Digitalization and health
Steps to Better Health
Dr. Verina Wild studies the impact of digitalization and globalization on healthcare systems, and explores the ethical implications of this development for the individual and society as a whole.
In 2018, more than ever, the way is the means. There are now many incentives for taking to the open road other than the desire to reach a specific location. The new mantra is that movement brings its own reward. Smart watches count the traveler’s paces and congratulate her when she breaches the 10,000 mark. And thanks to fitness apps on smartphones, one can compare one’s performance with that of all the other hopefuls. Strenuous physical activity is now seen as the elixir of life, and absolutely indispensable for health. There are now hundreds of thousands of fitness apps available for installation on smartphones worldwide. Providers of health insurance are already offering refunds on premiums to clients who assiduously exercise – and can prove it by means of a digital record. These bonus schemes are designed not only to stimulate people to indulge in physical activity, but also to take part in medical screening programs or remember to get an annual flu shot. Germany’s statutory health insurers now pay out, on average, 141 euros per adult customer per year. The idea behind these schemes is to convince the consumer that, in the field of healthcare, prevention pays off.
Modern medicine essentially owes its rise and early successes to its focus on acute conditions. In recent decades, this emphasis has shifted decisively in the direction of chronic disorders, such as diabetes and cardiovascular diseases, says Dr. Verina Wild of LMU‘s Institute for the Ethics, History and Theory of Medicine. In July 2015, a new law designed to strengthen disease prevention measures and active health maintenance came into force in Germany. The law mandated that the country’s statutory health insurers shall invest more than 500 million euros annually in measures designed to further these goals.
As a medical ethicist, Verina Wild is primarily interested in the ethical dimensions of these developments. One crucial issue that they raise is the question of where the responsibility for health maintenance ultimately lies – with the State, with local institutions such as schools, with healthcare professionals or with the individual? “The answer to this question has profound implications for the future of health insurance systems,” she points out, “for it will most probably determine how much of the cost is paid collectively by the community of all insured persons and how much is borne by the individual patient concerned.”
A shift in the perception of the welfare state
The bonus schemes now offered by health insurers emphasize the individual’s responsibility for health maintenance. They form part of the political shift towards a “carrot-and-stick” approach that began with the reform of unemployment and social benefits introduced by Federal Chancellor Gerhard Schröder in 2003. These measures constituted a turning point in the concept of the welfare state, and since then the State has continued to retreat from its previous role as an assured source of support for those in need. Meanwhile, many people have accepted the idea that if people are overweight or suffer from chronic back pain, it’s because they don’t take enough exercise – and are therefore lazy. For Verina Wild, however, the question of personal responsibility for one’s health is inextricably linked with the issue of justice. “Research clearly shows that there is a strong correlation between health risks and socio-economic status.” The lower one’s living standard, the greater the risk of becoming overweight or developing diabetes. “Given that the risk of illness is closely linked to one’s socioeconomic status, how much of the responsibility for health maintenance can be assigned to the individuals concerned – even in cases of conditions such as obesity or addiction?” in this perspective, other factors move to the fore – such as working conditions, the consequences of unemployment, educational opportunities, quality of accommodation or the costs of a healthy diet.
Verina Wild is one of the few medical ethicists in German-speaking countries whose approach to such issues does not focus solely on individual responsibility, but also considers health at the societal level. The field of public health ethics is a discipline that is long established in universities in the Anglophone world. Wild, who has herself worked as a physician, is particularly interested in the interdisciplinary nature of the problem. “The question of what can be regarded as ethical in the context of public health is closely tied up with issues relating to the notion of justice, which are the stuff of political philosophy. But it also impinges on social epidemiology, insofar as it involves the collection and analysis of population-based health data.”
The process of globalization also has significant repercussions for national healthcare systems, which also raise complex ethical questions. In a study carried out in collaboration with Christine Bally-Zenger entitled “Alt werden im Paradies” (“Growing Old in Paradise”), Wild looked at one aspect of the phenomenon of medical tourism – the migration of elderly persons who require long-term nursing-home care. What are the implications of German senior citizens who move to nursing homes in Thailand because the costs of care are much lower there? The ethical dimensions of this development extend from the impact on familial relationships to the burdens it imposes on less well developed and endowed healthcare systems around the globe. In the receiving countries, the influx of patients from abroad can exacerbate inequality in the provision of healthcare, if the better trained local doctors and nurses choose to care for foreign invalids or other medical tourists, instead of helping to improve the quality of healthcare available to the native population. But this trend also raises questions for the migrants’ compatriots. Is it fair, for instance, that financial status alone should decide whether or not a patient in need of nursing care can go abroad to get it? Is it not the duty of the State to ensure that all its citizens, irrespective of their personal wealth, can receive such care at home?
