Therapieentscheidungen lösen in klinischen Teams häufig Unsicherheiten und Konflikte aus, insbesondere wenn es um schwerkranke Patienten geht. Fallen Entscheidungen vornehmlich situationsgeleitet, sind bestimmte Patientengruppen einem Risiko der Unter-, Über- oder Ungleichversorgung ausgesetzt. Der Metap-Leitfaden unterstützt Ärzte, Pfleger und Therapeuten daher in ihrer ethisch reflektierten Entscheidungskompetenz mit verschiedenen Orientierungs- und Entscheidungsinstrumentarien. Diese berücksichtigen eine gerechte Zuteilung der Ressourcen.

Medizinethische Entscheidungsfindungsmodelle müssen nachweisen können, weshalb die mit ihnen getroffenen Entscheidungen richtig oder zumindest „belastbar“ sind. Hierfür sind theoretische Rechtfertigungsansätze aus der Ethik unverzichtbar. Der Klinischen Ethik wird aber mitunter ein Mangel an theoretischer Fundierung vorgeworfen. Um diesem Vorwurf entgegenzutreten, soll unter Bezugnahme auf ein Projekt der Klinischen Ethik („METAP“) die ethische Unterstützung in Form der ethischen Fallbesprechung und der Ethikkonsultation mittels Prinzipienethik und Diskursethik gerechtfertigt werden. Prinzipienethik und Diskursethik können einander über das Medium der ethischen Fallbesprechung oder Ethikkonsultation fruchtbar (...) ergänzen. So können einige theoretische und praktische Schwächen der beiden Ansätze durch den jeweils anderen abgefedert werden. Die Diskursethik übernimmt bspw. die Sicherung der ethischen Gültigkeit von moralischen Entscheidungen bzw. Handlungsnormen und vermindert dadurch ein Rechtfertigungsdefizit, welches bei einem rein prinzipienorientierten Verfahren auftritt. Umgekehrt antwortet die Prinzipienethik u. a. auf Fragen der ethischen Angemessenheit und dient v. a. der adäquaten Einzelfallentscheidung. Durch die Integration des einen Ansatzes in den anderen ist eine umfassendere Rechtfertigungsleistung erzielbar als bei einem alleinigen Einsatz von Prinzipienethik oder Diskursethik. Selbst wenn einige Herausforderungen bestehen bleiben und auch das integrierte Modell moralische Dissense nicht immer verhindern kann, vermag es durch seine „doppelte“ Absicherung (Prinzipien und Diskurs) ein praktisches Vertrauen in die getroffene ethische Entscheidung zu stärken und so der Klinischen Ethik mehr „Robustheit“ zu geben, als sie bisher besitzt. (shrink)

Eine patientengerechte Versorgung ist ein hohes Ziel. Unangemessene Behandlung wie Unter- oder Überversorgung zu erkennen und zu vermeiden, stellt Ärztinnen/Ärzte und Pflegende am Krankenbett vor schwierige Entscheidungen. Hier ist die Entwicklung von praxistauglichen Orientierungshilfen angezeigt, die wissenschaftlichen Kriterien genügen und nicht allein auf Konsens beruhen. Die vorliegende Arbeit versucht, zentrale Normen zur Vermeidung von Über- und Unterversorgung zu formulieren und theoretisch zu fundieren. Dafür wird auf Basis einer Interessen-basierten Ethik eine Graduierung der Autonomie vorgenommen, indem zwischen schwacher und starker Autonomie (...) unterschieden wird. (shrink)

Eine patientengerechte Versorgung ist ein hohes Ziel. Unangemessene Behandlung wie Unter- oder Überversorgung zu erkennen und zu vermeiden, stellt Ärztinnen/Ärzte und Pflegende am Krankenbett vor schwierige Entscheidungen. Hier ist die Entwicklung von praxistauglichen Orientierungshilfen angezeigt, die wissenschaftlichen Kriterien genügen und nicht allein auf Konsens beruhen. Die vorliegende Arbeit versucht, zentrale Normen zur Vermeidung von Über- und Unterversorgung zu formulieren und theoretisch zu fundieren. Dafür wird auf Basis einer Interessen-basierten Ethik eine Graduierung der Autonomie vorgenommen, indem zwischen schwacher und starker Autonomie (...) unterschieden wird. (shrink)

In this paper we assume that ‘theory’ is important for Clinical Ethics Support Services (CESS). We will argue that the underlying implicit theory should be reflected. Moreover, we suggest that the theoretical components on which any clinical ethics support (CES) relies should be explicitly articulated in order to enhance the quality of CES.A theoretical framework appropriate for CES will be necessarily complex and should include ethical (both descriptive and normative), metaethical and organizational components. The various forms of CES that exist (...) in North-America and in Europe show their underlying theory more or less explicitly, with most of them referring to some kind of theoretical components including ‘how-to’ questions (methodology), organizational issues (implementation), problem analysis (phenomenology or typology of problems), and related ethical issues such as end-of-life decisions (major ethical topics).In order to illustrate and explain the theoretical framework that we are suggesting for our own CES project METAP, we will outline this project which has been established in a multi-centre context in several healthcare institutions. We conceptualize three ‘pillars’ as the major components of our theoretical framework: (1) evidence, (2) competence, and (3) discourse. As a whole, the framework is aimed at developing a foundation of our CES project METAP.We conclude that this specific integration of theoretical components is a promising model for the fruitful further development of CES. (shrink)

