Solidarity with Whom? The Boundary Problem and the Ethical Origins of Solidarity of the Health System in Taiwan.

Publicly-funded health systems, including those national health services and social or National Health Insurances, are institutionalized solidarity in health. In Europe, solidarity originated from the legacies of labor movements, the Judeo-Christian traditions, and nationalist sentiments in the re-construction Era after the WWII. In middle-to-high income East Asian countries, such as Japan, Taiwan, Korea, the health systems were built on different grounds and do not have such ethical origins of solidarity. As health systems in Europe and East Asia are both facing sustainability crises due to aging population, stagnant economy, changing boundaries, and advancing medical technologies, how those systems with the European solidaristic ethical traditions can be revived and how those without the European traditions could survive become a matter of theoretical interests and an urgent policy problem to be addressed. Drawing on contemporary theories of solidarity, this essay analyzes the boundary problem and its impact on the sustainability of the health system in Taiwan. It then considers two plausible origins of solidarity in Taiwan. One is the re-emerged civic nationalism, and the other is an ethos of common life. It is argued that after years of implementation, the National Health Insurance in Taiwan might have shaped the social values and people's habits and formed an ethos of common life. Such ethos could be an ethical origin of solidarity in non-western societies and help the health systems endure the prolonged sustainability crises.

Conflicting demands on a modern healthcare service: Can Rawlsian justice provide a guiding philosophy for the NHS and other socialized health services?

We explore whether a Rawlsian approach might provide a guiding philosophy for the development of a healthcare system, in particular with regard to resolving tensions between different groups within it. We argue that an approach developed from some of Rawls' principles - using his 'veil of ignorance' and both the 'difference' and 'just savings' principles which it generates - provides a compelling basis for policy making around certain areas of conflict. We ask what policies might be made if those making them did not know if one was patient, doctor, nurse or manager - in this generation or the next. We first offer a brief summary of Rawls' approach and how we intend to extrapolate from it. We examine how this adapted Rawlsian framework could be applied to specific examples of conflict within healthcare; we demonstrate how this framework can be used to develop a healthcare service which is both sustainable (in its training and treatment of staff, and in encouraging research and innovation) and open (to protect the powers and opportunities of those using the health service). We conclude that while Rawls' approach has previously been rejected as a means to address specific healthcare decisions, an adapted veil of ignorance can be a useful tool for the consideration of how a just health service should be constructed and sustained. Turning the theoretical into the practical (and combining Rawls' thought experiment with Scanlonian contractarianism), managers, doctors, patients, carers and nurses could come together and debate conflicting issues behind a hypothetical veil.

Obligation and the Changing Nature of Publicly Funded Healthcare.

This article explores the relationship between obligation and publicly funded healthcare. Taking the National Health Service (NHS) as the focal point of discussion, the article presents a historical analysis of the shifting nature and function of obligation as it relates to this institution. Specifically, and drawing inspiration from recent literature that takes seriously the notion of the tie or bond at the core of obligation, the article explores how the forms of social relation and bonds underpinning a system like the NHS have shifted across time. This is undertaken via an analysis of Aneurin Bevan's vision of the NHS at its foundation, the importance today of the patient (and the individual generally) within publicly funded healthcare, and the role of contract as a contemporary governance mechanism within the NHS. A core feature of the article is its emphasis on the impact that a variety of economic factors-including privatisation, marketisation, and the role of debt and finance capital-are having on previously settled understandings of obligation and the forms of social relation underpinning them associated with the NHS. It is therefore argued that an adequate analysis of obligation in healthcare law and related fields must extend beyond the doctor-patient relationship and that of state-citizen of the classical welfare state in order to incorporate new forms of relation, such as that between creditor and debtor, and new actors, including private healthcare providers and financial institutions.

[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]. / Standards für die Behandlung im Maßregelvollzug nach §§ 63 und 64 StGB : Interdisziplinäre Task-Force der DGPPN.

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

[Changes in the German Medicinal Product Act imposed by the EU regulation on clinical trials]. / Änderungen des Arzneimittelgesetzes durch die EU-Verordnung zu klinischen Prüfungen.

