Exploring the Ethical Challenges of Conversational AI in Mental Health Care: Scoping Review

Meadi, M. R., et al. (2025)

JMIR Mental Health, 12, e60432.

https://doi.org/10.2196/60432

Abstract

Background: Conversational artificial intelligence (CAI) is emerging as a promising digital technology for mental health care. CAI apps, such as psychotherapeutic chatbots, are available in app stores, but their use raises ethical concerns.

Objective: We aimed to provide a comprehensive overview of ethical considerations surrounding CAI as a therapist for individuals with mental health issues.

Methods: We conducted a systematic search across PubMed, Embase, APA PsycINFO, Web of Science, Scopus, the Philosopher’s Index, and ACM Digital Library databases. Our search comprised 3 elements: embodied artificial intelligence, ethics, and mental health. We defined CAI as a conversational agent that interacts with a person and uses artificial intelligence to formulate output. We included articles discussing the ethical challenges of CAI functioning in the role of a therapist for individuals with mental health issues. We added additional articles through snowball searching. We included articles in English or Dutch. All types of articles were considered except abstracts of symposia. Screening for eligibility was done by 2 independent researchers (MRM and TS or AvB). An initial charting form was created based on the expected considerations and revised and complemented during the charting process. The ethical challenges were divided into themes. When a concern occurred in more than 2 articles, we identified it as a distinct theme.

Conclusions: Our scoping review has comprehensively covered ethical aspects of CAI in mental health care. While certain themes remain underexplored and stakeholders’ perspectives are insufficiently represented, this study highlights critical areas for further research. These include evaluating the risks and benefits of CAI in comparison to human therapists, determining its appropriate roles in therapeutic contexts and its impact on care access, and addressing accountability. Addressing these gaps can inform normative analysis and guide the development of ethical guidelines for responsible CAI use in mental health care.

Here are some thoughts:

From a clinical perspective, the most immediate ethical tension identified in this review is the conflict between increasing accessibility and ensuring nonmaleficence (doing no harm). While proponents argue that CAI can bridge care gaps by offering constant availability and reaching those who fear stigma, the risks regarding safety and crisis management are profound. The review highlights that CAI systems often fail to contextualize user cues, leading to inappropriate responses in critical situations, such as suicidality. Furthermore, the phenomenon of AI "hallucinations"—where the system presents false information as fact—poses a unique danger in mental health, potentially exacerbating eating disorders or anxiety through misinformation. The lack of strong clinical evidence is also concerning; despite the commercial "hype," a significant portion of these tools have not been subjected to rigorous clinical studies to prove their efficacy compared to active controls.

Technologically, the "black box" problem creates a significant barrier to integrating CAI into professional practice. The review notes that the opacity of machine learning algorithms makes it difficult to explain how a CAI arrived at a specific therapeutic intervention, which undermines the principle of explicability and trust. This lack of transparency complicates accountability; if a CAI harms a patient, it remains unclear whether the responsibility lies with the developers, the deploying clinicians, or the algorithm itself—a concept known as the "responsibility gap". For board-certified professionals, who are bound by codes of ethics to demonstrate reasonable care, relying on a system that cannot explain its decision-making process is ethically precarious.

Virtual Mental Health Care and Suicide-Related Events

Tenso, K., Strombotne, K., et al. (2024).

JAMA Network Open, 7(11), e2443054.

https://doi.org/10.1001/jamanetworkopen.2024.43054

Key Points

Question  Is the shift from face-to-face to virtual mental health service delivery associated with the risk of suicide-related events?

Findings  In this cohort study assessing 66 387 data points from 16 236 unique veterans, a 1% increase in the percentage of virtual mental health visits relative to the total visits was associated with a statistically significant 2.5% decrease in suicide-related events.

Meaning  The results of this cohort study suggest that offering virtual mental health care in addition to in-person care may reduce suicide-related events.

Abstract

Importance  The rising suicide rates in the US emphasize the need for effective prevention. While telehealth has transformed access to mental health care, the impact of telehealth on suicide outcomes is unknown.

Objective  To evaluate the association of virtual mental health services with individual-level suicide-related events (SREs).

Conclusions and Relevance  Findings from this cohort study using a retrospective quasi-experimental design found that an increase in virtual mental health visits relative to total visits was associated with a statistically significant decrease in SREs, suggesting that providing virtual mental health services may reduce suicide-related outcomes.

------------------------

Here are some thoughts:

This research investigates the connection between virtual mental health care and suicide-related events among veterans. Using data from the Veterans Health Administration, the study found a statistically significant decrease in suicide-related events associated with an increase in virtual mental health visits, suggesting that providing virtual mental health services may reduce suicide-related outcomes. The study controls for various factors that could influence both virtual care utilization and suicidal behaviors, employing an instrumental variable (IV) probit model to address potential confounders and reverse causality. The study concludes that virtual mental health care may be protective in terms of suicide-related outcomes, supporting the expansion of telehealth services within the VHA.

Second Circuit finds post-9/11 congressional ‘torture’ report not subject to FOIA

Nika Schoonover

Courthouse News

Originally posted 5 Aug 24

A report produced by Congress on the CIA’s post-9/11 detention and interrogation program is not covered by the federal freedom of information law, a Second Circuit panel found Monday.

