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  1. Søren Holm
  1. Correspondence to Søren Holm, JME, CSEP, School of Law, Manchester University, Williamson Building, Oxford Road, Manchester M13 9PL, UK; soren.holm{at}

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End-of-life practices in German palliative care

We know that end-of-life practices in medicine vary widely across countries. The paper by Schildman et al (see page 327) reports a questionnaire survey of all members of the German Society for Palliative Medicine using the German language version of the EURELD survey instrument.1 The study has a good response rate of 55.8% and finds that decisions to withdraw or withhold treatment are very common, but that German physicians estimate that the life-shortening effects of most of these decisions are very limited, although in 17 of 234 cases the life-shortening effect was estimated to be more than 1 month.

Extended cognition and end-of-life care for patients with dementia

Another interesting and somewhat provocative paper in this issue also discusses end-of-life issues, in this case decision making for patients with dementia (see page 339). The paper first outlines the standard options of advance directives, substituted judgement or best interest, but argues that none of them take proper account of the fact that the clinical course in dementia is usually very protracted and that during this protracted course decision-making becomes a temporally and socially extended practice. Drawing on theories of situated cognition in cognitive science the author argues that the cognition and the content of the mind of the person with dementia becomes extended into and supported by the social environment. In a certain sense the mind of the person with dementia becomes partially constituted by these external resources and the morally relevant decision-making body becomes extended to involved people in the social environment.

Researching sensitive issues—parental distress and perinatal postmortems

Research ethics committees are often loath to let researchers research areas where recalling a particular experience can cause significant distress. The paper by Breeze et al describes a study of parents' views concerning perinatal postmortems (see page 364). Recalling these experiences can clearly cause distress and the Research Ethics Committee to which the study was submitted imposed a number of conditions on the approval. As part of the study the researchers also asked participating parents about their attitudes to taking part in research. Of those parents who filled in this part of the questionnaire 73% stated “that completing the questionnaire had helped them feel better about the decision whether or not to consent to postmortem.” None of the parents reported any adverse effects or distress caused by the research!

Essential empathy?

Is empathy an essential attribute of a good doctor and must it be taught to medical students? The loss of empathy is often lamented and many regulatory bodies emphasise the importance of empathy in students and doctors. But is it really that important? Smajdor et al (see page 380) argue that: (1) it is not clear exactly what empathy is, (2) it is not clear whether empathy can be taught, and (3) that empathy as commonly understood is neither necessary nor sufficient to guarantee good practice.

The authors argue that good communication with patients is necessary for good practice and that a very thin version of ‘empathy’ is necessary to achieve that good communication. But this thin version of ‘empathy’ differs from thicker conceptions of empathy as conceived in moral philosophy, sociology or psychology.

Personal responsibility and priority setting

Should people engaging in risk behaviours receive lower priority for scarce healthcare resources? Bringedal and Feiring have studied the views of a representative sample of Norwegian physicians and find that a significant proportion think that it should, even though this is in direct conflict with the official norms stated in the Norwegian patient act (see page 357). Their results also show that attitudes towards different kinds of risk behaviour varies widely with ‘poor quality nutrition’ being at one end of the spectrum and ‘smoking’ at the other.


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