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La eutanasia en Bélgica.The experience of the Netherlands in relation with the legalization and practice of euthanasia is better known in Spain than the Belgian experience in this matter. But the historical process of social debate in Belgium has many specific details which should be known by Spanish healthcare professionals, bioethicists, politicians and lawyers. This paper begins with a comparative analysis of both countries: Spain and Belgium and follows with a description of the milestones of the historical process of debating and, finally, passing the Belgian Law on Euthanasia in 2002. The next chapter consists of a description of the main contents of this important Law. The paper continues then with an approach to the epidemiology of the practice of euthanasia in Belgium and finishes with a description of the different positions of the actors of the process. Two positions are described more in depth: the opinion of the specialists in palliative care, and the opinion of the Catholic Church. The paper ends underlining the reason for the incorporation of the Belgian experience on euthanasia to the debate about the possibility of legalizing euthanasia in Spain.
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How medical students think about ethical issues.Although bioethics has become an established part of medical school curricula, relatively little is known about how students apply didactic material to clinical problem-solving situations. Each of 92 second-year students (54 men and 38 women) at the University of California, Irvine, College of Medicine in 1991-92 wrote a paper identifying and attempting to resolve a clinical ethical dilemma of his or her choice. The papers were then coded for content, use of ethical theories and principles, degree of resolution, and level of personal orientation (i.e., evidence of personal involvement in the dilemmas). Data were analyzed by student sex and age, using chi-square tests of significance and correlational analysis. The students had no difficulty in identifying a range of ethical dilemma. Most students appeared to have understood and become familiar with the major ethical theories and principles currently in use, and to have employed them correctly. A majority of the students were able to successfully resolve their ethical dilemmas. Differences between the men and the women students were found regarding choice of topic, ethical principles used (p = .03), and level of personal orientation (p < .01). The women tended to be interested in issues involving broad social perspectives; to favor arguments emphasizing the rights of patients and families; and to incorporate personal responses, as well as abstract theories, in their assays. The men tended to be interested in issues involving personal control, authority, and responsibility; to advocate utilitarian, cost-containment thinking, and to rely exclusively on abstract, logical arguments. Further research should determine whether these differences can be identified in actual clinical decision making, and whether the differences have implications for the nature or quality of clinical decisions.
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Bone graft substitutes for the treatment of traumatic fractures of the extremities [Knochenersatzmaterialien zur Behandlung von traumatischen Frakturen der Extremitäten][english] Bone graft substitutes are increasingly being used as supplements to standard care or as alternative to bone grafts in the treatment of traumatic fractures.The efficacy and cost-effectiveness of bone graft substitutes for the treatment of traumatic fractures as well as the ethical, social and legal implications of their use are the main research questions addressed.A systematic literature search was conducted in electronic medical databases (MEDLINE, EMBASE etc.) in December 2009. Randomised controlled trials (RCT), where applicable also containing relevant health economic evaluations and publications addressing the ethical, social and legal aspects of using bone graft substitutes for fracture treatment were included in the analysis. After assessment of study quality the information synthesis of the medical data was performed using metaanalysis, the synthesis of the health economic data was performed descriptively. 14 RCT were included in the medical analysis, and two in the heath economic evaluation. No relevant publications on the ethical, social and legal implications of the bone graft substitute use were found. In the RCT on fracture treatment with bone morphogenetic protein-2 (BMP-2) versus standard care without bone grafting (RCT with an elevd high risk of bias) there was a significant difference in favour of BMP-2 for several outcome measures. The RCT of calcium phosphate (CaP) cement and bone marrow-based composite materials versus autogenous bone grafts (RCT with a high risk of bias) revealed significant differences in favour of bone graft substitutes for some outcome measures. Regarding the other bone graft substitutes, almost all comparisons demonstrated no significant difference.The use of BMP-2 in addition to standard care without bone grafting led in the study to increased treatment costs considering all patients with traumatic open fractures. However, cost savings through the additional use of BMP-2 were calculated in a patient subgroup with high-grade open fractures (Gustilo-Anderson grade IIIB). Cost-effectiveness for BMP-2 versus standard care with autologous bone grafts as