David Rodriguez

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.

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

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.

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.

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.

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.