A blog from the Centre for Research Ethics & Bioethics (CRB)

Month: March 2024

The doubtful beginnings of philosophy

Philosophy begins with doubt, this has been emphasized by many philosophers. But what does it mean to doubt? To harbor suspicions? To criticize accepted beliefs? In that case, doubt is based on thinking we know better. We believe that we have good reason to doubt.

Is that doubting? Thinking that you know? It sounds paradoxical, but it is probably the most common form of doubt. We doubt, and think we can easily explain why. But this is hardly the doubt of philosophy. For in that case philosophy would not begin with doubt, but with belief or knowledge. If a philosopher doubts, and easily motivates the doubt, the philosopher will soon doubt her own motive for doubting. To doubt, as a philosopher doubts, is to doubt one’s own thought. It is to admit: I don’t know.

Perhaps I have already quoted Socrates’ famous self-description too many times, but there is a treasure buried in these simple words:

“when I don’t know things, I don’t think that I do either.”

The oracle at Delphi had said of Socrates that he was the wisest of all. Since Socrates did not consider himself more knowledgeable than others, he found the statement puzzling. What could the oracle mean? The self-description above was Socrates’ solution to the riddle. If I am wiser than others, he thought, then my wisdom cannot consist in knowing more than others, because I do not. But I have a peculiar trait, and that is that when I do not know, I do not think I know either. Everyone I question here in Athens, on the other hand, seems to have the default attitude that they know, even when I can demonstrate that they do not. Whatever I ask them, they think they know the answer! I am not like that. If I do not know, I do not react as if I knew either. Perhaps this was what the oracle meant by my superior wisdom?

So, what did Socrates’ wisdom consist in? In beginning with doubt. But must he not have had reason to doubt? Surely, he must have known something, some intuition at least, which gave him reason to doubt! Curiously, Socrates seems to have doubted without good reason. He said that he heard an inner voice urging him to stop and be silent, just as he was about to speak verbosely as if he knew something: Socrates’ demon. But how could an “inner voice” make Socrates wise? Is that not rather a sure sign of madness?

I do not think we should make too much of the fact that Socrates chose to describe the situation in terms of an inner voice. The important thing is that he does not react, when he does not know. Imagine someone who has become clearly aware of her own reflex to get angry. The moment she notices that she is about to get angry, she becomes completely calm instead. The drama is over before it begins. Likewise, Socrates became completely calm the moment he noted his own reflex to start talking as if he knew something. He was clearly aware of his own knowledge reflex.

What is the knowledge reflex? We have already felt its activity in the post. It struck us when we thought we knew that a wise person cannot doubt without reason. It almost drove us mad! If Socrates doubted, he must have had good reason! If an “inner voice” inspired doubt, it would not be wisdom, but a sure sign of madness! This is the knowledge reflex. To suddenly not be able to stop talking, as if we had particularly good reason to assert ourselves. Socrates never reacted that way. In those situations, he noted the knowledge reflex and immediately became perfectly calm.

The value of becoming completely calm just when the knowledge reflex wants to set us in motion is that it makes us free to examine ourselves. If we let the knowledge reflex drive our doubts – “this is highly dubious, because…” – we would not question ourselves, but assert ourselves. We would doubt the way we humans generally doubt, because we think we have reason to doubt. Of course, Socrates does not doubt arbitrarily, like a madman, but the source of his doubt becomes apparent only in retrospect. Philosophy is love for the clarity we lack when philosophizing begins. Without this loving attitude towards what we do not know, our collective human knowledge risks becoming a colossus on clay feet – is it already wobbly?

When the knowledge reflex no longer controls us, but is numbed by philosophical self-doubt, we are free to think independently and clearly. Therefore, philosophy begins with doubt and not with belief or knowledge.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Plato. “The Apology of Socrates.” In The Last Days of Socrates, translated by Christopher Rowe, 32-62. Penguin Books, 2010.

This post in Swedish

Thinking about thinking

Better evidence may solve a moral dilemma

More than 5 million women become pregnant in the EU every year and a majority take at least one medication during pregnancy. A problem today is that as few as 5% of available medications have been adequately monitored, tested and labelled with safety information for use in pregnant and breastfeeding women. The field is difficult to study and has suffered from a lack of systematically gathered insights that could lead to more effective data generation methodologies. Fragmentation and misinformation results in confusing and contradictory communication and perception of risks by both health professionals and women and their families. For the doctor who prescribes the medicine, a genuine moral dilemma arises. In order not to expose the child to risks, the lack of good scientific evidence in many cases means that, for precautionary reasons, the drug treatment is discontinued or the mother is advised not to breastfeed. At the same time, the mother benefits most from the prescribed medicine and we know that breastfeeding is good for both the newborn and the mother.

