The ethics of digital mental health aren’t just about the NHS

A short contribution made by Mark Brown to a digital ethics roundtable event on 24th May 2021.

Technology has the capacity to cross boundaries. It can find its way into the secrets of people’s lives like a woodlouse finds its way into a damp home.

What is important is to recognise that the prize is not always worth the destruction required to win it. Public facing technology requires the acceptance and the continued interaction by the public for it to provide any benefit at all. Such technology needs to work with the grain of people’s lives, not against it. This requires a focus on the needs of the user even more than a consumer application, as the end result for the individual is likely to be neither direct or immediate. It also requires the user to trust not only the intervention but also the reason why the technology is being suggested or prescribed to them right here, right now. If the user feels fobbed off, short-changed, misled or oversold, then a quick installation and a long, lingering half-life for the app or service, unused and eventually deleted.

People can get their heads around how personal data that makes them identifiable might used in other than their best interest, but are far less sure of the ways in which data can contribute to predictive models, algorithmic identification or even the automating of decision making. The ethics of data do not just apply to the individual, but to the individual as part of a far wider group upon which products derived from their data might be used to impose unwelcome outcomes.

It is especially important that we are careful in mental health, as our mental health system is linked to macheries of law which can override the human rights of an individual for their own good. Malign or benign paternalism can be turbo-charged through the use of digital technology.

Large and predatory technology companies are well aware that mental health is a wicked problem about which increasing numbers of people are concerned. We must be exceedingly careful that mental health does not become a testing ground for lucrative, society changing technology development, justified by the outstanding need to do something.

Technology presents the possibility for personalisation at scale and the delivery of specialised care without the requirement for density of need in a particular geographical location. It gives the chance trials of one, of something far better than ‘we build an app and we give it to everyone.’

I’m most excited about ecological momentary interventions and ecological momentary measurements, bringing together as they do smartphone technology and the promise of ‘just in time’ intervention. Even this is fraught with ethical danger.

Imagine developing a digital phenotype that could tell you whether someone currently had a particular mental health challenge with greater accuracy than through observation, formulation, self-accounts. Imagine that this phenotype could also be used predictively. And that this phenotype could be derived from non-medical, non patient identifiable data. Imagine that it wasn’t the NHS that held the data. Imagine it was available to anyone who was prepared to pay for it. Like an insurer. Or a government Or private entities.

Technology can rupture the barrier between inner states and outer observation. Whether this a force for good or ill will depend not on the technology itself but on the purpose to which it is put.

Luckily, most stuff that is out in the wild at present is awful and most stuff that could actually have transformative power is too far from the understanding of commissioners and clinicians to actually be put into wide scale action. So, for now, the point is largely moot. But vigilance is required, with far more urgency and applications than ever before. Someone somewhere is very near, as I speak, to creating something amazing that could also be absolutely terrible.

@markoneinfour