Ethics parallel research: an approach for (early) ethical guidance of biomedical innovation

Developer perspectives on the ethics of AI-driven neural implants: a qualitative study

Convergence of neural implants with artificial intelligence (AI) presents opportunities for the development of novel neural implants and improvement of existing neurotechnologies. While such technological innovation carries great promise for the restoration of neurological functions, they also raise ethical challenges. Developers of AI-driven neural implants possess valuable knowledge on the possibilities, limitations and challenges raised by these innovations; yet their perspectives are underrepresented in academic literature. This study aims to explore perspectives of developers of neurotechnology to outline ethical implications of three AI-driven neural implants: a cochlear implant, a visual neural implant, and a motor intention decoding speech-brain-computer-interface. We conducted semi-structured focus groups with developers (n = 19) of AI-driven neural implants. Respondents shared ethically relevant considerations about AI-driven neural implants that we clustered into three themes: (1) design aspects; (2) challenges in clinical trials; (3) impact on users and society. Developers considered accuracy and reliability of AI-driven neural implants conditional for users' safety, authenticity, and mental privacy. These needs were magnified by the convergence with AI. Yet, the need for accuracy and reliability may also conflict with potential benefits of AI in terms of efficiency and complex data interpretation. We discuss strategies to mitigate these challenges.

Improving shared decision-making about cancer treatment through design-based data-driven decision-support tools and redesigning care paths: an overview of the 4D PICTURE project

Background

Patients with cancer often have to make complex decisions about treatment, with the options varying in risk profiles and effects on survival and quality of life. Moreover, inefficient care paths make it hard for patients to participate in shared decision-making. Data-driven decision-support tools have the potential to empower patients, support personalized care, improve health outcomes and promote health equity. However, decision-support tools currently seldom consider quality of life or individual preferences, and their use in clinical practice remains limited, partly because they are not well integrated in patients' care paths.

Aim and objectives

The central aim of the 4D PICTURE project is to redesign patients' care paths and develop and integrate evidence-based decision-support tools to improve decision-making processes in cancer care delivery. This article presents an overview of this international, interdisciplinary project.

Design methods and analysis

In co-creation with patients and other stakeholders, we will develop data-driven decision-support tools for patients with breast cancer, prostate cancer and melanoma. We will support treatment decisions by using large, high-quality datasets with state-of-the-art prognostic algorithms. We will further develop a conversation tool, the Metaphor Menu, using text mining combined with citizen science techniques and linguistics, incorporating large datasets of patient experiences, values and preferences. We will further develop a promising methodology, MetroMapping, to redesign care paths. We will evaluate MetroMapping and these integrated decision-support tools, and ensure their sustainability using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework. We will explore the generalizability of MetroMapping and the decision-support tools for other types of cancer and across other EU member states.

Ethics

Through an embedded ethics approach, we will address social and ethical issues.

Discussion

Improved care paths integrating comprehensive decision-support tools have the potential to empower patients, their significant others and healthcare providers in decision-making and improve outcomes. This project will strengthen health care at the system level by improving its resilience and efficiency.

More ethics in the laboratory, please! Scientists' perspectives on ethics in the preclinical phase

In recent years there have been calls to improve ethics in preclinical research. Promoting ethics in preclinical research should consider the perspectives of scientists. Our study aims to explore researchers' perspectives on ethics in the preclinical phase. Using interviews and focus groups, we collected views on ethical issues in preclinical research from experienced (n = 11) and early-stage researchers (ESRs) (n = 14) working in a gene therapy and regenerative medicine consortium. A recurring theme among ESRs was the impact of health-related preclinical research on climate change. They highlighted the importance of strengthening ethics in relations within the scientific community. Experienced researchers were focused on technicalities of methods used in preclinical research. They stressed the need for more safeguards to protect the sensitive personal data they work with. Both groups drew attention to the importance of the social context of research and its social impact. They agreed that it is important to be socially responsible - to be aware of and be sensitive to the needs and views of society. This study helps to identify key ethical challenges and, when combined with more data, can ultimately lead to informed and evidence-based improvements to existing regulations.

