David Rodriguez

Background: Contemporary societies are rife with moral disagreement, resulting in recalcitrant disputes on matters of public policy. In the context of ongoing bioethical controversies, are uncompromising attitudes rooted in beliefs about the nature of moral truth? Methods: To answer this question, we conducted both exploratory and confirmatory studies, with both a convenience and a nationally representative sample (total N = 1501), investigating the link between people’s beliefs about moral truth (their metaethics) and their beliefs about moral value (their normative ethics).Results Across various bioethical issues (e.g., medically-assisted death, vaccine hesitancy, surrogacy, mandatory organ conscription, or genetically modified crops), consequentialist attitudes were associated with weaker beliefs in an objective moral truth. This association was not explained by domain-general reflectivity, theism, personality, normative uncertainty, or subjective knowledge. Conclusions: We find a robust link between the way people characterize prescriptive disagreements and their sensibility to consequences. In addition, both societal consensus and personal conviction contribute to objectivist beliefs, but these effects appear to be asymmetric, i.e., stronger for opposition than for approval.

Since the 1960s, scientists, engineers, and healthcare professionals have developed brain–computer interface (BCI) technologies, connecting the user’s brain activity to communication or motor devices. This new technology has also captured the imagination of publics, industry, and ethicists. Academic ethics has highlighted the ethical challenges of BCIs, although these conclusions often rely on speculative or conceptual methods rather than empirical evidence or public engagement. From a social science or empirical ethics perspective, this tendency could be considered problematic and even technocratic because of its disconnect from publics. In response, our trinational survey (Germany, Canada, and Spain) reports public attitudes toward BCIs (N = 1,403) on ethical issues that were carefully derived from academic ethics literature. The results show moderately high levels of concern toward agent-related issues (e.g., changing the user’s self) and consequence-related issues (e.g., new forms of hacking). Both facets of concern were higher among respondents who reported as female or as religious, while education, age, own and peer disability, and country of residence were associated with either agent-related or consequence-related concerns. These findings provide a first look at BCI attitudes across three national contexts, suggesting that the language and content of academic BCI ethics may resonate with some publics and their values.

The main aim of this article is to reflect on the impact of biases related to artificial intelligence (AI) systems developed to tackle issues arising from the COVID-19 pandemic, with special focus on those developed for triage and risk prediction. A secondary aim is to review assessment tools that have been developed to prevent biases in AI systems. In addition, we provide a conceptual clarification for some terms related to biases in this particular context. We focus mainly on nonracial biases that may be less considered when addressing biases in AI systems in the existing literature. In the manuscript, we found that the existence of bias in AI systems used for COVID-19 can result in algorithmic justice and that the legal frameworks and strategies developed to prevent the apparition of bias have failed to adequately consider social determinants of health. Finally, we make some recommendations on how to include more diverse professional profiles in order to develop AI systems that increase the epistemic diversity needed to tackle AI biases during the COVID-19 pandemic and beyond.

Organ Donation after Medical Aid in Dying (OD-MAiD) is currently practised in four countries: Belgium, Canada, the Netherlands, and Spain. While OD-MAiD shares some similarities with MAiD (absent the possibility of organ donation) and with standard organ donation protocols, the combination of OD and MAiD involves unique circumstances that present novel ethical challenges. These challenges revolve around donors' consent and protection, the dead donor rule, and organ allocation. This paper explores these moral challenges and proposes strategies to ensure ethical safeguards in the context of OD-MAiD. An underlying question is whether OD-MAiD, if permitted, should follow the ethical guidelines of living donation or deceased donation, as these two practices commonly operate under distinct moral paradigms. While the living donation paradigm is centred on the protection of donors' interests and emphasises individual choice by allowing donors to decide who receives their organs, the deceased donation framework places more emphasis on enabling recipients to benefit from transplant, and organ allocation is typically based on impartiality. OD-MAiD also raises ethical concerns about how the possibility of donation could influence a patient's decision to seek euthanasia and/or interfere with optimal end-of-life care. Proposing organ donation to individuals considering MAiD could conceivably create pressure to proceed with euthanasia, either to realise a social good or to satisfy the needs of loved ones (if a family member requires an organ). This may undermine the patient's autonomy or well-being at the end of life.

