On the normativity of evidence - Lessons from philosophy of science and the "VALIDATE" project

"Evidence" is a key term in medicine and health services research, including Health Technology Assessment (HTA). Randomized clinical trials (RCTs) have undoubtedly dominated the scene of generating evidence for a long period of time, becoming the hallmark of evidence-based medicine (EBM). However, due to a number of misunderstandings, the lay audience and some researchers have sometimes placed too much trust in RCTs compared to other methods of investigation. One of the principal misunderstandings is to consider RCTs findings as isolated and self-apparent pieces of information. In other words, what has been essentially lacking was the awareness of the value-context of the evidence and, in particular, the value- and theory-ladenness (normativity) of scientific knowledge. This paper aims to emphasize the normativity that exists in the production of scientific knowledge, and in particular in the conduct of RCTs as well as in the performance of HTA. The work is based on some lessons learned from Philosophy of Science and the European project "VALIDATE" (VALues In Doing Assessments of healthcare TEchnologies"). VALIDATE was a three-year EU Erasmus+ strategic partnerships project (2018-2021), in which training in the field of HTA was further optimized by using insights from political science and ethics (in accordance with the recent definition of HTA). Our analysis may reveal useful insights for addressing some challenges that HTA is going to face in the future.

Ethics of digital therapeutics (DTx)

Digital therapeutics (DTx) are a subset of digital health which are often coupled with artificial intelligence (A.I.) techniques and machine learning systems. DTx differ from common wellness apps or medication reminder tools in that they require "rigorous" clinical evidence. They are emerging as a new treatment option and are being applied in a variety of areas, including type II diabetes, hypertension, chronic respiratory problems, obesity, insomnia, Alzheimer's disease, various types of dementia or addiction (smoking, alcohol, drugs), anxiety, depression, autism, learning disabilities, and attention deficits. Today, there are roughly 35 to 40 products on the market, 8 of which approved by regulatory agencies. The value of the global DTx market was estimated at USD 1.8 billion in 2018, and it is expected to reach USD 8.9 billion by 2027. Implementing DTx across healthcare systems raises a number of ethical concerns. The present article aims to provide an overview of the main ethical issues pertaining the assessment, implementation, and use of this emerging technology. The final purpose is to support and facilitate an open and transparent deliberation with regard to DTx.

Ethical and medico-legal issues of TOETVA procedure and simulation on cadavers: a scoping review

Conventional open thyroidectomy is still considered the gold standard for thyroid surgery. Transoral endoscopic thyroidectomy vestibular approach (also known as TOETVA) is often considered to be more advantageous than the other approaches, such as minimally invasive video assisted thyroidectomy, thyroidectomy via breast/axillary/retroauricular access, bilateral axillo-breast approach and axillo-bilateral breast approach. In this scoping review, we discuss the risks and the benefits of this surgical approach and its medico-legal and ethical implications, particularly focusing on the importance of practice on cadavers. Currently, there is little scientific evidence supporting TOETVA, since there are few papers on the comparison with the traditional open thyroidectomy that have been published and thus little data on the long-term outcomes of TOETVA are available. Since the better cosmetic outcome currently represents the main indication for this surgical technique, substantial medico-legal and ethical issues arise. Moreover, practice on cadavers can help surgeons to develop the technical and non-technical skills required to perform efficiently and safely this new surgical procedure.

Informed Consent and Advance Care Directives: Cornerstones and Outstanding Issues in the Newly Enacted Italian Legislation

This article's authors delve into, and comment on, some of the key provisions within law no. 219, passed in 2017, which came into full effect in 2018. The legislation presents several innovative aspects: (a) communication time is equated to care; (b) patients may turn down lifesaving treatments, yet doctors must put in place all suitable support processes, from a psychological standpoint as well, in order to make sure that patients make informed decisions in full awareness; (c) refusal to treatment may be expressed prior to the onset of the disease making the patient incapable, as long as the advance directive is laid out by a mentally capable adult who has been provided with all relevant medical information available as to the consequence of a refusal to undergo a given treatment; (d) artificial nutrition and hydration are tantamount to treatment; thus, they may not be carried out and kept in place in absence of valid consent; (e) patients may appoint a healthcare proxy holder, tasked with interacting with doctors and caregivers and expressing consent or refusal; (f) patient will, whether current or advance, must be complied with even under emergency or urgency conditions, provided that clinical conditions and circumstances make it possible to acquire it; (g) doctors may disregard advance directives only when specifically provided for by the law; (h) patients may not demand treatment deemed to be illegal or running counter to ethical codes or scientific evidence. The new legislation, therefore, is meant to uphold the right to exercise self-determination as well as the patient's quality of life, yet ensuring that doctors remain fully capable of making the decisions that they are best positioned to. Summary: The Italian Parliament has for the first time regulated the issue of consent and refusal of healthcare treatments, whether currently expressed or advance. This article elaborates on recent Italian legislation that details a patient's right to consent to or refuse treatment in advance, including refusal of artificial nutrition and hydration, the duty of doctors in the event of an emergency, the shared planning treatment, the role of durable power of attorney, and advance healthcare directives.

