Particularly since the start of the Covid-19 pandemic, telemedicine—which uses various communication technologies to connect patients with healthcare providers––has expanded dramatically. Even outside of emergency situations, the relatively low-tech telemedicine modalities of secure messaging, videoconferencing, and remote monitoring have been hailed as potential bridges across the wide and common gaps in access to in-person healthcare. Moreover, some advocates think telemedicine should become our first point of contact with healthcare systems to increase efficiency in brick-and-mortar clinics. 

But although ethicists have debated both the accuracy of telemedicine’s claim to increase healthcare access and the potential consequences of increased telemedicine use for the doctor-patient relationship, little attention has been paid to the hands-on caregiving still needed to make telemedicine function. While keeping popular focus on the physician and other high-status caregivers, telemedicine delegates work and ethical responsibility to more precariously positioned caregivers. My current work highlights the practical and ethical contributions of this neglected but under-supported care work, arguing that these in situ caregivers must be the focus of care theoretical analyses as well as telemedicine interventions themselves.

Consider a case of the kind of delegation I have in mind. Contemporary telemedicine as most people have experienced it in the past four years brings the clinic into the patient’s home. Here, the clinic creeps into the household. Home-based visits are particularly common for the remote monitoring of chronic conditions, especially conditions that limit the user’s mobility. Among the numerous effects of “bringing the clinic home” is the involvement of family members and other paid and unpaid caregivers in the medical visit itself: many telemedicine users require assistance in setting up the necessary equipment for the virtual visit, or in moving their bodies to enable a virtual exam. 

While some in situ caregivers in this context will be paid home health aides, personal care assistants, or long-term care workers, many will instead be informal caregivers within the home who typically lack medical training. Furthermore, the participation of family and community caregivers in the telemedical delivery process is as yet unregulated, instead dependent on the discretion of the remote physician. Whether assisting in physical maneuvers or present as emotional support, the at-home partner becomes the patient’s locus of care: the physical proximity of the in situ caregiver places the burden of immediate response on their shoulders. In situ caregivers, both paid and unpaid, are some of the most precariously positioned supports on which healthcare systems depend, but their efforts go unnoticed and unsupported in telemedical practices that focus on quality of care provided by the distant physician. 

The similarities between the dynamic of delegation I describe and other forms of distant care help show why we shouldn’t discount the value of the virtual caring connection entirely. Care theorists have maintained that care can, indeed, take place across great distance. But in order for western feminist allies, for instance, to care for distant others without veering into paternalism or neocolonialism, care theorists have suggested that distant allies should support on-the-ground efforts driven by those closest to the need in question. The distant connection can be both practically useful and evidence of a genuinely caring disposition but carrying out the caring action demands the insights and labor of in-person efforts.

Similarly, bolstering the value of care in the context of telemedicine will first require practical commitments to the basic social web undergirding our lucrative innovations and our more prestigious caring professions. Such practical commitments will include materially supporting the formal and informal caregivers making telemedicine work, as well as patients themselves, so that they are able to engage telemedicine where it is in fact the best option available. This support might take the form of subsidizing internet services to allow for greater connectivity. Another avenue of material support for in situ caregivers might provide more significant training on and longer-term access to at-home monitoring technologies. Medical support for unpaid caregivers, including robust training and on-call guidance for home-based medical tasks, as well as psychological support for the emotional weight of these tasks, is likewise called for. There lurks a danger, however, in turning this need for support into digital and marketized care partner “coaching” endeavors which make such support dependent on private funds––and which themselves often rely on telepresence appointments.

Like other approaches to distant care, telemedicine continues to rely on direct, in-person caregiving for its meaning and success in ways that risk further entrenching the existing hierarchies that care theory seeks to dismantle. Without negating the utility of telemedical interventions, particularly under crisis circumstances, my work identifies the relationships—to non-physician healthcare workers, to home caregivers, and to patients themselves—that remain both ethically and medically crucial. It is within these relationships that we can find the primary locus of care, and therefore it is in these relationships that we must invest if we are to ensure that effective caring attends telemedical interventions. 

Mercer Gary Bio

Image credit: Intel Free Press, CC BY-SA 2.0 https://creativecommons.org/licenses/by-sa/2.0, via Wikimedia Commons