Rosana Trivino

BackgroundIn 2021, Spain passed Organic Law 3/2021, which regulates euthanasia and represents an extension of rights to make decisions in the context of health care. According to the Law, the state must guarantee access to Medical Assistance in Dying (MAiD) through health services. Therefore, the involvement of health professionals is crucial. The aim of this work is to analyse the perspectives of health professionals on the provision of MAiD. Particular attention is paid to the social impact of the Law, the conceptual problems it raises, and the distribution of rights and responsibilities of professionals and patients, as well as the procedural aspects included in the regulation, the experiences of professionals regarding MAiD, and the implementation differences observed among regions.MethodsIt was an exploratory qualitative research applying a thematic analysis through semi-structured interviews with physicians and nurses from primary care, hospital care, and palliative care, recruited from three Autonomous Communities in Spain (Madrid, Catalonia, and Andalusia) between March and May 2023.ResultsA total of 25 interviews were conducted with medical and nursing professionals, 17 women and 8 men. The information collected was organised according to these discursive axes: social impact of the Law; terminological and conceptual problems; rights and responsibilities of professionals and patients; procedure (time limits, role of professionals); experiences of professionals regarding MAiD; and differences in implementation among the regions of the study. For this analysis, the participants’ positions on the provision of MAiD were considered.ConclusionsThe professionals interviewed generally express a positive assessment of the legal safeguards of MAiD Law in Spain. However, challenges remain in its implementation, such as perceived legal ambiguities, assessment of suffering, and balancing autonomy. Structural inequalities and limited support may affect access and provider well-being. Strengthening professional training, teamwork, and institutional resources, as well as a relational approach, is essential. The findings offer practice-based guidance for policy and clinical care and highlight the need for further research on real-world impacts.

In 2021, Spain passed Organic Law 3/2021, which regulates euthanasia and represents an extension of rights to make decisions in the context of health care. According to the Law, the state must guarantee access to Medical Assistance in Dying (MAiD) through health services. Therefore, the involvement of health professionals is crucial. The aim of this work is to analyse the perspectives of health professionals on the provision of MAiD. Particular attention is paid to the social impact of the Law, the conceptual problems it raises, and the distribution of rights and responsibilities of professionals and patients, as well as the procedural aspects included in the regulation, the experiences of professionals regarding MAiD, and the implementation differences observed among regions. It was an exploratory qualitative research applying a thematic analysis through semi-structured interviews with physicians and nurses from primary care, hospital care, and palliative care, recruited from three Autonomous Communities in Spain (Madrid, Catalonia, and Andalusia) between March and May 2023. A total of 25 interviews were conducted with medical and nursing professionals, 17 women and 8 men. The information collected was organised according to these discursive axes: social impact of the Law; terminological and conceptual problems; rights and responsibilities of professionals and patients; procedure (time limits, role of professionals); experiences of professionals regarding MAiD; and differences in implementation among the regions of the study. For this analysis, the participants’ positions on the provision of MAiD were considered. The professionals interviewed generally express a positive assessment of the legal safeguards of MAiD Law in Spain. However, challenges remain in its implementation, such as perceived legal ambiguities, assessment of suffering, and balancing autonomy. Structural inequalities and limited support may affect access and provider well-being. Strengthening professional training, teamwork, and institutional resources, as well as a relational approach, is essential. The findings offer practice-based guidance for policy and clinical care and highlight the need for further research on real-world impacts.

This work is aimed to analyze the difficulty of establishing clear limits between conscientious objection and civil disobedience taken as example the specific case of those healthcare professionals opposed to the Spanish Royal Decree 16/2012. The approval of this law, directed to the sustainability of the National Health System, meant a change in the previous configuration of the constitutional right to healthcare, characterized by being public and freely accessible to all the inhabitants in the country. As a consequence, undocumented migrant people had no longer a universal access to healthcare. In this situation, some healthcare professionals expressed their opposition to the law providing their services to undocumented patients. Might this behavior be considered a form of conscientious objection? Was a case of civil disobedience? Was just an act of altruism? Plausible answers to these questions will be argued along this paper.

