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Background and Challenge: Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive., Method: The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate., Result: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.

Extracorporeal life support systems (ECLS) are life-sustaining measures for severe cardiovascular diseases, serving as bridging treatment either until cardiovascular function is restored or alternative treatment, such as heart transplantation or the implantation of permanent ventricular assist devices is performed. Given the insufficient evidence and frequent urgency of implantation without initial patient consent, the ethical challenges and psychological burden for patients, relatives and the interprofessional intensive care team are significant. As with any treatment, an appropriate therapeutic goal for ECLS treatment based on the indications and patient informed consent is mandatory. In order to integrate the necessary ethical considerations into everyday clinical practice, a structured algorithm for handling ECLS is proposed here, which takes ethical aspects into due account. [ABSTRACT FROM AUTHOR]

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An important prerequisite for the success of the digitisation of the healthcare system are risk-literate users. Risk literacy means the ability to weigh potential benefits and harms of digital technologies and information, to use digital services critically, and to understand statistical evidence. How do people find reliable and comprehensible health information on the Internet? How can they better assess the quality of algorithmic decision systems? This narrative contribution describes two approaches that show how the competence to make informed decisions can be promoted.Evidence-based and reliable health information exists on the Internet but must be distinguished from a large amount of unreliable information. Various institutions in the German-speaking world have therefore provided guidance to help laypersons make informed decisions. The Harding Center for Risk Literacy in Potsdam, for example, has developed a decision tree ("fast-and-frugal tree"). When dealing with algorithms, natural frequency trees (NFTs) can help to assess the quality and fairness of an algorithmic decision system.Independent of reliable and comprehensible digital health services, further tools for laypersons to assess information and algorithms should be developed and provided. These tools can also be included in institutional training programmes for the promotion of digital literacy. This would be an important step towards the success of digitisation in prevention and health promotion.

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Observes that the demand for values education is generally accompanied by rational skepticism. Argues that critical rationalism does not intend to provide a basis for concrete value education, but to lay a foundation for the mediation of attitudes as the basis for individual decisions about which values to commit to. (DSK)

Die externe Begutachtung ist ein wesentliches Element des Berufungsverfahrens, das bei der Beurteilung der Legitimität der von der Berufungskommission erstellten Listenreihung der Bewerber:innen von kommissionsexternen Akteur:innen herangezogen wird. Mittels eines explorativen Forschungsprozesses wird die Frage beantwortet, wie die Kommission diese Legitimation herzustellen versucht. Es wird gezeigt, dass die Kommission unterschiedlichen Maßstäben der Legitimität unterliegt. Die Einhaltung des rechtlichen Rahmens dient der formalen Legitimation der Entscheidung; die inhaltliche Legitimation wird über die Einholung und Berücksichtigung der Fachexpertise hergestellt. Ferner wird gezeigt, wie diese Anforderungen über Praktiken der Kommission im Umgang mit dem Bewertungsprozess erfüllt werden. Die gewonnenen Erkenntnisse werden unter Einbeziehung bewertungssoziologischer Überlegungen diskutiert. External reviews are an essential element of the professorial appointment procedure, which is intended to support the decision-making process of the appointment committee. However, external reviews are also used by university bodies external to the committee to assess the legitimacy of the appointment committee's shortlist of candidates. Based on an exploratory research process, this paper examines how the appointment committee attempts to establish this legitimacy. It is shown that the committee is subject to different measures of legitimacy. On the one hand, the appointment committee must comply with the legal framework in order to formally legitimize the decision. On the other hand, the decision must be substantively legitimized by obtaining and considering the external reviews. The paper then reveals how these requirements are met through practices of the appointment committee in handling the valuation process. The findings are discussed in the light of sociology of valuation. [ABSTRACT FROM AUTHOR]

