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Schmidt; H. Pages: 583 - 584 Abstract: Earlier this year, the International Association of Bioethics (IAB) hosted the biennial World Congress of Bioethics (WCB) in Doha, Qatar. Understandably, controversy surrounded the decision to hold the conference there. Opponents thought Qatar’s human rights record rendered it incompatible with the IAB’s mission.1 2 Proponents felt that the location was overall justified to advance equitable participation in the WCB.3 4 The discussion about the Qatar venue was an important one. But unlike in real estate, where the mantra of ‘location, location, location’ highlights the often singular importance of geophysical coordinates, the debate about equity in global bioethics scholarship and practice is broader than where the WCB takes place. As we entered the intercongress time frame, it is helpful to consider in what other ways the IAB—and leading journals such as the JME—can contribute to equity in bioethics outside of events such... PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2024-110358 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Thom, R; Ayares, D, Cooper, D. K. C, Dark, J, Fovargue, S, Fox, M, Gusmano, M, Locke, J, McGregor, C, Parent, B, Ravanan, R, Shaw, D, Dorling, A, Cronin, A. J. Pages: 585 - 591 Abstract: This manuscript reports on a landmark symposium on the ethical, legal and technical challenges of xenotransplantation in the UK. King’s College London, with endorsement from the British Transplantation Society (BTS), and the European Society of Organ Transplantation (ESOT), brought together a group of experts in xenotransplantation science, ethics and law to discuss the ethical, regulatory and technical challenges surrounding translating xenotransplantation into the clinical setting. The symposium was the first of its kind in the UK for 20 years. This paper summarises the content of the expert lectures showcasing the progress which has been made in xenotransplantation including—the history of xenotransplantation, advances in gene edited animals and progress towards clinical xenotransplantation. We then set out the ethical and legal issues still to be resolved. Finally, we report the themes of the roundtable discussion highlighting areas of consensus and controversy. While the detail of the legal discussion was directed towards the UK, the principles and summary reported here are intended to be applicable to any jurisdiction seeking to implement clinical xenotransplantation. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109298 Issue No:Vol. 50, No. 9 (2024)
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Ugar, E. T; Malele, N. Pages: 592 - 595 Abstract: Recently clinicians have become more reliant on technologies such as artificial intelligence (AI) and machine learning (ML) for effective and accurate diagnosis and prognosis of diseases, especially mental health disorders. These remarks, however, apply primarily to Europe, the USA, China and other technologically developed nations. Africa is yet to leverage the potential applications of AI and ML within the medical space. Sub-Saharan African countries are currently disadvantaged economically and infrastructure-wise. Yet precisely, these circumstances create significant opportunities for the deployment of medical AI, which has already been deployed in some places in the continent. However, while AI and ML have come with enormous promises in Africa, there are still challenges when it comes to successfully applying AI and ML designed elsewhere within the African context, especially in diagnosing mental health disorders. We argue, in this paper, that there ought not to be a homogeneous/generic design of AI and ML used in diagnosing mental health disorders. Our claim is grounded on the premise that mental health disorders cannot be diagnosed solely on ‘factual evidence’ but on both factual evidence and value-laden judgements of what constitutes mental health disorders in sub-Saharan Africa. For ML to play a successful role in diagnosing mental health disorders in sub-Saharan African medical spaces, with a precise focus on South Africa, we allude that it ought to understand what sub-Saharan Africans consider as mental health disorders, that is, the value-laden judgements of some conditions. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109711 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Pozzi, G; De Proost, M. Pages: 596 - 597 Abstract: Introduction In their contribution, Ugar and Malele1 shed light on an often overlooked but crucial aspect of the ethical development of machine learning (ML) systems to support the diagnosis of mental health disorders. The authors restrain their focus on pointing to the danger of misdiagnosing mental health pathologies that do not qualify as such within sub-Saharan African communities and argue for the need to include population-specific values in these technologies’ design. However, an analysis of the nature of the harm caused to said populations once their values remain unrecognised is not offered. Building on Ugar and Malele’s considerations, we add a further perspective to their analysis by showing the need to design considering intended values to avoid the occurrence of epistemic injustices.2 First, we argue that failing to acknowledge the hermeneutical offerings of the populations interacting with these systems can qualify as contributory injustice. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2024-110059 Issue No:Vol. 50, No. 9 (2024)