The entry into force of Regulation (EU) No. 536/2014 of the European Parliament, the Council of 16 April 2014 for clinical trials on medicinal products for human use, and repealing Directive 2001/20/EC necessitated amendments to the national legislation on medicinal products. These changes mainly concern the sixth chapter of the German Medicinal Products Act (Arzneimittelgesetz, AMG) and the elimination of the GCP (good clinical practice) ordinance for clinical trials that will be covered by the regulation in the future. Sections 41a, 41b and 41c, which came into force in December 2016, regulate the registration procedure, the procedural rules and the business distribution plan according to which the responsibilities of the registered ethics committees for the authorisation procedures will be determined and cooperation with the federal higher authorities will be handled. All other amendments in the sixth chapter will not enter into force until the date of application of the regulation - presumably in the fourth quarter of 2018. In the future, Section 40a will regulate the general prerequisites - in particular the basic procedures for cooperation between the federal higher authority and the ethics committees - in addition to the provisions of the regulation. Section 40b governs special prerequisites for clinical trials and contains, in particular provisions for the informed consent in clinical trials with minors and incapacitated adults. Further changes concern, among other things, the transfer of previous regulations of the GCP ordinance into the AMG and adjustments regarding reporting obligations in the context of clinical trials in the AMG.

[Decision Support for the Therapy Planning for Young Refugees and Asylum-Seekers with Posttraumatic Disorders]. / Entscheidungshilfe zur Therapieplanung bei jugendlichen Flüchtlingen und Asylbewerbern mit Traumafolgestörungen in der ambulanten Praxis.

Decision Support for the Therapy Planning for Young Refugees and Asylum-Seekers with Posttraumatic Disorders Due to the Convention on the Rights of the Child and § 6 of the Asylum Seekers' Benefit Act, there are legal and ethical obligations for the care of minor refugees suffering from trauma-related disorders. In Germany, psychotherapeutic care of adolescent refugees is provided by specialized treatment centers and Child and Adolescent psychiatries with specialized consultation-hours for refugees. Treatment of minor refugees is impeded by various legal and organizational barriers. Many therapists have reservations and uncertainties regarding an appropriate therapy for refugees due to a lack of experience. This means that only a fraction of the young refugees with trauma-related disorders find an ambulatory therapist. In a review of international literature, empirical findings on (interpreter-aided) diagnostics and therapy of young refugees were presented. Practical experiences on therapeutic work with traumatized young refugees were summarized in a decision tree for therapy planning in the ambulatory setting. The decision tree was developed to support therapists in private practices by structuring the therapy process.

No payments, copayments and faux payments: are medical practitioners adequately equipped to manage Medicare claiming and compliance?

The complexity of Medicare claiming means it is often beyond the comprehension of many, including medical practitioners who are required to interpret and apply Medicare every day. A single Medicare service can be the subject of 30 different payment rates, multiple claiming methods and a myriad of rules, with severe penalties for non-compliance, yet the administrative infrastructure and specialised human resourcing of Medicare may have decreased over time. As a result, medical practitioners experience difficulties accessing reliable information and support concerning their claiming and compliance obligations. Some commentators overlook the complexity of Medicare and suggest that deliberate misuse of the system by medical practitioners is a significant contributor to rising healthcare costs, although there is currently no empirical evidence to support this view. Quantifying the precise amount of leakage caused by inappropriate claiming has proven an impossible task, although current estimates are $1-3 billion annually. The current government's proposed copayment plan may cause increases in non-compliance and incorrect Medicare claiming, and a causal link has been demonstrated between medical practitioner access to Medicare education and significant costs savings. Medicare claiming is a component of almost every medical interaction in Australia, yet most education in this area currently occurs on an ad hoc basis. Research examining medical practitioner experiences and understanding regarding Medicare claiming and compliance is urgently required to adapt medicine responsibly to our rapidly changing healthcare environment.

Prenatal screening, reproductive choice, and public health.