Papal schisms were moments of decision-making in which the whole of Christianity was called upon to choose one contender for the papacy over the other. The Tractatus de scismaticis, composed in Salzburg around 1165, discusses the different choices available to contemporaries during the Alexandrine schism (1159-1177). In his treatise the anonymous author attempts to examine the conflict on a conceptual level and make sense of the current organisational crisis; in his endeavours he comes across a previously unobserved phenomenon which he refers to as neutralitas. The Tractatus' reference to the behavioural pattern is the first (and until the Late Middle Ages only) use of the term in the context of church politics. As yet both the term and the phenomenon it describes have received little attention from medievalists. The aim of the present paper is to closely investigate and define the concept in question and to discuss whether neutralitas was a valid course of action, equal to choosing one or the other (anti-)pope. First, taking into consideration the Tractatus as well as other treatises composed during the Alexandrine schism neutralitas is defined as a temporary state of indecision during a prolonged process of decisionmaking. Therefore, neutralitas has to be strictly distinguished from our modern understanding of neutrality. Secondly, the analysis of the phenomenon's treatment within contemporary sources shows that neutralitas was perceived as a form of deviant behaviour. It was determined to be a disruptive factor on both a conceptual and an operational level, as the concept not only contradicted established patterns of thought but was also perceived as an obstacle in the process of resolving the schism. Ultimately, the present paper argues that neutralitas did not amount to a viable form of decision-making. Neutralitas was a mere act of evasion. Maintaining a 'neutral' stance was impossible during a (high medieval) papal schism. [ABSTRACT FROM AUTHOR]

The news of the ill-starred military encounter at Vezekény on 26 August 1652 had unusually strong reverberations in Hungary and Europe. Judged by the contemporaries, those killed in the clash – including four members of the aristocratic Esterházy family – set an inspiring example of moral courage in the teeth of Turkish superiority in numbers: in a hopeless battle they chose perseverance to the end, that is, heroic self-sacrifice instead of surrendering. In addition to numerous quondam utterances including some quality works of literature, testifying to the intrepidity and fighting value of the Hungarian estates, two works of the applied arts – the subject matter of the paper – were also created with the aim of perpetuating the glorious memory of the fallen heroes. In the years after the accession of Leopold I, Holy Roman Emperor (1658–1705) and King of Hungary (1657–1705) the politically active Hungarian estates had to acknowledge to their dismay that in the top echelon of the Viennese court the plan of an anti-Ottoman campaign – or any action to retaliate the incessant plundering and captive taking raids causing great casualties – was not on the agenda. A group of the politically active Hungarian estates had to draw the very severe conclusion which was hard to face up to. In order to prevent the slow but sure dissipation of “royal Hungary” they were forced to do something. And since they had no other chance, they were reduced to take the step which was tantamount to the renunciation of the earlier generations’ and their own political credo. Consequently, in their opinion, they were obliged to offer cooperation with the Porte, even if it entailed the degradation of the remains of the country to the status of a vassal state. Obviously, such a step – the ultima ratio – if it were to come about, would entail (would have entailed) serious consequences for the foreign, West European attitude toward the country, the Kingdom of Hungary. In this situation the intention or plan of the malcontens Hungarian lords had to incorporate some response to the prospective and understandable antipathy – and to the intrigues of the Viennese court. They would have to issue manifestos, statements with convincing arguments and forward them to West European towns and courts, first of all to Rome, to the decision-makers of the papal curia from where the greatest influence on public opinion could be expected. The essential message of these manifestos, which are not known among completed documents but survive in fragments in diverse aristocratic archives, was a firm and irrevocable determination: the vow and pledge that the population would keep their faith, their religion during vassalage as well and – in this sense – would continue to be the stronghold of respublica christiana, the Christian community. The promotion and stressing of this pledge as well as the demonstration of a peculiar interpretation of the past with the tools of visual art was the original and basic function of the unsigned engraving from the second half of the 1660s discussed in detail in the paper. Oddly enough, it was made at a time – without notable, well known iconographic antecedents – when the Kingdom of Hungary in her helpless situation was getting ever farther away from becoming (one of) the bulwark(s) or safeguard(s) of the Christian community. The client for whom the engraving was made must have been Count Ferenc (Franz) Nádasdy, the mastermind of the failed initiative and head of the anti-Habsburg conspiracy of the aristocracy – himself a sincere advocate and vigorous supporter of reviving Catholicism. The historic military events of the last one and a half decades in the seventeenth century – the triumphant termination of the Ottoman wars in Hungary, the expulsion of the Turks – overruled the original meaning of the time-honoured adage known all over Europe, the idea that Hungary was one of the safeguards/bulwarks of the western Christian community. Although it might have lost its topicality, it did not fall out of public remembrance. It underwent some modification, some shift of tone, the militant slogan of mobilization giving way to reference to the heroic deeds of the forefathers, to the glorious past, the historical merits of the kingdom, of Hungaria. Added to this – by way of a conclusion – is the profound conviction rooted in historical experience that it was not in vain to persevere above their strength against the pagan world power in calamitous times. To the contrary, the nation owed her well-nigh miraculous survival to it. After all, the fact that her disintegration and perdition could be avoided must have been by the will of divine providence. This idea is conveyed in a visual language by an extremely effective composition, an engraving made in Augsburg in the first decade of the eighteenth century undoubtedly upon a Hungarian commission. What were the Abbot of Pannonhalma P. Aegidius Karner’s ideas or intentions to have this engraving made? In the closing section of the paper an attempt is made to answer this question. [ABSTRACT FROM AUTHOR]

