[Effectiveness and Ethical Evaluation of Nudging to Promote the Self-Management in Diabetes Mellitus Type 2]. / Wirksamkeit und ethische Bewertung von Nudging-Interventionen zur Förderung des Selbstmanagements bei Diabetes Mellitus Typ 2.

BACKGROUND: Nudges offer a wide range of options for protecting health in everyday life that supplements traditional public health measures. Against this background, we conducted initial investigations on the effectiveness and ethical aspects of different nudges for promoting self-management of patients with diabetes mellitus type 2 in the context of Disease Management Programs (DMPs). METHODS: The ethical assessment of the nudges was done within the systematic framework of Marckmann et al. (2015) for public health ethics. The existing evidence on the effectiveness of nudges was summarised by means of a narrative literature review. RESULTS: Target agreements with implementation plans, reminder, feedback reports, shared appointments of patients with physicians, peer mentoring, and behavior contracts are nudging interventions with moderate interference with personal rights and relatively unproblematic ethical requirements, which have demonstrated effectiveness in different contexts. Default enrollment for patient training courses, involvement of partners, confrontation with social norms, and shocking pictures may be effective as well; however, they interfere more deeply with the freedom and privacy of patients and, therefore, are bound to stronger ethical requirements and restrictions. The evidence base is still insufficient, especially for social support measures by relatives and peers. CONCLUSIONS: Nudging offers a wide range of targeted interventions for supporting self-management of patients with chronic diseases, the potential of which has not yet been fully realized. Particularly promising interventions should be tested in pilot studies for their acceptance, effectiveness and cost-effectiveness in the context of DMPs.

Specification and other methods for determining morally relevant facts.

Specification is an integral part of Tom L Beauchamp and James F Childress' principlist approach to biomedical ethics. At the same time, the authors give much space conceding to critics that the method has significant limits. Although their pointing to limitations is not unreasonable as such, the emphasis Beauchamp and Childress put on them does not serve countering the critics' view that specification is insufficient for its intended purpose in applied ethics. This paper defends specification against Carson Strong's critique, showing that his casuistic approach shares strong structural and functional similarities with specification. It concludes with the more general point that specification or some closely related method for determining morally relevant facts of concrete cases and issues is indispensable for any account of applied ethics. Beauchamp and Childress should endorse and defend specification more vigorously than they appear to do.

Applying the four-principle approach.

The four-principle approach to biomedical ethics is used worldwide by practitioners and researchers alike but it is rather unclear what exactly people do when they apply this approach. Ranking, specification, and balancing vary greatly among different people regarding a particular case. Thus, a sound and coherent applicability of principlism seems somewhat mysterious. What are principlists doing? The article examines the methodological strengths and weaknesses of the applicability of this approach. The most important result is that a sound and comprehensible application of the four principles is additionally ensured by making use of the organizing meta-principle of common morality, which is the starting point and constraining framework of moral reasoning.

Common morality: comment on Beauchamp and Childress.

The notion of common morality plays a prominent role in some of the most influential theories of biomedical ethics. Here, I focus on Beauchamp and Childress's models in the fourth and fifth edition of Principles of Biomedical Ethics as well as on a revision that Beauchamp proposed in a recent article. Although there are significant differences in these works that require separate analysis, all include a role for common morality as starting point and normative framework for theory construction in combination with a coherence theory of moral justification. I defend to some extent the existence and empirical significance of common morality, as delineated by Beauchamp and Childress in different versions, but criticize its normative role. It is neither convincing as a moral foundation nor well compatible with a standard coherentist justification. I suggest that the authors should give up the foundational account for a more modest account of common morality as resource of well-established moral insights and experiences, which have proved generally valid but neither sufficient nor infallible. Beauchamp's latest proposal appears as a step in this direction; indeed, it may be the beginning of the end of his common-morality theory.

Discussing living wills. A qualitative study of a German sample of neurologists and ALS patients.

Patients suffering from amyotrophic lateral sclerosis (ALS) eventually lose their ability to communicate their treatment preferences in later stages of the disease. A living will enables ALS patients to specify their choices concerning life-sustaining treatment in advance. Our premise was that completion of a living will should be preceded by a discussion between patient and physician. We conducted a qualitative study of a sample of 15 neurologists and 15 ALS patients from two neurology centers in Germany. Our aim was to explore how discussions about living wills are undertaken. Data analysis followed grounded theory techniques. Our findings showed that both the patients and the physicians considered living wills to be closely connected to forthcoming death. Physicians waited for respiratory failure to occur before they informed ALS patients about living wills, an information strategy that we called the "wait-and-see-policy". The patients completed their living will when they had accepted the hopelessness of their disease. They mostly used living will forms and did not see the necessity to set down disease-specific preferences. They intended to wait for symptoms to emerge before they made the decision about whether or not to accept life-sustaining treatment. The patients as well as the physicians pursued a wait-and-see policy towards end-of-life care, thus weakening the purpose of living wills. Our results point to the necessity and importance of an open and honest patient-physician communication which is a prerequisite for the discussion of living wills.