Professor at Departments of Neurology and Biochemistry
and Chief of the Neuroethics Studies Program at the Pellegrino Center for Clinical Bioethics
Georgetown University Medical Center


James Giordano, PhD, MPhil, is Professor in the Departments of Neurology and Biochemistry, Chief of the Neuroethics Studies Program of the Pellegrino Center for Clinical Bioethics, and Co-director of the O’Neill-Pellegrino Program in Brain Science and Global Health Law and Policy at Georgetown University Medical Center, Washington, DC, USA. He is also Distinguished Visiting Professor of Brain Science, Health Promotions and Ethics at the Coburg University of Applied Sciences, Coburg, Germany, and was formerly 2011-2012 JW Fulbright Foundation Visiting Professor of Neurosciences and Neuroethics at the Ludwig-Maximilians University, Munich, Germany.


So, if you really look back, what you tend to see is that this has been growing, not necessary leaps and bounds, but has been growing steadily in a very evolutionary way over at least the past 25 to 30 years. I think that the past 10 to 15 years has really evidenced much more of an impact with regard to the sophistication of the systems, bidirectionality, and also the trust in practice.

Well I think telemedicine has gotten the probably greatest utility in the idea of using tele for what tele is- remote access and the remote provision of care. So for those individuals who may not necessarily have access to the type of services and resources that may be required for various types of clinical intervention, telemedicine or telehealth, depending on how you look at it, could provide a whole host of resources that allow assessment, interaction, diagnostics, and certain types of care. It may also allow distal care, remote care so that the patient becomes much more conjoined if you will, to their own care as being someone who can then access that and take it. So something quite simple, for example, is that, now, look we demonstrate to a patient how to take a medicament, how to do something with regard to their own rehabilitation, how to engage postures, etc. might be actually accomplished by a distance. And so in this way, what it may do is that it may literally bridge the gap between the patient who may be somewhat inaccessible to medical care and the medical care may be somewhat inaccessible to the patient, and providing that bridge by virtue of the viability of the teletechnology.

Well, I think what you tend to find is that at the polar opposites, you see those that embrace it as something that is going to be very, very beneficial to both extending the practice and deepening the integrity of the practice. And on the other side, diametrically,  those that really see this as something that needs to be at the very very least to be viewed with caution, if not suspicion. The reality of it, is that it probably exists somewhere in between like anything else, this technology is a tool. And there are always going to be biases based upon what the tool is developed for, how the tool is used. Moreover, what can happen is, the longer that tool is around, the greater the possibility for potential misuse, and in some cases, intentional abuse. So like anything else, we have to really engage the technology as technology, techne – logos, a rational accounting of the tool itself, and those of us who developed the tool and use the tool in all of its various applications.

It is exceedingly helpful because it allows patients access not only to a provider, but perhaps to multiple providers. I mean here we could envision something like a conference call, where now you have multiple providers with multiple specialties who are now interfacing with that particular patient. It’s sort of like taking a patient to a medical department store, if you will. So they can go from one clinician to the other, on-site and not necessarily having to move from the comfort of their own home or some other site. So they don’t necessarily have to be there to be there.

It also allows certain nuances of the interaction to be stored- to be filmed, to be replayed. So that the clinician and perhaps the patient can also then have a record of that for a variety of different uses. For their own edification, certainly for a subsequent assessment, and also, let’s face it, we are living in litigious times. This is now something that becomes part of the patient’s record, where an actual videography of the patient’s encounter with the clinician is now durable.

As we become more sophisticated with this type of telemedical technology, we will develop those tools and those techniques that allow for a much more subjectively rich, and more finely grained interaction that will be both much more accomplished on the part of the clinician, and also I think, much more viable and valuable to the patient.

What ethical issues could be involved, well certainly, since you are communicating at a distance, the security of the line given the probity of that interaction between the clinician and patient is paramount. And what I mean by that is quite simple: this is personal information, and it is bounded by all of the necessary HIPAA (Health Insurance Portability and Accountability Act) regulations that define what that communication between this patient and that clinician may be. It’s held relatively as sacrosanct, and the physician holds that in trust. Is this in some way purloingable, in other words, might this information once it gets out there on the air, be “hacked”? Clearly, to be able to affect this type of telemedicine in an effective way, there must be multiple systems, and maintaining the security of that line and/or the information, particularly the information is then recorded, well, that’s a factor.

One of the other concerns will be, well, how secure is any information that is then being transmitted over the general computer ways, whether it is through the cyber ether so to speak, so could this information be purloined, engaged, hacked, or changed. So it may very well be that given the specificity of this, its broadening embrace, a larger scope, and perhaps realization of its potential utility, at that point we may need some specialized technology 1) to ensure he actual technical value and capability and 2) to ensure the ethical, legal probity of this in the variety of circumstances to which we then apply it.

The larger question is, in these benefits, what are the burdens, what are the risks, and what harms can be incurred? So making sure that we are engaging in the ethical legal, and of course policy discourse early on, and continuing to do so as 1) the technology evolves, and 2) we define what may be those deleterious aspects of the technology, we then need to correct and do so appropriately. I think that’s a hand in hand process.

Well, as the technology develops, not only in sophistication but in its capability, will we as a society become more amenable to taking that technology and absorbing it, and increasing its relative value within the various spheres in which it could be applied, so that we are then seeing the broader and broader views. And I think that it is just a matter of time.