[175 years of anesthesia and narcosis-Towards a "human right to unconsciousness"]. / 175 Jahre Anästhesie und Narkose ­ Auf dem Weg zu einem "Menschenrecht auf Ohnmacht".

The Ether Day, a key moment in the history of mankind, commemorates its 175th anniversary on 16 October 2021. On that day the dentist William T. G. Morton successfully gave the first public ether anesthesia in Boston. From then on it was possible to save people from pain with justifiable risk and at the same time to protect them from psychological damage by inducing unconsciousness. The German philosopher Peter Sloterdijk, one of the most renowned and effective philosophers of our times, deduced that from then on humans, to some extent, had a right to unconsciousness when in psychophysical distress. This postulate unfolded from his concept of "anthropotechnics" developed around 1997, meaning the idea of treating human nature as an object of possible improvements. According to Sloterdijk, in favorable cases a synthesis of man and technology can result in a significant improvement of human capabilities in the sense of "enhancement", i.e. an increase, an improvement or even an expansion of intellectual, physical or psychological possibilities, as it were in a transgression of the human (so-called transhumanism). Man should go into vertical tension, i.e. strive for higher aims and exploit his inherent potential, he should not dwell in the horizontal. This is not meant as an appeal but as an imperative: "You must change your life!". In this context modern anesthesia may prove helpful: be operated on by others in order to undergo an enhancement. Or, in its most extreme form, the operation in the "auto-operational curved space", a person can even operate on himself as has been dramatically demonstrated by Rogozov, a young Russian physician and trainee surgeon who successfully performed a self-appendectomy under local anesthesia at the Novolazarevskaya Antarctic Station in 1961; however, the implementation of this idea is a long way off. On the one hand, many countries lack qualified personnel in sufficiently large numbers to perform even vital operations with patients under anesthesia. On the other hand, over the decades it has become clear that anesthesia is obviously beneficial for mankind in that it offers relief from pain and psychological stress but that it can also often show its dark side: substance abuse, use of anesthetics in torture and in executions. In addition, the role of anesthetics in resuscitation, palliative care, and allaying executions is unclear or controversial. Finally, the necessary formal legal steps to acknowledge a "human right to unconsciousness" have not yet been implemented.

[Prevention of nosocomial transmission of human immunodeficiency virus (HIV) from HIV-positive healthcare workers. Recommendations of the German Association for the Control of Viral Diseases (DVV) e.V. and the Society for Virology (GfV) e.V]. / Prävention der nosokomialen Übertragung von humanem Immunschwächevirus (HIV) durch HIV-positive Mitarbeiterinnen und Mitarbeiter im Gesundheitswesen. Empfehlungen der Deutschen Vereinigung zur Bekämpfung der Viruskrankheiten (DVV) e.V. und der Gesellschaft für Virologie (GfV) e.V.

To the best of our knowledge, the German Association for the Control of Viral Diseases (DVV) e.V. and the Society for Virology (GfV) e.V. are the first in Europe to provide precise recommendations for the management of health care workers (HCWs) who are infected with human immunodeficiency virus (HIV). Requirements for HIV-infected HCWs need to be clearly defined. With a permanent viral burden of less than or equal to 50 copies/mL, HIV-positive HCWs are allowed to perform any surgery and any invasive procedure, as long as the infected HCW uses double-gloving, undergoes follow-up routinely by occupational medicine professionals, undergoes a quarterly examination of viral burden, and has a regular medical examination by a physician who has expertise in the management of HIV. Unrestricted professional activity is only possible with a strict compliance to take antiretroviral therapy and if the HIV-infected HCW strictly adheres to the recommended infection control procedures. Complete compliance with the recommendation almost certainly leads to no HIV transmission risk in patient care.

[Living wills under close scrutiny: Medical consultation is indispensable]. / Patientenverfügung auf dem Prüfstand: Ärztliche Beratung ist unerlässlich.

Since September 2009 the handling of living wills has been regulated by law. Even though a medical consultation is not imperative for the drawing up of a living will, first surveys have shown that medical information about clinical pictures and treatment options lead to an important specification of living wills. For the first time in Germany, a questionnaire has been developed to investigate the impact of medical consultations on the content of living wills. It revealed that nearly all the people surveyed who had already drawn up a living will wished to change the content of their completed will after attending the seminar because the previous version was no longer in accordance with their wishes. In the light of the frequent difficulties in hospitals concerning how to apply a living will to an actual clinical situation, we believe structured medical consultations to be indispensable.

[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.

[Noninvasive and invasive bladder cancer: diagnostics and treatment]. / Nichtinvasives und invasives Harnblasenkarzinom: Diagnostik und Therapie.

