{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T08:26:03Z","timestamp":1787646363022,"version":"build-2736575974"},"reference-count":41,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T00:00:00Z","timestamp":1769904000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T00:00:00Z","timestamp":1769904000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["DIGITAL HEALTH"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:p>Artificial intelligence (AI) integration into digital health care delivery is rapidly expanding and is increasingly viewed as a promising approach for improving access to care, strengthening diagnostic decision-making, and addressing persistent health inequities experienced by Indigenous populations. Although AI-enabled digital health applications offer potential benefits such as scalability, personalization, and improved clinical decision support, they also raise critical ethical concerns related to equitable implementation, culturally grounded design, representative data usage accountability, privacy protection, and Indigenous data sovereignty. A coherent ethical governance framework is necessary to guide the responsible development, deployment, and evaluation of AI applications implemented in digital health solutions involving Indigenous communities. A narrative review was conducted to critically assess recent literature (2020\u20132025) addressing ethical considerations in the integration of AI into digital health care delivery for Indigenous populations. Searches were performed in MEDLINE, PubMed, Web of Science, and Scopus using terms related to artificial intelligence, digital health, Indigenous populations, and ethics, with supplementary grey literature searches conducted to identify policy and implementation reports. Studies were selected based on relevance to AI-enabled digital health initiatives implemented in digital health contexts involving Indigenous communities in Canada, the United States, Australia, New Zealand, and the United Kingdom, and were synthesized using thematic narrative analysis. Six themes denoting ethical domains were identified: (1) co-design of AI technologies, (2) culturally grounded implementation, (3) bias and representative data, (4) accountability, transparency, and intelligibility, (5) privacy and Indigenous data sovereignty, and (6) resource accessibility. These domains function as interconnected components of ethical governance, with participatory governance and Indigenous data sovereignty emerging as foundational cross-cutting principles. The proposed framework is not intended as a pan-Indigenous or one-size-fits-all model. Instead, it is conceptualized as a flexible, distinctions-based ethical governance framework that must be adapted to the specific cultural, geographic, and governance contexts of individual Indigenous communities. Based on this analysis, we propose a conceptual ethical governance framework to support policymakers, clinicians, health systems, digital health developers, as well as Indigenous communities in identifying ethically appropriate safeguards across the lifecycle of AI-enabled digital health initiatives planned or implemented in Indigenous communities.<\/jats:p>","DOI":"10.1177\/20552076261481276","type":"journal-article","created":{"date-parts":[[2026,8,22]],"date-time":"2026-08-22T09:18:25Z","timestamp":1787390305000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Ethical governance of artificial intelligence in digital health for Indigenous populations: A narrative review and conceptual framework"],"prefix":"10.1177","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8615-4024","authenticated-orcid":false,"given":"Amal","family":"Khan","sequence":"first","affiliation":[{"name":"University of Saskatchewan"},{"name":"Virtual Health Hub"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alyson S. N.","family":"Bear","sequence":"additional","affiliation":[{"name":"Virtual Health Hub"},{"name":"Whitecap Dakota Nation"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mairyn","family":"Rackow","sequence":"additional","affiliation":[{"name":"University of Saskatchewan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cassandra Opikokew","family":"Wajuntah","sequence":"additional","affiliation":[{"name":"University of Saskatchewan"},{"name":"Virtual Health Hub"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kenneth","family":"Lai","sequence":"additional","affiliation":[{"name":"University of Saskatchewan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Veronica","family":"McKinney","sequence":"additional","affiliation":[{"name":"Virtual Health Hub"},{"name":"University of Saskatchewan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Costa","sequence":"additional","affiliation":[{"name":"Virtual Health Hub"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ivar","family":"Mendez","sequence":"additional","affiliation":[{"name":"Virtual Health Hub"},{"name":"University of Saskatchewan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,8,22]]},"reference":[{"key":"e_1_3_6_2_2","unstructured":"Singh AK Singh M. Handbook on augmenting telehealth services: using artificial intelligence. CRC Press."