Hasil untuk "Medical philosophy. Medical ethics"

Xinxin LU, Zhigang LI, Longwen FU

This study analyzes the dilemmas of end-of-life medical decision-making autonomy among Chinese patients through a "relation–power" framework. The root of these dilemmas lies in the disconnection between a rights-centered institutional design and relational medical practice. The challenges in implementing living wills illustrate how autonomy in end-of-life care is constrained within relational networks: the static nature of texts conflicts with the dynamic realities of clinical practice, and the realization of rights is affected by structural social barriers. A deeper issue is the power imbalance among the "physician–patient–family" triad, resulting in suspended patient wishes, pressured family decision-making, and physicians' risk-averse withdrawal. Addressing these issues requires moving beyond a purely rights-based approach by legislatively clarifying responsibilities, establishing shared decision-making mechanisms, and fostering a supportive social culture, thereby enhancing substantive autonomy through dynamic power coordination.

Editorial Neogranadina

Philip Kreniske, Holly Isenberg, Fred Nalugoda et al.

Abstract Background For research on sensitive topics like HIV, it is critical to understand the capacity of adolescents to provide informed consent, as parental consent has been identified as the greatest barrier to adolescent participation in biomedical research. In many countries including low-and middle-income countries, where 90% of adolescents live, adolescents can consent to sexual and reproductive healthcare but require parent/guardian permission to participate in research before age 18 – leading to adolescent underrepresentation and systematic exclusion from biomedical and behavioral studies. Among adults, research has identified effective biomedical HIV prevention tools such as pre-exposure prophylaxis (PrEP) that have successfully decreased HIV transmission. Youth in East and Southern Africa have the highest HIV incidence in the world, yet less than 1% of biomedical HIV prevention trials include minor adolescents. Thus, developmentally tailored HIV prevention and care research for adolescents and young adults is urgently needed. Methods Improving understanding of Capacity to consent to sensitive biomedical Research among adolescents in Rakai Uganda (ICARE) will leverage The Rakai Community Cohort Study (RCCS) to test adolescent capacity to consent to biomedical research, identify differences in developmental decision-making, characterize eligibility for, beliefs about and interest in oral and injectable pre-exposure prophylaxis (PrEP), and construct a digital toolkit for including adolescents in biomedical research. The RCCS presents a unique opportunity to compare cognitive capacity to consent for biomedical research among adolescents with and without prior research experience at three developmental stages – early (10–14 years), middle (15–17 years), and late (18–19 years) – with the cognitive capacity of their parents/guardians. Discussion Limited data are available on adolescents’ actual capacity to consent, particularly in low-and middle-income countries and low resource, high HIV prevalence settings. Findings will contribute to addressing a major barrier to research participation through an examination of the capacity of adolescents to comprehend risks, benefits, and the other elements of informed consent and, therefore, to provide informed consent to biomedical research. ICARE has the potential to offer guidance for ethical boards seeking to harmonize adolescent treatment and prevention with research procedures, thus addressing a major barrier to adolescent research participation.

Gaya Mehenni, Fabrice Lamarche, Odette Rios-Ibacache et al.

We present MedHal, a novel large-scale dataset specifically designed to evaluate if models can detect hallucinations in medical texts. Current hallucination detection methods face significant limitations when applied to specialized domains like medicine, where they can have disastrous consequences. Existing medical datasets are either too small, containing only a few hundred samples, or focus on a single task like Question Answering or Natural Language Inference. MedHal addresses these gaps by: (1) incorporating diverse medical text sources and tasks; (2) providing a substantial volume of annotated samples suitable for training medical hallucination detection models; and (3) including explanations for factual inconsistencies to guide model learning. We demonstrate MedHal's utility by training and evaluating a baseline medical hallucination detection model, showing improvements over general-purpose hallucination detection approaches. This resource enables more efficient evaluation of medical text generation systems while reducing reliance on costly expert review, potentially accelerating the development of medical AI research.

Jason Granstedt, Prabhat Kc, Rucha Deshpande et al.

Computer methods in medical devices are frequently imperfect and are known to produce errors in clinical or diagnostic tasks. However, when deep learning and data-based approaches yield output that exhibit errors, the devices are frequently said to hallucinate. Drawing from theoretical developments and empirical studies in multiple medical device areas, we introduce a practical and universal definition that denotes hallucinations as a type of error that is plausible and can be either impactful or benign to the task at hand. The definition aims at facilitating the evaluation of medical devices that suffer from hallucinations across product areas. Using examples from imaging and non-imaging applications, we explore how the proposed definition relates to evaluation methodologies and discuss existing approaches for minimizing the prevalence of hallucinations.

LASA Team, Weiwen Xu, Hou Pong Chan et al.

