Cited by 108Ethics and Social Impacts of AIArtificial Intelligence in Healthcare and EducationEthics and bioethics in healthcare

Ethical implications of conversational agents in global public health

Open access
Luxton, David D·2020·Bulletin of the World Health Organization

AI snapshot

Written from the paper’s full text.

TL;DR

Conversational agents (chatbots and embodied virtual agents) could help fill global shortages in health-care and mental health services, but their widespread use raises ethical challenges around bias, harm, privacy and inequitable access. The author argues for revised professional ethics codes and an international working group to ensure ethical deployment.

Key findings

The paper is a commentary/analysis rather than an empirical study, so it reports no primary data; its claims are framed around cited figures and ethical argument.

  • Mental health worker supply is estimated at as low as 2 per 100 000 population in low-income countries versus more than 70 per 100 000 in high-income nations, creating service gaps that conversational agents might help address.
  • Conversational agents are susceptible to design and algorithmic bias, including preference for particular racial or ethnic backgrounds, and to bias from missing data, misclassification, measurement error and small sample sizes that produce inaccurate predictions for subgroups.
  • Because agents function with some autonomy, there is risk of harm when systems fail to detect imminent safety risks (e.g., a user revealing suicidal thoughts with immediate plans to die); some patients, such as those with significant psychotic symptoms or cognitive deficits, may not be suitable candidates.
  • Most companies market health-related conversational agents for information or training rather than as replacements for health professionals, so requirements such as duty-to-warn are unheeded.

Methods

This is a non-systematic commentary/analysis in the Bulletin of the World Health Organization; no study design, sample or formal analysis is reported. The argument is organized thematically around risks (bias, harm, privacy, inequitable access) and a proposal to revise or develop professional ethics codes and practical guidelines, potentially via a WHO-coordinated international working group.

Limitations

Not stated in the paper (the text does not include a limitations section). Evident from the text: the piece is a narrative commentary without empirical data, systematic review methodology or formal evidence synthesis, so its claims rest on cited literature and the author's argument; the cited workforce figures come from a 2017 WHO Mental Health Atlas reference rather than original analysis.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.2471/blt.19.237636

Cites

8 of 8 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 27 cited sources checked · 0 supported · 0 flagged

  • Premisecitation
    § Ethical implications of conversational agents in global public health

    Conversational agents are potentially more reliable than humans because they are not affected by fatigue, burnout and cognitive errors.

    “They are also potentially more reliable than humans are because they are not affected by fatigue, burnout and cognitive errors.3”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Luxton, 2014, Recommendations for the ethical use and design of artificial intelligent care providers., Artif Intell Med source

      Not checked in the free run.

  • Premisecitation
    § Ethical implications of conversational agents in global public health

    Users may experience less anxiety when discussing private concerns, such as disease exposure risk behaviours, with a conversational agent than they would with another person.

    “Thus, users may experience less anxiety when discussing private concerns, such as disease exposure risk behaviours, with a conversational agent than they would with another person.3,4,7”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [3] Luxton, 2014, Recommendations for the ethical use and design of artificial intelligent care providers., Artif Intell Med source

      Not checked in the free run.

    • cites [4] Laranjo, 2018, Conversational agents in healthcare: a systematic review., J Am Med Inform Assoc source

      Not checked in the free run.

    • cites [7] Bickmore, 2010, Response to a relational agent by hospital patients with depressive symptoms., Interact Comput source

      Not checked in the free run.

  • Premisecitation
    § Ethical implications of conversational agents in global public health

    Affective computing techniques can provide conversational agents with the capability to recognize and express emotions.

    “Affective computing techniques can then provide the conversational agent with the capability to recognize and express emotions”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [2] Hudlicka, 2015, Artificial intelligence in behavioral and mental healthcare.

      Not checked in the free run.

    • cites [3] Luxton, 2014, Recommendations for the ethical use and design of artificial intelligent care providers., Artif Intell Med source

      Not checked in the free run.

