Regina Müller

The development of artificial intelligence (AI) in medicine raises fundamental ethical issues. As one example, AI systems in the field of mental health successfully detect signs of mental disorders, such as depression, by using data from social media. These AI depression detectors (AIDDs) identify users who are at risk of depression prior to any contact with the healthcare system. The article focuses on the ethical implications of AIDDs regarding affected users’ health-related autonomy. Firstly, it presents the (ethical) discussion of AI in medicine and, specifically, in mental health. Secondly, two models of AIDDs using social media data and different usage scenarios are introduced. Thirdly, the concept of patient autonomy, according to Beauchamp and Childress, is critically discussed. Since this concept does not encompass the specific challenges linked with the digital context of AIDDs in social media sufficiently, the current analysis suggests, finally, an extended concept of health-related digital autonomy.

Consumer-targeted sleep tracking applications (STA) that run on mobile devices (e.g., smartphones) promise to be useful tools for the individual user. Assisted by built-in and/or external sensors, these apps can analyze sleep data and generate assessment reports for the user on their sleep duration and quality. However, STA also raise ethical questions, for example, on the autonomy of the sleeping person, or potential effects on third parties. Nevertheless, a specific ethical analysis of the use of these technologies is still missing so far. The aim of the current analysis is to identify the characteristics of sleep tracking apps and to explore the specific ethical aspects associated with this form of self-tracking. Firstly, the field of mobile health applications was screened for STA to explore their typical functions and target user groups. Secondly, an ethical analysis was conducted focusing on the three ethical dimensions: (1) medicalization, (2) vulnerability, and (3) relationality. The analysis indicates that these three normative dimensions are decisive for assessing STA and that the ethical profile of this technology varies greatly depending on the respective user group. As the three dimensions medicalization, vulnerability, and relationality play a distinguishing role in the use of STA, they should be especially addressed in responsible development and implementation of STA. In addition, the analysis helps to evaluate the use of STA, in terms of different risks for specific user groups, the sensitive contexts of usage, and potential interference with the intimacy of third parties.

Zusammenfassung Im internationalen Diskurs sind feministische Perspektiven auf die Medizinethik bereits etabliert. Demgegenüber scheinen diese bislang nur vereinzelt in den deutschsprachigen medizinethischen Diskurs eingebracht zu werden. In diesem Artikel untersuchen wir, welche feministischen Perspektiven im deutschsprachigen medizinethischen Diskurs vertreten sind, und schlagen weitere Ansätze für eine feministische Medizinethik vor. Zu diesem Zweck zeichnen wir mittels einer systematisierten Literaturrecherche feministische Perspektiven im deutschsprachigen medizinethischen Diskurs seit der Etablierung der Medizinethik als eigenständiger institutionalisierter Disziplin nach. Wir analysieren, welche Themen bereits innerhalb der Medizinethik aus einer feministischen Perspektive untersucht worden sind, und identifizieren Leerstellen. Basierend auf der Literaturrecherche, unseren eigenen Vorarbeiten sowie der Zusammenarbeit in der Arbeitsgruppe in der Akademie für Ethik in der Medizin „Feministische Perspektiven in der Bio- und Medizinethik“ stellen wir drei Thesen vor, die aus unserer Sicht einer Weiterentwicklung des deutschsprachigen medizinethischen Diskurses dienen können. Die erste These bezieht sich auf die Ziele feministischer Medizinethiken und besagt, dass diese (epistemische) Gerechtigkeit anstreben. Die zweite These stellt zentrale Eigenschaften von feministischen Medizinethiken als kritisch und kontext-sensibel heraus. In der dritten These diskutieren wir Intersektionalität und Postkolonialismus als theoretische Ansätze, die zu einer epistemisch gerechten, kritischen und kontext-sensiblen Medizinethik beitragen können. Wir argumentieren, dass feministische Perspektiven grundständig verankert werden sollten. Der Artikel schließt mit einem Ausblick auf die Arbeit der im letzten Jahr gegründeten Arbeitsgruppe in der Akademie für Ethik in der Medizin „Feministische Perspektiven in der Bio- und Medizinethik“.

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.

Trust and trustworthiness are essential for good healthcare, especially in mental healthcare. New technologies, such as mobile health apps, can affect trust relationships. In mental health, some apps need the trust of their users for therapeutic efficacy and explicitly ask for it, for example, through an avatar. Suppose an artificial character in an app delivers healthcare. In that case, the following questions arise: Whom does the user direct their trust to? Whether and when can an avatar be considered trustworthy? Our study aims to analyze different dimensions of trustworthiness in the context of mobile health app use. We integrate O'Neill's account of autonomy, trust, and trustworthiness into a model of trustworthiness as a relational concept with four relata: B is trustworthy with respect to A regarding the performance of Z because of C. Together with O'Neill's criteria of trustworthiness (honesty, competence, and reliability), this four-sided model is used to analyze different dimensions of trustworthiness in an exemplary case of mobile health app use. Our example focuses on an app that uses an avatar and is intended to treat sleep difficulties. The conceptual analysis shows that interpreting trust and trustworthiness in health app use is multi-layered and involves a net of interwoven universal obligations. At the same time, O'Neill's approach to autonomy, trust, and trustworthiness offers a normative account to structure and analyze these complex relations of trust and trustworthiness using mobile health apps.

