INTRODUCTION. The principle of most favored nation (MFN) has long been used as an international legal instrument for regulating international trade between States in relation to customs duty rates. The main feature of the principle lies in the role that a third State plays in a bilateral legal relationship: participants (subjects) of a legal relationship are required to automatically provide the partner State (the authorized party) with any benefit granted to any third state, for example, a low rate of customs duty on imported goods or commodities. And, on the contrary, has the right to demand and receive such a privilege from the obligated party. The provision or receipt of a reduced rate for goods from the partner state is formalized and carried out by an act or acts of internal law (customs tariff, customs code, etc.), and this introduces a change in the internal customs regime of the interacting states. The principle of the most favored nation between two States is enforced and applies if the partner States receive benefits for goods in the partner State under the same most-favored-nation regime in comparison with the benefits granted to a third State for similar goods. The need to compare, contrast and equalize internal legal regimes in a coordinated sphere of relations at the most favorable level is an essential feature of the MFN principle, the main specific method of regulation. Over the past centuries, the MFN principle has come a long way in its formation and development, and today a new look at it is needed.MATERIALS AND METHODS. The study of this topic and the solution of the task was carried out on the basis of a wide range of materials from the practice of using the MFN principle and its interpretation, the theoretical sharpening of many aspects, and the use of methodological tools traditional for the humanities (law) sciences.THE RESEARCH RESULTS. During the development of the topic, the history of the formation and development of MFN principle, its significance for the international law order and the prospects for its use as a norm of international law, as a principle and method of regulation appear in a slightly new light.DISCUSSION AND CONCLUSIONS. Despite the extensive scientific literature on MFN principle, there are still many unresolved, contradictory opinions and positions about its nature and essence, its normative force and effectiveness, its impact on interstate relations and its place in the global legal system. MFN principle appears today not only as a norm and principle of international law, but also as a principle-institutio, as a method (mechanism) of regulation. At the same time, the scope of its application is expanding, and the regulatory method embedded in it allows for the use of MFN in other potentially suitable areas. MFN principle is turning into an unit of interbranch law formation. In the international trading system and the international trade law order, MFN principle until recently possessed cogent properties, merging into a kind of trinity with the principle of national treatment and the principle of non-discrimination. With the modern transformation of the international system and the world order, MFN principle, as a universal, global principle, is reproduced at the regional and interregional levels, undergoing fragmentation characteristic of international law as a whole. At the same time, MFN principle has become and remains an integral part of the internal content of many fundamental principles of international law, as well as part of the generalizing principle of peaceful coexistence of States and civilizations.
Law of nations, Comparative law. International uniform law
This paper introduces a novel visual mapping methodology for assessing strategic alignment in national artificial intelligence policies. The proliferation of AI strategies across countries has created an urgent need for analytical frameworks that can evaluate policy coherence between strategic objectives, foresight methods, and implementation instruments. Drawing on data from the OECD AI Policy Observatory, we analyze 15-20 national AI strategies using a combination of matrix-based visualization and network analysis to identify patterns of alignment and misalignment. Our findings reveal distinct alignment archetypes across governance models, with notable variations in how countries integrate foresight methodologies with implementation planning. High-coherence strategies demonstrate strong interconnections between economic competitiveness objectives and robust innovation funding instruments, while common vulnerabilities include misalignment between ethical AI objectives and corresponding regulatory frameworks. The proposed visual mapping approach offers both methodological contributions to policy analysis and practical insights for enhancing strategic coherence in AI governance. This research addresses significant gaps in policy evaluation methodology and provides actionable guidance for policymakers seeking to strengthen alignment in technological governance frameworks.
External maritime policy is the common sea transport principles of action which are supported by the EU in the international maritime organizations and especially in the IMO. Sea transport is the backbone of EU’s trade and an essential pillar of cross border support of global supply chains. So the external maritime policy is required to comply with a set of international legislation. IMO is the United Nations specialized producer of maritime law and agreements. EU cannot participate in the IMO sessions due to its legal status as a supranational political and economic union. But it maintains an observer position. This situation does not serve its external maritime policy. EU’s Member States are also independent Members of the IMO and some of them define its decisions. Recently, EU has been engaged in an effort to jointly represent its Member States in the IMO through the absolute primacy of EU law over national law. This means that EU wishes all its Member States to express the common EU positions in the IMO. It is about an indirect muzzle of Member States by the EU in the IMO’s decision making committees. This practice has been well understood by some EU’s maritime Member States and creates an ongoing confrontation. Leader of that confrontation is Greece as a traditional maritime state. Greece intends to challenge the EU introducing an initiative of unilateral representation of its positions in the IMO. To this scope, it exchanges views with other EU’s Member States in order to form a coalition. This article portrays the institutional controversy in EU’s external maritime policy by the unilateral initiative of Greece in the IMO and points out that the EU’s decisions on maritime policy are perhaps a stake for its future.
