Responsibility Gap(s) Due to the Introduction of AI in Healthcare: An Ubuntu-Inspired Approach.

Due to its enormous potential, artificial intelligence (AI) can transform healthcare on a seemingly infinite scale. However, as we continue to explore the immense potential of AI, it is vital to consider the ethical concerns associated with its development and deployment. One specific concern that has been flagged in the literature is the responsibility gap (RG) due to the introduction of AI in healthcare. When the use of an AI algorithm or system results in a negative outcome for a patient(s), to whom can or should responsibility for that outcome be assigned? Although the concept of the RG was introduced in Anglo-American and European philosophy, this paper aims to broaden the debate by providing an Ubuntu-inspired perspective on the RG. Ubuntu, deeply rooted in African philosophy, calls for collective responsibility, and offers a uniquely forward-looking approach to address the alleged RG caused by AI in healthcare. An Ubuntu-inspired perspective can serve as a valuable guide and tool when addressing the alleged RG. Incorporating Ubuntu into the AI ethics discourse can contribute to a more ethical and responsible integration of AI in healthcare.

Managing risks for genetic conditions in donor sperm treatment: current practices in Belgian fertility clinics.

RESEARCH QUESTION: How do fertility clinics in Belgium manage risks for genetic conditions in donor sperm treatment? DESIGN: An electronic questionnaire was distributed to all fertility clinics in Belgium in June 2023, focusing on treatments with anonymous sperm donors from 2018 to 2022. Responses from 15 clinics were analysed anonymously using IBM SPSS statistics. RESULTS: All clinics assessed donor risks, including a personal and family history, conventional karyotyping and (for 83.3% of the clinics) carrier screening for common autosomal recessive conditions. For recipients, 58.3% of the clinics relied only on a personal and family history. Despite efforts, the suspicion or detection of genetic conditions in donor sperm treatment was prevalent, with 9.4 adverse events reported per 100 children born. When adverse events occurred, most clinics (58.3%) would not inform the donor if no additional genetic testing was needed. Around 1 in 4 (26.7%) clinics always informed recipients about an adverse event possibly related to their donor. An equal number (26.7%) categorically ruled out the use of spermatozoa from a donor after an adverse event was traced back to his DNA, and 53.3% would not consider using the donor when the adverse event was not genetically confirmed. For the other clinics, deciding when to disclose new genetic risk information or when to allow the use of a donor linked to an adverse event was a complex matter involving different considerations. CONCLUSION: Although suspected or detected genetic conditions linked to donor treatments were common, there was wide variation in how Belgian clinics prevented and managed these situations.

Attitude of Belgian women towards enucleated egg donation for treatment of mitochondrial diseases and infertility.

RESEARCH QUESTION: What is the attitude of Belgian women of reproductive age towards enucleated egg donation? Does the willingness of women to donate differ when they would donate enucleated or whole eggs? DESIGN: In 2022, an online survey was conducted among a representative sample of 1000 women in Belgium aged 18-50 years. The item on willingness to anonymously donate enucleated eggs was dichotomized into those willing to donate and those not willing to donate or uncertain. RESULTS: No statistically significant difference was found between the willingness to donate enucleated eggs and whole eggs (whether anonymously or identifiably). Anonymity, however, affected the willingness to donate, with considerably fewer women willing to donate identifiably. The respondents were divided about their parental status if they were to donate enucleated eggs, with less than one-half (44%) not considering themselves to be a genetic mother. Women willing to donate enucleated eggs anonymously were less likely to view themselves as a genetic mother of the child compared with others. Fewer than one in five considered the technique unacceptable because the resulting child would carry genetic material of three persons. CONCLUSIONS: Women in the general population did not show a greater willingness to donate enucleated eggs than whole eggs. The fact that the respondents were strongly divided on whether or not they would consider themselves to be a genetic mother of the resulting child may explain this result. Other factors, such as the potential high risk for the child, may also have contributed to less willingness.

Age-related hearing loss and "hearables": An agenda for moral considerations.

