ICU Management & Practice, Volume 20 - Issue 3, 2020
PRINT OPTIMISED
Use Case COVID-19-ICU Bethany Hospital Germany
Medicine is an activity of special dignity at all times. Healthcare professionals
are responsible actors and have to consider the business of operating ethics.
Weighing up values under considerable time pressure, existential fates and
critically discussed evidence is a considerable challenge for them, not only in
pandemic times but always.
Ethics as Superpower in Medicine
Medicine has been an activity of a special
dignity since ancient times and not only
in Greek, Roman and Christian context of
standards. Principally essential, methodically
and, last but not least, ethically. Without
being able to clarify the differentiated
medical-historical and history of ideas
references here, it should be mentioned
that the Hippocrates (Bergdolt 2004) -Fan
Galenos builds his Definitiones medicae on the τέχνη, in which the ιατρική
assumes primary responsibility for his
healing action, which is always primarily aimed at the non-harming well-being
of the patient: τέχνη ιατρική (Schubert
and Leschhorn 2006). With τέχνη both
craftsmanship as well as art and science
are addressed - a dimensioning that is
not only relevant in terms of terminology
and academia, which still puts doctors
and the surrounding superstructure of
politics, society, economy and technology in a relationship that is not always
easy to balance. It is not without reason
that the ethical dimension is of particular importance, because it is about people
and their ethical essence. Hence: Without
ethics, an ethical foundation there is no
medicine in the full sense of the word.
Perhaps proper prevention, diagnostics,
therapy and aftercare, maybe outcomes
in the interest of the patient, maybe also
a feasible job in the sense of doctors and
nursing staff, in the end maybe even
financially affordable, innovative, agile
and digital in a cleverly constructed public
health system – and there, where organised
privately, even linked to efficient, legal
and legitimate business models. All that is
ostensibly “medicine” within a functionalist
health system without ethics. On closer
inspection, however, it becomes clear that
“medicine” in the full sense can only be
legitimate medicine, carried out by actors
who bear moral responsibility. Medicine
is much more than healing technique.
Therefore, doctors should not be
replaced by artificial intelligence or nurses
by robots [maybe they could someday
(Wandschneider 2020; Crockett (2019)],
but should only be supported by them within the framework of the ethical general
mandate in the sense of a positive outcome
and experience for the patients (and the
doctors and nurses) - as exemplified by
the Smart Hospital (Werner, et al. 2020);
Heinemann 2018a; Heinemann 2018b)
platform as a genuine combination of
medical and economic goals with digital
means under the clear primacy of humanity. People are not broken and need to be
repaired, they need empathic and dignified healing.
“Medicine is one of the areas of life in
which the need for ethical action becomes
inevitable: Where people are weak, exposed
and in need of help, they not only want
to be sure that nothing illegal is happening to them, but that everything that is
legally required is being done. If people
are faced with illness in life, they immediately understand that legal requirements
and prohibitions are inadequate and that,
beyond the wording of the legal book, it
is much more important to follow good
laws as intended. This, however, transcends
the area of legality, i.e. a hard standardisation of human action that is threatened
with punishment, with regard to ethics”
(Heinemann and Miggelbrink 2011).
Medical action is therefore the accomplishment of a skill and duty that cannot be
exhaustively recorded in descriptive-real
scientific categories, because the sphere of
ethics – values, duty, normative realm –
cannot be deduced from the facts. Hume
and (!) Kant were right: The world is as
it is, because in this world it is possible
do to what needs to be done for moral
reasons (Heinemann 2013; Hösle 1987).
Health and illness are not simply facts,
but rather states with normative valence
(Gethmann-Siefert 1996). In the current
situation of a pandemic, which confronts
late-modern societies in the West, the
already demanding task of the ethical foundation and practical feasibility of effective
medical ethics can be characterised as an
even more acute challenge for the medical
profession (Doctors, and, always included:
the nurses; but also the administrative
stuff and all professions and basically all
occupational groups that are part of the
health care system in the broadest sense).
On the one hand, because in the field of the
long tradition of medical ethics itself, the
discourses relevant to ethics as a discipline
of philosophy about the nature and validity of ethical propositions are constantly
emerging. Between ethical-universalistic
and casuistic-relativistic basic orientation, legions of ethics span, sometimes
as a large theoretical framework (mostly
in the classics such as Aristotle, Kant or
in utilitarianism, but not only there, also
in the ethics of religions or alternative
concepts), sometimes as a deliberately
modest, pragmatic approach. Shopping
in the Ethics-Supermarket? (Heinemann
and Miggelbrink 2011). Well, there is an
important difference between freedom
and relativism.
However, in addition, these alternative
theoretical offers are provoked by factual
developments in technological as well
as social areas, which mostly ironically precede ethics as a normative theory of
descriptive morality (and even on this
point there is no agreement) – just think
of the digital transformation of medicine
and healthcare. On the other hand, since
medicine in its noble basic task – at least
as it is understood here – often has little
time, too little time for ethical reflections, out of the hard-factual nature of
a clinical reality. This explains why, since
Hippocrates, those ethical approaches
have been popular in medicine that try
to grasp medical action neither with hard
principles nor with a detailed case report,
but with so-called “middle principles”
(Potthast 2008; Brenner 2006). However,
especially where time becomes critical,
and even more critical than perhaps most
of the time anyway – namely, especially
during the first wave of a pandemic –
medical ethics actually becomes the real
superpower that once again exceeds the
already important professional excellence.
Especially in times of perhaps already
over-dynamic scientific development, a
research pressure not previously known
in this way, and on the other hand socially
broad denial of science, associated with
an enemy that appears mysterious and
still keeps its true nature from us – SARSCoV-2 – the question is more than urgent
how to actually deal with the patients
who manifestly suffer from COVID-19.
Which ethical considerations play a role
here? How can they be justified? Which
sound arguments can be given?
In this context, two questions are repeatedly discussed professionally and publicly:
First: The triage in the rationing of
intensive care services – which was not
yet necessary in Germany – when capacity
is overloaded, and the question of how
to deal with the therapy of a disease for
which no causal therapy is available yet.
