Psychedelic-assisted therapy will soon be approved for adults. If the history of adult psychiatric drugs is any guide, adolescents will not be far behind — which makes the question of how they should be included in research an urgent one. That question has typically been framed through the lens of autonomy, and specifically through the adolescent’s capacity to consent to participation. We argue that for psychedelics, an equally important dimension of autonomy lies in what happens afterward: in the adolescent’s capacity, or lack of capacity, to shape the environment in which therapeutic change has to take root.

The last time a major class of depression drugs was approved for adults, adolescents received it through off-label prescribing long before the rigorous testing required to determine the risk-benefit profile in that population. SSRIs reached millions of young people this way: not through malpractice, but because the absence of paediatric trials leaves clinicians with adult-licensed drugs and adolescent patients in distress, and a difficult choice between prescribing off-label or not prescribing at all. This means safety and efficacy questions for paediatric populations get answered in clinical practice rather than in the context of research trials. Indeed, a network meta-analysis found that only one of fourteen antidepressants had a favourable risk-benefit balance in young people, and that some were associated with increased suicidality.

Adolescent mental health is in a worse state now than when SSRIs emerged. Clinicians, parents, and suffering young people are looking for better options – and psychedelic-assisted therapy (P-AT), with its promising adult results, will be a tempting one. But the felt urgency to respond to this need must not lead us to repeating the mistakes we made with SSRIs. The sentiment that children and adolescents are not just “little adults” is well-worn, but it bears repeating: we need sensitivity to differences not just in their biology, but in their psychology and social context.

Getting that sensitivity right requires adolescent-specific evidence that, at present, we simply do not have. Khaleel Rajwani and Brian Earp have argued that this needs to change. If P-AT is licensed for adults but no adolescent trials follow, the SSRI pattern will repeat. This means we need P-AT trials in adolescents. But what should they look like?

At least in part, the answer comes from taking adolescent autonomy seriously – but in a way that the existing bioethical conversation has not yet foregrounded. The protection and promotion of patient autonomy is, for many, the foremost among bioethical principles, and a central concern in paediatric research ethics. Adolescent decision-making capacity develops unevenly, perhaps especially in risk evaluation, future orientation, and susceptibility to authority. It makes sense, then, that the familiar challenges around adolescent autonomy in research ethics foreground the decision to participate – whether a young person can meaningfully consent to being enrolled in the first place. As we argue in a newly published paper, there is reason to think that adolescent autonomy is just as ethically salient after the drug has been administered. The reason has to do with how psychedelics seem to work.

Psychedelics appear to create a time-limited window of enhanced plasticity: a period in which entrenched, harmful, or counterproductive patterns become more open to being reshaped. Preclinical research provides robust evidence that psychedelics enhance structural and functional neuroplasticity. Confirming this directly in living human brains is not yet possible. But if psychedelics temporarily make the brain more open to being reshaped, then what it is that does the reshaping probably matters: not just any psychological support or psychotherapy that follows the drug session, but also the person’s relationships, daily circumstances, and the quality of support available to them.

The plasticity-enhancing effects of psychedelics are often lauded as a straightforwardly positive thing, and not without cause: enhanced openness to change is one of the reasons psychedelics are thought to be transdiagnostically effective. But plasticity is not inherently good or bad: inasmuch as psychedelics support the reshaping of patterns of thought or behaviour, it follows that adverse influences during this window could be actively counterproductive to recovery, perhaps even harmful. In one study of people who experienced prolonged difficulties after naturalistic psychedelic use, key risk factors included stressful circumstances, lack of social support, and young age. If we take seriously, as many do, the idea that post-psychedelic psychotherapy is particularly effective because it acts during a period of heightened plasticity, then we must take equally seriously that adverse environments during this same period could undermine or reverse therapeutic gains.

But people don’t need to be passive recipients of their environments. In our research, some of the most successful adult P-AT patients renegotiated or restructured their lives following treatment: pruning draining relationships, investing in nourishing ones, pursuing long-suppressed interests. This active reshaping of one’s social environment during the post-treatment window may be part of how therapeutic gains consolidate. The acute experience generates insight and renewed motivation; adult autonomy allows the patient to turn that into lasting change.

The autonomy of adolescents – or rather, the relative lack of autonomy of adolescents, complicates this process. The developmental trajectory of adolescence is precisely the gradual gaining of influence over one’s own social environment. But relative to a typical adult, teenagers have far less ability to select, avoid, or seek out the social inputs that shape their recovery. Their daily lives are largely determined by the norms of the family home and the routines of schooling.

In short, we should think very carefully before giving adolescents plasticity-enhancing drugs, and then returning them to the very environments in which their distress first emerged.

We argue that taking these considerations seriously has concrete implications for how adolescent P-AT should be designed, at least at first: it invites approaches that attend to the family and relational world the adolescent will return to, not just the individual sitting across from the therapist. “Readiness for treatment” should encompass not only the patient but also the environment they will return to.

Adult psychedelic trials already ask about family history, typically to screen for first-degree relatives with psychosis as an exclusion criterion. This is sensible. But for an adolescent patient, the family is more than a source of inherited risk. It is also a large part of the relational environment the patient will return to during the period of heightened sensitivity discussed above. A family history limited to parental psychiatric diagnoses may suggest biological vulnerability, but on its own tells you little about the emotional climate the adolescent will return to, the capacity of caregivers to absorb and support change, or the relational patterns that may have contributed to their difficulties in the first place. Adolescent P-AT needs a sense of the family the adolescent is going back to, not just the family they are descended from.

Concretely, attending to the post-treatment environment the adolescent returns to might include psychoeducation for caregivers about the post-treatment sensitivity window, assessment of family functioning to identify where additional support is needed, and access to brief, evidence-based family interventions with demonstrated effects on both caregiver self-efficacy and child mental health outcomes. It would also likely involve integration support that extends well beyond the protocol-defined number of sessions developed for adult trials.

And it might, in some cases, look stranger still: it is conceivable that the best application of P-AT to improve at least some adolescents’ mental health could be its judicious use in one or both parents, with integration involving a mix of family and individual therapy. This is not without precedent in spirit, if not in modality: family systems approaches have long recognised that treating the relational context around the patient can be more effective than treating the patient alone, and brief family interventions already have a strong evidence base in adolescent mental health. This is more work and more expense for an already resource-intensive modality. But the alternative is the pattern that produced the SSRI story.

The logic here is not confined to adolescents. Anyone whose environment is both adverse and resistant to individual modification may face a version of the same problem. There are early signals that the population-level benefits of psychedelics are diminished in groups facing structural disadvantage. If the post-treatment environment is part of the mechanism, not merely a backdrop to it, then attending to that environment is not an optional extra but a core design question. Psychedelics might loosen entrenched maladaptive patterns. They cannot, by themselves, alter the circumstances that produced them.

Eddie Jacobs, DPhil (@eddietalksdrugs) is a postdoctoral fellow in psychedelic science at the Center for Psychedelic and Consciousness Research, Johns Hopkins and Associate Director of the Hub at Oxford for Psychedelic Ethics

Bryony Insua-Summerhays, DClinPsych is a Senior Clinical Psychologist in the NHS

The post How Should Adolescents Be Included in Clinical Psychedelic Research? appeared first on Bioethics Today.

In American hospitals, beneath the noise of day-to-day clinical work, a quieter, more insidious shift has taken place—a linguistic one that is eroding the physician’s identity. After two decades of practice across three continents, I have been called many things: healer, doctor, advisor, confidant, and student. Only in the United States have I been routinely referred to as a “provider.” To an administrator, it’s harmless shorthand. To me—and to physicians and patients—it is a term that hollows out the profession, reduces patients to consumers, and flattens the sacred art of medicine into a mere commercial transaction. I refuse to accept it.

My odyssey unfolded in northern Pakistan. There, the title “doctor” carries an almost spiritual weight. Patients address you as Doctor Sahib—a mark of respect for your expertise, yes, but also for your role as a trusted guide with moral and social gravity. Medicine there was deeply personal and communal; it was woven into the community. No one ever “provided” care; we practiced it, and language reflected that truth.

Singapore was different—a landscape of ruthless efficiency and high-tech precision. Yet, even in that hyper-modern system, the language remained sharp. I was still a doctor. The title signified a clear contract of competence and reliability, reinforcing professional identity rather than impeding efficiency. There was no room for bureaucratic euphemism in the clinical encounter. Studies on professional identity formation underscore that such linguistic anchors are central to how clinicians internalize ethical responsibility and meaning in their work.

Then came London and the NHS. While the word “provider” appeared in high-level policy documents to describe massive organizations or NHS Trusts, they have largely kept it out of the exam room. Physicians were doctors—full stop. The distinction was vital: titles reflected the ethical weight of the decisions we made at the bedside. This separation is intentional. System-level abstraction may serve administrators, but bedside medicine depends on moral clarity. Narrative medicine and general internal medicine literature consistently show that patients experience care relationally, not institutionally.

When I moved across the pond to the United States, I expected to find the pinnacle of medical advancement. Instead, I often encountered a culture drowning in corporate euphemism. In emails, EHR prompts, and “patient-facing” brochures, I had become a “provider.” It isn’t just a semantic annoyance; it reflects a broader, darker transformation in American healthcare, where market forces reign supreme. Analyses of medical language demonstrate a broader cultural move away from individuals and toward populations, metrics, and standardization. To call a physician a “provider” implies we are interchangeable—cogs in a supply chain rather than professionals with specific, grueling training. It blurs the vital lines between physicians, nurse practitioners, and physician associates, collapsing distinctions between years of training, scopes of practice, and professional accountability. Needless to say, collaboration is essential, yet respect does not require homogenization. True teams function best when roles are clear, not when they are diluted into a gray administrative soup. Evidence from team-based care repeatedly shows that clarity of roles—not their erasure—improves safety and performance. Ambiguity diffuses responsibility and increases cognitive error.

For millennia, physicians have been entrusted with the most vulnerable moments of the human experience, something impossible to put a price tag on. However, the term “provider” commodifies the doctor-patient relationship. When I sit with a patient receiving a terminal diagnosis, I am not “providing a service.” I am holding a space for their fear and their hope. I still think of an elderly patient with heart failure who once spent an hour telling me about his life’s regrets. That wasn’t a billing code. It was the essence of the job. Narrative accounts across specialties emphasize that meaning in practice often resides in these quiet, unmeasured moments.

Moreover, the dehumanizing effect of this corporate dialect is a potent contributor to the ongoing burnout crisis amongst US physicians. Burnout in American medicine is often attributed to workload and documentation, but growing scholarship highlights moral injury—the distress that arises when systems force clinicians to act against their values. When we are reduced to “providers,” it becomes easier for a system to treat us as data points—imposing quotas and metrics that value volume over judgment, presence, and the human soul. In an age of rampant misinformation, patients deserve to know exactly who is treating them. Titles signal training, accountability, and authority. When patients know whether they are seeing a physician, they can contextualize advice and responsibility—particularly in high-stakes or end-of-life decisions. Transparency promotes trust, and trust is the only foundation upon which healing can happen.

Change is possible. The American Medical Association has already pushed to abandon “provider” in favor of “physician.” It’s time for hospitals and insurers to catch up. But more importantly, it’s up to us. A gentle correction— “Please, call me doctor”—goes a long way in honoring the commitment we’ve made to our patients, our profession, and our own well-being. It reasserts not ego, but responsibility.

I am a doctor. It’s time we reclaimed the title—and the soul of the profession.

Kalimullah Jan, MD, is an Instructor in the department of Neurosurgery (Neuroendovascular) at the Medical College of Wisconsin, Milwaukee.

The post In Every Country I Practiced, I Was a Doctor — Until America appeared first on Bioethics Today.

The term “social media manipulation” was coined to describe how the features of social media algorithms (e.g., hypernudging and microtargeting) and the uncontrolled proliferation of misinformation bots influence users online and offline. Social media companies have been the target of speculation from politicians, journalists, and the public as cultivators of misinformation and radicalization. Senators from both sides of the aisle have called out divisive content about social media’s detrimental impact on young people. These arguments are not new. Websites like 4chan have been publicly discussed as hotbeds for far-right radicalization that encourage dangerous behaviors like doxxing, swatting, and in some cases, mass violence. Taken together, social media manipulation and the ability of (even a few) bad actors to gain significant exposure, we see that the average user’s social and political reality can be easily distorted. Further, these apps can even have the ability to influence what values are embodied and expressed through the development of new social norms.

So we ask, if there’s evidence that social media influences and manipulates user behavior, then is it possible that social media also influences users’ moral sensibilities?

Using a case study, we hypothesize that the tendency for social media algorithms to generate moral outrage is re-integrating and normalizing disavowed value systems, like eugenics. For example, Dej and Antwon are Black disability influencers with Osteogenesis Imperfecta (OI), who collectively have over one million TikTok followers. As influencers, videos of their lives are routinely the target of discussions on lifestyle choices of people with disabilities. A (now deleted video) announcing the birth of their daughter, who was also born with OI, led to severe public outrage (See Figure 1). Responses from other creators and commenters started with concerns for the child and evolved into a debate on whether disabled people should have children. 

On TikTok consensus is driven by “likes,” where the most liked comments rise to the top. For instance, the top comment with 180 thousand likes, called Dej and Antwon’s actions, “[The] Most selfish thing ever😭 I wouldn’t forgive my parents.” This is particularly of concern, because it characterizes Dej and Antwon as bad parents for having a child with a disability. This discourse reflects a pervasive eugenics practice of publicly evaluating disabled people’s reproductive choices and applying moral judgment. While it is unclear what values and beliefs people hold outside of the comment section, the app and comment section alike have created an environment where eugenics and other disavowed value systems (i.e. racism) are tolerated and engaged. 

As such, we posit that one of the largest places everyday people gather to debate morality, ethics, and morally acceptable social norms, is TikTok. As a field, bioethicists should interrogate the possibility of social media changing moral realities. The discussions occurring online have larger implications for society, but determining their impact on moral sensibilities is more challenging to empirically capture compared to shopping trends or voting behavior.

Despite the need for bioethicists to engage with online content, it is unclear how we are supposed to navigate the ethically complex conversations or how to rigorously study its users. Should we engage in social media, as influencers or fact checkers? How should we invest in empirical bioethics research on TikTok and other social media apps? How should bioethicists intervene in what seems to be a mass social and moral backsliding event? We invite bioethicists to think deeply about how to respond.

