Duties of Candour in Healthcare: The Truth, the Whole Truth, and Nothing but the Truth?

The creation of professional and statutory duties of candour has formalised the requirement for clinicians and healthcare organisations to be honest with patients and families when treatment has gone wrong. This article explains the background to creating both duties, analyses the concept of candour, the role of apologies, and considers evidence about compliance. It argues that making candour a statutory requirement appropriately reflects the ethical imperative of telling the truth about harm and is a powerful signal for honesty. However, being candid is not easy in the context of complex professional cultures, the realities of delivering care in under-funded health systems, and in the shadow of possible legal and regulatory proceedings. Proposals in the current Health and Care Bill to create investigatory 'safe spaces' which prohibit the disclosure of information submitted to the Health Service Safety Investigations Body undermine candour. This article argues against such proposals, which are both wrong in principle and highly problematic in practice. Candour should be respected as a cardinal principle governing not only the conduct of those providing care, but also those who investigate such incidents. Harmed patients and their families deserve to know the whole truth.

Artificial intelligence interventions focused on opioid use disorders: A review of the gray literature.

BACKGROUND: With the artificial intelligence (AI) paradigm shift comes momentum toward the development and scale-up of novel AI interventions to aid in opioid use disorder (OUD) care, in the identification of overdose risk, and in the reversal of overdose. OBJECTIVE: As OUD-specific AI interventions are relatively recent, dynamic, and may not yet be captured in the peer-reviewed literature, we conducted a review of the gray literature to identify literature pertaining to OUD-specific AI interventions being developed, implemented and evaluated. METHODS: Gray literature databases, customized Google searches, and targeted websites were searched from January 2013 to October 2019. Search terms include: AI, machine learning, substance use disorder (SUD), and OUD. We also requested recommendations for relevant material from experts in this area. RESULTS: This review yielded a total of 70 unique citations and 29 unique interventions, which can be sub-divided into five categories: smartphone applications (n = 12); healthcare data-related interventions (n = 7); biosensor-related interventions (n = 5); digital and virtual-related interventions (n = 2); and 'other', i.e., those that cannot be classified in these categories (n = 3). While the majority have not undergone rigorous scientific evaluation via randomized controlled trials, several AI interventions showed promise in aiding the identification of escalating opioid use patterns, informing the treatment of OUD, and detecting opioid-induced respiratory depression. CONCLUSION: This is the first gray literature synthesis to characterize the current 'landscape' of OUD-specific AI interventions. Future research should continue to assess the usability, utility, acceptability and efficacy of these interventions, in addition to the overall legal, ethical, and social implications of OUD-specific AI interventions.

Leaving patients to their own devices? Smart technology, safety and therapeutic relationships.

BACKGROUND: This debate article explores how smart technologies may create a double-edged sword for patient safety and effective therapeutic relationships. Increasing utilization of health monitoring devices by patients will likely become an important aspect of self-care and preventive medicine. It may also help to enhance accurate symptom reports, diagnoses, and prompt referral to specialist care where appropriate. However, the development, marketing, and use of such technology raise significant ethical implications for therapeutic relationships and patient safety. MAIN TEXT: Drawing on lessons learned from other direct-to-consumer health products such as genetic testing, this article explores how smart technology can also pose regulatory challenges and encourage overutilization of healthcare services. In order for smart technology to promote safer care and effective therapeutic encounters, the technology and its utilization must be safe. CONCLUSION: This article argues for unified regulatory guidelines and better education for both healthcare providers and patients regarding the benefits and risks of these devices.

Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study.

