Making use of non-invasive prenatal testing (NIPT): rethinking issues of routinization and pressure.

First mapping the main ethical issues surrounding prenatal testing, we then analyze which concerns are specific to non-invasive methods. Presupposing the privatization premise for reproductive autonomy in fundamentally liberal societies, we go on to specify common concerns about non-invasive prenatal testing (NIPT) covered by the term 'routinization', and conceptually unravel the frequently expressed worry of increasing 'pressure' to test and/or terminate affected pregnancies. We argue that mindful decision-making should be a key educational goal (not only) of NIPT counseling which could be achieved through stepwise disclosure. In addition, we identify indirect social pressure as the most plausible threat to reproductive freedom. While continuous efforts need to be made to prevent such pressure - not least by ensuring balanced availability of options -, restricting testing options, and thus freedom of choice, cannot be the answer to this concern. Lastly, we suggest abandoning the vague term 'routinization' and instead focusing on specified concerns to enable a fruitful debate.

[Placebos and placeboids in clinical practice: conceptual and ethical considerations]. / Placebos und Placeboide in der therapeutischen Praxis ­ begriffliche und ethische Überlegungen.

Reflecting on results of recent placebo research, this article analyzes relevant key concepts and ethical positions. "Placeboids" and possibly open-label placebo treatments should replace any deceptive use of sham medication. Their use should give rise to a critical consideration of the modern patient-physician relationship.

[Wife against advance directive: a case-inspired legal and ethical clarification]. / Ehefrau contra Patientenverfügung: eine kasuistisch inspirierte rechtliche und ethische Klärung.

Advance directives and durable powers of attorney are two increasingly used tools for patients' precedent autonomy; however, their combined use, as recommended by major institutions in Germany, might in reality result in various discrepancies between the wording and interpretation of the directive and the surrogate's understanding of the patient's relevant will. In one of the possible conflict constellations, the surrogate wants to overrule a relevant and unambiguous advance directive by reference to a privileged access to the patient's "real" treatment preferences or the presumed will of the patient. Such cases, which must be strictly distinguished from cases with real or alleged leeway for interpretation in the advance directive, can lead to normative uncertainty as well as to substantial psychological distress for all persons involved. Based on an exemplary real clinical case from 2015 (which did not go to court) legal, ethical and pragmatic aspects of the described constellation are discussed. Ethically, caution should be exercised against a relapse into a masked treatment paternalism, which currently seems to be partly caused by judicial exegesis.

Holding donated human bodies in conservation: A novel interactive safe-keeping system meeting high ethical and safety standards.

"Mortui vivos docent". Learning from donated bodies is widely considered a corner stone in pre-clinical education, advanced clinical training, and scientific progress in medicine. Making such use of dead human bodies must, of course, accord with high ethical standards and legal constraints. Piety and respect towards donors require using their remains (i) for valuable purposes, (ii) with what we call 'practical decency', (iii) in an efficient way, and (iv) with the utmost safety for all parties involved. With regard to these goals, practical aspects of preservation, safekeeping procedures (for up to several years), and complete documentation become of great importance, but have so far only been realized unsatisfactorily. Here, we describe the new Safe-Keeping System-Münster (SKS-Münster) that has been developed and implemented in the Anatomy Department of the University of Münster. Integrated components of the system include a paternoster transport system, a removal station with ventilation and an air barrier, RFID transponder technology, and an easy to use software package allowing the system together to provide all required functions in an unprecedented way.

Psychiatrists' views on different types of advance statements in mental health care in Germany.

