Ethics in the Virtual World 9781846636332, 9781846636325

Citation preview

jices cover (i).qxd

20/08/2007

13:45

Page 1

ISSN 1477-996X

Volume 5 Number 1 2007

Journal of

Information, Communication and Ethics in Society Ethics in the virtual world Guest Editor: John Strain

www.emeraldinsight.com

Journal of Information, Communication & Ethics in Society

ISSN 1477-996X Volume 5 Number 1 2007

Ethics in the virtual world Guest Editor John Strain

Access this journal online _________________________

2

Editorial advisory board __________________________

3

GUEST EDITORIAL Ethics in the virtual world John Strain ___________________________________________________

4

Ethical issues in the use of electronic health records for pharmacy medicines sales Richard Cooper ________________________________________________

7

A phenomenological perspective on clinical communication and interaction: the case of electronic health records Lars Botin ____________________________________________________

20

Assessing students’ ethical development in computing with the defining issues test: challenges to be addressed Suzy Jagger and John Strain _____________________________________

33

Book reviews_____________________________________

43

Note from the publisher ___________________________

47

Access this journal electronically The current and past volumes of this journal are available at:

www.emeraldinsight.com/1477-996X.htm You can also search more than 150 additional Emerald journals in Emerald Management Xtra (www.emeraldinsight.com) See page following contents for full details of what your access includes.

CONTENTS

www.emeraldinsight.com/jices.htm As a subscriber to this journal, you can benefit from instant, electronic access to this title via Emerald Management Xtra. Your access includes a variety of features that increase the value of your journal subscription.

Structured abstracts Emerald structured abstracts provide consistent, clear and informative summaries of the content of the articles, allowing faster evaluation of papers.

How to access this journal electronically

Additional complimentary services available

To benefit from electronic access to this journal, please contact [email protected] A set of login details will then be provided to you. Should you wish to access via IP, please provide these details in your e-mail. Once registration is completed, your institution will have instant access to all articles through the journal’s Table of Contents page at www.emeraldinsight.com/1477-996X.htm More information about the journal is also available at www.emeraldinsight.com/ jices.htm

Your access includes a variety of features that add to the functionality and value of your journal subscription:

Our liberal institution-wide licence allows everyone within your institution to access your journal electronically, making your subscription more cost-effective. Our web site has been designed to provide you with a comprehensive, simple system that needs only minimum administration. Access is available via IP authentication or username and password.

E-mail alert services These services allow you to be kept up to date with the latest additions to the journal via e-mail, as soon as new material enters the database. Further information about the services available can be found at www.emeraldinsight.com/alerts

Emerald online training services Visit www.emeraldinsight.com/training and take an Emerald online tour to help you get the most from your subscription.

Key features of Emerald electronic journals Automatic permission to make up to 25 copies of individual articles This facility can be used for training purposes, course notes, seminars etc. This only applies to articles of which Emerald owns copyright. For further details visit www.emeraldinsight.com/ copyright Online publishing and archiving As well as current volumes of the journal, you can also gain access to past volumes on the internet via Emerald Management Xtra. You can browse or search these databases for relevant articles. Key readings This feature provides abstracts of related articles chosen by the journal editor, selected to provide readers with current awareness of interesting articles from other publications in the field. Non-article content Material in our journals such as product information, industry trends, company news, conferences, etc. is available online and can be accessed by users. Reference linking Direct links from the journal article references to abstracts of the most influential articles cited. Where possible, this link is to the full text of the article. E-mail an article Allows users to e-mail links to relevant and interesting articles to another computer for later use, reference or printing purposes.

Xtra resources and collections When you register your journal subscription online, you will gain access to Xtra resources for Librarians, Faculty, Authors, Researchers, Deans and Managers. In addition you can access Emerald Collections, which include case studies, book reviews, guru interviews and literature reviews.

Emerald Research Connections An online meeting place for the research community where researchers present their own work and interests and seek other researchers for future projects. Register yourself or search our database of researchers at www.emeraldinsight.com/ connections

Choice of access Electronic access to this journal is available via a number of channels. Our web site www.emeraldinsight.com is the recommended means of electronic access, as it provides fully searchable and value added access to the complete content of the journal. However, you can also access and search the article content of this journal through the following journal delivery services: EBSCOHost Electronic Journals Service ejournals.ebsco.com Informatics J-Gate www.j-gate.informindia.co.in Ingenta www.ingenta.com Minerva Electronic Online Services www.minerva.at OCLC FirstSearch www.oclc.org/firstsearch SilverLinker www.ovid.com SwetsWise www.swetswise.com

Emerald Customer Support For customer support and technical help contact: E-mail [email protected] Web www.emeraldinsight.com/customercharter Tel +44 (0) 1274 785278 Fax +44 (0) 1274 785201

Editorial board

EDITORIAL BOARD Professor Alison Adam Information Systems Institute, University of Salford, UK E-mail: [email protected] Professor Porfirio Barroso Complutense University of Madrid and Pontifical University of Salamanca, Spain E-mail: [email protected] Associate Professor Shifra Baruchson-Arbib Department of Information Science, Bar-Ilan University, Israel E-mail: [email protected] Andrew Bissett School of Computing & Management Sciences, Sheffield Hallam University, UK E-mail: [email protected]

Associate Professor Shalini Kesar Department of Computer Science and Information Systems, Southern Utah University, USA E-mail: [email protected] Kai Kimppa Department of Information Technology, University of Turku, Finland E-mail: [email protected] Professor Wanbil Lee University of Hong Kong and Hong Kong Polytechnic, China E-mail: [email protected] Professor David Lyon Department of Sociology, Queen’s University at Kingston, Canada E-mail: [email protected]

Associate Professor Philip Brey Department of Philosophy, Twente University, The Netherlands E-mail: [email protected]

Dr Antonio Marturano Faculty of Economics, Catholic University of the Sacred Heart, Italy E-mail: [email protected]

Professor Terrell Ward Bynum Research Center on Computing & Society, Southern Connecticut State University, USA E-mail: [email protected]

Professor James H. Moor Department of Philosophy, Dartmouth College, USA E-mail: [email protected]

Associate Professor Jean Camp School of Informatics, Indiana University, USA E-mail: [email protected]

Professor Keith W. Miller Department of Computer Science, University of Illinois at Springfield, USA E-mail: [email protected]

Professor Rafael Capurro International Center for Information Ethics, Stuttgart Media University, Germany E-mail: [email protected]

Professor Kiyoshi Murata Cyber Research Institute of Business Information Ethics, Meiji University, Japan E-mail: [email protected]

Professor Go¨ran Collste Centre for Applied Ethics, Linko¨ping University, Sweden E-mail: [email protected]

Associate Professor Nancy Pouloudi Department of Management Science and Technology, Athens University of Economics and Business, Greece E-mail: [email protected]

Professor Alessandro D’Atri Research Centre on Information Systems, Luiss ‘‘Guido Carli’’ University, Italy E-mail: [email protected] Professor Dag Elgesem Department of Information Science and Media Studies, The University of Bergen, Norway E-mail: [email protected] Professor Paul Foley The Business School, De Montfort University, UK E-mail: [email protected] Professor Krystyna Gorniak-Kocikowska Research Center on Computing & Society, Southern Connecticut State University, USA E-mail: [email protected] Professor Donald Gotterbarn Software Engineering Ethics Research Institute, East Tennessee State University, USA E-mail: [email protected] Professor Frances Grodzinsky Computer Science Department, Sacred Heart University, USA E-mail: [email protected] Associate Professor Kenneth Einar Himma Department of Philosophy, Seattle Pacific University, USA E-mail: [email protected] Professor Chuck Huff Department of Psychology, St Olaf College, USA E-mail: [email protected] Professor Deborah Johnson Department of Science, Technology, and Society, University of Virginia, USA E-mail: [email protected] Professor Amin Kashmeery Oxford Academy for Advanced Studies and University of Durham, UK E-mail: [email protected]

3

Professor Charles Raab School of Social and Political Studies, The University of Edinburgh, UK E-mail: [email protected] Dr Emma Rooksby School of Social and Cultural Studies, The University of Western Australia, Australia E-mail: [email protected] Reverend Dr John Strain Digital World Research Centre, University of Surrey, UK E-mail: [email protected] Dr Stanislaw Szejko Department of Software Engineering, Gdansk University of Technology, Poland E-mail: [email protected] Professor Barrie Thompson School of Computing and Technology, University of Sunderland, UK E-mail: [email protected] Professor Jeroen Van den Hoven Department of Philosophy, Delft University of Technology, The Netherlands E-mail: [email protected] Professor John Weckert Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Australia E-mail: [email protected] Dr Emma Weitkamp Faculty of Applied Science, University of the West of England, UK E-mail: [email protected] Dr Duan Weiwen Institute of Philosophy, Chinese Academy of Social Sciences, China E-mail: [email protected] Dr Xiaojian Wu Newcastle Business School, University of Northumbria, UK E-mail: [email protected]

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 p. 3 # Emerald Group Publishing Limited 1477-996X

The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-996X.htm

JICES 5,1

GUEST EDITORIAL

Ethics in the virtual world John Strain University of Surrey, Guildford, UK

4 Abstract

Purpose – The purpose of this viewpoint paper is to provide an overview of three papers included in a Special Issue of the Journal of Information Communication Ethics and Society, entitled Ethics in the Virtual World. Design/methodology/approach – The papers were chosen because they reflect three key themes in computing, ethics and society. These are: the explosion in the number of opportunities for accessing sensitive data in the health sector; the risks inherent in designing information systems through technical procedures that fail to address the human character of the environments they are intended to serve; and the need to teach computing ethics to students of computing. All three articles draw on philosophical approaches to ethics and well as technical aspects of system use, system design and pedagogy, respectively. Findings – The papers demonstrate the interdisciplinary nature of computing ethics and the contested political issues at stake in using and designing information systems. Originality/value – This editorial viewpoint paper presents the hypothesis that the ethical issues once embodied in socio-technical systems theory have a particular salience for the contemporary ethical debates concerning computing ethics. Keywords Ethics, Health services, Information systems Paper type General review

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 pp. 4-6 q Emerald Group Publishing Limited 1477-996X

This special issue is devoted to Ethics in the Virtual World. This was the theme selected for the Second International Conference on Teaching Applied and Professional Ethics in Higher Education held at what is now Roehampton University in September 2005. The conference invited papers on ethical issues that arose in computing practice which would need to be addressed in teaching computing ethics. Three papers delivered at the conference have been revised and developed for this issue. They have been chosen because they reflect three major and continuing themes in computing, ethics and society. The first of these is the explosion in the number of opportunities for accessing confidential and sensitive data that are afforded by the digital mediation of data, particularly in the health sector. Making information available to those who can make effective and appropriate use of it also creates abundant opportunities for the abuse of data. Part of the crisis faced by health services in many nations is the inability to manage this delicate balance between protecting data and making it accessible. Richard Cooper explores the ethical issues that arise in extending opportunities to access health records to allied health care professionals such as community pharmacists. The second theme concerns the risks inherent in designing information systems that draw on technical procedures that fail to address the distinctively human character of the environments these systems are intended to serve. This second article by Lars Botin, draws on a similar context to Richard Cooper’s, that of electronic health care records. But the ethical focus is different in both. Cooper is concerned with the ethics of use of

these systems. Botin is concerned with the ethics of design. Suzy Jagger and I in the third article are concerned with the teaching of professional computing ethics in the undergraduate curriculum and how the outcomes of such teaching are assessed. In examining the significance of the “Defining Issues Test” for such assessment, the importance of articulating the ethical character of what is being assessed is highlighted. Unlike the Botin and Cooper, article, the Jagger and Strain article is not a report of a completed piece of research. It is rather an examination of the ethical issues involved in research in progress. This examination is considered of interest beyond the confines of the particular research project. Both Botin and Jagger in their different projects bring a phenomenological turn to understanding computing ethics. All three articles report projects that draw on philosophical approaches to ethics and well as system use, system design and pedagogy, respectively. The three papers stretch across a number of disciplines and reflect the intrinsically interdisciplinary nature of computing ethics. Richard Cooper’s article exposes the contested political issues at stake in making use of information systems. The deregulation of certain medicines allows many proprietary medicines, hitherto available only by prescription, to be freely available by purchase over the counter at pharmacies. But this has generated increased responsibilities for community pharmacists to ensure that the medicines being purchased are fit for purpose and appropriate for the patient. Both might be assessed by asking the patient-customer for information that would allow the assessment to be formed. Alternatively, they might be assessed by the pharmacist accessing the individual’s electronic health care record if these records were made available to the pharmacist. These alternatives draw on different political traditions. Asking the patient or customer for information that might be given, accurately, truthfully or otherwise, draws on the tradition of respect for individual freedoms and a Kantian approach to personal autonomy. Authorising pharmacists to access relevant data from an electronic system draws on a more dirigiste approach to data, reflecting the primacy of the duty of care in advancing patient benefit and well-being and a utilitarian approach to well-being. Such relationships between the political and ethical principles and access to data are also reflected in the avenues to information upon which patients draw. The promotion of deregulation and the emphasis on putting the patients’ choices first depends on patients having information about the availability and utility of medicines. The internet, with its own particular architecture of access has been a major source of this information. Thus, the internet services a concept of data access that promotes de-regulation and patient autonomy. The healthcare records system services the duty of care to patients. Different approaches to the structure of information systems support different approaches to human relationships in the social and political context. This is worth remembering in the design of information systems. Botin’s article provides an important case study of how a systematic and logical approach to the design of information systems can significantly misrepresent the lived experiences of those who work in complex organizations such as healthcare. Methods are needed which can describe the rich array of relationships and communication within organizations which are not described in such logical mechanisms as organization charts, these concerns reflect long standing prescriptions for socio-technical approaches to system design and

