Bioethical Dimensions of Health Misinformation in Ambulatory Care Settings: A Conceptual Review Proposing an Integrated Three-Level Framework

1. Introduction

Health misinformation is not a new phenomenon, but its scale and structural significance have been transformed beyond recognition in the digital era. Patients accessing primary healthcare, specialist outpatient clinics, consultation-diagnostic points, and community pharmacies present with increasing frequency with health beliefs shaped by sources of questionable epistemic quality [1,7]. The World Health Organization designated the concurrent epidemic of information and misinformation that accompanied the COVID-19 pandemic as an “infodemic” and classified it as a public health threat of comparable magnitude to the pathogen itself [2]. The problem, however, long predates the pandemic: from anti-vaccine narratives circulating on social media for decades before 2020 [28] to pervasive misinformation about cancer treatment, the substitution of dietary supplements for pharmacotherapy, and the self-management of chronic conditions such as diabetes [29], health misinformation pervades clinical encounters across the full spectrum of ambulatory settings.

Existing responses to health misinformation have predominantly framed it as a problem of individual communication competency: healthcare professionals need better debunking skills, patients need higher health literacy, and clinical interactions need to be better designed. This framing is inadequate. It systematically underestimates the degree to which the capacity to respond ethically to misinformation is determined not by clinician skill alone but by organizational conditions—consultation time, training, and institutional procedures—and by systemic factors, chief among them the structural inequalities in access to reliable health information that reproduce themselves regardless of individual competence [9,15]. The consequence is that clinically skilled and ethically motivated healthcare professionals routinely experience moral distress precisely because organizational and systemic conditions prevent them from responding as their professional judgment requires [23].

This paper argues that health misinformation in ambulatory care constitutes a three-level structural problem—clinical, organizational, and systemic—and that an ethically coherent response requires coordinated intervention across all three levels simultaneously. We propose an integrated framework combining Beauchamp and Childress’ four principles of biomedical ethics [3] to diagnose tensions at the clinical level, the 4i FACT framework [9] to structure the organizational response, and the concept of epistemic injustice [20,21] to reveal the systemic dimension. These three frameworks are individually insufficient yet mutually complementary: integrated, they produce a model whose analytical reach exceeds what any constituent framework achieves in isolation. This constitutes the original contribution of the present paper.

A secondary contribution is the empirical contextualization of prebunking (cognitive inoculation) as an ethical rather than merely strategic tool, together with its operationalization within the realistic time constraints of ambulatory consultations. The study is conducted as a conceptual review [6] drawing on literature in bioethics, public health, health communication, and healthcare management.

2. Conceptual Framework: Three Lenses and Their Limits

This analysis employs three complementary frameworks, selected because each is analytically strongest at a different level of the problem. A critical prerequisite to their combined application is an honest account of what each framework is unable to accomplish alone.

2.1. Principlism: Diagnostic Strength, Prescriptive Limitations

Beauchamp and Childress’ four principles of biomedical ethics [3]—respect for autonomy, beneficence, non-maleficence, and justice—constitute the most widely applied framework in Western clinical bioethics. Their prima facie character means they are binding as a general rule but subject to context-specific weighing. In complex misinformation situations, this yields the framework’s principal strength: the capacity to name, articulate, and map the types of tension present in a given encounter.

Principlism’s equally important limitation was identified at an early stage by Clouser and Gert [25], who argued that the four principles lack a unifying theory capable of resolving conflicts among them: when autonomy and beneficence pull in opposite directions—as they routinely do in misinformation encounters—principlism diagnoses the tension but offers no determinate resolution. This is not a fatal flaw but a structural feature that demands supplementation. In the present framework, the 4i FACT model provides the organizational prescriptive layer that principlist analysis alone cannot supply.

