Künstliche Ernährung bei Demenzkranken

Definition of the problem: There is an evident shortage of gerontopsychiatric professional nursing staff and concepts of care for aged patients with dementia. Both are absolutely required since understaffing especially affects the feeding of demented people. Arguments: Inserting a tube (PEG) to assure adequate nutritional intake cannot solve the problem of insufficient and inappropriate nursing. Tube feeding may veil the underlying problems of the nursing staff in nursing homes. The relationship with the patient and the preservation of his own world of experiences are important aspects of the care. One of the crucial problems is the difficulty in understanding the meaning of the patient’s behavior and detecting the patient’s will. Many physical causes have to be excluded before refusal of nutrition can be interpreted and explained as the patient’s will. Conclusion: The use of tube feeding for demented patients’s comfort is a point of controversy and has to be an individual decision. It seems however that artificial nutrition in the terminal phase is more a matter of assuaging the conscience of healthcare professionals rather than providing a benefit for the patient.     

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.     

Sollte es ein favorisiertes Modell klinischer Ethikberatung für Krankenhäuser geben? – Erfahrungen aus den USA

Definition of the problem Although ethics consultation services (ECS) are commonplace in hospitals in the United States there is a lack of empirical data regarding which model of ECS (individual consultant, committee, or team) best achieves its goals. The initial debate about a potential best model ebbed away without a consensus. This article argues that the goals of ECS range from being “the patient’s advocate” to “the conscience of the institution”. The article discusses which model is best equipped to achieve the respective goal and which tasks, composition of ECS and standards should follow from the goal. Arguments The argument is based, firstly, on the analysis of interviews with five chairs of ethics committees of Harvard teaching hospitals. All of them bring 20 years of expertise in ethics consultation with all three consultation models to the table. Secondly, the article reviews the relevant literature and empirical studies about ECS in the US and Germany. Conclusions In sum the model of a small consultation team affiliated to a larger committee seems best equipped to change individual patient care and the ethicality of an organisation. This model covers most of the goals of ECS, retains the virtues of both – committees and consultants – without succumbing to the limitations of either.     

法人目的范围外行为效力的比较研究

法人目的范围外行为是否有效,一直为民法学界争论。与国外立法、司法实践和学理相比较,我国长期以来奉行法人目的范围外行为无效的观点,这无疑对我国市场经济的发展产生了负面影响,不利于我国企业参与国际竞争。因此,从顺应市场经济发展的要求和保护交易安全的目的出发,我国应当明确规定法人目的外行为不得对抗善意第三人,并且在《合同法》的基础上完善对法人目的范围外行为的法律规制,建立完善先进的法人制度。     

Künstliche Ernährung

Definition of the problem: Artificial nutrition is closely related to fundamental questions of meaningful and adequate medical treatment, limits of therapy, quality of life, and euthanasia. Arguments: The meaning of all terms used in the debate about artificial nutrition has to be critically analyzed with regard to implicit, often unconsciously presumed values. Ethical decision-making must be preceded by careful consideration of all medical aspects including comprehensive review of the previous and actual situation of an individual patient and fair-minded assessment of the intended therapeutic aim. Presupposing the patient’s autonomy and self-determination—sometimes even surrogated—stereotypes of the ethical debate and proceedings, latent conflicts or presumed priority of medical solutions will be discussed, just as the further clinical management. Conclusion: The aim is to jointly develop an appropriate and individual solution, which—despite results—can be integrated into the patient’ s concept of life.     

Allokationsethik aus Sicht des Personalmanagements im Krankenhaus

Definition of the problem It is widely acknowledged that resource allocations are taking place at various levels of the health care system. On the macro level, resources are allocated according to societal and political considerations within the system as a whole. On the micro level, it is the health care organization where allocations have to be made. Ethical analyses of this micro level usually deal with decisions of health care professionals since they affect patients directly. Arguments Allocation decisions by management are of less interest to the ethical literature, although they define the framework for patient care. In this respect, this concerns not only the use of drugs or infrastructure but also of human resources. Human resource management, therefore, is deeply involved in allocation decisions and, thereby, must shoulder a threefold responsibility: towards the health of the patient, the employees, and the organization. The objective of this article is to analyze the ethics of allocation that derives from this threefold responsibility from the perspective of human resource management in a hospital. Conclusion For an adequate ethical analysis of allocation in a hospital, human resource management has to be considered, since personnel is the most precious resource to allocate in a hospital.     

Auf dem Weg zur „ökonomischen Indikation“ zum Schwangerschaftsabbruch bei therapierbaren Erbleiden?