Guest editorial

5

JICES 5,1

6

for ethnographic approaches to capturing requirements for system design that have been familiar to those in the Computer Supported Cooperative Work (CSCW) initiative. Indeed, a recent special issue of the CSCW journal is devoted to healthcare systems, (Procter et al., 2006). Botin’s article has a significance in taking us beyond the issues of success and failure in the design of systems and into the ethical domain of the damage done to human relationships in failures through inadequate design. There is within the socio-technical literature an implicit and sometimes explicit concern with ethical issues of design. The earliest studies of Trist and Bamforth (1951) drew on a psychoanalytic approach to organizations (albeit long before the advent of digital information systems) that drew on claims about human well-being that were inescapably ethical. Mumford (1996) drew attention to political as well as ethical concerns in system design, one might wonder if more recent quests in ethnographical approaches to system design have lost sight of these ethical concerns. There would be a particular irony in the ethical potential of socio-technical design to be lost at a time when the public agenda of ethics has rarely been more clear. All these issues of system use and system design create rich and diverse scenarios which suggest opportunities through which computing students might learn computing ethics. Suzy Jagger has introduced some innovative ways of using debates in teaching ethics in the undergraduate computing curriculum. These debates provide opportunities for students to shape their judgements through interaction with each other in response to ethical dilemmas inherent in scenarios. Jagger is seeking to evaluate how these learning experiences contribute to the formation of a capability for ethical judgement as measured in the defining issues test. But the defining issues test is constrained by a somewhat Kantian view of ethical development. That is to say that the capability for ethical judgement is considered as a progression from the adoption of self-regarding concerns, through the adoption of concerns about how well one’s ethical concerns conform to socially accepted norms, through to the adoption of Kant’s ethical ideal, the categorical imperative of universalisable moral maxims. But there is little scope within the defining issues test for understanding how students might articulate their own accounts of what matters most to them in their ethical judgements. By including such accounts in an action research project scope is created to provide a more nuanced understanding of how people express their ethical development in addition to how Kant and Kohlberg would have it described. References Mumford, E. (1996), Systems Design: Ethical Tools for Ethical Change, Macmillan, London. Procter, R., Rouncefield, M., Balka, E. and Berg, M. (2006), “Computer Supported Cooperative Work (CSCW) Special Issue: CSCW and Dependable Healthcare Systems”, Vol. 15 Nos 5/6, pp. 413-8. Trist, E.L. and Bamforth, K.W. (1951), “Some social and psychological consequences of the longwall method of coal getting”, Human Relations, Vol. 4, pp. 3-38. Corresponding author John Strain can be contacted at: [email protected] To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-996X.htm

Ethical issues in the use of electronic health records for pharmacy medicines sales Richard Cooper

Ethical issues in the use of EHRs

7

School of Pharmacy, Centre for Pharmacy, Health and Society, University of Nottingham, Nottingham, UK Abstract Purpose – Pharmacy sales of over-the-counter medicines in the UK represent an economically significant and important mechanism by which customers self-medicate. Sales are supervised in pharmacies, but this paper seeks to question whether patients’ electronic health records (EHRs) – due to be introduced nationally – could be used, ethically, by pharmacists to ensure safe medicines sales. Design/methodology/approach – Using theoretical arguments, three areas of ethical concern are identified and explored in relation to pharmacists’ access to EHRs-consequentialsim, analogies and confidentiality/privacy. Findings – Consequentialist arguments include positive benefits to customer’s welfare and control of medicine of abuse, but negative economic healthcare burdens and consequences due to potentially increased or paradoxically, decreased presentation of patients to doctors. Socially accepted analogous practices – credit checks, existing pharmacy access to information and hospital treatment – are then argued to be ethically relevant and supportive of access. Privacy and confidentiality are then considered as reasons not to allow EHR access. A contrasting view is that pharmacy access to EHRs is another form of surveillance and hence the question of pharmacists’ assess to EHRs may be answered negatively by empirical research that locates pharmacy customers as expert users and identifies confidentiality and privacy concerns about information technology in healthcare more generally. Originality/value – This paper offers a unique and valuable contribution to the debate about healthcare professionals’ role-based access to patients’ medical records and offers a reflection on the ethical concerns surrounding patient information and the rival concerns of patient qua customer autonomy and safety. Keywords Pharmaceuticals industry, Ethics, Medicines, Customer records, Health services, United Kingdom Paper type Conceptual paper

Introduction There has been considerable academic and public debate about the application of information technology (IT) within healthcare in the form of electronic health records (EHRs). Questions have been raised about whether such schemes are compulsory, what patient information will be recorded and stored, who may access EHRs and for what purpose and whether patient privacy and confidentiality are significant concerns. In this paper, ethical issues are identified in relation to a previously unexplored application of EHRs – to the sale of over-the-counter (OTC) medicines in pharmacies. Specifically, the paper’s focus is upon whether community pharmacists (or pharmacy staff) should have access to patients’ EHRs when selling OTC medicines to ensure that such sales are safe and appropriate. Pharmacist access to EHRs has been identified generally in terms of “role-based” access situations such as UK pharmacists’ increasing involvement in medicine use reviews and supplementary prescribing. But it is argued

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 pp. 7-19 q Emerald Group Publishing Limited 1477-996X DOI 10.1108/14779960710822656

JICES 5,1

8

in this paper that pharmacists’ role in supplying OTC medicines may be relevant to the use of EHRs but ethically problematic and that pharmacists may be increasingly seen as “agents of surveillance” (Harding and Taylor, 2002). The paper begins by briefly reviewing the background to the proposed introduction of EHRs in the UK generally. The importance of the OTC medicine sales in UK pharmacy is then developed, together with a consideration of how such sales are presently supervised in pharmacies. Three distinct areas of ethical concern are then developed in relation to pharmacists’ access to EHR for OTC medicine sales: consequentialist arguments such as concerns about customer’s welfare, medicine abuse, economic consequences and use of medical staff; analogous practices such as credit checks, existing pharmacy access to information and hospital treatment; privacy and confidentiality concerns, especially in relation to recording pharmacy medicine sales. The paper concludes, however, by reflecting on whether pharmacy access to EHRs might be decided, not upon the ethical concerns raised in this paper but instead, upon empirical research that locates pharmacy customers as expert users (Hibbert et al., 2002) and identifies concerns about the confidentiality and privacy of EHR and IT (Porteous et al., 2003). Electronic health records Medical records of some description have been used within health-care for many years and were originally in paper or card form. In the UK, the creation of the NHS in 1948 prompted a standardized envelop, card and folder system but the storage and maintenance of such records were not regulated and were held only by the institution where they were needed. So a hospital would have one set of records and a doctor’s surgery another, for example. IT advances during the late twentieth century have meant that some form of computer record is commonplace across healthcare but these are usually still held by one particular institution and are still neither standardised nor readily accessible to other health-care professionals. With the publication of “Information for Health” (Department of Health, 2002), the UK Government set out its intention to improve record keeping in healthcare and the NHS and make the best use of advances in IT. Key concepts included allowing the patient greater access to, and control over, their medical health records, fostering greater links between health-care organizations and institutions and providing a life-long “cradle to grave” document of a person’s health and medicines. In 2003, the NHS Care Records Service was introduced, proposing that all patients in England would have an individual electronic care record in the form of both a summary and also a more detailed record. Role-based access controls were planned, setting-out conditions for healthcare professionals’ access to EHRs in terms of the type of data that could be access and for what purpose. The importance of OTC medicine sales in UK pharmacies To understand the relevance of EHRs for OTC medicine sales in UK community pharmacies, it is important to identify how significant such sales are in relation to their contribution to the UK economy, the NHS, the pharmacy profession and customers. This will then be followed be a consideration of how such sales are presently regulated in community pharmacies. It is estimated that sales of medicines in the UK represent more than a £2 billion industry (The Proprietary Association of Great Britain, 2006).

Although not restricted to pharmacies alone, the OTC medicines’ market is an economically significant one but also one that is recognised as being central to the role of community pharmacy. In “A vision for Pharmacy in the New NHS” (Department of Health, 2003), the UK government identified key areas in which community pharmacy could develop and contribute more to healthcare in the UK. Alongside a number of extended roles such as supplementary prescribing, medicines use reviews and diagnostic testing, the sale of OTC medicines and allied advice was recognized as being significant and it was noted that: . . . the traditional role of pharmacies as a readily accessible source of advice and medicines continues to be an essential part of our overall vision for primary care [. . .]. The availability of a wider range of effective over the counter medicines, in a safe environment with access to professional advice, will increase patient choice, support improvements in public health, and make fuller use of pharmacists’ professional skills and knowledge (Department of Health, 2003, pp. 10-11).

Although UK community pharmacies and OTC medicine sales are distinct from the NHS and represent profit-making commercial transactions, they are, as the above quotation notes, important for healthcare generally in the UK. A trend towards increasing self-care has made the OTC medicine’s market even more important, with customers increasingly being viewed as “expert users” (Hibbert et al., 2002). A related trend is the increasing reclassification of medicines from prescription only medicine (POM) status – those available only when prescribed by a doctor – to pharmacy or general sales list status, allowing them to be sold in community pharmacies or anywhere, respectively. About 72 medicines were deregulated in the period 1983-1999 in the UK (BMA, 2005) and more recent products have included simvastatin, omeprazole, sumatriptan, chloramphenicol eye drops and levonorgestrol emergency hormonal contraception. The aims of such de-regulation have been to provide the public with greater access to medicines and support self-care but it may also be argued that deregulation of medicines might reduce the ever-increasing cost of medicines in the NHS. Allowing customers to purchase medicines previously only prescribed effectively offsets the costs that would otherwise be borne by the NHS and may also reduce indirect NHS costs such as the time and resources of NHS staff prescribing such medicines. This may represent a concern about economic justice and it has been claimed (Bond, 2001, p. 7) that: This overcomes the ethical conflict between increasing the pharmacy role at the expense of a free NHS, at least for those patients who are exempt from prescription charges.

One further significance of the sale of medicines from pharmacies is that they may have social value and represent, in a sociological sense, a valued transformation process. Dingwall and Wilson (1995, p. 195) have argued that, “the social object of pharmacy is the symbolic transformation of the inert chemical into the drug” and this transformation has considerable social significance since it re-imposes some sense of social order against the unpredictable or uncontrollable nature of biology. In a historical context, this transformation previously involved pharmaceutical skills in actually preparing a medicine but this process has become increasingly routine and hence the transformation is symbolic. According to such accounts, OTC sales of medicines have significance for society but, importantly, also for pharmacy as a way of

Ethical issues in the use of EHRs

9

JICES 5,1

re-defining itself as the occupational roles change from tradition and increasingly routine and even delegated dispensing tasks, to other activities. Despite the significance of OTC medicine sales, one further aspect must be considered before it is possible to explore the ethical arguments about associated EHR use and this involves how OTC medicine sales are supervised in pharmacies to ensure that they are safe and appropriate.

10 Existing supervision of OTC medicines and information sources Presently, OTC medicine sales within pharmacies in the UK involve a professional and a legal responsibility on the part of the pharmacist to ensure the safe and responsible use of such medicines. Delegation of such sales is common to appropriately trained pharmacy staff since pharmacists are often involved in the core dispensing activities within community pharmacies. However, it is recognized that a pharmacist should be in “personal control” of a pharmacy and so protocols are often used to regulate medicine sales by trained pharmacy staff. The Royal Pharmaceutical Society (RPSGB) in the UK recognizes the need for such sales to be made appropriately and sets out specific guidelines (RPSGB, 2006, p. 96) noting that: The public is entitled to expect that medicines purchased over the counter will be safe, effective and appropriate for the condition to be treated and the intended recipient [. . .] Pharmacists or assistants must obtain sufficient information to allow an assessment to be made that self-medication is appropriate.

Of particular relevance to this paper is the phrase “sufficient information” and this could be any information about a patient and their condition that may be relevant to the decision as to whether to sell an OTC medicine. A number of protocols have been advanced to assist in this information gathering and decision-making process and these include, for example, the mnemonics ENCORE (Li Wan Po and Li Wan Po, 1997) and the popular “2WHAM” (Anon, 1989), which list a number of key questions that should be asked of prospective medicine purchasers. The latter approach includes five-key questions to ensure that an appropriate medicine sale can be made and these are listed below: (1) Who is the medicine for? (2) What are the symptoms? (3) How long have the symptoms lasted? (4) Action already taken? (5) Medicines currently being taken? From this simple mnemonic, it is clear that pharmacists and pharmacy staff may require a considerable amount of information in relation to OTC medicine sales and although pharmacy assistants have claimed to use such approaches regularly, research involving observations of OTC medicines sales has found that, on average, only two questions were asked and in 40 percent of cases, customers were not asked about other medicine use (Watson et al., 2006). It is now possible to identify the relevance of patient EHRs to the sale of pharmacy OTC medicines and raise the question of whether pharmacy access to EHRs would lead to a more thorough and safe supply of medicines, by ensuring that an accurate, comprehensive and authoritative record were available.

Whilst some questions in mnemonics such as “2WHAM” are obvious and easy to pose and respond to, others may require more sensitive questioning and more detailed replies from patients. Moreover, some are subjective such as the presenting symptoms and their duration but EHRs have relevance in terms of assisting pharmacists and pharmacy staff in gathering the necessary information in relation to questions such as current medication, existing medical conditions and drug sensitivities, for example. Access to data contained within EHRs would provide an authoritative account of such relevant information and allow pharmacists and staff to make an informed decision about whether an OTC sale is appropriate for a patient qua customer. Having identified the significance of the OTC market and the relevance of access to EHRs in helping gather the relevant information to make a safe and appropriate medicine sale, it will now be argued that three distinct areas of ethical concern-consequentialist arguments, analogies and privacy and confidentiality – are relevant to a consideration of the application of EHRs to this area of healthcare. Consequentialist arguments Perhaps, the most obvious ethical argument related to pharmacy access to EHRs for OTC medicine sales is that having access to a comprehensive, accurate and up-to-date record such as an EHR would enable a more thorough check of the suitability of a medicine for a customer to be made. This could lead to improvements in individuals’ welfare and would help minimize any inappropriate and unsafe supplies being made, based upon incorrect or incomplete information. Access to EHRs has been advocated generally within pharmacy and the American Society of Health-System Pharmacists (1999), for example, has stated that pharmacist access to EHRs would “provide quality care and ensure the safe use of medications.” However, despite these general claims for increased access to appropriate patient details by healthcare professionals such as pharmacists, it may be argued that patients already do provide information in terms of their existing medication and medical conditions as part of their responses to the questioning they receive from pharmacists and pharmacy assistants. To demand further information in terms of accessing EHRs would be to merely confirm what has already been disclosed. However, this argument is probably only sustainable in an ideal situation, where it could be assumed that patients have good recall and understanding of all the relevant medical and pharmacological information that the pharmacist or assistant would require to make a safe and appropriate sale. In practice, this may not occur and it may be that pharmacists or assistants encounter customers who are either forgetful and neglect to mention an important fact, or who are aware of all their medical details but erroneously fail to recognize the significance or relevance of disclosing such information, or lack the capacity to understand the question. In such situations, these customers believe they are providing what they think is needed and so access to EHRs would appear to be ethically justified in terms of consequentialism – the argument being that having pharmacist access would lead to more beneficial consequences in terms of patient happiness or welfare since a medicine supply would occur that was based upon actual facts rather than omissions, errors or incapacity. It is not only problems with customers’ responses to questions about their health and medication information which may be problematic and, as was noted earlier, but also research suggests that pharmacy counter assistants do not make sufficient use of the 2WHAM protocol when

