Asian Bioethics Review最新文献

Risk prediction in emergency medicine (EM) holds unique challenges due to issues surrounding urgency, blurry research-practise distinctions, and the high-pressure environment in emergency departments (ED). Artificial intelligence (AI) risk prediction tools have been developed with the aim of streamlining triaging processes and mitigating perennial issues affecting EDs globally, such as overcrowding and delays. The implementation of these tools is complicated by the potential risks associated with over-triage and under-triage, untraceable false positives, as well as the potential for the biases of healthcare professionals toward technology leading to the incorrect usage of such tools. This paper explores risk surrounding these issues in an analysis of a case study involving a machine learning triage tool called the Score for Emergency Risk Prediction (SERP) in Singapore. This tool is used for estimating mortality risk in presentation at the ED. After two successful retrospective studies demonstrating SERP’s strong predictive accuracy, researchers decided that the pre-implementation randomised controlled trial (RCT) would not be feasible due to how the tool interacts with clinical judgement, complicating the blinded arm of the trial. This led them to consider other methods of testing SERP’s real-world capabilities, such as ongoing-evaluation type studies. We discuss the outcomes of a risk–benefit analysis to argue that the proposed implementation strategy is ethically appropriate and aligns with improvement-focused and systemic approaches to implementation, especially the learning health systems framework (LHS) to ensure safety, efficacy, and ongoing learning.

A significant and important ethical tension in resource allocation and public health ethics is between utility and equity. We explore this tension between utility and equity in the context of health AI through an examination of a diagnostic AI screening tool for diabetic retinopathy developed by a team of researchers at Duke-NUS in Singapore. While this tool was found to be effective, it was not equally effective across every ethnic group in Singapore, being less effective for the minority Malay population than for the Chinese majority. We discuss the problematic normative nature of bias in health AI and explore the ways in which bias can interact with various forms of social inequalities. From there, we examine the specifics of the diabetic retinopathy case and weigh up specific trade-offs between utility and equity. Ultimately, we conclude that it is ethically permissible to prioritise utility over equity where certain criteria hold. Given that any medical AI is more likely than not to have lingering bias due to bias in the training data that may reflect other social inequalities, we argue that it is permissible to implement an AI tool with residual bias where: (1) its introduction reduces the influence of biases (even if overall inequality is worsened), and/or (2) where the utility gained is significant enough and shared across groups (even if unevenly).

Deception in research is contentious, as ethical codes stress informed consent, yet complete disclosure may jeopardise validity. Indian Council for Medical Research (ICMR) guidelines classify deception into active, incomplete, and authorised forms. This study explores the ethical justification for incomplete (partial disclosure), permissible instances, and the dilemma faced by ethics committees in balancing scientific rigour and participant protection. The qualitative, non-experimental cross-sectional research, using in-depth interviews, identifies themes through thematic analysis. Findings reveal challenges for ethics committees, as incomplete information hampers understanding, amongst others. The paper proposes an ethics committee framework, urging researchers to minimise or avoid partial deception and recommending institutional awareness campaigns and standard operating procedures for minimal-harm studies using partial disclosure. Therefore, it proposes that partial disclosure should be justified by the 3Vs—value, validity, and veracity to preserve research integrity.

Japan has been reported as a country with high levels of vaccine hesitancy. However, a lack of comprehensive reviews studying factors for vaccine hesitancy for the COVID-19 vaccines in the Japanese context from the perspective of ethical controversy exists. Using a narrative review method, we reviewed factors associated with vaccine hesitancy to the COVID-19 vaccines and examined issues related to ethical controversy among the Japanese population. Factors associated with vaccine hesitancy include concerns about vaccine safety, suspicion of vaccine inefficacy, mistrust of the government, and low perceived threat. Factors associated with vaccine acceptance include environmental factors, factors related to Japanese cultural values, including collectivism and social norms, and positive attitudes toward information provided by authorities. Unique backgrounds in Japan are historical events such as the anti-HPV vaccine campaigns, the accessible medical system fostering high expectations of zero risk, and cultural factors of caring social norms influencing vaccine acceptance. Ethical controversies arise from preferences and practices at the individual or national level around individual rights versus public health benefits. Healthcare professionals and public health experts should continue dialoguing with the critical mass, practitioners, and policymakers, considering the ethical dilemmas surrounding individual rights and public health benefits. Insights obtained from this study indicate the need to develop tailored strategies to enhance vaccine acceptance while respecting individual autonomy within the Japanese context.

Hospitalized patients lacking the mental capacity to consent to treatment may demand to be discharged from the hospital against medical advice. Forced custody of these patients, including the use of restraints, may be required if the plan is to proceed with treatment. This raises ethical concerns with regard to depriving people of their liberty. The determination of the wishes and values of the patient and her best interests may sometimes vary, depending on the assessor or the clinical team entrusted to perform the evaluation. We therefore propose the following triad for clinicians when determining the best interests for this group of patients to ensure ethical and legal soundness as well as in providing consistency in approach. Firstly, the treatment should serve as a rescue response. Secondly, any restraint deployed must be proportionate with a foreseeable end. Her liberty and autonomy interests should be enhanced by the treatment. Thirdly, the patient’s family must be supportive. This paper analyzes the use of the triad approach on two clinical cases, both assessed as lacking in mental capacity to decide on treatment and insisting to be discharged. Using this approach, we could justify how the contrasting outcomes, one in which the voluntary discharge was acquiesced versus the other, which was not acquiesced, were reached. We also examine the compatibility of the triad approach with the obligations under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD).

The dilemmas and uncertainties related to determining mental capacity and surrogate decision-making are universally recognised as one of the most important concepts in the field of clinical ethics. In Malaysia, healthcare practitioners often find both determining decision-making capacity of patients, and identifying surrogate decision makers for incapacitated patients confusing. This paper explores the concepts of decision-making capacity and surrogate decision-making, identifying key components and associated principles such as substituted judgement and best interests. It reviews current provisions and guidances available in Malaysia that are related to these issues, including the Power of Attorney Act 1949 (revised 1990), Mental Health Act 2001, and various guidelines. It then highlights the challenges encountered in the local clinical setting due to the lack of specific legislation and clear guidance. Finally, this paper provides recommendations for improvements to address these issues in order to safeguard both the clinical practice of healthcare professionals and the rights of patients. These recommendations include the establishment of a regulatory framework with four main domains: clear and objective criteria for mental capacity assessment, provisions for advance decision-making while patients still possess mental capacity, a ladder or hierarchy of surrogate decision-makers, and provisions for appropriate surrogate decision-making standards, as well as the need for advocacy and awareness education among both the general public and healthcare professionals.