The "Ought-Is" Problem: An Implementation Science Framework for Translating Ethical Norms Into Practice

Governance of research and product improvement studies in consumer mental health apps. Interviews with researchers and app developers

Consumer mental health apps (MHAs) collect and generate mental health-related data on their users, which can be leveraged for research and product improvement studies. Such studies are associated with ethical issues that may be difficult for researchers and app developers to assess. To improve ethical study conduct, governance through rules, agreements and customs could be relied upon, but their translation into practice is subject to barriers. This qualitative interview study with 17 researchers and app developers looked into the role and impact of governance standards on consumer MHA studies. Interviewees experienced a significant number of rules, agreements and customs, although not all of the governance standards that can potentially be applicable. Standards did have an impact on the interests of researchers and app developers, app users and society, but this impact was mediated by several barriers related to their conceptualization and implementation. Conceptualization barriers impacted the development of a standard, the inclusion of relevant concepts and the coordination between standards. Implementation barriers concerned the resource cost of understanding a standard, as well as suboptimal enforcement. The framework developed in this study can support more effective efforts to improve the governance of future consumer MHA studies.

How do medical students deal with the topic of racism? A qualitative analysis of group discussions in Germany

BACKGROUND

Anti-racism is part of the medical professional ethos. Nevertheless, racism pervades medicine on individual, institutional, and structural levels. The concept of habitus helps to understand deficiencies in enacting anti-racism in practice. We use a habitus-based framework to analyse how medical students in Germany deal with the topic of racism. The research questions are: What are medical students' understandings of racism? How do they deal with the topic in discussions? What difficulties do they face in such discussions?

METHODS

In a qualitative-explorative research design, we conducted six online group discussions with 32 medical students from medical schools all over Germany. Data analysis combined qualitative methods from thematic qualitative content analysis and the documentary method.

RESULTS

We identified five typical ways of dealing with the topic of racism in discussions. The first one ('scientistic') orientates action towards the idea of medicine as an objective science, justifies the use of racial categories as scientific, and defines racism based on intention. The second ('pragmatic') orientates action towards tacit rules of clinical practice, justifies the use of racialised categories as practical and defines racism as an interpersonal problem. The third ('subjectivist') lacks a clear orientation of action for dealing with the topic of racism and instead displays uncertainty and subjectivism in understanding racialised categorisations as well as racism. The fourth ('interculturalist') orientates action towards an ideal of intercultural exchange, understands racialised categorisations as representing cultural differences and interprets racism as prejudice against cultures. The fifth ('critical') orientates action towards sociological scholarship, understands racialised categorisations as social constructs and views racism as a structural problem.

CONCLUSION

The results presented help to understand preconditions of enacting anti-racism in medicine and point to difficulties and learning needs. The heterogenous ways of dealing with the topic require a differentiated approach in medical education.

Bridges and Mechanisms: Integrating Systems Science Thinking into Implementation Research

We present a detailed argument for how to integrate, or bridge, systems science thinking and methods with implementation science. We start by showing how fundamental systems science principles of structure, dynamics, information, and utility are relevant for implementation science. Then we examine the need for implementation science to develop and apply richer theories of complex systems. This can be accomplished by emphasizing a causal mechanisms approach. Identifying causal mechanisms focuses on the "cogs and gears" of public health, clinical, and organizational interventions. A mechanisms approach focuses on how a specific strategy will produce the implementation outcome. We show how connecting systems science to implementation science opens new opportunities for examining and addressing social determinants of health and conducting equitable and ethical implementation research. Finally, we present case studies illustrating successful applications of systems science within implementation science in community health policy, tobacco control, health care access, and breast cancer screening.

The relationship between speculation and translation in Bioethics: methods and methodologies

There are increasing pressures for bioethics to emphasise 'translation'. Against this backdrop, we defend 'speculative bioethics'. We explore speculation as an important tool and line of bioethical inquiry. Further, we examine the relationship between speculation and translational bioethics and posit that speculation can support translational work. First, speculative research might be conducted as ethical analysis of contemporary issues through a new lens, in which case it supports translational work. Second, speculation might be a first step prior to translational work on a topic. Finally, speculative bioethics might constitute different content altogether, without translational objectives. For each conception of speculative bioethics, important methodological aspects determine whether it constitutes good bioethics research. We conclude that whether speculative bioethics is compatible with translational bioethics-and to what extent-depends on whether it is being employed as tool or content. Applying standards of impact uniformly across bioethics may inappropriately limit speculative bioethics.

