Walk into almost any public space and take a survey of the wrists. Chances are you will meet at least one Fitbit, Jawbone, Apple Watch, or any number of other brands of wearable technology. Such devices have been adopted as a part of daily life in American society because they are associated with health and wellness, accessible in stores and online without a prescription, and are worn as accessories that have a fashion currency. Wearable technology, also known as wearable sensors or biotrackers, is broadly defined by Lucia Vesnic-Alujevic et al. as “portable devices [that] collect specific data from the body.” While the most recognizable wearables are packaged as a wrist-hugging personal fitness tracker and goal-setting devices, wearable technology is beginning to offer relevant data for clinical and rehabilitation medicine.
An article published in the Annals of Emergency Medicine titled “Interrogation of Patient Smartphone Activity Tracker to Assist Arrhythmia Management” describes the first recorded instance of using a Fitbit (a popular brand of wearable biotracker) in medical decision-making. In the article, the emergency room department extracted data from a patient’s Fitbit Charge HR by using his Fitbit cellphone app to determine the onset time of his atrial fibrillation. This information proved essential in administering proper and timely treatment when neither the patient nor his wife recalled a history of cardiac disease and the patient himself did not sense an abnormal pulse. Thus, where the patient’s capacity to feel his own bodily rhythms failed, his Fitbit device not only record vital information, but also provide it for the doctors.
According to the authors of the Annuals of Emergency Medicine report, “The increased use of these devices [wearable sensors] has the potential to provide clinicians with objective clinical information before the actual patient encounter.” Indeed, wearable, over-the-counter, non-FDA-approved biotrackers, as a clinical tool, raises questions about privacy, consent, knowledge about one’s health and body, and access. In particular, patients and individuals in the healthcare field will need to re-orientate their approach to informed consent, privacy, and biodata to recognize the unique challenges technology presents to a bioethical landscape that is, at times, still operating under pre-technology procedures. Further, if Fitbit and other wearables are to become fully incorporated into the clinical setting, medical professionals and biotech companies will need to establish new systems for recognizing cultural, bodily, and experiential diversity that impacts how patients approach and interact with wearable technology, as well as practical access to material necessary to operate such technology.
While over-the-counter wearables are not approved for medical diagnosis, they could still be used at the discretion of physicians in medical decision-making. This means discussion about how patients can preemptively indicate consent to let doctors access their data needs to occur, especially in cases where patients are unable to verbally consent because they are not conscious.
Accessing the apps associated with wearable trackers often allows viewers to access information about sleep, weight, food intake, and daily activity. It should also be noted that while viewing the wearable fitness app the physician is also gaining access to the patient’s cell phone which can contain a wealth of confidential information. Questions of the right to privacy arise in this light. If there is no way to restrict the access of the Fitbit data to heartrate (or other specific physiological data relevant for medical decision-making), then should the physician be given access to the app at all? On one hand, the Fitbit simply records numbers that the physician could gain access to through patient interviews or application of clinically-approved technology like a Sphygmomanometer. On the other hand, Fitbit users share their data with the Fitbit company as well as members of their social media circle. Why should the same data be considered private in one situation (the clinic) and public in another (as part of a fitness community)?
In the new age of biodata tracking, one recommendation for overcoming issues of data sharing in the clinic is to revise consent procedures to recognize a technologically-inflected biomedical, scientific, clinical landscape. When cell phone apps hold the potential to tell doctors when an individual had a cardiac incident, it is essential to find ways to retrieve such information from a fully consenting individual who has been made aware of the consequences of sharing technological information. The bioethics of wearable technology demonstrate the pressing need for those in the health fields to begin discussing and constructing new informed consent policies that recognize the potentially important data that resides in a patient’s phone and secure, effective ways to extract that data.
In light of questions of data security and protection, one is also tasked with exploring the way such data will be used. Most are familiar with wearable fitness tracker “Wellness Programs.” Under these programs work-spaces encourage employees to purchase and wear biotrackers like Fitbits and sync their data with the workplace log. Often, these wellness programs are framed as competitions and allow individuals and teams to compete against one another to acquire the most steps per day. At first glance, these programs appear problematic, but Fitbit has provided an impressive “Wellness Community Pledge” that addresses the ethical issues that might arise from a fitness challenge that uses wearable biotrackers. These guidelines attend to the potential for coercion by highlighting the voluntary nature of wellness challenges. In his review paper, Matthew B. Hoy notes that despite the health benefits that work places and insurance companies report, ultimately, incentive programs that rely on wearable fitness trackers have the “potential to be used as a way to force people to be active.” This could occur in both the workforce and medical arenas. Hoy turns to a slippery slope argument, claiming “it is not a great leap from incentivizing positive behaviors to punishing unwanted behaviors.” This form of speculation, while a possibility, misses the more immediate threat to regulatory behavior at work and in the clinic. Rather than punishing, data from wearable fitness trackers presents the possibility for increased regulation of behavior and the potential for exclusion or denial of services if said behavior is not successful. One need only turn to Patel et al.’s discussion of wearable biotrackers as a means of monitoring compliance by at-risk patients. However, it is important to note that policy holders do not have to wear Fitbits. Likewise, clinical medicine has not progressed to the point of using Fitbits as part of monitoring patient compliance (the possibility is still in the neophyte stage of scientific research). Indeed, those researchers who are working on the role of direct-to-consumer wearables in healthcare believe such devices could lead to better predicative outcomes for patients as well as reduced healthcare costs. Yet, the looming possibility of exclusion and control also present issues for when and with whom patients feel comfortable sharing their data. Thus, it is in this early stage, when Fitbits and other fitness wearables are still being studied, that bioethicists need to make a claim for the protocol used in the clinical application of such technology.
The issues surrounding wearable biotrackers are prone to change as technology becomes more sophisticated. For example, less than two years ago access was an ethical issue for many fitness trackers. Fitness trackers were designed for a particular mode of movement performed by able-bodied individuals. The diverse range of human embodiment, and the array of movements made by people with physical disabilities rarely registered with typical fitness trackers. This was a noted problem many wheelchair users noted. Yet, as of this posting, the Apple Watch now offers technology that can register the activity of a spectrum of bodies in movement, including wheelchair users. Perhaps this is one of the upsides of technology: it’s ever-evolving nature affords space to address ethical issues through each new iteration of the device.
As clinicians and patients discover new ways to incorporate widely-accessible technology into the medical care and even health policy, the conversation surrounding the ethics of these devices will need to grow and evolve along with the technology.
Hoy, Matthew B. “Personal Activity Trackers and the Quantified Self.” Medical Reference
Rudner, Joshua et al. “Interrogation of Patient Smartphone Activity Tracker to Assist Arrhythmia Management.” Annals of Emergency Medicine (2016): 1-3.
Vesnic-Alujevic, Lucia, Melina Breitegger, Ângela Guimarães Pereira. “’Do-It-Yourself’ Healthcare? Quality of Health and Healthcare Through Wearable Sensors.” Science and Engineering Ethics (March 30, 2016): 1-18.