Digital awareness has gained importance in the public discourse in the past years. In other words, there is a growing need to anticipate, identify, and understand the nature of the opportunities and risks of digital technologies, so that they are not implemented and adopted hastily and without knowledge of their ethical, legal, and social implications. Among the many digital technologies available to us, health apps have a particular place because of their prolific and relentless development, their ever-growing commercial value, their increasing accessibility and user-friendliness, and their promise to improve our health and access to care and reduce mortality, hospitalisations, health care costs, and medical errors. But unfortunately, there is also a growing number of people using unreliable health apps. Despite these advances and promises, the relentless pace of health app development raises concerns about privacy and data protection. In addition, as data from health apps are increasingly integrated into medical decision-making, the issue of physician accountability arises. How do we determine that the app on which we place our hopes is actually based on scientific evidence? Such considerations highlight the ethical challenges that directly affect the accountability of digital health, that is, the set of health aspects related to the digital world. We tackle the issue with Marta Fadda, a postdoctoral researcher and lecturer in the Biomedical Ethics course at the Faculty of Biomedical Sciences of Universitą della Svizzera italiana.
What characteristics do these technologies need to have to be considered reliable and elicit our trust?
Before defining the characteristics that apps must exhibit to be perceived as trustworthy, it is essential to dwelling on the concept of trust itself. Trust is something that is given as individuals. It is never blind, nor is it given unconditionally or monolithically, but instead is a relational (between at least two parties) and multifactorial concept, which could be summarised in the following pattern proposed by philosopher Onora O’Neill:
We trust if:
- we believe...
- ...that a person or group of people...
- ...will do something specific...
- ...in a competent...
- ...and credible way.
To trust in a health app means, according to this pattern, to relate to someone (in this case, the app developers) and to believe that they will provide health benefits under the banner of accuracy, integrity, and credibility. Trustworthiness refers to the attributes that cause an individual to consider another individual or entity worthy of their trust. To be perceived as reliable or trustworthy, developers must strategically flag their honesty, competence, and trustworthiness to make users feel comfortable putting their trust in them. A 2015 survey assessed why users adopt, abandon, or continue using health apps and found that distrust in developers is one of the main reasons many users discontinue using these tools. This distrust likely stems from the increased suspicion about developers’ actual competence, honesty, and credibility.
From content to user control...
Various checklists and scales are available to help users of health apps evaluate specific attributes underlying trustworthiness, such as quality and effectiveness. The checklist developed and published by van Haasteren in 2019 allows users to answer a series of questions about the app’s information content, organisational features, social influence, technological features, and the control offered to the user to determine the degree of trustworthiness of the app they are going to use. Included are questions about measurement accuracy, any external certifications, security guidelines, the developer’s reputation, privacy and data security considerations, and freedom of control.
What conclusions can we draw here?
Digital awareness necessarily passes through the concept of trust. It entails becoming aware of what it means to trust digital health technologies and what elements make these tools worthy of our trust.
O’Neill, Honora (2002). A Question of Trust: The Bbc Reith Lectures 2002. Cambridge University Press.
Adjekum A, Blasimme A, Vayena E. Elements of Trust in Digital Health Systems: Scoping Review. J Med Internet Res. 2018 Dec 13;20(12):e11254.
van Haasteren A, Gille F, Fadda M, Vayena E. Development of the mHealth App Trustworthiness checklist. Digital Health. https://journals.sagepub.com/doi/10.1177/2055207619886463
Murnane, EL, Huffaker, D, Kossinets, G. Mobile health apps: Adoption, adherence, and abandonment. UBICOMP/ISWC 2015: 261’264 .