 High rates of poverty in Indigenous communities are linked to social exclusion, lower social cohesion, increased

crime, and mental health problems, including anxiety, low self esteem, depression, and hopelessness.
 Access to health care for on reserve Indigenous populations is a continuing problem.
 Many Indigenous Nurses are the first point of care contact for health care in their community, and a significant
number report working in a nursing station or outpost setting far from a major centre and without a physician in
their community
 The added complexity of providing culturally sensitive and competent community driven care is something that
many Indigenous nursing graduates state is not emphasized or included in curricula in nursing school's, and they
report feeling unprepared for this challenge.
The concept of empowerment is closely linked with that of autonomy, justice and the role of the nurse as a patient
advocate.

Distributive Justice
The bioethical principle of distributive justice, one of the four principles developed by Beauchamp and Childress (1991)
of the Kennedy Institute of Ethics, concerns the common good for most people. It concerns the just or fair distribution of
health benefits within the society and thus is grounded within the moral theory of utilitarianism. Distributive justice is the
idea that physicians (and nurses) should broaden their perspective to include the needs of the entire group of patients and
the needs of society as a whole, instead of caring only for their individual patients. The greatest good should be done for
the greatest number of patients within the allotted budget; no individual patient has a right to maximal care. Distributive
justice seeks to substitute a group ethic for medicine's traditional patient-centered ethic. It justifies a minimalist standard
and reduced costs of care for whoever is paying.
Test your knowledge: Which moral theory do you think is inspired by distributive justice?
(Answer: Utilitarianism)
"Allocation of scarce resources" is a recurring refrain in this discussion. Indeed distributive justice only becomes an issue
when there is scarcity. What resources are scarce? Cost containment, also termed "resource allocation," is a euphemism
for rationing. Rationing health care involves denying some potential benefits to certain people against their wishes; it is an
abuse of power.
Link to our case study - Mr. C is in need of a kidney but let's say there is only 1 kidney left and 3 people ( a 15 year old
boy; A 45 year old woman and Mr. C an elderly man with history of drug and alcohol abuse) waiting for it. Now the
principle of distributive justice is at play and we all will use our "values" to decide who gets the kidney...
Autonomy
In previous modules we discussed the principle of autonomy in great detail. We illustrated that respect of choices of
treatments by competent individuals is paramount. The notion of obtaining informed consent and discussing with clients
the pros and cons of getting or not getting a transplant is a significant part of addressing and respecting autonomy. Each
organ donation scenario might have a different context.
Link to our case study - Mr. C is very frail, lives alone with minimal income and has a history of drugs and alcoholism.
He wants a new kidney and believes it will save his life. However, when there are limited kidneys to transplant, what does
respecting his autonomy and choice really mean here? If he does not get a kidney transplant he might die but if he does,
he still will eventually die because of his sever health condition. Maybe the solution here would be to show him that we
are not abandoning him if he does not get a kidney by providing him with services to support him and alleviate his
suffering. What should these services look like?
Non compliance is when a patient refuses or does not adhere to medical treatments. It seems to be too early to judge Mr. C
as a non compliant patient. However Doane (2014) argues that a barrier to respecting patients' autonomy is when
healthcare providers view them as "non-compliant". In order for the kidney transplant to be successful Mr. C must adhere
to strict lifestyle changes (regular visits, diet, change drinking habits, etc) and these might be expensive and difficult to
achieve.
Scarcity of Resources: How to Fairly allocate Scare resources in light of COVID -19? (Wall, A.E; Pruettt, T., Stock, P.,
Testa,G.(2020)
The way that we currently put allocation of scarce resources, primarily transpant organs, into practice is a two-step
process.
To achieve utility ( the benefit or outcome of receiving the resource) if a patient is deemed to have an acceptable
potential to benefit from transplantation, he or she is listed AND To ensure justice, when an organ becomes available for
transplant, a match run determines the order in which listed patients are prioritized for that organ (who gets the
organ first).