Ethische Leitlinien für die klinische Praxis erfreuen sich zunehmender Beliebtheit. Damit klinisch-ethische Leitlinien aber überhaupt erfolgreich wirksam werden können, ist noch Pionierarbeit zu leisten. Solche Leitlinien müssen wissenschaftlich stärker fundiert und ihre praktische Anwendbarkeit muss verbessert werden. In dieser Arbeit werden die ersten Schritte des Projekts METAP zur methodischen Entwicklung und praktischen Implementierung einer Leitlinie für eine patientengerechte Versorgung am Krankenbett beschrieben und zur Diskussion gestellt. Das Projekt orientiert sich methodisch an der Entwicklung medizinischer Leitlinien und generiert damit eine forschungs- (...) und konsensgestützte Leitlinie, die systematischer Evaluation und Modifikation unterliegt und Rechenschaft über ihre wissenschaftliche Fundierung gibt. Zusätzlich zur Leitlinie bietet das Projekt in der Form eines Handbuchs ein Entscheidungsfindungsverfahren an, welches unter anderem deliberative Aspekte unterstützt. Das Handbuch konzentriert sich auf ethische Fragen der Mikroallokation und liefert darüber hinaus Informationen über empirische, ethische und rechtliche Grundlagen für Therapieentscheidungen. Anhand eines Eskalationsmodells können unterschiedliche Instrumente nach Bedarf als ethische Lösungsstrategien eingesetzt werden, von der Kurzfassung im Kitteltaschenformat („Leporello“) mit den wichtigsten Fakten, weiterführenden Texten und Empfehlungen mit normativen und prozeduralen Hinweisen, über stationsinterne Lösungsversuche bis hin zum Ethikkonsil. Klinische Partner sind von Beginn an aktiv in den Entwicklungsprozess eingebunden und verbessern so die Praxistauglichkeit und Akzeptanz sowie die Ausrichtung des Instrumentariums an den tatsächlichen Bedürfnissen. Dieses partnerschaftliche, partizipative Vorgehen scheint eine wichtige Voraussetzung dafür zu sein, dass METAP in der Klinik Fuß fassen konnte. (shrink)

As the implementation of new approaches and procedures of medical ethics is as complex and resource-consuming as in other fields, strategies and activities must be carefully planned to use the available means and funds responsibly. Which facilitators and barriers influence the implementation of a medical ethics decision-making model in daily routine? Up to now, there has been little examination of these factors in this field. A medical ethics decision-making model called METAP was introduced on three intensive care units and two (...) geriatric wards. An evaluation study was performed from 7 months after deployment of the project until two and a half years. Quantitative and qualitative methods including a questionnaire, semi-structured face-to-face and group-interviews were used. Sixty-three participants from different professional groups took part in 33 face-to-face and 9 group interviews, and 122 questionnaires could be analysed. The facilitating factors most frequently mentioned were: acceptance and presence of the model, support given by the medical and nursing management, an existing or developing ethics culture, perception of a need for a medical ethics decision-making model, and engaged staff members. Lack of presence and acceptance, insufficient time resources and staff, poor inter-professional collaboration, absence of ethical competence, and not recognizing ethical problems were identified as inhibiting the implementation of the METAP model. However, the results of the questionnaire as well as of explicit inquiry showed that the respondents stated to have had enough time and staff available to use METAP if necessary. Facilitators and barriers of the implementation of a medical ethics decision-making model are quite similar to that of medical guidelines. The planning for implementing an ethics model or guideline can, therefore, benefit from the extensive literature and experience concerning the implementation of medical guidelines. Lack of time and staff can be overcome when people are convinced that the benefits justify the effort. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Sozzini’s Ghost: Pierre Bayle and Socinian TolerationBarbara Sher TinsleyPierre Bayle’s Philosophical Commentary (1686–87), a Huguenot exile’s response to the Revocation of Nantes, established its author as a defender of free conscience for pagans, Muslims, Jews, atheists, Catholics, Protestants, Anabaptists, and Socinians. 1 The virtues of Pagans and Atheists are most fully treated in Bayle’s work on the comet. 2 In this work pagans, Catholics (whom Bayle equated with pagan (...) idolators), and atheists were compared to the advantage of the latter, a conclusion that caused widespread scandal and for which Bayle was obliged by his church to write an apology or clarification found in his Dictionary. 3 In toleration there was no juste milieu. 4 Everyone must act according to conscience no matter how errant. Bayle reiterated a position taken in his criticism of the Jesuit Louis Maimbourg’s History of Calvinism. 5 In it Bayle first enunciated the principle that he noted frightened readers and caused a scandal, namely, that error disguised as truth must be allowed all the privileges of truth, i.e., must be permitted to be believed by those convinced they had found truth. This doctrine of errant conscience was basic to Bayle’s understanding of God and man’s search for Him; and after his death it became basic to concepts of individualism, free [End Page 609] inquiry, free speech, and inalienable rights, concepts which were all made concrete during the Enlightenment. Forcing conscience was wrong. 6Bayle’s lack of partisanship in treating religious history invited criticism from Calvinists in Holland. He wrote to Mr. Pecher, a minister at Emmerick, that in his Dictionary he had avoided passionate prejudice with respect to Jesuits or to any other subject. 7 But had he also avoided an indifference to dogma? Not according to his chief critic who was his erstwhile patron turned enemy, Pierre Jurieu, Pastor of the Reformed church of Rotterdam and theologian in the Ecole Illustre. This school, founded expressly for Bayle and Jurieu by the city council of Rotterdam, 8 allowed Bayle to teach philosophy and history. Since Jurieu thought Bayle “indifferent” to dogma, he believed him to be a covert Socinian or atheist. In 1693 he managed to have Bayle dismissed from his teaching post.Indifference was a concept that started with the ancients, particularly Stoics, Skeptics, and Cynics, who regarded everything except virtue as matters of indifference, a posture with which many of Bayle’s writings, though not all, seemed to agree. In scholastic logic indifferentism meant that things were neither particular nor universal but indifferently so according to the viewpoint from which they were regarded. Jurieu made the charge of indifferentism in 1687. 9 He remarked then of Bayle’s concept of the erring conscience that it was “developed with a view to establishing tolerance and a general indifference of all sects and even of all religions.” 10 Bayle was not indifferent to doctrine. He remained loyal to the Reformed faith, defended orthodoxy, and in a letter to his cousin protested that he was ready to show that his work on comets contained nothing that was contrary to right reason, Scripture, or the Confession of faith of the Reformed Church. 11 Paul Dibon noted that Bayle was especially consistent in his concern for divine transcendance rather than indifference. 12 Henry Kamen wrote that Bayle wrote in “complete theological indifference,” 13 a statement ignoring Bayle’s disapproval of much theological heterodoxy, the orthodoxy of others. While Bayle was usually non-partisan, he was never indifferent. Kamen’s remark contrasts [End Page 610] with Theodore Rabb’s, who wrote that Jean Bodin and Bayle took their stand on “the equality of all beliefs” 14 a statement suggesting indifference, but in a positive rather than negative way.Bodin’s own religion was particularly problematic. Tolerant for his age, a whole century before Bayle, Bodin, a Carmelite friar for several years, had already repudiated forcing conscience. In his book on the state he warned that those who do so merely create more intransigence among their already alienated subjects. 15 He also insinuated that a multiplicity of religions—“all the religions of all people”—including natural religion, Jupiter’s... (shrink)