Personalized 3D printed scaffolds: The ethical aspects

Personalized 3D printed scaffolds are a new generation of implants for tissue engineering and regenerative medicine purposes. Scaffolds support cell growth, providing an artificial extracellular matrix for tissue repair and regeneration and can biodegrade once cells have assumed their physiological and structural roles. The ethical challenges and opportunities of these implants should be mapped in parallel with the life cycle of the scaffold to assist their development and implementation in a responsible, safe, and ethically sound manner. This article provides an overview of these relevant ethical aspects. We identified nine themes which were linked to three stages of the life cycle of the scaffold: the development process, clinical testing, and the implementation process. The described ethical issues are related to good research and clinical practices, such as privacy issues concerning digitalization, first-in-human trials, responsibility and commercialization. At the same time, this article also creates awareness for underexplored ethical issues, such as irreversibility, embodiment and the ontological status of these scaffolds. Moreover, it exemplifies how to include gender in the ethical assessment of new technologies. These issues are important for responsible development and implementation of personalized 3D printed scaffolds and in need of more attention within the additive manufacturing and tissue engineering field. Moreover, the insights of this review reveal unresolved qualitative empirical and normative questions that could further deepen the understanding and co-creation of the ethical implications of this new generation of implants.

The ethical aspects of exposome research: a systematic review

In recent years, exposome research has been put forward as the next frontier for the study of human health and disease. Exposome research entails the analysis of the totality of environmental exposures and their corresponding biological responses within the human body. Increasingly, this is operationalized by big-data approaches to map the effects of internal as well as external exposures using smart sensors and multiomics technologies. However, the ethical implications of exposome research are still only rarely discussed in the literature. Therefore, we conducted a systematic review of the academic literature regarding both the exposome and underlying research fields and approaches, to map the ethical aspects that are relevant to exposome research. We identify five ethical themes that are prominent in ethics discussions: the goals of exposome research, its standards, its tools, how it relates to study participants, and the consequences of its products. Furthermore, we provide a number of general principles for how future ethics research can best make use of our comprehensive overview of the ethical aspects of exposome research. Lastly, we highlight three aspects of exposome research that are most in need of ethical reflection: the actionability of its findings, the epidemiological or clinical norms applicable to exposome research, and the meaning and action-implications of bias.

The ethics of gene therapy for hemophilia: a narrative review

Gene therapy is expected to become a promising treatment, and potentially even a cure, for hemophilia. After several years of research, the first gene therapy product has been granted conditional market authorization by the European Union in August 2022. The recent progress in the field also has implications on the ethical aspects of hemophilia gene therapy. Reviews conducted in the 2000s mainly identified questions on the ethics of conducting early-phase clinical trials. However, since then, the knowledge on safety and efficacy has improved, and the field has moved toward clinical application, a phase that has its own ethical aspects. Therefore, we conducted a narrative review to take stock of the ethical aspects of hemophilia gene therapy. Based on our analysis of the literature, we identified 3 ethical themes. The theme Living up to expectations describes the existing hopes for gene therapy and the unlikelihood of the currently approved product becoming a permanent cure. In the theme Psychosocial impacts, we discuss the fear that gene therapy will impact the identity of people with hemophilia and their need for psychosocial support. The theme Costs and access discusses the expected cost-effectiveness of gene therapy and its implications on accessibility worldwide. We conclude that it may be necessary to change the narratives surrounding gene therapy, from describing it as a cure to describing it as one of the many treatments that temporarily relieve symptoms and that there is a need to reevaluate the desirability of gene therapy for hemophilia, given the availability of other treatments.

How to embed ethics into laboratory research

Health-related innovation in biotechnology requires anticipating potential bioethical implications. In this article, we present a strategy to embed ethics in a group of early-stage researchers performing research in gene therapy and regenerative medicine in the laboratory phase. We conducted a series of focus group meetings with early-stage researchers who work in biotechnology laboratories. The objective was to reflect on the bioethical challenges of their own work and to promote the integration of research ethics with laboratory practice. The activity was assessed with questionnaires completed by the researchers before and after the meetings, and the analyses of the focus groups' content. As a result of the focus group series, all participants changed their perspectives about ethical issues regarding their planned research, developed the ability to reflect and debate on research ethics and had increased awareness of ethical issues in their own research activities. Half of them made changes in their research work. The study provides a concrete strategy to embed ethics and to strengthen responsibility in laboratory research. It is a strategy that allows to perform ethics reflection "on site" and in "real time" and complements the classic strategy of ethics assessment of the research protocol before starting the research procedure.