A further limitation emerges from feminist bioethics and care ethics. Held [27] and other care ethics theorists argue that autonomy-centred frameworks systematically undervalue the relational and dependency dimensions of clinical encounters. In primary care settings where nurses maintain years-long relationships with patients, the morally relevant dimension is often not the patient’s independent decision-making capacity but the relational context within which that capacity is exercised and developed. Care ethics thus offers a complementary lens—one particularly relevant for nursing and community pharmacy—that foregrounds the clinician’s responsive attentiveness to the patient’s evolving epistemic state across time, in contrast to the principlist focus on discrete decision-making moments.

2.2. The 4i FACT Framework: Organizational Clarity Without Ethical Direction

Magenheimer and Christian’s 4i FACT (Framework for Advancing Communication and Trust) [9] organizes infodemic management strategies across four levels: informational (content and access), individual (personal competency), interpersonal (relational dynamics), and institutional (governance and policy). The framework is analytically strong at identifying where interventions should be located and who bears responsibility for delivering them.

Its critical limitation is axiological neutrality: the 4i FACT framework specifies how to intervene effectively but not what constitutes an ethically justified intervention. A misinformation management programme that systematically prioritized administratively convenient responses over those addressing structural informational inequality would be fully 4i FACT-compliant and ethically deficient. Principlist analysis and epistemic injustice theory supply the normative direction that the 4i FACT framework requires but does not itself provide.

2.3. Epistemic Injustice: Structural Reach Beyond the Clinical Encounter

Fricker’s concept of epistemic injustice, developed in the clinical context by Heggen and Berg [20] and Blease et al. [21], identifies a form of injustice that occurs when a patient is unfairly treated as a knowing subject—when their knowledge, experience, or capacity to evaluate information is deprecated, dismissed, or systematically excluded. Two forms are particularly relevant here: testimonial injustice (the credibility deficit suffered by patients whose epistemic authority is undervalued in the encounter) and hermeneutical injustice (the structural absence of interpretive resources that would allow patients to make sense of their health experiences).

The distinctive contribution of epistemic injustice theory to the present framework is its systemic reach: it explains why individually skilled and organizationally supported clinical responses to misinformation may still reproduce informational inequality when patients from marginalized groups encounter structural deficits that no individual clinician or single organization can remedy. This justifies a third level of analysis—the systemic level—that is irreducible to the sum of clinical encounters and organizational procedures.

2.4. The Complementarity Argument

Principlism identifies what is ethically at stake in the encounter and provides a vocabulary for naming tensions (Level 1). The 4i FACT framework identifies which organizational structures must be activated to make ethical responses possible (Level 2). Epistemic injustice theory reveals the structural mechanisms through which informational inequality is reproduced independently of individual and organizational intervention (Level 3). The three frameworks are not competing alternatives but nested complements: each is necessary, none is sufficient, and together they constitute the integrated three-level model proposed in Section 8.

3. Methods

3.1. Study Type and Rationale

This study employs a conceptual review methodology, defined by Jaakkola [6] as a research approach that uses existing literature to develop, refine, or challenge theoretical concepts and frameworks. A conceptual review synthesizes insights from multiple disciplines to produce an original conceptual contribution—in this case, the three-level integrated framework—that is not reducible to a summary of the existing literature. It differs from a systematic review in not applying a PRISMA-based selection procedure or formal quality assessment, and from a narrative review in its commitment to an explicit, a priori analytical structure. This methodology is appropriate for emerging multidisciplinary topics where the primary need is conceptual mapping and theoretical integration rather than effectiveness synthesis [6].

3.2. Literature Search Strategy

Literature searches were conducted in January 2026 and updated in July 2026. Databases searched: PubMed/MEDLINE, Scopus, and Web of Science (primary); CINAHL and the Philosopher’s Index (supplementary); Google Scholar (supplementary, first 150 results per query screened). The Scite.ai platform was used to identify highly cited publications and trace citation networks. Search term groups comprised: (1) misinformation terminology (health misinformation, medical disinformation, infodemic, vaccine hesitancy); (2) bioethical terminology (bioethics, patient autonomy, epistemic injustice, Beauchamp Childress, principlism, care ethics); (3) ambulatory context (ambulatory care, primary health care, community pharmacy, outpatient specialist care); (4) EBM and communication terminology (evidence-based medicine, shared decision-making, health literacy, debunking, prebunking, inoculation theory); (5) organizational dimensions (moral distress, healthcare management, infodemic management). Terms within each group were combined with OR; groups were combined with AND.

