Kommentar II

Ohne Zusammenfassung

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Monika Bobbert (2002) Patientenautonomie und Pflege. Begründung und Anwendung eines moralischen Rechts. Campus,Frankfurt am Main,New York, 380 S., 29,90 Euro,ISBN 3-593-37128-6

Rezensionen

Monika Bobbert (2002) Patientenautonomie und Pflege. Begründung und Anwendung eines moralischen Rechts. Campus, Frankfurt am Main, New York, 380 S., 29,90 Euro, ISBN 3-593-37128-6     

Reproduktionsmedizin und embryonale Stammzellforschung – aktueller Problemstand und gesetzlicher Regelungsbedarf

Ohne Zusammenfassung

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Leistungsrechtliche Konsequenzen einer Behandlungsablehnung bei untergebrachten Patienten – Chancen und Risiken einer Anwendung von Vorausverfügungen in der Psychiatrie

Definition of the problem

Patient’s advance directives offer a possibility to keep autonomy even in the case of acute psychiatric disease. The advance directives may in some cases interfere with law when patients, who are suffering from acute psychiatric disease, are coerced to psychiatric treatment by law. Thereby it is possible that patients who are kept in psychiatric treatment involuntary cannot receive treatment because of their documented autonomous will. In these cases economical questions interfere with treatment of psychiatric patients who are coerced for in-patient treatment, but deny medical treatment: in those cases in-patient treatment is typically not covered by German health insurance.

Arguments

The text illustrates the ethical conflict consisting of coerced in-patient treatment by law and the denial of treatment by patients advance directives.

Conclusion

The paper discusses joint crisis plans as a possibility for increasing treatment compliance and decreasing coerced in-patient treatment.

     

Prinzipien und Diskurs – Ein Ansatz theoretischer Rechtfertigung der ethischen Fallbesprechung und Ethikkonsultation

Definition of the Problem Models of decision making in medical ethics have to establish themselves as being able to lead to ethically right or at least “credible” decisions. For this purpose, approaches of theoretical justification stemming from ethics are vital. However, clinical ethics is sometimes criticized for theoretical deficits. In order to address this criticism, we will try to justify ethical case discussion and ethics consultation by principlism and discourse ethics by referring to a clinical ethics project (METAP). Arguments Principlism and discourse ethics can fruitfully complement each other when used in ethical case discussion or consultation. Thereby, some theoretical as well as practical weaknesses of both approaches can be mitigated. Discourse ethics, for example, safeguards the ethical validity of moral decisions and norms for action, respectively, thus mitigating shortcomings of justification when using principlism. Conversely, principlism answers questions concerning ethical adequacy and functions particularly as a safeguard for appropriate decisions in the individual case. Conclusion By using a combination of these two approaches, a broader justification seems possible rather than by relying on principlism or discourse ethics alone. Even if some challenges persist, and even if the combined model cannot always prevent dissent, it may strengthen practical confidence in the ethical decision by its ?double“ safeguards (principles and discourse). This could render clinical ethics more ?robust“ that have been missing so far.     

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.     

Normative Rahmenbedingungen der Rekrutierung und Nutzung extrahierter Zähne in Forschung und Lehre

Definition of the problem Every extracted tooth is primarily the private property of the patient concerned. It is subject to his or her autonomy-based right to self-determination. This largely undisputed fact contrasts with the practical need for extracted teeth for research and teaching. Thus, testing new materials and techniques for root canal fillings is inconceivable without the use of extracted teeth, as is the practical dental (endodontic, tooth preserving or prosthetic) education of future dentists as part of their university studies. Recently, there has been an increase in criticism of the conventional practice of acquisition and use of extracted teeth. Therefore, the present article is devoted to the question of how the ethical and legal conditions for the use of extracted teeth can be reconciled with the requirements of teaching and research. Arguments Related to this are the questions of (1) the indication for extraction, (2) the risk of commercialization and external pressure, (3) the appropriate time frame for informing the patient, (4) the extent of the duty to inform the patient and (5) the manner and the extent of the documentation. The article presented consists of an ethical and legal analysis of the problem areas mentioned above, taking into account the relevant legislation and available literature. Conclusion The study leads to the conclusion that the recruitment and the use of extracted teeth are ethically and legally permissible under certain clearly defined conditions.     