Multimodal Large Language Models (MLLMs) have demonstrated impressive capabilities in understanding common visual elements, largely due to their large-scale datasets and advanced training strategies. However, their effectiveness in medical applications remains limited due to the inherent discrepancies between data and tasks in medical scenarios and those in the general domain. Concretely, existing medical MLLMs face the following critical limitations: (1) limited coverage of medical knowledge beyond imaging, (2) heightened susceptibility to hallucinations due to suboptimal data curation processes, (3) lack of reasoning capabilities tailored for complex medical scenarios. To address these challenges, we first propose a comprehensive data curation procedure that (1) efficiently acquires rich medical knowledge data not only from medical imaging but also from extensive medical texts and general-domain data; and (2) synthesizes accurate medical captions, visual question answering (VQA), and reasoning samples. As a result, we build a multimodal dataset enriched with extensive medical knowledge. Building on the curated data, we introduce our medical-specialized MLLM: Lingshu. Lingshu undergoes multi-stage training to embed medical expertise and enhance its task-solving capabilities progressively. Besides, we preliminarily explore the potential of applying reinforcement learning with verifiable rewards paradigm to enhance Lingshu's medical reasoning ability. Additionally, we develop MedEvalKit, a unified evaluation framework that consolidates leading multimodal and textual medical benchmarks for standardized, fair, and efficient model assessment. We evaluate the performance of Lingshu on three fundamental medical tasks, multimodal QA, text-based QA, and medical report generation. The results show that Lingshu consistently outperforms the existing open-source multimodal models on most tasks ...

Henriette Bruun, Louise Milling, Daniel Wittrock et al.

Abstract Background Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. Methods We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. Results We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. Conclusion Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.

Laura del Carmen Rueda Castro

Resumen El equipo de formación en bioética de carreras sanitarias en la Universidad de O´Higgins, Chile, diseña sus cursos según las necesidades locales. Se realiza una investigación cualitativa tomando la cohorte de ingreso de 2018 cuyo propósito fue identificar las necesidades formativas en bioética de la comunidad local para el rediseño de los cursos. Los cursos impartidos en tres años consecutivos cambian el primer semestre del 2020 debido a la crisis sanitaria. Esta reflexión revisa si la participación, producción colectiva y cuestionamiento se conservan como logro de los propósitos formativos en los cursos impartidos presencial. Dada la contingencia y los resultados obtenidos, se modifica el programa y diseño presencial a uno virtual, puesto que se han conocido los requerimientos estudiantiles. De la experiencia docente sistematizada y presentada, se concluye que aún frente a la situación de contingencia sanitaria se alcanzan los objetivos para la formación en bioética.

