This 44-chapter volume tackles a quickly-evolving field of inquiry, mapping the existing discourse as part of a general attempt to place current developments in historical context; at the same time, breaking new ground in taking on novel subjects and pursuing fresh approaches. The term "A.I." is used to refer to a broad range of phenomena, from machine learning and data mining to artificial general intelligence. The recent advent of more sophisticated AI systems, which function with partial or full autonomy and (...) are capable of tasks which require learning and 'intelligence', presents difficult ethical questions, and has drawn concerns from many quarters about individual and societal welfare, democratic decision-making, moral agency, and the prevention of harm. This work ranges from explorations of normative constraints on specific applications of machine learning algorithms today-in everyday medical practice, for instance-to reflections on the (potential) status of AI as a form of consciousness with attendant rights and duties and, more generally still, on the conceptual terms and frameworks necessarily to understand tasks requiring intelligence, whether "human" or "A.I.". (shrink)

In their forthcoming article, ‘What makes a medical intervention invasive?’ De Marco, Simons, and colleagues explore the meaning and usage of the term ‘invasive’ in medical contexts. They describe a ‘Standard Account’, drawn from dictionary definitions, which defines invasiveness as ‘incision of the skin or insertion of an object into the body’. They then highlight cases wherein invasiveness is employed in a manner that is inconsistent with this account (eg, in describing psychotherapy) to argue that the term invasiveness is often (...) used to explicitly or implicitly reference interventions that do not fall under the standard account. The authors offer an alternative ‘schematic’ definition of invasiveness, whereby medical interventions entail an underlying context-independent property of ‘basic invasiveness’ and may be understood both relative to each other and to a context-specific threshold of what is ‘invasive’. 1 We propose that the meaning of terms such as ‘invasiveness’ is necessarily heterogeneous,... (shrink)

In their forthcoming article, Shavelson and colleagues (2023) identify a key ethical concern associated with medical aid-in-dying (MAiD) laws in the eleven US jurisdictions where the practice is le...

We read with interest Dominic Wilkinson’s article “Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?” on the utility of the Clinical Frailty Score in...

There exists in academic medicine a core ethical issue that is seldom pursued: trainees are frequently not the best person in the operating room at a given intervention being performed, and yet as a profession we understand a fundamental need to afford them opportunities to perform. Academic centres are traditionally associated with a higher quality of care than non-academic centres, suggesting that practical measures exist within teaching hospitals that effectively mask the clinical discrepancies between trainees and their preceptors. Nonetheless, we (...) are bound by our ethical commitments as physicians to balance the obligations of care with the duty to teach. In order to ethically validate the model of ‘surgeon as teacher’, we propose that there must be a reconciliation of the tensions between traditional professional values in medicine with the constraints inherent in a time-bound utilitarian medical system. Ultimately, we must consciously accept that ensuring the longitudinal availability of skilled surgeons in society aligns more closely with our core ethical obligations as outlined in the social contract that medical professionals maintain with the general public than does the ethical demand to provide unreservedly individual-focused patient care. It is the duty of individual practitioners, as a necessity of lineage to maintain and fulfil our greater duties to society, to foster deontological relationships where possible within this utilitarian system while accepting short-term imperfection in our practice. There are no data in this manuscript. (shrink)

Objective: To examine the role of explainability in machine learning for healthcare (MLHC), and its necessity and significance with respect to effective and ethical MLHC application. Study Design and Setting: This commentary engages with the growing and dynamic corpus of literature on the use of MLHC and artificial intelligence (AI) in medicine, which provide the context for a focused narrative review of arguments presented in favour of and opposition to explainability in MLHC. Results: We find that concerns regarding explainability are (...) not limited to MLHC, but rather extend to numerous well-validated treatment interventions as well as to human clinical judgment itself. We examine the role of evidence-based medicine in evaluating unexplainable treatments and technologies, and highlight the analogy between the concept of explainability in MLHC and the related concept of mechanistic reasoning in evidence-based medicine. Conclusion: Ultimately, we conclude that the value of explainability in MLHC is not intrinsic, but is instead instrumental to achieving greater imperatives such as performance and trust. We caution against the uncompromising pursuit of explainability, and advocate instead for the development of robust empirical methods to successfully evaluate increasingly inexplicable algorithmic systems. (shrink)

As Alfandre and colleagues describe in “Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures”, efforts to maintain standards of care durin...