COVID-19 has prompted us to think differently when allocating scare resources, to think in terms of the ethical values
framework for rationing absolutely scarce health-care resources, not just utility and justice.
The four ethical values that guide rationing of absolutely scarce health-care resources are:
1. to maximize benefit
2. treat people equally
3. promote and reward instrumental value, and
4. prioritize the sickest patients.
1. Maximizing benefit can be conceptualized as saving the most lives and saving the most life years.
2. Treating people equally is based on the principle of justice, which sets rules for how to treat people with the same need
for a scarce resource in the same way (eg, first come, first served as done with kidney allocation or random selection so
as not to advantage those with quicker and easier access to hospitals).
Consider equity rather than equality when seeking justice. Equity suggests that those who need the resource most get
priority (save the most lives) where as equality says that we are all equal and should have the same access to the scarce
resource (random allocation or first come first serve)
3. Promoting and rewarding instrumental value means giving priority of treatment to those who have made
contributions (eg, health-care workers, those involved in research) or to those who are likely to make contributions in the
future (eg, health-care.workers who can return to the workforce and treat patients). Example: Doctors and nurses get
the COVID vaccine first
4.prioritizing the worst off requires determining who is the worst off and what they should be prioritized for. Who makes
these decisions? Are they in a position of power and privillege?
These authors suggest we add to the principles of Justice and Utility through the application of these ethical values in
tandem with COVID-19 risks layered into the decision making framework for allocating scarce resources such as organ
transplanation.
The ethical debate over child priority in post-mortem organ allocation: Schicktanz a,S., Simon a,S., Raphael c
S., Ahlert d,M. (2020).
Implicitly or explicitly and with different age-group thresholds (priority setting who gets the scarce resource), they give
persons under the age of 18 or sometimes 16 years relative priority in the allocation of kidneys, heart, lungs, or livers.
“Relative priority” means that age or “child” status is taken into account alongside other medico-ethical criteria
such as high emergency or high benefit. This principle, these author call the “child priority rule,” is often referred to
as a “pediatric bonus” in allocation scoring systems. children with kidney failure are generally ranked higher for
allocation priority than adults with kidney failure because they belong to the younger age group. Should they is that
fair/just?
Scarcity is the current reality of organ allocation—at least for a great number of countries—and is unlikely ever to be
resolved.
Two recent position papers by Belgian and Australian ethicists have triggered a debate over whether the ethical
argumentations and the practical implications of child priority rules in organ allocation guidelines are really ethically
justifiable.
Do you think that practice guidelines of using age thresholds (such as <18 or <16 years old or over 65 or 75 years old)
can have unintended, problematic implications? What if we make a rule that all persons over the age of 70 cannot
receive life saving resources such as a ventilator or a surgical intervention? Should we exclude all resources based on
age or just scarce ones? Should we allocate resources based on age?
The pathway to transplantation consists of at least three steps:
1. being referred for assessment
2. being assessed and listed; and
3. receiving an organ once listed
The ethical debate in the literature included in the review refers almost exclusively to the last step, during which specific
allocation decisions are made.
 Health care practitioners are permitted to rely on
an assertion from a person that he/she is the
substitute decision-maker. A formal statement
that the person is the substitute decision-maker is
not necessary to give or refuse consent to a
treatment, admission to a care facility or a
personal assistance service on behalf of an
incapable person.

It is difficult to clarify advocacy vs. paternalism,

but strategies such as knowing the patient,
clarifying information, and educating all involved
are initial steps in distinguishing advocacy from
paternalism. Conclusion. Truly ‘knowing’ patients,
their life experiences, values, beliefs and
wishes can help clarify the ‘thin line’ and gain a
grasp of these difficult to distinguish theoretical
concept

Early literature on this concept identified two types ofpaternalism: (1) harm paternalism; and (2) benefit paternal-ism
(Johnstone 1999). Harm paternalism’s hallmark is theethical principle of maleficence, which is designed to preventthe
individual from self-harm. That is, the healthcareprovider intervenes to prevent the patient from inflictingself-
harm. Benefit paternalism uses the ethical principal ofbeneficence, by which a ‘good’ is performed that would
nototherwise have occurred. Beauchamp and Childress (2001)divide paternalism into two forms: weak and strong
pater-nalism. Weak paternalism is the inability of the individual tomake an autonomous decision due to a compromised
state.Strong paternalism, in contrast, involves interventions thatare anticipated to benefit the individual, despite the
fact thattheir refusal of the intervention is informed, voluntary andautonomous (Beauchamp & Childress 2001).
