Cristian Timmermann

The climate and further environmental crises have motivated calls for the medical profession to act by taking on additional responsibilities. These calls to assume responsibilities towards environmental protection and to systematically consider the health impacts of these crises greatly vary in their scope and demandingness. Through a review of journal publications, we have mapped the various calls for physicians to take on responsibilities in relation to these crises as individuals and as a professional group. These professional responsibilities, obligations or duties were grouped in four broad categories of physicians’ roles as (i) medical practitioners, (ii) medical scientists, (iii) facility (co-)managers, and (iv) citizens. In sum, these responsibilities go beyond actions within the individual patient-physician relationship and setting, demanding from physicians to get involved within their institution, their community, engage with policy-makers, and also concern themselves with the health effects of environmental changes also on distant others, such as people in other parts of the world and future generations.

In this thesis we have examined the complex interaction between intellectual property rights, life sciences and global justice. Science and the innovations developed in its wake have an enormous effect on our daily lives, providing countless opportunities but also raising numerous problems of justice. The complexity of a problem however does not liberate society as a whole from moral responsibilities. Our intellectual property regimes clash at various points with human rights law and commonly held notions of justice.

Climate change, ecological degradation and global inequalities are symptoms of an eco-social polycrisis that threatens global health and health equity. This polycrisis is deeply rooted in Western value systems. These can be described as anthropocentric and individualistic and support the prevailing neoliberal economic model. Bioethics is now called to respond to the urgent health-related ethical challenges of the polycrisis and has recently begun to engage with Planetary Health and One Health in this regard. Both have mainly emerged in the Western scientific community and understand human health to be inextricably linked to the state of environmental and structural societal determinants. We argue that bioethics should indeed embrace holistic or integrated understandings of health but also carefully revisit the foundational Western value systems at the root of the polycrisis. If Planetary Health and One Health stay grounded in Western value systems, an extensive conceptual engagement might be problematic for bioethics. Instead of turning to Western concepts of health, bioethics should engage deeply with Indigenous and non-Western ways of knowing and critically reflect on its own role in inadvertently maintaining the status quo.

Various understandings of “resilience” dominate debates on climate change without consensus on its ethical implications. Individualistic interpretations can conflict with ethical values like minimizing population harms and countering health inequities. More systemic, ecological interpretations may overlook justice concerns, such as who is more burdened or marginalized regarding climate impacts. This article argues for integrating a normative, justice-oriented approach to resilience, informed by feminist and intersectional theory. It outlines six principles: build in redundancies and diversification; foster knowledge acquisition and sharing; increase social cohesion, connectivity and willingness to cooperate; improve participation and facilitate polycentric governance; protect regenerative capacities; and implement preventive measures.

While there is agreement on the need to improve sustainability in university hospitals, there are strong differences of opinion on how such goals interact with responsibilities of the medical profession, including research activities. To facilitate sustainability transitions in university hospitals, we need to gain a better understanding of the multiple incentive structures and ethical responsibilities related to sustainability that influence the physicians working there. Furthermore, there needs to be greater awareness and systematic consideration of the health co-benefits of sustainability transitions. Both are necessary to prevent the sustainability agendas in hospital settings from becoming deadlocked due to disagreements over priorities and implementation, despite initial consensus in principle.

The rapid expansion of the public discussion and research on just transition implies the risk of watering down either justice or the (eco-)socio-technical transition itself. We create a theoretical notion of just transition boundaries and propose it to help consider non-negotiable limits to just transition discourse and make sense of negotiations within such limits. Just transition boundaries are comprised of ecological and social boundaries. They determine that just transition-processes must bring societies effectively within the safety thresholds of the two most critical planetary boundaries, climate change and biodiversity loss, and must do that by means and supportive measures that protect vulnerable groups from falling or getting stuck below social minimums in those processes. Boundaries leave room for plural values and visions for realizing transitions and remaining within safe thresholds in community-specific conditions. Context-specific additions to what just transition should cover are possible insofar as they do not contradict or risk just transition boundaries. In addition to justifying and conceptualizing just transition boundaries, we reflect on its implications for policymaking and research.

