"Just" accuracy? Procedural fairness demands explainability in AI-based medical resource allocations.

The increasing application of artificial intelligence (AI) to healthcare raises both hope and ethical concerns. Some advanced machine learning methods provide accurate clinical predictions at the expense of a significant lack of explainability. Alex John London has defended that accuracy is a more important value than explainability in AI medicine. In this article, we locate the trade-off between accurate performance and explainable algorithms in the context of distributive justice. We acknowledge that accuracy is cardinal from outcome-oriented justice because it helps to maximize patients' benefits and optimizes limited resources. However, we claim that the opaqueness of the algorithmic black box and its absence of explainability threatens core commitments of procedural fairness such as accountability, avoidance of bias, and transparency. To illustrate this, we discuss liver transplantation as a case of critical medical resources in which the lack of explainability in AI-based allocation algorithms is procedurally unfair. Finally, we provide a number of ethical recommendations for when considering the use of unexplainable algorithms in the distribution of health-related resources.

La historia se repite: una ética para dos pandemias / History repeats itself: an ethic for two pandemics

La irrupción del virus de la inmunodeficiencia humana (VIH) en la década de los 80 trajo consigo conflictos éticos que supusieron un desafío para la Bioética. Surgieron, entre otros, problemas de confidencialidad, estigmatización, justicia, deber de asistencia y de investigación. Si hasta entonces la reflexión bioética había estado centrada en los conflictos protagonizados por el respeto a la autonomía individual, el VIH puso el acento en las necesidades de la comunidad. Casi cuatro décadas después, la pandemia de COVID-19 ha devuelto a la actualidad bioética los conflictos éticos propios de la salud pública. Las cuarentenas, las diversas restricciones a la movilidad, la imposición de mascarillas, la asistencia sanitaria con protección deficiente, el racionamiento de recursos escasos, la investigación con prisas, el reparto de la vacuna, la estigmatización y la discriminación, el pasaporte inmunitario o la moralización de la enfermedad infecciosa han subrayado la necesidad de un marco ético que ayude a reflexionar y justificar las decisiones de salud pública. En este artículo revisamos y analizamos los conflictos éticos que surgieron con el VIH y cómo han reaparecido y se han reinterpretado con la pandemia de la COVID-19.(AU)

The emergence of the human immunodeficiency virus (HIV) in the 1980s brought ethical conflicts that meant a bioethics challenge. Among others, issues of confidentiality, stigmatization, justice, duty of care and investigation arose. Bioethical reflection had been focused on conflicts involving respect for individual autonomy, nevertheless HIV highlighted the needs of the community. Almost four decades later, the COVID-19 pandemic has brought the ethical conflicts typical of public health back to the bioethical scene. Quarantines, various restrictions on mobility, the obligation of masks, poorly protected health care, rationing of scarce resources, rushed research, the vaccines allocation, stigmatization and discrimination, the immune passport, or the moralization of infectious disease have highlighted the need for an ethical framework that helps to reflect and justify public health decisions. In this article we review and analyze the ethical conflicts that arose with HIV and how they have reappeared and been reinterpreted with the COVID-19 pandemic.(AU)

Public Perception of Organ Donation and Transplantation Policies in Southern Spain.

BACKGROUND: This research explores how public awareness and attitudes toward donation and transplantation policies may contribute to Spain's success in cadaveric organ donation. MATERIALS AND METHODS: A representative sample of 813 people residing in Andalusia (Southern Spain) were surveyed by telephone or via Internet between October and December 2018. RESULTS: Most participants trust Spain's donation and transplantation system (93%) and wish to donate their organs after death (76%). Among donors, a majority have expressed their consent (59%), and few nondonors have expressed their refusal (14%). Only a minority are aware of the presumed consent system in force (28%) and feel sufficiently informed regarding the requirements needed to be an organ donor (16%). Participants mainly consider that relatives should represent the deceased's preferences and be consulted when the deceased's wishes are unknown, as is the case in Spain. CONCLUSION: Public trust in the transplant system may contribute to Spain's high performance in organ donation. High levels of societal support toward organ donation and transplantation do not correspond with similar levels of public awareness of donation and transplantation policies in Spain.