Definition of the problem:

The development of substitution therapies for enzyme defects has fundamentally improved the prognosis and quality of life of affected patients, but such treatments are extremely costly. In recessive diseases of that type, there is a high risk for future siblings of an affected child of depending on the same kind of expensive treatment.

Arguments:

With respect to the ongoing debate about the allocation of healthcare resources, prospective carrier parents resp. pregnant women tend to be urged to restrain from further children or to terminate a pregnancy with an affected fetus. Currently, such an "economic indication" for termination appears remote for legal reasons as well as under the ethical aspect of individual procreative freedom. In the near future, however, social pressure as well as possible a-priori denials of coverage by private health insurers for future children of carrier parents may undermine the decision autonomy of parents of children with treatable hereditary diseases.     

Ein klares Jein!

Definition of the problem. Research on extracorporeal human embryos is a controversial issue in both the general public and in science. This article focuses on the public perception of this issue. Method. Over 400 people were sent a survey by mail in which they were asked about their attitudes towards research on extracorporeal embryos. Results. Our results revealed that the German public regards the method of embryo extraction as significant for their attitude towards embryo research. The majority of people were in favor of clear legal restrictions. The public was most ambivalent in their attitudes towards a legalization of embryo research. On the other hand, they had more definite opinions concerning a ban on embryo research and an introduction of strict legal regulations. A high level of ambivalence was a contributing factor in the choice of the middle category on the attitude scale. The study showed that lay persons evaluate the dilemma of embryo research similarly to experts. Although some people stated that they would welcome a legalization of embryo research, this was accompanied by a high level of ambivalence.     

Intersex(e) und alternative Heilungsstrategien

Definition of the problem: Medical intervention in cases of intersexuality are premised upon dominant communitarian gender norms that view the intersexed child as a deviation in need of treatment. Under this view, “healing” is understood as the successful integration of the intersexed individual into a clearly demarcated gender as brought about through medical treatment. This presumes, on the one hand, that untreated intersexed individuals cannot successfully “heal”, and on the other, that treated individuals experience medical intervention as a means for “healing”. Arguments: Exploration of medical literature and first-person accounts of both treated and untreated cases of intersexuality bring into question these presumptions. Instead, the literature demonstrates the importance of the core values of self-acceptance of variability, overcoming isolation by coming together with others with similar conditions, and truth-telling as the fundamental means by which these individuals find “healing”. Conclusion: This would suggest that medical intervention in order to overcome social liminality in cases of intersexuality may not be the most effective means of “healing”. Rather, medical management must redirect its efforts to overcome the response to intersexuality, and not view the condition itself as pathological.     

„Doctor knows best“? – Eine Analyse der Arzt-Patient-Beziehung in der TV-KrankenhausserieDr. House

Definition of the problem Ideas of physicians addressed and represented in the media affect public opinion as well as individual views about doctors. This article examines the representation of the medical profession in the U.S. serial dramaHouse M.D., with a focus on the physician–patient relationship between Dr. Gregory House and his patients. Combining the perspectives of medical ethics and media studies, the ethical discussion will be framed and supported by a detailed analysis that considers the show’s dramatic composition as well as the genre history of medical drama.Arguments The analysis of the physician–patient relationship is based on the four categories established by Emanuel/Emanuel. The interdisciplinary investigation reveals that House, the show’s leading character, can be read as a counterpoint to the ‘modern doctor’ and the principles of care, non-directivity, and informed consent. However, this does not mean that House is nothing more than a plea for paternalism. Rather, he should also be evaluated in light of the general ideals of a doctor held in society, e.g., scientific and medical competence or trust in evidence-based medicine.Conclusion The complex conception of House frequently exposes ethical dilemmas of medical care and conflicts between physicians and patients. The impressively dramatized, audiovisual representation of such ethical conflicts within medicine is an important part of the public discourse about the medical profession. Thus, it remains a highly relevant issue for further critical reflection, as well as empirical research on media effects.     

Vorausverfügte Therapieablehnungen in Situationen von Eigen- oder Fremdgefährdung. Ethische und rechtliche Überlegungen zur Umsetzung von Patientenverfügungen in der Psychiatrie

Definition of the problem

In case of court-ordered involuntary hospitalization due to danger to self or to others psychiatric advance directives can lead to clinically and ethically challenging situations – especially when they contain (total) treatment refusals. In such situations, patients can neither be discharged from hospital nor medically treated.

