Development and Presentation of an Ethical Framework for Health and Medical Apps


Keywords: mHealth, apps, heaslthcare, medical ethics


The ubiquity of mobile applications makes it difficult to weigh up opportunities and potential risks. One significant aspect of an ethical assessment regarding the development and use of health and medical apps is the lack of clear and consistent guidelines and measures of value. Aim: The aim of this paper was to identify the main ethical determinants associated in the context of health and medical apps and develop a framework for ethical reflection. Methods: A systematic literature search in the database PubMed was undertaken and the journal Biomed Central Medical Ethics was hand searched and 32 met the review criteria. On this basis of the review an interview guide was developed and five purposively selected experts on the field of payers, science, consumers, medical ethics and society were interviewed regarding health and medical apps. Results: There is a lack of consistent and clear guidelines regarding the use of health and medical apps in literature. Indeed, findings refer to established biomedical principles. The interviews identified that several insecurities related to legal and regulatory issues are common. On the other hand, many advantages of the use of health and medical apps have been pointed out by experts. Conclusion: Debates on ethics and the use of health and medical apps should play a significant role in public discussion. Ethical endpoints cannot be considered isolated from each other, and must be regarded as a complex network of aspects connected with each other. Further research should concentrate on the development of consistent guidelines and a framework for reflection of occurring ethical concerns.

Author Biographies

Pinar Tokgöz, Universität Bielefeld

Bachelor of Science

Hannah Eger, Bielefeld University

Bachelor of Science

Sarah Sharlyn Funke, University of Bielefeld

Bachelor of Science

Alexander Gutjar, University of Bielefeld

Bachelor of Science

Thuy Nguyen-Thi, University of Bielefeld

Bachelor of Science

Christoph Dockweiler, University of Bielefeld

Jun.-Prof. Dr. at School of Public Health Bielefeld University


Neumann K, Larisch K, Dietzel J, et al. Digitale Versorgungsprodukte: Chancen nutzen, sichere Wege in den Markt schaffen. Berlin, IGES, 2016.

Gigerenzer G, Schlegel-Matthies K, Wagner GG. Digitale Welt und Gesundheit. eHealth und mHealth – Chancen und Risiken der Digitalisierung im Gesundheitsbereich. Berlin, SVR, 2016.

Fischer F, Krämer A. eHealth in Deutschland. Berlin,Heidelberg ,Springer Berlin Heidelberg, 2016.

Rossmann C, Krömer N. mHealth in der medizinischen Versorgung, Prävention und Gesundheits- förderung. In: Fischer F, Krämer A, editors. eHealth in Deutschland. Berlin, Heidelberg: Springer Berlin Heidelberg; 2016;441-456.

World Health Organization. mHealth. New horizons for health through mobile technologies. Geneva, WHO, 2011.

Albrecht UV. Chancen und Risiken von Gesundheits-Apps (CHARISMHA). Hannover, Medizinische Hochschule Hannover, 2016.

Beauchamp TL, Childress JF. Principles of biomedical ethics (7th edition). New York, Oxford University Press, 2013.

Mayring P. Qualitative Inhaltsanalyse. Grundlagen und Techniken. Beltz, Weinheim, 2010.

Albrecht UV, Reichertz PL. Health apps – sound and trustworthy? World Med J 2015;61(2):75-77.

Arora S, Yttri J, Nilsen W. Privacy and security in mobile health (mhealth) research. Alcohol Res 2014;36(1):143-150. PMID: 26259009.

Barton AJ. The regulation of mobile health applications. BMC Med 2012;10(46):1-4. DOI:10.1186/1741-7015-10-46.

Carter A, Liddle J, Hall W, Chenery H. Mobile phones in research and treatment. ethical guidelines and future directions. JMIR Mhealth Uhealth 2015;3(4),e95. DOI:10.2196/mhealth.4538.

Chaet D, Clearfield R, Sabin JE, Skimming K. Ethical practice in telehealth and telemedicine. J Gen Intern Med 2017;32(10):1136-1140. DOI: 10.1007/s11606-017-4082-2.

Eagleson R, Altamirano-Diaz L, McInnis A, et al. Implementation of clinical research trials using web-based and mobile devices. Challenges and solutions. BMC Med Res Methodol 2017;17(1):43. DOI:10.1186/s12874-017-0324-6.

Gilmartin C, Arbe-Barnes EH, Diamond M. Varsity medical ethics debate 2018: constant health monitoring - the advance of technology into healthcare. Philos Ethics Humanit Med 2018;13(12):1-7. DOI: 10.1186/s13010-018-0065-0.

Harari GM, Lane ND, Wang R, et al. Using smartphones to collect behavioral data in psychological science. Opportunities, practical considerations, and challenges. Perspect Psychol Sci 2016;11(6):838-854. DOI: 10.1177/1745691616650285.

Ho A, Quick O. Leaving patients to their own devices? Smart technology, safety and therapeutic relationships. BMC Medical Ethics 2018;19(18):1-6. DOI:10.1186/s12910-018-0255-8.

Kacetl J, Maresova P. Legislative and ethical aspects of introducing new technologies in medical care for senior citizens in developed countries. Clin Interv Aging 2016;11:977-984. DOI:10.2147/CIA.S104433.

Labrique AB, Kirk GD, Westergaard RP, Merritt MW. Ethical issues in mHealth research involving persons living with HIV/AIDS and substance abuse. AIDS Res Treat 2013;189645:1-6. DOI:10.1155/2013/189645.

Lhotska L, Cheshire P, Pharow P, Macku D. Non-technical issues in design and development of personal portable devices. In: Hofdijk J, et al. editors. Transforming healthcare with the internet of things. Proceedings of the EFMI Special Topic Conference 2016, Paris. Amsterdam, IOS Press, 2016. 46-50.