Background: Ethics support services are growing in Europe to help doctors in dealing with ethical difficulties. Currently, insufficient attention has been focused on the experiences of doctors who have faced ethical difficulties in these countries to provide an evidence base for the development of these services.Methods: A survey instrument was adapted to explore the types of ethical dilemma faced by European doctors, how they ranked the difficulty of these dilemmas, their satisfaction with the resolution of a recent ethically difficult case (...) and the types of help they would consider useful. The questionnaire was translated and given to general internists in Norway, Switzerland, Italy and the UK.Results: Survey respondents ranged in age from 28 to 82 years, and averaged 25 years in practice. Only a minority reported having access to ethics consultation in individual cases. The ethical difficulties most often reported as being encountered were uncertain or impaired decision-making capacity , disagreement among caregivers and limitation of treatment at the end of life . The frequency of most ethical difficulties varied among countries, as did the type of issue considered most difficult. The types of help most often identified as potentially useful were professional reassurance about the decision being correct , someone capable of providing specific advice , help in weighing outcomes and clarification of the issues . Few of the types of help expected to be useful varied among countries.Conclusion: Cultural differences may indeed influence how doctors perceive ethical difficulties. The type of help needed, however, did not vary markedly. The general structure of ethics support services would not have to be radically altered to suit cultural variations among the surveyed countries. (shrink)

