生物医学领域人工智能应用的伦理问题

人工智能在生物医学领域的应用正在加速发展,在公共卫生、临床诊疗、健康管理方面展露出广阔的发展前景,同时也引起了许多潜在和现存的伦理困境。目前,讨论比较集中的伦理议题有:1)人工智能的道德地位;2)人工智能应用引起的各种公平性问题;3)个人权利与公共利益之间的张力问题。本文试图对上述议题进行初步的探讨,从平衡的观点出发,提出若干原则供学术界共同讨论和批评。     

Urban bioethics: adapting bioethics to the urban context.

Urban bioethics is an area of inquiry within the discipline of bioethics that focuses on ethical issues, problems, and conflicts relating to medicine, science, health care, and the environment that typically arise in urban settings. Urban bioethics challenges traditional bioethics (1) to examine value concerns in a multicultural context, including issues related to equity and disparity, and public health concerns that may highlight conflict between individual rights and the public good, and (2) to broaden its primary focus on individual self-determination and respect for autonomy to include examination of the interests of family, community, and society. Three features associated with urban life-density, diversity, and disparity-affect the health of urban populations and provide the substrate for identifying ethical concerns and value conflicts and creating interventions to affect population health outcomes. The field of urban bioethics can be helpful in creating ethical foundations and principles for public health practice, developing strategies to respect diversity in health policy in a pluralistic society, and fostering collaborative work among educators, social scientists, and others to eliminate bias among health professionals and health care institutions to enhance patients' satisfaction with their care and ultimately affect health outcomes. Educational programs at all levels and encompassing all health professions are needed as a first step to address the perplexing and important problem of eliminating health disparities. Urban bioethics is both contributing to the social science literature in this area and helping educators to craft interventions to affect professional attitudes and behaviors.     

The ethics of cultural competence.

Cultural competence curricula have proliferated throughout medical education. Awareness of the moral underpinnings of this movement can clarify the purpose of such curricula for educators and trainees and serve as a way to evaluate the relationship between the ethics of cultural competence and normative Western medical ethics. Though rarely stated explicitly, the essential principles of cultural competence are (1) acknowledgement of the importance of culture in people's lives, (2) respect for cultural differences, and (3) minimization of any negative consequences of cultural differences. Culturally competent clinicians promote these principles by learning about culture, embracing pluralism, and proactive accommodation. Generally, culturally competent care will advance patient autonomy and justice. In this sense, cultural competence and Western medical ethics are mutually supportive movements. However, Western bioethics and the personal ethical commitments of many medical trainees will place limits on the extent to which they will endorse pluralism and accommodation. Specifically, if the values of cultural competence are thought to embrace ethical relativity, inexorable conflicts will be created. The author presents his view of the ethics of cultural competence and places the concepts of cultural competence in the context of Western moral theory. Clarity about the ethics of cultural competence can help educators promote and evaluate trainees' integration of their own moral intuitions, Western medical ethics, and the ethics of cultural competence.     

Geneticists' views on science policy formation and public outreach

Though much research about the public's views of scientists, genetic research and its moral, ethical, and social implications exists, little has been done to investigate how scientists view their own role(s) in public discussions and policy formation related to genetic research and technologies. We interviewed 20 academic geneticists in the United States about their perceptions of the roles they and others (e.g., professional societies, the public, ethicists, and elected officials) do and should play in the formation of science policy, the communication of science to the public, and the public discussions of moral and ethical issues raised by scientific advances. The participants in our study thought that scientists should be more actively involved in public outreach and science policy formation, but frequently they felt ill-equipped and unsupported by their peers and institutions to pursue these activities. Furthermore, many were skeptical of or did not trust elected officials--who they consider uninformed about the issues and too driven by political agendas--to formulate sound science policy. They do, however, have faith in the ability of scientific societies to influence policy effectively, and some thought that societies should play a larger role, both in science policy and as a liaison between scientists and the public. Finally, participants offered suggestions for increasing the involvement and influence of scientists in science-policy formation and public discourse.     

Paying the Piper: Additional Considerations of the Theoretical,Ethical and Moral Basis of Financial Incentives for Health Behaviour Change

Lynagh, Sanson-Fisher and Bonevski’s article entitled “What's good for the goose is good for the gander. Guiding principles for the use of financial incentives in health behaviour change” (Int J Behav Med 20:114–120, 2012) reviews evidence for the use of financial incentives for encouraging health behaviour change. Their discussion of the practical and moral issues involved is a timely contribution which will encourage consideration of the implications of such interventions. In this response to their paper, I suggest that there are also broader aspects that we must consider before developing principles for public policy intervention. First, we must include good theories that explain in a great deal more depth what we mean by health-related behaviours, and secondly, we need to understand the location of these behaviours in social life and within structural inequalities. To ignore these fundamental aspects of health is to risk increasing social injustice and worsening health inequalities, a facet of the morality of health promotion activities which is not touched upon by the Lynagh et al. paper.     

