare ethics can be
defined as the ethical regulations and requirements
while handling sensitive and private data such as
patients’ records (Mittelstadt and Floridi, 2016).
The existence of Insurance and employment
discrimination is due to the data leakage particularly
in data sharing with institution-based information,
unauthorized access and disclosure of health
information, which can lead to embarrassment and
other physical and mental harms to the users
(Denecke et al, 2015). What ethical issues will arise
with smart healthcare, or how ethical principles apply
to online health research is a challenge for current
researchers, health care workers and patients. In this
article, we begin to study these issues, the first part
will cover the background of IoT and smart medical
care, the second part will describe and analyze the
ethical issues caused by smart medical care, and
finally the last part will put forward the following
suggestions and solutions on these problems.
2 THE VISION OF IoT
TECHNOLOGY IN SMART
HEALTHCARE
Internet of Things (IoT) technology is quickly
changing the way people live. The concept of IoT has
Chang, V., Cao, Y., Li, T., Shi, Y. and Baudier, P.
Smart Healthcare and Ethical Issues.
DOI: 10.5220/0007737200530059
In International Conference on Finance, Economics, Management and IT Business (FEMIB 2019), pages 53-59
ISBN: 978-989-758-370-4
Copyright
c
2019 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
53
been proposed for only 30 years while its
development is amazingly fast, especially in recent
years. Relevant products and concepts have been
launched, such as sports bracelets, smart watches,
smart toys, smart cars, smart homes, smart cities and
so on. Medical healthcare has always been a very
important part of our life, since people’s health can be
ensured by using the services of the medical and
healthcare industry. However, the defective public
healthcare system, high expenditure and low
coverage have puzzled the government and residents
for a long time, healthcare issues have become one of
the social principal contradictions that affect the
social harmony. As the concept of precision medicine
has constantly been put forward, which points out that
the goal of medical development is to meet the
specific needs of individuals. As a result, it is
necessary to establish a smart medical information
network platform system to enable patients to enjoy
quality medical services with shorter treatment time
and less medical expenses. The application of IoT
technology has spawned a new concept of smart
medical care, referred to as WIT120. IoT can help
hospitals intelligently manage medical resources and
help medical staff to effectively process patient's
medical record information. Additionally, IoT can
provide material management visualization, digitize
medical information, and become a solution to the
shortage of healthcare resource, which is a
fundamental cause of uneven utilization and the
physician-patient relationship.
Figure 1: IoT layers.
As shown in Fig. 1, the IoT platform has a multi-
tiered architecture with four different layers. The
sensing layer is the first layer designed to connect the
world and collect data through different types of
devices. The second layer is the network layer that
supports data conversion. The third layer is the
service layer, which is mainly used to meet user needs
by creating and processing various services. The
fourth layer is the interface layer that provides
interactive approaches for operators and other
applications, as in this stage all information would be
parsed, rendered and delivered smoothly. However,
for each IoT system, potential risks can be identified
such as the data privacy securities of end-users. If the
IoT security is compromised, end users’ data can be
extracted by the untrusted authentication (Mittelstadt
and Floridi, 2016). In addition, this can also lead to
personal safety risks. Protecting the IoT e-health
environment should be considered as a complex and
severe problem (Farahani et al., 2018).
First-generation of tele-healthcare devices is
relatively simple, such as smart pillboxes or
communication devices, which can call the medical
centers or remind users to take medicine on time, but
these settings often require the users to trigger.
Second-generation devices have more sensors and no
longer need users intervention, such as some wireless
automatic alarms. The third-generations of equipment
can process, collect and analyze data, and can
continuously detect the user's life (Technology meets
healthcare). For example, the remote life detector, the
user can use the device to test his blood pressure,
pulse oxygen, heart rate, body temperature, blood
sugar, etc., these data are uploaded to the server
through the network. If abnormal data is observed, an
alarm will be triggered, and the doctor or
housekeeper
will contact the user. Early intervention may reduce
the occurrence of emergencies and reduce the risk of
hospitalization (Mittelstadt and Floridi, 2015).