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Razali, H. Y. H; Yusof, A. N. M. Pages: 598 - 599 Abstract: In their paper ‘Designing AI for mental health diagnosis: challenges from sub-Saharan African value-laden judgements on mental health disorders’, Ugar and Malele focused on the challenges and considerations surrounding the design and implementation of artificial intelligence (AI) and machine learning (ML) technologies for diagnosing mental health disorders in South Africa. Although the authors recognise the application of AI and ML in healthcare, they put forward the challenges, particularly in adopting Wakefield’s hybrid theory, where elements of naturalism and normativism are combined in defining mental disorders. They argue that a generic or universally designed AI or ML would not be appropriate in countries with strong and varied local contexts. Hence, they believe that current and future AI developers should consider the cultural nuances, value systems and contextual factors in designing and implementing AI technologies for mental health diagnosis in Africa. When the authors argue that a universal definition of mental... PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2024-110086 Issue No:Vol. 50, No. 9 (2024)
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de Lucca Silveira; M. P. Pages: 600 - 601 Abstract: Ugar and Malele1 critique the use of ‘generic’ technologies like artificial intelligence (AI) and machine learning (ML) for mental health diagnoses, particularly in sub-Saharan African countries. They highlight how these AI medical tools often overlook traditional perspectives and local contexts. The article has the merit of working on ethical issues regarding the particularities and risks of using AI and ML for health diagnosis in the Global South, an urgent and neglected topic. According to the authors, the use of these AI technologies leads to overgeneralisation in diagnosing mental disorders, which could be especially problematic in the mental health field because of value-laden judgements intrinsic to the definition of mental health disorders. This argument is theoretically grounded in the hybrid conceptualisation of mental disorders proposed by Wakefield.2 This author’s perspective incorporates both factual and value components in defining mental disorders, framing them as context-dependent ‘harmful dysfunctions’... PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2024-110054 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Lee; J.-Y. Pages: 602 - 603 Abstract: Introduction Ugar and Malele write that generic machine learning (ML) technologies for mental health diagnosis would be challenging to implement in sub-Saharan Africa due to cultural specificities in how those conditions are diagnosed. For example, they say that in South Africa, the appearance of ‘schizophrenia’ might be understood as a type of spiritual possession, rather than a mental disorder caused by a brain dysfunction. Hence, a generic ML system is likely to ‘misdiagnose’ persons whose symptomatology matches that of schizophrenia in the South African context. The authors thus claim that ‘a generic or universal design cannot be effective given the heterogeneity of value judgements in defining what mental health disorders are in different contexts’.1 Should we take this to mean that ML systems ‘should not be designed with a generalised perception of mental disorders,’1 as the authors suggest' On the contrary, my view is... PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2024-110037 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Ugar, E. T; Malele, N. Pages: 604 - 605 Abstract: Introduction This commentary aims to respond to some criticism against our paper entitled ‘Designing AI for Mental Health Diagnosis: Challenges from sub-Saharan value-laden Judgments on Mental Health Disorders’.1 While we are sympathetic to the invaluable critiques of some authors, we show that some misunderstanding arises in reading our conceptualisation of the condition we use as a central example of disease in our paper. A brief recap of our argument We argue, in our paper, that there are obvious context-specific value judgments when it comes to mental health disorders, which obscures an application of generic machine learning (ML) in the diagnosis of these conditions. To contextualise our contention, our understanding of mental health disorder is grounded in Jerome Wakefield’s2 hybrid theorisation of disease as that which encompasses aspects of the normativist and naturalist accounts of health. Wakefield theorises that facts are necessary but... PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2024-110244 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Schaefer; G. O. Pages: 606 - 611 Abstract: Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI) is an ethical framework developed by the WHO for using unproven interventions in public health emergencies outside the context of medical research. It is mainly intended for use when medical research would be impracticable, but there is still a need to systematically gather data about unproven interventions. As such, it is designed as something of a middle ground between clinical and research ethical frameworks.However, I argue that MEURI does not truly lie at the intersection of clinical care and research. Due to its intent, structure and oversight requirements, it takes on most of the crucial features of research, to the point that it is best understood as a form of research. As a result, cases where MEURI could practicably be applied should instead make use of existing research frameworks. For those circumstances where research is truly impracticable, a more straightforward oversight system than MEURI is needed. While existing practices of compassionate use have some applicability, proposals to make use of clinical ethics committees to oversee unproven interventions may help achieve the right balance in acting in a patient’s best interests when the relevant evidence base is weak. