Medical Ethics

Background Biobanks are fundamental infrastructures for medical research, and their sustainable development depends on public participation and support. Older adults are at high risk of age-related diseases, making their biospecimens particularly valuable for scientific research. Amid global population aging, understanding the perceptions and willingness of older adults regarding biobank participation is essential. However, empirical evidence on this topic remains scarce in China. Methods A cross-sectional survey was conducted using a self-administered questionnaire among 1,143 Chinese participants, of whom 745 (65.18%) were (...) aged ≥ 60 years (older group) and 398 (34.82%) were aged 20–60 years (control group). The questionnaire covered demographic information, awareness of biobanks, donation willingness, informed consent preferences, and related attitudes. Chi-square tests and Spearman’s rank correlation were used for statistical analysis. Results Awareness of biobanks among older adults was low, with 14.96% of the total sample reporting having heard of biobanks, willingness to donate was divergent, with 34.03% of the total sample expressing willingness. The primary motivations were “research will improve disease diagnosis and treatment” (41.03%) and “understanding my own health” (30.10%). Major concerns included “potential harm to personal health” (35.52%) and “privacy leakage” (34.12%). Regarding informed consent, 32.28% opposed the “broad” consent model, 53.98% were unaware of the right to withdraw consent at any time, and 36.48% opposed the use of samples beyond the initial consent scope. Age was positively correlated with awareness (ρ = 0.326) and donation willingness (ρ = 0.227) (both P < 0.001). Chi-square tests showed that age, marital status, income, education, self-rated health, and activities of daily living were influencing factors of donation willingness (all P < 0.05). Conclusions Older adults have limited knowledge of biobanks but display a split willingness, a substantial minority (34.03% of the total sample) expressed willingness, with a notable proportion remaining uncertain, forming an “awareness-willingness gap”. Their donation decisions are driven by both altruistic and self-oriented motives, whereas concerns center on health risks and privacy protection. There is a substantial information deficit regarding informed consent. These findings highlight the need for tailored public communication, optimized consent procedures (e.g., tiered consent), enhanced privacy protection, and transparent governance to promote the informed and sustained participation of older adults in biobank research. (shrink)

Physician advertising is increasingly prevalent, yet public perceptions remain mixed. This study explores Iranian public attitudes toward physician advertising, focusing on exposure, credibility, professionalism, and regulatory concerns. A cross-sectional survey was conducted among 384 residents of Tehran to assess their views on physician advertising. Data were analyzed to identify trends in exposure, trustworthiness, perceived professionalism, and regulatory preferences. Results revealed mixed perceptions, with 70% of respondents reporting recent exposure to physician advertising, primarily via social media. While 74.7% acknowledged advertising’s role (...) in increasing public knowledge, only 34.9% found advertisements trustworthy. Younger respondents were more likely to believe physician advertisements contribute to health anxiety. Notably, 88% supported stricter advertising regulations. Although physician advertising offers informational benefits, concerns about credibility, professionalism, and ethical standards persist. The findings underscore the need for enhanced regulation and transparency to maintain public trust while ensuring the accurate dissemination of healthcare information. (shrink)

Background Identifying individuals with undiagnosed HIV remains a global challenge. Mobile health (mHealth) approaches that leverage social networks hold potential to increase HIV testing uptake but also raise ethical considerations. Methods We conducted a qualitative study in Moshi, Tanzania, to examine how a pilot test of an SMS-based confidential referral system for HIV testing (CONSORT) was experienced by individuals sending and receiving testing invitations. Focus group discussions were conducted prior to the pilot, while phone-based interviews were conducted both before and (...) after pilot implementation. Data were analyzed thematically using the four ethical principles of mHealth delivery: transparency, agency, accountability, and equitable access. Results Interpretations of message origin and purpose varied, shaping levels of trust and engagement. While many participants viewed the messages as supportive reminders, a few expressed confusion or concern about why they were selected. Attitudes also varied regarding the sharing of phone numbers without prior consent, with some participants viewing this as acceptable and others raising privacy concerns. Perceptions of confidentiality, message timing, and message content influenced acceptability of the intervention. These perspectives informed modifications to the design of the CONSORT system. Conclusions Ethical considerations were integral to participant experiences of CONSORT, demonstrating the need for participatory, context-specific design of mHealth interventions. (shrink)

Background Antimicrobial resistance (AMR) is an important health threat in Southeast Asia, where over-the-counter (OTC) antibiotic sales remain widespread. However, the ethical tensions shaping these informal dispensing practices remain underexplored. Methods Thirty in-depth interviews were conducted among community members, drug dispensers, and healthcare providers in Siem Pang district, northeast Cambodia to explore local perceptions of antibiotic use and the ethical dilemmas surrounding OTC sales. Participants were recruited through purposive and snowball sampling. Coding and thematic analysis were conducted in NVivo 15. (...) Results Five major themes were identified. Firstly, knowledge and perceptions of antibiotics, their use, and AMR revealed a limited understanding of antibiotic mechanisms and AMR. Secondly, perceived accessibility versus perceived safety of OTC antibiotics as financial and logistical barriers to formal care made informal sources more attractive despite perceived risks. Thirdly, collective versus individual health, whereby treatment decisions prioritize the perceived immediate needs of the individual or household over public health concerns. Fourthly, patient autonomy versus professional responsibility, as an emphasis on autonomy in informal care-seeking was not matched by reliable information or professional responsibility. Finally, justification and personal moral codes, through which informal dispensers framed selling antibiotics as socially responsible or economically necessary. Conclusion Limited knowledge and financial pressures drive dispensers and consumers to prioritize individual needs over collective risk, sustaining informal OTC antibiotic use. Ethical tensions emerge within systemic constraints, highlighting that interventions must address both economic incentives and knowledge gaps. (shrink)

Latin America is a region characterized by cultural diversity and complex social dynamics with distinct subcultures shaped by Indigenous, Afro Caribbean, and European influences. Accordingly, traditions, beliefs, and social structures vary across different countries and ethnic groups. However, many countries in the region share historical trajectories marked by colonial legacies, uneven development, and enduring structural inequalities. These trajectories have shaped contemporary conditions and are reflected in some common regional challenges, including political and economic instability, socioeconomic disadvantage, and corruption. These broader (...) conditions partly provide the context in which emerging neurotechnologies are perceived and governed in the region. To explore this issue, we focus on Argentina and Mexico, two countries with strong macroeconomic indicators compared to others in the region and important contributors to neuroscience and neurotechnology research, including high-profile neuroscience research centers. We conducted four mini-focus groups (2 groups with Mexican experts (n = 9) and 2 with Argentinian experts (n = 7)). Data was analyzed qualitatively using thematic content analysis by coding and organizing the data systematically, identifying similarities and differences across. Both Mexico and Argentina have a strong neuroscience tradition and internationally recognized research centers, yet the development and deployment of neurotechnologies is limited and uneven, largely concentrated in a few institutions. In both countries there is regulatory uncertainty and the presence of structural barriers such as chronic underinvestment in science and technology, limited interdisciplinary collaboration, and regional disparities in access. In the focus groups in Mexico, participants tended to focus on the lack of capacity building and dissemination, as well as the dependency on innovations from the Global North. In Argentina, participants underscored the enduring influence of psychoanalysis in how neuroscience and neurotechnologies are perceived and used, and they also expressed concerns around the dual use of neurotechnology. While Mexico and Argentina have their own regulatory and sociocultural landscapes, they share several commonalities with respect to neurotechnology innovation. Our findings highlight the need for better understanding the socio-politico factors shaping perspectives on neurotechnology and for more effective dissemination and interdisciplinary collaboration. (shrink)

Artificial intelligence (AI)-supported learning is increasingly used in medical education, including doctor–patient communication training. Such systems may provide virtual dialogue practice, immediate structured feedback, reflection prompts and opportunities for further practice after feedback. However, educational usefulness does not necessarily imply ethical acceptability. This study examined changes in medical students’ ethical and acceptability-related perceptions before and after participation in an AI-supported doctor–patient communication learning pathway. This longitudinal empirical ethics survey was nested within a course-based randomised educational trial but was analytically independent (...) of the parent trial’s educational outcome analysis. Surveys were administered after random allocation to the AI-supported pathway but before exposure to AI-supported learning functions (T0), at the end of the 8-week course (T1), and at the 3-month follow-up (T2). The main analysis focused on students in the AI-supported pathway with complete T0–T1–T2 ethics-related scale data and analysable T2 open-text responses (n = 31). The open-text question was included only at T2. The primary comparison was the within-participant T0–T2 change across six ethics-related domains. Two domains showed statistically significant T0–T2 changes. Trust in AI feedback decreased from 3.86 (0.55) to 3.20 (0.62), with a mean change of − 0.66 (95% confidence interval [CI] − 0.88 to − 0.42), Cohen’s dz = − 1.04 and Holm–Bonferroni-adjusted p < 0.001. Room to question AI outputs increased from 2.71 (0.68) to 3.67 (0.58), with a mean change of 0.96 (95% CI 0.69 to 1.23), Cohen’s dz = 1.29 and Holm–Bonferroni-adjusted p < 0.001. The remaining four domains showed small, non-significant changes after Holm–Bonferroni correction. T2 open-text responses indicated that students recognised the formative value of AI feedback while emphasising critical use, teacher supervision, preservation of interpersonal interaction and clearer data governance. This exploratory longitudinal empirical ethics survey showed that, following participation in an AI-supported doctor–patient communication learning pathway, two of the six ethics-related domains showed statistically significant changes: trust in AI feedback decreased, while perceived room to question AI outputs increased. These findings support continued attention to ethics-focused evaluation and clear governance arrangements in AI-supported learning pathways. (shrink)