Within the project ConcePTION, several studies are underway to investigate the effect of drugs both during pregnancy and during breastfeeding. Based on the need to meet regulatory requirements, procedures have been established for breast milk collection, informed consent, shipping, storage and analysis of pharmacokinetic properties (how drugs are metabolized in the body). Five demonstration studies are conducted. The University of Oslo is doing such a study on a drug called Levocetirizine, the University Hospital of Toulouse is studying Amoxicillin and the University Hospital of Lausanne is studying the drug Venlafaxine.

In Sweden, in two demonstration studies, we will collect breast milk and blood samples from the mother and the child for two drugs: metformin, which is used in the treatment of type 2 diabetes and prednisolone, which is used in the treatment of for example rheumatoid arthritis. In both cases, there is limited data, which is partly old, from the 1970s, and partly analyzed with outdated methods. Both studies are approved by The Swedish Medical Product Authority (MPA) as low intervention clinical trials (see below). 

The studies are a collaboration between Uppsala University and several clinical centers: Sahlgrenska University Hospital/East in Gothenburg, Örebro University Hospital, Center for Clinical Children’s Studies, Astrid Lindgren Children’s Hospital in Stockholm, Södra Älvsborgs Hospital in Borås and Umeå University Hospital, with adjacent biobanks. Breast milk from the woman and blood samples from both woman and child will be transported to Uppsala Biobank for storage and analyzed with mass spectrometric methods at the Department of Pharmacy at Uppsala University. Informed consent is obtained both for the sampling and for the possibility of conducting future research on the stored samples. Collaborating biobanks are: Uppsala Biobank, Biobank West in Gothenburg, Örebro Biobank, Stockholm Medical Biobank and Biobank North in Umeå. 

Through these two studies, research biobanks with breast milk and associated blood samples are established for the first time in Sweden. In the long run, doctors and women who become pregnant can get better information for their recommendations and decisions regarding the use of medicines. 

ConcePTION is funded by the Innovative Medicines Initiative (IMI), which is a collaboration between the European Commission and the European Medicines Federation. 

Approvals by the Swedish Medical Product Authority (MPA): Dnr: 5.1.1-2023-090592 and 5.1.1-2023-104170.

Mats G. Hansson, photo by Mikael Wallerstedt

Written by…

Mats G. Hansson, senior professor of biomedical ethics at Uppsala University’s Centre for Research Ethics & Bioethics.

This post in Swedish

Part of international collaborations

Women on AI-assisted mammography

The use of AI tools in healthcare has become a recurring theme on this blog. So far, the posts have mainly been about mobile and online apps for use by patients and the general public. Today, the theme is more advanced AI tools which are used professionally by healthcare staff.

Within the Swedish program for breast cancer screening, radiologists interpret large amounts of X-ray images to detect breast cancer at an early stage. The workload is great and most of the time the images show no signs of cancer or pre-cancers. Today, AI tools are being tested that could improve mammography in several ways. AI could be used as an assisting resource for the radiologists to detect additional tumors. It could also be used as an independent reader of images to relieve radiologists, as well as to support assessments of which patients should receive care more immediately.

For AI-assisted mammography to work, not only the technology needs to be developed. Researchers also need to investigate how women think about AI-assisted mammography. How do they perceive AI-assisted breast cancer screening? Four researchers, including Jennifer Viberg Johansson and Åsa Grauman at CRB, interviewed sixteen women who underwent mammography at a Swedish hospital where an AI tool was tested as a third reviewer of the X-ray images, along with the two radiologists.

Several of the interviewees emphasized that AI is only a tool: AI cannot replace the doctor because humans have abilities beyond image recognition, such as intuition, empathy and holistic thinking. Another finding was that some of the interviewees had a greater tolerance for human error than if the AI tool failed, which was considered unacceptable. Some argued that if the AI tool makes a mistake, the mistake will be repeated systematically, while human errors are occasional. Some believed that the responsibility when the technology fails lies with the humans and not with the technology.

Personally, I cannot help but speculate that the sharp distinction between human error, which is easier to reconcile with, and unacceptably failing technology, is connected to the fact that we can say of humans who fail: “After all, the radiologists surely did their best.” On the other hand, we hardly say about failing AI: “After all, the technology surely did its best.” Technology does not become subject to certain forms of conciliatory considerations.

