Olympia Lioupi

Conflicts arise when surrogates request life-sustaining treatments that clinicians consider medically futile. This article proposes that early presumptive medical mediation with opt-out provisions should become the default initial offer for resolving such disputes. Grounded in Rawlsian procedural justice and the virtue of epistemic humility, and informed by limited and indirect evidence from healthcare mediation and ICU communication-facilitation programs, this approach offers a fair-process dialogue that can support patient-centered deliberation and clinician integrity when embedded within appropriate legal and ethical safeguards. Mediation offers four procedural advantages: (a) protected and appropriately inclusive voice, (b) confidential caucus, (c) interest-based framing, and (d) outcome ownership. Unlike arbitration or ethics committee determinations, mediation is structured around voluntary participation, mediator neutrality and confidentiality. It does not impose a binding outcome or reallocate legal decision-making authority. These procedural features distinguish mediation from adjudicative or advisory processes, although their comparative effectiveness is context-dependent. Statutory “safe-harbor” models, such as the Texas Advance Directives Act, illustrate how structured dispute-resolution frameworks can be embedded in policy, although they do not themselves constitute mediation. Embedding an early, structured offer of mediation in end-of-life policy may reduce escalation and strengthen the procedural legitimacy and acceptability of decision-making when voluntariness and appropriate clinical, ethical and legal safeguards are maintained. However, it cannot guarantee agreement, shorter ICU stays, reduced litigation, or substantively correct ethical outcomes.

Decisions about vector-borne zoonotic disease control often have to be made before the evidence is complete. Human surveillance, entomological observations, animal reservoir or sentinel data, environmental indicators, and modelling outputs may provide warning before human disease patterns are clear. In some settings, early action can prevent harm, yet it can also impose social, economic, ecological, animal-welfare, liberty-related, and trust-related burdens. Technical risk assessment remains necessary, although it may need to be complemented by ethical analysis. In this conceptual manuscript, we propose a seven-step One Health ethical decision-making framework that links integrated evidence and transmission plausibility to precaution, proportionality, equity, One Health trade-offs, legitimacy, feedback, impact evaluation, and adaptation. Its contribution lies not in introducing new ethical principles, but in integrating them into an iterative governance sequence and proposing medical bioethics mediation for persistent value conflict. Illustrative domains include West Nile virus, dengue, Zika, Crimean–Congo haemorrhagic fever, and other mosquito-, tick-, and sand fly-borne zoonotic threats.

Background: The outbreak of COVID-19 in Greece prompted extensive public health measures, including the first national lockdown and the suspension of in-person schooling. Recognizing the significant role of children in community transmission due to their contacts in schools, school absenteeism data began to be systematically recorded as a potential indicator of outbreak patterns. Objectives: This study aims to explore the utility of incorporating school absenteeism data in an early warning surveillance system for respiratory infections, particularly in predicting the onset and spread of diseases such as COVID-19 and influenza. Methods: We utilized school absenteeism data from primary schools and kindergartens in the Municipality of Larissa for the 2022–2024 school years, alongside health data from the University Hospital of Larissa (UHL). These included incidence rates of respiratory infections, COVID-19, and flu cases, which were cross-referenced with absenteeism patterns. Results: The analysis showed that peaks in absenteeism often preceded increases in cases of respiratory infections, COVID-19, and flu, suggesting absenteeism as a potential early warning indicator. Notable divergences in patterns were observed during school closures for holidays, which posed challenges in data continuity and surveillance effectiveness. Conclusions: School absenteeism data significantly enhances the capability for early detection and monitoring of respiratory disease outbreaks. To improve future surveillance and outbreak prediction, integrating more comprehensive data sources and refining predictive models to accommodate educational calendar variations is recommended.

