Jump to comment:

• Premature Neonates, Vegetative State and Nutrition: Political Power Clashes with Medical Autonomy
  Giuseppe Gristina
  Published on: 17 June 2009

• Published on: 17 June 2009

  Premature Neonates, Vegetative State and Nutrition: Political Power Clashes with Medical Autonomy

  • Giuseppe Gristina, Medical Doctor
  • Other Contributors:
    • Davide Mazzon, Maria Serenella Pignotti, Gaetano Iapichino, Ida Rosa Salvo, Francesco Procaccio, Virginio Bonito,Luciano Orsi, Manrico Gianolio, Marcello Orzalesi, Aldo Pagni, Demetrio Neri

  PREFACE 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 "...

  Show More

  PREFACE 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.

  CONCLUSION 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.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top