Ethical preparedness in genomic medicine: how NHS clinical scientists navigate ethical issues.

Much has been published about the ethical issues encountered by clinicians in genetics/genomics, but those experienced by clinical laboratory scientists are less well described. Clinical laboratory scientists now frequently face navigating ethical problems in their work, but how they should be best supported to do this is underexplored. This lack of attention is also reflected in the ethics tools available to clinical laboratory scientists such as guidance and deliberative ethics forums, developed primarily to manage issues arising within the clinic.We explore what ethical issues are being experienced by clinical scientists, how they think such issues could be best analysed and managed, and whether their practice might be enhanced by more situated approaches to ethics deliberation and practice such as ethical preparedness. From thematic analysis of cases presented by clinical scientists at a specially convened meeting of the UK Genethics Forum, we derived three main ethical themes: (1) the redistribution of labour and responsibilities resulting from the practice of genomic medicine; (2) the interpretation and certainty of results and (3) the proposal that better standardisation and consistency of ethical approaches (for example, more guidelines and policy) could resolve some of the challenges arising.We argue that although standardisation is important for promoting shared understandings of good (including ethical) practice, supplementary approaches to enhance and sustain ethical preparedness will be important to help clinical scientists and others in the recently expanded genetic/genomic medicine environment foster quality ethical thinking.

Does the Duty of Rescue support a moral obligation to vaccinate? Seasonal influenza and the Institutional Duty of Rescue.

Seasonal influenza poses a significant public health risk in many countries worldwide. Lower immunity and less influenza virus circulating during the pandemic has resulted in a significant increase in cases since the lifting of COVID-19 restrictions in 2022. The seasonal influenza vaccine offers effective protection and is safe for use in large numbers of the population. This article asserts that a moral obligation to vaccinate against influenza can be understood as an Institutional Duty of Rescue. The traditional understanding of the Duty of Rescue encounters issues with force and scope, making it difficult to apply to rescue cases in general, as well as being overdemanding for the individual agent. An Institutional view of the Duty of Rescue addresses these difficulties, looks at the wider context of rescue and leaves room for discussion on collective, preventative rescue measures. This makes the concept well suited to supporting a moral obligation to vaccinate against influenza as part of a collective effort on the part of institutional organisations.

Tsunami-tendenko follows the antiextinction principle, not utilitarianism.

This paper examines the concept of 'tsunami-tendenko,' a guideline suggesting that individuals prioritise their own safety over aiding others during large-scale disasters. Kodama defends tsunami-tendenko against accusations of egoism by arguing that the principle can be justified ethically on consequentialist (or more precisely, utilitarian) grounds. Kodama asserts that attempting to assist others during such disasters heightens the risk of 'tomo-daore,' where both the rescuer and the victim may perish. He claims that having people focus solely on saving themselves can maximise the overall number of lives saved. However, we challenge Kodama's assertion that utilitarianism inherently favours tsunami-tendenko over mutual assistance during disasters. Instead, this paper proposes an alternative ethical foundation for tsunami-tendenko grounded in the 'antiextinction principle,' which prioritises minimising the potential for catastrophic outcomes. When considering the ethics of responding to disaster, it is important to distinguish between maximising the number of lives saved (utilitarianism) and minimising the risk of tomo-daore (antiextinction principle). This distinction may be overlooked if the distribution of probabilities is not considered. We conclude that the antiextinction principle aligns more naturally with tsunami-tendenko, emphasising the avoidance of catastrophic outcomes-a concern not always addressed by utilitarianism. Therefore, tsunami-tendenko should be regarded as a societal guideline aimed at preserving community sustainability by averting total destruction.

If Marc is Suzanne's father, does it follow that Suzanne is Marc's child? An experimental philosophy study in reproductive ethics.

In this paper, we report the results from an experimental reproductive ethics study exploring questions about reproduction and parenthood. The main finding in our study is that, while we may assume that everyone understands these concepts and their relationship in the same way, this assumption may be unwarranted. For example, we may assume that if 'x is y's father', it follows that 'y is x's child'. However, the participants in our study did not necessarily agree that it does follow. This means, at the very least, that we need to make sure all parties in a debate have the same relationships in mind when talking about reproduction and parenthood. Moreover, it gives us reason to explore more carefully the conditions which support or undermine the connections between these concepts. This cannot come from purely theoretical reasoning, nor from empirical research alone, but from the alliance between the two.

The unnecessary 'more'-compared to ROPA: a reply to Mangione.