Translational Neuroethics: A Vision for a More Integrated, Inclusive, and Impactful Field

As early-career neuroethicists, we come to the field of neuroethics at a unique moment: we are well-situated to consider nearly two decades of neuroethics scholarship and identify challenges that have persisted across time. But we are also looking squarely ahead, embarking on the next generation of exciting and productive neuroethics scholarship. In this article, we both reflect backwards and turn our gaze forward. First, we highlight criticisms of neuroethics, both from scholars within the field and outside it, that have focused on speculation and lack of skepticism; the dearth of consideration of broader social issues such as justice and equality, both with regard to who speaks for neuroethics as a field and who benefits from its recommendations and findings; and the insufficient focus on the practical impact of our ethical work. Second, we embrace the concept of "translational neuroethics" to outline a vision for neuroethics that is integrated, inclusive, and impactful. Integration can help us identify more pertinent, real-world issues, and move away from speculation; inclusivity can help ensure that the questions we attend to are not merely relevant to a single subgroup but aim toward just distribution of benefits; and impact can help us think beyond guidelines and recommendations to focus on implementation. Our goal is for this call to action to help shape neuroethics into a discipline that develops rigorous research agendas through relationships with interdisciplinary partners, that is broadly inclusive and attends to issues beyond novel neurotechnologies, and that is devoted to the translation of scholarship into practice.

A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability

BACKGROUND

A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way.

METHODS

A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.'s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs' usability, applicability, and testability.

RESULTS

A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability.

CONCLUSIONS

Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.

Another implementation science is possible: engaging an 'intelligent public' in knowledge translation

As the world contends with the COVID-19 pandemic, scientific expertise has permeated political discourse and the phrase 'following the science' is being used to build trust and justify government decision-making. This phrase reflects a problematic assumption that there is one objective science to follow and that the use of scientific knowledge in decision-making is inherently neutral. In this article, we examine more closely the dense and intricate relationships, values, politics, and interests that determine whose knowledge counts, who gets to speak, who is spoken for, and with what consequences, in the translation of scientific knowledge. Drawing key insights from Stengers' Manifesto for Slow Science, we argue that implementation science has a central role to play in problematising the historic dominance of certain voices and institutional structures that have come to symbolise trust, rigour, and knowledge. Yet to date, implementation science has tended to overlook these economic, social, historical, and political forces. Fraser's conception of social justice and Jasanoff's 'technologies of humility' are introduced as useful frameworks to extend the capacity of implementation science to engage the broader public as an 'intelligent public' in the translation of knowledge, during and beyond the pandemic.

Empirical studies on how ethical recommendations are translated into practice: a cross-section study on scope and study objectives

BACKGROUND

Empirical research can become relevant for bioethics in at least two ways. First, by informing the development or refinement of ethical recommendations. Second, by evaluating how ethical recommendations are translated into practice. This study aims to investigate the scope and objectives of empirical studies evaluating how ethical recommendations are translated into practice.

METHODS

A sample of the latest 400 publications from four bioethics journals was created and screened. All publications were included if they met one of the following three criteria: (1) evaluative empirical research, (2) non-evaluative empirical research and (3) borderline cases. For all publications categorized as evaluative empirical research we analyzed which objects (norms and recommendations) had been evaluated.

RESULTS

234 studies were included of which 54% (n = 126) were categorized as non-evaluative empirical studies, 36% (n = 84) as evaluative empirical studies, and 10% (n = 24) as borderline cases. The object of evaluation were aspirational norms in 5 of the 84 included evaluative empirical studies, more specific norms in 14 (16%) studies and concrete best practices in 65 (77%) studies. The specific best practices can be grouped under five broader categories: ethical procedures, ethical institutions, clinical or research practices, educational programs, and legal regulations.

CONCLUSIONS

This mapping study shows that empirical evaluative studies can be found at all stages in the translational process from theory to best practices. Our study suggests two intertwined dimensions for structuring the field of evaluative/translational empirical studies in bioethics: First, three broader categories of evaluation objects and second five categories for types of best practices.

TRIAL REGISTRATION

The methodology used was described in a study protocol that was registered publicly on the Open Science Framework ( https://osf.io/r6h4y/ ).

Acceptable objectives of empirical research in bioethics: a qualitative exploration of researchers' views

BACKGROUND

This is the first qualitative study to investigate how researchers, who do empirical work in bioethics, relate to objectives of empirical research in bioethics (ERiB). We explore reasons that make some objectives more acceptable, while others are deemed less acceptable.

