Anti-Aging Medicine

The BMBF research project “The distribution of scarce health resources between disease orientation and preference fulfillment: the implications of anti-aging medicine in terms of health, the ethics of justice, and the economy” as part of the the BMBF Forschungsverbund (Research Association). On the ethical boundaries of preference-based medicine An interdisciplinary analysis of anti-aging medicine."

Partners

Project/General objective

Description of the subproject (allocation)

Publications

 

Contact

Partners

  • Subproject 1: Development Status and Prospects of Anti-Aging Medicine

Dr. Dipl.-Komm.wirt Holger Gothe

Head of the Department of Health Services Research,

Institute for Health and Social Research GmbH, Berlin

  • Subproject 2: On the differentiation between fulfilling wishes and alleviating suffering

Prof. Dr. Lore Hühn

Professor of Philosophy (with a focus on ethics),

Faculty of Philosophy, Albert Ludwigs University of Freiburg

  • Subproject 3: Implications of anti-aging medicine for the self-conception of medicine and the doctor-patient relationship

Professor Dr. Giovanni Maio

Department of Bioethics, Interdisciplinary Center for Ethics

Faculty of Medicine, Albert Ludwigs University of Freiburg

  • Subproject 4: The distribution of scarce health resources between disease orientation and preference fulfillment: the implications of anti-aging medicine in terms of health, the ethics of justice, and the economy

Professor Dr. Georg Marckmann, MPH

Department of Medical Ethics, Institute for Ethics and the History of Medicine University of Tübingen

Clinical Partners:

Professor Dr. Leena Bruckner-Tuderman

Director of the Department of Dermatology, University Hospital Freiburg

Professor Dr. Wolfgang Heiß

Medical Director of the Center for Geriatrics and Gerontology, University Hospital Freiburg

Professor Dr. Hans-Peter Zahradnik

Head of the Division of Endocrinology and Reproductive Medicine, University Hospital Freiburg

 

Project/General Objective

 

Project: On the ethical boundaries of preference-based medicine. An interdisciplinary analysis of anti-aging medicine

Funded by the German Federal Ministry for Education and Research (01.07.06-30.06.09)

1. Project objective: Analysis of the development status and prospects of anti-aging medicine

2. Project objective: Establish criteria in order to distinguish between alleviating suffering and fulfilling wishes in anti-aging medicine

3. Project objective: Analysis of the implications of anti-aging medicine for the goals and self-conception of medicine and the doctor-patient relationship

4. Project objective: Analysis and assessment of the implications of anti-aging medicine with regard to resource allocation

The central aim of this project is to develop criteria so that the ethical boundaries of preference-based medicine can be formulated with regard to anti-aging medicine. Whether the described approaches of anti-aging medicine are legitimate depends on fundamental issues. Ostensibly, it is a matter of laying down boundaries between desirable and undesirable anti-aging measures. At the meso-level, a balance between the benefits and risks can be determined, but studying this level will only superficially resolve the issue of establishing boundaries, for it is necessary to take several other issues into consideration when it comes to such optimizing changes.

(1) Every ethical perspective in the field of biomedicine relies on having a precise understanding of the current state of knowledge in the medical field; for only through the realization of both the current state of knowledge and what can realistically be expected from the development of biomedical research will it be possible to conduct a well-founded ethical analysis. Therefore, an ethical perspective will also depend on collecting facts and determining what developments are to be expected. Given the heterogeneity and developmental dynamics, an assessment of the current and expected possibilities of anti-aging measures is all the more necessary: ​​Which approaches are currently being pursued in the development of anti-aging measures? What concrete measures can already be found in practical use? What developments can be anticipated in the field of anti-aging medicine in the future? Only on the basis of careful assessment of the current status and prospects of development can a reasonably valid estimation of the ethical implications of anti-aging medicine be made. Moreover, the rather exaggerated hopes and fears associated with anti-aging medicine (both of which can be harmful to the individual) need to be remediated (see Project 1).

