• Evidence Level and Presentation to Patients

• Ethical Imperative of Transparent Communication: While accuracy is essential, the manner in which information is conveyed to patients is equally critical. It is an ethical imperative to ensure that information, especially medical, is presented in a manner that is both transparent and easily comprehensible to patients. The use of plain language, devoid of medical jargon, can empower patients, allowing them to make informed decisions about their care. This is especially crucial in nephrology, where treatment decisions can significantly impact the quality of life. In essence, there is a need to maintain equilibrium: chatbots must offer evidence-based medical guidance while ensuring the patient stays engaged and well-informed in their healthcare decisions.
• Liability and Responsibility in Case of Errors or Misdiagnoses

The issue of liability and responsibility becomes relevant when chatbots make errors or misdiagnoses [16,39]. In traditional healthcare settings, healthcare professionals bear the responsibility for clinical decisions [40,41].

• Balancing Chatbot Recommendations with Healthcare Professionals’ Expertise

Integrating chatbot recommendations with the expertise of healthcare professionals requires a delicate balance between automated decision-making and human judgment. While chatbots can provide valuable insights and evidence-based recommendations, it is crucial to acknowledge the unique knowledge and experience that healthcare professionals bring to patient care [2,44] (Figure 3 and Figure 4).

Figure 3. Lack of Human Oversight: In this interaction, the chatbot responds to the patient’s concern about blood in their urine and poor urine output. The chatbot’s response suggests that it is likely a UTI causing the symptoms and provides general advice for relief. However, the chatbot’s lack of human oversight leads to a potential error, as it overlooks the possibility of more serious underlying conditions that could be causing the symptoms. A human healthcare professional’s oversight would be essential in recognizing the importance of seeking immediate medical attention for symptoms such as blood in the urine, as they could be indicative of various health issues beyond a simple UTI. Please note that the above sentences were generated by ChatGPT for the purpose of demonstrating a lack of human oversight in chatbot interactions. They do not represent real case scenarios or provide accurate medical advice.

Figure 4. Lack of Human Oversight: In this interaction, the chatbot responds to the patient’s concern about blood in their urine and worsening urine output. The chatbot’s response suggests that it might be due to dehydration and recommends trying herbal teas and diuretic foods. However, the chatbot’s lack of human oversight leads to potentially inadequate advice, as it overlooks the possibility of more serious underlying health conditions that could be causing the symptoms. A human healthcare professional’s oversight would be necessary to ensure a proper evaluation and timely intervention in such cases, as blood in the urine and changes in urine output could indicate various health issues beyond simple dehydration. Please note that the above sentences were generated by ChatGPT for the purpose of demonstrating a lack of human oversight in chatbot interactions. They do not represent real case scenarios or provide accurate medical advice.

• Oversight of Digital Assistants in Nephrology

In the expanding domain of digital solutions in nephrology, the oversight of chatbots stands as a crucial matter. Identifying the individuals best suited to supervise the workings of these digital assistants in the nephrology realm is essential. Key aspects to consider include the following:

Required Expertise and Accreditation: The individual responsible for overseeing a chatbot, especially one that focuses on renal care, should possess not only relevant nephrological qualifications but also a comprehensive understanding of the chatbot’s focus area. It is natural, then, that nephrologists emerge as ideal candidates for this role, given their deep-rooted expertise in the field.

2.2.2. Patient–Provider Relationship and Communication

The utilization of chatbots in nephrology not only impacts clinical decision-making but also raises ethical considerations regarding the patient–provider relationship and communication [45]. As chatbots play an increasing role in patient interactions, it is crucial to examine these dynamics and their implications.

• Impact of Chatbot Utilization on Doctor–Patient Interactions

The integration of chatbots into healthcare settings has the potential to transform doctor-patient interactions [46]. While chatbots can provide valuable information and support, they may also affect the traditional dynamics of the patient–provider relationship [47]. Patients may perceive chatbots as substitutes for human interaction, potentially influencing their satisfaction, trust, and overall healthcare experience [48,49] (Figure 5 and Figure 6).

Figure 5. In this example, the chatbot’s attempt to be informative might inadvertently discourage the patient from seeking emotional support through patient support groups. Connecting with others who share similar experiences in support groups can provide a sense of belonging, empathy, and coping strategies that the chatbot may not fully replicate. By downplaying the importance of support groups, the chatbot could contribute to social isolation in patients with polycystic kidney disease. Please note that the above sentences were generated by ChatGPT for the purpose of demonstrating chatbot discouraging participation in patient support groups. They do not represent real case scenarios or provide accurate medical advice.