Paul A. Lombardo

Photo ID 193201183 © Orathai Mayoeh| Dreamstime.com ABSTRACT A US Public Health Service study conducted after World War II led to a research scandal involving the intentional infection of 1300 Guatemalans with syphilis and other STIs. That news initially prompted an apology by President Obama to the President of Guatemala and an investigative report from the Presidential Commission for the Study of Bioethical Issues. Despite promises from the US Department of Health and Human Services to invest $1.8 million to “improve the treatment and prevention of HIV and other sexually transmitted diseases,” there is no record that such funding nor any money to compensate the families of people victimized in the research debacle has reached Guatemala. Litigation followed public disclosures. This article analyzes the litigation and explores the likelihood that this lawsuit may represent another episode in the re-victimization of people in Guatemala who still await redress for the wrongs done to their families more than 70 years ago. INTRODUCTION Nine years after its initial filing, In re Estate of Alvarez v. Rockefeller Foundation, the case to recover damages for the infamous World War II-era syphilis experiments that the US Public Health Service (PHS) conducted in Guatemala has been dismissed by Fourth Circuit Court of Appeals.[1] The plaintiffs sought compensation as victims and descendants of victims of studies in which approximately 1300 Guatemalans were intentionally infected with sexually transmitted infections (STIs), and more than 5000 individuals had biological samples taken without proper consent. After the court rejected claims in 2022 that Johns Hopkins University and Bristol-Meyers Squibb should be held liable for the Guatemala scandal, the Rockefeller Foundation was the only remaining defendant. The Foundation had a longstanding interest in research to find a cure for syphilis. Lawyers representing alleged victims in the Guatemala research claimed that responsibility should accrue to Rockefeller because Thomas Parran was on its board and Frederick Soper was its Associate Director and a board member. Both were intimately involved in the experiments. In this US case, plaintiffs claimed the court should assign responsibility and allow them to recover damages. Its conclusion makes it extremely unlikely that legal action will lead to compensation for those victims now or anytime in the future. The lawsuit described in this article raises the question of whether litigation is an effective avenue for addressing discoveries of historic injustices stemming from breaches of research ethics. Litigation may revictimize the very populations who endured harms during the original experiments. In this case, more than six decades after the studies themselves, and ten years after the details of those studies were publicly revealed, many of the people who became entangled in this litigation are arguably worse off as a result because they endured additional hardships during the litigation, their avenue to justice through the US courts is now foreclosed, and their credibility was called into question throughout the case. BACKGROUND The PHS/Guatemala experiments occurred between 1946-1948, and related studies continued into the 1950s. However, the entire research plan did not become publicly known until the 2010 publication of an historian’s analysis of an archival collection, and a subsequent bioethics commission report in 2011.[2] The PHS researchers who designed the Guatemala studies were attempting to hone methods of prophylaxis against STIs for members of the US military and hoped to take advantage of the then newly discovered power of penicillin as a cure for STIs. Led by John Cutler,[3] a team of PHS doctors collaborated with health professionals in Guatemala City to design a series of experiments that monitored sexual intimacy between prisoners and commercial sex workers who had been confirmed to be carrying an STI. The experiment then moved on to manually infecting prison inmates, psychiatric patients, and soldiers, with syphilis, gonorrhea, and chancroid. Between 1946 and 1953, PHS researchers also conducted serology studies on samples of blood and cerebrospinal fluid they had obtained via cervical and lumbar punctures on prisoners, orphans, school children, patients in a psychiatric hospital, and leprosy patients in Guatemala.[4]   The research was conducted without consent, without appropriate disclosures, and, in many cases, using the most vulnerable institutionalized populations. While formal standards of ethics for biomedical research later emerged in documents like the Belmont report and were adopted as part of US law, the consensus of scholars studying the Guatemala experiments is that they violated ethical standards at the time they were carried out, and the scientists and physicians who participated, well aware of their ethical toxicity, intentionally kept them hidden.[5] A few experts in the STI field knew the details of these experiments, but the US government deliberately concealed them from public view for more than sixty years. The public exposure of John Cutler’s papers clarified the scope of the studies, sometimes likened more to torture than medical experimentation, and placed the episode in Guatemala alongside the most infamous of research scandals.[6]  News of the scandal initially prompted an apology by President Obama to the President of Guatemala. Lawsuits followed. I.     Litigation Public exposé of the experiment’s details led to condemnation of the studies, which in turn prompted calls for legal action. The first lawsuit related to the PHS/Guatemala research, Garcia v. Sebelius, was a class action suit filed on behalf of victims against the US Government in 2011. A federal trial court called the Guatemala STI experiments a “deeply troubling chapter in our Nation’s history” but determined that the law shielded the government against such claims under the principle of sovereign immunity. The court declared itself “powerless to provide any redress…” and dismissed the suit in 2012.