[HIV prevention in young homosexual men. A medical ethical challenge]

Although considerable progress in the treatment of patients with AIDS has been achieved over the recent years, AIDS remains a non-curative disease. Therefore the prevention of new infections with HIV is an important goal for medicine and public health. However, during recent years the number of new HIV-infections in young gay men increased. New empirical data from the U.S. and the U.K. suggest that the traditional prevention methods fail to reach young gay men in Western countries who become HIV-infected by unsafe sex within intimate relationships. The paper discusses these problems from the perspective of medical ethics. New approaches to sex education and prevention of HIV and other sexually transmitted diseases are developed and the importance of personal values, responsibility, intimacy and emotions are emphasized.

Advance directives in patients with Alzheimer's disease. Ethical and clinical considerations

Advance patient directives are various forms of anticipatory medical directives made by competent individuals for the eventuality of future incompetence. They are therefore appropriate instruments for competent patients in the early stage of Alzheimer's disease to document their self-determined will in the advanced stages of dementia. Theoretical objections have been expressed against the concept of advance patient directives (problems of authenticity and identity) which, however, cannot negate the fundamental moral authority of advance patient directives. Therefore, patients, family members, and physicians should make use of the appropriate form of advance directive as part of common treatment and care planning. Advance directives, when utilized intelligently, represent appropriate instruments for shared decision-making by patient, family members and physician. They should be utilized to a greater extent, particularly for the treatment planning of demented patients.

[Mental competence and informed consent. Clinical practice and ethical analysis]

The doctrine of informed consent has become a legal and ethical standard in psychiatry today. However, ethical problems arise if patients lose the capacity to give informed consent due to their psychiatric disorders. Particularly in the field of psychiatry, the assessment of competence of informed consent to medical treatment and participation in clinical trials is a controversial issue. New empirical data suggest that a high percentage of psychiatric patients are incompetent according to defined standards for assessing their capacity to make treatment decisions. Assessing competence according to a sliding scale integrates the ethical principles of autonomy and beneficence and provides help in assessing competence in clinical practice.

Analysis of relationships between Aegilops tauschii and the D genome of wheat utilizing microsatellites

Sixty Aegilops tauschii accessions and 60 European hexaploid wheat varieties were analyzed with 14 wheat microsatellite (WMS) primer sets to (i) study the phylogeny of Ae. tauschii, (ii) search for a specific genotype of Ae. tauschii most closely related to the D genome of hexaploid wheat, and (iii) narrow down the presumed birthplace of the latter. An average of 6.5 and 4.0 alleles per locus was detected in Ae. tauschii and in wheat, respectively. The highest genetic diversity of Ae. tauschii was found in Transcaucasia and southeast of the Caspian Sea. Distribution of the 87 alleles (without null alleles) found in Aegilops did not allow differentiation of the species into the two subspecies strangulata and tauschii. Excluding null alleles, 41 alleles occurred parallel in wheat and in Aegilops. Data obtained in this study supports the view of the D genome of hexaploid wheat being a composite of several sources but does not support subsp. strangulata as the possible major source of the D genome. The highest number of region-specific alleles (three) in Ae. tauschii occurring also in the D genome of wheat, and therefore most indicative for its evolution was found in present-day Georgia, where subsp. strangulata is not endemic.

[Advance directives in clinical practice]

DEFINITIONS

In the United States advance directives were developed since the late 60s in order to improve patients' medical decision making in case of incompetence in the future. In Germany 3 types of advance directives exist: 1. "Patientenverfügungen". 2. "Berreuungsverfügugen" and 3. "Vorsorgevollmachten".

EMPIRICAL STUDIES

In empirical studies, mostly from the US, the implementation of advance directives into clinical practice and the attitude of physicians, patients, relatives and the general population have been examined. This review article provides results of theses studies in text and tables.

CONCLUSION

Against the will of patients and of the general population advance directives are not often used in clinical practice. Physicians talk with patients about treatment procedures more often than they talk about end of life decisions. Informing patients about advance directives opens the chance to improve palliative care and respects their choices and values at the end of their lives.

[Medical and ethical problems in the classification of psychiatric disorders. The "Wurzburger Schlussels" of 1933]

In 1930 a new classification of mental disorders, later on known as "Würzburger Schlüssel", was developed and tested for two years. It replaced the "Reichsirrenstatistik" from 1901, and included new disease entities. This pragmatical classification was mainly descriptive including a few elements regarding aetiology and course of disease. The "Würzburger Schlüssel" put emphasis on addictions (especially alcoholism), psychopathy (in teenagers as well as in adults) and on the sequelae of syphilis. However, most of the diseases in elderly patients were not classified as being due to the various descriptive disease entities, but to the age related category. The fundamental problems of the development and practice of a classification of psychic disorders and the accompanying medical and ethical problems, which are still important today, are discussed.

[Self determination of patients in social psychiatric practice. A medical ethics model and its practical application]

To protect patients' autonomy, valid informed consent must be given prior to medical treatment. This includes disclosure of information, understanding, ability to decide freely, and competence/capacity of the patient. However, a psychiatric disorder may disturb the ability to make a choice of their own. These patients have lost their competence to give valid informed consent. In everyday practice of social psychiatry, it is of particular interest to have objective and valid criteria to identify the incompetent patient. These problems are discussed in a case report, and four criteria (understanding, reasoning, decision making and appreciation of the disorder) are presented to diagnose the patients' competence.

