The ethics of mHealth as a global phenomenon

Over the last years, mHealth technologies in combination with internet-driven data exchange are being widely implemented in many countries.1 These involve a diverse range of apps, wearables, implants and other digital devices that purport to improve health. With the increasing use of smartphones worldwide, a growing percentage of the global population has access to powerful handheld tools that are in almost continuous use and interaction with other devices and users, enabling, among other things, the real time sharing of health data and resulting in a near ubiquitous network of health data technologies. mHealth thus has the potential to widely impact on individual health, on health care provision, health care systems and public health throughout the world, and independently from the physical territory where the user is placed.

This development is endorsed by political and industrial stakeholders, also on a global scale. The World Health Organization (WHO), for example, published a report in 2018 on mHealth claiming that “The spread of digital technologies and global interconnectedness has a significant potential to accelerate Member States' progress towards achieving universal health coverage, including ensuring access to quality health services.”2

This special issue is part of our broader research within the project “META - mHealth: Ethical, Legal, Social aspects in the technological age3”. In this editorial we want to emphasize that the global and globalized scope of mHealth is essential to this technology, but is too often neglected in the ethical and social discussions. Increasingly, providers, developers and marketing companies are organized as international companies, with some of them carrying massive market interest and power, and apps can be downloaded across the globe. The generated data are globally collected and processed. Users are connected via global digital networks too. mHealth also facilitates new forms of patient activism, dissolving geographical boundaries through their global connectivity, but potentially creating new barriers and inequalities.4 Various mHealth technologies are utilized to tackle urgent issues in global health,5 while the mass generation of (health) data as a global phenomenon and the many related opportunities and challenges are debated among scholars and policy makers.6

The rapid developments in the mHealth field are particularly significant for influencing user self-diagnosis, self-monitoring, health prevention, and remote management of chronic and acute conditions. Such far-reaching developments that impact health in all its bio-psycho-social dimensions have ethical implications on an individual, societal and global scale. However, most ethical discussions are Western-centric, despite the significance of the ethical implications that arise from a global, globalized and international perspective,7 for example: Whose understanding of health and particular cultural norms does mHealth technology reflect? How do predominantly Western mHealth market and power dynamics influence and shape the normative concepts of (global) health, public health and health justice? How are local contexts and their understandings of health, health care and privacy accounted for? How are profits, benefits and burdens of globalized mHealth distributed? How does mHealth technology affect population health in different parts of the world? Which global and local socio-economic inequalities do these technologies help to reduce or risk to exacerbate? Which steps are needed to mitigate bias and discrimination in mHealth and prevent detrimental impact on marginalised and vulnerable groups (on the grounds of race, gender, class etc), in order to create better conditions for global health (justice)?

In 2021 we have organised the Brocher workshop “The ethics of mHealth as a global phenomenon”, which explored a variety of ethical concerns raised by the globalisation of mHealth. Themes that we discussed encompassed concerns of intersectionality, prioritarian ethics for structurally vulnerable populations and global South(s) contexts and issues stemming from the privatization of mHealth in the broader context of public health and global health justice. Debates at the workshop have built the foundations for the four papers in this special issue, which involves the work of some of the workshop participants and other international colleagues.

In the first paper, Karola Kreitmair explores concerns of empowerment in a booming global market with mHealth. In particular, she investigates whether “direct to-consumer” (DTC) mHealth technology facilitates five elements identified by her as constitutive to empowerment: knowledge, control, responsibility, the availability of good choices, and healthy desires. Considering the likelihood that DTC mHealth technology may be enhancing merely the feeling and perception of these elements – instead of empowerment itself – she argues that the language of DTC mHealth technology as a tool of empowerment is problematic.

The second paper by Tereza Hendl and Ayush Shukla takes a closer look at the potential of digital health technologies for democratizing health care. The researchers observe that dominant debates envision democratization with digital health as a matter of access: to health information, health care, and patient empowerment. Yet, building on the growing pool of empirical data on digital health, they argue that these technologies come short of materializing these goals, given the unequal health outcomes they facilitate. As such, they argue that not only debates on democratization need to be connected to concerns of social determinants of health but also debates on the impact of digital health need to go far beyond democratization and engage with concerns of health justice.

The third paper by Meadi et al. explores the ethics of mental health chatbots (MHCBs), which are increasingly used across the globe. The authors observe that the rapidly advancing MHCB technologies lack empathic understanding, which has adverse consequences for psychotherapy. Arguing that such limitations pose a threat to the quality and safety of care, Meadi et al. raise concerns about the increasingly widespread use of chatbots in mental health care, while discussing the need for establishing ethical boundaries for the use of MHCBs.

The fourth paper by Bianca Jansky, Tereza Hendl and Azakhiwe Nocanda zooms in onto patient-led open-source innovation for Type 1 Diabetes. The authors note that user-led innovation is commonly perceived as a bottom-up type of innovation. Yet, taking into consideration the broader global context shaped by stark socio-economic inequalities, it becomes apparent that the means of innovation are out of reach to many, especially structurally marginalised, racialized and non-Western populations. This not only means that results of innovation are themselves largely inaccessible to these populations, but also that it is unclear whether they are safe and beneficent to them. In response, the authors argue that proactive strategies are needed to ensure that open-source patient-led innovation will be more globally accessible, center the agency and health needs of the most underserved populations, as well as facilitate equitable and just health benefits.

The discussion about mHealth as a global phenomenon has many more ramifications, and we urge scholars to conceptualise the technology also as a global one, and to keep exploring the resulting ethical and social questions. In our view, the central goal of mHealth should be to improve individual, population and global health, including health equity. Much work is necessary, to formulate ethical norms and approaches to ethics that will be empirically informed and will account for structural inequalities and concerns of (global) health equity. We hope that this special issue will provide readers with ‘food for thought’ and inspire more work that will adapt, rethink and redefine existing concepts and strategies, and where necessary, adding new concepts in order to understand the bigger picture better and to adapt ethical analytic tools on the path to global health justice.