Rapid advances in digital hearing technologies, also known as hearables, are expected to disrupt the direct-to-consumer health market. For older adults with higher incidence of hearing loss, such disruption could reduce hearing problems, increase accessibility to hearing aids, and mitigate related stigmas. This paper delves into the intersection of disruptive innovation and hearables within the realm of biomedical ethics. Through a comprehensive exploration, we shed light on the ethical implications surrounding hearables. By critically evaluating the key ethical advantages and drawbacks, we find that no single concern presents an insurmountable a priori objection to hearables. We conclude with some ideas to maximize the benefits of hearables and further promote opportunities for equitable hearing health.

Screening embryos for polygenic disease risk: a review of epidemiological, clinical, and ethical considerations.

BACKGROUND: The genetic composition of embryos generated by in vitro fertilization (IVF) can be examined with preimplantation genetic testing (PGT). Until recently, PGT was limited to detecting single-gene, high-risk pathogenic variants, large structural variants, and aneuploidy. Recent advances have made genome-wide genotyping of IVF embryos feasible and affordable, raising the possibility of screening embryos for their risk of polygenic diseases such as breast cancer, hypertension, diabetes, or schizophrenia. Despite a heated debate around this new technology, called polygenic embryo screening (PES; also PGT-P), it is already available to IVF patients in some countries. Several articles have studied epidemiological, clinical, and ethical perspectives on PES; however, a comprehensive, principled review of this emerging field is missing. OBJECTIVE AND RATIONALE: This review has four main goals. First, given the interdisciplinary nature of PES studies, we aim to provide a self-contained educational background about PES to reproductive specialists interested in the subject. Second, we provide a comprehensive and critical review of arguments for and against the introduction of PES, crystallizing and prioritizing the key issues. We also cover the attitudes of IVF patients, clinicians, and the public towards PES. Third, we distinguish between possible future groups of PES patients, highlighting the benefits and harms pertaining to each group. Finally, our review, which is supported by ESHRE, is intended to aid healthcare professionals and policymakers in decision-making regarding whether to introduce PES in the clinic, and if so, how, and to whom. SEARCH METHODS: We searched for PubMed-indexed articles published between 1/1/2003 and 1/3/2024 using the terms 'polygenic embryo screening', 'polygenic preimplantation', and 'PGT-P'. We limited the review to primary research papers in English whose main focus was PES for medical conditions. We also included papers that did not appear in the search but were deemed relevant. OUTCOMES: The main theoretical benefit of PES is a reduction in lifetime polygenic disease risk for children born after screening. The magnitude of the risk reduction has been predicted based on statistical modelling, simulations, and sibling pair analyses. Results based on all methods suggest that under the best-case scenario, large relative risk reductions are possible for one or more diseases. However, as these models abstract several practical limitations, the realized benefits may be smaller, particularly due to a limited number of embryos and unclear future accuracy of the risk estimates. PES may negatively impact patients and their future children, as well as society. The main personal harms are an unindicated IVF treatment, a possible reduction in IVF success rates, and patient confusion, incomplete counselling, and choice overload. The main possible societal harms include discarded embryos, an increasing demand for 'designer babies', overemphasis of the genetic determinants of disease, unequal access, and lower utility in people of non-European ancestries. Benefits and harms will vary across the main potential patient groups, comprising patients already requiring IVF, fertile people with a history of a severe polygenic disease, and fertile healthy people. In the United States, the attitudes of IVF patients and the public towards PES seem positive, while healthcare professionals are cautious, sceptical about clinical utility, and concerned about patient counselling. WIDER IMPLICATIONS: The theoretical potential of PES to reduce risk across multiple polygenic diseases requires further research into its benefits and harms. Given the large number of practical limitations and possible harms, particularly unnecessary IVF treatments and discarded viable embryos, PES should be offered only within a research context before further clarity is achieved regarding its balance of benefits and harms. The gap in attitudes between healthcare professionals and the public needs to be narrowed by expanding public and patient education and providing resources for informative and unbiased genetic counselling.

'Do I want children later in life?' Reproductive intentions of 1700 adolescents.

