[Rationality and freedom in medicine: the case of electroconvulsive therapy]. / Rationalität und Freiheit in der Medizin: Der Fall der Elektrokrampftherapie.

There are no rational reasons why electroconvulsive therapy (ECT) should not be subject to the same criteria in its clinical application as any other treatment in medicine. Associations referring to historical events and their presentation in the media do not provide convincing arguments against the clinical use of ECT. In order to offer ECT to patients, scientifically solid evidence with respect to its clinical results must be available. As this scientific evidence is clearly given, ECT must be offered to the patients. A well-informed, reflected medicine must not withhold an effective treatment like ECT from the patients and medicine should not be influenced by associations but only by scientific evidence, even though the exact mechanisms of action of ECT are not known in detail. The image of ECT has clearly improved during the last decades thereby increasing the hope that unjustified arguments against ECT will lose their impact.

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 authorized surrogate must assert the patient's will. The role of the guardianship court is clarified: it only needs to be involved in cases of disagreement as to the patient's will. The new German law thus combines more legal certainty with a liberal emphasis on patient autonomy and flexible, adaptable regulations.

[Ethical aspects of aesthetic medicine]. / 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.

[Globalization in medical research]. / Globalisierung in der medizinischen Forschung.

The globalization of clinical research is gaining momentum. In particular, emerging countries, such as Brazil, India, Russia and South Africa show a significant increase in clinical trials. This trend is generating various ethical problems, which are examined in the present article. Sometimes, generally accepted ethical rules, such as the evaluation of clinical trials by ethics commissions are not respected and sometimes conflicts are generated which are difficult to resolve. For instance, it is controversial which standard of care researchers and sponsors have to provide in an international study. These conflicts are exacerbated by a fundamental dilemma: more research on diseases prevalent in developing and emerging countries is necessary. At the same time, the protection of study participants in those countries creates particular challenges. In recent years, international commissions and guidelines have achieved significant progress in solving these conflicts; however, the further development has to be analyzed very carefully. Incentives for better research on neglected diseases have to be created. Undesirable developments and abuse have to be prevented by appropriate international ethical standards.

The German IVF Register as an Instrument to Document Assisted Reproductive Technologies.

The German IVF Register (Deutsches IVF-Register [D.I.R]) has been collecting and publishing data on the use of IVF and related methods in Germany since 1982. It is the only institution which provides information for all of Germany on procedures and their success rates. For this reason it plays an important role in the provision of information to the public, to patients, political decision-makers and the scientific community. However, the register does not have the data of all centers offering treatment in Germany nor does it have complete datasets on all reported treatments. The register accepts retrospective data entries, it does not publish the success rates of individual centers and up until 2015 it did not provide a summary of information which was suitable for non-specialists. The D.I.R has been the focus of criticism in the past. Even today, the information it provides to the scientific community, the public, political decision-makers and potential patients on the outcomes of assisted reproduction is insufficient. The documentation of reproductive medicine procedures in other countries is much more meaningful.

Uninformed Decisions? The Online Presentation of Success and Failure of IVF and Related Methods on German IVF Centre Websites.

Background: Patients increasingly use the internet as a source of medical information before initial contact with doctors and during treatment. This applies to reproductive medicine too, where the internet could offer patients the chance to inform themselves in advance about specific procedures and the treatment centres that offer them. In this way it could potentially contribute to informed patient decision-making. This article analyses the web presence of German fertility treatment centres with respect to the provision of information on success rates, risks and side effects of treatment. Methods: Analysis of published success rates and information on the risks and adverse effects of IVF and related methods on German IVF centre websites. Results: Over half of the 129 centres (62.02 %) state a general success rate or their own institution's success rate. Less than a quarter (24.03 %) states their own institution's pregnancy rate and only 7.75 % their own birth rate. The published success rates are mostly pregnancy rates (pregnancy per embryo transfer), which by definition are higher than baby take-home-rates creating unrealistic expectations. Only 61 centres (47.29 %) mention risks and side effects of the procedures offered, and that in varying detail. Only 7 centres (5.43 %) provide information on the risk of psychological stress associated with unsuccessful fertility treatment. Conclusion: There is insufficient opportunity for women and their partners to inform themselves adequately on the internet in advance of treatment about available treatment methods, their success rates and associated risks/side effects; this applies both to specific facilities as well as to the procedures in general. In contrast to other countries, in Germany there is a lack of discussion on content requirements for fertility treatment facility websites.

[Loneliness of the physician and the "vital drive for history". On the historical self concept of medicine by Richard Koch]. / Die Einsamkeit des Arztes und der "lebendige Drang nach Geschichte". Zum historischen Selbstverständnis der Medizin bei Richard Koch.

