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Molldrem S, Smith AKJ, Subrahmanyam V. Toward Consent in Molecular HIV Surveillance?: Perspectives of Critical Stakeholders. AJOB Empir Bioeth 2024; 15:66-79. [PMID: 37768111 DOI: 10.1080/23294515.2023.2262967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND The emergence of molecular HIV surveillance (MHS) and cluster detection and response (CDR) programs as key features of the United States (US) HIV strategy since 2018 has caused major controversies. HIV surveillance programs that re-use individuals' routinely collected clinical HIV data do not require consent on the basis that the public benefit of these programs outweighs individuals' rights to opt out. However, criticisms of MHS/CDR have questioned whether expanded uses of HIV genetic sequence data for prevention reach beyond traditional public health ethics frameworks. This study aimed to explore views on consent within MHS/CDR among critical stakeholders. METHODS In 2021 we interviewed 26 US HIV stakeholders who identified as being critical or concerned about the rollout of MHS/CDR. Stakeholders included participants belonging to networks of people living with HIV, other advocates, academics, and public health professionals. This analysis focused on identifying the range of positions among critical and concerned stakeholders on consent affordances, opt-outs, how to best inform people living with HIV about how data about them are used in public health programs, and related ethical issues. RESULTS Participants were broadly supportive of introducing some forms of consent into MHS/CDR. However, they differed on the specifics of implementing consent. While some participants did not support introducing consent affordances, all supported the idea that people living with HIV should be informed about how HIV surveillance and prevention is conducted and how individuals' data are used. CONCLUSIONS MHS/CDR has caused sustained controversy. Among critical stakeholders, consent is generally desirable but contested, although the right for people living with HIV to be informed was centrally supported. In an era of big data-driven public health interventions and routine uses of HIV genetic sequence data in surveillance and prevention, CDC and other agencies should revisit public health ethics frameworks and consider the possibility of consent processes.
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Affiliation(s)
- Stephen Molldrem
- Institute for Bioethics and Health Humanities, The University of Texas Medical Branch, Galveston, TX, USA
| | - Anthony K J Smith
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Vishnu Subrahmanyam
- Institute for Bioethics and Health Humanities, The University of Texas Medical Branch, Galveston, TX, USA
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McCradden M, Hui K, Buchman DZ. Evidence, ethics and the promise of artificial intelligence in psychiatry. JOURNAL OF MEDICAL ETHICS 2023; 49:573-579. [PMID: 36581457 PMCID: PMC10423547 DOI: 10.1136/jme-2022-108447] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/29/2022] [Indexed: 05/20/2023]
Abstract
Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine's understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a potential epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry.
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Affiliation(s)
- Melissa McCradden
- Joint Centre for Bioethics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Bioethics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Genetics & Genome Biology, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Katrina Hui
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Coghlan S, Leins K, Sheldrick S, Cheong M, Gooding P, D'Alfonso S. To chat or bot to chat: Ethical issues with using chatbots in mental health. Digit Health 2023; 9:20552076231183542. [PMID: 37377565 PMCID: PMC10291862 DOI: 10.1177/20552076231183542] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
This paper presents a critical review of key ethical issues raised by the emergence of mental health chatbots. Chatbots use varying degrees of artificial intelligence and are increasingly deployed in many different domains including mental health. The technology may sometimes be beneficial, such as when it promotes access to mental health information and services. Yet, chatbots raise a variety of ethical concerns that are often magnified in people experiencing mental ill-health. These ethical challenges need to be appreciated and addressed throughout the technology pipeline. After identifying and examining four important ethical issues by means of a recognised ethical framework comprised of five key principles, the paper offers recommendations to guide chatbot designers, purveyers, researchers and mental health practitioners in the ethical creation and deployment of chatbots for mental health.
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Affiliation(s)
- Simon Coghlan
- School of Computing and Information Systems, The University of Melbourne
| | - Kobi Leins
- School of Computing and Information Systems, The University of Melbourne
- Department of War Studies, King's College London
| | - Susie Sheldrick
- School of Computing and Information Systems, The University of Melbourne
| | - Marc Cheong
- School of Computing and Information Systems, The University of Melbourne
| | | | - Simon D'Alfonso
- School of Computing and Information Systems, The University of Melbourne
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Molldrem S, Smith AKJ, McClelland A. Predictive analytics in HIV surveillance require new approaches to data ethics, rights, and regulation in public health. CRITICAL PUBLIC HEALTH 2022. [DOI: 10.1080/09581596.2022.2113035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Stephen Molldrem
- Bioethics and Health Humanities, The University of Texas Medical Branch at Galveston, Texas, United States
| | - Anthony K J Smith
- Centre for Social Research in Health, UNSW Sydney, New South Wales, Australia
| | - Alexander McClelland
- Institute of Criminology and Criminal Justice, Carleton University, Ottawa, Ontario, Canada
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Gooding PM, Clifford DM. Semi-Automated Care: Video-Algorithmic Patient Monitoring and Surveillance in Care Settings. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:541-546. [PMID: 34787791 DOI: 10.1007/s11673-021-10139-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/03/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Piers M Gooding
- Melbourne Law School, University of Melbourne, 185 Pelham Street, Parkville, VIC, 3052, Australia.