PURPOSE: In the past decades, a positive attitude towards having children has been reported in young people. The current generation of adolescents is increasingly concerned about environmental cataclysm which may have an impact on their desire for children. The purpose of this study is to depict the current attitudes in Flemish adolescents towards having children. MATERIALS AND METHODS: All secondary schools in Flanders (Belgium) were invited to distribute an anonymous online survey among their pupils in the last two years of secondary education. In total, 1700 adolescents participated and provided quantitative and qualitative data on their reproductive intentions. RESULTS: Most pupils expressed a desire for children (60.2%), 24.7% were undecided and 10.8% were not willing to have children. Significantly more boys than girls would like to have children (67.0% versus 61.7%, p < 0.01). Adolescents who were uncertain about having children or not interested, reported financial reasons and loss of freedom as most important reasons. CONCLUSIONS: While most adolescents would like to have children in the future, one in four adolescents is undecided and one in ten indicates a wish to remain childless; reasons for wanting children are rather personal, reasons for not wanting children are rather pragmatic.

A desire for parenthood is no longer the norm: 60% of Flemish adolescents would like to build a family, but many are considering a future without children.

The information, control, and value models of mobile health-driven empowerment.

Mobile health tools are often said to empower users by providing them with the information they need to exercise control over their health. We aim to bring clarity to this claim, and in doing so explore the relationship between empowerment and autonomy. We have identified three distinct models embedded in the empowerment rhetoric: empowerment as information, empowerment as control, and empowerment as values. Each distinct model of empowerment gives rise to an associated problem. These problems, the Problem of Interpretation, the Value Alignment Problem, and the Priority Problem, show that mobile health tools in their current form are either insufficient for empowerment or are self-defeating. These digital health technologies encourage users to adopt an individualized conception of autonomy, one that may weaken the doctor-patient relationship and undermine practices in shared decision making, and ultimately may not deliver on improving the health outcomes for those that need it the most.

ESHRE guideline: number of embryos to transfer during IVF/ICSI†.