Aim: In this paper we review the current literature on the clinical problem that some patients do not achieve response after adequately conducted psychotherapy. We explicate our understanding of nonresponse and treatment resistance including the operational definitions, summarize the theoretical explanations and empirical studies and put forward possible study designs and treatment options. Methods: Literature search using PubMed and Web of Science. Results: For the domain of psychotherapy, the term treatment resistance does not seem appropriate; instead, we use the more descriptive terms nonresponse and recurrent nonresponse. Generally, this topic is far less represented in psychotherapy than in pharmacotherapy. Controlled switching studies with a switch from pharmacotherapy to psychotherapy are rare and those switching from one psychotherapeutic approach to another are nearly nonexistent. Building on clinical considerations, we propose a flow-chart for clinical decision making after nonresponse in psychotherapy. Discussion: Learning from errors is highly beneficial. This principle should be more consistently followed up in psychotherapy research as well as in supervision and training. Guidelines should include consensual and evidence-based advice on how to deal with nonresponse and recurring nonresponse. [ABSTRACT FROM AUTHOR]

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Strategies for Shared Decision-making in Therapy for Patients with Oncological Disease - Quo vadis? Abstract. Shared decision-making (SDM) for therapeutic interventions in oncology is a complex process in which numerous person-, treatment-, and context-related factors can influence the choice of suitable treatment options and final treatment decisions. SDM plays a crucial role in this process by supporting the inclusion of the patient in the doctor-patient encounter and in treatment decision-making. Preference-sensitive decisions can render SDM a particular burden for the patient. Both physicians and patients see the lack of patient preparation as limiting the effectiveness of SDM. Electronic or web-based patient decision aids could help prepare patients with an oncologic diagnosis for the SDM process in advance of the physician-patient encounter. The aim of this review is to provide an up-to-date overview of the role of SDM and its future development in oncology. In doing so, the use of patient decision aids within a phase model of SDM for oncology will be highlighted with particular emphasis on the potential use of Chatbot technology to prepare patients for participation in SDM and to optimize physician-patient communication. The paper also highlights some major research gaps for the future development of Chatbots as patient decision aids in oncology.

Patient Decision Aids for Values Clarification and Preference Elicitation - Challenges and Developments Abstract. Shared decision-making is especially appropriate when the available evidence does not indicate which medical intervention is the better option, so that the final decision depends on the patient's personal values and preferences. The process of value clarification and preference elicitation can be time-consuming and cognitively and emotionally demanding for patients. Increasingly, decision aids provide tasks (e.g., on benefit-harm trade-offs) to help patients work through this process, better prepare for medical consultations, and make values-congruent medical decisions with their physicians. Most clinically validated decision aids are paper-based flyers and educational brochures. There are also computer-, audio-, video-, or web-based decision aids. The web-based aids make little use of the potential of interactive technologies, despite the known benefits of these technologies. The aims of this paper are to provide an overview of decision aids for and challenges of values clarification and preference elicitation and to highlight some developments in interactive web-based technologies that might facilitate values clarification and preference elicitation.

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States the need for a close and continuous interrelationship between theory and practice in the reform of teacher education. Describes the guiding notions of a "uni-phasic" reform project which addresses problems of theory-based decision making and implementation in the reform process. (Author/GEA)

The COVID-19 pandemic poses unprecedented challenges for the German health care system. What is already the case in some other countries, may occur in Germany in the near future also: Faced with limited ICU resources, doctors will be forced to decide which patients to treat and which to let die. This paper examines the legal implications of such decisions. It takes up arguments from the general discussion on prioritization in medicine. A constitutional hurdle for the application of utilitarian criteria (in particular patients' age or social role) comes from the principle that every human life is of equal value and must not be traded off against others ("life value indifference"). However, the limits that the Grundgesetz (German Basic Law) sets for state actions do not apply directly to doctors. According to the Musterberufsordnung (professional code of conduct), doctors act based on their conscience and the requirements of medical ethics and humanity. The implications of this normative standard for the prioritizing in an exceptional situation as the COVID 19 pandemic have not been sufficiently clarified. This uncertainty leads to emotional and moral burdens for doctors. The authors conclude that the German law grants a limited freedom of choice that allows physicians to apply utilitarian criteria in addition to purely medical decision algorithms., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