However, there are always new headlines
presenting many ideas, studies, trials and
more that at least give hope for a therapeutic perspective (not to mention the
question of solid immunity). Fortunately, the triage pandemic has not yet reached
Germany (also because Italy was hit so
hard first - and people in Germany were
in fear and therefore behave very carefully); Descriptive and ethical balancing
between need and prognosis is often a
hardly manageable scenario that is difficult
to bear for patients and doctors - when
need outweighs availability. The basic
tendency of rationalisation is ultimately
the utilitarian economic form of “medicine” in the dangerous narrow focus on
prioritising the prognosis category. The
patient-specific, medical decision, on
the other hand, will always be based on
weighing up neediness and prognosis
(under the premise of scarce resources) –
which can also be valid if it is considered
that, in hardship cases, an extremely poor
prognosis would make treatment despite
neediness unjust because of the bad situation. If there are enough inpatient beds
for ventilation are available (assuming
here - for now - that this form of treatment
would be the first choice for a COVID-19
patient), not every patient can be treated
in the sense of ex-ante triage. Keeping
capacities free for expectable COVID-19
patients in the sense of ex-ante triage is
again conflicting with the principle of
avoiding damage (“Primum non nocere”).
Ex-post triage, however, would also not
be ethically justifiable because further
treatment with prospects of success must
not be interrupted in order to initiate a
new treatment. The weakest are often not
protected by triage in the conflict between
non-harm and justice.
Obviously, the old principle of "Primum
non nocere" comes into focus. This
often-quoted sentence is of course not
by Hippocrates, who also hardly wrote
Latin (Smith 2005). Not even by Galenos, but probably by the English doctor
Thomas Inman (Smith 2005). Whatever
the reconstruction of the history of ideas,
the question of how this principle can be
justified for itself and/or in the context
of other principles, and secondly how those principles can be applied, remains
as a systematic return – here with the
concrete second example alongside the
triage medicine, on the important question
of which treatment option for COVID-19
is appropriate to medical ethics in terms
of avoiding damage.
The latter example has recently been the
subject of wide controversy in a kind of
“conflict between the faculties” between
clinical pneumologists at the Bethany
hospital in Moers (Germany) and professional and other submissions (more on
this below in the Bethany case). This
is not an easy question, because it has
descriptive-technical (data, evidence,
etc.) and ethical aspects. The following
considerations primarily serve to sort those
aspects and develop some arguments for
a damage-sensitive initial treatment and
then to illuminate the current ventilation
debate in this broad context.
Do-No-Harm in the Context of the Big Four: Autonomy, Non-maleficence, Beneficence and Justice
Indeed, as American bioethicists, Beauchamp and Childress (2001) have, in a
sense, revived and re-launched a tradition
that has shaped the discussion on medical
ethics since the late 1970s. The authors
clearly saw that on the one hand principles
and material contents of norms, i.e. values,
are necessary in medicine but nevertheless represent a considerable challenge
in concrete application. Beauchamp and
Childress do not speak of principles in the
sense of the first principles or ultimate,
universal foundations of metaphysics, but
rather of principles of “medium scope,"
which generate orientation knowledge
and open and advance the discourse, and
do not lead to a dissolvable dissent at the
beginning, so to speak. Since medical
ethical issues are often massively driven
by dissent, it certainly makes sense to
turn to more pragmatic and, in a sense,
more modestly justified theory of ethics.
The disadvantage is, of course, that only a kind of “lowest common denominator” is
possible on the basis of well-understood
convictions (which of course does not
mean that these common beliefs are automatically irrational or simply unacceptable
on closer philosophical examination, but
these four principles that Beauchamp and
Childress have introduced into the debate
are, strictly speaking, fungible). And
Beauchamp and Childress must assume
that most people share common understandings of a basic set of ethical values.
But the authors do not articulate any
further moral-philosophical claim. The
decisive point is that it is not only about
beneficence and nonmaleficence in the
classic sense, but that the well-known
two principles are expanded to include
autonomy and justice, and a quasi-system
is created; which, however, understandable
against the background of the pressure
of discourse, does not even have to deal
with a hard claim to truth (as a cognitivist
ethic would have to do). But all this comes
at the price of a complex and thus not
easy-to-use relation of beneficence and
nonmaleficence (same with autonomy
and justice). "Harm" for Beauchamp and
Childress means "…thwarting, defeating,
or setting back of some party’s interest"
(Beauchamp and Childress 2001), which
in the medical context of course not the
same as wrongdoing. "The relationship
between the act of doing good and the
absence of doing harm is complex, but
they seem to be independent concepts.
Beneficence and non-maleficence (as well
as autonomy and justice) are prima facie
duties, which is to say, their violation is
ethically wrong unless it is justified by
another prima facie duty” (Schwarz 2004).
Nonmaleficence is an essential hurdle, a
limitation for medical options.
A way is being sought, so to speak,
to find an ethic that on the one hand
still uses the term "principle" and thus
formulates the certain strong claim in the
sense of the Kantian tradition that it is
not just mere reasoning or thinking, on the other hand, in the sense of the Aristotelian doctrine of virtue, is formulated
sufficiently concrete to motivate action and
a productive discourse, but thirdly, in the
sense of utilitarianism, allows conceptual
elements that are to be weighed up and
also to be understood quantitatively. In
the end, this mediates between the level
of the individual case and the principle
in such a way that the actually necessary
hierarchy of principles is omitted and
these fundamental questions are shifted
to the individual level of interpretation
and weighting.
This is quite unusual, because autonomy
as well as justice are traditionally associated with extensive conceptual claims. It
is particularly striking that Beauchamp
and Childress argue more procedurally
in the sense of American pragmatism,
which in this case is ultimately given an
old-continental principle articulation,
without shying away from very specific
values and their ethical characteristics,
which in turn apply to the specific case
and thus places the physician under specific
responsibility on site. The mid-level ethics
of Beauchamp and Childress is a material
ethics without a systematic justification
framework. The idea of such a middle
position is very suggestive, because it
promises good results with relatively little
discursive use, quite comparable to the
Rawls approach, who advocates a reflective equilibrium between principles and
applications. To mark the coherence of
statements that are mutually justified, but
do not understand justification as a strong
philosophical system, but much more
modestly as only a contentual context, was
also the driving force for Rawl’s idea, on
the one hand, to convey justice with utilitarian logic, and on the other hand bring
the rather heterogeneous ideas of justice
at least into discussion from an airplane
perspective in his “Theory of Justice."
