Identifying and Ranking Ethical Issues of the Internet of Things in Medical Sciences using Stepwise Weight Assessment Ratio Analysis

Introduction he use of the Internet as a global communication network has undergone a dramatic change which enables millions of machines and smart objects to connect and cooperate with each other. This technology is known as the Internet of Things (IoT) (1) which exchanges information through a variety of devices and tools with different connections. These objects work together to create new applications, provide services, and achieve common goals. The IoT aims to enable objects to connect to every device or person that can receive or send information via any path or network at any time and place (2). Due to the growing trend of IoT, it is predicted that by the end of 2020, about 50 billion objects will have been connected to the Internet (3). This connectivity has attracted the attention of companies, T Please Cite This Article As: Ronaghi MH, Mohammadi H. Identifying and Ranking Ethical Issues of the Internet of Things in Medical Sciences using Stepwise Weight Assessment Ratio Analysis. Health Spiritual Med Ethics. 2020;7(4):25-32. Abstract


Introduction
he use of the Internet as a global communication network has undergone a dramatic change which enables millions of machines and smart objects to connect and cooperate with each other. This technology is known as the Internet of Things (IoT) (1) which exchanges information through a variety of devices and tools with different connections. These objects work together to create new applications, provide services, and achieve common goals. The IoT aims to enable objects to connect to every device or person that can receive or send information via any path or network at any time and place (2).
Due to the growing trend of IoT, it is predicted that by the end of 2020, about 50 billion objects will have been connected to the Internet (3). This connectivity has attracted the attention of companies, governments, and citizens around the world and has resulted in a parallel increase in research in industry and universities (4). Within the domain of IoT, each object can be uniquely defined and equipped with sensors in the form of an Internet network. Today, the Internet and its related tools are dramatically integrated into the lives of individuals and businesses (5).
IoT technology uses IP-based Service-Oriented Architecture (SOA) to create integration and interaction among the components (6). The IoT is used in various industries, including a technology that has revolutionized medical care and is used to monitor people and collect patient information. It is projected that about 40% of IoT technology services will be related to the healthcare domain by the end of 2020 (7). The need for telecommunications equipment and their effective use has been proved in the field of healthcare and medicine due to such factors as massive amounts of medical data, time strains in data analysis, the importance of transaction speed, as well as high sensitivity and accuracy.
The IoT can be used in a variety of medical fields, including remote patient care systems, emergency alert systems, fitness programs, chronic illnesses, and geriatric care. These applications may include heart rate monitoring systems, blood pressure measuring systems, health monitoring systems, artificial pacemakers, wearable sensors, and hearing aids (8,9). The users' unawareness and the development of this technology have led to various vulnerabilities and attacks on IoT systems. These vulnerabilities have been exacerbated by the widespread use of new technologies, such as Radio Frequency Identification (RFID), Near Field Communication (NFC), sensors, as well as the third, fourth, and fifth generation telecommunications networks, leading to the emergence of Information security threats and new risks in this new environment (10).
The IoT uses sensors and trackers to identify and track different devices and people. Despite the unlimited benefits of this technology, it poses numerous challenges, especially to the security and privacy of individuals. It is of utmost importance to address these issues and observe ethical considerations. The users need to trust the security of IoT devices and their related services; moreover, it is vital to consider social behaviors, the ethical use of technologies, and the safety of these systems (11). The regulation of social relations based on ethical principles assumes critical importance in the use of various technologies. In numerous work and life domains, if people do not adhere to moral principles, there is no detrimental external force to deter them from violating each other's rights (12).
Informed consent is the mainstay of ethics and law, and stakeholders reserve the right to obtain information and ask questions (13). Informed consent in medical ethics has received assiduous attention and consideration, especially in the last few decades. Nonetheless, this concept dates back to ancient medicine and was fundamentally developed in the 19th and 20th centuries (14). The concept of informed consent is explained in citizens' interaction with the digital to regulate behavior with personal data since the consent of a data source (e.g., a patient or citizen) is often necessary for the user to process and legitimately use personal data.
To provide informed consent for the application of personal data, the users must have a sound knowledge of how their personal information will be used by the applications and equipment. People with inadequate information and expertise in the information and communication technology may find it difficult to develop such awareness (15). Accordingly, based on the ethical principles, every technology must be used with the full knowledge of the user. In this regard, transparent information regarding the use of personal information should be provided in the form of an agreement.
Many IoT devices and tools may have lowlevel and inefficient information security (16,17). IoT security is one of the daunting challenges presented to the successful implementation of IoT devices. The ease of connecting and accessing IoT devices has increased the possibility of serious security issues. Moreover, this trend is on the rise due to the widespread distribution of heterogeneous devices and their possible connection without requesting a license or even informing their owners (11).