Social media platforms are shaping and reshaping perspectives on, attitudes towards experts, expectations of public institutions, political beliefs, and possibly moral values, without much engagement from bioethicists. As a complex AI age is on the precipice, public health is dismantled, and our government officials push mis- and disinformation, we must keep our fingers on the pulse of the commentary that is happening on TikTok. If not, bioethicists risk ceding influential public discourse to voices that may undermine ethical reasoning, public trust, and evidence-based decision-making.

Figure 1

Taylor Montgomery, MPH is a doctoral student at Johns Hopkins University Berman Institute of Bioethics

Odia Kane, PhD, MPH, is a post-doctoral fellow at the Johns Hopkins University Berman Institute of Bioethics and Institute of Assured Autonomy

The post TikTok Ethics: Social Media’s Influence on Moral Values appeared first on Bioethics Today.

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Bioethics exists to help us think clearly about difficult medical decisions, especially when those decisions affect individuals who cannot speak for themselves. At its core, bioethics asks a set of enduring questions: Who decides? Who bears the risks? And what obligations do we have to protect the most vulnerable?

These questions arise across medicine, but they take on particular urgency in discussions of routine infant circumcision. The practice is often framed in terms of culture, religion, or potential health benefits. Far less frequently examined is how it aligns with the ethical framework that guides modern medical decision-making.

When we apply the four central principles of bioethics—autonomy, beneficence, non-maleficence, and justice—we are confronted with a critical question: Does routine infant circumcision meet the ethical standards medicine claims to uphold?

This question is not limited to clinicians or ethicists. It is relevant to anyone concerned with children’s rights, bodily autonomy, and the integrity of medical practice.

Autonomy and the Limits of Proxy Consent

Autonomy is a foundational principle of modern healthcare. It is operationalized through informed consent—the expectation that individuals understand and agree to medical interventions affecting their bodies.

Infants, of course, cannot provide consent. Parents are therefore entrusted with making decisions on their behalf. Ethically, however, this authority is not without limits. Proxy decision-making is generally justified when it serves the child’s best medical interests or addresses a clear and present health need.

Routine infant circumcision does not fit neatly within this framework. It involves the removal of healthy, functional tissue from a non-consenting individual, typically without medical necessity. Because the procedure is irreversible, the individual affected is permanently deprived of the opportunity to make this decision for themselves.

From a bioethical standpoint, this raises a central concern: if respect for autonomy is a core value in medicine, how do we justify performing a non-therapeutic, irreversible procedure on someone who cannot consent?

Non-Maleficence and the Question of Harm

The principle of non-maleficence—commonly expressed as “do no harm”—requires clinicians to avoid exposing patients to unnecessary risk. This obligation is particularly strong when the patient is otherwise healthy.

Circumcision is a surgical intervention, and like all surgeries, it carries inherent risks. These include pain, bleeding, infection, and, in rare cases, more serious complications. While many procedures occur without major incident, the ethical question is not simply whether harm is common, but whether the risk of harm is justified at all.

In most areas of medicine, surgical risks are considered acceptable when they are necessary to treat disease or prevent significant future harm. Routine infant circumcision, by contrast, is generally performed on healthy individuals without a medical indication.

This leads to a straightforward ethical inquiry: Is it appropriate to expose a child to surgical risk when there is no immediate medical need?

Beneficence and the Evaluation of Claimed Benefits

Beneficence requires that medical interventions provide a meaningful benefit to the patient—one that justifies any associated risks.

Proponents of routine circumcision often cite potential health benefits, including reduced risks of certain infections. Bioethics, however, demands that such claims be evaluated in context. Many of the conditions referenced—such as urinary tract infections or sexually transmitted infections—can be addressed through less invasive means, including hygiene, education, and medical treatment.

This is reflected in the positions of many healthcare systems globally. Medical organizations in Europe, Canada, and other regions have concluded that the potential benefits of routine infant circumcision are insufficient to justify performing surgery on healthy children.

The ethical question, then, is not whether some benefit may exist, but whether those benefits are substantial enough to warrant an irreversible intervention before the individual can weigh those factors independently.

Justice and Consistency in Ethical Standards

Justice, in bioethics, concerns fairness and the consistent application of ethical principles. Modern medicine places strong emphasis on protecting children from non-therapeutic interventions that may compromise bodily integrity.

In many contexts, societies have established clear protections against irreversible, non-medically necessary procedures performed on minors. These protections are grounded in respect for autonomy and bodily integrity, and in the recognition that children deserve heightened safeguards.

Applying the principle of justice requires us to examine whether similar ethical standards are being applied consistently across different types of medical interventions. When comparable principles are invoked in one context but not another, it raises questions about coherence in ethical reasoning.

Justice, therefore, invites careful reflection on whether current practices align with the broader commitments medicine makes to protect vulnerable populations.

Culture, Tradition, and Ethical Reflection

For many families, circumcision is closely tied to cultural or religious identity. Acknowledging ethical concerns does not require dismissing or devaluing these traditions.

Bioethics plays a critical role in helping societies navigate the intersection of tradition and evolving ethical standards. Throughout history, medical practices have changed as our understanding of human rights, consent, and patient autonomy has developed.

Engaging in ethical reflection allows for a respectful examination of long-standing practices. The aim is not to challenge identity, but to consider whether current medical practices are consistent with the ethical principles that guide contemporary healthcare.

A More Ethically Coherent Approach

Bioethics does not offer simple answers, but it does provide a framework for evaluating complex questions. When the principles of autonomy, non-maleficence, beneficence, and justice are applied to routine infant circumcision, they collectively point toward the need for caution.

One potential approach is to defer the decision until the individual is capable of participating in it. When a person is mature enough to understand the medical, ethical, cultural, and personal implications, they can make an informed choice aligned with their own values.

Such an approach preserves individual freedom while respecting bodily autonomy and minimizing unnecessary risk.

Why This Conversation Matters

At its core, bioethics is concerned with protecting those who are most vulnerable. Infants and children depend on others—parents, clinicians, and society—to safeguard their interests.

When ethical principles are applied consistently, medicine becomes more trustworthy and more humane. When they are applied selectively, they can undermine both credibility and patient protection.

The discussion surrounding routine infant circumcision is ultimately a reflection of how seriously we take the principles we claim to uphold. It asks whether our practices align with our commitments to autonomy, protection from harm, and equal consideration.

These are not abstract concerns. They go to the heart of what ethical medicine requires—and how a society chooses to protect those who cannot yet protect themselves.

Justin Bonyai, BS serves on the Board of Intact Global as Secretary–Treasurer and Director of Operations and Engagement

The post Why Bioethics Matters in the Debate Over Routine Infant Circumcision appeared first on Bioethics Today.

At present, carebots offer a promising solution for monitoring sleep patterns and promoting healthy rest routines, and for non-pharmacological pain management prompts. During periods of elevated stress, anxiety, irritability, or agitation, these carebots can guide patients through calming exercises and grounding techniques. Finally, they could help reduce isolation and emotional distress often experienced by patients living with MCI or dementia by connecting them with friends, family, or available support groups. Our own initial pilot study (publication forthcoming) found that compatibility and quality of social interaction were of the greatest interest to older adults and care partners. Nearly all interviewees perceived carebots to be a valuable companion to manage loneliness in older populations, with one interviewee even describing it as an “emotional support robot.” Still, concerns about patronizing or infantilizing language were widely shared. Situated task plans with a voice interaction loop can generate real-time and emotionally aware conversations that also promote personalized responses with users.

These prospective benefits conflict with notable concerns about deception where carebots could mislead users by falsely displaying human traits, while also separating older persons from human contact. Given that Pepper robots like Sava can have rich expressions, including the use of body language, utilize multimodal communication, analyze voice tones, and recognize human emotions, these fears could be warranted. Their open platform is designed to support a variety of applications and work with numerous large language models (LLM)s, but they can be justified in assistive roles only if the privacy of user data can be secured and is protected against external actors. Unlike the current industry standard, the LLM must be made private-by-design – locally hosted, offline, with multiple levels of encryption and authentication.

Moreover, dynamic world models – adaptive simulations used by an AI system that simulate real-world environments and physics using a combination of textual, visual, and movement data – can enable a system to identify solutions on a case-by-case basis to better predict patient needs, like when a patient becomes unresponsive during an emergency. A robot like Sava can be conditioned to simulate both high- and low-risk scenarios which require a complex response, though constant evaluation by human partners is needed to ensure data privacy and value alignment with notable stakeholders. Given the ongoing issues caused by the black-box problem, where an AI system’s logic cannot be understood due to hidden connections between nodes in the network, it is important to implement transparent ethical guidance functions that specify to the system what constitutes a correct course of action. The Agent-Deed-Consequence (ADC) model for instance can develop a moral judgment of a situation by weighing considerations according to one’s character (agent), the quality of their actions (deed), and the possible consequences in a given situation based on user data in the dynamic world models. Then, the model can generate a solution that is operationalized in a carebot or other AI system using deontic logic – where ethical components like these can be represented as operators in the algorithm to determine what is obligatory, permissible, prohibited, and so forth.

Ethical guidance functions like these would arguably equip carebots like Sava with the parameters to make decisions in a range of cases. For example, while following the orders of human users is essential, so is distinguishing between potential intruders who might wish to enter a home or a concerned neighbor who heard a fall. Gauging user intentions can sometimes mean recognizing sarcasm, assessing the probability of harm from multiple outcomes, and evaluating the action in question – such as whether a person intends to self-harm. More importantly, these functions can guide robots during moments of impasse, such as when commands conflict. For instance, it is vital to know when it is responsible to dispense medication, even if a patient is not requesting it.

Introducing social partners like Sava into elder care is a novel way of managing patient needs and alleviating caregivers of burdens associated with daily care in a rapidly aging society, so long as robots are implemented in an ethical and effective manner. They must not be seen as replacements for proven and reputable care systems of professional medical experts, but they may represent an essential piece of technology to support these systems in the near future. Effective deployment will mean not only avoiding serious cases of harm, but supporting persons in the IADLs that they experience on a daily basis. Ethical guidance means ensuring that the carebot has the tools to differentiate between competing commands, can react quickly and proficiently in both high-risk and low-risk situations, and is maintained offline to protect user data. If employed properly, carebots might constitute the next wave of social innovation in elder care. If not, they may become the cause of a social backlash, and perhaps even a new winter of AI.

Shaun Respess, Daniel Blalock, Edgar Lobaton, Christopher B. Mayhorn, Arnav Jhala, Shawn Standefer, Jonathan Young, and Veljko Dubljevic

The post The Promises and Challenges for Ethical Carebots appeared first on Bioethics Today.

My great-aunt chose medical assistance in dying (MAiD) in Alberta, Canada. It was sad – all death is – but it brought us comfort knowing that her death was autonomous, compassionate and mattered. And now, legislation threatens to take that choice away from others.

On March 18^th, Alberta introduced Bill 18: the Safeguards for Last Resort Termination of Life Act – a bill that claims to “protect” patients but undermines the exact principles MAiD was built upon. Not only does this Bill dictate who may receive MAiD, but it dictates how clinicians may discuss and facilitate access to it. For a province heavily embedded in personal freedom, this Bill sharply undermines an Albertan’s right to autonomy.

An Attack on Ethical Medical Practice

One of the most troubling proponents of Bill 18, is its prohibition of physicians and nurse practitioners from referring patients beyond Alberta’s borders for MAiD eligibility assessments. This is a direct contradiction of medical providers’ moral obligation of duty to refer.

Duty to refer exists for this very situation. While it would be unethical to require medical providers to conduct legal treatments opposing their personal values (conscientious objection), medical providers cannot impede access to it. By banning all refers, Alberta has legislated clinical abandonment – leaving patients without a pathway to the care they are legally entitled to consider.

A Harmful Narrative about Marginalized Patients

Supporters of Bill 18 point to concerns that MAiD is a readily available and encourage treatment for marginalized patients. In a CBC news interview, a family physician stated that healthcare workers offer marginalized patients MAiD, rather than social supports for poverty or social isolation. While this elicits emotion, rightfully so, the national data and evidence prove this statement to be incorrect.

In Canada, Track 2 recipients (those who do not have a foreseeable death within 12 months) tend to have higher income and are less socially marginalized. In fact, 95% of Track 2 recipients with disabilities had supportive services, and no one can legally receive MAiD due to poor housing, poverty or inadequate supports.

In our current political climate, medical distrust is at an all-time high – false information and narratives based on fear, not facts, only deepens public distrust.

12-Month Prognosis Requirement Ignores Medical Reality

Bill 18 would limit MAiD eligibility to patients who are expected to die within 12 months. While this sounds straightforward, anyone who has worked in healthcare can attest to the fact that prognostication is inherently uncertain.

A qualitative study of MAiD assessors found that distinguishing Track 1 cases (reasonably foreseeable death) from Track 2 cases is often complex and highly individualized, relying heavily on clinical judgment rather than rigid timelines. Assessors emphasized that illness trajectories can vary widely, and decisions cannot be reduced to an arbitrary cutoff.

Federal reporting shows that Track 2 MAiD patients account for only 4.1% to 4.4% of cases. Yet, Bill 18 treats this small number of cases as justification to restrict access across the entire province.

Safeguards Already Exist

Alberta proposed Bill 18 with the misconstrued belief that patients need further protection. However, Canada already has one of the most comprehensive MAiD safeguard legislations in the world.

Under federal law:

• A minimum 90‑day assessment period for Track 2 cases
• Two independent practitioners to confirm eligibility
• Condition‑specific expertise by at least one assessor (or consultation with someone who has it)
• Full disclosure of all medical, palliative, disability, and community support options
• Voluntary, written, witnessed requests — with the option to withdraw at any time

These safeguards are explicit, robust and nationally standardized.

What Albertans Need

MAiD was created to offer patients enduring intolerable suffering a compassionate choice. Bill 18 undermines that choice by restricting information, limiting referral pathways and imposing unrealistic timelines.

My great-aunt had the dignity of choice at the end of her life, and Bill 18 threatens to take that away from others.

If Alberta wants to protect vulnerable people, then it should invest in increased medical funding, mental-health services, disability supports and social services – not restrict access to a federally protected medical option that allowed my great-aunt a death rooted in autonomy, compassion and evidence.

