Reusing dialyzer in low income countries: A good cost saving tactic with complex ethics.

Despite almost universal practice of dialyzer reuse from the earliest days of haemodialysis, reusing dialyzer always remains a controversial issue and several ethical concerns have been raised. Some of the important are safety of reuse over single use, informed consent of the patient, conflict of interest on the part of physician or manufacturer, fiscal responsibility and environmental stewardship. Indeed, at the beginning of this century, there was a drastic shift of practice in favour of single use in developed countries due to availability of biocompatible haemodialyzers, at favourable price. Despite this mega shift, dialyzer reuse is still widely practised in low-income countries. Considering cost inflation and limited medical resources in such countries, dialyzer reuse may be justified as a cost-saving strategy for this part of world. However, it poses the same ethical questions to us which were a matter of debate for the western world in the 1980s and 1990s. This review of literature was planned to revisit and highlight these concerns.

[What you can do when dealing with emergencies in the dementia setting]. / Notfälle bei Demenz - was Sie tun können.

Frequent emergencies in patients with dementia include aggressiveness, screaming, day/night reversal, other behavioral disorders, and falls. They are often caused by delirium, especially if there has been a rapid change in the patient's state of health. Hypoactive delirium in particular is difficult to recognize in the dementia setting. Acute somatic diseases bear a different meaning in dementia than in non-dementia patients, and priorities must be given to the impaired cerebral performance. In addition to medical decisions, ethical ones need to be made. Special attention should be paid to the resources of the caregiver network. This article describes both non-pharmacological and pharmacological treatment modalities when dealing with emergencies in dementia patients.

The ethics of 'fail first': guidelines and practical scenarios for step therapy coverage policies.

In an effort to control health costs, payers are increasingly turning to step therapy (or "fail first") policies in pharmacy benefit design. These policies restrict coverage of expensive therapies unless patients have already failed treatment with a lower-cost alternative. More than other utilization management tools such as formulary tiering, step therapy raises important ethical concerns regarding the proper balance between cost control and the ability of patients and clinicians to tailor care to the needs of the individual patient. This article provides eight design criteria to guide the ethical development and evaluation of step therapy policies and describes six clinical scenarios in which step therapy may be appropriate. The ethical criteria and scenarios are intended to provide guidance and transparency for insurers, patients, clinicians, and policy makers in choosing and paying for the appropriate therapies.

[Comments on ethical hospital management]. / Anmerkungen zur ethischen Krankenhausführung.

An ethical hospital management will be discussed under the topics (financial) resources, responsibility, quality and focus on patients.

Medicine and the holistic understanding of the human being: ultrasound examination as dialog.

Ultrasound can capture the living nature of a person. This capturing of life depends greatly on experience as well as sense of touch, intuition, sense of speech, and not least a sense for the distinctiveness of every person. Performing ultrasound is not simply the application of a technique but rather a merging of man and technology in the framework of an interpersonal encounter. Therefore, as much should be invested in the interpersonal nature of the encounter as in the development of the technical principles of the ultrasound probe. To effectively perform ultrasound, it is necessary to avoid viewing ultrasound from a purely technical view and to always remember the importance of the relationship to the patient, particularly during the technical examination.

Legal, ethical, and economic implications of breaking down once-daily fixed-dose antiretroviral combinations into their single components for cost reduction.

The availability of generic lamivudine in the context of the current economic crisis has raised a new issue in some European countries: breaking up the once-daily fixed-dose antiretroviral combinations (FDAC) of efavirenz/tenofovir/emtricitabine, tenofovir/emtricitabine, or abacavir/lamivudine, in order to administer their components separately, thereby allowing the use of generic lamivudine instead of branded emtricitabine or lamivudine. The legal, ethical, and economic implications of this potential strategy are reviewed, particularly in those patients receiving a once-daily single-tablet regimen. An unfamiliar change in antiretroviral treatment from a successful patient-friendly FDAC into a more complex regimen including separately the components to allow the substitution of one (or some) of them for generic surrogates (in the absence of a generic bioequivalent FDAC) could be discriminatory because it does not guarantee access to equal excellence in healthcare to all citizens. Furthermore, it could violate the principle of non-maleficence by potentially causing harm both at the individual level (hindering adherence and favouring treatment failure and resistance), and at the community level (hampering control of disease transmission and transmission of HIV-1 resistance). Replacing a FDAC with the individual components of that combination should only be permitted when the substituting medication has the same qualitative and quantitative composition of active ingredients, pharmaceutical form, method of administration, dosage and presentation as the medication being replaced, and a randomized study has demonstrated its non-inferiority. Finally, a strict pharma-economic study supporting this change, comparing the effectiveness and the cost of a specific intervention with the best available alternative, should be undertaken before its potential implementation.

