Euthanasia and physician-assisted suicide for patients with depression. Thought-provoking remarks

Euthanasia and medical assistance in dying entail daunting ethical and moral challenges, in addition to a host of medical and clinical issues, which are further complicated in cases of patients whose decision-making skills have been negatively affected or even impaired by psychiatric disorders. The authors closely focus on clinical depression and relevant European laws that have over the years set firm standards in such a complex field. Pertaining to the mental health realm specifically, patients are required to undergo a mental competence assessment in order to request aid in dying. The way psychiatrists deal and interact with decisionally capable patients who have decided to end their own lives, on account of sufferings which they find to be unbearable, may be influenced by subjective elements such as ethical and cultural biases on the part of the doctors involved. Moreover, critics of medical aid in dying claim that acceptance of such practices might gradually lead to the acceptance or practice of involuntary euthanasia for those deemed to be nothing more than a burden to society, a concept currently unacceptable to the vast majority of observers. Ultimately, the authors conclude, the key role of clinicians should be to provide alternatives to those who feel so hopeless as to request assistance in dying, through palliative care and effective social and health care policies for the weakest among patients: lonely, depressed or ill-advised people

Physical restraint in psychiatric care: soon to fall out of use?

International directives all recommend that using restraints on psychiatric patients should be avoided, yet scientific literature shows that such practices are still largely in use. This article aims to lay out strategies that could be put in place in order to gradually discard the use of restraints, particularly through a “restraint-free” approach, nursing, logistic–environmental pathways, and locally centered health care provision. All such tools have proven valuable for the purpose of safeguarding the health of psychiatric patients. Hence, the failure to put in place such measures may lead to litigation and lawsuits against physicians and particularly health care facilities. Undoubtedly, the ability to effectively implement such methods largely depends on the financial resources available, which in countries such as Italy are poorer than in others. Still, the risk of being sued and held professionally liable may constitute a factor in raising awareness among operators, facilities, and public health care management, leading to the implementation of policy changes aimed at minimizing the use of restraints

An overview of trends in the regulation of clinical ethics committee; an opinion from the Italian National Bioethics Committee [Una visión general de las tendencias en la regulación por los comités de ética clínica: una opinión del Comité Nacional Italiano de Bioética]

In 2017, the Italian National Bioethics Commttee (INBC) released an opinion paper titled "Clinical ethics committees". Said document advocates for the creation of "clinical bioethics committees" in every suitable setting and lays out a set of guidelines aimed at regulationg such committees' function. The recommendations deal primarily with the independence, requirements for counselling, structures, composition, tasks, placement, coordination, requisite competences, regulations. In the opinion's contents there are: a) the need to entrust counselling and training on ethical issues within clinical practice to different committees than those that deal with ethical assessment of scientific trial and experimentation; b) the laying out of all the various functions and related competences required of the ethics committes' members; c) the necessity that all counselling pratices be carried out by each committee as a whole, rather than a single expert member; d) Committee's independece. The authors elaborate on each one of the above mentioned aspects and highlight the importance of INBC's recommendations in order to improve the quality standards of care delivered "to each patient's bed".En el 2017, el Comité Nacional Italiano de Bioética (CNIB) publicó un artículo de opinión titulado “Comités de Ética Clínica”. Dicho documento aboga por la creación de “comités clínicos de bioética” en cada entorno adecuado, y establece un conjunto de directrices destinadas a regular las funciones de tales comités. Las recomendaciones se refieren principalmente a la independencia, los requisitos para el asesoramiento, las estructuras, la composición, las tareas, la ubicación, la coordinación, las competencias requeridas, las regulaciones. En los contenidos de la opinión se plantean: a) la necesidad de confiar el asesoramiento y la capacitación en cuestiones éticas dentro de la práctica clínica a diferentes comités que aquellos que se ocupan de las evaluaciones éticas de los ensayos científicos y la experimentación; b) la presentación de las diversas funciones y competencias requeridas por los miembros de los comités de ética; c) la necesidad de que todas las prácticas de asesoramiento sean llevadas a cabo por cada comité como un todo, y no por un solo miembro experto; d) independencia del comité. Los autores detallan cada uno de los aspectos mencionados anteriormente y resaltan la importancia de las recomendaciones de CNIB para mejorar los estándares de calidad de la atención brindada “a la cabecera de la cama de cada paciente”

Ethical and medico-legal remarks on uterus transplantation: may it solve uterine factor infertility?