Uncontrolled environment, heterogeneity, scalability, and resource restraints are recognized as the main features of the IoT (1). Therefore, the data collected by various cameras and microphones may be sent by smart displays and other similar devices to the manufacturer's servers for data analysis without the knowledge and consent of users (18). Technical analysis is a major part of the security issues in IoT devices, that is to say, although many components have some security features, such as passwords to restrict user access, these passwords are typically set to factory defaults and never change (19).
In addition, default passwords are available online (20); consequently, experts can hack these devices intentionally or out of curiosity, thereby violating privacy and affecting security issues (21). In terms of information security, any device or portal should have a 32-character password that requires uppercase and lowercase letters, numbers, and symbols; moreover, this password should be changed on a daily basis. Nevertheless, this is only the technical aspect of security issues, and specialized training on the use of devices is necessary to achieve higher security (4).
There is controversy over the issues of IoT privacy and security since IoT devices can analyze and share large amounts of user data (22). Even in the event of public awareness of privacy breaches on the Internet, in IoT development, these risks are likely to increase due to the massive amount of collected and processed data. This data may be related to individuals and patients, their daily activities, the increasing relationship between the digital world and real life, and the use of new devices and tools, such as wearable sensors in the medical field (23).
Some measures are being implemented to protect the privacy of cyberspace users; however, the majority of legal challenges of IoT have not been addressed yet. The General Data Protection Regulation (EU GDPR) has been involved in this field for several years and has initiated fundamental measures to increase data protection. Courts also set an agenda for the recognition of digital privacy rights (4). Finally, the IoT, with its numerous sensors and integrated communications, provides a good opportunity to gather personal information which can significantly affect a person's privacy.
Therefore, the privacy of people using the IoT can be protected by the following measures: setting strict rules to protect the confidentiality of user data, assigning specialized judicial units for possible problems in this area, and informing people about how their personal information would be used. One of the differences between IoT and the traditional Internet is the active nature of the equipment and objects in the real world and the surrounding environment. One of the ethical priorities is to reduce or eliminate the disadvantages of using these tools and equipment (24).
One of the effective measures to prevent physical damage or undesirable threats is the hardware safety of the IoT which protects the environment from such damages. In this regard, it is indispensable to develop an IoT system with high security and reliability to create newly designed architectures that provide a safe and secure system environment (11). Physical safety in the IoT means planning and rational prediction of the behavior of equipment, as well as preventing unexpected and unwanted behaviors (25). One of the main pillars of the physical safety of devices is the supervision of government and executive bodies, as well as the establishment of safety standards. This is also reflected in the design of vehicles and production equipment in the field of IoT (26).
Trust in the IoT means that the behavior of users and technology developers would be predictable if system components do their job properly (27). Trust in IoT is a matter of great concern which can be aggravated by the interaction among objects. Three categories of IoT trust must be addressed: trust in a "thing," (2) trust in a network of "things," and (3) trust that the environment and context that the network will operate in is known and that the network will be fit for purpose in that environment, context, and at a specific point in time (28). Considering the mutual interaction between trust and ethics (29), it can be concluded that gaining the trust of users in the field of IoT is a moral behavior which increases the trust of the audience.
Due to the importance of IoT technology in the field of medicine, in their study, Ronaghi and Hosseini ranked IoT services in the field of health using the fuzzy analytic hierarchy process. The results of the mentioned study showed that the management of chronic diseases and emergency medical services are given priority. It was also found that policymakers in the field of IoT technology should first be aware of the role of this technology in saving lives. As the next priority, investment in IoT can help control and monitor the behaviors of the elderly, patients, and children (30).
In another study, the existing literature on effective ways of designing the IoT in the field of medical care was first critically evaluated. Thereafter, a new semantic model is proposed for patients' electronic health using four layers of sensors, network layer, internet layer, and service layer (31). Along the same lines, Mahbanooei et al. identified and ranked the E-Health Codes of Medical Ethics. In the referred research, the snowball method was used for sampling and the fuzzy hierarchical analysis method was used for data analysis. The results of this study demonstrated that among the E-Health codes of medical ethics, privacy, increasing the quality of e-services, and professionalism in online health care take on an added importance in hospitals (32).
In their study, Atlam and Wills examined the security and confidentiality of the IoT and analyzed the security of smart cities from different perspectives (11). Compared to previous studies, there is a research gap regarding the importance of the challenges presented by the use and localization of the IoT in Iran. In light of the aforementioned issues, the present study aimed to identify and rank the ethical challenges presented by IoT technology in the field of medical sciences from the perspective of Iranian experts.

