Urgent decision-making during the early COVID-19 pandemic raised complex ethical challenges, in particular concerning how to reach and include marginalized populations. To examine these issues, we conducted a qualitative study based on twenty-three semi-structured interviews with pandemic decision-makers and representatives of marginalized populations in Germany and Israel, focusing on decisions made in 2020 before vaccines were available. Key ethical themes emerged, including decision-making with ethical relevance under intense time pressure, the dominance of biomedical framings often at the expense of social considerations, inadequate attention to populations in bio-psycho-socially vulnerable positions, and the exclusion of stakeholders from decision-making processes. These findings have critical normative significance, highlighting issues of justice in the distribution of burdens and benefits, underscoring the importance of epistemic humility in acknowledging uncertainty and diverse forms of expertise, and affirming the moral obligation to integrate considerations of psycho-social vulnerabilities into public health. To inform future policy, we recommend establishing equitable governance structures to ensure broader stakeholder representation, implementing inclusive communication strategies to reach marginalized groups, and strengthening ethically informed crisis preparedness. Such measures can better align urgent public health decision-making with principles of justice, protection from harm, inclusion, and moral responsibility.

BACKGROUND:Digitalization in the German healthcare system is advancing. Digital services are increasingly being incorporated into mental healthcare. RESEARCH QUESTION:This questionnaire study examined the assessment of professionals working in mental healthcare regarding the opportunities and challenges of digital health services. It takes digital health applications (DiGA) and non-DiGA (apps and web services without reimbursement and governmental regulation) into account. METHOD:The online questionnaire included e.g. Likert scales for assessing the success of therapy, the quality of care, the doctor-patient relationship and the willingness to undergo further training. The quantitative questions were supplemented by free text comment fields. RESULTS:Based on 200 participants the analysis shows that a slight majority do not incorporate digital services into their therapy. The majority of respondents stated that digital services can support prevention and psychoeducation; however, whether they could meet the requirements in other areas of psychotherapy was mostly considered questionable. Challenges were largely seen in the high costs and insufficient information available to practitioners. In addition, the risk of exacerbating health inequalities (e.g., due to insufficient digital literacy) was discussed. DISCUSSION:It can be concluded that digital services can certainly add value to mental healthcare; however, the sustainable integration into care is linked to improvements in structural conditions (such as the cost-benefit ratio and better information for those providing treatment) as well as consideration and compensation for socially unequal access conditions.

Marginalization is a widely studied phenomenon and recognized as a critical topic in relation to health, shaping health inequities, access to resources, health outcomes, and policy decisions. However, despite its normative importance for health and justice, its conceptual role in bioethics remains unclear. This paper critically examines how marginalization is addressed in bioethics, analyzing its meaning, conceptual usage, and potential for further normative theorization. By exploring available definitions and how marginalization appears in bioethical literature, recurring patterns and conceptual gaps are identified. The analysis reveals two major findings. First, while definitions from disciplines beyond bioethics provide valuable insights, marginalization has not been normatively theorized as a distinct conceptual phenomenon within bioethics. Instead, dynamics of marginalization are largely addressed through established bioethical concepts, such as vulnerability or epistemic injustice. Second, it stands out that the contemporary redefinition of vulnerability in bioethics increasingly incorporates discussions on systemic exclusion and structural injustice, both central to marginalization. This raises the question of whether marginalization requires distinct conceptualization in bioethics or if its core dimensions are already encompassed by existing approaches and concepts. Consequently, this paper argues that further conceptual debate on marginalization is needed to assess its potentially distinct contributions to bioethics. It develops arguments for making space for the concept of marginalization within bioethics in its own right. To address these conceptual gaps, this paper calls for a more explicit normative analysis of marginalization to establish its role in bioethical discourse and to clarify its implications for equitable health, healthcare practices, and policies.

