High-throughput phenotyping for non-destructive estimation of soybean fresh biomass using a machine learning model and temporal UAV data

BACKGROUND

Biomass accumulation as a growth indicator can be significant in achieving high and stable soybean yields. More robust genotypes have a better potential for exploiting available resources such as water or sunlight. Biomass data implemented as a new trait in soybean breeding programs could be beneficial in the selection of varieties that are more competitive against weeds and have better radiation use efficiency. The standard techniques for biomass determination are invasive, inefficient, and restricted to one-time point per plot. Machine learning models (MLMs) based on the multispectral (MS) images were created so as to overcome these issues and provide a non-destructive, fast, and accurate tool for in-season estimation of soybean fresh biomass (FB). The MS photos were taken during two growing seasons of 10 soybean varieties, using six-sensor digital camera mounted on the unmanned aerial vehicle (UAV). For model calibration, canopy cover (CC), plant height (PH), and 31 vegetation index (VI) were extracted from the images and used as predictors in the random forest (RF) and partial least squares regression (PLSR) algorithm. To create a more efficient model, highly correlated VIs were excluded and only the triangular greenness index (TGI) and green chlorophyll index (GCI) remained.

RESULTS

More precise results with a lower mean absolute error (MAE) were obtained with RF (MAE = 0.17 kg/m2) compared to the PLSR (MAE = 0.20 kg/m2). High accuracy in the prediction of soybean FB was achieved using only four predictors (CC, PH and two VIs). The selected model was additionally tested in a two-year trial on an independent set of soybean genotypes in drought simulation environments. The results showed that soybean grown under drought conditions accumulated less biomass than the control, which was expected due to the limited resources.

CONCLUSION

The research proved that soybean FB could be successfully predicted using UAV photos and MLM. The filtration of highly correlated variables reduced the final number of predictors, improving the efficiency of remote biomass estimation. The additional testing conducted in the independent environment proved that model is capable to distinguish different values of soybean FB as a consequence of drought. Assessed variability in FB indicates the robustness and effectiveness of the proposed model, as a novel tool for the non-destructive estimation of soybean FB.

Going north: adaptation of soybean to long-day environments

This article comments on:

Zhu X, Leiser WL, Hahn V, Würschum T. 2023. The genetic architecture of soybean photothermal adaptation to high latitudes. Journal of Experimental Botany 74,2987–3002

In plant breeding, understanding genetic variation in the photoperiodic control of flowering time of crop plants such as soybean is a prerequisite for managing adaptation to new environments. Zhu et al. (2023) analyzed a large diversity panel of >1500 early maturity soybean lines to disclose the genetic architecture behind the timing of flowering and maturity. Their findings confirm known maturity loci and reveal new candidate genes and alleles as well as environmental interactions of individual quantitative trait loci (QTLs) for flowering and maturity time. The results shed light on the complexity of the regulatory network which controls the timing of flowering in soybean. This supports the fine-tuning of plant architectures through the combination of stem termination and flowering genes towards a better adaptation of soybean to high latitudes or other stressful environments.

Carbohydrate metabolism enzymes and phenotypic characterization of diverse lines of the climate-resilient food, feed, and bioenergy crop Camelina sativa

Climate change poses tremendous pressure on agriculture. Camelina sativa is an ancient, low-input, high-quality oilseed crop for food, feed and industrial applications that has retained its natural stress tolerance. Its climate resilience, adaptability to different growth conditions, and the qualities of its seed oil and cake have spurred the interest in camelina. However, due to a period of neglect it has not yet undergone intensive breeding and knowledge about this multi-purpose crop is still limited. Metabolism is strongly associated with plant growth and development and little information is available on camelina primary carbohydrate metabolism. Here, eight camelina lines from different geographic and climatic regions were characterized for important growth parameters and agricultural traits. Furthermore, the activities of key enzymes of the carbohydrate metabolism were analysed in leaves, seedpods, capsules, and developing seeds. The lines differed in shoot and leaf morphology, plant height, biomass formation as well as in seed yield and seed oil and protein content. Key carbohydrate metabolism enzymes showed specific activity signatures in leaves and reproductive organs during seed development, and different lines exhibited distinct enzyme activity patterns, providing a valuable basis for developing new physiological markers for camelina breeding programs.

