Presented at the M.S. and Ph.D. Programs in Data Science for Health Care, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand on November 14, 2019

1. Research Ethics & Ethics for
Health Informaticians
For Ramathibodi M.S. & Ph.D. Programs
in Data Science for Health Care
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital, Mahidol University
November 14, 2019
http://www.SlideShare.net/Nawanan

2. 2
Outline
• Introduction to Ethics & Bioethics
• Ethical Issues in Health Informatics
• Information Ethics & Clinical Decision Making
• Case Studies

3. 3
Introduction to
Ethics & Bioethics

4. 4
Introduction to Ethics & Bioethics
• Ethics
▪ a set of moral principles: a theory or system of moral values
▪ the principles of conduct governing an individual or a group
▪ the discipline dealing with what is good and bad and with
moral duty and obligation
• Moral
▪ of or relating to principles of right and wrong in behavior
▪ conforming to a standard of right behavior
• Norm
▪ A principle of right action binding upon the members of a
group and serving to guide, control, or regulate proper and
acceptable behavior
Source: Merriam-Webster Dictionary

5. 5
? Option 1
Option 2
Society’s Standard
Standard of Acceptable Behaviors in Society

6. 6
Law as Standard of Acceptable Behaviors
? Option 1
Option 2
Law

7. 7
Professional Code of Conduct as Standard
of Acceptable Behaviors
? Option 1
Option 2
Professional Code of Conduct

8. 8
Ethics as Standard of Acceptable Behaviors
? Option 1
Option 2
Ethics

9. 9
Reality
? Option 1
Option 2
Law
Professional Code of Conduct
Ethics

10. 10
Reconciling Conflicts
• Law
▪ Is explicit but...
▪ Often requires interpretation
▪ Slow to create; outdated; sometimes not keep
up with technologies or social changes
▪ Conflicting laws
• Professional Code of Conduct
▪ Often explicit, but similar issues with law
▪ Only focuses on narrow & traditional
professional practice

11. 11
Reconciling Conflicts
• Ethics
▪ Implicit
▪ Requires interpretation, making arguments
and debates
▪ Is often the basis when law is created
▪ Helpful in cases where law & code of
conduct don’t cover or are conflicting

12. 12
Branches of Ethics
• Descriptive ethics
▪ What do people think is right?
• Normative ethics
▪ How should people act? (prescriptive)
• Applied ethics
▪ How do we take moral knowledge and put it into
practice?
• Meta-ethics
▪ What does “right” even mean?
Source: http://en.wikipedia.org/wiki/Outline_of_ethics

13. 13
Sample Areas in Applied Ethics
• Business ethics
• Bioethics
▪ Study of typically controversial ethics brought about by
advances in biology and medicine
• Decision ethics
• Professional ethics
▪ Computer ethics
▪ Journalism ethics and standards
▪ Research ethics
▪ Legal ethics
▪ Marketing ethics
▪ Medical ethics
▪ Nursing ethics
Source: http://en.wikipedia.org/wiki/Outline_of_ethics http://en.wikipedia.org/wiki/Bioethics

14. 14
Some Terms in Ethics
• Ethical Issue
• Ethical Dilemma
▪ A complex situation that often involves an apparent
mental conflict between moral imperatives, in which
to obey one would result in transgressing another.
• Ethical Principle
▪ a standard of conduct defining the kind of behavior
an ethical person should and should not engage in.
(Josephson, 2010)
▪ Provides a guide to making decisions & establish
criteria by which decisions will be judged by others.
(Josephson, 2010)
Source: http://en.wikipedia.org/wiki/Ethical_dilemma
http://josephsoninstitute.org/business/blog/2010/12/12-ethical-principles-for-business-executives/

15. 15
Historic Cases in Bioethics
• Real cases of unethical or controversial
professional practice or research practice
• Raised important ethical issues
• Led to development of important ethical
principles in use today

16. 16
Nazi Human Experimentation & Murder
Source: http://isurvived.org/TOC-I.html#I-6_MedExp

17. 17
Nazi Human Experimentation & Murder
• Doctors’ Trial at
Nuremberg, Germany
• Gave rise to the
Nuremberg Code, a set
of research ethics
principles for human
subject research
Source: http://en.wikipedia.org/wiki/Doctors%27_Trial http://en.wikipedia.org/wiki/Nuremberg_Code

