Digital medicine, or “telemedicine,” is currently being promoted as a part of environmental sustainability within health care institutions. The National Institute for Health Research’s (NIHR) Carbon Reduction Guidelines recommends participating in telemedicine through “measuring outcomes remotely by phone, mail, or the internet whenever possible”and encouraging record linkage—with participant consent—to routine data.482 Theological bioethicists can also encourage digital medicine as a way to promote distributive justice.483 Both telemedicine and teleclinics are examples of practices that support conservation.
1. Telemedicine
Telemedicine is defined as “the use of electronic information to communicate technologies to provide and support healthcare when distance separates the
participants.”484 The concept of telecommunication in medicine, or telemedicine, predates the Internet by a few decades. Its original use can be traced to the National Aeronautics and Space Administration (NASA), which tracked vital physiological data of astronauts and transmitted the information from the spacecraft and spacesuits to a monitoring
482 National Institutes for Health Research (NIHR), “Carbon Reduction Guidelines,” (October 2010): 1-20,
at 12, at www.nihr.ac.uk/files/NIHR_Carbon_Reduction_Guidelines.pdf
483 There is a methodological difference in technological solutions to the environmental crisis (i.e. trust that
the current and future technologies, such as geoengineering, can be implemented to mitigate climate change) and use of technology to assist in conservation, such as telemedicine. I believe that the latter approach is more in line with conservationist priorities, in the truest sense of the term “conserve.”
484 Aparajita Dasgupta and Soumya Deb, “Telemedicine: A New Horizon in Public Health in India,” Indian
location on earth.485
Telemedicine encompasses both services and delivery mechanisms. The
American Telemedicine Association, which was established in 1993, describes services of telemedicine as primary care and specialist referral services; remote patient
monitoring; consumer medical and health information; medical education among
telemedicine services, and networked programs that link tertiary care hospitals and clinics with outlying clinics. Delivery mechanisms of telemedicine include point-to-point
connections using private high-speed networks; monitoring centers for in-home care; and web-based, e-health patient service sites as platforms.486
Telemedicine has the potential to green the medical industry by reducing travel to and from clinics. Streaming meetings by digital connections reduces the need for
commuting—which often depends on fossil fuels to power trains, cars, and busses. The NHS advocates “provid(ing) incentives for low carbon transport; and promot(ing) care closer to home; telemedicine,” and of course, walking and biking when possible as a part of their Carbon Reduction Strategy.487
Telemedicine can also conserve paper through electronic medical records (EMR). In 2014, EMR Modernizing Medicine®, in Boca Raton, Florida, created EMA™ the electronic medical assistant.488 EMA saves immense amounts of paper by preventing
485 Patricia A. Armstrong, Zakhour I. Youssef, and Rashid L. Bashshur, Telemedicine: Explorations in the
Use of Telecommunications in Health Care (Springfield, IL: Charles C. Thomas, 1975); R.L. Bashshur and Joseph Lovett, “Assessment of Telemedicine: Results of the Initial Experience,” Aviation, Space, and Environmental Medicine 48, no. 1 (1977): 65-70.
486 American Telemedicine Association, “What is Telemedicine?,” (2012), at
http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VOSrC8ZcN4u See also Touch Survery, “Home,” (2015) at https://www.touchsurgery.com/
487 NHS Sustainable Development Unit, Saving Carbon, Improving Health: NHS Carbon Reduction
Strategy for England (London: NHS Sustainable Development Unit, 2009), 11.
record printouts, streamlining health care, and aiding in better patient outcomes.489 EMA
also has the potential to eliminate obstacles to health care access.490 The NHS Carbon
Reduction Strategy recommends, “all NHS organisations should make training and
equipment available that promote tele, video and web-conferencing.”491 In addition to reducing carbon emissions, telemedicine and its adjunct—like teleclinics—can assist in distributive justice.
2. Teleclinics
Teleclinics are virtual health care centers that “provide an opportunity for standardization and equity in provision of healthcare, both within individual countries and across regions and continents.”492 Teleclinics can mitigate physician shortages by remotely linking patients to doctors. They can also employ health care assistants to provide basic medical care under the supervision of a virtual doctor. Still, advocates of telemedicine warn that it “cannot be (a) substitute for physicians in developing countries where resources are scarce and public health problems are in plenty… however, it can supplement the current health scenario.”493 Telemedical clinics in India are a case study of distributive health care justice that also conserving resources.