Under which conditions are changes in the treatment of people under involuntary commitment justified during the COVID-19 pandemic? An ethical evaluation of current developments in Germany

The COVID-19 pandemic poses significant challenges in psychiatric hospitals, particularly in the context of the treatment of people under involuntary commitment. The question arises at various points in the procedure for and process of involuntary commitment whether procedural modifications or further restrictive measures are necessary to minimise the spread of COVID-19 and protect all people involved from infection. In the light of current developments in Germany, this article examines under which conditions changes in the treatment of people under involuntary commitment are ethically justified in view of the COVID-19 pandemic. Among others, we discuss ethical arguments for and against involuntary commitments with reference to COVID-19, the use of different coercive interventions, the introduction of video hearings, an increased use of video surveillance and interventions based on the German Infection Protection Act. We argue that strict hygiene concepts, the provision of sufficient personal protective equipment and frequent testing for COVID-19 should be the central strategies to ensure the best possible protection against infection. Any further restrictions of the liberty of people under involuntary commitment require a sound ethical justification based on the criteria of suitability, necessity and proportionality. A strict compliance with these criteria and the continued oversight by external and independent control mechanisms are important to prevent ethically unjustified restrictions and discrimination against people with the diagnosis of a mental disorder during the COVID-19 pandemic.

Spermidine and other functional phytochemicals in soybean seeds: Spatial distribution as visualized by mass spectrometry imaging

Soybean seeds contain phytochemicals such as polyamines and isoflavones, which have been identified as functional components mediating health benefits in association with the consumption of soy foods. While a clear picture of the spatial distribution of these components within the seed is lacking, such information would be important to enhance or reduce their concentration in respective foods through processing. Thus, the objective of the present study was to visualize the most relevant components with respect to their distribution in soybean seeds. Mature soybean seeds were subject to atmospheric-pressure scanning-microprobe matrix-assisted laser desorption/ionization (AP-SMALDI) combined with a Fourier-transform orbital trapping mass spectrometer to generate high-resolution chemical images of phytochemical distribution. Based on seed cross sections, differential distributions of functional components were found between soybean cotyledon and germ (shoot, hypocotyl, root) regions. Spermidine and spermine were present in higher concentrations in the germ rather than in cotyledons with highest concentrations in root and shoot meristem tissues. Differential concentrations of spermidine and other components between the germ and cotyledon regions were confirmed by seed fractioning. In contrast to polyamines spermidine and spermine, the different types of daidzein, glycitein, and genistein isoflavones were all visualized in root parenchyma tissue exclusively. Overall, mass spectrometry imaging of soybean seeds revealed clear insights into the differential distribution of functional phytochemicals. Based on their distribution and depending on specific needs, spermidine and isoflavones can either be enriched or reduced during food processing by separating cotyledon and germ fractions.

Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals' and patients' view: a qualitative interview study

BACKGROUND

Treating legally committed patients on open, instead of locked wards is controversially discussed and the affected stakeholders (patients, mental health professionals) have ambiguous views on the benefits and disadvantages. The study aims to assess the opinions and values of relevant stakeholders with regard to the requirements for implementing open wards in psychiatric hospitals.

METHODS

Semi-structured interviews were conducted with 15 psychiatrists, 15 psychiatric nurses and 15 patients, and were analyzed using qualitative content analysis.