Die Digitalisierung im deutschen Gesundheitssystem schreitet voran. Immer häufiger werden digitale Angebote in die psychische Gesundheitsversorgung einbezogen. Diese Fragebogenstudie untersucht die Einschätzung von Fachpersonal, welches in der psychischen Gesundheitsversorgung tätig ist, bezüglich Chancen und Herausforderungen digitaler Gesundheitsangebote. Dabei werden digitale Gesundheitsanwendungen (DiGA) und Nicht-DiGA (Apps und Webangebote ohne staatliche Regulierung und Rückerstattung durch Krankenkassen) berücksichtigt. Die Onlineumfrage umfasste u. a. Likert-Skalen zur Bewertung des Therapieerfolgs, der Versorgungsqualität, des Arzt-Patienten-Verhältnisses sowie der Fortbildungsbereitschaft. Die quantitativen Fragen wurden durch Freitextkommentarfelder ergänzt. Basierend auf 200 Teilnahmen zeigt die Analyse, dass die geringfügige Mehrheit keine digitalen Angebote in die Therapie einbezieht. Die Befragten gaben überwiegend an, dass digitale Angebote in der Prävention und Psychoedukation unterstützen können; ob sie jedoch den Anforderungen in weiteren Bereichen der Psychotherapie gerecht werden könnten, wurde meist als fraglich angesehen. Herausforderungen wurden größtenteils in den hohen Kosten und unzureichenden Informationsmöglichkeiten der Behandelnden gesehen. Zudem wurde das Risiko einer Verstärkung gesundheitlicher Ungleichheiten (u. a. durch unzureichende digitale Kompetenz) thematisiert. Es lässt sich folgern, dass digitale Angebote in der psychischen Gesundheitsversorgung durchaus einen Mehrwert leisten können. Ihre nachhaltige Integration in die Versorgung ist jedoch an eine Verbesserung der strukturellen Rahmenbedingungen (wie das Kosten-Nutzen-Verhältnis und eine bessere Informiertheit der Behandelnden) sowie Berücksichtigung und Ausgleich sozial ungleicher Zugangsbedingungen gebunden.

Aim: In October 2022, the World Medical Association integrated environmental sustainability, public health, global health, considerations of inequities as well as the well-being of future generations into its revised International Code of Medical Ethics for physicians. Broader responsibility for environmental and societal issues was thereby codified into medical professionalism. Theoretical work on a normative foundation for such a comprehensive understanding of responsibility is scarce. This paper aims to contribute to the normative side of a contemporary professional identity formation (PIF) in medicine. It develops an “ethos in connection” which helps to justify broadening physician responsibility and integrating environmental and societal dimensions. Methods: It is asserted that defining and understanding health and responsibility are the decisive elements of the normative foundation for a contemporary PIF. The paper proposes a comprehensive bio-psycho-socio-planetary model of health. Relevant elements of the philosophical work by Iris Marion Young on responsibility are summarized. These comprise the social connection model, distribution of responsibility and relational egalitarianism. Results: The bio-psycho-socio-planetary model of health and Young’s theory of responsibility are integrated to establish an “ethos in connection” to provide the normative foundation guiding the PIF of today. Some challenging issues are discussed, for instance concerning whether and how it differs from a public health ethos and what practical implications follow. Conclusion: The paper concludes that the climate and environmental crises are not the decisive driving forces behind what this paper calls an “ethos in connection”, as the need for such an ethos has been prevalent long before these crises became issues of highest priority. Nonetheless, the severity of health impacts and the inequality in causation and distribution of the multi-layered climate and environmental crises increase the urgency to further develop the PIF of today.