Table 1 summarizes records at each selection stage. The final corpus of 65 publications was subjected to directed content analysis; 29 are directly cited in the present paper as most representative of the themes identified across the three analytical frameworks and three levels of the proposed model.

3.3. Inclusion and Exclusion Criteria

Included: peer-reviewed publications (empirical, review, conceptual, and normative) in English or Polish, published 2010–2026, with the exception of foundational works underpinning the conceptual frameworks (Beauchamp and Childress, Sackett et al., Fricker). Excluded: editorials and conference abstracts without full text; studies confined to inpatient hospital settings with no reference to ambulatory or community care contexts.

3.4. Application of the Analytical Framework

All 65 publications were subjected to directed content analysis using the three a priori frameworks as primary coding categories and the three levels (clinical, organizational, systemic) as secondary coding dimensions. Each identified bioethical issue was assigned to at least one framework and at least one level. Coding consistency was monitored through cross-checking of assignments between co-authors; discrepancies were resolved by consensus. Publications with the highest potential impact (Scite.ai Smart Citations score and citation count) were prioritized in constructing the argument, without applying formal citation thresholds as an inclusion criterion.

4. Health Misinformation in Ambulatory Care: Scope, Varieties, and Contexts

Health misinformation is understood here as a factual health-related claim that is currently unsupported by scientific evidence [29]. This encompasses misinformation disseminated without intent to deceive as well as deliberate disinformation; the ethical challenge for ambulatory care personnel is equivalent regardless of origin.

The thematic scope of misinformation encountered across ambulatory settings is wide and extends substantially beyond the COVID-19 pandemic context that dominates recent literature. Pre-pandemic analyses documented persistent anti-vaccine narratives on social media platforms [28]; misinformation about alternative cancer treatments constitutes a clinically significant problem in oncological ambulatory care [29]; false claims about dietary supplements as alternatives to pharmacotherapy are common in primary care consultations on diabetes management and cardiovascular disease [7]. The epidemiology of health misinformation exposure shows consistent patterns: susceptibility correlates with health and digital literacy rather than with general educational attainment, and exposure to misinformation increases with social media use irrespective of socioeconomic status [7].

Three distinct ambulatory contexts warrant separate analysis, each generating structurally different ethical conditions.

In primary healthcare, the defining ethical feature is relational continuity: nurses and general practitioners maintain multi-year relationships with patients, creating conditions for care ethics-based attentiveness to evolving epistemic states [13]. Time pressure is acute—fifteen to twenty minutes per visit in most European systems—and misinformation encounters are frequent [15]. The relational dimension constitutes an ethical resource that principles analyses have tended to underutilize.

In specialist outpatient care, patients often arrive with misinformation specifically relevant to their condition—particularly in oncology, endocrinology, and reproductive medicine. The encounter is typically episodic rather than relational, and the asymmetry of specialist expertise is greater. Misinformation correction by specialists carries high epistemic authority [8] but risks epistemic condescension if not embedded in shared decision-making frameworks [5].

In community pharmacy, the consultation is brief—typically under five minutes—but occurs at the point of medication dispensing, a moment of high patient receptivity. Pharmacists encounter misinformation about drug interactions, supplement substitutions, and vaccine contraindications. Their epistemic authority is well recognized; however, the brevity of their consultations renders sustained prebunking impractical without dedicated micro-intervention protocols.

5. Bioethical Dimensions of Health Misinformation: Level 1 Analysis

5.1. Patient Autonomy: Formal, Substantive, and Relational Dimensions

The principle of respect for autonomy obliges healthcare professionals to honor the patient’s capacity to make decisions grounded in their own values and preferences [3]. Beauchamp and Childress specify three conditions for autonomous action: intentionality, understanding, and freedom from controlling influences. Health misinformation systematically violates the third condition without applying visible coercion: it controls belief-formation by corrupting the informational environment from which decisions emerge.

