Ethics is frequently taught by referring to reference cases, moral dilemmas and readings on the evolution of the discipline as some ethical issues arise due to technological innovations. Some fundamental ethical principles pertain to professional standards or so-called codes of conduct. This is also part of the sociology of professions which includes the societal and political role professions and professionals. The medical profession has been subject to ample research already. And yet it is important to notice that there is a renewed effort to include into the teaching of ethics “The hard truths about medicine and the Holocaust”. (AMA J Ethics. 2021;23(1): E59-63. doi: 10.1001/amajethics.2021.59). Eugenics were practices well before WWII. “Legal coercive sterilization, which progressed to the notorious “euthanasia” (medically sanctioned murder) program” (p.59) were the beginning. Medical doctors were not reluctant to implement the Nazi medical doctrines. “Most joined eagerly, earlier, and in much greater numbers than other professionals” (Chelouche, 2021; Kater MH, 1989). Physicians made the horrors of Nazi ethics efficient in its implementation. Nazi physicians had a strict ethical code which priorities obedience to the state rather than to the individual.
Research and experiments conducted by medical doctors during Nazi rule is analysed by Weindling (2015). In summary he states “Nazi experiments were accepted forms of science at the time, conducted not only in concentration camps but also in hospitals and clinics across Germany”. This concise overview of recent research by Tessa Chelouche in this field is not only important to teaching ethics in the medical and care professions, but it is of high relevance to much broader audiences and many more professions like judges. Only the awareness and guarding against a renewed failure to respect human values and human rights of the individual allow us to advance humanity. Decentralisation of power, checks and balances, professions following widely accepted principles rather than authoritarian rules can avoid another failure. Teaching about this is a “conditio sine qua non” and not a nice to have part of the curriculum in schools as well as professional colleges. 
Overwork
In a country where most people subscribe to the “protestant work ethic” it is not easy to raise the issue of overwork. Yet, overwork needs to be become an issue of concern. In combination with overwork comes too little rest. Particularly the lack of rest and sleep is likely to cause serious medium and/or long-term effects. Burn-out is only one of the more obvious and drastic experience of exhaustion. The lifestyle of overwork has direct causal links to malnutrition and cardio-vascular risk factors. Once triggered these processes are even harder to control. The run on meditation exercises is only reiterating the huge difficulties to find a balance or antidote to overwork.
The Pew Research Center in Washington has published results from a survey in 2023 that shows that only about half of American people take the full vacation they are entitled to. The evidence of pervasive overwork in the U.S., not limited to the higher executive branches of employees, is hugely unhealthy. Physical and mental health is endangered and the cost to individuals and society are immense. Who cares? Well, we should care. (1) Documentation and monitoring this trend are the first elements of a strategy to counter these effects. Keep spreading the message that overwork is not without serious risks and mostly is followed by huge costs, someone will have to pay. (2) Start to analyse why we glorify overwork and keep doing so for centuries. The strive for higher pay, more money, higher profits, wealth or social prestige is a powerful driving force, of course. Legal measures or taxation to curb extra benefits of overtime have apparently had only marginal effects as they are circumvented, if people are too much focused on the immediate earnings effects. (3) Examine the question, why we glorify overwork? The Harvard Business Review published an article on this on 28th of August (just after the vacation period) to blame the culture of “workaholic” behaviour. In short, if your self-concept is defined exclusively through work, you will be doomed for overwork and its consequences. The next shot of overwork satisfies the urge for self-esteem and most likely also recognition from peers, colleagues and supervisors. This is an unbelievably heavy drug and addiction terribly hard to resist. (4) Who keeps pushing the agenda of overwork? We know for sure that it is not your children. If you have none, you will be at a higher risk to overwork and to push the overwork agenda compared to others, just because compared to families your time budget leaves more reserve capacity for time to rest. Employers set powerful incentives to reward any form of overtime and thereby overwork not only in pecuniary form, but also more rapid career advancement. Strongest and most addictive is your very own behaviour not to respect limits to working time. (5) Remedies to overwork are only partly in your own command. Of course, getting more sleep, doing more exercise, walk instead of drive to work are all fine. However, we need to address the danger of addiction, especially when we do not want to admit our dependency on overwork for self-esteem and recognition by others. Getting together with like-minded persons, for example, in trade unions, will make it easier to get collective solutions to isolated overwork. Higher wages should allow you to get more rest as you earn the same absolute amount with less input of hours. The danger of working even more, because the incentive to put in an extra hour of work has risen at the same time. Be aware of this “duality of higher pay”. Societies have lots of reasons to redistribute work. Between women and men, young and old as well as the “overworked” and “underworked”. 