Background Research ethics committees (RECs) and institutional review boards provide independent ethical oversight of health-related research. In Japan, the Pharmaceuticals and Medical Devices Agency (PMDA) increasingly conducts regulatory science (RS) research, which aims to generate scientific evidence to support regulatory decision-making. However, nationwide REC structures in Japan, and their alignment with the needs of RS oversight, have not been described. Methods We conducted a nationwide cross-sectional descriptive study using publicly available data from the Research Ethics Review Committee Reporting System of (...) Japan (June 5, 2024). Committee size, gender composition, and members’ professional expertise were analyzed by institution type. We compared these findings with structural requirements in Japanese regulations and guidelines. In addition, we conducted a complementary literature-based analysis of PMDA-affiliated RS research using PubMed. Major Medical Subject Headings (MeSH) terms were examined to identify dominant research areas and to contextualize the REC structure within the current landscape of RS research. Results A total of 2,604 RECs comprising 26,786 members were identified nationwide. The mean committee size was 10.3. Overall, committees commonly included multiple lay members, with 68.0% of institutions having at least two public representatives. In contrast, a substantial gender imbalance was observed, with 70.1% of committee members being male across all institutional categories. Committee composition varied by institution type. Analysis of MeSH terms in PMDA-affiliated RS research publications showed frequent focus on regulatory review, pharmacovigilance, advanced biomedical technologies, and clinical trial methodology. Conclusions Japanese RECs were characterized by variation in committee size, occupational composition, and lay representation, while substantial gender imbalance persisted. Variations in committee composition reflected institutional differences in research characteristics. In the context of RS research, REC structures that incorporate relevant expertise alongside diverse perspectives may help inform discussions on ethical review practices. (shrink)

Older adults’ low adoption of healthcare robots indicates that their lived processes of acceptance remain insufficiently understood. This gap is not merely technical but also ethical, involving questions of dignity, relational integrity, and autonomy in later life. This study aimed to develop a theory-grounded framework of how older adults pragmatically evaluate healthcare robots in home-based aging contexts, with particular attention to the ethical and relational considerations shaping their acceptance decisions. We applied Computational Grounded Theory (CGT) to 16 in-depth interviews with (...) community-dwelling older adults in Shanghai, China. Data collection continued until thematic saturation was reached. Data analysis followed a three-stage CGT procedure: (1) LDA topic modeling for initial pattern detection; (2) constant comparative analysis for thematic refinement; (3) Word2Vec-based semantic analysis for category-level coherence assessment. Six themes emerged, converging into a model of pragmatic acceptance: acceptance is not a stable preference but a conditional stance triggered by anticipated self-care decline. Older adults consistently positioned robots as intergenerational supplements—not replacements—for family care, prioritizing preservation of filial bonds while offloading instrumental burdens. Acceptance was shaped by tensions between utility and interpersonal warmth, and further conditioned by perceived control, trust in human agents (e.g., children), and core ethical concerns regarding dignity and autonomy. This framework shifts focus from technology-centric models (e.g., TAM) to a care-centered, culturally-embedded process. By integrating self-care theory, culturally embedded care ethics, and technology acceptance, it provides an explanatory lens that goes beyond a narrow usefulness-trust paradigm. It reveals that ethical acceptability—not functional performance—is the ultimate gatekeeper of robot integration in intimate care settings. For designers, it supports avoiding anthropomorphism that implies substitution of children; for policymakers, it advocates family-technology collaborative care models. In the present study, the CGT approach incorporated computational tools within a researcher-led interpretive process to assist pattern detection and provide clearer documentation of analytic steps. (shrink)

Background Reproductive donation tourism is a complex phenomenon with profound ethical implications which also affects Iran. However, studies in this context are limited. This study explores the ethical challenges associated with donor-based reproductive tourism from the perspective of Iranian clinicians, focusing on how they interpret these challenges within Iran’s legal, religious, and institutional context. Methods A conventional content analysis study was used to explore the ethical concerns in donation-related reproductive tourism perceived by clinicians in Iran. Twenty-two experts who were actively (...) involved in the field of infertility treatment, were recruited purposefully from ART centers in Tehran and the Ministry of Health of Iran in 2025. Data collection was done through in-depth, semi-structured interviews. Analysis was carried out by MAXQDA.24 software and the Graneheim and Lundman approach. A conceptual model was also proposed to explain the interaction of challenges involved in this phenomenon. Results Data analysis resulted in four themes: (1) Legal and structural heterogeneity of countries; (2) Clinical uncertainty and physical and genetic concerns in reproductive donation; (3) Synergistic moral, psychological, identity, social, and cultural-religious implications and secrecy in reproductive donation; (4) Justice, commodification, exploitation and demand in fertility tourism. These challenges can raise concerns related to justice, exploitation, commodification, and the rights of donor-conceived children. Conclusion This treatment method in Iran is surrounded by multidimensional and interwoven concerns that mutually reinforce each other. These findings indicate that reproductive donation tourism is not merely a legal and clinical issue but one that raises significant ethical concerns, requiring careful consideration of fundamental principles of medical ethics in both national and international policy-making. Therefore, developing and sharing integrated international legal and ethical frameworks to support ethically responsible and regulated reproductive care, is essential. (shrink)

Background Clinical ethics support (CES) is increasingly recognised as essential in healthcare, yet its evaluation remains challenging due to the complexity of CES practices and the latent, psychosocial nature of relevant outcomes. The European Moral Case Deliberation Outcomes Instruments (Euro-MCD original and 2.0) represents important steps in operationalising CES outcomes. However, there remains a need for a further theoretically grounded and psychometrically robust instrument. This study aimed to revise the Euro-MCD 2.0 and to develop and psychometrically test a new measurement (...) instrument for CES. Methods A sequential mixed-methods instrument redevelopment and validation design was used, guided by an abductive, theory-driven approach. Content validity processes involved conceptual framing, item revision, item development, and cognitive evaluation. Construct validity processes involved psychometric testing using survey data, incorporating principal component analysis and complementary item-level assessments. Results The revision of Euro-MCD 2.0 resulted in the Clinical Ethics Support Measurement Instrument (CES-MI), assessing ethical competence and ethical climate. Ethical competence comprises holding moral judgement, being responsive, and acting with moral courage (9 items, using a 5-point scale assessing perceived difficulty). Ethical climate comprises permissive dialogue, supportive relationships, and managing ethical concerns together (7 items, using a 4-point scale assessing perceived extent). Measurement properties were generally strong: targeting was appropriate, response categories functioned as intended, and only minor issues, such as limited local dependencies were observed. Reliability indices were high, unidimensionality was supported across the constructs, and no differential item functioning was detected by sex or intervention groups. Conclusions The CES-MI is a coherent, theoretically grounded, and psychometrically robust instrument for measurement, suitable for both clinical practice and research. The strong validity likely reflects the extensive qualitative and psychometric work underpinning the CES-MI, together with a user-friendly response format that supports reflective and authentic self-assessment. Next steps include examining the instrument’s sensitivity to change over time for example by exploring whether open-ended follow-up questions could deepen understanding of concrete changes, as well as, assessing applicability across diverse healthcare settings. (shrink)