Patientenverfügungen und Advance Care Planning bei Demenz und anderen kognitiven Beeinträchtigungen

Definition of the problem

Advance directives for later states of grave cognitive impairment that are typical for late stages of dementia meet with more far-reaching reservations than advance directives for other states of reduced competence. One of the reasons seems to lie in the ethical and psychological conflicts arising from advance directives demanding nontreatment of additional diseases or the abstention from artificial nutrition in situations in which patients show no signs of suffering from their condition.

Arguments

In this article, it is argued that a “mixed” ethical strategy be used for these cases.

Conclusion

Advance directives in the legally defined sense, especially if drawn up in a process of advance care planning, should be followed in order to avoid that advance directives as an instrument of patient autonomy are rendered futile to a degree incompatible with confidence that wishes for terminating medical treatment will be followed. In contrast, the authority of “care directives” without recognized legal status should be restricted to cases in which there is concordance between the patient’s will as expressed in the directive and the patient’s “natural” will in the relevant situation.

     

Governance und Gesundheit – Beobachtungen zur strukturellen und kulturellen Ver?nderung in Krankenh?usern

Definition of the problem

Corporate Governance is being established throughout German hospitals. This might prove to be a further step in the economization of public health services, with alienating effects on core characteristics of therapeutic interaction.

Arguments

This article outlines (1) the origin, design and function of Corporate Governance, (2) how processes of managerialization, economization, and commercialization presently transform hospitals, and (3) the impact of Corporate Governance on hospitals in Germany.

Conclusion

The moral implications of Corporate Governance need further research and critical ethical scrutiny.     

Passive, indirekt und direkt aktive Sterbehilfe – deskriptiv und ethisch tragfähige Unterscheidungen?

Zusammenfassung.   In der Auseinandersetzung um die Frage, ob aktive Sterbehilfe mit dem ?rztlichen Ethos vereinbar ist, werden h?ufig deskriptive Unterscheidungen wie Tun vs. Unterlassen, aktiv vs. passiv oder auch intendieren vs. in Kauf nehmen benutzt, um eine kategorische moralische Differenz zwischen T?ten und Sterbenlassen auszuweisen. Als zus?tzliche Schwierigkeit erweist sich dabei zum einen, da? zentrale Begriffe zwischen einer deskriptiven und einer ethischen Bedeutung changieren, und zum anderen, da? die Kennzeichnung des Problems (z.B. Sterbehilfe) selbst ethisch nicht neutral ist. Nach der Entwicklung einer ethisch neutralen Problemstellung werden kategorische Argumente gegen die ethische Zul?ssigkeit aktiver Sterbehilfe diskutiert und verworfen. Anschlie?end werden Begründungen diskutiert, die mittels intrinsischer oder extrinsischer Situationsmerkmale eine ethische Unzul?ssigkeit aktiver Sterbehilfe aufzuweisen versuchen. Dabei zeigt sich, da? graduelle ethische Unterschiede zwischen passiver, indirekt und direkt aktiver Sterbehilfe begründbar sind, die ein jeweils h?heres Ma? an Rechtfertigungsgründen erfordern.      

Zur Rolle und Verantwortung von Ärzten und Forschern in systemmedizinischen Kontexten: Ergebnisse einer qualitativen Interviewstudie

Background

Systems medicine is characterized by the integration of large amounts of data from manifold data sources and links approaches of systems biology and medical science with informatics and predictive methods of mathematical modeling. This results in a close cooperation of physicians and scientists. Therefore, the expertise of researchers becomes increasingly important regarding the processing and interpretation of patient data. This raises questions of how cooperation between the different actors is managed and to what extent and how the roles and ascribed responsibilities of physicians and scientists change in the context of systems medicine.

Methods

To answer these questions, we conducted a qualitative interview study with physicians and researchers from different fields of systems medicine in order to reconstruct their experiences and perceptions.

Results and conclusions

Based on the empirical analysis two conceptions of systems medicine can be identified. The first conception is characterized by a clear division of competences and tasks between physicians and researchers: researchers serve as service providers, physicians as translational, interdisciplinary trained experts. In the second conception, the division of competences and tasks between physicians and researchers can no longer strictly be drawn: professionals act as a multidisciplinary team, implying close mutual cooperation. Both conceptions indicate (potential) role conflicts of physicians and researchers particularly resulting from the discrepancy between medical and science ethos as well as their specific norms of conduct and objectives. As a consequence, from a normative perspective, it should be clarified which responsibilities legitimately can be attributed to physicians and researchers working in systems medicine. In this regard, it seems to be appropriate to differentiate between more patient-orientated contexts of medical care and fields of basic research.

