Background Consent policies for post-mortem organ procurement (OP) vary throughout Europe, and yet no studies have empirically evaluated the ethical implications of contrasting consent models. To fill this gap, we introduce a novel indicator of governance quality based on the ideal of informed support, and examine national differences on this measure through a quantitative survey of OP policy informedness and preferences in seven European countries. -/- Methods Between 2017–2019, we conducted a convenience sample survey of students (n = 2006) in (...) Austria (AT), Belgium (BE), Denmark (DK), Germany (DE), Greece (GR), Slovenia (SI) and Spain (ES), asking participants about their donation preferences, as well as their beliefs and views about the policy in place. From these measures, we computed indices of informedness, policy support, and fulfilment of unexpressed preferences, which we compared across countries and consent systems. -/- Results Our study introduces a tool for analyzing policy governance in the context of OP. Wide variation in policy awareness was observed: Most respondents in DK, DE, AT and BE correctly identified the policy in place, while those in SI, GR and ES did not. Respondents in opt-out countries (AT, BE, ES and GR) tended to support the policy in place (with one exception, i.e., SI), whereas those in opt-in countries (DE and DK) overwhelmingly opposed it. These results reveal stark differences in governance quality across countries and consent policies: We found a preponderance of informed opposition in opt-in countries and a general tendency towards support–either informed or uninformed–in opt-out countries. We also found informed divergence in opt-in countries and a tendency for convergence–either informed or uninformed–among opt-out countries. -/- Conclusion Our study offers a novel tool for analyzing governance quality and illustrates, in the context of OP, how the strengths and weaknesses of different policy implementations can be estimated and compared using quantitative survey data. (shrink)

Deceased organ donation is widely considered as a case of easy rescue―that is, a case in which A may bestow considerable benefits on B while incurring negligent costs herself. Yet, the policy implications of this observation remain unclear. Drawing on Christopher H. Wellman’s samaritan account of political obligations, the paper develops a case for a so-called opt-out system, i.e., a scheme in which people are defaulted into being donors. The proposal’s key idea is that we may arrange people’s options in (...) specific ways for the sake of others. (shrink)

An effective method to increase the number of potential cadaveric organ donors is to make people donors by default with the option to opt out. This non-coercive public policy tool to influence people’s choices is often justified on the basis of the as-judged-by-themselves principle: people are nudged into choosing what they themselves truly want. We review three often hypothesized reasons for why defaults work and argue that the as-judged-by-themselves principle may hold only in two of these cases. We specify further (...) conditions for when the principle can hold in these cases and show that whether those conditions are met is often unclear. We recommend ways to expand nationwide surveys to identify the actual reasons for why defaults work and discuss mandated choice policy as a viable solution to many arising conundrums. (shrink)

This essay explores three issues in respect for autonomy that pose unfinished business for the concept. By this, I mean that the dialogue over them is ongoing and essentially unresolved. These are: whether we ought to respect persons or their autonomous choices; the role of relational autonomy; and whether nonhuman animals can be autonomous. In attending to this particular set of unfinished business, I highlight some critical moral work left aside by the concept of respect for autonomy as understood in (...) Beauchamp and Childress’ Principles of Biomedical Ethics. Specifically, while significant pragmatic traction is gained by the authors’ focus on autonomous choice, carving such a focus out from the broader questions of moral respect and the autonomy of the person leaves aside a number of questions that we might have thought a view about respect for autonomy in biomedicine ought to answer. These include: How should physicians respond when autonomous patients make decisions that appear nonautonomous? What is the impact of the view that autonomy is “relational” for cross-cultural differences in how autonomy is respected? If chimpanzees can be autonomous, what does that mean for how they should be treated? (shrink)