Brianne Helfrich, Bioethics PhD

The post My Great Aunt Had a Choice. Bill 18 Threatens That for Others. appeared first on Bioethics Today.

Three cases appear in almost every bioethics course: the Tuskegee Syphilis Study, the death of Jesse Gelsinger, and the story of Henrietta Lacks. All three are taught as cautionary tales about what happens when research goes wrong. But only two of them have legal endings.

Tuskegee led to congressional hearings, the Belmont Report, and the regulatory framework that governs human subjects research today. It also resulted in a government apology and a $10 million settlement with the men who had been studied and their families. The Gelsinger case, the death of an 18-year-old in a gene therapy trial, brought program shutdowns, federal investigations, a settlement with his family, and lasting reforms to how conflicts of interest in research are disclosed and managed. Both stories are taught, correctly, as examples of how bioethics and law respond to harm.

The story of Henrietta Lacks has been taught the same way. It should not be.

What actually happened to Henrietta Lacks?

In 1951, Lacks was treated for cervical cancer at Johns Hopkins. Cells from her tumor were taken without her knowledge or consent and became the HeLa cell line, now one of the most widely used tools in biomedical research, cited in more than 100,000 scientific publications. But even though her name was always associated with the cells, her story was unknown to the public until Rebecca Skloot’s 2010 multi-prize winning book, The Immortal Life of Henrietta Lacks. The book,and subsequent movie,  brought renewed scrutiny to how her cells had been obtained and used. For decades, her family sought recognition and restitution. Courts turned them away. Courts consistently held that patients do not retain property rights in excised tissue once it is removed from the body, leaving little room for legal claims based on ownership.

A serious wrong had occurred, the world had acknowledged it, and Johns Hopkins itself eventually said it could have done more, but there was no legal remedy. Case closed.

Except it was not. New lawyers and new strategies to recharacterize her claims have brought them back to life.

What is changing, and why does it matter?

In August 2023, Thermo Fisher Scientific settled a lawsuit brought by the Lacks estate. In February 2026, Novartis reached a similar settlement. Litigation is still active against other companies. A federal court has already allowed one of these claims to move forward.

The legal theory is not about ownership of cells. It is about unjust enrichment: the principle that one party should not retain profits derived from another’s materials without compensation. Think of it this way: if your neighbor builds a fence using lumber that was yours without asking, the law does not just say that was wrong. It asks whether they should have to pay you for the benefit they received. That is the question courts are now asking about companies that have made enormous profits from HeLa cells.

This is a modest but significant shift. These claims do not revisit the core holding that patients lack property rights in excised tissue, but instead operate alongside it. Courts are not saying Lacks or her family ever owned the cells. But they are saying that profiting from them without compensation might be unfair in a way the law can and should address. That is meaningfully different from where things stood even five years ago.

So what should we be teaching?

Bioethics courses should absolutely continue to teach the Lacks case as a story about consent, exploitation, and race. That history is essential and it has not changed. But they should stop teaching it as though it is over. Casebooks and syllabi that present Lacks as a closed episode obscure an active and evolving area of law.

The Lacks case raises questions that remain genuinely open. When biological materials taken from a patient decades ago continue to generate profit today, what, if anything, do the companies using them owe? Should we judge those obligations by the standards of 1951, or by what we now expect of institutions? Is acknowledging a wrong enough if the benefits from that wrong are still flowing to someone else?

These are not hypotheticals. They are being argued in federal court right now. Students who learn the Lacks case as a closed chapter are being deprived of the most important part of the story.

Tuskegee and Gelsinger teach students what it looks like when institutions are held accountable. The Lacks case teaches something harder: that accountability is not inevitable, that it can take generations, and that the people most affected sometimes have to keep fighting long after the world has decided the story is done.

The facts of the Lacks case are singular, but the underlying issue is not. In Moore v. Regents of the University of California, a 1990 California Supreme Court case, John Moore sued after learning that his physicians had patented a cell line developed from his spleen, removed during cancer treatment, without his knowledge. He lost. The California Supreme Court held that patients do not retain property rights in excised tissue, emphasizing concerns that recognizing such rights could interfere with research by restricting access to biological materials. That ruling became the legal foundation that shut down the Lacks family’s property claims for decades. What has changed is not that courts are overturning Moore. They are not. What is changing is that unjust enrichment offers a different path, one that asks not who owns the cells but whether it is fair to keep all the profits from them.

That shift raises its own questions worth teaching. If companies face legal risk whenever they build products from tissue with a traceable source, will they become more cautious about using such materials at all? Will researchers stop sharing cell lines freely? Will the next HeLa cell line never be developed because no one wants the liability? These are not hypothetical concerns, and they do not have easy answers. They are exactly the kind of questions bioethics should be asking.

Henrietta Lacks died in 1951. Her cells remain in laboratories around the world. The companies that profit from them remain in business. Her family remains in court.

This is not a closed case. It is an ongoing one. Bioethics should teach it that way.

Jennifer S. Bard, JD, MPH, PhD, (@profbardlaw.bsky.social) is a professor of law at the University of Cincinnati College of Law and a professor of medicine, department of internal medicine, at the University of Cincinnati College of Medicine.

The post Updating the Canon: The Story of Henrietta Lacks Is Not Over appeared first on Bioethics Today.

In an effort to justify the growing landscape of AI use in healthcare, there have been countless studies and empirical arguments—ranging from concerns with the actual AI systems to patient perspectives on AI use in healthcare. However, many such studies tend to focus on the question of how to make the use of AI in healthcare more ethical, rather than challenging whether it should be used at all.

In fact, this seems reflective of the most common justification for AI use that I see parroted by both experts and lay people alike: AI is here and it’s here to stay, it’s up to us to adapt accordingly.

I find this justification rather strange and lacking any argumentative force. If I broke into your house and said that I’m here and here to stay and that you’d better just adapt to it, you probably wouldn’t be compelled by the force of my argument and let me stay. Similarly, such a justification for the use of AI in healthcare should not be accepted, and the rejection of this fallacious argument should be reflected in the informed consent process when any AI is to be used systematically in patient-centered healthcare.

For instance, one recent paper discussing disclosure of AI use in clinical care claims, without justification, that “Ultimately, AI will become a routine part of clinical care…” The paper goes on to claim that informed consent should only be required if AI is making independent decisions or if the use of AI deviates from accepted standard uses. This argument rests on the assertion that if the use of AI is the accepted medical standard in a given context, then it can be assumed that patients are consenting implicitly. This assertion rests on a misapplication of the medical standard argument, however, as the medical standard in this case is constructed upon unethical uses of AI to a significant degree.

One recent study found that approximately 65% of US hospitals use AI to assist their predictive models, most commonly for inpatient health trajectories and to identify high risk outpatients. One could argue that 65% is too low to be considered the accepted medical standard, but this would be far too ambiguous to present a strong argument for or against. Rather, there’s a far more troubling number coming out of this study—less than half of these hospitals are evaluating their AI models for bias.

The accepted medical standard argument should lose all force if it is discovered that the standard is not serving the patient’s best interest. Further still, according to Paige Nong, PhD, author of the aforementioned study, the unchecked bias of such AI models is disproportionately affecting poor and rural communities, as it is often under-resourced hospitals that are unable to properly screen AI models for bias. Despite the high percentage of hospitals using these models, it isn’t reasonable to assume that patients are implicitly consenting to put themselves at risk of receiving lower quality healthcare due to the unchecked biases of these AI models. To prevent such a risk, patients ought to be informed of AI use in their healthcare and be given the option to opt out—especially in cases of prediction of identification.

However, some might object that such a goal is impractical for several reasons. The first, and likely most common reason, would be that it’s simply too much of a hassle. Such an objection rests on the idea that most people simply don’t care that much—to require patients to undergo the informed consent process for AI use would be a waste of time for both the patient and the healthcare system. The other reason would be that such decisions should fall upon the shoulders of healthcare leadership, not the patients. In this sense, healthcare leadership has a duty to prevent the biases of AI systems from potentially harming patients, it shouldn’t be the duty of patients to attempt and avoid such systems altogether.

Such objections fail to capture the scope of general perspectives on AI use. Regarding the latter of the two reasons, it is equally impractical to assume that healthcare leadership will implement AI systems with the patient’s best interests in mind. In more affluent healthcare systems, AI is seen as a long term investment that will help to keep costs down. And as already noted, less affluent healthcare systems simply lack the resources to screen for bias. As for the former reason—that people simply won’t care enough—this sentiment severely underestimates just how much people dislike AI. One recent poll of registered voters in the US came in with over half of the participants believing that the risks of AI outweigh the benefits.

And beyond just polls a report from More Perfect Union found that in just one three month period in 2025, 20 data center projects were blocked or delayed by community organizing or pushback. Many people are indifferent to AI, but just as many people adamantly oppose it.

Regardless of the reasons, studies show that many people are exasperated by the constant encroachment of AI into nearly every facet of their lives. In this sense, it would seem absurd not to disclose AI usage in the informed consent process—AI optimists would be happy to hear it’s being used while AI pessimists would be relieved to avoid many of the ethical concerns that surround it.

Of course, I could be wrong about all of this. AI could truly benefit medicine and safely become standard use. The key term here is “safely.” The ethical concerns are just too great to overlook. Just because more than half of US hospitals are using it, with many of these using it despite serious concerns of bias, it doesn’t mean it’s right to just assume patients are implicitly consenting.

As parents love to ask their children, “if all of your friends jumped off a cliff, would you do it too?”

Seamus Donahue, MA is the Program Manager for the Indiana University Center for Bioethics.

The post AI, Informed Consent, and Fallacious Reasoning appeared first on Bioethics Today.

February 27, 2026

The death of an immigrant detainee at an El Paso, Texas facility has been ruled a homicide, according to the final autopsy report obtained by NBC News. Geraldo Lunas Campos, 55, originally from Cuba, died January 3rd at Immigration and Customs Enforcement’s Camp East Montana facility at Fort Bliss, Texas.

“Based on the investigative and examination findings, it is my opinion that the cause of death is asphyxia due to neck and torso compression. The manner of death is homicide,” the El Paso County, Texas medical examiner concluded in a January 30th report.

When ICE first reported his death in a Jan. 9 press release, it stated that Lunas Campos had experienced “medical distress.” The agency said medical staff responded, initiated lifesaving measures, and requested emergency medical services. In an email to NBC News on Thursday, January 29th, a Department of Homeland Security spokesperson stated that Lunas Campos had attempted to take his own life and that the security staff had “immediately intervened to save his life.”

There are reports of other deaths and abuses at other ICE detention and processing centers in Texas, including the South Texas ICE Processing Center in Pearsall and the South Texas Family Residential Center in Dilley, and theFort Bliss Camp Montana tent city in El Paso.

Detainees report being given rotten food, inconsistent access to necessary medications, lack of prenatal care, lack of regular access to recreational areas, exposure to raw sewage, and physical and sexual abuse. There are also reports of inadequate laundry and cleaning services for detainees’ uniforms, which creates hygiene issues, and recent reports of outbreaks of scabies, measles, and other infections at multiple ICE facilities.

Inadequate medical care, a lack of access to proper sanitation, edible food, and clean water, particularly for vulnerable persons, including pregnant women, young children, the elderly, mentally ill, and those with underlying health issues, create dangerous conditions for people in these ICE facilities and are of great concern as human rights violations.

The International Committee of the Red Cross (ICRC) has a mandate under the Geneva Conventions (Article 126 of the Third Geneva Convention (1949) and Article 143 of the Fourth Geneva Convention (1949)) to visit prisoners of war, civilian internees, and other detainees to monitor conditions, ensure humane treatment, and facilitate contact with families. Suspicious deaths and apparent inhumane conditions make it clear that the Red Cross ought to promptly visit, examine, and report on the detention/prison ICE facilities in Texas.

Please initiate visits to ICE facilities in Texas to defend the human rights of powerless, vulnerable detainees imprisoned in inhumane conditions.

Arthur Caplan, PhD

Retiring professor of medical ethics, NYUGSOM, Ridgefield CT

(Institutional Affiliations Listed for Identification Only)

Signees:

1. Vardit Ravitsky, PhD, The Hastings Center for Bioethics
2. Keisha Ray, PhD
3. Dena S. Davis, JD, PhD 
4. Brendan Parent, JD
5. Jennifer Lewin, PhD
6. Lisa Kearns, MS, MA
7. Robert Baker, 
8. Vincent J. Palusci, MD, MS
9. Eileen Harrigan, MDre
10. Phoebe Friesen, PhD
11. Bryan Pilkington, PhD
12. Sunil Aggarwal, MD, PhD, University of Washington
13. Mary-Lou Weisman BA
14. Ghaiath Hussein, MD, PhD
15. Carolyn Riley Chapman, PhD MS
16. James Lytle, JD
17. Brian H. Childs, PhD, Mercer University School of Medicine
18. Susan Gilbert
19. Lisa DeTora, PhD, Hofstra University
20. Katie Grogan, DMH
21. Dale Jamieson, Ph.D., Professor Emeritus, New York University
22. Andrew McFadyen, MHSc
23. Lena Milam
24. Melissa Moorehead
25. Kathleen Bachynski, PhD, Muhlenberg College
26. Mark Kuczewski, PhD
27. Richard N. Gottfried, JD, former NY State Assembly Member and Health Committee chair
28. Samantha Klitenic, JD
29. Jill Fisher, PhD
30. Catharine E. Krebs, PhD
31. Linda Granowetter MD, Clinical Professor of Pediatrics, NYU Grossman School of Medicine (retired)
32. Thalia Arawi, PhD, T2P Center for Health Ethics Training & Consultancy
33. Howard P. Forman MD, Yale School of Medicine
34. Liza-Marie Johnson MD, MPH, MSB, St. Jude Children’s Research Hospital
35. Lea Brandt, PhD, OTD, MA, University of Missouri Center for Health Ethics 
36. Andy Flescher, PhD, Stony Brook University
37. Monica Rose McLemore PhD, MPH, RN, FADLN, FNYAM, New York University
38. R. Alta Charo, JD, Professor Emerita of Law & Bioethics, University of Wisconsin
39. Eric M. Meslin, PhD, FRSC, FCAHS, ICD.D
40. Joel Michael Reynolds, PhD, Georgetown University and School of Medicine
41. J. Russell Teagarden, DMH
42. Quill R Kukla, PhD, Georgetown University
43. Cory Ellen Gatrall, PhD, RN, University of California, San Francisco
44. Paul Kelleher, PhD
45. Luis F. Angel MD   NYULangone Health
46. Daniel Suárez-Baquero PhD, MSN, RN, University of Washington
47. Carl Elliott MD PhD, University of Minnesota
48. Amy Haddad, MSN, PhD, MFA, FAAN, Creighton University
49. Paul Root Wolpe, Ph.D., Emory University
50. Debra DeBruin, PhD, University of Minnesota
51. Gustavo Ortiz-Millan, PhD
52. Nancy Berlinger, PhD, The Hastings Center for Bioethics
53. Omisade Burney-Scott, The Black Girl’s Guide to Surviving Menopause 
54. Grover C. Gilmore, PhD
55. Stuart  Kaufer, LMSW
56. Doug Opel MD, MPH, University of Washington School of Medicine
57. John Entwistle MD PhD, Thomas Jefferson University
58. Maria Merritt, PhD, Johns Hopkins University
59. Samuel Gorovitz, Ph.D, Dr.Sci.(Hon), Syracuse University
60. Jennifer Needle-Suarez, MD, MPH, University of Minnesota
61. Kenneth W Goodman, PhD, FACMI, FACE, University of Miami
62. Robert D. Truog, MD, MA Harvard Medical School 
63. Gwendolyn P. Quinn, Ph.D., FAACE, 
64. Anna Valdez, PhD, RN, Professor of Nursing, Sonoma State University
65. Brian S. Carter, MD, FAAP, University of Missouri-Kansas City School of Medicine
66. Vanessa Northington Gamble, MD, PhD, The George Washington University
67. Keren Ladin, PhD, MSc Tufts University
68. Laurie Zoloth, Ph.D., University of Chicago
69. Nanette Elster, JD, MPH
70. David DeGrazia, PhD, George Washington University 
71. Robert Cook-Deegan, MD, Arizona State University
72. Rowan Kim, MS, Rosalind Franklin University of Medicine and Science
73. Bruce Gelb, MD FACS, NYU Langone Health
74. James Tabery, PhD
75. Brandon Brown, MPH, MPH, University of California, Riverside
76. Peter Ochs, Ph.D., University of Virginia
77. Stuart Rennie, Ph.D.
78. Nancy M. P. King, JD
79. Susan Resneck Pierce, Ph.D.
80. Jonathan D. Moreno, Ph.D., University of Pennsylvania
81. Matthew K. Wynia, MD, MPH, University of Colorado
82. Sarah C. Hull, MD, MBE, Yale School of Medicine
83. Jeremy A. Greene, MD, PhD, Johns Hopkins University School of Medicine
84. Michelle N. Meyer, PhD, JD
85. Kathleen M. Boozang, JD, LLM, Seton Hall Law
86. Anita Ho, PhD, MPH, UCSF/UBC
87. Barron Lerner, MD, PhD, NYU Langone Health 
88. Eric T. Juengst, Ph.D, UNC-Chapel Hill
89. Nadia N. Sawicki, JD, MBe, Loyola University Chicago School of Law
90. Nathaniel Mamo, MA, NYU Grossman School of Medicine
91. Julian Wilson, The Black Girl’s Guide to Surviving Menopause
92. Max F. Kramer, Ph.D.
93. Jean Cadigan, PhD, UNC-Chapel Hill
94. Kate Saylor, Ph.D.
95. Timothy F. Murphy, Ph.D., University of Illinois College of Medicine
96. Ann M. Heesters, PhD, University of Toronto
97.  Claire Young, MPH
98. Daniel Wikler, Ph..D., Harvard School of Public Health, emeritus
99. Richard Klein, formerly FDA
100. Walter Glannon, PhD
101. Bonnie Steinbock, PhD
102. Eileen Sullivan-Marx, PhD, RN, FAAN, NYU
103. Karla FC Holloway, PhD. 
104. Holly K. Tabor, PhD, Stanford University School of Medicine
105. Alyssa Burgart, MD, MA, Stanford University School of Medicine
106. Michele Goodwin, J.D., LL.M., SJD, Georgetown Law
107. Deborah R. Barnbaum, PhD, Kent State University 
108. Harald Schmidt, PhD, University of Pennsylvania
109. Jason T. Eberl, PhD, Saint Louis University 
110. Steven Goodman, MD, PhD, Stanford University
111. Rosamond Rhodes, Icahn School of Medicine at Mount Sinai 
112. Jeffrey Blustein, Ph.D CUNY
113. Linda Tewksbury, MD
114. Leonard M. Fleck, Ph.D. Michigan State University
115. James Silk, MA, JD, Yale Law School
116. Kaija Freborg, DNP, RN, Sonoma State University
117. Elliot Dorff, Rabbi, Ph.D., American Jewish University
118. Joel T. Wu JD MPH MA, University of Minnesota
119. Chelsey R. Carter, MPH, PhD, Yale School of Public Health 
120. Carl H. Coleman, JD, Seton Hall Law School
121. Robert Swidler, MA, JD
122. Emily E. Anderson, PhD, MPH
123. Kara B. Ayers, PhD
124. Esther Berkowitz, MBChB, MA
125. Jeffrey Spike, PhD, The George Washington University School of Medicine
126. Sharon Gray, MA, RN, HEC-C
127. Paula Goodman-Crews, LCSW, MSW, HEC-C
128. Jessica F Berkowitz, MD 
129. Frances Batzer, MD, MBE
130. Katie Clark, DNP
131. Jelena Kalinić, MA, science communicator
132. Thomas E. Merchant, Juris Doctor, MS
133. Diana Harris, PhD, MBE
134. Jamie Webb, PhD
135. Eli Weber, PhD, Kaiser Permanente, SCAL–San Bernardino County Area
136. Diane M Korngiebel, DPhil
137. Thomas D. Harter, PhD
138. Lawrence Gostin, Distinguished University Professor, Georgetown Law
139. Joanne Lynn, MD
140. Carol Shoshkes Reiss, PhD, Professor Emerita, NYU
141. Audrey R. Chapman, PhD, UConn School of Medicine
142. Connie M. Ulrich, PhD, MSN, RN, FAAN
143. Miriam Merad, MD PhD, Icahn  school of medicine at Mount Sinai 
144. Angela Starkweather, PhD, ACNP-BC, RN
145. Linda Ohler, MSN, APRN, CCTC, FAAN, FAST Retired, NYU
146. Sara Taub, MD, MBE
147. Melissa Heidelberg, MSBE
148. Katherine Taylor, JD, PhD
149. Cody Feikles, PhD(c), MA, MTS, HEC-C, OSF Healthcare
150. Rafael Escandon, DrPH, HEC-C, DG Bioethics, Seattle, WA 
151. E. Goldblatt Hyatt, DSW, MBE
152. Susan L Herrmann, PhD, MA, MSW 
153. Cheryl Bettigole, MD, MPH, MA, University of Pennsylvania
154. Amal Dadi, MA
155. Joy Frestedt, PhD, CPI, RAC, FRAPS, FACRP; Frestedt Incorporated, MN 
156. Victoria Velasquez-Feikles, PhD(c), MSc
157. Mayli Mertens, PhD, Atlas Bioethics Center
158. Rachel Groth, PhD
159. Drew Lewis, MD
160. Allison Squires, PhD, RN, New York, NY

The post An Open Letter to the American Red Cross and the International Red Cross: Calling for Immediate Humanitarian Visits to ICE Internment Facilities in Texas appeared first on Bioethics Today.

This editorial appears in the March Issue of the American Journal of Bioethics

ncreasing attention has been devoted to questionable research practices (QRPs) in the health and behavioral sciences. Practices such as presenting post hoc findings as if they were a priori hypotheses, failing to report null results in a study with multiple outcomes, and manipulating sample sizes or covariates to yield statistically significant results (“p-hacking”), are ethically and practically problematic because they create the impression that research findings are more robust than they actually are. More generally, they can foster cynicism about the scientific endeavor and skepticism about the findings from health and behavioral science research. Miscitations are another QRP that has generally received less attention than QRPs focused on methodological and statistical issues.

According to Cobb et al., miscitation is a “failure to adhere to the practice of providing a complete and correct account of the cited content of a study” (300). Citations can be accurate, partially accurate (omitting relevant context or nuance that would qualify the findings), or inaccurate (making claims contrary to or irrelevant to the findings from the cited study). Miscitations in scientific papers can impede theory development, contribute to a false consensus in which researchers assume that particular findings are more consistent than they are, and support the implementation of interventions whose empirical support is weaker than presumed. Although these are all serious concerns, miscitations of scientific studies in government reports and other documents that inform public policy can have even more wide-ranging harmful consequences. These documents are often used to set funding priorities, justify laws and regulations, and guide public health decisions. Distortion of the evidence-base can result in a misallocation of scarce resources, where research and policies supporting dubious, ineffective, or harmful interventions are promoted, while efforts into promising and well-established interventions may be undermined. These effects may compound over time, threatening individual and public health outcomes (including increased injuries, disability, and death) and eroding public trust in the scientific enterprise (see, for example, the impact of The Joint Commission’s pain standards on the opioid epidemic). Consequently, it is essential that the citations to empirical research in “The Make America Healthy Again (MAHA) Report”, which aims to set government policy for improving children’s physical and mental health, should be free from inaccuracies.

When it was first released, the MAHA Report garnered attention for citing studies that did not exist. A revision of the report deleted all but one of these phantom studies, but some researchers whose work was cited in the report claimed that their work did not find what the report claimed it found. Despite these anecdotal reports, there has not been a systematic review of the citation accuracy of the MAHA Report. Assessing whether these high-profile miscitations were anomalies or whether they reflect a more pervasive pattern in the MAHA report can help discern whether the scientific literature was used to accurately inform evidence-based policies (i.e., policies and recommendations were made following a careful review of the evidence) or whether the research citations were used as rhetorical window dressing to bolster preconceived beliefs.

We applied Cobb et al.’s tripartite coding system to the 154 citations to peer-reviewed empirical studies cited in the MAHA Report. Because we were interested in how the authors of the MAHA Report used scientific research to support their claims, we limited coding to peer-reviewed empirical studies (including meta-analyses) and did not code citations to narrative reviews, policy papers, commentaries, government documents, etc. Each citation was independently coded by two of the coauthors, and the pairings were rotated so that each author coded roughly the same number of citations with each of the other coauthors. After completing their independent coding, the two raters met and resolved any discrepancies in their ratings. If, after discussion, the two raters were unable to reach agreement, they assigned the less critical code to the citation, giving the MAHA Report the benefit of the doubt and providing a lower bound estimate of the rate of miscitations. We examined interrater reliability using the initial codes provided by the independent raters before they resolved any discrepancies. A weighted kappa was used to assess the level of interrater agreement for these ordinal data. Kappa corrects for chance agreement, so values between .61–.80 are evidence of substantial agreement and values greater than .81 are indicative of almost perfect agreement. The weighted kappa for the present study was substantial, .69 (95% CI [.60–.78]).

Only 75 (48.7%) of the 154 citations to peer-reviewed studies in the MAHA Report were accurate, whereas 48 (31.2%) were partially accurate, and 31 (20.1%) were inaccurate. These results represent a strikingly high rate of inaccurate and partially accurate citations. By contrast, Cobb et al. found that 81.2% of the citations in major psychology journals were accurate. Our recent review of citation accuracy in American Psychological Association amicus briefs found that 20.3% of the citations were partially accurate and that 6.9% of the citations were inaccurate. Perfect citation accuracy may be aspirational, but when fewer than half of a document’s citations are accurate, epistemic integrity is seriously weakened and the reliability of the evidence becomes unclear. In the context of health care policies affecting children, this uncertainty raises concerns regarding the ethical principles of beneficence and nonmaleficence by obscuring whether recommendations accurately reflect established risks and benefits. Implementing policies with unclear evidentiary support can have long-lasting consequences, particularly in developmental samples.

Although a detailed review of all the inaccurate citations in the MAHA Report is beyond the scope of this editorial, a sampling of the inaccurate and partially accurate citations in the report can give readers a sense of the problem. In a section outlining “proven harms” of overtreatment, the MAHA Report cited Waters et al. to support the claim that “Adenotonsillectomy for children with sleep apnea, an historically common procedure, conferred no benefit in trials” (p.60), when in fact Waters et al. reported that “Improvements were seen for polysomnogram arousals and apnea indices and for parent reports of symptoms…, behavior…, overall health, and daytime napping” (1), so the claim that adenotonsillectomy provided no benefits is a gross misrepresentation of the study. The MAHA Report cited Hibbs et al.’s analysis of data submitted to the Vaccine Adverse Event Reporting System (VAERS) to support the claim that “Many health care professionals do not report to VAERS because they are not mandated to do so or they may not connect the adverse event to a vaccination” (63). Hibbs et al. examined the reporting of vaccination errors (e.g., inappropriately scheduled vaccination, storage and dispensing errors) and not adverse reactions to vaccines.

Partially accurate citations can often be as misleading as inaccurate citations. For example, the report cited Sofi et al.’s meta-analysis to support the claim that “Research also consistently links diets centered on whole foods to lower rates of obesity, type 2 diabetes, heart disease, certain cancers, and mental illness” (p. 26). Although this meta-analysis found associations between a Mediterranean diet and lower heart disease and cancer, none of the supporting citations examined obesity or diabetes. More importantly, some of the whole foods highlighted within the MAHA Report as beneficial—including beef and whole milk—are rarely consumed within a Mediterranean diet. To support its call for reducing food safety regulations, the MAHA report wrote “the implementation of the Hazard Analysis and Critical Control Points (HACCP) system has further complicated operations for smaller producers without the expertise or capital to navigate such comprehensive safety protocols”, citing Dima, Radu, and Dobrin. Although readers could reasonably assume that this study examined US producers, the MAHA Report failed to note that Dima et al. investigated the Romanian meat industry. As a final example the MAHA Report wrote, “Tympanostomy tubes for recurrent ear infections, despite being recommended by professional societies, did not reduce infections in trials—showing common surgeries cause harm without offering benefits”, citing Hoberman et al. Hoberman et al. found that tubes did not improve outcomes compared to antibiotic treatment; however, several secondary treatment outcomes did favor the tube group and there was minimal evidence of serious adverse events during the 2-year monitoring period in either treatment arm. Omitting that the comparison was an active treatment may not have been a serious miscitation, except that the MAHA Report also advocated against the use of antibiotics writing “Antibiotics are over-prescribed to millions of US children annually, causing serious harms like rashes, diarrhea, recurrent infections, allergic reactions, and antibiotic resistance”.