In the aftermath of the terrorist attacks of September 11, 2001, the Senate Select Committee on Intelligence generated a report on the Detention and Interrogation Program conducted by the CIA. The committee then transmitted the report to various agencies covered under the federal Freedom of Information Act.

In late 2014, the committee produced only an executive summary of its findings which revealed the CIA’s interrogation tactics were more gruesome and ineffective than previously acknowledged. The heavily redacted report showed that interrogations included waterboarding, sleep deprivation and sexual humiliation such as rectal feeding.

In the Second Circuit panel’s Monday ruling, the court cited another Second Circuit decision from 2022, Behar v. U.S. Department of Homeland Security, where the court determined that an entity not covered by FOIA, such as Congress, would have to show that it manifested a clear control of the documents, and that the receiving agency is not free to “use and dispose of the documents as it sees fit.”

The info is here.

Here are some thoughts:

A recent decision by the Second Circuit panel has found that a report produced by Congress on the CIA's post-9/11 detention and interrogation program is not covered under the federal Freedom of Information Act (FOIA). The report, which details the CIA's use of enhanced interrogation techniques such as waterboarding and sleep deprivation, was generated by the Senate Select Committee on Intelligence in the aftermath of the 9/11 attacks.

The court's ruling centered on the issue of control and ownership of the report, citing a previous decision in Behar v. U.S. Department of Homeland Security. The panel found that Congress had manifested a clear intent to control the report at the time of its creation, and that subsequent actions did not vitiate this intent.

The decision affirms a lower court's dismissal of a complaint filed by Douglas Cox, a law professor who had submitted FOIA requests to various federal agencies for access to the report. Cox argued that the report should be subject to FOIA disclosure, but the court found that he had failed to address a relevant precedent in his oral arguments.

Legal experts have noted that the exclusion of the document from FOIA is a matter of Congress' intent to control the document, highlighting the lack of transparency in congressional records. The decision underscores the limitations of FOIA in accessing sensitive information, particularly when it comes to congressional records.

Navigating the Challenges of Conservators or Adult Guardians in Psychiatric Practice

Dike, C. C. (2024).

Psychiatric News, 59(07).

https://doi.org/10.1176/appi.pn.2024.07.7.48

An inpatient psychiatrist and her team are caught in a quandary. A hospitalized patient with chronic respiratory compromise is demanding to receive a COVID vaccination, but his conservator of person, also known as adult guardian in some states, is refusing to consent to the vaccination. Staff members suspect that the conservator’s refusal to approve the vaccination was driven by the conservator’s religious and spiritual beliefs. They also believe the patient’s best interest will be better served by getting the vaccination, given the patient’s underlying serious medical condition.

A different scenario is playing out in a sister hospital. A medically compromised patient admitted for psychiatric treatment is refusing the recommended COVID vaccination, but her conservator is insisting the psychiatrist should proceed with the injection, including holding or strapping down the patient to administer it. The psychiatrist is reluctant to do so over the patient’s objection but is worried about disregarding the request of the patient’s conservator.

Examples such as these—in which conserved patients’ requests are disapproved by their conservator—are common in psychiatric practice. Areas of conflicts include refusal to provide funds for cigarettes, certain food items, phones or computers, and alcoholic beverages and decisions regarding where to live. Often, the treating psychiatrist is caught in the middle.

The entire article is here.

Here are some thoughts:

This article wrestles with the ethical tightrope mental health professionals walk when treating patients with conservators. Balancing patient autonomy and their best interests is complex. While conservators are meant to protect those unable to care for themselves, the system can infringe on patient choice. The article emphasizes respecting patients' wishes whenever possible, and that mental health professionals must be vigilant for potential conservator abuse.  Ultimately, mental health professionals must act as patient advocates, focusing on their well-being (and in court if necessary). Even when court decisions go against the patient's wishes, the mental health professional's ethical duty remains - to support the patient through the situation (aka patient autonomy).

New California Court for the Mentally Ill Tests a State’s Liberal Values

Tim Arango

The New York Times

Originally posted 21 March 24

Here is an excerpt:

The new initiative, called CARE Court — for Community Assistance, Recovery and Empowerment — is a cornerstone of California’s latest campaign to address the intertwined crises of mental illness and homelessness on the streets of communities up and down the state.

Another piece of the effort is Proposition 1, a ballot measure championed by Gov. Gavin Newsom and narrowly approved by California voters this month. It authorizes $6.4 billion in bonds to pay for thousands of treatment beds and for more housing for the homeless — resources that could help pay for treatment plans put in place by CARE Court judges.

And Mr. Newsom, a Democrat in his second term, has not only promised more resources for treatment but has pledged to make it easier to compel treatment, arguing that civil liberties concerns have left far too many people without the care they need.

So when Ms. Collette went to court, she was surprised, and disappointed, to learn that the judge would not be able to mandate treatment for Tamra.

Instead, it is the treatment providers who would be under court order — to ensure that medication, therapy and housing are available in a system that has long struggled to reliably provide such services.

“I was hoping it would have a little more punch to it,” Ms. Collette said. “I thought it would have a little more power to order them into some kind of care.”

