David Rodriguez

Este libro es un homenaje a la trayectoria intelectual y académica de la profesora María Teresa López de la Vieja, Catedrática emérita de la Universidad de Salamanca. En él se trazan algunos de los caminos que, con su obra, nos invita a transitar. El volumen recoge contribuciones de colegas de varias nacionalidades y procedentes de diversos ámbitos de reflexión que le son afines: la filosofía moral y política, la literatura, la teoría de la argumentación, los estudios feministas, las éticas aplicadas, la bioética. Los capítulos que componen este libro dan voz a varias generaciones de investigadoras e investigadores que han acompañado y acompañan su andadura académica y que aquí dialogan con ella haciendo propias sus preocupaciones intelectuales. Con su participación contribuyen al justo reconocimiento de su dedicación a la labor docente e investigadora.

The debate over the determination of death has been raging for more than fifty years. Since then, objections against the diagnosis of brain death from family members of those diagnosed as dead-have been increasing and are causing some countries to take novel steps to accommodate people’s beliefs and preferences in the determination of death. This, coupled with criticism by some academics of the brain death criterion, raises some questions about the issues surrounding the determination of death. In this paper, we discuss some of the main approaches to death determination that have been theoretically proposed or currently put into practice and propose a new approach to death determination called "weak pluralism" as a reasonable ethical and political alternative to respect diversity in death determination.

Bioethicists involved in end‐of‐life debates routinely distinguish between ‘killing’ and ‘letting die’. Meanwhile, previous work in cognitive science has revealed that when people characterize behaviour as either actively ‘doing’ or passively ‘allowing’, they do so not purely on descriptive grounds, but also as a function of the behaviour’s perceived morality. In the present report, we extend this line of research by examining how medical students and professionals (N = 184) and laypeople (N = 122) describe physicians’ behaviour in end‐of‐life scenarios. We show that the distinction between ‘ending’ a patient’s life and ‘allowing’ it to end arises from morally motivated causal selection. That is, when a patient wishes to die, her illness is treated as the cause of death and the doctor is seen as merely allowing her life to end. In contrast, when a patient does not wish to die, the doctor’s behaviour is treated as the cause of death and, consequently, the doctor is described as ending the patient’s life. This effect emerged regardless of whether the doctor’s behaviour was omissive (as in withholding treatment) or commissive (as in applying a lethal injection). In other words, patient consent shapes causal selection in end‐of‐life situations, and in turn determines whether physicians are seen as ‘killing’ patients, or merely as ‘enabling’ their death.

The ethics of deceased organ procurement (OP) is supposedly based on individual consent to donate, either explicit (opt-in) or presumed (opt-out). However, in many cases, individuals fail to express any preference regarding donation after death. When this happens, the decision to remove or not to remove their organs depends on the policy’s default option or on family preferences. Several studies show that in most countries the family plays a significant and often decisive role in the process of decision-making for OP. Depending on the country, the family may be allowed to take different kinds of actions in different situations, and this may be granted either by law or by clinical practice only. This adds much complexity to the usual classification of consent policies in two categories: opt-in and opt-out. Here we propose a novel and comprehensive taxonomy of the models of consent for OP according to three variables: (1) the deceased’s wishes, if any, (2) family wishes, if any, and (3) default policies. By analysing these models of consent, we show that they rely on at least three different concepts of autonomy: individual autonomy, relational autonomy, and family autonomy. In light of this analysis, we discuss the ethical debates surrounding two policy approaches: presumed consent and family veto.

La normalización de la precariedad entre las personas jóvenes está entrando en lo que parece una nueva fase. De la mano de, entre otros factores, los discursos empresariales y la teoría del capital humano, estamos asistiendo a una vuelta de tuerca en la presión sobre la juventud: ya no basta con la búsqueda «activa» de empleo, ahora hay que invertir en uno mismo como «empresario de sí mismo» y, en esta lógica, si es preciso hay que optar por la «movilidad internacional». Presentamos una revisión teórica y conceptual alrededor de lo que se conoce como fuga de cerebros y su justificación discursiva. Estamos ante un proceso que probablemente dejará una marca importante en una generación que ha visto truncadas sus posibilidades de transición a situaciones estables, idealmente identificadas con el mundo adulto.Normalization of precariousness among young people is entering in a new phase. Led by, among other factors, the human capital theory, we are witnessing a twist in pressure on young people: it is no longer enough with «active» job search, now you have to invest in yourself as entrepreneur of yourself’ and in this logic, maybe young people must choose for the «international mobility», which is represented as a cosmopolitan option. We present a theoretical and conceptual review around what is known as brain drain and its discursive justification. We are facing a process that will probably leave a significant mark on a generation whose chances of transition to stable situations have been truncated, ideally identified with the adult world.