Figure 2: IoT in smart healthcare.
As shown in Fig. 2, smart healthcare can use IoT
technologies to create a healthcare information
platform and databases. This can interlace patients,
healthcare providers, devices and medical databases
together to achieve efficient interactions and
communications between people, equipment and
information (Farahani et al., 2018). Through the
wireless network and handheld PDA to connect
various medical instruments, so that medical staff can
grasp the medical record information of each patient
at any time, and quickly formulate the diagnosis and
treatment plan. Patients and doctors can easily access
medical imaging materials and medical orders
FEMIB 2019 - International Conference on Finance, Economics, Management and IT Business
54
remotely. The patient's referral information and
personal medical records can be accessed through any
medical network in any hospitals (Ballantyne and
Mulhall, 1999). Internet of Things technology makes
healthcare services more convenient and cheaper as
follows. First, the use of wireless medical devices can
greatly reduce the financial burden of public
healthcare. Second, Telehealth or self-service
medical treatment is realized through digitalization,
which relieves the imbalance of medical resources
(Mayo Clinic, 2017). Third, medical information
shared can help healthcare platforms to be developed
equally across the world. Last but not the least, it is
suitable with the modernization of healthcare services
and the improvement of healthcare standards. This
can be further improved using AI and big data
services. Diagnosis can be provided to users with
better quality and accuracy (Chang, 2018).
Smart healthcare is a huge and complex
interconnection system consisting of three parts: the
smart hospital system, the regional health system, and
the family health system. The Smart Hospital System
includes two major parts, one is the part of the
Hospital Information System, the Laboratory
Information Management System (LIS), the Picture
Archiving and Communication Systems (PACS), the
transmission system and the doctor workstation,
which mainly focuses on the data collection, storage,
processing, extraction and exchange of patient
personal medical records and administrative
information. Another part of smart hospital includes
the application of remote image transmission,
massive data calculation in the construction process
of digital hospitals, and the improvement of medical
service level, such as remote visit, remote visit,
automatic alarm, clinical decision system and smart
prescription. The regional health system is a
combination of a regional healthcare platform and a
public healthcare system, which is mainly responsible
for collecting, processing, and transmitting all
information recorded by communities, hospitals,
medical research institutions, and health regulatory
agencies, and formulate Electronic Health Record
(EHR) to prevent and control the diseases from
spreading. The family health system is the health
insurance closest to the residents, who can become
the source of a large amount of medical data and the
terminal of all services. The existing smart
medication system can already include automatic
reminder time, taking contraindications, remaining
doses, etc. The collection and processing of data in
smart healthcare can help doctors reduce diagnosis
time and improve accuracy. The users’ physical
condition is regularly recorded, and the doctor can
judge the cause through a long-term course of disease,
not just the current symptoms. At the same time, big
data can also be used for diagnosis, and doctors are
responsible for more complicated consultations and
prescription drugs. These medical devices help to
improve the users’ self-management capabilities
(Stowe and Harding, 2010).
The smart healthcare is convenient to both
patients and medical staff, but these advantages
combined with ethical issues. Recently, remote health
monitoring is one of the main application example in
the Internet of Healthcare Things (IoHT). Under these
circumstances, the process of healthcare is shifted
from hospitals back into the resident homes. Such
technologies and devices include several parts such as
websites of health information, on-line network,
automated telephone counseling, interactive health
promotion programs, and e-mail exchanges, which
means the personal data is also shifted from paper into
digital world. As in the world of institutional EHR,
access to the personal health records (PHR) data can
be exposed to inappropriate third-party, which is a
threat to individuals’ privacy and arise ethical
problems (Sholla, Naaz and Chishti, 2017).