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The involvement of patients in German healthcare lags far behind the required level. Despite the subject status of patients in the healthcare system, possibilities for codecision and active participation are rare. This paper points out structural fields of patient involvement, how a profound quality of participation can be ensured, and how implementation can be designed.Aiming at a higher acceptance of medical care decisions for persons affected, the integration of personal experience and knowledge is reasonable and necessary for the design and development of the healthcare system. Patients must be offered an education imparting information and competences for their participation. Learning modules from different training providers should transmit professional expertise as well as general systematic and methodical skills. Because of the key role the patient occupies administrating their health data, educational services should also be offered in this area. Possibilities for patient participation are offered at all interfaces between healthcare facilities, services, and products. Furthermore, decisions on allocations by the statutory health insurance and higher federal authorities require the participation of patients. However, this involvement requires a preceding democratic legitimation.For efficient patient involvement in the German healthcare system, regulatory challenges must be overcome by all involved parties in the healthcare system. The time for implementation has come.

Background: In recent times - also due to new laws - a good "indication quality" has been called for. The aim of this paper is to contribute to the debate about "indication quality" by looking into the meaning of the term "indication" as well as the meaning of an adequate understanding of quality., Methods: Initially, a conceptual analysis is made of how indication is an integral part of the therapeutic decision-making process between physician and patient, in which, next to evidence-based elements, also normative elements are included (step 1). In the second part, 2 different types of quality are contrasted (step 2): an externally quantifiable, standardized quality (Q-quality) and a quality pertaining to the individual physician, based on professional ethical values and principles (T-quality)., Results: For good "indication quality" it is suggested that both types of quality are included. As for Q-Quality, quantitative measures with selected quality indicators are proposed. Regarding T-Quality, qualitative, discursive procedures are more appropriate., Conclusions: It is suggested that the term "indication quality" be used for the quality of the whole therapeutic decision-making process including the indication itself. The indication should be based on profession-specific values rather than on other contextual or "private" ethical foundations. The legal and societal preconditions should set positive impulses for both ways of understanding the term "quality"., Competing Interests: Mitherausgeberschaft: Dörries A, Lipp V: Medizinische Indikation. Stuttgart: Kohlhammer, 2015, (© Georg Thieme Verlag KG Stuttgart · New York.)

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From Augustus' principate onward, the Roman emperor was heavily involved in religious matters – as priest and as monarch. He was on the one hand responsible for the pax deorum and on the other hand used religion for his self-representation. It is mainly within these fields that the emperor encountered the diverse forms of divination. The interpretation of prodigies had always been an essential part both of government action and of private decision making, and it is important to keep the two areas separate when considering the emperor's involvement with divination and its practitioners. This paper concentrates on how the policies of the Christian emperors concerning these matters developed during the 4th century. It further asks whether their legislation should be exclusively understood as part of an effort of depaganisation, or whether it was to some extent a continuation of the policies of their pagan predecessors. [ABSTRACT FROM AUTHOR]

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No doubt, the public should be involved in healthcare decision making, especially when decision makers from politics and self-government agencies are faced with the difficult task of setting priorities. There is a general consensus on the need for a stronger patient centeredness, even in HTA processes, and internationally different ways of public participation are discussed and tested in decision making processes. This paper describes how the public can be involved in different decision situations, and it shows how preference measurement methods are currently being used in an international context to support decision making. It distinguishes between different levels of decision making on health technologies: approval, assessment, pricing, and finally utilization. The range of participation efforts extends from qualitative surveys of patients' needs (Citizen Councils of NICE in the UK) to science-based documentation of quantitative patient preferences, such as in the current pilot projects of the FDA in the US and the EMA at the European level. Possible approaches for the elicitation and documentation of preference structures and trade-offs in relation to alternate health technologies are decision aids, such as multi-criteria decision analysis (MCDA), that provide the necessary information for weighting and prioritizing decision criteria., (Copyright © 2015. Published by Elsevier GmbH.)