This literature review provides an overview of ethical approaches used at the intersection of climate change, the environment and health. Six ethical approaches are discussed: (i) rights- based approaches, concentrating on human rights, animal rights and environmental rights; (ii) justice approaches, discussing issues of distribution, relations, climate health justice, future generations, and interspecies justice; (iii) integrated concepts of health, such as One Health and Planetary Health; (iv) Indigenous and non-Western perspectives, introducing the significance of biocultural heritage, harmonious relationships, and decolonisation movements; (v) professional responsibilities towards the environment among health workers and other professions; and (vi) ethical principles in relation to climate change and the environment. A concise assessment is provided on how each of these ethical approaches may inform policy and practice addressing climate change, environmental degradation and health.

Purpose: The method of diagnosing diabetic retinopathy (DR) through artificial intelligence (AI)-based systems has been commercially available since 2018. This introduces new ethical challenges with regard to obtaining informed consent from patients. The purpose of this work is to develop a checklist of items to be disclosed when diagnosing DR with AI systems in a primary care setting. Methods: Two systematic literature searches were conducted in PubMed and Web of Science databases: a narrow search focusing on DR and a broad search on general issues of AI-based diagnosis. An ethics content analysis was conducted inductively to extract two features of included publications: (1) novel information content for AI-aided diagnosis and (2) the ethical justification for its disclosure. Results: The narrow search yielded n = 537 records of which n = 4 met the inclusion criteria. The information process was scarcely addressed for primary care setting. The broad search yielded n = 60 records of which n = 11 were included. In total, eight novel elements were identified to be included in the information process for ethical reasons, all of which stem from the technical specifics of medical AI. Conclusions: Implications for the general practitioner are two-fold: First, doctors need to be better informed about the ethical implications of novel technologies and must understand them to properly inform patients. Second, patient's overconfidence or fears can be countered by communicating the risks, limitations, and potential benefits of diagnostic AI systems. If patients accept and are aware of the limitations of AI-aided diagnosis, they increase their chances of being diagnosed and treated in time.

Agriculture is one of the dimensions where climate change is having its most devastating effects. As the impact of climate change affects disproportionally those who have contributed the least to it, i.e., the smallholder farmers in the Global South, and who at the same time are the ones with the least disposable income to adapt to these changes, it leads to a major challenge for global justice. This chapter introduces different forms of inequality that are aggravated by climate change, discusses the implications of emphasizing on mitigation and adaptation to the new climatic conditions, argues for the need to reduce the multiple wastages in agriculture and food consumption and the importance of building resilient farming systems, presents the challenges of innovating fairly to respond to the climate emergency, and analyzes the ethical implication of changing landscapes and land uses. It concludes by listing the main challenges of compensating for climate injustices.

Definition of the problem The umbrella term “explicability” refers to the reduction of opacity of artificial intelligence (AI) systems. These efforts are challenging for medical AI applications because higher accuracy often comes at the cost of increased opacity. This entails ethical tensions because physicians and patients desire to trace how results are produced without compromising the performance of AI systems. The centrality of explicability within the informed consent process for medical AI systems compels an ethical reflection on the trade-offs. Which levels of explicability are needed to obtain informed consent when utilizing medical AI? Arguments We proceed in five steps: First, we map the terms commonly associated with explicability as described in the ethics and computer science literature, i.e., disclosure, intelligibility, interpretability, and explainability. Second, we conduct a conceptual analysis of the ethical requirements for explicability when it comes to informed consent. Third, we distinguish hurdles for explicability in terms of epistemic and explanatory opacity. Fourth, this then allows to conclude the level of explicability physicians must reach and what patients can expect. In a final step, we show how the identified levels of explicability can technically be met from the perspective of computer science. Throughout our work, we take diagnostic AI systems in radiology as an example. Conclusion We determined four levels of explicability that need to be distinguished for ethically defensible informed consent processes and showed how developers of medical AI can technically meet these requirements.

This paper presents an ethical framework designed to support the development of critical data literacy for research methods courses and data training programmes in higher education. The framework we present draws upon our reviews of literature, course syllabi and existing frameworks on data ethics. For this research we reviewed 250 research methods syllabi from across the disciplines, as well as 80 syllabi from data science programmes to understand how or if data ethics was taught. We also reviewed 12 data ethics frameworks drawn from different sectors. Finally, we reviewed an extensive and diverse body of literature about data practices, research ethics, data ethics and critical data literacy, in order to develop a transversal model that can be adopted across higher education. To promote and support ethical approaches to the collection and use of data, ethics training must go beyond securing informed consent to enable a critical understanding of the techno-centric environment and the intersecting hierarchies of power embedded in technology and data. By fostering ethics as a method, educators can enable research that protects vulnerable groups and empower communities.