There would be no talk of reconciliation
here, no synthesis is pursued. Only under
the (strict) conditions in the thought experiment of the "original position" can
at least the process be called fair (Rawls
2009). The epistemological challenges
that Rawls and ultimately Beauchamp and
Childress buy into with this approach, of
course, lie in avoiding the last principles
and thus also the final foundation. Coherence is the condition for the possibility
of a reflective equilibrium; it does not
arise from that. Now, to remain in the
concrete example of medicine, there are
quite a few different variants, to find
such a balance of consideration or, as
Beauchamp and Childress say, a balance of
the principles in their sphere of application: How should one reasonably choose
between the different options? Obviously,
coherence is certainly important in itself,
but does not justify whether reality has to
adapt to ethical principles or vice versa.
From the basic idea of a balance, no decision can be justified if – what actually
happens in medical practice – the ideas
of how such a balance should look like
are different. "Empirically adopted beliefs
become transparent, but ultimately they are
only a mirror of the - in the specific case
American - belief system in which they
are determined” (von Engelhardt (2005),
In other words: "The scientific-theoretical
decision between induction and deduction
is not made in principle – quite comparable to the scientific approach. Standards
have to prove themselves in practice, just
as a "good theory" in Popper's sense must
have the property of failing in practice"
(Heinemann and Miggelbrink 2011),
On the one hand, it explains pretty well
why Beauchamp and Childress's approach
was so successful in medicine as in bioethics (although criticised by the deductivist (Gert, Culver, Clouser) and casuistic
(Jonsen, Toulmin) side (Heinrichs 2006).
Nevertheless, the differentiation of the four
principles remains highly demanding and
their weighing up in concrete cases even
more. "How such a procedure can give
solid, action-focused orientations without
ultimately becoming merely arbitrary in its
desired meta-ethics freedom is, however,
a core problem of many commonsense
ethics (Beauchamp and Childress speak
of a “common morality”). In the end,
there is a naturalistic fallacy here. This
could only be avoided in the long term
with an actually 'absolute' – that is, the
last-justified – ethics, but admittedly an
unpopular alternative even for medical
ethicists” (Heinemann and Miggelbrink
2011), On the one hand, the four principles
in question are endorsed and applied in
practice, for example, when it comes to
a concrete case discussion. However, even
with these principles, the term “principle”
is still criticised, although it was not
understood as it was seen – namely that
the one principle, which is logically and
ontologically more valuable than the other
principle, would necessarily abolish the
latter principle. Basically, Beauchamp and
Childress offer a kind of heuristic in which
concrete orientation knowledge can be
developed in the discourse. “Certainly, one
can complain that every ethical principle
(be it a regulatory one like Beauchamp
and Childress or constitutive) creates a
virtual consensus to a certain extent, a
consensus on principles that practically
every reasonable person would agree with
anyway. But the more material the ethics
become, the less likely a consensus is:
What to do if a patient prefers a solution
that is not optimal for the doctor, or hard
diagnoses from the doctor's point of view
are unreasonable for the patient, or the
doctor in the clinic can only use his working
hour once and has to decide at the micro
level (Engelhart 1996) where he allocates
this resource (a question regarding the
principle of justice)?” (Heinemann and
Miggelbrink 2011).
With the principle of autonomy, Beauchamp and Childress think of positive and
negative freedom. On the one hand, as
an absence of coercion and manipulation,
on the other hand, of course, as the presence of an emphatic promotion of those
conditions, in order to ensure a reasonable,
understandable freedom of dexperiment of the "original position" can
at least the process be called fair (Rawls
2009). The epistemological challenges
that Rawls and ultimately Beauchamp and
Childress buy into with this approach, of
course, lie in avoiding the last principles
and thus also the final foundation. Coherence is the condition for the possibility
of a reflective equilibrium; it does not
arise from that. Now, to remain in the
concrete example of medicine, there are
quite a few different variants, to find
such a balance of consideration or, as
Beauchamp and Childress say, a balance of
the principles in their sphere of application: How should one reasonably choose
between the different options? Obviously,
coherence is certainly important in itself,
but does not justify whether reality has to
adapt to ethical principles or vice versa.
From the basic idea of a balance, no decision can be justified if – what actually
happens in medical practice – the ideas
of how such a balance should look like
are different. "Empirically adopted beliefs
become transparent, but ultimately they are
only a mirror of the - in the specific case
American - belief system in which they
are determined” (von Engelhardt (2005),
In other words: "The scientific-theoretical
decision between induction and deduction
is not made in principle – quite comparable to the scientific approach. Standards
have to prove themselves in practice, just
as a "good theory" in Popper's sense must
have the property of failing in practice"
(Heinemann and Miggelbrink 2011),
On the one hand, it explains pretty well
why Beauchamp and Childress's approach
was so successful in medicine as in bioethics (although criticised by the deductivist (Gert, Culver, Clouser) and casuistic
(Jonsen, Toulmin) side (Heinrichs 2006).