RESULTS

The interviewees identified conceptual, personnel and spatial requirements necessary for an open door policy. Observation and door watch concepts are judged to be essential for open wards, and patients appreciate the therapeutic value they hold. However, nurses find the door watch problematic. All groups suggest seclusion or small locked divisions as a possible way of handling agitated patients. All stakeholders agree that such concepts can only succeed if sufficient, qualified staff is available. They also agree that freedom of movement is a key element in the management of acutely ill patients, which can be achieved with an open door policy. Finally, the interviewees suggested removing the door from direct view to prevent absconding.

CONCLUSIONS

For psychiatric institutions seeking to implement (partially) open wards, the present results may have high practical relevance. The stakeholders' suggestions also illustrate that fundamental clinical changes depend on resource investments which - at least at a certain point - might not be feasible for individual psychiatric institutions but presumably require initiatives on the level of mental health care providers or policy makers.

Immunological differences between insect venom-allergic patients with and without immunotherapy and asymptomatically sensitized subjects

BACKGROUND

Currently available tests are unable to distinguish between asymptomatic sensitization and clinically relevant Hymenoptera venom allergy. A reliable serological marker to monitor venom immunotherapy (VIT) does also not exist. Our aim was to find reliable serological markers to predict tolerance to bee and vespid stings.

METHODS

We included 77 asymptomatically sensitized subjects, 85 allergic patients with acute systemic sting reactions, and 61 allergic patients currently treated with VIT. Levels of sIgE and sIgG₄ to bee and vespid venom, rApi m 1, and rVes v 5 were measured immediately after allergic sting reactions or before sting challenges and 4 weeks later. All sting challenges were tolerated. The inhibitory activity was determined using BAT inhibition and ELIFAB assay.

RESULTS

Median sIgG₄ levels were 96-fold higher in VIT patients (P < .001) while sIgE/sIgG₄ ratios were consistently lower (P < .001). The ELIFAB assay was paralleled by low sIgE/sIgG₄ ratios in VIT patients, showing markedly higher allergen-blocking capacity (P < .001). An almost complete inhibition of the basophil response was seen in all patients treated with vespid venom, but not in those treated with bee venom. Four weeks after the sting, sIgE and sIgG₄ levels were increased in allergic and asymptomatically sensitized patients, but not in VIT patients.

CONCLUSION

Immunological responses after stings varied in bee and vespid venom-allergic patients. In patients under VIT, sIgE and sIgG₄ remained completely stable after sting challenges. Monitoring VIT efficacy was only possible in vespid venom allergy, and the sIgG₄ threshold for rVes v 5 had the highest sensitivity to confirm tolerance. The BAT inhibition test was the most reliable tool to confirm tolerance on an individual basis.

Treatment recommendations within the leeway of clinical guidelines: A qualitative interview study on oncologists' clinical deliberation

Background

Recommending the optimal treatment for an individual patient requires a well-balanced consideration of various medical, social and ethical factors. The interplay of these factors, interpretation of the patient’s situation and understanding of the existing clinical guidelines can lead to divergent therapy recommendations, depending on the attending physician. Gaining a better understanding of the individual process of medical decision-making and the differences occurring will support the delivery of optimal individualized care within the clinical setting.

Methods

A case vignette of a 64-year-old patient with locally advanced pancreatic adenocarcinoma was discussed with oncologists in 14 qualitative, semi-structured interviews at two academic institutions. Relevant factors that emerged were ranked by the participants using the Q card sorting method. Qualitative data analysis and descriptive statistics were performed.

Results

Oncologists recommend different therapeutic approaches within the leeway of the relevant clinical guidelines. One group of participants endorses a rather aggressive and potentially curative approach with a combination chemotherapy following the FOLFIRINOX protocol to provide the patient with the best chances of resectability. The second group suggests a milder chemotherapy approach with gemcitabine, highlighting the palliative approach and the patient’s quality of life. Clinical guidelines are generally seen as an important point of reference, but are complicated to apply in highly individual cases.