Introduction: There is currently no binding, internationally accepted and successful approach to ensure global equitable access to healthcare during a pandemic. The aim of this ethical analysis is to bring into the discussion a legally regulated vaccine allocation as a possible strategy for equitable global access to vaccines. We focus our analysis on COVAX (COVID-19 Vaccines Global Access) and an existing EU regulation that, after adjustment, could promote global vaccine allocation. Methods: The main documents discussing the two strategies are examined with a qualitative content analysis. The ethical values reasonableness, openness and transparency, inclusiveness, responsiveness and accountability serve as categories for our ethical analysis. Results: We observed that the decision-making processes in a legal solution to expand access to vaccines would be more transparent than in COVAX initiative, would be more inclusive, especially of nation states, and the values responsiveness and accountability could be easily incorporated in the development of a new regulation. Discussion: A legal strategy that offers incentives to the pharmaceutical industry in return for global distribution of vaccines according to the Fair Priority Model is an innovative way to achieve global and equitable access to vaccines. However, in the long term, achieving the Sustainable Development Goals will require from all nations to work in solidarity to find durable solutions for global vaccine research and development. Interim solutions, such as our proposed legal strategy for equitable access to vaccines, and efforts to find long-term solutions must be advanced in parallel.

Climate change, pollution, and deforestation have a negative impact on global mental health. There is an environmental justice dimension to this challenge as wealthy people and high-income countries are major contributors to climate change and pollution, while poor people and low-income countries are heavily affected by the consequences. Using state-of-the art data mining, we analyzed and visualized the global research landscape on mental health, climate change, pollution and deforestation over a 15-year period. Metadata of papers were exported from PubMed®, and both relevance and relatedness of terms in different time frames were computed using VOSviewer. Co-occurrence graphs were used to visualize results. The development of exemplary terms over time was plotted separately. The number of research papers on mental health and environmental challenges is growing in a linear fashion. Major topics are climate change, chemical pollution, including psychiatric medication in wastewater, and neurobiological effects. Research on specific psychiatric syndromes and diseases, particularly on their ethical and social aspects is less prominent. There is a growing body of research literature on links between mental health, climate change, pollution, and deforestation. This research provides a graphic overview to mental healthcare professionals and political stakeholders. Social and ethical aspects of the climate change-mental health link have been neglected, and more research is needed.

Background: The internationalization of clinical studies requires a shared understanding of the fundamental ethical values guiding clinical studies. It is important that these values are not only embraced at the legal level but also adopted by clinicians themselves during clinical studies. Objective: Our goal is to provide an insight on how clinicians in Germany and Poland perceive and identify the different ethical issues regarding informed consent in clinical studies. Methods: To gain an understanding of how clinicians view clinical studies in the countries they work in, we carried out semi-structured problem-centered interviews per telephone in Poland (n = 6) and Germany (n = 6). Our interviewees concentrated on three main topics: an appraisal of the normative framework, challenges in the information process and the protection of all participants in clinical studies. Results: Clinicians generally supported the normative framework, even though they considered it quite complex. In the two study countries, a widely noted dilemma in the information process was whether to overburden participants with extensive information or risking leaving out important facts. Clinicians were ready to exclude larger population groups from participating in clinical studies when the information process could not be carried out with standard procedures or when their inclusion was ethically sensitive. Conclusion: Clinicians need to gain a better understanding of the consequences of excluding larger population groups form participating in clinical studies. They should seek assistance in improving the information process for the inclusion of underrepresented groups in clinical studies.

