In this paper we assume that ‘theory’ is important for Clinical Ethics Support Services (CESS). We will argue that the underlying implicit theory should be reflected. Moreover, we suggest that the theoretical components on which any clinical ethics support (CES) relies should be explicitly articulated in order to enhance the quality of CES.A theoretical framework appropriate for CES will be necessarily complex and should include ethical (both descriptive and normative), metaethical and organizational components. The various forms of CES that exist (...) in North‐America and in Europe show their underlying theory more or less explicitly, with most of them referring to some kind of theoretical components including ‘how‐to’ questions (methodology), organizational issues (implementation), problem analysis (phenomenology or typology of problems), and related ethical issues such as end‐of‐life decisions (major ethical topics).In order to illustrate and explain the theoretical framework that we are suggesting for our own CES project METAP, we will outline this project which has been established in a multi‐centre context in several healthcare institutions. We conceptualize three ‘pillars’ as the major components of our theoretical framework: (1) evidence, (2) competence, and (3) discourse. As a whole, the framework is aimed at developing a foundation of our CES project METAP.We conclude that this specific integration of theoretical components is a promising model for the fruitful further development of CES. (shrink)

The debate and implementation of Clinical Ethics Consultation is still in its beginnings in Europe and the issue of the patient's perspective has been neglected so far, especially at the theoretical and methodological level. At the practical level, recommendations about the involvement of the patient or his/her relatives are missing, reflecting the general lack of quality and practice standards in CEC. Balance of perspectives is a challenge in any interpersonal consultation, which has led to great efforts to develop “technical”approaches, e.g., (...) in psychological counseling or psychotherapeutic treatment. In ethics, unbalance or partiality is a matter of justice and has provoked significant theoretical work, also relevant for practical medical ethics. A lack of balance seems to be particularly serious in those situations, where ethical conflict is triggering a consultation and where the “parties” involved may try to persuade the consultant that their particular opinion is the most convincing; but to our knowledge the connection between patient/relatives involvement and balance has not yet been discussed in the context of CEC. Central questions of access and involvement of the patient and his/her relatives will be analysed and discussed regarding the challenge of balance and the adequate role or attitude of a Clinical Ethics Consultant. It is argued that the Clinical Ethics Consultant should have a methodological awareness regarding the concepts of “neutrality” versus “advocacy” in his/her role and try to achieve a balanced procedure that allows for an optimum of change of perspectives. The argumentation is developed along the narrative of a real case study. Recommendations concerning the involvement of the patient or the relatives are formulated for the practice of CEC. (shrink)

Large‐scale characterization of the human microbiota has largely focused on Western adults, yet these populations may be uncharacteristic because of their diets and lifestyles. In particular, the rise of “Western diseases” may in part stem from reduced exposure to, or even loss of, microbes with which humans have coevolved. Here, we review beneficial microbes associated with pathogen resistance, highlighting the emerging role of complex microbial communities in protecting against disease. We discuss ways in which modern lifestyles and practices may deplete (...) physiologically important microbiota, and explore prospects for reintroducing or encouraging the growth of beneficial microbes to promote the restoration of healthy microbial ecosystems. (shrink)

Initiating clinical ethics support in psychiatry and maintaining its continuity appear to be easy. This is contradicted by the observed delay or lack of CESiP, e.g. ethics consultation. On the basis of a published literature search and the discussion of practical experiences over 2.5 years 10 tasks and relating challenges of initiating and maintaining CESiP are formulated and illustrated by examples. Referral to experiences is grounded on the systematic documentation of ca. 100 CESiP activities. The tasks and challenges illustrate how (...) CESiP was initiated and maintained in child and adolescent, adult and forensic psychiatry. Each example is followed by a “rule of thumb” that was found useful in our centre. Discussion: Suggestions I–III are of organisational nature, IV–X have explicit ethical content concerning the ethos or professionalism of the ethics consultant and CES practice. Their realisation requires a minimum of stability of CESiP and considerable consultancy experience. (shrink)