In an effort to reassess the status of Phenomenology of Perception and its relation to The Visible and the Invisible, this essay argues that Merleau-Ponty's engagement with Husserl's text and his discussion of the “field of presence” in La temporalité are intended to think through the field in which time makes its appearance as one of passage. Time does not show itself as presence or in the present but manifests itself as Ablauf, as lapse or flow, an écoulement that is (...) simultaneously an explosion, an éclatement. Merleau-Ponty's account of temporality in these pages is thus legible as recovering the primordial experience of time as a self-differentiating déhiscence in its dual power of articulation and erosion. Time is thus simultaneously the vehicle of the world's appearance and of its “disarticulation”, the passage of a rhythm of affirmation and disintegration. Merleau-Ponty's account of temporality in Phenomenology of Perception is oblique, somewhat fragmentary and circuitous.11 References to Merleau-Ponty's works cite the French followed by the English translation. I will use the abbreviation PhP for Phenomenology of Perception and VI for The Visible and the Invisible. Other texts by Merleau-Ponty will be referenced by the title. References to Husserl and Heidegger use the German followed by the translation. I will use the abbreviations ZB for the Zeitbewußtsein lectures; FT for Formale und transzendentale Logik; EU for Erfahrung und Urteil; and SZ for Sein und Zeit. View all notes While of course this phenomenon comes under close scrutiny in La temporalité, a brief inspection of this text as a whole finds it to be virtually everywhere.22 The theme of temporality is introduced as early as the Preface to Part I, “Experience and Objective Thought” and appears again in almost every subsequent chapter: the first chapter of Part I ; in his discussion on number blindness and Goldstein's patient known as Schneider in La spatialité du corps et la motricité ; in the sexuality chapter ; in the discussion of memory in La corps comme expression et la parole ; in Le sentir ; in the discussion of depth in L'espace ; in La chose et le monde naturel ; in Autrui et le monde humain and in Le cogito. Rather than providing the perhaps much called for synopsis of these scattered accounts of time or trying to locate a unified account in Phenomenology of Perception through such a synopsis, this essay will focus only on La temporalité, particularly the discussion of Husserl's diagram from the Zeitbewußtsein and the “champ de présence”. View all notes It is this apparent ubiquity that will motivate scholars such as Renaud Barbaras to claim that “… the entire structure of Phenomenology of Perception rests on a chapter devoted to temporality”.33 Barbaras The Being of the Phenomenon, 218. View all notes In spite of this ubiquity and apparent centrality, however, the treatment of temporality seems to neglect a systematic and thoroughgoing approach, and whether this work manages to address this theme with a sufficient degree of rigor remains open to debate. Furthermore, beyond the scattered and fragmented appearance of temporality in the text, the chapter devoted to its exploration contains numerous, well-recognized problems.44 Merleau-Ponty's misinterpretation of Bergson in this chapter has received much warranted attention. Alia Al-Saji, for example, has criticized Merleau-Ponty's account of temporality in this chapter of Phenomenology of Perception for this misreading as well as its perhaps too uncritical infatuation with Husserl and his emphasis on presence. See Lawlor Thinking Through French Philosophy, Al-Saji “The Temporality of Life” and “A Past Which Has Never Been Present” and Barbaras “The Turn of Experience”. View all notes Among these difficulties, Merleau-Ponty's engagement with Husserl's lectures on time-consciousness, the Vorlesungen zur Phänomenologie des inneren Zeitbewußtseins,55 The 1928 publication of the Zeitbewußtsein, edited by Heidegger, is what appears in the bibliography of Phenomenology of Perception. This version, from the Jahrbuch für Philosophie und phänomenologishe Forschung, as Brough notes, appears as “Part A” of Husserliana X. The notes that constitute this version of the text, furthermore, as Heidegger mentions in his preface to the Jahrbuch version and which Brough repeats were heavily edited by Husserl's assistant at the time, Edith Stein. Merleau-Ponty's references to the Zeitbewußtsein cut across various moments of the text and do not focus on one section in particular, and in fact, he actually references section 11, “Urimpression und retentionale Modifikation”/“Primal impression and retentional modification” in his discussion of the field of presence. As Al-Saji has noted, the extent to which Merleau-Ponty's account of time in La temporalité centres the account of time on “the living present” can be shown to be at play behind the misreading of Bergson. While I do not wish to dispute the specifics of her compelling reading, it is nonetheless worth noting that Al-Saji's reading of the Zeitbewußtsein only focuses on Appendix V, “Gleichzeitigkeit von Wahrnehmung und Wahrgenommenem”/“Simultaneity of Perception and the Perceived”. View all notes looms large, as it seems that his discussion of what he designates as le champ de présence or “field of presence” commits him to the ontological primacy of the present in his account of time. As a result, this earlier work appears to confine itself to a metaphysics organized around the privilege and authority of the present in establishing the structure of time.66 Leonard Lawlor has convincingly argued against this interpretation. Following the famous remark at the end of Le Sentir about “a past which has never been present”, Lawlor argues that precisely because Merleau-Ponty's critique of Bergson is a straw man – that is, because his critique of Bergson is based on a misreading – a closer inspection of Le Sentir and La temporalité shows Merleau-Ponty to be committed to the ontological primacy of an “originary” past. See Lawlor Thinking Through French Philosophy, 89. Marratto, following Lawlor, takes up the charge of a metaphysics of presence in Phenomenology of Perception in dialogue with Derrida. Marratto argues that Derrida's reading selectively overlooks “the very imporant dimensions of difference, discontinuity, and delay and non-self-presence in Merleau-Ponty's descriptions”, located particularly in the latter's theory of subjectivity. I agree with Marratto's assessment, and my aim here is to deepen it by turning in more detail to La temporalité. View all notes This apparent commitment to the ontological primacy of the present, for some readers, has also functioned as an index for tracking the revision of Phenomenology of Perception that is said to figure in The Visible and the Invisible, where a metaphysics of the present is replaced with a commitment to the primacy of an original past, signalling a significant break in the development of Merleau-Ponty's thought.77 This has bearing on the debate mentioned above as the question of temporality and Merleau-Ponty's evolving relationship with Bergson are also cited as part of the index for tracking the differences between Phenomenology of Perception and The Visible and the Invisible. What we see, according to this reading, is Merleau-Ponty move away from a more strictly phenomenological orientation of Phenomenology of Perception, an orientation that is said to adversely mediate his early, critical stance with respect to Bergson, toward a progressively less Husserlian and more Bergsonian stance in The Visible and the Invisible. While he does not specifically address Merleau-Ponty's engagement with Bergson, Marratto's reading also places a special emphasis on the significance of the past, specifically Merleau-Ponty's reference to a “past which has never been present”. It is also not my intention to enter into the question of Merleau-Ponty's relationship with Bergson. Rather, I will restrict my remarks specifically to Merleau-Ponty's engagement with Husserl and the Zeitbewußtsein in La temporalité in order to show that there are grounds for at least questioning one of the premises of the interpretation mentioned above, namely that Phenomenology of Perception is unequivocally legible as committed to the ontological primacy of the present. As will become clear later in the essay, I also dispute interpretations that would place the emphasis on the ontological primacy of an original past. For my own views on the significance of a “past which has never been present”, see Whitmoyer “The Primary Silence of the Past”. View all notes In considering the manner in which the Zeitbewußtsein figures in La temporalité and Merleau-Ponty's discussion of the field of presence, it will do to think about the parameters in which his engagement with Husserl is staged more generally. It seems that Merleau-Ponty never considered his task in terms of the perhaps false alternative of fidelity and heresy, because “any commemoration is also a betrayal”, and because the task of the interpreter is, as he famously notes, thinking through that “unthought-of element … which is wholly his [Husserl's] and yet opens out on something else”.88 Merleau-Ponty, Signes, 203/160. This methodological dictum is developed in more detail in the notes to the course offered on Husserl's Origin of Geometry in 1959–1960. “We are saying not that Husserl was that, but that Husserl was not only what they say, was also another, bearer of an unthought”. View all notes Following Merleau-Ponty's own indications, we could suggest that Husserl's text, rather than a source of orthodoxy, functions as a point of orientation through which Merleau-Ponty marks out his own theory of temporality.99 I will not, therefore, address the question of the “accuracy” of his interpretation of Husserl because, according to Merleau-Ponty himself, this question presupposes that the author, in this case Husserl, has a privileged access to his thought, as if there is some kernel or essence of what a philosopher thought that interpreters can either get right or wrong. As the remarks in “The Philosopher and His Shadow” make clear, interpretation can never really avail itself of this presupposition and in this manner the question of accuracy is precisely the wrong question. View all notes This essay argues that his discussion of the Zeitbewußtsein in Phenomenology of Perception does not offer an account of time that “centers around the living present”, as some have argued,1010 Al-Saji “A Past Which Has Never Been Present”, 42–44. View all notes but that the discussion of the field of presence and what follows are rather intended to account for the field of temporal phenomenalization – not as a presence – but as écoulement, passage and flux. Time, therefore, does not appear in the present or as presence, but manifests itself as a flow and movement that is simultaneously an éclatement, an eruption, and a self-differentiating “dehiscence”.1111 A favorite word of Merleau-Ponty, borrowed from botany, where it designates the splitting open of a seed-pod or flower as well as medicine, where it refers to the splitting open of a healed or partially healed wound. The idea here is that, in its flow and passage, time splits open in a process of differentiation – which is simultaneously a process of degeneration, decay, and what Merleau-Ponty will term in The Visible and the Invisible, “disarticulation”. View all notes Time's passage is not determined, organized and oriented in advance in accordance with a transcendental synthesis that would give it shape and form, privileging one temporal dimension over another, so much as it is understood in terms of a splitting open, or to use another favoured locution of Merleau-Ponty, a “deflagration”.1212 In Eye and Mind, Merleau-Ponty speaks of the “deflagration of being”. Metaphors of explosiveness and dissonance populate his attempt to think being otherwise than as structure, form, and stability. Here I will focus particularly on écoulement, flux and éclatement, eruption, because these are the terms he uses in his discussion of time in La temporalité. See Merleau-Ponty L’Œil et l'esprit, 64/369. View all notes To this extent, Merleau-Ponty's account of temporality in Phenomenology of Perception cannot be said to orient itself in terms of the ontological primacy of any one temporal dimension – past, present, or future – but is more accurately understood as an attempt to recover the primordial experience of time as the simultaneity of écoulement and éclatement – an account that thinks time in its dual power of phenomenalization and erosion, the “pulse [pulsation] of my existence, its systole and diastole”.1313 Merleau-Ponty PhP, 337/332. View all notes Time is the vehicle of the world's appearance, and at the same time of its “disarticulation” [désarticulation],1414 This is a term Merleau-Ponty uses in The Visible and the Invisible in a well-known working note entitled “ Transcendence – forgetting – time”. See Merleau-Ponty VI, 247/197. View all notes the vehicle through which “becoming” – rather than being – shows itself. This process of phenomenalization, precisely because it is temporal, never achieves the density of fully realized being – the sense of this becoming is never fully articulate – but is perpetually subject to a temporal erasure that necessitates its repetition and reiteration. Time, in other words, is the principle of the world's eloquence – it is that thanks to which things have and make sense and simultaneously the principle of the world's murmuring stutter, the principle through which the sense of things remains incomplete and even erodes, decays, and degenerates. To begin, I will turn to Merleau-Ponty's reading of Husserl's diagram from the Zeitbewußtsein, which opens his attempt to “arrive at authentic time”.1515 Merleau-Ponty PhP, 477/483. View all notes Rather than simply rehearsing Husserl's discussion of primal impression, retention and protention, Merleau-Ponty's analysis of the diagram provides an opportunity for raising two problems: the problem of time's representability and the problem of its synthesis. Rather than through an “act intentionality” carried out by a transcendental subjectivity, time appears in accordance with an “operative intentionality” always already under way. Turning to the section of La temporalité aptly entitled “Passive Synthesis”, we see that Merleau-Ponty's analysis of the diagram leads him to the paradox of passive synthesis and what he calls, following Husserl, “transition synthesis”. Time does not show itself punctually – time appears neither as presence nor in the present – but only in the dual movement of its flux, its écoulement, and its éclatement, its explosive, self-differentiating unfurling. These reflections, finally, bring Merleau-Ponty into dialogue with Heidegger on what the latter called the Zusammenhang des Lebens. The “unity of a life”, accordingly, is not a question of any “resolution”, but is a function of our immersion in this temporal dehiscence. The important lesson to be learned from Merleau-Ponty's engagement with Husserl's Zeitbewußtsein is not something about the ontological primacy of one temporal dimension over another but what Merleau-Ponty famously calls in The Visible and the Invisible the “passivity of our activity”1616 Merleau-Ponty VI, 270/221. View all notes and our immersion in time's power of disarticulation. (shrink)

