Intraoperative application of mixed and augmented reality for digital surgery: a systematic review of ethical issues.

Introduction: Head-mounted displays (HMDs) that superimpose holograms onto patients are of particular surgical interest as they are believed to dramatically change surgical procedures by including safety warning and allowing real-time offsite consultations. Although there are promising benefits of mixed and augmented reality (MR/AR) technologies in surgery, they also raise new ethical concerns. The aim of this systematic review is to determine the full spectrum of ethical issues that is raised for surgeons in the intraoperative application of MR/AR technology. Methods: Five bibliographic databases were searched for publications on the use of MR/AR, HMDs and other devices, their intraoperative application in surgery, and ethical issues. We applied qualitative content analysis to the n = 50 articles included. Firstly, we coded the material with deductive categories derived from ethical frameworks for surgical innovations, complications and research. Secondly, clinical aspects with ethical relevance were inductively coded as ethical issues within the main categories. Thirdly, we pooled the ethical issues into themes and sub-themes. We report our findings according to the reporting guideline RESERVE. Results: We found n = 143 ethical issues across ten main themes, namely patient-physician relationship, informed consent, professionalism, research and innovation, legal and regulatory issues, functioning equipment and optimal operating conditions, allocation of resources, minimizing harm, good communication skills and the ability to exercise sound judgement. The five most prevalent ethical issues are "Need for continuous research and innovation", "Ensuring improvement of the learning curve", "MR/AR enables new maneuvers for surgeons", "Ensuring improvement of comfort, ergonomics, and usability of devices," and "Not withholding MR/AR if it performs better". Conclusions: Recognizing the evidence-based limitations of the intraoperative MR/AR application is of paramount importance to avoid ethical issues, but clinical trials in surgery pose particular ethical risks for patients. Regarding the digital surgeon, long-term impact on human workforce, potentially harmful "negative training," i.e., acquiring inappropriate behaviors, and the fear of surveillance need further attention. MR/AR technologies offer not only challenges but significant advantages, promoting a more equitable distribution of surgical expertise and optimizing healthcare. Aligned with the core principle of social justice, these technologies enable surgeons to collaborate globally, improving training conditions and addressing enduring global healthcare inequalities.

Should Artificial Intelligence be used to support clinical ethical decision-making? A systematic review of reasons.

BACKGROUND: Healthcare providers have to make ethically complex clinical decisions which may be a source of stress. Researchers have recently introduced Artificial Intelligence (AI)-based applications to assist in clinical ethical decision-making. However, the use of such tools is controversial. This review aims to provide a comprehensive overview of the reasons given in the academic literature for and against their use. METHODS: PubMed, Web of Science, Philpapers.org and Google Scholar were searched for all relevant publications. The resulting set of publications was title and abstract screened according to defined inclusion and exclusion criteria, resulting in 44 papers whose full texts were analysed using the Kuckartz method of qualitative text analysis. RESULTS: Artificial Intelligence might increase patient autonomy by improving the accuracy of predictions and allowing patients to receive their preferred treatment. It is thought to increase beneficence by providing reliable information, thereby, supporting surrogate decision-making. Some authors fear that reducing ethical decision-making to statistical correlations may limit autonomy. Others argue that AI may not be able to replicate the process of ethical deliberation because it lacks human characteristics. Concerns have been raised about issues of justice, as AI may replicate existing biases in the decision-making process. CONCLUSIONS: The prospective benefits of using AI in clinical ethical decision-making are manifold, but its development and use should be undertaken carefully to avoid ethical pitfalls. Several issues that are central to the discussion of Clinical Decision Support Systems, such as justice, explicability or human-machine interaction, have been neglected in the debate on AI for clinical ethics so far. TRIAL REGISTRATION: This review is registered at Open Science Framework ( https://osf.io/wvcs9 ).

The birth of the "digital turn" in bioethics?

The so-called "empirical turn" in bioethics gave rise to extensive theoretical and methodological debates and has significantly shaped the research landscape from two decades ago until the present day. Attentive observers of the evolution of the bioethical research field now notice a new trend towards the inclusion of data science methods for the treatment of ethical research questions. This new research domain of "digital bioethics" encompasses both studies replacing (or complementing) socio-empirical research on bioethical topics ("empirical digital bioethics") and argumentative approaches towards normative questions in the healthcare domain ("argumentative digital bioethics"). This article draws on insights taken from the debate on the "empirical turn" for sounding out perspectives for the newly developing field of "digital bioethics." We particularly discuss the disciplinary boundaries, chances and challenges, and potentially undesirable developments of the research field. The article closes with concrete suggestions on which debates need to be initiated and which measures need to be taken so that the path forward of "digital bioethics" will be a scientific success.

Conflicting Aims and Values in the Application of Smart Sensors in Geriatric Rehabilitation: Ethical Analysis.