Bioethics emerged as a discipline in the 70s of the last century. One of its main objectives has been to analyze clinical cases that pose moral problems. This analysis is generally carried out by a multidisciplinary group, the Health Care Ethics Committee, which is comprised of ethical experts or healthcare providers assisted by a facilitator, depending on the context. Different methodologies are used in these situations. The deliberative method, in its various configurations, is the most widely used in many Committees. Identify whether the deliberative method is included in regulated undergraduate and postgraduate teaching; analyze whether a single model can be identified or whether there is heterogeneity in the proposals. A bibliographic review was carried out, following the scoping review method. With respect to the first objective, there is no evidence on the teaching and use of the deliberative method in the Faculties and Schools of Medicine and Nursing, the emphasis is placed on training oriented to the resolution of clinical cases and a certain deliberative proposal is developed from them, more pragmatic than ethical-philosophical. In relation to the second objective, differences are observed between the two most prevalent schools (D. Gracia and B. Molewijk), with the model proposed by Gracia being used more in the Spanish-speaking world, and Molewijk's model in the English-speaking world. It can be seen that D. Gracia's proposal is more philosophical and Molewijk's more pragmatic. Finally, it is considered pertinent to further disseminate the deliberative method and its advantages, as well as its potential for bioethics education.

À la lumière de la législation actuelle sur l’aide médicale à mourir (AMM; aussi appelée euthanasie et suicide assisté) dans différents pays du monde, certains arguments ont été consacrés au droit à l’objection de conscience pour les professionnels de la santé dans ces pratiques spécifiques. Les objectifs de cette étude exploratoire sont de fournir une vue d’ensemble des motivations et des causes qui se cachent derrière l’objection de conscience identifiée par la littérature précédente selon les expériences des professionnels et de vérifier si ces motivations correspondent aux débats théoriques sur l’objection de conscience. Comme le montrent les résultats, il existe une dissonance entre les motivations incluses dans la définition traditionnelle et courante de l’objection de conscience utilisée dans les cadre théoriques et spéculatifs et les facteurs réels que les études empiriques relèvent comme motivations déclarées pour s’opposer à l’AMM. Par conséquent, soit nous envisageons de nouveaux facteurs à inclure dans les causes de la “conscience”, soit nous acceptons qu’il existe des motivations qui ne sont pas réellement applicables à l’objection de conscience et qui devraient être traitées par d’autres moyens. L’objection de conscience à l’AMM étant multiforme, il peut y avoir différents types de motivations qui agissent en même temps. Il est donc pertinent de rééquilibrer les considérations théoriques et empiriques pour bien comprendre la complexité du phénomène et ainsi donner des pistes sur la meilleure façon de traiter l’objection de conscience.

For years, the sexual and reproductive health of women with intellectual and developmental disability or disabilities has been insufficiently addressed by institutions and family members due to a lack of information, training, and, sometimes, religious issues. In this context, contraceptive digital pills can enhance the sexual and reproductive control of this population group. Digital pills could help to improve adherence to treatments aimed to prevent unwanted pregnancies, as well as allowing women and their caregivers to exert better drug intake control. However, there are some ethical risks to consider that may outweigh these benefits. This study sets out to explore the ethical considerations that should be taken into account in the case of a potential roll‐out of contraceptive digital pills as a way of improving the sexual and reproductive health of these women.

Bioethics emerged as a discipline in the 70s of the last century. One of its main objectives has been to analyze clinical cases that pose moral problems. This analysis is generally carried out by a multidisciplinary group, the Health Care Ethics Committee, which is comprised of ethical experts or healthcare providers assisted by a facilitator, depending on the context. Different methodologies are used in these situations. The deliberative method, in its various configurations, is the most widely used in many Committees. Identify whether the deliberative method is included in regulated undergraduate and postgraduate teaching; analyze whether a single model can be identified or whether there is heterogeneity in the proposals. A bibliographic review was carried out, following the scoping review method. With respect to the first objective, there is no evidence on the teaching and use of the deliberative method in the Faculties and Schools of Medicine and Nursing, the emphasis is placed on training oriented to the resolution of clinical cases and a certain deliberative proposal is developed from them, more pragmatic than ethical-philosophical. In relation to the second objective, differences are observed between the two most prevalent schools (D. Gracia and B. Molewijk), with the model proposed by Gracia being used more in the Spanish-speaking world, and Molewijk's model in the English-speaking world. It can be seen that D. Gracia's proposal is more philosophical and Molewijk's more pragmatic. Finally, it is considered pertinent to further disseminate the deliberative method and its advantages, as well as its potential for bioethics education.

