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.

     

PID auf Aneuploidie des Embryos?

Definition of problem

At least in some cases, testing for aneuploidy as part of preimplantation genetic diagnosis (PGD) can be medically useful for pregnancy care. The current legal situation in Germany seems to not generally exclude PGD to detect a maldistribution of chromosomes in an embryo, but testing would require approval by a PGD ethics committee on a case-by-case basis and a well-reasoned application by the concerned woman. This article examines ethically and legally whether fundamental reasons prevent PGD commissions from admitting requests to perform aneuploidy tests as part of PGD.

Arguments

Three constellations – each with differing ethical implications – can be distinguished in which testing for aneuploidy could be considered or could occur: Testing for aneuploidy can (i) be the main reason for in vitro fertilization (IVF), which in itself is not medically indicated; (ii) IVF is done as infertility treatment in which case PGD and aneuploidy testing could be done additionally; or (iii) PGD with IVF is indicated in order to prevent a congenital disease or chromosomal aberration leading to a diagnosis of aneuploidy as an incidental or additional finding. Ethical arguments which could lead to a general rejection of aneuploidy testing are the prevention of discrimination against people with aneuploidy, as well as the protection of embryos. These concerns oppose constellation (i), but do not apply to (ii) and (iii). Yet there are at least three ethical arguments in favour of an admissibility of a request for aneuploidy testing: the “good practice” of IVF, the duty to the emerging child and the parent’s right to have a voice in the discussion.

Conclusion

Aneuploidy testing as part of PGD is not ruled out by legal or ethical reasons and should be openly discussed by the relevant German ethics commissions.

     

Tod des Körpers oder Tod der Person?

Definition of the problem

Within the current philosophical debate on the adequate definition of human death, death is defined either as the death of the body or the death of the person. However, the application of these notions leads to several practical conflicts, which can be seen first and foremost in the brain-death debate and the discussions on how to increase organ donation.

Arguments

The conflicts are based in both a dualistic and objectivistic notion of the human being which are implied in both definitions of death. In order to solve these conflicts, we are in need of a nondualistic concept of human being which at the same time enables us to elaborate a first- and second-person perspective on death. On the basis of Helmuth Plessner’s philosophical anthropology, such an integrative concept of death can be developed.

Conclusion

Following this concept, it seems reasonable to abandon the brain-death criterion as the criterion for human death and to fundamentally reform the current information campaigns for organ donation.

     

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.

     

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.

     

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.