Biobank consent models are contested globally. The EU’s GDPR Article 89, the US revised Common Rule (2018), and international guidelines offer divergent approaches to balancing participant autonomy and research efficiency. Despite ongoing policy debate, empirical evidence comparing research ethics oversight bodies (IRBs) with potential participants remains limited, particularly in Asia, where rapid biobank development has proceeded with limited stakeholder input. Taiwan’s Human Biobank Management Act provides an opportunity to examine whether governance frameworks adequately address diverse stakeholder concerns. This cross-sectional survey (...) compared the perspectives of 154 patients and 147 institutional review board (IRB) members in Taiwan regarding biospecimen consent preferences, privacy concerns, governance-related attitudes, and willingness to provide biospecimens. Participants completed a questionnaire including a single item assessing willingness to provide biospecimens, a 6-item privacy concern scale, and a 4-item governance-related confidence/expectations index derived from governance-related items in the original questionnaire, as well as items on consent model preferences. Multivariable logistic regression was used to identify independent predictors of willingness to provide biospecimens. Patients more frequently endorsed tiered consent (61.0% vs. 45.6%, p = 0.012) and were more willing to provide biospecimens (61.7% vs. 47.6%, p = 0.014) than IRB members. Privacy concerns did not differ significantly between groups (p > 0.05), and governance-related index scores were also similar across groups. In the multivariable analysis, IRB membership was independently associated with lower willingness to provide biospecimens (adjusted odds ratio AOR = 0.52, p = 0.010), whereas higher governance-related index scores were associated with greater willingness (AOR = 2.08, p = 0.010). Other variables, including age, sex, marital status, education level, prior research participation, and high privacy concern, were not significant predictors. These findings suggest that willingness to participate in biobank research is shaped by stakeholder role and governance-related attitudes, not by consent model preferences alone. Consent models should therefore be considered one component of a broader governance framework that also includes transparency, oversight, and privacy protections. Because the governance-related index likely captures multiple related dimensions, including governance expectations, support for regulatory safeguards, and confidence in oversight mechanisms, rather than trust alone, the observed associations should be interpreted cautiously. Future research using psychometrically validated measures of trust, governance literacy, and risk perception will be important for disentangling these constructs and confirming the nature of the observed relationships. (shrink)

Background Deceased donor organ procurement presents distinct ethical challenges for transplant teams, yet moral distress among these professionals remains understudied, particularly in low-donation settings. This study measured moral distress levels among organ procurement team members at a Serbian tertiary centre and examined factors associated with distress intensity. Methods This cross-sectional study administered a transplantation-adapted Moral Distress Scale-Revised (MDS-R) to 22 active transplant team members at the University Clinical Centre of Vojvodina in 2023 (response rate 78.6%, 22/28). The adapted Serbian-language instrument (...) demonstrated excellent internal consistency (Cronbach’s α = 0.89); however, it has not undergone full psychometric validation for transplantation contexts. We analysed MDS-R total composite scores (frequency × intensity, range 0–336) across professional groups and examined correlations with demographic and professional variables using non-parametric statistics. Results Mean MDS-R total composite score was 82.4 ± 31.8 (range 38–132), suggesting substantial moral distress in this sample. Compared with published point estimates from ICU (69.5) and emergency settings (71.2), our estimate was numerically higher, but the 95% CI overlapped both reference values; cross-study comparisons are descriptive only. Significant differences emerged across professional groups (Kruskal–Wallis H = 8.73, df = 4, p = 0.013, η² = 0.28): vascular surgeons reported the highest observed scores (96.4 ± 27.3), though with only four participants this finding requires cautious interpretation. Post-hoc analysis revealed a significant difference between vascular surgeons and transplant coordinators (adjusted p = 0.018). Years of transplantation experience correlated negatively with distress (Spearman’s ρ = − 0.47, 95% bootstrap CI [–0.73, − 0.12], p = 0.02). Highest-intensity distress items in the full sample were family communication dilemmas (3.5 ± 0.8) and donor body objectification concerns (3.4 ± 0.9). Nearly 60% of participants reported having considered leaving transplantation; intention to leave correlated with MDS-R scores (Spearman’s ρ = 0.52, bootstrap 95% CI [0.18, 0.76], p = 0.01), although reasons for considering departure were not systematically collected. Conclusions Organ procurement team members in this low-donation setting reported substantial moral distress. While vascular surgeons had the highest observed scores, this finding may reflect role-specific factors, demographic differences, or other unmeasured confounders, and requires confirmation in larger samples. The association between moral distress and self-reported intention to leave transplantation, though exploratory, highlights the need for further investigation of retention-focused support strategies in procurement teams. (shrink)

Pain assessment often follows a hierarchy: self‐report is treated as the gold standard, while behavioural and physiological evidence are used when the report is unavailable. This protects patients against professional disbelief but can make those unable to self‐report appear unable to contribute to knowledge about their pain. I argue that verbal report and nonverbal expression belong to one interpretive practice while retaining different epistemic roles. Self‐report carries presumptive first‐person authority because it conveys experience, meaning, and preferences. Behavioural evidence is indirect, (...) context‐dependent, and fallible, but it is genuine evidence. Physiological evidence is less specific and should remain an adjunct. When self‐report is unavailable, what changes is not the kind of pain a patient may have but the evidence available and what it can justify. Drawing on the social communication model of pain, nursing accounts of tacit and relational knowledge, phenomenology, and epistemic injustice, I use functional distress to name an organised pattern of clinically significant change. The functional‐distress framework explains when that pattern supports suspicion of pain. It is not another assessment instrument; it shows how clinicians combine validated tools with timing, relationships, clinical context, alternative explanations, and reassessment. Functional distress does not prove pain. It can provide reversible grounds for suspicion; separately, risk, vulnerability, and reversibility may justify a proportionate precautionary response. The ethical task is to preserve first‐person authority without treating patients who cannot exercise it as epistemically absent. (shrink)

Organisational justice has emerged as a key area of interest given the challenges of protecting the health and well‐being of nurses in healthcare organisations. Existing research shows significant conceptual and methodological limitations that must be addressed to achieve a more comprehensive and ethically grounded understanding of nurses’ needs in the healthcare system. This article explores how nurses experience their working conditions within public healthcare organisations through a theoretical lens of social justice to unveil the systemic injustices embedded within them. Adopting (...) a critical discourse analysis approach, this study draws on 31 semi‐structured interviews with nurses working within the public healthcare sector in the Balearic Islands (Spain), informed by Nancy Fraser's feminist theory of justice. The findings illustrate that nurses conceptualised organisational justice as the condition that allows them to practice their profession in accordance with their professional ethos. This novel understanding of organisational justice underscores the economic, social, cultural and political manifestations of gendered injustices nurses face in their daily practice and that prevent them from being considered as peers in the social life of healthcare organisations. This study highlights the imperative to rethink organisational justice through a lens that accounts for the gendered nature of care and nursing work. Nancy Fraser's theory of justice emerges as a groundbreaking framework that offers novel insights to guide this transformative endeavour. (shrink)

Vulnerability is widely invoked in healthcare, bioethics, and nursing, yet it remains poorly defined because universal human susceptibility, situational exposure to harm, and clinical frailty are frequently treated as interchangeable. This conceptual ambiguity is particularly significant following a fall, when older adults may be understood predominantly through physical risk, functional decline, and the need for protection. Through an interpretative analysis drawing on nursing philosophy, feminist bioethics, phenomenological accounts of embodiment, and nursing ethics, this paper critically examines the distinction between frailty (...) and vulnerability in older adults following a fall. It argues that frailty describes a multidimensional clinical condition involving reduced physiological reserve, whereas vulnerability also emerges through lived experience, relationships, material resources, and institutional practices. A fall may therefore intensify vulnerability not only through bodily disruption but also through changes in dependence, decision‐making authority, and participation in everyday life. Nursing care occupies an ethically ambivalent position within this process: protective interventions may reduce avoidable harm while simultaneously restricting agency or generating pathogenic vulnerability. To address this tension, the paper develops the concept of responsive protection as an ethical orientation for post‐fall nursing care. Responsive protection requires protective practices to be negotiated with older adults, proportionate to the risks and burdens involved, and revisable as circumstances and capacities change. The paper concludes that safety, relational autonomy, and dignity should be understood as interdependent dimensions of an ethical nursing response to post‐fall vulnerability. (shrink)

Background Ethical debate on nudging in clinical decision-making has largely focused on whether nudges are transparent, autonomy-respecting, and permissible. I argue that this framing is incomplete as the ethical question is not whether nudges are acceptable, but what healthcare organisations owe patients when interventions succeed, fail, or leave the main source of unsafe care unaddressed. This article develops a framework for evaluating when organisations should move beyond nudges or boosts. Methods I conducted a conceptual analysis of behavioural interventions in clinical (...) decision-making and examined three intervention levels, i.e., nudges, boosts, and system redesign. I interpreted their outcomes as evidence that can update a working hypothesis about the likely limiting source of impaired decision quality. I then developed an escalation framework specifying when organisations are ethically required to move between intervention levels. Results The analysis suggests that intervention outcomes can help update hypotheses about whether an important constraint on clinical decision quality is contextual, capability-based, or structural. I introduce the concept of institutional moral displacement, in which organisations respond to structurally generated problems with individual-level interventions, thereby shifting responsibility onto clinicians. The framework is diagnostic rather than sequential, i.e., where evidence already locates the dominant constraint in organisational structure, structural intervention is warranted directly, and interventions at different levels may be combined rather than exchanged. A verified failure does not by itself establish where the constraint lies, but it shifts the burden of justification onto the organisation. An intervention that improves an average outcome while widening a clinically meaningful gap between patient groups is not adequate for the disadvantaged group and may warrant escalation on that group’s behalf. On this view, continued reliance on lower-level interventions becomes ethically problematic once available evidence indicates that the true source of harm lies elsewhere. Conclusions Ethical evaluation of behavioural interventions in healthcare should focus not only on the permissibility of nudges, but also on organisations’ obligations to escalate when lower-level interventions do not address the best-supported source of unsafe care. A diagnostic escalation approach better protects patients, preserves clinician autonomy where possible, and clarifies when competence-building or structural reform is ethically required. (shrink)

