Einwilligungsfähigkeit: inhärente Fähigkeit oder ethisches Urteil?

Definition of the problem

Because determining a patient’s decision-making competence has far-reaching ethical and legal implications, the concept of competence must be clearly understood. The criteria for competence are commonly defined in terms of mental abilities; more basic questions as to whether competence refers to an inherent ability or to an ethical judgment are rarely discussed in more detail.

Arguments

A central aspect of this distinction between ability and judgment concerns the significance of ethical considerations relating to paternalism and its legitimacy. Where competence is conceived as inherent ability, such considerations follow a determination of competence; where it is conceived as ethical judgment, these matters become constitutive of understanding and determining competence.

Conclusion

Despite the observed tendency to understand competence ideally as an inherent ability, actual practice suggests that, to the contrary, competence is conceived as a matter of ethical judgment. These conflicting tendencies may account for associated conceptual controversies, especially with regard to risk-relative evaluations. Moreover, conceived as judgment, determinations of competence need not adhere rigidly to definitions of autonomy, and so are better able to deal with the inherent ambiguity of this notion.

     

Grundbefähigungsgleichheit im Gesundheitswesen

Zusammenfassung  Die Frage nach der Gerechtigkeit im Gesundheitswesen wird aus der Perspektive einer allgemeinen Theorie der Gerechtigkeit betrachtet. Diese Theorie ist ein Befähigungsansatz, der zwischen 1) der Grundversorgung aller Bürger mit Grundbefähigungen, 2) einem gerechten Anteil an den Früchten gesellschaftlicher Kooperation und 3) individuell erstrebten Gütern und Leistungen differenziert. Die Anwendung dieser Theorie reagiert auf charakteristische Probleme der Allokation im Gesundheitssektor: den prinzipiell ungedeckten Bedarf, die mangelnde Zurechenbarkeit des Bedarfes und die asymmetrische Informationsstruktur zwischen Patienten und Leistungserbringern.

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Moral und Abhängigkeit

Definition of the problem:

Being satisfied with one’s work depends on professional autonomy, which is attributed to the medical profession to a high degree, combined with specialized knowledge and moral authority for vital questions. That is why physicians enjoy a high reputation. At the beginning of a person's medical career, moral competence is developed nearly completely, but specialized knowledge must be learned. Hospitals, in which further medical education regularly takes place, are still traditionally hierarchically organized today. Unfortunately, feudalistic or military structures hinder autonomous moral decisions and cause structural irresponsibility.

Arguments:

Obstructions and pressure by superiors, financial restrictions, arrogance and trying to make one's mark are shown in typical conflict situations. Stress, discontent, moral conflicts and illness, even including burn out are possible. Commitment and creativity by employees are prevented and mistakes cannot be constructively managed. Thus, patients may suffer unreasonably or be hurt.

Conclusion:

There is a risk to subordinate moral principles under other interests, not only with subordinates but also with superiors. Ways to create a culture that promotes autonomy among physicians and between different professions are discussed. Therefore it is necessary to institutionalize communication based on a reciprocal high regard in a team with people treated as equal partners, who are then able to discuss moral questions in a discourse.     

Ethische Aspekte der künstlichen Ernährung bei nichteinwilligungsfähigen Patienten

Zusammenfassung  Der Beitrag untersucht mögliche Kriterien für die normative Bewertung der künstlichen Ernährung bei nichteinwilligungsfähigen Patienten. Der in der aktuellen Diskussion immer wieder unternommene Versuch, den verpflichtenden Charakter bestimmter Formen der Ernährung aufgrund ihrer Zuordnung zu den Kategorien Basisbetreuung oder Remedia ordinaria zu begründen, erweist sich als naturalistischer Fehlschluss. Die Rechtfertigung der künstlichen Nahrungs- und Flüssigkeitszufuhr setzt vielmehr—wie die jeder anderen medizinischen Maßnahme—voraus, dass ihre Durchführung medizinisch begründet und vom Patienten gewollt ist. Dies trifft grundsätzlich auch auf den nicht mehr einwilligungsfähigen Patienten zu; bei diesem kommt es auf den früher erklärten oder mutmaßlichen Willen an.

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Ethikkonsultation oder psychologische Supervision? Kasuistische und methodische Reflexionen zu einem ungeklärten Verhältnis

Definition of the problem

The relationship between ethics consultation (EC) and psychological supervision (PS), established, for example, in the psychiatric context or palliative care, has received little investigation. This amounts to a research gap on the specific practice of the two approaches that contributes to an uncertainty or even conceptual lack of clarity in the perception of both users and—partly—providers, especially regarding possible indication criteria. In this paper, we will study commonalities and differences of EC and PS as well as their methodological and practical characteristics by mutually referring to two clinical case examples from both approaches also highlighting emerging contrasts.