well as for other bone graft substitutes in fracture treatment has not been determined yet. Although there were some significant differences in favour of BMP-2, due to the overall poor quality of the studies the evidence can only be interpreted as suggestive for efficacy. In the case of CaP cements and bone marrow-based bone substitute materials, the evidence is only weakly suggestive for efficacy. From an overall economic perspective, the transferability of the results of the health economic evaluations to the current situation in Germany is limited.The current evidence is insufficient to evaluate entirely the use of different bone graft substitutes for fracture treatment. From a medical point of view, BMP-2 is a viable alternative for treatment of open fractures of the tibia, especially in cases where bone grafting is not possible. Autologous bone grafting is preferable comparing to the use of OP-1. Possible advantages of CaP cements and composites containing bone marrow over autogenous bone grafting should be taken into account in clinical decision making. The use of the hydroxyapatite material and allograft bone chips compared to autologous bone grafts cannot be recommended. From a health economic perspective, the use of BMP-2 in addition to standard care without bone grafting is recommended as cost-saving in patients with high-grade open fractures (Gustilo-Anderson grade IIIB). Based on the current evidence no further recommendations can be made regarding the use of bone graft substitutes for the treatment of fractures. To avoid legal implications, use of bone graft substitutes outside their approved indications should be avoided.<br>[german] Bei der Behandlung von traumatischen Frakturen werden zusätzlich zur Standardtherapie und ggf. alternativ zu Knochentransplantaten zunehmend verschiedene Knochenersatzmaterialien eingesetzt.Es stellt sich die Frage nach der Wirksamkeit, Kostenwirksamkeit sowie nach ethischen, sozialen und juristischen Implikationen beim Einsatz von Knochenersatzmaterialien bei traumatischen Frakturen.Eine systematische Literaturrecherche wird in den medizinischen elektronischen Datenbanken MEDLINE, EMBASE etc. im Dezember 2009 durchgeführt. In die Bewertung werden randomisierte kontrollierte Studien (RCT) ggf. mit gesundheitsökonomischen Analysen sowie Publikationen zu ethischen, sozialen sowie juristischen Aspekten einbezogen. Die medizinische Informationssynthese erfolgt nach Bewertung der Studienqualität u.a. in Form von Metaanalysen, die gesundheitsökonomische Informationssynthese deskriptiv.14 RCT werden in die medizinische und zwei Analysen in die gesundheitsökonomische Bewertung einbezogen, zu ethischen, sozialen und juristischen Aspekten werden keine Publikationen identifiziert. Beim Vergleich Bone morphogenetic protein (BMP)-2 gegenüber Standardtherapie ohne Knochentransplantat bei Frakturen ergeben sich in einem RCT (mit erhöhtem Verzerrungspotenzial) signifikante Unterschiede zugunsten BMP-2 bezüglich mehrerer Endpunkte. Bei Calciumphosphat (CaP)-Zementen und knochenmarkhaltigen Kompositmaterialien zeigen sich beim Vergleich gegenüber Knochentransplantaten in den RCT (alle mit hohem Verzerrungspotenzial) signifikante Unterschiede zugunsten der Knochenersatzmaterialien bezüglich einzelner Endpunkte. Bei allen anderen Materialien finden sich in fast allen Vergleichen keine signifikanten Unterschiede.Die BMP-2-Anwendung zusätzlich zur Standardbehandlung ohne Knochentransplantation führt bei Betrachtung aller Patienten mit traumatischen offenen Frakturen zur Kostenerhöhung. Einsparungen durch zusätzlichen BMP-2-Einsatz lassen sich allerdings bei der Patientensubgruppe mit hochgradig offenen Frakturen (Gustilo-Anderson-Grad-IIIB) errechnen. Die Kostenwirksamkeit beim BMP-2-Einsatz vs. Standardbehandlung mit Knochentransplantation sowie beim Einsatz anderer Knochenersatzmaterialien ist bisher nicht ermittelt. Aufgrund der schlechten Studienqualität kann trotz einiger signifikanter Unterschiede zugunsten BMP-2 nur von einigen starken Hinweisen, bei CaP-Zementen und knochenmarkhaltigen Knochenersatzmaterialien nur von wenigen schwachen Hinweisen auf eine Wirksamkeit ausgegangen werden. Die Ergebnisübertragbarkeit aus den bewerteten gesundheitsökonomischen Analysen auf die heutige Situation in Deutschland mit gesamtwirtschaftlicher Perspektive ist eingeschränkt.Die Evidenzlage zum Einsatz von Knochenersatzmaterialien ist unbefriedigend. Aus medizinischer Sicht ist der Einsatz von BMP-2 bei Patienten mit offenen Tibiafrakturen eine Therapieoption, insbesondere wenn keine Knochentransplantation infrage kommt. Dem Einsatz von Osteogenic protein (OP)-1 ist die Knochentransplantation vorzuziehen. Mögliche Vorteile beim Einsatz von CaP-Zementen und knochenmarkhaltigen Kompositmaterialien gegenüber einer Knochentransplantation sollen in die klinische Entscheidungsfindung einbezogen werden. Der Einsatz des Hydroxylapatitmaterials und der Allograft-Knochenchips kann gegenüber einer Knochentransplantation nicht empfohlen werden.Aus gesundheitsökonomischer Sicht ist der Einsatz von BMP-2 zusätzlich zur Standardbehandlung ohne Knochentransplantation nur bei Patienten mit hochgradig offenen Frakturen (Gustilo-Anderson-Grad-IIIB) als kostensparend zu empfehlen. Es können keine weiteren Empfehlungen zum Einsatz von Knochenersatzmaterialien bei Patienten mit Frakturen oder Nonunions gemacht werden. Zur Vermeidung von juristischen Implikationen soll der Einsatz von Knochenersatzmaterialien außerhalb der zugelassenen Indikationen vermieden werden.