[Change in therapy target and therapy limitations in intensive care medicine. Position paper of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine]. / Therapiezieländerung und therapiebegrenzung in der intensivmedizin. Positionspapier der Sektion Ethik der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin.

The task of physicians is to maintain life, to protect and re-establish health as well as to alleviate suffering and to accompany the dying until death, under consideration of the self-determination rights of patients. Increasingly more and differentiated options for this are becoming available in intensive care medicine. Within the framework of professional responsibility physicians must decide which of the available treatment options are indicated. This process of decision-making is determined by answering the following question: when and under which circumstances is induction or continuation of intensive care treatment justified? In addition to the indications, the advance directive of the patient is the deciding factor. Medical indications represent a scientifically based estimation that a therapeutic measure is suitable in order to achieve a defined therapy target with a given probability. The ascertainment of the patient directive is achieved in a graded process depending on the state of consciousness of the patient. The present article offers orientation assistance to physicians for these decisions which are an individual responsibility.

[Care of polytrauma and the conflict between "acting and omitting". Medical, ethical and legal aspects in the current debate on the legal validity of patient directives]. / Polytraumaversorgung im Spannungsfeld von "Tun oder Unterlassen". Medizinische, ethische und rechtliche Aspekte der aktuellen Debatte um die Verbindlichkeit von Patientenverfügungen.

When treating the seriously injured, physicians are called upon to take into account not only what is medically possible, but also what is ethically and legally viable. This results in an area of conflict between 'acting and omitting', in which medical actions have to be weighed up and justified with regard to the individual diagnosis, prognosis and will of the patient. In this paper the medical, ethical and legal aspects of this problematic area are illustrated using a case example, and placed in the context of the current debate on the legal validity of the extent and liability of advance patient directives.

[Discontinuing parenteral nutrition, patient self-determination and legal sanctions in treatment limitations. On the legal questions of physician-assisted death]. / Einstellung von Sondenernährung, Patientenverfügung und gerichtliche Genehmigung der Therapiebegrenzung. Zu Rechtsfragen ärztlicher Sterbehilfe.

Since the Federal High Court decided the "Case of Kempten" in 1994, German Law allows discontinuation of life-sustaining treatment even when the patient's life could be extended by a number of months. Unfortunately, the court gives little normative criteria regarding the conditions under which "helping to die" is legal. Instead of such criteria, the will of the patient is underlined as being decisive. Therefore, the legal problems have shifted to the determination of the patient's will and substituted consent; written living will, power of attorney and consent of the court have become more important within the law of euthanasia. Along with a general description of the legal limits of euthanasia, the scope of application of these civil law institutes will be discussed.

[Legal binding character of guidelines]. / Zur rechtlichen Verbindlichkeit von Leitlinien.

Guidelines as recommendations by the medical associations concerning the diagnosis and treatment of certain diseases do not have the character of judicial norms. However, they may have an impact on decision-making in court. Within social security insurance law, and especially in medical malpractice litigation, the medical standard has become a legal term. As far as statements in guidelines render the actual standard as affirmed, the more binding is their character with respect to judicial questions. This article deals with this interplay between medical quality assurance and the legal demands on medical action. As a basis for discussion of this issue the relevant jurisdiction will be represented. Its impact on the guidelines for child and adolescent psychiatry will be pointed out as a concrete example.

[Children and adolescents with mental disorders as orphans of managed care?]. / Psychisch kranke Kinder und Jugendliche als Waisenkinder des Wirtschaftlichkeitsgebots?

Failure of incentive to investigation in infantile pharmaceutical trials has lead to insufficient supply with drugs within pediatrics and child- and adolescent psychiatry in Germany. In practice, drugs that are approved for adults are used to treat minors as a remedy. In many areas such "off label use" has become the medical standard and is therefore owed by the doctor under medical malpractice law. The principle of economy, that rules the law of public health insurance, forbids the prescription of drugs, that are not tested. However, as minors have the right to equal protection, the principle of economy can not prohibit off label use to the determent of minors. By virtue of the European orphan drug direction we can expect an improvement of drug supply in the field of pediatrics and child- and adolescent psychiatry in the long run. But meanwhile it would be unethical and unlawful to deny minors through restrictions on drug prescription a standard treatment, where the medical standard demands off label use of a pharmaceutical product.