The info is here.

Here is a summary:

California's new CARE Court (Community Assistance, Recovery and Empowerment) is a court system designed to address the issues of mental illness and homelessness. It aims to provide court-ordered care plans for individuals struggling with severe mental illness who are unable to care for themselves. This initiative tests the state's liberal values by balancing individual liberty with the need for intervention to help those in crisis.

How to Deal with Counter-Examples to Common Morality Theory: A Surprising Result

Herissone-Kelly P.

Cambridge Quarterly of Healthcare Ethics.

2022;31(2):185-191.

doi:10.1017/S096318012100058X

Abstract

Tom Beauchamp and James Childress are confident that their four principles—respect for autonomy, beneficence, non-maleficence, and justice—are globally applicable to the sorts of issues that arise in biomedical ethics, in part because those principles form part of the common morality (a set of general norms to which all morally committed persons subscribe). Inevitably, however, the question arises of how the principlist ought to respond when presented with apparent counter-examples to this thesis. I examine a number of strategies the principlist might adopt in order to retain common morality theory in the face of supposed counter-examples. I conclude that only a strategy that takes a non-realist view of the common morality’s principles is viable. Unfortunately, such a view is likely not to appeal to the principlist.

The info is here.

Herissone-Kelly examines various strategies principlism could employ to address counter-examples:

Refine the principles: This involves clarifying or reinterpreting the principles to better handle specific cases.

• Prioritize principles: Establish a hierarchy among the principles to resolve conflicts.
• Supplement the principles: Introduce additional considerations or context-specific factors.
• Limit the scope: Acknowledge that the principles may not apply universally to all cultures or situations.

Herissone-Kelly argues that none of these strategies are fully satisfactory. Refining or prioritizing principles risks distorting their original meaning or introducing arbitrariness. Supplementing them can lead to an unwieldy and complex framework. Limiting their scope undermines the theory's claim to universality.

He concludes that the most viable approach is to adopt a non-realist view of the common morality's principles. This means understanding them not as objective moral facts but as flexible tools for ethical reflection and deliberation, open to interpretation and adaptation in different contexts. While this may seem to weaken the theory's authority, Herissone-Kelly argues that it allows for a more nuanced and practical application of ethical principles in a diverse world.

You Can't Win at Morality

Kurt Gray, Will Blakey, and Carlos Rebollar

Moral Understanding Substack

Originally posted 26 OCT 22

Here is an excerpt:

Moral Ideals

Most of us want to do good in the world, and follow a set of moral guidelines, or “ideals.” But the word “ideals” has dangerous roots. The etymology of the very word “ideal” implies perfection, which we authors believe is bad.

 In 1796, Immanuel Kant used the word “ideal” to describe a hypothetically perfect person, thing, or state. It may have been easy for Kant to fetishize the perfect moral person, but it’s not clear that he is the best role model for us modern people (or anyone else). Kant was a weird guy. He once likened sex to sucking dry a lemon (scholars think he died a virgin), he thought you had to tell the truth even if it meant the slaughter of an innocent family, and he thought it was a good idea to get a portrait taken that highlighted his giant bald forehead and left most of his face in darkness (see picture).

Despite Kant’s questionable judgment, an ideal-driven ethics is widely promoted. Christianity’s most popular role model is Jesus, and they say he was perfect. Tony Robbins, self-help guru, says that we should become the best version of ourselves. The reasoning goes, “if our ideals are unachievable, that’s the whole point! They’re supposed to make you shoot for the moon.” This is why Kant’s idealism is so seductive. We think it’ll make us never stop improving ourselves. When it comes to role models, we don’t search for pretty good people, we search for moral perfection and emulate it to the best of our abilities.

As advocates for increasing moral understanding in the world, we are not arguing that people should stop striving to do good. But we do think that the quest for moral perfection can lead us astray. “The perfect is the enemy of the good” is a quote that’s useful in a lot of cases, but it’s especially useful when it comes to morality.

We argue that striving for moral perfection or “trying to win at morality,” has at least two main drawbacks: First, it can contribute to unhealthy thinking, and second, it can deter us from taking steps in the right direction. Instead, we propose that striving for more moral good (not the most) and practicing moral humility can help us do good in the world around us.

Anxiety is the Dizziness of Freedom… When Your Goal is Perfection

Achieving moral perfection is tricky because, as we saw with Janet, answers to the “most moral good” are uncertain. And this is a problem because uncertainty about big questions doesn’t feel good.

Take these big questions: Is God real? Are we living in a simulation? Why are we here and what is the meaning of life? For many, the uncertainty inherent in these questions is a background feature of life. But for others, including me (Will), it is too often an anxiety-provoking challenge. I struggle with “existential OCD,” a psychological disorder involving anxiety resulting from intrusive thoughts and discomfort about these big life questions. Not knowing why we’re all here or where we’re all going often stresses me out. But I’ve largely been able to combat this stress through therapy and renegotiating a better relationship with uncertainty.

The info is here.

