Methodological Reflections on the Contribution of Qualitative Research to the Evaluation of Clinical Ethics Support Services

This article describes a process of developing, implementing and evaluating a clinical ethics support service intervention with the goal of building up a context-sensitive structure of minimal clinical-ethics in an oncology department without prior clinical ethics structure. Scholars from different disciplines have called for an improvement in the evaluation of clinical ethics support services (CESS) for different reasons over several decades. However, while a lot has been said about the concepts and methodological challenges of evaluating CESS up to the present time, relatively few empirical studies have been carried out. The aim of this article is twofold. On the one hand, it describes a process of development, modifying and evaluating a CESS intervention as part of the ETHICO research project, using the approach of qualitative-formative evaluation. On the other hand, it provides a methodological analysis which specifies the contribution of qualitative empirical methods to the (formative) evaluation of CESS. We conclude with a consideration of the strengths and limitations of qualitative evaluation research with regards to the evaluation and development of context sensitive CESS. We further discuss our own approach in contrast to rather traditional consult or committee models.

"History, Theory and Ethics of Medicine": The Last Ten Years. A Survey of Course Content, Methods and Structural Preconditions at Twenty-nine German Medical Faculties

Objective: "History, Theory, Ethics of Medicine" (German: "Geschichte, Theorie, Ethik der Medizin", abbreviation: GTE) forms part of the obligatory curriculum for medical students in Germany since the winter semester 2003/2004. This paper presents the results of a national survey on the contents, methods and framework of GTE teaching. Methods: Semi-structured questionnaire dispatched in July 2014 to 38 institutions responsible for GTE teaching. Descriptive analysis of quantitative data and content analysis of free-text answers. Results: It was possible to collect data from 29 institutes responsible for GTE teaching (response: 76%). There is at least one professorial chair for GTE in 19 faculties; two professorial chairs or professorships remained vacant at the time of the survey. The number of students taught per academic year ranges from <100 to >350. Teaching in GTE comprises an average of 2.18 hours per week per semester (min: 1, max: 6). Teaching in GTE is proportionally distributed according to an arithmetic average as follows: history: 35.4%, theory 14.7% and ethics 49.9%. Written learning objectives were formulated for GTE in 24 faculties. The preferred themes of teaching in history, theory or ethics which according to respondents should be taught comprise a broad spectrum and vary. Teaching in ethics (79 from a max. of 81 possible points) is, when compared to history (61/81) and theory (53/81), attributed the most significance for the training of medical doctors. Conclusion: 10 years after the introduction of GTE the number of students and the personnel resources available at the institutions vary considerably. In light of the differences regarding the content elicited in this study the pros and cons of heterogeneity in GTE should be discussed.

Cannabis for Cognitive Enhancement as a New Coping Strategy? Results From a Survey of Students at Four Universities in Germany

BACKGROUND

Cognitive Enhancement (CE) is often discussed in relation to stimulant drugs, such as amphetamines (AMPH). However, there is some evidence that cannabis (CAN) can be used for CE.

OBJECTIVE

This study compares the knowledge, prevalence, and perceived effects of and factors associated with the knowledge of or use of CAN versus AMPH for CE among undergraduate students at four German universities.

METHODS

A survey was taken of 1,538 students at four German universities. It investigated their knowledge and use of CAN and AMPH for CE as well as associated factors. Descriptive and analytic (Mann-Whitney-U test, Fisher's exact test, logistic regression) statistics were obtained using SPSS.

RESULTS

Responses were obtained from 1,026 participants (57.2%) at three universities from the Universitätsallianz Metropole Ruhr (UAR) (Bochum, Dortmund, Duisburg-Essen) and 512 respondents (68.3%) in Mainz. We observed lifetime prevalence rates of 3.5% for the use of CAN and 2.1% for the use of AMPH for the purpose of CE. CAN users perceived pressure to perform as more of a burden than AMPH users (mean: 3.2, CAN users: 4.7, AMPH: 2.9; p =.042). CAN users used the substances for studying for exams significantly less often than AMPH users (p =.025), and CAN users perceived less of an enhancing effect of the drug compared to AMPH users (p <.001).

