Large language models in medical ethics: useful but not expert.

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.

The PHERCC Matrix. An Ethical Framework for Planning, Governing, and Evaluating Risk and Crisis Communication in the Context of Public Health Emergencies.

Risk and crisis communication (RCC) is a current ethical issue subject to controversy, mainly due to the tension between individual liberty (a core component of fairness) and effectiveness. In this paper we propose a consistent definition of the RCC process in public health emergencies (PHERCC), which comprises six key elements: evidence, initiator, channel, publics, message, and feedback. Based on these elements and on a detailed analysis of their role in PHERCC, we present an ethical framework to help design, govern and evaluate PHERCC strategies. The framework aims to facilitate RCC, incorporating effectiveness, autonomy, and fairness. It comprises five operational ethical principles: openness, transparency, inclusivity, understandability, and privacy. The resulting matrix helps understanding the interplay between the PHERCC process and the principles of the framework. The paper includes suggestions and recommendations for the implementation of the PHERCC matrix.

Beyond Trade-Offs: Autonomy, Effectiveness, Fairness, and Normativity in Risk and Crisis Communication.

This paper addresses the critiques based on trade-offs and normativity presented in response to our target article proposing the Public Health Emergency Risk and Crisis Communication (PHERCC) framework. These critiques highlight the ethical dilemmas in crisis communication, particularly the balance between promoting public autonomy through transparent information and the potential stigmatization of specific population groups, as illustrated by the discussion of the mpox outbreak among men who have sex with men. This critique underscores the inherent tension between communication effectiveness and autonomy versus fairness and equity. In response, our paper reiterates the adaptability of the PHERCC framework, emphasizing its capacity to tailor messages to diverse audiences, thereby reducing potential stigmatization and misinformation. Through community engagement and feedback integration, the PHERCC framework aims to optimize the effectiveness of communication strategies while addressing ethical concerns. Furthermore, by involving affected communities in the communication strategy from the onset, the framework seeks to minimize ethical trade-offs and enhance the acceptance and effectiveness of public health messages.

International expert meeting on the donation and use of human milk: Brief report.

Where a mother's own milk is not available or is insufficient, donor human milk (DHM) processed by a human milk bank (HMB) is the recommended next best alternative. HMBs exist in over 65 countries. However, most countries have yet to establish national policies or programmes that support the provision of DHM. In July 2019, a group of international experts in fields relevant to human milk banking gathered at a meeting organised by the Institute of Biomedical Ethics, University of Zurich, and co-sponsored by the World Health Organisation. Prompted by the growing interest globally in creating and sustaining HMBs and addressing current safety and ethical concerns and standards, the aims of the meeting were to define knowledge gaps, determine the need for and scope of global guidelines and provide recommendations on steps that need to be taken at the international level. Following wide-ranging discussions that included the integration of milk banks into health care systems, strategy and policy, quality and safety, the use of DHM and associated ethical considerations, the overall conclusion of the meeting was that in the absence of global recommendations on the implementation, operation and regulation of HMBs, evidence-based guidance is urgently needed.

A CRISPR response to pandemics?: Exploring the ethics of genetically engineering the human immune system.

Ethical challenges should be addressed before gene editing is made available to improve the immune response against emerging viruses.

Ethics of the algorithmic prediction of goal of care preferences: from theory to practice.

Artificial intelligence (AI) systems are quickly gaining ground in healthcare and clinical decision-making. However, it is still unclear in what way AI can or should support decision-making that is based on incapacitated patients' values and goals of care, which often requires input from clinicians and loved ones. Although the use of algorithms to predict patients' most likely preferred treatment has been discussed in the medical ethics literature, no example has been realised in clinical practice. This is due, arguably, to the lack of a structured approach to the epistemological, ethical and pragmatic challenges arising from the design and use of such algorithms. The present paper offers a new perspective on the problem by suggesting that preference predicting AIs be viewed as sociotechnical systems with distinctive life-cycles. We explore how both known and novel challenges map onto the different stages of development, highlighting interdisciplinary strategies for their resolution.