Methods
The applied research was conducted using the combined method in the winter of 2019. In the first part of the research, the related studies and articles in the field of IoT ethics were reviewed, and the relevant codes were extracted using the content analysis method. In the second part, Stepwise Weight Assessment Ratio Analysis (SWARA) method was used to rank moral indicators. It is one of the multicriteria decision-making methods that was developed by Kersuliene et al. in 2010 which enables decision-makers to select, evaluate, and weigh the indicators (33).
The greatest advantage of this method over similar methods lies in its ability to evaluate the accuracy of experts' opinions about the weighted indicators during the method process. In addition, experts can consult with each other which makes the results more accurate, compared to other multi-criteria decisionmaking methods (34). The main steps of weighting based on the SWARA method are as follows (33): Step 1: Sorting the indicators Step 2: Determining the relative importance of each indicator (Sj) Step 3: Calculating the coefficient Kj. The Kj coefficient which is a function of the relative importance of each indicator is calculated using Equation 1.
Step 4: Calculating the initial weight of each indicator: the initial weight of the indicators can be calculated using Equation 2. In this regard, it should be noted that the weight of the first indicator, which is the most important indicator, is considered equal to 1. Step 5: Calculating the final normal weight: in the last step of the SWARA method, the final weight of the indicators, which is also considered the normalized weight, is calculated by Equation 3.
The panel of research experts included 15 managers and information technology experts working in medical universities. They were selected due to their familiarity with IoT technology, as well as experience in the field of medical sciences. To adhere to ethical considerations, the experts participated in the study with full knowledge of the objective of the research and could withdraw from the study at any time.

Result
Based on the results of library studies, five factors were identified as ethical challenges in the field of IoT. The results of the content analysis are displayed in Table 1. Table 2 illustrates the results of weighting based on the SWARA method. The informed consent (0.259) and privacy (0.227) were given the most weight, followed by information security (0.195), trust (0.171), and physical safety (0.148), respectively. Table 1. Ethical challenges in the field of the internet of things Ethical issue Sources Informed consent (13), (14), (15) Information security (4), (11), (16), (17), (18), (19),

Discussion
IoT technology has risen in importance due to the increasing growth of smart tools, network communication, various tools, and equipment. The IoT has a wide application in different fields, including medical science and health; nonetheless, it is presented with numerous challenges as other innovative technologies do. In this regard, the way of data transmission among the devices has given rise to daunting ethical challenges in this field. Therefore, the present study sought to identify and rank the ethical challenges presented to the IoT in medical sciences. Based on the results, users' awareness and informed consent were the most important ethical challenge in this field from the perspective of medical experts.
In the same vein, in a study performed by Allhoff and Henschke (4), informed consent was introduced as one of the ethical issues in the field of IoT technology. Due to the possibility of access to personal information of patients and users of smart tools, people must be aware of the amount and type of the exchanged information; therefore, in the first instance, the user should acknowledge this possibility. Privacy was the second most important indicator from the experts' point of view. The studies conducted by Weber (22) and Baldini et al (23) also highlighted the importance of privacy in the use of the IoT.
In this regard, to observe privacy, people must have controlled access to network data. The next priority of ethical challenges was information security. This finding is consistent with the results of the studies carried out by Atlam and Wills (11), Urquhart and McAuley (17), and Ronaghi and Hosseini (30). Accordingly, the method of information transmission in the network and prevention of network attacks help to manage network security. Trust has become one of the challenges faced by the users of this technology due to the newness of IoT technology, some users' insufficient knowledge, as well as the remote controls of various network devices. Accordingly, building trust in users and patients using IoT equipment and awarenessraising in this area can facilitate the implementation of IoT technology. Physical safety was identified as the last ethical challenge in the field of IoT. This security can be enhanced by the use of well-known equipment and sensor manufacturers, the conclusion of contracts with experienced companies in the field of IoT, and network controls.
One of the limitations of the present study was the evaluation of ethical challenges from the perspective of experts. Therefore, it is suggested that the views of patients and users of IoT tools be assessed in future research. Furthermore, is recommended that indeterminate techniques, such as fuzzy and grey methods, be applied to obtain real information in the evaluation of people's opinions.

Conclusion
IoT technology has wide applications in medicine, such as fall detection, wearable sensors, and remote continuous monitoring of patients. As illustrated by the results of the present study, the most important ethical challenges of medical IoT included informed consent and privacy. Therefore, health policymakers should issue stringent regulations on the application of these devices in the field of healthcare and medicine. These regulations should be developed based on information dissemination and obtaining the consent of patients and users so that executives will be required to inform patients about these issues. As a final note, to minimize network attacks and unauthorized access to information and maintain information security in IoT, it is suggested to properly configure the application server settings, run training courses on information confidentiality, and use secure information platforms, such as firewalls.

Conflict of interest
The authors declare that they have no conflict of interest regarding the publication of the present article.