Autonomy, perhaps one of the most central tenets in ethics related to aging, refers to the older person’s ability to preserve decision-making rather than to relinquish it to another person. In the context of technology, autonomy may relate to a person’s ability to have control over information flow and communication. The use of social and communication/information technologies creates needs for decisions about access and privacy. For example, can a family member read the elder’s chart? Also, with whom should the doctor communicate – only with the patient or also with family members and, if so, which family members in particular?

Teachings from Immanuel Kant and other philosophers have taught us to think about respect for people and their autonomy as a process [7]. Put another way, the ends may not justify the means if the elderly person’s preferences are not being honored. One example that we will come back to is the use of technology to monitor elderly people in their homes. While these signals may be helpful for early detection of problems, such as falls, they may not be acceptable if they result in loss of privacy for the elder. Data from focus groups of elderly people and caregivers provide rich food for thought. As one older gentleman noted, “we want technology to rescue us, not spy on us” [8].

For elderly people, autonomy is likely to diminish as cognition declines. Making prearranged plans for information control and sharing may be helpful for preserving and honoring peoples’ wishes, even when they are unable to make decisions for themselves.

Consent refers to a person’s ability to give permission while understanding the trade-offs of a particular decision. Assent refers to the ability of a person who is deemed unable to consent, often due to cognitive impairment, to voice willingness to adhere to a particular decision [9]. In the context of information and communication technologies, consent and assent may be most frequently applied when using patient portals or communicating with electronic tools, including the delegation of family as proxy users, or when using technology to monitor elderly people at home. If a patient with some level of cognitive impairment dissents with sound reason to the use of a technology, such as a home-monitoring device, this should be incorporated into the decision-making. Patients with cognitive impairments may have difficulty understanding some of the discussions regarding consent for online services, such as risks to privacy, but even when patients have some cognitive impairment, their wishes and preferences about how communication occurs should be respected.

In our case of Melanie and Addie, Addie has some form of forgetfulness that could represent mild cognitive impairment. At this time, however, she appears to have the ability to represent her interests and preferences for communication flow. She acknowledges that she wishes Melanie to be involved. Our geriatrician may go on to ask if it is okay for Melanie to have access to Addie’s records and under what circumstances, if any, it would be acceptable to be in touch with Melanie directly.

Another vector in ethical frameworks is that of beneficence or benefit. We assume that patients, families, and clinicians are using technology to help improve or optimize health on the older person’s behalf. In some cases, however, beneficence from the perspective of the family members or clinician may be at odds with the perspective of the patient when it interferes with the patient’s autonomy. Put another way, what benefits one person may not benefit the other, and therefore beneficence depends on values, goals, and perspectives [10, 11]. Let’s return to the example of home monitoring. Melanie may suggest that a home-monitoring device be used by Addie that would provide warnings for falls or untaken medications (putative benefit for the health and well-being of Addie). Addie may find, however, that such a device is not acceptable because it is too intrusive (autonomy – she has the right to decide). In such a scenario, beneficence and autonomy are potentially at odds. In these circumstances, determining the goals of the intervention is important; what is beneficial to Melanie (peace of mind) may not provide any benefit to Addie. In these cases, it can be challenging for all parties involved to navigate what should happen, and intra-family negotiations are often required. Ultimately, centering discussions around the goals of the patient will likely bring some clarity to the conversation.

Clinicians have a duty to safeguard patient information, but the use of information technology provides some inherent risks. These risks can be managed with good information habits and by following best practices. However, we sometimes will see where security is at odds with usability, especially in the consumer space. Clinicians and supporters of elderly people, such as family members, will need to consider trade-offs of optimal usability with privacy and security and often have to balance the privacy risks to the elderly person with the benefit of the service [12]. A common example is the use of traditional e-mail, which is typically not secured or encrypted, compared with the use of a dedicated and secured patient portal for messaging. E-mail is available to nearly all – most individuals are using it already for other purposes – and many people may feel comfortable with this technology. In contrast, a portal requires additional steps to use including a distinct visit and log-in to the site using a separate username and password. Some elders, who are comfortable with traditional e-mail, may find this confusing or cumbersome.

Elderly people may be especially vulnerable to breaches in security. The Federal Trade Commission has noted that about a fifth of identity theft complaints reported to the agency were for people over the age of 60 [13]. In particular, the most common type of fraud focuses on healthcare or health insurance. Elderly people may have less facility with technology and, as such, be potentially be more trusting of nefarious e-mails and content such as phishing attacks, where an e-mail or website purports to ask for information for legitimate purposes but instead collects and uses the information for malicious purposes. Elders may be more susceptible to scams from the phone, web, social media, and e-mail. Funds, including savings and social security payments, may be at risk.

It is important to understand how to apply the above principles to scenarios clinicians may encounter. For each medium, we will (1) review the context and frame the issues, (2) consider issues in the context of the guiding principles, and (3) provide practical suggestions for geriatricians.