La eficiencia no basta. Análisis ético y recomendaciones para la distribución de recursos escasos en situación de pandemia / Efficiency is not enough. Ethical analysis and recommendations for the allocation of scarce resources in a pandemic situation

Objetivo: Elaborar una herramienta de apoyo que ayude a tomar decisiones en el marco de la pandemia de COVID19. Método: Se parte de una búsqueda de diferentes recomendaciones éticas surgidas en España sobre priorización de recursos sanitarios escasos en la pandemia de COVID19, así como de una revisión narrativa de modelos teóricos sobre distribución en pandemias para definir una fundamentación ética. Finalmente, se extraen recomendaciones para su posible aplicación en distintos ámbitos asistenciales. Resultados: Se identifican tres principios, igualdad estricta, equidad y eficiencia, que se sustancian en criterios de distribución específicos. Conclusiones: Se propone un modelo de distribución de recursos sanitarios escasos en situación de pandemia que parte de un procedimiento de toma de decisiones y adapta los criterios de distribución a los escenarios de la atención sanitaria: atención primaria, residencias sociosanitarias y atención hospitalaria. (AU)

Objective: To develop a support tool to decision-making in the framework of the COVID19 pandemic. Method: Different ethical recommendations that emerged in Spain on prioritizing scarce health resources in the COVID19 pandemic first wave were searched; it was conducted a narrative review of theoretical models on distribution in pandemics to define an ethical foundation. Finally, recommendations are drawn to be applied in different healthcare settings. Results: Three principles are identified; strict equality, equity and efficiency, which are substantiated in specific distribution criteria. Conclusions: A model for the distribution of scarce health resources in a pandemic situation is proposed, starting with a decision-making procedure and adapting the distribution criteria to different healthcare scenarios: primary care settings, nursing homes and hospitals. (AU)

[Efficiency is not enough. Ethical analysis and recommendations for the allocation of scarce resources in a pandemic situation]. / La eficiencia no basta. Análisis ético y recomendaciones para la distribución de recursos escasos en situación de pandemia.

OBJECTIVE: To develop a support tool to decision-making in the framework of the COVID-19 pandemic. METHOD: Different ethical recommendations that emerged in Spain on prioritizing scarce health resources in the COVID-19 pandemic first wave were searched; it was conducted a narrative review of theoretical models on distribution in pandemics to define an ethical foundation. Finally, recommendations are drawn to be applied in different healthcare settings. RESULTS: Three principles are identified; strict equality, equity and efficiency, which are substantiated in specific distribution criteria. CONCLUSIONS: A model for the distribution of scarce health resources in a pandemic situation is proposed, starting with a decision-making procedure and adapting the distribution criteria to different healthcare scenarios: primary care settings, nursing homes and hospitals.

Reticencia vacunal: análisis del discurso de madres y padres con rechazo total o parcial a las vacunas / Vaccine hesitancy: discourse analysis of parents who have not fully or partially vaccinated their children

Objetivo: Analizar y comprender los discursos reticentes a la vacunación, particularmente los de las personas que han decidido no vacunar a sus hijos/as. Métodos: Estudio cualitativo con cinco entrevistas individuales y dos grupos focales con personas que optaron por no vacunar a su hijos/as en la provincia de Granada. Resultados: Padres y madres manifiestan un sistema de creencias en salud diferente al paradigma biomédico. Desde el punto de vista ético, justifican su posición a partir del derecho a la autonomía y la responsabilidad de sus decisiones. Como argumentos concretos, dudan de la administración de varias vacunas simultáneamente en edades muy tempranas de manera sistemática y sin individualizar cada caso, temen efectos adversos y no entienden la variabilidad en el calendario vacunal. Conclusiones: Los discursos reticentes responden al conflicto de individualidad vs. colectividad: padres y madres, en defensa de su derecho a una crianza sin interferencias del Estado, centran su responsabilidad en el bienestar individual de sus hijos/as independientemente de las consecuencias que su acción u omisión conlleve a la colectividad. En su gestión de los riesgos, elevan los derivados de vacunar por encima de las consecuencias individuales y colectivas de no hacerlo. Las vacunas que más dudas generan son aquellas con mayor controversia en el ámbito científico. La transparencia en la comunicación de efectos adversos, el respeto de las autoridades a otros conceptos de salud/enfermedad, el destierro del término «antivacunas» del lenguaje mediático y científico, y el desarrollo de espacios de diálogo son puentes por construir

