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Organ donation

Re: Nudges in a Post-truth World 

19 Jul, 17 | by bearp

Guest Post: Nathan Hodson 

In a recent article in the Journal of Medical Ethics, Neil Levy has developed a concept of “nudges to reason,” offering a new tool for those trying to reconcile medical ethics with the application of behavioural psychological research – a practice known as nudging. Very roughly, nudging means adjusting the way choices are presented to the public in order to promote certain decisions.

As Levy notes, some people are concerned that nudges present a threat to autonomy. Attempts at reconciling nudges with ethics, then, are important because nudging in healthcare is here to stay but we need to ensure it is used in ways that respect autonomy (and other moral principles).

The term “nudge” is perhaps a misnomer. To fill out the concept a bit, it commonly denotes the use of behavioural economics and behavioural psychology to the construction of choice architecture through carefully designed trials. But every choice we face, in any context, already comes with a choice architecture: there are endless contextual factors that impact the decisions we make.

When we ask whether nudging is acceptable we are asking whether an arbitrary or random choice architecture is more acceptable than a deliberate choice architecture, or whether an uninformed choice architecture is better than one informed by research.

In fact the permissibility of a nudge derives from whether it is being used in an ethically acceptable way, something that can only be explored on an individual basis. Thaler and Sunstein locate ethical acceptability in promoting the health of the person being nudged (and call this Libertarian Paternalism — i.e. sensible choices are promoted but no option is foreclosed). An alternative approach was proposed by Mitchell: nudges are justified if they maximise future liberty. Either way the nudging itself is not inherently problematic.

Detailing the relevant psychological research, Levy outlines how our responses to new information are influenced by our understanding of the source. Does the source stand to benefit from persuading us? Does the source wish us good or ill? These are classified as Messenger factors in the Behavioural Insights Team’s1 MINDSPACE classification.

Levy goes on to show how sensitivity to these factors makes evolutionary sense and as such constitutes part of our subconscious reasoning. Nudges that promote appropriate sensitivity to the factors, then, do not subvert our rationality; they apply or appeal directly to it.

There is huge scope within Levy’s grouping of nudges for interventions that do not threaten autonomy. For example the “N” in MINDSPACE stands for “norms.” An attuned sensitivity to group norms is adaptive in the same way as are messenger factors. But there is another group of nudges that actively promote autonomy.

The challenges to healthcare and wider society in this purportedly post-truth era demand improved quality of public debate and individual deliberation, and nudges can help. Building on Mitchell’s notion that nudges can be good if they increase future liberty and taking a rich conception of autonomy maximised through reflection and rationality, we could conceive of nudge-based policies which maximise current autonomy.  more…

No Pain, All Gain: The Case for Farming Organs in Brainless Humans

10 Jun, 17 | by Iain Brassington

Guest post by Ruth Stirton, University of Sussex (@RuthStirton) and David Lawrence, Newcastle University (@Biojammer)

It is widely acknowledged that there is a nationwide shortage of organs for transplantation purposes.  In 2016, 400 people died whilst on the organ waiting list.  Asking for donors is not working fast enough.  We should explore all avenues to alleviate this problem, which must include considering options that appear distasteful.  As the world gets safer, and fewer young people die in circumstances conducive to the donation of their organs, there is only so much that increased efficiency in collection (through improved procedures and storage) can do to increase the number of human organs available for transplantation. Xenotransplantation – the transplantation of animal organs into humans – gives us the possibility of saving lives that we would certainly lose otherwise.

There are major scientific hurdles in the way of transplanting whole animal organs into humans, including significant potential problems with incompatibility and consequent rejection.  There is, however, useful similarity between human and pig cells, which means that using pigs as the source of organs is the most likely to be viable.  Assuming, for the moment, that we can solve the scientific challenges with doing so, the bigger issue is the question of whether we should engage in xenotransplantation.

A significant challenge to this practice is that it is probably unethical to use an animal in this way for the benefit of humans. more…

Personal Responsibility Within Health Policy: Unethical and Ineffective

23 Sep, 16 | by miriamwood

Guest Post by Phoebe Friesen

Re: Personal responsibility within health policy: unethical and ineffective

If someone who has smoked two packs a day for thirty years and someone who has never smoked but is unfortunate enough to inherit a genetic condition are both in need of heart surgery, who should be given priority?

Should an alcoholic be placed on the liver transplant list, even if they continued to drink against their doctor’s advice?

