[Indication Quality: Concepts and Ethical Implications]. / Indikationsqualität. Konzeption und professionsethische Implikationen.

BACKGROUND: In recent times - also due to new laws - a good "indication quality" has been called for. The aim of this paper is to contribute to the debate about "indication quality" by looking into the meaning of the term "indication" as well as the meaning of an adequate understanding of quality. METHODS: Initially, a conceptual analysis is made of how indication is an integral part of the therapeutic decision-making process between physician and patient, in which, next to evidence-based elements, also normative elements are included (step 1). In the second part, 2 different types of quality are contrasted (step 2): an externally quantifiable, standardized quality (Q-quality) and a quality pertaining to the individual physician, based on professional ethical values and principles (T-quality). RESULTS: For good "indication quality" it is suggested that both types of quality are included. As for Q-Quality, quantitative measures with selected quality indicators are proposed. Regarding T-Quality, qualitative, discursive procedures are more appropriate. CONCLUSIONS: It is suggested that the term "indication quality" be used for the quality of the whole therapeutic decision-making process including the indication itself. The indication should be based on profession-specific values rather than on other contextual or "private" ethical foundations. The legal and societal preconditions should set positive impulses for both ways of understanding the term "quality".

Institutional challenges for clinical ethics committees.

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of "alibi ethics". CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs.

Implementing clinical ethics in German hospitals: content, didactics and evaluation of a nationwide postgraduate training programme.

The Hannover qualifying programme 'ethics consultation in hospitals', conducted by a four-institution cooperation partnership, is an interdisciplinary, scientifically based programme for healthcare professionals interested in ethics consultation services and is widely acknowledged by hospital managements and healthcare professionals. It is unique concerning its content, scope and teaching format. With its basic and advanced modules it has provided training and education for 367 healthcare professionals with 570 participations since 2003 (until February 2010). One characteristic feature is its attractiveness for health professionals from different backgrounds. Internationally, the Hannover programme is one of the few schedules with both academics and non-academics as target groups and a high participation rate of physicians. The concept of the Hannover programme is in great demand, and its schedule is continuously optimised through evaluation. The goals of enabling healthcare professionals from different professional backgrounds to define and reflect ethical problems, to facilitate and support the process of decision-making and to work out structures for their own institutions seem to have been achieved. However, in order to obtain effective and sustainable results, participation in the programme should be supplemented regularly by in-house training sessions or individual expert consultations. Future challenges include new thematic courses and providing a network for former participants, especially when they come from non-academic hospitals. The network is a reasonable platform to discuss participants' experiences, successes and pitfalls. A further task will be research on how the programme's concept can support the sustainability of ethics structures in the various institutions.