The four principles: Can they be measured and do they predict ethical decision making?

ABSTRACT: BACKGROUND: The four principles of Beauchamp and Childress - autonomy, non-maleficence, beneficence and justice - have been extremely influential in the field of medical ethics, and are fundamental for understanding the current approach to ethical assessment in health care. This study tests whether these principles can be quantitatively measured on an individual level, and then subsequently if they are used in the decision making process when individuals are faced with ethical dilemmas. METHODS: The Analytic Hierarchy Process was used as a tool for the measurement of the principles. Four scenarios, which involved conflicts between the medical ethical principles, were presented to participants and they made judgments about the ethicality of the action in the scenario, and their intentions to act in the same manner if they were in the situation. RESULTS: Individual preferences for these medical ethical principles can be measured using the Analytic Hierarchy Process. This technique provides a useful tool in which to highlight individual medical ethical values. On average individuals have a significant preference for non-maleficence over the other principles, however, and perhaps counter-intuitively, this preference does not seem to relate to applied ethical judgements in specific ethical dilemmas. CONCLUSIONS: People state they value these medical ethical principles but they do not actually seem to use them directly in the decision making process. The reasons for this are explained through the lack of a behavioural model to account for the relevant situational factors not captured by the principles. The limitations of the principles in predicting ethical decision making are discussed.     

Issues and ethical problems of stem cell therapy--where is Hippocrates?

Stem cells and their therapeutic use present many questions associated with ethical problems in medicine. There is great effort on the part of physicians to help millions of patients while there are ethical problems with the use of new methods and technologies and all of these are affected by economic and political influences. How will the current generation deal with these problems? Medicine, in this begard, is experiencing a stormy evolution of human culture in the relationships between disease, patient and doctor. Philosophy approaches the same juncture of human culture, but seemingly from the other side. Both disciplines are facing a great problem: How to unite the content of current human morality and the desire for health? Both philosophers and physicians perceive this deficit in human culture as it does not provide immediately usable normatives, which the living generation of healthy and ill is waiting for. It may be said that medicine, as many times before, has reached a stage where it cannot rely only on the proved axiologic values from the past, ethical normatives or cultivated moral sense of its subjects. Medicine has no other alternative than to take an active part in resolution of interdisciplinary problems originating from philosophic-biologic or philosophic-medical inquiries of axiologic, ethical, and moral issues. Our paper indicates some ways of the search in forming ethical principles of the stem-cell therapy from the view of biologists and physicians. New ways are recommended in theoretical-methodological interdisciplinary research, especially, in theoretical and experimental biology, and theoretical and clinical medicine, as well as philosophy. In this paper important ethical problems are pointed out in order to find answers to some key problems connected with cell therapy and the use of stem cells.     

Viewpoint: why the clinical ethics we teach fails patients.

The clinical ethics framework that is typically taught to medical students and residents is deeply flawed, and the result of using this framework exclusively to resolve ethical conflicts at the bedside is compromised patient care. The author calls this framework the principlist paradigm and maintains that it blinds clinicians from seeing the full set of moral obligations they have to the patient and limits the range of options they see as available to navigate through ethical conflicts. Although it is important for the moral obligations it does recognize (e.g., those based on the principles of autonomy, beneficence, nonmaleficence, and justice), the principlist paradigm should not be used as the only moral template for case analysis. The author illustrates the paradigm's limitations with a clinical case study, in which the treating clinicians failed to recognize three important moral obligations to the patient: the obligation to express regret, the obligation to apologize, and the obligation to make amends. The failure to recognize these widely accepted moral obligations can have tragic consequences. The principlist paradigm undertrains clinicians for the complex ethical dilemmas they face in practice, and medical ethics educators need to rethink the tools they offer student clinicians to guide their ethical analysis. The author advocates a reexamination of this standard approach to teaching clinical ethics.     

Legal harmonization and reproductive tourism in Europe

Legislation of ethical issues illustrates the uneasy mix of ethics and politics. Although the majority has the political right to express its moral views in the law, a number of important ethical values like autonomy, tolerance and respect for other people's opinions urge the majority to take the minorities' position into account. Ignoring pluralism in society will inevitably lead to reproductive tourism. Although European legislation and harmonization in the domain of medically assisted reproduction is presented as a partial solution to this phenomenon, it is argued that European legislation should be avoided as much as possible. Regulation of these private ethical matters should be left to the national parliaments. A soft or compromise legislation will keep reproductive travelling to a minimum. Reproductive tourism is a safety valve that reduces moral conflict and expresses minimal recognition of the others' moral autonomy.     