In this paper we assume that ‘theory’ is important for Clinical Ethics Support Services (CESS). We will argue that the underlying implicit theory should be reflected. Moreover, we suggest that the theoretical components on which any clinical ethics support (CES) relies should be explicitly articulated in order to enhance the quality of CES.A theoretical framework appropriate for CES will be necessarily complex and should include ethical (both descriptive and normative), metaethical and organizational components. The various forms of CES that exist (...) in North-America and in Europe show their underlying theory more or less explicitly, with most of them referring to some kind of theoretical components including ‘how-to’ questions (methodology), organizational issues (implementation), problem analysis (phenomenology or typology of problems), and related ethical issues such as end-of-life decisions (major ethical topics).In order to illustrate and explain the theoretical framework that we are suggesting for our own CES project METAP, we will outline this project which has been established in a multi-centre context in several healthcare institutions. We conceptualize three ‘pillars’ as the major components of our theoretical framework: (1) evidence, (2) competence, and (3) discourse. As a whole, the framework is aimed at developing a foundation of our CES project METAP.We conclude that this specific integration of theoretical components is a promising model for the fruitful further development of CES. (shrink)

Ethische Leitlinien für die klinische Praxis erfreuen sich zunehmender Beliebtheit. Damit klinisch-ethische Leitlinien aber überhaupt erfolgreich wirksam werden können, ist noch Pionierarbeit zu leisten. Solche Leitlinien müssen wissenschaftlich stärker fundiert und ihre praktische Anwendbarkeit muss verbessert werden. In dieser Arbeit werden die ersten Schritte des Projekts METAP zur methodischen Entwicklung und praktischen Implementierung einer Leitlinie für eine patientengerechte Versorgung am Krankenbett beschrieben und zur Diskussion gestellt. Das Projekt orientiert sich methodisch an der Entwicklung medizinischer Leitlinien und generiert damit eine forschungs- (...) und konsensgestützte Leitlinie, die systematischer Evaluation und Modifikation unterliegt und Rechenschaft über ihre wissenschaftliche Fundierung gibt. Zusätzlich zur Leitlinie bietet das Projekt in der Form eines Handbuchs ein Entscheidungsfindungsverfahren an, welches unter anderem deliberative Aspekte unterstützt. Das Handbuch konzentriert sich auf ethische Fragen der Mikroallokation und liefert darüber hinaus Informationen über empirische, ethische und rechtliche Grundlagen für Therapieentscheidungen. Anhand eines Eskalationsmodells können unterschiedliche Instrumente nach Bedarf als ethische Lösungsstrategien eingesetzt werden, von der Kurzfassung im Kitteltaschenformat („Leporello“) mit den wichtigsten Fakten, weiterführenden Texten und Empfehlungen mit normativen und prozeduralen Hinweisen, über stationsinterne Lösungsversuche bis hin zum Ethikkonsil. Klinische Partner sind von Beginn an aktiv in den Entwicklungsprozess eingebunden und verbessern so die Praxistauglichkeit und Akzeptanz sowie die Ausrichtung des Instrumentariums an den tatsächlichen Bedürfnissen. Dieses partnerschaftliche, partizipative Vorgehen scheint eine wichtige Voraussetzung dafür zu sein, dass METAP in der Klinik Fuß fassen konnte. (shrink)

Clinical ethics consultation not only interprets moral issues at the bedside and is not restricted to giving support for the “technical” handling of these moral issues, but it has to substantively address moral values, norms, and conflicts in the process of discussing cases and problems. We call this the normative dimension and use normative in the sense of embracing moral values and convictions of persons and groups, norms, and relevant professional and ethical guidelines as well as legal frameworks. The roles (...) and activities of the consultant as a person and the quality of CEC as a process are discussed in the American Society of Bioethics and Humanities’ Core Competences for Healthcare Ethics Consultation. (shrink)

Despite the increasing interest in clinical ethics, ethics consultation as a professional service is still rare in Europe. In this paper I refer to examples in the United States. In Germany, university hospitals and medical faculties are still hesitant about establishing yet another “committee”. One of the reasons for this hesitation lies in the ignorance that exists here about how to provide medical ethics services; another reason is that medical ethics itself is not yet institutionalised at many German universities. The (...) most important obstacle, however, may be that medical ethics has not yet demonstrated its relevance to the needs of those caring for patients. The Centre for Ethics and Law, Freiburg, has therefore taken a different approach from that offered elsewhere: clinical ethics consultation is offered on demand, the consultation being available to clinician(s) in different forms. This paper describes our experiences with this approach; practical issues are illustrated by a case study. (shrink)