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In the fourteenth and fifteenth centuries, so called monarchical orders were founded at many European courts. These orders cultivated a splendid knightly culture, although the great age of chivalry seemed long to be over. By comparing two of these orders, the Order of the Golden Fleece and the Order of the Crescent, this paper examines the role of their founders, Philipp of Burgundy and René of Anjou, and their relationship towards the other members based on the statutes of both institutions. Therefore this paper focusses on the constitutional shaping of the orders as well as on different processes of decision-making and symbolic semantics, which played an essential role at different events. It is argued that while René of Anjou emphasized the aspect of equality by different means, Philipp of Burgundy presented himself as a primus inter pares, being both a brother and a lord. [ABSTRACT FROM AUTHOR]

Objective: In daily practice, a veterinarian has to judge information and decide whether it can be adequately implemented for a given case. In this context, it is vital to base decisions on the most recent and reliable scientific findings. In Germany, every practitioner must take part in 20 to 40 hours annually of continuing education. To outline the current assessment and employment of evidence-based veterinary medicine (EBVM), we surveyed practitioners concerning continuing education and their skills in obtaining and evaluating scientific information., Materials and Methods: A survey amongst veterinary practitioners was conducted throughout five continuing education courses between May 2010 and November 2011. The questionnaire contained 32 questions concerning demographic data and profession (n = 4), qualification (n = 3), continuing education (n = 5) and skills related to EBVM (n = 20). Besides evaluating the statements of all participants, veterinarians were classified based on the type of practice and their statements compared., Results: In total, 293 questionnaires were returned. The majority of small animal practitioners (58.3%) and those working with food animals (54.9%) declared being capable of comprehending scientific talks or papers in English without difficulty. 10.4% of all practitioners neglected reading veterinary journals on a regular basis, while 20.8% stated they regularly read English veterinary journals. The majority of the practitioners sought advice from their employer or a colleague. They attributed a high or very high quality to both these information sources. Almost every participant (92.6%) stated that they consulted medical books, and 88.6% certified this information source as being of high or very high quality. 68.6% of the practitioners evaluated their skills in finding suitable literature as high or very high. However, only approximately half (52.1%) of all participants attributed themselves a high ability to evaluate the quality of the literature found., Conclusion and Clinical Relevance: Most practitioners are very limited in their ability to assess the evidence of scientific information. Therefore, courses that introduce EBVM should be taught in both veterinary and postgraduate education to train critical appraisal of information and to support decision-making based on valid, clinically relevant data.

Background: Public reporting (PR) has been gaining more weight as a mechanism for patient steerage. According to the theory of PR, patients use information about the quality of health care providers before making decisions and selecting health-care providers. This paper contributes further knowledge on the effectiveness of PR and identifies critical success factors. These should be taken into account when implementing PR in the German health care system., Methodology: The peer-reviewed English, Spanish, and German language literature was searched in the following five databases: The Cochrane Library, Medline (via PubMed), ISI Web of Knowledge, EconLit, and PsycINFO (since 2005). In addition, reference lists of the included studies and reviews were screened in order to identify previously published studies., Results: In total, 21 studies were identified regarding the impact of 12 different PR instruments on patient steerage. An impact could be demonstrated in 9 studies, 7 studies showed mixed results, while 5 studies could not show any effect on patient steerage. 20 studies were carried out in the US environment, 1 study in Germany. The most researched instrument is the New York State Cardiac Surgery Reporting System (N=8)., Conclusion: PR can be effective in steering patients when seeking a health-care provider, especially for elective procedures. To be successful, information provided must be reliable, easily understandable, should further represent real news, and be disseminated widely. Besides this, it has to be applicable and modifiable according to individual preferences., (© Georg Thieme Verlag KG Stuttgart · New York.)

Basing on empirical evidences of three case study research projects related to rural Austria, the present paper aims at investigating the spatial mobility of inhabitants of rural regions throughout the life course. The particular decisions to migrate are manifold and depend on the personal need for settledness extend and nature of the personal decision-making competence, as well as the role of rational and emotional influencing factors and the resulting loyalty to locality. While the desire of children as well as young senior citizens for settledness correlates with a great significance of emotional influencing factors (family, well-being, memories), rational aspects are prevailing in the phase of entering the labor market and establishing a professional life. As a consequence the urban areas, although unknown are preferred in comparison to the rural communities of origin. The challenge for rural communities lies not only in different definitions of quality of life but also in a not yet recognized heterogeneity within the separate age groups. [ABSTRACT FROM AUTHOR]