| | - David M Clifford
- Melbourne Law School, University of Melbourne, 185 Pelham Street, Parkville, VIC, 3052, Australia
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"With a PICC line, you never miss": The role of peripherally inserted central catheters in hospital care for people living with HIV/HCV who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103438. [PMID: 34593288 DOI: 10.1016/j.drugpo.2021.103438] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND People who use drugs (PWUD), and especially those who inject drugs, are at increased risk of acquiring bloodborne infections (e.g., HIV and HCV), experiencing drug-related harms (e.g., abscesses and overdose), and being hospitalized and requiring inpatient parenteral antibiotic therapy delivered through a peripherally inserted central catheter (PICC). The use of PICC lines with PWUD is understood to be a source of tension in hospital settings but has not been well researched. Drawing on theoretical and analytic insights from "new materialism," we consider the assemblage of sociomaterial elements that inform the use of PICCs. METHODS This paper draws on n = 50 interviews conducted across two related qualitative research projects within a program of research about the impact of substance use on hospital admissions from the perspective of healthcare providers (HCPs) and people living with HIV/HCV who use drugs. This paper focuses on data about PICC lines collected in both studies. RESULTS The decision to provide, maintain, or remove a PICC is based on a complex assemblage of factors (e.g., infections, bodies, drugs, memories, relations, spaces, temporalities, and contingencies) beyond whether parenteral intravenous antibiotic therapy is clinically indicated. HCPs expressed concerns about the risk posed by past, current, and future drug use, and contact with non-clinical spaces (e.g., patient's homes and the surrounding community), with some opting for second-line treatments and removing PICCs. The majority of PWUD described being subjected to threats of discharge and increased monitoring despite being too ill to use their PICC lines during past hospital admissions. A subset of PWUD reported using their PICC lines to inject drugs as a harm reduction strategy, and a subset of HCPs reported providing harm reduction-centred care. CONCLUSION Our analysis has implications for theorizing the role of PICC lines in the care of PWUD and identifies practical guidance for engaging them in productive and non-judgemental discussions about the risks of injecting into a PICC line, how to do it safely, and about medically supported alternatives.
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Molldrem S, Hussain MI, McClelland A. Alternatives to sharing COVID-19 data with law enforcement: Recommendations for stakeholders. Health Policy 2020; 125:135-140. [PMID: 33390280 PMCID: PMC7648186 DOI: 10.1016/j.healthpol.2020.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/14/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022]
Abstract
In jurisdictions around the world, police have been enforcing COVID-19-related measures. Researchers and civil society agree: criminalizing illnesses does more harm than good. We describe two North American jurisdictions that share coronavirus data with police. COVID-19 data policies will likely have broad ramifications for health data policy. We present seven concrete alternatives to sharing health data with law enforcement.
During the COVID-19 pandemic, in some jurisdictions, police have become involved in enforcing coronavirus-related measures. Relatedly, several North American jurisdictions have established COVID-19 data sharing protocols with law enforcement. Research across a range of fields has demonstrated that involving police in matters of public health disproportionately impacts the most vulnerable and does more harm than good. This is reflected in the consensus against COVID-19 criminalization that has emerged among civil society organizations focused on HIV, human rights, and harm reduction. The European Data Protection Board has also released guidelines against re-uses of COVID-19 data for law enforcement purposes. This article offers an overview of the harms of criminalizing illnesses and strategies for health stakeholders to seek alternatives to sharing COVID-19 data with police agencies while facilitating interoperability with healthcare first responders. It also presents case studies from two North American jurisdictions – Ontario and Minnesota – that have established routine COVID-19 data sharing with police. We recommended seven alternatives, including designating COVID-19 data as sensitive and implementing segmented interoperability with first responder agencies. These guidelines can help ensure that health information technology platforms do not become vehicles for the criminalization of COVID-19, and that health data stay within the health system.
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Affiliation(s)
- Stephen Molldrem
- Department of Anthropology, University of California, Irvine, Irvine, CA, USA.
