Due to the spread of COVID-19, a key challenge was to reduce potential staff shortages in the healthcare sector. Besides recruiting retired healthcare workers, medical students were considered to support this task. Commitment of medical students in Germany during the COVID-19 pandemic was evaluated using an online survey, with particular focus on their burdens and anxieties. This survey was distributed to students within a 2-week period in April and May 2020. Ultimately, 1241 participants were included in the analysis. (...) During the pandemic, 67.9% of the participants reported that they had volunteered. Furthermore, 88.9% stated that they were against compulsory recruitment in this context. Students who volunteered had a significantly lower anxiety index than non-committed students. Additionally, students were more concerned about infecting other patients and relatives than themselves. Higher levels of anxiety were related to lower levels of commitment. A mandatory assignment during the pandemic was rejected by the students and does not seem to be necessary due to the large number of volunteers. (shrink)

It is interesting, that with the notable exception of the Cologne-based geneticist Benno Müller-Hill, German historians of medicine have not bothered a great deal with looking into German medical history during the Third Reich. We owe Pennsylvania State University's Robert N Proctor a great deal of gratitude for uncovering more and more of this history, and for making it accessible in a highly readable format. Proctor has established himself rapidly as the pre-eminent US American historian of science (...) on all aspects of Nazi medical research and health policy. In this most recent book Proctor looks at Nazism's pioneering contributions in public health research and policy, as well as in environmental health, occupational health, and preventive medicine. This book holds some disturbing lessons for those who hold the view that basically good people will undertake ethical research, and support good health …. (shrink)

In September 1998 the Bundesrztekammer, i.e., the German Medical Association, published new principles concerning terminal medical care. Even before publication, a draft of these principles was very controversial, and prompted intense public debate in the mass media. Despite some of the critics' suspicions that the principles prepared the way for liberalization of active euthanasia, euthanasia is unequivocally rejected in the principles. Physician-assisted suicide is considered to violate professional medical rules. In leaving aside some of the (...) notions customarily used in the euthanasia debate, e.g., passive euthanasia, the principles emphasize the obligation of physicians to offer and the right of patients to receive palliative care. The principles explicitly list modalities of basic treatment that are indispensable in all cases, such as the obligation to satisfy hunger and thirst. This statement is meant to resolve the dispute on nutrition and hydration at the end of life, as it shifts the focus of care from maintaining physiological parameters to satisfying subjective needs. For patients in a persistent vegetative state, artificial feeding is held to be obligatory. Yet, the principles make reference to recent German jurisdiction which permit the stopping of artificial feeding if it is in accordance with the patient's presumed will. Additionally, the wording concerning this issue is found to remain unclear. Patients' autonomy is strengthened by explicitly welcoming advance directives as a means to ascertain patients' wills. The principles mark some changes compared to earlier documents. They deserve careful analysis and should be considered in the international debate on issues concerning the end of life. (shrink)

It is interesting, that with the notable exception of the Cologne-based geneticist Benno Müller-Hill, German historians of medicine have not bothered a great deal with looking into German medical history during the Third Reich. We owe Pennsylvania State University's Robert N Proctor a great deal of gratitude for uncovering more and more of this history, and for making it accessible in a highly readable format. Proctor has established himself rapidly as the pre-eminent US American historian of science (...) on all aspects of Nazi medical research and health policy. In this most recent book Proctor looks at Nazism's pioneering contributions in public health research and policy, as well as in environmental health, occupational health, and preventive medicine. This book holds some disturbing lessons for those who hold the view that basically good people will undertake ethical research, and support good health …. (shrink)

BackgroundBioethics can play an important role in addressing diversity both in and outside of academia, setting precedents for meaningful contributions to public discourse, research, teaching, training, and policy development. However, in order to do so, these conversations also need to reflect on the issue of diversity within the field of bioethics across the globe. This study aims to examine current gender representation and diversity at medical ethics and humanities institutes in Germany, the German-speaking areas of Switzerland, and Austria.MethodsA (...) total of forty-nine medical ethics and humanities institutes from Germany (n=42), the German-speaking areas of Switzerland (n=5), and Austria (n=2) were included in the study. Institutes websites were reviewed in the first week of March 2021 and the details of each staff member listed on the website recorded.ResultsOverall, a total of 964 staff members were identified at the forty-nine German-speaking medical ethics and humanities institutes. Just over half (530/964; 55%) of all staff were female. There were significant differences between gender in some staff positions: 64.6 per cent (31/48) of directors were male (χ2(1)=4.1, P=.04); 62.7 per cent (84/134) of student assistants were female (χ2(1)=8.6, P=.003); and 83.7 per cent (77/92) of administrative staff were female (χ2(1)=41.8, P<.001). There were no significant differences between staff gender for researchers and lecturers, or associated researchers. In addition, 65.5 per cent (19/29) of researchers and lecturers who had a professor title were male, but the difference between genders was not found to be significant. However, significantly more of the researchers and lecturers who had completed a habilitation were male (75.8% (25/33); χ2(1)=8.8, P=.003). When comparing the institute director’s gender presentation with staff gender presentation, it was found that male-led institutes had 53.4 per cent (286/536) female staff overall but had 52.7 per cent (136/258) male researchers and lecturers. However, the difference between genders were not found to be significant. On the other hand, female-led institutes had significantly more female staff overall (59.9% (223/372); χ2(1)=14.7, P<.001) and also significantly more female researchers and lecturers (58.9% (119/202; χ2(1)=6.4, P=.01).ConclusionsThere has been a significant push to address gender diversity in German-speaking academia, and this study finds overall good gender parity in medical ethics and humanities institutes. However, there has not been a similar openness to discussing issues of systemic racism or how other forms of inequality affect academic diversity. Taking diversity seriously requires opening up conversations around intersectionality, including difficult conversations around race and cultural background that have long been taboo in German-speaking countries. (shrink)

