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Blockchain in Medicine: What are the Ethics?

Every fortnight, we hand over the blog to one of the London Shapers, to give you a flavour of what they do, how they think and what's really going on in our hearts and minds. Today's piece comes from Anuraag Vazirani who is a medical student at the University of Oxford.

Technological advances over the past four decades have transformed screening, diagnosis, and treatment in medicine. Automation of laboratory equipment has enabled accurate blood tests to be performed in the thousands within minutes. CT scans can be completed in an equally short period, and are used to diagnose a range of conditions almost instantly. Handheld ultrasound probes give doctors the freedom to examine internal structures on a hospital ward (or even outside the hospital), and robotic equipment is being developed to assist surgeons in theatre.

More recently, there has been a marked effort to improve administration of healthcare, and in particular to transfer paper medical records onto electronic systems. These newer systems facilitate doctors’ access to medical records across institutions, the ability to mine data for population-level insight, as well as easier administration, and simple patient access to records. However, several risks accompany the shift to electronic storage. The system may have less integrity, as records can be more susceptible to modification. There is also a risk of data theft and loss to attacks by hackers. If not implemented correctly, it may also be difficult to audit data.

Blockchain is a fast-developing technology best known for managing cryptocurrency transaction ledgers, and increasingly applied to other fields. A blockchain is an electronic spreadsheet-like document, an identical copy of which is stored on every computer associated with that blockchain (Figure 1).

Figure 1: A typical Blockchain

When a change to the ledger is requested, more than half of the network must agree to the change. The change is confirmed when one computer on the network solves a particular cryptographic problem. Computers are motivated to join and maintain the network by the reward they receive when they are the first to solve a problem. In Bitcoin, the reward is a fraction of the bitcoin currency. In other blockchain systems, the reward may differ. In addition to cryptocurrency, applications of blockchain now include managing power networks, coordinating supply chains, and various applications in medicine including pharmacy drug management, and electronic medical records.

Alongside technological advances in medicine, there has been a shift away from the paternalistic model of medicine to more autonomous models, in which the patient takes an active role in their own medical care (Figure 2). Patients are more aware of and interested in their own medical management, and are more able to research treatments, side effects, and complications for themselves. Patients also have a right to inspect their medical records, and to control what they are used for, and who can access them.

Figure 2: Patient-doctor relationship models (Reach, G. 2014)

The use of a Blockchain to manage medical records is increasing worldwide. It is a secure online system which allows the easy transfer of data to those who need it, whilst protecting against the risks of unwanted data modification, and against hackers, whilst putting the keys in the hands of the patient, who can control how their data is used. Estonia manages all of its citizens’ medical and other government records on a blockchain, and companies across the world are following suit.

One particular consideration for every new treatment, technology, or solution in healthcare is whether it can be implemented ethically, as changes in medical practice can be detrimental if ill-considered. This is especially the case for newer technologies of which we have little practical experience.

For medical records, ethical questions predominantly arise around who will be able to add, modify, or access patient data. Although traditionally only accessible to doctors, patients can now request to access medical records relating to them, and there are only rare ethical grounds on which the clinician could refuse this request, when not withholding data might lead to someone being harmed.

In addition to doctors directly involved in a patient’s care, it might for example be necessary for a clinician in another hospital to access records in order give an opinion on a patient’s condition. A new system must be able to cope with these requirements, whilst managing data in a secure way. Another example of data use might be the use of data for a regular hospital audit, to ensure standards of care are maintained.

Researchers also use data for individual studies, and to determine population trends. Typically, patients must consent to the use of their data for research. During the coronavirus pandemic however, researchers have been able to use patient data without consent of the individual for research directly related to the virus - a balance between public health and the right to privacy.

Another consideration for Blockchain in particular relates to the reward for solving the cryptographic problem. Records are not a currency, and although the reward may be minimal, it could be seen as unethical for individuals or organisations to make any profit from managing medical data.

These ethical considerations matter, not only because they have legal force and political status, but so that the integrity of patient data, and dignity, can be protected.

Related work:

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