Urban Wiesing

A new law on advance directives in Germany

This article presents the new German law on advance directives from 1 September 2009. The history of the parliamentary process of this law is described, the present regulations are explained, their relevance for medical practice discussed and shortcomings are identified. Finally, the new law is compared with other regulations in the international context. Previously established legal practice in Germany has now become largely confirmed by the new law: An advanced directive must be respected in any decision concerning medical treatment, regardless of the stage of the illness. It can be informally revoked at any time, even with limited decision-making capacity. Nobody may be obliged to issue a directive in any way. Advance directives do not need notarisation or routine updating after certain time intervals. Provided that the patient, who is no longer mentally competent, has issued a lasting power of attorney (Bevollmächtiger), or provided that the patient has been appointed a healthcare proxy by the courts (Betreuer), this authorised surrogate must assert the patients will. The role of the guardianship court is clarified: it only needs to be involved in cases of disagreement as to the patients will. The new German law thus combines more legal certainty with a liberal emphasis on patient autonomy and flexible, adaptable regulations.

Cognitive neuroenhancement: false assumptions in the ethical debate.

The present work critically examines two assumptions frequently stated by supporters of cognitive neuroenhancement. The first, explicitly methodological, assumption is the supposition of effective and side effect-free neuroenhancers. However, there is an evidence-based concern that the most promising drugs currently used for cognitive enhancement can be addictive. Furthermore, this work describes why the neuronal correlates of key cognitive concepts, such as learning and memory, are so deeply connected with mechanisms implicated in the development and maintenance of addictive behaviour so that modification of these systems may inevitably run the risk of addiction to the enhancing drugs. Such a potential risk of addiction could only be falsified by in-depth empirical research. The second, implicit, assumption is that research on neuroenhancement does not pose a serious moral problem. However, the potential for addiction, along with arguments related to research ethics and the potential social impact of neuroenhancement, could invalidate this assumption. It is suggested that ethical evaluation needs to consider the empirical data as well as the question of whether and how such empirical knowledge can be obtained.

The ethics of genetic screening

Contributors. Preface. The Wilson and Jungner Principles of Screening and Genetic Testing D. Shickle. Genetic screening, information and counselling in Austria G. Hauser.The Belgian perspective on genetic screening K. Dierickx. Thalassemia prevention in Cyprus. Past, present and future P. Ioannou. Some developments in genetic screening in Finland V. Launis. Genetic screening: Ethical debates and regulatory systems in France A. Boue. Screening in Germany: Carrier screening, pre-natal care and other screening projects T. Schroeder-Kurth. Population screening in Greece for prevention of genetic diseases C. Metaxotou, A. Mavrou. Ethics and genetic screening in the Republic of Ireland D. Dooley. Genetic screening in the Netherlands. The state of the debate R. Hoedemaekers. Genetic screening and genetic services in Slovakia V. Ferak. Historical and social background. Introduction H. ten Have. From eugenics to genetic screening. Historical problems of human genetic applications H.-P. Kroner. Genetics in Germany. History and hysteria U. Wiesing. A sociological perspective on genetic screening M. Levitt. Moral and philosophical issues. Introduction R.F. Chadwick, U. Wiesing. Genetic information and care I. Porn. Genetic screening, genetic testing and privacy J. Sandor. Reconciling liberty and the common good? Genetic screening in the Republic of Ireland D. Dooley. Genetic screening and testing. A moral map R. Hoedemaekers. The genetic testing of children A. Clarke. Index.

Should Performance-Enhancing Drugs in Sport be Legalized under Medical Supervision?

This review examines the question of whether performance-enhancing drugs should be permitted in sport under the control of physicians, and evaluates the expected outcomes of such a scenario. Such a change in regulation would need to be tightly controlled because of the risks involved. The results of legalizing performance-enhancing drugs in competitive sport would be either unhelpful or negative, and the unwanted aspects of doping control would not disappear. Athletes, including children and adolescents who wanted to pursue competitive sports, would be forced to take additional, avoidable health risks. The ‘natural lottery’ of athletic talents would be compensated for only partially by use of performance-enhancing agents. It would also be complemented by another ‘natural lottery’ of variable responses to doping measures, combined with the inventiveness of doping doctors. There would be no gain in ‘justice’ (i.e. fairer results that reflected efforts made) for athletes as a result of legalizing doping. Legalization would not reduce restrictions on athletes’ freedom; the control effort would remain the same, if not increased. Extremely complicated international regulations would have to be adopted. The game of the ‘tortoise and the hare’ between doping athletes and inspectors would remain because prohibited but not identifiable practices could still provide additional benefits from use of permissible drugs. Audience mistrust, particularly toward athletes who achieved outstanding feats, would because it would still be possible that these athletes were reliant on illegal doping practices. Doping entails exposing the athletes to avoidable risks that do not need to be taken to increase the appeal of a sport. Most importantly, the function of sport as a role model would definitely be damaged. It is not necessary to clarify the question of what constitutes the ‘spirit of sport’ and whether this may be changed. From a practical point of view, a legalization of performance-enhancing drugs in sport should not be considered for the simple reason that it has no advantages but many disadvantages.