Ethical issues in the use of EHRs

11

JICES 5,1

12

selling OTC medicines (Watson et al., 2006). The reality of community pharmacy work is that it is not an ideal environment and many factors may prevent the necessary gathering of relevant information. Customers are increasingly seen as expert users (Hibbert et al., 2002), for example, and may not share the belief that information gathering in the form of multiple questioning is necessary when purchasing OTC medicines (Morris et al., 1997). In this commercial and consumerist environment, the ability to access EHRs would minimize the risk of omitting questions relating to medicine use and existing medical conditions. A further example of when access to EHRs could be justified concerns less innocent failures on the part of the customer to provide a full account of their necessary details. This may include patients who intentionally lie or deceive when questioned and who may do so, perhaps, because of drug addiction, embarrassment about a medical condition, or because they believe that disclosing medical and medicine information about themselves might prevent them obtaining a medicine that they wanted (Cooper et al., 2006). There is empirical evidence that abuse of OTC medicines may be a common occurrence in UK pharmacies and empirical research has found that between 1 and 700 incidents of medicine misuse may have occurred in a three month period in one Welsh community (Hughes et al., 1999) and that 66 percent of a sample of Northern Ireland pharmacists believed there was OTC medicine misuse in their area (Pates et al., 2002). Given this empirical data, having access to an EHR would allow a more thorough assessment to be made as to the appropriateness of a medicine, which existing approaches might not be able to. In all the arguments so far advanced, the ability of pharmacists or assistants to access EHRs would mean that a more appropriate decision about supplying a medicine could be made, fulfilling the RPSGB’s requirement for “sufficient information.” Of course, appeals to consequences should take into account the unhappiness of a patient denied a medicine that they wanted but there are strong counter-claims that the long-term or overall amount of suffering caused by drug addiction, to use this example, would outweigh any immediate inconvenience or suffering for a customer. Wider costs to society in terms of addiction may also need to be calculated, involving long-term additional health problems and incapacity. Two further consequentialist arguments may be advanced that, in contrast to the above claims that EHR access would be justified because of the prevention of any harm to customers, would mean that access to EHRs should not be permitted due to other less obvious or indirect consequences. Furthermore, these arguments would be applicable not only to pharmacy access but also EHR access for other healthcare professionals. Firstly, it may be argued that if pharmacists accessed EHRs then customers qua patients may be less likely to seek medical assistance from their doctors. Of concern is that if EHR access were allowed, then patients would be less likely to disclose personal information about themselves to doctors or other relevant medical staff if they thought that such personal information would then be available to others to view, especially if this were of an embarrassing or sensitive nature. The obvious potential consequence of this scenario is that the overall happiness, welfare or well-being of patients would be reduced since medical help would not be sought and illnesses might remain untreated or diagnoses delayed. Despite this appearing to mean that NHS costs could be saved, as medical staff would not be consulted and so supporting pharmacy access, cost burdens upon the NHS may still occur in situations

where, for example, potentially serious conditions are not be detected earlier and lead to potentially more serious and costly complications in treatment later – a similar argument to that used to support primary prevention measures in medicine. Secondly, however, and paradoxically given the consequence just advanced, patients may in fact be more likely to visit their doctor than purchase an OTC medicine if pharmacists were allowed EHR access. This may occur since only by actually visiting a pharmacy to buy an OTC medicine would a patient’s EHR be accessed so by not using the pharmacy and using other medical staff such as a doctor instead, patients would avoid such access occurring. An obvious consequence if patients go instead to NHS sources of treatment rather than a pharmacist is that there may be a resultant increase in the financial burdens upon the NHS and its staff. A utilitarian calculation of this sort could be potentially wide-ranging and even mean that, indirectly, others may suffer too as recourses are unavailable for others. According to these arguments then, restrictions upon who has access to EHRs should be made in order that patients retain trust in their doctors not to routinely disclose information to others so that treatment can be sought and also so that purchases of OTC medicines can be made without fear of access occurring. Applied to pharmacy, this would support non-access since routine pharmacist access to EHRs may tend to undermine the patient’s trust in their doctor or the patient’s propensity to present and hence obtain treatment for medical conditions. Of course, as noted in the introduction, two forms of EHR are envisaged in the UK – a summary and a detailed care record and the above concerns may be considered more applicable to the latter record, which would contain much more detailed and potentially sensitive data. Arguments from analogy In addition to these consequentialist arguments relating to overall happiness or welfare, it may be argued that there are already situations where disclosure of individuals’ information occurs. Such ethical reasoning is referred to as arguing by analogy and would involve considering similar practices and by comparing them with pharmacist access to EHR and OTC sales, reveal an inconsistency in practice. Hence, identify a current practice analogous to accessing EHRs that is allowed and socially accepted, may strengthen the case for the proposed use of EHRs in OTC sales. Although arguing by analogy may be problematic since it relies upon comparisons (which may not be exact) rather than an intrinsic concern for a given practice, it represents a valuable form of ethical argumentation. In this section, it is argued that there are several analogous practices currently accepted in society and more specifically in healthcare, which may support pharmacy access to EHRs. These involve the increasing prevalence of loyalty cards and the collection of customers’ purchasing data and habits, credit checks, existing pharmacy checks and medical record access in hospitals and these are considered in turn. Sharing a similarity to OTC medicines is the analogy of loyalty cards used increasingly by retail businesses to reward customers when purchasing goods. However, in addition to these loyalty schemes involving rewards, the collection and use of information regarding that customer is also integral to their use. By recording the type of purchases made, loyalty cards amass important data relating to consumer spending patterns, which may have additional benefits for companies in terms of strategic marketing, advertising and product range. This analogy occurs in the

Ethical issues in the use of EHRs

13

JICES 5,1

14

commercial sector, like OTC medicine sales, and appears to be an increasingly accepted practice when purchasing goods and its similarity raises the question as to why, if customers are happy to have their purchases recorded and kept on record to be accessed by other parties, should records such as EHRs not be used in sales of medicines? Two problems with this analogy are that the type of data held is dissimilar and it would be unfair to compare consumer product purchases with sensitive health and medication data and the fact that such loyalty card schemes are voluntary. An analogy that may be more fitting also occurs within the commercial sector and involves applications for credit, where customers appear to accept that a check will be made by the lender in relation to the credit worthiness of that customer. This information is available in the form of credit records held by companies such as Experian, Callcredit or Equifax in the UK, who also make overall calculations of credit ratings that influence consumer’s ability to obtain credit. These checks are made routinely and it is not possible for the customer to prevent such checks other than to simply not apply for credit. Information stored in such records ranges from whether they are home owners or renting, for example, to much more sensitive data such as previous loan defaults, county court judgments, bankruptcy and whether they have been refused credit. This practice appears to bear much more similarity to OTC medicines sales and EHR access since the use of a credit check is not optional and the data held could be argued to be sensitive, albeit dissimilar to that held on an EHR. To the claim that there is something intrinsically more personal and sensitive about one’s health and medication records, it may be countered that data about convictions, debts and prosecutions are similarly sensitive and that these are also combined into a credit rating that may be embarrassing if not high enough to ensure an successful application for credit. It may be possible to argue that the nature of the transaction itself is not analogous and that applications for credit are manifestly different from OTC purchases. Similarities exist in that they are both common commercial transactions with societal worth. It may be easier to frame the analogy, then, in terms of whether customers would be prepared to allow credit checks but not EHR checks because of the greater value or social worth of credit as compared to medicine. Another group of analogies relate directly to pharmacy and involve comparisons with present practices that involve access to, or requests for, data. Such analogies contribute to the claim that pharmacists may be increasingly considered to be “agents of surveillance” (Harding and Taylor, 2002). Firstly, there is a requirement in England that pharmacy staff ask those NHS patients claiming certain forms of state benefit and exemption from prescription fees for evidence of such exemption. Although patients can still obtain prescription medicines without providing evidence, the absence of supporting evidence must be noted by pharmacy staff on the prescription. However, this is not an all or nothing scenario in the way that credit checks operate since the patient who does not provide evidence of exemption may still receive their medication – the only effect of such non-disclosure is that a mark is made on the prescription and the patient may be subsequently asked to provide evidence or pay a fine. Hence, despite this analogy occurring in the community pharmacy setting and involving certain the potential disclosure of personal information, such checks are not mandatory and so would not analogously support pharmacy access to EHRs for medicine sales. One further analogy that is presently used in community pharmacy is the accessing of a patient’s medication data, which is recorded routinely when dispensing prescriptions in

the form of a patient medication record (PMR). PMRs have been used within pharmacies for many years and although they do not represent a complete record of medication and usually nothing of a patient’s medical history, they are used, and indeed are recommended, in some OTC sales. For example, the recent deregulation of simvastatin prompted the RPSGB (2004) to advise that accessing a PMR would be advisable. Empirical research also suggests that pharmacists may use such PMR data without the consent of customers and computer software has been developed to link OTC sales to PMR records (Cooper, 2007). It may be argued that if such practices currently occur and are even suggested as good practice for some OTC sales, then the use of more comprehensive and accurate records such as EHRs would be justified. One final analogy that involves pharmacists directly, although not in the community setting, concerns patients in hospital and the routine accessing of their records by a number of healthcare practitioners, including pharmacists. The extent of such access is illustrated by Seigler (1991, p. 1518), who calculated that, for one of his patients in a routine hospital visit in America: . . . at least 25 and possibly as many as 100 health professionals and administrative personnel at our university hospital had access to the patient’s records and that all of them had a legitimate needs, indeed a professional responsibility, to open and use that chart.

Seigler’s example illustrates the range of health professionals who may be routinely and, in his view, justifiably involved in patient care. In terms of an analogy, could the sale of an OTC medicine be compared to the treatment of a patient in hospital? It may be argued that in both the hospital and the community, it is the welfare of the patient or customer than concerns the pharmacist and one would not normally expect the hospital pharmacist to rely, like community pharmacists often have to, an individual’s testimony of their medication and medical history. Dissimilarities are obvious in that the patient admitted to hospital may require more acute or specialized care or there may be an urgent need to treat and the concept of self-care and expert medicine users is hard to extend to that of the hospital setting. Despite these concerns, the analogy appeals and may support the use of EHRs in medicine sales. Privacy and confidentiality The third area of ethical argument in relation to pharmacists’ access to EHRs for OTC sales concerns the claim that customers qua patients should be entitled to privacy with respect to their medical data and hence be able to control whether information about them is accessible to others and for what purpose? These concerns are not unique to this paper’s focus upon pharmacy access and the Department of Health in the UK, for example, has recently conceded that patients may be able to opt out of parts of the proposed EHR or permitting patients to allow access to only certain parts of a record or when an emergency medical situation arises (Care Record Development Board, 2006). At the heart of many such public concerns is the claim that patients should have privacy and confidentiality with respect to data about their health and medicines. Despite being sometimes confused or used interchangeably, the concepts of privacy and confidentiality have ethical significance and, if sustained, would support claims by the patient not to allow pharmacy access to EHRs for medicine sales. Despite its everyday usage, the concept of privacy is rather hard to define for the purposes of ethical or even legal analysis. In legal terms, there has been considerable reluctance to

Ethical issues in the use of EHRs

15

JICES 5,1

16

legislate in relation to privacy, possibly due the perceived primacy of liberty more generally. However, legislation in the form of the Human Rights Act 1998 now establishes several protective rights to privacy in the UK, and Article 8 in particular – the right to respect for privacy and family life – states that “everyone has the right to respect for his private and family life, his home and his correspondence” and this prohibits interference except in the interests of: . . . public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.

As well as its legal status, privacy may be seen in ethical terms as a possible manifestation of the broader concept of autonomy and, as such, represents a practical aspect of a freedom from interference. Of course, this argument is not new and it is beyond the scope of this paper to rehearse the varied points relating to privacy in relation to wider social concerns but it may be generally remarked that some limitations in relation to privacy are usually accepted in society, arguably for the overall benefit of that society, just as are found in the drafting of the above Human Rights Act. For example, as noted in the previous section, we allow relaxations in privacy with respect to credit card checks and medical examinations upon hospital admission. Hence, although privacy has become an increasingly important value in society – a concern perhaps not unrelated to the increasing use of IT in many areas of individuals’ lives – it may be challenged by broader, often consequentialist concerns, that consider the health and welfare of not only individuals but also society more generally. If privacy can be seen to be an important principle but one for which derogations are available for public safety or the protection of health, can the principle of confidentiality be used in relation to pharmacy access to EHRs? Confidentiality is argued to arise as an ethical concern in two ways: firstly, by imposing a duty upon pharmacists accessing an EHR to not disclose patient data and, secondly, whether information specifically obtained in an OTC medicine sale is confidential and whether this should be written to an EHR. Regarding the first point, maintaining confidentiality is recognized as a central responsibility for pharmacists in relation to them developing new roles and the American Society of Health-System Pharmacists (1999, p. 163), for example, notes that: . . . with access to the patient’s health record comes the pharmacist’s professional responsibility to safeguard the patient’s rights to privacy and confidentiality. Within health systems, all authorized practitioners should be encouraged to communicate freely with each other but to maintain patient confidentiality and privacy.

Despite such statements, the public remain concerned about confidentiality breaches (Porteous et al., 2003) and the community setting may be problematic, despite the increasing use of private consultation rooms, for example, and the introduction of personal NHS cards to allow only authorized pharmacy staff to access computers. The second confidentiality concern involves a feature of EHRs not considered so far, namely whether pharmacists could not only access EHRs but also write data to them, too. Considered in this way, confidentiality becomes an issue not in terms of the data held already on the record necessarily (although this is still a concern) but in terms of whether information from OTC medicine sales should be written to an EHR and

potentially made available to other healthcare professionals. In clinical terms, this may be advantageous in situations where medicine misuse was suspected and would allow a record to be kept of how often a customer was purchasing a product and also in situations where compliance is a concern such as the recent reclassification of simvastatin, for example. Considered ethically, this may be justified due to a Consequentialist calculation of overall welfare and prevention of harm but would require the consent of customers for records of OTC sales to be made which may be problematic, according to some empirical findings. The majority of patients in one study, for example, did not want OTC medicine use information passed back to their doctor and 29 percent wanted no pharmacy information at all to be available to their doctor (Porteous et al., 2003). It may be argued, however, that the recording of OTC medicine sales and their potential accessing by others is analogous to the recording of spending patterns previously identified in the use of loyalty card schemes. Again, the question of EHR use in OTC sales may involve a societal consideration of the value of medicines compared to not only other healthcare practices but also other societal goods such as material consumer goods. Conclusions IT developments in patients’ medical records have been argued in this paper to raise a number of ethical concerns in the context of their potential application to areas of healthcare than are often overlooked in the literature. Hopefully, this paper represents an attempt to consider not only relevant empirical research which has identified customers’ concerns about EHRs but also a number of ethical and practical issues which have been argued to be important in considering if and how IT can be used in this area of healthcare. Although there has been a tendency to view IT in a technologically deterministic way, as always being beneficial to healthcare and even with an associated political agenda (Timmermans and Berg, 2003), focusing upon possible ethical issues reveals a number of different concerns that may have an influence upon customer and patient welfare. However, it may be that, despite the ethical arguments advanced in this paper, recognizing customers as increasingly expert users of medicines coupled with public concerns about confidentiality and privacy and pharmacists as agents of surveillance, will prove more persuasive. References American Society of Health-System Pharmacists (1999), “ASHP statement on the confidentiality of patient health care information”, American Journal of Health-System Pharm, Vol. 56, p. 1664. Anon (1989), “NPA Launches Training with W-WHAM”, Pharmaceutical Journal, Vol. 243, p. 40. BMA (2005), Over-the-Counter Medication, BMA, London. Bond, C. (2001), “POM to P – implications for practice pharmacists”, Primary Care Pharmacy, Vol. 2, pp. 5-7. Care Record Development Board (2006), NHS Care Record Guarantee, available at: www. connectingforhealth.nhs.uk/news/crdb_guarantee? (accessed January 21, 2007). Cooper, R.J. (2007), “Ethical problems and their resolution amongst UK community pharmacies: a qualitative study”, Unpublished PhD thesis, University of Nottingham, Nottingham.