"Data makes the story come to life:" understanding the ethical and legal implications of Big Data research involving ethnic minority healthcare workers in the United Kingdom-a qualitative study

The aim of UK-REACH ("The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers") is to understand if, how, and why healthcare workers (HCWs) in the United Kingdom (UK) from ethnic minority groups are at increased risk of poor outcomes from COVID-19. In this article, we present findings from the ethical and legal stream of the study, which undertook qualitative research seeking to understand and address legal, ethical, and social acceptability issues around data protection, privacy, and information governance associated with the linkage of HCWs' registration data and healthcare data. We interviewed 22 key opinion leaders in healthcare and health research from across the UK in two-to-one semi-structured interviews. Transcripts were coded using qualitative thematic analysis. Participants told us that a significant aspect of Big Data research in public health is varying drivers of mistrust-of the research itself, research staff and funders, and broader concerns of mistrust within participant communities, particularly in the context of COVID-19 and those situated in more marginalised community settings. However, despite the challenges, participants also identified ways in which legally compliant and ethically informed approaches to research can be crafted to mitigate or overcome mistrust and establish greater confidence in Big Data public health research. Overall, our research indicates that a "Big Data Ethics by Design" approach to research in this area can help assure (1) that meaningful community and participant engagement is taking place and that extant challenges are addressed, and (2) that any new challenges or hitherto unknown unknowns can be rapidly and properly considered to ensure potential (but material) harms are identified and minimised where necessary. Our findings indicate such an approach, in turn, will help drive better scientific breakthroughs that translate into medical innovations and effective public health interventions, which benefit the publics studied, including those who are often marginalised in research.

A Literature Review on Ethics for AI in Biomedical Research and Biobanking

BACKGROUND

Artificial Intelligence (AI) is becoming more and more important especially in datacentric fields, such as biomedical research and biobanking. However, AI does not only offer advantages and promising benefits, but brings about also ethical risks and perils. In recent years, there has been growing interest in AI ethics, as reflected by a huge number of (scientific) literature dealing with the topic of AI ethics. The main objectives of this review are: (1) to provide an overview about important (upcoming) AI ethics regulations and international recommendations as well as available AI ethics tools and frameworks relevant to biomedical research, (2) to identify what AI ethics can learn from findings in ethics of traditional biomedical research - in particular looking at ethics in the domain of biobanking, and (3) to provide an overview about the main research questions in the field of AI ethics in biomedical research.

METHODS

We adopted a modified thematic review approach focused on understanding AI ethics aspects relevant to biomedical research. For this review, four scientific literature databases at the cross-section of medical, technical, and ethics science literature were queried: PubMed, BMC Medical Ethics, IEEE Xplore, and Google Scholar. In addition, a grey literature search was conducted to identify current trends in legislation and standardization.

RESULTS

More than 2,500 potentially relevant publications were retrieved through the initial search and 57 documents were included in the final review. The review found many documents describing high-level principles of AI ethics, and some publications describing approaches for making AI ethics more actionable and bridging the principles-to-practice gap. Also, some ongoing regulatory and standardization initiatives related to AI ethics were identified. It was found that ethical aspects of AI implementation in biobanks are often like those in biomedical research, for example with regards to handling big data or tackling informed consent. The review revealed current 'hot' topics in AI ethics related to biomedical research. Furthermore, several published tools and methods aiming to support practical implementation of AI ethics, as well as tools and frameworks specifically addressing complete and transparent reporting of biomedical studies involving AI are described in the review results.

CONCLUSIONS

The review results provide a practically useful overview of research strands as well as regulations, guidelines, and tools regarding AI ethics in biomedical research. Furthermore, the review results show the need for an ethical-mindful and balanced approach to AI in biomedical research, and specifically reveal the need for AI ethics research focused on understanding and resolving practical problems arising from the use of AI in science and society.

