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.

     

Alter Wein in neuen Schläuchen? Ethische Implikationen der Individualisierten Medizin

Definition of Problem In recent years, individualized medicine (IM) has become a buzz word in the academic as well as public debate surrounding health care. Like any technological development, however, it has (potential) ethical implications which have to be taken into account to enable an appropriate development and application of individualized preventive and therapeutic measures. Arguments An ethical assessment of IM poses several methodological challenges arising from the heterogeneity of the problem area as well as IM’s conceptual ambiguity and early stage of development. Against this background, we first specify the term IM to sharpen the context of our further considerations. On this basis we second present a heuristic typology of (possible) ethical implications of IM. Conclusion IM has potential ethical implications which mostly are well-known from other biomedical contexts. Moreover, these implications differ decisively with regard to different IM measures. On this account, an adequate ethical strategy requires evaluating each individualized approach separately.     

Das Verbot der pränatalen Diagnostik spätmanifestierender Erkrankungen im deutschen Gendiagnostikgesetz – eine Diskussion medizinischer und rechtlicher Aspekte und deren Implikation für die medizinethische Diskussion

Definition of the problem The German Genetic Diagnosis Act (Genetic Diagnosis Act, GenDG) became effective on February 1, 2010. Although this act was welcomed by many, the debate surrounding some regulatory areas, for example, screening newborns, continues. One aspect of this new legislation, however, has received little attention: the prohibition of prenatal diagnosis of so-called late-onset diseases—where first symptoms only develop after completion of the 18th year of life—constitutes an internationally unique prohibition. In this publication, we would like to contribute to a more differentiated discussion of § 15(2) GenDG that sanctions this diagnosis. Arguments and conclusion There are arguments supporting this prohibition (especially the right of the child not to know). However, based on medical concerns as well as an analysis of ethical and legal pros and cons, we conclude that maintaining this general prohibition of diagnosing late-onset diseases might be insufficient as well as inconsistent with other regulations; thus, possible alternatives are discussed.     

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.     

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.     

Sozial-epidemiologische und ethische Ansätze zur Bewertung der gesundheitlichen Ungleichheit

Definition of the problem Low socio-economic status is often associated with increased morbidity and mortality. In this paper, an appraisal of these health inequalities is offered from a social-epidemiological point of view, focussing on the question: who is responsible for the increased health risks of people in low status groups? Arguments Health behavior can explain just a small part of these health inequalities, making it even more important to look at other causes. Important are, for example, the social differences concerning harmful living conditions (noise, etc.), harmful working conditions, and also concerning access to health care. These social-epidemiological results can be well integrated into the ethical discussion. Conclusion Who is responsible for what part of the health inequalities? This question is often the starting point of heavy disputes. They can be solved only if the social-epidemiological and ethical discussions are better linked to one another.     

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.

     

Einfluss einer elektronischen Patientenakte (EPA) auf das Arzt-Patienten-Verhältnis: eine systematische Übersicht der medizinethischen Implikationen

Background

In a model project, the implementation of a comprehensive, personal electronic patient record (PEPA) shall not only improve consistency of care, but also realize the right to informational self-determination to the effect that every patient is made administrator of a data-cloud containing all his medical data. A systematic literature review on the topic “electronic health records (EHR)” anticipates possible ethical challenges in connection with the mentioned PEPA. Of the initial 2487 publications, 51 articles were analyzed: 30 empirical studies, 10 medical ethics analyses, and 11 comments.

Results

In the empirical studies, a more comprehensive medical record was described as an initial effect. The option for access to the EMR by the patient resulted in a better understanding of the needed medical care and thereby higher compliance by the patient. An improvement of the quality of medical care was attributed to prevention of medical errors through the access to records by the patient, a more effective utilization of physician–patient visitations and an improved understanding of the therapeutic concept. Studies also showed a strengthening of the bond of trust in the physician–patient relationship. Concerns were related to data security, possible decline in the personal physician–patient relationship and potential excessive demands on the patient.

Discussion

In an assessment of the EMR, weighing beneficence against patient autonomy plays a major role. Concerns by medical ethics pertaining to a loss of trust or a disturbance of the physician–patient relationship could not be proven empirically. The feared risks to data security were weighed by those affected in favor of the potential benefits of the EMR. Provided that data are protected, the PEPA has the potential to influence the physician–patient relationship positively through participation of the patient. The specific ethical challenges associated with the co-administration of PEPA will be examined in the pilot project.

     

Das Eigentliche des Todes. Ein Beitrag zur Be-Lebung der Debatte über Hirntod und Transplantation

Definition of the problem

Contemporary debates on the moral permissibility of the donation and transplantation of vital organic material often focus on the definition of and criteria for the determination of death. However, death cannot be experienced in the same fashion as life as it is its contradictory negation; death is not-life. Any attempt to define death must, therefore, proceed from and be based on a definition of life.

Arguments

This article argues that life cannot be reduced to a set of empirically observable properties or functions but can only be explained comprehensively from a philosophical perspective. Taking this perspective allows us to establish that life is the “actus primus” (soul) of all animate beings.

Conclusion

Applying this “soul criterion of death” necessitates the conclusion that the explantation of vital organic material from a person whose brain has stopped functioning is always a violation of the dead-donor rule as the person is dying but not dead.     

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.

     

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.

     

Rechtliche und ethische Aspekte grenzüberschreitender Gesundheitsversorgung innerhalb der Europäischen Union

Definition of the problem Patient mobility and cross-border healthcare are phenomena of daily healthcare practice within the EU. With the Directive “on the application of patients’ rights in cross-border healthcare”, the EU in 2011 issued a comprehensive regulatory framework. No inventory or systematic assessment of ethical issues in this context exists. Argumentative strategy The current legal situation of cross-border healthcare within the EU and its historic development are presented. Based on a patient typology focusing on different patient motivations for crossing the border to receive healthcare, ethical issues of cross-border healthcare within the EU are discussed. ConclusionThe possibility of crossing borders for receiving planned healthcare in the EU—which is under certain conditions also reimbursed by health insurance and national health service schemes—potentially increases the autonomy of some patients. However, especially when considered from a justice perspective that asks for real equal opportunities for everyone, many ethical issues are conceivable that are not sufficiently studied or considered in the policy making process.     

Selbstbestimmung und Selbstverständnis – Themenschwerpunkte im Umgang mit der Patientenverfügung

Ohne Zusammenfassung     

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.     

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.