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Benzinger L, Ursin F, Balke WT, Kacprowski T, Salloch S. Should Artificial Intelligence be used to support clinical ethical decision-making? A systematic review of reasons. BMC Med Ethics 2023; 24:48. [PMID: 37415172 PMCID: PMC10327319 DOI: 10.1186/s12910-023-00929-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Healthcare providers have to make ethically complex clinical decisions which may be a source of stress. Researchers have recently introduced Artificial Intelligence (AI)-based applications to assist in clinical ethical decision-making. However, the use of such tools is controversial. This review aims to provide a comprehensive overview of the reasons given in the academic literature for and against their use. METHODS PubMed, Web of Science, Philpapers.org and Google Scholar were searched for all relevant publications. The resulting set of publications was title and abstract screened according to defined inclusion and exclusion criteria, resulting in 44 papers whose full texts were analysed using the Kuckartz method of qualitative text analysis. RESULTS Artificial Intelligence might increase patient autonomy by improving the accuracy of predictions and allowing patients to receive their preferred treatment. It is thought to increase beneficence by providing reliable information, thereby, supporting surrogate decision-making. Some authors fear that reducing ethical decision-making to statistical correlations may limit autonomy. Others argue that AI may not be able to replicate the process of ethical deliberation because it lacks human characteristics. Concerns have been raised about issues of justice, as AI may replicate existing biases in the decision-making process. CONCLUSIONS The prospective benefits of using AI in clinical ethical decision-making are manifold, but its development and use should be undertaken carefully to avoid ethical pitfalls. Several issues that are central to the discussion of Clinical Decision Support Systems, such as justice, explicability or human-machine interaction, have been neglected in the debate on AI for clinical ethics so far. TRIAL REGISTRATION This review is registered at Open Science Framework ( https://osf.io/wvcs9 ).
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Affiliation(s)
- Lasse Benzinger
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Frank Ursin
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Wolf-Tilo Balke
- Institute for Information Systems, TU Braunschweig, Braunschweig, Germany
| | - Tim Kacprowski
- Division Data Science in Biomedicine, Peter L. Reichertz Institute for Medical Informatics of Technische Universität Braunschweig and Hannover Medical School, Braunschweig, Germany
- Braunschweig Integrated Centre for Systems Biology (BRICS), TU Braunschweig, Braunschweig, Germany
| | - Sabine Salloch
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Moodley K, Kabanda SM, Kleinsmidt A, Obasa AE. COVID-19 underscores the important role of Clinical Ethics Committees in Africa. BMC Med Ethics 2021; 22:131. [PMID: 34563181 PMCID: PMC8465788 DOI: 10.1186/s12910-021-00696-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 08/13/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has magnified pre-existing challenges in healthcare in Africa. Long-standing health inequities, embedded in the continent over centuries, have been laid bare and have raised complex ethical dilemmas. While there are very few clinical ethics committees (CECs) in Africa, the demand for such services exists and has increased during the COVID-19 pandemic. The views of African healthcare professionals or bioethicists on the role of CECs in Africa have not been explored or documented previously. In this study, we aim to explore such perspectives, as well as the challenges preventing the establishment of CECs in Africa. METHODS Twenty healthcare professionals and bioethicists from Africa participated in this qualitative study that utilized in-depth semi-structured interviews with open-ended questions. Themes were identified through thematic analysis of interviews and open-ended responses. RESULTS Kenya and South Africa are the only countries on the continent with formal established CECs. The following themes emerged from this qualitative study: (1) Lack of formal CECs and resolution of ethical dilemmas; (2) Role of CECs during COVID-19; (3) Ethical dilemmas presented to CECs pre-COVID-19; (4) Lack of awareness of CECs; (5) Lack of qualified bioethicists or clinical ethicists; (6) Limited resources to establish CECs; (7) Creating interest in CECs and networking. CONCLUSIONS This study illustrates the importance of clinical ethics education among African HCPs and bioethicists, more so now when COVID-19 has posed a host of clinical and ethical challenges to public and private healthcare systems. The challenges and barriers identified will inform the establishment of CECs or clinical ethics consultation services (CESs) in the region. The study results have triggered an idea for the creation of a network of African CECs.