Since the 1960s, organ procurement policies have relied on the boundary of death—advertised as though it were a factual, value‐free, and unobjectionable event—to foster organ donation while minimizing controversy. Death determination, however, involves both discoveries of facts and events and decisions about their meaning (whether the facts and events are relevant to establish a vital status), the latter being subjected to legitimate disagreements requiring deliberation. By revisiting the historical origin of the dead donor rule, including some events that took place in France prior to the report by the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, I want to recall that those who first promoted the DDR did not take into account any scientific rationale to support the new proposed criteria to determine death. Rather, through a process of factual re‐semantization, they authorized themselves to decide about the meaning of death in order to implicitly prioritize the interests of organ recipients over those of dying people.

In this issue of the Report, James L. Bernat proposes an innovative and sophisticated distinction to justify the introduction of permanent cessation as a valid substitute standard for irreversible cessation in death determination. He differentiates two approaches to conceptualizing and determining death: the biological concept and the prevailing medical practice standard. While irreversibility is required by the biological concept, the weaker criterion of permanence, he claims, has always sufficed in the accepted standard medical practice to declare death. Bernat argues that the medical practice standard may be acceptable on the ground that proving circulatory or brain permanence is sufficient to assure complete accuracy for death diagnosis. The topic requires public deliberation: processes to survey people's opinions and mechanisms to channel their opinions into policy-making. What is at stake is the nature of our society. Do we want an expertocracy, in which an enlightened few design policies for the greater good of the majority and exploit the lack of public knowledge to achieve compliance?

This study examined health professionals’ (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)—controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios—BD, uncontrolled DCD and controlled DCD—were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors’ loss of circulatory function could be reversed, and raises questions about “death” as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs’ discomfort must be further identified and addressed

Determinar el momento exacto en que tiene lugar la muerte siempre ha sido un problema de difícil resolución. Las propuestas tradicionales y contemporáneas para justificar los criterios legales de determinación de la muerte se han visto condicionadas por intereses sociales —en particular, recientemente, relativos a los trasplantes de órganos—. Los criterios legalmente aceptados para declarar la muerte siguen careciendo de soporte conceptual o científico. En este contexto de ausencia de consenso sobre la demarcación exacta de la frontera entre la vida y la muerte, estas son algunas de las preguntas que abordo en este artículo: ¿Cómo podemos definir la muerte? ¿Es la determinación de la muerte una tarea basada únicamente en hechos, o también en juicios de valor? ¿Equivale la muerte cerebral a la muerte humana? ¿Qué papel le corresponde a la bioética en los debates relativos a la determinación de la muerte y la obtención de órganos?

This book offers a theoretical and practical overview of the specific ethical and legal issues in pediatric organ transplantation. Written by a team of leading experts, Ethical Issues in Pediatric Organ Transplantation addresses those difficult ethical questions concerning clinical, organizational, legal and policy issues including donor, recipient and allocation issues. Challenging topics, including children as donors, donation after cardiac death, misattributed paternity, familial conflicts of interest, developmental disability as a listing criteria, small bowel transplant, and considerations in navigating the media are discussed. It serves as a fundamental handbook and resource for pediatricians, transplant health care professionals, trainees, graduate students, scholars, practitioners of bioethics and health policy makers.

Despite continuing controversies regarding the vital status of both brain-dead donors and individuals who undergo donation after circulatory death (DCD), respecting the dead donor rule (DDR) remains the standard moral framework for organ procurement. The DDR increases organ supply without jeopardizing trust in transplantation systems, reassuring society that donors will not experience harm during organ procurement. While the assumption that individuals cannot be harmed once they are dead is reasonable in the case of brain-dead protocols, we argue that the DDR is not an acceptable strategy to protect donors from harm in DCD protocols. We propose a threefold alternative to justify organ procurement practices: (1) ensuring that donors are sufficiently protected from harm; (2) ensuring that they are respected through informed consent; and (3) ensuring that society is fully informed of the inherently debatable nature of any criterion to declare death