Thousands of Medical Professionals Urge Supreme Court To Uphold Roe: ‘Provide Patients With the Treatment They Need’

Phoebe Kolbert

Ms. Magazine

Originally posted 21 JUN 22

Any day now, the Supreme Court will issue its decision in Dobbs v. Jackson Women’s Health Organization, which many predict will overturn or severely gut Roe v. Wade. Since the start of the Dobbs v. Jackson hearings in December, medical professionals have warned of the drastic health impacts brought on by abortion bans. Now, over 2,500 healthcare professionals from all 50 states have signed a letter urging the Supreme Court to scrap their leaked Dobbs draft opinion and uphold Roe.  

Within 30 days of a decision to overturn Roe, at least 26 states will ban abortion. Clinics in remaining pro-abortion states are preparing for increased violence from anti-abortion extremists and an influx of out-of-state patients. The number of legal abortions performed nationwide is projected to fall by about 13 percent. Many abortion clinics in states with bans will be forced to close their doors, if they haven’t already. The loss of these clinics also comes with the loss of the other essential reproductive healthcare they provide, including STI screenings and treatment, birth control and cervical cancer screenings.

The letter, titled “Medical Professionals Urge Supreme Court to Uphold Roe v. Wade, Protect Abortion Access,” argues that decisions around pregnancy and abortion should be made by patients and their doctors, not the courts.

The info from Ms. Magazine is here.

Here is how the letter begins:

Medical Professionals Urge Supreme Court to Uphold Roe v. Wade, Protect Abortion Access

As physicians and health care professionals, we are gravely concerned that the U.S. Supreme Court appears prepared to end the constitutional right to an abortion. We urge the Supreme Court to to scrap their draft opinion, uphold the constitutional right to an abortion, and ensure that abortions remain legal nationwide, as allowed for in Roe v. Wade. In this moment of crisis, we want to make crystal clear the consequences to our patients’ health if they can no longer access abortions.

Abortions are safe, common and a critical part of health care and reproductive medicine. Medical professionals and medical associations agree, including the American Medical Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American College of Nurse Midwives and many others.

Prohibiting access to safe and legal abortion has devastating implications for health care. Striking down Roe v. Wade would affect not just abortion access, but also maternal care as well as fertility treatments. Pregnancy changes a person’s physiology. These changes can potentially worsen existing diseases and medical conditions.

As physicians and medical professionals, we see the real-life consequences when an individual does not get the care that they know they need, including abortions. The woman who has suffered the violation and trauma of rape would be forced to carry a pregnancy.

Denying access to abortion from people who want one can adversely affect their health, safety and economic well-being, including delayed separation from a violent partner and increased likelihood of falling into poverty by four times. These outcomes can also have drastic impacts on their health.

The entire letter is here.

South Carolina bill permits health care providers refuse non-emergency care based on beliefs

Brooke Migdon

The Hill

Originally posted 1 APR 22

Story at a glance

• Legislators in South Carolina on Friday passed a bill which would allow healthcare providers to deny care based on their personal beliefs. It would also apply to insurance companies, which may be entitled to refuse to pay for care.

• The bill would also protect those who decline to provide medical services from civil, criminal or administrative liability.

• Some say the bill, known as the “Medical Ethics and Diversity Act,” would disproportionately affect the LGBTQ+ community, as well as women and people of color.

South Carolina lawmakers on Friday passed a bill allowing medical professionals and insurance companies to deny care based on personal belief. Some say the legislation, which now heads to the state Senate for consideration, would disproportionately impact LGBTQ+ people, women, and people of color.

Under the bill, titled the “Medical Ethics and Diversity Act,” South Carolina law would be altered to excuse medical practitioners, health care institutions and health care payers from providing care that violates their “conscience.” It would also shield those who decline to provide medical services to patients from civil, criminal or administrative liability.

Dozens of state residents in February testified against the bill, calling it vague and overbroad. They also shared concerns that the legislation would disproportionately impact marginalized communities.

In a statement on Friday, Human Rights Campaign Legal Director Sarah Warbelow said she finds it “disturbing” that politicians in South Carolina are prioritizing individual providers’ beliefs over the wellbeing of patients.

“This legislation is dangerously silent in regards to the needs of patients and fails to consider the impact that expanding refusals can have on their health,” she said. “Religious freedom is a fundamental American value that is entirely compatible with providing quality, non-discriminatory healthcare. It is not a license to deprive others of their rights simply because of personal beliefs.”

Warbelow said the bill sends a message to patients with non-medical views inconsistent with that of their doctors that they are “not equal members of society entitled to dignity and respect.”

The info is here.

Editor's Note: Those politicians who pass laws based on culture wars are clearly violating the principle-based ethics on which all medical ethics rely.  If they pass harmful laws that conflict with health care ethics, then they are not fit to serve.

The Moral Injury of COVID: How Will Nurses Survive?

Diane M. Goodman

MedScape.com

Originally posted 11 FEB 22

Here are some excerpts:

According to recent statistics, 1 in 5 nurses have retired from active duty since the pandemic began. Far from feeling like heroes, nurses now feel exhausted, demoralized, underappreciated, and severely overworked. They are broken in ways that cannot be repaired.

Recently, an intensive care unit nurse abandoned his shift in the middle of the night and walked off into the unknown only to be found deceased 2 days later. What happened to this caregiver? Was his distress so severe he could not communicate pain? One can only wonder.