STUDY QUESTION: Which clinical and embryological factors should be considered to apply double embryo transfer (DET) instead of elective single embryo transfer (eSET)? SUMMARY ANSWER: No clinical or embryological factor per se justifies a recommendation of DET instead of eSET in IVF/ICSI. WHAT IS KNOWN ALREADY: DET is correlated with a higher rate of multiple pregnancy, leading to a subsequent increase in complications for both mother and babies. These complications include preterm birth, low birthweight, and other perinatal adverse outcomes. To mitigate the risks associated with multiple pregnancy, eSET is recommended by international and national professional organizations as the preferred approach in ART. STUDY DESIGN, SIZE, DURATION: The guideline was developed according to the structured methodology for development and update of ESHRE guidelines. Literature searches were performed in PUBMED/MEDLINE and Cochrane databases, and relevant papers published up to May 2023, written in English, were included. Live birth rate, cumulative live birth rate, and multiple pregnancy rate were considered as critical outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS: Based on the collected evidence, recommendations were discussed until a consensus was reached within the Guideline Development Group (GDG). A stakeholder review was organized after the guideline draft was finalized. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE: The guideline provides 35 recommendations on the medical and non-medical risks associated with multiple pregnancies and on the clinical and embryological factors to be considered when deciding on the number of embryos to transfer. These recommendations include 25 evidence-based recommendations, of which 24 were formulated as strong recommendations and one as conditional, and 10 good practice points. Of the evidence-based recommendations, seven (28%) were supported by moderate-quality evidence. The remaining recommendations were supported by low (three recommendations; 12%), or very low-quality evidence (15 recommendations; 60%). Owing to the lack of evidence-based research, the guideline also clearly mentions recommendations for future studies. LIMITATIONS, REASONS FOR CAUTION: The guideline assessed different factors one by one based on existing evidence. However, in real life, clinicians' decisions are based on several prognostic factors related to each patient's case. Furthermore, the evidence from randomized controlled trials is too scarce to formulate high-quality evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS: The guideline provides health professionals with clear advice on best practice in the decision-making process during IVF/ICSI, based on the best evidence currently available, and recommendations on relevant information that should be communicated to patients. In addition, a list of research recommendations is provided to stimulate further studies in the field. STUDY FUNDING/COMPETING INTEREST(S): The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, the literature searches, and the dissemination of the guideline. The guideline group members did not receive payment. DPB declared receiving honoraria for lectures from Merck, Ferring, and Gedeon Richter. She is a member of ESHRE EXCO, and the Mediterranean Society for reproductive medicine and the president of the Croatian Society for Gynaecological Endocrinology and Reproductive Medicine. CDG is the past Chair of the ESHRE EIM Consortium and a paid deputy member of the Editorial board of Human Reproduction. IR declared receiving reimbursement from ESHRE and EDCD for attending meetings. She holds an unpaid leadership role in OBBCSSR, ECDC Sohonet, and AER. KAR-W declared receiving grants for clinical researchers and funding provision to the institution from the Swedish Cancer Society (200170F), the Senior Clinical Investigator Award, Radiumhemmets Forskningsfonder (Dnr: 201313), Stockholm County Council FoU (FoUI-953912) and Karolinska Institutet (Dnr 2020-01963), NovoNordisk, Merck and Ferring Pharmaceuticals. She received consulting fees from the Swedish Ministry of Health and Welfare. She received honoraria from Roche, Pfizer, and Organon for chairmanship and lectures. She received support from Organon for attending meetings. She participated in advisory boards for Merck, Nordic countries, and Ferring. She declared receiving time-lapse equipment and grants with payment to institution for pre-clinical research from Merck pharmaceuticals and from Ferring. SS-R received research funding from Roche Diagnostics, Organon/MSD, Theramex, and Gedeo-Richter. He received consulting fees from Organon/MSD, Ferring Pharmaceuticals, and Merck Serono. He declared receiving honoraria for lectures from Ferring Pharmaceuticals, Besins, Organon/MSD, Theramex, and Gedeon Richter. He received support for attending Gedeon Richter meetings and participated in the Data Safety Monitoring Board of the T-TRANSPORT trial. He is the Deputy of ESHRE SQART special interest group. He holds stock options in IVI Lisboa and received equipment and other services from Roche Diagnostics and Ferring Pharmaceuticals. KT declared receiving payment for honoraria for giving lectures from Merck Serono and Organon. She is member of the safety advisory board of EDQM. She holds a leadership role in the ICCBBA board of directors. ZV received reimbursement from ESHRE for attending meetings. She also received research grants from ESHRE and Juhani Aaltonen Foundation. She is the coordinator of EHSRE SQART special interest group. The other authors have no conflicts of interest to declare. DISCLAIMER: This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (full disclaimer available at https://www.eshre.eu/Guidelines-and-Legal).

Deconstructing self-fulfilling outcome measures in infertility treatment.

The typical outcome measure in infertility treatment is the (cumulative) healthy live birth rate per patient or per cycle. This means that those who end the treatment trajectory with a healthy baby in their arms are considered to be successful and those who do not are considered to have failed. In this article, we argue that by adopting the healthy live birth standard as the outcome measure that defines a successful fertility treatment, it becomes an interpretative self-fulfilling prophecy: those who achieve the goal consider themselves successful and those who do not consider themselves failures. This is regardless of the fact that having children is only one out of many ways to alleviate the suffering related to infertility and that stopping fertility treatment can also be a positive decision to move on to other goals, rather than a form of "giving up," "dropping out," "nonadherence," or failure. We suggest that those seeking fertility treatment would be served better by an alternative outcome measure, which can be equally self-fulfilling, according to which a successful treatment is one in which people leave the clinic released from the suffering that accompanied their status as infertile when they first entered the clinic. This new outcome measure still implies that walking out with a healthy baby is a positive outcome. What changes is that walking out without a baby can also be a positive outcome, rather than being marked exclusively as a failure.

Do genomic passports leave us more vulnerable or less vulnerable? Perspectives from an online citizen engagement.

