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1.
Gesundheitswesen ; 81(11): 933-944, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31614386

RESUMO

OBJECTIVES: "Medical necessity" (MedN) is a fuzzy term. Our project aims at concretising the concept between medical ethics, social law, and social medicine to support health care regulation, primarily within Germany's statutory health insurance system. In a previous publication we identified MedN as a tripartite predicate: A specific clinical condition requires a specific medical intervention to reach a specific medical goal. Our two-part text searches for and discusses criteria to classify medical methods as generally medically necessary (medn), provided a non-trivial clinical condition and a relevant, legitimate, and reachable goal actually exist. In this paper we present the first part of our results. METHODS: Based on an extensive ethical, sociolegal and sociomedical body of literature, and starting with an non-controversial case vignette (thrombolysis in acute stroke), we generally followed a critical reconstructive approach. First we defined the term "medical method". In several interdisciplinary rounds, we then collected and discussed criteria from three sources: methods to develop clinical practice guidelines as compendia of indication rules, the National Model of Prioritisation in Swedish Health Care, and the HTA Core Model of the European Network for Health Technology Assessment as an instrument of political counselling. RESULTS: We identified general clinical efficacy and benefit as the 2 main "medical" criteria of MedN. As a third - epistemic - criterion, the corresponding bodies of evidence are always to be considered. Since clinical and prioritising guidelines grade their recommendations, the question arises whether MedN should be conceptualised as a dichotomous or finer graded predicate. In accord with German social law we advocate for the binary form. Further discussions focused on multifactorial MedN-configurations, the range of the term, and the variability of evidence requirements. CONCLUSIONS: No matter how the content of MedN is conceptualised, it seems impossible to include its criteria in an algorithm. So deliberative effort is indispensable at any stage of developing a programme to classify medical methods as medically necessary.


Assuntos
Ética Médica , Avaliação da Tecnologia Biomédica , Algoritmos , Alemanha , Humanos
2.
Gesundheitswesen ; 81(11): 945-954, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31597188

RESUMO

OBJECTIVES: "Medical necessity" (MedN) is a fuzzy term. Our project aims at concretising the concept between medical ethics, social law, and social medicine to support health care regulation, primarily within Germany's statutory health insurance system. In Part I, we identified efficacy, (net)benefit, and the corresponding bodies of evidence as obligatory criteria of MedN. This is the second part suggesting and discussing further criteria. METHODS: See Part I RESULTS: (Part II): As further MedN-criteria we critically assessed a method's effectiveness and acceptance in routine care, its potential beneficiaries, theoretical fundament, cost, and being without alternative as well as patients' self-responsibility, cooperation, and preferences. Since MedN has both lower and upper bounds, we had to consider certain cases of mis- and overuse, due for instance to "indication creep" or "disease mongering". CONCLUSIONS: The additional criteria neither establish MedN (when met singly or together) nor exclude it (when not met). If MedN is rejected in view of the 3 obligatory criteria then further information does not overturn the verdict. If a method is already assessed as being medn then further criteria do not make it "more or less necessary". Though we advocated for a binary MedN-concept (Part I) we are nonetheless convinced that not all medical methods deemed medn are equally medically relevant. Respective differences within the range of MedN could be assessed by techniques to prioritise medical conditions, methods, and aims.


Assuntos
Assistência à Saúde , Ética Médica , Alemanha , Humanos , Legislação Médica , Programas Nacionais de Saúde
3.
Z Evid Fortbild Qual Gesundhwes ; 137-138: 27-35, 2018 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-30539786

RESUMO

With its "Münsteraner Memorandum on Alternative Practitioners" the author collective "Münsteraner Kreis" has recently criticized current German double standards for physicians versus alternative practitioners with regard to minimal competency and to quality assurance. The authors' main goal was to attract attention to the problem and to provide systematic arguments in favor of a healthcare system that is serving patients' needs more appropriately. Reactions to the Memorandum were numerous, divergent in their evaluations, often constructive, and frequently emotionally heated. Here, we collect, analyse and evaluate only the critical voices in order to sharpen the positions presented in the Memorandum, upgrade them if necessary, and identify areas in need of further research. For greater clarity, we standardize the objections, sort them into categories, subject them to theoretical and empirical plausibility analysis, and discuss their significance for the positions we have adopted.


Assuntos
Competência Clínica , Terapias Complementares , Assistência à Saúde , Alemanha , Humanos
4.
Artigo em Alemão | MEDLINE | ID: mdl-30176687

RESUMO

The briefing of patients is part of the daily routine of clinical anaesthesiologists and a central element for justification of medical treatment. It is increasingly apparent that such conversations can significantly affect the success of treatment by eliciting placebo and nocebo effects. Placebo effects are psychosocially caused clinical improvements, mediated by neurobiological mechanisms, which would be omitted in the case of hidden application. Nocebo effects are deteriorations, caused by the same mechanism. Anesthesiologists can make use of the knowledge about placebo and nocebo effects to increase positive impact on the outcome of treatment and to reduce negative effects at the same time. To do so legitimately, physicians have to balance the respect for patients' autonomy, the benevolence, and the non-maleficence for their patients. Patient's autonomy remains the supreme principle of the briefing about treatment and is institutionalized by the informed consent paradigm. Positive and negative expectations are to be handled by patient-oriented communication, but hard paternalistic deceptions and omissions are ethically unjustifiable. We will examine the practical strategies that could be used to deal with the imminent conflict between profound information and optimising placebo and nocebo responses. One key stone of these strategies is the pilot model. It helps to shape briefings as individually required and to promote the wellbeing and autonomy of our patients at the very same time.