Child abuse and exploitation pose significant threats to the health and well-being of children. While the Taiwanese government
introduced the Protection of Children and Youth Welfare and Rights Act in 2011 to address these issues, progress has been slow. This paper aims to examine the evolution of Taiwan’s child protection system (CPS), with a particular focus on interdepartmental collaboration. Through the collection of legislation, statistics, conference proceedings, and reports, this study analyzes the working model between law enforcement and public health. Three cases of collaboration between law enforcement and public health at the community level are presented: social safety net programs, early intervention for child abuse, and trauma-informed training for first responders. The accomplishments and challenges of each project are discussed, along with a review of the CPS in relation to the United Nations (UN) strategy INSPIRE’s approaches. Although Taiwan has shown a commendable emphasis on prevention and family support, the collaboration between law enforcement and public health is still in its early stages. The next crucial step is to strengthen integration in the early stages of identifying, assessing, and referring cases of child abuse and neglect. This can be achieved by generating more evidence on effective working models and promoting their implementation.
Human settlements. Communities, Social pathology. Social and public welfare. Criminology
Digital Sovereignty must be on the agenda of every modern nation. Digital technology is becoming part of our life details, from the vital essentials, like food and water management, to transcendence in the Metaverse and Space. Protecting these digital assets will, therefore, be inevitable for a modern country to live, excel and lead. Digital Sovereignty is a strategic necessity to protect these digital assets from the monopoly of friendly rational states, and the threats of unfriendly Malicious states and behaviors. In this work, we revisit the definition and scope of digital sovereignty through extending it to cover the entire value chain of using, owning, and producing digital assets. We emphasize the importance of protecting the operational resources, both raw materials and human expertise, in addition to research and innovation necessary to achieve sustainable sovereignty. We also show that digital sovereignty by autonomy is often impossible, and by mutual cooperation is not always sustainable. To this end, we propose implementing digital sovereignty using Nash Equilibrium, often studied in Game Theory, to govern the relation with Rational states. Finally, we propose a digital sovereignty agenda for different country's digital profiles, based on their status quo, priorities, and capabilities. We survey state-of-the-art digital technology that is useful to make the current digital assets sovereign. Additionally, we propose a roadmap that aims to develop a sovereign digital nation, as close as possible to autonomy. Finally, we draw attention to the need of more research to better understand and implement digital sovereignty from different perspectives: technological, economic, and geopolitical.
The paper demonstrates that the Charter of the United Nations contains some incompatible norms, a fact that directly impacts the organization’s system of collective security. The voting procedure of the Security Council, privileging its permanent members, stands in open contradiction to the Charter’s principle of “sovereign equality” of all member states. Article 27(3) of the Charter makes uniform enforcement of the prohibition of the international use of force impossible because it effectively exempts the organization’s five permanent members. Those states can block any decision of the Council even in cases when they are themselves party to a dispute. The problem is further aggravated by a lack of checks and balances in the UN system in general. The International Court of Justice has no competence to rule on the Security Council’s use of its vast coercive powers under Chapter VII of the Charter. The supreme executive organ of the UN can act as “index in causa sui.” Thus, the lack of a separation of powers – in tandem with the statutory privilege of some of the most powerful states – makes the “rule of law” an elusive idea in the intergovernmental system of the United Nations.
Law, Political institutions and public administration (General)
Se analiza la situación del derecho a la salud en Venezuela a través de los parámetros exigidos por la prohibición de regresividad de los derechos sociales, con miras a determinar si en dicho país existe un retroceso en el acceso y disfrute efectivo del derecho a la salud. Para ello, se estudia, en primer lugar, la prohibición de regresividad de los derechos sociales con énfasis en la regresividad de los resultados de una política pública. En segundo lugar, se revisa el contenido del derecho a la salud, entendiéndolo como un derecho prestacional que requiere de un desarrollo político, legislativo, económico y técnico para garantizar su expansión y cobertura a toda la población. En tercer lugar, se presentan los datos de la encuesta nacional de hospitales (ENH) desarrollada desde el año 2014 por la organización Médicos por la Salud y el Grupo de Investigación de Enfermedades Infecciosas y Tropicales de Venezuela (GIDETI) y los resultados del seguimiento al presupuesto público nacional que realiza la organización Transparencia Venezuela para evidenciar la situación actual del derecho a la salud en Venezuela, presentando como último punto, las conclusiones correspondientes. La metodología utilizada para esta comunicación es de tipo exploratoria, secundaria y documental. Se realizó la búsqueda de publicaciones académicas sobre el tema de estudio y se revisaron los datos recopilados por las organizaciones mencionadas. Posteriormente se procedió al análisis de la información y los datos para responder la premisa de la investigación. Se concluye que en Venezuela existe un retroceso en el disfrute y acceso del derecho a la salud que ha puesto en riesgo la vida de los venezolanos, lo que evidencia un incumplimiento del Estado de garantizar el disfrute efectivo de los derechos sociales, lo que agrava la situación de emergencia humanitaria compleja que atraviesa este país.
Law of nations, Law in general. Comparative and uniform law. Jurisprudence
If simple entropy in the Bekenstein-Hawking area law for a Schwarzschild black hole is replaced with 'negative' quantum conditional entropy, which quantifies quantum entanglement, of positive-energy particles of the black hole relative to its outside, a paradox with the original pair-creation picture of Hawking radiation, the first law for black hole mechanics and quantum mechanics is resolved. However, there was no way to judge experimentally which area law is indeed adopted by black holes. Here, with the no-hair conjecture, we derive the perfect picture of a second law of black hole thermodynamics for any black hole from the modified area law, rather than Bekenstein's generalized one from the original area law. The second law is testable with an event horizon telescope, in contrast to Bekenstein's. If this is confirmed, the modified area law could be exalted to the first example of fundamental equations in physics which cannot be described without the concept of quantum information.
