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AI-Assisted Consent in Paediatric Medicine: Ethical Implications of Using Large Language Models to Support Decision-Making
Obtaining informed consent in paediatrics is an essential yet ethically complex aspect of clinical practice. Children have varying levels of autonomy and understanding based on their age and developmental maturity, with parents traditionally playing a central role in decision-making. However, there is increasing recognition of children’s evolving capacities and their right to be involved in care decisions, raising questions about facilitating meaningful consent, or at least assent, in complex medical situations. Large language models (LLMs) may offer a partial solution to these challenges. These generative AI systems can provide interactive, age-appropriate explanations of medical procedures, risks, and outcomes tailored to each child’s comprehension level. LLMs could be designed to adapt their responses to young patients’ cognitive and emotional needs while supporting parents with clear, accessible medical information. This paper examines the ethical implications of using LLMs in paediatric consent, focusing on balancing autonomy promotion with protecting children’s best interests. We explore how LLMs could be used to empower children to express preferences, mediate family disputes, and facilitate informed consent. However, important concerns arise: Can LLMs adequately support developing autonomy? Might they exert undue influence or worsen conflicts between family members and healthcare providers? We conclude that while LLMs could enhance paediatric consent processes with appropriate safeguards and careful integration into clinical practice, their implementation must be approached cautiously. These systems should complement rather than replace the essential human elements of empathy, judgment, and trust in paediatric consent.
The heart of palliative care is relational: a scoping review of the ethics of care in palliative medicine.
BACKGROUND: Palliative care, perhaps more than any subspecialty in healthcare, is deeply relational and engages patients and families at times of great vulnerability. Ethics of care, or relational ethics, developed through contributions from feminist ethics, offers conceptual tools and ways of thinking that seem especially suited to palliative care practice. AIM: To identify and describe studies and theoretical analyses applying the ethics of care to palliative care (both adult and paediatric), specifically, its use to guide and improve practice and education for palliative care practitioners. DESIGN: We conducted a scoping review of six databases covering clinical, social science and normative ethics scholarship and conducted a thematic analysis of the findings and ethical discussions or arguments. DATA SOURCES: Databases searched included PubMed, CINAHL, PsychINFO, EMBASE, Web of Science and Philosopher's Index from 1982 to November 2024. RESULTS: 30 publications meeting our inclusion criteria were identified. Major themes reflected the relational obligations, attributes and character traits ideally developed in palliative care providers in their work and relationships with patients and families, including responsiveness, connectedness and hope, as well as in caring for ourselves and each other on palliative care teams. An emerging literature recognises the special guidance for palliative care for children. CONCLUSIONS: Clinical and ethical scholarship in palliative care reveals a valuable but still underexplored connection between the ethical commitments within the ethics of care tradition and palliative care training and practice. Ethics of care addresses important gaps in training, particularly having to do with practitioners' relationships and ways of being with patients, families, colleagues and themselves.
Implied consent for HIV testing in the UK: time for a new approach?
Despite HIV infection being a treatable chronic illness and the many advances in testing for HIV, late diagnosis is still common, with associated avoidable morbidity and mortality. Requirements for explicit consent for HIV testing in the UK differ from those for other blood tests and are major barriers to testing. We argue that the disparity is illogical and outdated. We propose a model for normalising HIV testing that allows for routine testing in various health-care settings via implied consent, where other blood tests are performed. Inclusion of testing for hepatitis B and hepatitis C might also be incorporated into this model. The ethical argument for this approach is principally beneficence towards people with undiagnosed infection and the people they might infect. Patient autonomy would be maintained using systems allowing for individuals to opt out of implied consent.
Linking microscopy to diffusion MRI with degenerate biophysical models: an application of the Bayesian EstimatioN of CHange (BENCH) framework
Abstract Biophysical modelling of diffusion MRI (dMRI) is used to non-invasively estimate microstructural features of tissue, particularly in the brain. However, meaningful description of tissue requires many unknown parameters, resulting in a model that is often ill-posed. The Bayesian EstimatioN of CHange (BENCH) framework was specifically designed to circumvent parameter fitting for ill-conditioned models when one is simply interested in interpreting signal changes related to some variable of interest. To understand the biological underpinning of some observed change in MR signal between different conditions, BENCH predicts which model parameter, or combination of parameters, best explains the observed change, without having to invert the model. BENCH has been previously used to identify which biophysical parameters could explain group-wise dMRI signal differences (e.g. patients vs. controls); here, we adapt BENCH to interpret dMRI signal changes related to continuous variables. We investigate how parameters from the dMRI standard model of white matter, with an additional sphere compartment to represent glial cell bodies, relate to tissue microstructure quantified from histology. We validate BENCH using synthetic dMRI data from numerical simulations. We then apply it to ex-vivo macaque brain data with dMRI and microscopy metrics of glial density, axonal density, and axonal dispersion in the same brain. We found that (i) increases in myelin density are primarily associated with an increased intra-axonal volume fraction and (ii) changes in the orientation dispersion derived from myelin microscopy are linked to variations in the orientation dispersion index. Finally, we found that the dMRI signal is sensitive to changes in glial cell load in the brain white matter, though no single parameter in the extended standard model was able to explain this observed signal change.