Ethical issues in the use of EHRs

17

JICES 5,1

18

Cooper, R.J., Bissell, P. and Wingfield, J. (2006), “Dilemmas in dispensing, problems in practice? Ethical issues and law in UK community pharmacy”, Clinical Ethics, Vol. 2 No. 2, pp. 103-8. Department of Health (2002), Delivering 21st Century IT Support for the NHS National Specification for Integrated Care Records Service Consultation Draft, Department of Health, London, p. 18. Department of Health (2003), A Vision for Pharmacy in the New NHS, Department of Health, London. Dingwall, R. and Wilson, E. (1995), “Is pharmacy really an incomplete profession?”, Perspectives on Social Problems, Vol. 7, pp. 111-28. Harding, G. and Taylor, K. (2002), “Social dimensions of pharmacy: (2) power, status and pharmacy”, Pharmaceutical Journal, Vol. 269, pp. 440-2. Hibbert, D., Bissell, P. and Ward, P. (2002), “Consumerism and professional work in community pharmacy”, Sociology of Health and Illness, Vol. 24 No. 1, pp. 46-65. Hughes, G.F., McElnay, J.C., Hughes, C.M. and McKenna, P. (1999), “Abuse/misuse of non-prescription drugs”, Pharmacy World and Science, Vol. 21, pp. 251-5. Li Wan Po, A. and Li Wan Po, A. (1997), Non-Prescription Drugs, Blackwell, Oxford. Morris, C.J., Cantrill, J.A. and Weiss, M.C. (1997), “One simple question should be enough: consumers’ perceptions of pharmacy protocols”, International Journal of Pharmacy Practice, Vol. 5, pp. 64-71. Pates, R., McBride, A., Li, S. and Ramadan, R. (2002), “Misuse of over-the-counter medicines: a survey of community pharmacists in a South Wales health authority”, Pharmaceutical Journal, Vol. 268, pp. 179-82. Porteous, T., Bond, C., Robertson, R., Hannaford, P. and Reiter, E. (2003), “Electronic transfer of prescription-related information: comparing views of patients, general practitioners, and pharmacists”, British Journal of General Practice, Vol. 53, pp. 204-9. The Proprietary Association of Great Britain (2006), IRI 2005 OTC Market Size Statistics, available at: www.pagb.co.uk (accessed January 21, 2007). RPSGB (2004), Practice Guidance on: Sale of Over-the-Counter Simvastatin, Royal Pharmaceutical Society of Great Britain, London. RPSGB (2006), Medicines, Ethics and Practice: A Guide for Pharmacists, 30th ed., Royal Pharmaceutical Society of Great Britain, London. Seigler, M. (1991), “Confidentiality in medicine: a decrepit concept”, New England Journal of Medicine, Vol. 307 No. 24, pp. 1518-21. Timmermans, S. and Berg, M. (2003), “The practice of medical technology”, Sociology of Health and Illness, Vol. 25, pp. 97-114. Watson, M.C., Bond, C.M., Johnston, M. and Mearns, K. (2006), “Using human error theory to explore the supply of non-prescription medicines from community pharmacies”, Quality & Safety in Health Care, Vol. 15, pp. 244-50. .

Further reading Anon (2003), The Public View on Electronic Health Records, Health Which? Ltd, Hertford. National Audit Office (2006), Department of Health, The National Programme for IT in the NHS, National Audit Office, London. RPSGB (2000), Prescription only Medicines Reclassified to Pharmacy only Medicines, Royal Pharmaceutical Society of Great Britain, London.

Watson, M., Hart, J., Bond, C. and Johnson, M. (2005), “Is the supply of non-prescription medicines from community pharmacies guideline compliant?”, International Journal of Pharmacy Practice, Vol. 13, p. R65, (supp). Watson, M.C., Bond, C.M., Grimshaw, J.M. and Johnston, M. (2006), “Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting”, Quality and Safety in Healthcare, Vol. 15, pp. 53-7.

Ethical issues in the use of EHRs

19 Corresponding author Richard Cooper can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-996X.htm

JICES 5,1

20

A phenomenological perspective on clinical communication and interaction The case of electronic health records Lars Botin Aalborg University, Aalborg, Denmark Abstract Purpose – The purpose of this paper is to investigate how people communicate in organisations. Design/methodology/approach – The approach in doing this is based on two pillars. One being a philosophical phenomenological approach dealing mainly ethical questions concerning communication and interaction in designing and implementing electronic health records (EHR). The other is videoobservation of work procedures in hospitals because appropriate for unveiling tacit knowledge in an organisation. Findings – The paper discusses the inappropriate design and implementation of actual EHR’s in the Danish hospital system. Where the technology is based on hierarchical and economic structured managerialist thinking and doing, that eliminates the everyday knowledge of nursing staff and the patient. Originality/value – The value of this paper that it lays forward the inappropriate paradigmatic thinking of hospital systems concerning communication and interaction in designing and implementing EHRs. Keywords Communication, Phenomenology, Ethics, Customer records, Hospitals, Denmark Paper type Research paper

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 pp. 20-32 q Emerald Group Publishing Limited 1477-996X DOI 10.1108/14779960710822665

Introduction As scientists we observe the world in order to gain knowledge concerning a particular field of investigation. This knowledge has to be sufficiently communicable for scientific validation; and then applied in a more pragmatic and ethical way, for the common good. This process of observation can be conducted in a variety of ways. The involvement and entanglement of the observer in the process varies as we choose different mental “lenses” through which we observe the world. I follow the approach of Latour (1999) and others that total objectivity is impossible in modern science, since the empirical and natural world is in itself affected by purposes and values of people who interact with it, hence eliminating the concept of pure objectivity. Each field of observation is constructed by human beings who interact with other human subjects and with technologies, all of which have an impact on the choice of lens. This applies to the activity of creating new knowledge in the field of clinical interaction and communication in the health care system. In this paper, I focus on the development and implementation of electronic health records (EHR) in the Danish healthcare system. To help sharpen the focus on the problem, the paper first addresses the significance of choosing to study clinical communication and interaction. Secondly, the method used for observation, grounded in ethnography and phenomenological philosophy and methodology will be described. Thirdly the particular observations are described.

Fourthly, the knowledge gained from these observations, linked to a specific context bounded by particular time, space, culture and society is described. Knowledge is situated and discursive and this is a key principle adopted in drawing conclusions from the observations. The fifth and final section of the paper will explore implications for problem solving and design-engineering based on both the ontology and methodology of the study, both of them being inter-related. The study lies in the field of praxis. Its major concern is to produce practical knowledge, which can help the engineer/designer/developer in producing meaningful and pragmatic technology concerning clinical interaction and communication, rather than with theoretical science. The significance of clinical interaction and communication within a phenomenological approach Since, human beings are “intentional” beings (either as intentional subjects or objects of other peoples intentions), communication performed both subject to subject, subject-to-object and object to object needs to be considered. Interaction and communication takes place at the level of personhood that reaches beyond individuals conceived of as physical systems of flesh and blood. This suggests the need for a multi-perspective understanding of particular human and organisational contexts and for the generation of knowledge that goes beyond the traditional understanding of interaction and communication in organizations, frequently grounded in positivist organizational theory. Such an approach was characterised by Hutchison (1938) in the field of economics: It’s a program that begins with facts rather than assumptions. Those facts should be obtained by statistical investigations, questionnaires to consumers and entrepreneurs, the investigation of family budgets and the like. This is the only scientific method open to the economist.

The procedures of interaction and communication within an organization dominated by a positivist ontology are typically described through the precise articulation of rules and regulations explicated in manuals or working-procedures for various categories of staff. The construction of these prescriptions is hierarchical from senior management down, to minor actors in the hierarchy: secretaries and clerks of the medical and nursing staff in our field of investigation. Information and orders are passed upwards and downwards in the system, and conduct is defined and prescribed within a technical and mechanical rationality that makes it possible for the management to measure productivity, by the means of statistical investigation and questionnaires. Rather than adopt a positivist approach, this paper adopts a different approach which rejects a strict separation between a human actor and the circumstances of the actor’s activity is adopted here. Instead of strict separation between the subject and external world that Descartes emphasised, I adopt an approach which recognises the instrinscally “engaged” character of human action, an approach characterised by the concept of Lebenswelt or “lifeworld” that phenomenological philosophy introduced. The concept draws on the manner in which people always find themselves “thrown” into a particular circumstance in life (the thrownness that Heidegger described in Being and Time) rather than first discovering an “I” which is distinct from any circumstance.

Clinical communication

21

JICES 5,1

22

In this paper, I shall refer to this concept of lebenswelt as “Lifeworld”. Lifeworld escapes the somewhat tyrannical rationality of managerialist and positivist thinking and action. Attempts to understand organisational life within a positivist approach have truncated the very qualitative core of the lifeworld as quantitative criteria have been introduced in support of a positivist systemic paradigm: Through the image of fully institutionalized modern medicine, hospitals, banks of life-support equipment, the inscrutable terminology, the rigid regime and hierarchy, one’s own body rendered alien, regulated, labeled, categorized, rearranged, manipulated, scrutinized and dissected, we experience the powerful and pervasive idea of the subject as a defenseless matter becoming integrated into a wider frame of reference in which the institutional and organizational aspects of medicine . . . focus their conspiratorial attention upon it (Boss, 1986).

Interaction and communication have been regarded as quantifiable indicators by which we might optimize technical support systems. The methods adopted for this have drawn on assumptions from natural science and Cartesian separation of actor and circumstance. This means that measurements have been made which depend on accounts of the world which represent the world and its contents (including human beings) as detached objects without a will or purpose of their own. This appears to give a sound and solid basis for decision-making within a systemically positivist world, where everything has to be put in diagrams and numbers. But it leaves out major parts of the richness of interaction and communication that actually takes place amongst individuals and artefacts in the real world. So the question arises: what should be done to complement the relevant knowledge already at hand concerning people in interaction and communication in the medical and clinical world of the health care system? First of all, we should emphasise the aspect of care. Care lies at the heart of human interaction and communication and it cannot be comprehended in a mode which separates the human actor from the circumstances of caring activity and concern. It cannot therefore be measured within a positivistic systemic approach. Within the lifeworld approach, the relationship of mind and body is seen as a whole, as understood in the ontology of Spinoza, explained by Deleuze (1990). This means that subjectivity and ethics are both at stake from the very beginning. The key question is how can we, not just describe, in a positivistic sense, subjectivity, but how can we derive, with a transparent methodology, the basis for tools which support ethical conduct in an organization, producing practical knowledge that can be used by that very same organization? In the lifeworld approach, everything depends upon the optics and tools used. Instead of using theories and methods from the positivist systems paradigm, interaction and communication is understood from a phenomenological perspective. This relates to the very core of care, interaction and communication. In the lifeworld approach, knowledge concerning theories and concepts will not be enhanced, but our knowledge and understanding of the world inhabited by the people who practise care in the health care sector will be improved. Practical applications will be understood which will help them. The emphasis is on praxis and takes account of unspoken features. It allows tacit knowledge to be unveiled and enriches our understanding of what happens in organisations such as healthcare systems. The aim is, by observation,

to understand the full meaning of the inhabitants’ lifeworld of clinical interaction and communication in the health care system. Communication and interaction take place beyond words, hence defying the preferred and situated way of communicating and interacting within the health care service as understood in the positivistic paradigm. At the upper level of the health care hierarchy we notice how administration and medical staff communicate upwards and downwards through words and terms which are strictly related to the paradigmatic hierarchical system. The administration communicates in a bureaucratic and management-oriented language. Doctors communicate in an international terminology influenced by archaic latin. This validates a general model of healthcare as the eradication of disease through the identification of symptoms. A diagnosis is generated which makes it possible to produce a prognosis for the predictable course of the disease. The language and communication is highly reductive and relates to positivistic thinking and acting within the system: . . . [T]he increased clinical emphasis on the objective components of disease, which are thereby separated from what the patient subjectively feels and perceives, leads to a problem of explanation in the long run. The gap between the population’s perception of disease and the doctor’s perception of disease widens, thus making the conditions for communication more difficult (Gannik, 2000).

This may in the end lead to harmful results, because the patient is represented in a system where actions are standardized according to practice of diagnosis and prognosis. It is not the purpose of this paper to investigate such risks, but simply to observe that system-development in EHR based on the “natural history of disease” may threaten the success of what is being sought: . . . [H]health institutions are largely dominated by the biomedical sciences, constituting a biomedical conception of health and disease, forms of treatment, etc. These conceptions are founded on models of explanation and proof, almost exclusively derived from a positivist philosophy of science (Damkjær, 2000).