Mario Gleirscher, Nikita Johnson, Panayiotis Karachristou
et al.
The coordinated assurance of interrelated critical properties, such as system safety and cyber-security, is one of the toughest challenges in critical systems engineering. In this chapter, we summarise approaches to the coordinated assurance of safety and security. Then, we highlight the state of the art and recent challenges in human-robot collaboration in manufacturing both from a safety and security perspective. We conclude with a list of procedural and technological issues to be tackled in the coordinated assurance of collaborative industrial robots.
Benfords law states that for scale- and base-invariant data sets covering a wide dynamic range, the distribution of the first significant digit is biased towards low values. This has been shown to be true for wildly different datasets, including financial, geographical, and atomic data. In astronomy, earlier work showed that Benfords law also holds for distances estimated as the inverse of parallaxes from the ESA Hipparcos mission. We investigate whether Benfords law still holds for the 1.3 billion parallaxes contained in the second data release of Gaia (Gaia DR2). In contrast to previous work, we also include negative parallaxes. We examine whether distance estimates computed using a Bayesian approach instead of parallax inversion still follow Benfords law. Lastly, we investigate the use of Benfords law as a validation tool for the zero-point of the Gaia parallaxes.
Giordano De Marzo, Andrea Gabrielli, Andrea Zaccaria
et al.
The rank-size plots of a large number of different physical and socio-economic systems are usually said to follow Zipf's law, but a unique framework for the comprehension of this ubiquitous scaling law is still lacking. Here we show that a dynamical approach is crucial: during their evolution, some systems are attracted towards Zipf's law, while others presents Zipf's law only temporarily and, therefore, spuriously. A truly Zipfian dynamics is characterized by a dynamical constraint, or coherence, among the parameters of the generating PDF, and the number of elements in the system. A clear-cut example of such coherence is natural language. Our framework allows us to derive some quantitative results that go well beyond the usual Zipf's law: i) earthquakes can evolve only incoherently and thus show Zipf's law spuriously; this allows an assessment of the largest possible magnitude of an earthquake occurring in a geographical region. ii) We prove that Zipfian dynamics are not additive, explaining analytically why US cities evolve coherently, while world cities do not. iii) Our concept of coherence can be used for model selection, for example, the Yule-Simon process can describe the dynamics of world countries' GDP. iv) World cities present spurious Zipf's law and we use this property for estimating the maximal population of an urban agglomeration.
The problem of estimating certain distributions over $\{0,1\}^d$ is considered here. The distribution represents a quantum system of $d$ qubits, where there are non-trivial dependencies between the qubits. A maximum entropy approach is adopted to reconstruct the distribution from exact moments or observed empirical moments. The Robbins Monro algorithm is used to solve the intractable maximum entropy problem, by constructing an unbiased estimator of the un-normalized target with a sequential Monte Carlo sampler at each iteration. In the case of empirical moments, this coincides with a maximum likelihood estimator. A Bayesian formulation is also considered in order to quantify posterior uncertainty. Several approaches are proposed in order to tackle this challenging problem, based on recently developed methodologies. In particular, unbiased estimators of the gradient of the log posterior are constructed and used within a provably convergent Langevin-based Markov chain Monte Carlo method. The methods are illustrated on classically simulated output from quantum simulators.
We present the discovery of a slowly-evolving, extragalactic radio transient, FIRST J141918.9+394036, identified by comparing a catalog of radio sources in nearby galaxies against new observations from the Very Large Array Sky Survey. Analysis of other archival data shows that FIRST J141918.9+394036 faded by a factor of ~50 over 23 years, from a flux of ~26 mJy at 1.4 GHz in 1993 to an upper limit of 0.4 mJy at 3 GHz in 2017. FIRST J141918.9+394036 is likely associated with the small star-forming galaxy SDSS J141918.81+394035.8 at a redshift z=0.01957 (d=87 Mpc), which implies a peak luminosity $νL_ν\gtrsim 3\times10^{38}$ erg s$^{-1}$. If interpreted as an isotropic synchrotron blast wave, the source requires an explosion of kinetic energy ~10^{51} erg some time prior to our first detection in late 1993. This explosion could plausibly be associated with a long gamma-ray burst (GRB) or the merger of two neutron stars. Alternatively, FIRST J141918.9+394036 could be the nebula of a newly-born magnetar. The radio discovery of any of these phenomena would be unprecedented. Joint consideration of the event light curve, host galaxy, lack of a counterpart gamma-ray burst, and volumetric rate suggests that FIRST J141918.9+394036 is the afterglow of an off-axis (`orphan') long GRB. The long time baseline of this event offers the best available constraint in afterglow evolution as the bulk of shock-accelerated electrons become non-relativistic. The proximity, age, and precise localization of FIRST J141918.9+394036 make it a key object for understanding the aftermath of rare classes of stellar explosion.
Yunfan Gerry Zhang, Vishal Gajjar, Griffin Foster
et al.