[The national public discourse on priority setting in health care in German print media]. / Eine Analyse des nationalen öffentlichen Priorisierungsdiskurses in deutschen Printmedien.

Germany's Central Ethics Committee of the Federal Chamber of Physicians (FCP) and other relevant national actors called for a public discourse on priority setting in health care. Politicians, members of a Federal Joint Committee and health insurance representatives, however, refused to promote or participate in the establishment of a public discussion. A change to that attitude only became apparent after former FCP President Hoppe's opening speech at the annual FCP assembly in Mainz in 2009. The present paper applies the Sociology of Knowledge Approach to Discourse, implemented through Qualitative Content Analysis and elements of Grounded Theory, to examine the development of the national public discourse in leading German print media. It creates a matrix that represents the discourse development between May 2009 and May 2010 and reflects central actors, their "communicative phenomena" and their interactions. Additionally, the matrix has been extended to cover the period until December 2011. Hoppe's arguments for priority setting in health care are faced with a wide opposition assuming opposing prerequisites and thus demanding alternative remedies. The lack of interaction between the different parties prevents any development of the speakers' positions. Incorrect accounts, reductions and left-outs in the media representation add to this effect. Consequently, the public discussion on priority setting is far from being an evolving rational discourse. Instead, it constitutes an exchange of preformed opposing positions.

[Incentivising personal responsibility: conceptual clarification and evidence]. / Anreize für Eigenverantwortung: Begriffsbestimmung und Evidenzlage.

Two meanings of personal responsibility are distinguished, and different policy options for promoting health and responsibility are presented. Key insights from research seeking to promote personal responsibility through health information and incentives are outlined and discussed with regard to their potential to improve health and reduce cost. Data is presented on the socioeconomic characteristics of incentive programme users. It is concluded that due to different factors the availability of data regarding the effectiveness of incentive programmes is unsatisfactory. Evaluation requirements set out in the German Social Security Code (SGB V) should focus not only on cost, but should also extend to changes in health status and the socioeconomic status of users: provisions should be revised accordingly.

[Ethical basis of priority setting in healthcare]. / Ethische Grundlagen der Priorisierung im Gesundheitswesen.

The debate about priorities in healthcare has also started in Germany. Because of the special moral significance of health and healthcare, priority setting in healthcare also involves ethical issues. After clarifying the relationship between priority setting and rationing, I first discuss whether it is ethically acceptable or even mandated to set priorities in healthcare. If this first question is answered with "yes", the following question is how the priorities can be determined in an ethically defensible way. I will try to show that it is impossible to justify priorities in healthcare within a liberal theory of justice that is neutral towards substantive conceptions of the good life. We rather need a deliberative decision process about how we want to live in the face of illness, suffering, and death. Only by reference to a substantial concept of a good life is it possible to define and justify healthcare priorities. A national priority-setting commission could play an important role in stimulating this deliberation and developing general recommendations according to which criteria and procedures priorities should be set in the German healthcare system. The application of this general framework requires the cooperation of medical scientific and physician organizations.

Discount medical cards: innovation or illusion?

Discount medical cards have come under increasing scrutiny by regulators and law enforcement officials as a result of mounting consumer-reported problems. For their study, the authors tested five cards available in the Washington, D.C., metro area; interviewed card company representatives, state attorneys general insurance regulators, and insurance agents; and reviewed court and administrative actions. While some cards provide a measure of value, other cards were found to have serious drawbacks, including: high-pressure sales tactics; misleading or inaccurate promotion; exaggerated claims of savings; difficulty finding participating doctors; and providers who failed to give cardholders promised discounts. Some discount card companies are seeking to reform the market through a trade association and voluntary code of conduct. Still, legislative and regulatory interventions will be needed to protect consumers in an unregulated and growing market.