Figure 1 shows how communication and interaction within a health care organization took place at the time of the study. The management, organisational and bureaucratic language at the upper level, contaminated by acronyms and abbreviation, make the language and communication incomprehensible to the other actors in the field. This means that the healthcare providers are more “knowing” than the actors (patients and nurses perhaps) at a lower level in the hierarchy. The transfer of data, from one box to another is increasingly made through intermediaries who are more aware of the actual meaning of the message than the receiver. All actors in the field are to some extent familiar with one common tool – language – but the specific vocabulary is limited hierarchically. In the development of digital communication through computational devices –the software and hardware are accessible to only a few actors in the field. Shutters and barriers are evermore governing the direction of electronic systems for reasons that may be thought beneficial, i.e. in order to protect the patient’s confidentiality perhaps. But the result is that communication and interaction is restricted and power is placed in a few hands following a prescribed hierarchy. There are widespread attempts to replace paper records by EHR. Paper records can be chaotic and can be manipulated at all levels, but there is transparency. It can, in

Clinical communication

23

JICES 5,1

24

Adminstration communicating and visualising through economic language and models (positivist)

Doctors communicating and visualising through terminology concerning diagnosis and prognosis. (positivist)

Clerks and secretaries communicating through praxis and everyday language. (phenomenological)

Figure 1. Boxes of professions and how communication apparently is performed

Nurses communicating and visualising through both clinical terminology and everyday language (positivist/phenomenological)

Patients and relatives communicating and visualising through subjective perceptions and feelings. (phenomenological)

principle, be accessed by even the lowest actor in the health care system. In contrast, the architecture of the new electronic patient record is hierarchically designed, which means that information is restricted as it gets more confidential, not necessarily to the benefit of the patient. This means that the EHR is turning into a black-box comparable to the way we produce engines for automobiles today. Once a mechanic was able to repair/interact with an engine with a wide repertoire of possible decisions. He could even put non-authorized items in the engineer to make it function. Today the auto-mechanic orders authorized spare parts from the company and is increasingly less knowledgeable about the overall user function of the engine and its total construction. One might fear that the same evolution will take place with EHR records if they are constructed with actors increasingly left out of the design of the system and power is in the hand of administrations and system-developers. Communication and interaction is restricted in bureaucratically ordered organisations such as health care systems because of their very hierarchical construction. As shown in Figure 1, communication within boxes is easily overlooked because the everyday routines and events of lifeworld are not taken into consideration by system-developers and decision-makers who focus on dramatic changes in the box (believing perhaps they are acting innovatively and dynamically). The assumptions of Henry Ford’s factory system and of F W Taylor’s scientific management are embedded in the dynamics of thinking and acting, as systems are developed (Hounshell, 1984). Meaningful and caring activities by all staff in the system are threatened by the lack of transparency and the hiding of possibilities of interacting with systems. None of this is to adopt the assumptions of technological determinism – the notion that we are powerless before the inexorable “progress” of technology as predicted by positivistic models. But participatively designed, socio-technical systems that take into

account the “real world” communication of caring people, doctors, nurses, clerks, patient and relatives need to figure more strongly in design agendas. The investigation made at various wards in Danish hospitals had this specific aim from the outset. The particular study from which conclusions are drawn sought to document and register how communication and interaction was getting evermore “directed” in a top/bottom direction as new technology was suggested (in this case a trial EHR). The project sought to document the abundance of practical knowledge held by decision-makers and professionals that could too easily be destroyed by the new technology. Communication and interaction regarding the boxes of various professions communication (Figure 1) is difficult, if not impossible. There is an ontological gap between those in the upper part of the diagram and those below that arises from different rationales for decision-making and different priorities for action. The extent of these differences are such as to generate a different character for the activities pursued by both: hence a difference in ontology. The arrows, representing actual communication and interaction, are pointing in all directions and show communication taking place in abundant routes. But several break-downs take place in the communication and there is little real mutual understanding of reality in the system (Gadamer, 1960). It is a one-way communication. Secretaries and clerks react to the demands of patients, nurses, doctors and administration, as does the patients. Nurses and doctors interact and enter into dialogue although it is the doctor that has the decisive word. So the self-understanding of the lifeworlds inhabited by different actors is made clear. Communication and interaction is made evident and a model is generated to enable developers of EHR to take this into account. If we look at the development in Denmark concerning the construction of EHR, innumerable conferences and meetings have been held, but secretaries and clerks have never been considered as actors in the system and treated as important to the design of a new future organisation which is matched socio-technically to a new EHR system. The IT administrator of the healthcare system of the county of Copenhagen stated in 2005 that secretaries would become redundant in the future and hence disappear from the organization (Christoffersen, 2005). This might mean that patients would lose one of the most important group of interlocutors in the system and be left with nurses alone who are pressed by the system to communicate evermore in a biomedical and scientific language. This approach to technology is in many ways dependent on how technology was developed in the nineteenth and twentieth century, and does not take into consideration the new concept of technology as it was defined by Bijker et al. (1987), and described by Hoogenhuis and Koelega (2001): Technology is not seen anymore as simply an individual tool or machine or a specific way (or technique) of manipulating things and people. The new “definition” of technology is that it is an interconnected body of (scientific) knowledge, skills, instruments (hardware and software), products, organisational methods and structures in research, production, marketing, and use, and of the values that are expressed in all these parts. These studies show that almost everyone is involved in processes of developing, implementing and revising technology, be it in their role as a scientist, engineer, or businessman or as consumer, politician, voter, trade unionist, member of an environmental group et cetera. Technological development is a collective activity and the borders between technology and its context has become permeable.

Clinical communication

25

JICES 5,1

26

The self-understanding of the health care system, relying on Cartesian theoretical knowledge, implied in the construction of systems designed from a positivist standpoint, leads to the disjunction of patient and citizen. But is the self-understanding of people’s lifeworlds reflected in the accounts given in reports based on statistical knowledge, questionnaires and interviews? Or is it if that another investigative tool is needed to reveal that the such reports can be systematically misleading, relying on criteria of truth which might be coherent and consistent, but do not correspond with the lifeworlds articulated by actors. One might say that the system is coherent and consistent like the universe Tolkien portrayed in the The Lord of the Rings – but there is no place for ordinary human beings in the shire. Such misdrawn systems reflect the “modernist narrative of progress” (Latour, 1999) where efficiency is closely related to objectivity and things are increasingly more and more scientifically correct for utility, but the subjectivities, values and feelings of people’s lifeworlds, becomes evermore distant and irrelevant in any discussion concerning the relationship between technology and humans (Latour, 1999). One way of looking at reality in order to reflect people’s lifeworlds is to use the mobile video-camera into detect practical and tacit knowledge layered in everyday life practice and bodily communication and interaction, hence lifeworld. The approach draws on the phenomenological perspective of the unfinished work of the French philosopher Maurice Merleau-Ponty. The method Observation is, in the western world, mainly based on what we see. Technologies are and have been, since the invention of the camera obscura in the Italian Renaissance, developed in order to enhance our visual perception, to the exclusion of other senses. The digital video-camera is in one sense just another tool that relates to the hegemony of the eye, although sound is present in the recording. Observation with the video reflects, paradoxically, the positivist way of dealing with knowledge and science. But as long as this is taken into considerations in the analysis of what is recorded, emphasis can be given to body language, emotion and the unveiling of tacit knowledge, thereby taking into account the lifeworld in the final conclusions. In mobile video observation, participating subjects are part of the investigator/investigated relationship in a particular time and space. This has an impact on the investigated field. Methodologically, it means there is a difference between the stationary video observation and the traditional written questionnaires. But there are also certain affinities to the interview as an investigative tool. There is a constant negotiation between the investigator and the field. This negotiation is both situated and reflective involving the empirical data, the interpreter and those interviewed (Kvale, 1996). It is also important to understand that the technical device is an extension, expansion and enhancement of the body, bringing forth properties and qualities inherent in the human body (McLuhan, 1964). Within the phenomenological approach the body possesses the capability of “prelogical synthesis” acting meaningfully and reasonably in any situation and position without any formal reasoning process. And as the US philosopher of technology states: “Technics is the symbiosis of artefact and user within human action” (Ihde, 1990). Referring to the well-known picture by Heidegger (1977):

In driving a nail with a hammer (as opposed to thinking of a hammer), I need not make use of an explicit representation of a hammer. My ability to act comes from my familiarity with hammering, not my knowledge of the hammer.

Clinical communication

In questionnaires and interviews, we are recalling and remembering situations and things, which means we are “thinking of the hammer” and analysing in an empirical analytical way. The method of observation is entangled with the world and seeks to reveal this very same aspect of entanglement in the investigated world. The risk is that many blind spots will occur and the unseen and the unheard may remain secret to the observer. But as Martin Heidegger writes in Holzwege (1950):

27

Wood is an old name for forest. In the wood are paths that mostly wind along until they end quite suddenly in an impenetrable thicket. They are called ”woodpaths.” Each goes its peculiar way, but in the same forest. Often it seems as though one were identical to another. Yet it only seems so. Woodcutters and foresters are familiar with these paths. They know what it means to be on a woodpath (Heidegger, 1993).

This means that as we proceed in the world we are constantly on woodpaths, which are not dead ends, but unpredictable and out of mechanical control. We are forced to enter into unknown territory and to retrace our steps in order to understand the meaning. If we, like the woodcutter, are familiar with the path, we will know by intentions and experience how to act properly on that path. The observations Observations of clinical interaction and communication have been made over two years. They were made by a group of researchers from Aalborg University (DK), at various wards, out-patient departments and offices in the Danish health care system. The first set of observations focused on a ward-round at a geriatric ward in the County of Copenhagen and a diabetic ward at a hospital in the County of Aarhus. The second set focused on secretaries and clerks at hospitals in the County of Aarhus and the County of North Jutland. A third set concerned the employment of telemedicine in the County of North Jutland with a focus on the interaction and communication between patient and caretakers through technological devices. Video observations were mainly made by two or three observers who all carried and operated a mobile video camera. The observers were dressed appropriately for the context, which in some cases meant wearing civil clothing and a white robe, like a Danish medical doctor. The video camera was carried on the body, leaving the operator free to act appropriate to the circumstances encountered. All the observations were made during the same period of time and following the same characters at different wards. Using two or three observers allowed multiple perspectives on situations to be articulated, hence defying one of the major blind spots of the technological device: The registration is flat, determined and two dimensional, whilst the personal observation is three dimensional and involves all our senses. The capacity of the human eye to focus and perspective is drastically reduced through the choices of the operator. The camera does not know of being and participation in the interaction, even though the entire video observation as a process involves participation to some degree. The camera does not capture important signals as smell, taste or temperature and the specific perspective impact (like a television) is a filter (Arendt Rasmussen, 1997, p. 64).

JICES 5,1

28

The multi-perspective approach was inspired by the analytical cubism as it was performed by Pablo Picasso and Georges Braque from 1908 to 1913, because an attempt to show the “real” and relativistic picture of existence, time and space. Some of the editing of the material was, for the same reason, performed as a context panorama, with four windows, showing the same figure or scene from different angles. Immediately after the registrations the observers would discuss what they had experienced during the registration. Post it notes were used to identify likely points of common understanding of a situation. This was a key principle in the first editing of the recording. The result of the editing was presented to the major figures in the dramas recorded, and a discussion would take place. The aim of the discussion was to achieve a mutual, rather than a unified picture of reality, reflecting a strong social constructivist content, deriving from hermeneutics and phenomenology. This would lead to yet another editing, where the mutual picture of reality would continue to emerge. The second result of the editing process would be presented to all the “actors”. The presentation was videotaped in order to get facial and bodily reactions of the actors as they relived the situation, this was made in order to complete the picture and capture the essence of the method. The registrations of the reactions were used as a tool in the final editing, and constitute the core of phenomenology in the method. Result of the observations concerning clinical communication and interaction The results of the observations allowed considerable reflection on the organisation’s self-understanding and have led to changes within the organisation. Clearly, a situated qualitative research done within a limited range of time cannot change the basic ontologies and epistemologies of a system. But the exposure of highly inadequate communication and interaction as revealed in two particular video-sequences concerning doctor, nurse and patient, led to reactions of embarrassment amongst the actors and the viewers. The first sequence described a ward-round where the doctor was sitting at the bedside of a patient and the nurse was standing at the foot of the bed. A paper medical record was lying on the bed in reach of both the doctor and the nurse and in physical contact with the patient. The paper record was only consulted two times during the consultation which lasted 15 minutes. The sequence clearly showed the doctor as extraordinarily empathetic with the patient. She often touched the patient’s hand or leg creating an atmosphere of intimacy and confidence. The second sequence shows the same doctor after the introduction of a trial EHR. The trial EHR had been running for several months, so staff were familiar with the tool. In this sequence, we see the doctor alongside the bed of another patient and she is concerned with the screen and the images on the screen. The nurse is looking over the shoulder of the doctor. During the session that runs for ten minutes the doctor talks to the patient in order to explain what she is doing with the interface (the virtual patient), but her body and eyes is firmly directed towards the screen. Phenomenology tells us that we constantly relate to world and reality through bodily directedness and although the doctor sits next to the patient and so is physically close to the “subject matter” her attention is directed towards the virtual patient and she is much closer to the perfect digital image of the virtual patient than on the imperfect and sick physical presentation on the bed. She has lost the emphatic touch and the lifeworld has been overruled by the perfect clinical world of the virtual. The intimacy and confidence

which is necessary as we deal with disease and suffering is lost. The conversation between the doctor and the nurse is made on the premises of the biomedical paradigm, and the patient is excluded. The example evokes the experiences of the Canadian philosopher and sociologist Frank, 1991, p. 838 as he fell ill and was treated in the Canadian health care system:

Clinical communication

Real diagnostic work takes place away from the patient; bedside is secondary to screen side. For diagnostic and even treatment purposes, the image on the screen becomes the “true” patient, of which the bedridden body is an imperfect replica, less worthy of attention. In the screen simulations our initial certainty of the real (the body) becomes lost in hyper-real images that are better than the real body.