The current practice of late termination of pregnancy in Germany has been criticized by the German Medical Association as well as several sociopolitical groups. The controversy has especially concerned the time limit for the termination of pregnancies and the counseling process prior to that intervention. The criticism, in part, originates from the reform of the German Abortion Law in 1995, and demands for change led to legislative initiatives in 2008.

Background: Due to recent legislations on euthanasia and its current practice in the Netherlands and Belgium, issues of end-of-life medicine have become very vital in many European countries. In 2002, the Ethics Working Group of the German Association for Palliative Medicine (DGP) has conducted a survey among its physician members in order to evaluate their attitudes towards different end-of-life medical practices, such as euthanasia (EUT), physician-assisted suicide (PAS), and terminal sedation (TS). Methods: An anonymous questionnaire was sent (...) to the 411 DGP physicians, consisting of 14 multiple choice questions on positions that might be adopted in different hypothetical scenarios on situations of “intolerable suffering” in end-of-life care. For the sake of clarification, several definitions and legal judgements of different terms used in the German debate on premature termination of life were included. For statistical analysis t-tests and Pearson-correlations were used. Results: The response rate was 61% (n=251). The proportions of the respondents who were opposed to legalizing different forms of premature termination of life were: 90% opposed to EUT, 75% to PAS, 94% to PAS for psychiatric patients. Terminal sedation was accepted by 94% of the members. The main decisional bases drawn on for the answers were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of the national legal frame. Conclusions: In sharp contrast to similar surveys conducted in other countries, only a minority of 9.6% of the DGP physicians supported the legalization of EUT. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role for the respondents’ negative attitude towards EUT. Palliative care needs to be stronger established and promoted within the German health care system in order to improve the quality of end-of-life situations which subsequently is expected to lead to decreasing requests for EUT by terminally ill patients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Medical Ethics in a Time of De-CommunizationRobert Baker (bio)Ethics is often treated as a matter of ethereal principles abstracted from the particulars of time and place. A natural correlate of this approach is the attempt to measure actual codes of ethics in terms of basic principles. Such an exercise can be illuminating, but it can also obscure the circumstances that make a particular codification of morality a meaningful (...) response to specific historic circumstances. This is particularly true of the codes of medical ethics beginning to emerge from the post-Communist societies of Eastern Europe, which are, perhaps, best understood as artifacts of an era, rather than as expressions of abstract principles.The era in question is post-Communist. It is an era informed by a reaction to decades of Communism, which, of course, was more than an economic system or even an ideology; it was a form of life that permeated every aspect of civil society—advertising, art, literature, music. Medicine was not exempt. I recall entering an oncology ward in East Berlin and finding the patients seated around a large table making posters. Wondering whether this was a form of art therapy, I asked the head nurse what the patients were doing. She replied: it is "Party time—the portion of each week every citizen donates to the people and the Party." I looked again at the posters and saw that they honored Karl Marx on the 100th anniversary of his death: "1883-1983, The Struggle Goes On." The Party, the struggle, the people, were everywhere, and they penetrated and informed daily life even for terminal patients on a cancer ward.The interweaving of Communist practices into the warp and woof of daily life has profound implications for the post-Communist era. It means that East Europeans cannot simply rebuild; they must unweave Communist thought patterns—what might be called the ideostructure of Communism—from the fabric of their lives through a deliberate process of deCommunization. What remains after de-Communization depends upon [End Page 363] the historical relationship each country had with Communism. In Russia, removing Communist ideostructure sets the conceptual calendar back to 1918. For the Czechs, the calendar advances to the 1930s, leaving them with thought patterns that are Western, industrial, and democratic. In the rest of Eastern Europe the conceptual clock also tends to turn back to the 1930s, but at that time the conceptual frameworks were nationalist, anti-Western, and frequently fascist, or even Nazi.In Poland the situation is different. World War II opened with the Nazi invasion of the country—which Hitler (later joined by Stalin) subsequently occupied. After the war, the Soviet army controlled the country, which became a captive player in the Soviet sphere of influence (aptly denominated, "the Warsaw Pact"). Poland's pre-Communist thought patterns are nationalist, West-leaning, accepting of parliamentary structures, but also of authoritarian government. They are also Catholic.Catholicism to Poles is not merely a religion, it is a posture of opposition to their German (Nazi, antichristian) and Russian (Orthodox or atheist) occupiers. I toured Polish hospitals several times during the Communist period —always accompanied by one or more "tour guides." (Westerners were not allowed to roam Communist countries unescorted.) Almost all of my guides wore little pins adorned with the face of Lenin (not the hammer and sickle—a symbol of Soviet occupation). Most doctors and nurses, however, adorned themselves with Catholic icons—typically a crucifix. Their conspicuously displayed crosses symbolized less their embrace of Catholicism than their rejection of Communism. Catholicism, in the Polish context, was thus an affirmation of individual and national independence.De-Communizing Polish Medical Ethics: The Abortion ControversyIn Poland, de-Communization was initiated through a series of negotiations between Lech Walensa's Solidarity and the Communist Government. The Polish Code of Medical Ethics is an indirect consequence of these negotiations, which stipulated the dissolution of Communist medical organizations. They were to be replaced by a Polish Medical Chamber—a type of quasi-governmental body, common in Eastern Europe, which combines the functions of a governmental licensing agency with those of a national medical association. Medical chambers also set standards of professional conduct and (unlike... (shrink)

