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Anaesthetist helps Italian patient who wanted to die

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39079.456400.DB (Published 04 January 2007) Cite this as: BMJ 2007;334:9

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Court and medical profession in end of life decisions

The case of Piergiorgio Welby [1-2] lays itself to several
interpretations. However it is our opinion that most of all this case has
brought out how difficult it still is in Italy to recognize the
centrality of the patient’s point of view and will in the context of the
therapeutic relationship.

In fact apart from the conceptual and lexical confusions whereby
refusal of care, advance directives and euthanasia have all been put
together, the narrative of the case is straigthforward: the physician who
had Welby under his care refused, also because of his own ethical,
religious and professional convictions, to accept the repeated and
motivated requests of his competent patient to be put under sedation and
therefore to remove the artificial ventilator to which he had been connected since
1997.

The Court to which Welby had appealed confirmed that the Italian
legal system recognizes the right to refuse therapies, also in the case
life-saving therapies, but at the same time it acknowledged that, to date,
such right is not “concretely protected”, since there are no rules that
compel the physician always to respect the patients will. Consequently the
Court invited the legislator to fill this gap [3].

On the other hand, the position expressed with large majority by the
High Council of Health (Consiglio Superiore di Sanità-CSS that is the
technical-scientific consultation body of the Ministry of Health)
maintained that although “there is no doubt on the patient’s right to
refuse care if he is capable of auto-determination, many questions arise
concerning the interruption of life-sustaining treatments, the suspension
of which determine ‘sic et simpliciter’ the biological termination of
life”. Furthermore for the CSS it is necessary to reach a balance
“between the respect of the individual will and a frame of widely accepted
ethical principles which cannot and must not be absent in the decision
related to the end of life” [4]. In other words for the CSS the right of
the patient to refuse a treatment can be debated when dealing with the
withdrawal of life-sustaining treatments.

The confrontation between the two documents confirms that in Italy it
is still undefined and vague how the doctors should behave when confronted
with practical end of life decisions.

Large part of the doctors still agree that it is the doctor that must
decide if, when and how to suspend a treatment. This approach has also
been described in the recent European study EURELD, which showed that, in
case of end of life medical decisions, 44% of Italian doctors had not
consulted any other doctor or nurse and in 52% of the cases the decision
had not been discussed either with the competent patient or with his/her
relatives. Furthermore the total of non-treatment decisions in this study
appears to be much lower in Italy than in the other participating
countries (4% of the total of deaths as opposed to 14% to 28% in other
countries)[5].

[1]Turone F. Italy debates end of life decisions. BMJ 2006;333:719

[2]Turone F. Anaesthetist helps Italian patient who wanted to die.
BMJ 2007;334:9

[3]http://www.aduc.it/dyn/eutanasia/tribunale_welby.pdf

[4]http://www.ministerosalute.it/imgs/C_17_pubblicazioni_581_allegato.pdf

[5]van der Heide A. et al. End of life decision-making in six
European countries: descriptive studies. Lancet 2003; 362:345-50

Competing interests:
None declared

Competing interests: No competing interests

12 January 2007
Caterina Ferrari
bioethicist
Guido Miccinesi and Eugenio Paci
Center for the Study and Prevention of Cancer, 50100 Florence