Nurses across the country are suffering from moral injury.

(cut)

This is what nurses feel prepared to do, but it violates their moral code.

Nurses may be unfamiliar with the process of rationing care, but the pandemic has changed that perspective. Nurses are now dealing with a form of rationing that leaves them miserable, in tears, and in persistent distress.

Providing care for 10 patients as opposed to a maximum of five forces nurses to make appalling decisions. Which patient needs my attention now? Will another patient die while I am in this room? How can I choose without suffering lasting trauma from my decisions?

Nurses have repeatedly been placed in impossible situations throughout the pandemic.

Remember the early days of PPE shortages? Nurses went without appropriate attire to protect their peers, at times with fatal results. 

(cut)

The profession prides itself on delivering the highest quality care it can. But when was the last time nurses felt that they were meeting this standard? How can they? They are working in a system where their own needs are minimized to meet the demands of an ongoing COVID patient population.

Moral injury, which can lead to moral trauma if unresolved, is different from burnout. 

Moral injury affects our sense of right and wrong. Moral injury is different because it represents a situation of witnessing care or offering care that conflicts with our internal compass. It is witnessing patients die without loved ones, repeatedly, or instituting a crisis standard of care that feels endless, although no earthquake, tornado, or bus accident has occurred. It is a feeling of running behind without the possibility of ever getting a break.

Moral injury is lasting distress that leads to feelings such as guilt, anger, and shame. There are true psychological implications for this type of angst. 

The info is here.

Experts Are Ringing Alarms About Elon Musk’s Brain Implants

Noah Kirsch

Daily Beast

Posted 25 Jan 2021

Here is an excerpt:

“These are very niche products—if we’re really only talking about developing them for paralyzed individuals—the market is small, the devices are expensive,” said Dr. L. Syd Johnson, an associate professor in the Center for Bioethics and Humanities at SUNY Upstate Medical University.

“If the ultimate goal is to use the acquired brain data for other devices, or use these devices for other things—say, to drive cars, to drive Teslas—then there might be a much, much bigger market,” she said. “But then all those human research subjects—people with genuine needs—are being exploited and used in risky research for someone else’s commercial gain.”

In interviews with The Daily Beast, a number of scientists and academics expressed cautious hope that Neuralink will responsibly deliver a new therapy for patients, though each also outlined significant moral quandaries that Musk and company have yet to fully address.

Say, for instance, a clinical trial participant changes their mind and wants out of the study, or develops undesirable complications. “What I’ve seen in the field is we’re really good at implanting [the devices],” said Dr. Laura Cabrera, who researches neuroethics at Penn State. “But if something goes wrong, we really don't have the technology to explant them” and remove them safely without inflicting damage to the brain.

There are also concerns about “the rigor of the scrutiny” from the board that will oversee Neuralink’s trials, said Dr. Kreitmair, noting that some institutional review boards “have a track record of being maybe a little mired in conflicts of interest.” She hoped that the high-profile nature of Neuralink’s work will ensure that they have “a lot of their T’s crossed.”

The academics detailed additional unanswered questions: What happens if Neuralink goes bankrupt after patients already have devices in their brains? Who gets to control users’ brain activity data? What happens to that data if the company is sold, particularly to a foreign entity? How long will the implantable devices last, and will Neuralink cover upgrades for the study participants whether or not the trials succeed?

Dr. Johnson, of SUNY Upstate, questioned whether the startup’s scientific capabilities justify its hype. “If Neuralink is claiming that they’ll be able to use their device therapeutically to help disabled persons, they’re overpromising because they’re a long way from being able to do that.”

Neuralink did not respond to a request for comment as of publication time.

The info is here.

Public Deliberation about Gene Editing in the Wild

M. K. Gusmano, E. Kaebnick, et al. (2021).

Hastings Center Report

10.1002/hast.1318, 51, S2, (S34-S41).

Abstract

Genetic editing technologies have long been used to modify domesticated nonhuman animals and plants. Recently, attention and funding have also been directed toward projects for modifying nonhuman organisms in the shared environment—that is, in the “wild.” Interest in gene editing nonhuman organisms for wild release is motivated by a variety of goals, and such releases hold the possibility of significant, potentially transformative benefit. The technologies also pose risks and are often surrounded by a high uncertainty. Given the stakes, scientists and advisory bodies have called for public engagement in the science, ethics, and governance of gene editing research in nonhuman organisms. Most calls for public engagement lack details about how to design a broad public deliberation, including questions about participation, how to structure the conversations, how to report on the content, and how to link the deliberations to policy. We summarize the key design elements that can improve broad public deliberations about gene editing in the wild.

Here is the gist of the paper:

We draw on interdisciplinary scholarship in bioethics, political science, and public administration to move forward on this knot of conceptual, normative, and practical problems. When is broad public deliberation about gene editing in the wild necessary? And when it is required, how should it be done? These questions lead to a suite of further questions about, for example, the rationale and goals of deliberation, the features of these technologies that make public deliberation appropriate or inappropriate, the criteria by which “stakeholders” and “relevant publics” for these uses might be identified, how different approaches to public deliberation map onto the challenges posed by the technologies, how the topic to be deliberated upon should be framed, and how the outcomes of public deliberation can be meaningfully connected to policy-making.