BACKGROUND: Smart sensors have been developed as diagnostic tools for rehabilitation to cover an increasing number of geriatric patients. They promise to enable an objective assessment of complex movement patterns. OBJECTIVE: This research aimed to identify and analyze the conflicting ethical values associated with smart sensors in geriatric rehabilitation and provide ethical guidance on the best use of smart sensors to all stakeholders, including technology developers, health professionals, patients, and health authorities. METHODS: On the basis of a systematic literature search of the scientific databases PubMed and ScienceDirect, we conducted a qualitative document analysis to identify evidence-based practical implications of ethical relevance. We included 33 articles in the analysis. The practical implications were extracted inductively. Finally, we carried out an ethical analysis based on the 4 principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice. The results are reported in categories based on these 4 principles. RESULTS: We identified 8 conflicting aims for using smart sensors. Gains in autonomy come at the cost of patient privacy. Smart sensors at home increase the independence of patients but may reduce social interactions. Independent measurements performed by patients may result in lower diagnostic accuracy. Although smart sensors could provide cost-effective and high-quality diagnostics for most patients, minorities could end up with suboptimal treatment owing to their underrepresentation in training data and studies. This could lead to algorithmic biases that would not be recognized by medical professionals when treating patients. CONCLUSIONS: The application of smart sensors has the potential to improve the rehabilitation of geriatric patients in several ways. It is important that patients do not have to choose between autonomy and privacy and are well informed about the insights that can be gained from the data. Smart sensors should support and not replace interactions with medical professionals. Patients and medical professionals should be educated about the correct application and the limitations of smart sensors. Smart sensors should include an adequate representation of minorities in their training data and should be covered by health insurance to guarantee fair access.

Explicability of artificial intelligence in radiology: Is a fifth bioethical principle conceptually necessary?

Recent years have witnessed intensive efforts to specify which requirements ethical artificial intelligence (AI) must meet. General guidelines for ethical AI consider a varying number of principles important. A frequent novel element in these guidelines, that we have bundled together under the term explicability, aims to reduce the black-box character of machine learning algorithms. The centrality of this element invites reflection on the conceptual relation between explicability and the four bioethical principles. This is important because the application of general ethical frameworks to clinical decision-making entails conceptual questions: Is explicability a free-standing principle? Is it already covered by the well-established four bioethical principles? Or is it an independent value that needs to be recognized as such in medical practice? We discuss these questions in a conceptual-ethical analysis, which builds upon the findings of an empirical document analysis. On the example of the medical specialty of radiology, we analyze the position of radiological associations on the ethical use of medical AI. We address three questions: Are there references to explicability or a similar concept? What are the reasons for such inclusion? Which ethical concepts are referred to?

Aligning Patient's Ideas of a Good Life with Medically Indicated Therapies in Geriatric Rehabilitation Using Smart Sensors.

New technologies such as smart sensors improve rehabilitation processes and thereby increase older adults' capabilities to participate in social life, leading to direct physical and mental health benefits. Wearable smart sensors for home use have the additional advantage of monitoring day-to-day activities and thereby identifying rehabilitation progress and needs. However, identifying and selecting rehabilitation priorities is ethically challenging because physicians, therapists, and caregivers may impose their own personal values leading to paternalism. Therefore, we develop a discussion template consisting of a series of adaptable questions for the patient-physician encounter based on the capability approach. The goal is to improve geriatric rehabilitation and thereby increase participation in social life and well-being. To achieve this goal, we first analyzed what is considered important for participation on basis of the capability approach, human rights, and ethics of care. Second, we conducted an ethical analysis of each of the four identified dimensions of participation: political, economic, socio-cultural, and care. To improve compliance with rehabilitation measures, health professionals must align rehabilitation measures in an open dialogue with the patient's aspiration for participation in each dimension. A discussion template based on the capability approach allows for a proactive approach in patient information and stimulates a critical assessment of treatment alternatives while reducing the risk of imposing personal values.

Diagnosing Diabetic Retinopathy With Artificial Intelligence: What Information Should Be Included to Ensure Ethical Informed Consent?

Purpose: The method of diagnosing diabetic retinopathy (DR) through artificial intelligence (AI)-based systems has been commercially available since 2018. This introduces new ethical challenges with regard to obtaining informed consent from patients. The purpose of this work is to develop a checklist of items to be disclosed when diagnosing DR with AI systems in a primary care setting. Methods: Two systematic literature searches were conducted in PubMed and Web of Science databases: a narrow search focusing on DR and a broad search on general issues of AI-based diagnosis. An ethics content analysis was conducted inductively to extract two features of included publications: (1) novel information content for AI-aided diagnosis and (2) the ethical justification for its disclosure. Results: The narrow search yielded n = 537 records of which n = 4 met the inclusion criteria. The information process was scarcely addressed for primary care setting. The broad search yielded n = 60 records of which n = 11 were included. In total, eight novel elements were identified to be included in the information process for ethical reasons, all of which stem from the technical specifics of medical AI. Conclusions: Implications for the general practitioner are two-fold: First, doctors need to be better informed about the ethical implications of novel technologies and must understand them to properly inform patients. Second, patient's overconfidence or fears can be countered by communicating the risks, limitations, and potential benefits of diagnostic AI systems. If patients accept and are aware of the limitations of AI-aided diagnosis, they increase their chances of being diagnosed and treated in time.

