[Ethically responsible care for MDRO carriers]. / Ethisch verantwoorde zorg voor BRMO-dragers.

Dutch healthcare institutions are relatively successful in preventing outbreaks of antibiotic-resistant pathogens, thus protecting vulnerable patients. However, measures taken to prevent the introduction and spread of MDROs can be burdensome for asymptomatic carriers of such bacteria or for people who may have been exposed to them. This leads to ethical dilemmas. On the basis of a study of the impact of being a carrier and precautionary measures on carrier well-being, we present an ethical framework for responsible care for carriers. We argue that solidarity requires that the burden of prevention and control of resistance is to be shouldered by society as a whole. It is not right to see this problem primarily as a conflict between the protection of vulnerable patients on the one hand and carriers on the other.

Are there ethical differences between stopping and not starting blood safety measures?

BACKGROUND AND OBJECTIVES: Concern with the costs of blood safety is growing, which raises the question whether safety measures that reduce risk only marginally should be discontinued. Withdrawing such safety measures would allow reallocating resources to more efficient health care interventions, but it might raise moral objections. MATERIALS AND METHODS: This study evaluates two ethical arguments why discontinuing blood safety measures would be more objectionable than not implementing them. The first argument is that whereas withdrawing protective measures causes harm to patients, not starting protective measures 'merely' omits to prevent harm. The second argument is that patients who benefit from protective measures are historically entitled to the continuation of those protective measures. RESULTS: Both arguments are unconvincing. There is only a weak causal connection between removing blood safety measures and harms that transfusion recipients suffer. Moreover, patients are not entitled to the continuation of protective measures that prove very inefficient, unless applying these protective measures rectifies past injustice towards them. CONCLUSION: Unless stronger ethical objections can be found, blood system operators and regulators should be more willing to withdraw inefficient safety measures.

The ethics of mandatory vaccination against influenza for health care workers.

Vaccination of health care workers (HCW) in long-term care results in indirect protection of patients who are at high-risk for influenza. The voluntary uptake of influenza vaccination among HCW is generally low. We argue that institutions caring for frail elderly have the responsibility to implement voluntary programmes for vaccination against influenza of HCW. When uptake falls short a mandatory programme may be justified. The main justification stems from the duty of care givers not to harm one's patient when one knows there is a significant risk of harm and the intervention to reduce this chance has a favourable balance of benefit over burdens and risks.

[Pneumococcal vaccination; arguments for informing parents about the options available]. / Pneumokokkenvaccinatie; argumenten om ouders te informeren over de mogelijkheden.

Invasive pneumococcal disease in childhood causes meningitis, sepsis and pneumonia. Current pneumococcal vaccines are estimated to prevent 50% of Dutch pneumococcal meningitis and 40% of pneumococcal sepsis. In 2001, the Health Council of The Netherlands emphasised the importance of universal pneumococcal vaccination of small children. However, the Dutch Minister of Health, Welfare and Sports stated that the vaccine is too expensive for the national vaccination programme (NVP). Child health clinics do not educate parents about vaccines that are not available in the NVP, and therefore parents are not informed about the availability of an effective pneumococcal vaccine. We argue that child health clinic physicians should inform parents about the limitations of the NVP in order to put expectations about the programme into perspective. Educating parents that the NVP is very worthwhile but does not include every possible or available vaccine will strengthen confidence in the NVP. Parents who then want to know which effective vaccines are available should be provided with the information they request. In view of the Health Council recommendations, the pneumococcal vaccine should then be specifically mentioned.

Influenza vaccination in Dutch nursing homes: is tacit consent morally justified?

OBJECTIVES: Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study's objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified. DESIGN: A survey among nursing home physicians. SETTING & PARTICIPANTS: We sent a questionnaire to all (356) nursing homes in the Netherlands, to be completed by one of the physicians. RESULTS: We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03). CONCLUSIONS: In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures.

Report on the Dutch consensus development meeting for implementation and further development of population screening for colorectal cancer based on FOBT.

A consensus development meeting was held to evaluate whether or not in the Netherlands all requirements were fulfilled for implementation of population screening with FOBT for colorectal cancer, or whether consensus was present that fulfilment by additional research or organisational actions could be obtained within 2-3 years. There was consensus that all classical Wilson and Jungner (1968) criteria, and six additional ones added more recently, had already been fulfilled or could be fulfilled within 2-3 years. Consequently, it was concluded that a national population screening for colorectal cancer should be implemented and carried out in the Netherlands in line with current national and European cancer screening programmes. A list of organisational actions to be taken was established. Research that is needed before the actual national launch of the screening within 2-3 years has been defined. Priorities have to be set for research and organisational actions for the coming 2-3 years for the implementation of population screening. In addition, research suggestions have been defined for the next 10-15 years for evaluation and/or improvement of implemented FOBT screening, and for future screening methodology. It was considered essential that infrastructure for future research would be embedded in the screening programme. A project group to arrange this should be formed.