Polypharmacy
Each specialist treats a person or patient in her/his field of competence to the best of current knowledge. Well, marketing of pharmaceutical products is also a field of special competence. Medical doctors and pharmacists are largely competent intermediaries between the world of medical and pharmaceutical research, commercial interests and patients. As persons age, so-called multimorbidity is creeping into the daily life of many persons. After a certain age (75+), depending on country of residence to some extent, we all become patients. Although the basic problem has been known since the phenomenal rise of the pharmaceutical industry, little research is devoted to patients receiving multiple treatments with medical prescriptions from several specialists. In addition, we know there is a rather severe issue with compliance to prescriptions, for example, taking antibiotics for the whole prescribed period, to name just one. The interactions between several prescriptions and molecules administered to patients are very difficult to monitor and scientific tests of those are expensive and no pharmaceutical company really has an interest in such studies that might further add to the already long list of potential side effects. However, the study published by Daunt et al. (2023) reiterates the warnings that treatment of multimorbidity can have unwanted side-effects we do not really know about. General practitioners will have to take on the role for medical stewardship for their patients. Monitoring a patient’s digestion of a combination of medications becomes a prime role as of the age of 75, the paper specifies. Whereas a common believe tells us, taking more, will help more, the “daunting” truth might be, less can be more. (Source: Daunt, R., Curtin, D., & O’Mahony, D. (2023). Polypharmacy stewardship: A novel approach to tackle a major public health crisis. The Lancet Healthy Longevity. https://doi.org/10.1016/S2666-7568(23)00036-3. 
Nächste Welle
Die Surfenden unter uns wissen, „nach der Welle ist vor der (nächsten) Welle“. Altes Surferlatein, etwas abgenutzt, zugegeben. Aber in Zeiten mit Coronavirus #Covid_19 und der δ-Variante ist das #nichtLustig. Wer bekommt wann die 3. Impfung, das ist die Frage, überlegte schon Hamlet. Aus Hamlet ist längst die „Hamlet Machine“ geworden. Eine Armada von Modellierenden versucht Prognosen von Wellen und deren Auswirkungen vorherzusagen, denn riesige Finanzströme folgen solchen Projektionen. Haben sie noch keine Biotechnologieaktien in ihrem Depot, die mRNA Impfstoffe produzieren? So als Absicherung gegen höhere Krankenversicherungsbeiträge oder pandemiebedingte Risiken. Lassen wir uns also einfach das dritte Mal jetzt impfen und wir kommen höchstwahrscheinlich relativ unbeschadet durch den Winter. Die Feier zum 8-ten März werden wir wohl wieder ausfallen lassen oder verschieben, aber das ist Teil des „new normal“.
Pharma und Karma
Wieviel gutes Karma kann die Pharmaindustrie ansammeln. Das ist im Kern die Debatte rund um die Impfstoffe der verschiedenen Hersteller. Patentschutz hin oder her, schnelle Entwicklung hat kräftige Gewinne erzeugt, die sicher für die Erforschung anderer, neuerer Wirkstoffe benötigt werden. Das Unternehmen Johnson & Johnson hat jedoch ebenfalls Altlasten zu bewältigen. Asbest in Babyprodukten (s.u. ) das geht doch gar nicht, glauben wir immer noch. Achtung, nach jahrelangen Klagen, scheint sich ein hoher Preis für die Verwendung von Talk einzustellen, wie die FT am 2.6.2021 titelt. Industriepolitik, die das “Vorsorgeprinzip” verinnerlicht ist weitestgehend eine europäische Erfindung. In den USA gilt das nicht, da wird dann eben schneller produziert und dann die eventuellen Schäden kompensiert. Zumindest für die, die anschließend den Klageweg beschreiten kann dann eventuell eine hohe Entschädigung nach vielen Jahren und zusätzlichen Kosten erstritten werden. Gesundheit ist eben doch ein wenig Business oder viel Business. Das hat Boeing wohl so gesehen als die Boeing Jets 737 Max vom Himmel fielen. Europa mag es gerne langsamer und sicherer, aber das hat auch seinen Preis zumindest bei verspätet eintreffenden Impfstoffen für Risikogruppen. 
Asymptomatische Infektion
Es ist schon mehr als 1 Jahr her. Die Einzelfallprüfung zur asymptomatischen Infektion war uns bekannt. Alle Alarmglocken hätten klingeln müssen. Aber weit über München scheint die anschließende Veröffentlichung im New England Journal of Medicine nicht ernsthaft gewürdigt worden zu sein. Mit #Covid-19 Infizierte Personen sind ansteckend bevor sie selbst Symptome zeigen. Heute freundlich begrüßt, infiziert und einige Tage später selbst erst die typischen Symptome. Das SARS-CoV-2-Virus hat die kommunikativ weit überlegene Species Homo sapiens einfach ausgetrickstSARS-CoV-2-Virus hat die kommunikativ weit überlegene Species Homo sapiens einfach ausgetrickst, indem es kommunikatives Handeln (Bisous,Bisous, talk, talk) als Schwäche ausnutzt für eine rapide Übertragung. Wir müssen nicht gleich ins Schweigekloster umziehen, aber unsere Kommunikation auf digitale Medien temporär umleiten. Das sollte uns doch nicht schwer fallen, wir haben damit die Technik das Virus zu übertrumpfen. Nur wollen müssen wir es. Das Leid der 52.000 CoronaToten und deren Angehörigen wird es nicht mehr lindern können, aber weiteres Leiden und die Arroganz der Überlebenden bleibt uns hoffentlich erspart. Daher heißt es jetzt: Klaus ist allein zuhaus. 