BACKGROUND: The raison d'etre of healthcare profession regulators across the globe is to protect patients and the public from the risk of harm. In cases of serious misconduct, remediation is deemed to be an important factor when considering the risk of harm from a practitioner under investigation. Yet, we know very little about how regulators account for remediation in their decision-making, and whether it is consistent with the aim of risk reduction. This paper explores the role of remediation in decision-making in cases of serious misconduct before UK healthcare regulators. METHODS: We conducted interviews with 21 participants from across eight of the nine UK healthcare profession regulators, covering a range of roles in the decision-making process in misconduct cases. Interviews were conducted remotely by video call and digitally transcribed. Data were analysed using the framework analysis method. The initial framework was developed from existing literature and guidance documents from the regulators, and was subsequently refined through the various rounds of coding. RESULTS: Remediation influenced decision-making in three ways: (1) Some types of misconduct were deemed more inherently remediable than others. In cases involving dishonesty or sexual misconduct, remediation was less likely to serve as a mitigating factor. (2) Decision-makers often view remediation as a proxy indicator of practitioner insight. (3) Whether a practitioner had demonstrated their commitment to change through undergoing remediation was more likely to feed into decision-making at the point where current impairment was under consideration. CONCLUSIONS: Remediation plays a key role in decision-makers' judgements in cases of misconduct, particularly when these cases relate to clinical misconduct. In such cases, remediation informs judgements on the levels of practitioner insight and the risk of such misconduct being repeated. Our results suggest a need to develop remediation interventions that are explicitly geared towards the regulatory function of developing practitioner insight. Regulators should also consider the structure of their fitness to practise processes and whether there are appropriate opportunities for judgements on remediation to feed into decisions and to facilitate balanced and proportionate outcomes.

Expert evidence and medical manslaughter: vagueness in action.

This article examines the reliance placed on expert evidence in prosecutions of health professionals for gross negligence manslaughter, where juries must decide whether conduct goes beyond civil negligence and constitutes the crime of involuntary manslaughter. It argues that the test for liability is vague and examines some of the consequences of this. Given the vagueness of the offence, jurors are likely to place great reliance on expert medical evidence. Little is known about how experts negotiate the legal process, empirically speaking: how they approach their task, how they view their role as expert witnesses, and the attitudes, biases, and beliefs that may underpin their testimony. Drawing on the experiences and perceptions often medical experts, this article explores how experts manage the vagueness inherent in the task of interpreting and applying gross negligence. Experts appear to go beyond offering purely medical opinion and enjoy engaging with law and the legal process.

Empathizing and Sympathizing With Robots: Implications for Moral Standing.

This paper discusses the ethical nature of empathetic and sympathetic engagement with social robots, ultimately arguing that an entity which is engaged with through empathy or sympathy is engaged with as an "experiencing Other" and is as such due at least "minimal" moral consideration. Additionally, it is argued that extant HRI research often fails to recognize the complexity of empathy and sympathy, such that the two concepts are frequently treated as synonymous. The arguments for these claims occur in two steps. First, it is argued that there are at least three understandings of empathy, such that particular care is needed when researching "empathy" in human-robot interactions. The phenomenological approach to empathy-perhaps the least utilized of the three discussed understandings-is the approach with the most direct implications for moral standing. Furthermore, because "empathy" and "sympathy" are often conflated, a novel account of sympathy which makes clear the difference between the two concepts is presented, and the importance for these distinctions is argued for. In the second step, the phenomenological insights presented before regarding the nature of empathy are applied to the problem of robot moral standing to argue that empathetic and sympathetic engagement with an entity constitute an ethical engagement with it. The paper concludes by offering several potential research questions that result from the phenomenological analysis of empathy in human-robot interactions.

Trust in the context of patient safety problems.

PURPOSE: This paper considers some implications of recent developments relating to patient safety for understandings of trust in health care contexts. DESIGN/METHODOLOGY/APPROACH: Conceptual analysis focusing on patients' trust in health care providers and health care providers' trust in patients. FINDINGS: Growing awareness of the scale of the problem of iatrogenic harm has prompted concerns that patients' trust in health care providers may be threatened and/or become inappropriate or dysfunctional. In principle, however, patients' trust may be both well placed and compatible with current understandings of safety problems and efforts to address these. Contemporary understandings of patient safety suggest that, to be deemed trustworthy, health care providers should make vigorous efforts to improve patient safety, be honest about safety issues, enable patients to contribute effectively to their own safety, and provide appropriate care and support after safety incidents. Patients who trust health care providers need not be ignorant of patient safety problems and may be vigilant in the course of their care. Iatrogenic harms do not necessarily reflect breeches of trust (not all such harms are yet preventable), and patients who are harmed might in some circumstances appropriately forgive and resume trusting. Health care providers may feel vulnerable to patients in several respects. From their perspective, trustworthy patients will act competently to optimise the outcomes of their health care efforts and to preserve health care providers' good reputations where those are justified. Providers' trust in patients may strengthen patients' trust in them and facilitate safety improvement work. ORIGINALITY/VALUE: Shows how, in principle, trust can be compatible with current understandings of patient safety issues and may enhance efforts to improve patient safety.