29

The second set of observations of the medical secretaries and clerks includes a sequence that shows how the self-understanding of the organization can be “false”. A secretary is phoned by a chronic patient suffering from a gastro-enterological disease. He has a problem concerning medication. He is taking 100 milligram. instead of the prescribed 50 milligram. The reason why is that such a unit does not exist on the market and the pill splits into myriad parts when he tries to divide it. The secretary consults the record in order to affirm the story of the patient and subsequently calls for a doctor. She lays out the facts and the doctor asks if he should make a new prescription which takes into consideration the actual situation. The secretary says yes and says that she will phone the patient afterwards, because he has to have blood samples taken in order to find out if the new prescription is correct. All communication, interaction and decision-making are actually performed by the secretary, although we are dealing with a medical problem. This means that the view of the secretary as a mechanical and receiving “device” is false; she actually solves the problem for both the doctor and the patient. But the view and understanding of the secretary from the point of view of both administration, medical staff, nurses and herself, as can be deduced from positivistic accounts and interviews tells us that she is at the bottom of the system and can be replaced by a machine. In another sequence, a nurse is talking to a secretary about the handling of a newborn infant patient. The nurse cannot understand why the patient has to be examined in an out-patient department later next week, considering that the patient has recovered in the hospital. There is a suspicion of a dysfunction of the heart and the parents of the newborn patient, tell the nurse, they are worried. The secretary has the same opinion and as she knows the organisation and the procedures she takes up the phone immediately and talks to a secretary in the out-patient department. The newborn is moved from one list to another, and will be examined later the same day. No doctor was involved in the decision and the nurse was only consulted in order to affirm that the patient would be at the ward in order to be picked up. The findings of the investigation have had an impact on the organisation that controls and assess the development and implementation of EHR in Denmark. It has been decided to give more attention to the role of the secretary in the future health care organisation, because a lot of clinical interaction and communication passes through the “lower” part of the system. The system has to some extent become aware of the fact that the model of communication and interaction, which constitutes the framework for systemic development, is not covering adequately reality as it is manifested in everyday clinical communication and interaction. It is in between the boxes in the model that meaning and understanding is placed, which means that it is in

JICES 5,1

30

communication and interaction that reality is born and lives. The actual development of EHR systems in the western world risk failing to take this into account and as the technology “freezes” in the various systems, it is becoming evermore problematic. Perspectives and indications The study has shown that the self-understanding of the lifeworlds in the healthcare organisation and the alleged “objective” reality do not fit, with severe consequences for both staff and patients. One way of addressing this problem is to document and communicate the extent of the mismatch. The video observation has value in this respect because it is immediate and situated. The phenomenological video observation is a strong tool, because it is directed, empathetic and seeking authenticity in what it reveals. It enhances the nuanced richness of context and reality, whereas detached video observation does not take into account the way in interactivity and communication are key avenues of human and technological interactivity. The computer is used in a variety of ways: as mere typing machines, replacing a technology that it actually resembles, or as a mean for communication and interaction through mail and internet. It can be a tool for gaming in many ways replacing the analogous and physical world of plays and games. As we create models for communication and interaction in the clinical world, we are dealing with human beings and their lifeworlds. We are in a web of constant change and meaning/understanding is created dynamically as we move forward. The design of systems should be concerned with constructions of lifeworlds, hence taking into consideration how we interact, on a daily basis, with the actual technology. The indications for meaningful design shown by this study have been concerned with possibilities for communication and interaction between patients and medical/caring staff. These are currently becoming evermore restricted as systems are built in a manner which is “closing down” in their possibilities. The process is well described by Bijker et al. (1987) in The Social Construction of Technological Systems. The study also shows that communication and interaction within the professional order, i.e. clinical communication, takes place in another way than the actual system and the ongoing construction of EHR, tries to reflect. The organisation is not a hierarchical and systemic gestalt, with fixed laws and rules for communication and interaction. The methodological approach to the subject matter exposes this very aspect and the value of the investigative tool (video) is enhanced by the ontological foundations of the method. The study demonstrates the value of emphasising subjectivity and intentionality and need for design to be driven by human intentionality as it is revealed in reality, driven by intentions based on values and what Merleau-Ponty calls skhema (holdings). In doing this we are trying to emphasise ideas and values in order to engage in a dialogue. It might never turn into an objective given thing and as such legitimised, or becoming a fact, but we are willing and in place (Dasein, as Heigegger would have it), Berger and Luckmann, 1966). References Arendt Rasmussen, T. (1997), “Video mellem samtale og observationVideo mellem samtale og observation. (Video in between conversation and observation)”, in Alrø, H. and Dirkinck-Holmfeld, L. (Eds), Videoobservation, Aalborg University Press, Aalborg.

Berger, P.L. and Luckmann, T. (1966), The Social Construction of Reality, Anchor Books, Peterborough. Bijker, W., et al. (Eds) (1987), The Social Construction of Technological Systems, MIT Press, Cambridge, MA. Boss, P. (1986), “Vile bodies and bad medicine”, Screen, Vol. 27 No. 1, pp. 14-24. Christoffersen, S. (2005), “En af verdens mest avancerede patientjournaler. (‘One of the worlds most advanced patient records’)”, Indblik, Vol. 1. Damkjær, S. (2000), “Dimensions of the body”, in Gannik, D.E. and Launsø, L. (Eds), Knowledge and Society, Samfundslitteratur, Copenhagen. Deleuze, G. (1990), Expressionism in Philosophy: Spinoza, Zone, New York, NY. Frank, A.W. (1991), At the Will of the Body: Reflections on Illness, Houghton Mifflin, Boston, MA. Gadamer, H.G. (1960), Wahrheit und Methode, J.C.B. Mohr, Tu¨bingen. Gannik, D.E. (2000), “The social construction of diagnosis”, in Gannik, D.E. and Launsø, L. (Eds), Disease, Knowledge and Society, Samfundslitteratur, Copenhagen. Heidegger, M. (1977), The Question Concerning Technology, Harper & Row, New York, NY. Heidegger, M. (1993), Basic Writings, Harper and Collins, San Francisco, CA. Hoogenhuis, C.T. and Koelega, D.G.A. (2001), “Engineer’s tools for inclusive technological development”, in Goujon, P. and Dubreuil, B.H. (Eds), Technology and Ethics. A European Quest for Responsible Engineering, Peeters, Leuven. Hounshell, D. (1984), Form the American System to Mass Production, 1800-1932: The Development of Manufacturing Technology in the United States, Johns Hopkins University Press, Baltimore, MD. Hutchison, T.W. (1938), The Significance and Basic Postulates of Economic Theory, Augustus M. Kelley, New York, NY. Ihde, D. (1990), Technology and the Lifeworld, Indiana University Press, Bloomington, IN. Kvale, S. (1996), InterView. An Introduction to Qualitative Research Interviewing, Sage, London. Latour, B. (1999), Pandora’s Hope, Harvard University Press, Cambridge, MA. McLuhan, M. (1964), Understanding Media: The Extensions of Man, McGraw-Hill, New York, NY.

Further reading Dreyfus, H. and Dreyfus, S. (2000), Mind over Machine. The Power of Human Intuition and Expertise in the Era of the Computer, The Free Press, New York, NY. Frank, A.W. (1995), The Wounded Storyteller: Body, Illness and Ethics, Chicago University Press, Chicago, IL. Gannik, D.E. and Launsø, L. (Eds) (2000), Disease, Knowledge and Society, Samfundslitteratur, Copenhagen. Habermas, J. (1971), Knowledge and Human Interests, Hutchinson, London. Henriksen, L.B. et al. (2004), Dimensions of Change. Conceptualising Reality in Organisational Research, Copenhagen Business School Press, Copenhagen. Jonas, H. (1979), Das Prinzip Verantwortung, Insel Verlag, Frankfurt am Main. Lyotard, J.F. (1984), The Postmodern Condition: A Report on Knowledge, University of Minnesota Press, Minneapolis, MN. Merleau Ponty, M. (1994), The Phenomenology of Perception, Routledge, London.

Clinical communication

31

JICES 5,1

32

O’Brien, R. (2005), Bodies in Revolt. Gender, Disability, and a Workplace Ethic of Care, Routledge, New York, NY. Shusterman, R. (2000), “Somaaesthetics and the care of the self: the case of Foucault”, Monist, Vol. 83. Wittgenstein, L. (1983), Philosophical Investigations, Blackwell & Mott Ltd, Oxford. Corresponding author Lars Botin can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-996X.htm

Assessing students’ ethical development in computing with the defining issues test Challenges to be addressed

Assessing students’ ethical development 33

Suzy Jagger School of Business and Social Sciences, Roehampton University, London, UK, and

John Strain University of Surrey, Guildford, UK Abstract Purpose – The purpose of this research paper is to examine the early stages of a research project aimed at evaluating the pedagogic effectiveness of a teaching module in computing ethics. Design/methodology/approach – Scores of students’ cognitive capabilities to make moral judgements were measured before and after they had taken the module by means of the “Defining Issues Test” (DIT). This is a standard test of students’ capability to make moral judgement based on the work of Lawrence Kohlberg. Interviews were then used to help understand the results of the test. Findings – Results revealed low mean scores of post-conventional (P Score) thinking skills and wide variation in overall scores of capability for moral judgement. Interviews with the students about the course and the test revealed the importance of understanding students’ beliefs about the importance of ethics in interpreting the results. Research limitations/implications – Difficulties in matching “before and after” results for each subject limited the sample size in what was an early step in the overall research project. Practical implications – The results point towards the importance of addressing students’ own understanding of the importance of ethics when teaching computing ethics. Originality/value – The paper reveals some of the limitations of tests of capabilities for moral judgement which rely on strongly individualistic notions of ethics. It enables a new appreciation to be made of the strengths and weaknesses of assessing student moral development in higher education in terms of cognitive factors. Keywords Ethics, Computer studies, Students, Cognition Paper type Research paper

Introduction A number of attempts have been made to design assessment tools which measure the extent to which students at university acquire capabilities in ethical appreciation and reasoning; and hence acquire the capability to make decisions ethically. Many of these have been developed in the aftermath of Kohlberg’s (1984) seminal work in ethical development, building on the developmental approach to cognitive psychology of Piaget (1932). The defining issues test (DIT) is one of various instruments designed to measure ethical development which build on Kohlberg’s work. But there has been very little work in applying such tools to measuring the success of teaching computing ethics. This is a somewhat surprising gap given the importance attached by the British

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 pp. 33-42 q Emerald Group Publishing Limited 1477-996X DOI 10.1108/14779960710822674

JICES 5,1

34

computer society to their aspiration to enhance the professionalism of computing by including ethics in the computing curriculum and by making this inclusion a condition of accreditation of course. In the USA, the Computer Sciences Accreditation Board (CSAB) has published comparable requirements in their computing curricula. The aim of this paper is to examine some of the challenges to be addressed in measuring the success of teaching computing ethics. It draws on the early stages of an action research project to determine, firstly, to what extent teaching intervention succeeds in helping students develop ethical frameworks; and secondly to evaluate different teaching methods in their contribution to this goal. The context of the project is the teaching of computing ethics in a professional issues module at Roehampton University, South West London, UK. This course is designed to help first year undergraduate computing students to understand the ethical and legal issues associated with the profession and to help them develop capabilities in moral decision-making to meet the types of ethical dilemmas they may encounter in future careers. The course exposes students to values and ethical concerns that are widely debated. But, it is focused on scenarios that relate specifically to computing involving such issues as data protection and intellectual property. Teaching methods consist of group discussions of ethical scenarios designed specifically to be relevant to the student, step-by-step exercises in decision-making, and classroom debates. Lectures focus on legislation as well as the application of philosophical perspectives such as deontology, utilitarianism and virtue ethics. Data to help determine the effectiveness of the various teaching methods include testing (the DIT), tutorial workshops, results from assignments, and student interviews. It was considered that an implementation of the defining issues test might provide some indication of student progress in appreciating, evaluating and responding to ethical dilemmas. Results have yielded some surprising findings and provided rich insight into student ethical awareness to aid in the design of the next phase of the project. The paper is divided into four sections. First, a brief review of previous attempts to measure ethical development is provided together with the significance of action research in understanding ethical development. Secondly, the particular challenges in assessing the acquisition of ethical capability in computing are addressed. Thirdly, some initial findings from an action research project are explained. And finally, the significance of the findings in appreciating the strengths and weaknesses of assessing moral development in terms of cognitive factors is described together with the lessons learnt for the future of the project. Assessing ethical development and the significance of action research Ideally, evaluating an educational contribution to ethical development would begin with finding a suitable method for measuring significant changes in students’ attitudes, affective responses and behaviours between the start and completion of the educational intervention. However, research has generated nothing that comes very close to measuring all of these changes together. In the field of medical ethics measurement is obtained through “observation of that behaviour over a period of time”(QAA, 2002). For many educational courses the resources to measure changes and appropriate environments in which to observe students in practice do not exist. Considerable attention has been given to the relationship between moral behaviour and an individual’s level of moral sensitivity and judgement. Although, moral reasoning

skills alone are not sufficient to ensure high standards of conduct, they are, as Illingworth (2005) reminds us: “a necessary if not sufficient condition”. It is also widely accepted that these skills can be both taught and assessed. This confidence builds on the seminal work of Kohlberg and his theory of cognitive development in the moral domain, developed from his work in the 1950s with adolescent males. The theory identifies six stages representing three levels of thinking, pre-conventional, conventional and post-conventional (P Score). Very broadly, “pre-conventional” refers to basing ethical judgement on the safeguarding of one’s psychic self, recognising rules set by others and avoiding punishment; “conventional” refers to the grounding of ethical judgement on the need to preserve social norms and harmony, whether in local peer groups or wider society. “Post-conventional” refers to the basing of ethical judgement on more idealistic notions of justice and universal well-being. There has been considerable criticism of Kohlberg’s theory. Carr (1996) reminds us that his approach, like that of his mentor-in-chief, Piaget, is almost exclusively cognitive. Affective, motivational and behavioural dimensions of moral life receive little attention. Kohlberg himself responded, later in his life, to these criticisms but his idea of a “community of justice” in which social psychology of moral growth is fostered was never developed into a theory that was reconciled with the famous six stages. Gilligan (1982) advanced a considerable array of evidence to indicate that the importance attached by Kohlberg to reasoning in moral development reflected as significant androcentric bias and neglected a more “caring” approach to ethics favoured by women. However, little empirical evidence has been forthcoming to demonstrate gender differences in moral development. Furthermore, Gilligan’s objection misses the more fundamental characteristic of Kohlberg’s theory, that it assumes a moral universalism. This is the assumption that the spectrum of cognitive moral development is the same for all human beings, regardless of where each individual might figure on such a spectrum. This rational, neo-Kantian prescriptivism of Kohlberg is radically at odds with an Aristotelian account of the moral life in which dispositional aspects of each person’s character are acquired not just through cognitive development but through choice and the cultivation of sentiment in the contexts of cultures and circumstance experienced by individuals. Aristotelian approaches such as these have been developed in recent times, most notably, Macintyre (1981). None of these criticisms undermine a core tenet of Kohlberg’s approach that cognitive development of moral reasoning makes, at the least, a significant contribution to ethical development, even in the case of developing a capability, vis-a -vis virtue ethics, to know which virtue is significant in a particular scenario. Aristotelians and Kantians, as Carr points out, are not to be characterised in terms of a simple dualism between principles or dispositions, a rejection by Aristotelians of principles, which may figure in cognitive development, or a rejection by Kantians of dispositions, acquired through the education of our sentiments in moral practice. They differ in how principles and dispositions are related. An important implication of this relationship between principles and dispositions is that the measurement of students’ development of principled ethical judgement will be significantly illuminated by attempts to understand the student’s perceptions of what their ethical development, in a Kohlbergian sense, actually means to them in the own life stories. For this reason, the evaluation of the learning module through the objective