A proposal for limited criminal liability in high-accuracy endoscopic sinus surgery

The aim of the present study is to propose legal reform limiting surgeons' criminal liability in high-accuracy and high-risk surgery such as endoscopic sinus surgery (ESS). The study includes a review of the medical literature, focusing on identifying and examining reasons why ESS carries a very high risk of serious complications related to inaccurate surgical manoeuvers and reviewing British and Italian legal theory and case-law on medical negligence, especially with regard to Italian Law 189/2012 (so called "Balduzzi" Law). It was found that serious complications due to inaccurate surgical manoeuvers may occur in ESS regardless of the skill, experience and prudence/diligence of the surgeon. Subjectivity should be essential to medical negligence, especially regarding high-accuracy surgery. Italian Law 189/2012 represents a good basis for the limitation of criminal liability resulting from inaccurate manoeuvres in high-accuracy surgery such as ESS. It is concluded that ESS surgeons should be relieved of criminal liability in cases of simple/ordinary negligence where guidelines have been observed.

La Convenzione di Oviedo: l’idea di una coscienza comune europea in bioetica

Non disponibile / Not available

Why is it so difficult to integrate ethics in Health Technology Assessment (HTA)? The epistemological viewpoint

Ethics has been identified as a key element in Health Technology Assessment (HTA) since its conception. However, ethical issues are still not frequently addressed explicitly in HTA. Several valuable reasons have been identified. The basis of the article is the claim that ethics is often not part of HTA for "epistemological reasons". Hence, the main aim of the contribution is to explore in more details and emphasize them by using the fact/value dichotomy. Our conclusion is that current HTA configuration is predominantly based on the comparison among objective and empirically testable "facts", whilst ethics is not empirically testable. In this sense, there is a sort of "epistemological gap", which can explain why it is so difficult to integrate ethics in HTA. We suggest that the epistemological differences among the various domains of HTA are addressed more explicitly.

[Pneumothorax following dry needling treatment: legal and ethical aspects]

Trigger point "dry needling" is a technique used to treat myofascial pain. It involves using filiform needles which are inserted into muscles to give local pain relief. Few cases of serious adverse events following this treatment have been reported in the literature. In this paper we describe the case of a professional swimmer who developed pneumothorax after dry needling treatment and discuss the medicolegal and ethical aspects related to competencies and responsibilities of medical doctors and physiotherapists performing the procedure.

Health Technology Assessment of pathogen reduction technologies applied to plasma for clinical use

Although existing clinical evidence shows that the transfusion of blood components is becoming increasingly safe, the risk of transmission of known and unknown pathogens, new pathogens or re-emerging pathogens still persists. Pathogen reduction technologies may offer a new approach to increase blood safety. The study is the output of collaboration between the Italian National Blood Centre and the Post-Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy. A large, multidisciplinary team was created and divided into six groups, each of which addressed one or more HTA domains.Plasma treated with amotosalen + UV light, riboflavin + UV light, methylene blue or a solvent/detergent process was compared to fresh-frozen plasma with regards to current use, technical features, effectiveness, safety, economic and organisational impact, and ethical, social and legal implications. The available evidence is not sufficient to state which of the techniques compared is superior in terms of efficacy, safety and cost-effectiveness. Evidence on efficacy is only available for the solvent/detergent method, which proved to be non-inferior to untreated fresh-frozen plasma in the treatment of a wide range of congenital and acquired bleeding disorders. With regards to safety, the solvent/detergent technique apparently has the most favourable risk-benefit profile. Further research is needed to provide a comprehensive overview of the cost-effectiveness profile of the different pathogen-reduction techniques. The wide heterogeneity of results and the lack of comparative evidence are reasons why more comparative studies need to be performed.

