Medicina per "stranieri", questioni etiche per un approccio interculturale. Esperienze degli ambulatori di strada.

The research is composed of 4 chapters and investigates the operational methods of doctors and health workers who work in street clinics. The first chapter "Epistemological Aspects Characterising Social Research: Methodologies of Analysis in Applied Ethics" analyses the main theoretical and operational problems of intercultural medicine in street outpatients' clinics, a reality to which most of the time, irregular foreigners and foreigners in a situation of fragility turn. The second chapter "Intercultural Aspects in Health Communication" highlights the importance for doctors and health workers to know how to practise intercultural medicine even in the most difficult contexts: intercultural medicine is fundamental for a good development of the doctor-patient relationship and for facilitating the trust of the patient towards the health professional. In the practices of intercultural medicine, narrative medicine occupies a place of primary importance: it has a fundamental role because it makes it possible to explain the different meanings of illness and to build a personalised care relationship capable of increasing patient compliance. The training of the physician and of all health care personnel, starting from the university preparation, cannot today disregard the awareness and the responsibility that this reality entails: the contribution of social ethics and, in particular, the development of ethical competence, is, therefore, fundamental for every professional who intends to deal with his work in a responsible and conscious manner. The work of health professionals takes place within diversified structures, but which, at an organisational level, must take into account the new needs induced by a society increasingly characterised by ethnic and cultural pluralism: health professionals must therefore be placed in a position to work on the multiple existential meanings of illness, on the possible conflicts generated by this multiplicity, and to activate the resources and other services present in the area in a coherent manner: the ethical space is an organism in the process of being structured also in our country and modelled on the example of the Espace éthique dé l'assistance publique, operating in France for about thirty years, which could constitute a place, institutionally recognised, in which to bring together and develop the experiences gained in the practices of the street clinics and give greater vigour to an intercultural and narrative approach to therapeutic relationships. In the elaboration of the chapter, I carried out a comparative analysis of theories elaborated by scholars from various disciplinary fields (moral philosophers, anthropologists, physicians) regarding intercultural medicine, noting and describing the main limitations and ethical emergencies implied by the use of multiculturalist criteria and the exclusive reference to EBM. The analysis conducted allowed me to detect both the need for training, for care professionals, in intercultural medicine, in ethical competence, and the need, at the level of clinical governance, for the establishment of Ethical Spaces. The third chapter 'The right to health in the national context for regular and irregular foreign citizens. Analysis of regional cases' highlights how, although the right to health is a legal obligation of states, recognised at international level, it encounters numerous implementation problems, often making these rights 'rights on paper'. As widely recognised at the European level, at least from a formal point of view, immigration policies adopted by individual states must recognise migration not as an exceptional phenomenon to be managed according to emergency criteria, but rather, as a structural process connected to the very existence of society and tend to promote and implement wide-ranging actions aimed at promoting effective, humanitarian and safe actions that promote the integration and well-being of all citizens. All public and relevant institutional bodies, which interface daily with citizens and regulate the democratic life of society, are key players in integration processes, since they are the main producers of goods and services that are not for sale, but determine people's wellbeing: the public health sphere is one of the main providers of services to citizens and the promotion of integration also implies diversification both in terms of delivery and organisation of health services. At the national level, regional policies have two different approaches: bottom up and top down. On this basis, I have analysed and compared the health policies of six regions, highlighting their main strengths, limitations and ethical implications in relation to health policies and services aimed at migrants, with particular attention to irregular foreigners, who constitute the weakest and, for this reason, particularly significant group. The fourth chapter "The Right to Health for Irregular Foreigners in the Municipality of Genoa" examines three historical and consolidated experiences located in the Municipality of Genoa: their genesis, characteristics, organisation and functioning. In order to examine these three realities I conducted a quali-quantitative analysis by first examining the medical records of the people who go to these outpatient clinics and then administering twenty-five semi-structured interviews to all the volunteer health professionals involved in the street clinics investigated. Examination of the files allowed me to identify a substantial overlapping of clinical data and pathologies with respect to the surveys carried out at a national level, confirming the weight of determinants and confirming the healthy migrant vs exhausted migrant effect contemplated in the literature. I chose to devote special attention to the dental problem, which is recurrent and widespread in the most fragile segments of the population and which has a major impact on health even among foreigners: the right to oral health is recognised globally as an integral part of people's general wellbeing, but to date it remains largely unenforced At a national level, regional policies do not contemplate interventions dedicated to oral prevention in a coordinated and continuous manner, but only emergency interventions. I subsequently analysed the material using the NVivo programme with the aim of drawing a profile of the volunteer doctor, understanding his motivations, his attitude to intercultural medicine, and his degree of awareness. With the collaboration of the non-profit association Fondo Scuola Italia, I launched an oral hygiene education and prevention project in 13 primary school classes of the Istituti Comprensivi of the I, II, VI Municipio with a high frequency of foreign students. The course involved teachers and at the end of the course each pupil received a dental hygiene kit and a multilingual oral hygiene education guide. In addition to this project, with the collaboration of the Genoa City Council's Department of Social Policies, I had joined the oral education project for adults "The Right to Prevention" aimed at fragile citizens of the Genoa City Council and STP migrants. The project, financed by Mentadent and Unilever Italia Mkt Operations S.r.l. with the collaboration of the Italian Red Cross, the ANDI Onlus Foundation, Mentadent and a number of Rotary Clubs in District 2041 (Milan metropolitan district) through a mobile equipped unit, aims to guarantee even the most fragile categories of society the right to receive basic dental check-ups and treatment, thus promoting prevention, a correct dental hygiene routine and taking action to prevent numerous oral cavity pathologies and promote people's general wellbeing. Genoa was supposed to be the lead city for the initiative and operations were to be carried out in the period between April and May 2022: the outbreak of war in Ukraine and the intensification of migratory flows on the Balkan route meant that this mobile clinic had to be sent to Trieste so that, to date, it has not been possible to schedule its deployment for the project, the drafting of which can, however, be viewed on the sites of the promoting Associations. In summary, the analysis conducted in this thesis confirms the initial working hypothesis, i.e. the need to develop an intercultural approach in a society increasingly characterised by ethnic and cultural pluralism, overcoming the albeit laudable voluntarism that has characterised many significant experiences. In fact, organisational limitations of the NHS emerge, but also related to the actual awareness and ethical competence of doctors and health workers in dealing, from a non-emergency perspective, with cultural otherness, with particular reference to therapeutic and, more generally, care relationships. Two possibilities appear to be effectively feasible and interrelated today. One concerns staff training which, by placing ethical competence at the centre, could take as a model the one elaborated by J. Tronto, with the five phases of care identified by her, starting, however, from a biographical approach based on the awareness of otherness, of the incommensurability between cultures and the flexibility of languages. The second is the constitution of ethical spaces in the NHS structures which, using doctors, health professionals and ethics experts, constitute a place where it is possible to implement intercultural paths of common knowledge and co-responsibility in the management of the therapeutic relationship