The oppo-site of autonomy is heteronomy, or decision-making on thebasis of another rather than the individual
(Rubin 1998).
Qualitative studies of nursing advocacy have identified honouring autonomy, assisting withadvance directives, standing
up for others, controlling painand other symptoms, facilitating communication, accessingservices, interpreting the
system, and finding solutions asaspects of advocacy (Curtin 1979, Gadow 1980, Cartwrightet al.1997, Daniset al.1999,
Foleyet al.2002, Johnson2004, Valente 2004). The nursing literature classifies advo-cacy in three ways: (1) advocacy
motivated by a patient’sright to information and self-determination; (2) advocacy as aright to personal safety; and (3)
advocacy as a philosophicalprinciple in nursing (Vaartio & Leino-Kilpi 2005). However,when the concept of advocacy is
explored through theoreticaland ethical examples, it is not as easy to define.
Using Henderson’s definition of advocacy, it could be argued thatto truly advocate for patients, the nurse must know
thepatient on an individual basis and perform the activitiesthat the individual desires or values. If the nurse does
notknow the individual’s desires or values, the nurse respondsaccording to their personal beliefs on the matter.
Accordingto Curtin (1979), human advocacy is the basis of the nurse-patient relationship. The nurse expresses advocacy
by creatingan environment that is open and supportive to decision-making. To do this, nurses must possess a
sustained andintimate knowledge of the person as a distinct human being(Curtin 1979, Mallik 1997). Gadow (1980) takes
a similarperspective on advocacy, which she calls existential advocacy,and thus begins the ‘thin line’ where advocacy
and pater-nalism blend
According to Kohnke’s definition of advocacy, the nursesupplies the patient with the information needed to make
aninformed decision, but the nurse has the rightto choosewhether to advocateby disclosing the most current
andcorrect information. The nurse must decide whether to‘support’ the patient when the nurse feels that the
patienthas made therightdecision (advocacy) and must refrain from‘rescuing’ the patient when the nurse considers
that thepatient has not made the correct decision (paternalism)(Kohnke 1982). Although Kohnke does not directly
state this,it may be suggested that ‘supporting’ the individual ratherthan ‘rescuing’ the individual is the difference
betweenadvocacy and medical paternalism. When nurses ‘rescue’individuals by guiding their decision-making, they
are deny-ing the individuals’ autonomy and promoting heteronomy.

One strategy that nurses can use to respond to this kind of ethical dilemma isto ‘clarify the thin line’. This can be
accomplished by assessingthe patient’s and family’s knowledge of the situation. Afterassessment, nurses can clarify
concepts, and answer questionsabout care. This is consistent with Kohnke’s definition ofadvocacy. However, if the
physician withholds knowledge, thisputs the nurse in an awkward position. How much additionalinformation will help the
parents make an informed decision?If there is no clarification beyond the physician’s explanation,this is probably a case
of medical paternalism.

Strategies such as knowing the patient, clarifying information, and educating all involved in the decision-making
process help to ensure that advocacy occurs
ALCOHOLIC LIVER DISEASE TRANSPLANT ARTICLE
In general, Americans believe that an illness has a weaker claim morally to medical care when known personal conduct is
what put their health at risk ( Brudney, 2007 ).