Background There is limited practical guidance for researchers and oversight boards in identifying and addressing group-level risks in the context of repository-enabled research. The Community Health Interests for Researchers & Oversight Networks (CHIRON) Toolkit is a community co-designed, nudge-theory-informed online intervention developed to support repository researchers, ethics boards, and data access committees in systematically considering community-level interests and risks in their work. This study reports a qualitative evaluation of how the Toolkit was received when used across four repository-research settings. Methods (...) We piloted the CHIRON Toolkit at four sites between October 2024 and June 2025 with eleven participants, including repository researchers, data access committee members, and ethics professionals. We collected qualitative data through semi-structured interviews at three timepoints per site and through participant-completed exploration guides. We used reflexive thematic analysis to examine meanings participants attributed to their experiences, enriched by contextual analysis across four layers and community expert co-analysis of pilot data. Results Analysis identified nine parent themes across four contextual layers: transparency, context confusion, “not my job,” comfort versus challenge, readability and interpretation, US context, personal and professional identities, nudging versus instructing, and thinking together versus thinking alone. Themes were organized across four contextual layers ranging from toolkit design to societal context. Themes revealed a fundamental tension between transactional change—incremental improvements within existing institutional structures—and transformational change—structural reorientation toward community-centered governance. While CHIRON prompted meaningful reflection among participants, their responses were largely constrained by institutional norms, professional role boundaries, and organizational expectations. Community experts, through co-analysis, identified these shifts as promising but incomplete, consistently prioritizing community interests over institutional convenience. Conclusions Transactional governance tools like CHIRON are necessary but insufficient to ensure communities benefit from repository-enabled research. Complementary structural reforms—in oversight committee mandates, funder requirements, researcher training, and the redistribution of decision-making power—are needed to move from incremental improvement toward transformational, community-centered governance of repository-enabled research. (shrink)

Background Physician-assisted dying (PAD) remains prohibited in Sweden despite increasing public and professional support, and ongoing societal debate. Since medical students are future physicians, they constitute a relevant group for studying potential shifting attitudes to PAD. The present study examined Swedish medical students’ attitudes toward PAD, explored how ethical reasoning and individual characteristics relate to these attitudes, and assessed whether value-laden terminology influenced responses. Methods A cross-sectional mixed-methods study was conducted among medical students from all semesters and at all seven (...) Swedish medical faculties (2024–2025). Two parallel questionnaires, differing only in terminology (“physician-assisted dying” [PAD] versus “physician-assisted suicide” [PAS]), were electronically distributed. Each defined the practice as a physician prescribing lethal medication for patient self-administration and presented a clinical vignette designed to reflect a typical case under the Oregon Death with Dignity Act, structured questions and free-text response fields. Quantitative data from the questionnaires were analysed using chi-square tests and qualitative data using thematic analysis. In total, 2,107 responses were included (response rate 23%). Results Overall, 57% of the participants supported legalisation of the specific form of PAD described in the vignette, 23% opposed it, and 20% were undecided; 53% reported willingness to personally assist if legal, while 68% opposed mandatory participation. No significant differences were observed between questionnaire versions. Prioritisation of autonomy was associated with support for PAD and willingness to assist, whereas prioritisation of non-maleficence and beneficence was associated with opposition or uncertainty (p <.001). Religious belief was associated with more restrictive attitudes (p <.001). Qualitative findings highlighted tensions between ethical principles, professional responsibility, and concerns about societal and clinical consequences. Conclusions The findings suggest that Swedish medical students generally hold favourable attitudes towards the Oregon model of PAD examined in this study, reflecting a possible shift compared with previous studies. Nevertheless, views remained highly polarised, with respondents presenting strongly argued positions on both sides of the debate. Students’ attitudes toward PAD were shaped by ethical frameworks and religious beliefs. The results did not indicate that the choice of a potentially value-laden term such as PAS substantially influenced responses. (shrink)

Background Discrete choice experiments (DCEs) are quantitative preference-elicitation methods, developed largely within health economics, in which participants choose repeatedly between hypothetical scenarios composed of systematically varied attributes. Their growing use with children supports children’s right to be heard in decisions affecting their care, yet it also raises ethical challenges that general paediatric research ethics guidance does not address in operational detail: sustained cognitive demand, potential emotional distress, assent that can blur under clinical stress, parental influence, clinician–researcher role conflict, and the (...) processing of children’s personal data. Methods We developed a prospective ethical governance framework during the preparatory phase of the PREF-ANX Kids study (Preferences for Preoperative Anxiety Management in Children), a planned multicentre DCE examining preferences for nursing interventions to manage preoperative anxiety among children aged 6–12 years undergoing elective surgery in Portuguese public hospitals, their parents, and healthcare professionals. Development combined a pragmatic, non-systematic synthesis of ethical, regulatory, and methodological guidance with iterative structured discussion within an interdisciplinary team. No formal consensus method was applied, and no children or families were involved in development; we identify this as a limitation. Framework The framework comprises four domains operating across the research lifecycle: relational participation, cognitive and emotional safeguarding, reflexive professional responsibility, and privacy stewardship. For each domain it specifies planned procedures (continuous assent and dissent monitoring, adapted task burden, structured reflexive documentation, and a prospective data protection impact assessment) together with their normative justification, and it distinguishes elements specific to PREF-ANX Kids from elements potentially adaptable to other paediatric DCEs. Trade-offs between competing ethical and methodological priorities are made explicit rather than resolved silently. Conclusions The framework is prospective: it has not yet been implemented or empirically evaluated, and no claims of demonstrated effectiveness are made. It is intended to support transparent ethical planning of DCEs involving children aged 6–12 years and will be assessed during the PREF-ANX Kids study. Future refinement should incorporate co-design with children and families and empirical evaluation of feasibility, acceptability, participant experience, and data quality. (shrink)

BackgroundThe rapid integration of Large Language Models (LLMs) into health research presents a dual promise: to serve as an epistemic equalizer by lowering barriers to scientific participation, and a significant governance challenge, risking a “validity gap” where output volume outpaces integrity. Research Ethics Committees (RECs), tasked with safeguarding research, face a critical “purview weakness” in evaluating these opaque technologies. This tension is most acute in African contexts, where the need for innovation intersects with vulnerability to algorithmic colonization and where empirical (...) data on REC preparedness is absent.MethodsA qualitative study employing in-depth, semi-structured interviews was conducted with a purposively sampled cohort of 14 REC chairs, members, and research ethics office staff from health science institutions across South Africa. Data were collected between January and July 2024, transcribed verbatim, and analysed using inductive thematic analysis.ResultsAnalysis yielded five central themes namely: (1) understanding of LLMs, (2) perceived benefits of LLMs use in health research, (3) perceived challenges and concerns in the use of LLMs in health research, (4) human oversight – augmentation, not automation, and (5) fragmented AI literacy within the research. Respondents recognized significant benefits in administrative efficiency, research lifecycle support, and democratizing writing skills. Crucially, there was unanimous consensus that LLMs must only augment, not automate, ethics review. Human oversight was deemed irreplaceable for contextual understanding, empathy, and complex moral deliberation qualities respondents implicitly aligned with relational, Ubuntu-informed ethics.ConclusionSouth African ethics gatekeepers perceive LLMs as powerful but risky tools. Their insistence on human-centric governance, rooted in contextual and communal values, provides a vital counter-narrative to purely technocratic oversight models. These findings provide an urgent empirical foundation for developing context-specific AI governance guidelines in African and other LMIC health research systems. (shrink)

