Norbert Steinkamp

Ethical case deliberation on the ward. A comparison of four methods.

The objective of this article is to analyse and compare four methods of ethical case deliberation. These include Clinical Pragmatism, The Nijmegen Method of ethical case deliberation, Hermeneutic dialogue, and Socratic dialogue. The origin of each method will be briefly sketched. Furthermore, the methods as well as the related protocols will be presented. Each method will then be evaluated against the background of those situations in which it is being used. The article aims to show that there is not one ideal method of ethical case deliberation, which fits to all possible kinds of moral problems. Rather, as each of the methods highlights a limited number of morally relevant aspects, each method has its strengths and weaknesses as well. These strengths and weaknesses should be evaluated in relation to different types of situations, for instance moral problems in treatment decisions, moral uneasiness and residue, and the like. The suggestion arrived at on the basis of the findings of this paper is a reasonable methodological plurality. This means that a method can be chosen depending on the type of moral problem to be deliberated upon. At the same time it means, that by means of a method, deliberation should be facilitated.

Regulation of healthcare ethics committees in Europe

In this article, the question is discussed if and how Healthcare Ethics Committees (HECs) should be regulated. The paper consists of two parts. First, authors from eight EC member countries describe the status quo in their respective countries, and give reasons as to the form of regulation they consider most adequate. In the second part, the country reports are analysed. It is suggested that regulation of HECs should be central and weak. Central regulation is argued to be apt to improve HECs’ accountability, relevance and comparability. To facilitate biomedical citizenship and ethical reflection, regulation should at the same time be weak rather than strict. Independence of HECs to deliberate about ethical questions, and to give solicited and unsolicited advice, should be supported and only interfered with by way of exception. One exception is when circumstances become temporary adversarial to ethical deliberation in healthcare institutions. In view of European unification, steps should be taken to develop consistent policies for both Eastern and Western European countries.

Developing a Model of Healthcare Ethics Support in Croatia

Croatia is a transitional society in that it is a country emerging from a socialist command economy toward a market-based economy with ensuing structural changes of a social and political nature—some extending into the healthcare system. A legacy from our past is that, until now, Croatian healthcare institutions have had no real experience with clinical ethics support services. When clinical cases arise presenting complex ethical dilemmas in treatment options, the challenges presented to the medical team are substantial. The case described below recently occurred on a ward in a university hospital in Croatia. An unexpected request from the patient’s parents created a number of issues that needed to be addressed by the medical team, which was made more difficult by the lack of clinical ethics support services. Such cases press the question currently being debated as to what type of ethics support services would be suitable for Croatia and why.

Borrowed beauty? Understanding identity in Asian facial cosmetic surgery

This review aims to identify (1) sources of knowledge and (2) important themes of the ethical debate related to surgical alteration of facial features in East Asians. This article integrates narrative and systematic review methods. In March 2014, we searched databases including PubMed, Philosopher’s Index, Web of Science, Sociological Abstracts, and Communication Abstracts using key terms “cosmetic surgery,” “ethnic*,” “ethics,” “Asia*,” and “Western*.” The study included all types of papers written in English that discuss the debate on rhinoplasty and blepharoplasty in East Asians. No limit was put on date of publication. Combining both narrative and systematic review methods, a total of 31 articles were critically appraised on their contribution to ethical reflection founded on the debates regarding the surgical alteration of Asian features. Sources of knowledge were drawn from four main disciplines, including the humanities, medicine or surgery, communications, and economics. Focusing on cosmetic surgery perceived as a westernising practice, the key debate themes included authenticity of identity, interpersonal relationships and socio-economic utility in the context of Asian culture. The study shows how cosmetic surgery of ethnic features plays an important role in understanding female identity in the Asian context. Based on the debate themes authenticity of identity, interpersonal relationships, and socio-economic utility, this article argues that identity should be understood as less individualistic and more as relational and transformational in the Asian context. In addition, this article also proposes to consider cosmetic surgery of Asian features as an interplay of cultural imperialism and cultural nationalism, which can both be a source of social pressure to modify one’s appearance.

Ethics consultation in the clinic.

Peter Burkli* and Norbert Steinkamp1 Department Rechtswissenschaften, Maiengasse 51, 4056 Basel, Switzerland (∗Author for correspondence: Phone: 41612672488; E-mail: Peter.Buerkli@ unibas.ch); 1Department of Ethics, Philosophy and History of Medicine, University Medical Centre Nijmegen, 232 EFG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands (Phone: 31 24 36 15320; Fax: 31 24 354 02 54; E-mail: n.steinkamp@efg.umcn.nl)

The ethics of using placebo in randomised controlled trials: a case study of a Plasmodium vivax antirelapse trial

BackgroundThe use of placebos in randomised controlled trials is a subject of considerable ethical debate. In this paper we present a set of considerations to evaluate the ethics of placebo controlled trials that includes: social value of the study; need for a randomised controlled trial and placebo; standards of care; risks of harm due to administration of placebo and the harm benefit balance; clinical equipoise; and double standards. We illustrate the application of these considerations using a case study of a large ongoing multicentre, placebo-controlled, double-blinded, randomised trial to determine primaquine anti-relapse efficacy in vivax malaria.Main BodyThere is an urgent need for primaquine anti-relapse studies in order to rationalise the management of a potentially fatal disease. An ethical justification for the use of the placebo arm is provided on the grounds that the actual current applied standard of care in most endemic places does not include primaquine. It has also been argued that there is clinical equipoise among the primaquine study arms and that the risk of harms of being in the placebo arm is the risk of having relapse, which is no more than not being included in the trial, and that there are no double standards.ConclusionBased on our set of considerations, we conclude that a placebo arm is not only justified but imperative in this study. We propose that similar considerations should be prospectively applied to other placebo controlled trials and observational control arms where no treatment is offered.

Proportionaliteit van medisch-wetenschappelijk onderzoek met mensen.

De verhouding tussen de risico’s en het te verwachten nut van voorgenomen medisch-wetenschappelijk onderzoek met mensen moet acceptabel zijn.1 Hierover bestaat een breed gedeelde consensus (Loue 1999; Smith 1999). In dit kader wordt ook wel gesproken van proportionaliteit. In deze bijdrage wordt eerst op een algemene wijze nader op het begrip van proportionaliteit ingegaan. Het is een kernbegrip uit de bio-ethiek en werd voor het eerst ontwikkeld in samenhang met regulier medisch handelen. Daarnaast is het begrip tegenwoordig van groot belang bij de beoordeling van wetenschappelijk onderzoek met dieren. Op deze twee toepassingsdomeinen van het begrip van de proportionaliteit wordt in het kort ingegaan. Daarna worden de voor de bepaling van de proportionaliteit centrale begrippen ‘nut’ en ‘risico’ nader behandeld. Tot slot volgt een reflectie over de manier waarop binnen een Medisch-Ethische Toetsingscommissie (METC) een systematische afweging van de risico’s en het mogelijke nut van voorgenomen medisch-wetenschappelijk onderzoek met mensen doorgevoerd zou kunnen worden.