3 THE ETHICAL PROBLEMS
The healthcare service itself contains many ethical
issues (Summers, 2012). In general, there are four
principles to help people to deal with these ethical
issues, justice, autonomy, non-maleficence, and
beneficence (Breslin et al, 2005). In fact, in daily
medical services the situation is complicated. For
example, if someone wants to give up treatment to
maintain the quality of life, doctors will respect
patient’s choices based on the principle of autonomy,
but when patients are unconscious or unable to make
the right choices, this is an ethical issue that is
difficult to solve. There are also many controversial
points about the rights to be harmless. Generally
speaking, being harmful and harmless is often
determined by doctors based on the diagnosis results.
This judgment has subjective components that are
difficult for non-professionals to understand.
Whether it is harmful or not, it depends on different
people’s mindsets and understanding. This
contradiction is one of the important reasons for the
relationship between doctors and patients. According
to the principle of fairness, everyone should have
equal access to the same medical services. However,
only 1% of Americans occupy 23.7% of medical
resources, and the remaining 50% of Americans have
only 3.4% of resources (Cushman et al, 2010), this is
Smart Healthcare and Ethical Issues
55
obviously unfair. This phenomenon is mainly due to
the long-term lack of medical resources and uneven
distribution. The medical level and resources of big
cities or developed countries are much higher than
those of rural and developing countries. In other
words, if a person is born in a big modern city, he or
she can enjoy the high-quality services much easier
while the other person in rural areas may need to
spend more time and money to seek the same level of
services. Children and the elderly are often groups
that can enjoy extra benefits. However, in medical
services, children are often more favored because
considered as more important for the future, and
many resources are tilted towards children for an
ethical discrimination for the elderly (Organisation
mondiale de la santé, & World Health Organization,
2007).
For smart medical care sector, the similar ethical
issues of traditional medical care services still exist,
which is combined with other new high-risk ethical
issues, mainly caused using remote medical
equipment, social networks and unclear laws
.
3.1 Risk from Device Information
Leakage
Since every operator is independent, many links can
reveal user information. The low-level authorization
has a big risk of information leakage, while the high-
level authorization is likely to cause loss or error in
the information transfer process, which will directly
affect the final service quality. In any cases, the range
of capabilities of mobile devices depends on
manufacturer. Devices installed at home, or worn, can
collect body data in real time. Many manufacturers
claim that the more comprehensive the information is
acquired, the higher the quality of service will be, but
this boundary is not explained clearly. If hackers
invade the system to obtain data information, it is
difficult for users to be protected against this risk
(Cushman et al, 2010).
3.2 Risk from Social Network
Strong social networks make privacy more
challenging as personal data may be exposed without
the owners’ consent. Especially for young people,
social networking is their first choice for seeking
solutions (Denecke et al, 2015). It is difficult to
accuse some healthcare operators if users themselves
reveal their personal information in social networks.
In addition, some operators provide their own social
networks for users to exchange information, so that
users can consult through these social groups,
encourage each other, etc. Despite they can make
friends on social network, privacy and personal life
may have different outcomes, if disagreement has
raised to higher levels that expose sensitive
information or personal data leakage.
3.3 Ambiguities in the Laws
Although there are already some laws to protect
information security, many laws and regulations on
ethical issues are ambiguous. There is no clear
indication on the subject of responsibility and the
boundaries of information. For example, wrong
treatment and diagnosis may cause additional pain
and burden to the patient (Breslin et al, 2005).
Therefore, once information leakage occurs, it is still
difficult for patients to defend their rights through
legal channels. For example, when a device analyzes
the users’ data and draws a conclusion “do exercise”,
but the user's physical condition is not good, then how
to define responsibility if an accident occurs?
4 ETHICAL PROBLEM
ANALYSIS
4.1 Ethical Issues in Different
Population
The information protection of the elderly and children
and some special groups (disabled, fragile or weak
individuals) is also a problem. The information
authorizers are regarded as guardians. However,
legally speaking, their authorization has no legal
effect (Slovenko, 1998). For example, how much
information is given to the operator? The way
analysis results are returned to the operators is
unknown. Most of elderly people rather prefer to stay
at home, but around 35% of the elderly live in nursing
homes, which could represent potential users
(Rubenstein, 2006). They may not care if they are
monitored, but they are worried about whether the use
of these devices will be communicated to others.