In May 1912, reports on successful attempts at artificial insemination hit the German papers. Over the following months, the topic was taken up in medical lectures, in the debates of medical associations, and in medical journals. The technique—which had not much changed since the days of James Marion Sims—apparently triggered the imagination of scientists, medical doctors, journalists and authors. That artificial insemination met such interest, however, was not primarily due to its medical usefulness or (...) proven success. Given that insemination with donor sperm was out of the question for most doctors and that ideas about the fertile period within the menstrual cycle were erroneous, contemporary attempts at insemination in humans hardly ever worked. Public interest in this topic rather reflects the desires and expectations which contemporaries associated with artificial insemination and with modern, scientific medicine. What appears to be a comparatively straight forward, low-tech operation today was imagined as a way or creating life artificially. Thus the topic was able to mobilise fears and expectations. The debate not only reflected contemporary beliefs about the possibilities and dangers of modern medicine, it also addressed the meaning of reproduction and infertility and the future of gender relations. (shrink)

The guidelines of the >German Medical Association< for doctors treating the dying passed on 11. Sept. 1998 are trying to provide an ethically justified frame for medical decisions conceming the end of life. In certain justified cases they allow non-treatment decisions and allevation of pain and symptoms that might cause the patient's death while they strictly reject voluntary active euthanasia, non-voluntary euthanasia or assisted suicide.

During the Nazi era, most German physicians abrogated their responsibilities to individual patients, and instead chose to advocate the interests of an evil regime. In so doing, several fundamental bioethical principles were violated. Despite gross violations of individual rights, many physicians went on to have successful careers, and in many cases were honored. This paper will review the case of Hans Sewering, a participant in the Nazi euthanasia program who became the President-elect of the World Medical Association. (...) The appropriate stance for the medical and scientific community toward those who violate human rights and ignore fundamental ethical principles of the healing professions will be considered. (shrink)

An engaging, compelling and disturbing confrontation with evil...a book that will be transformative in its call for individual and collective moral responsibility." - Michael A. Grodin, M.D., Professor and Director, Project on Medicine and the Holocaust, Elie Wiesel Center for Judaic Studies, Boston University Human Subjects Research after the Holocaust challenges you to confront the misguided medical ethics of the Third Reich personally, and to apply the lessons learned to contemporary human subjects research. While it is comforting to believe (...) that Nazi physicians, nurses, and bioscientists were either incompetent, mad, or few in number, they were, in fact, the best in the world at the time, and the vast majority participated in the government program of "applied biology." They were not coerced to behave as they did-they enthusiastically exploited widely accepted eugenic theories to design horrendous medical experiments, gas chambers and euthanasia programs, which ultimately led to mass murder in the concentration camps. Americans provided financial support for their research, modeled their medical education and research after the Germans, and continued to perform unethical human subjects research even after the Nuremberg Doctors' Trial. The German Medical Association apologized in 2012 for the behavior of its physicians during the Third Reich. By examining the medical crimes of human subjects researchers during the Third Reich, you will naturally examine your own behavior and that of your colleagues, and perhaps ask yourself "If the best physicians and bioscientists of the early 20th century could do evil while believing they were doing good, can I be certain that I will never do the same?" · Presents relatively unknown aspects of human subjects research during the Third Reich · Reveals surprising relationships between German and American human subjects research · Dispels myths about Nazi human subjects research · Compels introspection and self-examination by today's medical and research practitioners · Addresses contemporary bioethical issues affecting vulnerable populations · Brings together experts in the history of medicine during the Third Reich and thoughtful new voices. (shrink)

The nursing profession in Germany is facing a public debate on legal and ethical questions concerning euthanasia on request and physician-assisted suicide. However, it seems questionable if the profession itself, individual nurses or the professional associations are prepared to be involved in such a public debate. To understand this hesitation, the present situation is considered in the light of the tradition and history of professional care in Germany. Obedience to medical as well as to religious authorities was long part (...) of nurses' professional identity, but is no longer relevant. The lack of reflection and discussion on how to take a balanced view of ethical and political questions concerning nursing, and the role and responsibility of nurses in end-of-life decisions and situations of caring for dying people are discussed using the situation of nurses in the Netherlands as a comparison. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

Background: The Self-Regulation of Eating Behavior Questionnaire is an economical way of assessing an individual's self-regulatory abilities regarding eating behavior. Such scales are needed in the German population; therefore, the purpose of the present study was the translation and validation of a German version of the SREBQ.Method: First, we conducted a pilot study after the translation procedure. Second, we assessed the final scale in a representative sample of the German population and its underlying factor structure. Further, we (...) tested for measurement invariance and evaluated the SREBQ's associations with related scales to explore convergent and discriminant validity. Finally, we considered differences in SREBQ based on sociodemographic variables and provided derived reference scores.Results: Factor analysis revealed deficiencies in the original model. Thus, we shortened the scale based on statistical considerations and the adapted version showed improved fit in Confirmatory Factor Analysis and reliability. We also found evidence for partial strict invariance, which means the measure is equivalent for the tested groups of age and gender. Item and scale psychometric properties of the shortened version were satisfactory. In terms of diagnostic validity, it was shown that individuals with higher body mass index have worse self-regulation of eating behavior than those with lower.Conclusion: In sum, the SREBQ evidenced good validity and reliability and is suitable for application in medical, psychological, and nutritional research. (shrink)

The Council on Ethical and Judicial Affairs of the American Medical Association examines physicians’ professional ethical responsibility in the event that the security of patients’ electronic records is breached.

