Respect, justice and learning are limited when patients are deidentified data subjects

• Published in: Learning health systems Vol. 6; no. 3; pp. e10303 - n/a
• Main Authors: Gross, Marielle S., Hood, Amelia J., Rubin, Joshua C., Miller, Robert C.
• Format: Journal Article
• Language: English
• Published: United States John Wiley & Sons, Inc 01-07-2022; John Wiley and Sons Inc; Wiley
• Subjects: Breast cancer; common rule; data use policy; deidentification; deidentified data; Ethics; federal regulations; Fiduciary responsibility; HIPAA; human subjects research; Informed consent; learning health systems; Patients; Policy Analyses; Privacy; structural justice; United States > US; structural justice; deidentified data; HIPAA; deidentification; federal regulations; common rule; ethics; human subjects research; learning health systems; data use policy
• ISSN: 2379-6146; 2379-6146
• DOI: 10.1002/lrh2.10303

Introduction
Critical for advancing a Learning Health System (LHS) in the U.S., a regulatory safe harbor for deidentified data reduces barriers to learning from care at scale while minimizing privacy risks. We examine deidentified data policy as a mechanism for synthesizing the ethical obligations underlying clinical care and human subjects research for an LHS which conceptually and practically integrates care and research, blurring the roles of patient and subject.
Methods
First, we discuss respect for persons vis‐a‐vis the systemic secondary use of data and tissue collected in the fiduciary context of clinical care. We argue that, without traditional informed consent or duty to benefit the individual, deidentification may allow secondary use to supersede the primary purpose of care. Next, we consider the effectiveness of deidentification for minimizing harms via privacy protection and maximizing benefits via promoting learning and translational care. We find that deidentification is unable to fully protect privacy given the vastness of health data and current technology, yet it imposes limitations to learning and barriers for efficient translation. After that, we evaluate the impact of deidentification on distributive justice within an LHS ethical framework in which patients are obligated to contribute to learning and the system has a duty to translate knowledge into better care. Such a system may permit exacerbation of health disparities as it accelerates learning without mechanisms to ensure that individuals' contributions and benefits are fair and balanced.
Results
We find that, despite its established advantages, system‐wide use of deidentification may be suboptimal for signaling respect, protecting privacy or promoting learning, and satisfying requirements of justice for patients and subjects.
Conclusions
Finally, we highlight ethical, socioeconomic, technological and legal challenges and next steps, including a critical appreciation for novel approaches to realize an LHS that maximizes efficient, effective learning and just translation without the compromises of deidentification.