Background and aim Healthcare professionals are regularly exposed to moral challenges in patient care potentially compromising quality of care and safety of patients. Preventive clinical ethics support aims to identify and address moral problems in patient care at an early stage of their development. This study investigates the occurrence, risk factors, early indicators, decision parameters, consequences and preventive measures of moral problems. Method Semi-structured expert interviews were conducted with 20 interprofessional healthcare professionals from 2 university hospitals in Basel, Switzerland. A (...) Likert scale questionnaire was completed by the interviewees and analysed using descriptive and inferential statistics. Results Healthcare professionals are frequently exposed to a variety of moral problems, such as end-of-life decisions, resource allocation and assessing the patient's will or decisional capacity. Thirty-four different risk factors for moral problems are identified, e.g. patient vulnerability, divergent values or world views, inadequate resources or poor ethical climate. Twenty-one early indicators are recognised such as disagreement between healthcare professionals, patients and relatives, emotional disturbances, gut feeling or conflict of conscience. A variety of preventive measures are suggested and presented in a preventive clinical ethics support process model. The most helpful measures are early ethical conversations with colleagues, early team-internal ethical case discussions and an ethics-trained contact person on the ward. Ethics training, kerbside consultations, proactive ethics consultations, ethics screening and rounds are also considered helpful. Conclusions Clinical ethics support services should not only offer reactive and complex, but also proactive and low-threshold support for healthcare professionals, patients and relatives. (shrink)

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying process. (...) Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