They could be concerned about their reputation and
the fact that neighbors could think that they cannot
take care of themselves affecting his normal social
interaction (Chung, et al, 2016). In order to achieve
the purpose of medical uses, these devices are likely
to embarrass users periodically, such as constantly
warning them not to do something because of certain
defects on users. Monitoring systems may force users
to have more permission to process data. For
example, if a user plans to get a fall alarm service, he
FEMIB 2019 - International Conference on Finance, Economics, Management and IT Business
56
or she must turn on the surveillance camera and keep
a 24-hour video. The system may create false data to
prove that the user is better than ever to pursue a
follow-up subscription services. These telemedicine
monitoring may result in fewer visits by family
members and psychological harm to some users. For
people with chronic conditions, their physical data
may be in an unhealthy state for a long time, which
may lead to anxiety and depression (Stowe and
Harding, 2010).
Different groups of people, countries and regions
have different expectations for medical services, and
their level of acceptance is different. The ethical
issues of one technology is solved in one region but
may still be problems in other regions (Kaplan and
Litewka, 2008). In addition, the application of smart
medical care will involve social issues. Many authors
(Finkelstein, Speedie and Potthoff, 2006) agree that
smart medical care can solve the problem of uneven
distribution of medical resources. Nevertheless, the
service and resource sharing of smart medical care is
based on a certain technology platform, which means
that users can receive these services cheaper and more
conveniently for the related medical equipment. In
this case, the unfairness may be more serious than the
original. For example, for a citizen without a
smartphone or computer, he or she has no way to use
all online service platforms, so it is not us who choose
to buy a mobile phone, but the environment forces us
to do so. Smart healthcare may reduce hospitalization
and reduce the financial burden, but so far there is not
enough data to support it (Stowe and Harding, 2010).
For example, there are studies that show that in some
cases the cost of telemedicine is higher (Henderson et
al, 2013). The benefits of this new technology may
only be enjoyed by the rich, while the poor may face
a scarce resource. Enterprise competition will
gradually transfer funds and resources to more
commercially valuable areas. The high burden of
traditional industries and the loss of customers will
inevitably lead to the retreat of service providers,
people who stick with traditional medical services,
their service quality may be reduced, which
artificially distinguishes the boundaries between the
poor and the rich.
4.2 Ethical Issues in Public Health
Thanks to the use of Internet technology and EHR,
patient data is almost always aggregated like a data
center. Is the analysis of these data a human test or a
contribution to public health? We need more tools to
help us to define the differences. Not using data can
be unethical, because data is more valuable in the
hands of medical staff, who are not only responsible
for a few patients, but in charge of a patient group or
even the entire public health. When he gets some
conclusions from patients’ previous data, whether he
should use these data to benefit the society
(Goodman, 2010).
There are many studies that have analyzed
telemedicine to save money (Finkelstein, Speedie and
Potthoff, 2006) or improve quality of life (Noel et al,
2004). These studies all try to avoid ethical risks, they
only study the people with full self-care ability, and
require patient who have the ability to install these
facilities. Moreover, they do not use any equipment
with recording or video recording or declare that the
video functions they use in the study have not been
approved by the government (Finkelstein, Speedie
and Potthoff, 2006). In fact, video functions are
essential in most telemedicine. For example,
rehabilitation training can effectively help users
complete the standard movements by education
through video. Therefore, these studies data do not
represent real usage and the data may be too
optimistic (Chang et al, 2011).
5 SECURITY AND PRIVACY
PROTECT SOLUTIONS
In order to protect consumer rights, we should insure
the privacy from multiple ways and sources. The
policy can provide a holistic protection and the setting
of technical authority can prevent each operator from
leaking information. Suggestions from several
aspects can be presented as follows.