(2) Initially, it will depend on how we are willing to deal with the symptoms of aging. The American bioethicist Eric Juengst stated the following in a publication from 2003: “if suffering is inimical to human flourishing, as so much of biomedicine tacitly assumes, then delaying age-associated illnesses as long as possible before death is the obvious goal, whether within or beyond the historical life span.” (Juengst 2003c). Here, Juengst makes suffering the legitimizing starting point for anti-aging measures. Similarly, Fossel - as mentioned above – formulated his definition of anti-aging medicine in view of suffering: “The field we represent is one that aims to prevent or reverse the aging process, in order to prevent the medical diseases and suffering that result from aging”(Fossel, 2002, p 320). In this definition, aging is clearly associated with suffering, which begs the question as to what kind of suffering is assumed here and when can one even begin to speak of a state of suffering in the context of aging that would be associated with a corresponding treatment imperative on the part of medicine? How important is the individual’s subjective perception of suffering? How can the concept of suffering be used consistently in this context? On an even more basic level: Is associating age with suffering ever justified? (See Project 2)

(3) Furthermore, it is necessary to assess to what extent the goals of anti-aging medicine reflect the legitimate goals of biomedicine. Can it be a legitimate goal of medical practice to prevent or completely stop the aging process? Does it fall within the realm of medical responsibility to fulfill the desires of exending the human lifespan? What responsibility does medicine have in commercially motivated propagation of anti-aging measures? The issue of responsibility, however, does not just become a concern in practical application; it arises simultaneously with the question concerning the legitimate goals of biomedicine. To what extent can this goal of medical research to extend human life expectancy be justified? At the basis of these questions is the systematic question concerning the extent to which a form of medical practice primarily geared towards preferences is consistent with self-conception and the goals of medicine. In a practical respect, it should be examined to what extent criteria for the ethical limits of preference-oriented medicine can be drawn from the considerations. In connection with the goals of medicine, a further question arises as to how an orientation towards preference effects physicians’ perception of their role and the doctor-patient relationship: Is it an ethically justifiable development to see doctors as someone providing a service and patients as their customers? What conflicts arise, in terms of the traditional role of the medical doctor, as a result of doctors being both ‘treaters’ of diseases and preference-oriented physicians all rolled into one? The fact that this is not a perfect scenario for the future is demonstrated by the controversies surrounding the health services provided for people who have national health insurance in Germany (individuelle Gesundheitsleistungen).

(4) In addition to basic philosophical questions, anti-aging medicine – similar to other forms of preference-oriented medicine – poses significant practical and ethical challenges for society, especially when it comes to the allocation of health care: how will the increasing availability of anti-aging medicine in the private sector effect equal opportunity in society? What questions with regard to intra- and intergenerational distributive justice arise in an aging society? Should anti-aging measures based on considerations from the ethics of justice be included in the services provided by national health insurance? Given the shortage of funds in the healthcare system, the economic implications of anti-aging medicine are of particular importance as well. The ideas converge in the rather pragmatic and relevant question as to how a clear line can be drawn between disease-oriented and purely preference-oriented medicine within the catalogue of standard healthcare benefits provided by national insurance policies. In a system in which the policyholder’s entitlement to healthcare services is linked to the presence of a disease (SGB V §11), preference-oriented anti-aging medicine, which is concerned with physical and mental states with questionable clinical significance, shows substantial difficulties in differentiating itself (see Subproject 5).

The multidimensionality of the problems associated with “anti-aging medicine” calls for a multidisciplinary approach in order to address the questions concerning medical theory, medical ethics as well as the economy from the appropriate perspective. Consequently, the ethical implications of preference-oriented anti-aging medicine can only be dealt with in the realm of a research association. The overall goal of the project is to provide an anthropologically sound ethical orientation for both medicine and the healthcare system when they are confronted the variety of areas in anti-aging medicine. By combining the research results from the individual subprojects, criteria for how to address primarily preference-oriented medical practice from an ethically sound perspective will be established, especially in terms of allocation in a publicly funded healthcare system and conditions of financial shortage.

 

Description of sub-project 4 (Allocation)

The allocation of limited medical resources between disease orientation and satisfying preferences: the implications of anti-aging medicine in terms of ethical justice, the economy and the healthcare system

Anti-aging medicine poses not only fundamental questions relating to anthropology, theory of medicine and the ethics of the individual, but also significant practical and ethical challenges for society as a whole and healthcare services, especially in view of a rapidly aging society. Due to the development of costs in the healthcare system, adding additional measures to the healthcare service catalogue will only be possible to a certain degree. Consequently, we must assume that anti-aging services will be available in the open market and privately funded. Moreover, a market-oriented allocation ends up leading to unequal access to anti-aging services due to the unequal distribution of income and wealth in the population. If anti-aging medicine improves the quality of life in old age and life expectancy, this will result in people who cannot afford to pay for the services being discriminated against.