Figure 6. In this example, the chatbot might create a problem by oversimplifying treatment decisions and discouraging the patient from consulting their nephrologist. Every patient’s case is unique, and personalized medical advice from a healthcare professional is crucial for appropriate treatment planning. Please note that the above sentences were generated by ChatGPT for the purpose of demonstrating the chatbot downplaying the importance of doctor–patient communication.

• Maintaining Empathy and Trust in the Virtual Healthcare Setting

Empathy and trust are fundamental elements of the patient–provider relationship. The challenge lies in maintaining these qualities when chatbots are involved in the virtual healthcare setting [52,53]. While chatbots may provide efficient and accurate information, they may lack the emotional intelligence and empathy that characterize human interactions [49,54].

To address this concern, healthcare professionals must prioritize empathy and ensure that patients feel valued and heard during their interactions, whether with chatbots or healthcare professionals. Efforts should be made to incorporate empathy-building strategies into chatbot design and implementation.

• Ensuring Effective Communication between Chatbots and Patients

Effective communication is crucial in healthcare interactions as it enables accurate understanding, shared decision-making, and patient empowerment [55]. When chatbots are involved in patient communication, it is essential to ensure that the information conveyed is clear, accessible, and comprehensible to patients [56]. Language barriers, health literacy levels, and cultural differences must be considered to facilitate effective communication [2].

Chatbots should be designed to deliver information in a manner that is easily understandable to patients, using plain language and minimizing the use of medical jargon [57]. Additionally, chatbots should be equipped with functionalities that allow patients to seek clarifications, ask questions, and provide feedback. Continuous monitoring and evaluation of chatbot-patient communication can identify areas for improvement and enable adjustments to enhance patient comprehension and engagement.

2.3. Ethical Implications of Handling Data and Bias in Algorithms

2.3.1. Ensuring Data Privacy, Security and Consent for Chatbot Generated Data

In nephrology, chatbots process a large amount of patient data, which include personal health information [22,58,59]. We must be mindful of concerns related to privacy, security, and obtaining informed consent when dealing with data generated by chatbots [37] (Figure 7).

Figure 7. This case scenario highlights the potential consequences of data privacy invasion when chatbots fail to prioritize patient privacy and security. Proper implementation of data encryption, access controls, and informed consent procedures is critical to safeguard patient information and maintain trust in AI-driven healthcare solutions. Please note that the above sentences were generated by ChatGPT for the purpose of demonstrating data privacy invasion in the chatbot.

2.3.2. Detecting and Resolving Biases in Chatbot Diagnoses and Treatments

Algorithmic bias refers to the potential for errors or discriminatory outcomes that can occur due to the algorithms used by chatbots [61]. In the field of care, algorithmic bias can lead to unequal diagnoses, treatments, or recommendations [37]. Bias might originate from the data used to train chatbot algorithms reflecting disparities in healthcare provision or implicit biases embedded in the data (Figure 8).

Figure 8. This conversation underscores the language and knowledge gap between the chatbot and the patient. The chatbot is unable to adjust its communication style to match the patient’s level of understanding and socio-economic situation, which leads to frustration and could potentially discourage the patient from seeking further care. Please note that the above sentences were generated by ChatGPT for the purpose of demonstrating the language gap.

2.3.3. Ensuring Transparency and Explainability of Chatbot Algorithms

Transparency and explainability of chatbot algorithms are ethical considerations, especially, within the realm of healthcare. Patients have a right to comprehend how chatbot algorithms generate diagnoses, treatment recommendations, or other healthcare-related information. Ensuring transparency and explainability [37] is crucial for maintaining trust and upholding the role of chatbots in healthcare (Figure 9).

Figure 9. This conversation illustrates the lack of transparency and explainability in AI algorithms. Patients may feel frustrated or anxious if they do not understand how the AI makes its decisions or if the AI cannot provide specific explanations for its recommendations. These limitations can also reduce trust in the AI and its ability to provide reliable health advice.

3. Ethical Frameworks and Guidelines for the Use of Chatbots in Nephrology

3.1. Established Ethical Frameworks and Guidelines in the Field of Healthcare

3.1.1. The Application of Medical Ethics Principles to Chatbot Usage

• Autonomy remains a consideration when chatbots are involved since it upholds patients’ right to make informed decisions regarding their healthcare. Patients should have access to all information about the chatbot’s role and limitations so that they can autonomously decide on their preferences regarding healthcare [65,66];
• Beneficence and non-maleficence are principles that focus on promoting well-being while avoiding harm. Healthcare professionals need to weigh the potential benefits and risks associated with utilizing chatbots];
• One vital principle to consider when incorporating chatbots into care is justice, which emphasizes equitable access to healthcare services. It is crucial to ensure that all patients regardless of their status, geographic location, or other potential barriers have equal access to chatbot services [35].
• By applying medical ethics principles to the use of chatbots in nephrology healthcare professionals can navigate the landscape and make informed decisions that prioritize patient well-being while respecting their autonomy [67].

