„Personalisierte Medizin“ in der Onkologie: Ärztliche Einschätzungen der aktuellen Entwicklung in der Krankenversorgung

Definition of the ProblemPublic discussions about “personalised medicine” indicate that this approach is associated with high expectations regarding its contribution to clinical practice. However, little is known about physicians’ perspectives on “personalised medicine”. This qualitative interview study aims to provide insight into physicians’ perceptions and views regarding clinical practice. Arguments/ResultsPhysicians in this sample view “personalised medicine” as a progress within medicine, but do not see a major departure from long-standing practices. As a major problem, physicians identified handling the amount of molecular and genetic information and integrating this information into the diagnosis and treatment. ConclusionTaking the results into account, one may ask whether “personalised medicine” is not the opposite of what its name connotes—a more patient-centred medicine. The strategies for handling the large amount of information raise novel challenges which are in contrast to the ideas of patient-centred medicine.     

Patientenverfügung und Behandlungsvereinbarung als Instrumente der Vorausplanung in der forensischen Psychiatrie

Definition of the problem

In Germany as well as in many other countries, mentally ill criminals who are not guilty by reasons of insanity can be sentenced to psychiatric treatment in forensic clinics. In 2011, the German Constitutional Court substantially strengthened these patients’ right to self-determination in case of treatment refusal.

Arguments

In this context, we discuss the significance of instruments of advance healthcare planning. First, we describe the context of psychiatric treatment in forensic clinics and the changes the new German legal regulations brought about. A case study helps to illustrate the consequences of treatment refusal for both patient and healthcare personnel.

Conclusion

Eventually, we discuss if and how advance directives and joint crisis plans can be useful in forensic clinics and how additional measures can help to facilitate patient self-determination.

     

Legalisierung der aktiven Sterbehilfe – Förderung oder Beeinträchtigung der individuellen Autonomie?

Definition of the problem Theorists who support the legalisation of active euthanasia usually base their arguments on the principle of autonomy. In their view the wish of a severely ill person not to continue his or her life must be respected. However, some opponents of the legalisation of active euthanasia refer to the principle of autonomy as well. Arguments They are concerned that patients may be held responsible for burdening others with the provision of care. Thus family members, physicians or nurses may exert pressure on patients to opt for active euthanasia. In this article it is argued that these worries are justified; the occurrence of social coercion poses a real danger. Conclusion However, neither the prohibition nor the permission of active euthanasia enables each individual to make an autonomous choice. Comparing the risks involved in both options, legalisation seems to be preferable to maintaining the status quo.     

Ethische Relevanz und faktische Mängel in der Kommunikation von Spezifika der Organspende nach Kreislaufstillstand

Introduction

In many countries, the number of organ donations after circulatory determination of death (DCDD) is increasing, although various aspects of DCDD are critically discussed in medical ethics. In our work, we identify ethically relevant aspects of the DCDD—in particular regarding preparatory measures and the irreversibility of the death criterion—and we investigate to what extent persons interested in becoming organ donors are informed about those issues.

Methods

We performed a comprehensive literature review on ethical issues of DCDD. Subsequently, we conducted a worldwide evaluation of organ donation organisations’ websites and an accompanying survey to investigate the extent to which ethically relevant aspects of DCDD play a role in the information of persons interested in becoming organ donors.

Results

We find that a majority of the organisations’ websites do not deal with the subject of DCDD, whereas the responsibles of the organisations surveyed emphasised the importance of education for potential donors.

Conclusion

We point out central issues about which persons willing to become organ donors should be informed if DCDD is practiced in their respective countries. In addition, we advocate that the criteria and the procedures for determining death in the context of transplantation medicine should be uniform in order to defuse some of the critically discussed aspects in the context of DCDD.