Recently, ethical guidelines for clinical practice have gained increased popularity, but in order to become useful they require more pioneer’s work. Clinical-ethical guidelines need to be based on a scientific foundation and their practicability must be improved. We present and put to discussion the initial steps of the METAP Project about the development and practical implementation of a clinical-ethical guideline dedicated to a fair resource-allocation at the bedside. -/- With its methodological orientation, the project represents a guideline which is based (...) on both research and consensus-building, undergoing systematic evaluation and modification. In addition to the guideline, the project comes with a manual (a tool kit) including a procedural instrument for making decisions supporting deliberative aspects. It focuses on issues of micro-allocation; furthermore, it provides empirical, ethical and legal basics for making fair treatment decisions that should help to prevent overtreatment, undertreatment or discrimination in patient care. We propose an Escalation Model with various instruments serving as problem solving strategies that correspond to the respective needs; these instruments include a pocket-summary (“Leporello”) with the most important facts; further reading material; normative and procedural recommendations; ward-specific strategies, and also the option of clinical ethics consultation. -/- Clinical partners have been actively involved in the developmental process from the beginning and contributed to the practical applicability, acceptance and a valid need-orientation of the whole tool kit. This partnership and the participatory approach seem to have helped METAP to gain a foothold in the clinic. (shrink)

The paper describes how ethics consultation can be valuable to health professionals, patients and their families in understanding and evaluating ethical values and their consequences in a particular situation. Ethics consultation as it is practised at the university hospital of Freiburg is a special professional service offered by members of an academic institution.The practical approach and the goals are illustrated by a case study showing the difficulties of deciding about the limitation of intensive care medicine after heart surgery in the (...) setting of maximum treatment. Here, the ethics consultation was initiated by the relatives of the patient who wanted a decision to withhold further life-sustaining treatment.Following the experiences in Freiburg, it is concluded that clinical ethicists have to cover a variety of relevant fields of knowledge, need special analytical skills, and should have professional competence in counselling, including conflict mediation or crisis intervention. (shrink)

What is the status of empirical contributions to bioethics, especially to clinical bioethics? Where is the empirical approach discussed in bioethics related to the ongoing debate about principlism versus casuistry? Can we consider an integrative model of research in medical ethics and which empirical methodology could then be valuable, the quantitative or the qualitative? These issues will be addressed in the first, theoretical part of the paper. The concept of the “embedded researcher” presented in this article was stimulated by the (...) two questions, (1) how can we safeguard that our research will yield valid and meaningful results to practice? and (2), how can we convince clinical colleagues that medical ethics offers relevant contributions to the analysis and solution of problems? One tentative answer has been our effort to elaborate a coherent methodological research approach in the field of end-of-life issues integrating qualitative and quantitative as well as casuistic methodologies. This development is characterized in the second part describing the ECOPE Study (short title)“Ethical Conditions Of Passive Euthanasia.” The achievements and limitations of the suggested approach of the “embedded researcher” are discussed referring to 3 examples of our joint studies about ethical issues concerning(1) critical decision-making in neonatology(2) limitation of treatment in intensive care(3) problems with doctor-patient conversation at the end of life in oncologyConclusions from our studies are put to discussion in the final part of the paper about how to further develop research in the field of end-of-life care and, maybe,clinical bioethics as a whole. (shrink)

Clinical ethics consultation has developed from local pioneer projects into a field of growing interest among both clinicians and ethicists. What is needed are more systematic studies on the ethical challenges faced in clinical practice and problem solving through ethics consultation from interdisciplinary perspectives. The Thematic Issue covers a range of topics and includes five recent studies from various European countries and the USA, focusing on issues such as the ethical difficulties of end of life decisions, experiences with newly developed (...) or well established ethics consultation services, and the expectations of physicians in various clinical fields who are still unfamiliar with clinical ethics consultation. The papers included illustrate the interface between different socio-cultural contexts and their ways of dealing with clinical ethics consultation. They deepen the dialogue on clinical ethics consultation that has emerged at the European and International level. (shrink)