CONCLUSIONS

A considerable number of students report having used CAN for CE. However, our research indicates differences in perceptions and experiences of CE between CAN and AMPH users. Further research on the role of CAN for CE and conceptual analyses to differentiate between different understandings of CE are warranted.

Research participants' perceptions and views on consent for biobank research: a review of empirical data and ethical analysis

BACKGROUND

Appropriate information and consent has been one of the most intensely discussed topics within the context of biobank research. In parallel to the normative debate, many socio-empirical studies have been conducted to gather experiences, preferences and views of patients, healthy research participants and further stakeholders. However, there is scarcity of literature which connects the normative debate about justifications for different consent models with findings gained in empirical research. In this paper we discuss findings of a limited review of socio-empirical research on patients' and healthy research participants' experiences and views regarding consent to biobank research in light of ethical principles for appropriate information and consent.

METHODS

Review question: Which empirical data are available on research participants' perceptions and views regarding information and elicitation of consent for biobank research? Search of articles published till March 1st 2014 in Pubmed. Review of abstracts and potentially relevant full text articles by two authors independently. As categories for content analysis we defined (i) understanding or recall of information, (ii) preferences regarding information or consent, and (iii) research participants' concerns.

RESULTS

The search in Pubmed yielded 337 abstracts of which 10 articles were included in this study. Approaches to information and consent varied considerably across the selected studies. The majority of research participants opted for some version of limited consent when being informed about such possibility. Among the factors influencing the type of preferred consent were information about sponsoring of biobank research by pharmaceutical industry and participants' trade-off between privacy and perceived utility. Studies investigating research participants' understanding and recall regarding the consent procedure indicated considerable lack of both aspects. Research participants' perceptions of benefits and harms differ across those studies.

CONCLUSION

The knowledge, perceptions and views of research participants who have undergone a consent procedure within the context of biobank research raise several questions on the issue of how to inform and elicit consent in an ethically acceptable way. In our empirical-ethical analysis we develop suggestions on how the practice of eliciting consent in the biobank context should be improved.

Decisions about Limiting Treatment in Cancer Patients: A Systematic Review and Clinical Ethical Analysis of Reported Variables

BACKGROUND

Survey research indicates that decisions about the provision and limitation of treatment near the end of life in patients with cancer vary considerably.

OBJECTIVES

The study objectives were to review the evidence on variables associated with explicit decisions about limitation of treatment in patients with cancer and to critically appraise the factors from a clinical ethics perspective.

METHODS

A search was conducted of studies published in EMBASE, CINAHL, PsycINFO, Assia, Current Contents Medicine, Belit, and Euroethics before February 5, 2014. Eligible studies reported data on explicit treatment limitation in patients with cancer and included a statistical analysis on possibly associated factors. Information on study participants, types of limited treatment, and variables associated with limiting treatment were extracted by two researchers independently. Data synthesis was performed jointly by researchers from oncology, medical ethics, and social sciences.

RESULTS

The search yielded 897 publications, of which 7 were relevant for this review. Factors significantly associated with decisions about limitation of treatment could be distinguished in three categories: first, sociodemographic variables such as the ethnic background of patients; second, health- or treatment-related variables including a lack of capacity in patients with cancer; and third, patients' preferences and the role of relatives in decisions about limitation of treatment. Limitations to this study are that the studies lacked a predefined hypothesis and they all had been conducted in Western countries.

CONCLUSION

The identified variables raise ethical issues with regards to possible influence of value judgments underlying decisions about limitation of treatment in end-of-life care.

Physician-assisted death with limited access to palliative care

Even among advocates of legalising physician-assisted death, many argue that this should be done only once palliative care has become widely available. Meanwhile, according to them, physician-assisted death should be banned. Four arguments are often presented to support this claim, which we call the argument of lack of autonomy, the argument of existing alternatives, the argument of unfair inequalities and the argument of the antagonism between physician-assisted death and palliative care. We argue that although these arguments provide strong reasons to take appropriate measures to guarantee access to good quality palliative care to everyone who needs it, they do not justify a ban on physician-assisted death until we have achieved this goal.