In her recent paper, Emanuele Mangione proposes combining maternal spindle transfer (MST) and reciprocal effortless in vitro fertilisation (ReIVF) to enable both females to have genetic and gestational ties with the same child, which can particularly benefit lesbian couples. This response rejects Mangione's proposal for the reason that the additional biological ties created by MST+ReIVF, compared with the reception of oocytes from partner (ROPA), are unnecessary. ROPA is currently the most effective method for redistributing biological ties within lesbian couples, allowing one member to provide the egg and the other to carry the fetus. The additional biological ties created by MST+ReIVF are quantitatively too small to significantly enhance parental bonding or couple relationships, and their potential harms to both prospective parents and children outweigh any minor benefits. Furthermore, like ROPA, MST+ReIVF fails to address deeper feminist concerns. Therefore, I propose a new idea: combining in vitro gametogenesis with ectogenesis, which can offer far more reproductive choices and greater potential to address deeper feminist concerns than MST+ReIVF.

What makes a medical intervention invasive?

The classification of medical interventions as either invasive or non-invasive is commonly regarded to be morally important. On the most commonly endorsed account of invasiveness, a medical intervention is invasive if and only if it involves either breaking the skin ('incision') or inserting an object into the body ('insertion'). Building on recent discussions of the concept of invasiveness, we show that this standard account fails to capture three aspects of existing usage of the concept of invasiveness in relation to medical interventions-namely, (1) usage implying that invasiveness comes in degrees, (2) that the invasiveness of an intervention can depend on the characteristics of the salient alternative interventions, and (3) that medical interventions can be invasive in non-physical ways. We then offer the beginnings of a revised account that, we argue, is able to capture a wider range of existing usage. Central to our account is a distinction between two properties: basic invasiveness and threshold invasiveness We end by assessing what the standard account gets right, and what more needs to be done to complete our schematic account.

'False hope' in assisted reproduction: the normative significance of the external outlook and moral negotiation.

Despite the frequent invocation of 'false hope' and possible related moral concerns in the context of assisted reproduction technologies, a focused ethical and conceptual problematisation of this concept seems to be lacking. We argue that an invocation of 'false hope' only makes sense if the fulfilment of a desired outcome (eg, a successful fertility treatment) is impossible, and if it is attributed from an external perspective. The evaluation incurred by this third party may foreclose a given perspective from being an object of hope. However, this evaluation is not a mere statistical calculation or observation based on probabilities but is dependent on several factors that should be acknowledgeable as morally relevant. This is important because it allows room for, and encourages, reasoned disagreement and moral negotiation. Accordingly, the object of hope itself, whether or not based on socially embedded desires or practices, can be a topic of debate.

UK doctors' strikes 2023-2024: still justified in the interests of public health, even in time-critical outpatient contexts.

We respond to David Wilkinson's arguments against our view of the ethicality of doctors' strikes and our claim that the 2023-2024 UK doctors' strikes are morally permissible and arguably supererogatory.Wilkinson proposes that in specialist outpatient settings, striking doctors should help arrange their own cover to prevent disproportionate harm to patients and to abide by the principles of non-maleficence and fiduciary duty. This hasn't happened during the 2023-2024 UK doctors' strikes; therefore, in his view, these strikes are morally impermissible. We reject Wilkinson's proposal on the grounds that the risk of disproportionate harm is adequately mitigated by existing arrangements and his interpretations of non-maleficence and fiduciary duty are overly demanding.We agree with Wilkinson that strikes put particularly high pressure on covering doctors in chronically under resourced specialisms. But this doesn't justify calling off or depowering doctors' strikes because, without effective strikes, under-resourcing is likely to continue and, ultimately, cause even more harm.Wilkinson argues that doctors cannot justifiably strike in the interests of public health because they don't have a broad duty to public health. We think they do have such a duty; however, we argue that doctors can justifiably strike in the interest of public health whether they have such a duty or not.Finally, we defend our claim that doctors' strikes can be supererogatory from Wilkinson's objections that there may be no such thing as supererogatory action and that our view absurdly entails that strikes can be supererogatory despite placing unfair demands on others.

The revised International Code of Medical Ethics: an exercise in international professional ethical self-regulation.

The World Medical Association (WMA), the global representation of the medical profession, first adopted the International Code of Medical Ethics (ICoME) in 1949 to outline the professional duties of physicians to patients, other physicians and health professionals, themselves and society as a whole. The ICoME recently underwent a major 4-year revision process, culminating in its unanimous adoption by the WMA General Assembly in October 2022 in Berlin. This article describes and discusses the ICoME, its revision process, the controversial and uncontroversial issues, and the broad consensus achieved among WMA constituent members, representing over 10 million physicians worldwide. The authors analyse the ICoME, including its response to contemporary changes and challenges like ethical plurality and globalisation, in light of ethical theories and approaches, reaching the conclusion that the document is a good example of international ethical professional self-regulation.

Consent-GPT: is it ethical to delegate procedural consent to conversational AI?

Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamental part of safe and ethical clinical practice. Currently, it is routine for a significant part of the consent process to be delegated to members of the clinical team not performing the procedure (eg, junior doctors). However, it is common for consent-taking delegates to lack sufficient time and clinical knowledge to adequately promote patient autonomy and informed decision-making. Such problems might be addressed in a number of ways. One possible solution to this clinical dilemma is through the use of conversational artificial intelligence using large language models (LLMs). There is considerable interest in the potential benefits of such models in medicine. For delegated procedural consent, LLM could improve patients' access to the relevant procedural information and therefore enhance informed decision-making.In this paper, we first outline a hypothetical example of delegation of consent to LLMs prior to surgery. We then discuss existing clinical guidelines for consent delegation and some of the ways in which current practice may fail to meet the ethical purposes of informed consent. We outline and discuss the ethical implications of delegating consent to LLMs in medicine concluding that at least in certain clinical situations, the benefits of LLMs potentially far outweigh those of current practices.

Assessing the performance of ChatGPT in bioethics: a large language model's moral compass in medicine.

Chat Generative Pre-Trained Transformer (ChatGPT) has been a growing point of interest in medical education yet has not been assessed in the field of bioethics. This study evaluated the accuracy of ChatGPT-3.5 (April 2023 version) in answering text-based, multiple choice bioethics questions at the level of US third-year and fourth-year medical students. A total of 114 bioethical questions were identified from the widely utilised question banks UWorld and AMBOSS. Accuracy, bioethical categories, difficulty levels, specialty data, error analysis and character count were analysed. We found that ChatGPT had an accuracy of 59.6%, with greater accuracy in topics surrounding death and patient-physician relationships and performed poorly on questions pertaining to informed consent. Of all the specialties, it performed best in paediatrics. Yet, certain specialties and bioethical categories were under-represented. Among the errors made, it tended towards content errors and application errors. There were no significant associations between character count and accuracy. Nevertheless, this investigation contributes to the ongoing dialogue on artificial intelligence's (AI) role in healthcare and medical education, advocating for further research to fully understand AI systems' capabilities and constraints in the nuanced field of medical bioethics.

Exploring the potential utility of AI large language models for medical ethics: an expert panel evaluation of GPT-4.

Integrating large language models (LLMs) like GPT-4 into medical ethics is a novel concept, and understanding the effectiveness of these models in aiding ethicists with decision-making can have significant implications for the healthcare sector. Thus, the objective of this study was to evaluate the performance of GPT-4 in responding to complex medical ethical vignettes and to gauge its utility and limitations for aiding medical ethicists. Using a mixed-methods, cross-sectional survey approach, a panel of six ethicists assessed LLM-generated responses to eight ethical vignettes.The main outcomes measured were relevance, reasoning, depth, technical and non-technical clarity, as well as acceptability of GPT-4's responses. The readability of the responses was also assessed. Of the six metrics evaluating the effectiveness of GPT-4's responses, the overall mean score was 4.1/5. GPT-4 was rated highest in providing technical (4.7/5) and non-technical clarity (4.4/5), whereas the lowest rated metrics were depth (3.8/5) and acceptability (3.8/5). There was poor-to-moderate inter-rater reliability characterised by an intraclass coefficient of 0.54 (95% CI: 0.30 to 0.71). Based on panellist feedback, GPT-4 was able to identify and articulate key ethical issues but struggled to appreciate the nuanced aspects of ethical dilemmas and misapplied certain moral principles.This study reveals limitations in the ability of GPT-4 to appreciate the depth and nuanced acceptability of real-world ethical dilemmas, particularly those that require a thorough understanding of relational complexities and context-specific values. Ongoing evaluation of LLM capabilities within medical ethics remains paramount, and further refinement is needed before it can be used effectively in clinical settings.

Justification of principles for healthcare priority setting: the relevance and roles of empirical studies exploring public values.

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification.

Ethics of college vaccine mandates, using reasonable comparisons.

In the paper 'COVID-19 vaccine boosters for young adults: a risk-benefit assessment and ethical analysis of mandate policies at universities,' Bardosh et al argued that college mandates of the COVID-19 booster vaccine are unethical. The authors came to this conclusion by performing three different sets of comparisons of benefits versus risks using referenced data and argued that the harm outweighs the risk in all three cases. In this response article, we argue that the authors frame their arguments by comparing values that are not scientifically or reasonably comparable and that the authors used values that represent grossly different risk profiles and grouped them into a set of figures to create an illusion of fair comparisons. We argue that absent the falsely skewed portrayals of a higher level of risk over benefit in their misrepresented figures, the five ethical arguments they presented completely fall apart.

Espousing the innocence of paediatric patients: an innocent act?