A recent editorial in Science argued that “checking citations is just as important as carrying out experiments” and noted that there was at least one citation in the MAHA Report where the “content was misrepresented”. Our systematic review found that in fact more than half of the citations were less than fully accurate. The MAHA Report accurately identified several legitimate concerns about the health and mental health of children in the United States. However, effective interventions should be informed by the science and evidence-based, rather than misrepresenting the research literature to claim support for questionable policies.

Notes

Interested readers can find a complete listing of all of the citations and their codes at https://osf.io/b4rew/overview?view_only=a84540244e314bb6835bc1350ddcc6d1

David K. Marcus, PhD; Keira L. Monaghan, Jessica L. Fales, PhD & Christopher T. Barry, PhD

The post Citation Accuracy in the Make America Healthy Again Report (MAHA) appeared first on Bioethics Today.

This editorial appears in the March Issue of the American Journal of Bioethics

The recent increases in the number of persons detained by ICE in the United States is affecting health care. Many health-care professionals and facilities that serve immigrant communities report a chilling effect on the number of patients willing to seek care. This problem was anticipated based on experiences in the first Trump administration. Similarly, hospitals prepared for the possibility that ICE would seek information regarding patient immigration status or come to a hospital seeking a particular patient. As a result, hospitals refreshed their “front-door policies” that require a judicial warrant in order to release information or to admit ICE agents to enter any private areas such as examination rooms. However, most hospitals did not prepare for an increase in the number of visits by patients presenting for care who are already in ICE custody. For instance,

A 24 year old woman is brought to the emergency department by three Immigration and Customs Enforcement (ICE) officers. The patient reports that she is pregnant and may be in labor. The emergency medicine physicians and staff wish to examine her and evaluate whether admission to the Labor and Delivery (L & D) unit is appropriate.

The ED resident physicians wish to take a complete history and examine the patient privately. They ask the ICE officers to step out of the patient’s room. The officers expressed that they preferred to remain in the room. The nurses contacted the hospital security office for assistance knowing that their security officers are familiar with the process of handling interactions with law enforcement agents who are guarding a patient.

A security officer arrived and provided the ICE agents with a summary sheet of the hospital’s Forensic Patient Policy. As that sheet did not specifically address the patient’s right to privacy, the officers remained at the bedside during examinations. They also handcuffed one of the patient’s arms to the bed rails as the policy directed. On the second day, the agents began to interfere with the patient’s meals. That is, they would move the food tray out of reach of the patient for several hours after it was delivered, presumably to motivate the patient to seek discharge.

Most hospitals have long had policies that govern the care of patients in the custody of law enforcement. These policies are called forensic patient policies and are largely unknown to most physicians and health-care workers. They are draconian and have ethically failed patients for many years. In the current environment, they motivate the hospital to engage in the moral mistreatment of patients in ICE custody. We suggest that bioethicists and health-care providers must advocate for the revision of these policies to support the mission of delivering humane patient care.

The Problem of Forensic Patient Policies

Perhaps the best guidance for health-care professionals and facilities confronting novel and stressful situations is to treat patients as patients. The health-care professionals in the situation described tried to respect basic patient privacy and dignity by asking the ICE agents to step outside the room. They were distressed that agents would handcuff a patient to the bed who posed no discernible safety concern.

Of course, hospitals cannot have different policies based on which law enforcement agency brings the patient to the facility and patients in ICE custody are assimilated to their forensic patient policies. As a result, this patient who posed no discernible threat to anyone in the facility was treated similarly to a violent criminal who poses an immediate threat.

The hospital security officer provided the ICE agents with the hospital protocol governing forensic patients. This protocol informed the agents that the hospital (a) required them to restrain the patient at all times by handcuffing at least one wrist to the bed railing, (b) that the law enforcement officers have jurisdiction over “patient privileges” and may restrict them at any time, and (c) that the agents must “guard” the patient at all times. The protocol also asserted that the medical and nursing staff will have control over all aspects of the patient’s medical care. However, it did not mention any of the usual patient rights such as privacy, confidentiality, or the requirements of informed consent for treatment.

Forensic patient policies are written from the perspective of hospital security and hospital general counsel. The overriding theme of such policies is minimizing the danger to hospital personnel. This is a highly laudable goal and health-care professionals are too often subject to violence and abuse. Nevertheless, the sudden arrival of an increased number of patients who are detained only for lack of immigration authorization, possessing no criminal history and posing little threat, calls for forensic patient policies that have greater flexibility. This will not only be more just for patients detained by ICE but for all forensic patients.

Forensic patient policies should platform good patient care and patient rights in addition to safety considerations. In doing so, they also lay out what law enforcement officers can expect and what is expected of them. Policies and protocols should assert that the facility respects the rights of patients as articulated by federal and state laws and established medical ethics. Thus, the facility supports patient privacy during history taking and medical examinations and interventions, the minimal use of restraints necessary, and access to basic human needs such as food, clothing, and toilets (Working Group on Policing and Patient Rights, Georgetown University Health Justice Alliance).

Similarly, the heart of contemporary medical ethics is the right of patients to make their medical decisions according to the established norms of informed consent. The policy should state clearly that forensic patients retain this right. Similarly, any patient “privileges” such as access to phones and outside visitors that may be under the discretion of the law enforcement officials should be clearly identified and noted as limited to those enumerated. This will avoid misunderstandings resulting from expansive interpretations of what constitutes a privilege, e.g., meals, by law enforcement officers.

Finally, health-care facilities should consider outlining an expectation of law enforcement officers that they will minimize their movements within the facility. The appearance of law enforcement officers in hospitals can be unexpected and unsettling to patients. As a result, the facility should consider offering assistance such as bringing meals to officers in order to avoid unsettling patients in areas such as cafeterias.

Let’s Do No Harm

In sum, the arrival of a new category of forensic patients, often vulnerable and nonviolent, has thrown a spotlight onto the failing of our forensic patient policies that are driven by fear and worst-case scenarios. We have an opportunity to develop new policies that balance safety with respect for the dignity of patients and help law enforcement officers to carry out their work without jeopardizing established norms of patient care.

Forensic patient policies and protocols should be thought of mainly in terms of their moral force and suasion. Law enforcement is most likely to respect these protocols because they understand that health-care institutions have particular norms that do not jeopardize their law enforcement mission.

While much attention may be justly focused on the inadequacies and irregularities of the way ICE agents conduct their business, bioethicists and hospitals can no longer dodge our responsibility to reform our practices and procedures. Failures to treat detainee patients with dignity and respect have an origin in the established policies of our institutions. We must do better for them and other forensic patients.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Mark Kuczewski, PhD; Amy Blair, MD; Theresa Nguyen, J.D.; M. Laura Garcia-Izaguirre, J.D; Gregory Dober, MA

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A recent New York Times investigative report by Mike McIntire describes how genetic and brain imaging data from thousands of U.S. children were used by a small group of researchers to advance a race science agenda. The data came from two large, federally funded studies—the Philadelphia Neurodevelopmental Cohort (PNC) and the Adolescent Brain Cognitive Development (ABCD) study—and were made available by the National Institutes of Health (NIH) to outside researchers in 2018 and 2020.

Dr. Bryan J. Pesta and colleagues analyzed data on home computers, outside of any official university role and without IRB oversight, and published numerous papers promoting the idea that there are biologically based, inherited differences in intelligence between races and ethnicities. The conclusions and figures from those papers spread through message boards, internet blogs, and various forms of social media to support white supremacist arguments. Even after these researchers faced sanctions and substantial ethical and scientific criticism, their work continued to spread and was cited by artificial intelligence platforms responding to queries about race and intelligence. This case is an example of successful Citizen Scientific Racism (CSR): the use of scientific methods and language to lend legitimacy to racist ideologies outside established systems of accountability. CSR is a particularly malignant example of counterscience that exposes a fundamental vulnerability of Open Science: it is a system built on assumptions of shared values, mutual accountability, and trustworthiness, but it can be misused to promote discriminatory and false ideals.

Open Science is a Vulnerable System

NIH strategic plans and policies strongly endorse Open Science and FAIR (findability, accessibility, interoperability, and reusability) principles for data stewardship. Researchers who collect large‑scale genomic data with federal funding are generally required to share de‑identified data through NIH‑managed repositories. The aim is to accelerate scientific discovery and improve health and medical care.

Study teams may request specific data use limits to ensure that future uses of acquired data align with the original informed consent. Researchers requesting data from controlled-access databases must explain their research goals and must promise to avoid stigmatizing research and adhere to responsible research practices.

In this case, those safeguards proved insufficient. The New York Times investigation points out significant weaknesses in NIH oversight, including inadequate scrutiny of applications to access data from NIH-controlled databases, overreliance on “good faith” compliance with policies prohibiting stigmatizing research, and failure to respond to reported violations in a timely manner. Dr. Pesta and colleagues were able to exploit these weaknesses to obtain access and use the data in ways that directly conflicted with the values and expectations of the families who had agreed to participate, families who trusted the study team, their institution, and the NIH to protect their data and use it for the greater good.

What those families may not have realized is that they were also placing their trust in the broader scientific community, and in society more generally.  The NIH is working to strengthen protections against inappropriate data release, but those protections exist in tension with data accessibility. If a major consideration in allowing access involves determining whether the researcher is legitimate, whether their research question is appropriate, then the system is vulnerable to subjectivity, bias, and political change.

Distrust Fuels Counterscience

One of the most concerning aspects of the misuse of PNC and ABCD data is the way that Dr. Pesta and colleagues continue to justify their actions, framing their work as the courageous pursuit of scientific knowledge in a battle against “woke condemnation,” ideological oppression, and constraints on academic freedom. These arguments are eerily similar to those used to justify the disruptive overhaul and politicization of government health agencies like the NIH, the Centers for Disease Control and Prevention, and the Federal Drug Administration. The very structures meant to safeguard scientific integrity and protect patients and research subjects from harm have been characterized by the Trump administration and the Make America Healthy Again (MAHA) coalition as classist institutions prioritizing liberal agendas, silencing outsiders, retarding scientific advancement, and preventing citizens from accessing innovative therapies.

In this same vein, in April 2025, a federal prosecutor at the Department of Justice sent a series of letters to top U.S. medical journals accusing them of biased publishing practices, being “partisans in various scientific debates,” and inquiring as to how the journals handle articles with “competing viewpoints.” Dr. Pesta claims that his research was censored because he was asking unpopular “dangerous” questions, and not because of any flaws in the research. And as the New York Times article points out, Dr. Pesta has reason to be encouraged, since the current political administration is enabling the active rejection of established scientific knowledge (e.g., the safety and efficacy of immunizations) and redirecting funding and regulatory protections towards research that aligns with their priorities – which include eliminating diversity, equity, and inclusion policies, research, and education.

Research priorities for federal funding often shift under the influence of different presidents. But the answers to questions about the proper aims of science, what research questions should be asked, and whether some types of research ought not be pursued should not depend on which political party is in power. These are normative ethical questions that ought to be considered within the historical and current social context, informed by an understanding of scientific rigor and validity, as well as bioethics and moral philosophy, for the answers will have a significant impact on human flourishing, and ultimately reflect the values of that society itself.

Towards a Shared Moral Vision for Open Science

In our current day of increasing political polarization and lack of social cohesion, a just Open Science can only be achieved through broader, more inclusive conversations that acknowledge the root causes of distrust in our fellow citizens and institutions, that seek to articulate shared values, and that center the inherent human dignity and value of all people. Achieving a shared moral vision of Open Science requires societal and institutional reforms in partnership with historically marginalized populations. Until then, the only mechanism that can ensure that a research participant’s data is used in accordance with their values is for the participant to retain ownership and control of their data. This is Genomic Dignity, the idea that all people have the right to own their genomic data, the right to control when, for how long, with whom, and for what purposes to share it, and the right to an auditable trail of its use. This level of ownership and control is possible through encryption and watermarking techniques that are currently being developed and tested. Other safeguards include requiring researchers to conduct analyses within a centralized computational environment, such as the All of Us researcher workbench, and limiting or completely eliminating downloading of data from the system. There is much work to be done to earn the trust of research subjects, particularly those from marginalized populations. Genetics researchers must exercise social responsibility to consider and prevent the potential for harmful misuse of their data and analyses. And yet they cannot and should not bear that burden alone. Institutions, funders, policymakers, and the broader public must share this responsibility if Open Science is to advance the common good rather than contribute to harm.

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The Department of Health and Human Services released the report, The Treatment of Pediatric Gender Dysphoria (herein “the report”), in November of 2025. The report was the basis for the justification of the proposed rules in 42 CFR parts 441, 457, and 482—changes to Medicaid funding for “sex-rejecting” procedures for children with particular emphasis on its ethical analysis:.

The HHS Review makes clear that ‘‘the evidence for benefit of pediatric medical transition is very uncertain, while the evidence for harm is less uncertain.’’  The HHS Review cites widely accepted principles of medical ethics to conclude that when ‘‘medical interventions pose unnecessary, disproportionate risks of harm, healthcare providers should refuse to offer them even when they are preferred, requested, or demanded by patients.

The report’s ethical analysis, however, is based on a narrow and selective interpretation of the evidence. It then proceeds to gravely misunderstand and misapply key ethical principles. The report’s ethical flaws potentially stem from the lack of expertise of its authors, none of whom included pediatric bioethicists or clinicians who work in the field of gender medicine. This is particularly notable for a distinctly pediatric ethical question. There is legitimate concern that these experts were excluded from the process that generated the report because the report was never intended to be an objective scientific and ethical analysis of pediatric gender care. Rather, its commissioning Executive Order, entitled “Protecting Children from Chemical and Surgical Mutilation“, claims to issue a blanket ban on gender care for those younger than 19. The report’s ethical analysis thus proceeds from a political mandate and should be met with the strongest of skepticism. Additionally, there is a growing body of peer-reviewed analysis detailing the scientific and methodological problems in the report.