International ethical regulations on placebo-use in clinical trials: A comparative analysis

The ethical aspects of placebo control in clinical trials have been extensively and controversially debated in the last decade. However, a thorough analytical comparison of the different existing international regulations, their terminologies and their ethical principles concerning placebo, is still missing. The central issue in the ongoing controversy is the justification of placebo-use, if proven treatment exists. All present versions of the examined guidelines propose such justifications, but each guideline differs from the others in relevant details. Therefore the conditions justifying placebo-use according to each guideline are the focus of our attention. We will first propose a formalized general principle that defines the ethical acceptability of placebo-use. Then we will analyse three categories of conditions put forward by the different documents: the risk of harm or burden, compelling scientific reasons, and the availability of proven treatment. The analysis shows important normative discrepancies and contradictions between the examined guidelines. Especially striking is the fact that some guidelines allow the participants in clinical trials to be exposed to a risk of serious harm, while others do not. Finally, we try to show how the normative difference of each guideline could influence the decision of researchers or IRBs concerning the ethical acceptability of placebo-use.

Ethische Aspekte der ästhetischen Medizin

The article examines the question whether and - if - under which conditions physicians should perform purely esthetic interventions. Starting point of the considerations is the special character of the medical profession and the necessity of the anticipated confidence in the system of medicine. The medical measures for aesthetic improvement are systematized. Medical measures to increase the wanted, positively felt attention of others are not compellingly required according to the medical ethic. Nevertheless they do not offend the ethos if high quality standards are insured: The measures must be presumably helpful for the patient; a thorough informed consent and avoidance of damage must be insured. Esthetic measures, in particular operations which are totally cosmetic, should be limited strictly if performed with children and adolescents. Nevertheless convincing arguments support medical-esthetic measures with children and adolescents to avoid stigmatization.ZusammenfassungDer Beitrag untersucht die Frage, ob und – wenn ja – unter welchen Bedingungen Ärzte rein ästhetische Interventionen vornehmen sollen. Ausgangspunkt der Überlegungen ist der besondere Charakter des ärztlichen Berufes und die Notwendigkeit des „antizipatorischen Systemvertrauens“. Überdies werden die ärztlichen Eingriffe zur ästhetischen Verbesserung systematisiert. Ärztliche Eingriffe, die einzig darauf abzielen, gewollte, positiv empfundene Aufmerksamkeit von anderen zu vermehren, sind nach ärztlichem Ethos nicht zwingend geboten. Sie verstoßen jedoch nicht dagegen, sofern hohe Qualitätsanforderungen gewährleistet sind: Die Maßnahmen müssen dem Patienten voraussichtlich nutzen, eine gründliche Aufklärung und die Schadensvermeidung müssen gewährleistet sein. Ästhetische Maßnahmen, insbesondere Operationen, die einzig der Vermehrung gewollter Aufmerksamkeit dienen, sollten bei Kindern und Jugendlichen eng begrenzt werden. Gleichwohl sprechen überzeugende Argumente dafür, bei Kindern und Jugendlichen Stigmatisierungen auch durch medizinisch-ästhetische Maßnahmen zu vermeiden.AbstractThe article examines the question whether and – if – under which conditions physicians should perform purely esthetic interventions. Starting point of the considerations is the special character of the medical profession and the necessity of the anticipated confidence in the system of medicine. The medical measures for aesthetic improvement are systematized. Medical measures to increase the wanted, positively felt attention of others are not compellingly required according to the medical ethic. Nevertheless they do not offend the ethos if high quality standards are insured: The measures must be presumably helpful for the patient; a thorough informed consent and avoidance of damage must be insured. Esthetic measures, in particular operations which are totally cosmetic, should be limited strictly if performed with children and adolescents. Nevertheless convincing arguments support medical-esthetic measures with children and adolescents to avoid stigmatization.

Zum Verhältnis von Geschichte und Ethik in der Medizin

SummaryThe article tries to clarify the relation between history of medicine and medical ethics. Therefore it distinguishes between the double meaning of the german word “Geschichte”, which means both: “development of events” and “story”. For the first option no systematic relation between history and ethics can be reconstructed. In the second sense historical knowledge can be a readable and worth reading text for the ethical debate. Therefore the methodological professionality of the historian is required.

True and false concerns about neuroenhancement: a response to ‘Neuroenhancers, addiction and research ethics’, by D M Shaw

In his critical comment on our paper in this journal, Shaw argues that ‘false assumptions’ which we have criticised are in fact correct (‘Neuroenhancers, addiction and research ethics’). He suggests that the risk of addiction to neuroenhancers may not be relevant, and that safety and research in regard to neuroenhancement do not pose unique ethical problems. Here, we demonstrate that Shaw ignores key empirical research results, trivialises addiction, commits logical errors, confuses addictions and passions, argues on a speculative basis, and fails to distinguish the specific ethical conditions of clinical research from those relevant for research in healthy volunteers. Therefore, Shaws criticism cannot convince.