Anti-aging services could then increase equality of opportunity within a single society and amongst different societies (Mackey 2003, Gems 2003, Chapman 2004). Thus, anti-aging procedures pose ethical questions regarding distributive justice: should all citizens have access to anti-aging services simply on the grounds of justice? How can one’s right to anti-aging procedures be ethically justified? Due to limited financial resources, one has to consider priorities as well: What is the importance of anti-aging procedures as compared with other health needs?

For the German healthcare system, the question as to which anti-aging services should be included in the healthcare service catalogue is of utmost importance: What services are individuals with national health insurance coverage entitled to? What are the ethical criteria for establishing a boundary between services that should be privately financed and those to be jointly funded? Particularly in the area of national health insurance, in which a policyholder’s entitlement to healthcare services is dependent upon the presence of illness (§§11 SGB V), anti-aging services make it difficult to draw a distinction between disease orientation and preference orientation. Thus, the question presents itself: Is there a normatively acceptable and flexible concept of illness that could serve as the decisive criterion for including anti-aging services in the national healthcare service catalogue? If the general concept of illness happens to reach its limits, alternative criteria should be determined that the allocation of services could be oriented towards.

In an aging population with an increasing number of chronically degenerative diseases, high demand for anti-aging services is to be expected. As a consequence, the increasing availability of anti-aging medicine will have a significant economic effect on our healthcare system as well: How can a healthcare system that is already financially strained due to an increasing old-age dependency ratio afford to spend money on procedures that would continue to increase life expectancy? In the worst-case scenario, anti-aging medicine could prolong the life span of the elderly without being able to eliminate age-related infirmity and illnesses. This would obviously not be in the interest of the individual and would have serious economic consequences for every publicly funded healthcare system. Thus, not only the healthcare system but also society as a whole would feel the effects of a longer life span (Chapman 2004). Even today, as life expectancy rises and birth rates drop, the number of older people steadily increases, and this trend could be exacerbated by anti-aging procedures. Firstly, forced population aging would limit society’s economic performance due to the fact that the number of economically active and productive people would decrease. Secondly, the extent of these effects depends for the most part on how successful anti-aging procedures are in not only prolonging life but also improving the quality of life. Lastly, an increasing old-age dependency ratio would aggravate the transfer of resources between the young and the old and pose significant problems concerning intergenerational justice.

Thus, not only the financial stability but also the sociopolitical acceptance of social protection systems would be put to the test.

The questions raised by anti-aging medicine concerning the ethics of justice, the economy as well as the healthcare system are addressed by the subproject “Allocation” in the following steps:

 

Step 1:

Analysis of implications of preference-oriented medicine in terms of allocation and the ethics of justice using anti-aging medicine as an example

The first step is to assess what implications with regard to the ethics of justice result from the increasing availability of anti-aging procedures. The focus will lie on questions concerning distributive justice: What effects does anti-aging medicine have on equal opportunity in society? Furthermore, it should be discussed which questions concerning intra- and intergenerational justice could arise if the number of older people in the population as a whole were to continue to increase as a result of anti-aging medicine.

 

Step 2:

Assessment of economic effects of anti-aging medicine

Given the ongoing expansion of costs in the healthcare system, the economic implications of anti-aging medicine gain in importance, particularly when it comes to including anti-aging services in the national healthcare service catalogue. Based on empirical findings on the benefit-cost ratio of anti-aging procedures, an assessment should be made as to how the increasing prevalence of these measures will impact healthcare spending. Various outcomes should be examined in order to determine their plausibility (see Juengst et al. 2003). Furthermore, the extent to which the three different goals of anti-aging procedures are associated with various economic implications should be determined as well. However, during the evaluation it is important to keep in mind that anti-aging medicine should be seen not only as a cost factor but also a growth market with significant economic potential. If there is insufficient data available on the cost-effectiveness of anti-aging procedures, the need for health economic evaluations must be specified.