The normative background of empirical-ethical research: first steps towards a transparent and reasoned approach in the selection of an ethical theory

BACKGROUND

Empirical-ethical research constitutes a relatively new field which integrates socio-empirical research and normative analysis. As direct inferences from descriptive data to normative conclusions are problematic, an ethical framework is needed to determine the relevance of the empirical data for normative argument. While issues of normative-empirical collaboration and questions of empirical methodology have been widely discussed in the literature, the normative methodology of empirical-ethical research has seldom been addressed. Based on our own research experience, we discuss one aspect of this normative methodology, namely the selection of an ethical theory serving as a background for empirical-ethical research.

DISCUSSION

Whereas criteria for a good ethical theory in philosophical ethics are usually related to inherent aspects, such as the theory's clarity or coherence, additional points have to be considered in the field of empirical-ethical research. Three of these additional criteria will be discussed in the article: (a) the adequacy of the ethical theory for the issue at stake, (b) the theory's suitability for the purposes and design of the empirical-ethical research project, and (c) the interrelation between the ethical theory selected and the theoretical backgrounds of the socio-empirical research. Using the example of our own study on the development of interventions which support clinical decision-making in oncology, we will show how the selection of an ethical theory as a normative background for empirical-ethical research can proceed. We will also discuss the limitations of the procedures chosen in our project. The article stresses that a systematic and reasoned approach towards theory selection in empirical-ethical research should be given priority rather than an accidental or implicit way of choosing the normative framework for one's own research. It furthermore shows that the overall design of an empirical-ethical study is a multi-faceted endeavor which has to balance between theoretical and pragmatic considerations.

[End-of-life practices of physicians in Germany]

BACKGROUND

Ethical questions at the end of life are at the centre of scientific and public debates. Up to the present there is scarcity of empirical data regarding physicians' end-of-life practices in Germany.

METHODS

Cross-sectional study among a random sample of German physicians by means of the questionnaire of the EURELD Consortium with additional questions on experiences and attitudes regarding physician assisted suicide.

RESULTS

734 physicians from five state chambers of physicians responded (response rate 36.9 %). 403 physicians reported about end-of-life practices regarding adult patients. Alleviation of symptoms took place in 86.7 % of cases and in 50.7 % medical treatment had been withheld. In three cases death was the consequence of a drug which was provided or administered by respondents. 20.7 % of respondents had been requested to perform physician-assisted suicide (PAS). 41.7 % of participants could not imagine participating in PAS, whereas 40.2 % could imagine this under certain circumstances. A prohibition of PAS by professional law war rejected by 33.7 %, 25.0 % support such a ban and 41.4 % were undecided.

CONCLUSION

Physicians in Germany perform a broad spectrum of end-of-life practices. The empirical findings can serve as a starting point for the reflection about an appropriate normative framework for physicians' end-of-life practices.

[Physician-assisted suicide and advance care planning--ethical considerations on the autonomy of dementia patients at their end of life]

Physician-assisted suicide (PAS), which is currently the subject of intense and controversial discussion in medical ethics, is barely discussed in psychiatry, albeit there are already dementia patients in Germany and other European countries who end their own lives with the assistance of physicians. Based on the finding that patients who ask for medical assistance in suicide often have in mind the loss of their mental capacity, we submit PAS to an ethical analysis and put it into a broader context of patient autonomy at the end of life. In doing so, we point to advance care planning, through which the patient autonomy of the person concerned can be supported as well as respected in later stages of the disease. If patients adhere to their autonomous wish for PAS, physicians find themselves in an ethical dilemma. A further tabooing of the topic, however, does not provide a solution; rather, an open societal and professional ethical discussion and regulation are essential.