},{"key":"e_1_3_6_3_2","doi-asserted-by":"publisher","DOI":"10.1177\/20552076251334422"},{"key":"e_1_3_6_4_2","unstructured":"World Health Organization (WHO). AI for Good. https:\/\/aiforgood.itu.int\/about-us\/un-ai-actions\/who\/ (2021 Accessed 18 February 2026)."},{"key":"e_1_3_6_5_2","doi-asserted-by":"publisher","DOI":"10.1177\/08404704241257144"},{"key":"e_1_3_6_6_2","doi-asserted-by":"publisher","DOI":"10.17269\/s41997-025-01037-1"},{"key":"e_1_3_6_7_2","doi-asserted-by":"publisher","DOI":"10.1515\/pjbr-2019-0004"},{"key":"e_1_3_6_8_2","doi-asserted-by":"crossref","unstructured":"Singh R Ansari AA Vyas S et al. AI ethics and challenges in healthcare. In: Handbook on augmenting telehealth services: using artificial intelligence. CRC Press pp. 93\u2013104.","DOI":"10.1201\/9781003346289-6"},{"key":"e_1_3_6_9_2","article-title":"First Nations and Artificial Intelligence Research Paper","author":"Animikwan D","year":"2024","unstructured":"Animikwan D. First Nations and Artificial Intelligence Research Paper. Chiefs of Ontario. https:\/\/chiefs-of-ontario.org\/first-nations-and-artificial-intelligence-research-paper\/ (2024, Accessed 18 February 2026).","journal-title":"Chiefs of Ontario"},{"key":"e_1_3_6_10_2","doi-asserted-by":"publisher","DOI":"10.4300\/JGME-D-22-00480.1"},{"key":"e_1_3_6_11_2","doi-asserted-by":"publisher","DOI":"10.1111\/eci.12931"},{"key":"e_1_3_6_12_2","unstructured":"Biblioth\u00e8que \/ Library. Systematic reviews. https:\/\/uottawa.libguides.com\/systematicreview\/planning (2017 Accessed 18 February 2026."},{"key":"e_1_3_6_13_2","article-title":"Rayyan\u2014a web and mobile app for systematic reviews - QCAI - Qatar Center for Artificial Intelligence","author":"Ahmad MS","year":"2016","unstructured":"Ahmad MS. Rayyan\u2014a web and mobile app for systematic reviews - QCAI - Qatar Center for Artificial Intelligence. QCAI - Qatar Center for Artificial Intelligence. https:\/\/qcai.qcri.org\/publications\/publications-ai-foundations-and-systems\/rayyan-a-web-and-mobile-app-for-systematic-reviews\/? (2016 Accessed 18 February 2026.","journal-title":"QCAI - Qatar Center for Artificial Intelligence"},{"key":"e_1_3_6_14_2","doi-asserted-by":"publisher","DOI":"10.1177\/1049732302238251"},{"key":"e_1_3_6_15_2","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2025.1524616"},{"key":"e_1_3_6_16_2","unstructured":"Ethics and governance of artificial intelligence for health. https:\/\/www.who.int\/publications\/i\/item\/9789240029200 (2021 Accessed 23 February 2026)."},{"key":"e_1_3_6_17_2","volume-title":"Care statement for indigenous data sovereignty","author":"Leonard K","year":"2023","unstructured":"Leonard K, Russo S, Martinez A, et al. Care statement for indigenous data sovereignty. Collaboratory for Indigenous Data Governance (The WAMPUM Lab), University of Waterloo, 2023."},{"key":"e_1_3_6_18_2","volume-title":"Exploring opportunities and challenges to predict, prevent, diagnose, and treat disease more precisely in Aotearoa New Zealand","author":"Precision health","unstructured":"Precision health. Exploring opportunities and challenges to predict, prevent, diagnose, and treat disease more precisely in Aotearoa New Zealand. Ministry of Health NZ. https:\/\/www.health.govt.nz\/publications\/precision-health-exploring-opportunities-and-challenges-to-predict-prevent-diagnose-and-treat (Accessed 19 February 2026."},{"key":"e_1_3_6_19_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00146-024-02065-0"},{"key":"e_1_3_6_20_2","volume-title":"Feedback to Department of Health and Aged Care on Safe and Responsible Artificial Intelligence in Health Care: About the Australian College of Rural and Remote Medicine (ACRRM)","author":"Australian College of Rural and Remote Medicine (ACRRM)","year":"2024","unstructured":"Australian College of Rural and Remote Medicine (ACRRM). Feedback to Department of Health and Aged Care on Safe and Responsible Artificial Intelligence in Health Care: About the Australian College of Rural and Remote Medicine (ACRRM). Australian College of Rural and Remote Medicine (ACRRM) 2024."},{"key":"e_1_3_6_21_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pdig.0000597"},{"key":"e_1_3_6_22_2","doi-asserted-by":"publisher","DOI":"10.3389\/fcomp.2022.1070493"},{"key":"e_1_3_6_23_2","doi-asserted-by":"publisher","DOI":"10.1007\/s41347-023-00348-9"},{"key":"e_1_3_6_24_2","doi-asserted-by":"publisher","DOI":"10.3389\/fdgth.2024.1449129"},{"key":"e_1_3_6_25_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40471-025-00362-w"},{"key":"e_1_3_6_26_2","unstructured":"Ethical Principles for AI in Medicine - RANZCR. https:\/\/www.ranzcr.com\/document\/ethical-principles-for-ai-in-medicine\/ (2019 Accessed 19 February 2026)."},{"key":"e_1_3_6_27_2","volume-title":"Ethics and Governance of Artificial Intelligence for Health: WHO Guidance","author":"World Health Organization","year":"2021","unstructured":"World Health Organization. Ethics and Governance of Artificial Intelligence for Health: WHO Guidance. World Health Organization, 2021."