Health Apps and their Positive and Negative Aspects. An Ethical Perspective

Essay, 2021

12 Pages, Grade: 1,0




1. Introduction

2. Conceptual classifications of health apps
2.1 eHealth and mHealth
2.2 Health apps and their delimitation from medical apps

3. Ethical aspects of health apps
3.1 Ethical questions
3.2 Discussion

4. Summary and conclusion


Notes: The literal quotations in the following, which were taken from the German language, have been translated by the author for a better readability. Due to the limitations of this work, the contents have been limited to the following.


BfArM Bundesinstitut für Arzneimittel und Medizinprodukte

(engl.: Federal Institute for Drugs and Medical Devices)

DiGA Digitale Gesundheitsanwendungen

(engl.: Digital Health Applications)

EC European Commission

FTC Federal Trade Comission

GKV Gesetzliche Krankenversicherung

(engl.: compulsary health insurance)

PDA Personal Digital Assistant

WHO World Health Organization

1. Introduction

Mobile health technologies, especially health apps, have gained a lot of notoriety in society in recent years and are here to stay as a key component of digitalization in healthcare (Cvrkel, 2018; Scherenberg & Liegmann, 2018). They reinforce the possibility of being able to directly influence one's own health in a self-determined manner. Especially through the smartphone, health-promoting measures such as sports or relaxation exercises can be carried out in time and location independence and usually in connection with games and fun. This and advertisements by celebrities or politicians in the (social) media considerably increase the attractiveness of a healthy lifestyle. (Scherenberg & Liegmann, 2018) A study conducted by the market research institute Bitkom Research in 2020, among 909 people, found that 75% of people aged 16 and older already use freely available health apps. Most frequently, with 38% of participants, apps are used for sports exercises at home. In addition, health and medical apps are already available on prescription, and 59% of Germans aged 16 and older can imagine using such an app. (Rohleder, 2020)

But are there only positive things to say about health apps, or do conflicts also come to light, especially from an ethical perspective? This will be clarified in the following. In order to be able to analyze and discuss these possible challenges, risks and also opportunities of this technological innovation, however, important background information must first be presented. - What is meant by the term health app? Into which categories and areas of application can they be divided? How do they differ from medical apps? What are their goals and benefits? (Scherenberg & Liegmann, 2018; Bendel, 2018)

2. Conceptual classifications of health apps

The term of digitalization is now present everywhere, in politics, business and also in society. Due to its broad range of topics, many meanings are attributed to it. Essentially, the word digitization is used to describe the process of transforming analog circumstances completely or partially into digital models for service delivery. This primarily saves human and financial resources and optimizes and dynamizes services. (Wolf & Stohschen, 2018) A proliferation of digital applications is also evident in the healthcare sector. In this context, the large number of people who deal with health issues themselves and use websites for research or exchange with others is particularly noticeable. The number of these people is increasing, as shown by the data collected on visits to and use of such portals and websites. The relevance of so-called health apps is also increasingly crystallizing in the social context. (Evers-Wölk et al., 2018) "The smartphone and in the future other mobile form factors will thus become ultimate assistants for users in everyday life, as well as potentially in health issues - as far as apps are concerned, those serving health-related topics are predicted to experience enormous market growth" (Albrecht & Jan, 2019, p. 417). In order to clarify the basic content and background of health apps, the terms ehealth, mhealth and health apps are first defined, explained and classified below.

2.1 eHealth and mHealth

Electronic health (ehealth) includes all "electronically supported activities in the health sector" (Evers-Wölk et al., 2018, p. 29). Historically, it is preceded by terms such as teleradiology, telediagnostics, and teleconsultation in the 1960s, telemedicine in the 1970s, and telematics and health telematics in the 1990s (Evers-Wölk et al., 2018). There is no clear definition of the term. The EU Commission describes ehealth as "tools and services that use information and communication technologies [...] to improve prevention, diagnosis, treatment, monitoring and management of health-related issues and to monitor and manage lifestyle-habits that impact health" (EC, 2013). "In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide [...]" (Eysenbach, 2001, p.1). The "e" in this context stands not only for electronic, but also for everything that such tools should take into account - efficiency, enhancing quality, evidence based, empowerment, encouragement, education, ethics, equity, entertainment, and easy to use (Eysenbach, 2001). Above all, eHealth is expected to bring increased efficiency and cost savings, thereby reducing the financial burden on the health care system (Groß & Schmidt, 2018).

The term mhealth means mobile health and is a subset of electronic health (Evers-Wölk et al., 2018). Just like ehealth, mhealth is used to optimize health outcomes, but mhealth makes use of mobile communication (Vital Wave Consulting, 2009). A precise definition was provided by the World Health Organization (WHO), according to which mhealth includes "medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices" (WHO, 2011, p.6). Thus, in addition to medical practices such as diagnosis and treatment, mHealth is also intended to serve prevention and health promotion, thereby also bringing about an increase in the quality of life of humanity (Endl et al., 2015; Vital Wave Consulting 2009). In accordance with this conceptual explanation, mhealth also includes so-called health apps.

2.2 Health apps and their delimitation from medical apps

Applications or application software, or apps for short, are application programs that run on IT- supported systems such as computers or cell phones. Today, the term "apps" is most often associated with applications for the smartphone. Some of these applications are pre-installed on the mobile device, others can be downloaded directly online via so-called app stores, such as Google Play or the Apple Store, free of charge or for a fee. (Koppay, 2012)

The term "health apps" is used to describe application programs for mobile devices, primarily smartphones and tablets, which aim to have a positive influence on the user's health. According to the WHO's definition of health (1948), their goal is to have a positive effect on physical, mental, and social well-being. (Evers-Wölk et al., 2018) With the help of health apps, health-related data can be recorded, processed, and graphically displayed. These data can be, for example, nutritional values, consumed food and stimulants, vital signs, sleep duration and quality, physical activities or mental states. Location data is also collected. (Barcena et al. 2014) Data can be collected directly via the mobile device or with the help of additional devices such as fitness bracelets or sensors (Evers-Wölk et al., 2018).