18. 18
Points from The Nuremberg Code (1)
• Voluntary consent of human subject is
absolutely essential
• Experiment should be to yield fruitful results
for the good of society, unprocurable by other
methods or means of study, and not random
and unnecessary in nature
• Should be based on animal study & knowledge
of natural history of disease
• Avoid all unnecessary physical & mental
suffering & injury
Source: http://en.wikipedia.org/wiki/Nuremberg_Code http://www.hhs.gov/ohrp/archive/nurcode.html

19. 19
Points from The Nuremberg Code (2)
• Avoid study where it’s believed death or
disabling injury will occur
• Risk should not exceed importance of study
problem
• Proper preparations to protect subjects against
risks
• Study conducted by qualified scientists
• Subjects can decide to terminate participation
• Researcher in charge must be prepared to
terminate study if continuing is believed to
likely to result in injury or death
Source: http://en.wikipedia.org/wiki/Nuremberg_Code http://www.hhs.gov/ohrp/archive/nurcode.html

20. 20
Beecher’s Article
• Originally published in 1966
• Described 22 examples of research studies with
controversial ethics conducted by reputable researchers
and published in major journals.
• “...unethical or questionably ethical procedures are not
uncommon” (Beecher, 1966)
• Full text reprinted in Bull World Health Organ.
2001;79(4):367-72 & available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566
401/pdf/11368058.pdf
Source: Beecher HK. Ethics and clinical research. N Engl J Med. 1966 Jun 16;274(24):1354-60.

21. 21
Common Ethical Problems in Research
• Lack of informed consent
• Coercion or undue pressure on volunteers (or on a parent
to volunteer his/her child)
• Use of a vulnerable population
• Exploitation of a vulnerable population
• Withholding information
• Withholding available treatment
• Withholding information about risks
• Putting subjects at risk
• Risks to subjects outweigh benefits
• Deception
• Violation of rights
Source: Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

22. 22
Tea Room Trade Study
• Investigated homosexual
practices in public restrooms. The
researcher went undercover and
acted as a “look out” to directly
observe men engaging in sexual
acts.
• He then identified 100 subjects
by tracing their car license
numbers.
• A year later, he distributed a
“social health survey” throughout
the communities where the
subjects lived.
Source: Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

23. 23
Tea Room Trade Study
• Ethical Issues
▪ Informed consent
▪ Deception
▪ Use of a vulnerable population
Source: Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

24. 24
Milgram Study
• Group Exercise #1
Source: http://en.wikipedia.org/wiki/Milgram_experiment

25. 25
Stanford Prison Experiment
• In 1971 Philip
Zimbardo, a psychology
professor at Stanford
University conducted a
study of psychological
effects of becoming a
prisoner or prison
guard.
Source: http://en.wikipedia.org/wiki/Stanford_prison_experiment http://www.prisonexp.org/

26. 26
Stanford Prison Experiment
• 24 male students
randomly assigned to
roles of prisoners and
guards in a mock prison
in a basement at
Stanford which
continued for several
days
Source: http://en.wikipedia.org/wiki/Stanford_prison_experiment http://www.prisonexp.org/

27. 27
Stanford Prison Experiment
• Participants adapted to their
roles beyond researcher’s
expectations
• Guards enforced authoritarian
measures, became
psychologically abusive &
harassed prisoners
• Some prisoners joined the
guards in the abuse
• Study stopped after 6 days
(before 2-week intended
period) when ethical issues
were raised
Source: http://en.wikipedia.org/wiki/Stanford_prison_experiment http://www.prisonexp.org/

28. 28
Stanford Prison Experiment
• Ethical Issues
▪ Risks in terms of
psychological harms
present that should be
anticipated and
permitted to continue
for some time
Source: http://en.wikipedia.org/wiki/Stanford_prison_experiment http://www.prisonexp.org/

29. 29
Tuskegee Study (1932-1972)
• Designed to document natural
history of syphilis in African-
American men
• There was no known treatment
for syphilis at the time
• Hundreds of men with and
without syphilis were enrolled
but they were misinformed
about the need for some of the
procedures.
• Some procedures were told as
necessary and free treatment
Source: Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