},{"key":"e_1_3_6_28_2","first-page":"9430","article-title":"AI scribes in rural and remote primary care: an antidote to physician burnout or Pandora\u00e2s Box","volume":"25","author":"Bressan T","year":"2025","unstructured":"Bressan T, Bakke A, Zelek B, et al. AI scribes in rural and remote primary care: an antidote to physician burnout or Pandora\u00e2s Box?. Rural Remote Health 2025; 25: 9430. https:\/\/doi.org\/10.22605\/rrh9430, Epub ahead of print.","journal-title":"Rural Remote Health"},{"key":"e_1_3_6_29_2","doi-asserted-by":"publisher","DOI":"10.2196\/22320"},{"key":"e_1_3_6_30_2","doi-asserted-by":"publisher","DOI":"10.1111\/ceo.14147"},{"key":"e_1_3_6_31_2","volume-title":"Ethical Principles for AI in Medicine","author":"The Royal Australian and New Zealand College of Radiologists","year":"2023","unstructured":"The Royal Australian and New Zealand College of Radiologists. Ethical Principles for AI in Medicine. The Royal Australian and New Zealand College of Radiologists, 2023."},{"key":"e_1_3_6_32_2","volume-title":"Artificial intelligence and Indigenous data sovereignty. Input paper for the Horizon Scanning Project \u2018The effective and ethical development of artificial intelligence: an opportunity to improve our wellbeing\u2019 on behalf of the Australian Council of Learned Academics","author":"Walter M","year":"2018","unstructured":"Walter M, Kukutai T. Artificial intelligence and Indigenous data sovereignty. Input paper for the Horizon Scanning Project \u2018The effective and ethical development of artificial intelligence: an opportunity to improve our wellbeing\u2019 on behalf of the Australian Council of Learned Academics. Australian Council of Learned Academies (ACOLA), Canberra, Australia, 2018."},{"key":"e_1_3_6_33_2","unstructured":"The Royal Australian and New Zealand College of Radiologists. Ethical Principles for AI in Medicine. The Royal Australian and New Zealand College of Radiologists."},{"key":"e_1_3_6_34_2","volume-title":"Declaration on the Rights of Indigenous Peoples","author":"United Nations","unstructured":"United Nations. Declaration on the Rights of Indigenous Peoples. https:\/\/www.un.org\/development\/desa\/indigenouspeoples\/declaration-on-the-rights-of-indigenous-peoples.html (Accessed 28 October 2025)."},{"key":"e_1_3_6_35_2","article-title":"Traditional Knowledge and Traditional Cultural Expressions","author":"Genetic Resources","unstructured":"Genetic Resources, Traditional Knowledge and Traditional Cultural Expressions. traditional-knowledge. https:\/\/www.wipo.int\/tk\/en\/ (Accessed 17 March 2026).","journal-title":"traditional-knowledge"},{"key":"e_1_3_6_36_2","volume-title":"The First Nations Information Governance Centre","author":"The First Nations Principles of OCAP\u00ae","year":"2020","unstructured":"The First Nations Principles of OCAP\u00ae. The First Nations Information Governance Centre. https:\/\/fnigc.ca\/ocap-training\/ (2020, Accessed 10 December 2024."},{"key":"e_1_3_6_37_2","unstructured":"CARE principles-Collective benefit. Authority to control Responsibility and Ethics. Global Indigenous Data Alliance (GIDA)."},{"key":"e_1_3_6_38_2","doi-asserted-by":"publisher","DOI":"10.1038\/sdata.2016.18"},{"key":"e_1_3_6_39_2","unstructured":"TCPS 2. (2022) \u2013 Chapter 9: Research Involving the First Nations Inuit and M\u00e9tis Peoples of Canada. https:\/\/ethics.gc.ca\/eng\/tcps2-eptc2_2022_chapter9-chapitre9.html (2023 Accessed 17 March 2026)."},{"key":"e_1_3_6_40_2","volume-title":"Ethics and governance of artificial intelligence for health: large multi-modal models","unstructured":"Ethics and governance of artificial intelligence for health: large multi-modal models. WHO guidance. https:\/\/www.who.int\/publications\/b\/70584? (Accessed 15 July 2026)."},{"key":"e_1_3_6_41_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.heliyon.2023.e16110"},{"key":"e_1_3_6_42_2","unstructured":"Principles respecting the Government of Canada\u2019s relationship with Indigenous peoples. https:\/\/www.justice.gc.ca\/eng\/csj-sjc\/principles-principes.html (2017 Accessed 20 February 2026)."}],"container-title":["DIGITAL HEALTH"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/20552076261481276","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/20552076261481276","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/20552076261481276","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T07:55:06Z","timestamp":1787644506000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/20552076261481276"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2]]},"references-count":41,"alternative-id":["10.1177\/20552076261481276"],"URL":"https:\/\/doi.org\/10.1177\/20552076261481276","relation":{},"ISSN":["2055-2076","2055-2076"],"issn-type":[{"value":"2055-2076","type":"print"},{"value":"2055-2076","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2]]},"article-number":"20552076261481276"}}