Ethics by opinion poll? The functions of attitudes research for normative deliberations in medical ethics

Empirical studies on people's moral attitudes regarding ethically challenging topics contribute greatly to research in medical ethics. However, it is not always clear in which ways this research adds to medical ethics as a normative discipline. In this article, we aim to provide a systematic account of the different ways in which attitudinal research can be used for normative reflection. In the first part, we discuss whether ethical judgements can be based on empirical work alone and we develop a sceptical position regarding this point, taking into account theoretical, methodological and pragmatic considerations. As empirical data should not be taken as a direct source for normative justification, we then delineate different ways in which attitudes research can be combined with theoretical accounts of normative justification in the second part of the article. Firstly, the combination of attitudes research with normative-ethical theories is analysed with respect to three different aspects: (a) The extent of empirical data which is needed, (b) the question of which kind of data is required and (c) the ways in which the empirical data are processed within the framework of an ethical theory. Secondly, two further functions of attitudes research are displayed which lie outside the traditional focus of ethical theories: the exploratory function of detecting and characterising new ethical problems, and the field of 'moral pragmatics'. The article concludes with a methodological outlook and suggestions for the concrete practice of attitudinal research in medical ethics.

Improving the quality of 'personalized medicine' research and practice: through an ethical lens

The evolving vision for personalized medicine (PM) implies a systems approach to the re-organization of healthcare and how we define the boundary between care and research. Calls for scaling PM up to a systems level requires a broad definition of quality not restricted to how the different elements of the system perform (e.g., laboratory quality control, biomarker prediction, biobanking, information systems, data sharing and security, and clinical outcomes) but how these elements work together to optimize population relevant quality indicators - effectiveness, affordability, system sustainability, public confidence and accessibility. Examples of PM-associated information technologies and innovative clinical evaluation methods with a focus on cancer medicine are provided to demonstrate how quality and ethics are inextricably linked to a PM systems approach. While current, traditional ethical standards sometimes challenge the PM approach, PM is challenging us to review ethical standards and improve ethical frameworks to meet new and future realities.

Medical expertise and patient involvement: a multiperspective qualitative observation study of the patient's role in oncological decision making

BACKGROUND

Decision making in oncology poses intricate ethical questions because treatment decisions should account not only for evidence-based standards but also for the patient's individual values and preferences. However, there is a scarcity of empirical knowledge about patient involvement in oncological decision making.

METHODS

Direct, nonparticipant observation was used as a qualitative research method to gain an understanding of the interplay between medical expertise and patient participation in oncological decision making. Based on a multiperspective approach, observations were performed in three settings (tumor conference, ward round, and outpatient clinic) in the oncology department of a German university hospital. The observation transcripts were analyzed using central features of qualitative data analysis.

RESULTS

Major differences were identified regarding the decision-making processes in the three settings related to the patient's presence or absence. When the patient was absent, his or her wishes were cited only irregularly; however, patients actively advanced their wishes when present. Preselection of treatments by physicians was observed, narrowing the scope of options that were finally discussed with the patient. Dealing with decisions about risky treatments was especially regarded as part of the physician's professional expertise.

CONCLUSION

The study reveals aspects of decision making for cancer patients that have been underexposed in the empirical and theoretical literature so far. Among these are the relevance of structural aspects for the decisions made and the practice of preselection of treatment options. It should be further discussed how far medical expertise reaches and whether therapeutic decisions can be made without consulting the patient.

[The new financial compensation system PEPP: an ethical analysis]

BACKGROUND

The new compensation system for psychiatric and psychosomatic institutions (German acronym: PEPP) not only constitutes a change in billing practices, but also necessitates an ethical investigation and analysis of possible consequences of the new legislation for those affected in practice.

MATERIAL AND METHODS

Following the presentation of the new PEPP and its consequences for psychiatric practice, problems and areas of conflict will be analyzed from an ethical perspective and discussed.

RESULTS

Ethical conflicts exist in the following areas: (1) in the attempt to standardize inpatient care and invoicing for mental illnesses, (2) in poorer treatment for severely ill patients in view of degressive per diem rates, (3) in false incentives due to threshold values e.g. for 1:1 health professional-patient ratios in the case of coercive measures and (4) due to the inappropriate use of a supposed normative neutral quantitative economic model for a qualitative work area that often takes place in human border zones such as complex inpatient care of severely mentally ill patients.

CONCLUSION

The ethical analysis of PEPP reveals that apart from the limited opportunities to improve efficiency, there is a considerable ethical risk of loss of quality in psychiatric inpatient care in particular for severely and chronically mentally ill patients.