The World Medical Association Launches A Revision of the Declaration of Geneva.

At its second General Assembly in 1948, shortly after its inception, the World Medical Association, the global organization of physicians which currently represents 112 national medical associations, adopted the Declaration of Geneva. It was conceived as a modern Hippocratic Oath and intended to be sworn by physicians upon admission to the medical profession. It was also an oath in response to the crimes committed by doctors during the Nazi era and thus exemplified a moral commitment in the face of moral failure. The extent to which the declaration is disseminated and used as an oath by physicians entering the medical profession varies greatly from country to country. In many parts of the world, the declaration is not recognized as a modern-day successor to the Hippocratic Oath. Nevertheless, the Declaration of Geneva – along with the Declaration of Helsinki, which addresses research – is considered one of the World Medical Association s most important documents. Over the past 67 years, the World Medical Association has only made minor changes to the Declaration of Geneva. The General Assembly recently issued a mandate to an internal workgroup to draw up a proposal for a revision of the declaration. A series of arguments motivated the World Medical Association to take this step. The International Federation of Medical Students Association, for example, alerted the World Medical Association to the fact that the Declaration of Geneva deviates from the Hippocratic Oath with regard to medical students. While the 2500-year-old Hippocratic Oath calls for mutual respect between students and teachers, the Declaration of Geneva states only that students must respect their teachers. It lacks a reference to the idea of reciprocity. The Declaration of Geneva is a document that emerged in the immediate aftermath of the war. In recent decades, respect for patient self-determination has been established as one of the most important principles of medical ethics. However, it is not mentioned in the Declaration of Geneva. This is in stark contrast to other, more recent documents of the World Medical Association, which explicitly emphasize the autonomy of the patient. And this begs the question of whether a document that does not mention patient self-determination can still be considered up-to-date and whether efforts should be made to overcome any inconsistencies between this and other World Medical Association documents. In the age of the Internet, it is important to ensure that documents can be found quickly and easily. But those who are unfamiliar with the proper name of the Declaration of Geneva would probably have difficulty finding it online. One way to improve the online discoverability of the declaration would be to add a subtitle – e.g. The Physician s Oath . The outcome of the revision process is yet to be decided, but the international workgroup, which is composed of members from different continents, cultures and religious backgrounds, will determine in the near future whether these or other factors should be incorporated into the declaration, or whether the declaration should be left unchanged. In either case, the basic principles and core content of the declaration should be maintained. The everyday life of physicians has changed significantly over the last 70 years. This trend will continue to gain speed in the future due to demographic and economic challenges, on the one hand, and medical and technical advances on the other. The moral standards of the profession, which influence the way medicine is practised, represent an important cornerstone of physician identity. It will be essential for the revision process to take into account the role the Declaration of Geneva can play in the future in terms of strengthening professional identity and adherence to professional ethics. The Declaration of Geneva is available on http://www. wma.net/en/30publications/10policies/g1/

Wozu bedarf es eines Medizinethikers

1. Das Fach medizinische Ethik hat mit der Besetzung des Lehrstuhls eine neue Stufe in der Professionalisierung erreicht. Die Wissenschaftssoziologie spricht gemeinhin von einer Amateurwissenschaft, solange ein Fach nur in kleineren professionellen Organisationen existiert. Der nächste Schritt zur entstehenden akademischen Wissenschaft ist an die Besetzung von Lehrstühlen gebunden. Folglich wurde die medizinische Ethik aus dem Amateurstatus erlöst und zu einer entstehenden akademischen Wissenschaft befördert. 2. Mit der medizinischen Ethik findet ein Fach Einzug in die medizinische Fakultät, das sich hauptamtlich den moralischen Normen und Werten widmen soll. Kein Fach einer medizinischen Fakultät hat vergleichbare Aufgaben. Zwar handeln alle Fächer einer medizinischen Fakultät nach bestimmten Normen – zumindest sollten sie es –, jedoch ist bislang keines angetreten, das diese Normen explizit zum Gegenstand seiner wissenschaftlichen Tätigkeit hätte. 3. Die medizinische Ethik verdankt ihre Existenz sicher auch der voranschreitenden Spezialisierung. Das kleine Fach behandelt aber ein großes, ein grundlegendes Thema der Medizin, das sich mehr oder weniger in allen Fächern einer medizinischen Fakultät wiederfinden läßt.2 4. Die medizinische Ethik konnte sich zwar erst in den letzten 20 bis 30 Jahren in der westlichen Welt akademisch institutionalisieren (siehe „Medical Ethics, History of“ in [14]; [19]). Gleichwohl ist die medizinische Ethik mindestens so alt ist wie die schriftlich über-