Since genomics is becoming commonplace in healthcare for the diagnosis, treatment, and prevention, the prospect of generating a genomic passport for all citizens is gaining traction. While this would have many advantages, it raises ethical issues requiring societal debate alongside academic reflection. Hence, Sciensano-the Belgian scientific Institute of Public Health-organised an online citizen engagement on genomic information usage, including a question on a genomic passport for all. The inductive thematic analysis of participants' contributions highlighted vulnerability as a fundamental concern, while this has not received sufficient attention so far in genomics. Participants expressed their vulnerability in two ways. First, the genomic passport would inform them about their ontological vulnerability. By revealing their constitutional weaknesses (predisposition to diseases), it reminds them that everyone is unavoidably and perennially at risk of being harmed. Second, the misuse of the genomic passport can add situational vulnerabilities (e.g., discrimination causing psychological and economic harm). Moreover, the fundamental uncertainty in genomics-how will such sensitive information be used, and how will the science evolve?-exacerbates these vulnerabilities. This article ends with recommendations to alleviate these vulnerabilities in genomics now and in the future in which the genomic passport may become a reality.

The curious case of "trust" in the light of changing doctor-patient relationships.

The centrality of trust in traditional doctor-patient relationships has been criticized as inordinately paternalistic, yet in today's discussions about medical ethics-mostly in response to disruptive innovation in healthcare-trust reappears as an asset to enable empowerment. To turn away from paternalistic trust-based doctor-patient relationships and to arrive at an empowerment-based medical model, increasing reference is made to the importance of nurturing trust in technologies that are supposed to bring that empowerment. In this article we stimulate discussion about why the move towards patient empowerment may not be able to keep clear of the criticism of trust in traditional patient-doctor relationships. First, we explore how such a shift in trust dynamics might corrode patient empowerment in the name of patient empowerment. Second, we examine how a translocation of trust may at best push the "trust issue" elsewhere and at worst make it harder to evaluate trustworthiness.

Enthusiasm, concern and ambivalence in the Belgian public's attitude towards in-vitro gametogenesis.

Given the controversial nature of research into in-vitro gametogenesis (IVG), this study set out to investigate the current attitudes towards IVG in the general Belgian population in order to anticipate potential future barriers and misunderstandings. A questionnaire was developed and incorporated into a web-based online survey and sent out to Belgians aged ≥ 18 years in September 2018 until a representative sample (by age, gender and region) of 1000 participants was reached. Respondents expressed an overall positive attitude towards IVG and its possible future applications, with the exception of the use of IVG in postmenopausal women. They were ambivalent about the importance of genetic parenthood and about the necessary experiments on animals and embryos to bring IVG to the clinic. While the willingness to accept greater risks for IVG than for other assisted reproductive technology treatments was low (17.5%), the use of spare in-vitro fertilization embryos to study those risks was acceptable for 55.8% of participants; embryo creation was acceptable for 38.1%; and experiments on mice and monkeys were acceptable for 45.3% and 30.4%, respectively. Finally, 85.6% of participants agreed that the Belgian Government should strictly regulate IVG. In conclusion, preclinical research into IVG and other reproductive technologies elicits a great diversity of attitudes towards the importance of genetic parenthood and the acceptability of embryo and animal research. There is a need for public dialogue on these topics.

Watson, autonomy and value flexibility: revisiting the debate.

Many ethical concerns have been voiced about Clinical Decision Support Systems (CDSSs). Special attention has been paid to the effect of CDSSs on autonomy, responsibility, fairness and transparency. This journal has featured a discussion between Rosalind McDougall and Ezio Di Nucci that focused on the impact of IBM's Watson for Oncology (Watson) on autonomy. The present article elaborates on this discussion in three ways. First, using Jonathan Pugh's account of rational autonomy we show that how Watson presents its results might impact decisional autonomy, while how Watson produces knowledge might affect practical autonomy. Second, by drawing an analogy with patient decision aids we identify an empirical way of estimating Watson's impact on autonomy (ie, value-congruence). Lastly, McDougall introduced the notion of value-flexible design as a way to account for the diverging preferences patients hold. We will clarify its relation with the established domain of value-sensitive design. In terms of the tripartite methodology of value-sensitive design, we offer a conceptual clarification using Pugh's account of rational autonomy, an empirical tool to evaluate Watson's impact on autonomy and situate a group of technical options to incorporate autonomy in Watson's design.

A qualitative study among patients with an inherited retinal disease on the meaning of genomic unsolicited findings.