The report’s authors claim that care for transgender youth has received little critical attention from bioethicists. This is both patently false and also assumes that the provision of pediatric gender affirming care (GAC) is somehow novel or exceptional, rather than being consistent with established principles of pediatric ethics. We previously responded to the report’s misapplication of pediatric bioethics. The well established four principles of bioethics applied to the current facts of GAC lead to comprehensive and individualized care in determining which patient will benefit rather than total bans on care for all.  

Respect for autonomy

Respect for autonomy is always a consideration in medical ethics and even in pediatrics. Beginning around the age of 13, adolescents have been shown to have a similar ability to make informed decisions as adults. Supported by parents, medical decision-making—weighing the burdens, benefits, risks, and alternatives—can be of equal quality to that of adults, even in GAC.

Adolescents have growing autonomy as they age, but there is still a need to support and constrain decision-making. The concept important to decision-making in ethics is capacity. Capacity is the ability to make decisions. It is decision-based, meaning the question is often “capacity for which decision?” As detailed by the AAP, but ubiquitous across medicine, capacity is demonstrated by the ability to evidence and communicate a choice, understand the relevant information and facts, appreciate the situations and consequences, and the ability to assess the information in a rational way. 

Statements in the report such as “…young people cannot deliberate about the relevant considerations in a manner that is appropriately attentive to the seriousness and complexity of the decision…” are speculative, overgeneralized, and highly value-laden. It is true that with burgeoning autonomy we want to support and even temper adolescent decision-making. It certainly will be true that some young people will lack this ability, but to say they all do is a clear misunderstanding of adolescent ethics and development. Respecting adolescent autonomy is important, even if it is not fully adhered to, and their capacity to make decisions should be assessed like any adult patient.  

Beneficence/Non-Maleficence

Beneficence and non-maleficence work together, in balance, to help determine where interventions fall within the spectrum of shared decision-making (SDM). The balance between these two principles can sometimes depend on patients’ and families’ values, or on how one views the amount or certainty of a treatment’s benefit relative to the potential burden it might bring. These considerations all works together to determine whether decisions in pediatrics fall within the zone of parental discretion.

The Report seems to suggest that no adolescent has ever benefited from gender affirming care. But many have benefited. The report argues that the benefits of GAC for adolescents are unreliable and that it has an unfavorable risk/benefit ratio. But this is an “…egregious misuse of the findings…” Gender affirming care has shown to benefit individuals who undergo care. Systematic reviews often assign the term low certainty to observational studies. Low certainty does not mean no benefit rather it means that SDM should occur to determine the benefit-to-burden ratio for an individual patient. In SDM, parents, the patient, and clinician decide together how the balance of benefits and burdens, along with the uncertainty fit for an individual patient in line with their individual values and preferences.

This is not unique in pediatrics. There are many interventions utilized through SDM that lack strong systematic review data. If everything done in medicine had such data, we would not need clinicians to synthesize the unique individual presentation, the current theory and evidence, the pharmacological and physiological data, and the unique values of the patient. And as such, it requires careful and thoughtful process by clinicians, along with parents and patients, to determine whether an individual child might benefit, when, and with what intervention. The data around GAC is similar to the data around many other types of medical care in pediatrics, for which patients find to be beneficial, even if not every patient will find it beneficial. It is important that good assessment, discussion, and decision-making are undertaken.

Justice

The report then applies justice to issues of diagnostic overshadowing for which other conditions may be present and symptoms may be misattributed to. The report makes a speculative claim that the “…gender clinic model of care becomes Maslow’s hammer to which every problem appears as a nail (233).” That GAC clinics are identifying every symptom as gender dysphoria is a significant and unsubstantiated accusation. The report’s source for this accusation is one clinician’s statement in a newspaper article and an op-ed for the Washington Post by that same clinician. The report claims, based on this one report, that this demonstrates an injustice being done by all GAC clinics. Yet, injustice seems more evident in condemning all care based on one unverified report. Justice in this case argues for what the Cass Review recommends is a coordinated and organized process to determine whether an adolescent may benefit from gender affirming care.

Conclusion

The report claims that bioethicists have not provided critical attention to pediatric GAC. Yet there have been pediatric bioethicists who have analyzed this care. These bioethicists overwhelmingly reject the report’s ethical conclusions based in the four principles of bioethics. Pediatric GAC is consistent with the four principles of bioethics. Adolescents have burgeoning autonomy and that should be respected as moral agents supported through SDM. The balance of beneficence and non-maleficence may be clinically different for different patients. Unreliable benefits in the evidence cannot be conflated with no benefits. In pediatric GAC the favorability of any treatment in terms of the proportion of benefit to burden will depend on many patient-specific factors. These require consideration through SDM that is utilized in nearly every clinical discussion in pediatrics. Justice in pediatric GAC argues for good process in determining which patient will benefit from which treatment. Justice requires access, not bans.     

The public comment period for the two proposed CMS rules ends February 17^th at 11:59 PM. However, the misapplication of pediatric bioethics framing the rhetorical narrative, along with an all-or-nothing, rather than a nuanced and thoughtful approach to this population, will continue to wield policy discussions.

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The campaign to drink whole milk seems to have exploded out of nowhere. Many suspect it is fueled by the powerful dairy industry, and that may be true, but here may be darker forces at work behind the sudden appearance of all the memes and videos showing so many prominent health officials and influencers proudly guzzling huge glasses  

As with the bizarre campaign started by conservatives in the early 2000s denouncing the supposed “War on Christmas,” many on the right seem to believe there has been a “war on whole milk.”  I don’t see much evidence of this claim. 

It is true that U.S. dietary guidelines and school lunch policies did once discourage full-fat dairy consumption, including the drinking of whole milk due to obesity concerns. A recent bill signed with great fanfare by President Trump reversed these guidelines, allowing schools to serve whole and 2% milk again. But some of my young students tell me that in their high schools, whole milk was always allowed, and it was not just available free for lunch for those kids relying on federally subsidized school lunches. In fact, whole milk has been readily available in every grocery store, bodega, and convenience store in the country for my entire very long life. We also know that Americans have, on the whole, been drinking more milk, especially whole milk, over the past few years. I occasionally drank it, preferring its taste to that of low-fat varieties.

So, if there hasn’t really been a war on whole milk then what is going on? Why the sudden vociferous obsession with drinking it?

As a student of and writer on the history of science and public health under fascist regimes, I am suspicious. Milk drinking is political. Drinking whole white milk has played a big role in racist and far-right thinking.

Fascists have used the beverage as a rallying cry for white supremacy since the days of Il Duce’s (Benito Mussolini’s) public health campaigns in Italy. The Nazis were enamored of whole milk as well (https://www.amazon.com/Racial-Hygiene-Medicine-Under-Nazis/dp/0674745787). In America, drinking whole milk has for years been a part of alt-right, white nationalist messaging in tweets, memes, and videos.

The neo-Nazi #MilkTwitter hashtag began shortly after a large gathering of white men descended on an anti-Trump art exhibit in 2018. The men carried cartons of milk and voiced explicitly racist, sexist, anti-Semitic and homophobic rants. After taking a swig of milk from his carton, one bare-chested man approached the camera and sneered. “An ice cold glass of pure racism.”

White nationalists in the U.S. and Europe note that many people of Northern European descent can digest lactose as adults. They link milk-drinking to an “evolved” or “superior” trait that other racial groups somewhat lack

Drinking whole milk is portrayed as a sign of strength and genetic health. The ability to drink it is used to mock non-whites and to promote a patriarchal ideal, which sneers at the “weak” soy milk drunk by leftists and feminized men. Images of white people chugging milk are popular on racist sites, e.g., “If you can’t drink milk, you have to go back.”

Racism and eugenics, sadly, may be playing a role in the sudden drive to fetishize drinking whole milk. Drinking whole milk is a dog whistle to far right, white nationalists. The campaign to promote whole milk may have many factors behind it, but at a time when eugenics, racism, and white nationalism fuel too much of our political rhetoric, the whole milk campaign must be swallowed with care.

Arthur Caplan, PhD is a soon-to-be-retired professor of medical ethics who lives in Ridgefield, CT.

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This editorial appears in the February Issue of the American Journal of Bioethics

Ambient intelligence (AMI) promises to transform healthcare across the continuum by embedding continuous sensing and interpretation into physical spaces where patients receive care. Ambient intelligence systems (AIS) use multimodal sensors to monitor and interpret activity in real time, offering more data, better predictions, and improved patient outcomes with less intrusion on clinicians’ time. Yet the very features that make AIS attractive—ubiquity, continuity, and automation also raises ethical concerns. While AIS allows for richer input streams that can improve detection of patient deterioration i.e. falls and relieve documentation burden, AIS also operates with a wide, indiscriminate gaze capturing patients, families, clinicians, and staff without the opportunity to opt out. Given the range of potentially conflicting interests among a diverse set of stakeholders, managing autonomy, privacy and consent have become extremely complex and without consensus on how they should be resolved.

Herington and Cho propose traditional bioethics is ill-equipped to address these concerns and instead propose a justice-first framework grounded in Rawlsian political philosophy. They argue that the original position and “veil of ignorance” may be better suited to address the challenges of AIS within a larger context. We propose an analogous argument where AIS is not solely an issue of clinical or research ethics, but rather that of public health ethics. Nancy Kass’s influential public health ethics framework was developed to address interventions where individual autonomy cannot be assumed when multiple stakeholders are involved. To utilize Kass’s framework with AIS, two clarifications are needed. First, we must distinguish between private and public domains. Traditional, patient centered bioethics focusing on clinician–patient interactions should still guide decisions in the private domain of individual care, particularly around informed consent, confidentiality, and respect for persons. However, our focus here is within the public domain consisting of shared spaces and infrastructure where AIS would exist in a hospital setting. Second, AIS must be understood as a public good and its use and implementation should not exist to solely benefit individual patients alone, but rather improve safety, quality, and efficiency on a systems level.

The Institute of Medicine describes public health as the effort to “ensure societal conditions under which people can lead healthier lives, mitigating threats to our health through collective action aimed at the community”. Kass, in turn, offers a six-question framework to guide ethical analysis of such interventions: What are the public health goals of the proposed program? How effective is the program in achieving its stated goals? What are the known or potential burdens? Can burdens be minimized, and are there alternatives? Is the program implemented fairly? How can the benefits and burdens of a program be fairly balanced? Within a public health framework, surveillance, data collection, and reporting take on a utilitarian view and such actions are deemed to confer a greater benefit to the overall health of the population compared to the burdens it imposes on individuals. We acknowledge that public health initiatives and AI/AIM have a different set of laws and regulations that support their directive.

What Are the Public Health Goals of the Proposed Program? How Effective Is the Program in Achieving Its Stated Goals?

In utilizing Kass’ framework, one of the goals of AIS is to implement earlier detection of clinical deterioration and reduction of preventable harm. Consider the use case of AIS in intensive care units (ICUs) where the sickest patients require minute-by-minute monitoring as a matter of life and death. Given these labor-intensive tasks, Dai and colleagues implemented an initial effort in the ICU to improve clinical detection and reduce documentation burden. They installed 2 cameras in 8 ICU rooms to continuously collect image data of vitals, ventilators, infusions, patient mobility, therapeutic interventions etc. for algorithm development. The investigators updated their notice of privacy practices and patients were made aware of the collection of image data as part of their routine care, appealing to a utilitarian rationale commonly used in public health research. Patients were informed these data would be used for clinical and research purposes. Additional privacy preserving measures were also taken to mask faces and sensitive areas of the image. Even with these mitigation measures, investigators acknowledged that errors in masking could not be entirely eliminated. Since these collected images were personal health information (PHI) under HIPAA, research use of these data also required storage on a secure server. Given its initial trial, further development and data collection will be required to demonstrate its effectiveness but also show significant promise of what is possible.

What Are the Known or Potential Burdens? Can Burdens Be Minimized, and Are There Alternatives?

The burdens associated with AIS are certainly present, and a public health ethics lens highlights why this deserves serious inquiry- not only because of the privacy and confidentiality considerations described above, but also because of the implications for liberty, self-determination, and justice. Scaling such systems to routine clinical use implies large, multi-institutional data infrastructures whose burdens and benefits may be unevenly distributed. Kass’s framework directs attention to whether these burdens fall disproportionately on certain patient populations or staff groups, and whether they are justified by demonstrated improvements rather than speculative gains. In keeping with public health ethics more broadly, the aim should be to favor approaches that impose fewer infringements on liberty, privacy, and justice without reducing benefit.

There is also a high risk for the dual-use of AIS resulting in intentional or unintentional misuse. In 2020, the NYPD used facial recognition for the mass surveillance of Black Lives Matter protestors, further exacerbating systemic discrimination. Trotsyuk et al. outlined concerns surrounding authoritarian surveillance and abuse of privacy, data misuse, and worsening inequities in 3 domains-drug and chemical discovery, generative models for synthetic data and ambient intelligence. They detail a multi-pronged framework to mitigate these risks by relying on existing ethical frameworks, regulatory measures, pre-built AI solutions, or design-specific solutions. If these avenues prove inadequate, they recommend researchers look to alternative approaches to accomplish their goal.

Is the Program Implemented Fairly? How Can the Benefits and Burdens of A Program Be Fairly Balanced?

Fairness and the balance of burdens and benefits must also be confronted directly for AIS. We endorse Herington and Cho’s justice-first approach, but argue that it should be operationalized within Kass’s public health framework rather than in abstract principle. From a procedural justice perspective, framing AIS as a public health intervention has practical implications for governance. Oversight should look less like ad hoc technology adoption and more like that of a coordinated large-scale screening or environmental health program, with formal institutional review processes that include ethics and privacy experts and stakeholders from across the institution, including patient representatives. These processes should be present with the goal of maximizing benefit, minimizing harms and remain iterative in nature. It should make explicit goals for AIS deployment, specify which metrics constitute success, commit to ongoing monitoring for unintended consequences, and have clear mechanisms through which concerns may be raised and addressed in a timely manner.

Distributive justice raises a different set of questions, balancing the benefits and burdens of such a technology. Some questions that may arise: who and what will AIS track? How will outputs be used-will AIS be used for quality improvement and patient safety functions or also inform performance evaluations? While institutional values and needs inevitably shape many of these choices, they should not be left to a few decision-makers-ethicists can play a key role in clarifying options, outline tradeoffs, and propose safeguards. A public health framework insists that such decisions be made transparently, with explicit attention to how benefits and burdens are distributed across different groups rather than simply accepted as collateral effects of innovation. It also underscores a basic proportionality claim: the greater the burdens imposed by AIS, the stronger the justification needed to demonstrate an even greater benefit.