Donazione e Volontariato

Attualmente il termine volontariato assume connotati molteplici e viene spesso considerato, comunemente, come un'azione altruistica finalizzata alla promozione di pratiche filantropiche. Il volontariato tuttavia assume una valenza più ampia e profonda, ponendosi come strumento di empowerment sociale e di self empowerment e costituendo una vera e propria palestra di democrazia funzionale allo sviluppo di una solida responsabilità etica capace di sviluppare e consolidare valori fondamentali quali la solidarietà, il bene comune, la giustizia e la gratuità. Il pluralismo valoriale caratterizzante i contesti del volontariato richiede un incontro e una capacità di confronto critico con diverse espressioni di alterità che si possono trovare a lavorare e offrire il proprio tempo e la propria disponibilità. Queste attività richiedono una scelta personale implicante la messa a disposizione del proprio tempo e delle proprie competenze con la consapevolezza che tali esperienze permettono di sviluppare capacità e sostenere, contemporaneamente, realtà che richiedono aiuto e assistenza. Nell'ambito della donazione di organi e tessuti la pratica del volontariato richiede una peculiare responsabilità e costituisce un impegno etico con altri soggetti esposti alla vulnerabilità e, pertanto, partecipi di un destino comun

La rivoluzione democratica della cura. Riflessioni sul pensiero di J. Tronto.

