AI Through Ethical Lenses: A Discourse Analysis of Guidelines for AI in Healthcare.

While the technologies that enable Artificial Intelligence (AI) continue to advance rapidly, there are increasing promises regarding AI's beneficial outputs and concerns about the challenges of human-computer interaction in healthcare. To address these concerns, institutions have increasingly resorted to publishing AI guidelines for healthcare, aiming to align AI with ethical practices. However, guidelines as a form of written language can be analyzed to recognize the reciprocal links between its textual communication and underlying societal ideas. From this perspective, we conducted a discourse analysis to understand how these guidelines construct, articulate, and frame ethics for AI in healthcare. We included eight guidelines and identified three prevalent and interwoven discourses: (1) AI is unavoidable and desirable; (2) AI needs to be guided with (some forms of) principles (3) trust in AI is instrumental and primary. These discourses signal an over-spillage of technical ideals to AI ethics, such as over-optimism and resulting hyper-criticism. This research provides insights into the underlying ideas present in AI guidelines and how guidelines influence the practice and alignment of AI with ethical, legal, and societal values expected to shape AI in healthcare.

[The ethics of IA in medicine must be based on the practical ethics of the healthcare relationship]. / L'éthique de l'IA en médecine doit reposer sur l'éthique pratique de la relation de soin.

THE ETHICS OF IA IN MEDICINE MUST BE BASED ON THE PRACTICAL ETHICS OF THE HEALTHCARE RELATIONSHIP. Artificial intelligence (AI) offers more and more applications on the Internet, smartphones, computers, telemedicine. AI is growing rapidly in health. Transdisciplinary, AI must respect software engineering (reliability, robustness, security), knowledge obsolescence, law, ethics because a wide variety of algorithms, more or less opaque, process personal data help clinical decision. Hospital or city doctors and caregivers question the benefits/risks/costs of AI for the patient, the care relationship, deontology and medical ethics. Drawing on 30 years of experience in AI and medical ethics, the author proposes a first indicator of the ethical risks of AI (axis 1) evaluated by the surface of a radar diagram defined on the other 6 axes: Semantics, Opacity and acceptability, Complexity and autonomy, Target population, Actors (roles and motivations). Highly autonomous strong AI carries the most ethic risks.

L'ÉTHIQUE DE L'IA EN MÉDECINE DOIT REPOSER SUR L'ÉTHIQUE PRATIQUE DE LA RELATION DE SOIN. L'intelligence artificielle (IA) offre de plus en plus d'applications de santé sur smartphones, ordinateurs, télémédecine, internet des objets. Transdisciplinaire, l'IA doit respecter l'ingénierie logicielle (fiabilité, robustesse, sécurité), l'obsolescence des connaissances, le droit, l'éthique, car une grande variété d'algorithmes, plus ou moins opaques, traitent des données personnelles dans l'aide à la décision clinique. Médecins et soignants hospitaliers ou libéraux s'interrogent sur les bénéfices, risques, coûts de l'IA pour le patient, la relation de soin, la déontologie et l'éthique médicale. S'appuyant sur trente ans d'expérience en IA et en éthique médicale, cet article propose un premier indicateur des risques éthiques de l'IA (premier axe) défini par la surface du diagramme radar des autres axes (sémantique ; opacité et acceptabilité ; complexité et autonomie ; population cible ; acteurs [rôles et motivations]). L'IA forte autonome est celle qui comporte le plus de risques éthiques.

Ethical challenges in health care during collective hunger strikes in public or occupied spaces.

