„Medizinische Notwendigkeit“: Herausforderungen eines unscharfen Begriffs

Definition of the problem

“Medical necessity” (MedN) is the central regulatory concept for decisions about which services are covered by German statutory health insurance. Despite its seeming objectivity and dependence on physicians’ expert judgment, the concept is by no means clearly defined.

Arguments

In this first of five planned papers on the conceptual analysis of MedN from the perspectives of philosophy and ethics of medicine, law, and (social) medicine, the focus lies on systemizing ongoing controversies.

Conclusion

Our goal is to come up with a so far missing foundation for detailed debates. We aim to clarify MedN’s conceptual structure, function, contextuality, and ambiguities as well as the fundamental limits of conceptual investigations for the normative questions at issue of regulating medical services.

     

Der Umgang mit „second victims“ als organisationsethische Aufgabe

Background and purpose

Adverse events and medical errors can have severe consequences for patients (“first victims”), but also for the involved health care professionals (“second victims”). Don Berwick, former director of the Boston Institute for Healthcare Improvement (USA), highlighted the support for “second victims” as an “ethical issue”. But there is no clarity about what “ethical issue” implies. This article aims to clarify this question from the perspective of organizational ethics.

Method

Starting with data from the literature, challenges are described and evaluated from the perspective of organizational ethics.

Results

Evidence suggests that current approaches for supporting “second victims” are not sufficiently effective to help professionals to cope with the psychological consequences of adverse patient events and medical errors. This not only has negative consequences for the involved professionals, but can also put patient safety again at risk. In the light of these data, an organizational ethics approach is needed to comply with Don Berwick’s claim to consider the support of “second victims” as an “ethical issue”. This approach fosters the congruence of the organization’s values that are declared and those that are practiced. Its normative foundation is rooted in the organization’s duty of care both for the patients and for the employees.

Conclusions

Using organizational ethics it is possible to conceptualize and visualize the support for “second victims” as a binding component of the safety culture of the organization. It is translated into the organization’s obligation to raise the awareness for the phenomenon and to provide the resources necessary to deal effectively with it, e.?g., evidence-based ethical guidelines, standardized procedures, staff training, and low-threshold coaching programs.

     

Visualisierungen und Visualisierungsstrategien in der Zahnheilkunde

Definition of the problem

The use of visualization in dentistry has increased rapidly within recent years. Besides the advantages in transfer of knowledge and clarification of complex facts, they also involve the risk of being used to direct or manipulate the patient. Against this background it is the aim of this article to problematize normative implications of current techniques and strategies of visualization. The analysis is focused on the field of use of visualization in dentistry, its potentials and limits as well as existing risks of manipulation and resulting normative requirements. The methodical basis of this article are the “principles of biomedical ethics” (principlism) by Beauchamp and Childress as well as the principle of veracity. Furthermore, available commercial literature and journal articles coping with this matter are analyzed.

Arguments

This analyzation leads to the result that available techniques and concepts of visualization contain a high risk of manipulatively being used especially in dental consulting and patient information. The ambiguity of these techniques must be taken into concern and they must be used to support direct information by a dental professional.

Conclusion

If this requirement is fulfilled the use of visualization offers the chance to instruct the patient, to enforce his autonomy and to meet the requirement of an “informed consent”.

     

Ethische Aspekte des Alter(n)s im Kontext von Medizin und Gesundheitsversorgung: Problemaufriss und Forschungsperspektiven

Definition of the problem

Due to the individual and societal consequences of demographic change, moral questions regarding old age and elderly persons are moving into the focus of public attention and of ethical debates in medicine, nursing and public health. In many of these debates, however, ageing as a process and old age as a phase of life is primarily considered from the angle of the respective practices, questions and problems discussed. What is missing is a perspective that comprises the different practical contexts, makes the underlying conceptions of age(ing) explicit and reflects their meaning for the ethical debate.

Arguments

The working group “Ageing and Ethics” in the Academy for Ethics in Medicine was established to contribute to such a more comprehensive perspective. This paper gives an overview of the central topics, problems and arguments in the contemporary medical, nursing and public health ethics discourses on age(ing) and marks open questions and desiderates.

Conclusions

A more intensive consideration of age(ing) can not only improve the theoretical basis of the pertaining debates in applied ethics but also shed light on some of the anthropological foundations and normative frameworks of ethical reasoning as such.

     

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.

     

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.

     

Dystopie und Methode: zur fiktionalen Verhandlung moralischer Überzeugungen in der Bioethik

Definition of the problem

The role of stories is well established in the traditions of narrative ethics and casuistry. However, from a methodological point of view, the inclusion of fictional works in moral deliberation remains yet unanswered. The paper explains the potential of dystopias for bioethics by means of selected examples and a critical reconstruction and expansion of existing approaches.