Arguments

This article discusses ethical challenges in the context of advance treatment refusals from an interdisciplinary perspective. We outline legal limitations of advance directives and normative preconditions of valid advance directives (such as mental capacity at the time of composition, applicability to the current life and health situation) and analyse them with regard to clinical practice. Hence, we elaborate on ethical arguments for and against the conduction of coercive measures and coercive treatments in situations of danger to self or to others. By identifying normatively relevant aspects, our paper further contributes to the objective of ethically justified clinical decision-making in the context of advance treatment refusals.

Conclusion

Finally, we summarize implications for clinical practice that follow from the legal authority of advance directives. On a general level, we discuss ethical tensions resulting from psychiatry’s legal obligation to intervene in situations of danger to self or to others in the context of advance treatment refusals. On the level of the individual physician-patient relationship, we outline professional offers for consultation. Further, we reflect on their potential to better inform patients about possible far-reaching consequences (total) advance treatment refusals could entail.

     

在场:从另一视角审视思想政治理论课教学贴近专业实际

思想政治理论课教学在场命题的提出是对传统教学模式的一种革新,它需要思想政治理论课教师变革传统的教学方式,并遵循思想政治理论课教学的规律、正确把握施教过程中的矛盾和冲突、把握思想政治理论课教学的本质特征;在此基础上,通过"去弊""、澄明""、再现"、"深化"各种途径,达到思想政治理论教学有效地贴近学生专业实际,增强思想政治理论课教学的吸引力和感染力。     

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.     

Krank oder behindert? Die Bedeutung tradierter Begriffssysteme und deren Anwendung f��r komplexe Syndrome

Definition of the problem This essay examines the relationship between the concept of disease and disability, thereby using the example of attention disorders. It takes as a point of departure Kleinman??s differentiation of disease, illness, and sickness and the distinction of disease and disability by the World Health Organization. The author suggests considering whether and how Kleinman??s differentiation of disease could be adapted to the concept of disability and in which way a modification could be useful for the understanding of concrete syndromes. Arguments Even though the WHO distinguishes disability and disease by means of classification since 1980, it is still not clearly determined either what chronic illnesses and psychological or cognitive syndromes are or whether they could be classified as disease by the International Classification of Diseases (ICD) or as disability by the International Classification of Functioning, Disability, and Health (ICF). Contrary to the ICD, the ICF allows for syndromes to be categorized in more detail. Conclusion Attention disorders and several cognitive abilities can be evaluated interdisciplinary, if not only their physical and psychological components but also their individual and societal components are considered. The professional and the personal perspective of the syndromes should be correlated. A clear conceptualized distinction between disease and disability is not possible.     

Strafbare Bestechlichkeit von Vertragsärzten und Ethik

Definition of the problem The potential corruptibility of contracted medical practioners has been controversially discussed for a long time: following the so-called “heart valve scandal”, numerous other pharmaceutical companies have also made the headlines when being accused of trying to bribe medical practioners. The issue not only raises judicial and sociopolitical questions, but also ethical questions. Thus far, only few reflections have been made on the matter. The medical profession has preferred to let politicians and legal professionals assess these aspects.Arguments The question of criminal bribery remains in its core a problem for the medical profession and medical ethics. In daily life, it is often difficult to recognize compensations as bribery. The border between harmless acceptance of gifts and possible corruption is often not very clear. It mostly remains in the moral perception of the doctors themselves to recognize the border between cooperation and corruption when dealing with a pharmaceutical company. Inevitably there will be conflicts between private and ethical interest of the medical professionals. Since the official ruling on the matter is insufficient, doctors are forced to decide individually what behavior is appropriate in each case.Conclusion Awareness of sociopolitical and professional-ethical conflicts of interest among doctors should be improved. It is desirable to establish a more agressive dialogue on the question of bribery of doctors.     

论军训对提高高职高专学生素质的作用

学生军训是集军事体能训练、军事理论学习、爱国主义、集体主义以及革命优良传统和思想品德教育于一体的综合性教育形式,是提高学生综合素质的一种非常有效的手段。学生军事训练具有鲜明的政治性,对学生的思想素质是一次全面的检阅和洗礼;学生军事训练具有法定的强制性,对学生的爱国意识有很大的增强作用;学生军事训练内容的针对性,对学生综合素质有较大的提升作用;学生军训管理的严格性,对学生的日常行为有较强的规范作用。     

„Alt werden im Paradies“ – Die ethischen Aspekte der Migration von pflegebedürftigen Menschen

Definition of the problem

The German-language media describes a new trend in long-term care: the migration of persons needing such care to nursing homes abroad, especially to Thailand or East Europe. This type of migration is perceived as a controversial practice. Various articles use terms such as “export of the elderly”, “gerontological colonialism” or “inhumane deportation”. These terms indicate that the migration of persons in need of long-term care from so-called high income countries to low and middle income countries might be problematic from an ethical point of view.

