Research on clinical ethics and consultation. Introduction to the theme

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 leve

"Alter" und "Kosten" -Faktoren beiTherapieentscheiden amLebensende? Eine Analyseinformeller Wissensstrukturenbei Ärzten und Pflegenden1

Zusammenfassung: 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 führe

Therapist-client sex in psychotherapy: attitudes of professionals and students towards ethical arguments

Data suggest that a substantial proportion of psychotherapists engage in therapist-client sex (TCS), violating national and international ethical guidelines. The objective of our study was to find a new and effective starting point for preventive interventions.; Using an online questionnaire, this study explored professionals' attitudes toward aspects of a TCS-case example influencing the tendency to pursue colleagues' TCS, including self-interest and responsibility ascribed to clients.; A total of 421 participants expressed preferences for courses of action and rated given information in a questionnaire. Results indicate that TCS is most often condemned for its inherent carelessness towards clients, its exploitative nature, the abuse of dependency and for counteracting the inherent intention of psychotherapy. Partial responsibility for TCS was attributed to clients by 41.3% of the respondents. Although self-interest related information was rated as an acceptable reason against pursuing TCS, a strong tendency exists to confront an abusive colleague, even at the risk of own disadvantages.; In the detailed discussion ethical arguments against TCS (other than the certainly inflicted, but hardly measurable harm) are elaborated. In particular the incompatibility of TCS with a psychotherapeutic relationship, the responsibility for TCS in the asymmetrical client-therapist relationship and the legitimacy of self-protection are discussed.; Reasoning against TCS can and should be based on explicit, ethical requirements for psychotherapists. Furthermore, integrating the topic in psychotherapists' training is encouraged and a discrete procedure to report a colleague's TCS is requested

Avoiding bias in medical ethical decision-making. Lessons to be learnt from psychology research

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-makin

Wie hilfreich sind "ethische Richtlinien" am Einzelfall?: Eine vergleichende kasuistische Analyse der Deutschen Grundsätze, Britischen Guidelines und Schweizerischen Richtlinien zur Sterbebegleitung

Zusammenfassung: Entscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende "Ethik-Richtlinien", die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen "Ethik-Richtlinien" bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu "Ethik-Richtlinien" aus Deutschland, der Schweiz und aus Großbritannien herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an "Ethik-Richtlinien" bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formulier

A "little bit illegal”? Withholding and withdrawing of mechanical ventilation in the eyes of German intensive care physicians

Research questions and background: This 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 conflic

Attitudes Toward Assisted Suicide and Life-Prolonging Measures in Swiss ALS Patients and Their Caregivers

Objectives: In Switzerland, assisted suicide (AS) is legal, provided that the person seeking assistance has decisional capacity and the person assisting is not motivated by reasons of self-interest. However, in this particular setting nothing is known about patients' and their caregivers' attitudes toward AS and life-prolonging measures. Methods: Data was retrieved through validated questionnaires and personal interviews in 33 patients and their caregivers covering the following domains: physical function according to the revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R), demographic data, quality of life, anxiety, depression, social situation, spirituality, burden of disease, life-prolonging, and life-shortening acts. Results: In patients the median time after diagnosis was 9 months (2-90) and the median Amyotrophic Lateral Sclerosis (ALS) FRS-R score was 37 (22-48). The majority of patients (94%; n = 31) had no desire to hasten death. Patients' and caregivers' attitudes toward Percutaneous Endoscopic Gastrostomy (PEG) and Non-Invasive Ventilation (NIV) differed. Significantly more patients than caregivers (21.2 versus 3.1%) stated that they were against NIV (p = 0.049) and against PEG (27.3 versus 3.1%; p = 0.031). Answers regarding tracheotomy were not significantly different (p = 0.139). Caregivers scored significantly higher levels of "suffering" (p = 0.007), "loneliness" (p = 0.006), and "emotional distress" answering the questionnaires (p > 0.001). Suffering (p > 0.026) and loneliness (p > 0.016) were related to the score of the Hospital Anxiety and Depression Scale (HADS) in patients. Conclusion: A liberal legal setting does not necessarily promote the wish for AS. However, the desire to discuss AS is prevalent in ALS patients. There is a higher level of suffering and loneliness on the caregivers' side. A longitudinal study is warranted

Finding their voices again: a media project offers a floor for vulnerable patients, clients and the socially deprived

‘DU bist Radio' (DBR) is an award winning [DBR has been awarded with the "Catholic Media Award of the German Bishops Conference, Prädikat WERTvoll” (2011), the Suisse "Media Prize Aargau/Solothurn” (2010), the German "Alternative Media Award” (2009) and was nominated for the "Prix Europa” (2009)] monthly radio format that goes on air on three Swiss radio stations. The purpose of this program which was first broadcast in 2009 is the development of a new media format which—without applying any journalistic (or other) filter and influence—conveys authenticity of expression amongst society's most vulnerable fellow citizens such as patients, clients and the socially deprived. So-called marginal groups are encouraged to speak for themselves, as a possible paradigm case for encouraging the inclusion of patients' and relatives' "unfiltered” voices in general and in clinical ethics as well. Before handing over the microphone to the groups in focus, a team of journalists, educated in medical ethics, over a period of 4days, teaches them on-site radio skills and craft. Once this task is completed and the actual production of the broadcast begins, the media crew does not exert any influence whatsoever on the content of the 1-h program. Thus, the final product is solely created and accounted for by the media-inexperienced participants, leading to unforeseen and often surprising results. It is discussed that the DBR approach of fostering authenticity of expression can serve as an enhancement to today's respect and autonomy oriented field of medical ethic