Arguments

By means of literary theories, it is proposed to include moral beliefs that motivate dystopias in coherent reflection and reasoning procedures. Furthermore, dystopia’s potential through socioculturally dense scenarios, a contemporary-historical context, and a sensitization to the moral relevance of language for bioethical research are systematically presented.

Conclusion

The methodological considerations provide, on the one hand, practical points of reference for didactic approaches and, on the other hand, for public deliberation. However, the analysis also shows that dystopias introduce their own moral positions beyond a mere illustration or warning.

     

Das deutsche Arzneimittelpatent – eine moralische Bewertung

Definition of the problem

This paper deals with the question whether the current German intellectual property right on pharmaceuticals is morally justifiable. To answer this question, I will map the relevant discourse and arrange the different positions with respect to their level of abstraction.

Arguments

I underline that both deontological and consequentialist arguments point out the moral deficits within the system.

Conclusion

The consequentialist position emphasizes the unsatisfying relationship between patented pharmaceutical costs and the number of innovations on the market. The deontological approach on the other hand highlights the dangers to citizens’ autonomy.

     

Selbstbestimmter Wille und das Recht auf assistierten Suizid

Definition of the problem

As concerns a right to assisted suicide it is not just controversial whether we have such a right but also to what it would entitle us.

Arguments

The article argues that this is a debate about what it takes for decisions to be worthy of respect. It is argued that those decisions should be respected that are autonomous exercises of the rights people have over themselves. It is further argued that decisions, which are exercises of rights, only create permissions neither reasons nor obligations.

Conclusion

This also applies to decisions to end one’s life.

     

Internationale Rekrutierung und Migration von Ärztinnen, Ärzten und Personal in Gesundheitsfachberufen: ein qualitatives Scoping Review der Public Health Literatur

Background

The international recruitment and migration of health workers has long been debated in the health policy literature. This study assesses to what extent the ethics of international recruitment are targeted in existing public health peer-reviewed literature, with a focus on concepts and in-depth consideration within articles. It further critically discusses hidden implications of this discourse regarding equity-creating health policy.

Methods

We conducted a qualitative scoping literature review searching the databases PubMed and Web of Science. Articles were assessed for quality using the Critical Appraisal Skills Program (CASP) checklist for qualitative research. Drawing on a thematic analysis approach, common themes across the sample were identified, coded and analyzed.

Results

A total of 17 articles were included in the analysis after searches and quality appraisal. These articles predominantly targeted nursing professions and physicians, and were written mainly by authors working in the Global North. Thematic analysis revealed that ethics are generally discussed in connection with overviews regarding the situation of health systems as well as regarding inequities between countries. Their focus lies more on migration between countries than between regions within a country. Proposed solutions are usually of an economic nature and range from global financial equalization between countries to national improvements in working conditions. Creative evaluation schemes for these solutions are rarely discussed in depth. Overall, the academic ethics discussion focuses predominantly on the health systems level, and views migration of health workers as problematic.

Conclusions

Our results suggest that academic research operates and aims to inform policy within the current system, without necessarily proposing fundamental changes to the status quo. Thus, an ethics discourse of health workforce recruitment may serve to increase awareness of inequalities without supporting radical change. Further research into intersectional aspects of health worker migration, including gender and ethnicity, may be useful for the discussion on inequities.

     

Breite Einwilligung (<Emphasis Type="Italic">broad consent</Emphasis>) zur Biobank-Forschung – die ethische Debatte

Definition of the problem

Ethical aspects of biobanking research are receiving increasing attention in the literature. It is particularly controversial which model of consent should be implemented in research biobanks.

Arguments

This paper outlines the ethical controversy surrounding various models of consent into biobank-based research. Following a brief introduction of established consent models, it delineates the development of alternative approaches and discusses the ethical and regulatory challenges associated with these. Relevant ethical principles are highlighted.

Conclusion

The article concludes that there are good reasons to trial a combination of initial broad consent with consent to governance for future biobanking research in Germany.

     

Patientenverfügung und Behandlungsvereinbarung als Instrumente der Vorausplanung in der forensischen Psychiatrie

Definition of the problem

In Germany as well as in many other countries, mentally ill criminals who are not guilty by reasons of insanity can be sentenced to psychiatric treatment in forensic clinics. In 2011, the German Constitutional Court substantially strengthened these patients’ right to self-determination in case of treatment refusal.

Arguments

In this context, we discuss the significance of instruments of advance healthcare planning. First, we describe the context of psychiatric treatment in forensic clinics and the changes the new German legal regulations brought about. A case study helps to illustrate the consequences of treatment refusal for both patient and healthcare personnel.