Ethical implications of visual neuroprostheses-a systematic review

Objective. The aim of this review was to systematically identify the ethical implications of visual neuroprostheses.Approach. A systematic search was performed in both PubMed and Embase using a search string that combined synonyms for visual neuroprostheses, brain-computer interfaces (BCIs), cochlear implants (CIs), and ethics. We chose to include literature on BCIs and CIs, because of their ethically relavant similarities and functional parallels with visual neuroprostheses.Main results. We included 84 articles in total. Six focused specifically on visual prostheses. The other articles focused more broadly on neurotechnologies, on BCIs or CIs. We identified 169 ethical implications that have been categorized under seven main themes: (a) benefits for health and well-being; (b) harm and risk; (c) autonomy; (d) societal effects; (e) clinical research; (f) regulation and governance; and (g) involvement of experts, patients and the public.Significance. The development and clinical use of visual neuroprostheses is accompanied by ethical issues that should be considered early in the technological development process. Though there is ample literature on the ethical implications of other types of neuroprostheses, such as motor neuroprostheses and CIs, there is a significant gap in the literature regarding the ethical implications of visual neuroprostheses. Our findings can serve as a starting point for further research and normative analysis.

Ethical Issues of Digital Twins for Personalized Health Care Service: Preliminary Mapping Study

BACKGROUND

The concept of digital twins has great potential for transforming the existing health care system by making it more personalized. As a convergence of health care, artificial intelligence, and information and communication technologies, personalized health care services that are developed under the concept of digital twins raise a myriad of ethical issues. Although some of the ethical issues are known to researchers working on digital health and personalized medicine, currently, there is no comprehensive review that maps the major ethical risks of digital twins for personalized health care services.

OBJECTIVE

This study aims to fill the research gap by identifying the major ethical risks of digital twins for personalized health care services. We first propose a working definition for digital twins for personalized health care services to facilitate future discussions on the ethical issues related to these emerging digital health services. We then develop a process-oriented ethical map to identify the major ethical risks in each of the different data processing phases.

METHODS

We resorted to the literature on eHealth, personalized medicine, precision medicine, and information engineering to identify potential issues and developed a process-oriented ethical map to structure the inquiry in a more systematic way. The ethical map allows us to see how each of the major ethical concerns emerges during the process of transforming raw data into valuable information. Developers of a digital twin for personalized health care service may use this map to identify ethical risks during the development stage in a more systematic way and can proactively address them.

RESULTS

This paper provides a working definition of digital twins for personalized health care services by identifying 3 features that distinguish the new application from other eHealth services. On the basis of the working definition, this paper further layouts 10 major operational problems and the corresponding ethical risks.

CONCLUSIONS

It is challenging to address all the major ethical risks that a digital twin for a personalized health care service might encounter proactively without a conceptual map at hand. The process-oriented ethical map we propose here can assist the developers of digital twins for personalized health care services in analyzing ethical risks in a more systematic manner.

Educating for Responsible Research Practice in Biomedical Sciences: Towards Learning Goals

New developments in the field of biomedicine can have extensive implications for society. To steer research efforts in a responsible direction, biomedical scientists should contribute to a forward-looking ethical, and societal evaluation of new developments. However, the question remains how to equip students sufficiently with the skills they need to contribute to this evaluation. In this paper, we examine how the four dimensions of Responsible Research and Innovation (anticipation, reflexivity, inclusivity, and responsiveness) inform the identification of learning goals and teaching approaches that contribute to developing these skills in biomedical scientists. We suggest that these educational approaches focus on the skills to anticipate intended and unintended outcomes, reflect on the epistemological and moral aspects of research practice, and be inclusive of the variety of voices in society. We argue that if these dimensions are properly integrated into biomedical curricula, they will help students develop the attitudinal aspects necessary for becoming responsive, and prepare them for implementing the dimensions of responsible research into their daily practice. This paper focuses specifically on skills biomedical scientists need for the responsible conduct of research. Therefore, our analysis results, at least in part, in domain-specific recommendations. We invite educators from other disciplines to do the same exercise, as we believe this could lead to tailored educational approaches by which students from various disciplinary backgrounds learn how they each have a role in contributing to socially robust and morally responsible research practice.

