In recent years, there has been a surge in the exploration and implementation of live remote exercise services (telerehabilitation), including within cancer care. Before the COVID-19 pandemic and the associated demand for remote care modalities, telehealth and telerehabilitation services were already the focus of research and development efforts, from randomized controlled trials (RCTs) [1] to economic analyses [2]. In some contexts, certain prepandemic efforts were promoted not as a way to improve quality of care for patients and clients but rather as a means to increase profitability or reduce costs in health systems [3,4]. Cost is not, in itself, a suspect motive. For patients, avoiding travel, parking, and the time consumed by journeys or regular commuting can be real benefits, and for health systems, savings could potentially fund other services. However, innovation in health care raises further considerations, among them quality of care, quality of health outcomes, and equitable access, to name a few. These are ethical questions as well as practical ones, and their relevance outlasts the circumstances that made remote care urgent. Looking beyond the pandemic setting, what must we do to provide these services in a responsible and ethical way?

This challenge is multifaceted and salient for the authors of this viewpoint. We contribute to the European Union (EU)–funded PREFERABLE-II project [5], a consortium of European and Australian researchers, which aims to evaluate the value and implications of live-remote exercise (ie, a key component of telerehabilitation) for people recovering from cancer treatment. While a large-scale RCT assessing (cost-)effectiveness is at the heart of the project, we also aim to advance an informed, multisector dialogue about the ethical, legal, and social implications (ELSI) of telerehabilitation as a new technologically mediated care modality.

As a viewpoint, this paper maps and illustrates the ethical landscape of telerehabilitation without surveying it. Our focal case is the synchronous, videoconference-based form of this modality. Asynchronous apps and recorded programs appear only where the issue at stake is not specific to that format. Furthermore, AI-assisted and sensor-based rehabilitation, the wider governance of digital health, cybersecurity, and cross-border digital health regulation, beyond the professional practice questions raised here, lie outside our scope.

Previous reviews of the ethics of eHealth and telemedicine (ie, principles not specific to telerehabilitation) highlight a range of principles that need to be considered, including autonomy, trust, privacy, dignity, fairness, beneficence, nonmaleficence, justice, and, of course, the priority of health care quality over the interests of technology vendors [6-10]. Prescriptions for “ethics” of telehealth therein are often limited to preventing conflicts of interest and ensuring informed consent, leaving the rest up to the health care provider. As some have already noted, the ethics of telehealth remains underresearched empirically, especially regarding users’ perspectives [6] and overall impact on quality of care [9]. This shortfall seems even more apparent in the specific area of telerehabilitation.

The gap, in our view, is not only empirical. The most pressing questions in the ethics of telerehabilitation are not only retrospective and risk-based (eg, “Is a given service safe and compliant?”) but prospective (eg, “Should the modality be offered, for whom, and why?”). We therefore adopt responsible innovation as a lens to understand this technology-mediated modality, reframing responsibility as the prospective and collective stewardship of innovation in the present rather than the after-the-fact allocation of liability [11]. Accordingly, the responsible innovation approach would recommend a review of the full range of concerns implied by “ethics of telerehabilitation,” including not only mainstream ethical principles like informed consent but also the societal impacts of the technology-mediated approach. Following Stilgoe et al [11], we distinguish 3 levels at which ethical questions can be posed: questions about the products of innovation (eg, its risks, benefits, and their distribution), its processes (eg, how standards are drawn up and who takes part), and its purposes (eg, why a modality is pursued, in whose interest, and against which alternatives). Conventional health-professional ethics largely addresses the first 2 levels. Responsible innovation retains these but extends analysis to the often neglected level of purpose, through 4 integrated dimensions: “anticipation,” “reflexivity,” “inclusion,” and “responsiveness” [11]. This means that innovation processes need to integrate active consideration of consequences, reflect on implicit and explicit values, include participation of diverse publics and stakeholders, and then actually respond to those inputs. These requirements are motivated not only by the practical need to adapt technology to its social context but also by the demands of democratic participation in most societies. Typically, participation of publics is restricted to influencing “how” (eg, how to obtain consent, how to choose a video app) rather than “why” a technological change is being implemented [12]. These 4 dimensions structure the sections that follow.