Aparajita Dasgupta and Soumya Deb report that from 2005-2008 the Indian Space
489 However, due to glitches in the telemedical systems that control patient records and medical
prescriptions, several people have died as a result of operator errors. These issues continue to be worked out as telemedicine moves forward. Christopher Rowland, “Hazards Tied to Medical Records Rush,” Boston Globe, 20 July 2014, at http://www.bostonglobe.com/news/nation/2014/07/19/obama-pushed- electronic-health-records-with-huge-taxpayer-subsidies-but-has-rebuffed-calls-for-hazards-monitoring- despite-evidence-harm/OV4njlT6JgLN67Fp1pZ01I/story.html
490 Another example of telemedicine is e-ICU centers, where “care of patients during the stabilization
process, evaluation for the appropriateness of transfer, and the prolonged provision of critical care during delays in transport” can be utilized. Randy S. Wax, “Canada: Where Are We Going?,” in ICU Resource Allocation in the New Millennium: Will We Say “No”?, David Crippen, ed. (New York: Springer, 2013), 123-129, at 126.
491 NHS Sustainable Development Unit, Saving Carbon, Improving Health, 48. 492 Dasgupta and Deb, “Telemedicine.”
Research Organisation telemedicine network “expanded to connect 45 remote and rural hospitals and 15 super-specialty hospitals.” And, with periods of overlap from 2006- 2008, the pilot project in Karnataka provided more than 10,000 tele-consultations.494 India, in particular, is a dramatic beneficiary of teleclinics due to its urgent medical requirements, poverty, and large population. In some cities in India, specific groups have health care needs met through teleclinics.
World Health Partners, started in 2008, is an Indian-based organization that works primarily in reproductive health care for women.495 Within three years they “established 116 telemedicine clinics (SKY Clinics) providing health services to 1,293 villages with an estimated population in excess of 6 million people.”496 Patients travel to teleclinics to utilize the service and partake in the technology. Through the use of video
conferencing—which included telemedical programs to read women’s blood pressure, temperature, heart rate, respiratory rate, and EKGs—over 288,000-couple years of contraception were delivered.497 Considering the vast need for contraceptive use among mothers and families in the developing world, the teleclinics of India will undoubtedly saved many lives, and improve the quality of life of millions of women.
Writing from the U.K., Andrew Thorniley believes that telemedicine “will allow instant access to all patient records, ongoing treatment and other consultations. The patient can, in some instances, be reviewed by a consultant elsewhere in the world… The
494 Ibid.
495 World Health Partners, “Background,” 2013, at http://worldhealthpartners.org/?p=4
496 Health Research for Action: U.C. Berkeley, “Telemedicine Social Franchising in Rural Uttar Pradesh,
India,” 2012, at http://www.healthresearchforaction.org/sph/telemedicine-social-franchising-rural-uttar- pradesh-india
497 Health Research for Action: U.C. Berkeley, “Telemedicine.” Couple years of contraception, or couple-
years of protection (CYP) refer to “the estimated protection provided by contraceptive methods during a one-year period.” See Jacqueline E. Darroch and Susheela Singh, “Estimating Unintended Pregnancies Averted by Couple-Years of Protection (CYP),” (New York: Guttmacher Institute, 2011): 1-10.
future is digital.”498 Telemedicine, inclusive of teleclinics, was not begun with
sustainability in mind, but it will reduce carbon emissions from travel, limit
pharmaceutical waste by monitoring adherence, and save thousands of pounds of paper from record printouts. And, if telemedicine was fueled by renewable sources, it could be totally carbon neutral. In addition to the many environmental benefits of telemedicine, the ability to reach those in developing and underdeveloped areas indicates distributive justice.
Telemedicine will be a feature of environmental bioethics in the 21st century,499 yet the potential for telemedicine is not without concern. Excitement about the possibility of telemedicine and teleclinics often overshadow the urgency to protect patients and serve the medical needs of vulnerable people without health care. Privacy and accessibility complicate the distribution and utilization of telemedicine and teleclinics. Vetting some lingering questions is the task of the next section.
498 Andrew Thorniley, “United Kingdom: Where Are We Going?,” in ICU Resource Allocation in the New
Millennium: Will We Say “No”?, David Crippen, ed. (New York: Springer, 2013), 177- 183, at 181. Italics in original.
499 New developments include: Aetna’s collaboration with Teladoc, a “U.S. board-certified licensed
(doctor) in your state,” that patients can contact 24-hours a day. A recent flyer advertising these services, for $40 or less per consult note, “with your consent Teladoc will provide information about your consult to you primary care physician.” TripAdvisor, “Aetna: Teledoc,” mail. The 17 July 2014 issue of Science magazine also highlighted several new developments, including an artificial intelligence program that is a computerized therapist, and machine learning that analyzes new mother’s activity and posts on Facebook and Twitter to predict post-partum depression. John Bohannon, “The Synthetic Therapist,” Science (17 July 2015): 250-251. Manifestation, “Eliza, Computer Therapist,” 2006, at
http://manifestation.com/neurotoys/eliza.php3/ Eric Horvitz and Deirdre Mulligan, “Data, Privacy, and the Greater Good,” Science (17 July 2015): 253-255. Also of note is the “text4baby” program. Women can download an app and sign up to receive free text messages reminding them of neonatal appointments. The app also offers advice, tips, and links to further health information. Voxiva,“Text4baby,” 2015, at https://www.text4baby.org/