Sleep deprivation combined with consecutive sleep phase advance as a fast-acting therapy in depression: an open pilot trial in medicated and unmedicated patients

OBJECTIVE

The authors' goal was to test the hypothesis that the antidepressant effect of total sleep deprivation can be maintained by initially avoiding sleep during a supposedly "critical" time period in the early morning.

METHOD

They studied 33 inpatients with major depression, melancholic type, all of whom responded positively to total sleep deprivation. Twelve of the patients were men and 21 were women; their mean age was 46.7 years (SD = 13.7). After total sleep deprivation, the patients started a sleep schedule from 5:00 p.m. to 12:00 midnight, which then was shifted back by 1 hour each day until a sleep time of 11:00 p.m. to 6:00 a.m. was reached.

RESULTS

Twenty (61%) of the 33 patients who responded to total sleep deprivation with an improved state of mood maintained this improvement during sleep phase advance therapy. Drug-free and medicated patients did not differ from each other.

CONCLUSIONS

The rapid amelioration of mood observed with total sleep deprivation can be preserved with a succeeding phase shift of the sleep period.

Informed consent in human experimentation before the Nuremberg code

The issue of ethics with respect to medical experimentation in Germany during the 1930s and 1940s was crucial at the Nuremberg trials and related trials of doctors and public health officials. Those involved in horrible crimes attempted to excuse themselves by arguing that there were no explicit rules governing medical research on human beings in Germany during the period and that research practices in Germany were not different from those in allied countries. In this context the Nuremberg code of 1947 is generally regarded as the first document to set out ethical regulations in human experimentation based on informed consent. New research, however, indicates that ethical issues of informed consent in guidelines for human experimentation were recognised as early as the nineteenth century. These guidelines shed light on the still contentious issue of when the concepts of autonomy, informed consent, and therapeutic and non-therapeutic research first emerged. This issue assumes renewed importance in the context of current attempts to assess liability and responsibility for the abuse of people in various experiments conducted since the second world war in the United States, Canada, Russia, and other nations.

[Responsibility for the individual or the whole? Ethical considerations on medical responsibility]

Physician's patients are often faced with a conflict of interests between the benefit and other interests (society, institutions). This problem has emerged in medical history since the 18th century when the traditional loyalty towards the individual patient was challenged by a social orientations in the physician's ethos. Current bioethical theories regarding this professional conflict of interest are discussed and applied to allocation problems in HMO-health plans. It is argued that the conflict of interests can only be solved if doctors set their professional priority on the healing relationship towards the individual patient.

["Informed consent" by the patient for publication of case reports. New guidelines by the "International Committee of Medical Journal Editors" (Vancouver Group)]

The "International Committee of Medical Journal Editors" has revised its guidelines regarding the protection of patients' rights to privacy in manuscripts submitted to biomedical journals. Information that might identify patients should not be published unless it is essential for scientific purposes and the patient has given written informed consent for publication after having been shown the manuscript to be published. This article discusses the new guidelines in the clinical context of psychiatry and psychotherapy. The ethical and legal problems raised concern (1) the informed consent process, (2) the content of scientific work and (3) the problem of third party consent (e.g. legal guardians).

[Treatment of depression with sleep deprivation and sleep phase advancement]

Total sleep deprivation (TSD) exerts beneficial but only transient effects on mood in approximately 60% of the patients with a major depressive disorder (MDD). The positive effect of TSD is generally reversed after the next night of sleep. A pilot study of our group indicated that a consecutive one week phase advance of the sleep phase stabilized mood in more than half of the patients who responded to TSD. However, the majority of patients in our pilot study had been treated concomitantly with antidepressive medication. To exclude a possible synergistic effect of simultaneous antidepressive medication and the sleep-wake manipulation in the present study eleven medicated and sixteen drug-free depressed patients were investigated. In two thirds of the patients relapse into depression after successful TSD could be prevented. This effect seemed to be independent of adjunct antidepressant pharmacotherapy. Ten of these patients were studied polysomnographically prior to and during the treatment. Data analysis revealed that during the advance of the sleep phase no prolonged partial sleep deprivation took place. At the end of the study REM % had even increased and REM latency was still short in spite of clinical improvement, thus contradicting the assumption that REM sleep suppression is a necessary prerequisite for antidepressive therapy. The results support the hypothesis of a "critical phase" in the morning hours during which sleep can reinduce depressive mood and, vice versa, prevention of sleep during this time may act antidepressively.

[Psychogenic paralysis of the arm after stereotactic brain biopsy]

A 45-year-old Turkish woman with a psychiatric history of depression and somatic disorder underwent an unnecessary stereotactic brain biopsy. After the procedure she developed severe palsy in the arm on the side of the operation without any somatic pathology. An integrative psychosomatic treatment approach focusing on the somatic problem improved the paralysis. Diagnostic and therapeutic issues in this case are discussed critically with reference to the literature.