Conclusion

The physician’s individual assessment of factors, such as biological age, general condition or prognosis, plays a decisive role in treatment recommendations, particularly in those cases which are not fully covered by guidelines. Judgment and discretion remain crucial in clinical decision-making and cannot and should not be fully ruled out by evidence-based guidelines. Therefore, a more comprehensive reflection on the interaction between evidence-based medicine and the physician’s estimation of each individual case is desirable. Knowledge of existing barriers can enhance the implementation of guidelines, for example, through medical education.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3783-6) contains supplementary material, which is available to authorized users.

Identification of mega-environments in Europe and effect of allelic variation at maturity E loci on adaptation of European soybean

Soybean cultivation holds great potential for a sustainable agriculture in Europe, but adaptation remains a central issue. In this large mega-environment (MEV) study, 75 European cultivars from five early maturity groups (MGs 000-II) were evaluated for maturity-related traits at 22 locations in 10 countries across Europe. Clustering of the locations based on phenotypic similarity revealed six MEVs in latitudinal direction and suggested several more. Analysis of maturity identified several groups of cultivars with phenotypic similarity that are optimally adapted to the different growing regions in Europe. We identified several haplotypes for the allelic variants at the E1, E2, E3 and E4 genes, with each E haplotype comprising cultivars from different MGs. Cultivars with the same E haplotype can exhibit different flowering and maturity characteristics, suggesting that the genetic control of these traits is more complex and that adaptation involves additional genetic pathways, for example temperature requirement. Taken together, our study allowed the first unified assessment of soybean-growing regions in Europe and illustrates the strong effect of photoperiod on soybean adaptation and MEV classification, as well as the effects of the E maturity loci for soybean adaptation in Europe.

Development of soybeans with low P34 allergen protein concentration for reduced allergenicity of soy foods

BACKGROUND

In soybean, at least 16 seed proteins have been identified as causing allergenic reactions in sensitive individuals. As a soybean genebank accession low in the immunodominant protein P34 (Gly m Bd 30K) has recently been found, introgression of the low-P34 trait into adapted soybean germplasm has been attempted in order to improve the safety of food products containing soybean protein. Therefore, marker-assisted selection and proteomics were applied to identify and characterize low-P34 soybeans.

RESULTS

In low-P34 lines selected from a cross-population, concentrations of the P34 protein as identified with a polyclonal antibody were reduced by 50-70% as compared to P34-containing controls. Using 2D electrophoresis and immunoblotting, the reduction of P34 protein was verified in low-P34 lines. This result was confirmed by liquid chromatographic-tandem mass spectrometric analysis, which revealed either a reduction or complete absence of the authentic P34 protein as suggested from presence or absence of a unique peptide useful for discriminating between conventional and low-P34 lines.

CONCLUSION

Marker-assisted selection proved useful for identifying low-P34 soybean lines for the development of hypoallergenic soy foods. The status of the P34 protein in low-P34 lines needs further characterization. In addition, the food safety relevance of low-P34 soybeans should be tested in clinical studies. © 2016 Society of Chemical Industry.

Editorial: Sustainable production of renewable energy from non-food crops

Since the world faced the petroleum crisis in the 1970s and people started to realize the limitation of fossil energy resources coupled with concerns over the effects of increasing carbon dioxide in the atmosphere, major efforts were devoted to the search for alternative energy sources.

Female preferences for male traits and territory characteristics in the cichlid fish Tropheus moorii

Female mate preferences for male traits and resource characteristics affect trait evolution and diversification. Here, we test the effects of male body traits and territory characteristics on within-population female preferences and on population-assortative mating in the cichlid Tropheus moorii. Within-population preferences of females were independent of male body size, coloration and territory size but were strongly dependent on territory quality and co-varied with male courtship activity. Courtship activity of individual males was contingent on the quality of their assigned territory, and therefore, courtship may not only indicate intrinsic male quality. On the basis of these results we suggest that female preferences for high-quality territories reinforce the outcome of malemale competition and ensure male mating success. Mating preferences of females for males of their own color variant (ascertained in a previous experiment) were not overturned when males of another color variant were presented in a superior territory, indicating that within- and between-population mate preferences of females depend on different cues.

