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.      

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.     

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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„Personalisierte Medizin“ in der Onkologie: Ärztliche Einschätzungen der aktuellen Entwicklung in der Krankenversorgung

Definition of the ProblemPublic discussions about “personalised medicine” indicate that this approach is associated with high expectations regarding its contribution to clinical practice. However, little is known about physicians’ perspectives on “personalised medicine”. This qualitative interview study aims to provide insight into physicians’ perceptions and views regarding clinical practice. Arguments/ResultsPhysicians in this sample view “personalised medicine” as a progress within medicine, but do not see a major departure from long-standing practices. As a major problem, physicians identified handling the amount of molecular and genetic information and integrating this information into the diagnosis and treatment. ConclusionTaking the results into account, one may ask whether “personalised medicine” is not the opposite of what its name connotes—a more patient-centred medicine. The strategies for handling the large amount of information raise novel challenges which are in contrast to the ideas of patient-centred medicine.     

Legalisierung der aktiven Sterbehilfe – Förderung oder Beeinträchtigung der individuellen Autonomie?

Definition of the problem Theorists who support the legalisation of active euthanasia usually base their arguments on the principle of autonomy. In their view the wish of a severely ill person not to continue his or her life must be respected. However, some opponents of the legalisation of active euthanasia refer to the principle of autonomy as well. Arguments They are concerned that patients may be held responsible for burdening others with the provision of care. Thus family members, physicians or nurses may exert pressure on patients to opt for active euthanasia. In this article it is argued that these worries are justified; the occurrence of social coercion poses a real danger. Conclusion However, neither the prohibition nor the permission of active euthanasia enables each individual to make an autonomous choice. Comparing the risks involved in both options, legalisation seems to be preferable to maintaining the status quo.     

Ethische Relevanz und faktische Mängel in der Kommunikation von Spezifika der Organspende nach Kreislaufstillstand

Introduction

In many countries, the number of organ donations after circulatory determination of death (DCDD) is increasing, although various aspects of DCDD are critically discussed in medical ethics. In our work, we identify ethically relevant aspects of the DCDD—in particular regarding preparatory measures and the irreversibility of the death criterion—and we investigate to what extent persons interested in becoming organ donors are informed about those issues.

Methods

We performed a comprehensive literature review on ethical issues of DCDD. Subsequently, we conducted a worldwide evaluation of organ donation organisations’ websites and an accompanying survey to investigate the extent to which ethically relevant aspects of DCDD play a role in the information of persons interested in becoming organ donors.

Results

We find that a majority of the organisations’ websites do not deal with the subject of DCDD, whereas the responsibles of the organisations surveyed emphasised the importance of education for potential donors.

Conclusion

We point out central issues about which persons willing to become organ donors should be informed if DCDD is practiced in their respective countries. In addition, we advocate that the criteria and the procedures for determining death in the context of transplantation medicine should be uniform in order to defuse some of the critically discussed aspects in the context of DCDD.

     

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.     

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.     

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.     

Informierte Einwilligung in der Demenzforschung. Eine qualitative Studie zum Informationsverständnis von Probanden

Background

Informed consent is a legal as well as ethical prerequisite in clinical research. For dementia research, informed consent can be a problem if subjects with dementia, whose capacity for understanding and thus also decision making might be limited, are to be examined. This might result in exclusion of dementia patients from research, as capacity for understanding and decision making are often equated with the ability for rational decision making. However, this valuation has been criticized at times for attaching too much importance to the cognitive aspect of decision making.

Methods

This qualitative study investigates the actual consent procedure of a clinical research study in Germany with regard to dementia patients’ subjective and objective understanding of informed consent information. Research participants were ten dementia patients, who volunteered in two clinical research studies, as well as their caregivers. Data were collected by use of semi-structured interviews.

Results

It was determined that the patients’ comprehension of informed consent information was rather limited. However, a number of patients were quite aware of this. In contrast, all caregivers claimed to have fully understood the provided information, while their objective comprehension was also incomplete. Several participants indicated that they did not attach much importance to the information given in the consent procedure and that their consent did not primarily depend on this information. Rather, participation in the research study for them seemed to be more of a problem-focused coping strategy for dealing with their diagnosis of dementia.

Conclusion

For research ethics these results raise the question whether the currently prevailing emphasis on the cognitive aspect of autonomous decision making, i.e., comprehension, may be too one-sided, and to what extent the “volitional” aspect in giving consent should be given greater consideration.

     

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.