In this chapter, we explore the question of on what grounds reports of clinical ethics support in general, including especially clinical ethics consultation, can or should be evaluated when using a peer review system. It is our contention that to evaluate clinical ethics consultation within a peer review system aiming at transparency and fairness, a defined and shared criteria of evaluation, i.e. an evaluation standard is required. When evaluating a performed ethics consultation, we can roughly distinguish between an internal standard, (...) which refers to the conceptualization of clinical ethics consultation held by the respective consultant or by the assessed clinical ethics support service themselves, and external standards. Most important is the way how an external standard is being defined: Is it just the standard of another service or colleague? Or is it the result of a larger consensus-building process of a relevant body representing a larger group of colleagues, such as the ASBH? Or does it even rely on the “evidence” of related research? An external standard, however, may rest on criteria that are not – or not fully – accepted by the evaluated CESS or individual ethics consultant. Identifying the internal standard of an observed ethics consultant’s work may also be challenging. From the evaluator’s perspective the responsibility for making an internal standard known and unequivocal lies with the “author” of the material. The potential gap between internal and external standards marks a methodological difficulty that as such has to be addressed within peer review evaluation. (shrink)

In a clinic-wide approach to establish liberal policies, a closed psychiatric ward was planned to be opened. The leaders of the multi-professional team of this ward requested continuous ethics support during the first few months after the transition from their previously closed ward into an open one. During the process of accompanying the team through this ethically sensitive period of institutional change, several variations of ethics consultation were developed: the ‘context-adjusted’ clinical ethics support. Some ethics consultations focused on a retrospective (...) evaluation of a patient case, in other ethics consultations consolidation of a previous case discussion was worked out, and/or reflections on fundamental ethical issues were included. Based on our experiences and the feedback of the team, we consider this context-adjusted clinical ethics support as feasible and effective. (shrink)

Definition of the problem: Doctor-patient-conversation is still a great challenge for doctors and patients despite intense discussion, legal normation, and multiple efforts. It seems to be particularly difficult in cases of telling the truth about diagnosis or prognosis which can be threatening to the patient.Method: It is shown by two case studies that the patient directs a specific need to the doctor which has been neglected in both the ethics discourse and in practical medicine: the need to evaluate the patient's (...) options for action at an argumentative-critical level. Derived from a general theory of language functions a model of doctor-patient-conversation is developed which allows for both ideal case typology as well as for problem analysis. Referring to a Three-Stages-Model of Doctor-Patient-Dialogue, an integrative model “Language and Relationship Between Doctor and Patient” is formulated which permits a better understanding of the processes and difficulties between doctor and patient.Conclusion: The integrative model presented may help to realize a more comprehensive doctor-patient-conversation. It may help as well to decide which of the components of this conversation may be selectively sufficient. Consequences for the conceptualization of the physician's role as well as the scope of the model in practice are discussed. (shrink)

ZusammenfassungDas Verhältnis zwischen Ethikkonsultation und der bspw. in psychiatrischen Arbeitsfeldern und im Palliativbereich etablierten psychologischen Supervision ist bisher wenig untersucht. Dieser Vergleich und die Abgrenzung von Ethikkonsultation stellen eine Forschungslücke dar. Anhand von zwei Fallvignetten aus der Praxis von EK und PS werden unter Kontrastierung mit dem jeweils anderen Ansatz Unterschiede und Gemeinsamkeiten im methodischen und praktischen Vorgehen sowie Kriterien der Unterscheidung analysiert. Als Ergebnis wird eine systematische Gegenüberstellung präsentiert, die folgende Merkmale umfasst: 1. Ziele jedes Ansatzes, 2. Einberufung, 3. (...) Gegenstand, 4. Fokus, 5. Methode/Prozess, 6. Rolle des Beraters, 7. Ergebnisse, 8. Dokumentation, 9. Bearbeiten von Emotionen, 10. Bearbeiten ethischer Fragestellungen. Trotz Überschneidungen der beiden Arbeitsformen erscheinen EK und PS nicht wechselseitig austauschbar; eine Vermischung wird nicht empfohlen. Als Fazit werden Hinweise zur Indikationsstellung von EK oder PS gegeben; dabei spielen auch die Motivation der Teilnehmenden und die zeitnahe Verfügbarkeit der Beratungsangebote eine Rolle. (shrink)

