Hammer or Measuring Tape? Artificial Intelligence and Justice in Healthcare

Artificial intelligence (AI) is a powerful tool for several healthcare tasks. AI tools are suited to optimize predictive models in medicine. Ethical debates about AI's extension of the predictive power of medical models suggest a need to adapt core principles of medical ethics. This article demonstrates that a popular interpretation of the principle of justice in healthcare needs amendment given the effect of AI on decision-making. The procedural approach to justice, exemplified with Norman Daniels and James Sabin's accountability for reasonableness conception, needs amendment because, as research into algorithmic fairness shows, it is insufficiently sensitive to differential effects of seemingly just principles on different groups of people. The same line of research generates methods to quantify differential effects and make them amenable for correction. Thus, what is needed to improve the principle of justice is a combination of procedures for selecting just criteria and principles and the use of algorithmic tools to measure the real impact these criteria and principles have. In this article, the author shows that algorithmic tools do not merely raise issues of justice but can also be used in their mitigation by informing us about the real effects certain distributional principles and criteria would create.

Voluntariness or legal obligation? An ethical analysis of two instruments for fairer global access to COVID-19 vaccines

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.

From General Principles to Procedural Values: Responsible Digital Health Meets Public Health Ethics

Most existing work in digital ethics is modeled on the "principlist" approach to medical ethics, seeking to articulate a small set of general principles to guide ethical decision-making. Critics have highlighted several limitations of such principles, including (1) that they mask ethical disagreements between and within stakeholder communities, and (2) that they provide little guidance for how to resolve trade-offs between different values. This paper argues that efforts to develop responsible digital health practices could benefit from paying closer attention to a different branch of medical ethics, namely public health ethics. In particular, I argue that the influential "accountability for reasonableness" (A4R) approach to public health ethics can help overcome some of the limitations of existing digital ethics principles. A4R seeks to resolve trade-offs through decision-procedures designed according to certain shared procedural values. This allows stakeholders to recognize decisions reached through these procedures as legitimate, despite their underlying disagreements. I discuss the prospects for adapting A4R to the context of responsible digital health and suggest questions for further research.

"Following orders" as a critique on healthcare allocation committees: An anthropological perspective on the role of public memory in bioethical legitimacy

The public perception of decision-making procedures as fair processes is a central means for establishing their legitimacy to make difficult resource allocation decisions. According to the ethical framework of accountability for reasonableness (A4R, hereafter), which specifies conditions for fair healthcare resource allocation, disagreements about what constitutes relevant considerations are a central threat to its perceived fairness. This article considers how an ethical principle grounded in the public memory of past traumatic events may become the topic of such disagreements. I demonstrate this through an anthropological case study of a recent public de bate concerning an Israeli healthcare allocation committee (HAC, thereafter), which determines state subsidies for new medical technologies as part of Israel's public healthcare system. Drawing upon ethnographic fieldwork about the HAC, I show how the public memory of Adolf Eichmann's trial constitutes a bioethical problem for the committee's legitimacy. Based on Arendt's and Bauman's writings that Nazi bureaucrats' manner of "following orders" was an ethical transgression, some patients contended that the committee has a historical responsibility to question its strict adherence to bureaucratic procedures. Since the committee did not have a direct link to the events of the Holocaust, other considerations seemed to them more relevant. I then present an offer that can settle this disagreement and maintain the HAC's legitimacy according to A4R. I conclude by discussing the contribution of empirical data to models of bioethical legitimacy.

A conceptual approach to the rationale for SARS-CoV-2 vaccine allocation prioritisation

Currently vaccines protecting from COVID-19 are a scarce resource. Prioritising vaccination for certain groups of society is placed in a context of uncertainty due to changing evidence on the available vaccines and changing infection dynamics. To meet accepted ethical standards of procedural justice and individual autonomy, vaccine allocation strategies need to state reasons for prioritisation explicitly while at the same time communicating the expected risks and benefits of vaccination at different times and with different vaccines transparently. In this article, we provide a concept summarising epidemiological considerations underlying current vaccine prioritisation strategies in an accessible way. We define six priority groups (vulnerable individuals, persons in close contact with the vulnerable, key workers with direct work-related contact with the public, key workers without direct work-related contact to the public, dependents of key workers and members of groups with high interpersonal contact rates) and state vaccine priorities for them. Additionally, prioritisation may follow non-epidemiological considerations including the aim to increase intra-societal justice and reducing inequality. While national prioritisation plans integrate many of these concepts, the international community has so far failed to guarantee equitable or procedurally just access to vaccines across settings with different levels of wealth.