“Focus on Practice”-Clinical Ethics Consultation on an Orthotopic Liver Transplant Case

El artículo presenta un caso clínico, dirigido en el año 2011 por el equipo de servicio de consulta ética clínica del Instituto de Bioética y Humanidades Médicas de la Facultad “Agostino Gemelli” de Medicina de la Universidad Católica del Sacro Cuore en Roma (Italia). El caso clínico se refiere a los dilemas éticos sobre las perspectivas del paciente para recibir un trasplante hepático ortotópico porque no era residente del país y carecía de un cuidador para asistirlo durante el periodo de seguimiento, así como de un lugar para quedarse después de la cirugía.

Prioritization of high-cost new drugs for HCV: making sustainability ethical

Hepatitis C virus (HCV) infection is a major health problem worldwide. Chronic HCV infection may in the long run cause cirrhosis, hepatic decompensation and hepatocellular carcinoma, with an ultimate disease burden of at least 350,000 deaths per year worldwide. The new generation of highly effective direct acting antivirals (DAA) to treat HCV infection brings major promises to infected patients in terms of exceedingly high rates of sustained virological response (SVR) but also of tolerability, allowing even the sickest patients to be treated. Even in the face of the excellent safety and efficacy and wide theoretical applicability of these regimens, their introduction is currently facing cost and access issues denying their use to many patients in need. Health systems in all countries are facing a huge problem of distributive justice, since while they should guarantee individual rights, among which the right to health in its broader sense, therefore not limited to healing, but extended to quality of life, they must also grant equal access to the healthcare resources and keep the distribution system sustainable. In the face of a disease with a relatively unpredictable course, where many but not of all chronically infected will eventually die of liver disease, selective allocation of this costly resource is debatable. In most countries the favorite solution has been a stratification of patients for prioritization of treatment, which means allowing Interferon-free DAA treatment only in patients with advanced fibrosis or cirrhosis, while keeping on hold persons with lesser stages of liver disease. In this report, we will perform an ethical assessment addressing the issues linked to access to new therapies, prioritization and eligibility criteria, analyzing the meaning of the term "distributive justice" and the different approaches that can guide us (individualistic libertarianism, social utilitarianism and egalitarianism) on this specific matter. Even if over time the price of new DAA will be reduced through competition and eventual patent expiration, the phenomenon of high drug costs will go on in the next decades and we need adequate tools to face the problems of distributive justice that come with it.

Ethical aspects of Fecal Microbiota Transplantation (FMT)

The importance of human microbiota in preserving human organism healthy is nowadays well acknowledged. The alteration of the microbiota can be the consequence of a persistent use of antibiotics or immunosuppressive medications or abdominal irradiation or surgery, wrong diet, or can be caused by surgery or anatomical condition. These alterations can cause many infections and diseases that today can be treated with Fecal Microbiota Transplantation (FMT), also called Bacteriotherapy, that is the administration of a fecal solution from a donor into the intestinal tract of a recipient. Although to date, FMT appears to be safe and without serious adverse effects, there are some ethical issues that are worthy to be investigated. The aim of this article is to highlight these issues in order to give some notes for a better implementation of this particular clinical practice.

A new ethical and medico-legal issue: vascular surgery and the postoperative cognitive dysfunction

Patients undergoing major surgery are at risk for postoperative cognitive dysfunction (POCD). The consciousness of the POCD arises new ethical and medico-legal issues that should be identified, managed and, if possible, prevented. Elderly patients still represent a real challenge for physicians and medical science. This challenge can be surmounted not only through technical progress but also by safeguarding the correct ethical behavior at the base of each relationship between a patient and his physician. Effective communication with the elderly patient is a prerequisite for clear and complete information, involving family members and caregivers when necessary. In every case, the identification of patients with pre-existing risk factors of POCD, shortening the period of time preceding the surgery and a proper technique of the procedure as well as physical and intellectual exercises, nutrition and medication play an important role in decreasing the incidence of neurocognitive deficits in the elderly.

Ethical assessment of hepatitis C virus treatment: The lesson from first generation protease inhibitors

Since chronic hepatitis C has mostly become curable, issues concerning choice and allocation of treatment are of major concern. We assessed the foremost ethical issues in hepatitis C virus therapy with 1st generation protease inhibitors using the personalist ethical framework within the health technology assessment methodology. Our aim was to identify values at stake/in conflict and to support both the physicians' choices in hepatitis C therapy and social (macro-) allocation decision-making. The ethical assessment indicates that: (1) safety/effectiveness profile of treatment is guaranteed if its use is restricted to the patients subgroups who may benefit from it; (2) patients should be carefully informed, particularly on treatment deferral, and widespread information on these therapies should be implemented; (3) since treatment was proven to be cost-effective, its use is acceptable respecting resource macro-allocation. Concerning individual (micro-) location criteria: (a) criteria for eligibility to treatment should be clearly identified and updated periodically; (b) information on criteria for eligibility/deferral to treatment for specific patients' subgroups should be made widely known. Interferon-based regimens will disappear from use within the next year, with the introduction of highly effective/tolerable combination regimens of direct-acting antivirals, thus profoundly changing social choices. Nonetheless, our model could support future ethical assessment since the evaluation pertaining ethical domains remains generally applicable.