[7] In response, the US Department of Health and Human Services promised $1.8 million to “improve the treatment and prevention of HIV and other sexually transmitted diseases … in Guatemala and to further strengthen ethical training on human research protections.”[8] No commitments were made to the victims, and no compensation was delivered to them in Guatemala. Because the Garcia case ruled out a suit against the US government, in 2015, plaintiffs filed another class action lawsuit against Johns Hopkins University, the Rockefeller Foundation, and pharmaceutical manufacturer Bristol Myers Squibb, demanding $1 billion in damages. The suit claimed that Johns Hopkins had been the faculty home for many members of the National Institutes of Health (NIH) syphilis study section that recommended that a grant of financial support be approved to fund the Guatemala project.[9] Most prominent in this group of Hopkins faculty members was Joseph Earle Moore. He chaired the study section and almost every review committee for the NIH that reviewed the study. The Rockefeller Foundation’s board eventually included Thomas Parran, Surgeon General at the time of the experiments and Rockefeller employee Frederick Soper, both of whom held roles critical to the study.[10] The three companies that previously made up Bristol Meyers Squibb manufactured the penicillin used in the experiments to test levels of efficacious dose to cure syphilis.[11] The plaintiffs contended that the web of connections among these entities and the researchers who “helped design, support, develop, encourage, and finance, and participated in and benefitted from the Guatemala Experiments,” made all three entities liable for the damages to compensate Guatemalan research subjects and their descendants. From the initial filing of the suit in 2015 until eighteen months later, defense lawyers attempted to have the case dismissed, arguing that delays in filing a claim violated the statute of limitations and the speculative nature of plaintiff damages rendered them legally inadequate to provide a causal link to the original experiments. In late 2016, the plaintiffs amended their claims a third time to address these issues. At that point, the plaintiff class included more than 800 people made up of spouses, children, and other descendants of deceased individuals alleged to have been part of the intentional infection experiments. But the largest numbers of listed plaintiffs were school children whose blood had been drawn for serology experiments. While the Presidential Commission had found no evidence supporting this assertion, some of the plaintiffs also claimed to be direct victims of intentional infection experiments conducted at their schools. The court found no evidence that the Rockefeller Foundation controlled or directed either Parran’s involvement in approving the Guatemala project or Soper’s more thorough engagement with the research as a staff member at the Pan American Sanitary Bureau (PASB). The Court stated, “The connection between TRF’s [Rockefeller] interest in finding a cure for syphilis and the work that Dr. Soper did while at PASB is simply far too attenuated to establish an agency relationship...there is no indication that TRF had the ability to exercise control over Soper.”[12] In 2024, with Rockefeller as the only remaining defendant, the motion to dismiss the suit wasgranted. While the litigation was still active, lawyers deposed people in Guatemala who had been responsible for identifying the plaintiffs named in the lawsuit. By March 2019, it became clear that serious irregularities had occurred in recruiting those participants.  Fraudulent testimony and unethical behavior in recruiting sparked the defendants to move for sanctions against the plaintiffs’ attorneys.[13] II.     Fraudulent Testimony                a.     Serology Experiments in Port of San José One kind of experiment conducted in Guatemala included serology testing on blood samples taken from school children. Norma Alicia Lorenzo Lopez was a plaintiff in the lawsuit and former director of the school at the remote Pacific coast town of Puerto San Jose, an initial location for blood draws in school studies during the late 1940s. She signed a copy of a letter certifying that historical records and the testimony of former students verified that plaintiffs were enrolled in school at the time of the experiments. But Lopez eventually admitted under questioning that relevant records for the school were destroyed years ago in several floods and earthquakes. She had no documents to confirm that claimant’s testimony was correct, nor did she have any personal knowledge of what happened. She then testified that she had no legal authority to issue certifications on behalf of the school and had violated the rules of the Ministry of Education in so doing. Additionally, she admitted that at least one person was dead at the time he was supposed to have given his sworn statement to her.[14] Fraudulent testimony unfortunately was not limited to Lopez. Under questioning, many named plaintiffs testified that they did not know why their or their family members’ names had been included among the victims. Another witness, Dr. Orozco Aguirre, reported that he tested hundreds of people who had given blood as children in Puerto San Jose. Some of them were supposed to have also claimed to be infected with syphilis by researchers. But in a hearing before the presiding judge, lead plaintiffs’ counsel confirmed that Aguirre had given false testimony.