Conclusion

Eventually, we discuss if and how advance directives and joint crisis plans can be useful in forensic clinics and how additional measures can help to facilitate patient self-determination.

     

Ethische Aspekte des Dolmetschens im mehrsprachig-interkulturellen Arzt-Patienten-Verhältnis

Definition of the problem

It is well-known that good physician–patient communication is decisive for proper treatment of a patient and the patient’s self-determination. In intercultural–multilingual situations, intense discussions are even more important when possible discrepancies on both sides regarding presuppositions and actual facts have to be bridged. Hence, in case of language barriers, the use of qualified interpreters is ethically required. In interpreter-mediated consultations, both physicians and interpreters face specific ethical challenges. When qualified interpreters are not available, physicians, in difficult ethical reflections, have to weigh options regarding alternative solutions. To date, these two issues have received little attention in medical ethics.

Arguments

Based on research about community interpreting and interpreter-mediated discourse, this paper, first, identifies central ethical challenges and the corresponding spheres of responsibility of physicians and interpreters. It discusses the need of language support, the risk of excluding patients from interpreter-mediated consultations, the observation of the interpreters’ ethical principles, the problem of ensuring confidentiality as well as the implications of cultural brokering. Second, the article approaches the physician’s options under nonideal conditions when no sufficiently qualified interpreter is available. Calling in a nonprofessional person for spontaneous interpreting, e.?g., a relative or a multilingual colleague requires ethical reflection. For this purpose, this article presents for the first time a framework based on nine criteria which can help physicians assess the ability of a specific person to interpret in a given physician–patient encounter and balance competing interests.

Conclusion

The ethical challenges in interpreter-mediated physician–patient interaction require qualified interpreting. Under nonideal conditions, the framework presented above supports physicians to select alternative solutions. However, it does not substitute long-term solutions on the macro level, e.?g., the funding of professional interpreting.

     

„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.

     

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.

     

Grenzen des Selbstbestimmungsrechts im psychiatrischen Behandlungskontext

Definition of the problem

The recent legal development emphasizes the right of self-determination of psychiatric patients decidedly even in the case of them lacking the capacity to give consent.

Arguments

Partly it is concluded that every coercive treatment would be inadmissible altogether. However, this is not just an inaccurate interpretation of applicable law, it furthermore relies on a reductionistic understanding of autonomy. In truth the boundaries between patients volition and (coercive) treatment have to be readjusted: This process gives importance to the instrument of medical treatment agreement without removing the area of permitted compulsion completely.

Conclusion

Its constitutionally required limitation to the inevitable extent demands precise regulations differentiating between several accommodation requirements; also institutional efforts for the implementation of an adequate structural und processual quality in psychiatric establishments are necessary.

     

„Othering“: Die Konstruktion des Anderen im Gesundheitswesen

Definition of the problem

The paper discusses how the construction of cultural differences gains influence on moral conflicts in health care and how the phenomenon of Othering can be dealt with in an ethically responsible way.

Arguments

The construction of difference is interpreted by reference to the concept of Othering which describes the dynamics of reinforcing asymmetries in relations between the Self and the Other. Different aspects of this concept and its relation to the anthropological unavoidableness of asymmetries between Self and Other are discussed.

Conclusion

Although an asymmetric perception and evaluation of conflicts is unavoidable, there are strategies to deal with Othering in an ethically responsible way in the context of health care. The basic ethical competence needed therefor is the capacity for critical self-reflection because this is a prerequisite for truly understanding and accepting the Otherness of the Other without falling back on cultural prejudices and stereotypes.

     

Leistungsrechtliche Konsequenzen einer Behandlungsablehnung bei untergebrachten Patienten – Chancen und Risiken einer Anwendung von Vorausverfügungen in der Psychiatrie

Definition of the problem

Patient’s advance directives offer a possibility to keep autonomy even in the case of acute psychiatric disease. The advance directives may in some cases interfere with law when patients, who are suffering from acute psychiatric disease, are coerced to psychiatric treatment by law. Thereby it is possible that patients who are kept in psychiatric treatment involuntary cannot receive treatment because of their documented autonomous will. In these cases economical questions interfere with treatment of psychiatric patients who are coerced for in-patient treatment, but deny medical treatment: in those cases in-patient treatment is typically not covered by German health insurance.

Arguments

The text illustrates the ethical conflict consisting of coerced in-patient treatment by law and the denial of treatment by patients advance directives.

Conclusion

The paper discusses joint crisis plans as a possibility for increasing treatment compliance and decreasing coerced in-patient treatment.

     

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.