David Rodriguez

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.

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 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.