Simple steatosis is the most prevalent histological finding, occurring in about 90% heavy drinkers, but it is quickly
reversible with alcohol abstinence
There are three key ethical principles revolving around the rationing of transplantable livers. First is the principle of
medical utility; it demands that organs be allocated first to patients who will experience the maximum medical benefit (
Anantharaju & Van Thiel, 2003 ). Patients with ALD do satisfy this requirement, but when considering the likelihood of
complications relating to de novo malignancies or comorbidities, they may not satisfy it as well as a patient without such
risk factors. Second is the principle of justice. This requires that all patients be given equal concern and respect when they
are in need of liver transplantation. Here, ethical questions are generated regarding potential wastage of allocated organs
by patients who may voluntarily revert to alcohol use ( Anantharaju & Van Thiel, 2003 ). Last is the principle of
autonomy, which considers the personal choices made by patients leading up to the need of liver transplantations (
Anantharaju & Van Thiel, 2003 ). Indiscriminate allocation of liver transplants to patients with ALD who may relapse, in
turn, endangering the function of the allocated organ, is not justifiable to the public in general

Access to Primary Care From the Perspective of Aboriginal Patients at an Urban Emergency Department
Three themes in the findings are discussed: (a) anticipating providers’ assumptions; (b) seeking help for chronic pain; and
(c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of
the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization,
and other forms of disadvantage.
Social suffering was conceptualized by Kleinman, Das, and Lock as resulting from the ways that social, economic, and
political power and related inequities shape human experiences, and how these forms of power shape responses to social
suffering. For example, “trauma, pain and disorders . . . are health conditions; yet they are also political and cultural
matters” (1997, p. ix). In this article, the term marginalized is used to emphasize that marginalization is entrenched in the
history of relations between Aboriginal people and the nation– state, and has resulted in social and structural inequities,
and a disproportionate burden of ill health and social suffering. These inequities cannot be glossed over as lifestyle,
behavioral, or cultural issues; rather, they are manifestations of the complex interplay of social, political, and economic
determinants that influence health status and access to health care. Health status for Aboriginal people is also shaped by
long-standing inequities in access to health care (Peiris, Brown, & Cass, 2008). Research continues to show that tacit and
sometimes overt discriminatory practices and policies in health care create barriers to accessing services (Adelson, 2005;
Bourassa, McKay-McNabb, & Hampton, 2004; Browne, 2007; McCall et al., 2009). Therefore, when analyzing access to
primary care services for Aboriginal people, it is important to examine the intersections between microlevel interactions
operating at the level of clinical practice, and wider social and historical contexts that shape health care relations and
access to services. In this article, we discuss findings from an ethnographic study in which we explored experiences of
access to primary care services from the perspective of Aboriginal people seeking help for health issues triaged as “stable
and nonurgent” at an emergency department (ED) located in a large city in Western Canada
Studies continue to show that factors associated with nonurgent use of the ED include poverty, homelessness, transience,
lack of a regular primary care provider, and social factors related to lack of support, marginalization, loneliness, and
extreme social and psychological distress

In Canada, inequities in access to health care and outcomes for Aboriginal people are well documented at a population
health level (Canadian Institute for Health Information, 2004; Peiris et al., 2008). For example, population level data show
that status First Nations people in urban areas use fewer community-based primary care services and have consistently
higher “preventable hospital admissions” (if patients had access to quality primary care in the community) compared to
other resident populations (British Columbia Provincial Health Officer, 2009). In British Columbia, for example, the age-
standardized mortality rate (ASMR) for “medically treatable diseases” (meaning those for which mortality could
potentially have been avoided through appropriate and timely health care intervention) has fluctuated between 2 and 5
times higher for the status First Nations population compared to other residents—rates that “more than likely reflect gaps
in access to primary care services” (p. 108). These proxy measures signal challenges with access to primary care services;
however, there remains a gap in knowledge concerning the social and contextual factors influencing access, particularly
from the perspective of Aboriginal people living in urban areas.