Herington and Cho are right to push beyond traditional bioethics and place justice at the center of ethical evaluation of AIS. An overarching public health ethics framework complements their justice-first approach by providing a concrete, operational set of questions that institutions can apply when deciding whether and how to deploy AIS. It acknowledges that AIS is not just another clinical tool, but a socio-technical infrastructure that alters the conditions of care for everyone who enters the space. Treating AIS as a public good for public health, rather than a series of isolated clinical innovations, may better align with the scale of its promise—and its risks.

Kate Luenprakansit, MD and Kevin Schulman, MD, MBA

The post Ambient Intelligence as a Public Good in Healthcare: What Public Health Ethics Can Teach Us appeared first on Bioethics Today.

This editorial appears in the February Issue of the American Journal of Bioethics

Despite significant promise in preliminary (i.e., proof-of-concept) stages, artificial intelligence (AI) sometimes fails to deliver meaningful impact in real-world environments on the metrics that matter most to patients, clinicians, and policymakers. Challenges arise not only from technical limitations but also from poor usability and misalignment with real-world clinical workflows. Recognizing this gap, usefulness has emerged as a key principle for evaluating AI systems. According to CHAI’s Responsible AI Guide, an AI solution is considered useful when it provides a tangible benefit to healthcare delivery and demonstrates not only validity and reliability but also usability. The Coalition for Health AI (CHAI) has prioritized usefulness as one of five essential focus areas for trustworthy AI, alongside fairness, safety, transparency, and security and privacy. This paper outlines the key insights from CHAI’s Usefulness Workgroup.
From a bioethical perspective, usefulness closely tracks with the principle of beneficence. An intervention that is accurate but unusable—for example, a tool misaligned with a specific care context—may fail to deliver meaningful benefit despite technical promise. In this sense, usefulness functions as the ethical complement to non-maleficence, asking not only whether AI avoids harm, but whether it reliably contributes to patient wellbeing.
CHAI’s approach to defining usefulness was shaped by input from a diverse set of stakeholders, including clinicians, developers, regulators, healthcare administrators, and patient advocates. Through an iterative consensus-based process—literature review, workgroup discussions, community-wide surveys, expert convenings, and independent review—CHAI synthesized a shared understanding of what makes AI useful in healthcare. Central challenges are ensuring that AI solutions are integrated seamlessly into clinical workflows, remain actionable for end users, and provide meaningful, measurable benefits. The consensus-driven guidelines offer a structured pathway for people developing AI solutions to achieve these three attributes. This requires that AI is thought about as a system made up of the AI model and interface as well as the clinical and/or operational workflow in the environment that enables safe and effective use. These guidelines help bridge the gap between technical innovation and practical implementation, advancing the field by providing insights developed through input from diverse stakeholders, which can advance AI toward the improvement of health care. Below we highlight some of the key considerations identified through this iterative, consensus-based engagement process. Additional details on the methods for developing the considerations have been reported elsewhere.

Overarching Considerations

Defining the Problem
The first, and most critical, step is defining the problem to be solved and evaluating if using AI is the right approach to address that problem. To do this, developers and program managers should engage early in human-centered design to avoid the pitfall of poor problem identification. While AI has the potential to solve many problems in healthcare, many problems do not require, nor are they best solved with AI solutions. It is important to understand the strengths and limitations of AI and only apply it when AI is fit for purpose.
Organizations should assess the overall operations of an enterprise and identify the most likely cost and value levers that could plausibly be impacted by AI solutions. This involves both a thorough assessment of the status quo—defining a basis from which improvement can be measured—as well as specific opportunities for AI integration to potentially improve the current workflow. Often referred to as ‘delivery science’ leveraging work system analysis, design thinking, process improvement, and/or implementation science, this problem definition phase requires proactively imagining the workflow that needs to execute for an AI tool to address the problem. For example, after an AI model flags a patient as high risk of readmission, what specific steps should the receiver of that prediction be expected to take? An effector arm may be necessary for a solution to achieve intended outcomes. For example, a deterioration index is likely to be more effective when paired with a 24 hr rapid response team. These resources need to be identified early in the design process. The problem definition phase can also comprise drafting representative evaluation samples and explicitly defining the input and output of the system. This simple construct is powerful and allows further design investigation to be grounded. The evaluation samples can be from real or synthetic sources, covering multiple dimensions and thus comprehensively defining the problem.

Assessing Benefits, Risks, and Costs
Once the problem and corresponding AI solution are identified, the next step is assessing the benefits, risks, and costs. For instance: What is the magnitude and frequency of the risks and benefits? Who will benefit from the AI? What roles and tasks may be negatively impacted by the tool? What are the risks if the AI is incorrect, and the end users accept AI recommendations unintentionally? While difficult to estimate, evaluating the number of workflows affected, the impact of AI on workflow efficiency, and the ability to integrate in existing digital workflows can help approximate deployment costs. Once the workflows are identified, it is possible to perform simulations using open-source software that estimates achievable benefit considering work capacity constraints.
There is growing recognition of the environmental costs of AI models; this, along with other cost and risk impacts should be included in a model to arrive at a “total cost of ownership.” This cost evaluation model is increasingly adopted, because it aims to take into consideration the multi-dimensional nature of AI and the layers of costs associated with designing and implementing AI solutions in complex enterprises. A similar model should be applied on the benefits side to estimate the expected value of AI solutions over time. With both the expected cost and expected value estimated, an organization can start to measure and track the return on investment (ROI) of AI. It is fully reasonable to assume that the fiscal capacity of each deployment may differ dramatically. For instance, a low-resource site may require off-site subscription models, while high-resource site may see the cost of compute-intensive models with continuous training as cost effective.

Workflow Integration
Workflow integration should be considered and assessed throughout the AI lifecycle. In our survey of the CHAI community at large, AI integration in workflow was rated as the most important issue across the AI lifecycle. Workflow integration is dependent on a technology’s fit within the sequence and flow of tasks, people, information, and tools as well as the broader work system at the individual, team, and organizational levels. Poor integration of technologies into clinical workflows can lead to frustration, low acceptance or abandonment, workarounds, and increased workload and cognitive burden. As such, it is no surprise that workflow integration is essential for useful, usable, and efficacious AI.

Individuals trained in human factors engineering, user experience, and implementation science should be involved in studying and redesigning current workflows to accommodate the new AI tool; this should begin early at stage 1 (see table 1) with continual assessment throughout development and after implementation. End users should be actively and meaningfully engaged in the human-centered design process. Additionally, workforce simulations can supplement qualitative assessments of workflow. To realize the benefits of AI, it is essential that the AI truly supports, rather than hinders, clinical (and other end user) work. This means that information provided by AI must be both accurate and timely to enable actionable information that augments an existing clinical workflow. Workflow integration can be simulated by implementing digital twins of the environments. This concept allows developers to better understand the implications of the AI systems without a full costly implementation. Without thoughtful workflow integration, output from AI-based solutions have the potential to contribute to burden on the clinician, continued care gaps or increased liability for the healthcare delivery organization.
When usefulness is insufficiently addressed, the consequences are not merely technical or operational. Poorly integrated AI solutions can exacerbate inequities in care delivery, contribute to clinician moral distress, and introduce new risks to patients through delayed, ignored, or misapplied recommendations. In such cases, AI may formally promise benefit while substantively undermining beneficence and non-maleficence.

Tailoring for Local Context
Going hand-in-hand with workflow integration, AI tools need to be adapted for the local context of use, in particular when implementing an AI system into a new setting. Several studies have demonstrated the need to validate AI solutions with local data as AI performance can vary from organization to organization. This aligns with the lifecycle stage 2 consideration “assess differences between development and implementation environments”. Yet, tailoring for local context goes well beyond the data. The entire sociotechnical system including the people, tasks, tools and technologies, physical environment, and organizational context need to be taken into account for implementation success. Usability is not an inherent quality of a system, rather it is an outcome of use within a specific work context. Therefore, a highly useful and usable AI-driven solution in one setting will not guarantee the same result when translated. Understanding local context must also include careful attention to workflow integration, as fit within local workflows is essential for successful AI adoption.

Trust
End users trust of AI is a multifaceted, important consideration across the development lifecycle. Trust affects end user reliance on systems, especially in complex settings with incomplete information. AI should be designed to support appropriate trust, meaning trust depends on the context of use and the AI’s purpose, process, and performance in that specific context and how the human might team with the AI model. The interface design and broader system architecture can support or hinder appropriate trust by end-users. Healthcare delivery organizations should also build trust in these solutions with their patient population. The impact of AI technology in the patients’ healthcare journey must be incorporated into the usefulness assessment. If not, harm to the patient could occur in the form of financial toxicity or other adverse outcomes. While some research has provided methods to inform the design of AI for appropriate trust, more work is needed in this area. Designers can communicate AI capabilities or limitations to end users through methods such as model fact labels, performance indicators, or system transparency elements. These are particularly beneficial when the AI solution employed relies on less interpretable “black-box’ methodology. Monitoring and incorporating end-user feedback into the design of AI can also enhance trust. Lastly, developing clinician and other end user competencies in AI can increase engagement among clinician stakeholders and enable appropriate trust.

Pilot and Deploy
The pilot and deployment phases provide an opportunity to verify whether the cost, benefit, and risk estimates in earlier stages are in line with their actual values. These steps can also validate whether end-user input and perceptions are being satisfactorily addressed in the real-world setting. Quantitative estimates of efficacy based on RCTs or quasi-experimental designs will, in general, be less biased than those based on observational studies. Stepped wedge study designs and difference-in-difference methods are increasingly popular to this end. These early values can also help establish benchmarks for comparison once the AI solution is being monitored in later stages. Generation of evidence showing effectiveness and positive outcomes is necessary to build trust among clinicians/end users but also medical societies and payers. This evidence generation will be necessary to advocate for reimbursement.

Monitor AI Solution Performance over Time
Despite a robust design and implementation process, new, unexpected issues are likely to occur following implementation of AI due to the nature of complex sociotechnical systems. AI performance can change throughout its use due to several factors such as new policies and patient populations, dataset shifts, and the impact of the model on predicted outcomes. To ensure reliability and maintain usefulness, usability, and efficacy, AI tools should be continually monitored after implementation. Proactive systems for monitoring should focus not only on AI performance, but also its impact on process measures and outcomes, and careful attention should be made to ensure fair and unbiased performance is delivered across various demographic subgroups. Additionally, mechanisms should be put in place to solicit and deploy end-user feedback on AI tools. For example, quick feedback mechanisms incorporated directly into interfaces (e.g., with an embedded Likert scale) can successfully gather real-time end-user feedback. Systems for adverse event reporting should also be in-place to gather data on safety issues impacting quality of care.

Conclusion
Even the most accurate and well-intentioned AI tools will fail to improve healthcare if they are not used by clinicians and other end users. Usefulness—defined by real-world impact, workflow fit, and contextual adaptability—must be a central benchmark for evaluating AI. Considerations such as usability, trust, and workflow integration, must be considered early and throughout development, rather than deferred to late-stage testing or post-launch adjustments. Early investment in these areas to proactively identify and resolve any issues with the AI design can enable more meaningful engagement with end users, reduces costly redesigns, and increases the likelihood that AI tools will be successfully adopted, sustained, and deliver meaningful clinical value. By embedding human-centered design and usability evaluation into every stage of development and implementation, health systems can bridge the gap between innovation and meaningful clinical benefit. Furthermore, by treating usefulness as an ethical obligation—and not merely a technical concern—AI governance can more fully honor the principle of beneficence, ensuring that AI-enabled care delivers meaningful benefits in real clinical settings.

Megan E. Salwei, PhD; Keith Morse, MD, MBA; Suchi Saria, PhD; Nigam H. Shah, PhD; Armando Bedoya, MD; Molly Beyer, MD; Alejandro Muñoz del Rio, PhD; Dennis Chornenky, MBA; Anthony Lin, MD; Sawan Ruparel; Daniel Kortsch, MD; Priyank Barbarooah; Morgan Hanger; Ashley N. Beecy, MD; Matthew Elmore, PhD & Nicoleta J. Economou-Zavlanos, PhD

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Recently, the Florida Supreme Court issued a ruling that a man, Angel Rivera, who provided sperm through an informal DIY at-home insemination for friends, did not automatically relinquish his parental rights.

In 2019, same sex couple Ashley Brito and Jennifer Salas wanted to create a baby. IVF is a costly proposition, ranging from $15,000 to $20,000 per cycle, and has only a 20% chance of success per single embryo cycle.

To sidestep these costs, Brito and Salas crafted their own arrangement with Rivera. Rivera provided sperm, and they used a plastic syringe from a drugstore kit to inseminate Brito. Once Brito learned she was pregnant, Brito and Salas got married. In 2020, Brito gave birth to a baby boy. 

Because Brito and Salas were married, both Brito and Salas were listed as the child’s two parents on the birth certificate. In Pavan v. Smith, the Supreme Court held that if a same sex couple welcomes a child, then both names should appear on the child’s birth certificate as legal parents. Pavan has resulted in subtle, yet massive implications – some children no longer have a legal Mom and Dad, but interchangeable, genderless parents.

The conflict began one year after the child was born, when Brito and Salas separated. After Salas moved out, Rivera and Brito filed a petition to recognize Rivera as the child’s legal father. This raised the question: did Rivera relinquish his parental rights? Was he really merely a sperm donor? 

Part of the conflict stems from a disagreement about Rivera’s role in the arrangement. IVF clinics require contracts to specify exactly who the parents are and clarify that donors do not have the rights or responsibilities of parents. In this case, Brito, Salas, and Rivera did not use an IVF clinic, and they did not have a written agreement. They all exchanged texts and photos of the child, in which Rivera referenced the child as “our son.” Salas, however, asserted she and Brito were the child’s only parents.

In Florida, the law on assisted reproductive technologies references married Mothers and Fathers seeking medical assistance from IVF clinics. This case, Brito v. Salas, clarifies that the law does not apply to casual sperm donation arrangements that occur outside a clinic setting. For Rivera, this means that he did not automatically surrender his parental rights through the informal agreement.

