Throughout the practice of medical care, the ethics of medicine have guided clinical practice. Doctors have practiced according to standards that call for healthcare to be provided in a manner that is beneficial to the patient, with the promise to do no harm and with protection of the privacy between the patient and the doctor. Quality healthcare is premised on those fundamentals because, if harm -- whether obvious or subtle -- is allowed and confidentiality is breached, the trust between the doctor and the patient is destroyed.
Modern science has expanded treatment options in ways that would astound Hippocrates. For example, while the ancient Greek father of medicine clearly understood the necessary parameters of the doctor-patient relationship, he could have had little idea of the special sensitivity that attends psychiatric and psychoanalytic practice in which patients must have the deepest trust and the greatest confidence in order to reveal not only the facts but also the fantasies, wishes, beliefs and aspirations that trouble them.
For the hospitalized patient, there may even be illusions, delusions and hallucinations that interrupt a productive life and could destroy it if they were revealed.
Now the drive to apply information technology to medicine threatens to undermine the ethical foundation of quality healthcare in a way that Hippocrates could understand, but to a degree that he probably could not have imagined. What some federal policymakers and information companies are proposing is to distribute the patient's personal medical information to those not directly involved in his care without the patient's permission and to do harm to the doctor-patient relationship in the name of expediency.
The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 were implemented on April 14, 2003, and substituted federal "regulatory permission" for the patient's informed consent in the disclosure of medical records for most purposes. Now some are advocating a nationwide "interoperable" electronic health-information network that would make a patient's health data widely available without the patient's informed consent, all in the interest of increased efficiency and lower costs.
Any such savings to the healthcare system in the near term are dubious, at best, considering the additional initial and ongoing costs of new electronic infrastructure, data conversion and endless updates, as well as the cost of training every clinician and support staff in the nation.
There has been little, if any, consideration given to the costs in human suffering and, perhaps, deaths resulting from the episodic failures that are inevitable with any computer system. And little attention has been paid to the "stunningly frequent" new medical errors and inefficiencies caused by such systems when doctors cannot decipher the information provided by the computer.
Nor has there been any serious consideration of the recent findings by the President's Commission on Critical Infrastructure Protection, which found that the nation's electronic information systems are "highly vulnerable" to unauthorized intrusions, those vulnerabilities are growing rapidly, and they cannot be addressed with current technology.
Members of the American Psychoanalytic Association, who discussed this issue at a recent conference in Seattle, understand more than most the critical nature of confidential communications. Patients in psychoanalysis or psychotherapy must feel free to discuss their deepest and most private thoughts and their saddest and most sensitive experiences, secure that these disclosures will not be revealed without their knowledge and informed consent.
Health IT should be employed, as any other medical device, in a manner that is consistent with traditional standards of medical practice and medical ethics. The technology should be applied cautiously in carefully monitored and controlled trials until an evidence-based conclusion can be reached that it is safe and effective for the more general treatment of patients.
The interest of policymakers and others in efficiency should never supplant the interest of doctors and their patients in the ethical practice of medicine if we are to preserve access to quality healthcare.
Jon Meyer is president of the American Psychoanalytic Association and Jon Pyles is the group's legal counsel.