Objective: To analyse and understand vaccination hesitancy discourses, particularly those of people who have decided not to vaccinate their sons and daughters. Methods: Qualitative study of five individual interviews and two focus groups with people who chose not to vaccinate their children in the province of Granada (Spain). Results: Mothers and fathers manifest a system of health beliefs different to the biomedical paradigm. From an ethical point of view, they justify their position based on the right to autonomy and responsibility for their decisions. Alleged specific reasons: they doubt administration of several vaccines simultaneously at an early age in a systematic way and without individualising each case; they fear adverse effects and do not understand the variations of the vaccination schedule. Conclusions: These vaccination hesitancy discourses respond to the individual vs collective conflict; parents defend their right to bring up their children without any interference from the state and focus their responsibility on the individual welfare of their sons and daughters, regardless of the consequences that their actions might have on the collective. In their management of risks, they consider those derived from vaccination more relevant than the individual or collective consequences of not doing so. The vaccines generating most doubts are the more controversial ones within the scientific world. Transparency in communication of adverse effects; authorities respect for other health/disease concepts; banishment of the term "anti-vaccines" from the media and scientific vocabulary, and developing spaces for dialogue are bridges to be built

[Vaccine hesitancy: discourse analysis of parents who have not fully or partially vaccinated their children]. / Reticencia vacunal: análisis del discurso de madres y padres con rechazo total o parcial a las vacunas.

OBJECTIVE: To analyse and understand vaccination hesitancy discourses, particularly those of people who have decided not to vaccinate their sons and daughters. METHODS: Qualitative study of five individual interviews and two focus groups with people who chose not to vaccinate their children in the province of Granada (Spain). RESULTS: Mothers and fathers manifest a system of health beliefs different to the biomedical paradigm. From an ethical point of view, they justify their position based on the right to autonomy and responsibility for their decisions. Alleged specific reasons: they doubt administration of several vaccines simultaneously at an early age in a systematic way and without individualising each case; they fear adverse effects and do not understand the variations of the vaccination schedule. CONCLUSIONS: These vaccination hesitancy discourses respond to the individual vs collective conflict; parents defend their right to bring up their children without any interference from the state and focus their responsibility on the individual welfare of their sons and daughters, regardless of the consequences that their actions might have on the collective. In their management of risks, they consider those derived from vaccination more relevant than the individual or collective consequences of not doing so. The vaccines generating most doubts are the more controversial ones within the scientific world. Transparency in communication of adverse effects; authorities respect for other health/disease concepts; banishment of the term "anti-vaccines" from the media and scientific vocabulary, and developing spaces for dialogue are bridges to be built.

Un modelo de deprescripción prudente / A prudent deprescription model

La estructura terapéutica de los sistemas sanitarios descansa en gran medida sobre la prescripción, lo que genera una tendencia mantenida a sumar fármacos en la historia clínica del paciente. Por el lado contrario, destaca una ausencia significativa de estímulos sobre los profesionales para la reevaluación de prescripciones y la retirada de aquellas con un balance riesgo/beneficio negativo o neutro, lo que supone una desviación de recursos sanitarios hacia el mantenimiento de tratamientos inútiles, cuando no dañinos. La deprescripción, como la retirada meditada de medicación que complementa una prescripción prudente, está dirigida a frenar esta desviación injusta de recursos hacia prescripciones no beneficentes, cuando no maleficentes (AU)

The therapeutic structure of health systems relies heavily on medical prescription, which generates a marked tendency to add drugs to a patient's medical history. There is an absence of incentives for professionals to reassess prescriptions and withdraw those with a negative or neutral risk/benefit. This can create a deviation of medical resources to the maintenance of useless or even harmful treatments. Deprescribing, a process of thoughtful medication withdrawal that complements moderate prescribing, is aimed to stop this unfair deviation of resources towards non-beneficial, if not maleficent, prescription (AU)

[A prudent deprescription model]. / Un modelo de deprescripción prudente.

The therapeutic structure of health systems relies heavily on medical prescription, which generates a marked tendency to add drugs to a patient's medical history. There is an absence of incentives for professionals to reassess prescriptions and withdraw those with a negative or neutral risk/benefit. This can create a deviation of medical resources to the maintenance of useless or even harmful treatments. Deprescribing, a process of thoughtful medication withdrawal that complements moderate prescribing, is aimed to stop this unfair deviation of resources towards non-beneficial, if not maleficent, prescription.