[Interdisciplinary cooperation in occupational health: ethical friction]. / Interdisciplinair werken bij arbeid en gezondheid: ethische fricties.

OBJECTIVE: To investigate which ethical considerations play a role in the assessment of absenteeism due to sickness and of disability, and how these are dealt with. DESIGN: Qualitative, exploratory study. METHOD: We conducted interviews with 32 individual professional practitioners: 8 occupational health physicians, 8 insurance company physicians, 8 general practitioners, and 8 psychologists, with the aid of a semi-structured questionnaire. During the interview we differentiated between 4 clusters of questions referring to the ethical, legal, interdisciplinary, and professional context, respectively. The study revealed only the spectrum of ethical considerations that played a role, and not the representativeness. For this reason the results did not allow for quantitative conclusions. RESULTS: Differences in the manner of thinking and behaving between health-care providers stem from differences in ethical considerations and in background beliefs. These differences hinder effective cooperation within the occupational health sector. CONCLUSION: To improve professional performance and to achieve more responsible decision-making those involved need to be aware of their ethical considerations and background beliefs and to make them explicit, possibly with the aid of a checklist.

For love or money? Attitudes toward financial incentives among actual living kidney donors.

Due to lengthening waiting lists for kidney transplantation, a debate has emerged as to whether financial incentives should be used to stimulate living kidney donation. In recent surveys among the general public approximately 25% was in favor of financial incentives while the majority was opposed or undecided. In the present study, we investigated the opinion of living kidney donors regarding financial incentives for living kidney donation. We asked 250 living kidney donors whether they, in retrospect, would have wanted a financial reward for their donation. We also investigated whether they were in favor of using financial incentives in a government-controlled system to stimulate living anonymous donation. Additionally, the type of incentive deemed most appropriate was also investigated. In general almost half (46%) of the study population were positive toward introducing financial incentives for living donors. The majority (78%) was not in favor of any kind of reward for themselves as they had donated out of love for the recipient or out of altruistic principles. Remarkably, 60% of the donors were in favor of a financial incentive for individuals donating anonymously. A reduced premium or free health insurance was the preferred incentive.

Altruistic donor triggered domino-paired kidney donation for unsuccessful couples from the kidney-exchange program.

Between January 2000 and July 2009, 132 individuals inquired about altruistic kidney donation to strangers. These donors were willing to donate to genetically and emotionally unrelated patients. Some altruistic donors wished to donate to a specific person, but most wished to donate anonymously. In domino-paired donation, the altruistic donor donates to the recipient of an incompatible couple; the donor of that couple (domino-donor) donates to another couple or to the waiting list. In contrast to kidney-exchange donation where bilateral matching of couples is required, recipient and donor matching are unlinked in domino-paired donation. This facilitates matching for unsuccessful couples from the kidney-exchange program where blood type O prevails in recipients and is under-represented in donors. Fifty-one altruistic donors (39%) donated their kidney and 35 domino-donors were involved. There were 29 domino procedures, 24 with 1 altruistic donor and 1 domino-donor, 5 with more domino-donors. Eighty-six transplantations were performed. Donor and recipient blood type distribution in the couples limited allocation to blood type non-O waiting list patients. The success rate of domino-paired donation is dependent on the composition of the pool of incompatible pairs, but it offers opportunities for difficult to match pairs that were unsuccessful in the kidney-exchange program.

"Living apart together": moral frictions between two coexisting organ transplantation schemes.