Integrating artificial intelligence in pathology: a qualitative interview study of users' experiences and expectations

Recent progress in the development of artificial intelligence (AI) has sparked enthusiasm for its potential use in pathology. As pathology labs are currently starting to shift their focus towards AI implementation, a better understanding how AI tools can be optimally aligned with the medical and social context of pathology daily practice is urgently needed. Strikingly, studies often fail to mention the ways in which AI tools should be integrated in the decision-making processes of pathologists, nor do they address how this can be achieved in an ethically sound way. Moreover, the perspectives of pathologists and other professionals within pathology concerning the integration of AI within pathology remains an underreported topic. This article aims to fill this gap in the literature and presents the first in-depth interview study in which professionals' perspectives on the possibilities, conditions and prerequisites of AI integration in pathology are explicated. The results of this study have led to the formulation of three concrete recommendations to support AI integration, namely: (1) foster a pragmatic attitude toward AI development, (2) provide task-sensitive information and training to health care professionals working in pathology departments and (3) take time to reflect upon users' changing roles and responsibilities.

Developing the building blocks to elucidate the impact of the urban exposome on cardiometabolic-pulmonary disease: The EU EXPANSE project

By 2030, more than 80% of Europe's population will live in an urban environment. The urban exposome, consisting of factors such as where we live and work, where and what we eat, our social network, and what chemical and physical hazards we are exposed to, provides important targets to improve population health. The EXPANSE (EXposome Powered tools for healthy living in urbAN SEttings) project will study the impact of the urban exposome on the major contributors to Europe's burden of disease: Cardio-Metabolic and Pulmonary Disease. EXPANSE will address one of the most pertinent questions for urban planners, policy makers, and European citizens: "How to maximize one's health in a modern urban environment?" EXPANSE will take the next step in exposome research by (1) bringing together exposome and health data of more than 55 million adult Europeans and OMICS information for more than 2 million Europeans; (2) perform personalized exposome assessment for 5,000 individuals in five urban regions; (3) applying ultra-high-resolution mass-spectrometry to screen for chemicals in 10,000 blood samples; (4) evaluating the evolution of the exposome and health through the life course; and (5) evaluating the impact of changes in the urban exposome on the burden of cardiometabolic and pulmonary disease. EXPANSE will translate its insights and innovations into research and dissemination tools that will be openly accessible via the EXPANSE toolbox. By applying innovative ethics-by-design throughout the project, the social and ethical acceptability of these tools will be safeguarded. EXPANSE is part of the European Human Exposome Network.

Mapping research strands of ethics of artificial intelligence in healthcare: A bibliometric and content analysis

The growth of artificial intelligence in promoting healthcare is rapidly progressing. Notwithstanding its promising nature, however, AI in healthcare embodies certain ethical challenges as well. This research aims to delineate the most influential elements of scientific research on AI ethics in healthcare by conducting bibliometric, social network analysis, and cluster-based content analysis of scientific articles. Not only did the bibliometric analysis identify the most influential authors, countries, institutions, sources, and documents, but it also recognized four ethical concerns associated with 12 medical issues. These ethical categories are composed of normative, meta-ethics, epistemological and medical practice. The content analysis complemented this list of ethical categories and distinguished seven more ethical categories: ethics of relationships, medico-legal concerns, ethics of robots, ethics of ambient intelligence, patients' rights, physicians' rights, and ethics of predictive analytics. This analysis likewise identified 40 general research gaps in the literature and plausible future research strands. This analysis furthers conversations on the ethics of AI and associated emerging technologies such as nanotech and biotech in healthcare, hence, advances convergence research on the ethics of AI in healthcare. Practically, this research will provide a map for policymakers and AI engineers and scientists on what dimensions of AI-based medical interventions require stricter policies and guidelines and robust ethical design and development.

Primate Organoids and Gene-Editing Technologies toward Next-Generation Biomedical Research

The improved ability to organize pluripotent stem cells (PSCs) into 3D structures in vitro has shed light on organoid technology to recapitulate organs and tumors in vivo. Advances in gene-editing technologies, particularly CRISPR-mediated techniques, offer tremendous potential in facilitating organoid research, including the study of development, disease modeling, and personalized medicine. This review discusses how the combination of two novel technologies - organoids and gene editing - not only contributes to revealing molecular events taking place during development and tumorigenesis but also has implications for biobanking, precision medicine, and other diverse biomedical applications.