Reasoning and results

As a result of the case-based and methodological analysis, distinctive criteria are presented. These include the following: (1) objectives of each approach, (2) access and demand characteristics, (3) content, (4) focus, (5) methodology, (6) role of consultant/counsellor, (7) results, (8) documentation, (9) working with emotions, (10) explicit reference to ethical issues.

Conclusions

While articulating an overlap identified and illustrated in the comparison between EC and PS and the respective case studies, we conclude that the two approaches should not be regarded as mutually exchangeable. Rather, we suggest that any mixture or combination of both cannot be recommended as this might lead to watering down the specificity of each approach and its respective strengths. Furthermore, preliminary suggestions are offered for the specific indication of EC or PS covering also pragmatic considerations such as the particular motivation of participants and the immediate availability of service.

     

Ethische Aspekte der Regularisierung ärztlichen Handelns

Zusammenfassung.   Die Ressourcenknappheit hat zu einer progredienten Regularisierung ?rztlichen Handelns geführt, überwiegend durch staatliche und institutionelle Richt- und Leitlinien. Aber nicht nur der Spardruck, sondern ebenso „offiziell” instrumentierte Wissenschaft kann ?rztliches Denken und damit ethische Reflexion behindern – selbst wenn sie in der optimalen Form evidenzbasierter Leitlinien auftritt. ”Futility” als Begriff ist in den USA l?ngst aus einer andauernden theoretischen Diskussion in die klinische Praxis eingedrungen. Vor allem bei bedrohlichen Erkrankungen am Ende des Lebens gibt es formalisierte Entscheidungswege; etwa im Sinne der prozeduralen Festlegung einer ”Do-Not-Attempt-Resuscitation Order” (DNAR). Unentrinnbar ist die Frage nach dem Sinn und der Vergeblichkeit ?rztlichen Handelns mit derjenigen nach der Entscheidungsmacht im medizinischen Alltag verknüpft. Regularisierungsversuche, die von der Makroebene der Gesundheits?konomie ausgehen, interferieren mit den h?ufig ebenso machtf?rmigen Entscheidungsprozessen in der unmittelbaren Patientenversorgung. Das gilt auch bei der Balance der Interessen von Patienten einschlie?lich ihrer pers?nlichen und juristischen Vertreter mit den fachlichen Ansprüchen der ?rzte. Die schlichte übernahme des Konzeptes der ”Futility” aus den USA ist angesichts der ungel?sten Komplexit?t der Interferenzen von Makro- und Mikroebene in Deutschland wenig sinnvoll, da es zu sehr auf die spezifischen Verh?ltnisse der amerikanischen Medizin zugeschnitten ist. Andererseits helfen die konkret praktikablen Kategorien der ”Futility” gegen das Ausufern von Grundsatzdiskussionen im europ?ischen Stil.      

Diskussion ethischer Aspekte zahnärztlicher Altersschätzung bei jungen Flüchtlingen durch Röntgendiagnostik

Definition of the problem

An increasing number of young refugees whose ages are not reliably known is thrusting the problem of medical and dental age estimation via x?ray examinations to the forefront of public discussion. Despite continual criticism of the organised German medical profession for this procedure and its associated radiation exposure for nonmedical purposes, x?raying the carpal bone, the clavicle or the teeth to determine age remains common practice. Consequently, the official verification of asylum seekers’ ages has considerable ramifications since refugee minors have particular rights.

Arguments

In previous discourse(s) about the proportionality of approximating the age of young asylum seekers via x?rays, the relevance of the radiological examination of the wisdom teeth is indeed always referred to; however, the specific role of dentists is by comparison rarely discussed from a medical–ethical perspective. As a matter of fact, in 2001 and 2008 the Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK; English: German Association for Dentistry, Stomatology and Orthodontics) published scientific position papers in which the comprehensive radiological verification of the age of young refugees is endorsed – with the distinct omission of an ethical discussion.

Conclusion

In light of these disparate findings, it should be investigated just how suitable, necessary and ethically appropriate dental procedures for the purposes of age determination are. The methodical foundations of this paper are (1) a comprehensive evaluation of available specialist literature, in addition to (2) a critical normative analysis of the main arguments presented by the named specialist society. Especially ethically discussing these position papers is a desideratum for ethics in dentistry. This discussion also serves as an opportunity to apply the international debate on age determination to Germany’s framework.