Research Ethics Committees and clinical research in Italy: where are we going?

Italian Ethics Committees (ECs) have entered a new phase because of the recent Law no. 189 of November 8 2012 and the Ministry of Health Decree of February 8 2013. The new norms have introduced important changes. In fact, ECs are now established not to serve a single hospital or research institution but to serve even Regions. Moreover, they are established on the basis of the number of inhabitants, research sites and expected amount of clinical trials. The implementation of the news norms into practice have produced a drastic reduction in the number of ECs. This fact could raise some issues but it could obtain some benefits. The paper explains the main steps of ECs and clinical research development in Italy. Special attention will be paid to recent trends. Moreover, the new norms will be illustrated, showing possible issues and benefits connected to their implementation.

E-recruitment based clinical research: notes for Research Ethics Committees/Institutional Review Boards

Patient recruitment is a critical point of today's clinical research. Several proposals have been made for improving it, but the effectiveness of these measures is actually uncertain. The use of Internet (e-recruitment) could represent a great chance to improve patient enrolment, even though the effectiveness of this implementation is not so evident. E-recruitment could bring some advantages, such as better interaction between clinical research demand and clinical research supply, time and resources optimization, and reduction of data entry errors. It raises some issues too, such as sampling errors, validity of informed consent, and protection of privacy. Research Ethics Committees/Institutional Review Boards should consider these critical points. The paper deals with Internet recruitment for clinical research. It also attempts to provide Research Ethics Committees/Institutional Review Boards with notes for assessing e-recruitment based clinical protocols.

An unusual case showing fatal rupture of a gastric ulcer or gastromalacia? The importance/role of histology for differential diagnosis

Gastromalacia is the acute autolytic erosion of the gastric wall. It generally occurs postmortem, and it appears as a slimy brownish black region of the wall which occurs principally in the gastric fundus. A 59-year-old woman died in the Emergency Department following a 2-day period of mild abdominal pain, vomiting, and diarrhea. A forensic autopsy was performed which revealed a rupture of the gastric fundus that had caused leakage of gastric content into the abdominal cavity. There was no macroscopic evidence of peritonitis, and the stomach wall adjacent to the rupture site showed marked thinning. The gross appearance was typical of gastromalacia. In contrast, histological observations revealed the presence of an ulcer at the site of perforation and a severe acute inflammatory reaction indicating a robust reaction with an antemortem rupture.

[Alcohol and work. Consensus Document of the La.R.A. (Workers representing a risk for others) group]

AIM

Current Italian legislation obliges employers to prevent workers who are occupationally at risk or who perform jobs that may be hazardous for the safety or health of third parties from consuming alcohol. The LaRA Group undertook to assess whether the law fully safeguards the health and safety of both workers and third parties, without impinging upon the civil rights of workers.

METHOD

A written document expressing agreement was produced following discussions between doctors, lawyers, bioethicists and social partners.

RESULTS

There are gaps and inconsistencies in current laws; the differences in local and regional provisions prevent authorities from applying a single strategy at national level. There should be a change in existing rules under which the employer's obligation to enforce the ban on consumption alcohol in the workplace is enacted solely by the "competent" physician whose institutional role is to safeguard and promote health. Some occupational categories that are subject to a ban on alcohol consumption do not currently under-go health surveillance. For example, if road transport drivers are not exposed to a specific occupational risk foreseen under another law, they can be placed under health surveillance only in those regions where the local laws contemplate this type of control. In other cases, the practice of assessing the risk to third parties and providing for compulsory health surveillance in the Risk Assessment Document, is considered by some jurists to be a "consuetudo praeter legem" and therefore acceptable in a field not yet covered by a specific law, but to be "contra legem" or unlawful by other jurists. Moreover, the competent physician who uses a breathanalyser or tests for alcohol addiction faces an ethical dilemma, since by communicating the results to an employer or authorities responsible for the issuing of licenses, he may be violating his professional oath of secrecy. Furthermore, the emphasis placed on testing has induced companies and inspectors to overlook educational and rehabilitation aspects. It is essential to involve general practitioners, educators and specialist services in addressing the problems of alcohol abuse so as to inform/train, recover and rehabilitate. The few studies available indicate that the rules are poorly enforced and that non-compliance may go unobserved.