Background: Smart sensors have been developed as diagnostic tools for rehabilitation to cover an increasing number of geriatric patients. They promise to enable an objective assessment of complex movement patterns. Objective: This research aimed to identify and analyze the conflicting ethical values associated with smart sensors in geriatric rehabilitation and provide ethical guidance on the best use of smart sensors to all stakeholders, including technology developers, health professionals, patients, and health authorities. Methods: On the basis of a systematic literature search of the scientific databases PubMed and ScienceDirect, we conducted a qualitative document analysis to identify evidence-based practical implications of ethical relevance. We included 33 articles in the analysis. The practical implications were extracted inductively. Finally, we carried out an ethical analysis based on the 4 principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice. The results are reported in categories based on these 4 principles. Results: We identified 8 conflicting aims for using smart sensors. Gains in autonomy come at the cost of patient privacy. Smart sensors at home increase the independence of patients but may reduce social interactions. Independent measurements performed by patients may result in lower diagnostic accuracy. Although smart sensors could provide cost-effective and high-quality diagnostics for most patients, minorities could end up with suboptimal treatment owing to their underrepresentation in training data and studies. This could lead to algorithmic biases that would not be recognized by medical professionals when treating patients. Conclusions: The application of smart sensors has the potential to improve the rehabilitation of geriatric patients in several ways. It is important that patients do not have to choose between autonomy and privacy and are well informed about the insights that can be gained from the data. Smart sensors should support and not replace interactions with medical professionals. Patients and medical professionals should be educated about the correct application and the limitations of smart sensors. Smart sensors should include an adequate representation of minorities in their training data and should be covered by health insurance to guarantee fair access.

Achieving energy sovereignty is increasingly gaining prominence as a goal in energy politics. The aim of this paper is to provide a conceptual analysis of this principle from an ethics and social justice perspective. We rely on the literature on food sovereignty to identify through a comparative analysis the elements energy sovereignty will most likely demand and thereafter distinguish the unique constituencies of the energy sector. The idea of energy sovereignty embraces a series of values, among which we identified: (i) accessibility, to allow access to everyone, (ii) empowerment and recognition, to develop and sustain capabilities to collaboratively produce solution-oriented energy system knowledge and effectively participate in governance, (iii) stewardship and sustainability, to be able to design and manage decentralised renewable systems in view of protecting the environment, (iv) self-sufficiency, to reduce the negative shocks of exploitative business practises, (v) resilience, to maintain production capacities while withstanding socioeconomic, political, environmental and climatic shocks, (vi) peace, to establish production systems that do not involve hostile relations, (vii) transparency and self-determination, to establish democratic decision-making mechanisms that give a voice to previously underrepresented groups and limit corporate takeover (viii) gender-justice, by acknowledging the contributions of women and eliminate barriers to their empowerment. With a conceptual framework of energy sovereignty, we present a rationale that draws on the key values to be considered when formulating policy solutions for the energy sector.

New technologies such as smart sensors improve rehabilitation processes and thereby increase older adults’ capabilities to participate in social life, leading to direct physical and mental health benefits. Wearable smart sensors for home use have the additional advantage of monitoring day-to-day activities and thereby identifying rehabilitation progress and needs. However, identifying and selecting rehabilitation priorities is ethically challenging because physicians, therapists, and caregivers may impose their own personal values leading to paternalism. Therefore, we develop a discussion template consisting of a series of adaptable questions for the patient–physician encounter based on the capability approach. The goal is to improve geriatric rehabilitation and thereby increase participation in social life and well-being. To achieve this goal, we first analyzed what is considered important for participation on basis of the capability approach, human rights, and ethics of care. Second, we conducted an ethical analysis of each of the four identified dimensions of participation: political, economic, socio-cultural, and care. To improve compliance with rehabilitation measures, health professionals must align rehabilitation measures in an open dialogue with the patient’s aspiration for participation in each dimension. A discussion template based on the capability approach allows for a proactive approach in patient information and stimulates a critical assessment of treatment alternatives while reducing the risk of imposing personal values.

Recent years have witnessed intensive efforts to specify which requirements ethical artificial intelligence (AI) must meet. General guidelines for ethical AI consider a varying number of principles important. A frequent novel element in these guidelines, that we have bundled together under the term explicability, aims to reduce the black-box character of machine learning algorithms. The centrality of this element invites reflection on the conceptual relation between explicability and the four bioethical principles. This is important because the application of general ethical frameworks to clinical decision-making entails conceptual questions: Is explicability a free-standing principle? Is it already covered by the well-established four bioethical principles? Or is it an independent value that needs to be recognized as such in medical practice? We discuss these questions in a conceptual-ethical analysis, which builds upon the findings of an empirical document analysis. On the example of the medical specialty of radiology, we analyze the position of radiological associations on the ethical use of medical AI. We address three questions: Are there references to explicability or a similar concept? What are the reasons for such inclusion? Which ethical concepts are referred to?