This case raises multiple ethical issues wrapped in the context of gamete donation. Intended parents using social sperm donations may assert that casual arrangements fulfill procreative liberty, the freedom and autonomy to create children. Using social sperm donations expands reproductive choice with a lower price tag and fulfills intended parents’ reproductive choices. Despite this, it can also induce confusion and create barriers if the “donor” perceives his role as something more, and tries to formally establish a relationship with the child.

It also raises three potential ethical issues relating to the child’s interests: (1) psychological well-being; (2) identity formation; and (3) human rights. Some evidence suggests that donor conceived persons may experience psychological distress, anger, or sadness related to their conception from donor gametes. Connection to genetic origins may be important to a person’s construction of identity and developing a sense of self. In the context of human rights, Article 7 of the United Nations Convention on Rights of the Child states that children have a right to know and be cared for by their parents. Some legal scholars interpret this provision to mean that laws should facilitate children being raised by their genetic parents, when possible. 

People considering informal sperm contributions should consider the risk and potential fallout from these arrangements. This has potential implications not only for sperm donations arranged through social media, but also casual relationships that result in a child where parties may hold different expectations for roles and responsibilities.

This decision leaves open the possibility that Rivera could file a claim as the child’s father to become more involved in the child’s life. This also raises a separate question: what happens if a court recognizes Rivera as the child’s father? Can, or should, a child have three legal parents?

For hundreds of years, the law recognized that a child has two parents: Mom and Dad. Situations such as adoption or using assisted reproductive technologies can modify a child’s legal parents – who is responsible for, and cares for the child. But several states have gone much further, declaring that children can have three legal parents, such as in cases involving polyamory and couples using sperm from a friend. Despite initial plans that everyone would happily raise the child together, these relationships became mired in conflict and arguments over how to split time with the child.

Navigating parental rights is a zero-sum game. If a right is enlarged to add more parents, it is diminished for the child’s biological parents. Children’s time, attention, and loyalty are finite resources. Adding more parents with decision-making authority comes with a cost and significant burden to the parent-child relationship, increasing the potential for conflict when managing and rearing the child. Children may feel pulled in multiple directions, which can leave children confused and adrift. 

Families should provide structure, stability, and a sense of identity. The law should facilitate relationships between fit, capable biological parents and their children. If faced with this question, courts and the state legislature should not make the mistake of trying to conform the law to social trends, but affirm that a child has only two legal parents.

Katherine Drabiak, JD is a Professor of health law, public health law, and medical ethics in the College of Public Health at the University of South Florida.

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The failure to adequately respond to women’s pain is especially salient in reproductive healthcare. For example, endometriosis diagnoses often require seeing multiple providers and can take 7-10 years to obtain. During this time, women’s excruciating symptoms tend to be undermined or attributed to mental illness, hysteria, and other gendered stereotypes. In these contexts, Black and Brown women experience disproportionate harm. Moreover, in standard reproductive medicine procedures like egg retrievals for IVF and IUD-insertions, women are often not warned of the extreme pain involved, are provided inadequate pain management during and after procedures, or are not given any pain management at all. Many clinicians underestimate the painfulness of these procedures and deem pain management unnecessary. In sum, women are expected to just deal with debilitating pain in a variety of context, as if that’s just part of what it means to be a woman. Of particular interest is the agonizing, gendered pain that women experience while undergoing C-sections. As recently reported in Season 2 of the podcast, The Retrievals, 8% of C-section patients in the United States –- which is over 100,000 patients per year –- are able to feel their surgery. In many cases, they literally feel their organs being taken out of their bodies! 

In what other context would we think it tolerable for patients to experience that degree of pain during surgery? 

The high frequency of pain during the above-mentioned procedures is due to a number of factors pertaining to how women and gender minorities tend to be regarded, or better, disregarded, in medical contexts. There is a harmful a combination of microaggressions, which create environments where women don’t feel comfortable expressing their pain; the credibility gap, where women aren’t considered to be credible knowers about their bodies; cultural health capital, where women (especially low-income women) might be unable to communicate their pain and other needs in ways that are recognized and respected by providers; testimonial injustice, which undermines women’s claims to pain on account of pervasive stereotypes that they are overly emotional or “hysterical”; testimonial smothering which prevents women from speaking up about their pain in the first place out of fear that they’ll be misunderstood or disbelieved; and specifically gendered and racialized pain dismissals which assume that women, especially Black women, have higher thresholds for pain and should just tough it out. Here, we are less interested in further diagnosing the problem of why women’s experiences of pain continue to be ignored and normalized in medical contexts and instead, consider what can – and should – be done about it. 

Many argue that in response to this problem, we need to better listen to women, empower them to be stronger advocates for themselves, and encourage them to take responsibility for their health. While we do not disagree with these claims –- of course women should speak up for themselves where possible, and of course health care professionals should listen to them! –- it’s long been the case that such individualistic approaches have not resulted in better outcomes for women. This solution remains insufficient due to the pervasiveness of stereotypes about women being overly emotional, weak, and attention-seeking; controlling images of Black women, and other gendered assumptions and biases about gender, race, and pain that are operative in clinical encounters, which already tend to be hostile to the possibility of hearing their voices. Moreover, patients who arrive at their appointments informed, want more specific information, ask precise questions, or make requests (e.g., for pain management) are often seen as “difficult patients” (a title distributed far more liberally to Black women patients). 

A central problem with the “women need to speak up for themselves” approach is that it puts the burden for solving the problem on individual women. Yet individual women lack power in physician-patient dynamics. Individual women implored to “empower themselves” are not going to solve this problem, nor should they be tasked with doing so!

Instead, we need to take a more structural approach and shift the responsibility to physicians and institutions that have personal, professional, and institutional power to make systemic changes that create environments and conditions that facilitate patients’ ability to speak up about their pain and, in turn, actually be heard. 

The first step is to better educate healthcare professionals about the serious pain involved in the procedures mentioned above. Though this seems like an enormous first step, the good news is that it is already beginning to happen. In July 2025, the American College for Obstetricians and Gynecologists changed its guidelines to recognize, for the first time, that these procedures can cause real pain, that standard pain management options “have limited or conflicting evidence supporting their effectiveness at providing adequate pain control during in-office gynecologic procedures,” and that patients ought to be informed and given better options. Such guidelines are a crucial first step toward changing institutional culture, attitudes around, and responses to women’s pain. 

The second step is to recognize that not all women feel pain the same way. As Dr. Karen Meckstroth, of the Obstetrics, Midwifery, and Gynecology Clinic at San Francisco General, notes, “[t]he way pain is understood and managed by health care professionals is also affected by systemic racism and bias of how pain is experienced. Specific populations, such as adolescents and those with a history of chronic pelvic pain, sexual violence or abuse, and other pain conditions, may also have increased or decreased tolerance of pain and resistance to pain medications.” Careful, compassionate, trauma-informed care must be given to all patients, especially those who are members of marginalized groups. 

The third step is to create contexts where women can actually be heard. This can be done by systematically building comprehensive pain-management plans into the standard of care, as opposed to leaving it up to individual providers to offer as, when, and how they see fit. An example of this is what obstetric anesthesiologist Dr. Heather Nixon has implemented in C-section pain management care, a strategy motivated by the common phrase that in medicine, “what’s measured matters.” Combining standardization and measurement, she’s built 15-minute pain checks into all C-section procedures, where anesthesia providers receive automated reminders to obtain a basic pain score from patients at these intervals. Scores of 3 and above trigger prompts for specific follow-up questions about the kind and location of pain, that help determine the best intervention. 

The fourth step is to adopt a better system of shared decision-making in clinical settings, one that caters to and is guided by individual patients’ past experiences, thresholds, preferences, and goals. As the 2025 ACOG report notes, “Shared decision making with the patient should be practiced when discussing pain-management options because options that work for one patient may not work for another.” Building upon this approach, the ACOG Committee on Clinical Consensus-Gynecology notes that “[f]uture research on pain and the management of pain must be more racially and ethnically diverse. Studies should include gender-diverse participants, focus on patient preferences and goals, and consider the needs of patients of various ages and those who have a history of trauma.” 

These structural and cultural steps to changing how we understand and implement pain management must be incorporated into medical education and training if we want to see effective, lasting changes moving forward. It is significant that national organizations like ACOG have (finally) recognized the seriousness and pervasiveness of the problem and have started implementing these changes. Other medical organizations and institutions must follow their lead. 

We can – and should – do more to recognize and respond to women’s pain in healthcare settings. Doing so is a matter of health justice for which we are all responsible. 

Lauren Freeman, PhD, is a Professor of Philosophy at University of Louisville.
Heather Stewart, PhD, is an Assistant Professor of Philosophy at Oklahoma State University.

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Mental health protections can be achieved through predictive modeling using data sets compiled from mood monitoring, language analysis of voice and logs or personal accounts, environmental variables, electrodermal responses (such as perspiration), variability in biorhythms (such as heart rate or sleep patterns), and other physiological markers. In space mission scenarios, parsing this information and identifying its meaning or indications, especially given the complexity of biological signals, can be achieved using natural language processing (NLP) and deep learning (DL) methods. Machine-learning-based stress detection and alerts can provide real-time analysis, accurate anomaly recognition, and suggest conversation or emotional support within therapeutic intervention. 

While continuous monitoring enables early detection, it also raises ethical concerns about psychological autonomy and surveillance, as it may be experienced as an extension of control rather than care. In space missions, where opportunities for agency are constrained, AI therapy systems can better support autonomy when their influence is transparent, limited, and designed to support astronauts’ long-term goals within space travel.

Higher use and proper calibration of wearables for each astronaut can further improve the effectiveness of systems using NLP and DL methods. They can supplement diverse data to provide more personalized recommendations for what therapeutic interventions an astronaut may need, informing more precise treatment decisions rather than a blanket wellness alert. 

However, this codification of intimate psychological data raises concerns of ownership, privacy, and trust, which may influence an astronaut’s willingness to engage with the system. While astronauts relinquish some autonomy to ensure mission safety and the development of more stable habitats for future crews, their contributions to these data sets should not compromise personal confidentiality. Because astronaut selection is highly competitive, psychological disclosure may be perceived as a risk to future mission eligibility. As such, limitations on data access and use are essential to ensure confident participation without fear of professional consequences.

Current AI assistant systems have proven effective, as demonstrated by the implementation of the Crew Interactive Mobile Companion (CIMON), which uses voice processing and NLP to assist astronauts in daily functions, increasing productivity while reducing stress. Initial uses revealed problems with linguistic interpretation, inaccurate emotion recognition, and suboptimal stress-mitigation suggestions that were not always appropriate to the individual’s specific needs. These issues highlight the ethical importance of addressing model bias and personalization, especially before expanding into medical-oriented AI tools. Future AI medical applications, such as the Crew Medical Officer Digital Assistant (CMO-DA), will use NLP and machine learning models trained on spaceflight medical literature and crew records to provide autonomous medical assistance. As these systems support and guide medical and psychological decisions, there is a risk that algorithmic authority may influence personal judgment and raise ethical concerns about automation complacency.

Technical issues concerning implementing these systems remain, including cybersecurity of the communication vectors, functionality in the resource-constrained environment of deep space, and handling high latency or noisy data. Since these solutions are intended to help astronauts in real-time and alleviate the wait for communication with ground stations, missions could use an on-board cloud server as a possible solution to make communication faster and more reliable.

Together, these operational and technical tensions raise ethical considerations when adapting these diagnostic and predictive models, especially when they are used for sensitive information such as health monitoring and intervention. These concerns become significant in therapeutic contexts, where there are ethically pressing apprehensions surrounding the harms of psychotherapy. Risks, such as therapeutic misconception, may lead users to overestimate an AI system’s capabilities for therapeutic support. AI conversational agents lack emotional depth and empathy and are unable to form or facilitate the human connection that therapeutic processes often need.

Clearly defining the role, purpose, and limitations of AI therapy can help minimize the ethical risks associated with its use. Outside the terrestrial environment, space offers limited opportunities for connection with human therapists. As such, astronauts represent a very unique and vulnerable population.

Astronauts are selected based on how well they perform and think in demanding conditions. They are healthy, rigorously trained for missions into deep space (excluding spaceflight participants and tourists), and possess select-in qualities, such as adaptability to high levels of stress or strong social communication skills. 

Since ethical concerns in psychotherapy directly relate to the users in question, astronauts can provide informed consent and interact with AI systems with greater caution than an average user, and are more likely to discern the limits of AI. In the case of space missions, when NLP and DL models, like those used with CIMON and CMO-DA systems, help predict, diagnose, or provide structured therapeutic exercises, they are deployed in contexts where the users (astronauts) are accustomed to role-playing training for mission scenarios and can engage with these systems as collaborative partners or use them for guided reflection. 

For instance, potential mental health therapies could range from supplementing sleep CBT adjustments to help cope with the 90-minute cycle of night and day, recommending engaging with family recordings, virtual or augmented reality via the HoloLens adapted with prerecorded simulations, relaxation techniques and yoga, chat-based support to carry on conversations, or religious and spiritual support. While AI therapies or tools can assist in these areas, there is no expectation that they are proper or equal replacements. 

Understanding its non-human nature and that AI models are meant to support, not replace human relationships, provides astronauts with transparency into its therapeutic benefits. Similarly, by having a responsive tool for emotional processing and privacy, it eases the burden of dual relationships of intercrew psychotherapy for the onboard physician, supporting overall crew health and harmony. AI therapeutic processes could further strengthen crew dynamics by recognizing overall crew patterns and moods, and by building coping strategies, teamwork, and conflict-resolution scenarios — all essential mission components that are served by good mental health. 

Given the importance of psychological health, informed consent, and crew harmony, NLP and DL can be ethically viable AI methodologies for deep space missions. To ensure astronaut autonomy and health while maintaining sensitivity to ethical responsibility in constrained environments, clear communication during pre-mission training about what astronauts can expect from these systems is recommended, alongside ground-based monitoring of the system’s efficacy when communication allows and with astronauts’ continuous consent.

While AI has been viewed with a critical or negative bias in academic philosophies of AI ethics, it can be accepted as beneficial within the practical contexts of human spaceflight if integrated with ethical caution, transparency, and operated within clearly defined limits. 

Olivia Bowers, MS, MBE, is the Managing Editor of Voices in Bioethics (Columbia University)

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