  • Premisecitation

    Some patients, such as those with significant psychotic symptoms or cognitive deficits, may not be suitable candidates for the use of conversational agents.

    “Also, some patients, such as those with significant psychotic symptoms or cognitive deficits, may not be suitable candidates for the use of conversational agents.3”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Luxton, 2014, Recommendations for the ethical use and design of artificial intelligent care providers., Artif Intell Med source

      Not checked in the free run.

  • Interpretationreasoning

    There are ethical challenges to widespread use of conversational agents despite their potential benefits.

    “Despite the potential benefits of the technology, there are ethical challenges to widespread use of conversational agents.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 5
  • May combine two claims. 6
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Ethical implications of conversational agents in global public health

    Speech recognition and natural language processing technologies can allow conversational agents to converse with humans.

    “Speech recognition and natural language processing technologies can allow conversational agents to converse with humans.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] Hudlicka, 2015, Artificial intelligence in behavioral and mental healthcare.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Ethical implications of conversational agents in global public health

    This shortage in health-care providers results in major gaps in services, contributing to unmet health-care needs and greater disease burden in underserved regions.

    “This shortage in health-care providers results in major gaps in services, contributing to unmet health-care needs and greater disease burden in underserved regions.1”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] WHO's Mental Health Atlas 2017 highlights global shortage of health workers trained in mental health [internet]. Geneva: World Health Organization; 2017. https://www.who.int/hrh/news/2018/WHO-MentalHealthAtlas2017-highlights-HW-shortage/en/ [cited 2019 May 19].

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Ethical implications of conversational agents in global public health

    Other uses of conversational agents include replacing nurses to provide hospital discharge planning, collecting relevant health information (such as public health surveys), training health-care providers by simulating patients, and providing public health information and education.

    “Other use of conversational agents include replacing nurses to provide hospital discharge planning, for collecting relevant health information (such as public health surveys), for training health-care providers by simulating patients, and for providing public health information and education.3,5–9”
    Quote in the paperNot a substantial claim0 of 6 sources checked
    • cites [3] Luxton, 2014, Recommendations for the ethical use and design of artificial intelligent care providers., Artif Intell Med source

      Not checked in the free run.

    • cites [5] Luxton, 2020, Innovations in global mental health.

      Not checked in the free run.

    • cites [6] Vaidyam, 2019, Chatbots and conversational agents in mental health: a review of the psychiatric landscape., Can J Psychiatry source

      Not checked in the free run.

    • cites [7] Bickmore, 2010, Response to a relational agent by hospital patients with depressive symptoms., Interact Comput source

      Not checked in the free run.

    • cites [8] Luxton, 2015, Artificial intelligence in behavioral and mental health care.

      Not checked in the free run.

    • cites [9] Rizzo, 2011, An intelligent virtual human system for providing healthcare information and support., Stud Health Technol Inform

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Ethical implications of conversational agents in global public health

    Conversational agents are being tested and used to provide and collect health-related information from people, and in some cases, provide treatment and counselling services.

    “Conversational agents are being tested and used to provide and collect health-related information from people, and in some cases, provide treatment and counselling services.4–6”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [4] Laranjo, 2018, Conversational agents in healthcare: a systematic review., J Am Med Inform Assoc source

      Not checked in the free run.

    • cites [5] Luxton, 2020, Innovations in global mental health.

      Not checked in the free run.

    • cites [6] Vaidyam, 2019, Chatbots and conversational agents in mental health: a review of the psychiatric landscape., Can J Psychiatry source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Ethical implications of conversational agents in global public health

    This capability gives conversational agents the ability to adapt to the changing states and needs of people while establishing empathetic relationships with them.

    “giving them the ability to adapt to the changing states and needs of people while establishing empathetic relationships with them.2,3”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [2] Hudlicka, 2015, Artificial intelligence in behavioral and mental healthcare.

      Not checked in the free run.