One widely held view of prenatal screening (PNS) is that its foremost aim is, or should be, to enable reproductive choice; this is the Pure Choice view. The article critiques this position by comparing it with an alternative: Public Health Pluralism. It is argued that there are good reasons to prefer the latter, including the following. (1) Public Health Pluralism does not, as is often supposed, render PNS more vulnerable to eugenics-objections. (2) The Pure Choice view, if followed through to its logical conclusions, may have unpalatable implications, such as extending choice well beyond health screening. (3) Any sensible version of Public Health Pluralism will be capable of taking on board the moral seriousness of abortion and will advocate, where practicable, alternative means of reducing the prevalence of disease and disability. (4) Public Health Pluralism is at least as well-equipped as the Pure Choice model to deal with autonomy and consent issues.

[Health inequalities and cost-effectiveness: what do important health policy actors say about this potential conflict situation?]. / Gesundheitliche Chancengleichheit und Kosten-Effektivität: Was sagen wichtige gesundheitspolitische Akteure zu diesem potentiellen Zielkonflikt?

The German statutory health-care system is based on the principle of solidarity and thus it is committed to the objective of 'equal chances'. From an economic perspective it is also important to emphasise that scarcity of resources continuously pushes the services towards cost control and towards increasing cost-effect-iveness. There could be conflicts between the 2 objectives 'equal chances' and 'cost-effectiveness', of course, for example if measures for increasing cost-effectiveness lead to increased financial burdens of the insured. To date it has not been studied if and how this potential conflict is discussed in Germany.In a first step we searched for German publications discussing this potential conflict focusing on 3 major public health journals (Das Gesundheitswesen, Bundesgesundheitsblatt, Ethik in der Medizin) and on the internet portal "gerechte-gesundheit.de". For the main part of the paper, we looked for publications from 4 major health policy actors (Bundesärztekammer, Zentrale Ethikkommission bei der Bundesärztekammer, Deutscher Ethikrat, Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen). All papers published since the year 2000 were included in the system-atic qualitative analysis.The analyses show that the potential conflict between 'equal chances' and 'cost-effectiveness' is rarely discussed in any detail, at most in an implicit way. It would be important, though, to have an explicit discussion, supported by scientifically based analyses and recommendations. One step towards this objective could be, for example, a closer cooperation between social-epidemiologists and health--economists.

[Patients' rights--doctors' duties]. / Patientenrechte--Arztpflichten (I).

On 26 February 2013 the new "Law on Patients' Rights" (hereinafter also the "Law") became effective. This Law strengthens patients' rights vis-à-vis the insurdnce company and also regulates patients' rights regarding their relation to the doctor. This has consequences for the laws on medical liability all doctors must consider. The doctor's performance is and remains a service and such service does not hold any guarantee of success. Nevertheless, this Law primarily reads as a "law on the duties of physicians". To duly take into account these duties and to avoid mistakes and misinterpretation of the Law, the Ethics Committee of the Consortium of Osteosynthesis Trauma Germany (AOTRAUMA-D) has drafted comments on the Law. Brief summaries of its effects are to be found at the end of the respective comment under the heading "Consequences for Practice". The text of the law was influenced particularly by case law, as continuously developed by the German Federal Court of Justice ("BGH"). The implementation of the Law on Patients' Rights was effected by the newly inserted sections 630a to 630h of the German Civil Code (the "BGB"), which are analysed below. The following comments are addressed to physicians only and do not deal with the specific requirements and particularities of the other medical professions such as physiotherapy, midwifery and others so on. Special attention should be paid to the comments on the newly inserted Duty to inform, which has to be fullfilled prior to any diagnostic or therapeutic procedure (sec. 630c para 2 sentence 1 BGB). Under certain conditions the doctor also has to inform the patient about the circumstances that lead to the presumed occurance of a therapeutic or diagnostic malpractice (sec. 630c para. 2 sentence 2 BGB), based on the manifestation of an undesired event or an undesired outcome. As before, the patient's valid consent to any procedure (sec. 630d BGB) is directly linked to the comprehensive and timely provision of information (sec. 630e BGB). Comprehensive documentation obligations regarding all procedures are stipulated in sec. 630f BGB. As before, the burden of proof still rests with the patient, unless a severe malpractice has been established (sec. 630h BGB). The definition of "severe malpractice" remains unchanged and is based on the case law of the Federal Court of Justice (BGH). The patient's obligations to preserve his or her health and to actively support the process of recovery and securing a positive outcome of the treatment are not explicitly mentioned in the Law. Nevertheless, the patient and the physician need to work closely together to achieve a successful result of the treatment. In case the patient does not give his or her cooperation, the physician should consider terminating the treatment relationship.