This observation gives rise to a critical distinction: between formal autonomy (the right to decide) and substantive autonomy (the capacity for decisions that are genuinely grounded in reliable information). Shielding formal autonomy while allowing misinformation to corrupt its epistemic basis is not a genuine exercise of respect for autonomy—it is an abdication of the beneficence obligation that underwrites the clinician’s epistemic authority. Correcting misinformation is not paternalism when it serves to restore rather than override the patient’s genuine epistemic agency. Garcia and O’Leary [12] document this tension in vaccine refusal contexts: clinicians who defer entirely to formal autonomy in the face of demonstrably false beliefs are not respecting autonomy but abandoning their obligations under beneficence.

Care ethics offers a distinct yet compatible analysis [27], one that foregrounds the relational context within which health decisions are made and the clinician’s responsive attentiveness to the patient’s epistemic needs across time, rather than the patient’s autonomous decision-making capacity as an isolated moral reference point. In the primary care setting, where nurse-patient relationships span years, this framing is often closer to what ethically sensitive practice actually looks like: the clinician does not approach each encounter as an autonomous decision-making moment to be respected or overridden but as a continuing relational process in which the patient’s capacity for health-related understanding is gradually built. Care ethics does not replace principlist autonomy analysis; it reveals a temporal dimension that principlism tends to flatten. The systematic building of health literacy [14] is the operational expression of this relational epistemic commitment.

5.2. Beneficence and Non-Maleficence: The Correction Obligation and Its Limits

Both beneficence and non-maleficence support the active correction of health misinformation; the weight of empirical evidence strongly favors such correction. Walter et al.’s meta-analysis [17] demonstrated that corrective interventions generally reduce false beliefs, with corrections from clinical domain experts producing the strongest effects. The concern most frequently invoked against active correction—the backfire effect, whereby correction allegedly strengthens false beliefs—has been substantially revised in recent research. Swire-Thompson et al. [18] showed that reported backfire effects are strongly associated with low measurement reliability rather than genuine psychological resistance; Wood and Porter [26] independently confirmed that the effect is elusive and inconsistently replicable across contexts. The appropriate conclusion is not that the backfire effect never occurs, but that it is context-dependent, not a generalizable barrier to correction, and should not constitute grounds for clinical inaction.

Non-maleficence nevertheless imposes real constraints on the form that correction may appropriately take. Confrontational or condescending correction risks damaging the therapeutic relationship that is itself an ethical resource in long-term ambulatory care [22]. Communication strategies that acknowledge the patient’s underlying concern while correcting the factual basis of the belief—motivational interviewing techniques adapted to misinformation contexts—substantially reduce this risk. Lotto et al. [10] extend the non-maleficence argument to the organizational level: providers that lack procedures for ethical misinformation management systemically harm patients through institutional inaction, not merely through the failures of individual encounters.

5.3. Justice and Epistemic Injustice: From Principle to Structure

The principle of justice, applied to health misinformation, requires equitable access to reliable health information as a good that distributes through healthcare systems. Naeem and Boulos [7] demonstrate that vulnerability to misinformation and access to its correction are simultaneously and unevenly distributed across health literacy, digital literacy, and socioeconomic status, creating cumulative disadvantage in populations already underserved by health systems.

Epistemic injustice theory [20,21] supplies the structural mechanism that principlist justice analysis characteristically leaves implicit. Testimonial injustice occurs when a patient’s credibility as an epistemic agent is systematically underweighted—their questions dismissed, their internet-sourced beliefs mocked rather than engaged. This form of injustice is particularly prevalent in encounters with patients from marginalized groups and, critically, increases rather than decreases susceptibility to misinformation: it redirects patients toward alternative epistemic communities—online advocacy groups, patient forums—that take their concerns seriously without subjecting them to epistemic scrutiny [21]. Hermeneutical injustice occurs when patients lack the conceptual resources to interpret or communicate their health experiences accurately—a structural deficit that no individual clinician can fully remedy.