    • cites [3] Luxton, 2014, Recommendations for the ethical use and design of artificial intelligent care providers., Artif Intell Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Ethical implications of conversational agents in global public health

    The supply of mental health workers in low-income countries is estimated to be as low as 2 per 100,000 population, compared with more than 70 per 100,000 in high-income nations.

    “The supply of mental health workers in low-income countries is estimated to be as low as 2 per 100 000 population, compared with more than 70 per 100 000 in high-income nations.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] WHO's Mental Health Atlas 2017 highlights global shortage of health workers trained in mental health [internet]. Geneva: World Health Organization; 2017. https://www.who.int/hrh/news/2018/WHO-MentalHealthAtlas2017-highlights-HW-shortage/en/ [cited 2019 May 19].

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Ethical implications of conversational agents in global public health

    Embodied conversational agents are used in therapeutic computer games and virtual reality environments to provide interactive skills training and treatments for conditions such as autism spectrum disorder, depression and anxiety disorders.

    “Embodied conversational agents are also used in therapeutic computer games and virtual reality environments to provide interactive skills training and treatments for conditions, such as autism spectrum disorder, depression and anxiety disorders.2,5”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [2] Hudlicka, 2015, Artificial intelligence in behavioral and mental healthcare.

      Not checked in the free run.

    • cites [5] Luxton, 2020, Innovations in global mental health.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The application of conversational agents across different countries and cultures is particularly susceptible to design biases if the organizations deploying the technology have not adequately considered the demographic characteristics and specific needs of the target end-users.

    “The application of conversational agents across different countries and different cultures is particularly susceptible to these design biases if the organizations deploying the technology have not adequately considered the demographic characteristics and specific needs of the target end-users.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The overt appearance and behaviour of conversational agents are susceptible to design biases, such as preference for particular racial or ethnic background in their design.
    • Rests on an assumption: The knowledge base used to train the machine-learning algorithms and the ways that the conversational agent generates new knowledge is also susceptible to bias that is less observable than physical appearance or overt language biases.
    • Rests on an assumption: The sources of bias in the data sets used to develop conversational agents may include problems with missing data, misclassification and measurement error and small sample sizes, resulting in underestimation and inaccurate predictions for subgroups of patients.
  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Because conversational agents function with some level of autonomy, there is a potential risk of harm to people if the technology does not adequately address scenarios when the system detects potential or imminent safety risks.

    “Since conversational agents function with some level of autonomy, there is a potential risk of harm to people if the technology does not adequately address scenarios when the system detects potential or imminent safety risks.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim.

    Interpretationreasoning

    User privacy, if not appropriately addressed, could potentially cause harm to users of conversational agents.

    “User privacy is another issue that if not appropriately addressed could potentially cause harm to the users of conversational agents.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Conversational agents can collect large amounts of private and sensitive information when people interact with them.
  • May combine two claims.

    Interpretationreasoning

    Many ethical and legal requirements that human health-care professionals should comply with, such as duty-to-warn, are unheeded because most companies market conversational agents for information or training rather than as replacements for health professionals.

    “Therefore, many of the ethical and legal requirements that human health-care professionals should comply with, such as duty-to-warn, are unheeded.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: At present, most companies that produce conversational agents for health-related uses market them to the public for providing information or training, and not as replacements for health professionals.
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  • The paper relies on this without support.

    Conversational agents may be perceived by users as being free from personal bias.

    “Conversational agents may also be perceived by users as being free from personal bias.”
  • The paper relies on this without support.

    Conversational agents can be replicated (scaled-up) easily and affordably to meet demand, and users can access them via the internet at any time and almost anywhere.

    “A benefit of conversational agents is that they can be replicated (scaled-up) easily and affordably to meet demand, and, unlike with human professionals, users can access them via the internet at any time and almost anywhere.”
  • The paper relies on this without support.

