Elisabeth Langmann

Marginalization is a widely studied phenomenon and recognized as a critical topic in relation to health, shaping health inequities, access to resources, health outcomes, and policy decisions. However, despite its normative importance for health and justice, its conceptual role in bioethics remains unclear. This paper critically examines how marginalization is addressed in bioethics, analyzing its meaning, conceptual usage, and potential for further normative theorization. By exploring available definitions and how marginalization appears in bioethical literature, recurring patterns and conceptual gaps are identified. The analysis reveals two major findings. First, while definitions from disciplines beyond bioethics provide valuable insights, marginalization has not been normatively theorized as a distinct conceptual phenomenon within bioethics. Instead, dynamics of marginalization are largely addressed through established bioethical concepts, such as vulnerability or epistemic injustice. Second, it stands out that the contemporary redefinition of vulnerability in bioethics increasingly incorporates discussions on systemic exclusion and structural injustice, both central to marginalization. This raises the question of whether marginalization requires distinct conceptualization in bioethics or if its core dimensions are already encompassed by existing approaches and concepts. Consequently, this paper argues that further conceptual debate on marginalization is needed to assess its potentially distinct contributions to bioethics. It develops arguments for making space for the concept of marginalization within bioethics in its own right. To address these conceptual gaps, this paper calls for a more explicit normative analysis of marginalization to establish its role in bioethical discourse and to clarify its implications for equitable health, healthcare practices, and policies.

Ageism and ableism are intersecting forms of marginalization that shape whose knowledge counts, whose needs are prioritized, and how care is structured in public health and bioethics. While both have been examined separately, their intersection – and the epistemic injustices that emerge from it – remains underexplored in dominant bioethical discourse. Drawing on disability studies, aging studies, and social epistemology, we conceptualize epistemic injustice at this intersection through two interrelated dynamics: absence (the exclusion of marginalized perspectives) and construction (the structural production of epistemic hierarchies). These dynamics manifest not only through testimonial and hermeneutical injustice, but also through institutional norms, policy frameworks, and professional practices that shape what is recognized as legitimate knowledge. Using illustrative examples from dementia care, chronic pain, and healthcare access, we argue that ageism and ableism function as epistemic forces that structure who is heard, what is knowable, and how bioethical discourse takes shape.

Intelligent assistive technology (IAT) is being developed to enable safe and autonomous ageing at home and is associated with supporting quality of life. These anticipated benefits must be balanced against potential unintended negative effects. This scoping review aims to identify and summarize the key ethical dimensions and frameworks discussed in the relevant scholarly literature. Furthermore, we examine whether the ethical dimensions identified can be derived from the four principles of bioethics, suggesting that, when properly specified, principlism could serve as a systematic framework for evaluating IAT. Thus, our review has two aims: identifying the ethical dimensions and frameworks currently discussed and investigating whether these frameworks can be structured according to the four principles or if additional principles are necessary. A systematic search across the databases PubMed, Web of Science, EMBASE, Belit, and PhilPapers, plus a manual search identified 535 publications, from which twenty-three studies were included. The results show twenty-one heterogeneous ethical dimensions, with similar matters considered across different categories. The review shows that key expectations and promises of developing and using IAT in this context mostly relate to the possibility of safely ageing at home and reducing healthcare costs. While assigning these ethical dimensions to the four principles of bioethics, it became clear that although all aspects discussed could be subcategorized, some ethical concerns might lose visibility or be inadequately addressed. We, therefore, conclude that the four principles generally provide a sufficient basis for evaluating these technologies.

Ageismus hat weitreichende Auswirkungen. Durch den erstmaligen Transfer und die Anwendung von Konzepten aus der feministischen Medizinethik eröffnet Elisabeth Langmann neue Perspektiven auf das Phänomen und ermöglicht ein tiefgreifendes Verständnis von Ageismus mit seinen vielfältigen Formen und Implikationen auf Gesundheit und Selbstbestimmung. Mit einer kritischen Analyse der Problematik zeigt sie außerdem Wege zu einer gerechteren Gesundheitsversorgung auf und gibt wertvolle Einsichten für alle, die sich mit den Chancen und Herausforderungen des Alterns im Kontext von Gesundheit beschäftigen.