The social epidemiology of tuberculosis
“Nowadays, when thinking about public health, we should never lose sight of its global dimensions,” says Wild. She serves on several of the panels that advise the World Health Organization and help shape its policies. One of these is devoted to infectious diseases such as tuberculosis. Effective treatment of tuberculosis requires strict adherence to a long-term regime of therapy, which may include periods in quarantine. It therefore involves measures that may constitute an infringement on the patient’s personal freedom. The disease is also socially stratified. The less privileged, in terms of their living quarters and working conditions, are more likely to contract the more serious and recalcitrant forms of the infection.
Wild is also regularly consulted as an acknowledged expert by the WHO on the medical and ethical problems raised by migration. In one of her recent publications, she traced one of the migration routes across the Sahara, and analyzed the situations in which fundamental ethical principles, which are formally set out in international declarations, are routinely flouted. “Migration is not going to stop any time soon. Global theories of justice can help us assess the degree of responsibility that high-income countries bear for the fate of people in the poorer regions of the world. Only if we are willing to do some hard thinking can we hope to find solutions for such complex global challenges.”
Wild’s latest project at LMU, which goes by the acronym ‘META’, brings her together with economists and IT specialists in a newly formed research group, which is financed by the Federal Ministry for Education and Research. Its aim is to assess the manifold ethical, social and legal implications of mobile health technologies. “With the advent of digital technologies, health has become a commodity that is now on offer and negotiable outside of a strictly medical context,” she says. The qualified physician is no longer the only party who dispenses health advice in private consultations, and suggests that the patient would benefit from a bit more exercise. Now the IT firms that develop and market health apps and mobile fitness monitors are m moving into the field. "We haven’t even begun to comprehend and dissect the ethical implications of this development,” says Wild. “Clearly, the Hippocratic Oath alone can no longer provide adequate guidance in this context.” Among other things, we need to understand the values that motivate the developers, and we must confront and compare these values with the preconceptions and expectations of consumers and politicians. Then there is the vital question of data security and protection which, however, seems to be of little concern to users. According to a recent survey, most consumers say that they would share health data acquired by mobile digital devices with their family doctors, and many profess their willingness to pass such data on to their insurers.
“I believe that apps and other new technologies have the potential to improve public health in many ways. But I sometimes have the impression that apps are touted as cure-alls, and the pervasive belief in their technological possibilities distracts attention from the real and very complex problems they raise,” says Wild. She has already assessed studies of the effects of the bonus systems and digital monitoring tools now offered by statutory health insurers. These studies suggest that many such measures do indeed have a short-term impact. Participants in such programs adopt a healthier diet and engage in sporting activities. But over the years, these positive effects tend to wear off, and things may even go into reverse. “Some people actually lead less healthy lives after such interventions than they did before. So far, there is no convincing medical evidence that these incentives cause any sustained change in behavior that makes people healthier than they would otherwise have been.”
Wild also points to the need for wide-ranging public debate on the unresolved ethical issues associated with the shift to a prevention paradigm, and the resulting changes to the healthcare system as a whole. This process will also entail the recognition and promotion of the positive effects that mobile technologies can have. But it must also address the more fundamental questions, such as the status and value of the notion of a caring society. “Essentially, these developments confront us with the question of what kind of society we wish to live in,” says Verina Wild. The wider consequences of digitalization for healthcare system also need to be considered and debated in much greater depth than they have been hitherto. “So far, the ethics of health apps has been dominated by the medical perspective and focused on the individual patient. We look on these apps as consumer goods, but we have no real idea where they are likely to lead us and what that will do to our societies. That is particularly problematic with respect to the wholesale harvesting of data and the nature of the algorithms used to analyze these vast caches of information.” Wild is convinced that apps are just the beginning and that future advances in artificial intelligence will transform our everyday lives in very many ways. “That will have far greater impact on our health and our behavior than an app that counts how many steps we take.”
PD Dr. med. Verina Wild is a staff member of LMU’s Institute for the Ethics, History and Theory of Medicine, which she joined in 2017. She also initiated the project META - Ethical, Legal and Social Aspects of Mobile Health, which is funded by the Federal Ministry of Education and Research, and which she now leads. In 2017 she received the Princess Therese of Bavaria Prize for her research work at LMU.