[Today's jobs in the healthcare sector are comparable to other professions]. / Gesundheitsberufe sind heute Berufe wie andere auch.

By applying current standards of job descriptions and performance profiles in the healthcare sector, this article focuses on the issue whether there are fundamental differences between physicians and other healthcare professionals compared to other professions. There are special requirements for physicians, such as a university degree, but the same also holds true for other professions. The increasing economization of the healthcare sector in recent years has led to a situation where differences in the standards for healthcare professionals when compared to other occupations are no longer apparent. Medical directors at university hospitals also have to conform to standards that are applied to executive managers in other businesses. Besides the obvious professional skills, communication with patients and collaborators, knowledge of economics and leadership competence are also mandatory. This does not exclude the impression that physicians and nurses subjectively see in their profession more than just a job but truly a vocation.

[Bioethics in medical institutions--new custom or help? The example of clinical ethics consultation at a University Medical Center]. / Bioethik in medizinischen Institutionen--Mode oder Hilfe? Das Beispiel der klinischen Ethikberatung eines Universitätsklinikums.

Although ethics committees are well established in the medical sciences for human clinical trials, animal research and scientific integrity, the development of clinical ethics in German hospitals started much later during the first decade of the twenty-first century. Clinical ethics consultation should be pragmatic and problem-centered and can be defined as an ethically qualified and informed conflict management within a given legal framework to deal with and resolve value-driven, normative problems in the care of patients. Clinical ethics consultations enable shared clinical decision-making of all parties (e.g. clinicians, patients, family and surrogates) involved in a particular patient's care. The clinical ethicist does not act as an ethics expert by making independent recommendations or decisions; therefore, the focus is different from other medical consultants. Ethics consultation was first established by healthcare ethics committees (HEC) or clinical ethics consultation (CEC) groups which were called in to respond to an ethically problematic situation. To avoid ethical dilemmas or crises and to act preventively with regard to ethical issues in individual patients, an ethics liaison service is an additional option to ethics case consultations which take place on a regular basis by scheduled ethics rounds during the normal ward rounds. The presence of the ethicist offers some unique advantages: it allows early recognition of even minor ethical problems and accommodates the dynamics of ethical and clinical goal-setting in the course of patient care. Most importantly, regular and non-authoritative participation of the ethicist in normal ward rounds allows continuous ethical education of the staff within the everyday clinical routine. By facilitating clinical ethical decision-making, the ethicist seeks to empower physicians and medical staff to deal appropriately with ethical problems by themselves. Because of this proactive approach, the ethics liaison service can make a significant contribution to preventative ethics in reducing the number of emerging ethical problems to the satisfaction of all parties involved.

[Healthcare occupations are "different"]. / Gesundheitsberufe sind "anders"

Healthcare requires careful coordination of several occupations. In order to attain the best possible result, including effectiveness and cost-efficiency, the specific expertise of each of these occupations must be clearly defined. Healthcare occupations, physicians and nurses, are indeed professions as opposed to mere "jobs". They are concerned with living but ill human beings and not with things. Reliance on a personal capacity of judgment is a decisive aspect of professions. Healthcare professionals perform best if they are granted specific independence relative to their work.

Medicine and the holistic understanding of the human being: ultrasound examination as dialog.