METHODS

Using qualitative exploratory study design, we interviewed bioethics researchers, who were selected to represent different types of scholars working in the field. The interview data of 25 participants were analyzed in this paper using thematic analysis.

RESULTS

From the eight objectives presented to the study participants, understanding the context of a bioethical issue and identifying ethical issues in practice received unanimous agreement. Participants also supported other objectives of ERiB but with varying degrees of agreement. The most contested objectives were striving to draw normative recommendations and developing and justifying moral principles. The is-ought gap was not considered an obstacle to ERiB, but rather a warning sign to critically reflect on the normative implications of empirical results.

CONCLUSIONS

Our results show that the most contested objectives are also the more ambitious ones, whereas the least contested ones focus on producing empirical results. The potential of empirical research to be useful for bioethics was mostly based on the reasoning pattern that empirical data can provide a testing ground for elements of normative theory. Even though empirical research can inform many parts of bioethical inquiry, normative expertise is recommended to guide ERiB. The acceptability of ambitious objectives for ERiB boils down to finding firm ground for the integration of empirical facts in normative inquiry.

Ethical, regulatory, and practical barriers to COVID-19 research: A stakeholder-informed inventory of concerns

Introduction

SARS-CoV-2 (COVID-19) has caused death and economic injury around the globe. The urgent need for COVID-19 research created new ethical, regulatory, and practical challenges. The next public health emergency could be worse than COVID-19. We must learn about these challenges from the experiences of researchers and Research Ethics Committee professionals responsible for these COVID-19 studies to prepare for the next emergency.

Materials and methods

We conducted an online survey to identify the ethical, oversight, and regulatory challenges of conducting COVID-19 research during the early pandemic, and proposed solutions for overcoming these barriers. Using criterion-based, convenience sampling, we invited researchers who proposed or conducted COVID-19 research to complete an anonymous, online survey about their experiences. We administered a separate but related survey to Institutional Review Board (IRB) professionals who reviewed COVID-19 research studies. The surveys included open-ended and demographic items. We performed inductive content analysis on responses to open-ended survey questions.

Results

IRB professionals (n = 143) and researchers (n = 211) described 19 types of barriers to COVID-19 research, related to 5 overarching categories: policy and regulatory, biases and misperceptions, institutional and inter-institutional conflicts, risks of harm, and pressure of the pandemic. Researchers and IRB professionals described 8 categories of adaptations and solutions to these challenges: enacting technological solutions; developing protocol-based solutions; disposition and team management; establishing and communicating appropriate standards; national guidance and leadership; maintaining high standards; prioritizing studies before IRB review; and identifying and incorporating experts.

Discussion and conclusions

This inventory of challenges represents ongoing barriers to studying the current pandemic, and they represent a risk to research during future public health emergencies. Delays in studies of a pandemic during a pandemic threatens the health and safety of the public. We urge the development of a national working group to address these issues before the next public health emergency arises.

Obligations of the "Gift": Reciprocity and Responsibility in Precision Medicine

Precision medicine relies on data and biospecimens from participants who willingly offer their personal information on the promise that this act will ultimately result in knowledge that will improve human health. Drawing on anthropological framings of the "gift," this paper contextualizes participation in precision medicine as inextricable from social relationships and their ongoing ethical obligations. Going beyond altruism, reframing biospecimen and data collection in terms of socially regulated gift-giving recovers questions of responsibility and care. As opposed to conceiving participation in terms of donations that elide clinical labor critical to precision medicine, the gift metaphor underscores ethical commitments to reciprocity and responsibility. This demands confronting inequities in precision medicine, such as systemic bias and lack of affordability and access. A focus on justice in precision medicine that recognizes the sociality of the gift is a critical frontier for bioethics.

Making Ethics Happen: Addressing Injustice in Health Inequalities

Health disparities-reduction research and implementation efforts are based on high ethical ideals. Given the cultural milieu in which research often occurs: How do we make these ideals happen? How do we bring about justice and fairness in health? Sisk and colleagues propose “implementation science” as a key to making an “is” from an “ought.” They suggest that bioethical and bioethics-motived research be collaborative and interdisciplinary, including both researchers of many types and the communities and individuals motivating the research activities who will most benefit from that research and outreach. We agree. However, we argue that Sisk and colleagues underemphasize the many cultural and cross-cultural factors in bringing research efforts to fruition, especially when researchers and research subjects inhabit somewhat different cultures. We illustrate this and offer guidelines for implementation based on known best practices for engaging and addressing racial health disparities in the US.