This article tries to identify the theory of medical history in the work of Richard Koch (1882-1949). Rejecting the wide-spread notion of medicine as a science he vigorously argued for a self-image of medicine as an art. From that point of view he built up his theory of medical history and histoography. He wanted medical histoography to be part of practical medicine.

[Not Available]. / Zum Verhältnis von Geschichte und Ethik in der Medizin.

The 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.

[End-of life decisions in intensive care units. Influence of patient wishes on therapeutic decision making]. / Therapiezieländerungen auf einer internistischen Intensivstation. Einfluss von Willensäußerungen der Patienten auf Therapieentscheidungen.

BACKGROUND: Among the ethical principles in medicine, respect for patient autonomy has gained the highest revaluation in recent decades. In Germany this was fostered by new legal regulations which came into effect in 2009 and clarified issues regarding end-of-life (EOL) decisions. In this study the influence of direct or mediated wishes of patient wills on EOL decisions in a medical intensive care unit (ICU) were investigated. METHODS: A retrospective analysis of all patients who died in the years 2009-2010 while being treated in the medical ICU of a large German university hospital was carried out. RESULTS: During the observation period 3,401 patients were treated in the ICU of whom 19 % (n=658) died in hospital. Of the 658 patients who died 126 (19 %) had received unlimited therapy, life support was withheld in 241 patients (37 %) and life support was withdrawn in 245 patients (37 %). In 46 patients (7 %) palliative care was instituted from the beginning of the ICU stay. In 104 cases (16 %) the patients themselves made the EOL decision and in 78 cases (12 %) an advance directive was given. A legal healthcare proxy was designated in 8 %. In 541 cases (82 %) the relatives were involved in the EOL decisions. No serious or unsolvable conflicts with relatives were experienced. Involvement of a court of law was not necessary in any of the cases. CONCLUSIONS: In a high percentage of the patients (81 %) who died during the course of intensive care treatment EOL policies were in place. The patients or their relatives were almost always involved in the decision making process. The current German law is in concordance with the established EOL practice in this intensive care unit.

[Limiting life-prolonging treatments: a practical guidance reflecting the current legislation in Germany]. / Begrenzung lebenserhaltender Massnahmen: Eine Handreichung für die Praxis auf der Grundlage der aktuellen Gesetzgebung.

From the general ethical and legal requirements of medical interventions it can be inferred when life-prolonging treatments can or should be limited: If the intervention has no benefit for the patient and/or the properly informed patient refuses to consent to the intervention. Two questions are especially challenging: When are medical interventions futile? And: How should decisions be made on behalf of incompetent patients? In accordance with prior high court rulings, the new Civil Law legislation in Germany provides three standards for proxy decision making: (1) the patients' written advance directive, (2) oral treatment preferences and substituted judgement, and (3) the patient's best interest. Thereby, (1) has priority over (2) and (2) has priority over (3). In addition, the article discusses conflicts between autonomy and well-being of the patient.

[Medical acting confronted with vague prognoses. Considerations about the structure of medical acting]. / Arztliches Handeln angesichts unklarer Prognosen. Uberlegungen zu den Grundstrukturen ärztlichen Handelns.

The article examines the structures of the medical acting, especially in oncology. It discusses how to address the issue of an adequate response to the structures of medical acting. In addition to a commitment to certain goals (for the benefit of patients, to do no harm, respect of autonomy of the patient) a doctor has to act according to the rules of art. This requires specialist knowledge and skills. Additionally the always remaining uncertainty of medical acting requires an internal disposition, which is also understood as a virtue.

The medical theory of Richard Koch I: theory of science and ethics.

Richard Koch first made his appearance in the 1920s with works published on the foundations of medicine. These publications describe the character of medicine as an action and the status of medicine within the theory of science. One of his conclusions is that medicine is not a science in the original sense of the word, but a practical discipline. It serves a practical purpose: to heal the sick. All medical knowledge is oriented towards this purpose, which also defines the physician's role. One kind of knowledge is diagnosis, which is strictly understood in relation to therapy, and is at the core of medical thinking. Diagnosis is not the assignment of a term of a species to a patient's disease: this would not do justice to the individuality of a clinical manifestation and would fail to provide a reason for individual therapy. Nevertheless, the terms assigned to diseases, although fictitious, are not useless, but assist in differentiating various phenomena. These conclusions carry ethical consequences. Because the task of helping the sick constitutes medicine, morals not only set ethical limits: medicine originates in a moral decision. If there are no diseases but only individual sick people, disease can not be defined as an abnormality. The individual benefit to the patient must not necessarily be the complete restoration of health. With its object being incalculable, medicine cannot guarantee its own success. Here the physician has to develop principles that allow for the best possible response to the challenges faced in varying situations of conduct.

