Gesundheitliche Vorausverfügungen und die Zeitstruktur guten Lebens

Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness

People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.

[Between trivialization and pathologization: Healthcare in old age and the temporal structure of a good life]

Definition of problem

Modern medicine is challenging traditional views of age(ing). What was long considered a "normal" sign of old age is now often perceived and treated as a disease. As a result, age-related health standards and treatment goals are shifting. The resulting scope between trivialization and pathologization of age(ing) requires ethical reflection.

Argument

This article explores the question of how notions of age(ing) are to be understood ethically in the context of medicine. We first provide an overview of the state of research on the role of age stereotypes in the healthcare of older people. The notions of age(ing) identified in this context are then analyzed from the perspective of teleological ethics.

Conclusions

What kinds of healthcare are reasonable and appropriate in old age has to be discussed in the context of the temporal structure of a good life.

Zeitdimensionen des menschlichen Lebens

Angesichts der zentralen Bedeutung, die die spezifische Zeitlichkeit unserer Existenz für Fragen der Lebensführung hat, liegt es auf der Hand, dass gerade auch im Bereich von Medizin und Medizinethik zeitliche Dimensionen eine wichtige Rolle spielen. Das Feld der dabei zu beachtenden temporalen Phänomene wird jedoch schnell unübersichtlich. Vor deren medizinethischer Bewertung erscheint deswegen eine philosophische Vorklärung relevanter Zeitunterscheidungen angezeigt. Eine solche Vorklärung nehmen wir in diesem Aufsatz in Angriff. Ziel ist die Entwicklung einer Matrix von temporalen Differenzierungen, die auch zur ethischen Orientierung medizinischer Praktiken herangezogen werden sollten. Auf der Basis der grundlegenden Unterscheidung zwischen der Zeit, in der sich unser Leben wie andere Prozesse auch abspielt, und der Zeitlichkeit, die dieses Leben wesentlich ausmacht, arbeiten wir vier Zeitfelder heraus: die lineare Zeit der chronologischen Ordnung von Ereignissen, die intersubjektive Zeit sozialer Interaktionen, die zyklische Zeit biologischer und sozialer Rhythmen und die biographische Zeit, in der Vergangenheit, Gegenwart und Zukunft existenzielle Bedeutungen annehmen und Endlichkeit und Irreversibilität von Lebensprozessen verhandelt werden. Zur Erläuterung dieser viergliedrigen Matrix greifen wir auf verschiedene Zeitphilosophien zurück, etwa auf solche aus der phänomenologischen Tradition oder aus der neueren analytischen Diskussion.