The legal and ethical aspects of telemedicine By BA Stanberry Royal Society of Medicine Press 172 pages £19.99

It is a hallowed tradition that all books about telemedicine have to start by pointing out that it isn't really new at all. 'The first telemedicine was practised 12,000 years ago, when Native American witch doctors sent smoke signals to neighbouring tribes asking for help in curing their sick chief. And today, doctors routinely fax pictures of the rashes on their patients' bottoms to consultant dermatologists at a nearby hospital.' That sort of thing.

By this means, the authors - who are generally telemedicine evangelists and buffs - hope to persuade the outside world of infidels that there aren't really any new medicolegal problems to be faced and that, at long last, it's all systems go for their new wave of medicine.

So it is with this book. But its author does at least admit that the 'routine' use of telemedicine will generate new types of encounter between patients and health services. That is where the ethical worries come in - even though the author's purpose is to persuade us that the current legal framework should cope and that there is no need for a new one.

As it happens, the NHS Executive's brand new information management strategy has just ordered a detailed study of the technical prospects for telemedicine, with the resulting national framework to be published early in 1999. So before health service managers get bound up in the technical minutiae, they could usefully spare a few train journeys to read up on the legal problems.

What are these problems then? As ever, where the medical profession is involved, confidentiality is high on the list. Ben Stanberry's approach is to list all the possible ways in which telemedical consultations could pose confidentiality dangers, and show how these have close enough parallels in conventional practice for them to be covered by existing law.

Some readers may be convinced by this, but the worry that telemedical data, in the course of its life, automatically passes well beyond the control of the professionals concerned was glossed over. The data is also copied and translated into different forms, many of them incomprehensible except to IT buffs. That worries me and I think it will worry many doctors too.

Liability is another hot potato, and here Mr Stanberry - a Cardiff University lecturer - admits that there are definite problems. First, there are as yet virtually no established standards of telecare. Second, training is likely to be patchy, at least to start with. Third, there is no tradition of delegating authority and sharing responsibility - carrying the risk that teleconsultants might take more on themselves than they are qualified to do.

Add this to the possible consequences of equipment malfunction or communication link failure, and the prospects look good for a clever lawyer who is looking for something 'not according to Bolam'. At least we can say that a remote live consultation on a bypass graft on new year's eve 1999 would be unwise.

I think this book glosses over the difficulties ahead, though I agree that other legal problems - for example the 'which jurisdiction?' issue, and regional limitations on doctors' qualifications to practice - seem less important here than in federal states like the US.

Few readers are likely to disagree with the author's concluding advice, though: 'If there is one lesson that teleconsultants could learn from what lawyers have done... it would be to keep them out of telemedicine as much as possible.' Well, if we can't kill them...

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