Assessing students’ ethical development 35

JICES 5,1

36

measure of the DIT was set within an action research project in which the students’ own perceptions would figure. Applying the DIT to a computing ethics module Discussions with computing undergraduates at Roehampton University indicate that they have above average levels of IT skills but often below average writing skills. The majority are male and from a wide variety of cultural and social backgrounds. The course contains a lower percentage of mature students than those on other courses and a low-entry level compared with computer science courses. In discussions with students at the beginning of the course, they often complained to their teacher (and author, Jagger) that they did not understand why they should have to take this module in computing ethics (it is compulsory for all single honours computing students). Many do not think ethics is important or relevant for them, preferring to take another more computer-orientated module. This is the environment in which the course begins. In such an adverse climate of opinion about the course the question arose as to whether significant learning could take place in the module. It was felt that a before and after model of study using the defining issues test might provide some useful information in relation to students’ moral reasoning capabilities and combined with a interview process afterwards it would help identify the students own perceptions of moral reasoning in their own moral lives. This might help elucidate the relationship between ethical reasoning and the acquisition of virtuous behaviour. A primary method of testing, devised by Kohlberg himself, is the Moral Judgement Interview a tool in which a participant reads a selection of ethical dilemmas and is asked a series of questions, responses of which are categorised using the six stages. There are several variations on this dilemma based approach. One such variation is the DIT designed over 20 years ago by James Rest at the University of Minnesota. It utilises Kohlberg’s six developmental stages but, classifies them into three “schemas”: personal interest (PI), maintaining norms (MN) and P Score. PI reflects the extent to which an individual identifies an ethical choice with personal loss or gain. MN reflects the extent to which ethical choice is equated with conformance to what would be regarded as normal or conventional. Post conventional reflects the extent to which ethics is considered in relation to universalisable principles. Rather than using free-responses to hypothetical moral dilemmas in an interview the DIT invites subjects to rate and rank 12 issues in terms of their importance in relation to a hypothetical dilemma. These rankings are then scored according to a scoring manual the results determining the degree to which a subject uses each of the three schemas. As with Kohlberg’s theory, the schema scores attempt to measure how people conceptualise social co-operation and it is therefore “a measure of the development of concepts of social justice” (Bebeau and Thoma, 2003). As well as the three schemas, rest devised the N2 score to combine “the acquisition of new thinking” (increase in P Score) with the “systematic rejection of simplistic thinking” (decrease in PI score) The N2 attempts to measure the degree to which P Score items are prioritised with the degree to which PI items are rated lower than P Score items. The two parts are combined into one score by adding the P score to the rating data weighted by three. This score is used particularly for measuring the effectiveness of educational intervention.

The DIT has gained a lot of popularity over the years as a suitable measurement due to its stringent validity testing, as well as the ease with which it can be administered, making it particularly suitable for educational environments and for “before and after” research models. Those particularly relevant to this study are briefly described here. Boyd (1982) implemented the DIT on a professional business course and concluded that ethics-based courses “significantly accelerate the rate of moral development” however he was not able to identify which learning interventions were most effective in that study. Dukerich et al. (1990) concluded moral reasoning scores are increased after group discussion – more so if the group leader has a high moral reasoning score. Cava (1990) reported an increase in DIT P scores as a result of the introduction of discussion about deontological and utilitarian theories into the classroom. Such discussion emphasised the need for students to be able to examine and express their own views. She suggested critical thinking and group interaction are key components in ethics education. Clarkeburn’s (2000) “before and after” study amongst 195 Bioscience Students at the University of Glasgow revealed a lower P score and N2 score than the US average (in both the control and test group). Clarkeburn also revealed some regression in her P and N2 scores. She reasoned that the low mean and regression could have been a result of the changing nature of university cohorts and suggests that greater demands and pressures imposed on students now working to finance their degrees, and more goal-orientated teaching, means universities are not providing environments conducive for moral development to take place. Wimalasiri (2001) also revealed lower P mean scores in a study on 106 Australian university students between the ages of 19 and 21. The results gave rise to questions as to whether the test is suitable for a non-US cohort due to cultural differences. Wimalasiri suggested that the dilemmas used in the DIT related somewhat exclusively to issues of right and legal justice. This “narrow domain” precluded the exposure of the development of a broader definition of a moral field and impeded the revelation of progress to a higher level of reasoning. It follows that it may be “incorrect to assume that subjects with lower scores, from different cultural environments, are ‘inferior’ in terms of the moral reasoning capability to their US counterparts”. Having said this he also remarks that “the theory and the DIT appear to be an acceptable and reliable frame of reference for studying moral reasoning levels of individuals in different cultures.” This indeed was the perspective of Kohlberg and Rest (Wimalasiri, 2001). Rest describes morality as “a social construction, evolving from the community’s experiences, particular institutional arrangements, deliberations and the aspirations that are voiced at the time and which win the support of the community” (Rest et al. 1999, P. 301). It follows that if this “common morality” is a result of shared ideals and beliefs within a specific community, then the measurement of such a morality is better served locally using tools refined for that particular audience. Although he believed ethical theory should be robust enough to have universal application, to measure to any accuracy may require a more local approach. The DIT has over 20 years of documentation to support validity with submissions from over 10,000 respondents (Bebeau and Thoma, 2003, p. 35) but the geographical location of submissions are primarily within the USA and Bebeau and Thoma acknowledge that even within this national spread, “caution should be used in interpreting these scores as data were not

Assessing students’ ethical development 37

JICES 5,1

38

selected to counterbalance the variability that appears to exist among college and professional school programmes” (Bebeau and Thoma, 2003, p. 34). Although, the scenarios chosen reflect universal issues (poverty, privacy, freedom of speech, euthanasia and repression), US primary and secondary school education is known to incorporate more overt representation of these issues than international counterparts. Although, there is no conclusive evidence to link moral development with improved ethical behaviour, there is evidence to suggest that learning does occur, at least in the short-term (Wright, 1995) and that the moral development measurement techniques, although far from perfect, go some way into providing indications for educators on best practice. Some initial findings The DIT was distributed to the students at the start of the 12 week module and was repeated at the end of the module. About 44 tests were completed and collected at the start of the module, six were removed due to incomplete answers and two more purged after analysis leaving 36 “before” students. 29 tests were collected at the end of the module of which three were purged. Of this set of data, 17 pairs of “before” and after sets were able to be matched and analysed. There were two main issues that emerged as a result of the implementation. The first related to the post conventional mean scores which were considerably lower (mean ¼ 23) than other studies for this age group. Previous research collected from the authors of the study based on over 2,000 responses of first year US college students showed a mean score of 32.32 (Bebeau and Thoma, 2003). Such a large difference in score could be highlighting the different educational experiences between US and UK cohorts. Thus, contrary to Clarkeburn’s conclusion that low scores may be a result of an emerging student environment at university unsuited to developing moral reasoning skills, the DIT itself may simply be failing to deliver an accurate reading of moral judgement levels due to the widely different cultural, social and educational backgrounds of the UK respondents. This conclusion is borne out in interviews with two students who experienced repeated low scores (described below) and who commented on both the language and structure of the test as being difficult to understand and follow. The other result was a significant increase in the N2 scores for the seventeen matched pairs. This was particularly encouraging as the index was designed to measure educational intervention. Anonymous course feedback documentation suggested an increase in the N2 score was consistent with student experience as a number of student evaluations made reference to the course improving ability to think and develop skills in decision-making. Although, the N2 scores showed a significant upward trend, it was nonetheless disconcerting to note inconsistent variations across the 17 subjects with six resulting in lower P Score scores than at the start of the course. In an effort to understand more accurately what may be happening with, three students were interviewed, one who exhibited a low score but showed significant improvement over the 12 weeks and two others who exhibited consistently low scores. The student who had achieved an increased P score (10-20) reported that he enjoyed the course saying, “it helped me in gaining an understanding of things I need to think about not just at uni but afterwards

when going into an IT career”. When questioned about why he thought he may have improved over the 12 weeks he stated: Before I didn’t really have that much understanding so obviously as the course went through I learned quite a lot whereas if I’d had an understanding before the test wouldn’t have changed that much. Hadn’t really thought about it too much – “professional issues in computing” hadn’t really crossed my mind so I learned quite a lot from it.

He described the debates as “helping me learn the different viewpoints of people” and “put things in perspective”. A second interviewee had a lower P score after the 12 weeks, (P ¼ 36 to 22). When questioned about whether the course had any impact on her dealing with ethical issues she replied, “it’s made me more politically aware of what different parties would suggest” and then cited two debates as being particularly helpful, the debate on children and computer games which highlighted her concern with regard to her little brother and the debate on illegal music downloading in which she stated that, as a result of this debate, she would categorically not download music illegally considering the practice entirely unfair to the artists. The student made the following comments concerning the DIT: . . .some of the words I didn’t actually understand – some of the political ones. I did find it quite a long thing and had to read through each one and wasn’t sure about that. Found it hard.

She described some of the wording as “peculiar” and that “it didn’t sound as I would normally understand words in an exam.” She stated that she had other coursework hand-ins due in and, whizzed through it quickly as shed already read it once 12 weeks earlier. When questioned about her experience in doing the “5 Step Method to Ethical Decision-making” she stated: . . .I had trouble with that one. I had to think a lot and I found it really really difficult to look into myself and think what would I actually do in that situation? I found it very hard to put myself in the point of view of someone else.

These comments suggest that although finding the test difficult to understand, the student is also battling with the concepts associated with “principled thinking”. In the case of the third student with a low score for both tests, (P ¼ 14 to 8) when asked about the course she replied: a lot of it went over my head to be honest. . . because it was so new and I didn’t have an interest in it at all so I did feel I was wasting my time. Some of it was helpful. You need to know your rights, copyright, different type of viruses, all that was good. In general, it was a bit over my head but I did pick up some information that was useful.

When asked whether she understood the test she replied: Yeah I did understand it and in some of the cases I put myself in that position and wow what would I do if I was in that position? If you were put in extreme cases what would you do? It did get you thinking.

But when asked about the second test she replied:

Assessing students’ ethical development 39

JICES 5,1

40

The first time round I done it properly but second time round just tried to remember what I’d done first time round. Some of it I didn’t really understand what they were saying and what they meant. It was a bit weird.

In both the last two cases, it should be noted that they were not told the results of the test until the end of the interview so as not to bias their comments. It was interesting to note that whilst student number two was very positive about the contents of the course and clearly got a lot out of it, student number three was not and only found some redeeming features upon reflection – yet both had a similar result from the DIT. Clarkeburn (2000) revealed significant regression in her study and maintained that the high level of fluctuation in both directions on the DIT scale can be put down to students being profoundly confused about moral decision-making methods and thus, having had these methods introduced to them, employed the methods inconsistently. She states, “Students were not only confused, but they predominantly used less sophisticated decision-making methods than expected for their age” Clarkeburn (2000, p. 34). In fact the low scores could be highlighting students’ attempts to apply these approaches but failing to do them effectively due to lack of practice. This could suggest the need to build into the syllabus methods to facilitate further use of these skills in later years. It also suggests the need to “go slower” in applying these methods, perhaps with more in-class exercises and formative assessment to ensure the concepts are implemented correctly. Conclusions This study has brought to light some important issues with regard to teaching and learning in computer ethics. First, student attitudes can be seriously ambivalent about the importance of ethics. One possible implication of this at that when ethical development is measured using the DIT there is a risk that the results are being confounded to an uncertain extent by the students sense of the importance of ethics. It is not clear that Rist seriously considered this in the development of the DIT. There is no apparent innate acknowledgement of the importance of ethics in this field held by the students, regardless of the importance attached to it by the computing profession. It does not follow of course, that the DIT cannot reflect significant changes in the development of ethical reasoning. But, it is a reminder that there are a host of other factors, affective and motivational in the aetiology of ethics. Secondly, the overall P Score scores were extremely low for this student cohort. They were far lower than expected. The result supports the view expressed by some students that the sense of idealism inherent in P Score thinking is not shared by the students. This is consistent with a particular line of criticism of the Kohlbergian tradition. Not everyone is convinced, it would seem, that the individualistic idealism of P Score thinking is particularly desirable. Hogan (1975) argued that it is dangerous for people to place their own personalised principles above society and the law, however well meaning. The debate over the scientific merits of the DIT have been complicated by some ambivalence about the desirability of what the test assumes to be the most ethically desirable stage of development. More particularly, it may be important in the context of this research to understand what the attitudes of the students are to the very criteria upon which their ethical development is being measured.

Within the limited scope of the study, there is evidence suggested by the increase of N2 scores, that teaching ethics using group-oriented approaches can have an impact on moral judgement capabilities. A key feature of the module was the incorporation of a debate as a learning exercise. The debate required everyone listen to different perspectives, to different possible answers to dilemmas, to different values with few constraints on what can be uttered. The DIT may provide useful indication of the pedagogic outcome of these debates in respect of ethical development. But it provided no indication of how the students views might have changed in relation to the key criteria of the DIT. To be specific, the students might have come to hold idealistic “post-conventional” thinking in lesser regard, after the debate than before. What might be regarded as ethical “regression” in DIT terms might in fact be educational progress in ethical reflection. At this stage, such considerations must be hypothetical. But they are pointers to the value of understanding not just progress in ethical principles but development in terms of students understanding of difference perspectives and their ability to empathise with others. Discussions with the students suggested teamwork such as debates, which requires students to take alternative viewpoints as well as working together for a common goal, inspire and motivate critical thought enabling moral decision-making. It is for this reason that the action research project might profitably include a qualitative and ideographic appreciation of how the students regarded the debate. The wording within the test itself is problematic for students from non US backgrounds, suggesting the DIT is less suited to a UK audience. Devising a UK equivalent test using the questionnaire/dilemma-based approach, but within a more specific “UK” (and indeed computer ethics) frame of reference may provide more accurate results and might be worth exploring further. The next stage in the study will include a focus on the debates by collecting data after each debate relating to student understanding of ethical issues specifically with regard to computing scenarios to help differentiate the debate itself as a method for improving ethical understanding. This data can then be compared with DIT scores. This will help clarify the relationships between the universalisable world of Kohlbergian ethical reasoning and the incommensurable worlds of virtue ethics developed by individuals for particular practices and communities. It points towards a research agenda which is both quantitative and qualitative. It also points towards an agenda which is rooted in the tradition of action research but one which combines quantitative and qualitative approaches. Knowledge is acquired from within the learning system rather than treating it as external the researcher’s world. The students are both subjects of tests and participants in qualitative research. The teacher is also a contributor to the quest for understanding of the significance of what is being taught in ethics. References Bebeau, M. and Thoma, S. (2003), Guide for DIT-2, Center for the Study of Ethical Development, Minneapolis, MN. Boyd, D.P. (1982), “Improving ethical awareness through the business and society course”, Business and Society, Vol. 20, pp. 27-31. Carr, D. (1996), “After Kohlberg: some implications of an ethics of virtue for the theory of moral education and development”, Studies in Philosophy and Education, Vol. 15, pp. 353-70.