Public collective hunger strikes take place in complex social and political contexts, require medical attention and present ethical challenges to physicians. Empirical research, the ethical debate to date and existing guidelines by the World Medical Association focus almost exclusively on hunger strikes in detention. However, the public space differs substantially with regard to the conditions for the provision of health care and the diverse groups of healthcare providers or stakeholders involved. By reviewing empirical research on the experience of health professionals with public collective hunger strikes, we identified the following ethical challenges: (1) establishment of a trustful physician-striker relationship, (2) balancing of medico-ethical principles in medical decision-making, (3) handling of loyalty conflicts and (4) preservation of professional independence and the risk of political instrumentalization. Some of these challenges have already been described and discussed, yet not contextualized for public collective strikes, while others are novel. The presence of voluntary physicians may offer opportunities for a trustful relationship and, hence, for ethical treatment decisions. According to our findings, it requires more attention to how to realise autonomous medical decisions in the complex context of a dynamic, often unstructured and politically charged setting, which ethical norms should shape the professional role of voluntary physicians, and what is the influence of the hunger strikers' collective on individual healthcare decisions. Our article can serve as a starting point for further ethical discussion. It can also provide the basis for the development of potential guidelines to support health professionals involved in public collective hunger strikes.

Rethinking Health Recommender Systems for Active Aging: An Autonomy-Based Ethical Analysis.

Health Recommender Systems are promising Articial-Intelligence-based tools endowing healthy lifestyles and therapy adherence in healthcare and medicine. Among the most supported areas, it is worth mentioning active aging. However, current HRS supporting AA raise ethical challenges that still need to be properly formalized and explored. This study proposes to rethink HRS for AA through an autonomy-based ethical analysis. In particular, a brief overview of the HRS' technical aspects allows us to shed light on the ethical risks and challenges they might raise on individuals' well-being as they age. Moreover, the study proposes a categorization, understanding, and possible preventive/mitigation actions for the elicited risks and challenges through rethinking the AI ethics core principle of autonomy. Finally, elaborating on autonomy-related ethical theories, the paper proposes an autonomy-based ethical framework and how it can foster the development of autonomy-enabling HRS for AA.

Using symbiotic empirical ethics to explore the significance of relationships to clinical ethics: findings from the Reset Ethics research project.

BACKGROUND: At the beginning of the coronavirus (Covid-19) pandemic, many non-Covid healthcare services were suspended. In April 2020, the Department of Health in England mandated that non-Covid services should resume, alongside the continuing pandemic response. This 'resetting' of healthcare services created a unique context in which it became critical to consider how ethical considerations did (and should) underpin decisions about integrating infection control measures into routine healthcare practices. We draw on data collected as part of the 'NHS Reset Ethics' project, which explored the everyday ethical challenges of resetting England's NHS maternity and paediatrics services during the pandemic. METHODS: Healthcare professionals and members of the public participated in interviews and focus group discussions. The qualitative methods are reported in detail elsewhere. The focus of this article is our use of Frith's symbiotic empirical ethics methodology to work from our empirical findings towards the normative suggestion that clinical ethics should explicitly attend to the importance of relationships in clinical practice. This methodology uses a five-step approach to refine and develop ethical theory based on a naturalist account of ethics that sees practice and theory as symbiotically related. RESULTS: The Reset project data showed that changed working practices caused ethical challenges for healthcare professionals, and that infection prevention and control measures represented harmful barriers to the experience of receiving and offering care. For healthcare professionals, offering care as part of a relational interaction was an ethically important dimension of healthcare delivery. CONCLUSIONS: Our findings suggest that foregrounding the importance of relationships across a hospital community will better promote the ethically important multi-directional expression of caring between healthcare professionals, patients, and their families. We offer two suggestions for making progress towards such a relational approach. First, that there is a change of emphasis in clinical ethics practice to explicitly acknowledge the importance of the relationships (including with their healthcare team) within which the patient is held. Second, that organisational decision-making should take into account the moral significance afforded to caring relationships by healthcare professionals, and the role such relationships can play in the negotiation of ethical challenges.

Envisioning the Future of Personalized Medicine: Role and Realities of Digital Twins.

