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Recently, escalating controversy has been generated in Italy concerning
end-of-life dilemmas. As a result, some recent health policies adopted by the Italian government
in compliance with the official point of view of the Roman Catholic Church
have rejected published scientific evidence. This article shows three examples of this situation where doctor's
autonomy in Italy is undermined by political power.
THE "ELUANA ENGLARO CASE"
For sixteen years, Ms. Englaro was in a permanent vegetative state (PVS)
due to a car accident. Before this event, Ms. Englaro had explicitly and
repeatly told her parents that if she had to face a PVS, they should let
her die without providing any vital life support. However, when Ms.
Englaro's tragedy occurred, the opposite occurred. After the initial
treatments in the Intensive Care Unit she was transferred to a long term
care facility where today she is still being cared for.
Her father has been involved for 16 years in legal proceedings to get the
State to respect his daughter's wishes, by requesting the withdrawal of
artificial nutrition (AN). In Italy, authoritative exponents of the Roman
Catholic Church insist that AN is not considered as medical therapy. This
is in complete contrast with the definition of AN by Medical Associations
However, the Italian High Court ruling for Ms. Englaro affirmed that,
"There is no doubt that the artificial feeding by nasogastric tube
constitutes a medical treatment".
Recently the same Court decided that Ms. Englaro's wishes, as represented
by her father, should be respected. In reply, the Minister of Health signed an official document preventing
public and private Italian hospitals from withdrawing AN from Ms. Englaro. Nevertheless, a medical team (one intensivist, ten nurses) withdrew AN from Ms. Englaro on February 6, 2009 and she died on February 9. At the moment a judicial inquiry is set up to investigate the medical team.
THE CASE OF PERSISTENT VEGETATIVE STATE GLOSSARY
The last example is represented by a "Glossary" regarding the PVS,
produced by a medical working group, appointed and chaired by the Vice-
Minister of Health and coordinated by a neurologist, President of the
World Federation of Catholic Physician's Associations.
The main issue of the Glossary is the question of the reversibility of
PVS. Three documents edited by the Multi-Society Task Force on PVS (USA,
1994), including the Royal College of Physicians of London (2003)
and the American Academy of Neurology (2006), represent the world leaders
on this issue. All these documents stipulate end points of: i) 12 months
from the onset of post-traumatic PVS; ii) 6 months for post-anoxic. These
limits today are internationally accepted as a cut-off for PVS definition.
On the other hand, it is evident that the prognostic evaluation must be
decided case-by-case; and the first document edited by the 1994 Task Force
stated that setting time limits gave only a probabilistic value.
Based on this sentence, the Glossary drafters concluded that
irreversibility from PVS could not be determined. They overlooked the
epistemological nature of medicine, in that medical choices must be based
on the highest degree of probability and on the minimum degree of
uncertainty in terms of scientific evidence for each specific illness
balanced together with the patient's best interests.
THE CASE OF NEONATES OF LOW GESTATIONAL AGE
138 physicians and 3 Scientific Boards signed an open letter that was
handed to the Minister of Health opposing a document on the clinical
treatment of neonates of extremely low gestational age (ELGA neonates)
released from the Ministry itself. This document was formulated by the
highest level of Italian Health Institution (Consiglio Superiore Sanità -
CSS) and proposed that gestational age (GA) is not a valid parameter for
evaluation of prematurity. It maintained that it was mandatory to sustain
life of ELGA neonates regardless of "no chances of survival" (
220+6 weeks GA), or those at risk of having severe and multiple
disabilities related to prematurity (230+6, 240+6 GA).
Contrary to the contents of the CSS document, there are two exhaustive
studies and fifteen guidelines from Perinatal Scientific Societies of nine
countries, including Italy, and recommendations from two International
Scientific Societies, giving conflicting advice. Therefore, the CSS
document was instead recommended as a guideline for clinical practice . In
addition, a document from the Italian neonatologists and obstetricians-
gynaecologists task-force (Carta di Firenze) was rejected by the Minister
of Health. This is the first time in the history of Medicine in the
Italian republic that politicians chose to intervene in a medical matter.
In regard to ELGA neonates, PVS and AN, all governmental documents have
manipulated the scientific evidence with ideological assumptions, strictly
adopting the official perspective of the Catholic Church. In this way a
great confusion has been created amongst scientific, bioethical, religious
and political domains. .
Furthermore, Italian Doctors involved in PVS patient and ELGA
neonates management and AN treatments are confronted with institutional
rules making their tasks more difficult in balancing clinical decisions
based on best scientific evidence with ethical principles.
This approach constitutes the core of a doctor's professionalism. There
must be restraints from any influence of ideological conditionings,
religious or not. The correct approach should also permit them to confront
and understand the difficult responsibilities arising from the ever
increasing complexity of clinical practice in a society where different
ethical systems coexist.