     

Individualisierte Medizin in der Diagnostik und prognostischen Einschätzung in der akuten myeloischen Leukämie mit normalem Karyotyp bei Erwachsenen unter 65 Jahren: eine systematische Literaturrecherche und Metaanalyse zu FLT3-ITD

Introduction

Diagnosis and classification of acute myeloid leukemia (AML) is based on cytological criteria and cytogenetic alterations. Individualization of diagnosis and therapy of AML normal karyotype AML (CN-AML) is increasingly possible due to detection of recurrent mutations. In this systematic review and meta-analysis, we examined the mutation FLT3-ITD in CN-AML.

Methods

A systematic search of all publications listed in the electronic databases Embase, Pubmed, Healthstar, BIOSIS, ISI Web of Knowledge and Cochrane was performed from 2000 up to March 2012 for the mutations fms-related tyrosine kinase 3 (FLT3-ITD) in CN-AML patients aged 15–65 years. The literature search included data extraction, qualitative, and quantitative synthesis of information in terms of a meta-analysis.

Results

In all, 18 studies were included and qualitatively analyzed for CN-AML. Three studies were included in the quantitative meta-analysis for CN-AML incorporating 1,203 patients. The FLT3-ITD mutation versus wild type showed a statistically significant worse prognosis with a hazard ratio for overall survival of 2.19 for CN-AML. Conclusion FLT3-ITD versus wild type FLT3 is associated with worse prognosis in AML. Diagnostic workup for AML should include mutation analysis of FLT3.     

Ethisches Handeln in der Berufspraxis: Das Triadengespräch als Methode des Lernens aus Misserfolgen

Definition of the problem

The starting point of this paper is the question of how the four ethical principles of professional work – respect for autonomy, care for beneficence, nonmaleficence, and justice – can be realized in professional practice. Along the physician-patient relationship the ethical foundation of any medical action is explained. An important part of this is learning from dissatisfying treatments. Therefore, the distinction between error and failure is explained.

Arguments

As an actionable approach for processing dental failures, the methodology of the triad conversation is presented in an empirical study. For this purpose, 21 failures were reconstructed in interviews with dentists. It will be shown whether and how a modified understanding of the dental failure was made possible by the triad conversation. The method is evaluated from the perspective of all involved dentists.

Conclusion

The results of the study show that the triad conversation, as a way of expansive learning, can obtain a prominent position for incorporating the experience of dental practitioners into professional knowledge, while at the same time creating an open culture for learning from failures. Finally, ethical implications dealing with failure in contrast to dealing with errors are discussed.

     

Macklins Substitutionsthese und der Begriff der Menschenwürde in der Bioethik

Definition of the problem

Ruth Macklin’s influential essay “Dignity is a useless concept” has revitalized a broad debate on the question whether the concept of dignity is meaningful in medical ethics. In this paper, I would like to examine Macklin’s so-called redundancy claim: according to this claim, the concept of human dignity can be replaced by other concept(s)—the concept of autonomy most prominent among them. What is the meaning of this claim?

Arguments

Starting from an analysis of Macklin’s arguments, I am going to show under which conditions a redundancy claim indeed leads to the eliminating consequences emphasized by its defenders—we should abandon the concept of dignity.

Conclusion

I am going to identify the advantages of her position both in comparison with more radical eliminative standpoints as well as positions that regard it as valid, but unanalyzable.     

Forschungsethik als integrativer Bestandteil der medizinisch-naturwissenschaftlichen Ausbildung. Zur interdisziplinären Entwicklung eines „Curriculums Forschungsethik“

Ohne Zusammenfassung

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Personalisierte Medizin und Informed Consent: Klinische und ethische Erwägungen im Rahmen der Entwicklung einer Best Practice Leitlinie für die biobankbasierte Ganzgenomforschung in der Onkologie

Definition of the problem Breakthrough discoveries in genomics allow the sequencing of the human genome within a couple of days at a reasonable price. In cancer research, whole genome sequencing helps to identify the molecular lesions that drive tumour growth and thereby provide the basis for the development of targeted therapies. However, genomic research also raises new ethical questions. The interdisciplinary EURAT project in Heidelberg (Germany) addresses these normative questions. It aims at developing an ethically and legally informed practice for biobank-based genomic research in Heidelberg. Arguments This paper gives an overview of the relevant ethical and clinical questions of biobank-based genomic sequencing with regard to the informed consent process. It also presents a code of conduct as an institutional ethics response to the following question: how research institutions can foster the responsible handling of genetic information in biobank-based research throughout the institution. Conclusion A thorough informed consent process and the code of conduct are elements of a best-practice guideline and should be a guide for responsible conduct of all employees who handle sensitive genetic data.     

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.