Review
A majority of respondents in the patient group consisted of men even though the latest figures show that more women are affected by cardiovascular diseases [40]. As for diabetes, as many men as women are told that they have diabetes every year [33]. For a good representation, it would’ve been better if the group of patients had consisted of about the same amount of men as women. It may be that implanting the medical implants treated in this thesis occurs more frequently in men than in women but, unfortunately, no figures are available to clarify this.

During the interviews, I was sometimes tempted to ask leading questions. In the beginning, I struggled not to let respondents stray from the subject as this made the interviews take longer than necessary. When replaying the first interviews, I became aware of these pitfalls, and this enabled me to avoid these mistakes in subsequent interviews. Some respondents were curious about my ideas about the hackability of RCMI’s. At first, I found it difficult to deal with because I did not want to influence the opinions of respondents. I eventually solved this by pointing out to respondents that the results of this study will be published in the STIN journal and that this article will also answer whether it is possible to crack a RCMI.

To a degree, it has been possible to answer the question to what extent people trust the possibilities of new medical implantation technologies that are remotely controllable as there was limited time for the implementation of this study. By involving multiple categories of respondents in the research, the execution was much more complicated than when the focus had only been on the patients. Nevertheless, this choice allowed me to dig deeper into the underlying dynamics that affect the ideas of patients, but it was still a small-scale research. More respondents should be interviewed to get a better understanding of the level of trust in the Netherlands regarding the wireless applications of RCMI’s as I noticed that the latest interviews still gave new insights.

Recommendations
Wireless features can provide greater conveniences but are not always indispensable. Respondents find the wireless functions on insulin pumps useful, but only for patients with an insulin pump would it be possible to turn off the wireless feature in case they think that it brings too many risks. They always may administer insulin manually. Patients with a pacemaker or ICD do not have the option to turn the wireless feature on their RCMI off. It’s built-in that these implants are always wirelessly accessible. This wireless feature is indispensable because it would otherwise not be possible to access the data on the pacemaker/ICD or to adjust the settings. These findings imply that it is important to consider if the pros outweigh the cons when considering the need for wireless applications on medical implants.  If a wireless option primarily provides conveniences but is not necessary, then it’s important to think about the extent it is responsible for implementing such applications. An example would be the plan to make the home-monitoring systems of pacemakers and ICDs wirelessly accessible to hospitals. It’s currently only possible to send data from the home monitoring system to the hospital. When it is possible to send data to the home-monitoring system from the hospital to make adjustments to the pacemaker/ICD, the patient doesn’t need to immediately go to the hospital if the RCMI is not functioning properly. However, it would make the device more complex and thus harder to secure. One may wonder to what extent this benefit weighs against the risk of hackers breaking into the device and taking control over pacemakers and ICDs. Although respondents can not imagine someone that would have an interest in doing this, it does not seem unreasonable to make sure that this is not possible by removing the option if it is not essential anyway.

Reliable research shows that there are risks associated with wireless applications on medical implants. Physicians and manufacturers should be obliged to inform patients about this, but in the case of pacemakers and ICDs, wireless accessibility is essential. One may wonder to what extent it is in the interests of this group of patients if they are informed about the risk of their RCMI being hacked. It would cause unnecessary fear. After all, they do not have a choice to decide if they want a pacemaker or ICD or not if they want to live longer, the risk of premature death is too big. A counterargument is that patients will find out about the hackability of RCMI’s through other channels anyway. For patients with diabetes, wireless functions are not necessary. Therefore, it is not unreasonable to inform them about the risks. This information can then be taken into account in the decision to take an insulin pump or not. If patients want to use an insulin pump, they can always decide to turn off the wireless applications on the insulin pump.

According to the study results, respondents found it hard to imagine that someone would be interested in hacking a RCMI. For future research, it would be interesting to investigate the ideas people have when thinking about hackers. One may ask about the average level of education, age, and gender, but also about the reasons hackers may have. How do respondents see hackers and is this view in line with studies done about hackers?