| | - Mustafa I Hussain
- Department of Informatics, University of California, Irvine, Irvine, CA, USA
| | - Alexander McClelland
- Institute of Criminology and Criminal Justice, Carleton University, Ottawa, ON, Canada
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Klugman CM. What is a Bioethics of the Oppressed in the Age of COVID-19? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:29-31. [PMID: 33016831 DOI: 10.1080/15265161.2020.1806397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Molldrem S, Smith AKJ. Reassessing the Ethics of Molecular HIV Surveillance in the Era of Cluster Detection and Response: Toward HIV Data Justice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:10-23. [PMID: 32945756 DOI: 10.1080/15265161.2020.1806373] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
In the United States, clinical HIV data reported to surveillance systems operated by jurisdictional departments of public health are re-used for epidemiology and prevention. In 2018, all jurisdictions began using HIV genetic sequence data from clinical drug resistance tests to identify people living with HIV in "clusters" of others with genetically similar strains. This is called "molecular HIV surveillance" (MHS). In 2019, "cluster detection and response" (CDR) programs that re-use MHS data became the "fourth pillar" of the national HIV strategy. Public health re-uses of HIV data are done without consent and are a source of concern among stakeholders. This article presents three cases that illuminate bioethical challenges associated with re-uses of clinical HIV data for public health. We focus on evidence-base, risk-benefit ratio, determining directionality of HIV transmission, consent, and ethical re-use. The conclusion offers strategies for "HIV data justice." The essay contributes to a "bioethics of the oppressed."
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Della Croce Y. Conceptualizing a Bioethics of the Oppressed: Oppression, Structure, and Inclusion. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:42-44. [PMID: 33016821 DOI: 10.1080/15265161.2020.1806386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Martani A, Geneviève LD, Poppe C, Casonato C, Wangmo T. Digital pills: a scoping review of the empirical literature and analysis of the ethical aspects. BMC Med Ethics 2020; 21:3. [PMID: 31914995 PMCID: PMC6950823 DOI: 10.1186/s12910-019-0443-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 12/27/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Digital Pills (DP) are an innovative drug-device technology that permits to combine traditional medications with a monitoring system that automatically records data about medication adherence as well as patients' physiological data. Although DP are a promising innovation in the field of digital medicine, their use has also raised a number of ethical concerns. These ethical concerns, however, have been expressed principally from a theoretical perspective, whereas an ethical analysis with a more empirically oriented approach is lacking. There is also a lack of clarity about the empirical evidence available concerning the application of this innovative digital medicine. METHODS To map the studies where DP have been tested on patients and discuss the ethically relevant issues evident therein, we performed a scoping review of the empirical literature concerning DP. RESULTS Our search allowed us to identify 18 papers reporting on studies where DP were tested on patients. These included studies with different designs and involving patients with a variety of conditions. In the empirical literature, a number of issues with ethical relevance were evident. At the patient level, the ethical issues include users' interaction with DP, personal sphere, health-related risks and patients' benefits. At the provider level, ethically relevant issues touch upon the doctor-patient relationship and the question of data access. At the societal level, they concern the benefits to society, the quality of evidence and the dichotomy device-medicine. CONCLUSIONS We conclude that evidence concerning DP is not robust and that more research should be performed and study results made available to evaluate this digital medicine. Moreover, our analysis of the ethically relevant aspects within empirical literature underscores that there are concrete and specific open questions that should be tackled in the ethical discussion about this new technological solution.
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Affiliation(s)
- Andrea Martani
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, Basel, Switzerland
| | - Lester Darryl Geneviève
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, Basel, Switzerland
| | - Christopher Poppe
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, Basel, Switzerland
| | | | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, Basel, Switzerland
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Gooding P. Mapping the rise of digital mental health technologies: Emerging issues for law and society. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 67:101498. [PMID: 31785726 DOI: 10.1016/j.ijlp.2019.101498] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/30/2019] [Accepted: 08/29/2019] [Indexed: 06/10/2023]
Abstract
The use of digital technologies in mental health initiatives is expanding, leading to calls for clearer legal and regulatory frameworks. However, gaps in knowledge about the scale and nature of change impede efforts to develop responsible public governance in the early stages of what may be the mass uptake of 'digital mental health technologies'. This article maps established and emerging technologies in the mental health context with an eye to locating major socio-legal issues. The paper discusses various types of technology, including those designed for information sharing, communication, clinical decision support, 'digital therapies', patient and/or population monitoring and control, bio-informatics and personalised medicine, and service user health informatics. The discussion is organised around domains of use based on the actors who use the technologies, and those on whom they are used. These actors go beyond mental health service users and practitioners/service providers, and include health and social system or resource managers, data management services, private companies that collect personal data (such as major technology corporations and data brokers), and multiple government agencies and private sector actors across diverse fields of criminal justice, education, and so on. The mapping exercise offers a starting point to better identify cross-cutting legal, ethical and social issues at the convergence of digital technology and contemporary mental health practice.
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Affiliation(s)
- Piers Gooding
- Melbourne Social Equity Institute & Melbourne Law School, University of Melbourne, 3010, Australia.
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Klugman CM, Dunn LB, Schwartz J, Cohen IG. Response to Open Peer Commentaries on "The Ethics of Smart Pills and Self-Acting Devices: Autonomy, Truth-Telling, and Trust at the Dawn of Digital Medicine". THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:W4-W7. [PMID: 30339081 DOI: 10.1080/15265161.2018.1514427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
| | | | | | - I Glenn Cohen
- d Petrie-Flom Center for Health Law Policy Biotechnology and Bioethics of Harvard Law School
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