[15] Aguirre eventually admitted that the effective date of the certificate presented to the court to show his qualifications to run a laboratory in Guatemala had been altered to conceal that it had expired. He also conceded under questioning that his expert report had been plagiarized, then altered to include data that would correspond with his planned testimony in support of the plaintiffs. As a result, plaintiffs’ counsel withdrew Dr. Orozco as an expert witness after his first day of testimony.                b.     STI Testing in Guatemala City Dr. Pablo Werner Ramirez Rivas, a physician consultant and medical expert for the plaintiffs, former Guatemalan Health Minister Roberto Paiz, and his wife Clara de Paiz had arranged “information sessions” to recruit plaintiffs. Werner’s testimony was intended to provide the factual foundation upon which several of the plaintiff’s claims were based. However, the day after Dr. Aguirre was withdrawn and only a few days before Dr. Werner was scheduled to testify, plaintiffs’ counsel also withdrew him as an expert. Additional reports emerged showing that Clara de Paiz was taken into custody in Guatemala in 2018, following charges by the International Commission Against Impunity in Guatemala with “active bribery” in connection with a scheme to influence the selection of Guatemalan judges in an unrelated case.[16] On March 11, 2019, the plaintiffs’ counsel disclosed that they were “going forward” with a more limited list of plaintiffs and claims. The number of Guatemalan plaintiffs was reduced dramatically; fewer than one hundred remained in the lawsuit. Thirteen of the most important eighteen plaintiffs—those who claimed direct infection in the original experiments or a family relationship to someone who was involved in those experiments — were dropped from the case. III.     Sanctions Against Plaintiffs’ Lawyers After extensive discovery, the defendants’ lawyers made a motion for sanctions against the plaintiffs’ lawyers. According to the defendants, depositions and other material “revealed that plaintiffs' claims are based on manufactured evidence, false sworn statements, and unsupportable allegations.”[17] The defendants accused the plaintiffs’ lawyers of doing just what the initial alleged wrongdoers did – withholding positive test results from plaintiffs. It was a major contention of the lawsuit that those who directed the PHS/Guatemala experiments actively deceived the victims. They did not inform victims in the 1940s that they were part of an experiment, that they had been infected with syphilis, or that their condition might expose other family members to infection. Nor did they provide medical care to infected victims or counsel them to seek it. In preparing for the lawsuit, plaintiffs were sent on bus trips lasting up to five hours to reach Guatemala City for syphilis testing. Although Dr. Aguirre claimed in sworn court documents that many of the plaintiffs tested positive for syphilis, their testimony indicated they were not informed of their infection status, nor was treatment offered to those who did test positive. Defendant’s arguments for sanctions declared that by withholding infection status from plaintiffs, their lawyers “did precisely what they had accused others of doing or, more precisely, of not doing.”[18] IV.     Unsatisfactory Outcome The original complaint in this case alleged that defendants, Johns Hopkins University, the Rockefeller Foundation, and Bristol Meyers Squibb, had “designed, developed, approved, encouraged, directed, oversaw, and aided and abetted nonconsensual, nontherapeutic, human subject experiments in Guatemala.”[19] But the trial court found that there was “insufficient evidence to support” that conclusion against any of the three defendant organizations. The defendants did not downplay the horrific nature of the PHS/Guatemala syphilis studies, nor the culpability of those who conducted them. They merely rejected the idea that they, as institutions, shared blame for the activities that the government planned, conducted, and subsequently hid from the public eye. In issuing its ruling, the court endorsed that conclusion, stating that any evidence of the defendant’s complicity in these actions “has been lost to the sands of time.”[20]  The court emphasized that this result “illustrates the limits of the court system to provide justice for every injustice,” concluding that other remedies were “beyond the power of this Court to grant.”[21] The final decision in this controversy yielded similar language. In a separate opinion, 4th Circuit Court of Appeals Judge J. Harvie Wilkinson said that people working with the Rockefeller Foundation had a relationship that “is too attenuated” to consider them agents of Rockefeller in carrying out the Guatemala experiments. “I thus concur . . . with some sadness” he said, “that the rule of law is not advanced as an instrument of justice by affixing liability where it does not belong.”[22] CONCLUSION We are left with an unsatisfactory ending to a scandal that festered over more than seventy-five years and legal drama unfolding over more than a decade. An appellate court decision now echoes what scholars and a presidential commission concluded as legal challenges began: “It was our own government . . . that was the driving force behind these monstrous wrongs.”[23] Fashioning remedies for the horrors of this and other scandals that may yet be uncovered in the archives of scientific and biomedical research remains a job that our own government should still be required to undertake.   When hidden scandals perpetrated by deceased individuals in government service are finally revealed, how should accountability be satisfied?  We know that suits against the government are exceedingly unlikely to be allowed. As this case has demonstrated, assessing damages against other institutions whose culpability cannot be proven is also likely to fail.  First steps taken by government commissions of inquiry that are free to investigate past wrongs and expose them to public scrutiny are a beginning, but never the end of the accounting. They allow some measure of recognition for victims, but those who are long dead can never be made whole.  