Nevertheless, the differentiation of the four
principles remains highly demanding and
their weighing up in concrete cases even
more. "How such a procedure can give
solid, action-focused orientations without
ultimately becoming merely arbitrary in its desired meta-ethics freedom is, however,
a core problem of many commonsense
ethics (Beauchamp and Childress speak
of a “common morality”). In the end,
there is a naturalistic fallacy here. This
could only be avoided in the long term
with an actually 'absolute' – that is, the
last-justified – ethics, but admittedly an
unpopular alternative even for medical
ethicists” (Heinemann and Miggelbrink
2011), On the one hand, the four principles
in question are endorsed and applied in
practice, for example, when it comes to
a concrete case discussion. However, even
with these principles, the term “principle”
is still criticised, although it was not
understood as it was seen – namely that
the one principle, which is logically and
ontologically more valuable than the other
principle, would necessarily abolish the
latter principle. Basically, Beauchamp and
Childress offer a kind of heuristic in which
concrete orientation knowledge can be
developed in the discourse. “Certainly, one
can complain that every ethical principle
(be it a regulatory one like Beauchamp
and Childress or constitutive) creates a
virtual consensus to a certain extent, a
consensus on principles that practically
every reasonable person would agree with
anyway. But the more material the ethics
become, the less likely a consensus is:
What to do if a patient prefers a solution
that is not optimal for the doctor, or hard
diagnoses from the doctor's point of view
are unreasonable for the patient, or the
doctor in the clinic can only use his working
hour once and has to decide at the micro
level (Engelhart 1996) where he allocates
this resource (a question regarding the
principle of justice)?” (Heinemann and
Miggelbrink 2011).
With the principle of autonomy, Beauchamp and Childress think of positive and
negative freedom. On the one hand, as
an absence of coercion and manipulation,
on the other hand, of course, as the presence of an emphatic promotion of those
conditions, in order to ensure a reasonable, understandable freedom of decision for
the patient. It is precisely in this sense that
patient autonomy is absolutely crucial and
the patient's right to sufficient, truthful
and, above all, understandable, comprehensive information can be derived. The
inform consent is the differentia specifica
between physical injury and medical
treatment and shows how differentiated
the autonomy principle can be thought.
Especially in times of digital transformation
of the medical and healthcare industry,
it will become even more important to
promote patient sovereignty as a form of
autonomy in dealing with health data and
new forms of doctor-patient relationship
(Heinemann and Matusiewicz 2020).
Apart from emergencies, in which the
patient is obviously not able to consent
voluntarily and freely, the focus must be
on the explanation of possible consequences by the responsible and treating
doctor for a patient, who of course also
has the appropriate power of judgment. An
indirect constraint, for example, because
the doctor's reasoning is too strong and
suggestive, is also not allowed. Here the
challenge of dealing with intensive care
medicine immediately arises – like the
overall increase in treatments and interventions not medically indicated in the
narrow sense.
The principle of justice does not make
it easier, at least as long as health needs to
be organised under scarcity. On the one
hand, this has to do with the fact that the
principle-theoretical and very demanding
basic questions of justice also resonate in
the form of a medium principle, such as
the challenge of finding the right criterion
(thinking of justice when it comes to the
recognition that rights that you ascribe to
yourself are also attributed to all equals, the
problem arises that “rights” and “equality”
cannot be precisely determined by justice
itself), on the other hand, the focus is on
the question of resource allocation and
performance justice move. For example,
justice is largely incompatible as a concept with utilitarian considerations, since justice
could only be promoted as a contribution
to increasing the overall benefit, while
from the Aristotelian point of view it is
easily addressable.
In the end, t Especially since the clever
distribution also encourages us to think
continuously about a certain discipline,
which has the best effect for the patient,
because in the end medical measures
should promote the well-being of the
patient. In reality, however, the vast majority of medical measures can be seen in
a certain risk context. This means that
weighing processes are necessary and
the principle of do-no-harm can clearly
conflict with the principle of beneficence,
the principle of justice and even with the
principle of autonomy.
Are there any good arguments for the
priority – as the “suprema lex” of the
doctor – of the nonmaleficence principle “Primum non nocere” over the
other principles of autonomy, justice and
beneficence? Which at least do not have
to be rebalanced every time, but could at
least formulate a cautious universal claim?
The case is not quite that simple, because
in the present situation, the patient's will
(ultimately his autonomy) must first be
highly respected, not least because a purely
classic-paternalistic doctor-patient relationship will survive itself descriptively. It is
not without reason that the free choice
of doctor is laid down in the relevant
professional regulations and thus, in turn,
contract autonomy in medical law. § 223
StGB (German Criminal Code) does not
apply to medical treatments precisely
because “voluntas aegroti suprema lex”
(autonomy, informed consent, posthippocratic Cooperation) is seen on the one
hand as a priority over “salus aegroti
suprema lex” (beneficience, Hippocratic
Paternalism), but on the other hand, this
contradiction has become fundamentally
questionable in today's patient cooperation
with the treating doctor. Salus ex voluntate
aegroti suprema lex. Education by the doctor and compliance and judgment of
the patient are only effective together. These
relationships are reflected in legitimate
laws (there is also illegitimate legality).
“As a doctor, decide as if you yourself are the
patient who does not want to harm themselves or
others!” says Steinvorth (1992) pointedly.
In a sense, the principle of nonmaleficence
(do no harm) is not to be thought of as
independent of the other three principles,
as was shown here with the example of
autonomy; the same applies, of course,
to beneficence, which ultimately depends
on the benefit, and even justice (suum
cuique), because minimising the risk while
at the same time maintaining innovation
perspectives (which is by no means an
obstacle) potentially promotes it, at least it
is not fundamentally excluded. Discussing
some recent interpretations, Steinvorth
comes up with five sensible reasons for
nonmaleficence as a wise priority rule of
action for doctors:
1. "Before choosing between risky
healing and safe damage reduction, the
doctor must choose the damage reduction because they do not bear the risk
themselves.
2. Compared to the health conditions
of his society or of mankind as a whole,
the doctor must prevent the prevention
of health damage from the promotion of
health perfection, because the prevention
of damage is a more urgent moral imperative for all people than the promotion of
perfection.
3. Orientation to the reduction in
damage binds the doctor to the patient's
will without delivering them to it. It also
places the patient's will on the condition
not to harm. It follows the most general
and widely recognized principle of action,
not to harm, and at the same time corresponds to the idea of human dignity and
the inviolability of his will.
4. The “primum non nocere” assigns
the doctor a smaller area of activity than
the “utilis esse." It therefore reduces the
conflicts between the doctor's obligation to the individual and to society. At the same
time, it encourages a smaller amount of
human conditions to be considered illness
than the “utilis esse." But if we can assume
with Hermann Lübbe (1988) that “the
health status of a cultural community,
objectively, rises if, subjectively, it uses the
predictor 'sick' restrictively," then we have
a specific medical reason for the priority
of the “primum non nocere."
