The Problem with Using Medical Boards to Regulate Misinformation

Some stakeholders called on medical boards to sanction physicians for spreading misinformation during COVID-19 and discussing off-label medications. In 2022, California passed AB 2098, which classifies physician dissemination of misinformation as unprofessional conduct subject to discipline by the state medical board. This article describes the purpose and function of state medical boards, the law relating to off-label prescribing, and why using medical boards to discipline physicians for discussing controversial opinions exceeds the traditional role of state medical boards. Though physicians do have a duty to provide accurate information to the public, defining misinformation is difficult and poses five distinct problems. Although California's law was repealed, this article asserts that disciplining physicians for disseminating misinformation could pose Constitutional concerns, hinder physicians' ability to practice medicine, or suppress information that is important to the public interest.

AI and machine learning ethics, law, diversity, and global impact

Artificial intelligence (AI) and its machine learning (ML) algorithms are offering new promise for personalized biomedicine and more cost-effective healthcare with impressive technical capability to mimic human cognitive capabilities. However, widespread application of this promising technology has been limited in the medical domain and expectations have been tampered by ethical challenges and concerns regarding patient privacy, legal responsibility, trustworthiness, and fairness. To balance technical innovation with ethical applications of AI/ML, developers must demonstrate the AI functions as intended and adopt strategies to minimize the risks for failure or bias. This review describes the new ethical challenges created by AI/ML for clinical care and identifies specific considerations for its practice in medicine. We provide an overview of regulatory and legal issues applicable in Europe and the United States, a description of technical aspects to consider, and present recommendations for trustworthy AI/ML that promote transparency, minimize risks of bias or error, and protect the patient well-being.

Eight Strategies to Engineer Acceptance of Human Germline Modifications

Until recently, scientific consensus held firm that genetically manipulated embryos created through methods including Mitochondrial Replacement Therapy or human germline genome editing should not be used to initiate a pregnancy. In countries that have relevant laws pertaining to heritable human germline modifications, the vast majority prohibit or restrict this practice. In the last several years, scholars have observed a transformation of scientific and policy restrictions with insistent calls for creating a regulatory pathway. Multiple stakeholders highlight the role of social consensus and public engagement for governance of heritable human germline modifications. However, in the drive to gain public acceptance and lift restrictions, some proponents provide distorted or misleading narratives designed to influence public perception and incrementally shift the consensus. This article describes eight discrete strategies that proponents employ to influence framing, sway public opinion, and revise policymaking of human germline modifications in a manner that undermines honest engagement.

What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics.

The Nuffield Council's green light for genome editing human embryos defies fundamental human rights law

In July 2018, the Nuffield Council on Bioethics released the report Genome editing and human reproduction: Social and ethical issues, concluding that human germline modification of human embryos for implantation is not 'morally unacceptable in itself' and could be ethically permissible in certain circumstances once the risks of adverse outcomes have been assessed and the procedure appears 'reasonably safe'. The Nuffield Council set forth two main principles governing anticipated uses and envisions applications that may include health enhancements as a public health measure. This essay provides a critique of three aspects in the Nuffield Council's Report: its presumption of therapeutic efficacy, its inflation of parental rights to create a certain type of child, and its reliance on a specially commissioned report that appears to distort key definitions in international law.

Geneva Statement on Heritable Human Genome Editing: The Need for Course Correction

As public interest advocates, policy experts, bioethicists, and scientists, we call for a course correction in public discussions about heritable human genome editing. Clarifying misrepresentations, centering societal consequences and concerns, and fostering public empowerment will support robust, global public engagement and meaningful deliberation about altering the genes of future generations.

The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act

BACKGROUND

Since the passage of the Patient Self-Determination Act, numerous policy mandates and institutional measures have been implemented. It is unknown to what extent those measures have affected end-of-life care, particularly with regard to the do-not-resuscitate (DNR) order.