Questions concerning the parent/ patient’s autonomy are seen as one of the most important reasons for requesting Ethics Consultations. Respecting parent/ patient’s autonomy also means respecting the patient’s wishes. But those wishes may be controversial and sometimes even go beyond legal requirements. The objective of this case series of 32 ECs was to illustrate ethically challenging parent / patients’ wishes during the first stages of life and how the principle of patient’s autonomy was handled. The case series has a qualitative (...) retrospective approach. A documentary sheet was designed de novo and information was gained from EC minutes and medical charts. The cases originate from the following specialties: reproductive medicine, obstetrics and neonatology as well as two interdisciplinary cases. Through the structured EC minutes aspects of patient / parents’ wishes could be identified explicitly. Overall the patient / parents’ wishes were not supported in 61% of the cases. Central reasons for rejection of patient / parent wishes were mainly the protection of the best interest of the unborn / new-born child as well as the rejection of clinical approaches that were regarded as being substandard treatment. The study shows that treatment decisions in reproductive medicine, obstetrics and neonatology raise substantial ethical questions leading to the request for ethics consultation. The systematic case series presented here gives insight into the ethical reflection carried out to support the clinicians in their decision-making and counselling. It shows that clinicians, after using ethics consultation, make deliberate decisions that do not “automatically” fulfil the treatment requests of the patients and parents. (shrink)

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or ethics consultation. (...) In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making. (shrink)

This editorial examines the evolving role of patients in European clinical ethics consultation services. While patient involvement has been theoretically supported in North America but often neglected in practice, European approaches show varying levels of patient participation - from committee membership to consultation involvement to full participation in ethical deliberations. Through analysis of a case involving end-of-life care and several commissioned papers exploring different national contexts, the authors highlight how patient involvement varies across Europe based on different healthcare systems and (...) cultural contexts. They note that while no single model of patient involvement is superior, ethics consultation without patient and family participation may miss critical perspectives needed for inclusive ethical deliberation. The authors conclude that practical considerations around consent, participation procedures and documentation need to be addressed as patient involvement increases, while acknowledging that cultural diversity across Europe will lead to different mechanisms for including patient voices. (shrink)

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context (...) in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of “alibi ethics”. CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs. (shrink)

ZusammenfassungEntscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

Entscheidungen der Therapiebegrenzung und in der Betreuung am Lebensende sind häufig komplex und von ethischen Problemen begleitet. Im Mittelpunkt der Untersuchung steht die entscheidende Frage, wie hilfreich existierende „Ethik-Richtlinien“, die eine ethische Orientierung bei solchen Entscheidungen geben sollen, in der klinischen Praxis tatsächlich sind. Die Frage, welchen Nutzen „Ethik-Richtlinien“ bei der Entscheidungsfindung haben oder haben können, wird hier exemplarisch an einem klinischen Fallbeispiel aus einer Ethik-Kooperationsstudie in der Intensivmedizin analysiert. Vergleichend werden hierzu „Ethik-Richtlinien“ aus Deutschland, der Schweiz und aus Großbritannien (...) herangezogen, die Gegenstand eines internationalen Projekts zur Analyse von Richtlinien waren. Die Möglichkeiten und Grenzen einer ethischen Orientierung an „Ethik-Richtlinien“ bei Entscheidungsproblemen der Therapiebegrenzung und in der Betreuung am Lebensende werden anhand der Fallstudie diskutiert und illustriert. Abschließend werden Schlussfolgerungen für die Entwicklung ethischer Richtlinien für die klinische Praxis formuliert. (shrink)

Wie muss ein ethischer Beratungsdienst strukturiert sein, damit er in moralischen Konfliktsituationen im klinischen Alltag angefragt wird und die Ratsuchenden ergebnisorientiert unterstützen kann? Nach welchen Kriterien lassen sich die Beratungsgespräche auswerten und bewerten? Zur Beantwortung dieser Fragen werden theoretisch fundierte Konzepte ethischer Fallbesprechung aus Nimwegen, Leuven und Basel herangezogen; dies geschieht vor dem Hintergrund der Erfahrungen mit der über zehnjährigen Entwicklung der ethischen Arbeit im Ev. Krankenhaus Bielefeld (EvKB). Als Resultat stellen wir einen strukturierten, multidisziplinären Ansatz vor, mit dem in (...) den Beratungsgesprächen die ethischen Dimensionen unterschiedlicher Vorstellungen herausgearbeitet und möglichst einvernehmlichen Lösungen zugeführt werden. Am Beispiel des EvKB lässt sich zeigen, dass der ethische Beratungsdienst auch in Zeiten knapper Ressourcen implementiert und praktiziert werden kann und eine Gesprächskultur schafft, die zu neuen Zielvariablen führt; hier spielen der Perspektivenwechsel und die Prozessgerechtigkeit eine zentrale Rolle und liefern zugleich Ansatzpunkte für unsere eigene Evaluationsstrategie. Zum aktuellen Stand der Evaluation klinischer Ethikberatung wird die internationale Literatur kritisch gewürdigt. Erste konzeptionelle Ansätze und Ergebnisse einer eigenen Evaluationsstrategie werden vorgestellt. Durch die Offenlegung hoffen wir, die Auseinandersetzung mit diesen Themen zu intensivieren. (shrink)

