Psychiatrists as forensic authorities: evaluation of dangerous habitual offenders in West Germany during the 1960s - the Helmut Hoinka case.

Background: Preventive detention for highly dangerous habitual offenders has been in force in Germany for 90 years. The necessity of this measure is hotly debated from a legal perspective. However, the assignment of preventive detention is largely determined by the opinion of medical experts. This article discusses the role of medical experts and the issues they face in evaluating the dangerousness of habitual offenders using the case of the marriage swindler Helmut Hoinka, prosecuted several times in the Federal Republic of Germany in the 1960s. Methods: Helmut Hoinka's case was chosen for analysis because of the rare opportunity to access detailed materials that allowed us to follow in detail the reasoning of the medical experts who evaluated Hoinka: medical reports stored in the Gerd Huber Archive at the University of Ulm, and Hoinka's court case from the State Archive of North Rhine-Westphalia. To examine these sources, we implemented the historical-critical method. Results: The medical experts who evaluated Hoinka were aware of the defendant's criminal record prior to the evaluation, which was a source of bias. In addition, the criteria for classifying the offender as a dangerous habitual offender were open to a wide range of interpretations. Hoinka's high level of intelligence was negatively emphasized. Some test results were considered unreliable because it was assumed that Hoinka had manipulated his answers. Personal value judgments were allowed in assessing Hoinka's personality. Hoinka's criminal behavior was considered a medical symptom of psychopathy because it violated general moral and social norms. The medical reports of both experts showed that the psychiatrists believed in the genetic nature of psychopathy and criminal behavior. Their criminological prognosis was fully supported by the court in imposing the sentence. Conclusion: Challenges to Hoinka's criminological prognosis were the experts' personal biases, their belief in the theory of genetic predisposition to crime, the lack of clear criteria for antisocial personality disorder, and the absence of forensic recommendations for "psychopathic" criminals. The experts' opinion on Hoinka's criminal predisposition was crucial to the imposition of the sentence.

User Perspectives of Geriatric German Patients on Smart Sensor Technology in Healthcare.

With consideration of the progressing aging of our societies, the introduction of smart sensor technology can contribute to the improvement of healthcare for older patients and to reductions of the costs of care. From the clinical and medico-ethical points of view, the advantages of smart sensor technology are copious. However, any ethical evaluation of an introduction of a new technology in medical practice requires an inclusion of patients' perspectives and their assessments. We have conducted qualitative, semi-structured, exploratory interviews with 11 older patients in order to gain their subjective opinions on the use of smart sensor devices for rehabilitation purposes. The interviews were analyzed using methods of qualitative content and thematic analyses. In our analysis, we have focused on ethical aspects of adoption of this technology in clinical practice. Most of the interviewees expressed their trust in this technology, foremost because of its accuracy. Several respondents stated apprehension that the use of smart sensors will lead to a change in the patient-healthcare professional relationship. Regarding costs of introduction of smart sensors into healthcare, interviewees were divided between health insurance bearing the costs and individual participation in corresponding costs. Most interviewees had no concerns about the protection of their privacy or personal information. Considering these results, improvement of users' technology literacy regarding possible threats connected with putting smart sensors into clinical practice is a precondition to any individual application of smart sensors. This should occur in the form of extended and well-designed patient information adapted to individual levels of understanding. Moreover, application of smart sensors needs to be accompanied with careful anamnesis of patient's needs, life goals, capabilities, and concerns.

Why do transgender individuals experience discrimination in healthcare and thereby limited access to healthcare? An interview study exploring the perspective of German transgender individuals.

BACKGROUND: Transgender individuals experience limited access to healthcare. This results not least from experiences of discrimination to which they are exposed in the health system. These contribute to transgender individuals having poorer health than cis individuals, i.e. individuals whose sex assigned at birth is in line with their gender identity. It is an ethical duty to take effective measures to minimize inequalities in medical care. At best, such measures should also be assessed as appropriate from the perspective of those affected in order to be accepted and thus effective. It is therefore important to know whether measures touch on the subjectively assumed reasons for experiences of discrimination. Hence, to be able to take appropriate measures, it is important to identify the reasons that transgender individuals see as causal for their experiences of discrimination in healthcare. METHODS: We conducted semi-structured interviews with 14 German transgender individuals and asked them about their own experiences of discrimination in healthcare and their assumptions on the reasons for discrimination. We analyzed the responses using the method of structured qualitative content analysis. RESULTS: 13 transgender individuals reported experiences of discrimination in healthcare. These emanated from different professional groups and took place in trans-specific as well as general medical settings. We were able to identify a total of 12 reasons that transgender individuals see as causal for their experiences of discrimination: (1) internalized trans-hostility and "protection" of cis individuals, (2) lack of knowledge/uncertainties regarding transition, (3) "protection" of a binary worldview, (4) binary worldview in medicine, (5) structural deficits, (6) asymmetric interactions with specialists, (7) current political debate, (8) view of transgender individuals as a "burden for society", (9) objectification, (10) homophobia, (11) misogyny/androcentrism and (12) discrimination as reaction to discrimination. CONCLUSIONS: German transgender individuals have a very differentiated picture regarding their subjective reasons for experiencing discrimination in healthcare. Overall, disrespect regarding gender identity and a confrontation with foreignness seems to be seen as the decisive factor. Thus, it is not enough to focus only on measures that aim to remedy the information deficit on the part of medical providers. Measures must be taken that can create a granting and respectful attitude towards transgender individuals.