'VaxTax': a follow-up proposal for a global vaccine pandemic response fund.

Equal access to vaccines has been one of the key ethical challenges during the COVID-19 pandemic. Most scholars consider the massive purchase and hoarding of vaccines by high-income countries, especially at the beginning of the pandemic, to be unjust towards the vulnerable living in low-income countries. A recent proposal by Andreas Albertsen of a vaccine tax has been put forward to remedy this problem. Under such a scheme, high-income countries would pay a contribution, conceptualised as a vaccine tax, dedicated to buying vaccines and distributing them to low and middle-income countries. Proceeding from this proposal, we critically assess the feasibility of a vaccine tax and suggest how to conceptualise and implement a vaccine tax in practice. We present our 'VaxTax model' and explore its comparative advantages and disadvantages while considering other possible measures to address the global vaccine access problem, also in view of future pandemics and disease outbreaks.

Black box algorithms in mental health apps: An ethical reflection.

Mental health apps bring unprecedented benefits and risks to individual and public health. A thorough evaluation of these apps involves considering two aspects that are often neglected: the algorithms they deploy and the functions they perform. We focus on mental health apps based on black box algorithms, explore their forms of opacity, discuss the implications derived from their opacity, and propose how to use their outcomes in mental healthcare, self-care practices, and research. We argue that there is a relevant distinction between functions performed by algorithms in mental health apps, and we focus on the functions of analysis and generation of advice. When performing analytic functions, such as identifying patterns and making predictions concerning people's emotions, thoughts, and behaviors, black box algorithms can be better than other algorithms to provide information to identify early signs of relapse, support diagnostic processes, and improve research by generating outcomes that lead to a better understanding of mental health. However, when carrying out the function of providing mental health advice, black box algorithms have the potential to deliver unforeseen advice that may harm users. We argue that the outcomes of these apps may be trustworthy as a complementary source of information, but express caution about black box algorithms that give advice directly to users. To reap the benefits of mental health apps based on black box algorithms and avoid unintended consequences, we critically need to know whether these algorithms are fulfilling the function of providing mental health advice.

Women's experiences with non-invasive prenatal testing in Switzerland: a qualitative analysis.

BACKGROUND: Prenatal genetic testing, in particular non-invasive prenatal testing (NIPT), as well as screening for risks associated with pregnancy, and counseling, play pivotal roles in reproductive healthcare, offering valuable information about the health of the fetus to expectant parents. This study aims to delve into the perspectives and experiences of women considering genetic testing and screening during pregnancy, focusing on their decision-making processes and the implications for informed consent. METHODS: A nationwide qualitative study was conducted in Switzerland, involving in-depth interviews with women who were 1 to 2 years post-partum, covered by basic compulsory Swiss insurance, including women with a migration background. Thematic analysis was employed to identify key themes and patterns in the data. RESULTS: The findings underscore the significance of effective communication during prenatal counseling, suggesting that healthcare providers could not only convey technical information but also support women in their decision-making processes. Women need comprehensive information about genetic testing and its implications, as well as the reasons for screening during pregnancy, as there might be a need to bridge knowledge gaps and clarify misconceptions. Furthermore, the study highlights the multifaceted nature of decision-making, with women considering factors such as uncertainty, values, emotional responses, and societal support systems. The concept of acceptance emerged as a crucial theme, with some women expressing their readiness to love and accept their child, regardless of genetic anomalies or disabilities. CONCLUSION: This study offers valuable insights into the perspectives and needs of women regarding prenatal genetic testing, screening, and counseling in Switzerland. It underscores the importance of enhancing the clinical interaction and informed consent process by providing comprehensive information, addressing misconceptions, and supporting women in decision-making about pregnancy management and the management of the child's health, following prenatal genetic testing, including NIPT. These findings can inform healthcare providers and policymakers in improving the quality of prenatal counseling, ensuring informed consent, and supporting women in making well-informed and meaningful decisions about genetic testing, and on the use of screening during pregnancy.