Given this background, we aim to generate a high-level viewpoint on the current state of telerehabilitation ethics and argue 3 things: First, the ethical content encoded in current guidance on telerehabilitation remains confined to the product and process levels of responsible innovation. The question of purpose—whether, for whom, and why remote rehabilitation should be offered—is left largely unasked. Second, the lived experience of users and professionals is itself part of the ethics of telerehabilitation and is not merely data to be assessed. Listening to what users and professionals actually experience turns two of the framework’s dimensions, anticipation and inclusion, from abstract principles into something that can guide practice. Third, the ethics of telerehabilitation, therefore, have to be institutionalized across these domains: the interpersonal and experiential quality of remote care, the legal and institutional conditions of delivery, and the positioning of telerehabilitation within the health system, where the central task is to keep telerehabilitation as an additional option that broadens access, rather than letting it become a primarily cost-driven replacement for in-person care. We address these arguments primarily to rehabilitation professionals, professional associations and standard-setting bodies, and, secondarily, to digital health and ELSI researchers, policymakers, and health system decision-makers who commission or implement telerehabilitation services.

From a responsible innovation perspective, we realized that the key ingredient for developing a mature ethics of rehabilitation is deeper engagement with user and professional experience. Engaging with feedback from our clients and patients, as well as published qualitative studies, provides us with a primary resource for two of the framework’s dimensions. It supports anticipation, understood not as the prescription of outcomes but as the surfacing of the plausible positive and negative experiences a modality makes possible, and inclusion, by bringing the situated perspectives of users, carers, and professionals to bear on the prior question of whether and how remote care should be offered. Altogether, this allows for a more comprehensive ethical reflection, especially in terms of posing the foundational “why” questions in this respect.

Our engagement with the qualitative literature was narrative and illustrative in intent: studies were selected purposively by the author team to represent the range of reported experience, including accounts of benefit and accounts of burden. The studies cited therefore serve as demonstrative instances that make the ethical questions concrete.

When the technology works as intended, many users see it as a positive option and a source of added well-being. Reported motivators include the convenience of staying at home, for example, to fulfill care responsibilities or to avoid difficult commutes to the clinic, broader access to meaningful human contact that might otherwise be inaccessible, and, in the case of longer treatment, a much-needed sense of support and continuity of care. Interviewees in one study called this “closeness at a distance” [24-26].

These examples of successful use of telerehabilitation show that remote care can align with professional rehabilitation ethics, especially those related to trust, informed consent, and autonomy, but success requires preparation, as one interviewed physiotherapist makes clear:

Crucially, not every context for telerehabilitation use is conducive to effective implementation, especially in the setting of supportive cancer care. Responsible innovation of telerehabilitation means addressing contextual factors that are not evenly distributed, such as clinical resources, internet availability, and software and camera technology [26,28-33]. Other significant factors include user age and digital literacy, choice of video platform, caregiver involvement, language and the need for an interpreter, institutional, and infrastructural readiness, cultural norms related to privacy, lack of touch, and interpersonal relationships.

In supportive cancer care, the distribution matters in both directions. The population is disproportionately older [34] and frequently living with comorbidity [35] or mobility limitations [36], which are precisely the conditions that make traveling to a clinic difficult, so for some patients remote delivery removes a barrier that in-person care imposes. The same population is also less likely to report high digital literacy [37,38] or a reliable connection [38], so, for others, the format substitutes one barrier for another. Sensory and cognitive impairments sharpen the point: platforms without captioning, screen-reader compatibility, or adjustable pacing exclude by design, and patients who need an interpreter face a service in which a third participant must be accommodated on a platform that is rarely built for one. Where such accommodations are unavailable, telerehabilitation does not extend access; it redistributes it, and an equity claim made for the modality in general can be false for the individual patient in front of the professional.