Apnoea suppresses brain activity in infants
Apnoea—the cessation of breathing—is commonly observed in premature infants. These events can reduce cerebral oxygenation and are associated with poorer neurodevelopmental outcomes. However, relatively little is known about how apnoea and shorter pauses in breathing impact brain function in infants, which will provide greater mechanistic understanding of how apnoea affects brain development. We analysed simultaneous recordings of respiration, electroencephalography (EEG), heart rate, and peripheral oxygen saturation in 124 recordings from 118 infants (post-menstrual age: 38.6 ± 2.7 weeks [mean ± standard deviation]) during apnoeas (pauses in breathing greater than 15 seconds) and shorter breathing pauses between 5 and 15 seconds. EEG amplitude significantly decreased during both apnoeas and short breathing pauses compared with normal breathing periods. Change in EEG amplitude was significantly associated with change in heart rate during apnoea and short breathing pauses and, during apnoeas only, with oxygen saturation change. No associations were found between EEG amplitude changes and apnoea/pause duration, post-menstrual age, or sleep state. As apnoeas often occur in premature infants, frequent disruption to brain activity may impact neural development and result in long-term neurodevelopmental consequences.
Simulated kangaroo care in very preterm infants does not reduce physiological instability: the COSYBABY randomised controlled cross-over trial.
INTRODUCTION: Infants who are born very preterm experience frequent episodes of physiological instability including apnoea, oxygen desaturation and bradycardia due to immaturity of the pulmonary and nervous systems. Parental contact, such as kangaroo care, may reduce physiological instability. However, there may be long periods when parents cannot be with their baby. The BABYBE SYSTEM® is a medical device designed to simulate kangaroo care. METHODS: We conducted a randomised cross-over trial to determine whether episodes of apnoea and other episodes of physiological instability were reduced when infants were on an active BABYBE mattress. Each infant was included in the study for five consecutive days, with successive 12-h periods of the BABYBE® mattress being switched on or off. Episodes of physiological instability were identified from recordings of the vital signs monitors and compared with clinical notes. Generalised estimating equations models were used to compare physiological instability when the BABYBE mattress was switched on vs. off. RESULTS: A total of 23 infants born before 32 weeks' gestation were included in the main analysis. There was no significant difference between the number of apnoeic episodes infants experienced in the 12-h period when the BABYBE mattress was on compared with when the mattress was switched off (difference between conditions = 1.5 apnoeas, 95% CI: -0.2-3.2, p = 0.09). The number of episodes of apnoea identified from vital signs recordings were much higher than those documented in the clinical records (a total of 1,157 apnoeic episodes were identified across all infants from vital signs recordings compared with a total of 27 documented in clinical/nursing notes of the same infants). DISCUSSION: This trial does not provide evidence of a benefit of the BABYBE mattress for improving physiological stability in preterm infants. This study provides confirmation of the under-recognition of apnoeic episodes in clinical notes and the benefit of assessing electronic recordings of vital signs to gain a more complete picture of physiological stability.
Pain in women: bridging the gender pain gap.
Bridging the gender pain gap requires collaborative efforts that address female-specific biological and psychosocial dimensions of pain through evidence-based, compassionate and empathy-driven approaches.
Pain management in preterm infants with necrotizing enterocolitis: an international expert consensus statement
Abstract Necrotizing enterocolitis (NEC) is probably the most painful intestinal disease affecting infants born preterm. NEC is known to cause highly severe and prolonged pain that has been associated with adverse short- and long-term effects. However, research on pain management in infants with NEC is scarce. This is likely due to its low incidence and very acute occurrence. As a result, the optimal pain management for these vulnerable infants remains unknown, and analgesic therapy practices are highly variable. Therefore, we aimed to establish expert-based consensus recommendations on pain management for NEC. Experts of the European Society for Paediatric Research (ESPR) Special Interest Groups on Neonatal pain and NEC were invited to participate in two consensus meetings. Prior to the first hybrid consensus meeting, an online survey provided input for potential recommendations. During the consensus meetings, experts shared clinical expertise and voted on recommendations. An expert consensus statement, comprising nine recommendations on optimal pain assessment and pain treatment in infants with NEC, was developed. Expert recommendations included regular pain assessments with a neonatal pain scale with additional assessments on indication and pre-emptive administration of analgesic therapy (e.g., paracetamol and an opioid) in infants with NEC stage ≥ II. Conclusion: This expert consensus statement provides clinical recommendations essential for any healthcare professional caring for premature infants with NEC. The recommended guidance this statement provides on pain management strategies is key to preventing and reducing pain in this vulnerable population. What is Known: • Necrotizing enterocolitis (NEC) is a very painful disease, making effective pain management essential.• Current pain management practices for infants with NEC are highly variable. What is New: • This expert consensus statement provides recommendations on optimal pain assessment and pain treatment in infants with NEC.• These clinical recommendations may help better prevent pain in these vulnerable infants.
Pandemic Ethics From COVID-19 to Disease X
From COVID-19 to Disease X Dominic Wilkinson, Julian Savulescu. Dunham , A. , Rieder , T. , and Hymbryd , C. ( 2020 ) , A bioethical perspective for navigating moral dilemmas amidst the COVID - 19 pandemic , Journal of the American ...
How to Peer Review a Systematic Review: A Peer-Reviewer's Guide to Reviewing Reviews
Systematic reviews hold significant academic weight, but poor execution can render them misleading and unreliable. To help improve the quality of systematic reviews, the peer review process plays a crucial role. Peer reviewing systematic reviews requires a distinct skill set compared to reviewing primary research studies. Systematic reviews differ in their methodology and reporting standards, necessitating a structured approach to evaluation. This commentary offers guidance on best practice when peer reviewing systematic reviews, with an emphasis on synthesis of quantitative data from clinical trials. In this article, nine key topics are covered, namely correct classification of review type, adherence to systematic methods, pre-registration, methodological and reporting quality, search strategy evaluation, risk of bias assessment, evidence synthesis methods, data and code availability, and use of standardized assessment tools. By helping to ensure best practice is followed for each of these topics, peer reviewers can play a crucial role in upholding the methodological integrity of systematic reviews, ensuring they contribute reliable and meaningful evidence to the scientific literature.