The authors themselves emphasize that the participants in the study saw AI as a valuable tool in mammography, but held that the tool cannot replace humans in the process. The authors also emphasize that the interviewees preferred that the AI tool identify possible tumors with high sensitivity, even if this leads to many false positive results and thus to unnecessary worry and fear. In order for patients to understand AI-assisted healthcare, effective communication efforts are required, the authors conclude.

It is difficult to summarize the rich material from interview studies. For more results, read the study here: Women’s perceptions and attitudes towards the use of AI in mammography in Sweden: a qualitative interview study.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Viberg Johansson J, Dembrower K, Strand F, et al. Women’s perceptions and attitudes towards the use of AI in mammography in Sweden: a qualitative interview study. BMJ Open 2024;14:e084014. doi: 10.1136/bmjopen-2024-084014

This post in Swedish

Approaching future issues

Mobile apps to check symptoms and get recommendations: what do users say?

What will you do if you feel sick or discover a rash and wonder what it is? Is it something serious? If you do not immediately contact healthcare, a common first step is to search for information on the internet. But there are also applications for mobiles and online, where users can check their symptoms. A chatbot asks for information about the symptoms. The user then receives a list of possible causes as well as a recommendation, for example to see a doctor.

Because the interaction with the chatbot can bring to mind a visit to the doctor who makes a diagnosis and recommends action, these apps raise questions that may have more to do with these tempting associations than with reality. Will the apps in the future make visiting the doctor redundant and lead to the devaluing of medical professions? Or will they, on the contrary, cause more visits to healthcare because the apps often make such recommendations? Do they contribute to better diagnostic processes with fewer misdiagnoses, or do they, on the contrary, interfere with the procedure of making a diagnosis?

The questions are important, provided they are grounded in reality. Are they? What do users really expect from these symptom checker apps? What are their experiences as users of such digital aids? There are hardly any studies on this yet. German researchers therefore conducted an interview study with participants who themselves used apps to check their symptoms. What did they say when they were interviewed?

The participants’ experiences were not unequivocal but highly variable and sometimes contradictory. But there was agreement on one important point. Participants trusted their own and the doctor’s judgments more than they trusted the app. Although opinions differed on whether the app could be said to provide “diagnoses,” and regardless of whether or not the recommendations were followed, the information provided by the app was considered to be indicative only, not authoritative. The fear that these apps would replace healthcare professionals and contribute to a devaluation of medical professions is therefore not supported in the study. The interviewees did not consider the apps as a substitute for consulting healthcare. Many saw them rather as decision support before possible medical consultation.

Some participants used the apps to prepare for medical appointments. Others used them afterwards to reflect on the outcome of the visit. However, most wanted more collaboration with healthcare professionals about using the apps, and some used the apps because healthcare professionals recommended them. This has an interesting connection to a Swedish study that I recently blogged about, where the participants were patients with rheumatoid arthritis. Some participants in that study had prepared their visits to the doctor very carefully by using a similar app, where they kept logbook of their symptoms. They felt all the more disappointed when they experienced that the doctor showed no interest in their observations. Maybe better planning and collaboration between patient and healthcare is needed regarding the use of similar apps?

Interview studies can provide valuable support for ethical reasoning. By giving us insights into a reality that we otherwise risk simplifying in our thinking, they help us ask better questions and discuss them in a more nuanced way. That the results are varied and sometimes even contradictory is therefore not a weakness. On the contrary, we get a more faithful picture of a whole spectrum of experiences, which do not always correspond to our usually more one-sided expectations. The participants in the German study did not discuss algorithmic bias, which is otherwise a common theme in the ethical debate about AI. However, some were concerned that they themselves might accidentally lead the app astray by giving biased input that expressed their own assumptions about the symptoms. Read the study here: “That’s just Future Medicine” – a qualitative study on users’ experiences of symptom checker apps.

Another unexpected result of the interview study was that several participants discussed using these symptom checker apps not only for themselves, but also for friends, partners, children and parents. They raised their concerns about this, as they perceived health information from family and friends as private. They were also concerned about the responsibility they assumed by communicating the analyzes and recommendations produced by the app to others. The authors argue that this unexpected finding raises new questions about responsibility and that the debate about digital aids related to health and care should be more attentive to relational ethical issues.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Müller, R., Klemmt, M., Koch, R. et al. “That’s just Future Medicine” – a qualitative study on users’ experiences of symptom checker apps. BMC Med Ethics 25, 17 (2024). https://doi.org/10.1186/s12910-024-01011-5

This post in Swedish

We recommend readings