So‐called nudge policies utilize insights from behavioral science to achieve policy outcomes. Nudge policies try to improve people's decisions by changing the ways options are presented to them, rather than changing the options themselves or incentivizing or coercing people. Nudging has been met with great enthusiasm but also fierce criticism. This paper provides an overview of the debate on the ethics of nudging to date. After outlining arguments in favor of nudging, we first discuss different objections that all revolve around (...) the worry that nudging vitiates personal autonomy. We split up this worry into different dimensions of autonomy, such as freedom of choice, volitional autonomy, rational agency, and freedom as nondomination. We next discuss worries that nudging is manipulative, violates human dignity, and prevents more important structural reform. Throughout, we will present responses that proponents of nudging can muster. On the whole, we conclude that the objections fail to establish that the nudge program as a whole should be rejected. At the same time, they give us important guidance when moving towards an ethical assessment of nudges on a case‐by‐case basis. Towards the end, we provide some possible ways forward in debates around the ethics of nudging. (shrink)

The wishes of registered organ donors are regularly set aside when family members object to donation. This genuine overruling of the wishes of the deceased raises difficult ethical questions. A successful argument for providing the family with a veto must (a) provide reason to disregard the wishes of the dead, and (b) establish why the family should be allowed to decide. One branch of justification seeks to reconcile the family veto with important ideas about respecting property rights, preserving autonomy, and (...) preventing harm. These arguments are ultimately unsuccessful. Another branch of arguments is consequentialist, pointing out the negative consequences of removing the veto. Whether construed as concerning family distress or as a potential drop in the organs available, these arguments are unsuccessful; the first fails to recognize the tremendous distress associated with waiting for an organ, while the second has little supporting evidence. A final section considers and rejects whether combining some of the arguments just examined could justify the family veto. We should thus remove the family veto in organ donation. (shrink)

The federal system for allocating donated livers in the United States is often criticized for allowing geographic disparities in access to livers. Critics argue that such disparities are unfair on the grounds that where one lives is morally arbitrary and so should not influence one's access to donated livers. They argue instead that livers should be allocated in accordance with the equal opportunity principle, according to which US residents who are equally sick should have the same opportunity to receive a (...) liver, regardless of where they live. In this paper, we examine a central premise of the argument for the equal opportunity principle, namely, that geographic location is a morally arbitrary basis for allocating livers. We raise some serious doubts regarding the truth of this premise, arguing that under certain conditions, factors closely associated with geographic location are relevant to the allocation of livers, and so that candidates' geographic location is sometimes a morally non-arbitrary basis for allocating livers. Geographic location is morally non-arbitrary, we suggest, since by taking it into account, the UNOS may better fulfill its central goals of facilitating the effective and efficient placement of organs for transplantation and increasing organ donation. (shrink)

MacKay and Robinson (2016) claim that some legal procedures that regulate organ donations (VAC, opt-in, opt-out) bypass people's rational capacities and thus are “potentially morally worse than MAC”, which only employs a very mild form of coercion. We provide a critique of their argumentation and defend the opposite thesis: MAC is potentially morally worse than the three other options.

Many of our daily activities are now made more convenient and efficient by virtual assistants, and the day when they can be designed to instruct us in certain skills, such as those needed to make moral judgements, is not far off. In this paper we ask to what extent it would be ethically acceptable for these so-called virtual assistants for moral enhancement to use subtle strategies, known as “nudges”, to influence our decisions. To achieve our goal, we will first characterise (...) nudges in their standard use and discuss the debate they have generated around their possible manipulative character, establishing three conditions of manipulation. Secondly, we ask whether nudges can occur in moral virtual assistants that are not manipulative. After critically analysing some proposed virtual assistants, we argue in favour of one of them, given that by pursuing an open and neutral moral enhancement, it promotes and respects the autonomy of the person as much as possible. Thirdly, we analyse how nudges could enhance the functioning of such an assistant, and evaluate them in terms of their degree of threat to the subject’s autonomy and their level of transparency. Finally, we consider the possibility of using motivational nudges, which not only help us in the formation of moral judgements but also in our moral behaviour. (shrink)

