Anto Cartolovni

The healthcare system is undergoing transformation by shifting the current paradigm and implementing technology, particularly artificial intelligence (AI). AI in medicine shows promising results in many fields, while, on the other hand, certain challenges are emerging. This chapter presents the results of qualitative and quantitative research conducted with key stakeholders within digital health (patients, physicians, hospital managers, public policymakers, jurists, and IT engineers) and medical students. Through examining both the positive and negative aspects of AI, stakeholders analyse the implementation of AI and the future of healthcare, envisioning how they imagine Healthcare 5.0. AI is expected to accelerate and enhance accuracy in healthcare, contributing to better patient outcomes, particularly in prevention and triage. It is also anticipated to help address the shortage of physicians, reduce waiting lists, and lower costs. On the other hand, concerns have been raised about data quality, regulation, and standardisation, which could lead to adverse outcomes. Research participants highlighted a lack of awareness among patients about the importance of data, which could result in discrimination and a potential loss of humanity in healthcare.

The idea of moral injury in healthcare attracted much public attention during the recent COVID-19 pandemic. Duty to care, particularly in circumstances such as the pandemic, raised the awareness of the phenomenon of moral injury in nursing among practising nurse and nurse leaders and managers. The concept of moral injury was introduced originally from a military context, mostly identified, and observed among veterans. Some evidence from the early literature on the concept suggests that moral injury, as an experience, was conceptually confused with other existing experiences conceptualised as burnout and/or moral distress. This may have led to an under recognition and lack of awareness of moral injury as a discreet experience.Although the experiences conceptualised as moral injury, moral distress, and burnout have some commonalities in symptoms and outcomes, it is argued that as individual experiences these three differ in humanly and ethically important ways. It is further argued that these different experiences need to be recognised and addressed appropriately. Failing to do so may add to the rising number of nursing professionals leaving their profession.This reality raises significant challenges for both nurse leaders and managers and for healthcare organisations. It is incumbent on leaders and managers in healthcare organisations to be sensitive to the development of moral distress, moral injury, and burnout in staff members and colleagues, and to work to find ways to support the well-being of nurses and other healthcare practitioners, thus enabling them to flourish as persons and as healthcare professionals.In this chapter we will consider the evolving use of the concept of moral injury in the healthcare literature, including attempts to differentiate it from concepts of moral distress and burnout. We will also consider some of the factors identified as contributing to the experience of moral injury in individual practitioners. The chapter will conclude by suggesting some measures that can be taken to help ameliorate and or mitigate the experience of moral injury.

Background: Moral courage is defined as the courage to act in ethical conflicts based on individual or professional values despite the personal risks involved. Nurses justify their decisions to act morally courageously as part of their ethical decision-making. Objective: To describe registered nurses’ justifications for acting morally courageously, or not, in ethical conflicts where they needed moral courage. Research design: A narrative inquiry with a holistic content approach was used. Individual, in-depth interviews were conducted in January–February 2023. The data were analysed using holistic content analysis. Participants and research context: Fourteen registered nurses with experience in situations where they needed moral courage participated. The nurses came from the somatic, palliative, mental health, and substance abuse care fields in Finland. Ethical considerations: Good scientific practice was followed. Ethical approval was obtained before data collection from the university’s ethics committee. Findings: The nurses needed moral courage in ethical conflicts with patients present and between professionals. Individual responsibility, professional ethics, and emotions were identified as bases of nurses’ justifications for morally courageous acts. The justifications for acting morally courageously, or not, had individual, contextual, and organisational perspectives. Morally courageous acts included starting a discussion about the conflict with other professionals and reporting the situation in writing within one’s organisation. Discussion and conclusions: The identified bases and perspectives of justifications illustrate the complexity of nurses’ decision-making in ethical conflicts, either leading to morally courageous acts or not. These results can inform nursing practice and research in developing processes to strengthen nurses’ moral courage and examining relationships between moral courage and other concepts, such as moral resilience.

