[MacCAT-T between Claim and Practice - Challenges of Assessing Capacity for Consent in Dementia]. / MacCAT-T zwischen Anspruch und Praxis ­ Herausforderungen bei der Beurteilung von Einwilligungsfähigkeit bei Demenz.

BACKGROUND: Consent is a prerequisite for medical diagnostic and therapeutic action. There is no standardised procedure for assessing the ability to give consent. The most widely used tool for structured assessment is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). OBJECTIVES: People with dementia have impaired capacity to consent because of their disease. In order to answer the question to what extent structured assessment procedures can be usefully applied to people with dementia, we analyse the function, strengths and weaknesses of structured assessment procedures with a focus on the MacCAT-T and discuss suggestions for modification and further development of the tool. METHODS: Using the PubMed literature database, a systematic literature search and analysis was conducted on papers published since 2010, following PRISMA guidelines.Results Although the MacCAT-T is a valid and reliable tool, it cannot comprehensively address memory problems in people with dementia. It primarily measures cognitive functions. However, Decisions based on emotions, intuitions and values, are not captured by the MacCAT-T. Communicative limitations in people with dementia are not taken into account. CONCLUSIONS: It is recommended to provide information in simple language, written down and visualised for people with dementia. The development and elaboration of a graduated procedure for the examination of capacity to consent is indicated. The gradations of the scope and depth of the assessment to be determined should be based on the severity of the cognitive impairment, the benefit/risk ratio of the proposed medical intervention and the individual profile of affective functions and value-based imprints.

Artificial Intelligence in Reproductive Medicine - An Ethical Perspective.

Artificial intelligence is steadily being integrated into all areas of medicine. In reproductive medicine, artificial intelligence methods can be utilized to improve the selection and prediction of sperm cells, oocytes, and embryos and to generate better predictive models for in vitro fertilization. The use of artificial intelligence in this field is justified by the suffering of persons or couples who wish to have children but are unable to conceive. However, research into the use of artificial intelligence in reproductive medicine is still in the early experimental stage and furthermore raises complex normative questions. There are ethical research challenges because evidence of the efficacy of certain pertinent systems is often lacking and because of the increased difficulty of ensuring informed consent on the part of the affected persons. Other ethically relevant issues include the potential risks for offspring and the difficulty of providing sufficient information. The opportunity to fulfill the desire to have children affects the welfare of patients and their reproductive autonomy. Ultimately, ensuring more accurate predictions and allowing physicians to devote more time to their patients will have a positive effect. Nevertheless, clinicians must be able to process patient data conscientiously. When using artificial intelligence, numerous actors are involved in making the diagnosis and deciding on the appropriate therapy, raising questions about who is ultimately responsible when mistakes occur. Questions of fairness arise with regard to resource allocation and cost reimbursement. Thus, before implementing artificial intelligence in clinical practice, it is necessary to critically examine the quantity and quality of the data used and to address issues of transparency. In the medium and long term, it would be necessary to confront the undesirable impact and social dynamics that may accompany the use of artificial intelligence in reproductive medicine.

[Capable or incapable of giving consent? Assessing a patient's capacity to consent: Procedures and challenges in daily clinical practice]. / Einwilligungsfähig oder nicht? Zur Praxis der Prüfung von Einwilligungsfähigkeit im klinischen Alltag und deren Herausforderungen.

BACKGROUND/OBJECTIVES: The capacity of patients to give consent (CTC) is an indispensable prerequisite for informed consent to medical measures. When there is doubt about a patient's CTC, careful assessment is therefore required. Despite a broad theoretical discussion about the conception of CTC and possible procedures for its assessment, there is often a lack of orientation towards binding standardized procedural guidelines in everyday clinical practice. As a consequence, the results of CTC assessments are inconsistent, revealing both interdisciplinary and interindividual variability. In order to improve the quality of CTC assessment, more detailed knowledge about the procedures as well as the problems of CTC testing is needed. Therefore, the aim of this explorative telephone survey was to get an impression of the actual procedures that clinicians apply when in doubt about a patient's CTC. In particular, participants in the survey were asked about the weighting of individual CTC criteria and the difficulties with their application. METHODS: Based on structured questionnaires, telephone interviews with 26 physicians working in German hospitals in the fields of neurology, anaesthesiology, surgery, internal medicine, gynaecology, and reconstructive/aesthetic surgery were conducted. The answers were documented using the paper-and-pencil method, and answers to open questions were summarized with the help of a qualitative data analysis software and a thematic coding scheme. RESULTS: The majority of respondents reported that "sometimes to very often" they had doubts about their patients' CTC, with the examination being mostly conducted in an individual approach without formalized, standardized specifications. Regarding the question about the weighting of the seven assessment criteria proposed in the questionnaire, their importance was predominantly evaluated as being in the range of "partially important" to "very important". Difficulties in the clinical assessment were indicated in relation to the patients themselves, the relationship between physicians and patients, and the assessment situation. The perception of difficulties in the examination of CTC is apparently independent of the relevance attributed to the specific criterion for CTC. DISCUSSION AND CONCLUSION: Overall, the results show a high level of agreement with the relevance of the seven CTC criteria included in the survey, but at the same time revealed various verification difficulties. Some of the respondents would like to have more support in determining their patients' CTC. The survey results suggest that precise training and adequate time resources are paramount to this sensitive medical context.

