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.     

Differenz – Macht – Ethik

Definition of the problem

Cultural identity and the possibility of being able to also experience this in the situation of illness is a central part of culture-sensitive health care. Thus, basic knowledge of specific cultural characteristics and the ability to reflect on one’s own cultural roots is important. At the same time, there is a consensus that culture-sensitive care should not refer to stereotypes and refrain from a culture essentialist approach. The paper asks how differences and otherness is created in the field of medicine and which role bioethical arguments can and should play in this. From an ethical perspective, two aspects are highlighted in particular. First, how the existing differences are structurally anchored and are connected with questions of power and interest. Here we investigate which questions about cultural identity are helpful, especially from the perspective of the patient. Second, with regard to specific areas of action in health care, those approaches of culturally sensitive ethics that can be strengthened against this background are examined, so that everyday health care promotes dealing with cultural issues.

Arguments

The paper analyzes the function of differences in medicine and asks which types of differences are helpful for patient care.

Conclusion

Concepts of identity that can integrate contradictory aspects can support culture-sensitive care and an individualized attitude towards culture based on the needs of patients.

     

Legalisierung der aktiven Sterbehilfe – Förderung oder Beeinträchtigung der individuellen Autonomie?

Definition of the problem Theorists who support the legalisation of active euthanasia usually base their arguments on the principle of autonomy. In their view the wish of a severely ill person not to continue his or her life must be respected. However, some opponents of the legalisation of active euthanasia refer to the principle of autonomy as well. Arguments They are concerned that patients may be held responsible for burdening others with the provision of care. Thus family members, physicians or nurses may exert pressure on patients to opt for active euthanasia. In this article it is argued that these worries are justified; the occurrence of social coercion poses a real danger. Conclusion However, neither the prohibition nor the permission of active euthanasia enables each individual to make an autonomous choice. Comparing the risks involved in both options, legalisation seems to be preferable to maintaining the status quo.     

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.      

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.

     

Zum Verbesserungspotenzial schriftlicher Aufklärungsmaterialien zu (bio)medizinischen Forschungsvorhaben – Empirische Analyse von Antragsunterlagen einer Forschungsethikkommission

Background

One of the elementary prerequisites for medical research on and with humans is the patients’ or probands’ informed consent. To ensure informed consent, study participants must be—among other things—provided with high-quality information. We developed criteria to assess and evaluate the quality of various written patient information material.

Methods

Based on a catalogue addressing 117 single criteria, we assessed the quality of 128 randomly selected documents from study proposals submitted to the ethical committee of Luebeck University in 2006. Each criterion refers to one of six quality areas (such as “readability and comprehensibility” or “potential benefit and harm”).

Results

The documents on average satisfied half of the criteria with a range from 20–76% for single items. The area with the highest quality score was “consent form” (64%), while “potential benefit and harm” (35%) was the lowest. Material from drug trials showed a significantly higher quality than that from other study types. Only 21 out of 117 criteria were met in more than 80% of all relevant documents.

Conclusion

The study provides evidence for significant deficits in the information material from basic and clinical research projects presented to one academic research ethics committee. Researchers need support in developing and writing informed consent documents. Our set of criteria could be used to make them more sensitive to the various demands involved.     

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.     

Natürlicher Wille,Zwang und Anerkennung – Medizinethische Überlegungen zum Umgang mit nicht selbstbestimmungsfähigen Patienten in der Psychiatrie

Definition of the problem

In recent German jurisprudence, the requirements for compulsory treatment were tightened up and more emphasis is laid on the consideration of the so-called “natural will” of incompetent patients. Before taking recourse to compulsory treatment, physicians are accordingly obliged to make a last attempt to obtain an assent based on trust. Taking into account that such an attempt tends to take place against a background of informal coercion, an ethical dilemma arises: either physicians administer compulsory treatment and hence use straightforward physical coercion or they succeed in obtaining a trust-based assent yet only at the price of using some form of informal coercion, such as threatening, deceiving or manipulating.

Arguments

We argue that the solution to this dilemma can be found in the philosophical concept of recognition. In the current context, recognition should be understood as a specific attitude that manifests itself in a respectful interaction with patients on the part of the hospital staff.

Conclusion

Although in many cases of the type described above it is impossible to completely refrain from using (informal) coercion; in these cases one can nevertheless interact in a better or in a worse way with patients – and the better way is to give recognition to patients.

     

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.

---

     

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.

---

     

Froth flotation of scheelite – A review

Froth flotation of scheelite has regained new focus since the 2010s and research regarding floatability and reagents has made great progress over the years. The main objective was and remains the selective flotation of scheelite from other calcium-bearing minerals, in particular calcite, fluorite and apatite. Due to similar properties, most attempts have limited success or only specific application(linked to a type of ore or a location). This article aims at reviewing all general physical-chemical information on froth flotation of scheelite, including electrokinetic properties, influence of p H and already existing reagents as well as ones still under examination. It appears that chelating or mixed collectors and modified versions of sodium silicate and quebracho hold great promise for scheelite flotation, while the use of said depressants and/or promoters seems inevitable.     

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.

     

Persönlicher – besser – kostengünstiger? Kritische medizinethische Anfragen an die „personalisierte Medizin“

Definition of the problem “Personalised medicine” has recently gained considerable attention and has evoked a multitude of hopes in modern medicine. The identification of genetic markers enables more precise diagnoses, targeted therapy and more specific statements about the personal prognosis. Often used as a synonym for medical progress, personalised medicine promises to be more personal, better and cheaper than current medicine. Arguments (1) However, large achievements in basic genetic research do not necessarily mean better personal treatment for the majority of patients in clinical medicine. It is more likely that future clinical success in targeted therapies will be limited to subgroups of patients. In contrast, a considerable proportion of patients will have no personal benefit at all. (2) “Personalised medicine” is genetic biomarker-based targeted diagnostics and therapy. It does not focus on a more personal patient–doctor relationship, like patient-centred or person-centred medical care provides. (3) In fact so-called “personalised medicine” is a research- and economic-driven adventure governed by global stakeholders, e.g. pharmaceutical and biotechnology companies. Since economically independent and publically funded research is widely lacking, these private interest groups are setting the research agenda following their commercial interests. In this context and with the record of the current cost development of new cancer drugs in targeted therapies, there is no evidence for the promise of cost saving and of cheaper health care. (4) Furthermore “personalised medicine” is associated with ethical problems like priority setting and opportunity costs in solidarity-based public health care systems. “Personalised medicine” provides modern, highly specific and expensive diagnostics and treatments which will only serve subgroups of patients. At the same time research in other fields of clinical medicine which could serve more than some subgroups of patients, remain underfunded. A public debate on priority setting in medical research and treatment and about how societies and public health systems can influence the development of the research agenda regarding the priorities for future health care is needed. Conclusion Genetic biomarker-based “personalised medicine” does not contribute to a more personal treatment of individual patients, like in patient- or person-centred medical care. Subgroups of patients, e.g. in oncology, have medical advantages from the present progress in “personalised medicine”, but not the overall majority of patients. Empirical evidence is lacking for the promise of cheaper health care through “personalised medicine”; however, based on past experience an increase of cost is more likely.     

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.