The info is here.

I See Color

Khama Ennis

On The Flip Side

Original date: February 13, 2020

9 minutes worth watching: Patient biases versus professional obligations

Evaluating Tradeoffs between Autonomy and Wellbeing in Supported Decision Making

Veit, W., Earp, B.D., Browning, H., Savulescu, J.

American Journal of Bioethics 

https://www.researchgate.net/publication/354327526 

A core challenge for contemporary bioethics is how to address the tension between respecting an individual’s autonomy and promoting their wellbeing when these ideals seem to come into conflict (Notini  et  al.  2020).  This  tension  is  often  reflected  in  discussions  of  the  ethical  status  of guardianship and other surrogate decision-making regimes for individuals with different kinds or degrees of cognitive ability and (hence) decision-making capacity (Earp and Grunt-Mejer 2021), specifically when these capacities are regarded as diminished or impaired along certain dimensions (or with respect to certain domains). The notion or practice of guardianship, wherein a guardian is legally appointed to make decisions on behalf of someone with different/diminished capacities, has been particularly controversial. For example, many people see guardianship as unjust, taking too  much  decisional  authority  away  from  the  person  under  the  guardian’s  care  (often  due  to prejudiced attitudes, as when people with certain disabilities are wrongly assumed to lack decision-making capacity); and as too rigid, for example, in making a blanket judgment about someone’s (lack of) capacity, thereby preventing them from making decisions even in areas where they have the requisite abilities (Glen 2015).

It is  against  this  backdrop that  Peterson,  Karlawish, and  Largent (2021) offer  a  useful philosophical framework for the notion of ‘supported decision-making’ as a compelling alternative for  individuals  with  ‘dynamic  impairments’  (i.e.,  non-static  or  domain-variant  perceived mpairments  in  decision-making  capacity).  In  a  similar spirit,  we  have  previously  argued  that bioethics would benefit from a more case-sensitive rather than a ‘one-size-fits-all’ approach when it comes to issues of cognitive diversity (Veit et al. 2020; Chapman and Veit 2020). We therefore agree with most of the authors’ defence of supported decision-making, as this approach allows for case- and context-sensitivity. We also agree with the authors that the categorical condemnation of guardianships  or  similar  arrangements  is  not  justified,  as  this  precludes  such  sensitivity.  For instance, as the authors note, if a patient is in a permanent unaware/unresponsive state – i.e., with no  current  or  foreseeable  decision-making  capacity  or  ability  to  exercise  autonomy  –  then  a guardianship-like regime may be the most appropriate means of promoting this person’s interests. A similar point can be made in relation to debates about intended human enhancement of embryos and children.  Although some critics  claim that  such interventions  violate the autonomy  of the enhanced person, proponents may argue that respect for autonomy and consent do not apply in certain cases, for example, when dealing with embryos (see Veit 2018); alternatively, they may argue that interventions to enhance the (future) autonomy of a currently pre-autonomous (or partially autonomous) being can be justified on an enhancement framework without falling prey to such objections (see Earp 2019, Maslen et al. 2014). 

A pdf is here.

Nudgeability: Mapping Conditions of Susceptibility to Nudge Influence

de Ridder, D., Kroese, F., & van Gestel, L. (2021). 

Perspectives on psychological science 

Advance online publication. 

https://doi.org/10.1177/1745691621995183

Abstract

Nudges are behavioral interventions to subtly steer citizens' choices toward "desirable" options. An important topic of debate concerns the legitimacy of nudging as a policy instrument, and there is a focus on issues relating to nudge transparency, the role of preexisting preferences people may have, and the premise that nudges primarily affect people when they are in "irrational" modes of thinking. Empirical insights into how these factors affect the extent to which people are susceptible to nudge influence (i.e., "nudgeable") are lacking in the debate. This article introduces the new concept of nudgeability and makes a first attempt to synthesize the evidence on when people are responsive to nudges. We find that nudge effects do not hinge on transparency or modes of thinking but that personal preferences moderate effects such that people cannot be nudged into something they do not want. We conclude that, in view of these findings, concerns about nudging legitimacy should be softened and that future research should attend to these and other conditions of nudgeability.

From the General Discussion

Finally, returning to the debates on nudging legitimacy that we addressed at the beginning of this article, it seems that concerns should be softened insofar as nudges do impose choice without respecting basic ethical requirements for good public policy. More than a decade ago, philosopher Luc Bovens (2009) formulated the following four principles for nudging to be legitimate: A nudge should allow people to act in line with their overall preferences; a nudge should not induce a change in preferences that would not hold under nonnudge conditions; a nudge should not lead to “infantilization,” such that people are no longer capable of making autonomous decisions; and a nudge should be transparent so that people have control over being in a nudge situation. With the findings from our review in mind, it seems that these legitimacy requirements are fulfilled. Nudges do allow people to act in line with their overall preferences, nudges allow for making autonomous decisions insofar as nudge effects do not depend on being in a System 1 mode of thinking, and making the nudge transparent does not compromise nudge effects.