Background and aim Child and adolescent forensic psychiatry is fraught with complex medical, legal, and social tensions. The ethical challenges this entails for inhospital treatment have hardly been investigated, and specific support for health care professionals is lacking. This study identifies ethical issues and problems in this area and develops a tool for early detection and intervention of ethical problems in clinical practice. Methods A systematic literature search and an observational study in adolescent forensics at the University Psychiatric Clinics Basel (...) are conducted. The observation data are evaluated using a qualitative content analysis. The instrument is developed based on the results using a new method. Results In the literature search, 14 valid publications were identified that mainly address ethical conflicts in legal psychiatry, such as professional role conflicts, ethical problems in diagnostics and assessment, or confidentiality issues. Empirical or empirical–normative studies are missing. In the observational study, 24 ethical issues and specific conflicts were identified. Ethical questions about moral competencies of the adolescents, the quality of treatment, the handling of rules and sanctions, and freedom and privacy are particularly common. The Instrument for Early Detection and Intervention of Ethical Problems (FIEP) contains the four core elements risk factors, indicators, intervention planning and decision-making. Conclusions Inhospital treatment in forensic child and adolescent psychiatry reveals a broad spectrum of ethical issues with specific ethical problems, which are hardly investigated in literature so far. The FIEP instrument developed here supports health care practitioners in recognizing ethical problems at an early stage and addressing them efficiently. (shrink)

Combining knowledge of social policy and practice with insights from poststructural and feminist theory, the text demonstrates how democratic citizens and the political are continually recreated.

Overtreatment is when medical or dental services are provided with a higher volume or cost than is appropriate. This study aimed to investigate how a group of dentists in Switzerland, a wealthy country known to have high standards of healthcare including dentistry, evaluated the meaning of unnecessary treatments from an ethical perspective and, assessed the expected frequency of different possible behaviors among their peers.

In the Enneads Plotinus articulates an account of ‘creation’ following in the tradition, albeit critically, of Plato’s Timaeus. This article compares Hart’s account of creation, as expressed in The Beauty of the Infinite: The Aesthetics of Christian Truth , and other secondary literature, with that of Plotinus’s. Some significant differences and interesting parallels are highlighted.

Fundamental to spatial knowledge in all species are the representations underlying object recognition, object search, and navigation through space. But what sets humans apart from other species is our ability to express spatial experience through language. This target article explores the language ofobjectsandplaces, asking what geometric properties are preserved in the representations underlying object nouns and spatial prepositions in English. Evidence from these two aspects of language suggests there are significant differences in the geometric richness with which objects and places (...) are encoded. When an object is named (i.e., with count nouns), detailed geometric properties – principally the object's shape (axes, solid and hollow volumes, surfaces, and parts) – are represented. In contrast, when an object plays the role of either “figure” (located object) or “ground” (reference object) in a locational expression, only very coarse geometric object properties are represented, primarily the main axes. In addition, the spatial functions encoded by spatial prepositions tend to be nonmetric and relatively coarse, for example, “containment,” “contact,” “relative distance,” and “relative direction.” These properties are representative of other languages as well. The striking differences in the way language encodes objects versus places lead us to suggest two explanations: First, there is a tendency for languages to level out geometric detail from both object and place representations. Second, a nonlinguistic disparity between the representations of “what” and “where” underlies how language represents objects and places. The language of objects and places converges with and enriches our understanding of corresponding spatial representations. (shrink)

This article challenges a key tacit assumption underpinning legal and ethical instruments in health care, namely, that people are ideally bounded, independent, and often also strategically rational individuals. Such an understanding of personhood has been criticized within feminist and other critical scholarship as being unfit to capture the deeply relational nature of human beings. In the field of medicine, however, it also causes tangible problems. I propose that a solidarity-based perspective entails a relational approach and as such helps to formulate (...) new solutions to complex ethical and regulatory questions, ranging from caring for people at the end of their lives to improving policies for organ donation and better governance of health data. It also underscores the importance of universal health care. Although a solidarity-based perspective does not require health to be seen as an individually enforceable right, it does influence our understanding of individual rights: it draws attention to how their meaning is shaped by shared social practices. I conclude by arguing that, in light of current pressures for medicine to become more personalized, using a relational understanding of personhood to shape policies and practices is a much needed endeavor. (shrink)

BackgroundBiobanking biospecimens and consent are common practice in paediatric research. We need to explore children and young people’s (CYP) knowledge and perspectives around the use of and consent to biobanking. This will ensure meaningful informed consent can be obtained and improve current consent procedures.MethodsWe designed a survey, in co-production with CYP, collecting demographic data, views on biobanking, and consent using three scenarios: 1) prospective consent, 2) deferred consent, and 3) reconsent and assent at age of capacity. The survey was disseminated (...) via the Young Person’s Advisory Group North England (YPAGne) and participating CYP’s secondary schools. Data were analysed using a qualitative thematic approach by three independent reviewers (including CYP) to identify common themes. Data triangulation occurred independently by a fourth reviewer.ResultsOne hundred two CYP completed the survey. Most were between 16–18 years (63.7%, N = 65) and female (66.7%, N = 68). 72.3% had no prior knowledge of biobanking (N = 73).Acceptability of prospective consent for biobanking was high (91.2%, N = 93) with common themes: ‘altruism’, ‘potential benefits outweigh individual risk’, 'frugality', and ‘(in)convenience’.Deferred consent was also deemed acceptable in the large majority (84.3%, N = 86), with common themes: ‘altruism’, ‘body integrity’ and ‘sample frugality’. 76.5% preferred to reconsent when cognitively mature enough to give assent (N = 78), even if parental consent was previously in place. 79.2% wanted to be informed if their biobanked biospecimen is reused (N = 80).ConclusionProspective and deferred consent acceptability for biobanking is high among CYP in the UK. Altruism, frugality, body integrity, and privacy are the most important themes. Clear communication and justification are paramount to obtain consent. Any CYP with capacity should be part of the consenting procedure, if possible. (shrink)