Background Euthanasia remains a complex ethical, legal, and medical issue. Although euthanasia is not legally permitted in Türkiye, understanding medical students’ attitudes toward euthanasia is important for medical education, bioethical debate, and future policy discussions. This study aimed to adapt the Attitudes Toward Euthanasia scale into Turkish, evaluate its psychometric properties among medical students, and interpret the resulting factor structure within a medicolegal context. Methods The final analytical sample comprised 967 medical faculty students. Although law faculty students were initially included (...) in the study design, their low representation precluded meaningful psychometric evaluation; therefore, all analyses were conducted only with medical students. Linguistic equivalence was established through forward–backward translation, expert review, and pilot testing. Because previous cross-cultural adaptations had reported different factor structures, the dataset was randomly divided into two independent subsamples for exploratory factor analysis and confirmatory factor analysis. Analyses were based on the polychoric correlation matrix. Principal axis factoring was used for the exploratory phase, and the unweighted least squares with mean and variance adjustment estimator was used for the confirmatory phase. Reliability was evaluated using McDonald’s omega and stratified alpha. Results Exploratory factor analysis identified a two-factor structure, which was confirmed in the independent confirmatory subsample. The two factors were labeled Patient Request and Doctor’s Authority. The model showed adequate fit: comparative fit index = 0.977, Tucker–Lewis index = 0.970, root mean square error of approximation = 0.079, and standardized root mean square residual = 0.029. The two-factor solution differed from the original four-factor conceptual structure and suggested that patient request was interpreted together with severe suffering in this medical student sample. McDonald’s omega was 0.926 for Patient Request and 0.931 for Doctor’s Authority, and stratified alpha was 0.927 for the total scale. Item discrimination was statistically significant for all items. Conclusions The Turkish version of the Attitudes Toward Euthanasia scale appears to be a valid and reliable instrument for assessing euthanasia-related attitudes among Turkish medical students. Its two-factor structure, centered on Patient Request and Doctor’s Authority, supports its use in medical education, bioethics research, and cross-cultural comparisons. The findings also suggest that some ATE items may carry context-dependent meanings and should be further examined in future content-validity studies. (shrink)

Background Consistent compliance with hand hygiene is a crucial measure for the prevention of hospital-acquired infections. In recent years, various systems have been developed to support both nurses and doctors with improving their hand hygiene. However, the data sets collected to provide feedback offer the potential for excessive surveillance and punitive measures in cases of non-compliance, which creates an ethical conflict between promoting patient safety and preserving an ethically acceptable work environment for healthcare workers. Method By adopting an interdisciplinary socio-technical (...) approach and correlating the ethical concerns with the technological specification of such systems, the paper analyses this ethical conflict in detail. Results The paper demonstrates that optimized implementation strategies can minimize the ethical tensions. Additionally, the authors point out several aspects of the design process of such monitoring systems, including the active participation and involvement of staff, which positively contribute to the mitigation of this ethical conflict and also increase user acceptance of the systems. It also covers the deployment of a monitoring system in a hospital in Stralsund, Germany and discusses previous observations while simultaneously highlighting the problems with the design of the system according to the described ethical tensions. Conclusion While the installation of a hand hygiene monitoring system can benefit the awareness for hospital hygiene, the development of such systems remains an ongoing and evolving process, particularly regarding the resolution of the ethical conflict. This paper argues that such systems should be used in a non-punitive and transparent manner, developed participatively with medical staff, and implemented in ways that ensure the collected data are used positively and responsibly. (shrink)

Due to the widespread use of generative artificial intelligence (GenAI) in undergraduate medical education (UGME), this study aimed to develop a set of consensus-based principles for the responsible and ethical use of GenAI, established by medical students and faculty and further validated by international medical and artificial intelligence (AI) experts. A four-round modified Delphi process, an in-person idea-generation round, two structured rating rounds, and an external expert validation round were conducted between May 2025 and February 2026. The panel included medical (...) students (n = 13) and medical professors (n = 2) in the first three rounds, and international experts in medical education and AI (n = 9) in the final round. In Round 1, an open-ended question yielded 37 potential principles. In Rounds 2 and 3, these items were rated using a 7-point Likert scale (1 = Strongly Disagree, 7 = Strongly Agree) with space for written comments; median scores and interquartile ranges were used to assess the strength of agreement against predefined decision rules, and the principles were retained, reworded, consolidated, or excluded accordingly. In Round 4, the near-final principles were validated by 9 international experts in AI medical education, AI ethics, AI technology education, or senior medical educators involved with AI curricula. The process identified 14 consensus-based principles for the use of GenAI in UGME. Given the swift adoption of GenAI in medical education, students need explicit guidance for ethical and responsible use. We established an internationally informed, expert-validated set of principles for medical students’ use of GenAI through a student-partner Delphi study with external validation by a multinational expert panel. Institutions developing GenAI guidelines may adapt this framework for implementation in local educational contexts. (shrink)

Background Neurodiversity emerged from autistic self-advocacy communities in the mid-1990s. Other anti-stigmatization narratives are widely advocated to reduce autism-related stigma. In China, parent-led organizations and charitable organizations have played an indispensable role in challenging discriminatory attitudes and protecting the dignity of autistic individuals and their families, notably through anti-stigma narratives such as “Gūdúzhèng” [literally meaning “autism” with a focus on loneliness, an alternative term to avoid stigma], “children of the stars,” and “genius narrative.” However, the impact of these specific one-sided (...) beautification narrative strategies on access to medical resources and health equity remains under-researched, with limited attention to the potential unintended consequences of such positive narratives. Methods This study adopted a qualitative descriptive research design and selected four cities through purposive sampling. Data collection methods included semi-structured interviews and participant observation. Results The study drew three core conclusions: (1) Disability-removing narratives (such as “Gūdúzhèng”) may inhibit parents from applying for disability certificates for their children, hindering access to medical resources; (2) Homogenized terms (such as “Gūdúzhèng” and “genius”) obscured the heterogeneity of the autism spectrum and comorbid medical needs, reducing the supply of charitable medical resources; (3) Templated charitable fundraising narratives exacerbated the Matthew Effect in the allocation of charitable resources. Conclusion The jointly constructed homogenized and templated beautified narratives of autism are designed to reduce stigma and are pursued with the legitimate goal of safeguarding dignity. However, they inadvertently perpetuate reverse stigmatization and conceal the genuine medical and rehabilitation needs of autistic individuals, contributing to autism-related health inequality. This study emphasizes the urgent need for balanced narrative frameworks that integrate identity, dignity, and explicit recognition of autism spectrum heterogeneity and lifelong support needs. (shrink)

The link between spirituality and body donation is an important consideration, especially in Nigeria, where there is currently no formal body bequest program for medical education and research purposes. This study delved into students’ spiritual perspectives, gauging their impact on their willingness to donate their bodies for educational or research purposes. This cross-sectional study assessed 1158 Nigerian medical and allied health students who have been exposed to cadaver dissection via an online questionnaire developed from interviews and the Spirituality Orientation Inventory, (...) which included questions on spiritual beliefs, willingness, and reasons for body donation. Descriptive analysis and chi-squared tests were used to decide proportions and relationships between the study variables, with statistical significance set at p < 0.05. About students’ familiarity and attitudes towards body donation, 15.2% were unfamiliar with the concept. In terms of their stance, 35.23% expressed support for body donation, while nearly half, 49.49%, remained neutral on the subject. Most students (63.65%) refused to consider body donation after death. Only a few respondents (17.62%) were open to donating for education or research or if they would benefit from it (10.49%). More than half (56.24%) agreed that they followed their religion’s teachings. 76.37% believed in life after death, 40% were uncertain about reincarnation while 54.28% were unaware of their religion’s stance on body donation. However, belief in reincarnation is significantly associated with students’ willingness to donate their bodies (p = 0.026). Awareness of body donation among Nigerian medical students is low, with many expressing neutral attitudes and limited understanding of their religion’s stance. Willingness to donate is generally poor, and while spirituality plays a role, specific beliefs such as reincarnation appear more influential than overall religiosity. These findings highlight the need for targeted education and culturally sensitive awareness initiatives. (shrink)

Shared decision-making (SDM) in mainland Chinese clinical contexts is characterized by a persistent ethical tension between Confucian familism, which prioritizes collective family interests, and the Western principle of patient autonomy, which emphasizes individual rights. This tension has led to widespread clinical challenges, including family-driven protective information concealment and ambiguous boundaries between supportive and intrusive family involvement. Current literature lacks an integrated, culturally responsive framework to reconcile these tensions. This study therefore develops a Confucian ren-based model that harmonizes patient autonomy with (...) familial values within Chinese healthcare settings. We employed a dual methodology of theoretical reconstruction and clinical case analysis. First, we elucidated the conceptual structure, strengths, and limitations of Confucian benevolence ethics (e.g., familism, filial piety, graded love) in medical decision-making. Second, illustrative clinical cases were examined to assess the consequences of excessive family intervention on autonomy and outcomes. Finally, a cross-culturally informed model was developed through critical engagement with the Whānau Ora approach (New Zealand) and Hong Kong’s “moderate familism” practice. Two illustrative clinical cases from mainland Chinese practice are analyzed to demonstrate how the proposed model addresses real-world ethical dilemmas. We propose a tiered collaborative decision‑making model centered on patient autonomy, with moderated family involvement serving as a flexible boundary. Ethical prioritization varies by context. (1) For routine treatment decisions, family‑led decision‑making, supported by structured family meeting documentation, is applied when patients delegate authority or lack capacity, thereby ensuring cultural alignment and efficiency. (2) In high‑risk interventions, mandatory tripartite shared decision‑making (clinician–patient–family) is initiated, utilizing decision aids to integrate clinical evidence, patient values, and familial concerns. (3) For end‑of‑life care, advance directives take precedence, with multidisciplinary ethics committees mediating disagreements. This framework repositions Confucian relational ethics as a resource for reinforcing patient subjectivity, establishing a “moderate familism” model that harmonizes patient, family, and clinician roles. It not only addresses institutional contradictions between legal individualism and cultural collectivism in Chinese medical practice but also offers a multicultural-sensitive paradigm for global bioethics. (shrink)