Improperly addressed, contextual factors become a narrative of clients’ rejection of technology [31]:

Qualitative work with rehabilitation experts suggests that remote delivery does not dissolve the therapeutic alliance but redistributes it: verbal guidance substitutes for manual correction, nonverbal cues are constrained by camera position and image quality, and touch, where it is needed at all, is applied by a relative under instruction [39]. Two further shifts follow from the supervised character of rehabilitation. Movement quality, gait, balance, and pain behavior are judged through observation and physical examination, and what the camera frame narrows should be stated to the client as part of consent instead of being absorbed silently into professional judgment. Remote delivery can also shift the immediate capacity to respond to a fall or another adverse event from the professional to the household, so, where fall risk is material, the presence of another person may become a precondition of the service and not an optional convenience [22,39].

Most importantly, in line with guideline recommendations, most qualitative studies report a preference for telerehabilitation as a supplement, not a replacement, for in-person care. Such a preference follows naturally from the fact that the need for and effectiveness of telerehabilitation are both entangled with the specific social context of its use.

Read against the 4 dimensions of responsible innovation, this material hints at aspects the guidelines leave undone. It supplies raw material for anticipation, since it surfaces the plausible harms and benefits a modality makes possible before they are formalized as risks. It is a route to inclusion, since it is where users, carers, and frontline professionals speak. Additionally, it makes responsiveness testable, since a service that never revises its design in the light of such accounts is not responsive in any meaningful sense. What this material cannot supply on its own is reflexivity, which requires the professions themselves to examine the assumptions built into remote delivery.

This section takes up that task in part for our consortium. Designing the PREFERABLE-II trial required us to decide how remote exercise would be delivered, and those decisions raised ethical questions we had not completely anticipated. We report what our discussions surfaced as situated experience of the kind this viewpoint treats as ethically informative, and we offer them as hypotheses for study rather than findings about frequency.

One of the issues discussed was the fostering of healthy group dynamics. Group-based telerehabilitation offers an opportunity to learn from peers and experience connectedness. However, the telerehabilitation setting prohibits “physical” peer-interaction, such as collaborative exercises. Also, it might make it more difficult to pick up the subtle forms of communication required for effective peer-to-peer and patient-rehabilitation professional interactions. Members of our consortium have also suggested the need for clear guidance on liability for accidents, especially when seeing clients outside their normal in-person jurisdiction, as well as the question of whether consent needs to be obtained from clients’ household members, who may not want to be recorded. Fairness, too, has become a logistical question, as we plan how to provide space, internet bandwidth, and equipment to participants who may lack those resources [22], while also considering whether functional limitations or safety concerns make live, remote exercise unsuitable.

Some concerns appear less pressing in practice, at least in some of the work of PREFERABLE-II partners. Initial unease among trainers about seeing clients’ homes often shifted into rapport, as it somehow creates a sense of closeness for them, even though they know the patients only online. Postpandemic familiarity with online interaction may also have eased adoption for potential users. Furthermore, some of our colleagues report that the absence of touch has been less of an obstacle than expected. In a trainer survey, most exercise components were rated as equally or more-effective when delivered live-remotely, though 52% and 71% judged resistance and agility training less effective [40]. Some suggest the format may support performance because trainers demonstrate the exercises more often and the camera naturally provides direct feedback.

Telerehabilitation has not yet generated a dedicated ethics literature on area-specific best practices. To our knowledge, there is no scholarly or professional consensus on what “ethical” or “responsible” telerehabilitation requires in concrete terms. Within the PREFERABLE-II project, we expect to develop our own methods to address the positive and negative potentials of remote care, as well as to answer socioethical questions. However, we believe these dimensions of practice also deserve broader consideration in rehabilitation research streams and in the development of more concrete evidence-based professional guidelines globally.