In 2023, the National Heart, Lung, and Blood Institute (NHLBI) organized a workshop to identify research gap areas in organ donation after circulatory determination of death (DCDD). We present the findings of the DCDD ethics working group. Heart DCDD, as all DCDD, may disrupt optimal end‐of‐life care. Irrespective of organ donation, research opportunities include identifying which processes of withdrawal of life‐sustaining therapy offer optimum patient comfort, how best to ensure patient comfort at the end of life, and how to better understand patients' preferences for end‐of‐life care. Whether heart DCDD breaches the Dead Donor Rule (DDR) depends on its interpretation, the validity and rationale of the determination of death, and the DCDD protocol used. Further research could clarify the interpretation of the DDR, the concept and determination of death, the time the cessation of brain function ensures that the patient is beyond neuro‐cognitive harm, the implications of thoracoabdominal normothermic regional perfusion on the determination of death and on brain functions, and the type of consent and level of information required for different DCDD techniques.

Several studies have explored differences between North American and European doctor patient relationships. They have focused primarily on differences in philosophical traditions and historic and socioeconomic factors between these two regions that might lead to differences in behaviour, as well as divergent concepts in and justifications of medical practice. However, few empirical intercultural studies have been carried out to identify in practice these cultural differences. This lack of standard comparative empirical studies led us to compare differences between France and the USA regarding end-of-life decision-making. We tested certain assertions put forward by bioethicists concerning the impact of culture on the acceptance of advance directives in such decisions. In particular, we compared North American and French intensive care professional's attitudes toward: (1) advance directives, and (2) the role of the family in decisions to withhold or withdraw life-support.

For almost 30 years, until 2012, Spain had benefitted from a public healthcare system with universal coverage. That year, a new law denied ordinary healthcare for undocumented adult migrants. This law is in blunt contradiction to the idea that healthcare is a fundamental human right. We argue in this chapter that not only a deep and flagrant injustice results from that law, but also an ineffective health system, because important population groups remain out of health control, treatment and prevention, and because denying healthcare to undocumented migrants has not been translated into significant savings. This situation has provoked a strong backlash, from the Spanish society at large and, in particular, among health professionals who have decided to become conscientious objectors against the governmental request to withdraw healthcare from undocumented migrants. Interestingly, in this case, claims of conscience are not associated with personal interest or convictions—as they usually are—but rather with an ethical decision by professionals to take care of their patients, regardless of their administrative status. Promoting social justice is a foundational purpose of welfare states. When they fail in this objective, conscientious objection may become an instrument of last resort to uphold people’s rights.

The increasing application of artificial intelligence (AI) to healthcare raises both hope and ethical concerns. Some advanced machine learning methods provide accurate clinical predictions at the expense of a significant lack of explainability. Alex John London has defended that accuracy is a more important value than explainability in AI medicine. In this article, we locate the trade-off between accurate performance and explainable algorithms in the context of distributive justice. We acknowledge that accuracy is cardinal from outcome-oriented justice because it helps to maximize patients’ benefits and optimizes limited resources. However, we claim that the opaqueness of the algorithmic black box and its absence of explainability threatens core commitments of procedural fairness such as accountability, avoidance of bias, and transparency. To illustrate this, we discuss liver transplantation as a case of critical medical resources in which the lack of explainability in AI-based allocation algorithms is procedurally unfair. Finally, we provide a number of ethical recommendations for when considering the use of unexplainable algorithms in the distribution of health-related resources.