Charity or empowerment? The role of COVAX for low and middle-income countries.

What has the past reaction to the COVID-19 pandemic taught us? We have seen that many low and middle-income countries (LMICs) still lack access to vaccines, and it seems little progress has been made in the last few months and year. This article discusses whether the current strategies, most notably, vaccine donations by the international community and the COVID-19 global access facility COVAX, offer meaningful solutions to tackle the problem. At the centre of our analysis, we compare the concepts of "donations" and "charity" with "vaccine equity" and the "empowerment" of poorer countries. We suggest that the achievement of fair global vaccine production requires that our global approach is supportive of the idea of empowerment. We, therefore, need structural reforms, which would most importantly include capacity building, to positively impact this goal and to take the interests of the global poor seriously.

Blacklisting Health Insurance Premium Defaulters: Is Denial of Medical Care Ethically Justifiable?

Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons - who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly describe blacklisting in the context of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced.

AI support for ethical decision-making around resuscitation: proceed with care.

Artificial intelligence (AI) systems are increasingly being used in healthcare, thanks to the high level of performance that these systems have proven to deliver. So far, clinical applications have focused on diagnosis and on prediction of outcomes. It is less clear in what way AI can or should support complex clinical decisions that crucially depend on patient preferences. In this paper, we focus on the ethical questions arising from the design, development and deployment of AI systems to support decision-making around cardiopulmonary resuscitation and the determination of a patient's Do Not Attempt to Resuscitate status (also known as code status). The COVID-19 pandemic has made us keenly aware of the difficulties physicians encounter when they have to act quickly in stressful situations without knowing what their patient would have wanted. We discuss the results of an interview study conducted with healthcare professionals in a university hospital aimed at understanding the status quo of resuscitation decision processes while exploring a potential role for AI systems in decision-making around code status. Our data suggest that (1) current practices are fraught with challenges such as insufficient knowledge regarding patient preferences, time pressure and personal bias guiding care considerations and (2) there is considerable openness among clinicians to consider the use of AI-based decision support. We suggest a model for how AI can contribute to improve decision-making around resuscitation and propose a set of ethically relevant preconditions-conceptual, methodological and procedural-that need to be considered in further development and implementation efforts.

Concerns Around Opposition to the Green Pass in Italy: Social Listening Analysis by Using a Mixed Methods Approach.

BACKGROUND: The recent introduction of COVID-19 certificates in several countries, including the introduction of the European green pass, has been met with protests and concerns by a fraction of the population. In Italy, the green pass has been used as a nudging measure to incentivize vaccinations because a valid green pass is needed to enter restaurants, bars, museums, or stadiums. As of December 2021, a valid green pass can be obtained by being fully vaccinated with an approved vaccine, recovered from COVID-19, or tested. However, a green pass obtained with a test has a short validity (48 hours for the rapid test, 72 hours for the polymerase chain reaction test) and does not allow access to several indoor public places. OBJECTIVE: This study aims to understand and describe the concerns of individuals opposed to the green pass in Italy, the main arguments of their discussions, and their characterization. METHODS: We collected data from Telegram chats and analyzed the arguments and concerns that were raised by the users by using a mixed methods approach. RESULTS: Most individuals opposing the green pass share antivaccine views, but doubts and concerns about vaccines are generally not among the arguments raised to oppose the green pass. Instead, the discussion revolves around the legal aspects and the definition of personal freedom. We explain the differences and similarities between antivaccine and anti-green pass discourses, and we discuss the ethical ramifications of our research, focusing on the use of Telegram chats as a social listening tool for public health. CONCLUSIONS: A large portion of individuals opposed to the green pass share antivaccine views. We suggest public health and political institutions to provide a legal explanation and a context for the use of the green pass, as well as to continue focusing on vaccine communication to inform vaccine-hesitant individuals. Further work is needed to define a consensual ethical framework for social listening for public health.