It was only after James P. Lovette's death, in 2006, that I discovered that the twenty‐four‐year‐old colleague and friend with whom I had spent so many afternoons debating issues in organ transplantation had been the first successful child heart transplantee in the world and one of the longest‐living survivors of a second transplant. During the years we met, he never even hinted at the fact that three different hearts had beaten in his chest. The revelation that his life had been an almost uninterrupted chain of medical challenges suddenly made me appreciate his quirkiness in a whole new light.Organ transplantation crudely exemplifies a traditional moral dilemma between means and ends: in order to save a life, someone else has to die. Bioethicists involved in this field have the role of identifying the ethical issues surrounding organ donation and helping others to argue in an intelligible and convincing way. In my view, bioethicists have the obligation to foster a discussion as open and transparent as possible on these matters. Still, I sometimes fear that I may be helping to cause unnecessary harms to potential recipients who are desperately waiting for a vital organ. Scholars would be chillingly cold if their quest for truth systematically came at the cost of lives lost. Every life can be meaningful and provide meaning to many others. This is true even with organ recipients, who often have short lives full of considerable suffering.

The ever‐increasing demand for organs led Spain, France, and other European countries to promote uncontrolled donation after circulatory determination of death (uDCDD). For the same reason, New York City has recently developed its own uDCDD protocol, which differs from European programs in some key ways. The New York protocol incorporates a series of technical and management improvements that address some practical problems identified in response to European uDCDD protocols. However, the more fundamental issue of whether uDCDD donors are dead when organs are procured remains problematic for the New York City protocol and, indeed, for all uDCDD protocols. In the United States, two amendments to the legal criteria of death have been suggested to avoid a formal violation of the dead donor rule in DCDD protocols: first, replacing the requirement “irreversible” with the weaker term “permanent,” and second, using the term “circulatory” instead of “cardiac” to identify the key function that must be lost to declare death. While intended to facilitate controlled DCDD, these modifications create a problem for uDCDD protocols: if extracorporeal membrane oxygenation is introduced to preserve the organs, then circulation is restored after death is declared. In this issue of the Hastings Center Report, Kevin Munjal and colleagues call for a new ethical construct and policy so that uncontrolled and controlled DCDD can coexist.

En los últimos treinta años se ha transitado desde una concepción del capital humano como una macromagnitud económica a una idea de capital humano corporeizada en el individuo. Hemos asistido a una progresiva infiltración de dicha ideología del capital humano también en la vida de la juventud precaria. Nos centramos aquí en los jóvenes universitarios, para quienes el capital humano, ya de forma hegemónica, dirige y marca sus recorridos laborales y vitales. El análisis de los discursos de estos jóvenes nos permitirá explorar desde la imposición de la lógica de la movilidad laboral, a la sujeción a las formas de "emprendedor de sí mismo" y a la normalización, como parte del proceso de incorporación de capital humano, de formas de empleo progresivamente al margen de los derechos y garantías laborales clásicas del trabajo salariado.In the last thirty years it has been gone from a conception of the human capital as an economic macro magnitude to an idea of human capital embodied in the individuals. We have been witnesses of the progressive infiltration of this ideology of the human capital also in the life of precarious youth. We focus in the university young people, for those who the human capital, already of hegemonic form, directs and marks its labour and vital routes. The analysis of the discourses of these young people will allow us to explore the imposition of the logic of labour mobility, the subjection to the forms of «entrepreneur of itself» and also the normalization of forms of work progressively excluded from the rights and classic labour guarantees as a part of the process of incorporation of human capital.

Resumen: En el marco del estudio de los discursos gerenciales, se destacan en el presente texto algunas de las aportaciones de Medina-Vicent, especialmente el análisis de los procesos de individualización y despolitización de mensajes que entroncarían con las reivindicaciones del feminismo. En este contexto, se propone la incorporación del concepto foucaultiano de dispositivo para el estudio de los elementos que contribuyen a la difusión de los discursos gerenciales. Este concepto podría ser de utilidad en la investigación empírica, proporcionando una herramienta conceptual para estudiar como un sistema homogéneo de relaciones de saber y poder los distintos elementos que conformarían el dispositivo gerencial.: Within the framework of the study of managerial discourses, this text highlights some of the contributions of Medina-Vicent, especially the analysis of the processes of individualization and depoliticization of messages that are linked to the claims of feminism. In this context, the incorporation of the Foucauldian concept of dispositif is proposed for the study of the elements that contribute to the diffusion of managerial discourses. This concept could be useful in the empirical analysis, as well as providing a conceptual tool to study the different elements that make up the managerial dispositif as a homogeneous system of knowledge and power relations. Palabras clave: gerencialismo, dispositivo, herramientas disciplinarias. Keywords: managerialism, dispositif, disciplinary instruments.