[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.

The relationship between N isotopic fractionation within soybean and N2 fixation during soybean development

The contribution of N(2) fixation to overall soybean N uptake has most commonly been quantified by N isotope-based methods, which rely on isotopic differences in plant N between legumes and non-fixing reference plants. The choice of non-fixing reference plants is critical for the accuracy of isotope-based methods, and mismatched reference plants remain a potential source of error. Accurate estimates of soybean N(2) fixation also require information on N isotopic fractionation within soybean. On the basis of a previous observation of a close correlation between an expression of N fractionation within soybean and the proportion of plant N derived from atmosphere (%Ndfa) determined by (15) N natural abundance, this field study aimed at assessing the relationship between various expressions describing intraplant (15) N or N partitioning and %Ndfa during soybean development. Starting from a late vegetative stage until beginning senescence, the N content and N isotopic composition of shoots, roots and nodules of nodulated and non-nodulated soybeans was determined at eight different developmental stages. Regression analysis showed that %Ndfa most closely correlated with the difference in the N isotopic composition of shoot N minus that of root including nodule N, and that this relationship was similar to that obtained in a previous multi-site field study. We therefore consider this expression to hold promise as a means of quantifying %Ndfa independent of a reference plant, which would avoid some of the external sources of error introduced by the use of reference plants in determining %Ndfa.

[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.

[Compulsory treatment in psychiatry: an ethical analysis of the new legal regulations for clinical practice]

BACKGROUND

The new legal regulations of compulsory treatment in Germany require a change in clinical psychiatric practice as well as an ethical analysis of the consequences for those involved.

MATERIALS AND METHODS

The new legal regulations are reported and via ethical analysis new problematic fields, such as consequences of the new law are identified and discussed in the context of psychiatry and law.

RESULTS

The main ethical identified problems are care of mentally ill with mental competence who refuse medical treatment, the different normative assessment of compulsory treatment and mechanical fixation, the ambivalent role of the conversation between psychiatrist and patient in order to change the natural will of the patient to avoid compulsory measures, the ethical consequences of questionable financial incentives in the context of compulsory treatment and the contradictive legal regulations in the field.

CONCLUSIONS

The ethical analysis of the new law on compulsory treatment in Germany shows chances for improvement of clinical psychiatric practice as well as normative problematic regulations and fields of conflicts.

Genetic relationships and evolution in Cucurbita pepo (pumpkin, squash, gourd) as revealed by simple sequence repeat polymorphisms

Genetic relationships among 104 accessions of Cucurbita pepo were assessed from polymorphisms in 134 SSR (microsatellite) and four SCAR loci, yielding a total of 418 alleles, distributed among all 20 linkage groups. Genetic distance values were calculated, a dendrogram constructed, and principal coordinate analyses conducted. The results showed 100 of the accessions as distributed among three clusters representing each of the recognized subspecies, pepo, texana, and fraterna. The remaining four accessions, all having very small, round, striped fruits, assumed central positions between the two cultivated subspecies, pepo and texana, suggesting that they are relicts of undescribed wild ancestors of the two domesticated subspecies. In both, subsp. texana and subsp. pepo, accessions belonging to the same cultivar-group (fruit shape) associated with one another. Within subsp. pepo, accessions grown for their seeds or that are generalists, used for both seed and fruit consumption, assumed central positions. Specialized accessions, grown exclusively for consumption of their young fruits, or their mature fruit flesh, or seed oil extraction, tended to assume outlying positions, and the different specializations radiated outward from the center in different directions. Accessions of the longest-fruited cultivar-group, Cocozelle, radiated bidirectionally, indicating independent selection events for long fruits in subsp. pepo probably driven by a common desire to consume the young fruits. Among the accessions tested, there was no evidence for crossing between subspecies after domestication.