An Ethical Framework for Incorporating Digital Technology into Advance Directives: Promoting Informed Advance Decision Making in Healthcare.

Despite the presumed value of advance directives, research to demonstrate impact has shown mixed results. For advance directives to serve their role promoting patient autonomy, it is important that patients be informed decision makers. The capacity to make decisions depends upon understanding, appreciation, reasoning, and communication. Advance directives are in part faulty because these elements are often limited. The present paper explores how the application of digital technology could be organized around a framework promoting these four elements. Given the state of digital advancements, there is great potential for advance directives to be meaningfully enhanced. The beneficial effects of incorporating digital technology would be maximized if they were organized around the aim of making advance directives not only documents for declaring preferences but also ethics-driven tools with decision aid functionality. Such advance directives would aid users in making decisions that involve complex factors with potentially far-reaching impact and would also elucidate the users' thought processes to aid those tasked with interpreting and implementing decisions based on an advance directive. Such advance directives might have embedded interactive features for learning; access to content that furthers one's ability to project oneself into possible, future scenarios; review of the logical consistency of stated preferences; and modes for effective electronic sharing. Important considerations include mitigating the introduction of bias depending on the presentation of information; optimizing interfacing with surrogate decision makers and treating clinicians; and prioritizing essential components to respect time constraints.

Revisiting respect for persons: conceptual analysis and implications for clinical practice.

In everyday conversations, professional codes, policy debates, and academic literature, the concept of respect is referred to frequently. Bioethical arguments in recent decades equate the idea of respect for persons with individuals who are capable of autonomous decision-making, with the focus being explicitly on 'autonomy,' 'capacity,' or 'capability.' In much of bioethics literature, respect for persons is replaced by respect for autonomy. Though the unconditional respect for persons and their autonomy (irrespective of actual decision-making capacity) is established in Kantian bioethics, current argument and debates often revolve around a thin concept of autonomy, focusing on capacity and capability: persons are owed respect because they are 'rational beings' or with a focus on 'agency' and 'decision-making abilities.' However, these aspects alone are insufficient while engaging the concept of respect for persons, particularly in healthcare settings. This paper sets out to explore if the concept of respect for persons-as opposed to a thin concept of autonomy-could help us engage better in healthcare practices. We shall probe the practical value of the experiential aspect of respect-understood as the recognition of persons as respect-worthy through certain dispositions and deliberative acts-by reflecting on instances in clinical practice that tend to be dismissed as negligible or even unavoidable in a stressful environment such as a busy hospital. We shall argue that these instances are far from trivial but carry moral significance and express an unacceptable-disrespectful-attitude that can compromise the moral habitus in hospital settings. In our conclusion, we call for practicing recognition respect in the health professional-patient encounter by focussing on manners, attitudes, and behaviors. Furthermore, we call for continuous medical ethics education programs to address the moral significance of disrespectful behaviors and their manifestations in particular socio-cultural contexts.

[Shared Decision-Making as an Imperative of Modern Medicine?] / Gemeinsame Entscheidungsfindung als Imperativ der modernen Medizin?

Shared Decision-Making as an Imperative of Modern Medicine? Abstract. Shared Decision-Making (SDM) is a normative model of decision-making in the clinical context, in which physicians and patients assess alternative treatment options and jointly take value-based decisions based on the preferences of patients. It is important that the exchange of information is free and uncoerced and that the advantages and disadvantages of different treatment options are carefully considered. The aim of this article is to reconstruct SDM historically and conceptually and to embed the model in a normative theory of patient autonomy. Furthermore, we define the scope of SDM in clinical practice by pointing to the limits of the SDM model. Our aim is to determine under what conditions patients and doctors take decisions together, what role doctors shall play, and when patients potentially participate too much or too little in the decision-making process.

