Clinical ethics consultation, as an activity that may be provided by clinical ethics committees and consultants, is nowadays a well-established practice in North America. Although it has been increasingly implemented in Europe and elsewhere, no agreement can be found among scholars and practitioners on the appropriate role or approach the consultant should play when ethically problematic cases involving conflicts and uncertainties come up. In particular, there is no consensus on the acceptability of consultants making recommendations, offering moral advice upon request, (...) and expressing personal opinions. We translate these issues into the question of whether the consultant should be neutral when performing an ethics consultation. We argue that the notion of neutrality 1) functions as a hermeneutical key to review the history of CEC as a whole; 2) may be enlightened by a precise assessment of the nature and goals of CEC; 3) refers to the normative dimension of CEC. Here, we distinguish four different meanings of neutrality: a neutral stance toward the parties involved in clinical decision making, toward the arguments offered to frame the discussion, toward the values and norms involved in the case, and toward the outcome of decision making, that is to say the final decision and action that will be implemented. Lastly, we suggest a non-authoritarian way to intend the term “recommendation” in the context of clinical ethics consultation. (shrink)

The relationship between philosophy and science has always been complementary. Today, while science moves increasingly fast and philosophy shows some problems in catching up with it, it is not always possible to ignore such relationships, especially in some disciplines such as philosophy of mind, cognitive science, and neuroscience. However, the methodological procedures used to analyze these data are based on principles and assumptions that require a profound dialogue between philosophy and science. Following these ideas, this work aims to raise the (...) problems that a classical connectionist theory can cause and problematize them in a cognitive framework, considering both philosophy and cognitive sciences but also the disciplines that are near to them, such as AI, computer sciences, and linguistics. For this reason, we embarked on an analysis of both the computational and theoretical problems that connectionism currently has. The second aim of this work is to advocate for collaboration between neuroscience and philosophy of mind because the promotion of deeper multidisciplinarity seems necessary in order to solve connectionism’s problems. In fact, we believe that the problems that we detected can be solved by a thorough investigation at both a theoretical and an empirical level, and they do not represent an impasse but rather a starting point from which connectionism should learn and be updated while keeping its original and profoundly convincing core. (shrink)

During the first wave of the COVID-19 pandemic in Italy, practitioners had to make tragic decisions regarding the allocation of scarce resources in the ICU. The Italian debate has paid a lot of attention to identifying the specific regulatory criteria for the allocation of resources in the ICU; in this paper, however, we argue that deciding such criteria is not enough for the implementation of fair and transparent allocative decisions. In this respect, we discuss three ethical issues: (a) in the (...) Italian context, the treating physician, rather than a separate committee, was generally the one responsible for the allocation decision; (b) although many allocative guidelines have supported moral equivalence between withholding and withdrawing treatments, some health professionals have continued to consider it a morally problematic aspect; and (c) the health workers who have had to make the aforementioned decisions or even only worked in ICU during the pandemic often experienced moral distress. We conclude by arguing that, even if these problems are not directly related to the above-mentioned issues of distributive justice, they can nevertheless directly affect the quality and ethics of the implementation of allocative criteria, regardless of those chosen. (shrink)

Different methods are available in clinical ethics consultation. In our experience as ethics consultants, certain individual methods have proven insufficient, and so we use a combination of methods. Based on these considerations, we first critically analyze the pros and cons of two well-known methods in the working field of clinical ethics, namely Beauchamp and Childress’s four-principle approach and Jonsen, Siegler, and Winslade’s four-box method. We then present the circle method, which we have used and refined during several clinical ethics consultations (...) in the hospital setting. (shrink)

The Italian debate about the role of clinical ethics and ethics consultation has brought about the need to create a working group of Healthcare Ethics Consultation. The group began to take shape an...

