Critical care computing: Outcomes, confidentiality, and appropriate use

Society has become dependent on computers for acquiring, transmitting, storing, and processing data. Decision support systems are increasingly useful tools for conceptual sifting through the vast amounts of data acquired. These data are of extraordinary value for tuning the engines of health care delivery, for guiding national and global health policy, and for making the most of individual patient care and public health. Concomitantly, we have known for some time that the use of computers in medical settings raises ethical issues. The goal of this article has been to identify a set of ethical issues that accompany the development and deployment of computing tools in critical care settings, and to offer observations on the resolution of these issues. It is not illuminating to suggest that appropriate medical computing will involve the 'acquisition, transmission, storing and processing of health information.' What is needed is some sense of how we may acquire data ethically; to whom we may or should transmit it; how we ought to store it, and with what safeguards; and to what ends we process or otherwise perform operations on that data. All of these goals are made more challenging given that we labor in a context of scientific uncertainty. Progress in medical computing is exciting, not consoling. Still, there are a number of helpful signposts, and several have been acknowledged throughout: Use of a tool requires that we understand its functions and limitations. To use a tool in ignorance or hubris is inefficient. In carpentry, this is wasteful. In medicine, it is dangerous and wrong. Rigorous evaluation and testing provide a further understanding of the context and consequences of system use. Decision support systems help make clinical or scientific decisions; they do not help to solve problems related to ethics, values, and policy. Expressed another way, it can be said that many such problems are not caused by lack of information or processing power. Vulnerable patients may need special confidentiality protections. These protections must balance confidentiality with the need for rapid and accurate access to patient information. Researchers must regard attention to ethical issues as a core concern of biomedical science. Physicians and other providers also are entitled to protection against damage caused by confused or fallacious interpretations of data. It often cannot be determined in advance whether any particular decision is ethically appropriate. It is when facts are linked to values that ethical guidance is obtained. What we can do is offer standards or guidelines by which future decisions may be judged. Such standards will serve us well as we extend our use and reliance on computers in critical care and throughout medical practice.