6. Evidence-Based Medicine and Inoculation Strategies as Ethical Tools

6.1. EBM: Corrective and Autonomy-Building Functions

EBM—defined as the conscientious, explicit, and judicious use of current best evidence in clinical decision-making, integrating patient values and clinician expertise [4]—serves two distinct ethical functions in misinformation contexts. Its corrective function positions the clinician as an epistemic authority whose evidence-grounded correction carries the highest credibility among available correction sources [17]. Its autonomy-building function—less frequently theorized—lies in the use of EBM not to override the patient’s beliefs but to cultivate the health literacy foundation [14] from which genuinely substantive, autonomous health decisions can emerge over time.

Heggen and Berg [20] identify an important internal tension: EBM’s hierarchy of evidence can itself enact testimonial injustice when it systematically devalues patient experience as an epistemic input. Conditions characterized by significant experiential complexity—chronic pain, fatigue syndromes, long-term medication management—require integration of patient narrative alongside randomized evidence. Clinicians who deploy EBM as unidirectional evidence transmission rather than as a collaborative sensemaking process risk exchanging one epistemic problem (misinformation) for another (testimonial injustice). The ethical use of EBM in misinformation contexts therefore requires active listening alongside evidence presentation, not as a concession but as an integral ethical obligation.

6.2. Prebunking: Proactive Ethics and the Autonomy Argument

Prebunking (cognitive inoculation) is grounded in inoculation theory: advance exposure to weakened versions of manipulative argumentative techniques builds resistance to subsequent misinformation messages [16]. Lewandowsky and van der Linden [16] report moderate to large effectiveness (d ≈ 0.43) in a comprehensive evidence synthesis. Basol et al. [19] confirm cross-cultural robustness. Vivion et al. [24] demonstrate protective effects of prebunking messages for adults over 50 in COVID-19 vaccine contexts.

Prebunking is ethically preferable to debunking in two important respects. First, it addresses substantive autonomy proactively: rather than correcting a patient who has already formed a false belief—and whose sense of identity may be partly invested in that belief—it equips the patient with epistemic tools for independent evaluation before misinformation exposure. Second, it aligns with care ethics’ temporal dimension: it represents a relational investment in the patient’s long-term epistemic capacity rather than a transactional corrective intervention.

6.3. Practical Operationalization Within Ambulatory Consultation Time

A recurrent objection to prebunking as a clinical tool is its apparent incompatibility with consultation time constraints: how is a clinician to deliver a cognitively meaningful inoculation intervention within a fifteen-minute primary care visit or a three-minute pharmacy consultation? The objection conflates full-scale prebunking programmes with brief clinical micro-interventions, which are distinct formats with distinct evidence bases.

Brief prebunking messages [24] consisting of two to three sentences have demonstrated protective effects when delivered at moments of natural patient receptivity: at the initiation of a vaccination appointment (“You may encounter claims online that this vaccine causes X; these claims have been repeatedly examined and consistently found to be false because Y”), when prescribing medication associated with documented online misinformation (as is frequently the case in oncology, diabetes care, and immunology), or when providing a preventive health referral. These micro-interventions add no more than ten to twenty seconds to the consultation and require no specialized communication training beyond brief, standardized scripts.

The organizational prerequisite for brief clinical prebunking is the availability of condition- and context-specific scripts developed and validated at the organizational level—a Level 2 responsibility in the three-level model. Without organizational infrastructure, even highly motivated clinicians cannot implement brief prebunking routinely, because they lack standardized, evidence-reviewed messaging tailored to the specific misinformation variants prevalent in their setting. Community pharmacies, with the briefest encounters, require the most standardized scripts; primary care nurses with long-term relationships have the greatest flexibility for individualized, relationship-embedded prebunking.

7. Organizational and Managerial Context: Level 2 Analysis

The 4i FACT framework [9] identifies the institutional level as the primary determinant of the sustainability and equity of ethical responses to health misinformation. Individual clinical competencies are necessary but not sufficient: their consistent activation requires organizational conditions that the great majority of ambulatory care providers do not currently maintain [15,23].