Intervento "La rivoluzione democratica della cura. Riflessioni sul pensiero di J. Tronto" al Festival Nazionale Annuale di Bioetica e pubblicazione dell'intervento sul sito dell'Istitut

Migranti irregolari, disuguaglianze sanitarie e diritto alla salute: esperienze degli ambulatori di strada nel Comune di Genova

Introduzione e obiettivi Gli ambulatori di strada sono un modello di società solidale che si auto-organizza anche in assenza di input della Pubblica Amministrazione; nel Comune di Genova ho selezionato alcune realtà storiche di Volontariato sanitario e cittadinanza attiva. La ricerca si è posta un duplice obiettivo: 1) tracciare un profilo degli utenti ed evidenziare i cambiamenti e i bisogni di salute più frequentemente espressi; 2) rilevare le motivazioni sottese ai comportamenti dei medici volontari degli ambulatori di strada concentrandomi, in particolare, sull’interesse, la conoscenza e l’applicazione di pratiche di medicina interculturale e, più in generale sulle peculiarità di queste strutture con un’attenzione particolare agli effetti della pandemia Covid sul funzionamento delle stesse. Metodi/Azioni 1) Esame quali-quantitativo delle cartelle cliniche delle realtà indagate: AAICA: Nel quadriennio esaminato (2017-2021) sono state esaminate le 1858 cartelle aperte e le motivazioni delle 5202 visite effettuate; CAMICI e PIGIAMI: Esame e Codifica di 1200 cartelle cliniche dentistiche raccolte nel periodo 2006- 2020 SOLE LUNA: Esame e codifica di 137 cartelle cliniche dentistiche raccolte nel biennio 2018-2020; 2) Analisi di 25 interviste radioregistratore attraverso il Software NVivo (programma finalizzato all'analisi qualitativa computer assistita) Risultati I risultati relativi alla tipologia e alla cronicizzazione delle patologie registrate confermano quelli della letteratura di riferimento; durante la pandemia la totale assenza di riconoscimento da parte del SSR ha determinato la chiusura degli ambulatori di strada. La domanda di servizi di medicina di base e specialistici è, almeno dal punto di vista quantitativo, aumentata nel periodo post pandemico. Un ambito particolare di interesse è quello odontoiatrico tanto rilevante sul piano patologico quanto relativamente poco indagato. I medici volontari tendono ad integrare l'EBM con pratiche di medicina narrativa ma riconoscono di non essere formati alla medicina interculturale. Conclusioni Le politiche Sanitarie Regionali top down della Liguria rendono per gli stranieri irregolari la fruizione del diritto alla salute un percorso che, sebbene riconosciuto e tutelato legalmente, si rivela, di fatto, piuttosto parziale e discontinuo, e si rivelano inefficaci e inefficienti per la tutela della salute pubblica, per l'utilizzo dei servizi di medicina e, in particolare, per quelli di urgenza. Emerge, pertanto, la necessità di un cambio di prospettiva a livello politico regionale in un’ottica sistemica. Per l’effettiva applicazione di pratiche di medicina interculturale emerge la necessità di importanti riforme strutturali sia a livello formativo (inserimento di corsi dedicati trasversali alle diverse professionalità sanitarie e mediche a partire dalla formazione accademica ), sia a livello organizzativo e strutturale (apertura e gestione di servizi di rete e di spazi etici

Il dibattito sui diritti umani sociali: imperativi etici o formalizzazione giuridica?

La forza dei diritti non risiede nella loro natura giuridica, ma nella loro forza etica: essi esigono da chi ha in mano le sorti di uno Stato, il loro riconoscimento in ogni singolo individuo sotto forma di rispetto di certe libertà e non nel loro essere riconosciuti come giuridicamente formalizzati e possedenti un proprio valore giuridico.The strength of rights does not lie in their legal nature, but in their ethical strength: they demand that those in charge of the fate of a state recognize them in each individual in the form of respect for certain freedoms and not in their being recognised as legally formalized and possessing their own legal value