Germany has just started a public debate on priority-setting, rationing and cost-effectiveness due to the cost explosion within the German health care system. To date, the costs for German health care run at 11,6 % of its Gross Domestic Product (GDP, 278,3 billion €) that represents a significant increase from the 5,9 % levels present in 1970. In response, the German Parliament has enacted several major and minor legal reforms over the last three decades for the sake (...) of cost containment and maintaining stability of the health care system. The Statutory Health Insurance—SHI (Gesetzliche Krankenversicherung—GKV) is based on the fundamental principle of solidarity and provides an ethical and legal framework for implementing equity, comprehensiveness and setting the principles and rules for financing and providing health care services and benefits. Within the SHI system, several major actors can be identified: the Federal Ministry of Health, the 16 state ministries of health, the Federal Joint Committee (G-BA), the physicians (with their associations) and the hospitals (with their organizations) on the provider side, and the sickness funds with their associations on the purchasers’ side. This article reviews the structure and complexities of the German health care system with its major players and participants. The focus will be put on relevant ethical, legal and economic aspects for prioritization, rationalization, rationing and cost-effectiveness of medical benefits and services. In conclusion, this article pleads for open discussion on the challenging subject of priority-setting instead of accepting the implicit and non-transparent rationing of medical services that currently occurs at many different levels within the health care system, as it stands today. (shrink)

Objectives To determine the frequencies and types of limitation of medical treatment performed by physician members of the German Society for Palliative Medicine and to analyse the findings with respect to clinical and ethical aspects of end-of-life practices. Design Cross-sectional postal survey. Setting Data collection via the secretary of the German Society for Palliative Medicine using the German language version of the EURELD survey instrument. Subjects All 1645 physician members of the German Society for Palliative (...) Medicine. Main outcome measures Types and frequencies of limitation of treatment and possible determinants. Results 901 physicians participated in the study (response rate 55.8%). Participants reported limitation of treatment in 69.1% of cases. These decisions most often affected artificial nutrition (19%), chemotherapy (14%), antibiotics (11%) and medication other than antibiotics (11%). In the majority of eligible cases, physicians estimated the life-shortening effect of limitation of treatment to be <7 days. However, estimations differ depending on the medical measures in question. Bivariate statistical analysis indicated that withholding of treatment was performed significantly more frequently for patients aged ≥65 years (p=0.019). In addition, there were significant associations between the incidence of limitation of treatment and the different diseases reported by respondents as the underlying cause of death. Conclusion The findings of this study provide information on the current state of an ethically and clinically challenging aspect of clinical practice and can serve as a starting point for further interdisciplinary research on normative and empirical aspects of treatment decision-making at the end of life. (shrink)

BackgroundThe EU’s 2006 Paediatric Regulation aims to support authorisation of medicine for children, thus effectively increasing paediatric research. It is ethically imperative to simultaneously establish procedures that protect children’s rights.MethodThis study endeavours (a) to evaluate whether a template consent form designed by the Standing Working Group of the German-Research-Ethics-Committees (AKEK) adequately informs adolescents about research participation, and (b) to investigate associated phenomena like therapeutic misconception and motives for research participation. In March 2016 a questionnaire study was conducted among 279 (...) pupils (mean age 13.1 years) of a secondary school in northern Germany.ResultsA majority of participants showed a general good understanding of foundational research ethics concepts as understood from the AKEK consent form. Nevertheless, our data also suggests possible susceptibility to therapeutic misconception. Own health concerns and pro-social considerations were found to be significant motivational factors for participating in research, while anticipation of pain lessens likelihood of participation. Advice from trusted others is an important decisional influence, too. Furthermore, data security was found to be a relevant aspect of adolescents’ decision-making process.ConclusionBearing in mind adolescents’ generally good understanding, we infer the lack of knowledge about medical research in general to be one source of therapeutic misconception. To further improve the quality of consent we propose a multi-staged approach whereby general research education is completed before an individual becomes a patient or potential participant. To the best of our knowledge this is the first German questionnaire-study addressing issues of informed consent in a large under-age sample. (shrink)

A sudden paradigm shift has resulted in governmental measures that greatly impact the scope in which the ethics committees in Germany can perform their task of providing expert opinions for clinical research. The so-called “revaluation” of the Medical Device Law Deutsches Medizinproduktegesetz—MPG) is, in our opinion, not based on sound political and professional judgment. In accordance with the changed regulations, ethics committees are now seen as being sub-organs of the state medical associations or the medical faculties and (...) are therefore official authorities. It follows that the votes of ethics committees are then “sovereign acts” or authoritative measures! However, equality and justice speak against this misleading conclusion and its resulting consequence that an ethics committee’s vote is a sovereign act. This has, in turn, resulted in the public ethics committees obtaining their long-sought goal of having a state-sanctioned monopoly. The private ethics committees are not recognized as being authoritative bodies, nor are they to be seen as such in the future (i.e. such a status has been denied the Freiburg Ethics Commission International (FEKI) in Baden-Württemberg). This political mistake must be corrected, otherwise, conducting clinical research will become increasingly difficult. (shrink)