Moral and ethical problems of pre-natal diagnosis

The moral and ethical problems resulting from application of pre-natal diagnosis are identified: abortion, questions about euthanasia for defective newborns, and the concept of genetic health. A holistic approach to ethical problems is presented that includes attention to both principles and consequences.     

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.     

Management of acutely bleeding patients who refuse blood transfusion

Patients who refuse blood transfusions yet require them for continued health present difficulties to physicians. In the elective setting, physicians and patients can calmly discuss benefits, risks, alternatives and referral to special centers that have a niche practice in bloodless medicine. Care of the acutely bleeding patient who objects to transfusion presents a uniquely challenging situation. Patients may refuse based upon general health considerations or deeply held religious beliefs. In the exsanguinating patient, lengthy conversations are not options nor are referrals to specialized centers. Management of the acutely bleeding transfusion objector is presented and highlights the medical, moral, ethical and legal issues physicians will find themselves confronted with. Surgical and pharmacological interventions that may be of benefit will also be discussed.     

Ethical issues concerning genetic testing and screening in public health

Genetic testing (predictive analysis that determines genetic alterations in individuals for clinical purposes) and screening (programs that identify persons within a subpopulation who may be at a higher risk for a genetic disease or condition) are increasingly utilized to promote and improve the public's health. The proliferate use of genetic testing and screening may improve public health outcomes, but it also implicates significant ethical, legal, and social concerns. Within the context of conflicting ethical values from the individual and public health perspectives, individual values such as informed consent and privacy and discrimination protections must be respected. Legal and ethical attempts to exceptionalize genetic tests and information (as compared to other health information) to protect privacy and prevent discrimination are well intended, but can also be unjust and impractical. Respect for individual ethical rights has limits. Principles of public health ethics justify voluntary genetic testing and screening and sharing of data for population-based health purposes. Thus, individual rights should not always trump the use of genetic tests or screening programs (or information derived therefrom) for legitimate public health purposes.     

If students are not customers, what are they?

The answers to questions about the relationship between faculty and students-including medical students-depend on an understanding of the nature of teaching and the underlying ethical principles of our society. The authors maintain that teaching is purposive, rational, communal, and moral. They assert that Western society is based on the values of liberal democracy and that the key ethical principles for the professions that are derived from those values are autonomy, standard of care, and respect for democratic institutions. There are three candidates for ethical models on which to base the relationship between students and faculty. Two of them (clientism and paternalism) the authors reject. The one that they favor (the fiduciary model) is based on mutual trust and respect, which both students and faculty have responsibilities to maintain. Using that model, the authors conclude that students are, in some aspects, customers of faculty. This student-centered approach is balanced by treating society and other faculty as customers as well. Pathologies in medical education attributed to clientism (such as an obsession with marks and overemphasis on memorization) existed well before medical students were purportedly being treated as customers; perhaps it is not the student who is "broken" but the system in which the student is made to function. Whether students are called customers, clients, knowledge workers, or simply students, faculty must involve them more in shaping their education and in dealing with enduring problems that profoundly affect their learning.     

Integrating spirituality and psychotherapy: ethical issues and principles to consider

Professional and scientific psychology appears to have rediscovered spirituality and religion during recent years, with a large number of conferences, seminars, workshops, books, and special issues in major professional journals on spirituality and psychology integration. The purpose of this commentary is to highlight some of the more compelling ethical principles and issues to consider in spirituality and psychology integration with a focus on psychotherapy. This commentary will use the American Psychological Association's (2002) Ethics Code and more specifically, the RRICC model of ethics that readily applies to various mental health ethics codes across the world. The RRICC model highlights the ethical values of respect, responsibility, integrity, competence, and concern. Being thoughtful about ethical principles and possible dilemmas as well as getting appropriate training and ongoing consultation can greatly help the professional better navigate these challenging waters.     

Ethical and Professional Issues in the Implementation of Population-Level Parenting Interventions

This article discusses various ethical and professional issues associated with the implementation of a public health approach to the implementation of parenting interventions. The Triple P System Population Trial in the United States and the Every Family Initiative in Australia both employ the Triple P–Positive Parenting Program as a multilevel public health intervention aimed at strengthening parenting and family support community-wide. Implications of this experience are discussed for the rollout of large-scale parenting programs, with particular attention to a self-regulation framework that is useful in dealing with professional issues. Examples drawn from these initiatives illustrate the interaction between ethical and professional issues and the broader sociopolitical and cultural context within which an intervention is delivered. A sampling of issues includes multidisciplinary and competitive work environments, ensuring adequate population reach, promotion of accurate program information, anticipating potential barriers, and addressing organizational considerations.     

