Addressing bias in artificial intelligence for public health surveillance.

Components of artificial intelligence (AI) for analysing social big data, such as natural language processing (NLP) algorithms, have improved the timeliness and robustness of health data. NLP techniques have been implemented to analyse large volumes of text from social media platforms to gain insights on disease symptoms, understand barriers to care and predict disease outbreaks. However, AI-based decisions may contain biases that could misrepresent populations, skew results or lead to errors. Bias, within the scope of this paper, is described as the difference between the predictive values and true values within the modelling of an algorithm. Bias within algorithms may lead to inaccurate healthcare outcomes and exacerbate health disparities when results derived from these biased algorithms are applied to health interventions. Researchers who implement these algorithms must consider when and how bias may arise. This paper explores algorithmic biases as a result of data collection, labelling and modelling of NLP algorithms. Researchers have a role in ensuring that efforts towards combating bias are enforced, especially when drawing health conclusions derived from social media posts that are linguistically diverse. Through the implementation of open collaboration, auditing processes and the development of guidelines, researchers may be able to reduce bias and improve NLP algorithms that improve health surveillance.

Repairing moral injury takes a team: what clinicians can learn from combat veterans.

Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic's advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury-particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.

Radiological findings of COVID-19-related thromboembolic complications

BackgroundThe ongoing global pandemic of coronavirus disease 2019 (COVID-19) may cause, in addition to lung disease, a wide spectrum of non-respiratory complications. Among these are thromboembolic complications. The theories that explain the mechanism of thromboembolic complications of COVID-19 are accumulating rapidly, and in addition to the role of imaging for assessment of COVID-19 pneumonia, CT may be useful for identification of these complications, such as pulmonary embolism, ischaemic stroke, mesenteric ischaemia, and acro-ischaemia.ResultsThromboembolic manifestations were diagnosed in 10% of our patients (124 patients out of the total 1245 COVID-19 patients);56 patients (45.2%) presented with pulmonary embolism, 32 patients (25.8%) presented with cerebrovascular manifestations, 17 patients (13.7%) presented with limb affection, and 19 patients (15.3%) presented with gastrointestinal thromboembolic complications.Most of our patients had significant comorbidities;diabetes was found in 72 patients (58%), dyslipidemia in 72 patients (58%), smoking in 71 patients (57.3%), hypertension in 63 patients (50.8%), and morbid obesity in 40 patients (32.2%).Thromboembolic events were diagnosed on admission in 41 patients (33.1%), during the first week in 61 patients (49.2%), and after the first week in 22 patients (17.7%).ConclusionsThe incidence of thromboembolic complications in COVID-19 patients is relatively high resulting in a multisystem thrombotic disease. In addition to the crucial role of imaging for assessment of COVID-19 pneumonia, CT is important for assessment of the thromboembolic complications, such as pulmonary embolism, ischaemic stroke, mesenteric ischaemia, and peripheral ischaemia, especially in patients with elevated d-dimer levels and those with sudden clinical deterioration.

Utility of multidisciplinary meetings in paediatric and adolescent oncofertility

Study objective: Multidisciplinary meetings (MDMs) are increasingly implemented in complex care based on the principle that they lead to evidence-based treatment recommendations, foster adherence to clinical guidelines, induce better team performance and improve medical care. In oncofertility, the uncertain outcomes of fertility preservation procedures in children contribute to the complexity of decision-making. There is limited published information on the influence of MDMs on paediatric and adolescent oncofertility care. Aim(s): To describe the implementation, characteristics & outcomes of multidisciplinary meetings (MDMs) in a paediatric oncofertility setting. Method(s): A retrospective medical records review of oncofertility MDMs held between April 2020 and March 2021 at the Royal Children's Hospital Melbourne. Inductive content analysis of the reasons for MDM was undertaken. MDM documentation was scored out of 24, according to a Victorian Paediatric Integrated Cancer Service quality assurance checklist for MDMs, (1)) which included consent for MDM, nature of attendees, quality of discussion and documentation. Result(s): Of the 169 oncology patients treated at the Royal Children's Hospital between 1st April 2020 and 31st March 2021, MDMs were required for 40 patients (23.7%). The median number of clinical attendees was 10, and included craft groups from both paediatric and adult centres (oncology, oncofertility, gynaecology, clinical ethics, endocrinology, paediatric surgery, anaesthetics, haematology, fertility specialists and reproductive scientists). Fifty-four percent (n=22) of MDMs were for male patients (median age 8.4 [0.1-16.5] years) and 46% for females (n=18, median age 8.1[0.4-16.3] years). The commonest diagnoses presented at MDM were brain tumours (27.5%), leukemia (25%), and non malignant conditions (19.5%). Approximately 77% of all MDM patients were going to receive treatment that put them at high infertility risk and 62.5% had co-morbidities. MDMs included the following themes (i) likelihood of successful parenthood: disease progression, prognosis, neurocognitive decline;(ii) certainty or otherwise of planned treatment and infertility risks;(iii) mitigation of anaesthetic and surgical risks;(iv) ethical concerns;(v) organizational capacity and logistics in the face of covid restrictions or high dependent care between centres (vi) child and family of risks, expectations and their values regarding fertility preservation. In 87.5% of cases, it was deemed permissible to offer fertility preservation. The median score for the MDMs derived from the quality assurance checklist was 16. Conclussion: MDMs acted as a valuable educational and communication tool improving situational awareness, building shared mental models, assisting with risk mitigation and oncofertility planning.Copyright © 2023