[Patient Decision Aids for Values Clarification and Preference Elicitation - Challenges and Developments]. / Patienten-Entscheidungshilfen zur Werteklärung und Präferenzerhebung.

Patient Decision Aids for Values Clarification and Preference Elicitation - Challenges and Developments Abstract. Shared decision-making is especially appropriate when the available evidence does not indicate which medical intervention is the better option, so that the final decision depends on the patient's personal values and preferences. The process of value clarification and preference elicitation can be time-consuming and cognitively and emotionally demanding for patients. Increasingly, decision aids provide tasks (e.g., on benefit-harm trade-offs) to help patients work through this process, better prepare for medical consultations, and make values-congruent medical decisions with their physicians. Most clinically validated decision aids are paper-based flyers and educational brochures. There are also computer-, audio-, video-, or web-based decision aids. The web-based aids make little use of the potential of interactive technologies, despite the known benefits of these technologies. The aims of this paper are to provide an overview of decision aids for and challenges of values clarification and preference elicitation and to highlight some developments in interactive web-based technologies that might facilitate values clarification and preference elicitation.

Ethics of ICU triage during COVID-19.

INTRODUCTION: The coronavirus disease 2019 pandemic has placed intensive care units (ICU) triage at the center of bioethical discussions. National and international triage guidelines emerged from professional and governmental bodies and have led to controversial discussions about which criteria-e.g. medical prognosis, age, life-expectancy or quality of life-are ethically acceptable. The paper presents the main points of agreement and disagreement in triage protocols and reviews the ethical debate surrounding them. SOURCES OF DATA: Published articles, news articles, book chapters, ICU triage guidelines set out by professional societies and health authorities. AREAS OF AGREEMENT: Points of agreement in the guidelines that are widely supported by ethical arguments are (i) to avoid using a first come, first served policy or quality-adjusted life-years and (ii) to rely on medical prognosis, maximizing lives saved, justice as fairness and non-discrimination. AREAS OF CONTROVERSY: Points of disagreement in existing guidelines and the ethics literature more broadly regard the use of exclusion criteria, the role of life expectancy, the prioritization of healthcare workers and the reassessment of triage decisions. GROWING POINTS: Improve outcome predictions, possibly aided by Artificial intelligence (AI); develop participatory approaches to drafting, assessing and revising triaging protocols; learn from experiences with implementation of guidelines with a view to continuously improve decision-making. AREAS TIMELY FOR DEVELOPING RESEARCH: Examine the universality vs. context-dependence of triaging principles and criteria; empirically test the appropriateness of triaging guidelines, including impact on vulnerable groups and risk of discrimination; study the potential and challenges of AI for outcome and preference prediction and decision-support.

Developing global guidance on human milk banking.

Donor human milk is recommended by the World Health Organization both for its advantageous nutritional and biological properties when mother's own milk is not available and for its recognized support for lactation and breastfeeding when used appropriately. An increasing number of human milk banks are being established around the world, especially in low- and middle-income countries, to facilitate the collection, processing and distribution of donor human milk. In contrast to other medical products of human origin, however, there are no minimum quality, safety and ethical standards for donor human milk and no coordinating global body to inform national policies. We present the key issues impeding progress in human milk banking, including the lack of clear definitions or registries of products; issues around regulation, quality and safety; and ethical concerns about commercialization and potential exploitation of women. Recognizing that progress in human milk banking is limited by a lack of comparable evidence, we recommend further research in this field to fill the knowledge gaps and provide evidence-based guidance. We also highlight the need for optimal support for mothers to provide their own breastmilk and establish breastfeeding as soon as and wherever possible after birth.