Pain remains a persistent and ethically consequential problem in healthcare because recognizing another person's suffering requires judgements about testimony, credibility, and appropriate response. Yet, nursing responses to pain continue to be shaped by uncertainty about what pain is, how it is known, and how it should be responded to. Although nursing scholarship contains extensive work on pain knowledge, attitudes, barriers, and assessment tools, it offers less conceptual clarity on a central question raised by emerging technologies: what happens to nursing judgement (...) when artificial intelligence (AI)‐assisted systems claim to recognize pain? This paper argues that AI‐assisted pain recognition should be treated as a fallible adjunct to nursing judgement rather than as an objective arbiter of pain. Drawing on nursing philosophy, epistemic injustice, contemporary pain theory, and recent debates on nonverbal assessment and AI, I argue that pain is not merely a signal to be measured but a personal, embodied, and interpretively mediated experience disclosed through testimony, context, and clinical judgement. I further argue that epistemic humility, while necessary, is not sufficient for nursing practice. In response, I develop a nursing framework of relational discernment, grounded in presumptive respect for pain testimony, contextual triangulation, bias‐aware credibility judgement, relational accountability, and contestability of algorithmic outputs. This framework clarifies the nurse's role in recognizing and responding to pain under conditions of technological mediation and offers a philosophically grounded basis for more humane and ethically defensible pain assessment and management. (shrink)

This paper offers a philosophical critique of the moral economy of nursing research under conditions of commodification and metricisation. Using the concept of the junkification of research as an analytic lens, it examines tensions that may arise when institutional criteria such as publication volume, journal prestige, citation visibility, grant capture and speed of dissemination operate alongside criteria concerned with methodological rigour, conceptual contribution, ethical seriousness and practical significance. The paper does not claim that nursing research as a whole has become (...) junkified or that particular areas of nursing knowledge have been empirically demonstrated to be marginalised. Rather, it asks how contemporary evaluative conditions may shape what forms of scholarship are feasible, recognised and circulated. It argues that this question is especially important in nursing because nursing knowledge is simultaneously empirical, explanatory, interpretive, relational, situated and practice‐accountable. The paper further examines how marketised access and prestige structures can affect participation and epistemic recognition, and concludes by framing doctoral education, academic leadership, publishing, institutional assessment and professional governance as sites of disciplinary stewardship. (shrink)

Lateral violence among nurses is most often explained as oppressed group behavior: aggression displaced from an external oppressor onto peers. Drawing on the Korean phenomenon of taeeum, the harsh “breaking‐in” of novice nurses, this paper argues that such accounts leave two things unexplained. Why should the violence wear the language of care, teaching, and community? And why does it persist despite being named and condemned? It proposes that these features become intelligible only when the phenomenon is read not as an (...) absence of community but as its forgery. Taking Ubuntu's proposition that a person becomes a person through other persons, and Menkiti's claim that personhood is a communal attainment that can fail, the paper reconstructs the community as a directional apparatus whose purpose is to raise the novice into a person. It then rereads a meta‐synthesis of qualitative studies of taeeum and shows that the forms of community, including hierarchy, belonging, dialog, and care, remain fully in place while their direction is reversed. This state is named forgery: a structure that possesses every form of the genuine while betraying its purpose. The paper defends the concept against neighboring terms by a substitution test, argues that forgery has no single forger because in taeeum circulation is itself production, and thereby explains persistence: like counterfeit currency, forgery passes by acceptance rather than belief, so condemnation aimed at malice misses it. The same diagnosis is shown to hold in Confucian terms, where taeeum takes the ritual and discards the humaneness, and Ubuntu itself is shown to be subject to betrayal, distinguishing erosion (recoverable absence) from forgery (persisting misdirection). The account offers not a criterion for adjudicating cases but a way of seeing, returning to the nursing community a set of questions about the direction of its own relationships. (shrink)

Background End-of-life medical decision-making (EOL MDM) for (unborn) children is an integral part of perinatology. Medico-ethical guidelines for EOL MDM increasingly recommend shared decision-making (SDM) with parents. One argument for SDM is that parents prefer it. However, when SDM is distinguished from other forms of collaborative EOL MDM (cEOL MDM), parents’ role preferences are not uniform. We aimed at exploring 1) how parents who have experience with cEOL MDM for their (unborn) child derive their preference for a certain role and (...) 2) which role they prefer. Methods For this purpose, we used Meta-Ethnography (ME) to synthetize qualitative studies on parents’ perspectives on EOL DM. Results The synthesis of 16 articles resulted in a line of argument which explains a process of preference-formation: Parents who experience a certain role allocation can evaluate it differently at different time points, and may express their experience-based, informed preferences towards future decision-making (DM) as a willingness (not) to repeat their experience. At least four different practice models can be distinguished based on parents’ experiences: the tacit approval model, the recommendation acceptance model, the shared deliberation model and the preference determination model. Despite its prevalence in the theoretical literature and recommendation in several international guidelines, the shared deliberation model has only been described by parents in two studies. Parental preference-formation can be shaped through a process of dissonance reduction and a process of meaning-making. Most parents express the willingness to repeat their experience, regardless of their role in the cEOL MDM. Conclusion As adopted DM models, and consequently the level of parental involvement in perinatal end-of-life decision-making (EOL-MDM), as well as parents' preferences, vary considerably across different contexts, it is questionable whether guidelines should prescribe only one DM model. Rather than aiming to give parents maximum decision-making authority, physicians should adapt their choice of model to the specific situation. While parents’ expectations are one factor in deciding on the appropriate model, other factors, such as the infant's prognosis, also need to be considered. (shrink)

Xenotransplantation using genetically edited pig organs has been considered a promising solution to the global organ shortage. However, its successful implementation depends not only on scientific advance but also on public acceptance. Empirical evidence on public awareness, acceptance, and ethical concerns regarding xenotransplantation in China remains scarce. This study was conducted to investigate public familiarity with xenotransplantation, acceptance of the technology, and factors associated with acceptance. A cross-sectional survey was conducted among adults in mainland China based on a structured questionnaire. (...) A convenience sampling strategy was adopted. Data regarding demographic characteristics, familiarity with xenotransplantation, acceptance under a life-saving scenario, religious considerations, and perceived impact on human organ donation were collected. Descriptive statistics, binary logistic regression, and ordinal logistic regression were used for analysis. A total of 589 valid questionnaires were analyzed. The majority of respondents (85.57%) had at least heard of xenotransplantation, although only 4.92% reported being very familiar. In a hypothetical life-saving scenario, 36.67% reported they would definitely accept xenotransplantation, while 11.54% would definitely not. Acceptance was higher among males, younger adults, medical workers, and those familiar with the technology, and lower among individuals with higher education or perceived religious conflict. Perceived religious conflict was significantly associated with acceptance (OR = 0.22, p < 0.01). Respondents with more optimistic expectations of xenotransplantation were more likely to perceive that it would weaken willingness to donate human organs (OR = 5.49, p < 0.01). The main public concerns included clinical trial safety (75%), postoperative outcomes (74%), and costs (63%). Public familiarity with xenotransplantation in China remains limited, and acceptance is shaped by sociodemographic factors, religious beliefs, and familiarity with the technology. Transparent risk communication, culturally sensitive public engagement, and stratified information strategies are required to support responsible clinical translation into practice and ethical governance of xenotransplantation. (shrink)

Artificial intelligence (AI) is widely expected to mitigate global health inequities. However, current research mainly focuses on downstream issues such as algorithmic bias and data limitations and neglects upstream power structures and historical structural root causes. This study examines how AI deployment in global health may reproduce and reinforce structural inequities. A reflexive thematic analysis was conducted base on systematic searches of PubMed, Scopus, Embase, and Web of Science from database inception to April 2026. The search strategies combined three conceptual (...) domains: “AI”, “global health” and “justice”. Supplementary searches were performed through reference list screening, with final inclusion determined by relevance to the research theme. After screening a total of 554 records, 37 studies were ultimately included in the qualitative analysis. A comprehensive justice framework was constructed to identify how AI-related justice dilemmas emerged across global health systems, with the Global South and resource-limited contexts serving as critical sites where global power asymmetries became especially visible. The findings reveal that justice is not limited to the distribution of resources but also encompasses multiple dimensions, including procedural, historical and structural, epistemic, and reparative justice. AI justice reflects global power relations; effective equity transformation requires examining and reconstructing power structures in which AI is embedded. Whether AI ultimately bridges or widens global health inequities depends not on algorithmic sophistication but on the willingness to redistribute the power that shapes its design, deployment, and governance. (shrink)