5. It is easier to see what harms someone than what is good for them or for
their well-being. It is often not easy, but
easier. We generally know better, both for
ourselves and for others, what we do not
want than what we want. The more easily
recognisable application of a maxim alone
cannot give priority to it, but it must
confirm it if there is another reason for
it” (Steinvorth 1992).
The justification and application perspectives of the “Primum non nocere” are not
trivial, and yet there are some reasons to
be aware of at least one high-level principle of action of a medical ethic. In the
real dissent situations, especially in the
pandemic age, however, this theory has
to prove itself repeatedly in the collegial
discourse practice of conflicting medical
concepts of healing. Indeed, in practice
it can be observed that – as Sass puts
it succinctly – “[...] the academically
educated philosopher [but not only those,
SH/PS] […], who grew up in school
contexts, [finds] […] when weighing up
goods […] that different argumentation
patterns are used in different situations,
without evident justification conflicts or
reasons for having to justify them. We
argue categorically and rigorously with
Kant on questions of the prohibition
of killing. On questions of intervention
weighing up criteria of quality of life,
we calculate with Mill and others in a
utilitarian way. On issues of health care
allocation according to the Aristotelian
principle of equitable justice (everyone
their own!). In accident medicine and
in acute crises, the rules of paternalism and its heteronomous concept of interest apply, in triage situations pragmatic
rules and explicit unequal preference for
some at the expense of others” (Pöldinger
1991). Of course, the ethics in the corona
crisis have once again become essential;
however promising it may be, current
publications by the German Ethics Council
(ethikrat.org/fileadmin/Publikationen/
Ad-hoc-Empfehlungen/deutsch/ad-hocempfehlung-corona-krise.pdf) or the
AEM Academy for Ethics in Medicine e.
V. point this out.
Frontline Use Case Bethany Hospital, Moers, Germany – COVID19-ICU
A current example is the debate on the
dissenting of ventilation for acute COVID19 patients in Germany (the focus here;
of course, this debate was and is being
conducted internationally).
COVID-19 is a novel disease that was
first reported to the WHO in January
2020 as part of the pandemic with the
new SARS-CoV-2 virus (Guo et al. 2020).
To date, a causal therapy does not exist.
Although COVID-19 is asymptomatic to
mild in approx. 80 % of cases, approx. 15
% of patients have a severe and approx. 5
% have a critical course with severe pneumonia that can lead to respiratory failure
due to a severe oxygenation disorder (Wu
and McGoogan 2020). Initial therapeutic
recommendations therefore addressed in
particular the balancing of hypoxemia
with the aim of keeping oxygen saturation above at least 90 % (WHO 2020).
Based on the experience of the first
mass attack of patients at the time of the
outbreak of the pandemic in China and Italy,
recommendations were published – also
in Germany by an expert commission –
that included a strategy of early intubation
and invasive ventilation (Horovitz index
of ≤ 200) (Kluge et al. 2020). The entire
treatment concept was derived from the
principles of ARDS treatment. The treatment results of the critically ill, however, were very poor. In particular, the group
of invasively ventilated patients reported
from China was extremely bad with a
lethality of up to 97 % (Zhou et al. 2020;
Wang et al. 2020); the results from Great
Britain (lethality 66 %) (icnarc.org/OurAudit/Audits/Cmp/Reports) and New
York (lethality 88 % (Richardson et al.
2020) were also significantly worse than
those from invasive ventilation of a septic
shock. Even though some of these results
come from studies that were published
before all included patients had reached
the end point of discharge or death and
thus improved results from successful
treatments appear to be possible, they give
reason to critically question the indication and results of invasive ventilation in
patients with COVID-19 pneumonia. The
high mortality rate of the critically ill also
increases the need for targeted therapy.
Drugs were used early on during the
pandemic, which are usually used for other
viral diseases and which are intended to
inhibit the replication of the virus (e. g.,
the Ebola drug Remdesivir (Wang et al.
2020) or the AIDS drug Ritonavir/Lopinavir
(Tobaiqy et al. 2020) or to dampen an
excessive response of the human immune
system (e. g., drugs from rheumatology
such as dexamethasone (Horby et al. 2020)
or hydroxychloroquine (Magagnoli et al.
2020. However, the treatment results were
sometimes contradictory or even negative
(using the example of hydroxychloroquine
(Horby et al. 2020), so that – even if praised
as a “breakthrough drug” in the media
(aerzteblatt.de/nachrichten/113885/
Dexamethason-Studie-WHO-sieht-Durchbruch-im-Kampf-gegen-COVID-19) – no
general recommendation for the safe use
of these drugs could be made. In times
of medical uncertainty, however, it makes
sense from the risk assessment point of
view to rely on reliable knowledge and use
analogies. This can and should also include
and deliberately reflect the principle of
the "Primum non nocere."
At the Bethany Foundation Hospital in Moers (bethanien-moers.de/krankenhausbethanien-moers/infos-fuer-patienten1/
lungenklinik-lungenzentrum), the principle
of "primum non nocere" was the focus
from the beginning of the COVID-19 treatments. Here, the ethical reflection clearly
supported the medical judgment - despite
all the uncertainties and challenges. This
treatment concept, which has been referred
to in the media as the “Bethany Way” or
the “Moerser Model” (rp-online.de/nrw/
staedte/moers/corona-moerser-modellsoll-schule-machen_aid-49662005), is
based on the one hand on basic pathophysiological considerations, in particular for
the treatment of hypoxaemia (Köhler et al.