We report the detection of 72 new pulses from the repeating fast radio burst FRB 121102 in Breakthrough Listen C-band (4-8 GHz) observations at the Green Bank Telescope. The new pulses were found with a convolutional neural network in data taken on August 26, 2017, where 21 bursts have been previously detected. Our technique combines neural network detection with dedispersion verification. For the current application we demonstrate its advantage over a traditional brute-force dedis- persion algorithm in terms of higher sensitivity, lower false positive rates, and faster computational speed. Together with the 21 previously reported pulses, this observa- tion marks the highest number of FRB 121102 pulses from a single observation, total- ing 93 pulses in five hours, including 45 pulses within the first 30 minutes. The number of data points reveal trends in pulse fluence, pulse detection rate, and pulse frequency structure. We introduce a new periodicity search technique, based on the Rayleigh test, to analyze the time of arrivals, with which we exclude with 99% confidence pe- riodicity in time of arrivals with periods larger than 5.1 times the model-dependent time-stamp uncertainty. In particular, we rule out constant periods >10 ms in the barycentric arrival times, though intrinsic periodicity in the time of emission remains plausible.
The present study analyzes the preventive health care provisions for nationals and undocumented migrants in Germany, the Netherlands and Spain in light of four indicators derived from the United Nations Committee on Economic, Social and Cultural Rights’ General Comment 14 (GC 14). These indicators are (i) immunization; (ii) education and information; (iii) regular screening programs; and (iv) the promotion of the underlying determinants of health. It aims to answer the question of what preventive health care services for undocumented migrants are provided for in Germany, the Netherlands and Spain and how this should be evaluated from a human rights perspective. The study reveals that the access to preventive health care for undocumented migrants is largely insufficient in all three countries but most extensive in the Netherlands and least extensive in Germany. The paper concludes that a human rights-based approach to health law and policy can help to refine and concretize the individual rights and state obligations for the preventive health care of undocumented migrants. While the human rights framework is still insufficiently clear in some respects, the research concedes the added value of a rights-based approach as an evaluation tool, advocacy framework and moral principle to keep in mind when adopting or evaluating state policies in the health sector.
The nations are worth as much as it is worth their economies. In today's global world, people gain or lose independence primarily by how successful their economy is . Of course, freedom and independence of a people is defended in all fields, but the economic success is the key to success to all the rest. A society that is for us and the former socialist countries, termed transition, represents a return to predatory capitalism and the way in hypocritical, orchestrated democracy; it is now the world of lasting evil and bigger injustice that undermine the state and relentlessly pushing them into ,,peripheral capitalism' (Ljubisa Mitrovic). The word 'economy' is of Greek origin and translated into our language it means' skill of housekeeping (economy)'. What we habitually continue to call economy in the world today and in Serbia, we can not call the skill of keeping. The term 'economy' has long been superseded, in his place is the term 'chrematistics' also a word of Greek origin that means inserted enrichment. This term in use is introduced by Aristotle. This ancient philosopher emphasized that the economy and chrematistics are antipodes and that chrematistics destructive to society. By its nature, it leads to the destruction of the economy. Practically, it can be called 'destroyers skill of keeping the economy.' Today in the world and Serbia do not have the economy, we have chrematistics (speculation on commodity markets , pyramid schemes, the development of the securities market , games on the stock market ... ) . Chrematistics the trick word, and that's why we can replace it with the term 'casino-economy.' A new form of monarchy, which is expressed as a new imperialism, is not based on ' cunning mind' (Hegel ) and the 'spirit of the law' ( Montesquieu ), but the 'cunning of the economy', which is dominated by raw (Hobbes ) laws of the market and where the economy becomes policies. Figure of societies of Eastern Europe, where the neoliberal social Darwinism, disenfranchising the largest population, has created an entire class of poor, who are now struggling to realize their right to work, confirms the emptiness of neoliberal democracy. As a result of chrematistics in transit societis 'capitalism without capitalists' is created (Mladen Lazic) in which the capital, grabed during social conflicts, mediated by political elites, by which the redistribution of accumulated social wealth ended up largely in private hands. If proved, and it is, that the current neo-liberal approach and form (paradigm ) does not give the expected, and so the required results, then the need to search for a new paradigm of development and more prominent. We need one another, a different view of society and especially its development, freed from the constraints and domination of the theory and methodology of the global powers imposed as the only desirable (required ). So, we need a self-reflective approach to social issues especially in orthodox societies. It is a request that it turned to itself and see their potential and opportunities. This paper is an attempt to draw attention to the devastating consequences of chrematistics in the world, and especially in our society, but also to make an effort to search for the 'principle of hope' and point out the different possible directions of development of Serbian society. We are convinced that, as the basis of Western civilization with the neo-liberal development model is the social doctrine of Catholicism, Orthodox civilization, which can and should be the centerpiece and developer 'planetrly humanism' (Danilo Z. Marković) (which in the present Russia partly realized), there should be the social doctrine of Orthodoxy at the basis of Orthodox ethics and domestic economics.
History of scholarship and learning. The humanities
Marcello M. Bonsangue, Helle Hvid Hansen, Alexander Kurz
et al.