Objective: The establishment of patient-centered measures capable of empirically determining meaningful cognitive change after surgery can significantly improve the medical care of epilepsy patients. Thus, this study aimed to develop reliable change indices (RCIs) and standardized regression-based (SRB) change norms for a comprehensive neuropsychological test battery in the German language. Methods: Forty-seven consecutive patients with temporal lobe epilepsy underwent neuropsychological assessments, both before and 12 months after surgery. Practice-effect-adjusted RCIs and SRB change norms for each test score were (...) computed. To assess their usefulness, the presented methods were applied to a clinical sample, and binary logistic regression analyses were conducted to model the odds of achieving improvement in quality of life (QOL) after surgery. Results: The determined RCIs at 90% confidence intervals, and the SRB equations for each test score included in the test battery are provided. Cohen’s kappa analyses revealed a moderate mean agreement between the two measures, varying from slight to almost perfect agreement across test scores. Using these measures, a negative association between improvement in QOL and decline in verbal memory functions after surgery was detected. Significance: To the best of our knowledge, this study is the first to provide RCIs and SRB change norms necessary for the objective determination of neuropsychological change in a comprehensive test battery in the German language, facilitating the individual monitoring of improvement and decline in each patients’ cognitive functioning and psychosocial situations after epilepsy surgery. The application of the described measures revealed a strong negative association between improvement in QOL and decline in verbal memory functions after surgery. (shrink)

BackgroundThe EU’s 2006 Paediatric Regulation aims to support authorisation of medicine for children, thus effectively increasing paediatric research. It is ethically imperative to simultaneously establish procedures that protect children’s rights.MethodThis study endeavours (a) to evaluate whether a template consent form designed by the Standing Working Group of the German-Research-Ethics-Committees (AKEK) adequately informs adolescents about research participation, and (b) to investigate associated phenomena like therapeutic misconception and motives for research participation. In March 2016 a questionnaire study was conducted among 279 (...) pupils (mean age 13.1 years) of a secondary school in northern Germany.ResultsA majority of participants showed a general good understanding of foundational research ethics concepts as understood from the AKEK consent form. Nevertheless, our data also suggests possible susceptibility to therapeutic misconception. Own health concerns and pro-social considerations were found to be significant motivational factors for participating in research, while anticipation of pain lessens likelihood of participation. Advice from trusted others is an important decisional influence, too. Furthermore, data security was found to be a relevant aspect of adolescents’ decision-making process.ConclusionBearing in mind adolescents’ generally good understanding, we infer the lack of knowledge about medical research in general to be one source of therapeutic misconception. To further improve the quality of consent we propose a multi-staged approach whereby general research education is completed before an individual becomes a patient or potential participant. To the best of our knowledge this is the first German questionnaire-study addressing issues of informed consent in a large under-age sample. (shrink)

This code of practice for health professionals was prepared by a multi-professional group and reflects good clinical practice in encouraging dialogue about individuals' wishes concerning their future treatment. It has a broad practical approach, considers a range of advance statements, advises of dangers and benefits of making treatment decisions in advance and combines annotated code of practice with a quick pull out guide for easy reference.

1. Aim of the guidelines2. Principles of good practice3. Circumcision for medical purposes4. Non-therapeutic circumcision 4.1. The law 4.1.1. Summary: the law 4.2. Consent and refusal 4.2.1. Children’s own consent 4.2.2. Parents’ consent 4.2.3. Summary: consent and refusal 4.3. Best interests 4.3.1. Summary: best interests 4.4. Health issues 4.5. Standards 4.6. Facilities 4.7. Charging patients 4.8. Conscientious objection5. Useful addresses.

Governments are increasingly inviting patient organizations to participate in healthcare policymaking. By inviting POs that claim to represent patients, representation comes into being. However, little is known about the circumstances under which governments accept POs as patient representatives. Based on the analysis of relevant legislation, this article investigates the criteria that self-help organizations, a special type of PO, must fulfil in order to be accepted as patient representatives by governments in Austria and Germany. Thereby, it aims to contribute to the (...) discussion on the role of governments in steering SHOs. There are different degrees of regulation. Governments in both countries not only formulate explicit criteria for SHOs with respect to patient representation but also guide SHOs representing patients through implicit criteria for associations. We discuss the findings against concepts of responsiveness, authorization, and accountability. Our findings indicate that governmental steering is not negative per se as indicated by previous research but—depending on legislative criteria—can promote transparency and democratic quality in patient representation. (shrink)