Znyk et al. [15] document the primary structural barriers in Polish primary care: insufficient consultation time (cited by 51.4% of nurses as a barrier to effective health counselling), perceived patient non-receptivity (60.7%), and inadequate communication training. Silva et al. [13] show that primary care nurses experience this gap between ethical knowledge and structural impossibility as moral distress—a phenomenon that Giannetta et al. [23] confirm as systematically understudied in primary care relative to hospital settings. Moral distress is analytically important because it indexes organizational failure rather than individual inadequacy: when ethically motivated clinicians consistently cannot do what they know to be right, the problem is institutional, not personal.

The organizational response architecture differs across ambulatory settings. In primary care, the most impactful organizational interventions are extended consultation time protocols for patients presenting with chronic misinformation-driven non-adherence, and prebunking script libraries organized by condition and misinformation type. In specialist outpatient care, where encounters are episodic, the most valuable organizational investment is the embedding of misinformation screening within standard consultation protocols—analogous to falls risk or pain assessment tools already integrated into most outpatient workflows. In community pharmacy, organizational response centres on brief standardized scripts for the highest-frequency misinformation categories (supplement-drug interactions, vaccine contraindication myths, antibiotic resistance misunderstandings) and their systematic inclusion in dispensing workflows.

Operationalizing the 4i FACT framework at the institutional level requires four coordinated categories of action. At the informational level: curated, regularly updated evidence repositories cataloguing prevalent local misinformation variants, accessible to all clinical staff. At the individual level: standardized training in brief misinformation screening and correction, including prebunking script delivery. At the interpersonal level: structured peer supervision forums for ethical reflection on challenging misinformation encounters. At the institutional level: explicit governance structures assigning organizational accountability for misinformation management, measurable performance indicators, and dedicated resource allocation.

8. An Integrated Three-Level Framework for the Ethical Management of Health Misinformation in Ambulatory Care

The analytical work of Sections 2–7 grounds the present paper’s primary original contribution: a three-level integrated framework that makes explicit what remains implicit in each constituent framework applied in isolation. The framework’s central claim is that the ethical management of health misinformation requires coordinated intervention at three levels simultaneously; addressing any single level without the others yields outcomes that are partial, fragile, or inequitable.

At Level 1 (clinical encounter), the bioethical challenge is principally the tension between formal and substantive patient autonomy, and between beneficence and the real but overstated risk of communicative harm through correction. The analytical tool is principlist analysis; the operational response is active corrective communication (debunking) and brief cognitive inoculation (prebunking) delivered within the constraints of the specific ambulatory context.

At Level 2 (organizational), the ethical challenge is the structural production of moral distress through organizational conditions that render ethically appropriate Level 1 responses systematically impossible. The analytical tool is the 4i FACT framework; the operational response is organizational policy design addressing consultation time, training, script availability, and governance accountability.

At Level 3 (systemic/policy), the ethical challenge is the structural reproduction of informational inequality through which marginalized populations remain disproportionately exposed to misinformation and underserved by corrective interventions, regardless of the quality of Level 1 and Level 2 responses. The analytical tool is epistemic injustice theory; the operational response is health equity policy—digital health literacy programmes, equitable access to healthcare consultations, and redesign of health information infrastructure to reduce systematic credibility deficits in marginalized communities.

Table 2 presents the integrated framework, conceived not as a theoretical artefact but as an analytical and practical tool for healthcare providers, managers, and policymakers: each cell maps a specific ethical challenge at a given level onto a corresponding mode of ethical response.

The framework’s integrative logic operates as follows. Level 1 responses are necessary but not sufficient: without Level 2 organizational support, they are inconsistent, unsustainable, and generate moral distress. Level 2 responses are necessary but not sufficient: without Level 3 systemic measures, organizationally excellent providers may still serve patient populations with unequal misinformation exposure and unequal correction access. Level 3 responses are necessary but not sufficient: system-level equity policies require Level 2 implementation capacity and Level 1 clinical competency to produce actual health outcomes. The framework is therefore non-hierarchical: all three levels are simultaneously necessary, and none is privileged as the “real” solution.

