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.     

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.     

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.     

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