BackgroundThe UN Convention on the Rights of Persons with Disabilities, and the reformed guardianship law in Germany, require that persons with a disability, including people with dementia in Alzheimer’s disease (PwAD), are supported in making self-determined decisions. This support is achieved through communication. While content-related communication is a deficit of PwAD, relational aspects of communication are a resource. Research in supported decision-making (SDM) has investigated the effectiveness of different content-related support strategies for PwAD but has only succeeded in improving understanding, (...) which, although one criterion of capacity to consent, is not sufficient to ensure overall capacity to consent. The aim of the ‘spatial intervention study’ of the DECIDE project is to examine an innovative resource-oriented SDM approach that focuses on relational aspects. We hypothesise that talking to PwAD in their familiar home setting (as opposed to a clinical setting) will reduce the complexity of the decision-making process and enhance overall capacity to consent. MethodsPeople with a suspected or confirmed diagnosis of dementia in Alzheimer’s disease will be recruited from two memory clinics (N = 80). We will use a randomised crossover design to investigate the intervention effect of the decision-making place on capacity to consent. Besides reasoning capacity, which is part of overall capacity to consent and will be the primary outcome, various secondary outcomes (e.g., other aspects of capacity to consent, subjective task complexity, decisional conflict) and suspected moderating or mediating variables (e.g., meaning of home, demographic characteristics) will be assessed.DiscussionThe results of the study will be used to develop a new SDM strategy that is based on relational resources for PwAD. If a change in location achieves the anticipated improvement in capacity to consent, future research should focus on implementing this SDM strategy in a cost-effective manner in clinical practice.Trial registration: DRKS00030799. (shrink)

Culture can be defined as “group typical behaviour patterns shared by members of a community that rely on socially learned and transmitted information”. Once thought to be a distinguishing characteristic of humans relative to other animals it is now generally accepted to exist more widely, with especially abundant evidence in non-human primates, cetaceans, and birds. More recently, cumulative cultural evolution has taken on this distinguishing role. CCE, it is argued, allows humans, uniquely, to ratchet up the complexity or efficiency of (...) cultural traits over time. This “ratchet effect” gives the capacity to accumulate beneficial modifications over time beyond the capacities of a single individual. Mesoudi and Thornton define a core set of criteria for identifying CCE in humans and non-human animals that places emphasis on some performance measure of traits increasing over time. They suggest this emphasis is also pertinent to cultural products in the aesthetic domain, but is this the case? Music, art and dance evolve over time, but can we say they gain beneficial modifications that increase their aesthetic value? Here we bring together perspectives from philosophy, musicology and biology to build a conceptual analysis of this question. We summarise current thinking on cumulative culture and aesthetics across fields to determine how aesthetic culture fits into the concept of CCE. We argue that this concept is problematic to reconcile with dominant views of aesthetics in philosophical analysis and struggles to characterise aesthetic cultures that evolve over time. We suggest that a tension arises from fundamental differences between cultural evolution in aesthetic and technological domains. Furthermore, this tension contributes to current debates between reconstructive and preservative theories of cultural evolution. (shrink)