Can Artificial Intelligence be more effective than human instruction for the moral enhancement of people? The author argues that it only would be if the use of this technology were aimed at increasing the individual's capacity to reflectively decide for themselves, rather than at directly influencing behaviour. To support this, it is shown how a disregard for personal autonomy, in particular, invalidates the main proposals for applying new technologies, both biomedical and AI-based, to moral enhancement. As an alternative to these (...) proposals, this article proposes a virtual assistant that, through dialogue, neutrality and virtual reality technologies, can teach users to make better moral decisions on their own. The author concludes that, as long as certain precautions are taken in its design, such an assistant could do this better than a human instructor adopting the same educational methodology. (shrink)

Nudges involve designing social “choice contexts” to promote what “experts” regard as beneficial for individuals and the society, by making the “right” choices easier. The most common form of nudge...

Nudging is a tool of libertarian paternalism. It involves making use of certain psychological tendencies in order to help people make better decisions without restricting their freedom. However, some have argued that nudging is objectionable because it interferes with, or undermines, the rational decision-making of the nudged agents. Opinions differ on why this is objectionable, but the underlying concerns appear to begin with nudging’s threat to rational decision-making. Those who discuss this issue do not make it clear to what this (...) threat to rationality amounts. In this paper I evaluate what effect nudging has on our decision-making and I argue that it does not typically interfere with our rationality in a problematic way. Perhaps nudging is objectionable for other reasons, but we should not argue that nudging is objectionable based on concerns about rational decision-making. (shrink)

Default rules, taken as such, do not intrude on autonomy, even if they influence people without persuading them. If default rules give people certain rights automatically (such as the right to free...

MacKay and Robinson (2016) provide a critical analysis of four organ donation registration options using an expanded conception of manipulation introduced by Jennifer Blumenthal-Barby (Blumenthal-B...

BackgroundOrgan transplantation represents the most effective and acceptable therapy for end-stage organ failure. However, its frequent practice often leads to a shortage of organs worldwide. To solve this dilemma, some countries, such as Portugal, have switched from an opt-in to an opt-out system, which has raised concerns about respect for individual autonomy. We aimed to evaluate whether young university students are aware of this opt-out system so that they can make informed, autonomous and conscious decisions, as well as to identify (...) the factors that determine a positive attitude toward post-mortem organ donation.MethodsAn observational, cross-sectional study was developed and a questionnaire was administered to first-year students from six faculties of the University of Porto.ResultsOf the 841 participants, 60% were unaware that Portugal had adopted an opt-out system. Among the informed individuals, their main sources of information included social media, internet, and family. Furthermore, only 48% of all participants agreed with the current opt-out system. Female sex (p = 0.049; OR 1.393), knowledge of the law (p < 0.001; OR 4.749) and family being the primary source of information (p < 0.001; OR 2.855) were independent factors associated with a positive attitude toward post-mortem organ donation law.ConclusionsThere is a significant lack of knowledge among young university students regarding the presumed post-mortem organ donation law and how it works. Female sex, having family as a primary source of information and being aware of the presumed post-mortem organ donation law are the strongest independent factors that determine a positive attitude toward the opt-out system. (shrink)

Where a person is unable to make medical decisions for themselves, law and practice allows others to make decisions on their behalf. This is common at the end of a person’s life where decision-making capacity is often lost. A further, and separate, decision that is often considered at the time of death (and often preceding death) is whether the person wanted to act as an organ or tissue donor. However, in some jurisdictions, the lawful decision-maker for the donation decision (the (...) ‘donation decision-maker’) is different from the person who was granted decision-making authority for medical decisions during the person’s life. To date, little attention has been given in the literature to the ethical concerns and practical problems that arise where this shift in legal authority occurs. Such a change in decision-making authority is particularly problematic where premortem measures are suggested to maximise the chances of a successful organ donation. This paper examines this shift in decision-making authority and discusses the legal, ethical and practical implications of such frameworks. (shrink)