Lucivero F, Jongsma KR. A mobile revolution for healthcare? Setting the agenda for bioethics. J Med Ethics 2018;44(10):685–689. DOI: 10.1136/medethics-2017-10474.

Mittelstadt B, Fairweather B, Shaw M, McBride N. The ethical implications of personal health monitoring. Int J Technoethics 2014;5(2):37-60. DOI: 10.4018/ijt.2014070104.

Myers J, Frieden TR, Bherwani KM, Henning KJ. Ethics in public health research: Privacy and public health at risk: Public health confidentiality in the digital age. Am J Public Health 2008;98(5):793-801.DOI: 10.2105/AJPH.2006.107706.

Olff M. Mobile mental health: a challenging research agenda. Eur J Psychotraumatol 2015; 6:27882. DOI: 10.3402/ejpt.v6.27882.

Torous J, Roberts LW. The ethical use of mobile health technology in clinical psychiatry. J Nerv Ment Dis 2017;205(1):4-8. DOI: 10.1097/NMD.0000000000000596.

Vayena E, Salathé M, Madoff LC, Brownstein JS. Ethical challenges of big data in public health. PLoS Comput Biol 2015;11(2): e1003904. DOI: 10.1371/journal.pcbi.1003904.

Bauer M, Glenn T, Monteith S. Ethical perspectives on recommending digital technology for patients with mental illness. Int J Bipolar Disord 2017;5:6. DOI: 10.1186/s40345-017-0073-9.

Chan S, Godwin H, Gonzalez A, Yellowlees PM, Hilty DM. Review of use and integration of mobile apps into psychiatric treatments. Curr Psychiatry Rep 2017;19(12):96. DOI: 10.1007/s11920-017-0848-9.

Clar C, Dyakova M, Curtis K, et al. Just telling and selling. Current limitations in the use of digital media in public health: a scoping review. Public Health 2014;128(12):1066-1075. DOI: 10.1016/j.puhe.2014.09.009.

Groß D, Schmidt M. E-Health und Gesundheitsapps aus medizinethischer Sicht. Wollen wir alles, was wir können? Bundesgesundheitsbl 2018;61(3):349–357. DOI: 10.1007/s00103-018-2697-z.

Moore S, Tassé A-M, Thorogood A, et al. Consent processes for mobile app mediated research: systematic review. JMIR Mhealth Uhealth 2017;5(8):e126. DOI: 10.2196/mhealth.7014.

O' Doherty KC, Christofides E, Yen J, et al. If you build it, they will come. Unintended future uses of organised health data collections. BMC Med Ethics 2016;17(1):54. DOI: 10.1186/s12910-016-0137-x.

Sharp M, O´Sullivan D. (2017). Mobile medical apps and mHealth devices. A framework to build medical apps and mHealth Devices in an ethical manner to promote safer use – a literature review. Stud Health Technol Inform 2017;235:363-367. DOI: 10.3233/978-1-61499-753-5-363

Huckvale K, Prieto JT, Tilney M, Benghozi P -J, Car J. Unaddressed privacy risks in accredited health and wellness apps. A cross-sectional systematic assessment. BMC Med 2015;13:214. DOI: 10.1186/s12916-015-0444-y.

La Vega R de, Miró J. mHealth. A strategic field without a solid scientific soul. A systematic review of pain-related apps. PloS One 2014;9(7):e101312. DOI: 10.1371/journal.pone.0101312.

Matthew-Maich N, Harris L, Ploeg J, et al. Designing, implementing, and evaluating mobile health technologies for managing chronic conditions in older adults. A scoping review. JMIR Mhealth Uhealth 2016;4(2): e29. DOI: 10.2196/mhealth.5127.

Kunde L, McMeniman E, Parker M. Clinical photography in dermatology. Ethical and medico-legal considerations in the age of digital and smartphone technology. Australas J Dermatol 2013;54(3):192-197. DOI: 10.1111/ajd.12063.

Nebeker C, Murray K, Holub C, Haughton J, Arredondo EM. Acceptance of mobile health in communities underrepresented in biomedical research. Barriers and ethical considerations for scientists. JMIR Mhealth Uhealth 2017;5(6):e87. DOI: 10.2196/mhealth.6494.

Anderson K, Burford O, Emmerton L. Mobile health apps to facilitate self-care. A qualitative study of user experiences. PloS One 2016;11(5): e0156164. DOI: 10.1371/journal.pone.0156164.

Kant I. Grundlegung zur Metaphysik der Sitten. Hamburg, Meiner,1999.

Beauchamp TL, Childress JF. Principles of biomedical ethics (5th edition). Oxford, Oxford University Press, 2001.

Bürgerliches Gesetzbuch. (2013). Gesetz zur Verbesserung der Rechte von Patientinnen und Patienten. Available at:*%5B%40attr_id%3D%27bgbl113s0277.pdf%27%5D151540106408 accessed 13 December 2018.

Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44(5):681-692. PMID: 9032835.EU. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016. Official Journal of the European Union 2016: L 119/1 – 119/88.

Schloemer T, Schröder-Bäck P. Criteria for evaluating transferability of health interventions: a systematic review and thematic synthesis. Implementation Science 2018;13(88):1-17. DOI: 10.1186/s13012-018-0751-8.

How to Cite
Tokgöz, P., Eger, H., Funke, S. S., Gutjar, A., Nguyen-Thi, T., & Dockweiler, C. (2019). Development and Presentation of an Ethical Framework for Health and Medical Apps. Journal of the International Society for Telemedicine and EHealth, 7, e15 (1-8).
Original Research