Background Clinical trials often require women and girls of childbearing potential to adhere to contraceptive mandates, typically requiring the use of two forms of contraceptives for the duration of the study. Understanding adolescent perspectives on contraceptive mandates within HIV prevention and treatment trials is critical for evaluating whether and when such requirements are ethically justified and, if so, how they might be appropriately applied in trials involving this group. Methods We conducted semi-structured interviews with adolescents age 15–24 in the U.S. (...) on their perspectives about contraceptive requirements. Interviews were audio-recorded and transcribed verbatim. We used Nvivo qualitative analysis software to code transcripts, and then conducted thematic analysis to identify emergent patterns in adolescents’ perceptions of the advantages and disadvantages of requiring contraception use for adolescent participants of HIV research studies. Results Forty adolescents were interviewed in total. Overall, most participants expressed support for a contraceptive requirement. Regardless of their stance, perceived advantages and disadvantages of such requirements stood in tension, including the ability to prevent pregnancy and desires to become pregnant, desirable health benefits and concerning side effects, and voluntary participation and violated decisional autonomy. Conclusion Our findings illustrate that although contraceptive mandates are intended to facilitate and promote inclusion in research, they can simultaneously work to restrict adolescent participation in research and limit access to its potential benefits. In doing so, these requirements risk undermining their ethical justification and obstructing the generation of data needed to advance health outcomes for adolescents. (shrink)

BackgroundRapid population ageing in sub-Saharan Africa (SSA) is unfolding within fragile health systems, weak social protection, and limited geriatric and palliative services, creating ethical challenges in older adult care. This study critically reviews current literature and policy reports, synthesizes key themes, and proposes evidence-based recommendations for policy, practice, and research.MethodsThis scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology and reported following PRISMA-ScR guidelines. A comprehensive search of biomedical, ethics, social science, and grey literature databases was (...) undertaken to identify studies published between 2000 and 2025 on ethical issues in the care of older adults in Sub-Saharan Africa. Eligible English-language sources were screened by predefined inclusion criteria, and data were charted and synthesized thematically to map key ethical issues, concepts, and evidence gaps.ResultsWe identified multiple ethical challenges that affect older adult care in SSA, including justice, equity, autonomy, dignity, vulnerability, abuse, and ageism. Healthcare-related concerns involve unmet needs, resource allocation dilemmas, limited palliative and end-of-life care, and age-biased clinical decisions. Socially, weakening family support systems create moral tensions for caregivers. Policy analyses emphasise rights-based, culturally sensitive, and equitable approaches, highlighting the need for integrated ethical, social, and systemic care strategies.ConclusionsAddressing ethical issues in older care in SSA requires legally enshrined protections, health-system investments, public campaigns to counter ageism, supportive decision-making frameworks that respect cultural contexts and individual rights and strengthened research and surveillance. A right-based, culturally sensitive approach focused on the voices of older persons is essential.RegistrationThe protocol for this scoping review was registered on the Open Science Framework (OSF) and is available at https://doi.org/10.17605/osf.io/9axvw. (shrink)

Background Clinical Ethics Committees (CECs) are services for supporting healthcare professionals (HPs) in dealing with ethical issues in clinical practice. The CEC of the Local Health Authority (LHA) of Reggio Emilia was implemented in 2020 in the context of a research project (EVACEC) aimed at identifying how a CEC can be successfully normalized within a healthcare organization. This mixed-methods article describes the CEC’s dissemination, use and integration among HPs, with a focus on the experiences of those who required ethics consultation. (...) Methods Quantitative data on dissemination, knowledge, and use of CEC were gathered through an online survey sent to all HPs of the LHA and were analyzed by descriptive statistics. Qualitative data were collected by semi-structured interviews with those HPs who submitted an ethics consultation request and were analyzed by thematic analysis. Results Two hundred seventy-three HPs completed the survey, with 80.6% reporting to have faced at least one ethical issue in their clinical practice. 57.7% were aware of the service, with heterogeneous levels of knowledge about the CEC functions, composition, and target users; barriers to access were also identified. Among them, only 23.4% had actually utilized it and 85.7% of this subsample found it useful. From June 2022 to October 2022, 5 HPs who submitted a request to the CEC were interviewed. Thematic analysis revealed four themes: (i) a sense of loneliness in the decision-making process: seeking ethical support; (ii) valued features of the CEC: a source of mutual and expert support; (iii) how ethics consultation supports medical decision-making; (iv) trust, visibility, and access: key features to normalization. Conclusions Our findings show that when accessed, CEC offered support by providing multidisciplinary perspectives and fostering deliberation in morally complex situations. However, the limited awareness and use of the CEC among those HPs most exposed to ethical issues suggests that further institutional efforts (i.e. integrating ethics training into routine clinical practice and establishing clearer referral pathways), are required to improve its dissemination and ethical sensitivity among HPs. Further research is needed to assess the long-term impact of these implementation strategies to identify best practices for CEC normalization. Trial registration The protocol has been registered on ClinicalTrail.gov (registration n. NCT05466292). (shrink)

Genomic newborn screening (gNBS) has been proposed as an expansion of traditional newborn screening to enable early identification of hundreds of genetic conditions. As gNBS programs move from research pilots toward population-level implementation, the ethical, legal, and social implications (ELSI) have shifted from largely hypothetical concerns to pragmatic challenges embedded in program design, implementation, and evaluation. This study aimed to assess how gNBS researchers perceive and prioritize the most pressing ethical issues they encounter, in order to inform embedded empirical ethics (...) and support responsible scale-up of gNBS. We administered a survey to members of the International Consortium on Newborn Sequencing (ICoNS). The survey assessed researchers’ perspectives on ethical priorities across three phases of gNBS programs (design, implementation, and evaluation), perceived programmatic obligations, actions needed to build trustworthiness, and the relative importance of various outcome measures. Descriptive statistics were used to summarize responses to ranked choice and Likert-scale items, and open-ended responses were descriptively coded. Eighty-two participants completed at least one survey item. Participants identified decisions about which genomic results to return, access to follow-up care, and assessment of newborn clinical outcomes as the most pressing ethical challenges across program phases. Strong consensus emerged that gNBS programs have ethical obligations to ensure equitable access to sequencing, follow-up services, genetic counseling, and cascade testing for family members when indicated. To enhance trustworthiness, participants prioritized clear education and transparent communication over formal community advisory structures. Clinical outcomes for the child were consistently ranked as more important than familial psychosocial outcomes or program costs. Although many programs reported some form of public or participant engagement, approaches varied widely. These findings suggest substantial alignment between long-standing normative bioethics debates and the ethical pressures experienced by researchers. At the same time, comments indicating urgency, utilitarian reasoning, and concern about slowing implementation highlight the need for embedded ELSI expertise that can operate in parallel with scientific and clinical work. Embedded ethics research in gNBS programs is critical for guiding real-time decisions, mitigating unintended harms, and sustaining public trust as genomic screening expands. (shrink)

Background Health Research Ethics Committees (HRECs) play a pivotal role in safeguarding research participants and ensuring ethical conduct. The rapid integration of artificial intelligence (AI) into health research introduces novel ethical and operational complexities, including algorithmic opacity, bias, data governance challenges, and difficulties in post-approval monitoring. However, empirical evidence on how these AI-specific complexities affect HREC operations in Tanzania remains limited. This study explored operational challenges associated with ethical oversight of AI-related health research among HRECs in Tanzania. Methods An exploratory (...) qualitative study design was employed, involving 25 participants (15 HREC members and 10 secretariat staff) purposively selected from 10 HRECs across five zones of mainland Tanzania. In-depth interviews were conducted using a semi-structured guide. Data were transcribed, translated, and analyzed using inductive content analysis with thematic interpretation, supported by NVivo software. An audit trail, reflexive journaling, and data source triangulation were used to enhance credibility and trustworthiness. Results A total of 28 codes were generated and organized into 10 subthemes and four overarching themes. While general challenges such as limited funding, high workload, and staffing constraints persisted, AI-related protocols introduced additional operational burdens, including difficulties in assessing algorithmic validity, increased reliance on external technical experts, and challenges in reviewing large-scale datasets. Although 50% of secretariat staff had more than five years of experience, participants emphasized that the key limitation was not general experience but insufficient AI-specific technical expertise. Weak post-approval monitoring systems were particularly inadequate for tracking AI-driven studies. Conclusion Tanzanian HRECs demonstrate foundational governance capacity but face AI-specific operational and technical challenges that constrain effective oversight. Strengthening AI-focused training, technical advisory mechanisms, digital review systems, and sustainable financing is essential to support the ethical governance of emerging technologies. (shrink)

