Ineke Bolt

Competence assessment in minors, illustrated by the case of bariatric surgery for morbidly obese children

Clinicians have to assess childrens competence frequently. In order to do justice to children who are competent to make decisions and to protect incompetent children, valid assessment is essential. We address this issue by using bariatric surgery for morbidly obese minors as a case study. Our previous research indicated that opponents of bariatric surgery tend to be sceptical of the competence of adolescents to consent and inclined to set more stringent standards than proponents. Furthermore, there is the concern that minors wanting surgery are less able to make an autonomous decision than minors who do not wish to undergo surgery. Hence, few patients may be qualified as eligible. We argue for a risk-related standard, so that concerns are met, while at the same time preventing to set the bar too high, excluding paediatric patients who are most likely to benefit from surgery. This standard is also applicable in gastroenterology practice.

Wish-fulfilling medicine in practice: a qualitative study of physician arguments

There has been a move in medicine towards patient-centred care, leading to more demands from patients for particular therapies and treatments, and for wish-fulfilling medicine: the use of medical services according to the patients wishes to enhance their subjective functioning, appearance or health. In contrast to conventional medicine, this use of medical services is not needed from a medical point of view. Boundaries in wish-fulfilling medicine are partly set by a physicians decision to fulfil or decline a patients wish in practice. In order to develop a better understanding of how wish-fulfilling medicine occurs in practice in The Netherlands, a qualitative study (15 semistructured interviews and 1 focus group) was undertaken. The aim was to investigate the range and kind of arguments used by general practitioners and plastic surgeons in wish-fulfilling medicine. These groups represent the public funded realm of medicine as well as privately paid for services. Moreover, GPs and plastic surgeons can both be approached directly by patients in The Netherlands. The physicians studied raised many arguments that were expected: they used patient autonomy, risks and benefits, normality and justice to limit wish-fulfilling medicine. In addition, arguments new to this debate were uncovered, which were frequently used to justify compliance with a patients request. Such arguments seem familiar from conventional medicine, including empathy, the patient–doctor relationship and reassurance. Moreover, certain arguments that play a significant role in the literature on wish-fulfilling medicine and enhancement were not mentioned, such as concepts of disease and the enhancement–treatment dichotomy and ‘suspect norms’.

The Controversy Over Pediatric Bariatric Surgery

Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity—whether it should be considered primarily a medical condition or more a psychosocial problem—seem to affect the specialists’ normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents’ feelings regarding both being able to influence their child’s health and their child being able to control their own condition, and the adolescents’ sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views—e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure—play an important role in the acceptability of bariatric surgery for childhood obesity.

To dispense or not to dispense? Ethical case decision-making in pharmacy practice

In daily practice, pharmacists are regularly confronted with moral problems in which deciding what to do is not always a straightforward decision. In this contribution we show how the use of a specific method for moral deliberation can (in retrospect or prospective) aid moral judgements. We use the case of dispensing isotretinoin to demonstrate one ethical reflection method, namely the Utrecht Method.

Contextualizing Genetic Testing and Sequencing Results for Patients and Parents: The Need for Empirical-Ethical Research

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Viel Lärm um nichts

Neuroenhancement verspricht grose Verheisungen: jetzt schon, und sicherlich umso mehr in der Zukunft, konnen wir unsere Denkfahigkeit erhohen, die Aufmerksamkeit steigern, die Stimmungslage aufhellen, mehr mit unseren Sinnen wahrnehmen und mit mehr Sinnen wahrnehmen. Befurworter von Neuroenhancement nehmen oftmals bereitwillig an, dass durch diese Enhancements die Lebensqualitat der betroffenen Individuen erhoht wird. Die Steigerung der kognitiven Fahigkeiten oder, allgemeiner ausgedruckt, unserer Fahigkeiten im Allgemeinen mache unser Leben besser und darum sollten wir (Neuro-)enhancement befurworten (z.B. Harris 2007).

Botox voor het brein: de ethiek van psychofarmacologische enhancement

De ontwikkelingen op het gebied van de neurowetenschappen gaan snel. Naarmate kennis omtrent de invloed en werkingsmechanismen van psychofarmaca toeneemt, groeien de mogelijkheden om het psychisch functioneren van gezonde mensen te verbeteren, bijvoorbeeld wat betreft geheugen, concentratie of stemming. Wanneer dergelijke verbeteringen worden bereikt door middel van farmaca wordt gesproken van ‘psychofarmacologische enhancement’. Wanneer het gaat om het verbeteren of verfraaien van persoonlijkheidskenmerken wordt, naar analogie van de cosmetische chirurgie, ook wel de term ‘cosmetische psychofarmacologie’ gebruikt. Reeds bestaande voorbeelden van enhancement zijn het gebruik van methylfenidaat (Ritalin®) als ‘leerpil’ door studenten in de Verenigde Staten, en van modafinil (Modiodal®8) door luchtmachtpiloten (Wolpe, 2002).