Ist terminale Sedierung medizinisch sinnvoll oder ersetzbar?

Definition of the problem: When provided by a multidisciplinary team, symptom control in incurable patients at the end of life is highly effective in alleviating distressing symptoms. However, a number of patients remain in unbearable situations, that cannot even be relieved when taking care of physical, psychological, social and spiritual needs. Arguments and conclusion: In these extreme cases sedation is an effective measure. The term and provision of terminal sedation are controversial in many respects. A case presentation will illustrate the problem and show how terminal sedation can act as a tool for symptom control by palliative care experts even if it is no perfect answer to intolerable suffering in dying patients. Comparing relevant literature, medical, legal and psychosocial questions are discussed.     

Ethische Aspekte einer Begrenzung der ärztlichen Arbeitszeit

Definition of the problem: The regulation of resident work hours involves several ethical conflicts which need to be systematically explicated and weighted. Arguments and conclusion: The most important ethical principle when regulating work hours is to avoid harm resulting from overwork of physicians and from extreme division of labour. Additionally, other ethical principles have to be taken into account, in particular those of non-maleficence and beneficence for future patients and for physicians. The article gives reasons for preferences when ethical principles are conflicting and analyses the structural difficulties that unavoidably occur in any regulation of complex activities like those of physicians.     

Der Diskussionsentwurf des Gendiagnostikgesetzes

Ohne ZusammenfassungInteressenkonflikt: Der Autor ist als klinisch tätiger Humangenetiker von den Regelungen des GenDG unmittelbar betroffen; gesundheitspolitische Fragen, die unmittelbar Eigeninteressen berühren würden, sind jedoch nicht Gegenstand dieses Textes.

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Das Problem der verantworteten Therapieentscheidung in der Neonatologie

Definition of the problem: Physicians and nurses who work in neonatology—as in intensive care at all—are often forced to decide whether to stop or to continue with the treatment of a severely ill patient. The literature provides several decision making instruments, which are meant to help and to rationalize such decisions. Method and conclusion: Two of these instruments (“Schema zur ethischen Urteilsbildung nach dem Muster der aristotelischen Ethik”, Honnefelder 1994; “Nimwegener Methode für ethische Fallbesprechung”, Gordijn 1998) were tested by retrospectively examining two cases of our NICU. Results of our study show that the use of a decision making instrument is basically helpful. But the above mentioned instruments showed also shortcomings when used in the framework of neonatology. Therefore we developed the “Kölner Arbeitsbogen zur ethischen Entscheidungsfindung in der Neonatologie”, which is adapted to the specific needs of neonatology.     

Das Problem der Behindertenselektion bei der pränatalen Diagnostik und der Präimplantationsdiagnostik

Definition of the problem: Are selective abortion and preimplantation diagnosis to be criticized for discriminating against the disabled? Arguments and Conclusions: The answer is often said to depend on the position a person takes concerning the status of the embryo: If the embryo is a subject of human rights, the mother's decision not to accept the embryo (insofar as it may be justified at all) should be made irrespective of the child's disability status if the decision is to be non-discriminating. The following article (i) does not presuppose that the embryo is not a subject of human rights, (ii) argues that the mother is still not to be criticized for letting her decision depend on the disability status because many people consider, and everybody must be allowed to consider, such a status in matters concerning her or his sphere of privacy, (iii) argues that the intuitive reserve against preimplantation diagnosis in the German public debate is rooted in something else than a concern for the rights of the rejected embryo-individuals, and that the problem should be discussed accordingly.     

Überlegungen zum Krankheitsbegriff aus strahlentherapeutischer Sicht

Definition of the problem: The concept of disease should be presented under the view of clinical medicine using radiooncology as an example. The interactive dualism, as described by Switankowsky, is introduced as theoretical framework for understanding the nature of disease. According to this theory, the interaction between mind and body plays a central role to treat the patient with dignity and compassion. This is true for radiotherapy, where a holistic understanding of the patient is necessary. Actual analysis of the current clinical literature is made and nevertheless shows a reductionistic concept of disease, which is based mainly on objective criteria from the physician's view. Arguments and conclusions: Considering and applying the interactive dualism physicians can overcome the reductionistic view. The discussion between doctor and patient will get a leading role. Both physician and patient can develop a common concept while discussing the disease, so that according the interactive dualism objective and subjective criteria are considered. Limitations of this new definition need special attention and should be finally described.