In the years to come, artificial intelligence will become an indispensable tool in medical practice. The digital transformation will undoubtedly affect today’s medical students. This study focuses on trust from the perspective of three groups of medical students - students from Croatia, students from Slovakia, and international students studying in Slovakia. A paper-pen survey was conducted using a non-probabilistic convenience sample. In the second half of 2022, 1715 students were surveyed at five faculties in Croatia and three in Slovakia. Specifically, 38.2% of students indicated familiarity with the concept of AI, while 44.8% believed they would use AI in the future. Patient readiness for the implementation of technologies was mostly assessed as being low. More than half of the students, 59.1%, believe that the implementation of digital technology (AI) will negatively impact the patient-physician relationship and 51,3% of students believe that patients will trust physicians less. The least agreement with the statement was observed among international students, while a higher agreement was expressed by Slovak and Croatian students 40.9% of Croatian students believe that users do not trust the healthcare system, 56.9% of Slovak students agree with this view, while only 17.3% of international students share this opinion. The ability to explain to patients how AI works if they were asked was statistically significantly different for the different student groups, international students expressed the lowest agreement, while the Slovak and Croatian students showed a higher agreement. This study provides insight into medical students’ attitudes from Croatia, Slovakia, and international students regarding the role of artificial intelligence (AI) in the future healthcare system, with a particular emphasis on the concept of trust. A notable difference was observed between the three groups of students, with international students differing from their Croatian and Slovak colleagues. This study also highlights the importance of integrating AI topics into the medical curriculum, taking into account national social & cultural specificities that could negatively impact AI implementation if not carefully addressed.

It is a matter of fact that Europe is facing more and more crucial challenges regarding health and social care due to the demographic change and the current economic context. The recent COVID-19 pandemic has stressed this situation even further, thus highlighting the need for taking action. Active and Assisted Living technologies come as a viable approach to help facing these challenges, thanks to the high potential they have in enabling remote care and support. Broadly speaking, AAL can be referred to as the use of innovative and advanced Information and Communication Technologies to create supportive, inclusive and empowering applications and environments that enable older, impaired or frail people to live independently and stay active longer in society. AAL capitalizes on the growing pervasiveness and effectiveness of sensing and computing facilities to supply the persons in need with smart assistance, by responding to their necessities of autonomy, independence, comfort, security and safety. The application scenarios addressed by AAL are complex, due to the inherent heterogeneity of the end-user population, their living arrangements, and their physical conditions or impairment. Despite aiming at diverse goals, AAL systems should share some common characteristics. They are designed to provide support in daily life in an invisible, unobtrusive and user-friendly manner. Moreover, they are conceived to be intelligent, to be able to learn and adapt to the requirements and requests of the assisted people, and to synchronise with their specific needs. Nevertheless, to ensure the uptake of AAL in society, potential users must be willing to use AAL applications and to integrate them in their daily environments and lives. In this respect, video- and audio-based AAL applications have several advantages, in terms of unobtrusiveness and information richness. Indeed, cameras and microphones are far less obtrusive with respect to the hindrance other wearable sensors may cause to one’s activities. In addition, a single camera placed in a room can record most of the activities performed in the room, thus replacing many other non-visual sensors. Currently, video-based applications are effective in recognising and monitoring the activities, the movements, and the overall conditions of the assisted individuals as well as to assess their vital parameters. Similarly, audio sensors have the potential to become one of the most important modalities for interaction with AAL systems, as they can have a large range of sensing, do not require physical presence at a particular location and are physically intangible. Moreover, relevant information about individuals’ activities and health status can derive from processing audio signals. Nevertheless, as the other side of the coin, cameras and microphones are often perceived as the most intrusive technologies from the viewpoint of the privacy of the monitored individuals. This is due to the richness of the information these technologies convey and the intimate setting where they may be deployed. Solutions able to ensure privacy preservation by context and by design, as well as to ensure high legal and ethical standards are in high demand. After the review of the current state of play and the discussion in GoodBrother, we may claim that the first solutions in this direction are starting to appear in the literature. A multidisciplinary debate among experts and stakeholders is paving the way towards AAL ensuring ergonomics, usability, acceptance and privacy preservation. The DIANA, PAAL, and VisuAAL projects are examples of this fresh approach. This report provides the reader with a review of the most recent advances in audio- and video-based monitoring technologies for AAL. It has been drafted as a collective effort of WG3 to supply an introduction to AAL, its evolution over time and its main functional and technological underpinnings. In this respect, the report contributes to the field with the outline of a new generation of ethical-aware AAL technologies and a proposal for a novel comprehensive taxonomy of AAL systems and applications. Moreover, the report allows non-technical readers to gather an overview of the main components of an AAL system and how these function and interact with the end-users. The report illustrates the state of the art of the most successful AAL applications and functions based on audio and video data, namely lifelogging and self-monitoring, remote monitoring of vital signs, emotional state recognition, food intake monitoring, activity and behaviour recognition, activity and personal assistance, gesture recognition, fall detection and prevention, mobility assessment and frailty recognition, and cognitive and motor rehabilitation. For these application scenarios, the report illustrates the state of play in terms of scientific advances, available products and research project. The open challenges are also highlighted. The report ends with an overview of the challenges, the hindrances and the opportunities posed by the uptake in real world settings of AAL technologies. In this respect, the report illustrates the current procedural and technological approaches to cope with acceptability, usability and trust in the AAL technology, by surveying strategies and approaches to co-design, to privacy preservation in video and audio data, to transparency and explainability in data processing, and to data transmission and communication. User acceptance and ethical considerations are also debated. Finally, the potentials coming from the silver economy are overviewed.

