Dario Sacchini

Centrarse en la práctica”: ética clínica de consulta en un caso de trasplante hepático ortotópico

espanolEl articulo presenta un caso clinico, dirigido en el ano 2011 por el equipo de servicio de consulta etica clinica del Instituto de Bioetica y Humanidades Medicas de la Facultad “Agostino Gemelli” de Medicina de la Universidad Catolica del Sacro Cuore en Roma (Italia). El caso clinico se refiere a los dilemas eticos sobre las perspectivas del paciente para recibir un trasplante hepatico ortotopico porque no era residente del pais y carecia de un cuidador para asistirlo durante el periodo de seguimiento, asi como de un lugar para quedarse despues de la cirugia.DOI: 10.5294/pebi.2016.20.1.7 EnglishThe contribution describes a case report addressed in 2011 by the clinical ethics consultation service team of the Institute of Bioethics and Medical Humanities at the “Agostino Gemelli” School of Medicine of the Universita Cattolica del Sacro Cuore, Rome (Italy). The clinical case regards ethical dilemmas about the patient’s prospects for receiving an orthotopic liver transplant, because she was a non-resident and lacked a caregiver to assist her during the follow-up period, as well as a place to stay after liver transplant surgery.DOI: 10.5294/pebi.2016.20.1.7 portuguesEste artigo apresenta um caso clinico dirigido em 2011 pela equipe de servico de consulta etica clinica do Instituto de Bioetica e Humanidades Medicas da Faculdade de Medicina Agostino Gemelli, da Universita Cattolica del Sacro Cuore (Roma, Italia). O caso clinico se refere aos dilemas eticos sobre as perspectivas da paciente para receber um transplante hepatico ortotopico porque nao era residente do pais, carecia de um cuidador para assisti-la durante o periodo de observacao e de um lugar para ficar depois da respectiva cirurgia.DOI: 10.5294/pebi.2016.20.1.7The contribution describes a case report addressed in 2011 by the clinical ethics consultation service team of the Institute of Bioethics and Medical Humanities at the “Agostino Gemelli” School of Medicine of the Universita Cattolica del Sacro Cuore, Rome (Italy). The clinical case regards ethical dilemmas about the patient’s prospects for receiving an orthotopic liver transplant, because she was a non-resident and lacked a caregiver to assist her during the follow-up period, as well as a place to stay after liver transplant surgery. DOI: 10.5294/pebi.2016.20.1.7

Clinical Bioethics: Guideline on Initiation of and Withdrawal from Dialysis

The clinical issue of initiation of and withdrawal from dialysis for patients with chronic renal failure (CRF) is addressed evaluating for which patients the treatment is not indicated. Therefore, the initial question on the provision of dialytic procedure for all the patients who might obtain a benefit was alternated by an opposite problem: to understand, among the many candidates for dialysis, those who wouldn’t have a benefit. In fact, if the treatment is not able to offer the expected effectiveness, so configuring a medical futility or where the burdensomeness of the treatment (side effects, complications, etc.) exceed the benefits, it is ethically more appropriate not to start (or possibly withdraw) the treatment itself. Some scientific societies have edited specific guidelines. The article focuses on the last version of the Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis, Clinical Practice Guideline of the U.S. Renal Physician Association (RPA), that takes into account changes in epidemiology and clinical management of patients eligible for renal replacement treatment: mainly, increasingly advanced age, cardiovascular and metabolic disorders and comorbidity. The most compelling clinical issue is the identification of patients whose dialysis treatment is not beneficial in terms of survival and quality of health. Moreover, the RPA guidelines highlight the relevance of shared decision making as elective way for the physician-patient relationship. From the bioethics perspective, some lexical changes could reflect cultural changes: e.g., the term informed consent/refusal has been replaced by “information to the patient”, as well as “advance directive” by advance care planning. Some commentaries to RPA guidelines argue in favor of the reverse of some paradigms of North American bioethics: for example the overcoming of principle of autonomy towards a presumed restore of the principle of beneficence/ non-maleficence. In the appendix, a “Proposal for ethical guidelines for an appropriate indication for dialysis treatment” is offered to the debate. The document born from a common reflection and interaction between Hemodialysis Unit personnel of “Agostino Gemelli” Teaching Hospital (Rome, Italy) and clinical ethics consultations provided by ethicists of the Institute of Bioethics of the Universita Cattolica del Sacro Cuore (Rome, Italy) along the SINTEA Project (Integrated Service for Applied Bioethics) presented for the first time during a scientific meeting in 2010.

L’etica della sperimentazione sull’uomo dal processo di Norimberga ai comitati di etica

The article deals with how the journal “Medicina e Morale” has faced ethics in clinical trials, which represents a very large and complex bioethical issue, but also deontological one. This area comprises many questions and the literature is huge. It has risen after unethical clinical trials that have shocked the public and have produced a big rethinking about it. In general, from the ’60s to the ’80s of the XXth century, an intense commitment and interest have prevailed on the elaboration of the reference principles and on theoretical reflection on various issues, such as informed consent, the ethical significance of clinical research, the protection of vulnerable people, the risk acceptability). Since the ’90s onwards the development of codes, regulations, guidelines – that have guided the development of the discipline in a procedural and also deontological sense – has increased, probably due to the large diffusion of ethics committees. Particularly, the journal “Medicine and Morale” has always been present on these issues, since the beginning of its history, creating an original voice in the debate, as well as a dissemination tool (especially in the pre-internet era) of national and especially international documentation. The journal has been, especially in the last thirty years, a real national, and sometimes international, benchmark, offering original suggestions which are then accepted in guidelines and regulations.