With historical hindsight, it can be little questioned that the view of protozoa as unicellular organisms was important for the development of the discipline of protozoology. In the early years of this century, the assumption of unicellularity provided a sound justification for the study of protists: it linked them to the metazoa and supported the claim that the study of these “simple” unicellular organisms could shed light on the organization of the metazoan cell. This prospect was significant, given the state (...) of cytology circa 1910. In the wake of the major gains made in understanding nuclear division in the last two decades of the nineteenth century, cytology was suddenly confronted with many, seemingly less penetrable, problems. Several aspects of nuclear organization still remained unexplained, and recent research had revealed the presence in the cytoplasm of structures whose functions in cell life were unknown. Classical methods of cytology, relying on descriptive, morphological analysis, seemed ill equipped to resolve these questions.Hertwig's program for protozoology, grounded in the assumption of the fundamental unity of organization in protozoa and metazoa, offered a potential means for investigating these and other problems of cell theory. Linked to mainstream cytology, protozoology was advocated as a means of experimentally investigating key biolobical processes — reproduction, metabolism, and organelle morphology and physiology — less accessible in higher organisms. Protozoa were hailed as prime experimental organisms, in which cell structure and function could be more easily studied. Unlike the metazoan cell, they could be subjected to controlled experiments in which the external environment was modified and the effects monitored. Protozoa offered, in other words, a promising experimental means by which to investigate the cell — its structures and its processes.The success of this program within Germany was soon apparent. In contrast to the rather neglected state of the discipline in 1900, protozoology began to be recognized as more than a somewhat obscure area of study for specialists. In practical terms, this translated into greater numbers of students attracted to the field, increased institutional support for the discipline, and its elevation in status within the biological sciences as new developments, particularly in connection with medical applications, began to draw attention to the field.64The unicellular hypothesis also promoted the internal development of the science. It provided a rationale for introducing the various techniques used in cytology, embryology, physiology, and the new field of biochemistry as suitable research tools for protozoology as well. This vastly extended the research possibilities and facilitated the understanding of, among other things, protozoan organization, modes of reproduction, and evolutionary relationships. The new experimental grounding of the discipline in turn fitted in well with developments in biology at large: in contrast to the descriptive methodology that had predominated in the nineteenth century, this new experimental program placed protozoology at the forefront of the early twentieth-century movement to make biology an experimental science comparable to physics and chemistry.Yet the criticism of the unicellular hypothesis can also be seen as having served a valuable function within the development of the discipline. It focused attention on the study of protists as organisms in their own right, not simply as models for metazoan cells. More generally, it helped to remind biologists of the particular evolutionary assumptions that supported this conception. Dobell and other British critics pointed out, among other things, the association between the theory of recapitulation and the interpretation of protozoa as unicellular organisms. At the time when the recapitulation theory and the germ-layer doctrine were in decline, it was important to stress how these evolutionary ideas also entered into the contemporary concepts of subsidiary specialties. This was as true for protozoology as it was for cell theory itself. The chromidial theory, in its various guises, and the binuclearity hypothesis did in fact contain elements of recapitulationist reasoning, and they were open to criticism for the same kind of overly speculative theorizing that characterized this evolution theory. Dobell's critique forced protozoologists and cell theorists alike to review the theoretical postulates guiding their investigations.In the absence of further historical studies, it is hard to evaluate the consequences of this debate in later years. The issue was not whether protozoa were the precursors of metazoa — both sides accepted this. They disagreed over which particular protozoon had served as the ancestral form, and this, in turn, influenced their stance on the question of unicellularity. The situation is little changed today. Because the former question is still an open one, the latter remains so too. Both of the models for the origin of multicellular organisms — colonies of ciliates versus multinucleate protists — are still presented as possible mechanisms in modern textbooks of evolution. Unable to judge the dispute in terms of the ultimate validity of the competing conceptions, the historian requires other criteria. It perhaps becomes more important to evaluate the issues in the context of the internal and external stimulus they provided the discipline.65 In these terms, and from the present historical vantage point, Hertwig's research program for protozoology, based upon the unicellular hypothesis, appears to have been a successful one. (shrink)

The current article deals with the ethics and practice of physician-assisted suicide (PAS) and dying. The debate about PAS must take the important legal and ethical context of medical acts at the end of life into consideration, and cannot be examined independently from physicians’ duties with respect to care for the terminally ill and dying. The discussion in Germany about active euthanasia, limiting medical intervention at the end of life, patient autonomy, advanced directives, and PAS is not fundamentally (...) different in content and arguments from discussions led in other European countries and the United States. This must be emphasized, since it is occasionally claimed that in Germany a thorough discussion could not be held with the same openness as in other countries due to Germany’s recent history. Still, it is worthwhile to portray the debate, which has been held intensively both among experts and the German public, from the German perspective. In general, it can be stated that in Germany debates about questions of medical ethics and bioethics are taking place with relatively large participation of an interested public, as shown, for instance, by the intense recent discussions about the legalisation of advanced directives on June 18 2009, the generation and use of embryonic stem cells in research or the highly difficult challenges for the prioritizing and rationing of scarce resources within the German health care system. Hence, the current article provides some insights into central medical and legal documents and the controversial public debate on the regulation of end-of-life medical care. In conclusion, euthanasia and PAS as practices of direct medical killing or medically assisted killing of vulnerable persons as “due care” is to be strictly rejected. Instead, we propose a more holistically-oriented palliative concept of a compassionate and virtuous doctor-cared dying that is embedded in an ethics of care. (shrink)

