Beneficence

Beneficence is described as the duty of health care professionals to act in ways that benefit their patients and to take positive steps to prevent and remove harm from their patients 13. In the context of obstetric and gynecologic care, any analysis of the beneficence of telehealth must consider the demonstrated and theoretical potential for telehealth modalities to benefit patients, in terms of direct health benefits as well as logistic and financial benefits related to nonhealth resources. A growing body of recent research shows the potential for telehealth to provide concrete benefits for patients seeking a wide range of health care services 14. These telehealth interventions may improve outcomes by allowing more frequent engagement with patients, promoting healthy habits, improving patient education, lowering logistical barriers for patients to engage with care, or even improving the accuracy of patient-collected data by using remote devices to send clinical information directly to the physician 15. ACOG supports the use of telehealth care models to improve the quality of and increase access to obstetric and gynecologic care.

In the context of prenatal care, research shows the potential for telehealth to improve asthma control for pregnant patients 16, assist with smoking cessation during pregnancy 14 17 18 19, manage diabetes during pregnancy 14, and monitor patients with hypertension who are at risk of progression to preeclampsia 20. Models of prenatal care that incorporate both telehealth and in-person visits also may be particularly beneficial for patients 22 and promotes breastfeeding continuation 23 24.

In the context of gynecologic care, telehealth interventions have been demonstrated to improve contraception-continuation rates for both the oral contraceptive pill 25 and depot medroxyprogesterone acetate 26 and may present fewer logistical barriers for patients seeking an initial prescription for contraception 27. Patients with stress urinary incontinence significantly benefit from telehealth mobile applications providing patient education and guiding pelvic floor exercises 28, and telehealth models for medication abortion have been shown to maintain high rates of safety and efficacy without requiring in-person assessment 29.

Furthermore, research shows high levels of patient satisfaction with many obstetric and gynecologic telehealth care models. Patients who received a wide range of obstetric and gynecologic care report high satisfaction with telehealth models and interventions, including hybrid prenatal care visit schedules 30 31 32, surgical consultation from female pelvic medicine and reproductive surgery specialists 33, and medication abortion using telehealth 29. Patients who are satisfied with their care are more likely to remain engaged with care going forward, with the potential for longer-term benefits.

Aside from directly improving clinical outcomes, telehealth models and interventions also promote beneficence by allowing patients to receive high-quality health care without physically presenting to a health care facility. Although this aspect often is described as patient “convenience,” by taking the place of some or all traditional in-person health care visits, telehealth may decrease significant financial and logistical burdens for patients seeking care, such as the needs for patients to take time off of work or school, to arrange childcare, or to pay for and coordinate transportation 34 35 36 37 38. These logistical and financial benefits of telehealth may be most salient for patients with limited resources or less accommodating schedules or both and for those seeking types of care not available in person in their home regions 35 39. Transgender and neurodivergent individuals who might have had poor past experiences with in-person care and other patients with aversions to in-person care also may prefer and perceive fewer barriers with virtual care models 40.

Beyond these individual benefits, there is also potential for telehealth models and interventions to provide population-based benefits and to protect the health of the community overall. Although the principle of beneficence traditionally concerns benefits that directly accrue to the individual patient involved in the intervention, these population-level benefits intersect with the principles of communitarian ethics, which focus on the importance of the community and emphasize the influence the community has on individual human beings 34. Greater use of telehealth in appropriate clinical scenarios also respects the nature of in-person assessment as a finite resource in the community. In-person clinical care requires physical health care facility space, staff, and health care professional time, and the judicious use of telehealth allows these resources to be distributed more fairly among patients for whom the need for in-person care is greatest.

Nonmaleficence

Nonmaleficence is the principle that the health care team is obligated to avoid harm to patients 13. When presented with the opportunity to provide telehealth services as an alternative or complementary strategy to in-person care, physicians and patients may experience concerns regarding insufficient ability to achieve care quality, efficacy, and equity; interpersonal and systemic trust; and security of protected and vulnerable health information.

In a 2023 Special Statement on telemedicine quality and safety (42), the Society for Maternal-Fetal Medicine cited the potential for negative effects on several quality domains (of those proposed by the National Academy of Medicine in 2001), that should be considered in avoiding harm when providing telehealth Table 1.