Over the past two decades, modal epistemology has turned its attention to ordinary modal knowledge. This paper brings to the fore a neglected but central form of ordinary modal knowledge: knowledge of agentive modality, and in particular of our own abilities, which I call ‘ability knowledge’. I argue that modal epistemology as it is does not account for ability knowledge, by looking at the most promising candidate theories: perception-based, counterfactual-based, and similarity-based modal epistemologies. I then outline a more promising epistemology (...) for our ability knowledge, which relies on the experience of our own agency, and draw out some lessons for modal epistemology in general. (shrink)

Male aggression against females in primates, including humans, often functions to control female sexuality to the male’s reproductive advantage. A comparative, evolutionary perspective is used to generate several hypotheses to help to explain cross-cultural variation in the frequency of male aggression against women. Variables considered include protection of women by kin, male-male alliances and male strategies for guarding mates and obtaining adulterous matings, and male resource control. The relationships between male aggression against women and gender ideologies, male domination of women, (...) and female sexuality are also considered. (shrink)

Behandlungsfehler in der Psychotherapie sind bisher kaum erforscht. Eine empirisch gestützte Kategorisierung von Behandlungsfehlern stellt einen ersten Schritt dar, sich evidenzbasierten ethischen Empfehlungen zum Umgang mit solchen Fehlern zu nähern. Zielsetzung dieser Arbeit ist es, dafür erste Grundlagen zu erarbeiten, die auf Erfahrungen von Praktikern Bezug nehmen. Nach einer systematischen Literaturrecherche wurden 30 semistrukturierte Interviews mit approbierten Psychotherapeuten unterschiedlicher Ausrichtungen (Schulen) geführt und anhand der qualitativen Inhaltsanalyse nach Mayring ausgewertet. Die beschriebenen, alltäglich auftretenden Behandlungsfehler konnten in technische, normative, Einschätzungs- und (...) Systemfehler klassifiziert werden. Viele der technischen und Einschätzungsfehler wurden als reversibel angesehen; sie könnten sogar konstruktiv für die Behandlung nutzbar gemacht werden. Das Versäumnis, einen Fehler zu korrigieren, wurde als Hauptfehler betrachtet. Bei normativen Fehlern sei mit rechtlichen oder berufspolitischen Konsequenzen, aber auch mit Vertrauensverlust und Therapieabbruch zu rechnen. Für Systemfehler fühlten sich die befragten Therapeuten nicht verantwortlich; hier seien berufspolitische Änderungen nötig. Die Ergebnisse zeigen, dass die Befragten zu der Empfehlung tendieren, Psychotherapiepatienten in passender Form über Behandlungsfehler aufzuklären und in die entstehenden Konsequenzen einzubeziehen. Fazit: Psychotherapeuten äußern sich aufgeschlossen gegenüber einer transparenten, konstruktiven Fehlerkultur – eine wesentliche Voraussetzung für Fehlerprävention. Häufig resultiert erst durch die fehlende Korrektur eines (alltäglichen) Fehlers ein Behandlungsfehler, der Konsequenzen hat (z. B. Scheitern der Therapie). Um diesem entgegenzuwirken, zeichnet sich eine Befürwortung für eine passende Form der Patientenaufklärung über Fehler ab. (shrink)

Dealing with errors in psychotherapy is challenging, both ethically and practically. There is almost no empirical research on this topic. We aimed (1) to explore psychotherapists’ self-reported ways of dealing with an error made by themselves or by colleagues, and (2) to reconstruct their reasoning according to the two principle-based ethical approaches that are dominant in the ethics discourse of psychotherapy, Beauchamp & Childress (B&C) and Lindsay et al. (L).

This mixed method study (Explanatory Design - the Participant Selection Model) investigated the use of joint drawing (the Family Squiggle) as a family climate assessment tool for hearing families who have a deaf / hard of hearing (D/HH) child. The goal was to evaluate the possibilities of applying a quantitative approach to characterize the pictorial phenomena produced by hearing families who have a D/HH child, and then apply qualitative research approaches to better understand the meaning of these phenomena. Twenty-eight hearing (...) families (parents and child) whose child was diagnosed as D/HH and used hearing devices (hearing aids, implant) were recruited along with 16 families with a hearing child of a similar age enrolled in a mainstream school. The sessions involved a joint drawing followed by a family interview. In the quantitative stage, pictorial phenomena for which there was a significant association between the phenomena and the group of families were defined. These were: (1) The number of dominant images, (2) Images occupying less than a quarter of the page. (3) Images with accentuated outlines. (4) Moderate colorfulness with four to five colors in each drawing. (5) Minimal representation of the face. (6) Concrete rather than creative titles. (7) Muting of conflictual themes. (8) Images reminiscent of hearing devices (hearing aids, implant). In the qualitative phase, interviews were conducted with the hearing families with a D/HH child to better understand the meaning of these pictorial phenomena. The findings suggest that each of these phenomena represent the preoccupation of the family with deafness / being hard of hearing, capture a certain aspect of family dynamics, and together provide a broader and deeper picture of the family climate and the interactions between the child's family and hearing. This assessment tool may thus be utilized when verbal tools cannot be easily applied. (shrink)

Proceedings held May 1989. Topics include temporal logic, hierarchical knowledge bases, default theories, nonmonotonic and analogical reasoning, formal theories of belief revision, and metareasoning. Annotation copyright Book News, Inc. Portland, Or.

Respecting and protecting the confidentiality of data and the privacy of individuals regarding the information that they have given as participants in a research project is a cornerstone of complying with accepted research standards. However, in longitudinal studies, establishing and maintaining privacy is often challenging because of the necessity of repeated contact with participants. A novel internet-based solution is introduced here, which maintains privacy while at the same time ensures linkage of data to individual participants in a repeated measures design. (...) With the use of the anonymous repeated measurements via email (ARME) procedure, two separate one-way communication systems are established through ad hoc email accounts and a secure study website. Strengths and limitations of the approach are discussed. (shrink)