The development of new methods in the field of prenatal testing leads to an expansion of information that needs to be provided to expectant mothers. The aim of this research is to explore opinions and attitudes of gynecologists in Germany, Poland and Russia towards access to prenatal testing and diagnostics in these countries. Semi-structured interviews were conducted with n = 18 gynecologists in Germany, Poland and Russia. The interviews were analyzed using the methods of content analysis and thematic analysis. Visible in all three countries is a connection of prenatal medicine with the politically and socially contentious issue of pregnancy termination. Respondents in Poland and Russia concentrated on the topic of inadequate resources. Quality of information for expectant mothers is an important point in all three countries. Only in Germany was the issue of language barriers in communication raised. With regard to non-invasive prenatal testing (NIPT) respondents in Germany focused on the ethical issues of routinization of testing; in Poland and Russia they concentrated on fair access to NIPT. Challenges in all three countries arise from structural factors such as imprecise and prohibitive regulations, lack of resources or organization of healthcare services. These should be addressed on a political and medico-ethical level.

The scope and type of property rights recognized over the effectiveness of antibiotics have a direct effect on how those claiming ownership engage in the exploitation and stewardship of this scarce resource. We examine the different property claims and rights the four major interest groups are asserting on antibiotics: (i) the inventors, (ii) those demanding that the resource be treated like any other transferable commodity, (iii) those advocating usage restrictions based on good stewardship principles and (iv) those considering the resource as common heritage of humankind.

Synthetic foods advocates offer the promise of efficient, reliable, and sustainable food production. Engineered organisms become factories to produce food. Proponents claim that through this technique important barriers can be eliminated which would facilitate the production of traditional foods outside their climatic range. This technique would allow reducing food miles, secure future supply, and maintain quality and taste expectations. In this paper, we examine coffee production via biobased means. A startup called Atomo Coffee aims to produce synthetic coffee with the aim of saving ‘the taste of coffee’ from the effects of climate change. This decontextualisation of coffee production ignores the current and historical contributions of coffee farmers in two ways: the traditional varieties in taste of coffee and their cultural significance, and the potential shade-grown coffee plantations have in capturing carbon. In addition, synthetic coffee may lead to the loss of agricultural biodiversity and the removal of resources away from production systems that provide a safe space for tropical flora and fauna. How should the ‘taste of coffee’ be owned? We investigate the property regimes under which we could consider owning the taste of coffee as a ‘synthetic’ agrobiodiversity to help identify rights and responsibilities. Building on this analysis, we consider dimensions of responsible innovation and social justice to help guide synthetic foods as an agricultural innovation.

We are already past the point where climate change mitigation alone does not suffice and major efforts need to be undertaken to adapt agriculture to climate change. As this situation was both foreseeable and avoidable, it is urgent to see that particularly people who have historically contributed the least to climate change do not end up assuming most of the costs. Climate change will have the worst effects on agriculture in the tropical region in the form of droughts, extreme heat waves and massive storms. The historical unequal contributions to climate change and its unjustly distributed consequences morally oblige us to distribute global adaptation costs fairly. Yet to have a full understanding of the social implications of adapting to climate change we need to look beyond making adaptation technologies accessible and available. Using a social justice framework, I defend fair prices of adaptation technologies as a demand of justice in exchange, an allocation of research attention proportional to urgent global needs as distributive justice, inclusive technology development and governance as contributive justice and addressing the interests of future generations as intergenerational justice.

This paper aims to analyze the ethical challenges in experimental drug use during the early stage of the COVID-19 pandemic, using Germany as a case study. In Germany uniform ethical guidelines were available early on nationwide, which was considered as desirable by other states to reduce uncertainties and convey a message of unity. The purpose of this ethical analysis is to assist the preparation of future guidelines on the use of medicines during public health emergencies. The use of hydroxychloroquine, remdesivir and COVID-19 convalescent plasma in clinical settings was analyzed from the perspective of the ethical principles of beneficence, non-maleficence, justice and autonomy. We observed that drug safety and drug distribution during the pandemic affects all four ethical principles. We therefore recommend to establish ethical guidelines (i) to discuss experimental treatment options with patients from all population groups who are in urgent need, (ii) to facilitate the recording of patient reactions to drugs in off-label use, (iii) to expand inclusion criteria for clinical studies to avoid missing potentially negative effects on excluded groups, and (iv) to maintain sufficient access to repurposed drugs for patients with prior conditions.