9. Discussion

The integrated three-level framework proposed here advances the literature beyond what earlier single-framework analyses could achieve. Existing principlist analyses of health misinformation—including well-regarded work on vaccine refusal [12] and misinformation in digital health contexts [10,11]—are diagnostically rich but provide insufficient guidance for organizational and systemic response design, because the four principles are not action-guiding at those levels. The 4i FACT framework [9] provides organizational guidance but is ethically underdetermined: it would accommodate a misinformation management programme that was organizationally efficient yet epistemically unjust. Epistemic injustice theory [20,21] supplies the systemic ethical dimension but lacks the organizational and clinical operationalization that would make it actionable for healthcare providers. The integrated framework fills each of these gaps by nesting the three frameworks within a coherent level structure.

The framework also reconceptualizes moral distress [23]: rather than treating it as a psychological phenomenon requiring individual clinical support, it recasts moral distress as an organizational performance indicator that signals the need for structural remedy. When healthcare professionals consistently experience moral distress in response to health misinformation, the appropriate diagnosis is not insufficient individual resilience but insufficient organizational investment in Level 2 conditions. This reconceptualization has direct implications for healthcare management: the systematic monitoring of moral distress levels becomes a quality indicator for organizational misinformation management capacity, analogous to staff burnout surveillance as a proxy for broader organizational health.

The framework’s most practically novel element is the operationalization of prebunking within realistic ambulatory consultation time. Previous research on prebunking has focused predominantly on population-level media and social media delivery [16,19,24] rather than on the individual clinical encounter. The brief micro-intervention model proposed in Section 6.3 begins to bridge this translation gap, though the empirical validation of clinical micro-prebunking protocols remains a pressing priority for future research.

Several limitations constrain the present analysis. The conceptual review methodology prioritizes theoretical coherence and analytical reach over systematic evidence synthesis: the framework’s claims regarding organizational and systemic interventions are theoretically grounded but empirically undervalidated. The literature base is predominantly Anglo-Saxon and may not adequately capture the health system-specific features of Central and Eastern European ambulatory care contexts in which the study team is active. The absence of primary data means that the Level 2 and Level 3 claims in Table 2 represent analytical propositions rather than empirically tested recommendations. Future research should prioritize: (1) a scoping review of organizational misinformation management interventions in ambulatory care; (2) an empirical validation study of brief clinical prebunking micro-interventions in primary care and pharmacy settings; and (3) a multi-site cross-sectional study linking organizational misinformation management capacity with moral distress levels and patient health literacy outcomes in Central and Eastern European ambulatory care.

10. Conclusions

• Health misinformation in ambulatory care is a three-level structural problem—clinical, organizational, and systemic—that existing single-framework analyses cannot fully address. The integrated framework proposed here, combining Beauchamp and Childress’ four principles, the 4i FACT framework, and epistemic injustice theory across three levels, provides a coherent model for ethical misinformation management whose analytical scope exceeds that of any constituent framework.
• Healthcare providers bear organizational ethical responsibility for the Level 2 conditions that make consistent Level 1 responses possible: prebunking script libraries, consultation time policies, training programmes, and governance accountability structures. Moral distress among ambulatory care personnel is an indicator of Level 2 failure, not of individual inadequacy. Brief clinical prebunking micro-interventions are both ethically justified and feasible within realistic ambulatory consultation time, provided the organizational prerequisites are in place.
• Level 3 systemic responses—health equity policy, digital health literacy programmes, and the redesign of health information infrastructure—are indispensable for preventing the structural reproduction of informational inequality that renders populations from marginalized groups disproportionately vulnerable to health misinformation, irrespective of the quality of Level 1 and Level 2 interventions. The empirical validation of the integrated framework in Central and Eastern European ambulatory care contexts constitutes the most pressing item on the agenda for future research.