As long-term childhood cancer survivors are at risk for late effects, ongoing medical care is crucial to detect and treat physical illnesses as early as possible. However, previous research from around the world has shown that many adult survivors did not participate in long-term medical follow-up. This study aimed to provide insight into German survivors’ care situation, with a particular focus on barriers to follow-up care. We investigated a sample of adult CCS drawn from the German (...) Childhood Cancer Registry’s oldest cohort. Our analyses included data from a standardized medical examination, a self-report questionnaire, and in-depth interviews with a subsample. Half of the participants reported participating in some kind of medical follow-up. In a logistic regression analysis, attendance of medical follow-up care was associated with higher age. Reasons for non-attendance were assigned to four categories: lack of information about medical follow-up and/or its purpose, termination by the health care provider, structural barriers, and emotional-motivational aspects. The interviews contributed to a better understanding of how these reported barriers played out in the care of individual survivors. Further, they revealed that some survivors currently in medical follow-up had had periods without follow-up care in the past—which were also in many cases related to a lack of information, both on the part of health care providers and CCS themselves. The results indicated that a large proportion of long-term CCS do not receive the recommended follow-up care. Further, there is a great need for more information regarding the aims of long-term medical follow-up and available offers. This is an important prerequisite for CCS to make informed decisions. (shrink)

*The views expressed are the author's own. This article should not be construed as representing policies of the American Medical Association.

Governments are increasingly inviting patient organizations to participate in healthcare policymaking. By inviting POs that claim to represent patients, representation comes into being. However, little is known about the circumstances under which governments accept POs as patient representatives. Based on the analysis of relevant legislation, this article investigates the criteria that self-help organizations, a special type of PO, must fulfil in order to be accepted as patient representatives by governments in Austria and Germany. Thereby, it aims to contribute to the (...) discussion on the role of governments in steering SHOs. There are different degrees of regulation. Governments in both countries not only formulate explicit criteria for SHOs with respect to patient representation but also guide SHOs representing patients through implicit criteria for associations. We discuss the findings against concepts of responsiveness, authorization, and accountability. Our findings indicate that governmental steering is not negative per se as indicated by previous research but—depending on legislative criteria—can promote transparency and democratic quality in patient representation. (shrink)

*Disclaimer: The views expressed are the author's and should not be ascribed to the American Medical Association.

On 9 August 1994 the German legislature revised the German Drug Law (AMG). Included in the revision is a passage requiring, for the first time, that the sponsors and investigators of clinical studies involving human subjects first obtain the approval of an ethics committee before carrying out such studies. According to the legislation, which takes effect on 17 August 1995, approval is to come from 'an independent ethics committee, set up and administered according to state law [emphasis added]' (...) (1). Although it is clear according to the text that the 16 federal states have been empowered to establish ethics committees within their jurisdictions, this does not mean that the state governments are free to transfer exclusive authority in the matter to their respective medical associations, a step that would effectively abolish Germany's private ethics committees. First, the legislation does not rule out the authorization of private ethics committees. Second, as legal scholars attest, the exclusive control of ethics committees by the medical associations would constitute an illegal monopoly. Third, it is arguable that medical-association ethics committees fail to meet the one prior federal requirement, that of independence. There is a great deal of confusion in Germany today about which kinds of ethics committees (public and/or private) the states will sanction before 17 August 1995. In an attempt to sort things out we present a brief explanation of how ther came to be two kinds of ethics committees in Germany, review the legal battle between the two over the issue of authorization, point out how the German legislature, in passing the recent bill, has missed an opportunity to clarify the issue and, finally suggest why the administration of ethics committees by the medical associations may be incompatible with the requirement that ethics committees be independent. (shrink)

These essays, first presented at a conference, “Coping with Sickness,” held in Italy in 1997, address ethical and regulatory medical issues within a historical context. Many of the essays, while addressing interesting topics, combine policy analysis and critical cultural theory. Critical cultural theory can be intellectually engaging at times but is generally irrelevant to public officials concerned with specific policy issues.Coping with Sickness is the third and final volume derived from a series of conferences cosponsored by the European Science (...) Foundation and the Euroconferences Activity of the European Union. The eight essays are organized chronologically and cover a range of disparate topics: medical practitioners and the Spanish Inquisition , the history of autopsy legislation in German since 1800 , the history of “sadism” as a medical term in the nineteenth century , folk medicine in Holland in the late nineteenth century , abortion in Weimar Germany , drug testing in Africa in the early twentieth century , comparative policies toward STDs , and the debate over brain death in Germany . As might be expected in an anthology of this sort, the quality varies considerably. Nonetheless, the subjects addressed in this volume are engaging—much to the credit of the editors.Two pieces in particular represent the range of these collected essays. In “Vacher the Ripper and the Construction of the Nineteenth‐Century Sadist,” Angus McLaren, one of the best historians writing on the history of sexuality today, explores the “discovery” of sadism in the late nineteenth century by focusing on the dramatic trial of Joseph Vacher, who was charged in 1895 for the brutal sexual murder of a woman in Champuis. He later confessed to the murder and the sexual violation of another seven females and four males. Vacher had a long history of mental illness; indeed, he had been institutionalized in July 1893 following a failed attempt at suicide that left a bullet lodged in his head. At the trial the criminologist Alexandre Lacassagne was brought in as an expert witness to testify that Vacher was not insane but an antisocial sadist, as revealed by his dabbling in anarchism, vagabondism, and homosexuality. As a consequence, Vacher was found guilty and given a death sentence.McLaren finds in this trial an example of the social construction of a new medical concept, “sadism.” The emergence of the concept of sadism, he argues, reflected a “gendered notion” of defining appropriate male and female behavior; physicians at the turn of the century believed that “civilized men were most threatened, not by excess passion, but by the enervation spawned by urban life” . The concept of sadism was also employed by doctors to enhance their own authority and to alert the public to the dangers of a male manifesting “feminine traits” and to “beat back” homosexuality.There is much interesting conjecture to McLaren's study, but what policy lessons should be drawn from this remains unclear. If every concept is actually a social construction, reflecting the social anxieties of the age, then is the fashionable concept of social construction itself socially constructed to enhance the authority of the medical historian?More interesting methodologically is Claudia Wiesemann's absorbing essay on the historical debate in Germany over “brain death.” Relying on Ulrich Beck's social theory of simple and reflexive modernization, she shows that, when confronted with complex scientific questions, the public has to decide between competing plausible scientific claims; as a result, political groups make use of scientific expertise and counterexpertise to push their favorite practical and legal solutions. (shrink)