BackgroundEverybody has the right to decide whether to receive specific medical treatment or not and to provide their free, prior and informed consent to do so. As dementia progresses, people with Alzheimer’s dementia (PwAD) can lose their capacity to provide informed consent to complex medical treatment. When the capacity to consent is lost, the autonomy of the affected person can only be guaranteed when an interpretable and valid advance directive exists. Advance directives are not yet common in Germany, and their (...) validity is often questionable. Once the dementia diagnosis has been made, it is assumed to be too late to write an advance directive. One approach used to support the completion of advance directives is ‘Respecting Choices’®—an internationally recognised, evidence-based model of Advance Care Planning (ACP), which, until now, has not been evaluated for the target group of PwAD. This study’s aims include (a) to investigate the proportion of valid advance directives in a memory clinic population of persons with suspected AD, (b) to determine the predictors of valid advance directives, and (c) to examine whether the offer of ACP can increase the proportion of valid advance directives in PwAD.MethodWe intend to recruit at leastN = 250 participants from two memory clinics in 50 consecutive weeks. Of these, the first 25 weeks constitute the baseline phase (no offer of ACP), the following 25 weeks constitute the intervention phase (offer of ACP). The existence and validity of an advance directive will be assessed twice (before and after the memory clinic appointment). Moreover, potential predictors of valid advance directives are assessed.DiscussionThe results of this study will enhance the development of consent procedures for advance directives of PwAD based on the ACP/Respecting Choices (R) approach. Therefore, this project contributes towards increasing the autonomy and inclusion of PwAD and the widespread acceptance of valid advance directives in PwAD.Trial RegistrationDRKS, DRKS00026691, registered 15th of October 2021,https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00026691. (shrink)

Definition of the problem: Ethics consultation is one of the most important ways in which clinical ethicists can support both health-care providers and patients and their relatives in coping with ethical and existential challenges. The practice of ethics consultation, as performed at the Freiburg University Hospital is described and illustrated by a case report about the problem of treatment termination. The range of subject matters that come up in ethics consultations is analyzed. A research program in clinical ethics is summarized (...) that has been undertaken to pave the way for a specific and interdisciplinary analysis of needs; from there on, the investigation aims at further developing clinical ethics support services. Suggestions for criteria of competence for ethics consultants are formulated on the basis of both the author’s and international work. Finally, the issues of structural conditions for establishing clinical ethics in the German-speaking world are raised and the long-term prospect of ethics consultation as an instrument for learning and teaching ethics in the health-care system is highlighted. (shrink)

In an international survey of rationing we have found that European physicians encounter scarcity-related ethical difficulties, and are dissatified with the resolution of many of these cases. Here we further examine survey results to explore whether ethics support services would be potentially useful in addressing scarcity related ethical dilemmas. Results indicate that while the type of help offered by ethics support services was considered helpful by physicians, they rarely referred difficulties regarding scarcity to ethics consultation. We propose that ethics consultants (...) could assist physicians by making the process less difficult, and by contributing to decisions being more ethically justifiable. Expertise in bringing considerations of justice to bear on real cases could also be useful in recognising an unjust limit, as opposed to a merely frustrating limit. Though these situations are unlikely to be among the most frequently referred to ethics support services, ethics consultants should be prepared to address them. (shrink)

Clinical ethics support services are developing in Europe. They will be most useful if they are designed to match the ethical concerns of clinicians. We conducted a cross-sectional mailed survey on random samples of general physicians in Norway, Switzerland, Italy, and the UK, to assess their access to different types of ethics support services, and to describe what makes them more likely to have used available ethics support. Respondents reported access to formal ethics support services such as clinical ethics committees (...) (23%), consultation in individual cases (17.6%), and individual ethicists (8.8%), but also to other kinds of less formal ethics support (23.6%). Access to formal ethics support services was associated with work in urban hospitals. Informal ethics resources were more evenly distributed. Although most respondents (81%) reported that they would find help useful in facing ethical difficulties, they reported having used the available services infrequently (14%). Physicians with greater confidence in their knowledge of ethics (P = 0.001), or who had had ethics courses in medical school (P = 0.006), were more likely to have used available services. Access to help in facing ethical difficulties among general physicians in the surveyed countries is provided by a mix of official ethics support services and other resources. Developing ethics support services may benefit from integration of informal services. Development of ethics education in medical school curricula could lead to improved physicians sensititity to ethical difficulties and greater use of ethics support services. Such support services may also need to be more proactive in making their help available. (shrink)