     

Ethische Aspekte der Regularisierung ärztlichen Handelns

Zusammenfassung.   Die Ressourcenknappheit hat zu einer progredienten Regularisierung ?rztlichen Handelns geführt, überwiegend durch staatliche und institutionelle Richt- und Leitlinien. Aber nicht nur der Spardruck, sondern ebenso „offiziell” instrumentierte Wissenschaft kann ?rztliches Denken und damit ethische Reflexion behindern – selbst wenn sie in der optimalen Form evidenzbasierter Leitlinien auftritt. ”Futility” als Begriff ist in den USA l?ngst aus einer andauernden theoretischen Diskussion in die klinische Praxis eingedrungen. Vor allem bei bedrohlichen Erkrankungen am Ende des Lebens gibt es formalisierte Entscheidungswege; etwa im Sinne der prozeduralen Festlegung einer ”Do-Not-Attempt-Resuscitation Order” (DNAR). Unentrinnbar ist die Frage nach dem Sinn und der Vergeblichkeit ?rztlichen Handelns mit derjenigen nach der Entscheidungsmacht im medizinischen Alltag verknüpft. Regularisierungsversuche, die von der Makroebene der Gesundheits?konomie ausgehen, interferieren mit den h?ufig ebenso machtf?rmigen Entscheidungsprozessen in der unmittelbaren Patientenversorgung. Das gilt auch bei der Balance der Interessen von Patienten einschlie?lich ihrer pers?nlichen und juristischen Vertreter mit den fachlichen Ansprüchen der ?rzte. Die schlichte übernahme des Konzeptes der ”Futility” aus den USA ist angesichts der ungel?sten Komplexit?t der Interferenzen von Makro- und Mikroebene in Deutschland wenig sinnvoll, da es zu sehr auf die spezifischen Verh?ltnisse der amerikanischen Medizin zugeschnitten ist. Andererseits helfen die konkret praktikablen Kategorien der ”Futility” gegen das Ausufern von Grundsatzdiskussionen im europ?ischen Stil.      

Rechtliche Verbotsvorschläge der ärztlichen Unterstützung bei der Selbsttötung von schwerkranken Patienten

Definition of the problem In the current ethical debate on physician-assisted suicide in Germany new sanctions in criminal law are debated from different sides. Whereas in the beginning the debate focused only on the ban of organised forms of suicide assistance, the explicit licensing of assisted suicide is also now requested by physicians. Arguments Considering the approach to include prohibition of assisted suicide within the German Criminal Code, the article shows that the impunity of suicide and suicide assistance has a long tradition in Germany. The impunity of assisted suicide cannot only be systematically and factually justified, but also in terms of content. A criminalization can be neither legally nor ethically justified. Conclusion The authors advocate—with reference to different legal drafts in the German Federal Parliament (Deutscher Bundestag)—for an open discourse within the medical profession and for a revision of the professional law.     

Das ‚gute Leben‘ in der Bioethik

Definition of the problem Contemporary bioethics as an academic discipline mainly focuses on moral questions—according to its articulated self-concept and the explicit arguments in most areas of bioethical reflection. Concepts and theories of the good life are hardly considered.Arguments In reality the “good life” plays a much more important role than it is assumed, but mostly only in an implicit way. The article demonstrates this by referencing three selected fields of bioethical discussion. Hence the article argues that bioethics should turn the “good life” into an issue of intense, explicit and systematic consideration. Furthermore, the article provides an initial answer to the questions as to why the “good life” has been marginalized within bioethics up to this point and which function it can assume in future bioethical reflection.Conclusion The “good life” is the blind spot of bioethics. A more intensive and systematic consideration of the “good life” is a challenge for contemporary and future bioethics.     

Individuelle Gesundheitsleistungen in der vertragsärztlichen Versorgung

Definition of the problem

Within Germany’s statutory health insurance system Individual health services are offered (by physicians) or demanded (by patients) with increasing frequency establishing a "second health market". The services come from a wide and heterogeneous spectrum including highly beneficial and evidence-based methods (malaria prophylaxis), so far questionable (sputum cytology) or probably beneficial (osteodensitometry in high-risk populations) screening methods, dubiousand untested methods fromthe field of alternative and complementary medicine and various services to enhance beauty, fitness or wellness. The services are not, as a common characteristic, part of Germany’s official health care offer and have to be paid foron a strictly private basis.