Digital twins have emerged as a groundbreaking concept in personalized medicine, offering immense potential to transform health care delivery and improve patient outcomes. It is important to highlight the impact of digital twins on personalized medicine across the understanding of patient health, risk assessment, clinical trials and drug development, and patient monitoring. By mirroring individual health profiles, digital twins offer unparalleled insights into patient-specific conditions, enabling more accurate risk assessments and tailored interventions. However, their application extends beyond clinical benefits, prompting significant ethical debates over data privacy, consent, and potential biases in health care. The rapid evolution of this technology necessitates a careful balancing act between innovation and ethical responsibility. As the field of personalized medicine continues to evolve, digital twins hold tremendous promise in transforming health care delivery and revolutionizing patient care. While challenges exist, the continued development and integration of digital twins hold the potential to revolutionize personalized medicine, ushering in an era of tailored treatments and improved patient well-being. Digital twins can assist in recognizing trends and indicators that might signal the presence of diseases or forecast the likelihood of developing specific medical conditions, along with the progression of such diseases. Nevertheless, the use of human digital twins gives rise to ethical dilemmas related to informed consent, data ownership, and the potential for discrimination based on health profiles. There is a critical need for robust guidelines and regulations to navigate these challenges, ensuring that the pursuit of advanced health care solutions does not compromise patient rights and well-being. This viewpoint aims to ignite a comprehensive dialogue on the responsible integration of digital twins in medicine, advocating for a future where technology serves as a cornerstone for personalized, ethical, and effective patient care.

"I pray to God that greed never sets in": Community health workers' reflections on "care" during the Covid-19 pandemic.

BACKGROUND: Care provision received renewed attention during the Covid-19 pandemic as several healthcare providers vied for the coveted title of "frontline warrior" while they struggled to provide care efficiently under varying health system constraints. While several studies on the health workforce during the pandemic highlighted their difficulties, there is little reflection on what "care" or "caring" itself meant specifically for community health workers (CHWs) as they navigated different community and health systems settings. The aim of the study was to examine CHWs' care-giving experiences during the pandemic. METHODS: Twenty narrative interviews with CHWs including ASHAs (Accredited Social Health Activists) and ANMs (Auxiliary Nurse Midwives) were conducted in different states between July and December 2020. RESULTS: Our findings highlight the moral, affectual, and relational dimensions of care in the CHWs' engagement with their routine and Covid-19 related services, as well as the "technical" aspects of it. In this article, we argue that these two aspects are, in fact, enmeshed in complex ways. CHWs extend this moral understanding not just to their work, but also to their relationship with the health system and the government, as they express a deep sense of neglect and the lack of "being cared for" by the health system. CONCLUSION: CHWs' experiences demand a more nuanced understanding of the ethics of care or caring that challenges the binaries between the "technical" and moral aspects of care.

The selective deployment of AI in healthcare: An ethical algorithm for algorithms.

Machine-learning algorithms have the potential to revolutionise diagnostic and prognostic tasks in health care, yet algorithmic performance levels can be materially worse for subgroups that have been underrepresented in algorithmic training data. Given this epistemic deficit, the inclusion of underrepresented groups in algorithmic processes can result in harm. Yet delaying the deployment of algorithmic systems until more equitable results can be achieved would avoidably and foreseeably lead to a significant number of unnecessary deaths in well-represented populations. Faced with this dilemma between equity and utility, we draw on two case studies involving breast cancer and melanoma to argue for the selective deployment of diagnostic and prognostic tools for some well-represented groups, even if this results in the temporary exclusion of underrepresented patients from algorithmic approaches. We argue that this approach is justifiable when the inclusion of underrepresented patients would cause them to be harmed. While the context of historic injustice poses a considerable challenge for the ethical acceptability of selective algorithmic deployment strategies, we argue that, at least for the case studies addressed in this article, the issue of historic injustice is better addressed through nonalgorithmic measures, including being transparent with patients about the nature of the current epistemic deficits, providing additional services to algorithmically excluded populations, and through urgent commitments to gather additional algorithmic training data from excluded populations, paving the way for universal algorithmic deployment that is accurate for all patient groups. These commitments should be supported by regulation and, where necessary, government funding to ensure that any delays for excluded groups are kept to the minimum. We offer an ethical algorithm for algorithms-showing when to ethically delay, expedite, or selectively deploy algorithmic systems in healthcare settings.

Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals.

OBJECTIVE: Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress. DESIGN: Cross-sectional survey. SETTING: Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States. PARTICIPANTS: Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study. MAIN OUTCOME MEASURES: Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM). RESULTS: Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (ß= -0.357, p <.001) and patient safety culture (ß = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (ß = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82). CONCLUSIONS: We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.