, “Indigenous perspectives on access barriers are poorly represented and undervalued in the scientific literature”
The most common health issues that both Aboriginal and non-Aboriginal participants sought help for included
chronic pain symptoms, musculoskeletal injuries (mostly soft tissue injuries such as sprains, vs. fractures), and treatment
for abscesses and cellulitis. Examples of other reasons for seeking care among the Aboriginal participants included
postoperative abdominal pain, treatment for post-HIV exposure, and headache. Proportionally more non-Aboriginal
people were in the ED for intravenous antibiotic treatment.
our data show that the ED continues to be used by people whose health is shaped by experiences of social suffering
The elements of care inlude the following: professionalism, ethics and therapeutc relationships. Applying these
elements of care will help you maintain the client as the focus of your care while preserving your clients’ trust in
you, and the public’s trust in the nursing profession.
Personal Health Information Protection Act, 2004 (PHIPA
 The privacy legislaton establishes rules about the collection, use and disclosure of personal health information by
health information custodians and their agents.
 The legislation is designed to balance an individual’s right to privacy with the needs of health care providers
to access, use and share information.
 It also gives clients the right to consent to the collection, use and disclosure of their personal health information.
(PHIPA) requires health information custodians to obtain the consent of the individual or his or her substitute decision-
maker prior to the collection, use or disclosure of personal health information unless PHIPA provides otherwise.
 In some situations, health information custodians and agents are not authorized to access or share clients’ personal
health information without consent from the client.
•PHIPA further requires health information custodians to provide an individual or his or her substitute decision-maker
with a right to request access to records of personal health information about the individual
•Applicable in Ontario
 The Act does not apply to all personal health information, but only that which is collected, used and disclosed by
health information custodian
Personal Health Information:– as one of the most sensitive types of personal information that is frequently shared for a
variety of purposes, including care and treatment, health research, and managing our publicly funded health care system.
Health Informtion Custodians:
•Seven broad categories of health information custodians are included in the definition
•Persons involved in delivering health care services are included.
•Health care practitioners include anyone who provides health care for payment, whether or not the services are publicly
funded
•A person or organization described in section 3 of PHIPA who has custody or control of personal health information as a
result of or in connection with performing the person’s or organization’s powers or duties or the work.
For example:
• health care practitioners, long-term-care service providers, community care access corporations, hospitals and other
facilities, pharmacies, laboratories, a medical officer of health or a board of health, the Ministry of Health and Long-Term
Care, and others are specifically included in the definition
•. The Canadian Blood Services has been designated as a health information custodian by regulation
PHIPA (2004) Who this act applies to:
•The Act does not apply to all personal health information, but only that which is collected, used and disclosed by health
information custodians
• The Act also applies to the use and disclosure of personal health information by those persons who receive personal
health information from health information custodians
•Those who perform services on behalf of a health information custodian are defined as agents.
Agents of health information custodians are also required to follow the rules set out in the Act
For example:
Recipients may include insurance companies, employers, researchers, and others.
Those who perform services on behalf of a health information custodian are defined as agents.
Agents of health information custodians are also required to follow the rules set out in the Act.
Are you an Agent?
Under the Act, you are considered to be an agent if, with respect to personal health information:
•you are authorized to act on behalf of a custodian; and
•you perform activities for the purposes of a custodian rather than your own purposes;
•whether or not you have the authority to bind the custodian;
• whether or not you are employed by the custodian; and
• whether or not you are receiving remuneration.
Collection, Use and Disclosure of Health Information in PHIPA:
Collection
•Personal health information can be collected directly from the individual.
•Personal health information can be collected indirectly if:
the individual consents to it being collected indirectly;
the information is necessary for the individual’s care and it is not reasonable to accurately and completely collect it from
the individual or to do so in a timely manner;
•without consent if the individual is incapable of consenting and it is not reasonably possible to obtain substitute consent
in a timely manner.
Circle of Care:
To know whether you have a client’s consent to access or share personal health information, you must first understand the
concept of the circle of care.
The term ‘circle of care’ is used to describe whether a health information custodian or their agent can assume they have
a client’s implied consent to access or share personal health information or if they will need expressed consent.