Arguments

This article discusses chances and risks of the development within a normative framework and addresses five questions.How does selling and buying of "individual services" affect the traditional role of physicians, the identification of useful medical methods and services, our understanding of medicine and its goals, the traditional role of patients, the doctor-patient relationship and our understanding of the German statutory health insurance system?

Conclusion

Individual health services are for various and heterogeneous reasons attractive for both patients and doctors. Whereas medicine becomes more and more regulated, they seem to increase the degrees of freedom and range of options of each side. The services may however profoundly change the role and perception of the medical profession within a collectively financed health care system. Whether the second health care market can be effectively controlled and itself regulated is at present an open question.     

控制周期激励Van der Pol-Duffing振子的混沌

对周期激励Van der Pol-Duffing振子进行了研究:(x··)-μ(1-x2)(x·)-αx βx3=f cos ωt.首先运用相图分析、直接观察运动时间序列的方法发现,Van der Pol-Duffing振子在一定条件下会出现混沌行为.在实际工程中,混沌行为往往会导致振荡或不规则运动,甚至主系统的彻底崩溃,因此有必要抑制系统的混沌行为.文中采用周期激振力法对系统中的混沌行为进行了控制,并结合lyapunov指数谱进行了分析,结果表明Van der Pol-Duffing振子中的混沌运动得到了有效的控制.     

一类非线性Van der Pol-Duffing振子的隐藏吸引子

研究了一类非线性Van der Pol-Duffing振子的隐藏吸引子.运用经典动力系统Hopf分支理论,研究该非线性系统的周期轨、Hopf分支和其他动力学行为,通过谐波线性化方法和一种新的数值算法,来定位隐藏吸引子,并通过数值模拟对该非线性系统存在隐藏吸引子进行验证.     

改进的Van der Waals方程推算双组分的吸附平衡

借鉴热力学状态方程在气液平衡中的经验,修改了二维van der Waals状态方程,并在气固吸附平衡中应用。从纯组分的吸附等温线出发,推算气和二氧化碳混和物及二氧化碳和一氧化碳的混和物分别在C_u(I)Y沸石上的吸附平衡。还用另外三个吸附模型的计算和比较。它们是理想吸附溶液模型,Flory—Huggins活度系数方程的吸附空穴溶液模型及二维van der Waals状态方程。结果表明,本文改进的方程推算实验数据的效果比其它模型好,尤其是关于一氧化碳和二氧化碳在C_u(I)Y石上的吸附,络合吸附和物理吸附是同时发生的。     

Van der Pol—Duffing系统共振双Hopf分岔

研究时滞反馈van der Pol-Duffing系统的共振双Hopf分岔,讨论时滞量和位移反馈增益变化对双Hopf分岔的影响。利用Hopf分岔定理得到系统出现1∶2共振双Hopf分岔的充要条件;借助中心流形定理和平均化方法约化了系统,从理论上分析共振双Hopf分岔点附近的动力学行为,得到共振双Hopf分岔引起的各种周期解的近似解析解和稳定性条件;通过数值实验,验证了理论分析的正确性。结果表明,时滞和位移反馈增益不仅导致共振双Hopf分岔,而且会使系统出现多稳态周期运动。     

一类Van der Pol-Duffing系统的变结构滑模控制

研究了一类含有平方项和5次幂项的Van der Pol-Duffing系统的跟踪控制问题.首先,基于Lyapunov指数理论和分岔理论分析了该系统的复杂动力学行为,包括周期运动、倍周期分岔、混沌运动等;然后,在系统参数已知和未知的两种情况下,基于Lyapunov稳定性定理分别构造了两类简单的变结构滑模控制器对该系统的混...