Diversity awareness, diversity competency and access to healthcare for minority groups: perspectives of healthcare professionals in Croatia, Germany, Poland, and Slovenia.

Introduction: Due to cultural, language, or legal barriers, members of social minority groups face challenges in access to healthcare. Equality of healthcare provision can be achieved through raised diversity awareness and diversity competency of healthcare professionals. The aim of this research was to explore the experiences and attitudes of healthcare professionals toward the issue of social diversity and equal access to healthcare in Croatia, Germany, Poland, and Slovenia. Methods: The data reported come from semi-structured interviews with n = 39 healthcare professionals. The interviews were analyzed using the methods of content analysis and thematic analysis. Results: Respondents in all four countries acknowledged that socioeconomic factors and membership in a minority group have an impact on access to healthcare services, but its scope varies depending on the country. Underfunding of healthcare, language barriers, inadequate cultural training or lack of interpersonal competencies, and lack of institutional support were presented as major challenges in the provision of diversity-responsive healthcare. The majority of interviewees did not perceive direct systemic exclusion of minority groups; however, they reported cases of individual discrimination through the presence of homophobia or racism. Discussion: To improve the situation, systemic interventions are needed that encompass all levels of healthcare systems - from policies to addressing existing challenges at the healthcare facility level to improving the attitudes and skills of individual healthcare providers.

Artificial Intelligence-Based Clinical Decision Support Systems in Geriatrics: An Ethical Analysis.

OBJECTIVES: To provide an ethical analysis of the implications of the usage of artificial intelligence-supported clinical decision support systems (AI-CDSS) in geriatrics. DESIGN: Ethical analysis based on the normative arguments regarding the use of AI-CDSS in geriatrics using a principle-based ethical framework. SETTING AND PARTICIPANTS: Normative arguments identified in 29 articles on AI-CDSS in geriatrics. METHODS: Our analysis is based on a literature search that was done to determine ethical arguments that are currently discussed regarding AI-CDSS. The relevant articles were subjected to a detailed qualitative analysis regarding the ethical considerations Supplementary Datamentioned therein. We then discussed the identified arguments within the frame of the 4 principles of medical ethics according to Beauchamp and Childress and with respect to the needs of frail older adults. RESULTS: We found a total of 5089 articles; 29 articles met the inclusion criteria and were subsequently subjected to a detailed qualitative analysis. We could not identify any systematic analysis of the ethical implications of AI-CDSS in geriatrics. The ethical considerations are very unsystematic and scattered, and the existing literature has a predominantly technical focus emphasizing the technology's utility. In an extensive ethical analysis, we systematically discuss the ethical implications of the usage of AI-CDSS in geriatrics. CONCLUSIONS AND IMPLICATIONS: AI-CDSS in geriatrics can be a great asset, especially when dealing with patients with cognitive disorders; however, from an ethical perspective, we see the need for further research. By using AI-CDSS, older patients' values and beliefs might be overlooked, and the quality of the doctor-patient relationship might be altered, endangering compliance to the 4 ethical principles of Beauchamp and Childress.

Access to healthcare for people living with HIV: an analysis of judgments of the European Court of Human Rights from an ethical perspective.

Introduction: Although HIV has been part of our reality for over 30 years, people living with HIV (PLHIV) still experience restrictions regarding their access to healthcare. This poses a significant ethical problem, especially as it endangers achieving the goal of ending the HIV epidemic worldwide. The aim of this paper is to analyze the rulings of the European Court of Human Rights (ECtHR) regarding cases where PLHIV experienced restrictions on their access to healthcare. Methods: We conducted an analysis of the ECtHR database and were able to identify N = 28 cases dealing with restricted access to healthcare for PLHIV. A descriptive and thematic analysis was conducted to identify ways in which access to healthcare for PLHIV was restricted. Results: We were able to identify a total of four main categories, with denial of adequate therapeutic support as the main category with N = 22 cases (78.57%). Most of the judgments examined were filed against Russia (N = 12, 42.86%) and Ukraine (N = 9, 32.14%). A large proportion of PLHIV in the cases studied (N = 57, 85.07%) were detainees. Discussion: The analysis shows a clear condemnation of limited access to healthcare for PLHIV by the ECtHR. Ethical implications of the analyzed cases are discussed in detail.