Please wear a mask: a systematic case for mask wearing mandates.

This paper combines considerations from ethics, medicine and public health policy to articulate and defend a systematic case for mask wearing mandates (MWM). The paper argues for two main claims of general interest in favour of MWM. First, MWM provide a more effective, just and fair way to tackle the ongoing COVID-19 pandemic than policy alternatives such as laissez-faire approaches, mask wearing recommendations and physical distancing measures. And second, the proffered objections against MWM may justify some exemptions for specific categories of individuals, but do not cast doubt on the justifiability of these mandates. Hence, unless some novel decisive objections are put forward against MWM, governments should adopt MWM.

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.

Diversity in clinical research: public health and social justice imperatives.

It is well established that demographic representation in clinical research is important for understanding the safety and effectiveness of novel therapeutics and vaccines in diverse patient populations. In recent years, the National Institutes of Health and Food and Drug Administration have issued guidelines and recommendations for the inclusion of women, older adults, and racial and ethnic minorities in research. However, these guidelines fail to provide an adequate explanation of why racial and ethnic representation in clinical research is important. This article aims to both provide the missing arguments for why adequate representation of racial and ethnic minorities in clinical research is essential and to articulate a number of recommendations for improving diversity going forward.Appropriate racial and ethnic representation and fair inclusion help (1) increase the generalisability of clinical trial results, (2) equitably distribute any benefits of clinical research and (3) enable trust in the research enterprise.

Navigating our way through a hospital ransomware attack: ethical considerations in delivering acute orthopaedic care.

Ransomware attacks on healthcare systems are becoming more prevalent globally. In May 2021, Waikato District Health Board in New Zealand was devastated by a major attack that crippled its information technology system. The Department of Orthopaedic Surgery faced a number of challenges to the way they delivered care including, patient assessment and investigations, the deferral of elective surgery, and communication and patient confidentiality. These issues are explored through the lens of the four key principles of medical ethics in the hope that they will provide some guidance to future departments who may experience such attacks.

The harm principle, personal identity and identity-relative paternalism.

Is it ethical for doctors or courts to prevent patients from making choices that will cause significant harm to themselves in the future? According to an important liberal principle the only justification for infringing the liberty of an individual is to prevent harm to others; harm to the self does not suffice.In this paper, I explore Derek Parfit's arguments that blur the sharp line between harm to self and others. I analyse cases of treatment refusal by capacitous patients and describe different forms of paternalism arising from a reductionist view of personal identity. I outline an Identity Relative Paternalistic Intervention Principle for determining when we should disallow refusal of treatment where the harm will be accrued by a future self, and consider objections including vagueness and non-identity.Identity relative paternalism does not always justify intervention to prevent harm to future selves. However, there is a stronger ethical case for doing so than is often recognised.

COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities.