Definition of the problem Digital health technologies have gained significant importance in recent years. These technologies include symptom checker apps which use algorithms or artificial intelligence to provide users with analyses and recommendations based on their symptom input. Despite their widespread recognition, research shows mixed results regarding the accuracy of these apps, thus, limiting their current utility. The interdisciplinary CHECK.APP project examined the ethical, legal, and social aspects associated with symptom checker apps. Arguments The resulting recommendations presented here are directed towards various stakeholders, including users, physicians, developers, and public institutions. It is crucial to adopt a critical stance towards the use of symptom checker apps, promote health literacy and eHealth literacy, and ensure transparency regarding the data basis and user experiences. Moreover, there is a need for reliable and independent information sources that allow users and physicians to stay informed about current developments in the digitalization of healthcare. At the same time, developers are encouraged to follow clear guidelines on transparency, quality assurance, and accessibility. Additionally, policymakers are recommended to ensure the voluntary use of symptom checker apps and to create conditions that strengthen the health literacy of the population. Conclusion The recommendations presented here outline how symptom checker apps can be used responsibly to maximize potential benefits and minimize risks.

Definition of the problem Digital health technologies have gained significant importance in recent years. These technologies include symptom checker apps which use algorithms or artificial intelligence to provide users with analyses and recommendations based on their symptom input. Despite their widespread recognition, research shows mixed results regarding the accuracy of these apps, thus, limiting their current utility. The interdisciplinary CHECK.APP project examined the ethical, legal, and social aspects associated with symptom checker apps. Arguments The resulting recommendations presented here are directed towards various stakeholders, including users, physicians, developers, and public institutions. It is crucial to adopt a critical stance towards the use of symptom checker apps, promote health literacy and eHealth literacy, and ensure transparency regarding the data basis and user experiences. Moreover, there is a need for reliable and independent information sources that allow users and physicians to stay informed about current developments in the digitalization of healthcare. At the same time, developers are encouraged to follow clear guidelines on transparency, quality assurance, and accessibility. Additionally, policymakers are recommended to ensure the voluntary use of symptom checker apps and to create conditions that strengthen the health literacy of the population. Conclusion The recommendations presented here outline how symptom checker apps can be used responsibly to maximize potential benefits and minimize risks.

Endometriosis, a chronic inflammatory condition affecting 10% of biological women, is widely understudied and particularly overlooked in later life. Discussions surrounding endometriosis predominantly centre on medical gender bias during reproductive years, with limited attention to intersecting factors of discrimination and the impact of ageism on affected individuals. As endometriosis is framed as a disease of reproductive age, research is lacking when it comes to the effects of the illness on the older population. Symptoms in (post)menopausal individuals are frequently misattributed to other ailments due to ageist and sexist preconceptions, leading to prolonged diagnoses and mistreatment. This is a social justice issue in which age and sex contribute to the discrimination of a certain population – namely older biological women living with endometriosis. In this paper, we approach this issue from the perspective of epistemic justice. The experiences of the affected persons are shaped by a lack of knowledge about endometriosis among both the healthcare personal and the affected person, as well as a lack of acknowledgement and consideration of the persons experiences. Using the lens of epistemic justice, we develop an analytical model to understand the intersection of age and gender in the experiences of endometriosis patients. This article contributes to ongoing debates on epistemic injustice and intersectionality within medicine and healthcare, offering an analytical model that connects the critical approaches of epistemic injustice and intersectionality to address health injustice. Ultimately, this work advocates for a comprehensive, lifespan approach to endometriosis that acknowledges and addresses intersecting forms of discrimination.