The medical theory of Richard Koch II: natural philosophy and history.

Richard Koch(1) became known in the 1920s with works on basic medical theory. Among these publications, the character of medical action and its status within the theory of science was presented as the most important theme. While science is inherently driven by the pursuit of knowledge for its own sake, medicine pursues the practical purpose of helping the sick. Therefore, medicine must be seen as an active relationship between a helping and a suffering person. While elucidating this relationship, Koch discusses the fundamental elements of medicine found in natural philosophy and the relationship of medicine to its own history. One of his aims is to unite natural history and the history of ideas without reducing intellectual processes to biological ones. Koch considers free will as something intuitively certain. It must serve as an axiom which will capture human as well as non-human reality. Based on the fact that human free will, considered a psychic quality, evolved out of inanimate matter, Koch grants matter (proto-) psychic qualities. They are evoked through specific constellations of matter. - With regard to history, Koch rejects the notion of constant progress. The history of medicine has provided insights that cannot be surpassed but can be obscured. Historical self-contemplation serves as a means for avoiding any deviations which may prevent medicine from fulfilling its ultimate purpose. Koch connects nature and history through the concept of a unity between natural history and the historical development of medicine. Medicine is considered an especially complex development of a purposive reaction to harmful stimuli, a reaction which can already be encountered in unicellular organisms. Without intending to reduce historical and mental processes to biological ones, Koch sets for himself the aim of gathering different phenomena and presenting them in one encapsulating unity.

In vitro fertilization: regulations in Germany.

KIE: Conclusion: The short history of IVF gives the impression that traditional and valid norms of medical ethics have been forgotten in view of something tremendously new. The new ethical problems and the ethical challenges were acknowledged, but what was known and absoulutely standardized was forgotten. The Hippocratic tradition of "helping the sufferer" is used as an argument for IVF, but it is doubtful whether the practical application of IVF can easily be brought into accord with this tradition, although the therapy can be beneficial in an individual case. Nevertheless, further research is necessary to improve the poor success rates.... In this respect, conditions are not adequate to answer the question "therapy or experiment?" Patients have been misled by exorbitant success figures and have not been informed that IVF can in no way be regarded as clinically tested in all indications. The observation in 1990 of a commission of the Academy for Ethics within Medicine that "there are very many 'losers' in IVF and only a few 'winners'" should have aroused more attention. Assuming an authentic intention to help all concerned, why has one of the most spectacular projects in modern medicine received such a negative evaluation? The answer to the question is certainly complex. One of the factors involved is the momentum of technology; and medical ethical tradition was sacrificed because of the impending danger of missing a technological development.^ieng

[Responsibility of the physician in reproductive medicine]. / Zur Verantwortung des Arztes in der Reproduktionsmedizin.

The article explores the responsibility of the physician in reproductive medicine as a therapist of the couple and the child. It is based on the understanding of responsibility as a term with six relations. The article emphasizes that responsibility can only be ascribed to the physician with regard to the structure of the physicians acting.

[Auguste Böhner's death. Chronicle of a medical scandal, its background and its historical significance]. / Der Tod der Auguste Böhmer. Chronik eines medizinischen Skandals, seine Hintergründe und seine historische Bedeutung.

When the 15-year-old Auguste Böhmer, daughter of Caroline Schlegel and stepdaughter of August Wilhelm Schlegel, died on 12th July 1800, Friedrich Wilhelm Joseph Schelling was accused of being responsible for this tragic event, because he tried to treat her according to the medical system of John Brown. The ensuing scandal became a symbol for the danger of every progressive movement of that time: the Romantic literature, the natural philosophy of Schelling and Brownianism in its German version, represented by Andreas Röschlaub. An attempt is made to analyse the social and political background of the scandal and to argue the historical meaning as a fight against a fundamental reform of medicine.

Style and responsibility: medicine in postmodernity.

To what extent can postmodern developments be observed in modern medicine and which theories of postmodern philosophy can we draw on with regard to medicine's theoretical problem? This article explores these questions with special emphasis on the epistemological status of medicine, the concept of disease, and the anthropological model. It is examined whether medicine's inherent duty to act can be questioned in the light of the plurality that characterizes postmodernity. It is concluded that, according to postmodern philosophy, medicine should be characterized by a justified variety of paradigms. Cooperation within the variety must continue to be guaranteed, always in favor of the constitutive moral duty of medicine.