[Towards the revision of the Italian code of medical ethics: thoughts of an extremist.] / Verso la revisione del Codice di deontologia medica: riflessioni di un estremista.

In November 2022 the Italian medical council (Federazione nazionale degli ordini dei medici chirurghi e odontoiatri) started the revision of the Italian Code of medical ethics (Cme) with the first race dating back ten years. Since then, the Italian doctors are dealing with the scientific, ethical and economic challenges together with the more recent ones posed by the Sars-CoV-2 pandemic to the National health system underlying the ongoing crisis of the medical profession. Additionally, this critical context requires the doctors to develop new technological skills, a complete and effective adherence to the Ebm principles, a new view regarding the relationship with the other health care professionals and the related changes of clinical practices fostering a responsible use of resources. In brief, what is required nowadays from doctors is to rethink about the meaning of science, ethics, economics and public health and to make new and more appropriate connections between the instances conveyed by these different disciplines. The Cme main aim consists in providing appropriate rules in step with the current transformations of medicine and society to doctors for ethically acting in clinical practice, assuring the citizens, the institutions and law of the scientific competence, the protection of the fundamental rights of the sick person in compliance with the constitutional principles. Under this assumption and in line with the above mentioned professional crisis, at least the overall guidelines aimed to solve it should have been settled before starting the Cme review also in order to ensure the necessary coherence between the new contents drawing the doctors new social function and its codal systemisation. Unfortunately this stepwise approach was not considered.Lastly, to develop the new Cme looking towards the progress of medical profession, systematic and methodologically appropriate consultations would have been necessary to know, value and balance all the different positions of doctors, allowing them to be responsible for the change of their profession. However, such a decision was not made.

[The banality of evil in the migrants era.] / La banalità del male al tempo dei migranti.

In early November the Italian government, after having prevented two NGO ships with 751 migrants on board from docking in the port of Catania, allowed disembarkation only to migrants in critical health conditions, refusing it to others and ordering then to the ships to set sail. This episode, the latest in a series started in Italy between 2018 and 2019 during the previous right-wing government, is part of a sovereignist ideal and political framework, while the racist tendencies are clearly growing up in the country long ago. The event referred to and the social and political climate in which it took place evokes the theme of banality of evil about which Hannah Arendt and Primo Levi have written after the experience personally lived during the Nuremberg trial by the first author and in the Auschwitz killing field by the second one. The article offers a reflection on this matter and provides an answer to the question whether today it is still possible to speak in regard of the banality of evil and, if so, in what forms and meanings and with what responsibilities compared to those originally given from the two authors to the saying.

[Medical assistance in dying in Italy: a bill of law or just a political compromise?] / La morte volontaria medicalmente assistita in Italia: un disegno di legge o solo un compromesso politico?

INTRODUCTION: After two judgements by the Italian constitutional Court (the first one - No. 242/2019 - related to the decriminalisation, under well-defined conditions, of the article No. 580 of the penal code: support or incitement to commit suicide, and, the second - No. 50/2022 - related to the referendum held in regard to the partial repeal of article No. 579 of the penal code: murder of the consenting party), the issue of the physician assisted suicide (PAS) has been recently regulated by the bill of law No. 3101, approved by the Italian Chamber of Deputies, currently before the Senate and registered with the No. 2553. PURPOSE: To assess from the healthcare ethics perspective whether the bill of law can be considered an helpful legal tool to address the problems of both sick people who request PAS and the health professionals caring for them. FINDINGS: A systematic analysis of the bill of law has highlighted four critical issues: 1) PAS left out from the doctor-patient relationship; 2) the mutual exclusion between PAS and palliative care; 3) the dependency on life-sustaining treatments (DLST) to get PAS procedure as a condition discriminating against sick people not dependent (DLST represents one of the four conditions covered by the Italian constitutional Court judgement No. 242/2019 in order to exempt someone for the crime of aiding or inciting someone else to commit suicide); 4) the conscientious objection setting the rights of the doctor and the sick person against each other. Meaning. The bill of law does not take into account both the concrete problems of the sick people asking for hasten their death through the PAS procedure and those of the health professionals caring for them; it seems rather that the legislator's primary concern was to provide the follow-up to the solicitations of the Constitutional Court, only guaranteeing a political compromise. The bill of law therefore goes against the interpretation of the right as a system of rules taking into account the modern complexity of the disease-death paradigm which drawn up the law No. 219/2017.

[Task shifting: a derby between doctors and nurses or a resource for patients and health care systems?] / Task shifting: un derby tra medici e infermieri o una risorsa per i malati e i sistemi sanitari?