Volume 19, Issue 6, June 2019, Page 34-36.

In many jurisdictions, legal frameworks afford patients the opportunity to make prospective medical decisions or to create directives that contain a special provision forfeiting their own ability to object to those decisions at a future time point, should they lose decision‐making capacity. These agreements have been described with widely varying nomenclatures, including Ulysses Contracts, Odysseus Transfers, Psychiatric Advance Directives with Ulysses Clauses, and Powers of Attorney with Special Provisions. As a consequence of this terminological heterogeneity, it is challenging for healthcare (...) providers to understand the terms and uses of these agreements and for ethicists to engage with the nuances of clinical decision‐making with such unique provisions surrounding patient autonomy. In theory, prospective self‐binding agreements may safeguard patient's “authentic” wishes from future “inauthentic” changes of mind. In practice, it is unclear what may be comprised within these agreements or how—and to what effect—they are used. The primary focus of this integrative review is to curate the existing literature describing Ulysses Contracts (and analogous decisions) used in the clinical arena, in order to empirically synthesize their shared essence and provide insights into the traditional components of these agreements when used in practice, the requirements of their consent processes, and the outcomes of their utilization. (shrink)

The aim of a theoretically ideal process of informed consent is to promote the autonomy of the patient and to limit unethical physician paternalism. However, in practice, the nature of the medical profession requires physicians to act as ontological decision architects—based on the medical knowledge that they acquire through their experience and training, physicians ontologically determine a subset of viable courses of action for their patient. What is observed is not an unethical physician limitation or biasing of the patient towards (...) certain treatment options that violates patient autonomy or consciously undermines informed consent, but rather a more foundational paternalism that is necessarily inherent to the physician–patient relationship. In this article we argue for a recognition of this underlying physician paternalism and posit that this necessary paternalism is not a foil to patient autonomy, but rather a foundational aspect of the duties of the medical professional within the physician–patient relationship. (shrink)

The aim of a theoretically ideal process of informed consent is to promote the autonomy of the patient and to limit unethical physician paternalism. However, in practice, the nature of the medical profession requires physicians to act as ontological decision architects—based on the medical knowledge that they acquire through their experience and training, physicians ontologically determine a subset of viable courses of action for their patient. What is observed is not an unethical physician limitation or biasing of the patient towards (...) certain treatment options that violates patient autonomy or consciously undermines informed consent, but rather a more foundational paternalism that is necessarily inherent to the physician–patient relationship. In this article we argue for a recognition of this underlying physician paternalism and posit that this necessary paternalism is not a foil to patient autonomy, but rather a foundational aspect of the duties of the medical professional within the physician–patient relationship. (shrink)

BackgroundThe expectation of pandemic-induced severe resource shortages has prompted authorities to draft and update frameworks to guide clinical decision-making and patient triage. While these documents differ in scope, they share a utilitarian focus on the maximization of benefit. This utilitarian view necessarily marginalizes certain groups, in particular individuals with increased medical needs.Main bodyHere, we posit that engagement with the disability critique demands that we broaden our understandings of justice and fairness in clinical decision-making and patient triage. We propose the capabilities (...) theory, which recognizes that justice requires a range of positive capabilities/freedoms conducive to the achievement of meaningful life goals, as a means to do so. Informed by a disability rights critique of the clinical response to the pandemic, we offer direction for the construction of future clinical triage protocols which will avoid ableist biases by incorporating a broader apprehension of what it means to be human.ConclusionThe clinical pandemic response, codified across triage protocols, should embrace a form of justice which incorporates a vision of pluralistic human capabilities and a valuing of positive freedoms. (shrink)