Distributive laws of a monad T over a functor F are categorical tools for specifying algebra-coalgebra interaction. They proved to be important for solving systems of corecursive equations, for the specification of well-behaved structural operational semantics and, more recently, also for enhancements of the bisimulation proof method. If T is a free monad, then such distributive laws correspond to simple natural transformations. However, when T is not free it can be rather difficult to prove the defining axioms of a distributive law. In this paper we describe how to obtain a distributive law for a monad with an equational presentation from a distributive law for the underlying free monad. We apply this result to show the equivalence between two different representations of context-free languages.
Starting in December 2015, Wales will be the first nation in the United Kingdom to break away from convention and join the twenty-four European countries that have adopted presumed consent legislation to address the stagnant transplant rate and shortage of human organs. Hailed by many ministers in the National Assembly for Wales as the “most significant piece of legislation” since the United Kingdom was granted full lawmaking powers in 2011, the law hopes to alleviate the transplant list and save the lives of those who would normally die from waiting. [1] As is the case worldwide, there is a remarkable deficiency in donor organs, which fails to meet the demand for organ transplantation. In the United Kingdom, the active transplant waiting list has increased approximately eight percent each year, with the aging population and rising incidence of type-2 diabetes likely to worsen the strain on the transplantation system.[2],3 Support for the legislation has stemmed from the rising donation rates of other European countries, especially Spain, which has the highest rate of donors per million population (pmp) in the world, attributing this trend to the adoption of presumed consent legislation. With Wales being the latest country to go down the road of presumed consent, the question will inevitably rise: Should the United States take a more critical look at its current system of explicit consent and “required referral” for organ donation? In light of all the available empirical data, should the United States follow suit of its European counterparts and adopt presumed consent? What are the ethical concerns regarding such a proposal; and how does the nation’s previous attitudes toward presumed consent shape the conversation?
Opt-out vs. Opt-in
Presumed consent for organ donation is the systematic framework in which a deceased person’s consent to be an organ donor is assumed. Those wishing not to be donors must express their objection in a national registry or a family member must object to organ donation after the person’s death. Thus, presumed consent differentiates itself by being an “opt-out” system, whereas the majority of the world’s organ donation systems are “opt-in”, requiring an individual to register their intent as organ donors. Advocates of presumed consent often point to the successes of European nations such as Spain, Belgium, and Austria, highlighting how their donation rates significantly increased after the implementation of presumed consent. While Spain’s donation rate of 34.8 pmp is certainly remarkable on a global scale, 2,[3] it is necessary to undertake a systematic review of the empirical data in order to arrive at any assertive conclusion as to presumed consent’s potential for use in the United States.
In addition to the umbrella terms “presumed consent” or “opt-out” system, legislation can vary between countries, leading to the use of additional terms such as “hard” and “soft” to characterize the degree of emphasis placed on the views of the decedent’s relatives.2 For instance, in Spain physicians must take active steps to make sure that the decedent’s family does not object to the procurement of their organs. Therefore, the presumed consent law in Spain is “soft.” This is in direct contrast with the case in Austria where procurement will proceed under all circumstances, barring evidence of the decedent’s objection before death. The law in this case is relatively “hard” because the family is not consulted by doctors about their own objections to organ extraction. Irrespective of the “soft” or “hard” terminology, both forms of presumed consent have seemingly proven to be significant factors influencing the organ donation rate. Before the enactment of the legislation, the Austrian donation rate was 4.6 pmp. Within four years the rate increased to 10.1 pmp, and five years later the rate was 27.2 pmp. Three years after the adoption of presumed consent legislation, Belgium saw a rate increase from 18.9 to 41.3 pmp; and Singapore also saw an extraordinary increase from 4.7 to 31.3 pmp over a three-year period. In 1989, Spain’s donation rate was similar to that of the United Kingdom – 14 pmp – and over the past twenty years the rate has climbed to its current levels. To further contrast the United Kingdom and Spain, the rate of families refusing to give consent to organ removal has dropped to 15 percent in Spain, while the refusal rate in the United Kingdom still sits at approximately 40 percent, which is an attributing factor to the lagging donation rate overall. [4],[5]
Learning from the Spanish Experience
Have these notable increases in the rate of deceased organ donation simply resulted from the implementation of a presumed consent law? Or are there other factors that are hiding behind the numbers? The facts tend to favor towards the latter. For example, the jump from 10.1 to 27.2 donors pmp found in Austria is not only because of the presumed consent law. Rather, the five years that reflect this increase was a time of focused improvement upon the country’s transplantation infrastructure, which included the training of full-time transplant coordinators.2,[6] In addition, Spain’s rate increase was only measured a full ten years after the Spanish government passed the presumed consent legislation. From 1979 to 1989, the donation and refusal rate did not change much relative to the other European nations.2,4 It was in 1989 that Spain comprehensively reformed its organ procurement system, which included a number of innovations.
In Spain, the defining characteristic of the innovations is the placement of transplant coordinators at every procurement hospital—these coordinators have a unique educational profile that helps them quickly identify potential donors. Many coordinators are intensive care physicians that play increasingly active roles in the organ procurement process, such as approaching the potential donor’s family and checking for potential donors in and out of the intensive care unit on a daily basis. Because transplant coordinators are not members of the transplant team, but rather part of the in-house hospital staff, they can be placed throughout the country and especially in hospitals that have lower rates of deceased organ donation.4Moreover, the coordinators are trained and organized by a central agency, the Organización Nacional de Transplantes, which provides regular courses on the organ procurement process. This model has led to more than 11,000 medical professionals being trained as coordinators since 1991. 4 Thus, it was not the new presumed consent law by itself that triggered the rise and steady maintenance of a high donation rate but a widespread overhaul of how potential donors were identified in the places they are most likely to be found: the intensive care unit.