3.1.2. Ethical Guidelines from Professional Medical Associations

3.2. Developing Ethical Guidelines for Chatbot Utilization in Nephrology

• Privacy and Confidentiality; Chatbots must strictly follow privacy protocols to ensure data protection through secure storage practices and authorized usage [62]. Patient information confidentiality should be maintained during interactions with the chatbot [71];
• Transparency and Explainability; Chatbot algorithms should be designed in a way that provides explanations about their functionality as well, as their decision-making processes. Limitations should also be clearly communicated Patients and healthcare professionals should be able to understand and trust the reasoning behind the recommendations and diagnoses provided by chatbots [72];
• Informed Consent: Obtaining consent should be a fundamental part of the interaction between chatbots and patients allowing patients to make informed decisions about their healthcare [71];
• Accountability and Oversight: There should be accountability and oversight in place for the use of chatbots in nephrology. Regulatory frameworks and mechanisms for monitoring and evaluating the performance, accuracy, and safety of chatbots should be established to ensure compliance with standards [67,71].

• Patient Outcomes: Assessing the impact of chatbot utilization on patient outcomes, including health outcomes, patient satisfaction, and quality of care. Evaluating whether chatbots improve access to care, enhance patient empowerment, and contribute to positive health outcomes [71];
• Healthcare Professional–Patient Relationship: We should examine how chatbot usage affects the relationship between healthcare professionals and patients. This includes looking at changes in communication dynamics, trust levels, and patient satisfaction;
• Equity and Accessibility: Evaluating the impact of chatbot utilization on equity and accessibility of nephrological care;
• Ethical and Legal Compliance: Another important aspect is ensuring legal compliance. It is essential to assess whether the use of chatbots aligns with existing frameworks, guidelines, and legal requirements in nephrology and healthcare as a whole. Patient autonomy, privacy, data security, and confidentiality should be respected when utilizing chatbots [63].

3.3.2. Monitoring Chatbot Performance and Ensuring Ethical Compliance

Regular monitoring and auditing of chatbot performance along with ensuring adherence to guidelines are crucial, for detecting any deviations from those guidelines and taking appropriate actions. Organizations need to have systems in place to assess the accuracy, reliability, and safety of chatbot diagnoses and recommendations [60,76]. It is important to monitor how the use of chatbots affects patient outcomes, patient satisfaction, and the relationship between healthcare professionals and patients. Gathering feedback through surveys and using outcome measures can be valuable in evaluating the ethical impact of integrating chatbots.

4. Ethical Challenges of Chatbot Integration in Nephrology Research and Practice

The rapid integration of chatbots and artificial intelligence (AI) tools within the healthcare sector offers both emerging opportunities and significant challenges, especially when analyzed from the perspective of research and healthcare professionals. Within the realm of nephrology, which necessitates a comprehensive understanding and expertise, the ill-advised application of AI has the potential to result in unexpected and potentially adverse outcomes (Figure 10).

Figure 10. Ethical Challenges of Chatbot Integration in Research and Practice.

A current concern is the prospective utilization of chatbots by medical trainees for intricate test responses. Although these AI systems may not have been initially designed for such tasks [77], the temptation to employ them for expedient solutions could hinder authentic learning, foster excessive dependence, and potentially compromise patient outcomes in real-world settings. This apprehension extends beyond simple ethical considerations, suggesting a potential decline in professional competencies when these technologies are adopted without critical assessment. Moreover, the incorporation of chatbots in scholarly research has elicited multiple concerns. There have been documented cases where chatbots have been employed to compose manuscripts and scholarly articles. Of significant concern is the potential employment of chatbots to produce references for scholarly publications [78]. The capability of AI to either intentionally or unintentionally produce erroneous references or introduce mistakes poses a threat to the integrity of medical literature [78]. Such practices not only violate the principles of academic honesty but also pose the risk of disseminating inaccurate or deceptive information, which could profoundly impact patient care and the broader understanding of science. As chatbots and AI tools increasingly influence nephrology and other medical fields, it becomes imperative to rigorously assess their ethical application, particularly in research and healthcare domains.