BACKGROUND: Advance directives enable patients to ensure that treatment decisions will be based on their autonomous will, even if they are incompetent at the time at which the treatment decision is taken. Although psychiatric advance directives are legally binding in Germany and their benefits are widely acknowledged, they are still infrequently used in German psychiatric practice. AIMS: The aim of this study is to assess psychiatrists' attitudes toward the use of advance statements in mental health care. METHODS: A postal survey of psychiatrists in Germany was carried out to examine their views on advance statements in psychiatry. The survey addressed psychiatrists' experiences of and attitudes toward different types of advance statements, including psychiatric advance statements written by patients without any specific assistance, and joint crisis plans ( 'Behandlungsvereinbarungen'), where involvement of the clinical team is required. A total of 396 responded. RESULTS: Results suggest that generally speaking, respondents held favorable views on joint crisis plans for mental health care. In all, 80.7% of participants agreed that more frequent use of joint crisis plans in clinical practice would be desirable. However, clinicians' attitudes differ largely depending on the type of advance statement. Implications for the use of advance statements in psychiatry are discussed. CONCLUSION: The findings suggest that increasing the support structures available to train physicians and inform patients could lead to increased adoption of advance statements.

[Choosing Wisely - Klug Entscheiden: conceptual and ethical considerations]. / Choosing Wisely ­ Klug Entscheiden: begriffliche und ethische Überlegungen.

Choosing Wisely and Klug Entscheiden (KE) are recent physician-triggered campaigns that aim at identifying and reducing blatant over-treatment as well as - a specialty of KE - occurring under-treatment. This paper provides some conceptual and normative analyses of these campaigns' goals and justifications.

[CAM products as therapeutic placebos: theoretical and bioethical reflections]. / CAM-Präparate als therapeutische Placebos: wissenschaftstheoretische und medizinethische Überlegungen.

In Germany as well as in many other countries the project of 'integrating' CAM interventions into conventional medicine is currently underway. It is a highly contested endeavour. One backdoor of justifying CAM interventions - even if, according to the scientific standards of conventional medicine, they have been proved to lack specific effectiveness - is their use as therapeutic placebos. In this paper we will first discuss general critical considerations regarding deceptive placebo use and then argue that in the specific case of CAM interventions used as placebos general ethical reservations are reinforced by the fact that their use is prone to promote a non- or antiscientific attitude among physicians and patients, which we consider highly problematic.

[The concept of complementary and alternative medicine from the perspective of the philosophy of science and bioethics]. / Komplementär- und Alternativmedizin: der Begriff im Licht wissenschaftstheoretischer und -ethischer Überlegungen.

Decisions about therapeutic interventions to be made by physicians, patients, and healthcare purchasers essentially depend on their classification in a credible context of justification, especially in a world dominated by contradicting experts. To some extent, this framing is done by sorting terms and their undertones, including the case of so-called CAM measures. In this paper, the authors reflect on ways to deal with the term CAM and the underlying supply-side approaches to healthcare from a primarily science-oriented perspective.

Complementary and alternative drug therapy versus science-oriented medicine.

This opinion deals critically with the so-called complementary and alternative medical (CAM) therapy on the basis of current data. From the authors' perspective, CAM prescriptions and most notably the extensive current endeavours to the "integration" of CAM into conventional patient care is problematic in several respects. Thus, several CAM measures are used, although no specific effects of medicines can be proved in clinical studies. It is extensively explained that the methods used in this regard are those of evidence-based medicine, which is one of the indispensable pillars of science-oriented medicine. This standard of proof of efficacy is fundamentally independent of the requirement of being able to explain efficacy of a therapy in a manner compatible with the insights of the natural sciences, which is also essential for medical progress. Numerous CAM treatments can however never conceivably satisfy this requirement; rather they are justified with pre-scientific or unscientific paradigms. The high attractiveness of CAM measures evidenced in patients and many doctors is based on a combination of positive expectations and experiences, among other things, which are at times unjustified, at times thoroughly justified, from a science-oriented view, but which are non-specific (context effects). With a view to the latter phenomenon, the authors consider the conscious use of CAM as unrevealed therapeutic placebos to be problematic. In addition, they advocate that academic medicine should again systematically endeavour to pay more attention to medical empathy and use context effects in the service of patients to the utmost. The subsequent opinion discusses the following after an introduction to medical history: the definition of CAM; the efficacy of most common CAM procedures; CAM utilisation and costs in Germany; characteristics of science-oriented medicine; awareness of placebo research; pro and contra arguments about the use of CAM, not least of all in terms of aspects related to medical ethics.