Background/Objectives: Healthcare systems increasingly operate through dense networks of clinicians, managers, public health authorities, institutions, and communities. Disagreement is no longer confined to bedside decisions; it also affects coordination, legitimacy, and implementation at system level. Bioethics, administrative governance, and consultation processes address important parts of this problem, but they do not by themselves provide a dedicated process for handling persistent disagreement, mistrust, and competing values across actors and institutions. This paper proposes medical–bioethical mediation as a potential governance innovation for sustainable, efficient, and resilient healthcare systems. Methods: This is a conceptual framework paper based on an integrative synthesis of selected literature in clinical bioethics mediation, medical mediation, public health ethics, deliberative and participatory governance, trust, inter-organizational coordination, health governance, and health system resilience. It does not report empirical research or a systematic review. Results: The proposed population-level framework is organized around seven linked components: conflict identification, stakeholder mapping, ethical issue clarification, mediation, negotiated solutions, implementation, and feedback and learning. These components form three broader moments: diagnosis, mediated deliberation, and implementation with learning. The framework identifies mechanisms through which mediation may affect health system governance, including conflict transformation, structured ethical deliberation, participation, trust-building, coordination, and adaptive learning. Illustrative scenarios include resource allocation, inter-organizational coordination, public health restrictions, vaccine mistrust, and system reform. The framework is proposed as a hypothesis-generating governance model rather than as a tested intervention. Conclusions: Medical–bioethical mediation should be considered beyond the bedside as a possible system-level governance approach. Its potential value lies in helping health systems manage recurring ethical and institutional conflict more constructively and may strengthen the conditions for legitimacy, coordination, implementation, and learning. Its potential contribution should be understood as plausible but unproven at population level and should be evaluated through pilot implementation, economic analysis, and comparative case research.

Background/Objectives: Two diagnostic approaches for sleep studies are commonly used worldwide: in-laboratory polysomnography [PSG] and home sleep apnea testing [HSAT]. Although HSAT has gained increasing acceptance due to its convenience and lower cost, clinical criteria for HSAT use remain complex and cannot be inferred directly from AHI/ODI severity indices alone. The aim of the present exploratory study was to examine associations between routinely collected demographic, clinical, and symptom-related variables and objective indices of disease severity, namely the apnea–hypopnea index [AHI] and oxygen desaturation index [ODI] as an initial, hypothesis-generating step toward future patient-level model development and validation. Methods: A retrospective observational analysis was conducted in 1100 individuals who previously underwent in lab-polysomnography [PSG] at the University Hospital of Thessaly, Greece, between 2006 and 2023. Specific demographic, clinical and symptom-related variables were included in this study [six continuous and fifteen categorical], which were analyzed in relation to AHI and ODI values. A three-step process was carried out: variable selection followed a screening and backward elimination process. Multivariable linear regression models were subsequently estimated within a Bayesian framework using Hamiltonian Monte Carlo methods. Results: Out of 1100 individuals, the mean age was 51.9 years with the predominant gender being male [76%]. Obesity [65.6%] and hypertension [40.5%] were the most common comorbidities. For AHI, male gender, body mass index [BMI], Epworth Sleepiness Scale [ESS] score, reported breathing interruptions during sleep, and chronic obstructive pulmonary disease [COPD] were significant predictors. For ODI, significant predictors included male gender, BMI, ESS score, breathing interruptions during sleep, daytime sleepiness, obesity, and COPD. COPD showed an inverse association with both indices. Conclusions: These findings support the feasibility of integrating routinely available clinical variables within a Bayesian probabilistic framework to estimate disease severity pre-test probability. The current analysis may not constitute a validated tool for HSAT versus PSG selection; however, it is an initial, hypothesis-generating step toward future model development.

Conflicts erupt when surrogates request life-sustaining treatments that clinicians deem medically futile. This article proposes that early, presumptive medical mediation with opt-out provisions should become the default pathway for resolving such disputes. Grounded in Rawlsian procedural justice and the virtue of epistemic humility, and supported by empirical data on mediation programs, this approach offers a fairprocess dialogue that better safeguards both patient autonomy and clinician integrity than unilateral withdrawal or courtroom adjudication. Mediation delivers four advantages: (a) voice parity, (b) confidential caucus, (c) interest-based framing, and (d) outcome ownership. Unlike arbitration or ethics committee determinations, mediation preserves party self-determination, neutrality, and confidentiality, and does not impose binding outcomes. These outstrip traditional ethics consults and litigation. Statutory "safe-harbor" models such as the Texas Advance Directives Act illustrate how structured dispute-resolution frameworks can be embedded in policy, although they do not themselves constitute mediation. Embedding an early, structured offer of mediation, in end-of-life policy would curb litigation, shorten ICU stalemates, and yield ethically legitimate decisions, provided that voluntariness and procedural safeguards are maintained.