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Affiliation(s)
- Keymanthri Moodley
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Siti Mukaumbya Kabanda
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Anita Kleinsmidt
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Adetayo Emmanuel Obasa
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Maluwa VM, Maluwa AO, Mwalabu G, Msiska G. Assessment of ethical competence among clinical nurses in health facilities. Nurs Ethics 2021; 29:181-193. [PMID: 34346258 DOI: 10.1177/09697330211010259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ethical competence in nursing practice helps clinical nurses to think critically, analyse issues, make ethical decisions, solve ethical problems and behave ethically in their daily work. Thus, ethical competence contributes to the promotion of high-quality care. However, studies on ethical competence in Malawi are scanty. OBJECTIVES The aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi. METHODOLOGY A cross-sectional survey was conducted in four selected hospitals in Malawi with a sample of 271 clinical nurses. Data were collected using self-administered questionnaires, which included a Moral Competence Scale for Home Care Nurses. Descriptive statistics and logistic regression were computed for the dataset using STATA version 12.0. ETHICAL CONSIDERATION The study protocol complied with all ethical requirements and was approved by the College of Medicine Research Ethics Committee under the University of Malawi. RESULTS The clinical nurses in Malawi are ethically competent. However, there is a significantly high number (p < 0.05) of nurses 57% (n = 135) with low ethical competence. There was no significant association between respondents' demographic variables and level of ethical competence (p > 0.05). Three determinants of high ethical competence level (strong will, judgement skills and recognition of discrepancy of intention) were identified through a reduced model after stepwise logistic regression analysis. Furthermore, results show that indicators of ethical competence include caring, confidentiality and observance of nurses dressing code. The study has also confirmed that the Moral Competence Scale for Home Care Nurses is a reliable tool to assess ethical competence in low-resource settings. CONCLUSION The majority of nurses who completed the survey had low ethical competence. However, clinical nurses with high ethical competence level are required to competently manage complex ethical challenges in health facilities. Strategies for enhancing ethical competence such as continuing ethics education, establishment of ethics committees and provision of supportive supervision are recommended to enable nurses in Malawi attain a high level of ethical competence.
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Van Baarle EM, Potma MC, van Hoek MEC, Hartman LA, Molewijk BAC, van Gurp JLP. Lessons learned from implementing a responsive quality assessment of clinical ethics support. BMC Med Ethics 2019; 20:78. [PMID: 31675970 PMCID: PMC6824048 DOI: 10.1186/s12910-019-0418-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Various forms of Clinical Ethics Support (CES) have been developed in health care organizations. Over the past years, increasing attention has been paid to the question of how to foster the quality of ethics support. In the Netherlands, a CES quality assessment project based on a responsive evaluation design has been implemented. CES practitioners themselves reflected upon the quality of ethics support within each other's health care organizations. This study presents a qualitative evaluation of this Responsive Quality Assessment (RQA) project. METHODS CES practitioners' experiences with and perspectives on the RQA project were collected by means of ten semi-structured interviews. Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of the decisions. RESULTS The main findings illustrate the relevance of the RQA with regard to fostering the quality of CES by connecting to context specific issues, such as gaining support from upper management and to solidify CES services within health care organizations. Based on their participation in the RQA, CES practitioners perceived a number of changes regarding CES in Dutch health care organizations after the RQA: acknowledgement of the relevance of CES for the quality of care; CES practices being more formalized; inspiration for developing new CES-related activities and more self-reflection on existing CES practices. CONCLUSIONS The evaluation of the RQA shows that this method facilitates an open learning process by actively involving CES practitioners and their concrete practices. Lessons learned include that "servant leadership" and more intensive guidance of RQA participants may help to further enhance both the critical dimension and the learning process within RQA.
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Affiliation(s)
- Eva M Van Baarle
- Netherlands Defense Academy, Breda, the Netherlands. .,Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands.