Autonomy

Respect for autonomy refers to health care professionals' ethical obligation to support and respect patients in making decisions about their own care, including working to prevent limitations, including inadequate understanding, that undermine meaningful choice 13. In the context of telehealth, respect for autonomy includes questions about how patients engage with different modalities of telehealth, as well as whether to use telehealth in the first place.

For a number of reasons, patients may prefer and elect for in-person care when health care professionals believe that telehealth would be equally effective or even superior. These reasons, as described in the Nonmaleficence section, may include general discomfort with or distrust of new technology as well as concerns about confidentiality, including decreased privacy from family members or colleagues in the location where the patient initiates the remote visit or the security of the technology platform itself 37 58 59 60.

Alternatively, patients may prefer telehealth or decline in-person evaluation even when health care professionals recommend face-to-face care. These preferences may be secondary to logistical challenges in presenting for in-person care; financial concerns 61; stigma associated with reproductive health care 62; or health-related apprehensions, including infectious disease exposure 58.

The decision to use telehealth, in-person care, or a hybrid model of care including both modalities should incorporate shared decision making and consider risks, benefits, health care professional availability, and patient preferences. This process involves ongoing patient education, patient support, and engagement with affected patient communities. Health care professionals should share information about the potential benefits and limitations of telehealth with patients before initiation of telehealth and during individual telehealth visits and interactions 63. Obstetrician–gynecologists using telehealth modalities for patient care should provide targeted patient support for the initiation and continuation of telehealth, such as tipsheets for patients 65.

Patients still may have persistent concerns and choose to decline telehealth despite optimal education, support, and diligence on the part of obstetrician–gynecologists. Patients should not be unduly pressured to adopt telehealth, and obstetrician–gynecologists should support patients’ choices by offering entirely in-person care as an alternative whenever possible.

Obstetrician–gynecologists also should recognize that patient preferences regarding telehealth may change over time. Data suggest that increased patient-reported satisfaction with telehealth is positively correlated with previous exposure to telehealth and that patients who have used telehealth previously are more likely to choose it again 66 67. Furthermore, specific telehealth platforms and devices evolve rapidly, often in response to patient-usability feedback. A telehealth option that a patient initially declines may become more acceptable as that option develops new features or functionality. Obstetrician–gynecologists should reassess patients’ preferences regarding telehealth modalities periodically and update care plans as indicated.

Justice

Justice in health care represents complex concepts of ensuring equity across many domains, from equitable treatment of individuals to equitable allocation of health care benefits and burdens across societal groups and institutions 13. As discussed in ACOG Committee Opinion No. 390, Ethical Decision Making in Obstetrics and Gynecology, the complexity of achieving justice involves not only clinicians’ obligations to render to patients what is due to them, but also with the health care system’s role in the allocation of limited medical resources in the broader community 68.

When considering the effect on justice of incorporating telehealth into medical practice, we must consider both potential benefits and potential harm 63. Telehealth may increase access to medical care for patients for whom in-person evaluation is particularly burdensome (see Beneficence section). Telehealth can allow specialists to treat and evaluate patients for whom in-person evaluation would not be convenient nor even feasible (those in rural settings or where specialists are rare or where some gynecologic care is stigmatized, such as abortion or contraception care) 39 69 70 71. Multiple publications and reviews support the concept of increased access to care for vulnerable groups and those seeking sensitive care when telehealth is implemented as an alternative to or as an integrated option alongside in-person care.