Health apps can be categorized according to their areas of application. These are health promotion, primary prevention, and secondary prevention. Health promotion apps aim to strengthen health skills, resources, and protective factors. They support a healthy lifestyle through content of exercise, healthy nutrition, stress management and relaxation. (Scherenberg & Kramer, 2013) Examples include the 7Mind meditation & mindfulness app1 or the Samsung Health app2 for implementing healthy habits. Primary prevention apps are used to prevent disease by avoiding health risk factors through use (Scherenberg & Kramer, 2013). An example currently is the Corona-Warnapp3. Secondary prevention apps also serve to prevent disease, but target individuals with pre-existing risk factors, such as smokers (Scherenberg & Kramer, 2013). Examples include the apps Flamy4 for smoking cessation and Lifesum5 for weight management. All of these apps can be used independently by the user (Evers-Wölk et al., 2018).

Applications in the field of tertiary prevention belong to so-called medical apps and are to be distinguished from health apps. The main difference is that these are intended for patients and relatives. They serve to cope with illness and offer support in the area of self-help, especially for chronically ill patients, in order to better cope with everyday life. (Kramer, 2017) Also components of such apps are "[...] statistical evaluations, graphical representations of the course or the warning of exceeded limits as well as reminders of appointments or required medication" (Albrecht & Jan, p. 435). Apps for experts such as medical professionals, for decision support also count as medical- apps. (Kramer, 2017; Evers-Wölk et al., 2018).

Medical apps and also health apps can also be classified as medical devices under certain conditions. To do so, they must primarily support the detection, prevention, monitoring, examination, diagnosis, or treatment of disease, injury, or disability, or serve to regulate conception. (Kramer, 2017; BfArM, 2013) If this is the case, they can receive a CE marking after going through an evaluation process and be counted as Digital Health Applications (DiGA) (BfArM, 2013). This means that they "[...] can be prescribed by physicians and psychotherapists and [in the case of a cost liability] are reimbursed by the health insurance" (BfArM, 2013).

3. Ethical aspects of health apps

Ethics is a discipline of philosophy and was first named in this context by the Greek philosopher Aristotle (Düwell et al., 2006). The word ethics comes from the Greek word "ethos" and "means something like "custom, usage, habit", so that "ethical" would be considered to be acting in accordance with generally accepted norms" (Fenner, 2020). In the actual sense, however, these norms and traditions are subordinated to human reason. Ethical action thus describes a distinction between good and bad according to one's own reason. It is about behaving in the right way. (Düwell et al., 2006) Whether this is the case can be tested according to the categorical imperative according to the German philosopher Kant with the question "What would be if everyone acted like this?". Kant's ethics, however, forbids or enjoins some actions fundamentally, in independence of their consequences. That is why it is also called deontological ethics, which means ethics of duties. According to this, lying, torturing and killing a human being are morally forbidden. (Frey & Schmalzried, 2013) In general, however, there are many other ethics and sub-ethics besides Kant's ethics.

Medical ethics deals with the area of health apps. It "[...] examines moral thought and behavior in relation to the treatment of human illness and the promotion of human health, and asks what is morally desired and intended in dealing with human illness and health" (Bendel, 2018). With the implementation of apps, electronic assistance systems, and robotics in healthcare, medical ethics faces new questions (Bendel, 2018). In the following, the fundamental ethical issues of health apps are listed and then discussed.

3.1 Ethical questions

The goals and potential benefits of health apps have already been outlined. However, some conflicting goals arise from the areas and methods of application, which appear morally questionable and require ethical discussion (Fangerau). The consideration of possible risks and consequences is mandatory. This context gives rise to some questions that need to be discussed:

- Can the privacy of users be endangered and is there a danger of surveillance and control (Fangerau)?
- Is third-party control of the app in the sense of welfare permissible at all (Bendel, 2018)?
- Are the autonomy and personal data of the users sufficiently protected (Bendel, 2018)?
- How trustworthy is the content of these apps in terms of the quality, scientific nature and goals of the contributions (Kramer, 2017)?
- Can equity and equality in terms of accessibility for all segments of the population be guaranteed (Albrecht, 2018)?

3.2 Discussion

For the most part, health apps are available to end users free of charge for download from app stores. However, the development of an application is associated with many costs, which justifies the question of the developers' motivation. Frequently, work is done here in cooperation with players in the healthcare sector, who present advertising content in the apps. Two major representatives are the statutory health insurers and the pharmaceutical industry. While the health insurers primarily want to attract new customers, pharmaceutical companies try to encourage people to buy their products. The trustworthiness of the content is therefore often questionable. Therefore, it must be clearly marked when it is advertising content in order to clearly distinguish it from health information and not to mislead the consumer and, in the worst case, lose his trust. (Scherenberg & Kramer, 2013)







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Health Apps and their Positive and Negative Aspects. An Ethical Perspective
University of Applied Sciences Coburg
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health, apps, positive, negative, aspects, ethical, perspective
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Cesca Berg (Author), 2021, Health Apps and their Positive and Negative Aspects. An Ethical Perspective, Munich, GRIN Verlag,


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