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.

Voluntary stopping of eating and drinking in the age of medical assistance in dying: ethical considerations for physicians.

Since 2016, when medical assistance in dying (MAiD) became legal in Canada, healthcare professionals (HCPs) have become familiar with exploring and acting upon patients' wishes to hasten death (WTHD). In contrast to MAiD, the literature on the voluntary stopping of eating and drinking (VSED) is very limited and there are no standards of practice or legal guidance to support HCPs. In this article, the legal and ethical literature as regards VSED is critically reviewed and new standards of practice are proposed.

Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country.

BACKGROUND: Patient autonomy is a fundamental, yet challenging, principle of professional medical ethics. The idea that individual patients should have the freedom to make choices about their lives, including medical matters, has become increasingly prominent in current literature. However, this has not always been the case, especially in communist countries where paternalistic attitudes have been interwoven into all relationships including medical ones. Patients' expectations and the role of the doctor in the patient-physician relationship are changing. Croatia, as a transitional country, is currently undergoing this particular process. METHODS: Qualitative research was conducted by means of six focus group discussions held in the years 2012 and 2013 in Croatia. Focus groups were held separately with each of the following: first year and final (6(th)) year medical students, physicians engaged in medical ethics education, physicians practicing in a clinical hospital, family medicine residents and individuals representing patients with chronic disease. This research specifically addresses issues related to patient autonomy, in particular, the principles of truth telling, confidentiality, and informed consent. All focus group discussions were audio taped and then transcribed verbatim and systematized according to acknowledged qualitative analysis methods. RESULTS AND DISCUSSION: Patient autonomy is much more than a simple notion defined as the patient's right to make treatment decisions independently. It has to be understood in context of the broader socio-cultural setting. At present, both patients and medical doctors in Croatia are increasingly appreciating the importance of promoting the principle of autonomy in medical decision-making. However, the current views of medical students, physicians and patients reveal inconsistencies. CONCLUSIONS: Knowing how to respect the various facets of patients' autonomy should be part of physician's professional duties, and also be reflected in his or her core clinical competencies. For this reason greater importance should be dedicated to patient autonomy issues in medical education in Croatia.

Bilateral sequential adult cochlear implantation: who should receive priority in the context of a constrained health care system?

Resource allocation decisions have become increasingly necessary as the cost of health care habitually increases. Bilateral (second side) adult cochlear implantation (CI) is an example of a novel technology with accruing evidence of benefit, yet expense has limited universal employ. Currently at our centers, bilateral implantation is only provided under research protocol. In this article, we discuss the need for a principled approach concerning the distribution of a second device, both during this period of investigation and if ultimately an insured service. Allocation strategies, while extensively addressed in some arenas, have yet to be developed for second-side sequential adult CI. We advocate that physicians must assume an explicit role when both caring for individual patients as well as administering health care programs. We review social justice theories that inform resource allocation macrodecisions, and include a defence of age-based considerations. Our approach to patient selection for adult second-side CI sequentially considers clinical criteria (directly addressed in the article), a willingness to participate in rigorous research, and a 65 year cut-off. Ultimately, we employ random blinded selection for allocating bilateral CI among the remaining similarly situated individuals. This approach functions impartially and in a manner that is transparent for both patient and physician.

FLO: a cure for what ails healthcare?

Zimmerman et al. contend that it is only by providing front-line staff with the tools and the power to change practice that patient safety can be truly embedded in an institution. In this commentary, the author agrees with this argument and adds that patients and families must also have a central place at the table when it comes to addressing healthcare's failings.

Nurses' disclosure of error scenarios in nursing homes.

BACKGROUND: Little work has explored the disclosure of errors in nursing homes (NHs). PURPOSE: This paper reports how nurses would disclose hypothetical errors that occur in NH settings. METHOD: A cross-sectional survey was given to a randomly selected sample of registered nurses (RNs) and registered practical nurses (RPNs) working in Ontario, Canada NHs. RESULTS: Of 1,180 respondents, only half might provide full details and the cause of the error and provide steps in how the error would be prevented if they were in situations described by the hypothetical scenarios. Scenarios that were less serious had an almost 3 times higher likelihood of an explicit apology (OR 2.97; 95% CI 1.36-6.51; P = 0.007). Nurses who were RNs, had more education, had a prior history of disclosing a serious error, and agreed with full disclosure were more likely to respond to disclosing more information about the error. Nurses also reported numerous barriers to effective disclosure in their workplace. CONCLUSION: Improvements in NH safety culture are necessary to enhance the error disclosure process.

Nurses' perceptions of error reporting and disclosure in nursing homes.

Nurses have an obligation to disclose an error when one occurs. This study explored 1180 nurses' perceptions of error disclosure in the nursing home setting. Nurse respondents found disclosure to be a difficult process. Registered nurse respondents and nurses who had prior experience disclosing a serious error were more likely to disclose a serious error. The study has implications to improve nursing education, policy, and patient safety culture in the nursing home setting.