Application of Topic Modeling on Artificial Intelligence Studies as a Foundation to Develop Ethical Guidelines in African American Dementia Caregiving.

We applied natural language processing and topic modeling to publicly available abstracts and titles of 263 papers in the scientific literature mentioning AI and demographics (corpus 1 before Covid-19, corpus 2 after Covid-19) extracted from the MEDLINE database. We found exponential growth of AI studies mentioning demographics since the pandemic (Before Covid-19: N= 40 vs. After Covid-19: N= 223) [forecast model equation: ln(Number of Records) = 250.543*ln(Year) + -1904.38, p = 0.0005229]. Topics related to diagnostic imaging, quality of life, Covid, psychology, and smartphone increased during the pandemic, while cancer-related topics decreased. The application of topic modeling to the scientific literature on AI and demographics provides a foundation for the next steps regarding developing guidelines for the ethical use of AI for African American dementia caregivers.

Assistência ginecológica aos transgênero / Gynecological care for transgenders

Transgênero (trans) é um termo que alberga toda a diversidade de gênero. A incongruência de gênero faz parte desse espectro e refere-se à pessoa cuja identidade de gênero é oposta ao sexo que lhe foi atribuído no nascimento. A terapia hormonal de afirmação de gênero, bem como a cirurgia de afirmação de gênero, é necessária para adequar o corpo ao gênero ao qual a pessoa se identifica. Os homens trans necessitam da terapia com testosterona, que visa reduzir as concentrações de estradiol e incrementar a testosterona circulante para níveis fisiológicos masculinos, resultando em masculinização. A mulher trans receberá o estradiol, associado ou não a um antiandrogênico, visando reduzir a testosterona e incrementar o estrogênio para níveis femininos, resultando em feminização. A cirurgia de afirmação de gênero é, frequentemente, requerida para completar as modificações fenotípicas para o homem e a mulher trans. O ginecologista e obstetra tem um papel crucial no provimento de cuidados a essa população. O presente artigo visa sistematizar algumas ações que o ginecologista e obstetra pode oferecer e que têm potencial para melhorar a qualidade de vida dos homens e mulheres trans. (AU)

Transgenero (trans) is an umbrella term that encompasses all gender diversity. Gender Incongruity is part of this spectrum and refers to the person whose gender identity is opposed to the sex assigned to them at birth. Gender-affirming hormone therapy as well as gender-affirming surgery are necessary to adapt the body to the gender to which the person identifies. Trans men require testosterone therapy to reduce estradiol concentrations and increase circulating testosterone to male physiological levels resulting in masculinization. Trans women will receive estradiol associated or not with an antiandrogenic to reduce testosterone and increase estrogen to female levels resulting in feminization. gender-affirming surgery is often required to complete phenotypic modifications for trans men and women. The gynecologist and obstetrician plays a crucial role in to provide care to this population. This article aims to systematize some actions that the gynecologist and obstetrician can offer to improve the quality of life of trans men and women. (AU)

The Hospitalized Adolescent.

This clinical report provides pediatricians evidence-based information on the developmentally appropriate, comprehensive clinical care for hospitalized adolescents. Included in this report are opportunities and challenges facing pediatricians when caring for specific hospitalized adolescent populations. The companion policy statement, "The Hospitalized Adolescent," includes detailed descriptions of adolescent hospital admission demographics, personnel recommendations, and hospital setting and design advice, as well as sections on educational services, legal and ethical matters, and transitions to adult facilities.

Chapitre 5. L'innovation frugale au service de systèmes de santé durables.

Bioethics is sometimes presented as a series of universal guidelines aimed at regulating health care practices and research on human beings. Such a presentation, however, does not hold water in the face of the history of the discipline. Bioethics was born in the ideological context that prevailed in the United States in the 1960s and 1970s. Should we then abandon all hope of universality for ethical benchmarks that have proven their usefulness in illuminating health practices? By carefully distinguishing the universal from the uniform, this contribution shows, based on the work of G. Tangwa, that it is possible to respect the specificities of cultures around the world, while maintaining a universal aim for bioethics.