Lorsque la mère est dans l'impossibilité d'allaiter, l'Organisation mondiale de la Santé recommande d'opter pour le lait humain provenant de donneuses, tant pour ses propriétés nutritionnelles et biologiques que pour la contribution avérée qu'il apporte à la lactation et à l'allaitement quand il est utilisé à bon escient. Un nombre croissant de banques de lait humain s'établissent dans le monde entier, en particulier dans les pays à faible et moyen revenu, afin de faciliter la collecte, le traitement et la distribution de lait humain provenant de donneuses. Cependant, contrairement à d'autres produits médicaux d'origine humaine, il n'existe aucune norme minimale de qualité, de sécurité et d'éthique en la matière, et aucun organe de coordination global n'a été créé pour guider les politiques nationales. Dans le présent document, nous évoquons les principaux obstacles à la progression des banques de lait humain, notamment l'absence de définition claire ou de registre de produits; les problèmes relatifs à la réglementation, la qualité et la sécurité; ainsi que les questions éthiques entourant la commercialisation et l'exploitation potentielle des femmes. Jugeant cette progression limitée par le manque de données comparables, nous encourageons à mener d'autres recherches dans ce domaine pour combler les lacunes et fournir des orientations fondées sur des preuves. Nous soulignons également la nécessité d'offrir un soutien optimal aux mères afin qu'elles puissent produire leur propre lait et allaiter autant que possible immédiatement après la naissance.

La Organización Mundial de la Salud recomienda la leche humana donada tanto por sus ventajosas propiedades nutricionales y biológicas cuando no se dispone de la propia leche materna como por su reconocido apoyo a la lactancia y al amamantamiento cuando se utiliza de manera adecuada. Cada vez se crean más bancos de leche humana en todo el mundo, sobre todo en los países de ingresos bajos y medios, para facilitar la recogida, el procesamiento y la distribución de leche humana donada. Sin embargo, a diferencia de lo que ocurre con otros productos médicos de origen humano, no existen estándares mínimos de calidad, seguridad y ética para la leche humana donada ni un organismo mundial de coordinación que sirva de base a las políticas nacionales. En este documento se exponen los principales problemas que impiden el progreso de los bancos de leche humana, como la falta de definiciones claras o de registros de productos; los problemas relacionados con la regulación, la calidad y la seguridad; y las preocupaciones éticas sobre la comercialización y la posible explotación de las mujeres. Dado que el progreso de los bancos de leche humana se ve limitado por la falta de evidencias comparables, se recomienda seguir investigando en este campo para compensar los vacíos de conocimiento y proporcionar una guía asistencial. Asimismo, se destaca la necesidad de apoyar al máximo a las madres para que se provean de su propia leche materna y establezcan la lactancia materna tan pronto y siempre que sea posible después del nacimiento.

Recommendations on COVID-19 triage: international comparison and ethical analysis.

On March 11, 2020 the World Health Organization classified COVID-19, caused by Sars-CoV-2, as a pandemic. Although not much was known about the new virus, the first outbreaks in China and Italy showed that potentially a large number of people worldwide could fall critically ill in a short period of time. A shortage of ventilators and intensive care resources was expected in many countries, leading to concerns about restrictions of medical care and preventable deaths. In order to be prepared for this challenging situation, national triage guidance has been developed or adapted from former influenza pandemic guidelines in an increasing number of countries over the past few months. In this article, we provide a comparative analysis of triage recommendations from selected national and international professional societies, including Australia/New Zealand, Belgium, Canada, Germany, Great Britain, Italy, Pakistan, South Africa, Switzerland, the United States, and the International Society of Critical Care Medicine. We describe areas of consensus, including the importance of prognosis, patient will, transparency of the decision-making process, and psychosocial support for staff, as well as the role of justice and benefit maximization as core principles. We then probe areas of disagreement, such as the role of survival versus outcome, long-term versus short-term prognosis, the use of age and comorbidities as triage criteria, priority groups and potential tiebreakers such as 'lottery' or 'first come, first served'. Having explored a number of tensions in current guidance, we conclude with a suggestion for framework conditions that are clear, consistent and implementable. This analysis is intended to advance the ongoing debate regarding the fair allocation of limited resources and may be relevant for future policy-making.