CONCLUSIONS

The Group urges all employers to assess the risk for third parties caused by alcohol abuse and to devise a policy on alcohol. Controlling alcohol-related risks in the workplace calls for a better definition of the roles of Vigilance Bod-ies and Company Physicians together with a shift from a reactive to a proactive attitude of all the parties involved.

Ethical evaluation of risks related to living donor transplantation programs

The shortage of available cadaveric organs for transplantation and the growing demand has incresed live donation. To increase the number of transplantations from living donors, programs have been implemented to coordinate donations in direct or indirect form (cross-over, paired, and domino chain). Living donors with complex medical conditions are accepted by several transplantation programs. In this way, the number of transplants from living has exceeded that from cadaver donors in several European countries. No mortality has been reported in the case of lung, pancreas, or intestinal Living donations, but the perioperative complications range from 15% to 30% for pancreas and lung donors. In living kidney donors, the perioperative mortality is 3 per 10,000. Their frequency of end-stage renal disease does not exceed the United States rate for the general population. However, long-term follow-up studies of living donors for kidney transplantations have several limitations. The frequency of complications in live donor liver transplantation is 40%, of these, 48% are possibly life-threatening according to the Clavien classification. Residual disability, liver failure, or death has occurred in 1% of cases. The changes in live donor acceptance criteria raise ethical issues, in particular, the physician's role in evaluating and accepting the risks taken by the living donor. Some workers argue to set aside medical paternalism on behalf of the principle of donor autonomy. In this way the medical rule "primum non nocere" is overcome. Transplantation centers should reason beyond the shortage of organs and think in terms of the care for both donor and recipient.

Research ethics committee auditing: the experience of a university hospital

The authors report the first Italian experience of a research ethics committee (REC) audit focused on the evaluation of the REC's compliance with standard operating procedures, requirements in insurance coverage, informed consent, protection of privacy and confidentiality, predictable risks/harms, selection of subjects, withdrawal criteria and other issues, such as advertisement details and justification of placebo. The internal audit was conducted over a two-year period (March 2009-February 2011) divided into quarters to better value the influence of the new insurance coverage regulation that came into effect in March 2010 (Ministerial Decree of 14 July, 2009) and expand the requirements to safeguard participants in clinical drug trials including other critical items as information and consent and the risks to benefits ratio. Out of a total of 639 REC's opinions and research studies, 316 were reviewed. Regarding the insurance policy requirements, Auditor/REC non-compliance occurred only in one case. The highest number of Auditor/REC non-compliance was in regard to information and consent, which should have incurred a suspended decision rather than a favorable opinion. This internal audit shows the importance and the difficulty of the review process. For this reason, specific courses for members of the research ethics committee and for those who aspire to become auditors will be provided. There may also be efforts to improve the standard operating procedures already in place.

[Internet use in clinical trials]

Recruiting patients is a critical point of today's clinical research and, along the years, several solutions have been proposed, even if their efficacy seems to be doubtful. On the other hand, nowadays, Internet represents a great opportunity for improving clinical trial recruitments. Nevertheless, on-line recruitment services (e-recruitment) could ensure some advantages (such as facilitating interaction between supply and demand of clinical research, time and money savings/optimizations, data entry errors reduction), but also raise some issues (such as those related to sampling, information, consent, real identity of participants and risks for data breaches). The article debates on the difficulties to recruit patients for clinical research, in general, and e-recruitment particularly, discussing some ethical issues raised by internet enrolment.

The ethical and legal implications of nanotechnologies: a preliminary survey to picture the perceptions of law students and medical students

PURPOSE

The aim of this preliminary survey was to picture the current knowledge and opinions of law students and medical students about nanotechnologies.

MATERIALS AND METHODS

Data were collected in June 2012 by interviews with 60 students of the University of Camerino (Macerata, Italy) defined as "jurist population" and 159 medical students of the Università Cattolica del Sacro Cuore (Rome, Italy) defined as "medical population".

RESULTS

The Authors found that both law and medical students have some knowledge on what nanotechnologies are; with regards to the ethical issues and risks perception, both categories indicated that nanotechnologies generate bioethical issues. Nevertheless, a high percentage of respondents believed that neither existing technologies nor nanotechnologies pose risks for human health. Opinions on regulation of nanotechnologies are instead different.

CONCLUSIONS

These preliminary findings underlined the ambiguity surrounding nanotechnologies both concerning the bioethical dimension and risks perception and their regulation. These early data therefore showed a need of additional reflection on these technologies that should be investigated more in detail; moving from students, future scientists and regulators, these data could contribute to clarify the debate on them.