ZusammenfassungDie qualitative Interviewstudie analysiert informelle Wissensstrukturen von Pflegenden und Ärzten hinsichtlich der beiden Einflussfaktoren „Alter“ und „Kosten“ auf Therapieentscheide am Lebensende als Grundlage ethischer Meinungsbildung. Als Auswertungsmaterial dienen spontane Aussagen zu „Alter“ und „Kosten“, die nicht im Kontext von Fragestellungen zu Ageism oder Rationierung erhoben wurden. Diese Aussagen wurden einer Inhaltsanalyse unterzogen, und zwar anhand von qualitativen und quantitativen Analyseschritten.Die Studie zeigt, dass der Faktor „Alter“ wesentlich häufiger als Einflussfaktor auf Therapieentscheide am Lebensende genannt wird als der Faktor „Kosten“. Zudem (...) gibt es Hinweise auf mögliche Ungleichbehandlung sowie auf Überversorgung von Patienten am Lebensende. Die Befunde stützen die Annahme, dass Therapieentscheidungen eher auf informellen, nicht-institutionalisierten Prozessen beruhen. Eine stärker explizite Strukturierung des Prozesses zur Therapieentscheidung könnte die Risiken von Ungleichbehandlung und Überversorgung reduzieren und dadurch zu ethisch besser vertretbaren Ergebnisse führen. (shrink)

Ethics consultation is the most engaged aspect of clinical ethics, a field focused on ethical issues, questions, and conflicts arising in the course of patient care and delivery of healthcare services. Despite the skepticism of some academic bioethicists and criticism expressed by social commentators, clinical ethics, which began in North America, has expanded to Europe and many other parts of the world with the proliferation of healthcare institution ethics and ethics consultation support services. Along with the development and implementation of (...) ethics policies and guidelines for patient care through work on hospital ethics committees, clinical ethicists are increasingly involved in the ethics of healthcare organizational structures and processes and the day to day provision of ethics consultative services to health professionals, patients, and families. (shrink)

This book contains the results of two European/American preparatory workshops for the First World Conference on Ethics Codes in Medicine and Biotechnology (October 1997, Freiburg, Germany) supported by the leading national institutions in the field. It aims to stimulate research about codes, the effects of codification and other forms of implementing ethics. It breaks new ground with interdisciplinary and international discourse on the subject, emphasising the need for a complete collection of codes for systematic research and evaluation and filling the (...) gap in literature on the subject to date. (shrink)

Die qualitative Interviewstudie analysiert informelle Wissensstrukturen von Pflegenden und Ärzten hinsichtlich der beiden Einflussfaktoren „Alter“ und „Kosten“ auf Therapieentscheide am Lebensende als Grundlage ethischer Meinungsbildung. Als Auswertungsmaterial dienen spontane Aussagen zu „Alter“ und „Kosten“, die nicht im Kontext von Fragestellungen zu Ageism oder Rationierung erhoben wurden. Diese Aussagen wurden einer Inhaltsanalyse unterzogen, und zwar anhand von qualitativen und quantitativen Analyseschritten.Die Studie zeigt, dass der Faktor „Alter“ wesentlich häufiger als Einflussfaktor auf Therapieentscheide am Lebensende genannt wird als der Faktor „Kosten“. Zudem (...) gibt es Hinweise auf mögliche Ungleichbehandlung sowie auf Überversorgung von Patienten am Lebensende. Die Befunde stützen die Annahme, dass Therapieentscheidungen eher auf informellen, nicht-institutionalisierten Prozessen beruhen. Eine stärker explizite Strukturierung des Prozesses zur Therapieentscheidung könnte die Risiken von Ungleichbehandlung und Überversorgung reduzieren und dadurch zu ethisch besser vertretbaren Ergebnisse führen. (shrink)

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context (...) in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of “alibi ethics”. CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs. (shrink)