The paper is here.

We’ve Never Protected the Vulnerable

Aaron Carroll

The Atlantic

Originally posted 5 Sept 21

Here is an excerpt:

The Americans With Disabilities Act provides for some accommodations for people with disabilities or diseases in certain situations, but those are extremely limited. They also apply only to the afflicted. My friend’s wife, a teacher, couldn’t tell her school that she needed special treatment because someone was vulnerable in her life. The school implemented no precautions to reduce her chance of being exposed to illness and getting sick, in order to keep her husband safe at home. Neither could his kids demand changes at their schools. Asking schools to alter their behavior to protect relatives of students may seem like a big ask, but I couldn’t even persuade all of our close friends to get vaccinated against the flu to protect him.

COVID-19 has exposed these gaps in our public solidarity, not caused them. The way we handle influenza is the best example, as the infectious disease that usually causes the highest number of deaths each year. Even though the young and the old are at real risk from flu, along with the immunocompromised, we’ve almost never engaged in any special protections for these groups. I’ve begged people for years to get immunized to protect others, and most don’t listen. Other countries mask more during respiratory-virus seasons; almost no one even thinks of masking here. Few distance from others, even though that’s a more palatable option for most Americans. To the contrary, many people consider it a mark of pride to “tough it out” and come to work while sick, potentially exposing others.

Our current situation with COVID-19 is especially difficult because so many Americans believe they’ve already given more than enough. Any further adjustments to their life, even if they seem small, feel like too much to bear. It’s natural that Americans want to get back to normal, and I’m not arguing that we should lock down until no risk remains. I’m asking that we think about others more in specific settings. We don’t all have to wear a mask all the time, but we could get used to always carrying one. That way, if we are around people who might live with others at high risk, we could mask around them and stand a little farther away. We could cancel our evening plans or miss a concert if we’re sick. Is it really that hard to get a flu shot every year?

The info is here.

The prisoner’s dilemma: The role of medical professionals in executions

Elisabeth Armstrong

Journal of Medical Ethics

Originally posted 7 Sept 21

Here is an excerpt:

Clinician Participation in Executions is Either Wrong or Misguided

Clinicians might participate in executions out of an inappropriate commitment to capital punishment; this position of leveraging medical education and credentials to punish or harm has no grounding in ethical conversation. It is entirely inappropriate to undermine trust in the medical profession in service of one’s political or philosophical beliefs – those ought to be relegated to the voting booths.

However, some practitioners might be present at an execution out of a well-intentioned, but misguided commitment to preventing suffering. Their reasoning is along the lines, “If states are proceeding with an execution, shouldn’t a clinician be present to ensure there is no undue harm or suffering?” Writing on lethal injections, Dr. Sandeep Jahaur writes in the New York Times, “Barring physicians from executions will only increase the risk that prisoners will unduly suffer,” in violation of the Hippocratic Oath and the 8th Amendment of the US Constitution. He points out that no ethics board would allow the testing of execution drugs on human participants, therefore, in the absence of a “controlled investigation” it is important that a doctor is present to assist when things go awry.

Dr. Jahaur adds that if doctors (or other clinicians) do not assist, people with less experience are often called upon to insert catheters, assess and insert the IVs, mix and administer the drugs, monitor a patient’s vital signs, then confirm death; and of course, step in if anything goes wrong. Dr. Atul Gawande agrees that it is unlikely that a lethal injection could be performed without a physician without the occasional tragic mistake. As recently as October of 2014, the lack of involvement from clinicians resulted in the administration of an incorrect drug to an inmate – resulting in forty-three minutes of writhing and groaning before he died.

The Case for Ending Practitioner Participation

There is no denying that these cases of suffering are disturbing and compelling. Ultimately, however, the bioethical case for participation is grossly outweighed by the case against it: medical involvement on any level intrinsically violates the ethical principles of autonomy, beneficence, non-maleficence, and justice – compromising the foundations of the medical system. (Underline added.)

The info is here.

As a doctor in a COVID unit, I’m running out of compassion for the unvaccinated. Get the shot

Anita Sircar

The Los Angeles Times

Originally published 17 Aug 21

Here is an excerpt:

The burden of this pandemic now rests on the shoulders of the unvaccinated. On those who are eligible to get vaccinated but choose not to, a decision they defend by declaring, “Vaccination is a deeply personal choice.” But perhaps never in history has anyone’s personal choice affected the world as a whole as it does right now. When hundreds and thousands of people continue to die — when the most vulnerable members of society, our children, cannot be vaccinated — the luxury of choice ceases to exist.

If you believe the pandemic is almost over and I can ride it out, without getting vaccinated, you could not be more wrong. This virus will find you.

(cut)

If you believe if I get infected I’ll just go to the hospital and get treated, there is no guarantee we can save your life, nor even a promise we’ll have a bed for you.

If you believe I’m pregnant and I don’t want the vaccine to affect me, my baby or my future fertility, it matters little if you’re not alive to see your newborn.

If you believe I won’t get my children vaccinated because I don’t know what the long-term effects will be, it matters little if they don’t live long enough for you to find out.