Does someone who never works out and has poor eating habits have the same right to health care as someone who eats healthy and exercises every day?

Policy makers who are faced with the difficult task of distributing limited resources in health care need to determine which criteria are relevant, and questions related to ‘personal responsibility’ come up time and again. Within the field of medical ethics, many have argued that personal responsibility should be taken into account within health care policy. Advocates suggest that treatments will be more effective or provide longer-lasting solutions if illnesses are not self-caused, and argue that individuals who knowingly take health risks violate their obligation to take care of themselves and should therefore be treated differently. Others argue that there is no place for responsibility in health care policy, pointing out that there is no evidence for different treatment outcomes in individuals who did or did not contribute to their condition, and emphasizing the difficulty, if not impossibility, of determining how responsible someone is for a particular health problem.

more…

Intentionally Exposing Patients to HIV: When Might it be Ethical?

7 Jun, 14 | by BMJ

Guest Post by Bram Wispelwey, Ari Zivotofsky, and Alan Jotkowitz

Much has been made of the fact that over the last two decades HIV has transformed from an inevitable, agonising killer into a controllable chronic disease.  But have we reached a point where infecting someone with HIV in order to avoid other, potentially worse health outcomes might be justified?  In the realm of organ transplantation we found that if we are not yet there, perhaps we should be.

Our paper was in part inspired by what many considered a shocking ruling by former Israeli Chief Rabbi Eliyahu Bakshi-Doron, who decreed that it was consistent with Jewish religious law for HIV-negative individuals to receive HIV-positive organ transplants, even if the evidence indicates a possibility for the recipient to contract the disease.  Many considered this opinion premature because only recently had HIV-positive individuals been found to be good candidates for solid organ transplantation, and doctors in South Africa were still in the early research stages of examining kidney transplantation between HIV-positive individuals.  But in examining the ethical considerations of autonomy, beneficence, non-maleficence, and justice, we argue in our paper that Rabbi Bakshi-Doron’s opinion is ethically sound.

Focusing on the history of HIV in transplantation and using a comparison to current practice with regard to another infectious disease, cytomegalovirus, we demonstrate that disallowing HIV-negative candidates from receiving HIV-positive organs would be a significant limit on patient autonomy.  The elimination of the ban on this type of potentially life-saving (and improving) donation may also represent a more socially just option, as it would expand the donor pool and engender cost savings. HIV-positive to HIV-positive donation will soon be a reality in several countries; it’s time to think about going one step further.

 

Read the full paper here.

Give the gift of giving – donate someone elses organ or how the current online system for organ donation allows you to sign up others as long as you know a few details about them. Oops.

23 Apr, 12 | by David Hunter

Hattip to Nathan Emmerich for speculating about this on Facebook and then blogging about it here: Organ Donation: Why isn’t there an App for that?

There are a number of ways you can volunteer to donate your organs when you die in the UK, you can sign up when you get a drivers license, you can even sign up when you get a rewards points card at Boots – a pharmacy chain.

You can now sign up online to donate your organs directly at the NHS website, but as Emmerich points out there seems to be a gaping hole in the current system’s security. It appears that the only information you have to provide to prove your identity is your name and date of birth – both relatively easy pieces of information to find out. This means that you could sign up anyone as long as you have this information. They do send out a letter to confirm their consent but seeing as you can enter any address this doesn’t seem to be likely to prevent potential abuses.

I’m honestly surprised I haven’t heard about this already from the Daily Mail, it seems such an obvious and easily criticisable mistake for the NHS to make. Perhaps they don’t have any stock images of people looking confused as their organs are being removed…

Still now that we are here let’s discuss organ donation. There is considerable debate about whether we ought to have an opt in or opt out system of organ donation – this appears to be a new option “an others opt you in system…” And there doesn’t seem to be any way to change your mind and opt out using the online system. This seems well short of any appropriate standard of informed consent, or a useful system for organ donation.

Personally I suspect there is much to recommend changing the default setting to organ donation rather than not donating – think of it as nudging if you will. Certainly if this is all that respecting autonomy requires a robust opt out system will not violate it.

That said I suspect rather than concentrating on the head line question of opt in vs opt out, a fair number of lives could be saved simply by refining and improving the current system.

This also seems to present a moral dilemma for any consequentialists out there, think about all the lives you could save by volunteering your friends organs…

So what kind of system should we have for organ donation?

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