2005), and on the principle of nonmaleficence by avoiding the use of medication
have not been adequately tested in the
treatment of the novel disease, which is
still largely unknown ex ante, and in the
prophylaxis of expected complications
such as thrombosis, pulmonary embolism or pneumonia by using appropriate
medication. This strategy only provides for
invasive ventilation if other measures have
not stabilised the patient and intubation
seems vitally inevitable. Until then, either
oxygen therapy or, if it fails, non-invasive
ventilation will be used. The primary
goal is to support the patient as long as
possible in maintaining his physiological
conditions and to maintain spontaneous
breathing and vigilance. The effects of
positioning techniques such as lying on
your stomach or on your side with oxygen
therapy and with non-invasive ventilation – similar to invasive ventilation – are
systematically checked. It became clear
in the brief reconstructive sketch of the
technical dissent above that there were
deviations from the recommendations
made at the outset, since the indication
for intubation was not made dependent
solely on a limit value for oxygen saturation or the Horovitz index.
The basic pathophysiological relationships speak against this. Accordingly,
neither oxygen saturation alone nor the Horovitz index in pneumonia are suitable
for adequately assessing the risk of tissue
hypoxia. For this purpose, one should take
into account other control parameters
such as the oxygen content of the blood
or the ejection performance of the heart.
The Bethany protocol therefore includes
the recording of the basic parameters
of oxygen content, cardiac output and
respiratory rate. In addition, the patient
is continuously monitored for exhaustion
by a video camera. In addition to the
continuous measurement of the respiratory
rate, the ECG is also monitored. To assess
the course of the complex inflammatory
process, special laboratory parameters such
as the CRP and PCT, the LDH, and also
the D-dimers are determined daily. The
hygiene concept includes a single room,
video surveillance, restrictive patient contact
through care, thorough ventilation, NaCl
inhalations and a non-vented mask with
a configuration that prevents the release
of infectious aerosols. Neither in this
case nor in other cases treated later was
there any transfer to the hospital staff. The
corresponding results have already been
reported elsewhere on a case report. The
evidence for the outcome of non-invasive
ventilation grows (Karagiannidis et al.
2020). Referring to a current press release
of the Bethany Hospital in the context of
the visit of Federal Minister of Health Jens
Spahn and the Prime Minister of North
Rhine-Westphalia Armin Laschet, the
mortality of patients under therapy with
invasive ventilation would be a dramatic
97 percent in China, 88 percent in New
York and still 43 percent in Germany.
At Bethany Hospital, the mortality rate
for non-invasive therapy would be 1.6
percent. Further data will be published
in the near future (bethanien-moers.de/
print/krankenhaus-bethanien-moers/
ueber-uns/presse/pressemitteilungen/
pressearchiv-2020/pe-5720).
The expert recommendation on
restrained non-invasive ventilation was
given on March 12, 2020 (Kluge et al. 2020), and the WHO guidelines on intubation in the event of failure of oxygen
therapy appeared on March 13, 2020 (who.
int /docs/default-source/coronaviruse/
clinical-management-of-novel-cov.pdf).
On March 21, 2020 the “Association of
Pneumological Clinics (VPK)” chaired by
pulmonologist Thomas Voshaar (working
in the same Bethany hospital in Moers
(Germany) like the second author of
this article) recommended “[...] treatment of respiratory complications from
acute viral infection outside the intensive
care unit” (vpneumo.de/fileadmin/pdf/
VPK_Empfehlung_neu_21.03.2020.
pdf), which mainly focused on early and
intensive breathing support. On April 7,
2020, Voshaar made a similar statement in
the FAZ – “It is too often intubated and
invasively ventilated” ( faz.net/aktuell/
gesellschaft/gesundheit/coronavirus/
beatmung-beim-coronavirus-lungenfacharztim-gespraech-16714565.html) - which
was accompanied by a further intensification of the discussion in specialist circles,
but also in a wider public. The possible
negative consequences (lung damage,
etc.) of ventilation, which may not be
indicated at all, were subsequently the
subject of much controversy (especially
since a shortage of intensive care ventilators from a resource perspective had
been discussed, with the corresponding triage fears). On April 9, 2020, a
corresponding statement was published,
“Ventilation at COVID-19: Pulmonologists
Announce Recommendations for Seriously
Ill Patients” of the German expert association, “German Society for Pneumology
and Respiratory Medicine (DGP)," with
a clear rejection of the Bethany position:
“The significance of invasive and noninvasive ventilation in acute respiratory
failure and COVID-19 is currently being
much discussed and commented on. A
number of aspects are currently being
juxtaposed uncritically, and individual
opinions have a weight on the Internet
that – from the perspective of scientific societies – they should not get” (lifepr.
de/inaktiv/deutsche-gesellschaft-fuerpneumologie-und-beatmungsmedizin-ev/
Beatmung-bei-COVID-19-Lungenaerztekuendigen-Empfehlungen-fuer-schwerkranke-Patienten-an/boxid/794408). In the
position paper of the DGP dated April 17,
2020 "[…] on the practical implementation
of the differential therapy of acute respiratory insufficiency in COVID-19" (Pfeifer
2020), together with Thomas Voshaar, a
balancing position is presented, which
was essentially incorporated on June 19,
2020 in the S1 guideline "Recommendations for intensive care therapy of patients
with COVID-19” (awmf.org/uploads/
tx_szleitlinien/113-001l_S1_Intensivmedizinische-Therapie-von-Patientenmit-COVID-19_2020-06_1.pdf). There,
clause 10 states: “The implementation of
intensive care treatment for patients with
COVID-19 follows the essential ethical
principles such as autonomy, beneficence, nonmaleficence, justice and human
dignity. An admissible treatment measure
must meet two requirements: 1. for the
beginning or continuation, according to
the treating physicians, there is a medical
indication, and 2. the implementation
corresponds to the patient's will. If the
treatment measure tested meets both
requirements, treatment must be initiated
or continued. If one of the two conditions
are not met, a change in the therapy goal
and limitation of the therapy is not only
allowed, but even required."