As the 4th Circuit Court concluded, the judiciary is limited in its powers “to provide justice for every injustice.” What is needed beyond all else is a motive for a majority in Congress squarely to face scandals like those that occurred in Guatemala and craft a remedy that more fully addresses their causes and their consequences.  At this point, we have few, if any, models of what such remedies would look like, and almost no reason to believe that there is the political will to take on that task.  - [1] In re Estate of Alvarez v. Rockefeller Foundation, No. 22-1678, (4th Cir. 2024) March 20, 2024. https://caselaw.findlaw.com/court/us-4th-circuit/115960805.html [2] Reverby, S. “‘Normal exposure” and inoculation syphilis: a PHS ‘Tuskegee’ doctor in Guatemala, 1946–1948.” J Policy Hist 23, no. 1 (2011):6-28 [DOI: https://doi.org/10.1017/S0898030610000291]; Presidential Commission for the Study of Bioethical Issues (PCSBI), “Ethically Impossible”: STD Research in Guatemala from 1946 to 1948 (Washington, D.C.: Government Printing Office; 2011). https://bioethicsarchive.georgetown.edu/pcsbi/sites/default/files/Ethically%20Impossible%20(with%20linked%20historical%20documents)%202.7.13.pdf  The author was a senior advisor to the Presidential Commission for the Study of Bioethical Issues that issued Ethically Impossible, and he contributed to the research and drafting of the Report as a staff member. He testified by deposition under subpoena and without compensation in the lawsuit described in this article. [3] Cutler [1915-2003] also conducted the Tuskegee syphilis experiments, which included Black American research subjects who were intentionally not informed about the nature of the experiment or the availability of treatment. [4] Spector-Bagdady K, Lombardo P.A. “US Public Health Service STD Experiments in Guatemala (1946-1948) and Their Aftermath,” Ethics Hum Res. 2019;41(2):29-34. [DOI: 10.1002/eahr.500010] [5] See “The Guatemala Experiments—Looking Back, Looking Ahead, and Apportioning Blame,” Presidential Commission for the Study of Bioethical Issues, “Ethically Impossible:” STD Research in Guatemala from 1946 to 1948, 2011, GPO (Washington DC)107-108. [6] Presidential Commission for the Study of Bioethical Issues, “Ethically Impossible:” STD Research in Guatemala from 1946 to 1948, 2011, GPO (Washington DC)., https://bioethicsarchive.georgetown.edu/pcsbi/sites/default/files/Ethically%20Impossible%20(with%20linked%20historical%20documents)%202.7.13.pdf H. Brevy Cannon, “Arras, Bioethics Commission Condemn 1940s Guatemalan Syphilis Research as Unethical,” UVA Today, August 31, 2011, https://news.virginia.edu/content/arras-bioethics-commission-condemn-1940s-guatemalan-syphilis-research-unethical. [7] Garcia v. Sebelius, 867 F. Supp. 2d 125 (D.D.C. 2012). https://casetext.com/case/garcia-v-sebelius-2 [8] “HHS Commits Nearly $1.8 million to Health Initiatives in Guatemala and to Improving Global Human Research Protections,” Business Wire, January 10, 2012, [9] Alvarez v. Hopkins, complaint, Case 1:15-cv-00950-JKB Circuit Court Baltimore City (April 1, 2015). Spector-Bagdady K, Lombardo P.A. “’Something of an adventure’: postwar NIH research ethos and the Guatemala STD experiments,” J Law Med Ethics. 2013;41(3):697-710. [DOI: 10.1111/jlme.12080] [10] Thomas Parran [1892-1968] was Surgeon General of the US Public Health Service and approved the funding proposal that resulted in the experiments. He was also a member of the Rockefeller Foundation’s Board of Trustees and the Board of Scientific Directors of the foundation’s International Heath Division.  At times his government service and his work at Rockefeller overlapped the work that occurred in Guatemala. Frederick Soper [1893-1977] was an Associate Director at Rockefeller and in 1947 was assigned to work on the Guatemala experiments at the Pan American Sanitary Bureau (PASB). [11] Alvarez v. Hopkins, complaint, Case 1:15-cv-00950-JKB Circuit Court Baltimore City (April 1, 2015). The original complaint filed in the Circuit Court for Baltimore City, was moved to the United States District Court for the District of Maryland. [12]  In re Estate of Alvarez v. Rockefeller Foundation, No. 22-1678, (4th Cir. 2024) March 20, 2024. p. 15. [13] Defendant’s Opening Brief in Support of Request for Discovery and Motion for Sanctions, Case No. 1:15-cv-950 TDC, Document 262-1 Filed 04/09/19. [14]  Transcript of Norma Alicia Lorenzo Conducted on February 7, 2019, Case 1:15-cv-00950-TDC Document 263-5. [15] Preliminary Transcript of Hearing, Case 1:15-cv-00950-TDC Document 231-1 March 6, 2019., p. 3. [16]Defendant’s Opening Brief in Support of Request for Discovery and Motion for Sanctions, Case No. 1:15-cv-950 TDC, Document 262-1 Filed 04/09/19. Exhibit 8, at J.R.0778 (December 4, 2018, Exhibit 8 at J.R.0775 (record from Guatemala Central Registry of Detainees indicating when Clara de Paiz was taken into custody). She  was later acquitted of the bribery charges. [17] Estate of Arturo Giron Alvarez, et al., v. The Johns Hopkins University, et al., Defendant’s.Motion for Discovery and Sanctions, April 9, 2019; Memorandum Opinion https://law.justia.com/cases/federal/district-courts/maryland/mddce/1:2015cv00950/312057/350/ [18] Defendant’s Opening Brief in Support of Request for Discovery and Motion for Sanctions, Case No. 1:15-cv-950 TDC, Document 262-1 Filed 04/09/19. Case 1:15-cv-00950-TDC   Document 262-1. April 9, 2019, page 24 of 42. The motion for sanctions was not renewed after the case was dismissed. [19] Memorandum Opinion on Motion for Summary Judgment, Case 1:15-cv-00950-TDC Document 480, page 13 of 77. [20] Id., page 75 of 77 [21] Id., Page 76 of 77 [22] In re Estate of Alvarez v. Rockefeller Foundation, No. 22-1678, (4th Cir. 2024) March 20, 2024, Wilkinson, J., concurring at 20. [23] Id.

