Smart Healthcare and Ethical Issues

Victor Chang

, Yi Cao

, Taiyu Li

, Yujie Shi

and Patricia Baudier

Internatinal Business School Suzhou, Xi’an Jiaotong-Liverpool University, Suzhou, China

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

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

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

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

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

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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Smart Healthcare and Ethical Issues