If you believe I’ll just let everyone else get vaccinated around me so I don’t have to, there are 93 million eligible, unvaccinated people in the “herd” who think the same way you do and are getting in the way of ending this pandemic.

If you believe vaccinated people are getting infected anyway, so what’s the point?, the vaccine was built to prevent hospitalizations and deaths from severe illness. Instead of fatal pneumonia, those with breakthrough infections have a short, bad cold, so the vaccine has already proved itself. The vaccinated are not dying of COVID-19.

SARS-CoV-2, the virus that causes COVID-19, has mutated countless times during this pandemic, adapting to survive. Stacked up against a human race that has resisted change every step of the way — including wearing masks, social distancing, quarantining and now refusing lifesaving vaccines — it is easy to see who will win this war if human behavior fails to change quickly.

The info is here.

America’s long history of anti-science has dangerously undermined the COVID vaccine

Peter Hotez

The Dallas Morning News

Originally published 15 Aug 21

Here is an excerpt:

America’s full-throated enthusiasm for vaccines lasted until the early 2000s. The 1998 Lancet publication of a paper from Andrew Wakefield and his colleagues, which wrongly asserted that the measles virus in the MMR vaccine replicated in the colons of children to cause pervasive developmental disorder (autism), ushered in a new era of distrust for vaccine.

It also resulted in distrust for the U.S. Health and Human Services agencies promoting vaccinations. The early response from the Centers for Disease Control and Prevention was to dismiss growing American discontent for vaccines as a fringe element, until eventually in the 2010s anti-vaccine sentiment spread across the internet.

The anti-vaccine movement eventually adopted medical freedom and used it to gain strength and accelerate in size, internet presence and external funding. Rising out of the American West, anti-vaccine proponents insisted that only parents could make vaccine choices and they were prepared to resist government requirements for school entry or attendance.

In California, the notion of vaccine choice gained strength in the 2010s, leading to widespread philosophical exemptions to childhood MMR vaccines and other immunizations. Vaccine exemptions reached critical mass, ultimately culminating in a 2014–2015 measles epidemic in Orange County.

The outbreak prompted state government intervention through the introduction of California Senate Bill 277 that eliminated these exemptions and prevented further epidemics, but it also triggered aggressive opposition. Anti-vaccine health freedom groups harassed members of the Legislature and labeled prominent scientists as pharma shills. They touted pseudoscience, claiming that vaccines were toxic, or that natural immunity acquired from the illness was superior and more durable than vaccine-induced immunity.

Health freedom then expanded through newly established anti-vaccine political action committees in Texas and Oklahoma in the Southwest, Oregon in the Pacific Northwest, and Michigan and Ohio in the Midwest, while additional anti-vaccine organizations formed in almost every state.

These groups lobbied state legislatures to promote or protect vaccine exemptions, while working to cloak or obscure classroom or schoolwide disclosures of vaccine exemptions. They also introduced menacing consent forms to portray vaccines as harmful or toxic.

The Texans for Vaccine Choice PAC formed in 2015, helping to accelerate personal belief immunization exemptions to a point where today approximately 72,000 Texas schoolchildren miss vaccines required for school entry and attendance.

The info is here.

Should we be concerned that the decisions of AIs are inscrutable?

John Zerilli

Psyche.co

Originally published 14 June 21

Here is an excerpt:

However, there’s a danger of carrying reliabilist thinking too far. Compare a simple digital calculator with an instrument designed to assess the risk that someone convicted of a crime will fall back into criminal behaviour (‘recidivism risk’ tools are being used all over the United States right now to help officials determine bail, sentencing and parole outcomes). The calculator’s outputs are so dependable that an explanation of them seems superfluous – even for the first-time homebuyer whose mortgage repayments are determined by it. One might take issue with other aspects of the process – the fairness of the loan terms, the intrusiveness of the credit rating agency – but you wouldn’t ordinarily question the engineering of the calculator itself.

That’s utterly unlike the recidivism risk tool. When it labels a prisoner as ‘high risk’, neither the prisoner nor the parole board can be truly satisfied until they have some grasp of the factors that led to it, and the relative weights of each factor. Why? Because the assessment is such that any answer will necessarily be imprecise. It involves the calculation of probabilities on the basis of limited and potentially poor-quality information whose very selection is value-laden.

But what if systems such as the recidivism tool were in fact more like the calculator? For argument’s sake, imagine a recidivism risk-assessment tool that was basically infallible, a kind of Casio-cum-Oracle-of-Delphi. Would we still expect it to ‘show its working’?

This requires us to think more deeply about what it means for an automated decision system to be ‘reliable’. It’s natural to think that such a system would make the ‘right’ recommendations, most of the time. But what if there were no such thing as a right recommendation? What if all we could hope for were only a right way of arriving at a recommendation – a right way of approaching a given set of circumstances? This is a familiar situation in law, politics and ethics. Here, competing values and ethical frameworks often produce very different conclusions about the proper course of action. There are rarely unambiguously correct outcomes; instead, there are only right ways of justifying them. This makes talk of ‘reliability’ suspect. For many of the most morally consequential and controversial applications of ML, to know that an automated system works properly just is to know and be satisfied with its reasons for deciding.

The info is here.