Information provision and decision-making in assisted reproduction treatment: results from a survey in Germany

BACKGROUND

The objective of this study was to investigate the views of patients and experts in Germany on information provision and decision-making in assisted reproduction treatment (ART).

METHODS

Standard questionnaire techniques were used for interviewing Reproductive Physicians (n= 230), Psychosocial Counsellors (n = 66) and Patients (n = 1590). Descriptive data analyses and non-parametric tests for significance were performed.

RESULTS

Higher scores were assigned for information on the chances for treatment success and on direct, physical risks of fertility treatment than for information on the risks and burden of multiple pregnancies and on the emotional risks and burden associated with infertility treatment. Three-quarters (74%) of the Patients (P) reported that they had experienced an overwhelming desire for a child at some point during their treatment, and half (47%) stated that they had experienced the feeling of losing control over the situation. According to 25% of the Reproductive Physicians (RP) and 47% of the Psychosocial Counsellors (PC), patients are often or very often limited in their capacity to decide when to stop the treatment.

CONCLUSIONS

A significant number of patients in reproductive care in Germany are not well informed on all the aspects that are relevant for treatment decision-making, are overwhelmed by their desire for a child, lose control over the situation, and are limited in their capacity to end unsuccessful treatment. Information provision should be ensured and monitored during treatment by standardized safeguards. A strategy for stopping ART and embarking on alternative ways of coping with infertility should be installed from the outset of every treatment.

["Truth at the bedside"]

BACKGROUND AND RESEARCH QUESTION

Discussions with seriously ill patients are part of physicians' tasks. These discussions are very demanding with respect to communication skills. In this paper we present the concept of an obligatory postgraduate course for physicians on breaking bad news and the results of the course evaluation.

RESEARCH PARTICIPANTS AND METHODS

Physicians of 4 German hospitals in which the module was offered as an obligatory inhouse course. An interventional study without control group was carried out in which a questionnaire (closed-ended questions and Likert scales as well as open-ended questions) was distributed before and immediately after the course.

RESULTS

186 physicians (response rate: 88.6 %) participated in the study. 102 respondents (54.8 %) had broken bad news more than five times per month. 75 physicians (40.3 %) indicated that they had never participated in a teaching module on this topic prior to the course. Discussions about the end of life and disclosure about recurrence of the disease were rated most frequently as very difficult communication situations. Compared with the beginning of the course the respondents rated their communication skills significantly better at the end of the course. The course's relevance for clinical practice, teaching methods and the organisation of the course were rated positively.

CONCLUSION

The feedback of the participants indicates the practical relevance of professional training on difficult communication situations such as breaking bad news. The improved rating of communication skills may be interpreted as a positive effect of the course. In our view, observational studies as well as interprofessional teaching modules contribute to improved professional communication with patients about diagnosis, prognosis and treatment options.

[Treatment decisions in advanced cancer. An empirical-ethical study on physicians' criteria and the process of decision making]

BACKGROUND AND RESEARCH QUESTION

Physicians' decisions regarding the indication of medical treatment are central to the application or limitation of medical measures in advanced cancer. This qualitative study explores criteria and procedural aspects of treatment decisions with patients with cancer near the end of life from the perspective of oncologists.

RESEARCH PARTICIPANTS AND METHODS

In this qualitative interview study physicians working in the field of oncology were asked about their decisional criteria and procedural aspects of treatment decision making in cases of patients with advanced cancer. All interviews were audiotaped and transcribed. Qualitative data analysis was conducted in accordance with principles of "Grounded Theory".