The organ donation and transplantation (ODT) system heavily relies on the willingness of individuals to donate their organs. While it is widely believed that public trust plays a crucial role in shaping donation rates, the empirical support for this assumption remains limited. In order to bridge this knowledge gap, this article takes a foundational approach by elucidating the concept of trust within the context of ODT. By examining the stakeholders involved, identifying influential factors, and mapping the intricate trust relationships among trustors, trustees, and objects of trust, we aim to provide a comprehensive understanding of trust dynamics in ODT. We employ maps and graphs to illustrate the functioning of these trust relationships, enabling a visual representation of the complex interactions within the ODT system. Through this conceptual groundwork, we pave the way for future empirical research to investigate the link between trust and organ donation rates, informed by a clarified understanding of trust in ODT. This study can also provide valuable insights to inform interventions and policies aimed at enhancing organ donation rates.

Background: Several countries have recently changed their model of consent for organ donation from opt-in to opt-out. We undertook a systematic review to determine public knowledge and attitudes towards these models in Europe. Methods: Six databases were explored between 1 January 2008 and 15 December 2017. We selected empirical studies addressing either knowledge or attitudes towards the systems of consent for deceased organ donation by lay people in Europe, including students. Study selection, data extraction, and quality assessment were conducted by two or more reviewers independently. Findings: Awareness of the consent model was lower in opt-out countries than in opt-in countries. A majority of the public agrees with opt-in, regardless of the law in their own country. There are ambivalent attitudes regarding the opt-out system. The public tend to prefer opt-in and mandatory choice over opt-out when several options are offered. Interpretation: The assumption that people in opt-out countries are aware of the legal requirements to be excluded from the pool of potential donors is not supported by the results of this review. This is a concern, since ignorance hinders people's autonomy regarding organ donation decision-making. Higher awareness of consent model in opt-in countries may reflect greater efforts to inform the public through campaigns to motivate donation. Legal moves towards opt-out are at odds with people's expressed preferences. Main limitations of this review are the lack of data from some countries, study population heterogeneity, and methodological shortcomings.

Objectives To increase postmortem organ donation rates, several countries are adopting an opt-out (presumed consent) policy, meaning that individuals are deemed donors unless they expressly refused so. Although opt-out countries tend to have higher donation rates, there is no conclusive evidence that this is caused by the policy itself. The main objective of this study is to better assess the direct impact of consent policy defaults per se on deceased organ recovery rates when considering the role of the family in the decision-making process. This study does not take into account any indirect effects of defaults, such as potential psychological and behavioural effects on individuals and their relatives. Design Based on previous work regarding consent policies, we created a conceptual model of the decision-making process for deceased organ recovery that included any scenario that could be directly influenced by opt-in or opt-out policies. We then applied this model to internationally published data of the consent process to determine how frequently policy defaults could apply. Main outcome measures We measure the direct impact that opt-in and opt-out policies have per se on deceased organ recovery. Results Our analysis shows that opt-in and opt-out have strictly identical outcomes in eight out of nine situations. They only differ when neither the deceased nor the family have expressed a preference and defaults therefore apply. The direct impact of consent policy defaults is typically circumscribed to a range of 0%–5% of all opportunities for organ recovery. Our study also shows that the intervention of the family improves organ retrieval under opt-in but hinders it under opt-out. Conclusions This study may warn policy makers that, by emphasising the need to introduce presumed consent to increase organ recovery rates, they might be overestimating the influence of the default and underestimating the power granted to families.

The so-called uncontrolled donation after circulatory determination of death (uDCDD) have been implemented in several countries, including Spain and France, to increase the availability of organs for transplantation. These protocols allow obtaining kidneys, livers and lungs of patients who do not survive cardio-pulmonary resuscitation performed in out-of-hospital settings. Simultaneously with the development and recent proliferation of these protocols, some emergency teams have begun to employ unconventional methods of CPR, with still uncertain but promising results. The coexistence of these two possibilities raises some questions: At what point should attempts to save a patient with circulatory arrest be abandoned so that this individual can begin to be considered as a potential organ donor? How to manage potential conflicts of loyalties that may arise within emergency and procurement teams? How should the information to the families of those patients and potential organ donors be managed? This article gathers the conclusions of a workshop in which an interdisciplinary working group addressed these and other questions related to DCDD and non-conventional CPR.