 

Step 3:

Problems associated with allocating anti-aging medicine within the national health insurance system in Germany

The focus of the third step is to examine what problems arise as a result of the increasing availability of anti-aging services covered by national health insurance in terms of both funding and putting together a service catalogue. According to §§ 27 of the German Social Law Code (Sozialgesetzbuch (SGB)), insured individuals are “entitled to the treatment of a disease, if necessary, in order to identify or cure the disease, to prevent its exacerbation or alleviate the pain associated with the disease.” Thus, with regard to anti-aging procedures and their transition towards becoming purely ‘preference medicine’, it is necessary to determine whether the physical or psychological conditions that are being treated are in fact illnesses or not. If they are not, then they would not be covered by health insurance.

But, even in the presence of medical condition, policyholders are not entitled to unlimited services: “The services must be sufficient, appropriate and cost-effective; they may not exceed what is necessary.” (§12 SGB V) In addition to the clinical significance, criteria such as sufficiency, expediency, cost-effectiveness and necessity should be examined for their precision in anti-aging procedures. Further exceptions from general entitlement to treatment can be found in §34 SGB V: In addition to over-the-counter drugs, medications “that seek to improve quality of life are excluded, especially drugs that are supposed to treat erectile dysfunction, stimulation, increase virility, assist in quitting smoking, help to suppress or stimulate appetite, regulate body weight or improve hair growth.” Other medical drugs that are excluded from reimbursement are those “that are commonly prescribed for minor health problems” (§34 Abs. 2) In this context, it would be necessary to determine whether anti-aging procedures are primarily supposed to improve quality of life and whether the physical and psychological conditions constitute “minor health problems”.

National health insurance policies surely have much to do with establishing this boundary, but the brunt of the distinction rests on the concept of disease. This is a vague legal term that can be interpreted by case law. The following definition of disease has been widely accepted: "Accordingly, disease as defined by the law of national health insurance is an abnormal ... physical or mental condition that requires medical treatment and/or results in the inability for work.” (Werner, Wiesing 2002). The term ‘abnormal’ refers to a physical or mental condition that deviates from the norm as established by the concept of the healthy human being. Thus, general anthropological principles become relevant in this context, which will be discussed in detail in sub-project 4 (Theological Ethics). How can the concept of abnormality or that of the healthy human being be used for narrowing down the policyholder’s entitlement to services in anti-aging medicine? Of particular relevance here is the question as to whether the aging process constitutes a component of or a deviation from the concept of a healthy human being. In this context, preliminary work from the Institute for Ethics and the History of Medicine can be consulted.

 

Step 4:

Analysis of the current practice of allocation by national health insurance policies in the area between preference satisfaction and the treatment of disease

The fourth step aims to examine to what extent conclusions can be drawn for the allocation of anti-aging services based on how we currently deal with procedures in the area between disease orientation and preference satisfaction. In doing so, we must take into account not only the measures already available and attributed to anti-aging medicine but also other procedures located at the intersection between preference satisfaction and the treatment of disease. An example of this would be the discussion of sildenafil (Viagra®), which was also the topic of preliminary research at the Institute for Ethics and the History of Medicine in Tübingen (Werner, Wiesing 2002). With regard to the allocation of anti-aging measures, recommendations coming from academic communities, which make reference to both medication and anti-aging measures (the costs of which are not covered by national health insurance), should be examined in addition to the requirements of the national health insurance policies. The following questions must be addressed: What criteria are the recommendations each based on? Can they provide an ethical orientation for how to deal with anti-aging measures?


Step 5:
Specification of ethical considerations with regard to allocation for national health insurance policies using two select examples of anti-aging medicine

The general considerations regarding the allocation of anti-aging measures will be specified for the two select practical areas of anti-aging medicine, namely that of cosmetic surgery and the treatment of mild cognitive impairment, MCI): How can the allocation criteria defined in the German Social Law Code be applied to both of the practical areas of anti-aging medicine? To what extent is making a distinction by means of the concept of illness possible and reasonable? How stable are the concepts of “abnormality” and “the healthy human being”? Both areas of application pose significant challenges for a kind of allocation oriented towards the concept of illness, seeing as neither external signs of aging, such as developing wrinkles, nor minor cognitive impairment is of clinical significance. The symptoms associated with MCI stand for many of the age-related processes of decline that are characterized by a continuous transition from minor physical or mental impairments to manifest diseases (such as dementia associated with Alzheimer's). If the concept of illness proves not to be normatively acceptable and flexible enough, alternative criteria based on the ethics of justice would need to be established that speak for or against covering the costs of cosmetic procedures and measures for treating cognitive decline. For this purpose, the results from sub-project 2 (Philosophical ethics: subjective suffering) and sub-project 4 can be used: How relevant is subjective psychological strain for coverage of cosmetic surgery and the treatment of MCI? With the help of anthropological conceptions of the good life, can a concept of “the healthy human being” be developed that permits the establishment of a boundary between cosmetic procedures and anti-dementia drugs? The extent to which a standard term (see the concept of "normal species functioning") could be of assistance with regard to aging processes should be taken into consideration as well.