Clarifying assent in pediatric research

Assent is a relatively young term in research ethics, but became an often mentioned ethical requirement in current pediatric research guidelines. Also, the European Society of Human Genetics considers assent an important condition for the inclusion of children in biobanks. However, although many emphasize the importance of assent, few explain how they understand the concept and few have elaborated on the underlying grounds. In this paper, we will discuss the different underlying ethical principles of assent. In the first category, assent appears to be derived from informed consent. This understanding is grounded in respect for autonomy and protection against harm. We conclude that this interpretation of assent is not of added value as a majority of children cannot be considered competent to make autonomous decisions. In addition, other safeguards are more appropriate to protect children against harm. The grounds from the second category can be classified as engagement grounds. These grounds do justice to the specifics of childhood and are of added value. Furthermore, we argue that it follows that both the content and the process of assent should be adjusted to the individual child. This can be referred to as personalized assent. Personalized assent is an appeal to the moral responsibility and integrity of the researcher.     

Quality of medicines in resource-limited settings: need for ethical guidance

The quality of medicines is generally adequately assured by manufacturers and regulatory authorities for well-resourced settings, while the implementation of existing quality standards is challenged in many low- and middle-income countries. This situation of multiple pharmaceutical standards raises the question whether it could ever be ethically justified to compromise on the quality assurance of medicines depending on what individuals, communities, or societies can afford. In this paper, we contend that ethically, any unjustified exceptions to medicines’ quality assurance represents a violation of the principles of beneficence and non-maleficence. Exceptions are only acceptable in exceptional and temporary circumstances, if based on a meaningful quality risk assessment, guided by a rigorous ethical framework built on the principles of independence, technical competence, transparency, and accountability. We also discuss how such exceptional and temporary circumstances should be defined/justified. Finally, we propose that empirical bioethics should acknowledge the existence of these dilemmas in public health, and help to build a normative approach to dealing with them. Ideally, an international group of experts in quality assurance/regulatory affairs and health ethicists should be set up to take up this topic and formulate a Guide to Ethical Principles of Quality Assurance of Medical Products.     

Mobile eHealth interventions for obesity: a timely opportunity to leverage convergence trends

Obesity is often cited as the most prevalent chronic health condition and highest priority public health problem in the United States. There is a limited but growing body of evidence suggesting that mobile eHealth behavioral interventions, if properly designed, may be effective in promoting and sustaining successful weight loss and weight maintenance behavior changes. This paper reviews the current literature on the successes and failures of public health, provider-administered, and self-managed behavioral health interventions for weight loss. The prevailing theories of health behavior change are discussed from the perspective of how this knowledge can serve as an evidence base to inform the design of mobile eHealth weight loss interventions. Tailored informational interventions, which, in recent years, have proven to be the most effective form of conventional health behavior intervention for weight loss, are discussed. Lessons learned from the success of conventional tailored informational interventions and the early successes of desktop computer-assisted self-help weight management interventions are presented, as are design principles suggested by Social Cognitive Theory and the Social Marketing Model. Relevant computing and communications technology convergence trends are also discussed. The recent trends in rapid advancement, convergence, and public adoption of Web-enabled cellular telephone and wireless personal digital assistant (PDA) devices provide timely opportunities to deliver the mass customization capabilities, reach, and interactivity required for the development, administration, and adoption of effective population-level eHealth tailored informational interventions for obesity.     

Psychologists in Long-Term Care: Overview of Practice and Public Policy: Introduction to the Special Series

With the overall aging of the population and the concomitant need for the provision of mental health care for older adults, professional psychology in long-term care has come of age. Psychologists are now increasingly practicing in such traditional long-term care settings as nursing homes and in less traditional ones such as rehabilitation units, day centers, partial hospitaliza-tion programs, and hospices. The practice of psychology in long-term care is strongly influenced by public policy issues relating to Medicare, such as conditions of reimbursement, the rise of managed Medicare, and the continued disparity between payment for mental health and medical diagnoses. Ceropsychologists must be flexible in the form of their healthcare delivery to continue to provide quality services. The following articles in this special section on long-term care summarize the research on assessment and interventions for long-term care patients, outline the training opportunities available, and provide a decision-making framework for the common professional ethical/legal issues encountered in long-term care settings.