The systematic review of various studies conducted by Rithalia et al. also indicates that a number of other factors have a positive impact on the donation rate. The most obvious component of an increased donation rate is the availability of potential donors. Without a sizeable and renewable pool of donors from which to procure organs, the donation rate will remain stagnant and will fail to respond as the need increases. Interestingly, three studies conducted in Organization for Economic Cooperation and Development (OECD) countries considered the mortality rate from road traffic accidents and showed a significant correlation with donation rate.2 Additional studies illustrated that wealth and healthcare expenditures, measured in gross domestic product (GDP) per capita and health expenditure per capita, were strong predictors of high donation rates. 2 A review of European countries by Gimbel et al. also discovered that the percentage of the population enrolled in third-tier education, used to assess the influence of social demographics on donation rates, had a significant positive association.[7]Finally, there was an overall favorable relationship between the percent of the population that identified themselves as Roman Catholic and the donation rate.7,[8] This result is consistent with the popular suggestion that Catholicism tends to have more encouraging attitudes toward organ donation, recognizing it as a “service of life.”2 These statistics and correlations drive home the sentiment that presumed consent in and of itself cannot account for the rise in donation rates in European countries. Nor is the adoption of a presumed consent law a guarantee that the country will achieve high donation numbers.[9] This is further exhibited in Greece, where despite “presumed consent” legislation the donation rate remains at 6.9 pmp; thus supporting the argument that economic and social factors have influential roles to play.[10]
Conclusions such as these certainly make the case that presumed consent is not the sole predictor for improving the donation rate. Evaluating, understanding, and reforming the underlying economic and social circumstances hold great promise in changing the trend of organ donation. What presumed consent could provide, however, is a framework for expanding the availability of potential donors.[11] With a national survey finding a disparity between the number of Americans willing to donate organs and the number who are currently registered as donors,[12] the discussion concerning the adoption of presumed consent takes on a more significant role and scholars have urged for this change.[13],[14],[15]
In the United States, the donation rate is 26.1 pmp,[16],[17] placing it fourth worldwide.9 Yet, the waiting list for organ transplants has exceeded 122,000 and is anticipated to grow roughly 10 percent each year, which results in thousands of people dying while waiting for an organ.[18]This is all despite the fact that more than 28,000 transplants are performed each year in the United States, more than any other country.16 These facts are what drive the debate in the direction of presumed consent, for if the country is to save as many people as possible who are currently waiting on the transplant list, then legislators believe that presumed consent holds the key to reforming the decades-old “opt-in,” explicit consent model.
Philosophical Arguments
Promoters shape their arguments around the need to fundamentally change the American assumption that “absent specific notification to the contrary, decedents are best protected if we act as though they had autonomously willed that their organs not be donated for transplantation.”14 This is precisely the principle governing explicit consent for organ donation, in which a person during their lifetime, or a family member after their death, must clearly express the will to donate the organs. Cohen argues that this ideology should be reformed and replaced with the notion that the best way to protect the autonomous wishes of the deceased would be to assume that they would have willed for their organs to be used for “beneficial medical uses.” Furthermore, he espouses the “hard” form of presumed consent, stating that no permission should be sought from anyone in the absence of express refusal from the deceased. The basis for Cohen’s reasoning lies in his appeal to the moral argument: it is morally just—not only for the decedent, but also for the members of society who need organs—to remove the organs from the majority of individuals who would have wanted to donate their organs but left behind no indication of that wish. It is therefore morally unjust to violate their wishes and bury them with all their organs intact inside their bodies. Cohen characterizes this as a breach of autonomy; a breach that only a presumed consent policy would rectify, resulting in an increase in the number of decedents whose wishes are respected.
Veatch and Pitt counter Cohen’s claims by asserting that presumed consent is morally unacceptable because it results in the violation of a person’s fundamental right to be able to autonomously choose what happens to his or her body after death.[19] Whereas Cohen’s majority would have wished to have their organs removed, Veatch and Pitt’s minority prefer not to have their organs removed after death. If presumed consent were instated, then it would be easy to assume that many in the minority would fail to properly indicate their desire not to donate, much like the many in the majority who fail to properly indicate their desire to donate. What would result are instances in which individuals who wished to be buried with all their organs inside their body would have their organs removed. Veatch and Pitt posit this as a far more egregious violation of autonomy than the one found in Cohen’s argument. The current system of explicit consent, therefore, is in a better position to protect autonomy and respect the wishes of those who do not wish to donate.
Michael Gill attempts to reconcile the two sides of this debate, ultimately reaching the conclusion that presumed consent provides the most morally acceptable solution. He starts by acknowledging that mistakes will be made in either consent scheme. Regardless of how well explicit consent is instituted, there will be cases where those who wished to donate their organs will be buried with their organs intact. Similarly, regardless of how well presumed consent is instituted, there will be cases where those who did not wish to donate are buried with their organs removed. Gill emphasizes the moral duty to respect a person’s wishes concerning his or her body, but asserts that violating this duty by either mistakenly removing or not removing organs is equal. Both of these mistakes fail to bring about the “state of affairs the individual desired.” With the moral gravity of these mistakes being equal in Gill’s view, the moral question then becomes: Which consent scheme minimizes the moral harms and maximizes the moral benefits? It becomes easy to see from this line of thinking that the ethical fortitude sides with presumed consent, which is prone to make fewer mistakes than explicit consent.