Uterus transplantation was firstly tested with animal trials sixty-five years ago. Despite several successful attempts in human subjects, the different procedures still lay at the experimental stage, in need of further studies and investigations before they can be considered as standard clinical practices. Uterus transplant cannot be regarded as a life-saving procedure, but rather a method to restore woman ability to procreate, when lost, thus improving her quality of life. Uterus transplant is a complex surgical procedure and presents significant health threats. Medical staff should therefore always obtain informed consent from patients, emphasizing such risks. Before that, women undergoing uterine transplants should be thoroughly informed about the hazards inherent to the procedure and especially about the dangers of immunosuppressant drugs, administered after the surgery which may injure the fetus, eventually formed in the restored organ and even lead to its death, thus nullifying the purpose of the transplant itself. Therefore, the risk-benefit ratio of uterus transplantation needs to be carefully assessed and described

Medical use of cannabis: italian and european legislation

This review illustrates some brief considerations of the medical use of cannabis recently issued in Italy. History and uses of cannabis throughout centuries and different countries are illustrated together with a description of botany and active phytocannabinoids. Then, medical use of cannabis anti-pain treatment for patients resistant to conventional therapies is described in case of chronic neuropathic pain, spasticity, for anticinetosic and antiemetic effect in nausea and vomiting caused by chemotherapy, for appetite stimulating effect in cachexia, anorexia, loss of appetite in cancer patients or patients with AIDS and in anorexia nervosa, hypotensive effect in glaucoma resistant to conventional therapies and for reduction of involuntary body and facial movements in Gilles de la Tourette syndrome. Italian most recent legislation on medical cannabis is detailed with some law proposals, also showing the inconsistent legislation within European Union. Some final considerations of future studies are also reported

The COVID-19 pandemic and contact tracing technologies, between upholding the right to health and personal data protection

Countries responded to the COVID-19 pandemic with various levels of restrictions and lockdown in an effort to save lives and prevent the saturation and collapse of national health systems. Unfortunately, the blockades have entailed hefty socioeconomic costs. In order to contrast the spread of the virus, states have used contact tracing technology, in the form of mobile phone applications designed to track close contacts of those infected with COVID-19. Recent research has shown the effectiveness of this solution, particularly when used in conjunction with manual tracking. Nonetheless, the contact tracing app raises concerns due to the potential privacy implications. The authors have delved into the European legislation that protects privacy through the principles of proportionality and minimization, arguing that in order to quickly resolve the pandemic caused by COVID-19, one cannot blindly trust the exclusive help of technology. Instead, we need the involvement of health personnel, scientists, and no less importantly, the citizenry's sense of solidarity and the duty to abide by the rules of social distancing, the use of protective devices and hygiene rules to protect public health

Commentary – CRISPR-based techniques: Cas9, Cas13 and their applications in the era of COVID-19

The CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats)/ Cas9 (CRISPR-associated protein 9) system enables scientists to edit diverse genome types with relative ease, with the aim – in the near future – to prevent future human beings from developing genetic diseases. The new opportunities arising from the system are broad-ranging and revolutionary, but such prospects have also been the cause for alarm throughout the international scientific community. The authors have laid out a review of the trials carried out so far in terms of genome editing, for the ultimate purpose of weighing implications and criticisms. We feel that possible valuable alternatives, such as induced pluripotent stem cells should not be overlooked

Advance healthcare directives: moving towards a universally recognized right

Advance healthcare directives (AD) are still intensively animating debates in Europe and worldwide, leading to the enactment of different laws, according to the diverse legal, sociocultural, religious and philosophical traditions of each society1 . After a long complicated seemingly ever-lasting process, on the 14th of December 2017 the Italian Parliament finally approved the Law on “Informed consent and Advance healthcare directives” putting Italy on the same level as other European countries, which have previously regulated this complicated matter2 . The most controversial point of the law is represented by AD. Section 4 states that everyone able to make a proper judgment, regarding any possible future inability to self-determine, can, through AD, express their beliefs and preferences concerning health treatments, consent or refusal to any diagnostic or therapeutic choice, including artificial nutrition and hydration. One can also indicate a person of trust to represent him/her in the relationships with doctors and hospitals2 . Furthermore, the same provision specifies that the doctor is obliged to respect the AD, unless: a) the patient requests a treatment opposing the law or medical deontology, or b) the AD is clearly incongruous, or c) new and unpredictable therapies have come into force. Therefore, ADs are binding; conscientious objection is not foreseen. The reference of the law to medical deontology finds its rationale in section 38 of the Italian Code of Medical Ethics, updated in May 2014, where the requirements that AD must meet are stated3 . With this new law2 Italy conforms to the orientation of the other main European countries, obliging the respect of ADs, even if the limits are slightly different, France4 , Germany5 , Spain6 and England7 they are binding. We wish to draw the attention of the whole medical scientific community to this matter, advocating for an open dialogue to discuss the ethical and medical issues concerning AD, thereby facilitating the improvement and implementation of guidelines and policies to safeguard patients together with healthcare providers1 . There has been considerable progress in addressing all the ethical issues regarding AD and as a consequence of the constant innovation in medical science and an increase in life expectancy we can demand more research into this topic

Guidelines and best practices: remarks on the Gelli-Bianco law

The paper's authors aim to elaborate on the innovations brought by law n. 24/2017, issued by the Italian Parliament with a close focus on art. 5, which pertains to the drafting of guidelines and the adoption of best practices. The guidelines constitute in fact an element of innovation brought by the above-mentioned law, and compliance with them can shield from possible liability those health care professionals who find themselves embroiled in professional accidents while in the fulfillment of their duties. Besides, there are several critical aspects within the law that need to be highlighted as well. As far as best practices are concerned, the lawmakers who drafted the legislation make no mention as to the standards of evidence needed in order to characterize any given professional behavior as "best practice". The reform appears unlikely to be effective in providing doctors with clear behavioral standards, thus reducing the margin for liability claims against them