Assessing students’ ethical development 41

JICES 5,1

42

Cava, A. (1990), “Teaching ethics: a moral model”, Business & Economic Review, Vol. 36, pp. 10-13. Clarkeburn, H. (2000), How to Teach Science Ethics, Glasgow University, Glasgow. Dukerich, J.M., Nichols, M.L., Elm, D.R. and Vollrath, D.A. (1990), “Moral reasoning in groups: leaders make a difference”, Human Relations, Vol. 43, pp. 473-93. Gilligan, C. (1982), In a Different Voice: Psychological Theory and Women’s Development, Harvard University Press, Cambridge, MA. Hogan, R. (1975), “Theoretical egocentrism and the problem of compliance”, American Psychologist, Vol. 30, pp. 533-40. Illingworth, S. (2005), “Assessment with applied/professional ethics”, The Higher Education Academy, available at: http://prs.heacademy.ac.uk/documents/miscellaneous/ ethics-assessment.html Kohlberg, L. (1984), Essays on Moral Development: The Nature and Validity of Moral Stages,Vol. 2, Harper & Row, San Francisco, CA. Macintyre, A.C. (1981), After Virtue, Notre Dame, University of Notre Dame Press, Notre Dame, IN. Piaget, J. (1932), The Moral Development of the Child, The Free Press, New York, NY. QAA (2002), “Medicine benchmark”, Education. Rest, J., Narvaez, D., Bebeau, M. and Thoma, S. (1999), “A Neo-Kohlbergian approach: the DIT and schema theory”, Educational Psychology Review, Vol. 11, pp. 291-324. Wimalasiri, J.S. (2001), “Moral reasoning capacity of management students and practitioners: an empirical study in Australia”, Journal of Managerial Psychology, Vol. 16, pp. 614-34. Wright, M. (1995), “Can moral judgement and ethical behaviour be learned? A review of the literature”, Management Decision, Vol. 33, pp. 17-28. Further reading Crain, W.C. (1985), Theories of Development, Prentice-Hall, Englewood Cliffs, NJ. Staehr, L.J. and Byrne, G.J. (2003), “Using the defining issues test for evaluating computer ethics teaching”, Institute of Electrical and Electronics Engineers (IEEE) Transactions on Education, Vol. 46, pp. 229-34. Woodward, B.S. and Ashby, S. (2006), “Measuring growth and impact: ethical reasoning in the information systems technology field”, Issues in Information Systems, Vol. 7. Corresponding author Suzy Jagger can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

Book reviews Ethics and Technology: Ethical Issues in an Age of Information and Communication Technology Herman Tavani John Wiley & Sons Inc. Hoboken, NJ 2007 Keywords Ethics, Communications technologies Review DOI 10.1108/14779960710822683 “What do you teach, in Computer Ethics?” someone asked me, at a recent conference on computing and philosophy. “I teach Tavani!” was the spontaneous reply. Perhaps I can explain my unashamed bias: students of computer ethics face a major challenge in being required to grasp and use some of the essentials of a discipline that has engrossed intellectuals for nearly three thousand years. Most information and computing technology (ICT) academic subjects boast a body of technical knowledge that was born 5, 50, or at most 100 years ago, whereas ethics is a branch of philosophy and philosophers began making profound and lastingly-important contributions to their field well over two thousand years ago – the body of knowledge is overwhelming. If technically-inclined students are not to become disheartened by the learning materials of computer ethics, then these students must be offered a highly-structured subject with clear relevance to ICT careers of the future. Tavani achieved this structure and relevance in the first edition of Ethics and Technology and in the second edition he enhances the first by introducing analyses of newly-emerging issues and dilemmas created by technological progress. Nanotechnology, pervasive computing and virtual worlds catch the imagination of the technical student who can then be induced to consider the social consequences of these brilliant inventions. Tavani is renowned for his work as a bibliographer of the literature of computer ethics, and this allows him to draw on the widest possible range of sources to explain, illustrate and justify his view of what the pressing ethical issues are in ICT in the twenty-first century. The book deals comprehensively with the ethical issues that have come to be accepted as the standard moral dilemmas in ICT, such as privacy, security, intellectual property, censorship and digital social justice. Then, as mentioned above, a little more glitz and glamour is introduced with discussion of the newer ethical puzzles associated with technical innovation such as robotics and the complex scene of the virtual worlds in which many technology devotees now pass much of their real lives. The intended audience for the book includes not only ICT students and their teachers but, of course, library and information management scholars, as well as those in the fields of the social and behavioural sciences and people studying and researching in philosophical disciplines such as applied ethics. This claim of a wide audience seems to be justified, since the book’s depth of treatment of the range of important issues, from technologically enhanced human bodies to ICT workplace conditions, draws on and

Book reviews

43

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 pp. 43-46 q Emerald Group Publishing Limited 1477-996X

JICES 5,1

44

refers to the work of numerous authoritative scholars – not only computer ethicists but also legal experts and specialists in each of the fields that the issues touch upon. The student is introduced not only to the ethical issues in ICT today, but also to methods and frameworks that guide the development of a well-reasoned recommendation for solving the dilemma in question. Important ethical concepts and principles are covered so that the student is able to see how deontological and teleological approaches may be employed in evaluating ethical propositions. The rudiments of critical reasoning are discussed, illustrating some of the commonest fallacies and misconceptions that frequently lead to illogical and unwise conclusions. The student’s ethical toolkit then includes an awareness of what the issues and puzzles are, some principles that can be brought to bear on possible solutions, and elements of formal reasoned argumentation to evaluate proposals correctly. The fourth tool in the ICT ethical kitbag provided by Tavani is an understanding of professional responsibility and the codes of ethics or codes of conduct of some of the ICT associations and societies. The book is an excellent pedagogical aid, designed to support both teachers and students, with helpful introductions and summaries, the name of the precise topic displayed at the top of every page, and a comprehensive index. Each chapter is accompanied by a set of thought-provoking questions and exercises, a list of references and a separate list of further readings. The associated web site for the book supplies extensive information to enhance each chapter, such as the text of a number of ICT professional associations’ codes of ethics to accompany the chapter on professional ethics. A separate student site is provided, whilst the site for trainers and teachers offers ready-made presentations to assist with lectures, plus answers to the exercises. The diligent student who exits from a course on computer ethics such as is provided by Tavani’s book, will have acquired skills in detecting questionable situations involving ICT, working out where the ethical problem may lie, and thinking in a principled and logical manner about a selection of possible actions that might resolve the dilemma. Fortunately, there is a growing tendency in ICT education to define computer ethics as a core academic subject, and thus mandatory in all ICT degrees. That seems imperative, after reading the final chapters of this book, on the complexity of issues associated with emergent technology. Karen Mather Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Australia

Internet Politics Andrew Chadwick Oxford University Press ISBN 978-0-19-517773-2 Keywords Internet, Communications technologies, Ethics Review DOI 10.1108/14779960710822692 It is easy to see that the internet has had a profound effect on many areas of our lives. Despite this the study of the effects of technology upon our daily lives tends to be fragmented and therefore ultimately incomplete. This means that anyone attempting

to come to grips with the major changes caused by technology is required to bring together literature from several disciplines (law, computer ethics, sociology, media studies, etc.) to be able to obtain a fairly clear picture of the complexity of internet supported social interaction. To anyone interested in internet studies this fragmentation is an accepted reality but to the teacher this fragmentation is a source of frustration. In part this fragmentation is the result of the approach, scope and goals of the different disciplines attempting to research of the social effects of internet-based technologies. Andrew Chadwick is familiar with these problems since he has been a part of this research tradition over a longer period of time. His way of attempting to overcome this complexity is not to write a traditional book on e-government or e-democracy as might be expected but he elegantly avoids this trap by titling his new book Internet Politics (2006). This choice of title allows him the leeway to explore the many aspects of this field without being trapped in the usual reader expectations. He acknowledges this in the final chapter of the book when he writes: “Internet politics is a fast moving field characterized by uncertainty, paradox, overstatement and understatement.” When Chadwick recognizes that Internet Politics is a complex subject he does not do so as an excuse for omissions or simplifications. His book acknowledges the complexities and explores them with an in-depth use of theory and illuminating examples. He mixes the fundamental descriptions of how the internet functions both technologically, socially and organisationally with the innovative additions of the way in which individuals and groups use the internet. In the latter approach lies the recognition that it is not the technological or the organisational which makes the internet a topic of fascinating research but it is the social uses of technology which have created the innovative and fundamental changes in both on and offline behaviour. Technological advances alone have not created the social changes we are experiencing today. Recognising this Chadwick address the typical subjects of the access, the digital divide, internet governance (to name a few topics) but he is not satisfied with this, more formal, explanation of internet technology. In order to bring the breadth of this subject to the attention of the reader he explores the social fringes of internet use as a public sphere (including a good section on Habermas’ theories in relation to the internet) with topics such as interest groups and social movements, and the effects of blogging, social production of content and hacktivism (to name a few topics). In the typical literature, the latter topics are only mentioned in passing. This enhances their status as unimportant fringe occurrences rather than large-scale political and social movements. The lack of appreciation for these topics maintains the illusion that the internet is just another place similar, yet dissimilar to the offline world. And this place can and will be understood and controlled as soon as the adequate regulatory bodies are agreed upon and created by existing formally approved regulatory structures. Such a view is insufficient in understanding the internet, as it does not take into consideration the power of activism and social interaction online. This book is well researched, timely and readable – but who are its intended audience? By looking at its structure with its helpful chapter overviews, summaries and suggestions for recommended reading it may seem, at first glance, that this is a book for students. And it is. However, the wealth of references within the text and the generous bibliography show that Chadwick is not content with creating a work

Book reviews

45

JICES 5,1

46

for students. This book is an invaluable aid to the researcher. A novice will find it enlightening and to the more seasoned researcher it is both a useful refresher and a point of reference. As a teacher this book manages to impress both in its scope and its depth, it is an excellent fundamental text that will replace many of the existing works on e-government and e-democracy since it manages to encompass both topics and beyond. As a researcher familiar with the field it is full of reminders and additional information. But it leaves the advanced researcher wanting more. Chadwick has opened up the field of Internet Politics and immediately the researcher within demands to know his thoughts on the current stages of social networks. What are the political implications of the likes of Flickr, Second Life and Myspace? Where is wikipedia going? Should blogs be studied as a unified topic (because of their technological kinship) or do we need a more nuanced approach? Questions such as these keep popping up while reading Chadwick. The advanced reader wants instant gratification and more answers. In the internet age, it is frustrating to have to wait for a second edition. However, it is the mark of a good book that the reader closes its covers and is already anticipating a continuation of the discourse on Internet Politics. In conclusion therefore, Internet Politics should be required reading for anyone attempting to understanding the way in which the internet affects our lives. Mathias Klang Department of Applied IT, IT University, University of Go¨teborg, Sweden

Note from the publisher Emerald is delighted to be publishing the Journal of Information, Communication and Ethics in Society. The journal joins our diverse and expanding Information and Knowledge Management portfolio. Journals in the portfolio include: . Industrial Management & Data Systems . Information Management & Computer Security . Information Technology & People . International Journal of Pervasive Computing and Communications . International Journal of Web Information Systems . Internet Research . Journal of Systems and Information Technology . VINE: The Journal of Information and Knowledge Management Systems

Note from the publisher

47

Information about all our journals can be found at: www.emeraldinsight.com Emerald at 40 This year Emerald Group Publishing Limited celebrates its 40th Anniversary. As anyone with more than two score years under their belt (or approaching it) will know, 40 represents a milestone. It marks a point at which we have, or we are supposed to have, come to terms with the world and reached a good understanding of what we want from life. And for those of a more contemplative persuasion, it prompts us to reflect upon our earlier years and how we got to where we are. It is perhaps not so different for a company. In many ways, to reach the age of 40 for an organisation is quite an achievement. Emerald’s own history began in 1967 with the acquisition of one journal, Management Decision. The company was begun as a part-time enterprise by a group of senior management academics from Bradford Management Centre. The decision to found the company, known as MCB University Press until 2001 was made due to a general dissatisfaction with the opportunities to publish in management and the limited international publishing distribution outlets at this time. Through the creation and development of the journals, not only was this particular goal achieved, but also the foundations of a successful business were laid. By 1970, the first full-time employee was appointed and by 1975 there were five members of staff on the pay roll. In 1981, there were 20 members of staff and three years later the company had grown to a size which meant we had to move to larger premises – one-half of the current site at 62 Toller Lane. Through the 1990s Emerald came of age. In 1990, the first marketing database was introduced and several years later we acquired a number of engineering journals to add to our increasing portfolio of management titles. The IT revolution also began to impact upon the publishing and content delivery processes during this period. Writing in 2007, it seems hard to remember a time when information was not available at the click of a button and articles were not written and supplied in electronic format – and yet it was only 11 years ago that Emerald launched the online digital collection of

Journal of Information, Communication & Ethics in Society Vol. 5 No. 1, 2007 pp. 47-48 q Emerald Group Publishing Limited 1477-996X

JICES 5,1

48

articles as a database. The move was seen as pioneering and helped to shape the future of the company thereafter. The name of the database was Emerald (the Electronic Management Research Library Database) and in 2001 we adopted this name for the company. So, how does Emerald look in 2007? Emerald has grown into an important journal publisher on the world stage. The company now publishes over 190 journals and we have more than 200 members of staff. Emerald has always stressed the importance of internationality and relevance to practice in its publishing philosophy. These two principles remain the cornerstones of our editorial objective. The link between the organisation and academe that was so crucial in the foundation of the company continues to influence corporate thinking; we uphold the principle of theory into practice. Emerald also continues to carry the tag of an innovative company. Through our professionalism and focus on building strong networks with our various communities, we have launched and developed initiatives such as the Literati Network for our authors and a dedicated web site for managers. These innovations and many more, help to set us apart from other publishers. For this reason, we feel confident in stating that we are the world’s leading publisher of management journals and databases. It is important to us that we continue to strengthen the links with our readers and authors and to encourage research that is relevant across the globe. In more recent history we have, for example, awarded research grants in Africa, China and India. We also opened offices in China and India in 2006, adding to our existing offices in Australia, Malaysia, Japan and the USA. We would like to thank the editors, editorial advisory board members, authors, advisers, colleagues and contacts who, for the past 40 years, have contributed to the success of Emerald. We look forward to working with you for many years to come. Rebecca Marsh Publishing Director