    Developers can design conversational agents to have modifiable physical appearance and mannerisms, language and speech dialect, and other characteristics that match them to a user's cultural background, including race and ethnicity or socioeconomic status.

    “Developers can design conversational agents to have modifiable physical appearance and mannerisms, language and speech dialect, and other characteristics that match them to a user’s cultural background, including race and ethnicity or socioeconomic status.”
  • The paper relies on this without support.

    The overt appearance and behaviour of conversational agents are susceptible to design biases, such as preference for particular racial or ethnic background in their design.

    “The overt appearance and behaviour of conversational agents are susceptible to design biases, such as preference for particular racial or ethnic background in their design.”
  • The paper relies on this without support.

    The knowledge base used to train the machine-learning algorithms and the ways that the conversational agent generates new knowledge is also susceptible to bias that is less observable than physical appearance or overt language biases.

    “The knowledge base used to train the machine-learning algorithms and the ways that the conversational agent generates new knowledge is also susceptible to bias that is less observable than physical appearance or overt language biases.”
  • The paper relies on this without support.

    The sources of bias in the data sets used to develop conversational agents may include problems with missing data, misclassification and measurement error and small sample sizes, resulting in underestimation and inaccurate predictions for subgroups of patients.

    “The sources of bias in the data sets used to develop conversational agents may include problems with missing data, misclassification and measurement error and small sample sizes, resulting in underestimation and inaccurate predictions for subgroups of patients.”
  • The paper relies on this without support.

    At present, most companies that produce conversational agents for health-related uses market them to the public for providing information or training, and not as replacements for health professionals.

    “At present, most companies that produce conversational agents for health-related uses market them to the public for providing information or training, and not as replacements for health professionals.”
  • The paper relies on this without support.

    Conversational agents can collect large amounts of private and sensitive information when people interact with them.

    “Conversational agents can collect large amounts of private and sensitive information when people interact with them.”
  • The paper relies on this without support.

    Lack of education and low technology literacy are other issues that could limit people's access to and use of conversational agents, resulting in greater health-care disparities across populations.

    “Lack of education and low technology literacy are other issues that could limit people’s access to and use of conversational agents, resulting in greater health-care disparities across populations.”
  • The paper relies on this without support.

    As with traditional telemedicine (videoconferencing, telephone consultations and remote monitoring), limitations of the technology or end-user preferences may make conversational agents unsuitable to use.

    “As with traditional telemedicine (videoconferencing, telephone consultations and remote monitoring) limitations of the technology or end-user preferences may make conversational agents unsuitable to use.”
  • The paper relies on this without support.

    Most current health profession ethics codes and practice guidelines do not address the use of technologies that simulate and replace human professionals.

    “Most current health profession ethics codes and practice guidelines do not address the use of technologies that simulate and replace human professionals.”
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Cites

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Research works printed but not linked: 2

  1. Hudlicka, 2015, Artificial intelligence in behavioral and mental healthcare.
  2. Luxton, 2015, Artificial intelligence in behavioral and mental health care.

Cited by

Sorted by citations

Authors
Luxton, D. D.
Affiliations
University of Washington (US)
Corresponding author
Luxton, David D
Venue
Bulletin of the World Health Organization
Publisher
WHO Press
Published
2020-01-27
Volume
98
Issue
4
Pages
285-287
ISSN
0042-9686 (ISSN-L)
OpenAlex
W3014634077
Cited by
108
References
8
Citations by year
2026: 24 · 2025: 27 · 2024: 14 · 2023: 12 · 2022: 14 · 2021: 13 · 2020: 4
FWCI
13.84
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Bulletin of the World Health Organization (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Safety Research › Ethics and Social Impacts of AI
  • Health Sciences › Medicine › Health Informatics › Artificial Intelligence in Healthcare and Education
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
Keywords
chatbots, AI ethics, global public health, health communication, digital health
MeSH terms
Digital Technology, Communication, Health Services Accessibility, Humans, Mental Health Services, Public Health, Global Health, Bias, Privacy

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