As proved through a sound evidence, task shifting (TS) - the rational redistribution of tasks among health workforce teams - is an important strategy aimed at improving health of the most vulnerable and disadvantaged populations of the low- and middle-income countries by providing essential services and reducing or eliminating health inequalities. Clinical and epidemiological efficacy of many TS interventions has also been demonstrated in high-income countries. Systematic reviews show that TS can reduce morbidity and mortality by providing essential care for infectious and non-communicable diseases, for maternal and child health, for critically ill and injured patients. The results of some research programs concerning TS interventions offer a conceptualization and an in-depth evaluation of their positive effects on health equity. However, these results are often underestimated, or not considered, by medical institutions in some European countries such as Italy. On the contrary, the TS deserves greater attention and conceptual enhancement as a tool contributing to the development of new health care systems on one hand, and, on the other, to the renewal of the concept of health from the mere psycho-physical aspect to that connected to social risks in a society in which health inequalities continuously increase, affecting the most vulnerable groups. After providing a definition and clarifying the different implementation methods of TS, the article analyzes the key factors supporting its adoption and those that hinder it. Then, an assumption is put forward that TS could be part of a renewal process of both the public health care systems and the different health care professionals functions.

[Abortion: memories and thoughts of a physician.] / Aborto: ricordi e riflessioni di un medico.

In light of the recent ruling of the US Supreme Court overturning abortion rights, and drawing inspiration from a case came to his observation of hemorrhagic shock complicating an illegal abortion, the author briefly comments on the health, ethical, political and economic aspects that the denial of the right to terminate pregnancy entails for women, health care professionals and for the society as a whole.

[The dark price that non-covid patients are paying to covid pandemic: the "chinese boxes" of the public health crisis.] / Il prezzo pagato alla pandemia dai malati non covid: le scatole cinesi della crisi sanitaria.

In Italy, as in the other Western countries, during the different pandemic surges, the health care systems have undergone an unprecedented imbalance between health care resources demand and supply due to the huge number of patients affected by covid-19. In this dramatic scenario the access to the necessary hospital care for non-covid patients has been limited or precluded. Delays in diagnostic procedures or in caring for many acute or chronic diseases can result in a dangerous increase in their severity with a consequent increase in short and long-term related mortality. This is evident both with regard to time-dependent acute diseases, such as coronary artery syndromes or cerebrovascular diseases, and chronic degenerative diseases such as neoplasms. In this case the natural consequence of the interruption of the screening activities will require more complex treatments with a lower probability of a good outcome and higher mortality. Developing policies to promote healthcare access for non-covid patients population is an urgent task for governmental bodies and all decision makers to prevent a health crisis of unpredictable proportions. This narrative review is firstly aimed to set out the findings regarding the comparison between the trends of hospital admissions, surgical interventions, diagnostic and screening procedures for cardiac, cerebrovascular and oncological diseases before and during pandemic around the world; secondly, some public health policies are put forward in order to begin the restoration of medical services for non-covid patients.

[The Italian National Healthcare System and the SARS-CoV-2 pandemic: a foretold debacle? Reflections for changing.] / Il Sistema Sanitario Nazionale e la pandemia da SARS-CoV-2: un disastro annunciato? Riflessioni per un cambiamento.

Almost two years after the first official report from World Health Organization (WHO), the SARS-CoV-2 pandemic (covid-19) outreached 200 mln of cases around the world with an overall mortality equal to 2% (more than 4.5 mln of cases). In many countries, when the surge in cases of severe covid-19 respiratory failure has exceeded the availability of intensive healthcare resources (intensive care beds, respirators, human resources) clinicians were forced to triage intensive care unit (ICU) admissions. In order to support these difficult decisions, many scientific societies and national regulatory bodies developed guidelines to prioritize patients entitled to receive mechanical ventilation and other life support treatments. From an ethical point of view two main theoretical approaches - the egalitarian and the utilitarian one - have been suggested to identify the criteria to be adopted for triaging the ICU patients. In regard, there is a limited consensus until now and in many cases these different theoretical approaches gave rise to a clash of opinions contributing to additional difficulties for doctors. In Italy, the National Committee for Bioethics is the only public institution that, through an official document, has expressly taken a position on the issue of triage and rationing of resources, admitting its lawfulness in particular conditions as long as it is based on common clinical criteria of clinical appropriateness and ethical proportionality, underlining however the fundamental role of "preparedness". As the covid-19 crisis seems slowing down, the need to debate the triage criteria and the allocation of the scarce ICU resources it seems less pressing. Instead, it seems more useful to dwell on two aspects with respect to the choice of regulatory criteria for allocating resources: 1) the necessary interconnection between macro- and micro-allocation choices which ends up conditioning the decision-making processes relating to individual patients; 2) the opportunity for decision-makers and healthcare professionals to maintain a right level of "honesty" towards citizens and patients regarding the causes of the lack of resources and the decision-making processes that involve the need to make "tragic choices" at both levels.