Symptom Checker Applications (SCA) are mobile applications often designed for the end-user to assist with symptom assessment and self-triage. SCA are meant to provide the user with easily accessible information about their own health conditions. However, SCA raise questions regarding ethical, legal, and social aspects (ELSA), for example, regarding fair access to this new technology. The aim of this scoping review is to identify the ELSA of SCA in the scientific literature. A scoping review was conducted to identify the ELSA of SCA. Ten databases (e.g., Web of Science and PubMed) were used. Studies on SCA that address ELSA, written in English or German, were included in the review. The ELSA of SCA were extracted and synthesized using qualitative content analysis. A total of 25,061 references were identified, of which 39 were included in the analysis. The identified aspects were allotted to three main categories: (1) Technology; (2) Individual Level; and (3) Healthcare system. The results show that there are controversial debates in the literature on the ethical and social challenges of SCA usage. Furthermore, the debates are characterised by a lack of a specific legal perspective and empirical data. The review provides an overview on the spectrum of ELSA regarding SCA. It offers guidance to stakeholders in the healthcare system, for example, patients, healthcare professionals, and insurance providers and could be used in future empirical research to investigate the perspectives of those affected, such as users.

Definition of the problemFeminist approaches to medical ethics are well established in international discourses. By contrast, in the German-speaking medical ethical discourse, they still seem to be rather marginal. In this article, we analyze which feminist perspectives are prominent in German medical ethics and suggest new approaches.ArgumentsWe present our results from a systematized review of the literature, in which we identify existing feminist approaches within the German-speaking medical ethics discourse as well as research gaps. Based on the review, our preliminary research and discussions in the working group “Feminist perspectives in bio and medical ethics”, we defend three hypotheses aimed at advancing the German feminist medical ethical discourse. We posit that (1) feminist medical ethics aim at (epistemic) justice, (2) feminist medical ethics are critical and context-sensitive, and (3) intersectional and postcolonial approaches within feminist medical ethics may contribute to epistemically just, critical, and context-sensitive medical ethics.ConclusionWe argue that feminist perspectives should be implemented as a fundamental perspective in medical ethics because they can bring together key dimensions such as epistemically just, critical, context-sensitive, intersectional, and postcolonial thinking.

BackgroundPatient advocacy organizations (PAOs) have an increasing influence on health policy and biomedical research, therefore, questions about the specific character of their responsibility arise: Can PAOs bear moral responsibility and, if so, to whom are they responsible, for what and on which normative basis? Although the concept of responsibility in healthcare is strongly discussed, PAOs particularly have rarely been systematically analyzed as morally responsible agents. The aim of the current paper is to analyze the character of PAOs’ responsibility to provide guidance to themselves and to other stakeholders in healthcare.MethodsResponsibility is presented as a concept with four reference points: (1) The subject, (2) the object, (3) the addressee and (4) the underlying normative standard. This four-point relationship is applied to PAOs and the dimensions of collectivity and prospectivity are analyzed in each reference point.ResultsUnderstood as collectives, PAOs are, in principle, capable of intentionality and able to act and, thus, fulfill one prerequisite for the attribution of moral responsibility. Given their common mission to represent those affected, PAOs can be seen as responsible for patients’ representation and advocacy, primarily towards a certain group but secondarily in a broader social context. Various legal and political statements and the bioethical principles of justice, beneficence and empowerment can be used as a normative basis for attributing responsibility to PAOs.ConclusionsThe understanding of responsibility as a four-point relation incorporating collective and forward-looking dimensions helps one to understand the PAOs’ roles and responsibilities better. The analysis, thus, provides a basis for the debate about PAOs’ contribution and cooperation in the healthcare sector.

BackgroundThe West African Ebola virus epidemic from 2014 to 2016 is unprecedented in its scale, surpassing all previous and subsequent Ebola outbreaks since 1976. This epidemic provoked a humanitarian emergency that extended to different spheres of life, making visible ethical challenges in addition to medical, economic, and social ones. The present article aims to identify and differentiate the scope of ethical issues associated with the Ebola epidemic.MethodsAn online media analysis was performed on articles published from March 2014 to September 2015 in ten preselected academic journals (scientific press) and two online newspapers (lay press). Two methodological approaches were combined: a systematic literature search and a qualitative content analysis. An additional keyword search was conducted on the PubMed database for the period after the end of the Ebola epidemic (2016-2020) to obtain an overview of research dealing with medical ethics due to the epidemic and to compare these results with the identified ethical challenges.ResultsA total of 389 articles dealing with the subject fields “Ebola epidemic” and “ethics” were researched. For qualitative content analysis, the time span with the highest article density was selected and a total of 64 articles were included (15 scientific articles, 49 popular articles). Five core ethical challenges of the Ebola epidemic emerged: 1. Responsibility and Accountability, 2. Spillover Effects, 3. Research and Development, 4. Health Communication, and 5. Resource Allocation. Articles in academic journals were dominated by the discussion of normative aspects in the area of “research and development”, while newspaper articles focused on aspects of “responsibility and accountability”.ConclusionAn ethical discussion of the Ebola epidemic requires an examination of as many of the ethical dimensions involved as possible. The presented investigation of the two types of media with regard to the Ebola epidemic offers this possibility of a more comprehensive insight into this diversity as a basis for ethical discussions.

Smartphone apps might offer a low-threshold approach to the detection of mental health conditions, such as depression. Based on the gathering of ‘passive data,’ some apps generate a user’s ‘digital phenotype,’ compare it to those of users with clinically confirmed depression and issue a warning if a depressive episode is likely. These apps can, thus, serve as epistemic tools for affected users. From an ethical perspective, it is crucial to consider epistemic injustice to promote socially responsible innovations within digital mental healthcare. In cases of epistemic injustice, people are wronged specifically as epistemic agents, i.e., agents of the production and distribution of knowledge. We suggest that epistemic agency relies on different resource- and uptake-related preconditions which can be impacted by the functionality of passive self-tracking apps. We consider how this can lead to different forms of epistemic injustice (testimonial, hermeneutical, and contributory injustice) and analyze the influence of the apps’ use on epistemic practices on an individual level, in mental healthcare settings, and on the structural level.