Assuntos
Anestesiologistas , Comunicação , Efeito Nocebo , Educação de Pacientes como Assunto/ética , Efeito Placebo , Humanos , Assistência ao Paciente/instrumentação , Relações Médico-Paciente
5.
Z Evid Fortbild Qual Gesundhwes ; 109(3): 236-44, 2015.
Artigo em Alemão | MEDLINE | ID: mdl-26189175

RESUMO

Decisions about therapeutic interventions to be made by physicians, patients, and healthcare purchasers essentially depend on their classification in a credible context of justification, especially in a world dominated by contradicting experts. To some extent, this framing is done by sorting terms and their undertones, including the case of so-called CAM measures. In this paper, the authors reflect on ways to deal with the term CAM and the underlying supply-side approaches to healthcare from a primarily science-oriented perspective.


Assuntos
Terapias Complementares/ética , Terapias Complementares/tendências , Ética Médica , Filosofia Médica , Medicina Baseada em Evidências/ética , Alemanha , Acesso aos Serviços de Saúde/ética , Humanos , Efeito Placebo , Resultado do Tratamento
6.
Z Evid Fortbild Qual Gesundhwes ; 109(3): 245-54, 2015.
Artigo em Alemão | MEDLINE | ID: mdl-26189176

RESUMO

In Germany as well as in many other countries the project of 'integrating' CAM interventions into conventional medicine is currently underway. It is a highly contested endeavour. One backdoor of justifying CAM interventions - even if, according to the scientific standards of conventional medicine, they have been proved to lack specific effectiveness - is their use as therapeutic placebos. In this paper we will first discuss general critical considerations regarding deceptive placebo use and then argue that in the specific case of CAM interventions used as placebos general ethical reservations are reinforced by the fact that their use is prone to promote a non- or antiscientific attitude among physicians and patients, which we consider highly problematic.


Assuntos
Terapias Complementares/ética , Ética Médica , Medicina Integrativa/ética , Efeito Placebo , Atitude Frente a Saúde , Decepção , Medicina Baseada em Evidências/ética , Alemanha , Humanos , Resultado do Tratamento
7.
Z Evid Fortbild Qual Gesundhwes ; 106(6): 412-7, 2012.
Artigo em Alemão | MEDLINE | ID: mdl-22857728

RESUMO

Priority setting in medicine is generally regarded as an appropriate means for preparing just allocation of medical resources. By involving the general public or affected stakeholders in priority setting, advocates hope to legitimise this process and increase the acceptability of future decisions on resource allocation. Here, we differentiate between two ideal-typical methods of stakeholder involvement: 1) qualitative and 2) quantitative ones. We argue that the level of information of participants is important to the quality of the outcome of participatory events. Qualitative methods aim at fostering deliberative discussions among well-informed stakeholders. By contrast, quantitative methods usually do not have the capacity to ensure or, at least, control the level of information that participants use to guide their decisions. Hence, we conclude that in the context of priority setting qualitative and especially deliberative methods are preferable to quantitative approaches.


Assuntos
Comportamento Cooperativo , Tomada de Decisões Gerenciais , Alocação de Recursos para a Atenção à Saúde/organização & administração , Prioridades em Saúde/organização & administração , Comunicação Interdisciplinar , Programas Nacionais de Saúde/organização & administração , Política , Participação da Comunidade , Alemanha , Humanos
8.
Z Evid Fortbild Qual Gesundhwes ; 106(6): 426-34, 2012.
Artigo em Alemão | MEDLINE | ID: mdl-22857730

RESUMO

Fair rationing in publicly accessible health care has become a subject of current international debate. One suggestion is to cut reimbursement for any medical intervention below some threshold of small clinical benefit. One can further differentiate between thresholds of small expectable clinical benefit as such and thresholds of low chances for clinical success. Public acceptance of both types of thresholds has been tested in a population survey. Results are presented and discussed in this paper. (As supplied by publisher).


Assuntos
Alocação de Recursos para a Atenção à Saúde/organização & administração , Prioridades em Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/organização & administração , Programas Nacionais de Saúde/organização & administração , Redução de Custos/economia , Análise Custo-Benefício/economia , Análise Custo-Benefício/organização & administração , Alemanha , Alocação de Recursos para a Atenção à Saúde/economia , Prioridades em Saúde/economia , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/economia , Humanos , Futilidade Médica , Programas Nacionais de Saúde/economia , Aceitação pelo Paciente de Cuidados de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento
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