Urgent decision-making during the early COVID-19 pandemic raised complex ethical challenges, in particular concerning how to reach and include marginalized populations. To examine these issues, we conducted a qualitative study based on twenty-three semi-structured interviews with pandemic decision-makers and representatives of marginalized populations in Germany and Israel, focusing on decisions made in 2020 before vaccines were available. Key ethical themes emerged, including decision-making with ethical relevance under intense time pressure, the dominance of biomedical framings often at the expense of social considerations, inadequate attention to populations in bio-psycho-socially vulnerable positions, and the exclusion of stakeholders from decision-making processes. These findings have critical normative significance, highlighting issues of justice in the distribution of burdens and benefits, underscoring the importance of epistemic humility in acknowledging uncertainty and diverse forms of expertise, and affirming the moral obligation to integrate considerations of psycho-social vulnerabilities into public health. To inform future policy, we recommend establishing equitable governance structures to ensure broader stakeholder representation, implementing inclusive communication strategies to reach marginalized groups, and strengthening ethically informed crisis preparedness. Such measures can better align urgent public health decision-making with principles of justice, protection from harm, inclusion, and moral responsibility.

In Deutschland stehen mittlerweile zahlreiche Gesundheitsapps zur Verfügung, unterstützt durch das seit 2019 geltende Digitale-Versorgung-Gesetz (DVG). Solche digitalen Anwendungen wecken Hoffnungen auf einen gerechteren Zugang zur Gesundheitsversorgung, etwa für Menschen in ländlichen Regionen. Während bisherige Studien vor allem Nutzende und medizinisches Fachpersonal in den Blick genommen haben, gibt es bislang wenig empirische Forschung zu den Perspektiven von Stakeholdern in der App-Entwicklung. Dieser Beitrag basiert auf einer qualitativen Interviewstudie mit 16 Akteur:innen aus dem Bereich der Gesundheitsapp- und DiGA-Entwicklung. Die Daten wurden mittels reflexiver thematischer Analyse ausgewertet. Drei zentrale, teils überlappende Motivationen für das Engagement in diesem Feld lassen sich identifizieren: persönliche Erfahrungen als betroffene Person, beruflicher Hintergrund im Gesundheitswesen oder wirtschaftliches Interesse. Unabhängig von der Motivation, sich in diesem Bereich zu engagieren, sind sich die Befragten einig, dass Gesundheit ein besonderes Gut ist, das bestimmte moralische Verpflichtungen mit sich bringt. Gleichzeitig benennen sie rechtliche Unübersichtlichkeit und bürokratische Hürden als zentrale Herausforderungen. Die Ergebnisse zeigen, dass digitale Gesundheitsinnovationen in einem Spannungsfeld zwischen wirtschaftlichem Wachstum und sozialem Versorgungsauftrag stehen. Wir argumentieren, dass es besonders relevant ist, mehr über die Motivationen, erlebten Herausforderungen und leitenden Werte von Stakeholdern im Gesundheitsapp-Entwicklungskontext zu verstehen, da ihre Handlungen und Werterahmen die entwickelten Technologien prägen, die zunehmend Teil des Gesundheitssystems werden.

The climate and further environmental crises have motivated calls for the medical profession to act by taking on additional responsibilities. These calls to assume responsibilities towards environmental protection and to systematically consider the health impacts of these crises greatly vary in their scope and demandingness. Through a review of journal publications, we have mapped the various calls for physicians to take on responsibilities in relation to these crises as individuals and as a professional group. These professional responsibilities, obligations or duties were grouped in four broad categories of physicians’ roles as (i) medical practitioners, (ii) medical scientists, (iii) facility (co-)managers, and (iv) citizens. In sum, these responsibilities go beyond actions within the individual patient-physician relationship and setting, demanding from physicians to get involved within their institution, their community, engage with policy-makers, and also concern themselves with the health effects of environmental changes also on distant others, such as people in other parts of the world and future generations.

In Germany, a wide range of health apps is now available, supported by the Digital Healthcare Act (DVG), which has been in effect since 2020. These digital applications raise hopes for more equitable access to healthcare, particularly for people in rural areas. While previous studies have primarily focused on users and healthcare professionals, there is little empirical research on the perspectives of stakeholders involved in app development. This paper is based on a qualitative interview study with 16 actors from the field of health app and DiGA development. The data were analysed using reflexive thematic analysis. Three main, partially overlapping motivations for engaging in this field were identified: personal experiences as a patient, a professional background in healthcare, or economic interest. Regardless of their motivation, the interviewees agreed that health is a special good that carries certain moral obligations. At the same time, they cited legal ambiguity and bureaucratic obstacles as main challenges. The findings show that digital health innovations operate within a tension between economic growth and the social mandate of healthcare. We argue that understanding the motivations, challenges experienced, and values guiding stakeholders in health app development is particularly relevant, as their actions and values shape the technologies that are increasingly becoming part of the healthcare system.