RESULTS

17 research interviews had been analysed. Next to medical criteria the life-circumstances of the patients with respect to age and social situation as well as the perceived quality of the physician-patient-relationship were named as foundation for decisions about the application or limitation of medical treatment at the end of life. In addition situational factors such as time pressure or the available technical equipment were cited as relevant factors for the decisions. "Silent acquiescence" as the predominant decision making model which has been reconstructed on the basis of the narratives means that decisions about the limitation of medical treatment are not communicated explicitly within the physician-patient-relationship. This approach was justified by the interviewees in light of the long standing relationship between physicians and patients.

CONCLUSIONS

The decisional criteria and procedural aspects of decision making in patients with advanced cancer which have been elicited in this qualitative study inform the current scientific and societal debate on ethically relevant aspects of end-of-life decision making in medicine.

Information and participation in decision-making about treatment: a qualitative study of the perceptions and preferences of patients with rheumatoid arthritis

OBJECTIVES

To elicit the perceptions and preferences of patients with rheumatoid arthritis regarding information and participation in treatment decision-making. To analyse the patients' narratives on the background of the ethical discourse on various approaches to treatment decision-making.

DESIGN

In-depth interviews with themes identified using principles of grounded theory.

PARTICIPANTS

22 patients with long-standing rheumatoid arthritis.

MAIN OUTCOME MEASURES

Qualitative data on patients' perceptions and preferences regarding information and participation in decision-making about treatment.

RESULTS

Decision-making about treatment has been described by the patients as a process consisting of different stages with shifting loci of control and responsibility. Patients initially received one treatment recommendation and were not aware of alternative treatment options. Those participants in this study who wanted information about negative effects of a treatment cited "interest in one's own health" and the potential "use of information" as reasons for their preference. The physicians' expert knowledge and clinical experience regarding the effects of medication were cited as arguments by patients for a treatment recommendation.

CONCLUSIONS

The patients' accounts of decision-making about treatment differ from models of physician-patient relationship that have been put forward in ethical discourse. These differences may be relevant with respect to the starting point of an ethical analysis of treatment decision-making. Patients' accounts with respect to a lack of information on treatment alternatives point to ethically relevant challenges regarding treatment decision-making in clinical practice.

Ethical opinions and personal attitudes of young adults conceived by in vitro fertilisation

BACKGROUND

Today in vitro fertilisation (IVF) is a widespread and important technique of reproductive medicine. When the technique was first used, it was considered ethically controversial. This is the first study conducted of adult IVF-offspring in order to learn about their ethical opinions and personal attitudes towards this medical technology.

METHODS

We recruited the participants from the first cases of in vitro fertilisation in Germany at the Gynaecological Clinic of the University Hospital Erlangen. Our qualitative interview study consisted of in-depth, face-to-face interviews with 16 adults who had been conceived by IVF. Our data was analysed with methods of Grounded Theory.

RESULTS

For these adults, the most important factor influencing their personal attitudes towards IVF was the knowledge that they were deeply wanted children. The artificiality of their conception seemed irrelevant for their ethical opinion. All participants mentioned that it was important for them to be informed about the circumstances of their conception by their parents.

CONCLUSIONS

IVF seems to be a medical technique which, although it affects intimate aspects of human existence, can be integrated into the lives of the affected persons without any great difficulties. The findings suggest that parents should inform their children about their fertilisation at an early age and as part of a process over time, not only on a single occasion. Physicians should advise IVF-parents accordingly.

Decisions at the end of life: an empirical study on the involvement, legal understanding and ethical views of preregistration house officers

OBJECTIVES

To collect information on the involvement, legal understanding and ethical views of preregistration house officers (PRHO) regarding end-of-life decision making in clinical practice.

DESIGN

Structured telephone interviews.

PARTICIPANTS

104 PRHO who responded.

MAIN OUTCOME MEASURES

Information on the frequency and quality of involvement of PRHO in end-of-life decision making, their legal understanding and ethical views on do-not-resuscitate (DNR) order and withdrawal of treatment.