 Circle of care is not defined in the privacy legislation, but it appears in the Information and Privacy Commissioner
of Ontario’s resources
Before you access a client’s information, ask yourself the following questions:
First: Is this information necessary for me to provide care to this client? If your answer is yes, then you are in the client’s
circle of care and you have implied consent to access or share the health information with others in the circle of care.
But if your answer is no, which means you are not in the circle of care, you should then ask: do I have the client’s
expressed consent to access and share their personal health information? If your answer to this question is no, then you
cannot access or share the information.
If you are within the circle of care, you can assume that you have implied consent to collect, use and disclose client
health information.
If you are not in the circle of care, then you require expressed consent to access the health record.
For example, if a school administrator calls you to ask about the immunization status of one of your clients, you would not
be permiced to release the information without ge[ng expressed consent from the client, because the school administrator
is not within the circle of care. For more information about implied and expressed consent, read the Consent practice
guideline at www.cno.org/standards.
Must be capacitated to give consent directly:
• The individual must understand information relevant to the decision of whether to consent to the collection, use or
disclosure of personal health information, and
•Appreicate the reasonably foreseeable consequences of giving, not giving, withholding or withdrawing consent.
•Long-term care homes may presume that a resident is capable of consenting to the collection, use or disclosure of his or
her personal health information unless it is unreasonable to do so.

Incapacitated: the following persons (in the following order of priority) may provide consent on behalf of the resident:
1. A substitute decision-maker under section 9, section 39 and section 56 of the Health Care Consent Act, 1996 if
the purpose of the collection, use or disclosure is necessary for or ancillary to a decision about treatment under
Part II, a decision about admission to a care facility under Part III or a decision about a personal assistance service
under Part IV of the Health Care Consent Act, 1996 respectively;
 2. The resident’s guardian of the person or guardian of property, if the consent relates to the guardian’s authority to
make a decision on behalf of the resident;
3. The resident’s attorney for personal care or attorney for property, if the consent relates to the attorney’s authority
to make a decision on behalf of the resident; •
4. The resident’s representative appointed by the Consent and Capacity Board;
5. The resident’s spouse or partner;
6. A child or parent of the resident;
7. A parent of the resident with only a right of access;
8. A sibling of the resident; or • Any other relative of the resident.

Obtaining Consent Where the Resident is Deceased : the estate trustee or the person who assumed responsibility for
the administration of the estate
The Present and Future of Videoconferencing :
The College of Nurses of Ontario (CNO) does not provide specific guidelines on videoconferencing in healthcare but the
College of Physicians and Surgeons (CPSO) hightlights expectations of physicians that are using telemedicine to adhere
to the following:
 Act according to clinical practice standards
 Use technology that is of sufficient quality to enable the physician to provide quality care. (e.g., good quality
Internet speed, sound, visibility, comfortable place)
 Ensure that patient information remains confidential (eg. Ensuring the locations of physician and patient are
secure, and lines of communication are protected from interference)
The CNO expects Nurses to Adhere to The Health Care Consent Act, 1996 (HCCA) and The Substitute Decisions Act,
1992 (SDA) when obtaining informed consent in any context, including via videoconferencing.
Please review Appendix A: Advocating for Clients for specific strategies and prinicples Nurses ought to following from
the CNO Practical Guide to Consent to support obtaining informed consent from patients.
One of the ways for organizations/instituitions to ensure that the communication technology in use is of sufficient quality
and that the practice environment is secure is to carry out telemedicine sessions with a facility accredited by the Ontario
Telemedicine Network (OTN).
According to Ontario Telemedicine Network (OTN, 2013), one of the main ethical dilemmas is related to breaching
privacy and confidentiality because information can be leaked, lost in cyber space and unencrypted. Also other people can
be in the room and over-hear conversations without the patient's knowledge.
hese authors recommend recommended two-factor authentication without biometrics as a workable solution.
However, three-factor authentication including biometrics seems likely to be used once biometrics become more
common.
In this era of precision medicine, eHealth—the use of information and communication technology (ICT) for health—will
become indispensable. However, there are many problems related to eHealth, including security, informed consent for
data-sharing and secondary use, standardization, structuring, and deidentification.