Informed Consent in COVID-19-Research: An Ethical Analysis of Clinical Studies Performed during the Pandemic.

Health crises such as the current COVID-19 pandemic pose challenges to the conduct of clinical studies. Aspects of research ethics, such as obtaining informed consent (IC), can be complicated. We are concerned with whether or not the proper IC procedures were followed in the context of clinical studies at Ulm University in the years 2020 to 2022. We identified all protocols of clinical studies dealing with COVID-19 that the Research Ethics Committee of Ulm University has reviewed and voted on in the years 2020 to 2022. We then performed a thematic analysis regarding the following aspects: study type, handling of IC, type of patient information, means of communication, applied security precautions, and the approach to participants from vulnerable groups. We identified n = 98 studies that dealt with COVID-19. In n = 25 (25.51%), IC was obtained traditionally in written form, in n = 26 (26.53%) IC was waived, in n = 11 (11.22%) IC was obtained delayed, and in n = 19 (19.39%) IC was obtained by proxy. No study protocol was accepted that waived IC in case IC would have been required in times outside of pandemics. It is possible to obtain IC even in times of severe health crises. In the future, it is necessary to address in greater detail and with legal certainty which alternative methods of obtaining IC are possible and under which circumstances IC can be waived.

[Public mental health and patient autonomy-an area of conflict?] / Public Mental Health und Patientenautonomie ­ ein Spannungsfeld?

Public mental health (PMH) interventions aim to promote and improve the well-being of members of a society. PMH is based on a normative understanding of what well-being is and what factors contribute to it. Without necessarily disclosing it, measures of a PMH program may affect the autonomy of individuals if their personal perceptions regarding their own individual well-being differ from PMH's prescriptions for well-being oriented toward societal goals. In this paper, we discuss this potential tension between the possible goals of PMH and those of the addressees.

Sexual Self-Determination of Individuals with Intellectual Disabilities-A Possible Philosophical Conceptualization and Resulting Practical Challenges.

(1) Background: Self-determination is one of the central values of many societies. Self-determination concerns many areas of life, including sexuality. Unfortunately, the sexuality of individuals with intellectual disabilities (IID) is often discriminated against, and even in their everyday care, sexuality is often given too little space, not least because of knowledge deficits of parents and staff. A practicable conceptualization of sexual self-determination is a prerequisite for helping IID to achieve self-determined sexuality. The aim of this paper is to formulate such an applicable conceptualization and to discuss related challenges. (2) Method: This paper uses Harry Frankfurt's hierarchical conception of desires and the WHO definition of sexuality to develop a suitable understanding of sexual self-determination. (3) Results: The mentioned concepts offer promising tools to develop a conceptualization of sexual self-determination with high practical applicability. (4) Discussion: Sexual self-determination involves decision-making processes in relation to the different dimensions of sexuality. IID do need support to come to these decisions. Challenges that might be involved with such decision processes will be discussed.

Access to healthcare for disabled individuals: An analysis of judgments of the European Court of Human Rights from an ethical perspective.

Introduction: Individuals with disabilities (ID) suffer from restricted access to healthcare. This contributes to their poorer health status and constitutes an ethical challenge. The aim of this research was to systematically analyze judgments of the European Court of Human Rights (ECtHR) to illustrate examples of restricted access to healthcare for ID. Methods: Through a search in the ECtHR's database we identified judgments dealing with access to healthcare for ID. The search resulted in n = 329 judgments, of which n = 55 were included in the analysis. A descriptive statistic was performed on Articles of the European Convention on Human Rights and violation of these articles. Qualitative thematic analysis was conducted to group the judgments in thematic categories. Results: Most applications were filed against Russia (n = 23), followed by Poland (n = 8) and Ukraine (n = 7). The youngest applicant was 18, the oldest 72 years old. An overwhelming majority of cases dealt with disabled prisoners. Most of the judgments involved Article 14 and Article 8. We identified seven partially overlapping categories representing thematic patterns in the analyzed judgments. Discussion: Any restriction of access to healthcare can be considered a violation of human rights. However, the results show a relatively low total number of judgments dealing with limited access to healthcare for ID. This could be a further confirmation of the fact that ID still experience too little attention in our societies. Especially in the context of detention, ID is restricted from receiving the healthcare they require. Indirect ways of a restricted access to healthcare should not be overseen.