After 1945, the German medical community underwent a period of self-examination. The profession’s experience during the Nazi period raised profound questions concerning its ethical integrity and political allegiances. This paper considers the advent of medical nationalism, and shows how, in Berlin and in the Soviet zone of Germany, narratives were constructed to show a new and positive picture of German medicine.

Since its formation in 1947, the World Medical Association (WMA) has been a leading voice in international medical ethics. The WMA’s principal ethics activity over the years has been policy development on a wide variety of issues in medical research, medical practice and health care delivery. With the establishment of a dedicated Ethics Unit in 2003, the WMA’s ethics activities have intensified in the areas of liaison, outreach and product development. Initial priorities for the Ethics (...) Unit have been the review of paragraph 30 of the Declaration of Helsinki, the expansion of the Ethics Unit section of the WMA website and the development of an ethics manual for medical students everywhere. (shrink)

At one time, the American Medical Association had a strong pro-life position regarding unborn human beings. Using an online AMA archives database, this research note contrasts early AMA pro-life commentary with its eventual pro-choice position. Strong pro-life advocacy in the mid-to-late 1800s, led by doctors such as Horatio Storer, gave way in the 1900s to a waning of pro-life zeal, and eventually developed into a pro-choice stance on abortion.

As practicing clinicians, physicians are expected to uphold the ethical norms of their profession, including fidelity to patients and respect for patients’ self-determination. At the same time, as individuals, physicians are moral agents in their own right and, like their patients, are informed by and committed to diverse cultural, religious, and philosophical traditions and beliefs. In some circumstances, the expectation that physicians will put patients’ needs and preferences first may be in tension with the need to sustain the sense of (...) moral integrity and continuity that grounds a physician’s personal and professional life. This article examines the implications for patients, physicians, and the medical profession when tensions arise between a physician’s professional commitments and his or her deeply held personal moral beliefs. It offers guidance on when a physician’s professional commitments should outweigh personal beliefs as well as when physicians should have freedom to act according to the dictates of conscience while still protecting patients’ interests. (shrink)

Background: Only data of published study results are available to the scientific community for further use such as informing future research and synthesis of available evidence. If study results are reported selectively, reporting bias and distortion of summarised estimates of effect or harm of treatments can occur. The publication and citation of results of clinical research conducted in Germany was studied.Methods: The protocols of clinical research projects submitted to the research ethics committee of the University of Freiburg in 2000 were (...) analysed. Published full articles in several databases were searched and investigators contacted. Data on study and publication characteristics were extracted from protocols and corresponding publications.Results: 299 study protocols were included. The most frequent study design was randomised controlled trial , followed by uncontrolled studies , laboratory studies and non-randomised studies . 182 were multicentre studies including 97 international collaborations. 152 of 299 had commercial funding and 46 non-commercial funding. 109 of the 225 completed protocols corresponded to at least one full publication ; the publication rate was 48%. 168 of 210 identified publications were cited in articles indexed in the ISI Web of Science. The median was 11 citations per publication .Conclusions: Results of German clinical research projects conducted are largely underreported. Barriers to successful publication need to be identified and appropriate measures taken. Close monitoring of projects until publication and adequate support provided to investigators may help remedy the prevailing underreporting of research. (shrink)

The aim of this article is to follow Honig's intention of thinking inoperativity as a form of refusal. It demonstrates that Agamben's inoperativity entails an intensification of use that can circumvent the pitfalls associated with the language of 'demands,' or the need to rescue the city as the space of the political par excellence, all while preserving its potential for instituting change. I claim that all destitution entails instituting practices and forms of experimentation that modify the subject, and that, with (...) the help of Agamben, subjects are nothing other than these modifications. The wager of this short intervention, therefore, is that a form of refusal that pays critical attention not only to the suspension but also to the intensification of use that this suspension inherently entails is attainable, all while acknowledging that the city is shaped by anti-blackness. (shrink)

This article studies the unrestraint in beliefs associated with the overemphasizing of our beliefs. The author argues that the intolerance for other points of view appears (among other factors) because of a naively-objectivist understanding of philosophy, one which is based on two assumptions: first, philosophy is considered only as a theory and not an individual practice, not an experience, and second, the truth is considered as identical to a certain ideal-objective content that can be in one’s possession.There are true ideas (...) and proper words. If we learn these ideas, we will definitely seize the truth. The author opposes this understanding the notion of philosophy which is based on the experience of the encounter and upon reflexive comprehension of this experience. It is possible to minimize unrestraint in beliefs if we assume that all the points of view including our own are considered as belonging to the incomprehensible Absolute. (shrink)