| | - Marieke C Potma
- Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands.,Department of Care Ethics, University of Humanistic Studies (UvH), Utrecht, the Netherlands
| | - Maria E C van Hoek
- Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands
| | - Laura A Hartman
- Amsterdam UMC, VU University Medical Centre (VUmc), EMGO+, Amsterdam, the Netherlands
| | - Bert A C Molewijk
- Amsterdam UMC, VU University Medical Centre (VUmc), EMGO+, Amsterdam, the Netherlands.,Centre for Medical Ethics at the University of Oslo (UIO), Oslo, Norway
| | - Jelle L P van Gurp
- Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands.,IQ Healthcare Department, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
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Gschwandtner G, Dinges S, Kemetmüller E. Unterstützungsbedarf bei moralisch-ethischer Entscheidungsfindung erheben und organisieren. Konzeptuelle Aspekte und Strategien für ein Erhebungsinstrument zur Ethikberatung im Kontext der Pflege. Ethik Med 2019. [DOI: 10.1007/s00481-019-00542-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fuscaldo G, Cadwell M, Wallis K, Fry L, Rogers M. Developing clinical ethics support for an Australian Health Service: A survey of clinician's experiences and views. AJOB Empir Bioeth 2019; 10:44-54. [PMID: 30908109 DOI: 10.1080/23294515.2019.1576800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND International developments suggest that providing clinical ethics services to help clinicians negotiate ethical issues that arise in clinical practice is beneficial and reflects best practice in promoting high ethical standards and patient-centered care. The aim of this study was to explore the needs and experiences of clinical staff members to inform the development of future clinical ethics support. METHODS Health professionals at a large regional health service completed an online survey containing questions about the frequency of ethical and legal issues encountered in clinical practice, the type of situations that gave rise to the ethical and/or legal uncertainty or concern, how clinicians currently address these issues, and what support would be welcome. RESULTS The survey was completed by 369 staff members, including 61% with more than 10 years in the profession and 51% in nursing/midwifery. Two-thirds (66%) indicated they often considered ethical implications of their clinical decisions, and half (49%) often considered the legal implications. More than half (58%) were often/occasionally concerned about the ethically right thing to do. Patient requests for borderline treatment (47%), staff disagreements about patient care (48%), and patients declining recommended treatment (54%) were the most frequent reasons given for ethical or legal uncertainty. Sixty-nine percent of respondents indicated that the way their department addressed ethical issues could be improved and 85% agreed that there is a need for more discussion on ethical issues. The majority (82%) of respondents had encountered ethically challenging clinical situations where additional support would have helped. Common approaches to issues were discussion with colleagues/supervisor (91.1%), discussion at handover/group forums (50.8%), and consultation with guidelines/protocols (60.9%). CONCLUSIONS A majority of clinical staff members surveyed have encountered ethically/legally challenging cases daily for which they have often sought additional advice. This study indicates that many clinical staff members would welcome some form of additional clinical ethics support including advice and education.
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Affiliation(s)
- Giuliana Fuscaldo
- a Research Directorate , University Hospital Geelong, Barwon Health , Geelong , Australia
| | - Melissa Cadwell
- a Research Directorate , University Hospital Geelong, Barwon Health , Geelong , Australia
| | - Kristin Wallis
- a Research Directorate , University Hospital Geelong, Barwon Health , Geelong , Australia
| | - Lisa Fry
- a Research Directorate , University Hospital Geelong, Barwon Health , Geelong , Australia
| | - Margaret Rogers
- a Research Directorate , University Hospital Geelong, Barwon Health , Geelong , Australia.,b School of Medicine , Deakin University , Melbourne , Victoria , Australia
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Koskenvuori J, Numminen O, Suhonen R. Ethical climate in nursing environment: A scoping review. Nurs Ethics 2017; 26:327-345. [DOI: 10.1177/0969733017712081] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In the past two decades, interest in the concept of ethical climate and in its research has increased in healthcare. Ethical climate is viewed as a type of organizational work climate, and defined as the shared perception of ethically correct behavior, and how ethical issues should be handled in the organization. Ethical climate as an important element of nursing environment has been the focus of several studies. However, scoping reviews of ethical climate research in nursing have not been conducted to guide further research in this area. Objective: The purpose of this scoping review is to describe and analyze studies focusing on ethical climate in nursing environment to elicit an overall picture of the research in this field. Methods: A scoping review methodology guided by Arksey and O’Malley and Levac et al. was used. Studies were identified by conducting electronic searches on PubMed/MEDLINE, CINAHL, Web of Science Core Collection, PsycINFO, and Scopus and Philosophers’ Index databases. Of 1051 citations, 56 articles matched the inclusion criteria. Ethical considerations: This study was conducted according to good scientific guidelines. Findings: Ethical climate is a topical research area which has been explored with different methods and outcomes, in different environments, and has mainly been perceived positively. The focus of the studies was on finding associations between ethical climate and work-related factors such as job satisfaction, moral distress, and turnover intentions. Methodologically, research was rather homogeneous using quantitative, descriptive, and correlative research designs. Conclusion: Novel perspectives and more diverse methodological approaches paying attentions to issues affecting generalizability of the findings could expand our knowledge in this area.
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