Since the 19th century, innocence has been a hallmark of childhood. The innocence of children is seen as both a sanctity worth defending and a feature that excuses the unavoidable mistakes of adolescence. While beneficial in many settings, notions of childhood innocence are often entangled with values judgements. Inherent in innocence is the notion that that which we are innocent of is undesirable. Further, attributing innocence to some implies the tolerability of blame for others. This has unique implications in a medical setting. This essay explores the implications of espousing the innocence of paediatric patients. Ultimately, because attribution of innocence is both prone to bias and rooted in the same framework as blame, it degrades patient-centred care and compromises the patient-provider relationship. I argue that avoiding such characterisations may allow providers to more effectively promote paediatric health.

Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression.

Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.

Artificial intelligence in medicine and the negative outcome penalty paradox.

Artificial intelligence (AI) holds considerable promise for transforming clinical diagnostics. While much has been written both about public attitudes toward the use of AI tools in medicine and about uncertainty regarding legal liability that may be delaying its adoption, the interface of these two issues has so far drawn less attention. However, understanding this interface is essential to determining how jury behaviour is likely to influence adoption of AI by physicians. One distinctive concern identified in this paper is a 'negative outcome penalty paradox' (NOPP) in which physicians risk being penalised by juries in cases with negative outcomes, whether they overrule AI determinations or accept them. The paper notes three reasons why AI in medicine is uniquely susceptible to the NOPP and urges serious further consideration of this complex dilemma.

What does it mean for a clinical AI to be just: conflicts between local fairness and being fit-for-purpose?

There have been repeated calls to ensure that clinical artificial intelligence (AI) is not discriminatory, that is, it provides its intended benefit to all members of society irrespective of the status of any protected characteristics of individuals in whose healthcare the AI might participate. There have also been repeated calls to ensure that any clinical AI is tailored to the local population in which it is being used to ensure that it is fit-for-purpose. Yet, there might be a clash between these two calls since tailoring an AI to a local population might reduce its effectiveness when the AI is used in the care of individuals who have characteristics which are not represented in the local population. Here, I explore the bioethical concept of local fairness as applied to clinical AI. I first introduce the discussion concerning fairness and inequalities in healthcare and how this problem has continued in attempts to develop AI-enhanced healthcare. I then discuss various technical aspects which might affect the implementation of local fairness. Next, I introduce some rule of law considerations into the discussion to contextualise the issue better by drawing key parallels. I then discuss some potential technical solutions which have been proposed to address the issue of local fairness. Finally, I outline which solutions I consider most likely to contribute to a fit-for-purpose and fair AI.

Reassessing 'good' medical practice and the climate crisis.

In August 2023, the General Medical Council released the latest update of Good Medical Practice, which sets out the standards of patient care and professional behaviour to be expected of UK doctors. These updated guidelines offer some environmental considerations that previous standards did not include. This paper explores these latest additions to Good Medical Practice through the healthcare ethics lens of non-maleficence, beneficence, justice and autonomy, alongside trust and physician well-being, to make the case that the latest updates to Good Medical Practice do not go far enough in specifying the duties for doctors in responding to climate and ecological emergencies to be seen as ethically justifiable.The paper argues that given the health implications of the climate crisis and the harms associated with high-emission healthcare, as well as the co-benefits of climate action on health, there must be a stronger commitment from the medical regulator to ensure the groundwork is set for doctors to learn, understand and advocate for the importance and urgency of practicing sustainable healthcare. The case for this is strengthened by also examining the importance of maintaining public trust in the medical profession as advocates for public health, along with the notable societal and generational injustices that continue to deepen as the climate emergency escalates.The paper concludes by arguing that doctors can and should be a part of writing a new chapter for health in the climate era, but our standards for practice need to offer a strengthened starting point of consensus for what is expected of the medical profession for that to come to fruition and raise questions as to what doctors can and should do when they have questions over their own regulators' commitment to maintaining public health in relation to the climate and ecological crisis.

Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible.

In clinical ethics consultations, clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others. The reasoning process involves identifying and clarifying ethical values which are at stake or contested, and guiding clinicians, and sometimes patients and families, to think through ethically justifiable and available courses of action in clinical situations. There is, however, ongoing discussion about the various methods ethicists use to do this ethical deliberation work. In this paper, we make visible and accessible seven steps of facilitation used in the critical dialogue method of ethics consultation.We describe how the facilitation techniques serve two overall purposes. First, to identify ethically justified responses to ethical questions. Second, to assist participants to gain greater moral clarity, understanding and confidence to respond to ethical challenges as independent moral agents.By describing in detail facilitation steps for clinical ethics consultation, we aim to advance the scholarship of 'clinical ethics facilitation methods' and to demystify the ethical deliberation work undertaken by clinical ethicists.