How Does the United States Fit In?
Although Gill’s conclusion would certainly appease those fighting for the implementation of presumed consent, his notion is meant for a country with a stronger communitarian ethic; one in which the tenets of utilitarian moralism outweigh those of individual autonomy. Such a policy, however, goes “against the grain of American individualism.”13 As Orentlicher states, the United States has actually tried presumed consent on a limited basis for the past forty years, and it failed because it went either too far or not far enough. In allowing family members to overrule the presumption that the decedent would have preferred donation, presumed consent did not go far enough. This deference to the family in regard to organ donation never allowed presumed consent to surpass the real reason why decedents do not become organ donors, namely the refusal of family members to give consent.13 This is akin to the kind of “soft” presumed consent found in Spain. Spain places great importance upon the fact that death is not an isolated event involving the deceased, but instead engages the whole family. Spain realizes that any organ procurement system relies on the trust that exists between the patient’s family and the physicians or transplant coordinators. Undermining that trust would completely damage the entire organ donation process. This serves to highlight Spain’s accomplishment in keeping the refusal rate so low at 15 percent; which is achieved mainly through its extensive training of transplant coordinators, lack of donor registry , and enhanced capacity to identify potential donors.4 In essence, the Spanish model succeeds without much need for presumed consent.
According to Orentlicher, presumed consent in the United States went too far in regard to the fact that public officials attempted to bypass family members in an effort to avoid the possibility of family refusal. Such attempts only exacerbated concerns and fears that physicians would harvest organs from those who would not have wished for their removal. Starting in the late 1960s, state legislatures passed measures that authorized the removal of corneas, pituitary glands, and sometimes even hearts, lungs, kidneys, and livers if the decedent’s body came under the custody of a medical examiner or coroner. The lawmakers’ reasoning was rather simple – since the body of these individuals would already be subjected to a major intrusion in the form of an autopsy, then removal of an organ for the benefit of living persons was acceptable. This practice was supported and reinforced by the 1987 Uniform Anatomical Gift Act, but has since been discarded since the document’s 2006 revision and adoption by a vast majority of states.13 Therefore, the largest hurdle for presumed consent to conquer is that of public perception and attitudes against it. Because the registration process varies from state to state, many state legislatures have tried to bring up the issue of presumed consent, proposing opt-out systems. These have never gotten very far due to concerns about individual rights—another testament to the importance of autonomy, which is present in American minds. For example, Colorado tried to pass an opt-out law in 2011, but the lawmaker who introduced the bill was forced to pull it due to negative reactions from the public.10
There has been abundant skepticism about the possibility of presumed consent as a solution to close the organ gap that exists in the United States.11,[20] Researchers have concluded that despite the substantive differences in the laws themselves, presumed consent, in countries like Spain, does not differ dramatically from the application of explicit consent in the United States. In both the United States and Spain, primacy is given to respecting the wishes of the individual and the family. If anything, the experience in Spain has shown that what can truly improve the donation rate is diligent attention to the infrastructure of the organ transplantation system, using it to quickly and efficiently identify patients in the intensive care unit who are potential donors and taking the necessary steps to ensure that the organs are procured ethically and respectfully once death occurs. With respect to the procurement system currently in place in the United States, legislation was introduced by the Surgeon General that legally requires all hospitals to identify and refer potential donors to an organ donor organization.3 Potential donors are identified using clinical markers that are present in patients likely to be diagnosed as brain dead, and organ donor organizations are well-staffed with an extensive network of trained organ coordinators.
Alternatives to Presumed Consent
Comparatively, the transplantation environment of Spain and the United States is very similar. What is lacking, then, in the United States is not the adoption of presumed consent, but a method of improving the family refusal rate. This can be achieved through public policy that aims to increase the likelihood that individuals will document their wishes. Family members who are aware and confident in the decedent’s wish to donate his or her organs after death are more likely to respect these wishes and consent to organ procurement upon request. Orentlicher suggests that if everyone willing to donate were to officially register, then organ donation rates could increase by as much as 50 percent.13 Efforts such as the Hero Act in New Jersey have taken the initiative by mandating that New Jersey public schools provide information about organ and tissue donation and that material be included in the state’s Core Curriculum Content Standards for Comprehensive Health and Physical Education for grades 9–12.[21] The goal is to ensure that all residents have the “fundamental responsibility to choose whether to help save another’s life.”
Overcoming high refusal rates can also be done by combating the misconceptions that seem to be at the root of the refusals,13 such as the notion that organ donation violates certain religious ideals or that donation would affect the body’s appearance at an open casket funeral. Motivated physicians dedicated to the cause of organ donation have been the key for success in Spain,4and as such, physicians in the United States must develop the skills to delicately approach families. Gortmaker has found that this is best realized when the discussion about the patient’s death is separated from the discussion about organ donation, when organ procurement professionals join with hospital staff in the donation discussion, and when the request for donation takes place in a quiet, private setting.[22] Procurement professionals have also begun utilizing a “presumptive approach” when discussing organ donation with families, which is an approach that takes on a more value-positive tone and strives to encourage the family to consent to donation.[23] Application of strategies such as these may see refusal rate in the United States drop significantly, altering the transplantation landscape in ways that presumed consent legislation simply could not.