Yuxuan Zhou, Xien Liu, Chen Ning et al.

Large language models (LLMs) have excelled across domains, also delivering notable performance on the medical evaluation benchmarks, such as MedQA. However, there still exists a significant gap between the reported performance and the practical effectiveness in real-world medical scenarios. In this paper, we aim to explore the causes of this gap by employing a multifaceted examination schema to systematically probe the actual mastery of medical knowledge by current LLMs. Specifically, we develop a novel evaluation framework MultifacetEval to examine the degree and coverage of LLMs in encoding and mastering medical knowledge at multiple facets (comparison, rectification, discrimination, and verification) concurrently. Based on the MultifacetEval framework, we construct two multifaceted evaluation datasets: MultiDiseK (by producing questions from a clinical disease knowledge base) and MultiMedQA (by rephrasing each question from a medical benchmark MedQA into multifaceted questions). The experimental results on these multifaceted datasets demonstrate that the extent of current LLMs in mastering medical knowledge is far below their performance on existing medical benchmarks, suggesting that they lack depth, precision, and comprehensiveness in mastering medical knowledge. Consequently, current LLMs are not yet ready for application in real-world medical tasks. The codes and datasets are available at https://github.com/THUMLP/MultifacetEval.

Lim Zheng Jie, Kian Meng Yap

Traditional medical training faces challenges like ethical concerns, safety risks, and high costs. VR technology offers a promising solution but is limited by low complexity and lack of tactile feedback. This paper presents a cost-effective haptic VR surgery simulation which simulates realistic Kidney Transplant using commercial devices to enhance training authenticity and immersion. Trainees can conduct incision and anastomosis procedures using a haptic stylus device that provides tactile sensations. Results from the test with medical participants showed that haptic feedback positively enhances the VR medical training experience.

Yuan Tian, Shuo Wang, Guangtao Zhai

Face de-identification (DeID) has been widely studied for common scenes, but remains under-researched for medical scenes, mostly due to the lack of large-scale patient face datasets. In this paper, we release MeMa, consisting of over 40,000 photo-realistic patient faces. MeMa is re-generated from massive real patient photos. By carefully modulating the generation and data-filtering procedures, MeMa avoids breaching real patient privacy, while ensuring rich and plausible medical manifestations. We recruit expert clinicians to annotate MeMa with both coarse- and fine-grained labels, building the first medical-scene DeID benchmark. Additionally, we propose a baseline approach for this new medical-aware DeID task, by integrating data-driven medical semantic priors into the DeID procedure. Despite its conciseness and simplicity, our approach substantially outperforms previous ones. Dataset is available at https://github.com/tianyuan168326/MeMa-Pytorch.

Givon Zirkind

Medical imaging has kept up with the digital age. Medical images such as x-rays are no longer keep on film or; even made with film. Rather, they are digital. In addition, they are transmitted for reasons of consultation and telehealth as well as archived. Transmission and retrieval of these images presents an integrity issue, with a high level of integrity being needed. Very small artifacts in a digital medical image can have significant importance, making or changing a diagnosis. It is imperative that the integrity of a medical image, especially in a Region of Interest be identifiable and preserved. Watermarking and steganography are used for the purposes of authenticating images, especially for copyright purposes. These techniques can be applied to medical images. However, these techniques can interfere with the integrity of the picture. While such distortion may be acceptable in other domains, in the medical domain this distortion is not acceptable. High accuracy is imperative for diagnosis. This paper discusses the techniques used, their advantages and shortcomings as well as methods of overcoming obstacles to integrity.

Jiageng Wu, Xian Wu, Yefeng Zheng et al.

With appropriate data selection and training techniques, Large Language Models (LLMs) have demonstrated exceptional success in various medical examinations and multiple-choice questions. However, the application of LLMs in medical dialogue generation-a task more closely aligned with actual medical practice-has been less explored. This gap is attributed to the insufficient medical knowledge of LLMs, which leads to inaccuracies and hallucinated information in the generated medical responses. In this work, we introduce the Medical dialogue with Knowledge enhancement and clinical Pathway encoding (MedKP) framework, which integrates an external knowledge enhancement module through a medical knowledge graph and an internal clinical pathway encoding via medical entities and physician actions. Evaluated with comprehensive metrics, our experiments on two large-scale, real-world online medical consultation datasets (MedDG and KaMed) demonstrate that MedKP surpasses multiple baselines and mitigates the incidence of hallucinations, achieving a new state-of-the-art. Extensive ablation studies further reveal the effectiveness of each component of MedKP. This enhancement advances the development of reliable, automated medical consultation responses using LLMs, thereby broadening the potential accessibility of precise and real-time medical assistance.

Syed Javed, Tariq M. Khan, Abdul Qayyum et al.

Accurate segmentation of anatomical structures and abnormalities in medical images is crucial for computer-aided diagnosis and analysis. While deep learning techniques excel at this task, their computational demands pose challenges. Additionally, some cutting-edge segmentation methods, though effective for general object segmentation, may not be optimised for medical images. To address these issues, we propose Mini-Net, a lightweight segmentation network specifically designed for medical images. With fewer than 38,000 parameters, Mini-Net efficiently captures both high- and low-frequency features, enabling real-time applications in various medical imaging scenarios. We evaluate Mini-Net on various datasets, including DRIVE, STARE, ISIC-2016, ISIC-2018, and MoNuSeg, demonstrating its robustness and good performance compared to state-of-the-art methods.

Alvaro Angelo Salles, Luana Castelo

Resumo Este estudo revisa a caracterização dos princípios da privacidade e da confidencialidade em conexão com áreas da medicina em geral e da saúde mental em especial, propondo que a prática dos direitos e deveres envolvidos com os dois princípios deve ser preservada nos moldes ditados pela bioética. Privilegia-se a abordagem do saber psíquico, a fim de ampliar a compreensão da particular importância da confidencialidade nos processos terapêuticos. Salienta-se a conexão entre as mudanças tecnológicas e midiáticas ocorridas nas últimas décadas e o risco de comprometimento do sigilo médico, cuja quebra afetaria em definitivo a confiança do paciente quanto ao resguardo da privacidade de suas informações. Ao final, são feitas reflexões sobre o valor do suporte ético ao profissional de saúde, principalmente nos casos excepcionais em que lhe cabe tomar decisões sobre quebra de confidencialidade.