Patient-reported outcomes (PROs): the significance of using humanistic measures in clinical trial and clinical practice

Patient-reported outcome (PRO) is an "umbrella term" that covers a whole range of potential types of measurement but it is used specifically to refer to all measures quantifying the state of health through the evaluation of outcomes reported by the patient himself/herself. PROs are increasingly seen as complementary to biomedical measures and they are being incorporated more frequently into clinical trials and clinical practice. After considering the cultural background of PROs - that is the well known patient-centered model of medicine -, their historical profile (since 1914, the year of the first outcome measure) and typologies, the paper aims at debating their methodological complexity and implementation into practice. Some clinical trials and therapeutic managements utilizing patient-centered measures will be also analyzed.

[Patient-reported outcomes (PRO): historical profile, definitions, classifications and problems]

This contribution deals with the use, within healthcare systems, of patient-reported outcomes (PROs), i.e., all measures aimed at quantifying the state of health through the evaluation of outcomes reported by the patient himself. A survey of their cultural background, identified in the patient-centered model of medicine, is followed by a delineation of their historical profile (from 1914, the year of the first outcome measure, to the more recent examples of their use in clinical trial and practice), a classification based on the size they wish to detect and the reconstruction of the main lines of debate around their use in health care.

Outlining ethical issues in nanotechnologies

Nanotechnologies are an expression of the human ability to control and manipulate matter on a very small scale. Their use will enable an even and constant monitoring of human organisms, in a new and perhaps less invasive way. Debates at all levels--national, European and international--have pointed out the common difficulty of giving a complete, clear definition of nanotechnologies. This is primarily due to the variety of their components, to the fact that there is not just one technology but several. The most significant medical applications of nanotechnologies are in the diagnostic and the therapeutic fields, eg biosensors and molecular imaging, providing diagnosis and drug delivery with no invasive methods involved. Like any other emerging field, such technologies imply new possibilities for improving health but, on the other hand, they are still at an experimental stage and therefore should be implemented under rigorous safety testing before going on general release. For this purpose, the ethical, legal and social implications (ELSI) of nanotechnologies have been elaborated by study groups, in order to develop solutions before the results of the tests are diffused into medical practice. The aim of this paper is to define some of the ethical issues concerning biomedical applications and to evaluate whether there is a need for new or additional guidelines and regulations.

[Workers with alcohol and drug addiction problems. Consensus Document of the Study Group on Hazardous Workers]

BACKGROUND

Italian Law 81/08 (so-called "Unified Text of Laws on Health and Safety at Work"), came into force on 15 May 2008 and incorporates provisions related to medical surveillance of drug and alcohol dependency at the workplace.

OBJECTIVES

Occupational health traditionally addresses the issue of protection of worker from occupational hazards. The issue of protection of third parties from behaviour of workers resulting from drug and alcohol dependency implies an original methodological approach, involving full cooperation of employer, employees, and health and safety consultants.

METHODS

A consensus development meeting was organized under the leadership of the Italian Study Group on Hazardous Workers (La.R.A. group). The meeting brought together physicians of different specialties, legal experts and bioethicists, labour and management policy-makers, to discuss the issue and define the research data available, the standards that were appropriate, and which policies were fair.

RESULTS

The efficacy of medical surveillance, including workplace drug-testing, relies on a comprehensive policy, including written and verbal information on the use of alcohol and drugs on the job, training for supervisors and management, employee education, and employee assistance structures. Sample collection and testing should be carried out in accordance with standardized and tested procedures. Small businesses will need assistance, including development of model policies, setting up consortia for testing services and if necessary request for National Insurance benefits to reduce costs.

CONCLUSIONS

The recently introduced Italian legislation on occupational safety and health closely resembles Finnish law since it consists of a "double channel" for workplace drug testing. At recruitment, the employer is entitled to ask a job applicant for a certificate of "Job fitness", including drug tests, that can be issued only by a public health institution, where the job applicant works on a well-defined set of tasks which require accuracy, trustworthiness, independent judgement or a very good reaction capacity. The employer may also refer the employee to the public health institution to obtain a certificate in the course of an employment contract when there is a legitimate suspicion that the employee is working while under the effects of drugs or alcohol or that the employee is a drug addict. After recruitment, the physician responsible for medical surveillance of workers (the so-called "Competent Physician") is entitled to perform drug tests on employees. The need for a test is decided by the health care professional, not by the employer, and only a general report on the health of the employee ("fit", fit with restrictions" or "unfit") may be given to the employer. Workers positive for drug tests will be referred to a public health institution for re-testing and treatment.