Background Symptom checker apps (SCAs) are mobile or online applications for lay people that usually have two main functions: symptom analysis and recommendations. SCAs ask users questions about their symptoms via a chatbot, give a list with possible causes, and provide a recommendation, such as seeing a physician. However, it is unclear whether the actual performance of a SCA corresponds to the users’ experiences. This qualitative study investigates the subjective perspectives of SCA users to close the empirical gap identified in the literature and answers the following main research question: How do individuals (healthy users and patients) experience the usage of SCA, including their attitudes, expectations, motivations, and concerns regarding their SCA use? Methods A qualitative interview study was chosen to clarify the relatively unknown experience of SCA use. Semi-structured qualitative interviews with SCA users were carried out by two researchers in tandem via video call. Qualitative content analysis was selected as methodology for the data analysis. Results Fifteen interviews with SCA users were conducted and seven main categories identified: (1) Attitudes towards findings and recommendations, (2) Communication, (3) Contact with physicians, (4) Expectations (prior to use), (5) Motivations, (6) Risks, and (7) SCA-use for others. Conclusions The aspects identified in the analysis emphasise the specific perspective of SCA users and, at the same time, the immense scope of different experiences. Moreover, the study reveals ethical issues, such as relational aspects, that are often overlooked in debates on mHealth. Both empirical and ethical research is more needed, as the awareness of the subjective experience of those affected is an essential component in the responsible development and implementation of health apps such as SCA. Trial registration German Clinical Trials Register (DRKS): DRKS00022465. 07/08/2020.

Despite the diversity of ageing, society and academics often describe and label older persons as a vulnerable group. As the term vulnerability is frequently interchangeably used with frailty, dependence, or loss of autonomy, a connection between older age and deficits is promoted. Concerning this, the question arises to what extent it may be helpful to refer to older persons as vulnerable specifically in the context of health care. After analyzing different notions of vulnerability, I argue that it is illegitimate to conclude that older age is related to increased vulnerability. Much more, identifying older adults as a vulnerable group is closely related to ageism and can be associated with paternalistic benevolence and a tendency to overprotection, especially within health care. Additionally, even though older adults are more often in situations of increased vulnerability due to their potentially higher need for health care, I argue further that older adults mainly become a vulnerable group due to ageism. In this way, it can be concluded that the vulnerability of older adults does not originate in certain attributes of the group, but arises from a characteristic of society and, in turn, health personnel, namely ageism. Labeling older adults as vulnerable therefore is only helpful, when it is used to raise awareness of the widespread ageism in society, in this context, especially in the setting of health care, and the negative consequences thereof for older adults.

BackgroundThe concept of ‘successful ageing’ has been a prominent focus within the field of gerontology for several decades. However, despite the widespread attention paid to this concept, its intersectional implications have not been fully explored yet. This paper aims to address this gap by analyzing the potential ageist and ableist biases in the discourse of successful ageing through an intersectional lens.MethodA critical feminist perspective is taken to examine the sensitivity of the discourse of successful ageing to diversity in societies. The paper analyzes how ageist and ableist biases can manifest in the ways we conceptualize ageing, drawing on examples in the context of mental health.ResultsWe argue that the conventional approach to successful ageing is limited in its ability to account for the experiences of people who have faced intersectional discrimination throughout their lives. Drawing on examples in the context of mental health, we explore among others the link between depression and disabilities. Furthermore, we shed light on the negative impact of ageist and ableist attitudes concerning the diagnosis and treatment of dementia.DiscussionWe demonstrate how diversity is often overlooked in discussions of ageing well, and how ageist and ableist biases can manifest in the ways we conceptualize ageing. We argue that focusing solely on the health status as a means of achieving success fails to adequately counter ageism for all people. We further emphasize the role of structural factors, such as ageist attitudes, in shaping the experience of ageing and exacerbating health inequalities.ConclusionOverall, our findings emphasize the need for a more nuanced and inclusive understanding of ageing and therefore an intersectional approach to conceptions of ageing well that recognizes and addresses the biases and limitations of current discourses. Thereby, this paper offers valuable insights into the complex intersections between age and disabilities from a bioethical perspective, highlighting the need for a more inclusive and intersectional approach to ageing.