In vitro gametogenesis: A benefit for women at advanced and very advanced age? An ethical perspective.

Assisted reproductive technologies (ART) may be supplemented with in vitro gametogenesis (IVG). Although IVG is still experimental the question arises whether IVG offers any moral advantages compared to implemented methods. The aim of the paper is to present the landscape of ethical arguments in favour or against IVG. ART-related ethical issues in relation to reproductive autonomy, health risks for the woman and foetus, the welfare of the future child, the adverse effects of advanced motherhood, gender equality, and justice are similar for IVG, oocyte cryopreservation, and oocyte donation. IVG may have the following advantages: (I) the psychological and physical burden of stimulation and puncture of the oocyte could be avoided; (II) women do not necessarily have to cope with motherhood at young age; (III) ethical doubts associated with oocyte donation would be eliminated; (IV) by using IVG in combination with preimplantation diagnostics, it is more likely to find suitable oocytes or embryos to increase the probability of pregnancy; (V) women would have the opportunity to decide how many oocytes should be generated and how often an attempt should be made to achieve pregnancy. Simultaneously, however, the advent of IVG may lead to new moral disadvantages: pressure on women to give birth at an advanced age or pressure on women to follow 'male' career structures. Additionally, the reimbursement of costs related to IVG is an open question, especially if equal opportunities regarding motherhood are linked to demands for equal access to ART. An early discussion about the ethical, legal, and social consequences for IVG is necessary.

Treatment Decision-Making Capacity in Forensic vs Non-forensic Psychiatric Patients: A European Comparison.

Background: Consent to treatment is a cornerstone of medical ethics and law. Nevertheless, very little empirical evidence is available to inform clinicians and policymakers regarding the capacities of forensic patients with schizophrenia spectrum disorders (SSDs) to make decisions about their treatment, with the risk of clinical and legal inertia, silent coercion, stigmatization, or ill-conceived reforms. Study Design: In this multinational study, we assessed and compared with treatment-related decisional capacities in forensic and non-forensic patients with SSD. 160 forensic and 139 non-forensic patients were used in Austria, Germany, Italy, Poland, and England. Their capacity to consent to treatment was assessed by means of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Multiple generalized linear regression models were used to identify the socio-demographic and clinical variables associated with MacCAT-T scores. Study Results: In total, 55 forensic (34.4%) and 58 non-forensic patients (41.7%) showed high treatment-related decisional capacity, defined as scoring ≥75% of the maximum scores for the understanding, appreciation and reasoning, and 2 for expressing a choice. Forensic patients showed differences in their capacity to consent to treatment across countries. Of all socio-demographic and clinical variables, only "social support" was directly relevant to policy. Conclusions: Forensic patients have treatment-related decisional capacities comparable with their non-forensic counterparts. Social contacts might provide a substantial contribution towards enhancing the decisional autonomy of both forensic and non-forensic patients, hence improving the overall quality and legitimacy of mental health care.

Knowledge and attitudes on electroconvulsive therapy in Germany: A web based survey.

OBJECTIVE: The aim of this article is to examine knowledge and attitudes on electroconvulsive therapy (ECT) among the German population. METHOD: A web-based population survey based on a standardized questionnaire was used to examine knowledge and attitudes towards ECT as a treatment of severe depression among the general public (sample of 1000; representative in terms of age, gender and federal states of the German population). RESULTS: ECT is not well known and negatively connoted among the German population. A higher level of awareness and knowledge about ECT correlates with higher agreement to treatment with it. The analysis of feedback from the open question underlines the complexity of ECT: on the one hand, negative attitudes, stereotypes, and associations, and on the other hand interest, willingness, and acceptance to deal with the method were shown. CONCLUSION: The results suggest an urgent need for more information about the basic facts, psychiatric applications, and effectiveness of ECT in order to increase the level of awareness and knowledge, and thus the method's acceptance. An increase in acceptance would expand the therapeutic spectrum for the mentally ill. Correspondingly, persons affected and their relatives as well as physicians and healthcare professionals should be involved in awareness-raising measures.

Unfair discrimination in prenatal aneuploidy screening using cell-free DNA?

Non-invasive prenatal testing on the basis of cell-free DNA of placental origin (NIPT) changed the landscape of prenatal care and is seen as superior to all other up to now implemented prenatal screening procedures - at least in the high-risk population. NIPT has spread almost worldwide commercially, but only in a few countries the costs of NIPT are covered by insurance companies. Such financial barriers in prenatal testing can lead to significant restrictions to the average range of opportunities of pregnant women and couples, which on an intersubjective level can be defined as unfair discrimination and on an individual level weakens reproductive autonomy. Given that enabling reproductive autonomy is the main ethical justification for offering prenatal (genetic) testing, these barriers are not only an issue of justice in health care, but are potentially counteracting the primary purpose of these testing procedures.