Therapy of superficial bladder tumors is transurethral resection (TUR), and in cases of pT1 or high-grade tumors a re-TUR is indicated. Patients with carcinoma in situ receive intravesical chemotherapy or BCG for at least 3 months. Persistent carcinoma in situ may be treated by radical cystectomy. With the provision of a functionally adequate urinary diversion, cystectomy represents an effective treatment for patients with muscle-invasive bladder cancer without metastatic spread. Regional lymph node metastases can be found in up to 15% of stage T1 disease and are present in 33% of stage T3/4 lesions. Thus, lymphadenectomy gains diagnostic and possibly also therapeutic importance. For selected patients, who cannot be treated by radical cystectomy, multimodal concepts aiming to preserve the bladder are discussed. After or prior to cystectomy systemic chemotherapy may become necessary for some patients to positively affect the course of the disease in cases of locally advanced or metastatic lesions.

Models of ethical consultation: the Frankfurt model.

The Center for Medical Ethics at the Markus-Hospital in Frankfurt/Main is the first institute of its kind in Germany to be located within a confessional (Protestant) hospital, yet without being subordinate to hospital management--financed instead by the Protestant church of Hesse. Besides its main focus on ethical consultation for hospital employees and the execution of in-house seminars, the Center enjoys a close cooperation with the Protestant Academy Arnoldshain, where conferences and seminars can be held on bioethical issues outside the hospital boundaries and open to the interested public.

The patient's progress from this world to that which is to come: commentary on the Consensus Statement of the Working Group on Roman Catholic Approaches to Determining Critical Care.

The author comments on the consensus statement from the point of view of an ethics consultant in Germany. Since many hospitals in Germany are under considerable competitive pressure, mission statements are becoming more and more important in order to draw a distinction between the different hospital types and to convey the meaning of the corporate identity both internally and externally. The Consensus Statement, which provides basic orientation without going into too much detail, can be a helpful initial document. However, it does not deal with two specific problem areas which are examined more closely in the commentary: the application of risk-of-death algorithims in ICUs and the question of church membership of the caregivers to enable a proper preparation for death. The commentary also reveals certain difficulties in the discussion taking place in Anglo-Saxon countries and Continental Europe.

The concealed and the revealed: bioethical issues in Europe at the end of the second millenium.

Bioethical debate in Europe is partly a reaction to political endeavors and events. In line with the political goal of a united Europe, a European regulation is being sought for medical research and medical ethics ('Convention on Human Rights and Biomedicine'). A certain degree of ambivalence has come to the fore: whilst it does seem possible to reach a consensus (albeit a merely 'diplomatic' consensus) about complicated bioethical issues at an international level when certain controversial matters are excluded or a certain vagueness maintained, new principles are also required at a national level, for example when the medical profession of one state feels obliged to assume a 'local' stance, such as in the sensitive issue of termination of treatment. The individual contributions to this publication, together with various other current fields of bioethical conflict in Europe--especially Germany--are introduced below against a common background, namely that the original dividing line between the concealed and the revealed has shifted.

Sexual behaviour related to psycho-social factors in a population of Danish homosexual and bisexual men.

An anonymous self-administered questionnaire was distributed to (1) male members of the Danish Gay and Lesbian Association (2) through a gay magazine and (3) to readers of a gay pornographic magazine. For the purpose of this study sexual practices were classified into three categories taking into account the HIV-status of the respondent and his partner(s): safe sex (mutual masturbation, sex with condoms, sex without condoms between two HIV-positives), potentially safe sex (oral-genital sex without condoms irrespective of HIV-status, anal-genital sex without condoms between two HIV-negatives), unsafe sex (anal-genital sex without condoms between discordant partners or partners of unknown HIV status). Of the 2058 respondents 29.7% had had unsafe sex in the last 12 months. Multivariate analysis by recursive graphical models showed that sexual practice was directly related (that is conditionally dependent given the rest of the variables) to having a steady partner. Among men without a steady partner sexual practice was also directly related to age and number of partners showing an increase in unsafe sex with number of partners and a decrease with age. Thus of the men 16-19 years of age 43.5% had had unsafe sex irrespective of number of partners vs 5.7% of men older than 44 years and with one to two partners. Sexual practice was not directly related to any other demographic or psychosocial factor in the study. The adopted classification of sexual practice preclude that the high occurrence of unsafe sex could be explained by unsafe sex taking place among partners of concordant HIV status. The results emphasize the need for further preventive efforts to reduce transmission of HIV among homosexual men.

[Screening of donor blood for anti-HIV. Experiences from blood donor screening 1986-1988]. / Screening af donorblod for anti-HIV. Erfaringer fra bloddonorscreeningen 1986-1988.

During the period 1986-1988, approximately 1,200,000 portions of blood were anti-HIV screened in Denmark. A total of 19 donors were found to be anti-HIV positive and no increase in the frequency of anti-HIV blood donors has been observed during this period. At a subsequent interview, nine out of these 19 donors (47%) were shown to have risk factors for HIV infection. During the same period, a total of 12 cases of transfusion-associated HIV infection were found at follow-up control of recipients of blood from previous donations from donors demonstrated to be positive after 1986. Four of the cases were demonstrated to be positive by blood donor screening and eight in other ways. Finally, five cases of transfusion-associated HIV infection in recipients have been reported where no positive donor could be identified. One case of HIV infection could be attributed to transfusion with screened anti-HIV negative blood. On the basis of information from blood donor screening, it is concluded that the risk that a screened anti-HIV negative blood portion in Denmark can transmit HIV infection is less than one per 400,000.