Telehealth modalities also may be preferentially targeted toward and more easily accessible to patients from more privileged backgrounds, however. Wealth, technology experience, broadband or cell access, home privacy and other circumstances, and language fluency and literacy can lower or create barriers to the use of telehealth 9 60 72. Unequal availability and adoption of telehealth has the potential to exacerbate existing disparities by preferentially increasing the ability of privileged patient groups to access health care professionals more easily and more frequently. Research has identified that patient groups that traditionally face greater barriers in accessing health care also use telehealth relatively less frequently, even with the surge in telehealth rollouts during the COVID-19 pandemic. Non-White patients, patients with no insurance or public insurance 73 74 75, older patients, non–English-speaking patients, and patients with lower income 76 77 are less likely to use telehealth modalities when compared with White, younger, wealthier peers in the same regions and health systems. Further, identification of patients or groups who are at risk of underutilization or suboptimal care receipt when using telehealth modalities is not always straightforward. Even when patients are able to access telehealth and view it as beneficial, they may harbor concerns about being unable to express themselves well using telehealth 78. Obstetrician–gynecologists must be conscious of systemic barriers and choose telehealth modalities that minimize them, including considerations of language fluency and literacy.

A 2021 scoping review of patient-centered outcomes research identified that, “…the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations.” 79 Specific best practices in telehealth implementation cited include telehealth provision through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and practices that support patient-guided confidential sharing of personal health information 79. Pursuing equity in telehealth implementation centers on choosing telehealth modalities, platforms, and standards for conducting telehealth visits that are concordant with the needs of individuals and minimize barriers to uptake. Patient-eligibility criteria for telehealth must be considered carefully to avoid excluding patients for operational or logistical reasons who might otherwise be appropriate candidates. The ability of health care practices to achieve this can be aided by incorporation of community and patient input into the choice and usage of telehealth options 80. Further, health care professionals as consumers can support the development of telehealth platforms that diminish inequities, such as preferentially using software available in multiple languages.

Reimbursement is also a systemic issue that creates barriers to achieving justice in care delivery. According to a 2021 commentary by Ukoha et al 81, payment parity, which constitutes equal reimbursement for remote and in-person visits, is a measure that can combat financial disincentive to offer telehealth and is required to ensure equitable and widespread access. However, even when state programs adopt payment parity, community health centers still may experience lower reimbursement for remote visits and different telehealth modalities that provide the same care may be reimbursed differently. Lower reimbursement for audio-only visits may exacerbate disparities that stem from the “digital divide” created by differential technology access and literacy levels. In addition, regulatory, licensing, and payment policies often are based on face-to-face encounters, rendering parity payment laws potentially inadequate to fulfill the required coding elements in a virtual setting 1 82. Lack of payment parity between in-person and virtual care may particularly threaten hybrid models of care in which the same health care team and facility provides both types of care.

Reimbursement models should recognize the existence of such barriers to avoid disincentivizing obstetrician–gynecologists from offering telehealth to patients without broadband access or without more advanced technology available to them. Obstetrician–gynecologists and institutions should advocate for improved reimbursement parity models that recognize the value of clinician time and counseling complexity rather than focusing only on the physical setting of care. Obstetrician–gynecologists and health care systems have a responsibility to minimize barriers to all clinically appropriate telehealth modalities, including barriers posed by reimbursement disparity.

Finally, in aspiring to achieve justice in reproductive health care, we must consider whether obstetrician–gynecologists have an obligation to adopt telehealth into their practices. Adoption of innovative practices is integral to medical progress and simultaneously poses ethical challenges to patient safety and autonomy as outlined above. Clinician obligations with respect to these concepts are described in ACOG Committee Opinion No. 352, Innovative Practice: Ethical Guidelines 83. Furthermore, obstetrician–gynecologists considering how to incorporate telehealth may be limited by evolving political and regional regulations; states may have important restrictions on how and where telemedical care can be conducted, and health care professionals should familiarize themselves with relevant state laws and regulations. Similar to the historical adoption of other new practice models and technologies, such as minimally invasive surgery, practitioners of obstetrics and gynecology should assess burdens and requirements of telehealth incorporation with the same balance of expediency and caution. If the evidence continues to support the benefits of telehealth, it becomes increasingly incumbent on obstetrician–gynecologists to self-educate and adopt in accordance with the needs of their patient population.

Use of Language

The American College of Obstetricians & Gynecologists (ACOG) recognizes and supports the gender diversity of all patients who seek obstetric and gynecologic care. In the original portions of this document, authors seek to use gender-inclusive language or gender-neutral language. When describing research findings, this document uses gender terminology reported by investigators. ACOG's policy on inclusive language can be reviewed at https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/inclusive-language.