METHODS

Retrospective cohort study to assess associations of the frequency and timing of DNR orders with advance directive status, patient demographics, physician's specialty and extent of documentation of discussion on end-of-life care.

RESULTS

DNR orders were more frequent for patients on a medical service than on a surgical service (77.34% vs 64.20%, p = 0.02) and were made earlier in the hospital stay for medicine than for surgical patients (adjusted mean ratio of time from DNR orders to death versus total length of stay 0.30 for internists vs 0.21 for surgeons, p = 0.04). 22.18% of all patients had some form of an advance directive in their chart, yet this variable had no impact on the frequency or timing of DNR ordering. Documentation of DNR discussion was significantly associated with the frequency of DNR orders and the time from DNR to death (2.1 days with no or minimal discussion vs 2.8 days with extensive discussion, p<0.01).

CONCLUSIONS

The physician's specialty continues to have a significant impact on the frequency and timing of DNR orders, while advance directive status still has no measurable impact. Additionally, documentation of end-of-life discussions is significantly associated with varying DNR ordering rates and timing.

DNR patterns in cancer patients (pts) 16 years after the Patient Self Determination Act (PSDA)

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Background: In 1991, the PSDA required institutions receiving federal funding to inform pts about the right to refuse life prolonging treatments such as CPR. Studies conducted around 1991 suggest that most DNR orders are written by oncologists less than 3 days prior to death in hospitalized pts, raising ethical concerns. 16 years later, are oncology clinicians writing DNR orders earlier in cancer pts’ hospital course compared to non-cancer pts? Methods: We conducted a chart review of 284 of the 296 total adult deaths during 2005 at Indiana University Hospital. Demographic, diagnostic, and attending service info was collected from hospital billing records. Pts’ DNR status, timing of DNR orders, and presence of a written advanced directive (AD) were assessed through chart review. Results: 76 of 284 (26.8%) patients had cancer diagnoses. Of these, 59 had documented DNR orders. There was no difference in presence or absence of DNR orders at the time of death for cancer vs. non-cancer pts (77.6 vs 72.7%, p=0.35). Mean time from writing of the DNR order to death was 3.51 ± 4.61 days for cancer pts compared to 3.26 ±3.81 days for non-cancer pts (p=0.40), however, the majority of DNR orders written by oncologists were written less than 2 days prior to death. We calculated a ratio of the time between DNR order writing and death to the overall length of stay for cancer and non-cancer pts, excluding pts with very short lengths of stay ( = 5 days). In univariate analyses, this ratio trended toward statistical significance (p=0.08). In multivariate analyses, cancer pts had a higher ratio of the time between DNR order and death to LOS (0.30 vs 0.21, p=0.05). Existence of an AD had no significant impact on this ratio. Surgical specialists wrote DNR orders less frequently (64.2 vs 77.3%, p=0.02) and later than non-surgical specialists (mean 21 vs 10 days from admission, p=0.0008). Conclusions: In this study, DNR ordering patterns among hospitalized cancer and non-cancer pts have changed little since the PSDA. Although cancer pts on average had DNR orders written relatively earlier in their terminal hospital stay than non-cancer pts, the timing varied little from pts in prior studies. Although the majority of hospitalized pts in this sample died with DNR orders, these orders were written very late in their hospital stay.

No significant financial relationships to disclose.

Ethics, law, and commercial surrogacy: a call for uniformity

In the United States at this time, no uniform federal law exists regarding commercial surrogacy, and state statutory schemes vary vastly, ranging from criminalization to legal recognition with contract enforcement. The authors examine how commercial surrogacy agencies utilize the Internet as a means for attracting parents and surrogates by employing emotional cultural rhetoric. By inducing both parents and surrogates to their jurisdiction, agencies circumvent vast discrepancies in state statutory regulative schemes and create a distinct interstate business, absent an efficient regulatory framework or legal recourse in some circumstances. The authors propose a uniform federal regulatory scheme premised upon regulating interstate business transactions to create accountability and legal remedies for both the parents and the surrogate.