Fair allocation of cryopreserved donor oocytes: towards an accountable process

A growing number of people desire ART with cryopreserved donor oocytes. The allocation of these oocytes to couples and mothers to be is a 2-fold process. The first step is to select a pool of recipients. The second step is to decide who should be treated first. Prioritizing recipients is critical in settings where demand outstrips supply. So far, the issue of how to fairly allocate cryopreserved donor oocytes has been poorly addressed. Our ethical analysis aims to support clinics involved in allocation decisions by formulating criteria for recipient selection irrespective of supply (Part I) and recipient prioritization in case supply is limited (Part II). Relevant criteria for recipient selection are: a need for treatment to experience parenthood; a reasonable chance for successful treatment; the ability to safely undergo an oocyte donation pregnancy; and the ability to establish a stable and loving relationship with the child. Recipients eligible for priority include those who: have limited time left for treatment; have not yet experienced parenthood; did not undergo previous treatment with cryopreserved donor oocytes; and contributed to the supply of donor oocytes by bringing a donor to the bank. While selection criteria function as a threshold principle, we argue that the different prioritization criteria should be carefully balanced. Since specifying and balancing the allocation criteria undoubtedly raises a moral dispute, a fair and legitimate allocation process is warranted (Part III). We argue that allocation decisions should be made by a multidisciplinary committee, staffed by relevant experts with a variety of perspectives. Furthermore, the committees' reasoning behind decisions should be transparent and accessible to those affected: clinicians, donors, recipients and children born from treatment. Insight into the reasons that underpin allocation decisions allows these stakeholders to understand, review and challenge decisions, which is also known as accountability for reasonableness.

Emergency care, triage, and fairness

Triage is a widespread principle for prioritizing patients in emergency departments. The purpose of triage is to ensure that in emergency situations, whenever medical demand exceeds medical supply, limited resources should be directed to the case with the greatest clinical need. Triage fulfills this purpose by ranking patients according to how acute their condition is and then giving priority to the most acute ones. In this paper, I argue that this current practice of triage needs to be supplemented. Contemporary triage is based on a principle of preserving patients' core capabilities, which is relevant when it comes to prioritizing acute patients above sub-acute ones, but not for prioritizing among sub-acute patients, which is the largest group of emergency patients. Henceforth, I propose to supplement triage with what I term the real dialogue model, a framework that, when combined with enhanced professional autonomy for clinical decision-makers, enables fair prioritizing among sub-acute patients.

Ethical Challenges in the Provision of Dialysis in Resource-Constrained Environments

The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.

Ethical Dilemmas in Protecting Susceptible Subpopulations From Environmental Health Risks: Liberty, Utility, Fairness, and Accountability for Reasonableness

Various U.S. laws, such as the Clean Air Act and the Food Quality Protection Act, require additional protections for susceptible subpopulations who face greater environmental health risks. The main ethical rationale for providing these protections is to ensure that environmental health risks are distributed fairly. In this article, we (1) consider how several influential theories of justice deal with issues related to the distribution of environmental health risks; (2) show that these theories often fail to provide specific guidance concerning policy choices; and (3) argue that an approach to public decision making known as accountability for reasonableness can complement theories of justice in establishing acceptable environmental health risks for the general population and susceptible subpopulations. Since accountability for reasonableness focuses on the fairness of the decision-making process, not the outcome, it does not guarantee that susceptible subpopulations will receive a maximum level of protection, regardless of costs or other morally relevant considerations.

The accountability for reasonableness approach to guide priority setting in health systems within limited resources--findings from action research at district level in Kenya, Tanzania, and Zambia

BACKGROUND

Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT).

METHODS

This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods.

RESULTS

The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes.

CONCLUSIONS

District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.

Involving decision-makers in the research process: Challenges of implementing the accountability for reasonableness approach to priority setting at the district level in Tanzania

The past two decades have seen a growing call for researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice. However, there has been a little attention focused on documenting the challenges of dealing with decision-makers in the course of implementing a research project. This paper highlights a collaborative research project aiming to implement the accountability for reasonableness (AFR) approach to priority setting in accordance with the Response to Accountable Priority Setting for Trust in Health Systems (REACT) project in Tanzania. Specifically, the paper examines the challenges of dealing with decision-makers during the project-implementation process and shows how the researchers dealt with the decision-makers to facilitate the implementation of the REACT project. Key informant interviews were conducted with the Council Health Management Team (CHMT), local government officials and other stakeholders, using a semi-structured interview guide. Minutes of the Action Research Team and CHMT were analysed. Additionally, project-implementation reports were analysed and group priority-setting processes in the district were observed. The findings show that the characteristics of the REACT research project, the novelty of some aspects of the AFR approach, such as publicity and appeals, the Action Research methodology used to implement the project and the traditional cultural contexts within which the project was implemented, created challenges for both researchers and decision-makers, which consequently slowed down the implementation of the REACT project. While collaboration between researchers and decision-makers is important in bridging gaps between research and practice, it is imperative to understand the challenges of dealing with decision-makers in the course of implementing a collaborative research project. Such analyses are crucial in designing proper strategies for improved communication and for the utilisation of research projects over time.

Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania

Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R) approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context is imperative in fostering sustainability. Additionally, the study stresses the need to deal with power asymmetries among various actors in priority-setting contexts.