Gott + Schirach
Am heutigen 23.11.2020 ist es soweit. Die Fernsehübertragung des Theaterstücks „Gott“ von Ferdinand von Schirach läuft im Ersten. Nach spannender Lektüre erwarten wir nun die Abstimmung der selbstbestimmenden Personen, nicht der meist über Listen aufgestellten gewählten RepräsentantInnen des Volkes. Alles andere als ein klares Votum für eine legale Sterbehilfe und Selbstbestimmung ein ganzes Leben lang wäre eine Überraschung. So wird endlich die breite Diskussion geführt, die diese schwere Entscheidung für alle Beteiligten benötigt. Toll, denn der Grundwert der Selbstbestimmung gilt unbefristet. So ist es nie zu spät, auch eventuell erst am Ende eines Lebens Freiheit in einer letzten Entscheidung zu finden.
Abschließend ein Zitat aus dem Buch von Seite 177. “Ich bin kein Philosoph, aber, meine verehrten Damen und Herren, könnte nicht genau das es sein, was uns als europäische, als westliche Gesellschaft heute ausmachen sollte: nicht der zwanghafte Konsens, sondern, dass wir den friedlichen Dissens aushalten?”
Ein schönes Stilmittel – die rhetorische Frage, als Frage auf die wir keine Antwort erwarten, sondern beispielsweise, wie in diesem Falle, eine Zustimmung des Zuhörers einfordern.
Transparent health care
In times of live or die questions, country comparisons are informative. It is the time to endorse, again and again, complete transparency to facilitate learning across borders (see recently The Guardian 13.5.2020). China has not been very transparent at the onset of the Covid-19 pandemia. Other countries should not follow this track in terms of lack transparency. This appies equally to transparency of hospital and care professionals doing amazing jobs in these critical times. No doubt about this. In order to learn about the need for qualified employees in this crisis, I recommend the full thread of the tweets from “Mary Poppins” on what it means to administer a respiratory machine to a patient.
Ok, dann gehe ich heute mal ein bisschen auf die Beatmung ein.
Selbst in der Öffentlichkeit ist ja langsam angekommen, dass es nicht reicht, einfach mal schnell ein Beatmungsgerät hinzustellen.
Es muss von Menschen bedient werden, die sich auskennen.— Madame Poppins🇪🇺 (@marypoppins_77) April 2, 2020
The experience needed, the understanding of medical processes are only part of the story. Stress, mental overload, burn-out due to long-term shift-work and irregular working hours including frequent (unpaid?) overtime and lack of sufficient training may cause more fatalities than would otherwise be the case. Teamwork across shifts and weekends has to be effectively coordinated. Medication profiles need to updated and understood for adequate application from all team members not only the medical doctor or shift supervisor. In emergency situations panic control mechanism also are relevent features that have to be learned and experienced. In a previous analysis of data from 18.000 nurses in Canada we could provide evidence of the importance of some of these measures. Transparency is key. Cover-ups of past failures cost dearly in this global pandemia. Full paper.
http://www.ccsenet.org/journal/index.php/gjhs/article/view/0/38574
Health and Care
Some surveys in the social sciences remain a reference due to their interesting scope of questions included. The Canadian National Survey of the Work and Health of Nurses is such a survey since they “dared” to ask a representative sample of 18.000 nurses, health care workers and care assistants questions including medication errors, fall injuries, and complaints of older adults in Canada. The study by Zafar Mehdi, Ramzi Nasser, Hildegard Theobald and myself reveals the importance of further training and sufficient staffing to prevent medication errors, fall injuries and other complaints of patients. DOI: 10.5539/gjhs.v11n3p111
Besides the interesting results of this study based on a little used data set, the study should encourage and reward transparency of medical practices and analyses (relevant in #Covid-19). Hopefully many other studies, ideally with longitudinal designs, will build on this interesting kind of data collection. Evidence-based human resource policies should not stop in front of hospitals and care institutions. Unfortunately, such sensitive data are still rarely collected, although conclusions are helpful for nurses, patients and society as a whole.
The Link to the paper in the Global Journal of Health Sciences and the download is free of charge here. For science policy it is interesting to notice that the paper was part of a self-financed Ph.D. of Zafar Mehdi, accepted at the University of Vechta recently.