Marginale Wirksamkeit als Posteriorisierungskriterium – Begriffsklärungen und ethisch relevante Vorüberlegungen

Definition of the problem Rationing fairly remains a problem of great importance in most health care systems. While the scientific debate of this challenge is longstanding, few criteria of allocation have gained general approval within the literature and in policy making. In this article, we analyse the fairness and applicability of marginal effectiveness as a rationing criterion. Arguments In the so-called “futility-debate” of the 1990s, arguments for and against the concept of futile medical care were weighted against each other from the point of view of clinical medicine. At the time, the use of “futility” as a rationing criterion was strictly refused. In this article, we concentrate on a specific class of interventions which figured in this dispute, namely medical interventions with marginal effectiveness. We define two dimensions of marginal effectiveness and discuss several arguments in favour and against using these as rationing criteria. Arguments in favour are in particular: 1) the ethical advantages in comparison with cost-benefit-analyses, 2) the potential of transparent resource allocation, 3) the absence of discrimination, and 4) the compatibility with arguments from good clinical practice. However, we explore several problematic issues of definition and implementation which also have to be taken into account. Conclusion We argue that, barring pragmatic issues, marginal effectiveness is a fair and transparent rationing criterion which has many advantages when compared to other controversial criteria.     

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.     

Der DNA-Chip – Schlüsseltechnologie für ethisch problematische neue Formen genetischen Screenings?

Zusammenfassung.   Durch die Entwicklung der molekulargenetischen Diagnostik ist in den vergangenen Jahren nicht nur der individuelle Nachweis zahlreicher genetisch bedingter Krankheiten und Krankheitsdispositionen m?glich geworden, sondern darüber hinaus auch die Feststellung der verdeckten Anlagetr?gerschaft gesunder Probanden für rezessive Erbleiden. Die sich hieraus ergebende, unter ethischen Aspekten umstrittene M?glichkeit eines genetischen Populationsscreenings war bislang methodenbedingt auf wenige, meist seltene Leiden beschr?nkt. Die neue Technologie des „DNA-Chips“ er?ffnet durch die Synthese von Computertechnologie und Molekulargenetik die technische M?glichkeit des Massenscreenings auf eine gro?e Zahl, wie immer definierter, genetischer Defektanlagen für Erbleiden, aber auch genetisch mitbedingte Volkskrankheiten. Damit stellt der DNA-Chip das Handwerkszeug sowohl für eine verbesserte Pr?ventivmedizin als auch für neue Formen von genetischer Diskriminierung bis hin zur Eugenik dar. Es müssen daher dringend ethische Normen und rechtliche Rahmenbedingungen für den unmittelbar bevorstehenden Einsatz des DNA-Chips in der medizinischen Diagnostik erarbeitet werden.      

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.     

Ethische und rechtliche Aspekte im Umgang mit genetischen Zufallsbefunden – Herausforderungen und Lösungsansätze

Definition of the problem With an increasing number of genetic results obtained in whole genome analyses, the problem of incidental findings arises, i.e., findings that are discovered beyond the aims of the original investigation but have potential health or reproductive importance for patients or research participants. Since national or international guidelines have not been established, the authors discuss for Germany the current opinions about the management of incidental findings in clinical care and research. Arguments Following the German genetic diagnosis act (?Gendiagnostikgesetz“, GenDG), it is mandatory to inform about the possibility of incidental findings. It is part of the informed consent which findings are communicated to the patient, taking the right not to know and the protection of minors into account. In the research context, the GenDG is not valid; however, the disclosure of possible incidental findings should be also included in the consent documents. There is agreement that results of high clinical utility should be returned to participants, even if there is no obligation to do so. The following aspects have to be considered when dealing with incidental findings: (1) information given in the consent documents, (2) interpretation of genetic results according to high, moderate, possible, questionable or unknown clinical meaning, (3) processing of returning results at the present and in the future, and (4) decision about resources to evaluate the clinical utility, to communicate results and to transfer them into clinical practice. Conclusion There is urgent need for empirical research and policy development in the context of incidental genetic results. In addition, it is important to study how patients and participants understand and utilize incidental findings and to develop educative and communicative strategies.     

Können, sollen, müssen? Public Health-Politik und libertärer Paternalismus

Definition of the problem Due to the epidemiological transition that has occurred over the last few decades, diseases caused by behaviour have become one of the most important challenges for modern public health practice and policy. However, assigning responsibility for health and modifying behaviour are fraught with ethical problems. As of now, there is still the need for a theoretical model which manages to solve these issues successfully. Arguments Recently, libertarian paternalism has been heralded as a theoretical model which can inform policy making in public health and other areas of social policy. This article describes the account and discusses some of its problematic features. Conclusions To satisfy requirements of a fully argued normative account, libertarian paternalism lacks central elements of justification. However, it serves very well as a pragmatic tool providing original ideas for designing acceptable public health policy.     

Manifestation, Erklärung und Reduzierung gesundheitlicher Ungleichheiten

Definition of the problem Health inequalities are unintended consequences of the ways how social life and the economy are organized. Ways of living and individual preferences are also determining health inequalities, irrespective of whether being deliberate or imposed. Health inequalities have been reported for nearly all countries, for which data are available. These manifest in many different ways and over the whole life course for the most frequently occurring diseases. Arguments Usually social differentiation is conceptualized by using education, occupational position, and income. The relative effect magnitudes vary according to the type of health impairment considered. All indicators more or less depict control, i.e., opportunities for exercising influence and to participate. Control is a core construct of social psychological conceptions of distress. Beyond proximate effects of the social structure, recent studies are focussed on the life course. If pregnant women are exposed to distress or deprivation, the unborn child may experience impairments or may develop vulnerabilities to disease, if these effects occur during sensitive developmental periods. This “model of sensitive periods” is complemented by the “model of cumulative exposures”. The latter implies that disadvantageous conditions may accumulate over the life course and may be associated with increased disease susceptibility. Conclusion In order to reduce health inequalities, measures may be directed toward behavioral changes and living conditions, or they may include changes of laws. Changes of behavior will occur at different paces, varying readiness, and openness for change—depending on educational level. This will result in time-lagged effects entailing increasing health disparities, at least in the short term.     

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.

     

„Gesund – erfolgreich – gut? Zur Diskussion gerontologischer und politischer Leitbilder des Alterns“

Ethik in der Medizin -     

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.     

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.

     

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.

     

Natürlicher Wille,Zwang und Anerkennung – Medizinethische Überlegungen zum Umgang mit nicht selbstbestimmungsfähigen Patienten in der Psychiatrie

Definition of the problem

In recent German jurisprudence, the requirements for compulsory treatment were tightened up and more emphasis is laid on the consideration of the so-called “natural will” of incompetent patients. Before taking recourse to compulsory treatment, physicians are accordingly obliged to make a last attempt to obtain an assent based on trust. Taking into account that such an attempt tends to take place against a background of informal coercion, an ethical dilemma arises: either physicians administer compulsory treatment and hence use straightforward physical coercion or they succeed in obtaining a trust-based assent yet only at the price of using some form of informal coercion, such as threatening, deceiving or manipulating.

Arguments

We argue that the solution to this dilemma can be found in the philosophical concept of recognition. In the current context, recognition should be understood as a specific attitude that manifests itself in a respectful interaction with patients on the part of the hospital staff.

Conclusion

Although in many cases of the type described above it is impossible to completely refrain from using (informal) coercion; in these cases one can nevertheless interact in a better or in a worse way with patients – and the better way is to give recognition to patients.