In all, the talk about presumed consent seems to have taken a back seat since its abandonment in the latest version of the Uniform Anatomical Gift Act and public sentiment has proven to be a difficult obstacle to clear in recent years. Although it may always seem like an attractive solution to an issue that is at the forefront of medicine, the data illustrates that presumed consent is not what the United States is clamoring for. It begs for a solution that makes use of the current organ procurement infrastructure, expands the base of information available to potential donor registrants, and continues to build upon the trust between families and hospitals.
REFERENCES
[1] BBC News Wales. “Organ donation: Presumed consent to start in December 2015.” September 10, 2013.
[2] Amber Rithalia, Catriona McDaid, Sara Suekarran, Lindsey Myers, and Amanda Sowden. “Impact of presumed consent for organ donation on donation rates: a systematic review.” British Medical Journal, 2009.
[3] Simon Bramhall. “Presumed consent for organ donation: a case against.” Annals of the Royal College of Surgeons of England, 2011: 268-272.
[4] John Fabre, Paul Murphy, and Rafael Matesanz. “Presumed consent is unnecessary.” British Medical Journal, 2010: 922-924.
[5] European Union Directorate-General for Health and Consumers. “Key facts and figures on EU organ donation and transplantation.” 2010.
[6] M.F.X. Gnant, P. Wamser, P. Goetzinger, T. Sautner, R Steininger, and F. Muehlbacher. “The impact of the presumed consent law and a decentralized organ procurement system on organ donation: quadruplication in the number of organ donors.” Transplantation Proceedings, 1991: 2685-2686.
[7] Gimbel, RW, MA Strosberg, SE Lehrman, Gefenas E, and F Taft. “Presumed consent and other predictors of cadaveric organ donation in Europe.” Progress in Transplantation, 2003: 17-23.
[8] Neto, Giacomo Balbinotto, Ana Katerina Campelo, and Everton Nunes da Silva. “Impact of presumed consent law on organ donation: an empirical analysis from quantile regression for longitudinal data.” Latin American and Caribbean Law and Economics Association Annual Papers, 2007.
[9] Remco Coppen, Roland Friele, Richard Marquet, Sjef Gevers. “Opting-out systems: no guarantee for higher donation rates.” Transplant International, 2005: 1275-1279.
[10] Sydney Lupkin. Organ donation rates: How the US stacks up. June 18, 2013.
http://abcnews.go.com/Health/organ-donation-rates-us-stacks/story?id=19437070# (accessed May 5, 2014)
[11] Alberto Abadie and Sebastien Gay. The Impact of Presumed Consent Legislation on Cadaveric Organ Donation: A Cross Country Study. Working Paper, Cambridge, MA: National Bureau of Economics Research, 2004.
[12] Astellas Pharma US, Inc. Survey Finds Disconnect Between Number of Americans Willing to Donate Organs and Number Currently Registered as Donors. April 15, 2013.
http://newsroom.astellas.us/news-releases (accessed May 3, 2014).
[13] David Orentlicher. “Presumed consent to organ donation: Its rise and fall in the United States .” Rutgers Law Review, 2009: 295-331.
[14] Carl Cohen. “The case for presumed case to transplant human organs after death.” Transplantation Proceedings, 1992: 2168-2172.
[15] Gill, Michael B. “Presumed Consent, Autonomy, and Organ Donation.” Journal of Medicine and Philosophy, 2004: 37-59.
[16] Donate Life California. Presumed Consent: An Attractive Concept with Unattractive Results. May 8, 2014. http://donatelifecalifornia.org/education/faqs/presumed-consent/ (accessed May 8, 2014).
[17] Howard M. Nathan, Suzanne L. Conrad, Philip J. Held, Keith P. McCullough, Richard E. Pietroski, Laura A. Siminoff, Akinlou Ojo. “Organ donation in the United States.” American Journal of Transplantation, 2003: 29-40.
[18] U.S. Department of Health and Human Services. Organdonor.gov. May 8, 2014. http://www.organdonor.gov/index.html (accessed May 8, 2014).
[19] RM Veatch and JB Pitt. “The myth of presumed consent: ethical problems in new organ procurement strategies.” Transplant Proceedings, 1995: 1888-1892.
[20] BJ Boyarksy, EC Hall, NA Deshpande, RL Ros, RA Montgomery, DM Steinwachs, DL Segev. “Potential limitations of presumed consent legislation.” Transplantation, 2012: 136-140.
[21] New Jersey Driver Education. For Organ/Tissue Donation.
http://www.njdrivereducation.com/organ-donation (accessed May 7, 2014).
[22] Steven L. Gortmaker. "Improving the request process to increase family consent for organ donation." Journal of Transplant Coordination, 1998.
[23] Robert Truog. "Consent for organ donation - balancing ethical obligations." New England Journal of Medicine, 2008: 1210-1211.