Objective: This article presents the Medical Competency Training (MCT) in Climate-Sensitive Health Counseling (CSHC) of the medical faculty Augsburg. The development and implementation process is described and reflected upon. In integrating Planetary Health Education into the medical curriculum at the University of Augsburg, an attempt was made to address its complex requirements through collaboration among various university institutes. Project description: Three university institutes developed the MCT CSHC. It comprises in-person sessions and e-learning and is integrated into the 8th semester of the curriculum. The development process incorporated the chapter “planetary and global health” from the National Competency-Based Learning Objectives Catalog for Medicine, as well as criteria for high-quality planetary health education. The MCT CSHC imparts knowledge about environmental changes and their health consequences. It also fosters communication skills and an ethically reflected attitude. Results: The MCT CSHC was implemented from 2023 onwards. All characteristics of high-quality planetary health education, were incorporated into the MCT, with particular emphasis on developing transformative competencies, such as the ability to communicate in a climate-sensitive manner. The teaching materials were made publicly available. The MCT CSHC was further developed based on student and instructor feedback. Conclusion: The challenge of implementing a planetary health teaching format was met through the development and curricular integration of the MCT CSHC. Crucial to this success was the inclusion of three distinct institute perspectives on the scientific and practical topics arising within CSHC. A course evaluation to assess the learning objectives is planned.

Various understandings of “resilience” dominate debates on climate change without consensus on its ethical implications. Individualistic interpretations can conflict with ethical values like minimizing population harms and countering health inequities. More systemic, ecological interpretations may overlook justice concerns, such as who is more burdened or marginalized regarding climate impacts. This article argues for integrating a normative, justice-oriented approach to resilience, informed by feminist and intersectional theory. It outlines six principles: build in redundancies and diversification; foster knowledge acquisition and sharing; increase social cohesion, connectivity and willingness to cooperate; improve participation and facilitate polycentric governance; protect regenerative capacities; and implement preventive measures.

Climate change, ecological degradation and global inequalities are symptoms of an eco-social polycrisis that threatens global health and health equity. This polycrisis is deeply rooted in Western value systems. These can be described as anthropocentric and individualistic and support the prevailing neoliberal economic model. Bioethics is now called to respond to the urgent health-related ethical challenges of the polycrisis and has recently begun to engage with Planetary Health and One Health in this regard. Both have mainly emerged in the Western scientific community and understand human health to be inextricably linked to the state of environmental and structural societal determinants. We argue that bioethics should indeed embrace holistic or integrated understandings of health but also carefully revisit the foundational Western value systems at the root of the polycrisis. If Planetary Health and One Health stay grounded in Western value systems, an extensive conceptual engagement might be problematic for bioethics. Instead of turning to Western concepts of health, bioethics should engage deeply with Indigenous and non-Western ways of knowing and critically reflect on its own role in inadvertently maintaining the status quo.

Low socioeconomic status (assessed by indicators such as educational level or income) is often associated with increased morbidity and mortality. This has been shown in many empirical studies, also in Germany. There are numerous calls for political interventions aimed at reducing these health inequalities, in scientific discussions as well as in the public. Asked for scientifically based recommendations on how to proceed 'from data to action', we have to admit that we are still faced with many questions and few answers. Developing these recommendations poses many challenges such as, for example, how to integrate the expertise from different public health disciplines. The present study focuses on the cooperation between social epidemiology, public health ethics and health economics, as we believe that these three disciplines are of particular importance here. We briefly outline what each of them could contribute to the development of practical interventions aimed at reducing health inequalities. We particularly emphasize the importance of public health ethics, as it focuses on questions that to date have largely been neglected in the German discussion: How can we evaluate the empirical data and the proposed political interventions from an ethical point of view? Which health inequalities are 'unjust', and how can this normative judgement be justified? Based on the expertise from the three disciplines mentioned above, the aim is to pave the way 'from data to action' by developing a well-structured stepwise procedure for interventions aimed at reducing health inequalities. The joint scheme could be very beneficial not only for developing practical interventions, but also for further developing each discipline in itself. The simple scheme proposed here could be a starting point that helps specify many open questions on this path 'from data to action'.