 

Step 6:
Combining the results from the other sub-projects to develop an ethics-based model for the allocation of anti-aging services in national health insurance policies

In the final step, the results of the allocation project shall be combined with those of the other subprojects in order to develop an ethics-based model for the allocation of anti-aging services in national health insurance policies. It is to be anticipated that the concept of illness will not provide an adequate and normative orientation, particularly at the intersection between the treatment of disease and preference satisfaction where many anti-aging procedures currently reside. Consequently, it should be tested whether criteria for determining the services that national health insurance policies are required to offer can be established with the help of the concept of suffering (sub-project 2, philosophical ethics) or the “telos” of medicine (sub-project 3, medical ethics). Simply making reference to these fundamental concepts in practice will not suffice. Anti-aging measures should also been seen as a means: First of all, the goals of anti-aging medicine should be analyzed in terms of whether they are even plausible with the resources available. Second of all, the risk-benefit profile of the procedures themselves should be examined in order to protect the individuals concerned from false hopes or even harm to their health. Caution is advised, since many anti-aging procedures are used in off-label ways. These criteria should not only be considered with regard to narrowing down the spectrum of publicly funded healthcare services but also as these anti-aging services are allocated on the market. Particular attention should be given to what (legally sanctioned) provisions for the protection of the consumers should and can be made. Finally, the question as to how these thoughts on the allocation of anti-aging medicine can be generalized to other areas or preference-oriented medicine should be addressed.

 

 

Publications

The first publications of research association “Allocation” are still in process.

 

Relevant research

Prof. Dr. Georg Marckmann, MPH

Gesundheitsversorgung im Alter. Zwischen ethischer Verpflichtung und ökonomischem Zwang. Stuttgart: Schattauer Verlag 2003 (Hg.)

Gerechte Gesundheitsversorgung. Ethische Grundpositionen zur Mittelverteilung im Gesundheitswesen. Stuttgart: Schattauer Verlag 2003 (Hg. zus. mit P. Liening und U. Wiesing)

Krankenhaus und Soziale Gerechtigkeit. Stuttgart: Schattauer Verlag 2005 (Hg zus. mit M.G. Krukemeyer u. U. Wiesing)

Gleichheit und Gerechtigkeit in der modernen Medizin. Interdisziplinäre Perspektiven. Paderborn: Mentis Verlag 2005 (Hg. zus. mit O. Rauprich u. J. Vollmann)

Gesundheitsreform 2000 – ethische Überlegungen zum politischen Disput. Zeitschrift für Medizinische Ethik 1999;45(4):319-325 (zus. mit S. Bertsch)

Prioritäten im Gesundheitswesen. Zum Gutachten des Sachverständigenrates für die konzertierte Aktion im Gesundheitswesen. Ethik in der Medizin 2001;13(3):204-207

The Eurotransplant kidney allocation algorithm – moral consensus or pragmatic com-promise? Analyse & Kritik 2001;23:271-79

Kosteneffektivität als Allokationskriterium in der Gesundheitsversorgung. Zeitschrift für medizinische Ethik 2002;48(2):171-190 (zus. mit U. Siebert)

Siebert U. Prioritäten in der Gesundheitsversorgung: Was können wir aus dem „Ore-gon Health Plan“ lernen? Dtsch Med Wochenschr. 2002;127(30):1601-1604

Prioritäten im Gesundheitswesen. Zwischen Gerechtigkeit und gutem Leben. In: Brand A, Engelhardt Dv, Simon A, Wehkamp KH (Hg.) Individuelle Gesundheit ver-sus Public Health? Münster: Lit-Verlag 2002, S. 178-189

Verteilungsgerechtigkeit in der Gesundheitsversorgung. In: Düwell M, Steigleder K (Hg.) Bioethik. Frankfurt am Main: Suhrkamp 2003, S. 333-343

