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.     

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.     

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.

     

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.      

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.

     

Spezifische Bedarfe bei zahnärztlichen Patienten mit Demenz und ihre ethischen Implikationen

Definition of the problem

The central foundations of successful dental treatment consist of a trustful patient-dentist relationship, the professional and psychosocial expertise of the team treating the patient, and consideration of ethical aspects both during the therapeutic decision-making process and during the subsequent execution of therapy. This is especially true of the dental treatment of (mostly elder) persons with dementia, calling for an in-depth assessment of the various normative implications.

Arguments

In geriatric dentistry in particular, situational dilemmas regarding treatment often arise from specific constellations (e.?g. greatly reduced potential for dental therapy, lack of ability regarding oral hygiene and lack of individual patient responsibility) combined with an acute need for treatment and the necessary involvement of third parties. These dilemmas frequently place additional professional and normative demands on the dentist. The current contribution discusses this specific situation, first by way of theoretical discourse and subsequently with a case-related approach on the basis of two case histories.

Conclusion

It becomes clear here that classic state-of-the-art therapies are replaced by “compromise treatment” in many cases in geriatric dentistry. Such treatment follows divergent diagnostic and therapeutic rules, poses changed requirements in terms of communication and presents specific ethical challenges and pitfalls.

     

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.     

Einstellung einer künstlichen Ernährung und kritische Anfragen an die Rechtsprechung

Ohne Zusammenfassung

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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.     

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.

     

Wenn es persönlich wird in der „personalisierten Medizin“: Aufklärung und Kommunikation aus klinischer Forscher- und Patientenperspektive im empirisch-ethischen Vergleich

Definition of the problem In clinical research and practice, the new paradigm of “personalised medicine” raises questions about necessity, expectations, possibilities and risks. In an ongoing empirical–ethical study, we explore the perspectives of both researchers and patients regarding the implementation of “personalised medicine” in the treatment of locally advanced rectal cancer. This study focuses on ethically relevant aspects in practice, including expectations towards, counseling on, and decision for “personalized” treatment, or research. Methods We conducted interviews (with 19 researchers and physicians and 28 patients) and participant observations during physician–patient consultations (n = 50). Arguments Uncovering differences and similarities in the perspectives of affected patients and physicians will allow potential conflicts in clinical practice to be detected and addressed as early as possible. Conclusions We were able to demonstrate that patients and physicians have different perspectives on “personalised medicine”. This might lead to conflicts in clinical practice that should be addressed as early as possible.     

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.

     

Reproduktionsmedizin und embryonale Stammzellforschung – aktueller Problemstand und gesetzlicher Regelungsbedarf

Ohne Zusammenfassung

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