COVID-19 pandemic in ICU. Limited resources for many patients: approaches and criteria for triaging.

The COVID-19 pandemic has shattered the illusion that healthcare resource shortages that require rationing are problems restricted to low- and middle-income countries. During the pandemic surges, many high-income countries have been confronted with unprecedented demands for healthcare systems that dramatically exceeded available resources. Hospitals capacities were overwhelmed, and physicians working in intensive care units (ICUs) were often forced to deny admissions to patients in desperate need of intensive care. To support these difficult decisions, many scientific societies and governmental bodies have developed guidelines on the triage of patients in need of mechanical ventilation and other life-support treatments. The ethical approaches underlying these guidelines were grounded on egalitarian or utilitarian principles. Thus far, however, consensus on the approaches used, and, above all, on the solutions adopted have been limited, giving rise to a clash of opinions that has further complicated health professionals' ability to respond optimally to their patients' needs. As the COVID-19 crisis moves toward a phase of what some have called "pandemic normalcy," the need to debate the merits and demerits of the individual decisions made in the allocation of ICU resources seems less pressing. Instead, the aims of the authors are: 1) to critically review the approaches and criteria used for triaging patients to be admitted in ICU; 2) to clarify how macro- and micro-allocation choices, in their interdependance, can condition decision-making processes regarding the care of individual patients; 3) to reflect on the need for decision-makers and professionals working in ICUs to maintain a proper degree of "honesty" towards citizens and patients regarding the causes of the resource shortages and the decision-making processes, which, in different ways routinely and in crisis times, involve the need to make "tragic choices" at both levels.

Medical assistance in dying: just an ethical or legal issue?

According to current vital statistics suicide appears as a growing public health problem in most Western countries. However, suicide is rarely discussed in scientific journals, possibly because of a persisting moral stigma. As a consequence, the diverse bases of suicidal behavior are little understood while the role of Chronic-Degenerative Terminal Diseases (CDTD) has been poorly investigated. In the present study, the topic of suicidality was addressed in a clinical, holistic, perspective in an attempt to clarify how, in some chronically ill patients, the decision to end their own life is taken independently from mental disorders, being conversely, the expression of a rational psychological pattern which copes with the burden of chronic illnesses to become an integral part of their clinical spectrum. An assisted suicide (AS) request should therefore be considered from a clinical point of view and not only as an ethical or legal issue, in fact a holistic evaluation of the patient's situation must be performed, conferring the decisions making process a further in-depth line of thinking. In this study we first examined the relationship between suicide and CDTD as reported in the medical literature; then we reviewed the psychological theories which allegedly explain suicidal behavior; finally we discussed the possible role of a full-fledged palliative care in preventing suicide and in managing death requests by CDTD patients.

[What if my life is not worth living?] / Cosa fare se la mia vita non è più degna di essere vissuta?

In the culture of the Western countries suicide remains a taboo subject. Some of the risk factors for suicide are known, but the connections between non-communicable conditions (chronic-degenerative terminal diseases - CDTD) and suicide have been poorly explored until now. In contrast, the increasing legalization and public support for euthanasia (E) and physician assisted suicide (PAS) in Western countries make it important to understand this topic. Palliative care (PC) is a useful measure to counteract suicidal ideation, but many chronically sick people chose nevertheless to hasten death through E or PAS. In Western countries, where E and PAS are not legalized, "suicide tourism" started from 2001 towards Switzerland. This is the case of an Italian patient (dj Fabo) suffering from a severe post-traumatic disability. He recently died through PAS in that country supported by Mr. Marco Cappato, a member of Luca Coscioni Association who then incriminated himself, declaring he helped the patient reach Switzerland (in Italy violation of Criminal Code Art. 580). In October 24, 2018 the Italian Constitutional Court held that the absolute ban on assisted suicide provided for in Art. 580 of the Italian Criminal Code is unconstitutional under specific conditions such as a terminal illness causing physical and/or psychological unbearable suffering, requiring life supports being the patient still able to make decisions (ordinance n. 207/2018). The Court has asked Parliament to pass legislation before ruling on unconstitutionality of Art. 580. The Parliament has not passed a law on assisted suicide to date, then the Court will decide on September 24, 2019. Taking into account the content of the ordinance n. 207/2018, legal scholars and physicians, pooled in a Working Group, decided to open an interdisciplinary discussion on the physician assisted suicide issues drawing up the document entitled "Medical assistence to die, and law" (see the document in this issue of the journal) aimed to contribute to the public debate.

