„Medizinische Notwendigkeit“: Herausforderungen eines unscharfen Begriffs

Medical need and health need

I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I also argue against an overly strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort.

[Medical Necessity: A Notoriously Fuzzy and Therefore Dispensable Concept?]

The concept of a 'medical necessity' (medN) of interventions is used as a dichotomous attribute with steering and orientating function in various contexts without, however, being precisely defined. We see this lack as a virtue if medN is understood as the dynamic result of transparent, trustworthy, and coherent deliberative procedures on both facts and norms. We suggest using the medN concept relative to health care systems, but independent of economic aspects.

Carrier testing for autosomal recessive disorders: a look at current practice in Germany

Counseling recurrence risks for monogenic disorders is one of the mainstays of human genetics. However, in practice, consultations concerning autosomal recessive disorders exceed the simple conveyance of a 25 % recurrence risk for future offspring. Medical geneticists should be aware of the multifaceted way in which autosomal recessive disorders can pose a diagnostic and counseling challenge in their daily lives and of the pitfalls they might encounter. Although the intentional or incidental detection of carrier states for autosomal recessive diseases happens more and more frequently, our current practice when clarifying their associated reproductive risks remains unsystematic and often subjectively guided. We question whether the approach of focusing on small recurrence risks for a single familial disease with extensive single-gene tests in the partner of a known carrier truly addresses the counseling needs of a couple seeking preconceptional genetic advice. Different perspectives between patients and medical practitioners (or between different medical practitioners) on "acceptable risks" or the extent to which such risks must be minimized raise the question of whether existing professional guidelines need to be clarified.

Risk-Adjusted Prevention. Perspectives on the Governance of Entitlements to Benefits in the Case of Genetic (Breast Cancer) Risks

This article is a revised version of our proposal for the establishment of the legal concept of risk-adjusted prevention in the German healthcare system to regulate access to risk-reduction measures for persons at high and moderate genetic cancer risk (Meier et al. Risikoadaptierte Prävention'. Governance Perspective für Leistungsansprüche bei genetischen (Brustkrebs-)Risiken, Springer, Wiesbaden, 2018). The German context specifics are summarized to enable the source text to be used for other country-specific healthcare systems. Establishing such a legal concept is relevant to all universal and free healthcare systems similar to Germany's. Disease risks can be determined with increasing precision using bioinformatics and biostatistical innovations ('big data'), due to the identification of pathogenic germ line mutations in cancer risk genes as well as non-genetic factors and their interactions. These new technologies open up opportunities to adapt therapeutic and preventive measures to the individual risk profile of complex diseases in a way that was previously unknown, enabling not only adequate treatment but in the best case, prevention. Access to risk-reduction measures for carriers of genetic risks is generally not regulated in healthcare systems that guarantee universal and equal access to healthcare benefits. In many countries, including Austria, Denmark, the UK and the US, entitlement to benefits is essentially linked to the treatment of already manifest disease. Issues around claiming benefits for prophylactic measures involve not only evaluation of clinical options (genetic diagnostics, chemoprevention, risk-reduction surgery), but the financial cost and-from a social ethics perspective-the relationship between them. Section 1 of this chapter uses the specific example of hereditary breast cancer to show why from a medical, social-legal, health-economic and socio-ethical perspective, regulated entitlement to benefits is necessary for persons at high and moderate risk of cancer. Section 2 discusses the medical needs of persons with genetic cancer risks and goes on to develop the healthy sick model which is able to integrate the problems of the different disciplines into one scheme and to establish criteria for the legal acknowledgement of persons at high and moderate (breast cancer) risks. In the German context, the social-legal categories of classical therapeutic medicine do not adequately represent preventive measures as a regular service within the healthcare system. We propose risk-adjusted prevention as a new legal concept based on the heuristic healthy sick model. This category can serve as a legal framework for social law regulation in the case of persons with genetic cancer risks. Risk-adjusted prevention can be established in principle in any healthcare system. Criteria are also developed in relation to risk collectives and allocation (Sects. 3, 4, 5).

Die NIPT-Entscheidung des G-BA. Eine ethische Analyse

Aus einer ethischen Perspektive analysieren wir die vom Gemeinsamen Bundesausschuss (G-BA) im September 2019 für Deutschland vorgelegte Änderung der Mutterschaftsrichtlinien, welche die Finanzierung der nicht-invasiven Pränataldiagnostik (NIPT) durch die gesetzlichen Krankenversicherungen unter bestimmten Bedingungen vorsieht. Die Regelung enthält vier wesentliche Elemente: eine Zielbestimmung (Vermeidung invasiver Testmaßnahmen), ein Zugangskriterium (der Test muss für die Schwangere „geboten“ sein, um ihr eine Auseinandersetzung mit ihrer individuellen Situation zu ermöglichen), Aussagen zum Entscheidungsprozess (nach ärztlicher Beratung im Einzelfall) und eine in ihren Begründungen enthaltene normative Kontextualisierung (Schwangerschaftsabbruch nach §218 a StGB).

Es zeigen sich Spannungen, die um zwei Achsen oszillieren: (1) Das befürchtete Leiden aufgrund der Geburt eines Kindes mit Trisomie oder dem Nichtwissen darüber kann letztlich nur subjektiv, aus der Perspektive der Schwangeren beurteilt werden. (2) Die Bedeutung der Einzelfallentscheidung bleibt unklar, weil für die Beurteilung von Einzelfällen auch allgemeine Gesichtspunkte maßgeblich sein müssen. Gerade in seiner Paradoxie und Flexibilität könnte, wie wir argumentieren, das Modell des G‑BA aber eine gesellschaftspolitisch haltbare und ethisch letztlich vertretbare pragmatische Lösung darstellen.