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Markkula Center for Applied Ethics

Understanding the Ethics of Digital Mental Health Care: Telemedicine and Mental Health Apps

Orlando Caballero ’22

Gerald Herbert/Associated Press

Orlando Caballero ‘22 is a public health major with a  biology minor and a 2021-22 health care ethics intern at the Markkula Center for Applied Ethics. Views are his own. 


During the COVID-19 pandemic, medical and health-related institutions saw patients exhibit decreases in wellbeing and an increase in mental health problems across the board due to social distancing restrictions. In fact, it was found that during the pandemic, four in 10 adults in the U.S. reported symptoms of anxiety or depression, up from one in 10 adults from January to June 2019. Lastly, those with pre-existing symptoms of anxiety and depression only found a worsening of their conditions, leading to thousands across the globe in need of assistance. 

As a result of these broad trends affecting populations on a global scale, there was an accelerated move towards the implementation of digital tools for mental health care. Telemedicine became the predominant method of communication for mental health care, leading to broader access and fewer “no-shows” from patients. Mental health apps also became more prevalent in an effort to offer immediate care. However, in the rush to provide assistance to populations in need, it is evident that efficacy and safety regulations in the United States were not properly addressed, and that there are a myriad of ethical issues that have been brought forth as a result. 

Telemedicine With a Focus on The Patient-Physician Relationship

According to the American Medical Association (AMA), telemedicine should only be used as a supplement for live visits and only for patients with whom the practitioner has a pre-existing relationship. This is because the patient-doctor relationship is essential to delivering effective health care, as it allows for the fostering of mutual trust and empathy. However, due to the dynamics of the pandemic and increased need, not every patient has been able to develop a relationship with their physician prior to the utilization of telemedicine. This dynamic can lead to an imbalance in the patient-provider relationship, spanning from increased paternalism to unfamiliarity of the patient’s mindset and thought process.

 In addition, it should be noted that best practice for socially distanced care for patients with severe mental illness was and still is being explored, meaning that additional understanding of the efficacy of telemedicine in relation to mental health still needs further research. While medical institutions weren’t expected to have in-person care when COVID-19 was at its peak, we must remember that each patient deserves the best practices that are rooted in evidence, and we must move forward past the pandemic with that in mind.

Mental Health Apps With a Focus on Safety and Accountability

In the United States, the Food and Drug Administration (FDA) is in charge of the regulation of mental health apps. During the pandemic, FDA regulations were relaxed in order to quickly address the rapidly growing problem. From a benefit-to-cost perspective, this was a choice for the short-term, but there needs to be additional regulation in order to ensure there are high quality products on the market in the long term. 

In the beginning of the pandemic, it was notable that the economy slowed down and more individuals suffered from a financial standpoint. Subsequently, those in poor financial positions may have opted for mental health apps over higher quality, in-person care, displaying how those with lower socioeconomic status may still not be able to get the care they need. In addition, mental health developers and companies were and are still not fully liable for potential harms that patients may encounter as a result of ineffective mental health apps. The argument can be made that this is an unethical provider-patient relationship that is developing, as clients take all the risk while providers are able to benefit from a monetary standpoint regardless of proper care. 

As we begin to move forward past the pandemic, it is essential that regulations and quality control across the board for both telemedicine and mental health apps are raised to a higher level, and that patients are still given the choice to pursue quality in-person care. This is especially true when ensuring that healthcare institutions are not utilizing a “one-size-fits all” approach, as some patients may benefit more from digital sources of care, while others may prefer in-person approaches. Our communities deserve the best practices, access to quality health care, and a fair and equitable approach to the rapidly approaching digital age of healthcare, even if companies and insurers may not be able to benefit as much from a financial standpoint. 

Apr 7, 2022

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