     

Rechtliche Verbotsvorschläge der ärztlichen Unterstützung bei der Selbsttötung von schwerkranken Patienten

Definition of the problem In the current ethical debate on physician-assisted suicide in Germany new sanctions in criminal law are debated from different sides. Whereas in the beginning the debate focused only on the ban of organised forms of suicide assistance, the explicit licensing of assisted suicide is also now requested by physicians. Arguments Considering the approach to include prohibition of assisted suicide within the German Criminal Code, the article shows that the impunity of suicide and suicide assistance has a long tradition in Germany. The impunity of assisted suicide cannot only be systematically and factually justified, but also in terms of content. A criminalization can be neither legally nor ethically justified. Conclusion The authors advocate—with reference to different legal drafts in the German Federal Parliament (Deutscher Bundestag)—for an open discourse within the medical profession and for a revision of the professional law.     

Medikamentöse Gedächtnismodifikation zur Prävention der Posttraumatischen Belastungsstörung: eine ethische Bewertung

Definition of the problem Post-traumatic stress disorder (PTSD) is a severe psychological condition that can develop after experiencing traumatic events. In the context of the German military’s foreign deployments, cases of soldiers affected by PTSD have received public attention. Likewise, civil traumas carry a significant risk of subsequent PTSD development. Pharmacological approaches to PTSD prevention have been a subject of research for serveral years. The two most promising approaches—prevention using beta-blockers and glucocorticoids—are based on the notion that the long-term consolidation of traumatic events can be modulated by intervention in neuroendocrine stress axes. By blunting the emotional content of memories, a later development of PTSD could be prevented. Both approaches show promising results in pilot studies. Given the outstanding importance of memory both for the individual and for society such approaches of pharmacological memory modification (PMM) call for an in-depth discussion of the neuroethical implications. Arguments The article discusses five clusters of neuroethical problems: (1) the influence of PMM on normal psychological processing of traumatic memory, (2) the danger of uncoupling memory from reality, (3) the importance of emotional memories for moral behavior, (4) the social, legal and historical relevance of authentic memories, and (5) the potential of medicalization inherent in PMM. Conclusion Despite some serious ethical concerns we argue that, in view of the gravity of the disorder, PMM to prevent PTSD is generally justified, but should currently only be done within clinical trials. We present eight research ethics concerns that should be considered in such trials.     

Individuelle Gesundheitsleistungen in der vertragsärztlichen Versorgung

Definition of the problem

Within Germany’s statutory health insurance system Individual health services are offered (by physicians) or demanded (by patients) with increasing frequency establishing a "second health market". The services come from a wide and heterogeneous spectrum including highly beneficial and evidence-based methods (malaria prophylaxis), so far questionable (sputum cytology) or probably beneficial (osteodensitometry in high-risk populations) screening methods, dubiousand untested methods fromthe field of alternative and complementary medicine and various services to enhance beauty, fitness or wellness. The services are not, as a common characteristic, part of Germany’s official health care offer and have to be paid foron a strictly private basis.

Arguments

This article discusses chances and risks of the development within a normative framework and addresses five questions.How does selling and buying of "individual services" affect the traditional role of physicians, the identification of useful medical methods and services, our understanding of medicine and its goals, the traditional role of patients, the doctor-patient relationship and our understanding of the German statutory health insurance system?

Conclusion

Individual health services are for various and heterogeneous reasons attractive for both patients and doctors. Whereas medicine becomes more and more regulated, they seem to increase the degrees of freedom and range of options of each side. The services may however profoundly change the role and perception of the medical profession within a collectively financed health care system. Whether the second health care market can be effectively controlled and itself regulated is at present an open question.     