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109169 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Johnson, T; Jamrozik, E, Hurst, T, Cheah, P. Y, Parker, M. J. Pages: 612 - 617 Abstract: Nipah virus is a priority pathogen that is receiving increasing attention among scientists and in work on epidemic preparedness. Despite this trend, there has been almost no bioethical work examining ethical considerations surrounding the epidemiology, prevention, and treatment of Nipah virus or research that has already begun into animal and human vaccines. In this paper, we advance the case for further work on Nipah virus disease in public health ethics due to the distinct issues it raises concerning communication about the modes of transmission, the burdens of public health surveillance, the recent use of stringent public health measures during epidemics, and social or religious norms intersecting with preventive measures. We also advance the case for further work on Nipah virus disease in research ethics, given ethical issues surrounding potential vaccine trials for a high-fatality disease with sporadic spillover events, the different local contexts where trials may occur, and the potential use of unproven therapeutics during outbreaks. Further bioethics work may help to ensure that research and public health interventions for Nipah virus disease are ethically acceptable and more likely to be effective. Keywords:
Open access
PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109469 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Harmer; A. S. Pages: 618 - 621 Abstract: Seasonal influenza poses a significant public health risk in many countries worldwide. Lower immunity and less influenza virus circulating during the pandemic has resulted in a significant increase in cases since the lifting of COVID-19 restrictions in 2022. The seasonal influenza vaccine offers effective protection and is safe for use in large numbers of the population. This article asserts that a moral obligation to vaccinate against influenza can be understood as an Institutional Duty of Rescue. The traditional understanding of the Duty of Rescue encounters issues with force and scope, making it difficult to apply to rescue cases in general, as well as being overdemanding for the individual agent. An Institutional view of the Duty of Rescue addresses these difficulties, looks at the wider context of rescue and leaves room for discussion on collective, preventative rescue measures. This makes the concept well suited to supporting a moral obligation to vaccinate against influenza as part of a collective effort on the part of institutional organisations. Keywords:
COVID-19
PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109545 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Parent, B; Kates, O. S, Arap, W, Caplan, A, Childs, B, Dickert, N. W, Homan, M, Kinlaw, K, Lang, A, Latham, S, Levan, M. L, Truog, R. D, Webb, A, Root Wolpe, P, Pentz, R. D. Pages: 622 - 625 Abstract: Research involving recently deceased humans that are physiologically maintained following declaration of death by neurologic criteria—or ‘research involving the recently deceased’—can fill a translational research gap while reducing harm to animals and living human subjects. It also creates new challenges for honouring the donor’s legacy, respecting the rights of donor loved ones, resource allocation and public health. As this research model gains traction, new empirical ethics questions must be answered to preserve public trust in all forms of tissue donation and in the practice of medicine while respecting the legacy of the deceased and the rights of donor loved ones. This article suggests several topics for immediate investigation to understand the attitudes and experiences of researchers, clinical collaborators, donor loved ones and the public to ensure research involving the recently deceased advances ethically. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109413 Issue No:Vol. 50, No. 9 (2024)
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Authors:
van Gils-Schmidt, H. J; Salloch, S. Pages: 626 - 633 Abstract: Physicians frequently encounter situations in which their professional practice is intermingled with moral affordances stemming from other domains of the physician’s lifeworld, such as family and friends, or from general morality pertaining to all humans. This article offers a typology of moral conflicts ‘at the margins of professionalism’ as well as a new theoretical framework for dealing with them. We start out by arguing that established theories of professional ethics do not offer sufficient guidance in situations where professional ethics overlaps with moral duties of other origins. Therefore, we introduce the moral theory developed by Christine M. Korsgaard, that centres around the concept of practical identity. We show how Korsgaard’s account offers a framework for interpreting different types of moral conflicts ‘at the margins of professionalism’ to provide either orientation for solving the conflict or an explanation for the emotional and moral burden involved in moral dilemmas. Keywords:
Open access
PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2022-108500 Issue No:Vol. 50, No. 9 (2024)