In 2022, students at North American universities with third-dose COVID-19 vaccine mandates risk disenrolment if unvaccinated. To assess the appropriateness of booster mandates in this age group, we combine empirical risk-benefit assessment and ethical analysis. To prevent one COVID-19 hospitalisation over a 6-month period, we estimate that 31 207-42 836 young adults aged 18-29 years must receive a third mRNA vaccine. Booster mandates in young adults are expected to cause a net harm: per COVID-19 hospitalisation prevented, we anticipate at least 18.5 serious adverse events from mRNA vaccines, including 1.5-4.6 booster-associated myopericarditis cases in males (typically requiring hospitalisation). We also anticipate 1430-4626 cases of grade ≥3 reactogenicity interfering with daily activities (although typically not requiring hospitalisation). University booster mandates are unethical because they: (1) are not based on an updated (Omicron era) stratified risk-benefit assessment for this age group; (2) may result in a net harm to healthy young adults; (3) are not proportionate: expected harms are not outweighed by public health benefits given modest and transient effectiveness of vaccines against transmission; (4) violate the reciprocity principle because serious vaccine-related harms are not reliably compensated due to gaps in vaccine injury schemes; and (5) may result in wider social harms. We consider counterarguments including efforts to increase safety on campus but find these are fraught with limitations and little scientific support. Finally, we discuss the policy relevance of our analysis for primary series COVID-19 vaccine mandates.

Duty to Work During the COVID-19 Pandemic: A Cross-Sectional Study of Perceptions of Health Care Providers in Jordan.

INTRODUCTION: This study aimed to assess perceptions of duty to work among health care providers during the coronavirus disease 2019 response and to identify factors that may influence their perceptions. METHODS: This was a cross-sectional study conducted from April 1, 2020, to April 20, 2020, using an online survey distributed to health care providers in Jordan. Descriptive statistics were used, as well as chi-square test for independence to assess relationships between variables. RESULTS: A total of 302 questionnaires were included. Commitment to serve the community was the primary reason for coming to work (36%), followed by commitment to faith (29.6%). The major perceived barriers for coming to work were lack of appropriate personal protective equipment and appropriate training (62.6% and 53.5%, respectively). Males perceived higher work obligations than females in all potential barriers (P < .05), except for the lack of appropriate training. Nurses perceived higher work obligations than other health care providers despite the lack of appropriate training (χ2 = 11.83, P = .005), lack of effective vaccine or treatment (χ2 = 21.76, P < .001), or reported infection among coworkers (χ2 = 10.18, P = .03). DISCUSSION: While the majority of health care providers perceive an obligation to work during the coronavirus disease 2019 pandemic, specific conditions, mainly lack of protective gear and training, may significantly alter their perception of work obligation. Providing training and proper personal protective equipment are among the vital measures that could improve the work environment and work obligation during pandemic conditions.

Public attitudes about equitable COVID-19 vaccine allocation: a randomised experiment of race-based versus novel place-based frames.

Equity was-and is-central in the US policy response to COVID-19, given its disproportionate impact on disadvantaged communities of colour. In an unprecedented turn, the majority of US states used place-based disadvantage indices to promote equity in vaccine allocation (eg, through larger vaccine shares for more disadvantaged areas and people of colour).We conducted a nationally representative survey experiment (n=2003) in April 2021 (before all US residents had become vaccine eligible), that examined respondents' perceptions of the acceptability of disadvantage indices relative to two ways of prioritising racial and ethnic groups more directly, and assessed the role of framing and expert anchors in shaping perceptions.A majority of respondents supported the use of disadvantage indices, and one-fifth opposed any of the three equity-promoting plans. Differences in support and opposition were identified by respondents' political party affiliation. Providing a numerical anchor (that indicated expert recommendations and states' actual practices in reserving a proportion of allocations for prioritised groups) led respondents to prefer a lower distribution of reserved vaccine allocations compared with the randomised condition without this anchor, and the effect of the anchor differed across the frames.Our findings support ongoing uses of disadvantage indices in vaccine allocation, and, by extension, in allocating tests, masks or treatments, especially when supply cannot meet demand. The findings can also inform US allocation frameworks in future pandemic planning, and could provide lessons on how to promote equity in clinical and public health outside of the pandemic setting.

Principlist approach to multiple heart valve replacements for patients with intravenous drug use-induced endocarditis.

Medical professionals often deny patients who inject opioids a second or third heart valve replacement, even if such a surgery is medically indicated. However, such a position is not well defended. As this paper demonstrates, the ethical literature on the topic too often fails to develop and apply an ethical lens to analyse the issue of multiple valve replacements. This paper addresses this lacuna by analysing the case of Mr Walsh, a composite case which protects the identity of any one patient, through the principlist approach of Beauchamp and Childress. It argues that the hospital should offer Mr Walsh, a second valve replacement because the procedure is: medically indicated, autonomously requested, non-maleficent, beneficent and does not violate a formal account of justice. The paper concludes with clinical ethical guidelines for valve surgery for patients with opioid use disorder.

Facial recognition law in China.