Einstellung zu psychiatrisch-genetischer Forschung und prädiktiver Diagnostik

Zusammenfassung  Mit den Fortschritten im Bereich der psychiatrisch-genetischen Forschung gehen auch intensive Diskussionen bezüglich der daraus erwachsenden Implikationen einher. Hoffnungen wie Befürchtungen gegenüber der neuen Technologie und deren Folgen werden gleichermaßen zum Ausdruck gebracht. Über die Einstellung der Bevölkerung und insbesondere der Patienten mit affektiven oder schizophrenen Erkrankungen und ihrer Angehörigen in Deutschland war bisher allerdings wenig bekannt. Daher führten wir im Rahmen des Deutschen Humangenomprojektes erstmals eine Studie durch, um die Einstellungen und ihre beeinflussenden Faktoren zu erfassen. Wir entwickelten einen Fragebogen zur Erfassung der Erwartungen, Hoffnungen und Befürchtungen sowie der die Einstellung beeinflussenden Faktoren. Hiermit wurde eine repräsentative Stichprobe von 3077 Personen aus der Allgemeinbevölkerung am Telefon befragt. Weiterhin wurden mit 316 Patienten und 163 Angehörigen persönliche standardisierte Interviews anhand des Fragebogens durchgeführt. Die Mehrzahl der Befragten hatte eine positive Einstellung zu psychiatrisch-genetischer Forschung, äußerte jedoch gleichzeitig ethische Bedenken. Übereinstimmend waren die Befragten der Ansicht, dass Informationen aus genetischen Untersuchungen vertraulich behandelt werden sollten. Kleine, aber signifikante Unterschiede zwischen den Gruppen zeigten sich bezüglich der Einstellung zu präsymptomatischer genetischer Diagnostik. Unsere Ergebnisse weisen auf eine Ambivalenz der Befragten gegenüber der psychiatrisch-genetischen Forschung und Untersuchung hin: Neben einer überwiegend positiven Einstellung wurden auch moralische Bedenken geäußert.     

Ethische Aspekte des Dolmetschens im mehrsprachig-interkulturellen Arzt-Patienten-Verhältnis

Definition of the problem

It is well-known that good physician–patient communication is decisive for proper treatment of a patient and the patient’s self-determination. In intercultural–multilingual situations, intense discussions are even more important when possible discrepancies on both sides regarding presuppositions and actual facts have to be bridged. Hence, in case of language barriers, the use of qualified interpreters is ethically required. In interpreter-mediated consultations, both physicians and interpreters face specific ethical challenges. When qualified interpreters are not available, physicians, in difficult ethical reflections, have to weigh options regarding alternative solutions. To date, these two issues have received little attention in medical ethics.

Arguments

Based on research about community interpreting and interpreter-mediated discourse, this paper, first, identifies central ethical challenges and the corresponding spheres of responsibility of physicians and interpreters. It discusses the need of language support, the risk of excluding patients from interpreter-mediated consultations, the observation of the interpreters’ ethical principles, the problem of ensuring confidentiality as well as the implications of cultural brokering. Second, the article approaches the physician’s options under nonideal conditions when no sufficiently qualified interpreter is available. Calling in a nonprofessional person for spontaneous interpreting, e.?g., a relative or a multilingual colleague requires ethical reflection. For this purpose, this article presents for the first time a framework based on nine criteria which can help physicians assess the ability of a specific person to interpret in a given physician–patient encounter and balance competing interests.

Conclusion

The ethical challenges in interpreter-mediated physician–patient interaction require qualified interpreting. Under nonideal conditions, the framework presented above supports physicians to select alternative solutions. However, it does not substitute long-term solutions on the macro level, e.?g., the funding of professional interpreting.

     

Ärztliche Schweigepflicht und die Gefährdung Dritter

Definition of the problem: Medical confidentiality plays a crucial role for the trust-based relationship between patient and doctor. However, there are extremely difficult cases of medical confidentiality, for example when medical secrecy compromises or even puts at risk other people's safety. The Frankfurt high court has recently passed a bill which triggered an intense debate on medical law and ethics: A woman had accused her family doctor and demanded the assessment of damage as well as the payment of a high compensation because the doctor knew about her partner's AIDS infection but did not inform her, referring to medical confidentiality. Arguments: At least two aspects are difficult in this case: the right of disclosure on the one hand and the doctor's legal and moral duty of information on the other hand. This article elucidates the new bill's ethical and legal implications as well as the basic and new laws concerning compensation with regard to medical confidentiality. From the medical ethics' point of view it is obvious that concerning the question of the weighing of goods the higher and vital value should be decisive (principles of do no harm and beneficence; "Tarasoff"-duty to warn). Conclusion: The case mentioned above as well as other cases indicate, however, that in many doctor-patient relationships there is a deficiency of ethical reflection, dialogue and clear recommendations from official side. An interdisciplinary approach of medical ethics and medical law can be very fruitful.     

Ethische Fragen im Umgang mit transidenten Personen – Limitierende Faktoren des gegenwärtigen Konzepts von „Transsexualität“1

Definition of the problem:

The present social and medical behaviour towards transsexuality (transidentity) is experiencing growing resistance. This article investigates which semantic concept of transidentity is prevalent in Germany and to what degree the constituents of this concept limit the scope of discussions concerning transidentity and its ethical implications.