Questions concerning the parent/ patient’s autonomy are seen as one of the most important reasons for requesting Ethics Consultations. Respecting parent/ patient’s autonomy also means respecting the patient’s wishes. But those wishes may be controversial and sometimes even go beyond legal requirements. The objective of this case series of 32 ECs was to illustrate ethically challenging parent / patients’ wishes during the first stages of life and how the principle of patient’s autonomy was handled. The case series has a qualitative (...) retrospective approach. A documentary sheet was designed de novo and information was gained from EC minutes and medical charts. The cases originate from the following specialties: reproductive medicine, obstetrics and neonatology as well as two interdisciplinary cases. Through the structured EC minutes aspects of patient / parents’ wishes could be identified explicitly. Overall the patient / parents’ wishes were not supported in 61% of the cases. Central reasons for rejection of patient / parent wishes were mainly the protection of the best interest of the unborn / new-born child as well as the rejection of clinical approaches that were regarded as being substandard treatment. The study shows that treatment decisions in reproductive medicine, obstetrics and neonatology raise substantial ethical questions leading to the request for ethics consultation. The systematic case series presented here gives insight into the ethical reflection carried out to support the clinicians in their decision-making and counselling. It shows that clinicians, after using ethics consultation, make deliberate decisions that do not “automatically” fulfil the treatment requests of the patients and parents. (shrink)

Therapieentscheidungen lösen in klinischen Teams häufig Unsicherheiten und Konflikte aus, insbesondere wenn es um schwerkranke Patienten geht. Fallen Entscheidungen vornehmlich situationsgeleitet, sind bestimmte Patientengruppen einem Risiko der Unter-, Über- oder Ungleichversorgung ausgesetzt. Der Metap-Leitfaden unterstützt Ärzte, Pfleger und Therapeuten daher in ihrer ethisch reflektierten Entscheidungskompetenz mit verschiedenen Orientierungs- und Entscheidungsinstrumentarien. Diese berücksichtigen eine gerechte Zuteilung der Ressourcen.

Eine patientengerechte Versorgung ist ein hohes Ziel. Unangemessene Behandlung wie Unter- oder Überversorgung zu erkennen und zu vermeiden, stellt Ärztinnen/Ärzte und Pflegende am Krankenbett vor schwierige Entscheidungen. Hier ist die Entwicklung von praxistauglichen Orientierungshilfen angezeigt, die wissenschaftlichen Kriterien genügen und nicht allein auf Konsens beruhen. Die vorliegende Arbeit versucht, zentrale Normen zur Vermeidung von Über- und Unterversorgung zu formulieren und theoretisch zu fundieren. Dafür wird auf Basis einer Interessen-basierten Ethik eine Graduierung der Autonomie vorgenommen, indem zwischen schwacher und starker Autonomie (...) unterschieden wird. (shrink)

Background: Ethics support services are growing in Europe to help doctors in dealing with ethical difficulties. Currently, insufficient attention has been focused on the experiences of doctors who have faced ethical difficulties in these countries to provide an evidence base for the development of these services.Methods: A survey instrument was adapted to explore the types of ethical dilemma faced by European doctors, how they ranked the difficulty of these dilemmas, their satisfaction with the resolution of a recent ethically difficult case (...) and the types of help they would consider useful. The questionnaire was translated and given to general internists in Norway, Switzerland, Italy and the UK.Results: Survey respondents ranged in age from 28 to 82 years, and averaged 25 years in practice. Only a minority reported having access to ethics consultation in individual cases. The ethical difficulties most often reported as being encountered were uncertain or impaired decision-making capacity , disagreement among caregivers and limitation of treatment at the end of life . The frequency of most ethical difficulties varied among countries, as did the type of issue considered most difficult. The types of help most often identified as potentially useful were professional reassurance about the decision being correct , someone capable of providing specific advice , help in weighing outcomes and clarification of the issues . Few of the types of help expected to be useful varied among countries.Conclusion: Cultural differences may indeed influence how doctors perceive ethical difficulties. The type of help needed, however, did not vary markedly. The general structure of ethics support services would not have to be radically altered to suit cultural variations among the surveyed countries. (shrink)

This paper focuses on the topic of evaluation of clinical ethics consultation. The concept of evaluation seems to contain an internal tension: On the one hand, evaluation is seen as distorting the conceptual and normative content of the case under scrutiny and, on the other, the evaluative act is the most important use of judgment and an inescapable part of everyday life. As such, we maintain that evaluation is essential.

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying process. (...) Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or ethics consultation. (...) In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making. (shrink)