It is important to connect multiple hospitals and areas, or even cooperate internationally, to gather more data. In these
areas, work has already started on an international information-sharing framework.
In this and other related projects, how to obtain consent is an important issue, especially for new data-sharing or
secondary uses of data.
Encryption can be used to protect data but relies on authentication .
 The authentication of most current medical research using online methods employs only passwords.
 authentication is necessary both at the time of consent and at the time of login after consent and
registration.
Registration occurs when the registered user returns to the system. On those occasions, if other people can access the
service as that person, they will be able to see all of the information submitted previously. If they are then able to alter the
consent provision, that creates another risk. This means that security is based on authentication.
Another role of authentication is to prove intent:
 accessing the system without sufficient intention could violate the principle of autonomy.
 Ethical issues need to be considered carefully for proper authentication.
 Proof of intent has traditionally been the role of the signature.
 In conventional informed consent, signing is considered to express agreement.
 In cyberspace, entering information based on the user's personal details (e.g., about his/her own identity) is
considered to prove intent at the time of registration.
 Login must include a process of authentication as a registered participant. There are broadly three ways to do
this: (1) what you know, (2) what you have, and (3) what you are (Ogorman, 2003).
 1. “What you know” authenticates users based on something only they know, such as a password or secret
question. If this can be obtained or guessed by other people, they can impersonate the user.
 2. “What you have” authenticates users based on something they own, such as a device. This type of method can
be inconvenient, since users can only use preregistered devices, and loss or theft of the registered device could be
a security risk
 3. Biometric authentication, or “what you are” systems. These systems authenticate users via fingerprints,
faces, ears, voice print, or iris. Biometric information itself is sensitive and has an inherent problem that it cannot
be changed if leaked. Biometric authentication still suffers from problems of accuracy and cost, although it has
improved recently. An ideal biometric system should have complete accuracy. In the real world, no such
biometric system or technology currently exists.
 If participants use smart devices with biometric authentication systems to authenticate their identity in the
research system, the accuracy of the authentication is dependent on the type of smart device used.
Therefore, the research system itself cannot guarantee the security of the data which results in an ethical
issue; maintainig confidentiality and privacy of patients data.
 Another concern is that replication technologies such as three-dimensional printers and sound recording may
enable “cheating” of biometric authentication in the future, and systems which can authenticate accidentally,
such as a fingerprint sensor, cannot be used to prove intent.
 Before implementing any authentication system for an eHealth system consider the requirements for
authentication in eHealth:
 There are four main elements:
 1. First, it must be able to prevent impersonation.
 2. Second, it should demonstrate intent.
 3. Third, it should be able to be changed, even if a user loses or forgets the authentication key.
 4.It should be user-friendly.
 Some information security experts have proposed the use of three-factor authentication, which combines the
three categories of authentication.
 Three-factor authentication currently requires multiple steps, which means it is complicated to use; resulting in
decreases of usability and may prevent patients from participating in medical research.
 It is currently not practical to apply three-factor authentication to healthcare systems if the use of biometric
information is applied, which is directly linked to individuals and cannot be changed if it is leaked or lost.
 Solutions:
 A) The most practical means is two-factor authentication, as recommended in the latest guidelines from the US
National Institute of Standards and Technology (Grassi et al., 2017).
 Two-factor authentication combining “what you know” and “what you have” is currently the most viable. This
type of method could be used for obtaining consent through online methods and the exchange of health
information, such as genetic data.
 The acceptability of two-factor authentication is also dependent on the type of data that are stored or
exchanged in the system. For example, ordinary two-factor authentication may be acceptable for subjective
clinical or health data, such as blood pressure, which is measured at home or using smartphones.
However, methods with higher security may be necessary if individually identifiable data or information are
exchanged and stored; biometric authentication
 B) Include ethics committees to have governance over the following points:
 1. Does the authentication system prevent impersonation? (If needed, ask the ICT experts for advice.)