Rheumatology digital guidelines leave ethics mostly implicit, analysis finds

A qualitative analysis of leading rheumatology guidance found that international recommendations consistently recognize the practical benefits of telemedicine, mobile health and artificial intelligence, but rarely explain the ethical theories behind their choices. None of the five society documents examined explicitly invoked utilitarianism, deontology, virtue ethics or principlism, leaving value conflicts such as efficiency versus equitable access largely unexamined in the published text.

The study, published in Frontiers in Digital Health on 21 October 2026, assessed dedicated digitalization guidance from the American College of Rheumatology, the Asia Pacific League of Associations for Rheumatology and the European Alliance of Associations for Rheumatology. The sample comprised two ACR documents from 2023 and 2024, two EULAR documents from 2019 and 2022, and one APLAR telemedicine document from 2022. It was an interpretive document analysis rather than a systematic review or an evaluation of clinical outcomes.

Researchers searched PubMed and Google for English-language society publications from January 2019 through September 2025. Their terms combined the names of the three organizations with digitalization concepts including artificial intelligence, telemedicine, mobile health, rheumatology, guidelines, recommendations, points to consider and position statements. After screening 202 titles and abstracts and removing duplicates, the researchers selected five official guidance documents. They described this as the full set of dedicated digital guidance issued by those societies during the search period.

Two coders then applied a deductive framework built around three questions: whether ethical terms appeared, whether recommendations invoked or implicitly aligned with a normative theory, and whether trade-offs between competing values were acknowledged. The ethical vocabulary included autonomy, justice, beneficence, non-maleficence, informed consent, equity, data protection and privacy. The theoretical categories were principlism, utilitarianism, deontology or Kantianism, and virtue ethics. A fourth check considered tensions such as privacy versus innovation and efficiency versus equity.

All five documents mentioned data protection, privacy, patient-centeredness and access, but these terms were generally used as labels rather than developed into explicit arguments. The EULAR mobile health guidance, for example, lists user privacy and safety as criteria without defining how they should be handled when an application involves third-party services. The ACR artificial intelligence statement refers to bias and confidentiality, but the analysis found no detailed definition of those concepts or sustained discussion of their ethical implications.

The documents also did not explicitly cite any of the normative frameworks used in the analysis. Their recurring emphasis on system-level efficiency, population health benefits and technological progress resembled a utilitarian orientation in the researchers’ interpretation, but this pattern was not presented as an explicit ethical commitment. Nor was it balanced against deontological concerns such as individual rights, dignity and autonomy, or against the character and practical wisdom emphasized by virtue ethics. The authors described this as an interpretive hypothesis, not a demonstrated intention of the guideline developers.

Several difficult questions remained outside the documents. The ACR telemedicine statement acknowledged regional disparities, according to the analysis, without framing them as a justice problem requiring decisions about the equitable distribution of resources. APLAR recommendations referred to structural hurdles in the Asia-Pacific region but did not examine whether telemedicine could worsen inequalities for already marginalized patients. The study’s central distinction was between mentioning an ethical concept and showing how competing principles should be weighed when recommendations affect real people.

The authors cautioned that their result applies to the five selected publications and does not establish that ethical reasoning was absent from the committees’ internal deliberations. Practical pressures, an emphasis on implementation, editorial constraints and limited space could all have shaped the final texts. The analysis could identify only what was publicly documented, and it did not include interviews with developers. Its sample was also small, limited to English-language documents from three organizations, and focused on guidance specifically devoted to digitalization rather than broader ethics statements that touched on digital care only in passing.

Based on their findings, the researchers proposed minimum ethics components for future rheumatology guidance. They called for a dedicated section that identifies value tensions, explains how trade-offs were resolved and names the normative frameworks behind those judgments. They also recommended assessing effects on groups at risk of exclusion, including older, low-income, digitally excluded and non-native-speaking patients, with specific mitigation strategies. Guideline teams, they argued, should routinely include ethicists, patient advocates and social scientists alongside clinicians and technical experts, rather than treating them as occasional advisers.

The study is not a rejection of digital rheumatology. Its authors instead argue that tools such as telemedicine and algorithmic decision support can make preexisting value judgments more consequential by extending and scaling them. An AI system that improves population-level treatment allocation, for example, could also rely on opaque processes that weaken individual informed consent; expanding telemedicine may broaden access while excluding patients with limited digital literacy. By naming these conflicts, future guidelines could give clinicians and policymakers a clearer basis for deciding when the pursuit of aggregate benefit should be constrained by rights, dignity or equity. Whether current guidance becomes more ethically explicit remains an open question requiring broader and longitudinal research.

Subject of Research: Qualitative assessment of ethical reasoning in international rheumatology digitalization guidance

Article Title: From implicit assumptions to explicit ethics: assessment of normative frameworks in digitalization recommendations in rheumatology

Article References: Drexler, J., Richter, J. G., Buchkremer, R., Chehab, G., Killersreiter, B., & Thielscher, C. (2026). From implicit assumptions to explicit ethics: assessment of normative frameworks in digitalization recommendations in rheumatology. Frontiers in Digital Health, 8, Article 1928292. https://doi.org/10.3389/fdgth.2026.1928292

Image Credits: AI Generated

DOI: 10.3389/fdgth.2026.1928292

Keywords: digital health, rheumatology, telemedicine, artificial intelligence, clinical guidelines, medical ethics, health equity, normative frameworks, patient autonomy, data privacy, implicit, assumptions