From our perspective, priorities span 3 overlapping domains, each with its own addressee. These are the sites at which the question of purpose—whether, for whom, and why remote rehabilitation should be offered—is actually settled (Figure 1).

First and most obvious are the interpersonal and experiential dimensions of practice, for example, whether clients and professionals trust the modality, whether care goals are met, and whether professionals feel capable and well-equipped. Established principles such as safety and consent apply here as they do in person, but they are harder to satisfy at a distance, and the immediate response to an adverse event lies in specific protocols and potentially with the household. This is why the question of whether remote delivery suits a given patient is a judgment about an individual person and not about a service line. It weighs accessibility, digital skills, the risks of supervised exertion at a distance, and the patient’s own preference once the limits of the format have been explained. That means it belongs to the patient and the professional together and not to the organization commissioning the modality. Professional societies and rehabilitation curricula would correspondingly need to treat remote assessment, verbal guidance, and risk triage at a distance as examinable competencies and not as improvisations.

Second, and less obvious, are the legal and institutional challenges: does the service comply with relevant institutional norms and (inter-)national regulations? Who will provide training and regulatory support in fully adapting each instance of telerehabilitation to its context? Because of the technologically mediated interaction, shifting laws concerning data handling and digital services are likely to be invoked, and cross-border services become possible, although legally questionable. Associations and regulators would need to state what applies across jurisdictions, what liability attaches to an adverse event in a patient’s home, and whether the consent of household members is required.

Third, there is the systemic domain spanning questions of innovation within the health system in general. Was the approach developed with social context in mind, reflexively, and with opportunities for user input? How does it fit into existing health care offerings, and with what alternatives? Perhaps the greatest potential challenge at this societal level is preventing the premature replacement of in-person care and leaning more toward the availability of hybrid approaches, fully respecting the individual patient’s needs. Because telerehabilitation is defended here as one further option on the menu and not as a substitute, exclusion from it is not exclusion from care and no patient should be required to use it. That defense holds only for as long as the in-person route remains open: where it is withdrawn, those who cannot use the remote format lose access altogether. Another practical notion of this domain covers the reimbursement aspect. Where remote sessions are unbillable or reimbursed below in-person rates, provision depends on the goodwill of individual practices and on project funding of the kind that supports our own work. Where they are reimbursed more favorably the incentive may run toward substitution irrespective of what a given patient needs. The ethical question is therefore not whether telerehabilitation saves money but who books the savings and who carries the losses. Policymakers and regulators would accordingly need to decide the substitution question explicitly when setting reimbursement rules, so that a modality reported as a preferred supplement is not adopted as a replacement by budgetary default. A detailed health economic analysis within the PREFERABLE-II trial will show whether savings arise and where.

Looking ahead and beyond research, the ethics of telerehabilitation should be seen as a multisector conversation. Inclusive dialogue and iterative policymaking should align innovation with public needs. On that note, this viewpoint itself falls somewhat short of the inclusion it asks for. It was developed by researchers and clinicians without the direct involvement of patients or carers, whose perspectives would enrich, and, in places, might revise, the priorities we identify. Although there is no single organization or discipline that will be wholly responsible for realizing ethical telerehabilitation, the mark of a robust ethics discourse is the ability to pragmatically bring the full range of concerns to the awareness of multiple stakeholders. When read across the 3 domains, the 4 dimensions of purpose stand or fall together. Anticipation and inclusion without responsiveness leave what users report unanswered, and none of the 3 counts for much without the reflexivity that would have the professions examine the assumptions built into remote delivery in the first place.

To this end, the ethics of telerehabilitation should start with tailored research into how to bridge the gap between rehabilitation guidance and the specific problems of remote care, and work toward the institutionalization of ethics conversations across professional societies, rehabilitation curricula, interdisciplinary conferences, and affected publics. While our viewpoint is still preliminary in scope, we hope it may inspire future work in these directions.