"Primum non nocere" Against All Pandemic-Odds
Medicine is not an easy business. As
a patient you ask yourself: “Should I
emphatically demand ventilation as a
COVID-19 patient, or should I trust doctor
A's indication, when doctor B says otherwise and the experts obviously do not
agree anyway?” This question arises not
only existentially, but already in the case
of small sensitivities that motivate some
patients to have a very different culture of dialog with their own doctors. Both
ethical and medical reasons are addressed
here, doctor and patient. Doctors are not
gods, not even half-gods, but as good
doctors they are prepared for the daily,
often hard, examination of ethical values
in dilemma situations (for which very
good training is essential) and they can
and should cooperate with the patients and
vice versa. Asymmetry does not become
symmetry – but not least in the digital
age, it is another form of discourse. And
at the end of the treatment. Innovation
and nonmaleficience/beneficence fosters
when it comes down to research a special
patient-relation, because e.g. "without
patients volunteering to participate in
clinical research for fear of the possibility
of harm, the potential benefits would never
be realised and the progress of medicine
would come to a halt" (Schwartz 2004).
Patients are in turn dependent on a broader
base of solid knowledge (beyond fake news)
in order to choose the indeed healthy
middle of the argument beyond panic
and serenity in the spirit of Aristotelian
understanding of virtue. “Medicine rests
on a broad theoretical basis. But it is not
an exact natural science; although it uses
scientific methods, it is also philosophy,
and above all it is practical action under
ethical maxims” (Koslowski 1992). This
has to be remembered again and again.
The technical debates are not only to be
endured individually, but as the core of the medical ability to be innovative without
taking inappropriate risks, to be recognised for ethical reasons. It is important,
of course, that it is about the issue and
its positive effects (healing and damage
prevention) for the patient – not systemic
attributions in a hierarchical ordologic
of institutionalised medicine that is still
top hierarchical. Especially in the current
pandemic crisis of an unprecedented socioeconomic global extent (and probably also
medically very demanding), the position
of ethics is being brought to the centre.
Obviously, doctors do not have to have
the same professional view, and ethical
judgments can differ as well. The sensible,
open and collegial discourse of the medical
profession and related disciplines (such
as ethics, computer science, sociology ...)
is perhaps the best thing that is available
for the patient in order to achieve human,
effective and low-risk healthcare. In the
future, medicine in its application form
as medical and nursing activities (and
more forms we cannot even imagine
today) will continue to work according
to rules that are often controversial, but
can and should ultimately lead to good
outcomes for the patient. As seen, dissent
often arises less on the normative than on
the descriptive level. The question as to
which form of treatment is the one that
leads to the maximum possible success
for the lowest risk costs for the patient
is often disputed. Also, because medical research needs time to be good. And data
to be substantial. Perhaps one perspective
of digital medicine of the future is to be
able to resolve descriptive dissent more
quickly with more and, above all, better
data without involving patients in factual
treatments in the research. But even these
possibilities offered by digital technologies
will not be able to relieve the responsible
actors in the health care system from the
exhausting business of operating ethics.
Weighing up values under considerable
time pressure, existential fates and critically
discussed evidence is a considerable challenge for every responsible person, a real
superpower. Not only in pandemic times.
Acknowledgement
The authors would like to thank R. Kinsella
for assistance with the translation of this
text from German to English.
Conflict of Interest
None
Key Points
- Ethics is the Superpower in Medicine
- Do-no-Harm in the Context of the "The Big Four" "middle principles" in medical ethics
- Frontline Use Case Bethany Hospital, Moers, Germany – COVID-19-ICU: "Primum non nocere" against all Pandemic-Odds
References:
Beauchamp TL, Childress JF (2001) Principles of
Biomedical Ethics, Oxford (Original 1977)
Bergdolt K (2004) Das Gewissen der Medizin - Ärztliche
Moral von der Antike bis heute, München
Brenner A (2006) Bioethik und Biophänomen - Den Leib
zur Sprache bringen, Würzburg
Crockett LJ (2019): AI Ethics - The Thin Line between
Computer Simulation and Deception, in: Griffiths P,
Kabir M N (Eds.): ECIAIR 2019 European Conference on
the Impact of Artificial Intelligence and Robotics, Oxford,
80-87
von Engelhardt D (2005) Medizinethik im Wandel der
Zeit. Monatsschr Kinderheilkd 153, 42–47 (2005) -
https://doi.org/10.1007/s00112-004-1066-1
Engelhardt HT Jr (1996) The Foundation of Bioethics,
New York
Gethmann-Siefert A, Thiele F (Eds.) (2006) Ökonomie
und Medienethik, München
Guo R, Cao Q-D, Hong ZS et al. (2020) The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res, ;7(1):11. doi:10.1186/s40779-020-00240-0
Heinemann S, Miggelbrink R (2011): Medizinethik für Ärzte und Manager, in: Thielscher C (Ed.): Medizinökonomie, Berlin, 107-143
Heinemann S (2013): Godmode? Überlegungen zu Grundfragen und Perspektiven einer Videogamesethik, in: Compagna D, Derpmann S (Eds.): Soziologische Perspektiven auf Digitale Spiele, Wiesbaden, 67-94
Heinemann S, Miggelbrink R (2014): Shopping in the (Business) Ethics Supermarket? On the Relationship between Value Pluralism and Management, in: O`Riordan L, Zmuda, P, Heinemann S (Eds.) (2014): New Perspectives on Corporate Social Responsibility: Locating the Missing Link, Wiesbaden, 585-602
Heinemann S (2018a): Future medicine, today's healthcare - Is the “Smart Hospital” a chance for change?, in: HealthManagement.org, Volume 18, Issue 1, 68-70.
Heinemann S (2018b): Smart hospital ethics - Starting the dialogue, in: HealthManagement.org, Volume 18, Issue 3, 174-177
Heinemann S, Matusiewicz D (Eds.) (2020): Digitalisierung und Ethik in Medizin und Gesundheitswesen, Berlin
Heinrichs B (2006): Forschung am Menschen, Berlin
Horby P, Lim W, Emberson J et al. (2020) RECOVERY Collaborative Group. Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report medRxiv. doi: https://doi.org/10.1101/2020.06.22.20137273
Horby P, Mafham M, Linsell L et al. (2020) Effect of Hydroxychloroquine in Hospitalized Patients with COVID-19: Preliminary results from a multi-centre, randomized, controlled trial. medRxiv. doi: https://doi.org/10.1101/2020.07.15.20151852
Hösle V (1987): Begründungsfragen des objektiven Idealismus, in: Forum für Philosophie Bad Homburg (Eds.): Philosophie und Begründung, Frankfurt a. M., 212-267
Hösle V (1992): Praktische Philosophie in der modernen Welt, München
Hösle V (1993): Die Krise der Gegenwart und die Verantwortung der Philosophie, München
Hösle V (1997): Moral und Politik. Grundlagen einer Politischen Ethik für das 21. Jahrhundert, München
Karagiannidis C, Mostert C, Hentschker C et al. (2020). Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational study. The Lancet Respiratory Medicine. doi:10.1016/s2213-2600(20)30316-7
Kluge S, Janssens U, Welte et al. (2020) Empfehlungen zur intensivmedizinischen Therapie von Patienten mit COVID-19, Med Klin Intensivmed Notfmed 115, 175–177.