Ambient assisted living technologies are increasingly presented and sold as essential smart additions to daily life and home environments that will radically transform the healthcare and wellness markets of the future. An ethical approach and a thorough understanding of all ethics in surveillance/monitoring architectures are therefore pressing. AAL poses many ethical challenges raising questions that will affect immediate acceptance and long-term usage. Furthermore, ethical issues emerge from social inequalities and their potential exacerbation by AAL, accentuating the existing access gap between high-income countries and low and middle-income countries. Legal aspects mainly refer to the adherence to existing legal frameworks and cover issues related to product safety, data protection, cybersecurity, intellectual property, and access to data by public, private, and government bodies. Successful privacy-friendly AAL applications are needed, as the pressure to bring Internet of Things devices and ones equipped with artificial intelligence quickly to market cannot overlook the fact that the environments in which AAL will operate are mostly private. The social issues focus on the impact of AAL technologies before and after their adoption. Future AAL technologies need to consider all aspects of equality such as gender, race, age and social disadvantages and avoid increasing loneliness and isolation among, e.g. older and frail people. Finally, the current power asymmetries between the target and general populations should not be underestimated nor should the discrepant needs and motivations of the target group and those developing and deploying AAL systems. Whilst AAL technologies provide promising solutions for the health and social care challenges, they are not exempt from ethical, legal and social issues. A set of ELSI guidelines is needed to integrate these factors at the research and development stage.

Digital phenotyping represents an avenue of consideration in patients' self-management. This scoping review aims to explore the trends in the body of literature on ethical, legal, and social challenges relevant to the implementation of digital phenotyping technologies in healthcare. The study followed the PRISMA-ScR methodology :467–473, 2018. https://doi.org/10.7326/M18-0850). The review systematically identified relevant literature, characterised the discussed technology, explored its impacts and the proposed solutions to identified challenges. Overall, the literature, perhaps unsurprisingly, concentrates on technical rather than ethical, legal, and social perspectives, which limits understanding of the more complex cultural and social factors in which digital phenotyping technologies are embedded. ELS issues mostly concern privacy, security, consent, lack of regulation, and issues of adoptability, and seldom expand to more complex ethical issues. Trust was chosen as an umbrella theme of a continuum of major ELS and technical issues. Sustained critical analysis of digital phenotyping showed to be sparse and geographically exclusive. There is a continuum and overlap between ELS issues, suggesting the need for a holistic, interdisciplinary approach to each of the challenges posed by the various technologies of digital phenotyping.

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

Within the domain of public health, vector-borne diseases are among the most vehemently discussed issues. Recent scientific breakthroughs in genome editing technology provided a solution to this issue in the form of a gene drive that might decrease and even eradicate vector-borne diseases. Gene drives are engineered, and designed genes that can break typical inheritance rules and be passed to almost all of the carrier’s offspring. This genome editing and gene drive technology has become a powerful tool for ecological and environmental engineering, through which man can manipulate his surroundings, adjusting it to himself and directly mastering evolution and the ecosystem. Although the gene drive technology has been perceived as promising in the public health domain, ecological implications of its use are not to be underestimated. The primary aim of this paper is to overcome the ongoing discussion which mostly focuses on whether priority should be given to the environment or to public health, and to find an adequate answer and solution. In this quest to find the proper answer and solution, Pierre Teilhard de Chardin’s thought might be useful, especially his concepts of the biosphere and the noosphere which may provide some clarifications as to why we are at the moment so cautious with gene drive technology and how we need to move towards a better common future on earth.

Eilers Miriam, Gru¨ber Katrin, and Rehmann-Sutter Christoph’s latest edited volume, The Human Enhancement Debate and Disability: New Bodies for a Better Life, may at first seem to be just another book about human enhancement, on which there is a significant detailed literature. But, in fact, this book provides a novel16 perspective to the human enhancement debate by observing it through the disability lens, even as it gathers contributions from various experts from diverse fields. This interdisciplinary approach shows how disability and human enhancement are tightly correlated in the debate on the latter.

The primary intention of Ren and Canavero's article (2017) is to respond to various criticisms raised by their proposal of the head anastomosis venture (HEAVEN) procedure. Before we launch a deeper analysis of Ren and Canavero's article, I would like to draw attention to a sentence, “Unfortunately, humility is not a part of medical lore,” where they refer to the arrogance and unsuccessfulness of medical science to recognize the importance and breakthrough of the HEAVEN procedure. Interestingly, with this repeated citation, they acknowledge a familiar criticism of medical lore, so that we would expect that they provide a good example of the appreciation of humility in their present article.