The international human right to health states that people have claims to access goods, services, and infrastructure that protects an adequate standard of health. The current and forthcoming advances in artificial intelligence (AI), which significantly improve the quality and efficacy of medical care, could raise the current standard of healthcare owed under the right to health. In this paper, we identify three duties owed under the right to health and describe ways in which AI can uniquely or more efficiently fulfill (...) these duties, namely the duties to provide: access to good quality care that effectively improves patient health; equitable access to healthcare for all persons; and novel healthcare services that can only be achievable by medical AI. This paper will also consider some potential objections to our claim such as whether medical AI may undermine, rather than fulfil, the social determinants of health. We conclude that if medical AI can partially fulfil the right to health through increasing access and quality of healthcare, and if providing medical AI can be balanced against other obligations and rights, states will have corresponding duties to not unnecessarily restrict AI innovation through regulation and may even be required to invest in medical AI infrastructure to meet the right to health of their populations. (shrink)

Refusal to offer cardiopulmonary resuscitation (CPR) can provoke conflict and distress, even when the medical team judges it to be physiologically futile (PF). Some authors have argued that a time-limited trial of CPR— where it is performed to standard protocol but stopped after a short interval—represents an ethically tolerable compromise. Proponents argue that this approach is sincere and transparent, defuses conflict with families, and limits the harms of more protracted resuscitation attempts. In this article, we evaluate such claims, contend- ing (...) that time-limited codes (TLCs) of PF-CPR do not meet standards of veracity, do not significantly reduce harms, and, even if they were to satisfy a family’s desire for exhaustive treatment, do so by displacing more fundamental obligations to the patient themselves. We conclude that this is not an ethical strategy for managing conflict about code status in the critical care setting. (shrink)

The integration of AI-based conversational agents (CAs) in mental health aims to bridge the global “treatment gap.” However, high user attrition poses a critical ethical challenge, potentially compromising care continuity and distributive justice. This study quantifies attrition rates in AI-driven mental health interventions and evaluates their ethical implications for user autonomy and research integrity. Following PRISMA 2020 guidelines and registered with PROSPERO, this systematic review and meta-analysis synthesized evidence from six databases through September 2025. Employing a convergent parallel mixed-methods design, (...) we analyzed 39 independent studies. A random-effects model was used to calculate pooled attrition rates, while meta-regression explored the correlation between attrition and clinical efficacy (improvement in depressive/anxiety symptoms). Qualitative narrative synthesis was further applied to contextualize user experiences. The meta-analysis revealed a pooled attrition rate of 17.04% (95% CI, 11.46%-23.38%) for AI interventions. Generative AI-based CAs exhibited significantly lower attrition rates (9.25%) compared to retrieval-based systems (23.12%, p = 0.044). Subgroup analysis identified intervention target, delivery platform, interaction mode, engagement reminders and safety measures as key moderators of engagement. Crucially, a significant inverse association between retention and treatment efficacy was observed in depression interventions, where lower attrition correlated with larger effect sizes (β = 0.97, p = 0.043). Furthermore, a pervasive “reporting gap” exists regarding the qualitative reasons for user withdrawal. High attrition rates in AI-based mental health interventions may represent more than technical disengagement, potentially implicating the ethical principles of beneficence and non-maleficence by disrupting the continuity of care. While generative AI shows promise in fostering a perceived therapeutic alliance and mitigating attrition, the observed association between disengagement and diminished efficacy suggests a risk of exacerbating structural health disparities. To address these challenges, we propose the “Ethics-oriented Engagement Framework”(EEF), which integrates transparent accountability, autonomy balance, safety-by-design, and inclusive beneficence. This framework provides a normative roadmap to reconcile the tension between promoting user engagement and upholding the foundational ethical mandates of patient safety and justice. PROSPERO (CRD420251275051). (shrink)

Moral distress (MD) among healthcare workers (HCWs) has been linked to burnout, job dissatisfaction, and a diminished quality of patient care. Although the Measure of Moral Distress for Healthcare Professionals (MMD-HP) is widely used and validated in multiple languages to assess MD, a culturally adapted Malay version for Malaysia has not been developed despite the detrimental consequences of MD among HCWs. Therefore, our present study aims to address this gap by conducting a cross-cultural adaptation (CCA) and psychometric validation of the (...) MMD-HP in the Malay language to be utilised in Malaysia. Subsequently, the validated Malay MMD-HP is intended to facilitate the assessment of MD levels and sources among HCWs across diverse disciplines in a Malaysian tertiary hospital, thereby supporting the development of targeted strategies to mitigate MD and improve the healthcare workforce’s well-being. The MMD-HP questionnaire was translated into Malay language and culturally adapted for the Malaysian healthcare setting. The translated MMD-HP was administered to HCWs across 18 departments at Sarawak General Hospital (SGH) to evaluate construct validity and reliability and to assess the level and distribution of MD among HCWs from diverse disciplines at both the organizational and departmental levels. Construct validity was examined using factor analysis with promax rotation, while reliability was assessed through internal consistency using Cronbach’s alpha. Convergent and discriminant validity were assessed using composite reliability (CR), average variance extracted (AVE), the Fornell–Larcker criterion, and the heterotrait–monotrait (HTMT) ratio. The Malay version of the MMD-HP demonstrated excellent psychometric properties with high internal consistency (Cronbach’s alpha = 0.974). Convergent validity was supported, with composite reliability values ranging from 0.928 to 0.963 (threshold > 0.70) and average variance extracted between 0.624 and 0.684 (threshold > 0.50). Discriminant validity was confirmed using the Fornell–Larcker criterion and heterotrait–monotrait ratios < 0.85. Exploratory factor analysis revealed a three-factor structure (Clinical, Team, System), explaining 71.6% of the total variance, which was further evaluated by confirmatory factor analysis, indicating marginal model fit, with CFI = 0.875, TLI = 0.863, RMSEA = 0.101 (90% CI = 0.096–0.105), and SRMR = 0.053. System-level factors were the prominent source of MD among 527 HCWs in SGH, with doctors reporting higher adjusted total MD scores compared with nurses and other HCWs. The Malay MMD-HP demonstrates strong reliability and evidence of construct validity as an instrument for assessing MD among Malaysian HCWs, capturing experiences across clinical, team, and system levels, with system-level factors contributing most to MD. (shrink)

Background Artificial intelligence (AI) increasingly influences diagnosis, prognosis, triage, treatment, and resource allocation. Existing ethical and governance frameworks identify important values and lifecycle duties, but institutions still lack a shared encounter-level procedure specifying who must act, what must be checked and documented, and when an AI-supported decision should be overridden, paused, or escalated. Objective To map recurrent ethical and governance requirements in a purposively assembled source corpus and use the mapping transparently to construct an encounter-level deliberative model without presenting the (...) model as an automatic finding of the literature. Methods We conducted a critical narrative review with conceptual mapping of a heterogeneous source set identified through iterative scoping between January and March 2025. The review is not systematic, exhaustive, or representative. The master set contained 54 records; 11 duplicates and one non-evidence record were removed, leaving 42 retained sources. Thirty-five informed the primary conceptual mapping and seven served foundational, methodological, post-search, or companion-publication roles. Three members of the review team, including ADP, participated in source selection; the preserved records do not support a claim of independent triple screening or a retrospective agreement statistic. SWiM was removed. Selected ENTREQ transparency items and SANRA were used only as reporting and self-audit aids. Literature-derived findings, integrative inferences, and author-developed normative proposals were explicitly separated. Results Five recurrent domains were mapped: accountable clinical authority and meaningful human oversight; clinically meaningful explanation, uncertainty communication, and contestability; equity, bias, and distributive impact; lifecycle safety, security, and accountability; and proportional data governance, privacy, and patient agency. These domains informed, but did not prove, the author-developed seven-step Deliberative Clinical Cyberbioethics Model (D-CCM). Each step specifies accountable actors, mandatory inputs and records, four possible outputs (continue, continue with safeguards, pause/stop, or escalate), and escalation triggers. The model also includes five candidate patient-facing protections, explicit trade-off rules, four forms of drift or divergence, and scheduled and trigger-based revision. Comparison with WHO, UNESCO, NIST AI RMF, and FUTURE-AI positions the D-CCM as a complementary point-of-care translation layer. Conclusions Clinical Cyberbioethics is presented as a proposed integrative governance lens, not as an established new discipline. The D-CCM is a practice-oriented conceptual proposal informed by the mapping and requires prospective co-design, feasibility testing, reliability assessment, and outcome evaluation before it can be treated as a validated operational framework. (shrink)