30. 30
Tuskegee Study (1932-1972)
• After penicillin was found to be
safe & effective treatment for
syphilis in 1940s, they were not
given penicillin.
• The study continued to track
the men until 1972 when the
public became aware of study
• 28 deaths, 100 cases of
disabilities, and 19 cases of
congenital syphilis
Source: Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

31. 31
Tuskegee Study (1932-1972)
• Ethical issues
▪ Lack of informed consent
▪ Deception
▪ Withholding information
▪ Withholding available treatment, putting
subjects & families at risk
▪ Exploitation of a vulnerable group of
subjects who would not benefit from
participation (black men)
Source: Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

32. 32
The Belmont Report
• A report by the U.S. National Commission
for the Protection of Human Subjects of
Biomedical and Behavioral Research to
address ethical issues in the Tuskegee
Study
• Identifies 3 basic ethical principles for all
human subject research called “Belmont
Principles”
Source: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

33. 33
Belmont Principles
• Respect for Persons (or Autonomy)
• Beneficence
• Justice
Source: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

34. 34
Belmont Principles
• Respect for Persons (or Autonomy)
▪ Treat individuals as autonomous human
beings. People must be allowed to choose
for themselves
▪ We must also provide extra protection to
those with limited autonomy
▪ Autonomy includes mental capacity (ability
to understand and process information)
and voluntariness (freedom from control,
coercion, or influence of others)
Source: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

35. 35
Belmont Principles
• Beneficence
▪ Minimize harms and maximize benefits
within constraints of sound research
design
▪ Avoid research without a favorable risk-
benefit ratio
Source: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

36. 36
Belmont Principles
• Justice
▪ Treat people fairly and design studies so
that burdens and benefits are shared
equitably
▪ Select subjects equitably
▪ Avoid exploitation of vulnerable
populations or “populations of
convenience”
Source: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

37. 37
An Additional Ethical Principle
• Non-maleficence
• Primum non nocere
• “First, do no harm.”
• Included in the Hippocratic Oath
“...Whatever houses I may visit, I will
come for the benefit of the sick...”
Source: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
Bankert E, Cooper JA. History and ethical principles. Collaborative Institutional Training Initiative.

38. 38
Ethical Issues in Health
Informatics

39. 39
▪ Research ethics
▪ Leads to patient outcomes, including deaths
▪ Provider-patient relationship threatened by IT?
▪ “Rationing” of health care through CDSS
▪ Information risks
▪ Informatics practitioners as “professionals” with
specific skills, training, & competencies?
▪ Most common question “Who owns the data?”
Why Important in Informatics?
Source: Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes.
In Shortliffe (3rd Edition).

40. 40
ELSI
• ELSI - Ethical, Legal, and Social Issues
• These three aspects are often interrelated
• ELSI in Informatics
▪ AMIA ELSI-WG
http://www.amia.org/programs/working-groups/ethical-legal-social-issues
▪ Professional Code of Conduct
AMIA: http://www.amia.org/about-amia/ethics/code-ethics
IMIA: http://www.imia-medinfo.org/new2/pubdocs/Ethics_Eng.pdf

41. 41
IMIA General Ethical Principles in Informatics
• Information Privacy & Disposition
• Openness
• Security
• Access
• Legitimate Infringement
• Least Intrusive Alternative
• Accountability
Source: http://www.imia-medinfo.org/new2/pubdocs/Ethics_Eng.pdf

42. 42
Some ELSI References
• Anderson JG. The role of ethics in information technology decisions: a case-
based approach to biomedical informatics education. Int J Med Inform. 2004
Mar 18;73(2):145-50.
Anderson JG & Goodman KW (2002)
Shortliffe 3rd Edition (2006)
Chapter 10 by Goodman KW &
Miller RA

43. 43
Information Ethics &
Clinical Decision Making

44. 44
Issues
• Alert sensitivity & alert fatigue
Clinical Decision Support Systems (CDSSs)

45. 45
Workarounds

46. 46
• “Unanticipated and unwanted effect of health IT
implementation” (ucguide.org)
• Key Resources
▪ Ash JS, Berg M, Coiera E. Some unintended consequences of
information technology in health care: the nature of patient
care information system-related errors. J Am Med Inform Assoc.
2004 Mar-Apr;11(2):104-12.
▪ Campbell, EM, Sittig DF, Ash JS, et al. Types of Unintended
Consequences Related to Computerized Provider Order
Entry. J Am Med Inform Assoc. 2006 Sep-Oct; 13(5): 547-556.
▪ Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE,
Strom BL. Role of computerized physician order entry systems
in facilitating medication errors. JAMA. 2005 Mar
9;293(10):1197-203.
Unintended Consequences of Health IT

