Ethics and e-medicine.

The computer revolution has had enormous effect on all aspects of the practice of medicine from scheduling and billing, to treatments, to research and beyond. This article focuses on the impact of new internet technologies on relationships between physicians and patients. These forms e-medicine may be utilized outside the confines of a pre-existing relationship, and thus have the potential to replace rather than merely augment traditional medical care. They change the setting and nature of the physician-patient relationship and thereby alter how medicine is practiced.Initial discussions of this issue implied that e-medicine was problematic because it failed to create a physician-patient relationship. Emphasizing the gold standard of the face-to-face interaction, commentators argued that electronic communications were inferior to traditional physician-patient encounters. But there was little attention paid to the questions of why face-to-face encounters are important, and why electronic encounters are inadequate. It was simply assumed that physical contact was the crucial element of a physician-patient encounter and its absence undermined the electronic encounter. But the analysis is not this simple. While the concept of laying on of hands is well-embedded in medical literature, it is certainly not practiced in all encounters. Moreover, advances in electronic technologies have resulted in face-to-face equivalent interactions via electronic media. Using interactive real-time video conferencing and virtual reality technology, for example, a patient and physician can have an interactive, hands-on equivalent encounter.In fact, it makes no sense, from an ethics perspective, to talk as if an electronic encounter does not create a physician-patient relationship; it does. The issue is the extent of the relationship and thus the extent of the physician's obligations. Instead of focusing on the presence or absence of one factor, such as a physical exam, we would do better to ask what elements of the traditional encounter are necessary to provide a basis for ethical care. Each encounter between a physician and patient is different, and different elements may be required before engaging in particular interventions. The crucial issue I explore is the extent to which these new tools enable, or prevent physicians from meeting ethical standards of care.What are ethical standards of care? Good medical care, as so often has been pointed out, is not merely the provision of competent care, although technical competence is one part. The ideal physician is not merely a technician, but a healer. Drawing from work by Emanuel and Dubler, I examine six elements of the ideal physician-patient relationship - what they call the six C's: choice, competence, communication, compassion, continuity, and conflict of interest. My goal is to provide a framework for thinking about the impact of new technology on the physician-patient relationship, rather than definitive statements on the ethical acceptability of particular media.After evaluating each of these elements in detail, I conclude that electronic media are neither ethical nor unethical in and of themselves. Physicians should consider their use as technical tools, but be aware of potential effects on relationships with patients. Importantly, I stress that physicians should be trained in the appropriate use of electronic communication media, and that efforts should be made to promote access to useful technologies, particularly for underserved populations.