Opt-out consent for posthumous organ donation has been criticized for its lower evidential weight: a person's not opting out of donation is poorer evidence of their preferences than their opting in to it, because their not opting out could be due to unawareness, inertia, or lack of preference. Do people also perceive opt-out consent to have lower evidential weight, and how does this affect their downstream ethical judgments about the validity of consent and the appropriateness of families overriding it? Could the evidential weight of opt-out consent be augmented, and if so, how? In this paper, I use two survey experiments to address these questions. First, I find that when a potential donor has merely not opted out of donation (rather than opted in to it), participants are less likely to judge that this person has given valid, informed consent; are more likely to judge that hospitals should uphold a familial challenge to their consent; and are more likely to judge that this person prefers the family to override their decision. Secondly, I evaluate three augmentation measures that aim to increase this evidential weight; I find substantial public alignment with the theoretical claim that the consent process should involve a "selective occasion". I then draw some ethical implications about the deficiencies of opt-out consent and how we might improve it.
Various research ethics frameworks and guidelines assist researchers and research ethics committees (RECs) with ensuring ethically justified deception of participants. However, there remain challenges with balancing context-sensitivity and consistency: when applying ethics requirements during REC review; when handling ethics issues that only surface during the study; and when distributing the responsibility for these two tasks between researcher and REC. To support rigorous contextualization and responsibility allocation, we propose a relational research ethics framework, the "ABCDE of deception." By modifying prevalent ethics requirements and proposing corresponding implementation strategies, grounded in a social model of the researcher-participant interaction, it aligns REC review at study level with ethical decision-making during researcher-participant interactions. Specifically, the ABCDE of deception covers five modified requirements and corresponding implementation strategies: Attune, a situated and interpersonal researcher-participant analogue of ethics deliberation; Be as truthful as possible, which integrates truthfulness and deception in light of informational and methodological needs; Cap harms and wrongs, to identify risks and allocate the responsibility for their handling; Diligent safeguarding, to tackle identified risks; and Ensure equality, a practicable approach to identify and address (potential) social inequalities in deceptive studies. With the ABCDE of deception, we propose a tool for RECs and researchers engaging with deceptive studies, along with several avenues for the framework's future elaboration.
Violent behaviour by patients and families is a significant issue facing healthcare providers, with a particularly high prevalence in hospital emergency departments. Occupational violence and aggression (OVA) puts both staff and patients at risk of physical and psychological harm and can affect the delivery of timely patient care. To help address this issue, many healthcare settings have adopted zero-tolerance language in relation to OVA. Drawing on interviews with 25 emergency department staff in one Australian hospital, we argue that a more nuanced ethical approach is needed and develop a framework of values for responding ethically to OVA incidents in the emergency department. Staff are ethically and legally entitled to a safe working environment, and their safety should be protected. Yet some patients acting aggressively, including patients without capacity, need emergency medical or psychiatric healthcare and ways must be found to deliver such care. For some other patients and visitors however, removal from the hospital is ethically appropriate. The unique uncertainty and urgency of emergency department work means that six values are important in ethical responses to OVA: staff safety, the health needs of the patient acting aggressively, the patient's decision-making capacity, community safety, fair resource allocation, and compassion. We argue for an approach which prioritizes staff safety while also considering the other values, in order to generate nuanced ethical decisions which are sensitive to the range of OVA situations that arise in emergency departments.
The techno-fix argument, used to argue against technological interventions that address the consequences of social problems instead of their underlying causes, is increasingly invoked in biomedical discussions. However, especially in biomedicine, the techno-fix argument remains conceptually underdeveloped. Therefore, in this paper, we critically examine the techno-fix argument in the context of new biomedical technologies, using stem cell therapy as a central case study. First, a taxonomy is developed to determine if, and if so, for which conditions, new biomedical technologies such as stem cell therapy can be considered techno-fixes. Then, the ethical implications of the taxonomy are discussed. We argue that stem cell therapy functions as a techno-fix when developed for medical conditions and disabilities that are largely caused by an underlying social problem, and that its moral (un)desirability depends, at a minimum, on whether it (1) silences or highlights the social problem involved, and (2) hinders or supports the development of alternative, social solutions. With this paper, we aim to clarify and stimulate debate on how techno-fixes should be understood and evaluated within the context of biomedicine, and beyond.
Since drug overdose deaths began increasing in the United States, policy makers and the medical community have developed tools to try to address the crisis. Opioid Treatment Agreements (OTAs) are one such tool which purportedly seek to promote shared decision-making and informed consent with patients. OTAs are documents that clinicians present to patients when prescribing opioids for chronic pain that describe the risks of opioids and require patients to agree to certain conditions in order to receive their medication. This paper critically explores the ethics of three related features of OTA policies and guidance: First, OTAs typically integrate behavioral requirements that go beyond the detection of opioid misuse and diversion. Second, OTAs often designate for clinicians significant discretion in their responses to individual patient OTA violations. That is, codified in many OTAs is the clinician's discretionary power to decide to stop prescribing LTOT or to dismiss the patient from their practice altogether. Third, governmental policies that recommend OTA use often exempt patients with cancer or terminal illness, allowing them to access this type of chronic pain management without the same requirements. Each of these features may have been created in an attempt to address individual patient needs while also responding to an urgent public health crisis, but they also-on their own and working in concert - raise serious ethical concerns. We argue that these features identify some patients as "respectable" pain patients and others as less-so, risking compounding the stigmatization of pain management and exacerbating health disparities.
The editors of Bioethics chose to publish a special issue on the Gaza war, arguably one of the most contentious contemporary topics. This decision deserves praise for seeking to protect a space for rigorous engagement in a highly polarized debate. At the same time, such an undertaking is inherently risky. Herein, I try to assess whether the issue succeeds on its own terms, particularly its commitment to advancing ethical analysis within areas of established bioethical expertise. I argue that it falls short of these standards. While a few articles offer a robust ethical analysis of bioethical aspects related to the war, several others exhibit the very features the journal sought to avoid: they appear driven by personal conviction, limited in disciplinary rigor, and, in the case of empirical papers, to a certain extend fail to integrate normative analysis, remaining largely descriptive. Moreover, the issue displays a striking trend toward a highly condemnatory tone, raising questions about whether factors beyond the subject matter itself may have shaped the discourse. While the initiative is therefore praiseworthy for its stated goal, its execution is less convincing. Overall, the journal might have been better served by refraining from a dedicated special issue and instead continuing to solicit careful, methodologically rigorous contributions-such as the stronger pieces included here-that more faithfully reflect its stated aspirations and high editorial standards.
Some US jurisdictions allow physicians to offer a lethal drug dose to adults with terminal diagnoses under certain conditions. We explore the morality of medical assistance in dying (MAID) for a pregnant woman with a terminal diagnosis in the context of state fetal protection laws. Several states have enacted laws or had court decisions that in the name of fetal protection prohibit abortions with limited exceptions, impose penalties on those involved in prohibited abortions, require treatment for certain pregnant brain-dead women, and recognize the personhood of embryos and fetuses through judicial declarations or statutes, among other things. Against this legal background, we explore the carryover meaning of these laws as they might bear on seeking MAID while pregnant and defend a prima facie moral right for dying women to choose MAID under the conditions it is practiced in the United States.
