Newsgroups: bit.listserv.ethics-l
Date:         Thu, 30 Jul 1992 21:06:43 EDT
From:         "Mary B. Williams" <CGT18362@UDELVM.BITNET>
Subject:      Re: Ethics of Computer Use in Medicine

     Joe Trance asked if it is ethical for computer programs to be used in
 diagnosis and determining treatment for medically ill people.  In my opinion
 it would be ethically obligatory to use any computer programs which have been
 tested and shown to be at least as good as the average physician in diagnosing
 and determining treatment.  (As Marc Schwartz has pointed out in a previous
 answer to Trance's question, the testing of such programs, although rigorous,
 is far from perfect -- but let's face it:  the testing of physicians' skills
 in diagnosis and determining treatment is even further from perfect.)  The
 problem is not an ethical problem of whether an 'inhuman' machine should be
 allowed to decide the fate of a human being;  it is an educational problem of
 how we can educate people to use machines (particularly, for this discussion,
 computers) properly.

 	To give a specific example of the type of problem that is worrying
 many:  one of my students had a lumpectomy followed by radiation therapy.
 During the last of the radiation treatments she noticed a strange noise from
 the machine at about the time she expected to treatment to be over, and the
 treatment continued for a very significant period of time after that.  She
 asked the technician about the noise, and was told that that tended to happen
 when the machine was due for routine servicing.  She spoke with her physician
 that evening and told him that she was worried that the treatment had gone on
 for much longer than usual due to a malfunction of the machine.  The physician
 reassured her that the timing of the treatment was computer controlled and
 couldn't have malfunctioned. (!)  A short time later she developed a very
 unusual (for that tissue) type of cancer in the path of the radiation
 treatment.  The physician continued to deny that the machine could have
 malfunctioned.  --  Now the problem here is not that computer malfunction
 harmed a human being;  the problem is that the physician regarded the computer
 as a magically perfect machine.  We are all willing to accept the risk of harm
 from a rare malfunction of a machine, but we should not have to accept the
 multiplied risks of harm from the use of computer technology by people with
 inappropriate faith in the infallibility of the technology.

 	The concern expressed by Trance and others is, I think, rooted in a
 worry that physicians will similarly use diagnostic and treatment-
 determination programs as if they were perfect, or at least without the
 appropriate amount of skepticism.  This is a well-founded worry;  although the
 solution (the education of physicians into an appropriate understanding of the
 fallibility of computers) is easy to state, it is extremely difficult, perhaps
 impossible, to implement.  (Inappropriate overuse of high technology is a very
 American failing.  The huge overuse of the fetal monitor is just one case
 showing that American physicians are not dissuaded from overuse of a
 technology by overwhelming evidence that it is inappropriate.  Research has
 shown that fetal monitors are useful in high-risk births, but no study has
 ever shown them to be useful in normal-risk births and several studies have
 shown that in normal-risk births the use of fetal monitors increases the risk
 of harm to mother and infant.  Nevertheless, most American physicians
 routinely use fetal monitors in normal-risk births.  If we can't educate
 physicians into appropriate use of fetal monitors, can we expect to educate
 them into appropriate use of computers?)  The Luddite solution (destroy the
 technology) may be tempting.

 	But the Luddite solution will replace computer-generated harm with
 human-generated harm, for physicians also make mistakes in diagnosis and
 treatment-determination.  The question that must be asked is whether, on the
 average, the harms of use of the computerized system are greater than the
 harms of use of the non-computerized system.  (Utilitarianism provides a
 straightforward ethical basis for this conclusion, but I can't think of any
 reason for other ethical theories to come to a different conclusion.)

 	This question must be answered by testing for each diagnostic or
 treatment-determination system;  no general answer can be given.  However, it
 may be useful to point out some things we do know about physician fallibility.

 1.  Impossibility of keeping up with the field
 	No human being can read, assess, and utilize the hundreds of thousands
 of papers published each year in medicine.  (And certainly no practicing
 physician can.)  A computer program updated on a regular basis by experts in
 each of the fields it covers is much more likely to properly utilize the
 latest reliable information  -- and to discard earlier information that has
 been found to be unreliable.
 	An example of the failure to discard discredited information is found
 in the continued use by physicians of mastectomy in circumstances where
 research has shown that the less destructive lumpectomy is just as effective.
 This research as been so widely discussed that no decent surgeon could be
 ignorant of it.  But mastectomies are still very common in those
 circumstances.  Why so many surgeons continue to prefer mastectomy is a matter
 for speculation;  but as a patient I would prefer to be warned that my surgeon
 differs with the experts in the field, and a treatment-determination program
 would be a useful indicator of this.

 2.  Inadequacy of the average physician's clinical experience
 	Does the average physician have a significant advantage over computers
 in what England (in a previous message) refers to as "common sense and skills"
 and physicians refer to as "clinical experience"?  Sometimes, but .....  The
 physicians whose expertise on a particular disease forms the basis of the
 computer program have seen hundreds, or thousands, more cases of a reasonably
 rare disease than the average physician;  consequently in a difficult
 diagnosis the machine may well have a significant advantage.  (For myself, if
 my physician disagreed with a well-tested computer diagnostic program about a
 possibly serious condition, I would accept neither diagnosis;  I would pack up
 and consult an expert in the condition the program suggested and an expert in
 the condition my physician suggested.)

 	The real advantage of the properly educated physician (and I really
 mean "educated" rather than "trained") is that unlike the computer program
 he/she has the possibility of a flash of real originality -- perhaps of seeing
 the condition in a new gestalt.  But for the physician (as for the computer
 scientist, the philosopher, etc.) these flashes of real originality are rare;
 these flashes are valuable not primarily for the patient whose condition
 triggered the recognition, but for the many patients who will benefit because
 the knowledge gained from the insight is incorporated into later versions of
 the program.

 A couple of comments about specific suggestions that have been made:
 	England suggested that AMA or other organizational guidelines might be
 useful.  The experience with NIH consensus conferences (in which the experts
 in a particular medical field get together and issue a statement on their
 consensus about particular medical treatments, etc.) is that they have very
 little effect on medical practice.

 	Schwartz suggests that the FDA has a significant role in the regulation
 of computer systems used in patient care.  I couldn't tell whether he meant
 that they are regulating such systems or that they ought to.  I don't think
 they are yet (are they?), but I certainly think that FDA regulation would be a
 good idea to ensure that the systems are properly tested before being put into
 common use.

 +---------------------------------------------------------------------------+
 |  Mary B. Williams                          BITNET: CGT18362@UDELVM        |
 |  Center for Science and Culture                                           |
 |  University of Delaware                    VOICE:  302 831 1999           |
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