47. 47
Standard view
▪ With uncertainties around new technology, “scientific
evidence counsels caution and prudence.”
▪ Evidence & reason determine appropriate level of
caution
▪ If such systems improve care at acceptable cost in
time & money, there’s an obligation to use it
▪ Follows evolving evidence and standards of care
Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes.
In Shortliffe (3rd Edition).
Appropriate Use of Health IT

48. 48
Standard view
▪ For computer-assisted clinical diagnosis CDS, human
cognitive processes are more suited to complex task
of diagnosis than machine, and should not be
overridden or trumped by computers.
▪ When adequate CDS tools are developed, they should
be viewed and used as supplementary and subservient
to human clinical judgment
Appropriate Use of Health IT
Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes.
In Shortliffe (3rd Edition).

49. 49
Fundamental Theorem of Informatics
(Friedman, 2009)

50. 50
Standard view
▪ Practitioners have obligation to use tools responsibly,
through adequate training & understanding the
system’s abilities & limitations
▪ Practitioners must not ignore their clinical judgment
reflexively when using CDS.
Appropriate Use of Health IT
Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes.
In Shortliffe (3rd Edition).

51. 51
▪ Health IT “should be used in clinical practice only
after appropriate evaluation of its efficacy and the
documentation that it performs its intended task at an
acceptable cost in time & money”
▪ Qualified (licensed, trained & experienced) health
professionals as users
▪ Systems should be used to augment/supplement,
rather than replace or supplant individuals’ decision
making
▪ Adequate training
Appropriate Use of Health IT
Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes.
In Shortliffe (3rd Edition).

52. 52
▪ Follow standard of care & scientific progress
(evidence-based)
▪ System evaluation is ethically imperative
Ethics for Developers
Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes.
In Shortliffe (3rd Edition).

53. 53
Why Clinical Judgment Is Still Necessary?
• Nothing is certain in medicine & health care
• Large variations exist in patient presentations,
clinical course, underlying genetic codes, patient
& provider behaviors, biological responses &
social contexts
• Human is good at pattern recognition, while
machine is good at logic & computations.
• Diagnosis is often achieved through recognizing
clinical patterns
• Not everything can be digitized or digitally
acquired
• Experience, context & human touch matters

54. 54
“Learned Intermediary” Doctrine
• A defense doctrine used in the U.S. legal
system (and some other countries) which
states that “a manufacturer of a product has
fulfilled his duty of care when he provides all
of the necessary information to a ‘learned
intermediary’ who then interacts with the
consumer of a product.” (Wikipedia)
• Primarily used by pharmaceutical & medical
device manufacturers in defense of tort
lawsuits.
Source: http://en.wikipedia.org/wiki/Learned_intermediary

55. 55
“Learned Intermediary” Doctrine
• Because health IT developers can’t expect a
CDS advice (e.g., alerts & reminders) to be
100% appropriate for each individual patient,
clinical judgment is still necessary.
• Health IT developers & manufacturers are
protected from liabilities for
poor/inappropriate advices or for bad
outcomes associated with them, as long as
there is a clinician using it that can intervene
• What about software bugs (e.g. wrong dose
calculations)?

56. 56
“Learned Intermediary” Doctrine
• Applicability of this doctrine varies based
on legal jurisdictions, context of each
case, and legal arguments
• Recently, this doctrine has been noted by
some legal and informatics experts that it
doesn’t apply to health IT cases
• It remains unclear until there are rulings
from real legal cases

57. 57
Summary
• Ethical principles are guides and standards
of practice that can help us navigate
through situations that arise.
• History was full of unethical conduct
• 4 important principles in bioethics
▪ Respect for persons (autonomy)
▪ Beneficence
▪ Justice
▪ Non-maleficence

58. 58
Summary
• Ethical issues are present in informatics
practice (whether as developers, implementers,
executives, users, researchers, etc.)
• Codes of conduct & ethics codes by
professional organizations govern acceptable
& ethical behaviors by informaticians
• In use of health IT in clinical decision
making, there are standard & appropriate
guidelines that are based on ethical principles