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Campo-Engelstein, L; Andaya, E. Pages: 634 - 639 Abstract: The antiabortion movement is increasingly using ostensibly scientific measurements such as ‘fetal heartbeat’ and ‘fetal pain’ to provide ‘objective’ evidence of the moral status of fetuses. However, there is little knowledge on how clinicians conceptualise and operationalise the moral status of fetuses. We interviewed obstetrician/gynaecologists and neonatologists on this topic since their practice regularly includes clinical management of entities of the same gestational age. Contrary to our expectations, there was consensus among clinicians about conceptions of moral status regardless of specialty. First, clinicians tended to take a gradualist approach to moral status during pregnancy as they developed and viewed viability, the ability to live outside of the uterus, as morally significant. Second, in contrast to ‘fetal pain’ laws and philosophical discussions about the ethical salience of sentience, the clinicians in our study did not consider the ability to feel pain as a morally relevant factor in moral status determinations. Third, during previability and perviability, clinicians viewed moral status as a personal value decision, which should be made by pregnant people and parents of neonates. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2022-108392 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Lim; M. Y. H. Pages: 640 - 642 Abstract: The practice of medicine—and especially the patient-doctor relationship—has seen exceptional shifts in ethical standards of care over the past few years, which by and large originate in occidental countries and are then extrapolated worldwide. However, this phenomenon is blind to the fact that an ethical practice of medicine remains hugely dependent on prevailing cultural and societal expectations of the community in which it serves. One model aiming to conceptualise the dichotomous efforts for global standardisation of medical care against differing sociocultural expectations is the individualism-collectivism model, with the ‘West’ being seen as individualistic and the ‘East’ being seen as collectivistic. This has been used by many academics to explain differences in approach towards ethical practice on key concepts such as informed consent and patient autonomy. However, I argue that this characterisation is incomplete and lacks nuance into the complexities surrounding cross-cultural ethics in practice, and I propose an alternative model based on the ethics of clinical care in Hong Kong, China. Core ethical principles need not be culture-bound—indeed, their very existence mandates for them to be universal and non-derogable—but instead cultural alignment occurs in the particular implementation of these principles, insofar as they respect the general spirit of contemporary ethical standards. Keywords:
Editor's choice
PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/medethics-2022-108123 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Bernstein, M. H; Rosenfield, M. N, Blease, C, Magill, M, Terek, R. M, Savulescu, J, Beaudoin, F. L, Rich, J. D, Wartolowska, K. Pages: 643 - 646 Abstract: Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as ‘completely’ or ‘mostly’ unethical. Participants were also asked to rank-order the value of five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as the least valuable (even less valuable than an anecdote) and 35.7 .% viewing it as the most valuable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2022-108221 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Butler, C. R; Webster, L. B, Diekema, D. S. Pages: 647 - 649 Abstract: Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1) prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2) prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies—while potentially resulting in care that deviates from usual standards–support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2022-108262 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Simkulet; W. Pages: 650 - 652 Abstract: Hendricks set out to construct an antiabortion version of Jeff McMahan’s Embryo Rescue case in which you have two choices—(1) save a woman from an unwilling pregnancy or (2) save a fetus from being killed. In his Pregnancy Rescue case, he contends we ought to choose (2), which he thinks shows abortion is immoral. However, I argue the Pregnancy Rescue case is a false dilemma because you can save both. I propose an alternative, more elegant dilemma, the Ectogenesis Rescue case with the same choices (1) and (2). Hendricks also believes his case can serve as an antiabortion version of Thomson’s Violinist case, showing that abortion is immoral even if a fetus is not a person. However, while Thomson’s Violinist substitutes the fetus with a person, Hendricks fails to substitute the fetus with something that is not a person. I propose an alternative, the Snakebite Rescue case, which does this. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109454 Issue No:Vol. 50, No. 9 (2024)
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Authors:
Ferrario, A; Biller-Andorno, N. Pages: 653 - 654 Abstract: Large language models (LLMs) have now entered the realm of medical ethics. In a recent study, Balas et al examined the performance of GPT-4, a commercially available LLM, assessing its performance in generating responses to diverse medical ethics cases. Their findings reveal that GPT-4 demonstrates an ability to identify and articulate complex medical ethical issues, although its proficiency in encoding the depth of real-world ethical dilemmas remains an avenue for improvement. Investigating the integration of LLMs into medical ethics decision-making appears to be an interesting avenue of research. However, despite the promising trajectory of LLM technology in medicine, it is crucial to exercise caution and refrain from attributing their expertise to medical ethics. Our thesis follows an examination of the nature of expertise and the epistemic limitations that affect LLM technology. As a result, we propose two more fitting applications of LLMs in medical ethics: first, as tools for mining electronic health records or scientific literature, thereby supplementing evidence for resolving medical ethics cases, and second, as educational platforms to foster ethical reflection and critical thinking skills among students and residents. The integration of LLMs in medical ethics, while promising, requires careful consideration of their epistemic limitations. Consequently, a well-considered definition of their role in ethically sensitive decision-making is crucial. PubDate: 2024-08-21T02:23:51-07:00 DOI: 10.1136/jme-2023-109770 Issue No:Vol. 50, No. 9 (2024)