Arguments

There has hardly been any academic discussion on this phenomenon. On the basis of the media output and a few scientific articles, we establish that we are dealing with an ethically relevant topic. We then systematically identify relevant ethical aspects. These can be assigned to different levels: an individual-, a societal-, and a global-ethics level. On an individual level we discuss questions of autonomy, relations with relatives, the role of culture and traditions for well-being and best practice in long-term care. On the societal level we discuss structural problems in long-term care, and social justice-related questions. On the global level we connect our topic to the ethics discussion on medical tourism, brain drain and global (health) injustice.

Conclusion

In this paper we offer the first, systematic list of relevant ethical issues associated with migration of persons in need of long-term care. In order to proceed with a detailed normative analysis more empirical data on the phenomenon are needed.

     

Individuelle Entscheidungsfindung nach pränatal diagnostizierter schwerer fetaler Fehlbildung

Definition of the problem Prenatal medicine should not only aim at optimal therapy and birth planning, it should also help in decision-making with regard to continuing or terminating the pregnancy. After a pregnancy with a known severe fetal malformation, a third of the women retrospectively do not completely agree to their former decisions to continue or to terminate the pregnancy. Another third of the women are strongly uncertain about their decisions. How do social circumstances influence pregnant women’s decision making in this existential situation? How do they evaluate their decision and their experiences after the pregnancy? From the perspective of the affected women—what can be expected from physicians? Methodology Problem-centered and narrative interviews were carried out with 11 women. Criteria for the respondents were a completed pregnancy with prenatally diagnosed severe fetal malformation, which allowed a legal decision to continue or terminate the pregnancy. The analysis of the transcribed interviews was performed using qualitative content analysis according to Mayring and was computer-supported by the software ATLAS.ti. Results The retrospective satisfaction with the decision depends on finding an individual solution of an existing conflict between the basic attitude towards life in general (personal experience, prior knowledge, values) and the actually existing social circumstances (personal planning of life, family career and financial background). According to the individual analysis we classified four basic types. Women with a strong basic conflict experienced the birth rather negatively and suffered from psychopathological symptoms for a longer time. Sufficient reflection and a positive and accepting environment (patient–physician communication, adequate psychosocial support) strongly contributed to the satisfaction of the interviewees. Conclusion From the perspective of the affected women, expectations of prenatal physicians are presented.     

Ärztliche Schweigepflicht bei Kindeswohlgefährdung

Definition of the problem Medical confidentiality, which is one of the main pillars of medical ethics, has taken a decisive role in the latest discussions about the improvement of child protection laws. Inexplicit and plurivalent arrangements and procedures of how to legally handle child abuse cases when persons with legal custody refuse to take further support are seen as an obstacle for effective child protection. Arguments Non-specific legal regulations lead to task uncertainty and hesitation on the side of health care professionals, which can result in the delay or even prevention of necessary actions. Therefore, new laws on the federal level have been passed in order to establish certainty with regard to professional secrecy and in order to foster networking among the actors in the field of child protection. Conclusion The paper analyses and discusses these legal attempts at strengthening child protection. Although some of the federal laws have the potential of clarification, the great number of laws and their explication restricts their impact.     

Sorge für ein menschenwürdiges Lebensende in katholischen Pflegeeinrichtungen in Flandern (Belgien)

Definition of the problem

On 28 May 2002, a law on euthanasia was approved by the Belgian parliament. This makes Belgium the second country in the world (after the Netherlands) to have a law on euthanasia. Even though there is currently legal regulation of euthanasia in Belgium, very little is known about how this legal regulation could be translated into care for patients who request euthanasia. Moreover, Catholic health-care institutions need to clearly define their position in this difficult matter.

Arguments

The main point of this article is that everything possible should be done to provide support and assistance to the dying person and his or her family members, and to fulfil the individual’s wish for a dignified end of life. We recommend the implementation of the ‘palliative filter procedure’ in order to prevent as many euthanasia requests as possible. The main arguments in this article are based on a relational approach to the human individual, as exemplified in the personalist tradition of ethics.

Conclusion

A fully transparent and well-developed ‘palliative filter procedure’ that restricts, as far as possible, the number of euthanasia requests, could be considered as an ethically responsible answer by which Catholic health-care institutions could deal with the euthanasia law in Belgium.