Background: Biomedical research nowadays is increasingly carried out in multinational and multicenter settings. Due to disparate national regulations on various ethical aspects, such as informed consent, there is the risk of ethical compromises when involving human subjects in research. Although the Declaration of Helsinki is the point of reference for ethical conduct of research on humans, national normative requirements may diverge from its provisions. The aim of this research is to examine requirements on informed consent in biomedical research in Germany, Poland, and Russia to determine how each national regulatory framework relates to the provisions of the Declaration of Helsinki. Methods: For this analysis, we conducted a search of the legal databases “Gesetze im Internet” for Germany, “Internetowy System Aktow Prawnych” for Poland, and “ГAPAHT – Garant” for Russia. The search was complemented by a review of secondary literature contained in the databases Google Scholar, PubMed, Polish National Library, and eLibrary ru. We have identified 21 normative regulations containing provisions on informed consent in clinical research in all three countries. The content of these documents was systematically categorized and analyzed. Results: The normative framework in all three countries shows a strong commitment towards the core ethical principles of research envisaged in the Declaration of Helsinki. Nevertheless, provisions on informed consent vary between these three countries. The differences range from the method and language in which information should be provided, through the amount of information required to be disclosed, to the form of documenting consent or withdrawal. In the case of research on vulnerable groups, these differences are particularly visible. Conclusions: The identified differences can negatively impact the ethical conduct of international clinical studies. Attention needs to be paid that flexibilities within national regulations are not misused to undermine the protection of research subjects. Achieving global or regional legislative harmonization might prove impossible. Such lack of legal consensus reinforces the significance of the international ethical agreements.

Biomarker-based predictive tests for subjectively asymptomatic Alzheimer’s disease (AD) are utilized in research today. Novel applications of artificial intelligence (AI) promise to predict the onset of AD several years in advance without determining biomarker thresholds. Until now, little attention has been paid to the new ethical challenges that AI brings to the early diagnosis in asymptomatic individuals, beyond contributing to research purposes, when we still lack adequate treatment. The aim of this paper is to explore the ethical arguments put forward for AI aided AD prediction in subjectively asymptomatic individuals and their ethical implications. The ethical assessment is based on a systematic literature search. Thematic analysis was conducted inductively of 18 included publications. The ethical framework includes the principles of autonomy, beneficence, non-maleficence, and justice. Reasons for offering predictive tests to asymptomatic individuals are the right to know, a positive balance of the risk-benefit assessment, and the opportunity for future planning. Reasons against are the lack of disease modifying treatment, the accuracy and explicability of AI aided prediction, the right not to know, and threats to social rights. We conclude that there are serious ethical concerns in offering early diagnosis to asymptomatic individuals and the issues raised by the application of AI add to the already known issues. Nevertheless, pre-symptomatic testing should only be offered on request to avoid inflicted harm. We recommend developing training for physicians in communicating AI aided prediction.

By examining the global public good nature of pandemic preparedness we can identify key social justice issues that need to be confronted to increase citizens’ voluntary compliance with prevention and mitigation measures. As people tend to cooperate on a voluntary basis only with systems they consider fair, it becomes difficult to ensure compliance with public health measures in a context of extreme inequality. Among the major inequalities that need to be addressed we can find major differences in the extensiveness and intensiveness of quarantine experiences, lack of opportunities to participate in common efforts, hardship in complying with disease control recommendations, and an unfair distribution of the cooperative surplus.

Employing a social justice framework, this book examines the effects of innovation incentives and policies in agriculture. It addresses access to the objects of innovation, the direction of science and the type of innovations that are available, opportunities to participate in research and development, as well as effects on future generations. The book examines the potential value of preventive and reconciliatory measures, drawing on concepts from procedural and restorative justice. As such it offers a comprehensive analysis of the main social justice dimensions affected by agricultural innovation. It gives academics and policy analysts an extensive overview of the deep impact of innovation on society and the environment, and the expectations the general public has from the scientific community.