Unexpected findings in identifiable stored blood samples after analysis without consent: moral arguments for and against disclosure.

Obtaining informed consent for using blood samples in research is mandatory. However, sometimes no consent is obtained for analysis of identifiable blood samples in a second study. As a result, a moral dilemma raises in case a possibly pathogenic mutation is found. Should the involved person be informed that such a mutation has been detected? We present a case in which this problem occurred and discuss arguments for and against information disclosure.

[Abstention: arguments for stopping or withholding of life-sustaining treatment. Task Force Ethics, Philosophy and History of Medicine, Catholic University]. / Abstineren: argumentatie voor staken of afzien van levensverlengend handelen.

A decision to withhold or withdraw life-sustaining treatment can only be justified if one (or more) of three arguments apply: (a) the patient refuses the treatment concerned, (b) the therapy cannot produce the intended medical effect, or (c) the therapy may be effective, but the effects are not meaningful. Assessment of effectiveness is a medical professional judgement. This assessment should take into account the proportionality of medical (technological) means and ends. Treatment is meaningful if (a) it serves a reasonable purpose for the patient, and (b) the benefits outweigh the burdens for the patient. The patient's own view determines the meaningfulness of treatment. Physicians should talk with patients about the meaningfulness of life-sustaining treatment while there is time, to avoid the situation that such questions come up just when a patient has lost his capacity to communicate. In case a patient is incompetent, physicians should try to infer from previous utterances of the patient what he or she would have wished in this situation. If it is impossible to reconstruct the patient's view, there is no basis for withdrawing or withholding medically effective life-sustaining treatment.

[Kidney donation by a 'non-heart-beating' donor from an ethical perspective]. / Nierdonatie door een 'hartdode donor' ('non-heartbeating donor') in ethisch perspectief.

In asystolic patients, kidney donation is possible by using a non-heart-beating (NHB) donation procedure. This involves in situ perfusion of the kidneys by inserting a catheter into the femoral artery and flushing cold fluid through the kidneys. The introduction of an NHB donation programme leads to ethical questions concerning the guarantees for prudent procedure: How should death of a patient be defined in case of NHB donation? Is there a strict separation of responsibilities of the medical teams in the different phases of the procedure (patient treatment and actual donation procedure)? Are sufficient attention and care given to the relatives? Does the NHB donation procedure not interfere with the care of a patient who is expected to die soon? Extensive discussion with the Medical Ethics Committee of the University Hospital Nijmegen, the Netherlands, has led to a protocol for NHB kidney donation that meets the required guarantees.

[Controversies in hospital guidelines for non-resuscitation decisions]. / Controversen bij ziekenhuisrichtlijnen voor niet-reanimeerbesluiten.

Guidelines regarding non-resuscitation decisions sometimes raise conceptual and ethical questions. Establishing blood circulation and gas exchange is no useful criterium to determine the efficacy of resuscitation. A professional assessment of efficacy or medical futility of resuscitation may involve value judgements. These value judgements should not concern the life of the individual patient, but rather the objective of resuscitation in general. Furthermore, these judgements ought to be grounded on professional consensus. A patient should be informed of a non-resuscitation decision that has been taken, since in the normal course of events resuscitation is the correct treatment. Furthermore, a conversation serves not only to obtain informed consent but also to align the views and expectations of the patient and his treating physician. Suspension of a non-resuscitation policy during operations should be discussed with the patient. A physician is allowed to define the limits to the risks to which he wants to expose the patient.

[Informed consent and mental competence of the elderly in medical-scientific studies]. / Informed consent en beslisvaardigheid van ouderen bij medisch-wetenschappelijk onderzoek.

The decision whether a potential subject is competent or incompetent is a necessary and crucial part of conducting medical research in the elderly. The assessment of competency is required by the legal and ethical frameworks in which this research has to take place. The state of play in the national and international discussions of bills for legislation of this topic will be summarized. Especially the practical consequences of this forthcoming legislation for researchers will be explained. The ethical framework for medical research with elderly subjects will be described from a historical point of view. By means of a review of relevant literature the legal definition of competency will be operationalized and tests for its assessment will be discussed. Competency of consent is assessed by asking several questions about the essential elements of the study. The introduction of a try out of the study for a subject before asking consent ('experienced consent') is propagated as a method to optimize this consent of elderly subjects. Special conditions for giving the required information to elderly subjects, for the informed consent by proxy and for the inclusion of nursing-home residents, are discussed.