Ultrasound can capture the living nature of a person. This capturing of life depends greatly on experience as well as sense of touch, intuition, sense of speech, and not least a sense for the distinctiveness of every person. Performing ultrasound is not simply the application of a technique but rather a merging of man and technology in the framework of an interpersonal encounter. Therefore, as much should be invested in the interpersonal nature of the encounter as in the development of the technical principles of the ultrasound probe. To effectively perform ultrasound, it is necessary to avoid viewing ultrasound from a purely technical view and to always remember the importance of the relationship to the patient, particularly during the technical examination.

[Challenges of an integrative and personalised health care for health economics and the insurance system]. / Herausforderungen einer integrativen und personalisierten Gesundheitsversorgung für die Gesundheitsökonomie und das Versicherungssystem.

OBJECTIVES: "Stratifying medicine" is a topic of increasing importance in the public health system. There are several questions related to "stratifying medicine". This paper reconsiders definitions, opportunities and risks related to "stratifying medicine" as well as the main challenges of "stratifying medicine" from the perspective of a public health insurance. DEFINITION: The application of the term and the definition are important points to discuss. Terms such as "stratified medicine", "personalised medicine" or "individualised medicine" are used. The Techniker Krankenkasse prefers "stratifying medicine", because it usually means a medicine that tailors therapy to specific groups of patients by biomarkers. OPPORTUNITIES AND RISKS: "Stratifying medicine" is associated with various hopes, e. g., the avoidance of ineffective therapies and early detection of diseases. But "stratifying medicine" also carries risks, such as an increase in the number of cases by treatment of disease risks, a duty for health and the weakening of the criteria of evidence-based medicine. CHALLENGES: The complexity of "stratifying medicine" is a big challenge for all involved parties in the health system. A lot of interrelations are still not completely understood. So the statutory health insurance faces the challenge of making innovative therapy concepts accessible in a timely manner to all insured on the one hand but on the other hand also to protect the community from harmful therapies. Information and advice to patients related to "stratifying medicine" is of particular importance. The equitable distribution of fees for diagnosis and counselling presents a particular challenge. The solidarity principle of public health insurance may be challenged by social and ethical issues of "stratifying medicine". CONCLUSION: "Stratifying medicine" offers great potential to improve medical care. However, false hopes must be avoided. Providers and payers should measure chances and risks of "stratifying medicine" together for the welfare of the patients.

[Medical ethics in the undergraduate medical curriculum and in the health care system]. / Ethik und ärztliches Ethos im Medizinstudium und im Gesundheitswesen.

In German speaking areas, in the scientific establishment which is occupied with medical ethics in the narrower and wider senses, a vehement discussion has developed as to whether or not medical practitioners must ultimately advocate that which is understood to be modern medical ethics. Against the background of this discussion, this article takes up a position on these questions, not only theoretically, but also with reference to the fields of practice of medical studies, hospitals, and the health system. The article presents the proposals of the Institute for Ethics and Law in Medicine (University of Vienna) for the evaluation and further development of the theme of ethics within the framework of the Medical Curriculum of Vienna (MCW). Among other things, this requires an integrated model of levels of ethical competence.

[Information technology in medicine - some legal observations].

Information Technology (IT) and computing capabilities are revolutionizing the practice of medicine in an unprecedented way. Some current legal and ethical concerns evolving from this revolution are addressed, pointing to the emerging concepts in Israeli jurisprudence, which regards medical IT as an important contribution to patient empowerment, to medical risk management and in managing the resources of a national health system.

Ethical questions must be considered for electronic health records.

National electronic health record initiatives are in progress in many countries around the world but the debate about the ethical issues and how they are to be addressed remains overshadowed by other issues. The discourse to which all others are answerable is a technical discourse, even where matters of privacy and consent are concerned. Yet a focus on technical issues and a failure to think about ethics are cited as factors in the failure of the UK health record system. In this paper, while the prime concern is the Australian Personally Controlled Electronic Health Record (PCEHR), the discussion is relevant to and informed by the international context. The authors draw attention to ethical and conceptual issues that have implications for the success or failure of electronic health records systems. Important ethical issues to consider as Australia moves towards a PCEHR system include: issues of equity that arise in the context of personal control, who benefits and who should pay, what are the legitimate uses of PCEHRs, and how we should implement privacy. The authors identify specific questions that need addressing.