Köhler D.: CaO2-Wert zur Beurteilung der Sauerstoff-Organversorgung, Dtsch Arztebl 2005; 102(28-29): A-2026 / B-1711 / C-1615
Koslowski L (2020): Einführung, in: Ibid. (Ed.): Maximen in der Medizin, Stuttgart, 1-2
Lübbe H (1988): Über Gründe anwachsenden Normierungsbedarfs im ärztlichen und gesundheitspraktischen Alltag, in: Marquad O, Seidler E, Staudinger H J (Eds.): Ethische Probleme des ärztlichen Alltags, Paderborn, 104-108
Magagnoli J, Narendran S, Pereira F et al. (2020) Outcomes of Hydroxychloroquine Usage in United States Veterans Hospitalized with COVID19, Med, https://doi.org/10.1016/j.medj.2020.06.001
Pfeifer M, Ewig S, Voshaar T et al. (2020) Positionspapier zur praktischen Umsetzung der apparativen Differenzialtherapie der akuten respiratorischen Insuffizienz bei COVID-19 - Pneumologie, 74(06): 337-357 - doi: 10.1055/a-1157-9976
Pfeifer M, Ewig S, Voshaar T et al. (2020) Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19. Respiration. doi: 10.1159/000509104
Potthast T (2008): Pluralität in der Medizin: Werte - Methoden - Theorien, Freiburg
Rawls J (2009): A Theory of Justice, Cambridge (Original 1979)
Richardson S, Hirsch JS, Narasimhan M,et al. (2020) Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. doi: 10.1001/jama.2020.6775; [published correction appears in doi: 10.1001/jama.2020.7681]
Sass HM (1991) Differentialethik und Psychatrie, in: Pöldinger, W./Wagner, W. (Hrsg.): Ethik in der Psychiatrie - Wertebegründung - Wertedurchsetzung, Berlin, 95-118
Schubert C, Leschhorn W (2006): Hippokrates - Ausgewählte Schriften, Berlin - DOI: https://doi.org/10.1515/9783110361322
Schwartz G (2004): Hippocrates Revisited, in: Einstein J. Biol. Med. (2004) 21:33-34
Smith CM (2005): Origin and uses of primum non nocere--above all, do no harm!, in: J Clin Pharmacol. 2005;45(4):371-377 - doi:10.1177/0091270004273680
Steinvorth U (1992): Zum primum non nocere aus philosophischer Sicht, in: Koslowski, L. (Ed.): Maximen in der Medizin, Stuttgart, 33-39
Tobaiqy M, Qashqary M, Al-Dahery S, et al. Therapeutic management of patients with COVID-19: a systematic review. Infection Prevention in Practice. 2020;2(3):100061. doi:10.1016/j.infpip.2020.100061
Wandschneider D (2020): Technik, Berlin (Erstveröffentlichung 2004)
Wang Y, Zhang D, Du G et al. (2020) Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial [published correction appears in Lancet. 2020 May 30;395(10238):1694]. Lancet. 2020;395(10236):1569-1578. doi:10.1016/S0140-6736(20)31022-9
Wang Y,LuX, Chen H, Chen T et al. (2020) Clinical Course and Outcomes of 344 Intensive Care Patients with COVID-19. Am J Respir Crit Care Med. doi:10.1164/rccm.202003-0736LE
Werner JA, Forsting M, Kaatze T, Schmidt-Rumposch, A (Hrsg.) (2020) Smart Hospital - Digitale und empathische Zukunftsmedizin, Berlin
Wu C, Chen X, Cai Y et al. (2020) Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA internal medicine. doi:10.1001/jamainternmed.2020.0994
Wu Z, Mcgoogan J (2020) Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19. JAMA.323(13):1239-1242, https://doi: 10.1001/jama.2020.2648
Zhou F, Yu T, Du R et al. (2020) Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 395: 1054–1062
Online
References
https://www.aerzteblatt.de/nachrichten/113885/Dexamethason-Studie-WHO-sieht-Durchbruch-im-Kampf-gegen-COVID-19
(last access 07/16/2020)
https://www.awmf.org/uploads/tx_szleitlinien/113-001l_S1_Intensivmedizinische-Therapie-von-Patienten-mit-COVID-19_2020-06_1.pdf (last access 07/16/2020)
https://www.bethanien-moers.de/print/krankenhaus-bethanien-moers/ueber-
uns/presse/pressemitteilungen/pressearchiv-2020/pe-5720 (last access 08/28/2020)
https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/deutsch/ad-hoc-empfehlung-corona-krise.pdf (last access 07/16/2020)
https://www.faz.net/aktuell/gesellschaft/gesundheit/coronavirus/beatmung-beim-coronavirus-lungenfacharzt-im-gespraech-16714565.html (last access 07/16/2020)
https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports (last access 07/16/2020)
https://www.lifepr.de/inaktiv/deutsche-gesellschaft-fuer-pneumologie-und-beatmungsmedizin-ev/Beatmung-bei-COVID-19-Lungenaerzte-kuendigen-Empfehlungen-fuer-schwer-kranke-Patienten-an/boxid/794408 (last access 07/16/2020)
https://www.bethanien-moers.de/krankenhaus-bethanien-moers/infos-fuer-patienten1/lungenklinik-lungenzentrum (last access 07/16/2020)