Cadaveric transplantation and living transplantation exist side by side. Both practices help to alleviate organ need. They provide us with two separate moral schemes. Is it rational to keep them apart? The cadaveric system is organised along strict, impartial lines, while the living system is inherently partial and local. The ethical justification for this partial scheme seems to be that it merely supplements the cadaveric scheme: partial transplants do not come at the expense of cadaveric impartiality, but in fact significantly reduce the waiting time for patients on the list for a cadaveric transplant. This seemingly peaceful coexistence is challenged by new initiatives, among them living donation list exchange, and also the LifeSharers initiative, leading to practices that undermine cadaveric impartiality. Should we bemoan this fact, or should we move on towards a new balance in the relationship between cadaveric and living transplantation practices, towards a new moral weighing of impartial and partial values? I argue, against the background of a rapid growth of living donations, that we have good, ethical reasons--not only utilitarian ones--for giving the value of partiality a more prominent place in our policies.

Ethical considerations on consent procedures for emergency research in severe and moderate traumatic brain injury.

Therapeutic trials in TBI are subject to principles of Good Clinical Practice (GCP), to national legislation, and to international and European ethical concepts and regulations [e.g. 13]. The guiding principles underlying these investigations of treatment are respect for autonomy of research subjects, protection against discomfort, risk, harm and exploitation and the prospect of some benefit. Patients with significant TBI are mentally incapacitated, thus prohibiting obtaining consent directly from the subject. Various approaches to consent procedures are used as surrogate to subject consent: proxy consent, consent by an independent physician and waiver of consent. These approaches are reviewed. A questionnaire soliciting opinions was mailed to 148 EBIC (European Brain Injury Consortium) associated neuro-trauma centers in 19 European countries. 48% respondents believe that relatives were not able to make a balanced decision, 72% believed that consent procedures are a significant factor causing decrease in enrollment rate and 83% stated that consent procedures delay initiation of study treatment, resulting in possible harm if the agent has shown to be effective. 64% of the respondents considered TBI an emergency situation in which clinical research could be initiated under the emergency exception for consent. In new European legislation, emergency research under waiver of consent is not permitted. Nevertheless, we consider that randomising patients with TBI into carefully evaluated trial protocols without prior consent may be considered ethically justified.

[Cross-over transplantation; a new national program for living kidney donations]. / Gepaarde donorruil; nieuw landelijk programma voor nierdonatie bij leven.

In the Netherlands, cross-over kidney transplantation has been introduced as an extra option in the living kidney donation programme. In cross-over transplantation, patients who cannot be given their own partner's kidney for immunological reasons are given a kidney from the partner of another patient in exchange for a kidney from their own partner. There is no difference in the medical indications and contraindications between direct and indirect living donation. There are no ethical obstacles since the net gain for the two couples is no different from that of direct living kidney donation and because the exchange takes place on the basis of equality. One should be aware that the extra possibilities may result in more psychological pressure on potential donors. It is important that the donation procedures start at the same moment and that the wishes of patients and donors for anonymity be preserved. A successful cross-over kidney transplantation programme requires a large pool of donors and patients. Therefore, this has been organised in a national programme. The Dutch Transplantation Foundation is responsible for the allocation of cross-over kidneys. Organ trade will thus be impossible. The seven Dutch centres for kidney transplantation have developed a protocol.

Philosophical pitfalls in cosmetic surgery: a case of rhinoplasty during adolescence.

In the process of deciding to undergo cosmetic surgery for aesthetic reasons, people may err in various ways. Adolescents in particular run the risk of making errors, and both parents and surgeons have special moral responsibilities to avoid disappointments. Parents should face a number of moral issues; if they fail to do so, surgeons have a moral if not legal responsibility, to raise these issues and take a moral stand. In this paper, a number of pitfalls are specified from a philosophical perspective. A request for surgery should not be granted if patients do not meet the standards required for stable decision making and a balanced judgment, and particularly in those case where patients fail to understand the assumptions--in terms of human values--underlying the surgical intervention. Assessments of competence should go beyond formal conceptions of autonomy, and should, as will be shown, be made on an individual basis. Substantive questions of personal identity and identity formation, within the context of often rapid psychosocial development and emotional turmoil peculiar to adolescents, should be addressed. The key to the moral evaluation of this surgery therefore lies primarily in a patient's life story.