Kosteneffektivität der HPV-Diagnostik in der Zervixkarzinomfrüherkennung. Eine Übersicht zu Entscheidungsanalysen. Der Gynäkologe 2003;36(4):341-348 (zus. mit U. Siebert, G. Sroczynski u. P. Hillemanns)

Leitlinien zwischen Qualitätsverbesserung und Kostenkontrolle. In: Dietrich F, Imhoff M, Kliemt H (Hg.) Standardisierung in der Medizin - Qualitätssicherung oder Rationie-rung? Stuttgart: Schattauer Verlag 2003, S. 237-252

Prioritäten in der Gesundheitsversorgung. Einführung. In: Marckmann G, Liening P, Wiesing U (Hg.) Gerechte Gesundheitsversorgung. Ethische Grundpositionen zur Mittelverteilung im Gesundheitswesen. Stuttgart: Schattauer Verlag 2003, S. 277-282

Zur Funktion des Krankheitsbegriffs bei prospektiven und retrospektiven Vergütungs-formen. In: Mazouz N, Werner MH, Wiesing U (Hg.) Krankheitsbegriff und Mittelver-teilung. Baden-Baden: Nomos Verlagsgesellschaft 2004, S. 57-69

Normative Implikationen von Allokationskriterien am Beispiel der Kosteneffektivität. Graumann S, Grüber K (Hg.) Patient – Bürger – Kunde? Ethische Aspekte des Ge-sundheitswesens. Münster: Lit-Verlag 2004, S. 131-161 (zus. mit U. Siebert)

Mittelverteilung im Gesundheitswesen. In: Wiesing U (Hg.) Ethik in der Medizin. Ein Studienbuch. Stuttgart: Philipp Reclam jun., 2. Auflage 2004, S. 261-273

Alter als Verteilungskriterium in der Gesundheitsversorgung? – Contra. Dtsch Med Wochenschr 2005;130:351-352

Rationalisierung und Rationierung: Allokation im Gesundheitswesen zwischen Effi-zienz und Gerechtigkeit. In: Kick HA, Taupitz J, Gesundheitswesen zwischen Wirt-schaftlichkeit und Menschlichkeit. Münster: Lit Verlag 2005, S. 179-199

Eigenverantwortung als Rechtfertigungsgrund für ungleiche Leistungsansprüche in der Gesundheitsversorgung? In: Rauprich O, Marckmann G, Vollmann J, Gleichheit und Gerechtigkeit in der modernen Medizin.

Interdisziplinäre Perspektiven. Paderborn: Mentis Verlag 2005, S. 299-313

Implizite Rationierung im Krankenhaus. Ethische Implikationen am Beispiel der DRG-Vergütung. In: Krukemeyer MG, Marckmann G, Wiesing U, Krankenhaus und Soziale Gerechtigkeit. Stuttgart: Schattauer-Verlag 2005, S. 72-89 (zus. mit U. Wiesing)

Konsequenzen des demographischen Wandels für die medizinische Versorgung im Krankenhaus der Zukunft. In: Thiede A, Gassel H-J, Krankenhaus der Zukunft. Heidelberg: Dr. Reinhard Kaden Verlag 2006, S. 31-38

Verteilungsgerechtigkeit in der Gesundheitsversorgung. In: Schulz S, Steigleder K, Fangerau H, Paul NW (Hg.) Geschichte, Theorie und Ethik der Medizin. Eine Einführung. Frankfurt am Main: Suhrkamp 2006, S. 183-208

Public Health und Ethik. In: Schulz S, Steigleder K, Fangerau H, Paul NW (Hg.) Geschichte, Theorie und Ethik der Medizin. Eine Einführung. Frankfurt am Main: Suhrkamp 2006, S. 209-223

 

Contact

Professor Dr. Georg Marckmann, MPH

(Coordinator of sub-project 4: Allocation)
Institute for Ethics and the History of Medicine
University of Tübingen
Schleichstraße 8
D-72076 Tübingen
Phone: +49(0)7071/29-78032
Fax: +49(0)7071/29-5190
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Dr. phil. Hans-Jörg Ehni

(Research associate in sub-project 4: Allocation)
Institute for Ethics and the History of Medicine
University of Tübingen
Schleichstraße 8
D-72076 Tübingen
Phone: +49 / 70 71 / 29-7 80 16
Fax: +49(0)7071/29-5190

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.