[Information about safe sex for homosexual men--a consumer assessment of the efforts hitherto made in Denmark]. / Oplysning om sikker sex til maend med homoseksuel adfaerd--en brugervurdering af den hidtidige indsats i Danmark.

Self-administered anonymous questionnaires were included in the nationwide gay magazines "Pan" and "Cock" with the object of revealing the needs and possibilities of improved health educational effort in prevention of sexually transmitted HIV infection among homosexual and bisexual men. This was undertaken in March 1988 to illustrate the utilization and satisfaction of various sources of safe sex. The investigation reveals that campaigns about safe sex have been of great interest among the section of the target group which an investigation of this type could attract. In particular, the general efforts made by the Danish Health Board have attracted attention in a very broad section of men with homosexual contacts. Among those who employ the offers specifically made for the target gay group, considerable satisfaction is expressed. Compared with this, the employment of and satisfaction with medical help are considerably less. The significance of connections with a series of sociodemographic and subcultural subgroups are illustrated. Only where the gay-specific information is concerned was a significant association observed between receipt of information and the replier's reproduction of the given information about the risks involved in use of condoms. As regards the significance of single sources for sexual behaviour, a non-significant tendency was observed for persons who had received gay-specific written information to have a lower sex risk than those who had not received this information. It is recommended that the campaign hitherto initiated should be continued with intensification of AIDS prevention among the hidden homosexual men and men with sexual contacts with both sexes.

[Screening of donor blood for anti-HIV. Experiences from blood donor screening 1986-1988]. / Screening af donorblod for anti-HIV. Erfaringer fra bloddonorscreeningen 1986-1988.

During the period 1986--1988, approximately 1,200,000 portions of blood were anti-HIV screened in Denmark. A total of 19 donors were found to be anti-HIV positive and no increase in the frequency of anti-HIV blood donors has been observed during this period. At a subsequent interview, nine out of these 19 donors (47%) were shown to have risk factors for HIV infection. During the same period, a total of 12 cases of transfusion-associated HIV infection were found at follow-up control of recipients of blood from previous donations from donors demonstrated to be positive after 1986. Four of the cases were demonstrated to be positive by blood donor screening and eight in other ways. Finally, five cases of transfusion-associated HIV infection in recipients have been reported where no positive donor could be identified. One case of HIV infection could be attributed to transfusion with screened anti-HIV negative blood. On the basis of information from blood donor screening, it is concluded that the risk that a screened anti-HIV negative blood portion in Denmark can transmit HIV infection is less than one per 400,000.

[Sexual behavior in HIV antibody positive homosexual and bisexual men]. / Seksualadfaerd hos HIV-antistofpositive homo- og biseksuelle maend.

With the object of describing how their own health is experienced, the social circumstances and sexual behaviour in anti-HIV-positive homosexual and bisexual men, an anonymous questionnaire to be completed by the recipient was distributed in 1987 in connection with a placebo controlled investigation to assess the value of isoprinosin (Imunovir) in preventing the development of AIDS. 87% participated. Among the total of 85 participants, 78% considered that their health was good, 29% met family members and 75% friends at least once weekly. Fifty patients (65%) felt stressed in their daily lives which was definitely higher than in the normal population. All of the participants had altered their sexual behaviour in a manner which reduced the risk of HIV-transmission but 18 (21%) had had sexual behaviour known to transmit HIV within the past year. This behaviour occurred more frequently in young persons (p = 0.09) and in smokers (p = 0.03). In addition, no connection could be demonstrated between a series of possible determinants for this, which may, however, be due to the limited extent of the material. It is demonstrated that awareness that one is infected with HIV does not eliminate dangerous sexual behaviour in all cases.

HIV testing in Denmark: a nominator-denominator study.

In order to describe prevalence and trends of HIV infection, demographic variables, risk factors, and reasons for seeking testing, and self-administered anonymous questionnaire was distributed to approximately 75% of all individuals tested for antibodies to HIV on a voluntary basis, in all parts of the Danish health-care system, in November 1987 and in April 1988. The number of questionnaires returned was 2143 (55%). Overall, HIV prevalence was 1.2% and was highest among homosexual and bisexual men: 6% in November and 9% in April, with no statistical difference. Sixteen per cent of the men reported homosexual behaviour, 7% reported intravenous drug use, and 60% more than one opposite-sex partner within the last 12 months. No substantial difference was observed between reported risk factors in November and April. Overall, 18% had been tested at least once before; this figure rose to approximately 50% among homosexual men and intravenous drug abusers, a substantial number of whom had engaged in risk behaviour since the latest test. Sixty percent of men and 75% of women were tested at general practitioners', and 22% and 13% at sexually transmitted disease clinics; only 6% of men and 3% of women had used alternative test sites. It is concluded that studies of anti-HIV-tested people can give detailed information about patterns of HIV testing and indications of trends in HIV infection rates, thereby supplementing other forms of HIV surveillance.