Ethical Implications of Alzheimer's Disease Prediction in Asymptomatic Individuals through Artificial Intelligence.

Biomarker-based predictive tests for subjectively asymptomatic Alzheimer's disease (AD) are utilized in research today. Novel applications of artificial intelligence (AI) promise to predict the onset of AD several years in advance without determining biomarker thresholds. Until now, little attention has been paid to the new ethical challenges that AI brings to the early diagnosis in asymptomatic individuals, beyond contributing to research purposes, when we still lack adequate treatment. The aim of this paper is to explore the ethical arguments put forward for AI aided AD prediction in subjectively asymptomatic individuals and their ethical implications. The ethical assessment is based on a systematic literature search. Thematic analysis was conducted inductively of 18 included publications. The ethical framework includes the principles of autonomy, beneficence, non-maleficence, and justice. Reasons for offering predictive tests to asymptomatic individuals are the right to know, a positive balance of the risk-benefit assessment, and the opportunity for future planning. Reasons against are the lack of disease modifying treatment, the accuracy and explicability of AI aided prediction, the right not to know, and threats to social rights. We conclude that there are serious ethical concerns in offering early diagnosis to asymptomatic individuals and the issues raised by the application of AI add to the already known issues. Nevertheless, pre-symptomatic testing should only be offered on request to avoid inflicted harm. We recommend developing training for physicians in communicating AI aided prediction.

[Impotence and belief in witchcraft: a medical treatise by the Ulm town physician Wolfgang Reichart (1486-1547)]. / Impotenz und Hexenglauben: Ein medizinischer Traktat des Ulmer Stadtarztes Wolfgang Reichart (1486­1547).

BACKGROUND: The belief in witchcraft influenced medical thinking and action in the 16th century. In a hitherto unknown treatise on impotence, the Ulmian town physician Wolfgang Reichart (1486-1547) has rationally explained it by using medical concepts. MATERIALS AND METHODS: The treatise was transcribed, translated, and analyzed in terms of its sources, structure, and content. The results were compared with the concept of Johann Weyer (1515-1588). RESULTS: Reichart explains his patient's impotence as an acquired disease involving demons. Since demons act only naturally on the human body, the disease is naturally curable. The basis of the therapy is a medieval pathophysiological concept that combined ancient elements. CONCLUSIONS: Reichart's therapy differs from that of contemporary physicians because he treats the patient himself and does not send him to a theologian. Unlike Weyer, he offers a detailed pathophysiological concept in order to explain impotence medically.

The Pathophysiology and Therapy of Erectile Dysfunction in a Newly Discovered Treatise by Wolfgang Reichart (1486-circa 1547).

BACKGROUND: A newly-found treatise by Wolfgang Reichart (1486-circa 1547), town physician of Ulm, challenges the contemporary view that bewitchment as a cause of impotence defies any natural explanation. OBJECTIVE: To understand the pathophysiological concept and therapy of erectile dysfunction in Reichart's treatise by examination of his sources and previous concepts. METHODS: Source analysis of Reichart's treatise by comparison of the pathophysiological concepts and therapy of erectile dysfunction with original texts of the Corpus Hippocraticum (5th-3rd century BC) and Constantinus Africanus (11th century). RESULTS: By using rational thinking and medical knowledge mainly drawn from antiquity, especially Constantinus Africanus, Reichart shows that a supposed supernatural cause for impotence can be explained by reason and natural means. Reichart's treatise changes the view of bewitchment as cause of impotence. He makes eclectical use of previous concepts to explain his patient's condition. From the Middle Ages on, bewitchment was accepted as a cause for erectile dysfunction. Usually, physicians of that time accepted this etiology and advised a treatment based on theological concepts. Reichart challenges this view by emphasizing reason and medical knowledge as crucial for treating the patient, rejecting supernatural treatment approaches. CONCLUSIONS: In the 16th century, a type of rational thinking and medical knowledge emerges, which puts supernatural explanations into question and aims at treating patients with natural means. The analysis of Reichart's treatise is a much-needed contribution to understanding the historic development of pathophysiological concepts of and therapeutic measures for impotence, which is yet underresearched.

Dermatology in Ancient Rome: Medical ingredients in Ovid's "Remedies for female faces".