First, related devices causing information leakage
should be identified and protected. These include
unauthorized connection to sensors, medical devices,
gateways, fog nodes, and mobile devices that capture,
aggregate, process, and transmit medical data to the
cloud. Common attacks include tag cloning,
spoofing, RF interference, cloud polling, and direct
connections. To respond to threats, IoT devices must
always check and censor that the authentication is
truly part of the Smart Healthcare cloud, and that
strong authentication algorithms and key
management systems are used to ignore and block
unauthenticated requests. Second, IoT technologies
such as RFID and wireless sensor networks can
provide identity verification and tracking capabilities,
and network authorization and network firewalls can
be used to improve network security. All
authorization methods require two-factor
authentication, along with the device number and the
Smart Healthcare and Ethical Issues
57
password set by the user on the software. Third, at the
network level, common cyber-attacks include
eavesdropping, Sybil attacks, Sinkhole attacks, Sleep
Deprivation attacks, and Man-in-the-Middle attacks
should be identified and understood (Farahani et al.,
2018). To prevent such attacks, the system should use
a trusted routing mechanism, along with both
message integrity verification techniques and peer-to-
peer encryption based on encryption algorithms. Last
but not the least, training for users is also very
important, for example, end users should learn how to
avoid network’s attacks, choose strong passwords,
and not buy used equipment or equipment of
unknown source.
The most important thing is that all service
providers should strictly comply with the principle of
autonomy priority and provide multiple choices to
users. Users have the right not to use these functions
or freeze sensor usage and database at any time.
These monitoring devices should be less cameras
when possible or replace the cameras with other
technologies such as infrared sensing (Stowe and
Harding, 2010). Traditional medical services cannot
be eliminated, people should have the right to choose
between smart medical services and traditional
medical services.
6 DISCUSSION
Smart healthcare not only improves the quality of
medical care, but also prevents rising medical
expenses. It also enables service providers to search,
analyze, and use a wealth of scientific evidence to
support their diagnosis, while also benefit each group
of physicians, medical researchers, drug suppliers,
insurance companies, and more across the entire
healthcare ecosystem. A medical information
integration platform will be established to integrate
business processes between hospitals and medical
information. Resources can be shared and exchanged,
and cross-medical institutions can also make online
appointments and two-way referrals, which makes the
ideal residents' medical treatment model become a
reality. However, ethical issues brought by smart
medical care cannot be ignored. After all, the
development of smart medical care is unstoppable.
Developers and governments should anticipate these
ethical risks and minimize the harms caused by
ethical problems. If people lose their jobs or are under
discrimination due to information disclosure and
depression, it is difficult to compensate the loss of the
victims no matter how many advantages smart
medical care have achieved. At the same time,
traditional medical services should be abandoned, and
the quality of services should not be reduced. Smart
medical care is a part of the overall upgrade of
medical services, but not a complete replacement of
the medical system. The government needs to
consider the needs of different groups in different
regions and gradually improve the legal system. The
law is the strongest guarantee for developers and
users. The lack of legal enforcements will eventually
hurt every participant in the healthcare system.
Ideally, the smart healthcare system is managed by
local governments. All personal information
collected should be kept by government-administered
databases because public trusts the government more
than companies. The established trust relationship can
also promote medical services and help develop a
healthy ecosystem.
7 CONCLUSION
This article introduced the content, function and
application of IoT in smart healthcare. Importance of
healthcare ethics for different groups and usage
scenarios were discussed in detail. The social
relationship of smart medical care could be
complicated, since one person's information might be
obtained by many people and manufacturers without
their approval, which would cause many ethical
problems. Personal medical information would
provide a valuable and important personal asset. The
disclosure of this information could impact the user
that could be discriminated within the society. The
inappropriate use of information could also violate
the ethical bottom line. This paper proposed some
feasible solutions, mainly based on the technical
aspects of IoT. However, the government's
participation and intervention, and the education and
training of the public could be the core solution of
ethical risks. Every individual, government and
policy-maker should try to implement ethics and
ethical approval program together with IoT smart
medical services.
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