[Critical aspects of the management of "hazardous" health care workers. Consensus document]

BACKGROUND

A worker is considered to be hazardous to others when, in the course of performing a specific work task, his/her health problems (e.g., substance dependence, emotional disorders, physical disability, transmissible diseases) pose a risk for other workers' or the public's health and safety, or begins to interfere with ability to function in profession life. The presence of certain illnesses or the fact that a health care worker is impaired because of them do not necessarily imply that he, or she, is hazardous for others. Working in health care increases the probability that an impaired worker being hazardous for others. Management of hazardous workers requires new techniques and procedures, and specific policies.

OBJECTIVE AND METHODS

An interdisciplinary group of experts from medical, bioethical, legal and administrative disciplines, together with trade union and employers' representatives, is currently attempting to define a way to put prevention measures into practice in accordance with state laws and individual rights.

RESULTS

A consensus document is presented, covering critical aspects such as: social responsibility of the employer, risk management, informed consent, non compliance, confidentiality, responsibility of workers, disclosure of risk to patients, non-discrimination, counselling and recovery of impaired workers, effectiveness of international guidelines.

CONCLUSIONS

Occupational health professionals are obliged to adhere to ethical principles in the management of "hazardous" workers; the assessment of ethical costs and benefits for the stakeholders is the basis for appropriate decisions.

Ethical and juridical foundations of conscientious objection for health care workers

In front of the evolution of medicine and biotechnology, health care workers are called upon to take part within new biomedical practices, that may overcome the limit of acceptability, as it is perceived by their moral conscience. Issues as abortion, euthanasia, assisted suicide, artificial fertilisation, experimentation on human embryos and prescription of contraceptives and abortifacients call into play the right to conscientious objection of health care personnel, and in some cases, perhaps of physicians and pharmacists too. This recall--already present in many codes of professional conduct and medical ethics--sounds today as a necessity, which asks for a serious deepening of the content, the applicability and the new hypothesis of conscientious objection, in the light of bioethics and law. In particular, the self-determination and often exasperated autonomy of the patient within these practices makes a new principle of professional integrity arise, to protect the physician's conscientious convictions, if the request of the patient or society seem to violate some fundamental human values.

Evolution of truth-telling attitudes and practices in Italy

The debate on truth telling is at the core of contemporary biomedical ethics. Differences in truth telling arise from the delicate interplay between autonomy and beneficence in medicine, under the influence of cultural variables. Recently, a trend toward evolution of truth-telling practices has been noticed in countries previously known for non-disclosure. Italy is among them. This article analyzes in detail the different factors that have been influential in the Italian context, focusing on cancer patients. Medical profession, public discourse, medical deontology and legislators played an important role in Italy's shift toward the western autonomy predicament. A review of the scanty published data on informed consent and truth telling in Italy, however, consistently shows that partial or non-disclosure are still present. This seems to represent a general trend in nations traditionally centered on family and community values. The article explores these issues to achieve a better understanding of the specific Italian cultural context, while avoiding common stereotyping. The subject treated contributes to the growing debate on cultural diversity in medicine and in oncology.

Ethical implications of predictive DNA testing for hereditary breast cancer

Predictive medicine offers the possibility of detecting many common diseases that have a genetic basis, such as cancer; however, a genetic alteration might only indicate susceptibility to, not certainty of, disease. Whereas means for identifying a greater susceptibility to disease have been developed, effective interventions have progressed much more slowly. Awareness of one's susceptibility to disease without an actual possibility of intervention can lead to an unacceptable use of such information, or have a dramatic psychological impact on the person involved. Are the risks connected with the knowledge of susceptibility to genetic disease proportional to the benefits that such knowledge may provide? Does the knowledge of one's genetic condition constitute a service to the individual and society, or is this predominantly harmful for the person involved? The problem is vast, and involves medical, psychological, social, political and ethical dilemmas. These dilemmas, common to all predictive medicine, are most evident in predictive DNA testing for hereditary breast cancer. In our analysis, we will first examine the ethical values involved in genetic testing, highlighting the special ethical issues raised by predictive DNA testing for hereditary breast cancer. Next we will deal with genetic counseling, which, in our opinion, is the 'ethos' for ethically justifying predictive DNA testing.

