Italian court edict over discharge rules causes controversyBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1494 (Published 07 March 2011) Cite this as: BMJ 2011;342:d1494
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A recent sentence by the Italian Supreme Court (n. 8254, March 2,
2011, IV Criminal Code) has caused a furor in Italy because of its
implications for patient care and was even reported in the British Medical
Journal (2011; 342:d1494).
In brief, the case involved a cardiologist
working in a hospital near Milan, who in June 2004 released a patient
after 9 days of hospitalization for a serious heart attack and who was
being treated with a stent. Upon admission, the patient had presented with
acute pulmonary edema, indicating a seriously compromised myocardial pump.
The patient was at high cardiovascular risk because of obesity, a smoking
habit, dyslipidemia, and arterial hypertension that had gone untreated at
the patient's request. After consulting the hospital's guidelines, the
physician in the case decided to send the patient home after 9 days of
hospitalization, and the night after hospital discharge, the patient died.
The accusation stated that the patient was in such serious condition that
he should not have been released from the hospital. The first court
sentence condemned the physician to 8 months in prison with a fine of
Euros 50,000 to go to the patient's family. The Milan Appeals Court then
absolved the cardiologist on November 16, 2009. The Italian Supreme Court
has annulled the previous Appeals Court sentence and sent the cardiologist
to a further trial at the Milan Appeals Court, emphasizing the following
1) Following guidelines does not absolve the physician from civil and
2) In this specific case, no guidelines were produced to which the
3) The only duty of a doctor is to treat a patient with science and
conscience without being influenced by other needs, dispositions,
considerations, evaluations, or directives that are not pertinent
compared to those ends with which he/she is entrusted by the law and the
consequential relative responsibilities.
4) The physician should not place economic motivations over health
considerations and should not respect any rules that run contrary to the
needs of the patient.
Medical guidelines have been designed, beginning in the 1990s, for the
a) to provide optimal and updated use of instrumental and pharmacological
resources (including from an economic standpoint) for the treatment of the
most common pathologies; and
b) to make the quality of healthcare as uniform as possible for the most
The quality of medical guidelines derives from:
i) the participation of all involved specialists, such as cardiologists,
surgeons, critical care personnel, etc., in their design;
ii) basic updating of the most recent acquisitions and the programming of
periodic revisions; and
iii) the applicability of these in the clinic.
In the beginning, Italian physicians considered the use of guidelines to
be a loss of organizational autonomy, but later they began to view them as
legal reinforcement of the way in which they carry out their work.
However, the current trend in the Italian courts has been to emphasize
that medical practice contains a considerable "artistic" element, so that
each physician personalizes decisions in each case on the basis of
personal experience and professional capability.
The present case has called into question the certainty of legal
validation through uncritical reference to guidelines and directs a return
to personalized medical care through dependence on very general guidelines
for diagnosis and cure. Inevitably, this situation carries the following
* more conflict between physicians and hospital administrators, who tend
to want to reduce costs as much as possible by shortening hospital stays
and keeping the use of drugs to a minimum;
* the lack of secure rules governing the relationship between physicians
and patients, which can be in opposition to their therapeutic alliance
that otherwise puts the patient's needs first; and
* in the end, hospital organizational costs and payment of lawsuits having
the inevitable effect of raising healthcare costs without enhancing the
quality of the service.
One practical response to this situation, with all the objective
difficulties that it implies, would be for physicians to dedicate more of
their time to listening to patients and their family members. This tactic
would probably greatly reduce the risk of conflicts between both groups.
Early improved attention to the patient and his/her family members would
result in less loss of time and the expense that might ensue from a
potential legal conflict.
Paolo Sossai, MD, AGAF
Andrea Tiburzi, Atty
Competing interests: No competing interests