While there is agreement on the need to improve sustainability in university hospitals, there are strong differences of opinion on how such goals interact with responsibilities of the medical profession, including research activities. To facilitate sustainability transitions in university hospitals, we need to gain a better understanding of the multiple incentive structures and ethical responsibilities related to sustainability that influence the physicians working there. Furthermore, there needs to be greater awareness and systematic consideration of the health co-benefits of sustainability transitions. Both are necessary to prevent the sustainability agendas in hospital settings from becoming deadlocked due to disagreements over priorities and implementation, despite initial consensus in principle.

ZusammenfassungEin niedriger sozio-ökonomischer Status (erhoben über Indikatoren wie Schulbildung oder Einkommen) ist zumeist mit erhöhter Morbidität und Mortalität verbunden. Viele empirische Studien haben das belegt. Sowohl in der wissenschaftlichen als auch in der politischen Diskussion wird oft betont, dass diese gesundheitliche Ungleichheit verringert werden sollte. Die Frage, wie der Weg ,von Daten zu Taten‘ konkret aussehen könnte, lässt sich bisher jedoch erst ansatzweise beantworten. Wir stehen vor der großen Herausforderung, wissenschaftlich gut fundierte Vorschläge für die einzelnen Schritte auf diesem Weg zu entwickeln. Von der dafür erforderlichen breiten interdisziplinären Kooperation ist bisher aber nur wenig zu sehen. Im Mittelpunkt des vorliegenden Beitrages steht eine Frage, die u.E. hier von besonderer Bedeutung ist: Wie sind die empirischen Ergebnisse zur gesundheitlichen Ungleichheit und die daraus abgeleiteten gesundheitspolitischen Forderungen aus ethisch-normativer und aus gesundheits-ökonomischer Sicht zu bewerten? Wir konzentrieren uns daher auf die Kooperation zwischen Sozial-Epidemiologie, Public-Health-Ethik und Gesundheits-Ökonomie. Zunächst wird kurz erläutert, was jede dieser Disziplinen beitragen kann, wenn konkrete Maßnahmen zur Verringerung der gesundheitlichen Ungleichheit entwickelt werden sollen. Besonders hervorgehoben wird dabei die Bedeutung der Public-Health-Ethik, denn sie richtet den Fokus auf grundlegende und bisher weitgehend vernachlässigte Fragen wie zum Beispiel: Welche Ungleichheiten sind ,ungerecht‘, und wie lässt sich diese normative Bewertung ethisch begründen? Anschließend wird ein ,Stufenplan zur gesundheitspolitischen Entscheidungsfindung‘ vorgeschlagen. Er beschreibt einige grundlegende Schritte bei der Integration empirischer, normativer und ökonomischer Abwägungen. Der Stufenplan zeigt, wie wichtig ein klar strukturiertes Vorgehen ist, und dass die interdisziplinäre Zusammenarbeit den gesamten Prozess begleiten sollte, angefangen bei Datenerhebung und -analyse bis hin zur Entwicklung von Maßnahmen. Deutlich wird dabei auch, dass es auf diesem Weg ,von Daten zu Taten‘ noch viele offene Forschungsfragen gibt, und dass die Diskussion zum Thema ,wissenschaftliche fundierte Entwicklung von Maßnahmen zur Verringerung der gesundheitlichen Ungleichheit‘ gerade erst begonnen hat.