Diagnostic and therapeutic imaging in a case of cervical pregnancy. Clinical aspects and ethical implications

A case of a 37-year-old, 8 week pregnant woman come to the emergency service with the diagnosis of cervical pregnancy an metrorrhagia, is reported. Uterine artery embolization was performed to arrest the bleeding. BCF monitoring documented its disappearance after approximately 15 days with progressive decrease in serum beta-hCG levels. Once the death of the fetus was ascertained, placental detachment was facilitated with the administration of methotrexate therapy. In view of the curettage of the uterine cavity a second uterine artery embolization was performed. Twenty days after the diagnosis of abortion, curettage was performed and the patient could be discharged. The combined action of embolization, methotrexate therapy and curettage allowed to preserve the potential fertility of the woman.

A case of forearm amputation after ovarian stimulation for in vitro fertilization-embryo transfer

OBJECTIVE

To report a case of forearm amputation after ovarian stimulation for IVF-ET.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 41-year-old woman, who had coagulation disorder as a result of an ovarian hyperstimulation syndrome (OHSS) for IVF-ET.

INTERVENTION(S)

Retrospective evaluation of angiographic studies and surgical treatment.

MAIN OUTCOME MEASURE(S)

Medical follow-up after forearm amputation due to OHSS.

RESULT(S)

The patient underwent many cycles of IVF-ET with administration of purified FSH (75 IU 10 times per day, for 12 days) and chorionic gonadotropin (5,000 IU). The patient had a coagulation disorder as a result of OHSS, with thrombosis of the axillary vein, recurring after thromboarterectomy and leading to the paradoxical result of the amputation of an arm.

CONCLUSION(S)

An ethical evaluation of this case is mandatory, since the desire for pregnancy, the role of medical science, health, and human life itself are all factors involved.

Evaluation of the readability of information sheets for healthy volunteers in phase-I trials

OBJECTIVE

The aim of the present study was to assess whether information sheets/consent forms submitted to the healthy volunteers of the Clinical Pharmacology Unit (C.P.U.) panel at Glaxo-Wellcome (Verona, Italy) could be considered understandable and to verify the readability and comprehensibility of these documents. Since a volunteer bases his/her decision to take part in a study on the information sheet provided, it is of paramount ethical importance to know whether the sheet conveys all relevant information. In addition, a thorough awareness by the volunteer of the reasons and procedures of the study would increase compliance.

METHODS

Four indices were used: Flesh-Vacca, Kincaid, Gunning's Fog and Gulpease. All indices rate the degree of difficulty of a text, in the light of the level of schooling of the target population. The documents evaluated were information sheets presented to volunteers. The level of schooling of the population that participated in at least one study was determined: 61.7% of volunteers finished high school and 22.6% had a University degree or diploma; the remaining 15.7% did not finish high school or the datum was not available.

RESULTS

The results showed that, when the present study began, all information sheets were "readable" by all volunteers who had at least finished high school. After these preliminary results, some additional linguistic and graphic refinements were adopted in drawing up information sheets. Readability improved to such a degree that all information sheets could be understood by virtually all volunteers.

CONCLUSION

A number of suggestions were identified, which are set out in this paper to assist in the preparation of improved information sheets and a recommendation to value the readability of consent sheets before giving them to the volunteers. The suggestions were split into three categories: communications to the volunteer, text format and text organisation.

[Ethical questions in the treatment of the person in persistent vegetative state. The symbolic case of Nancy Beth Cruzan]

The article deals with a the ethical issues about treatment of Persistent Vegetative State (Pvs) patients. The Nancy Beth Cruzan case, the US woman who died after the withdrawal of tube feeding and hydration after seven years of Pvs is analysed as paradigmatic case. The ethical analysis face with the following issues: 1. Is the Pvs synonymous of cerebral death?; 2. How the tube feeding and hydration must be considered: ordinary or extraordinary, proportionate or disproportionate means? 3. The issue of the living will; 4. the economic impact of the management of the Pvs patients. The conclusion of the contribution is the following: the withdrawal of the artificial feeding and hydration of a Pvs patient must be considered as omissive euthanasia, and consequently it is an action ethically unacceptable, in the light of the Hippocratic medical tradition and of the person-centred ethics.

The new system of health care funding: ethical and social instances

Ethical instances emerging from the funding system introduced in Italy in 1995 and confirmed in 1999, aiming at the rationalization of National Health Service, are considered. Based on the observation that economic ethics in health care is mainly confronted by the topic of service organization, the causes of the increment in health expenditure, equity in health economy and relative theories are dealt with. The system of payment according to service provided, based on Diagnosis Related Groups is analyzed from the ethical viewpoint and its potentialities and limits are evidenced with respect to the sick person. Possible economy-oriented deviations, the health care service as enterprise can induced in health operators, are discussed.