RESULTS

Most PRHO participated in team discussions on the withdrawal of treatment (n = 95, 91.3%) or a DNR order (n = 99, 95.2%). Of them, 46 (44.2%) participants had themselves discussed the DNR order with patients. In all, it was agreed by 84 (80.8%) respondents that it would be unethical to make a DNR order on any patient who is competent without consulting her or him. With one exception, it was indicated by the participants that patients who are competent may refuse tube feeding (n = 103, 99.0%) and 101 (97.1%) participants thought that patients may refuse intravenous nutrition. The withdrawal of artificial ventilation in incompetent patients with serious and permanent brain damage was considered to be morally appropriate by 95 (91.3%) and 97 (93.3%) thought so about the withdrawal of antibiotics. The withdrawal of intravenous hydration was considered by 67 (64.4%) to be morally appropriate in this case.

CONCLUSIONS

PRHO are often involved with end-of-life decision making. The results on ethical and legal understanding about the limitations of treatment may be interpreted as a positive outcome of the extensive undergraduate teaching on this subject. Future empirical studies, by a qualitative method, may provide valuable information about the arguments underlying the ethical views of doctors on the limitations of different types of medical treatment.

Ethische Entscheidungen am Lebensende - Kenntnisstand und Einstellungen Medizinstudierender

BACKGROUND AND OBJECTIVE

Physicians are often confronted with ethical and legal questions at the end of life. In this study we asked medical students at the universities of Mainz and Berlin (Charité) about the "Guidelines on Physicians' Aid to the Dying" issued by the German Medical Association: their moral attitude and legal knowledge regarding the limitation of medical procedures at the end of life and their judgement about the quality of medical education on these topics.

METHODS

569 medical students in their 1. and 4. clinical semester as well as the final year of their studies in Mainz and students in their 5. year of studies in Berlin received a questionnaire containing 14 items relating to ethical and legal questions at the end of life.

RESULTS

308 (54.1%) completed the questionnaire. 7.8% knew the contents of the "Guidelines on Physicians' Aid to the Dying". Between 10% (use of catecholamines) and 62% (parenteral feeding) viewed withholding or withdrawing life-sustaining measures from dying patients as illegal. 39-72% held the view that measures of nutrition and hydration were part of the indispensable basic medical care for every patient. 12-26% were unsure with respect to their moral views about withholding and withdrawal of therapy. 82% felt insufficiently prepared for dealing with ethical questions at the end of life.

CONCLUSION

Only a minority of medical students was informed about ethical principles and legal regulations regarding end-of-life decisions. Teaching of ethical and legal knowledge and integration of these issues into clinical problem solving should be mandatory.

Klinische Ethikkomitees an deutschen Universitätskliniken

OBJECTIVE

Health Care Ethics Committees (HEC) are new ways of implementing clinical ethics in hospitals and nursing homes. In the US all health care institutions must provide some structure to handle ethical conflicts in everyday patients' care. However, in Germany only a minority of hospitals, often members of the Protestant or Catholic Hospital Associations, have founded HEC. No studies exist in regard to the situation at German university hospitals.

METHODS

In November 2002 we posted a questionnaire with 13 items to all medical directors (M) and directors of nursing (N) of the 36 German university hospitals.

RESULTS

The response rate was 82 %. Limitation of treatment, informed consent and the conflict between beneficience and autonomy are the most relevant ethical issues in everyday practice. N estimated the need for additional support of their staff in ethical issues higher than M. Improvement of interdisciplinary teamwork, further education in ethics and ethical guidelines have been identified in order to improve ethical professional performance. However, N mentioned the lack of time and the low priority of ethics more often than M as problems in implementing theses measures. Five German university hospitals are planning to establish a HEC and two hospitals want to employ a clinical ethicist.

CONCLUSION

Our data show a high need for information about HEC in German university hospitals. The tasks, working methods and chances for further development of HEC are neither known nor used in the majority of German university hospitals.