Safety incidents in family medicine.

OBJECTIVE: To discuss the characteristics of incidents reported to the Medical Safety in Community Practice (MSCP) safety learning system. METHODS: Members of family physician offices in the Alberta Health Services--Calgary zone, confidentially reported patient safety incidents via web or fax from September 2007 to August 2010. The incident reporting form contained both open-ended and closed questions. Incidents were reviewed for their characteristics. RESULTS: A total of 19 family practices participated in MSCP. A total of 264 useable reports were collected. Reporting was higher when practices first joined and then decreased. There was an average of 1.4 reports per month. Physicians submitted the majority of reports. Physicians and nurses were more likely to report an incident than office staff. The vast majority of reported incidents were judged to have 'virtually certain evidence of preventability' (93%). Harm was associated with 50% of incidents. Only 1% of the incidents had a severe impact. The top four types of incidents reported were documentation (41.4%), medication (29.7%), clinical administration (18.7%) and clinical process (17.5%). CONCLUSION: MSCP has developed and implemented the first safety learning system in Canada for family practice. All clinic members were encouraged to submit reports, but most of the incidents were reported by physicians. The vast majority of incidents reported were preventable with limited severity. The most frequently reported types of incidents fell into the categories of documentation and medication. The low reporting rates suggest that for family practices incident reporting may not be the most effective method to determine the types and frequency of incidents in family medicine.

Informed consent in the NICU setting: an ethically optimal model for research solicitation.

Recruiting patients for studies in the Neonatal Intensive Care Unit is a complex endeavour. Much discussion has occurred regarding the optimal recruitment "model" for this environment. This paper discusses current and suggested recruitment models for the NICU setting and presents a systematic approach to the consent process that focuses on the protection and promotion of parental autonomy. The proposed model incorporates several key considerations for an ethically optimal approach to the inclusion of neonates in research: informing parents about research and their rights prior to any solicitation, asking parents if they wish to be approached for research, approaching for one study at a time, assuring the study is relevant to the infants' current clinical status, minimising information overload, allowing parents appropriate time (which will vary from study to study) to consider their choice, and providing a waiting period between subsequent approaches. It is argued that parental ability to make a truly informed choice may be improved when following the proposed model.

Helicobacter pylori and the prevention of gastric cancer.

BACKGROUND: Helicobacter pylori is an important cause of stomach cancer that infects a substantial proportion of the Canadian adult population. H pylori can be detected by noninvasive tests and effectively eradicated by medical treatment. Screening for and treatment of H pylori may represent a significant opportunity for preventive oncology. METHODS: Cancer Care Ontario organized a workshop held in Toronto, Ontario, on October 24 and 25, 2002, to: review the current state of knowledge regarding H pylori treatment and cancer prevention; determine if there is currently sufficient evidence to consider the promotion of H pylori treatment for the purpose of cancer prevention; identify critical areas for research; and advise Cancer Care Ontario on H pylori and cancer prevention. RESULTS: Workshop participants developed a number of recommendations for research into the relationship between H pylori and stomach cancer, including determining the prevalence of infection in different regions of Canada, the pathogenetic sequence of carcinogenesis from H pylori infection, and the implementation of a prospective observational study. INTERPRETATION: Although the rate of H pylori infection is declining in Canada and the treatment of H pylori is generally accepted to be safe, the evidence to date may not warrant the implementation of population screening for H pylori infection to prevent gastric carcinoma in average-risk populations. Rather, a demonstration project is needed to estimate prevalence, evaluate the merits of screening, measure patient compliance and physician participation, develop education materials, establish a registry for monitoring and evaluation, and develop a quality assurance framework.

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

BACKGROUND: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. METHODS: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. RESULTS: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7- 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%-41.8%) and death in 20.8% (95% CI 7.8%-33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). INTERPRETATION: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.

To tell or not to tell? Professional and lay perspectives on the disclosure of personal health information in community-based dementia care.

Developments in information technology and the ongoing restructuring of health services to increase provision in community settings militate in favour of a streamlining of communications and the exchange of information about patients among health and social care providers. Yet the principles of confidentiality and privacy appear to inhibit this process. In order to explore the practical, ethical, and legal imperatives attendant upon personal health information exchange, we conducted a series of interviews with professional care providers, persons with early-stage dementia, and their family caregivers. The findings indicate some degree of discordance. Professionals reported valuing disclosure both to colleagues and family caregivers on the basis of its being in the patients' best interests. Patients also valued inter-professional exchange, but sought strong control over disclosure to family members. Family caregivers valued being kept informed of the patient's condition, even without the latter's consent. Implications for research and policy are discussed.