     

Starke und schwache Autonomie – eine hilfreiche Unterscheidung für die Vorbeugung von Unter- und Überbehandlung

Definition of the problem Patient-oriented care is a worthy goal. The recognition and avoidance of inadequate treatment, e.g., under-, or over-treatment, often results in doctors and nurses at the bedside being faced with making difficult decisions. The development of practical guidance that meets scientific criteria and is not solely based on consensus is highly desirable. Arguments The presented work attempts to formulate key standards to prevent over- and undertreatment and to confirm them theoretically. For this, a grading of autonomy is made by distinguishing between weak and strong autonomy, based on an interest-based ethics approach. Conclusions Interest-based ethics supports the view that orientation on strong autonomous decision making offers an optimal chance to promote well-being and may thereby help prevent a large proportion of under- and overtreatment.     

Kants kategorischer Imperativ als Management-Technik und Marketing-Strategie?

Problem

One of the German commercial hospital chains is trying to ground their business policy on elements of Kantian moral philosophy. Allegedly, the categorical imperative is inserted as a norm of conduct into the contracts of leading officers. We discuss whether the reference to Kantian ethics is sound and is suited to improving the moral standards of hospitals.

Arguments

Scrutiny of the companies' statements reveals that the categorical imperative is equated with the Golden Rule, which Kant explicitly rejects, and that the Golden Rule is distored. In addition, the texts ignore that the categorical imperative entails not only duties of respect but also duties of beneficence.

Conclusion

Kantian arguments may indeed have some impact on hospital organisation but if so they should be genuine. In the case at stake, they are misused. However, even this misuse indicates an intuition that running a hospital includes moral demands.     

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.     

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.     

Neuroethik – Geschichte,Definition und Gegenstandsbereich eines neuen Wissenschaftsgebiets

Definition of the problem

Fifteen years after establishing neuroethics as an international academic field, neuroethics has emerged as a vibrant, dynamic area of scientific research.

Arguments

Within a short period of a few years, specific conferences, journals, research funding programs, professional societies, and institutes were founded. Nonetheless, considerable disagreement about its definition and subject matter still remain. We argue for a differentiated conceptualization according to which the deliberate reflection of ethical problems arising from the neurosciences and their predominantly neurotechnological application belongs as much to neuroethics as does the ethical reflection of the neuroscience of morality. This does not comprise neuroscientific or neuropsychological research on morality itself, but includes the contemplation of the significance of such research for ethics and the law. Here, we provide an overview about the most important topics in neuroethics and elucidate the relevance of neuroethics for a vast diversity of societal domains reaching well beyond medicine and health care.

Conclusion

The great potential of neuroethics as a novel branch of academic research lies in finding new answers to pressing questions of high societal relevance by linking neurophilosophy and bioethics topics as well as its broad interdisciplinary network.

     

Internationale Rekrutierung und Migration von Ärztinnen, Ärzten und Personal in Gesundheitsfachberufen: ein qualitatives Scoping Review der Public Health Literatur

Background

The international recruitment and migration of health workers has long been debated in the health policy literature. This study assesses to what extent the ethics of international recruitment are targeted in existing public health peer-reviewed literature, with a focus on concepts and in-depth consideration within articles. It further critically discusses hidden implications of this discourse regarding equity-creating health policy.

Methods

We conducted a qualitative scoping literature review searching the databases PubMed and Web of Science. Articles were assessed for quality using the Critical Appraisal Skills Program (CASP) checklist for qualitative research. Drawing on a thematic analysis approach, common themes across the sample were identified, coded and analyzed.

Results

A total of 17 articles were included in the analysis after searches and quality appraisal. These articles predominantly targeted nursing professions and physicians, and were written mainly by authors working in the Global North. Thematic analysis revealed that ethics are generally discussed in connection with overviews regarding the situation of health systems as well as regarding inequities between countries. Their focus lies more on migration between countries than between regions within a country. Proposed solutions are usually of an economic nature and range from global financial equalization between countries to national improvements in working conditions. Creative evaluation schemes for these solutions are rarely discussed in depth. Overall, the academic ethics discussion focuses predominantly on the health systems level, and views migration of health workers as problematic.

Conclusions

Our results suggest that academic research operates and aims to inform policy within the current system, without necessarily proposing fundamental changes to the status quo. Thus, an ethics discourse of health workforce recruitment may serve to increase awareness of inequalities without supporting radical change. Further research into intersectional aspects of health worker migration, including gender and ethnicity, may be useful for the discussion on inequities.