Jiawei Mao, Shujian Guo, Yuanqi Chang et al.

Masked autoencoders (MAEs) have displayed significant potential in the classification and semantic segmentation of medical images in the last year. Due to the high similarity of human tissues, even slight changes in medical images may represent diseased tissues, necessitating fine-grained inspection to pinpoint diseased tissues. The random masking strategy of MAEs is likely to result in areas of lesions being overlooked by the model. At the same time, inconsistencies between the pre-training and fine-tuning phases impede the performance and efficiency of MAE in medical image classification. To address these issues, we propose a medical supervised masked autoencoder (MSMAE) in this paper. In the pre-training phase, MSMAE precisely masks medical images via the attention maps obtained from supervised training, contributing to the representation learning of human tissue in the lesion area. During the fine-tuning phase, MSMAE is also driven by attention to the accurate masking of medical images. This improves the computational efficiency of the MSMAE while increasing the difficulty of fine-tuning, which indirectly improves the quality of MSMAE medical diagnosis. Extensive experiments demonstrate that MSMAE achieves state-of-the-art performance in case with three official medical datasets for various diseases. Meanwhile, transfer learning for MSMAE also demonstrates the great potential of our approach for medical semantic segmentation tasks. Moreover, the MSMAE accelerates the inference time in the fine-tuning phase by 11.2% and reduces the number of floating-point operations (FLOPs) by 74.08% compared to a traditional MAE.

Nan Zhang, Yusen Zhang, Wu Guo et al.

Summaries of medical text shall be faithful by being consistent and factual with source inputs, which is an important but understudied topic for safety and efficiency in healthcare. In this paper, we investigate and improve faithfulness in summarization on a broad range of medical summarization tasks. Our investigation reveals that current summarization models often produce unfaithful outputs for medical input text. We then introduce FaMeSumm, a framework to improve faithfulness by fine-tuning pre-trained language models based on medical knowledge. FaMeSumm performs contrastive learning on designed sets of faithful and unfaithful summaries, and it incorporates medical terms and their contexts to encourage faithful generation of medical terms. We conduct comprehensive experiments on three datasets in two languages: health question and radiology report summarization datasets in English, and a patient-doctor dialogue dataset in Chinese. Results demonstrate that FaMeSumm is flexible and effective by delivering consistent improvements over mainstream language models such as BART, T5, mT5, and PEGASUS, yielding state-of-the-art performances on metrics for faithfulness and general quality. Human evaluation by doctors also shows that FaMeSumm generates more faithful outputs. Our code is available at https://github.com/psunlpgroup/FaMeSumm .

Bohao Yang, Chen Tang, Chenghua Lin

Medical Dialogue Generation serves a critical role in telemedicine by facilitating the dissemination of medical expertise to patients. Existing studies focus on incorporating textual representations, which have limited their ability to represent the semantics of text, such as ignoring important medical entities. To enhance the model's understanding of the textual semantics and the medical knowledge including entities and relations, we introduce the use of Abstract Meaning Representations (AMR) to construct graphical representations that delineate the roles of language constituents and medical entities within the dialogues. In this paper, We propose a novel framework that models dialogues between patients and healthcare professionals using AMR graphs, where the neural networks incorporate textual and graphical knowledge with a dual attention mechanism. Experimental results show that our framework outperforms strong baseline models in medical dialogue generation, demonstrating the effectiveness of AMR graphs in enhancing the representations of medical knowledge and logical relationships. Furthermore, to support future research in this domain, we provide the corresponding source code at https://github.com/Bernard-Yang/MedDiaAMR.

Yongshuo Zong, Yongxin Yang, Timothy Hospedales

A multitude of work has shown that machine learning-based medical diagnosis systems can be biased against certain subgroups of people. This has motivated a growing number of bias mitigation algorithms that aim to address fairness issues in machine learning. However, it is difficult to compare their effectiveness in medical imaging for two reasons. First, there is little consensus on the criteria to assess fairness. Second, existing bias mitigation algorithms are developed under different settings, e.g., datasets, model selection strategies, backbones, and fairness metrics, making a direct comparison and evaluation based on existing results impossible. In this work, we introduce MEDFAIR, a framework to benchmark the fairness of machine learning models for medical imaging. MEDFAIR covers eleven algorithms from various categories, nine datasets from different imaging modalities, and three model selection criteria. Through extensive experiments, we find that the under-studied issue of model selection criterion can have a significant impact on fairness outcomes; while in contrast, state-of-the-art bias mitigation algorithms do not significantly improve fairness outcomes over empirical risk minimization (ERM) in both in-distribution and out-of-distribution settings. We evaluate fairness from various perspectives and make recommendations for different medical application scenarios that require different ethical principles. Our framework provides a reproducible and easy-to-use entry point for the development and evaluation of future bias mitigation algorithms in deep learning. Code is available at https://github.com/ys-zong/MEDFAIR.