Exome-based testing for genetic diseases can reveal unsolicited findings (UFs), i.e. predispositions for diseases that exceed the diagnostic question. Knowledge of patients' interpretation of possible UFs and of motives for (not) wanting to know UFs is still limited. This lacking knowledge may impede effective counselling that meets patients' needs. Therefore, this article examines the meaning of UFs from a patient perspective. A qualitative study was conducted and an interpretative phenomenological analysis was made of 14 interviews with patients with an inherited retinal disease. Patients assign a complex meaning to UFs, including three main components. The first component focuses on result-specific qualities, i.e. the characteristics of an UF (inclusive of actionability, penetrance, severity and age of onset) and the consequences of disclosure; the second component applies to a patient's lived illness experiences and to the way these contrast with reflections on presymptomatic UFs; the third component addresses a patient's family embedding and its effect on concerns about disease prognosis and genetic information's family relevance. The complex meaning structure of UFs suggests the need for counselling procedures that transcend a strictly clinical approach. Counselling should be personalised and consider patients' lived illness experiences and family context.

An ethical exploration of pregnancy related mHealth: does it deliver?

Many pregnant women use pregnancy related mHealth (PRmHealth) applications, encompassing a variety of pregnancy apps and wearables. These are mostly directed at supporting a healthier fetal development. In this article we argue that the increasing dominance of PRmHealth stands in want of empirical knowledge affirming its beneficence in terms of improved pregnancy outcomes. This is a crucial ethical issue, especially in the light of concerns about increasing pressures and growing responsibilities ascribed to pregnant women, which may, in turn, be reinforced by PRmHealth. A point can be made that it would be ethically askew if PRmHealth does not lead to improved pregnancy outcomes, while at the same time increasing maternal duties to closely monitor fetal development. We conclude that more research is needed to get a view on the benefits and burdens of PRmHealth in order to ethically assess whether the latter are proportionate to the former. If not, there is a case in saying that endorsement of PRmHealth is overdemanding.

Follow-up in the field of reproductive medicine: an ethical exploration.

RESEARCH QUESTION: What ethical implications, issues and concerns play a role in conducting follow-up studies of children born after assisted reproductive technologies (ART)? DESIGN: Literature study and relevant experiences of academic medical centres in Brussels, Belgium, and Maastricht, the Netherlands were used to identify and analyse the most pertinent ethical implications, issues and concerns. RESULTS: According to recommendations from the European Society of Human Reproduction and Embryology, follow-up (ideally long term) of children conceived through medically assisted reproduction (MAR) should be an integral part of introducing new ART. With potentially risky new ART on the horizon, these recommendations need to be taken more seriously. Apart from practical barriers, such as funding, challenges for follow-up include securing active involvement of families of children conceived through MAR, starting with parents of young children, and ideally involving consenting adolescents and adults during a large part of their lives, possibly even into the next generation. CONCLUSIONS: From an ethical viewpoint, the most pertinent issues include the proportionality of the inevitable burdens and risks for families of children conceived through MAR, and the implications of the principle of respect for autonomy. The proportionality requirement is most critical when it concerns incompetent children, who should not be included in research with more than minimal burdens and risks if there is no reasonable expectation of benefit for themselves. With respect for autonomy, we argue that, when seeking voluntary consent for participating in follow-up studies that meet the condition of proportionality, professionals may encourage members of families of children conceived through MAR to partake in follow-up research.

Reporting, recording, and communication of COVID-19 cases in workplace: data protection as a moving target.

In response to concerns related to privacy in the context of coronavirus disease 2019 (COVID-19), recently European and national Data Protection Authorities (DPAs) issued guidelines and recommendations addressing a variety of issues related to the processing of personal data for preventive purposes. One of the recurring questions in these guidelines is related to the rights and responsibilities of employers and employees in reporting, recording, and communicating COVID-19 cases in workplace. National DPAs in some cases adopted different approaches regarding duties in reporting and communicating the COVID-19 cases; however, they unanimously stressed the importance of adopting privacy-preserving approaches to avoid raising concerns about surveillance and stigmatization. We stress that in view of the increasing use of new data collection and sharing tools such as 'tracing and warning' apps, the associated privacy-related risks should be evaluated on an ongoing manner. In addition, the intricacies of different settings where such apps may be used should be taken into consideration when assessing the associated risks and benefits.