Determination of Death: A Discussion on Responsible Scholarship, Clinical Practices, and Public Engagement.

The concept and determination of death by neurological or cardio-circulatory criteria play a crucial role for medical practice, society, and the law. Academic debates on death determination have regained momentum, and recent cases involving the neurological determination of death ("brain death") in the United States have sparked sustained public debate. The determination of death by neurological criterion (irreversible cessation of the whole brain or of the brain stem) is medically practiced in at least 80 countries. However, academic debates persist about the conceptual and scientific validity of death determined by neurological criterion. The cardio-circulatory criterion, which permits organ donation following cardio-circulatory arrest, has also recently been challenged. Given the presence of academic debates, several questions ensue about the responsible conduct of clinicians and scholars involved in clinical practices and academic research. This article identifies tension points for responsible practices in the domains of scholarship, clinical practice, and public discourse and formulates suggestions to stimulate further dialogue on responsible practices and to identify questions in need of further research.

[Rationing health care by thresholds for clinical benefit and its acceptance by the German population]. / Leistungsbeschränkungen in der Medizin nach Maßgabe von Nutzen-Schwellen: Akzeptanz in der deutschen Bevölkerung?

Fair rationing in publicly accessible health care has become a subject of current international debate. One suggestion is to cut reimbursement for any medical intervention below some threshold of small clinical benefit. One can further differentiate between thresholds of small expectable clinical benefit as such and thresholds of low chances for clinical success. Public acceptance of both types of thresholds has been tested in a population survey. Results are presented and discussed in this paper. (As supplied by publisher).

[Dealing with bottlenecks in health care--ethical issues]. / Engpässe medizinischer Versorgung--Ethische Aspekte.

Due to the ageing of our society and the enduring progress of medicine it will no longer be possible to provide universal access to everything health care providers could potentially offer. Therefore, we need a debate on legitimate health care claims and fair distribution of medical resources under conditions of scarcity - hence on matters of social justice. This paper will look at some general ethical aspects and some specific proposals for fair criteria of rationing in health care.

Challenges of educating for medical professionalism: who should step up to the line?

CONTEXT: The teaching of professionalism has recently become an important issue in medical education. Medical professionalism remains controversial, but several recently published institutional documents on professionalism seem to express an implicit, yet broad consensus on three points: that professionalism mainly consists of adherence to a specific set of professional attributes constitutive of medical role morality and readily identifiable as virtues of medical professionalism (VMP); that medical education needs to focus on the endowment of these attributes, and that medical ethicists should play a central role in assuming this educational responsibility. METHODS: This paper examines the assumption that the task of supporting the development of the VMP should primarily fall to medical ethicists. Considerations in favour of this position are weighted against a set of countervailing considerations. The latter include the charge that the VMP are too vague as educational guidelines, that they may not be teachable, and that the responsibility for their development must be shared across the medical faculty. CONCLUSIONS: Medical ethics educators are right to embrace the professionalism agenda on four conditions: that the limitations of addressing the formation of professional attributes in university-based teaching are recognised; that there is clinical as well as university-based evaluation of professional attributes; that the development of the VMP as a process of professional socialisation is seen as an interdisciplinary educational project, and that the examination and explanation of the cognitive grounds of the VMP are the focus of medical educators' activities.

[Medical ethics teaching]. / Medizinethik als Unterrichtsfach : Lernziele und Evaluation.

In most European countries, medical ethics has become a more or less established subject in medical school curricula. Accordingly, the need to evaluate its success has arisen. In our paper, we describe the controversial debate about the proper goals of teaching medical ethics. Secondly, we present an overview of current efforts to measure and evaluate the outcome and effect of different medical ethics teaching programmes on medical students and young physicians. We conclude that medical ethics teaching is amenable to a great variety of teaching and evaluation methods. Finally, we argue that medical ethics teaching should include: (1) the teaching of moral reasoning skills, (2) the instruction about relevant ethical knowledge, as well as (3) the development of certain character traits. Methods to evaluate ethical knowledge and moral reasoning skills are readily available, while the evaluation of the development of character traits poses important conceptual difficulties.