Although the prevalence of facial recognition-based COVID-19 surveillance tools and techniques, China does not have a facial recognition law to protect its residents' facial data. Oftentimes, neither the public nor the government knows where people's facial images are stored, how they have been used, who might use or misuse them, and to what extent. This reality is alarming, particularly factoring in the wide range of unintended consequences already caused by good-intentioned measures and mandates amid the pandemic. Biometric data are matters of personal rights and national security. In light of worrisome technologies such as deep-fake pornography, the protection of biometric data is also central to the protection of the dignity of the citizens and the government, if not the industry as well. This paper discusses the urgent need for the Chinese government to establish rigorous and timely facial recognition laws to protect the public's privacy, security, and dignity amid COVID-19 and beyond.

How low can you go? Justified hesitancy and the ethics of childhood vaccination against COVID-19.

This paper explores some of the ethical issues around offering COVID-19 vaccines to children. My main conclusion is rather paradoxical: the younger we go, the stronger the grounds for justified parental hesitancy and, as such, the stronger the arguments for enforcing vaccination. I suggest that this is not the reductio ad absurdum it appears, but does point to difficult questions about the nature of parental authority in vaccination cases. The first section sketches the disagreement over vaccinating teenagers, arguing that the UK policy was permissible. The second section outlines a problem for this policy, that it faces justified vaccine hesitancy. The third section discusses three strategies for responding to this problem, arguing that there may be no simple way of overcoming parents' reasons to resist vaccinations.

Sequential organ failure assessment, ventilator rationing and evolving triage guidance: new evidence underlines the need to recognise and revise, unjust allocation frameworks.

We respond to recent comments on our proposal to improve justice in ventilator triage, in which we used as an example New Jersey's (NJ) publicly available and legally binding Directive Number 2020-03. We agree with Bernard Lo and Doug White that equity implications of triage frameworks should be continually reassessed, which is why we offered six concrete options for improvement, and called for monitoring the consequences of adopted triage models. We disagree with their assessment that we mis-characterised their Model Guidance, as included in the NJ Directive, in ways that undermine our conclusions. They suggest we erroneously described their model as a two-criterion allocation framework; that recognising other operant criterion reveals it 'likely mitigate[s] rather than exacerbate[s] racial disparities during triage', and allege that concerns about inequitable outcomes are 'without evidence'. We highlight two major studies robustly demonstrating why concerns about disparate outcomes are justified. We also show that White and Lo seek to retrospectively-and counterfactually-correct the version of the Model Guideline included in the NJ Directive. However, as our facsimile reproductions show, neither the alleged four-criteria form, nor other key changes, such as dropping the Sequential Organ Failure Assessment score, are found in the Directive. These points matter because (1) our conclusions hence stand, (2) because the public version of the Model Guidance had not been updated to reduce the risk of inequitable outcomes until June 2021 and (3) NJ's Directive still does not reflect these revisions, and, hence, represents a less equitable version, as acknowledged by its authors. We comment on broader policy implications and call for ways of ensuring accurate, transparent and timely updates for users of high-stakes guidelines.

COVID-19 vaccination status should not be used in triage tie-breaking.

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public's trust, which for the time being would not be served by the inclusion of vaccination status.

Should coronavirus policies remain in place to prevent future paediatric influenza deaths?

The 2019-2020 to 2020-2021 influenza seasons in the USA saw a dramatic 99.5% decrease in paediatric mortality, with only one influenza death recorded during the latter season. This decrease has been attributed to a substantial reduction in transmission, resulting from the various restrictive measures enacted during the COVID-19 pandemic, onset March 2020. The relative disappearance of influenza raises specific policy questions, such as whether these measures should be kept in place after COVID-19 transmission reaches acceptable levels or herd immunity is achieved. Given the nature of these measures as liberty restricting, it is worth discussing their intended outcome and what values they promote. Do these measures in fact promote health, or simply give the comfort of safety while undermining long-term health and individual liberties? I argue that the year-long endurance of the pandemic well into 2021 may have flattened our value landscape into one where health reigns supreme. Discussions are underway regarding whether we should modify previously accepted health risks, such as the risk of contracting influenza. In this paper, I attempt to clarify the values that motivate our policies and discuss how our present historical context has appreciated the value of health. I also provide an analysis of various pandemic policies and their relation to influenza paediatric deaths. Ultimately, the cost of certain measures on values such as education, socialisation and liberty, among others, is too high to justify their use beyond regulating the spread of COVID-19.