BACKGROUND: In Roman medicine, face packs, plasters, unguents, and peelings were part of the therapy of dermatological diseases, but also served cosmetic purposes. Ancient medical textbooks inform us about the ingredients for these applications. Beyond medical literature, other genres contain information about dermatological applications. The Roman poet Ovid (43 BC-17 AD) wrote a didactic poem recording five recipes for topical applications for female faces (Medicamina faciei femineae). Researchers debate the relation of Ovid's poem to Roman medicine: Does the poem contain therapeutical or cosmetical information, or is it mere belles lettres? AIMS: The objective of the paper is to conduct a medico-historical classification of Ovid's poem by determining whether the ingredients of Ovid's recipes were thought to be effective by the authors of Roman medical textbooks. METHODS: First, translation and identification of the ingredients were carried out. Second, comparison of the ingredients' functions regarding the therapy of dermatological diseases in two important Roman medical textbooks was realized. For this purpose, several commentaries on the text of Ovid were used and a keyword search in Roman medical textbooks was performed. RESULTS: Ovid's five recipes contain 23 ingredients. All ingredients can be found in medical textbooks. We find that 14 of these ingredients serve cosmetic purposes, 17 serve the therapy of dermatological diseases, and 13 serve both. CONCLUSION: Ovid's recipes contain drugs that were considered effective by the authors of Roman medical textbooks. These drugs were recommended both for therapeutic and cosmetic purposes by the same authors. Therefore, Ovid's didactic poem is not mere belles lettres, but contains serious medical and cosmetical information. As far as we know, it is the first Roman text that contains dermatological recipes.

From poison to drug: new recipes discovered containing colchicine as a remedy for Podagra in Rome and Byzantium.

OBJECTIVES: In Antiquity, colchicine was used as a poison and as a remedy for Podagra. Research so far has revealed that the physician Alexander of Tralles was the first who used it in the 6th century AD. Alexander recommended a plant he called "Hermodaktylon", which takes off the pain in the feet immediately. "Hermodaktylon" is identified with Colchicum autumnale L., which contains colchicine in his bulbs and seeds. We will present new data that varieties of Colchicum were used for medical treatment of Podagra far earlier than hitherto known by research. METHODS: We performed a systematic full text search in Greek and Latin original sources of Antiquity for "Hermodaktylon"/"Hermodactylus" and for the synonyms "Ephemeron"/"Ephemerum", "Kolchikon"/"Colchicum", and "Bolbos (agrios)"/"bulbus (agrestis)". We analysed our findings with philological and historico-critical methods. RESULTS: There are 48 text passages in original sources. Lucian of Samosata (2nd century AD) was the first who mentioned a plant he called "bolbos" as a remedy for Podagra. The Byzantine physician Jacobus Psychrestes (5th century AD) developed two recipes. Aëtius of Amida (6th century AD) transmitted two recipes. One case with an overdose of colchicine was discovered which resulted in the death of a patient in Byzantine times. CONCLUSIONS: New specific recipes containing Colchicum were discovered. Jacobus Psychrestes and Aëtius used Colchicum systematically for the therapy of Podagra earlier than the 6th century AD. However, the therapeutic use of Colchicum was already known in the 2nd century AD.

[Gallstones and "liver obstruction" in medical texts of antiquity]. / Gallensteine und "Leberverstopfung" in den medizinischen Fachschriften der Antike.

INTRODUCTION: Gallstones are rarely mentioned in the medical texts of antiquity. The physician, Alexander of Tralles mentions-for the first time-stones in the gallbladder as a possible cause for obstructive jaundice. This designation is found in his textbook on medicine under the heading "obstruction of the liver". Based on that observation, we describe the ancient history of hepatic obstruction and investigate the connection with the rare reference of gallstones in the medical texts of antiquity. METHODS: First, we evaluated the medico-historical literature on bile-stones and liver obstruction in antiquity, which has been published since 1900. The identified ancient sources we have analyzed for the purposes of etiology, diagnostics and therapy. Second, we searched for additional ancient sources with a combined keyword search in Greek and Latin text databases to check the completeness of the mentions of gallstones and liver obstructions known from the research literature. RESULTS: There are two mentions of stones in the liver and gallbladder: Aristotle probably describes stones in the liver of slaughtered sacrificial animals and the late-antique physician, Alexander of Tralles, in the gallbladder of humans. The mechanical obstruction of the bile ducts as a cause of jaundice has been known since Diocles of Karystos (4th century BC). For the first time, Galen of Pergamon describes the disease pattern of a liver obstruction (2nd century AC). This was due to the coagulation of the yellow bile, one of the four humors of ancient humoral pathology. CONCLUSION: Although gallstones were rarely mentioned, the clinical presentation of gallstone disease was known to ancient authors of medical texts and was referred to as liver obstruction.