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.

Background In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals’ participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation. Methods We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model. Results We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy. Conclusions There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID.

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.

In the light of current legislation on Medical Aid in Dying ─euthanasia and assisted suicide─ in different countries worldwide, there have been some arguments devoted to the right to conscientious objection for healthcare professionals in these specific practices. The goals of this scoping review are to provide an overview of the motivations and causes that lie behind conscientious objection identified by previous literature according to professionals’ experience and to verify if these motives match with theoretical debates on conscientious objection. As the results show, there seems to be a dissonance between the motivations included in the traditional and mainstream definition of conscientious objection that is used in the theoretical and speculative framework and the actual factors that empirical studies note as reported motivations to object to Medical Aid in Dying. Hence, either we consider new factors to include as causes of “conscience”, or we accept that there are motivations that are not actually applicable to conscientious objection and should be addressed by other means. As conscientious objection in Medical Aid in Dying is multifaceted, we claim from the results that there can be different kinds of motivations acting at the same time. In any case, it is helpful to rebalance theoretical and empirical considerations to fully understand the complexity of the phenomenon and give some insights on how to deal with it.

Blind, deaf, and mute: the healthcare system regarding conscientious objection to abortion Resumen: A la luz de la obra de Fernando Broncano, Conocimiento expropiado (2020), este trabajo plantea la objeción de conciencia generalizada al aborto como un fenómeno que origina situaciones de injusticia epistémica. El acceso a la información, el disvalor del testimonio de las mujeres y el silencio cómplice, individual e institucional, perpetuador de la ignorancia sistémica son realidades que afectan a un número indeterminado de mujeres que requiere la interrupción de su embarazo. Para hacer frente al daño generado, se plantea cómo las redes y movimientos pro-elección distribuyen información y recursos sobre el aborto fuera del ámbito clínico y se organizan como fuerzas de resistencia epistémica, capaces de crear y compartir conocimiento en un ejercicio de democracia radical, en el sentido expresado por Broncano. Abstract: In accordance with Fernando Broncano’s work, Conocimiento expropiado (2020), this paper considers the widespread conscientious objection to abortion as a phenomenon that creates situations of epistemic injustice. Access to information, devaluation of women’s testimony, as well as individual and institutional complicit silence that perpetuates systemic ignorance, are realities that affect an indeterminate number of women who require the termination of their pregnancies. In order to address the damage generated, we consider how pro-choice networks and movements distribute information and resources on abortion outside the clinical sphere. They also organise themselves as forces of epistemic resistance, capable of creating and sharing knowledge in an exercise of radical democracy, in the sense expressed by Broncano. Palabras clave: Objeción de conciencia, aborto, injusticia epistémica, ignorancia institucional, resistencia epistémica. Keywords: Conscientious objection, abortion, epistemic injustice, institutional ignorance, epistemic resistance.

En diciembre de 2011, Samba Martine, interna del Centro de Internamiento para Extranjeros de Aluche, muere de una infección evitable por no haber sido diagnosticada y tratada de manera adecuada, a pesar de haber solicitado insistentemente asistencia sanitaria. La madre de Samba, con el apoyo de varias entidades sociales, denuncia los hechos y llega a los tribunales. Ocho años más tarde, en junio de 2019, se anuncia la absolución por homicidio imprudente del único responsable procesado. Nueve años más tarde, en octubre de 2020, el Ministerio de la Presidencia, Relaciones con las Cortes y Memoria Democrática emite una Resolución por la que se atiende la reclamación de responsabilidad patrimonial por el fallecimiento de Samba Martine. Tomando como punto de partida este caso, este trabajo tiene como objetivo analizar los factores que hacen de él un ejemplo de injusticia epistémica en tres niveles interrelacionados: micro, meso y macro. La relevancia de esta propuesta radica en mostrar cómo la dejación de funciones por parte de la Administración y sus instituciones contribuye a generar una ignorancia, que, combinada con la falta de credibilidad del testimonio de la víctima, tiene como resultado final su muerte. Lejos de ser un caso anecdótico, situaciones de injusticia epistémica como esta forman parte de la cotidianeidad de numerosas personas migrantes indocumentadas, que después de periplos de sufrimiento terminan internadas en limbos legales como los CIE.