The Italian law on informed consent and advance directives: its impact on intensive care units and the European legal framework.

The Italian Parliament has recently approved a law on informed consent, advance directives and advance care planning. The law also deals with health care proxy and health care decisions for minors and adults who are not able to give consent. The Italian law arrived quite late in comparison with other European countries. After several years of debate on the need to approve such a law, the focus has now shifted to the assessment of the legislative provisions and their impact on clinical practice. In this article, the authors firstly offer an overview of the findings from the empirical research regarding the use of the different legal tools in the field of intensive care medicine; secondly, they present the tools now provided by law no. 219/2017 particularly with regard to the decision-making processes in the Intensive Care Unit (ICU); thirdly, the authors offer a comparison between the new Italian law and other European legal orders, with special reference to France, Spain, Germany and England. The aim of the article is to assess the degree of innovation of the law vis-à-vis the previous framework.

Forgoing life-sustaining treatments in the ICU. To withhold or to withdraw: is that the question?

In the last decades, mortality from severe acute illnesses has considerably declined thanks to the advances in intensive care medicine. Meanwhile, critical care physicians realized that life-sustaining treatments (LST) may not be appropriate for every patient, and end-of-life care in the Intensive Care Unit (ICU) started to receive growing attention. Most deaths occurring in the ICU now follow a decision to forgo life-sustaining treatments (DFLST), which can be implemented either by withdrawing (WDLST) or withholding (WHLST) life-sustaining treatments. Despite the broad consensus about the equivalence of the two practices from an ethical point of view, the issue of the best option between WDLST and WHLST constantly gives rise to controversies in clinical practice. This review is not intended to take a stand for or against WDLST or WHLST. Based on available evidence, the definitions of the two practices are first presented. Secondly, the preferences of ICU physicians towards WDLST and WHLST are examined. Finally, some arguments are offered outlining pros and cons of WDLST and WHLST, stressing that the clinician's attention should focus on an early and thorough recognition of patients in need of a DFLST, rather than on the theoretical strength and weakness of the two practices. This approach will enable physicians to make informed decisions on how to implement the limitation of LSTs, considering the patients' clinical conditions and preferences, the circumstances and needs of their families.

[Healthcare services citizen's right and healthcare systems safeguard. Considerations rising from the Charlie Gard story.] / Diritto del cittadino alle prestazioni sanitarie e tutela dell'integrità del sistema sanitario. Riflessioni sul caso di Charlie Gard.

The story of Charlie Gard, an 11-month-old boy suffering from a rare inherited mitochondrial disease called 'infantile encephalomyopathic mitochondrial DNA depletion syndrome' and kept alive thanks to life supports, rises some issues regarding the provision of healthcare. Is there a right of an individual person to buy any healthcare benefits only because he has enough money to do so? If the answer is 'yes', in light of the distributive justice principle how do governments balance this right with the obligation to regulate health care systems ensuring that all treatments are useful and affordable for everybody? Many considerations of the best interest of patients can be found in this debate, but we cannot ignore neither the value of the scientific method as the cornerstone of the medical profession nor a commitment to support the moral integrity of clinical practice by refusing to provide treatments that do not meet a reasonable threshold of scientific justification evidence-based.

Palliative sedation: the position statement of the Italian National Committee for Bioethics.

In January 2016 the Italian National Bioethics Committee (NBC) published a position statement entitled Deep and continuous palliative sedation in the imminence of death, related to the use of sedation and analgesia for relief from pain and psychological distress in dying patients. In this statement the Committee points out the clinical and ethical appropriateness of palliative sedation as a therapeutic procedure. As a result, today palliative sedation has to be considered useful, scientifically safe and reliable, and acknowledged as an integral part of good clinical practice. At the same time, the position statement, once and for all, makes clear that palliative sedation cannot and must not be equated with the practice of euthanasia. Thus, this document should be known by health professionals caring for dying patients not only in palliative as well as in intensive care settings, but it should be also considered as a milestone aimed to encourage and ease a widespread implementation of this procedure in all health care settings.