Arguments:

It can be demonstrated that the present response towards transidentity is based on several hardly discussed but nevertheless controversial assumptions. These basic assumptions include (1) pathologisation of transidentity and its transfer into the responsibility of medicine, (2) the supposed primacy of surgical intervention (disregard of the post-surgical period), (3) the paradigm of only two genders (bigenderism), (4) the terminologically detectable “sexualisation” of this problem of identity and (5) the legal criterium that defines civil status or gender of a person by gonadal-morphological criteria.

Conclusion:

To pursue the goal of an ethically, medically and socially responsible interaction, the first intermediate requirement is an open discussion examining the assumptions listed above. Only the result of such a discussion allows the possibility of a more modern ethical response to transidentity.     

Demenz,Personalität und Praktische Selbstverhältnisse. Eine Auseinandersetzung mit den Möglichkeiten und Grenzen der Patientenautonomie Demenzbetroffener

Definition of the problem

Based on the positions of Ronald Dworkin, Rebecca Dresser and Agnieszka Jaworska, this paper analyzes the tension between prolonged and actual autonomy performed by dementia sufferers and combines the discussion concerning the autonomy of the persons involved with an account of practical selfhood, the patients are able to maintain in the first and second state of the illness.

Arguments

Theoretical background for this debate between the possibilities and limits of the autonomy of dementia sufferers is the distinction between two types of positions. The first one regards the concept of personhood as equivalent to the notion of human beings, the other one holds that both terms are not equivalent. These accounts help to classify the positions of Dworkin and Dresser. By the inclusion of Jaworska’s account, who ascribes persons affected with dementia a so-called capacity to value, this paper aims to show that the distinction between those approaches, which regard the concept of personhood as equivalent resp. not equivalent to the notion of human beings and which themselves argue for a broad resp. limited understanding of the patient autonomy of dementia sufferers, fall short.

Conclusion

Instead, following Jaworska and the patient’s capacities to perform value judgements, the paper points to a concept of personhood, which is not based on advanced rational abilities as it is claimed by non-equivalent accounts. However, this concept accepts weaker conditions for performing patient autonomy without being merged into an understanding of relational autonomy. Besides this, this approach can be extended to a broader concept of practical selfhood performed by dementia patients.

     

Über die Einheit des Menschen aus ärztlicher Sicht

Zusammenfassung.   Dem ?rztlichen Handeln kann sich die ph?nomenale Einheit des Menschen in den drei Schritten der k?rperlichen Untersuchung, der Anamnesenerhebung und der Therapie erschlie?en. Die Leiblichkeit ist dem Menschen Organ (potentiell auch personaler) Selbstempfindung, auch m?glicher selbstempfundener Einheit und Identit?t. Sofern der Leib als auf seine Gegenst?ndlichkeit (Objektivierbarkeit) reduzierter K?rper untersucht (diagnostiziert) wird, bedarf es der sach- und wertorientierten Begründung (der Indikation). Der Kranke ist als Subjekt, als Akteur seiner Leiblichkeit wie seiner Krankheit zu achten. Die Anamnesenerhebung fragt idealiter nach der Entwicklung der Krankheit und der Geschichte des Kranken in seiner Erkrankung. Geschichtlichkeit und Verg?nglichkeit als Perspektiven der Zeitlichkeit k?nnen mindestens fragmentarisch in der Geschichte des Kranken als Einheit biografischer Kontinuit?t und Identit?t deutlich werden. Der wechselseitige Reduktionszirkel begrenzter Wahrnehmung nur der Krankheit und die Ausblendung der biografischen Perspektive ist nicht wertfrei. Die Beschr?nkung auf das im Blick auf die Diagnostik und Therapie Gebotene und das dem Kranken Zutr?gliche ist aufgehoben in der Achtung der lebensgeschichtlichen Einheit des Kranken. In dem Therapieziel kann schlie?lich die Sinnfrage für den Kranken deutlich werden: Zweckorientierte Reparatur von Defekten oder Wiedererlangung und Erhaltung von Gesundheit und akzeptabler Lebensqualit?t. Darin werden Grundrechte und -ansprüche wie Werte, potentiell auch konflikthaft, deutlich.      

Ist die Institutionalisierung und Legalisierung der Suizidbeihilfe gefährlich?

Definition of the problem

The topic of this essay is the chances and risks of a possible legalization of assistance to suicide.

Arguments

Counterarguments against this legalization are discussed and analyzed in three thematic groups: "Slippery slope" arguments, arguments of "moral pressure", and the fear of the "loss of solidarity in society" and the "endangering of the physician-patient relationship".

Conclusion

These counterarguments prove to be non-cogent in the case of criteria and standards of suicide assistance in legal form being developed and controlled by the government.