Medical malpractice disputes often impose significant economic and time burdens on healthcare systems, patients, and providers. Mediation is a promising, efficient and cost-effective alternative to litigation. Our objective was to develop a quantitative tool that quantifies the economic and time savings associated with the adoption of mediation in medical malpractice cases. We created a user-friendly, freely available R/Shiny application to estimate the net present value (NPV) of monetary and time savings from mediation versus traditional litigation. Substantial economic and time savings were projected across all scenarios. In high-income countries, a decade of implementing mediation for 2,000 annual claims yielded an estimated NPV of €115.22 million (95% CrI €81.73–€149.27 million) and 13,349 court-years saved. Corresponding savings for middle- and low-income countries were €47.97 million and €13.77 million, with 16,052 and 12,705 court-years saved, respectively. The tool enables interested stakeholders and policymakers to quantify the benefits of medical mediation under different settings as its flexible structure allows users to define their own input distributions and assumptions according to local policy and legal contexts.

Medical mediation (MM) is a collaborative tool for resolving ethically complex disputes in healthcare. Background/Objectives: Though widely recognized in international clinical ethics, it has only been recently introduced in Greece. The objective of this study was (i) to quantify agreement with MM across three clinical scenarios, (ii) to estimate the proportion of professionals that support mediation and institutional training, and (iii) to identify distinct attitudinal profiles using latent class analysis (LCA). Methods: A structured, cross-sectional online questionnaire was completed by 431 healthcare professionals across Greece. The survey included three clinical vignettes (on (1) end-of-life care, (2) religious refusal of treatment, and (3) medical error disclosure), Likert-scale items on attitudes toward mediation, and demographic information. LCA was used to identify patterns of response across the scenarios and differentiate between strongly supportive, moderately supportive, and cautiously positive professional profiles. Results: Participants expressed strong support for mediation across all scenarios (median scores ≥ 9), with the highest support for medical error disclosure (mean 8.67 ± 2.10 and a median of 10). Most participants (97.2%, n = 419) considered mediation at least sometimes effective, and 80.7% (n = 348) endorsed institutional training. However, only 3.0% (n = 13) reported formal training and 1.9% (n = 8) reported being very familiar with MM. LCA revealed three distinct respondent profiles: strongly supportive (73.3%, n = 316), moderately supportive (14.6%, n = 63), and cautiously positive (12.1%, n = 52). Significant trends were observed across profiles for the perceived effectiveness of mediation and support for institutional training (p < 0.01). However, formal training and familiarity with mediation among the participants were low (<5%). Conclusions: Despite limited training and formal implementation, Greek healthcare professionals show high support for MM. The demand and need for structured mediation training and integration into the Greek healthcare system is strong. The identification of distinct attitudinal profiles provides insight into potential variation in organizational readiness for implementing structured mediation training

Background: Non-typhoidal (NT) Salmonella spp. constitutes a major cause of foodborne illness. Culture is the gold standard, but it is time consuming, whereas multiplex nucleic acid amplification tests (NAATs)/Polymerase Chain Reaction (PCR) offer faster detection with variable reported performance. Objectives: To compare the diagnostic accuracy of multiplex NAAT/PCR and culture for Salmonella spp. using various statistical models with or without a gold standard assumption. Methods: A systematic search (PubMed, Web of Science, Scopus; up to April 2024) identified 44 studies (55 comparisons). Diagnostic performance was evaluated using the frequentists bivariate model (BM) and Split Component Synthesis (SCS) and the Bayesian bivariate models (BBMs) and hierarchical summary ROC (BHSROC). Results: Across models, multiplex NAAT/PCR demonstrated high specificity (>98%) but model-dependent variability in sensitivity (85.5–94.8%), consistently substantial between study heterogeneity and threshold variation. The BM and BBM yielded a higher sensitivity estimate with narrower non-overlapping confidence intervals while SCS and BHSROC models, which are more robust to threshold differences, produced more conservative estimates with wider uncertainty. In Bayesian latent class analyses, culture remained highly accurate (Se: 97.17%, 95% CrI: 70.3–99.99; Sp: 96.06%, 95% CrI: 78.9–99.99), but with wide credible intervals indicating variation between studies, perhaps due to the different protocols used. Conclusion: Model choice affects inferred diagnostic accuracy, particularly when high heterogeneity is present. Both multiplex NAAT/PCR and culture showed high accuracy; hence, a combination of the two tests could optimise rapid diagnosis and treatment. Future research should include cost effectiveness and decision analysis to update the diagnostic algorithms.