In Italy, during the first wave of the Covid-19 pandemic, the Italian Society of Resuscitators and Pain Therapists (SIAARTI) and the Italian National Bioethics Committee (CNB) published ethical guidance on the allocation of scarce intensive care resources. In this paper, we outline and compare these documents in detail, highlighting differences and similarities. In particular, we argue that major differences exist with respect to the principles and values underpinning the documents and the normative allocation criteria proposed. Conversely, similarities can be traced (...) with respect to a functional rather than substantial endorsement of the age criterion, the importance of transparency, and the consideration over healthcare professionals’ responsibility regarding allocative decisions. In conclusion, we argue that Italy has lacked a comprehensive and publicly-accountable policy articulating principles and operational criteria geared to strengthen the “ethical preparedness” of the country in dealing with current and possible future public health emergencies. (shrink)

A Second level Master in “Clinical Bioethics Consultation” has been organized in Italy to offer an opportunity to offer an adequate training to carry out an ethics consultation in different health fields. The master has been promoted and realized by different institutions: Catholic University of Sacred Hearth in Rome, Insubria University in Varese, “Federico II” University in Naples, Lanza Foundation in Padua and the Local Health and Social Care Unit n.7 in Veneto Region. The aim of the master is train (...) ethics consultants to offer help regarding a correct decision, which will take by others. The choice must be as much as possible shared between patient, family and health care team. Ethics consultation can be primarily request by the physicians, nurses and health care staff such as support about a choice that wants to be the most appropriate and to clarify a dilemma between different options. Secondly an ethics consultation can be demand by the patient and the family members to find a clarification about their dilemmas and future choices. Also the administrative staff could ask the consultation, when it need to better explain ad example about a specific clinical case or a question concerned the health policy. (shrink)

In the last decades, new technologies have improved the survival of patients affected by chronic illnesses. Among them, left ventricular assist device has represented a viable solution for patients with advanced heart failure. Even though the LVAD prolongs life expectancy, patients’ vulnerability generally increases during follow up and patients’ request for the device withdrawal might occur. Such a request raises some ethical concerns in that it directly hastens the patient’s death. Hence, in order to assess the ethical acceptability of LVAD (...) withdrawal, we analyse and examine an ethical argument, widely adopted in the literature, that we call the “descriptive approach”, which consists in giving a definition of life-sustaining treatment to evaluate the ethical acceptability of treatment withdrawal. Focusing attention on LVAD, we show criticisms of this perspective. Finally, we assess every patient’s request of LVAD withdrawal through a prescriptive approach, which finds its roots in the criterion of proportionality. (shrink)

The article by Conrad et al. (AJOB Neuroscience, 2019, 10:1) does not take into account another, still hypothetical, procedure for cognitive enhancement (CE) which would be appropriate to consider in the surveys, i.e. the possibility to genetically enhance the cognitive abilities of a future individual using genome editing techniques. In this case, the conclusions of the article in the context of the “self-others difference” and “safety/naturalness” would be questioned. In fact, the results of the hypothetical surveys with the variant “genome (...) editing” could be significantly different from those obtained in the survey proposed by the authors: an individual would decide not for himself, but for the CE in a future child. In light of these considerations, we hold that the article highlights just the attitudes toward the principle of autonomy and redistributive justice; however, by introducing the new hypothetical scenario of CE with genome editing the attitudes toward the principles of beneficence and non-instrumentalisation could also be appreciated. Special attention to future generations is necessary to inform potential CE public policy, though using genome editing to enhance cognition abilities is just a future hypothetical perspective. (shrink)

The aim of this paper is to analyze an Intensive Care Unit case that required ethics consultation at a University Hospital in Northern Italy. After the case was resolved, a retrospective ethical analysis was performed by four clinical ethicists who work in different healthcare contexts. Each ethicist used a different method to analyze the case; the four general approaches provide insight into how these ethicists conduct ethics consultations at their respective hospitals. Concluding remarks examine the similarities and differences among the (...) various approaches and offer a reflection concerning the possibility of a shared resolution to the case. The authors’ efforts to come to a tentative consensus may serve as an example for professionals working in medical contexts that reflect an increasing pluralism of values. This article aims to respond to some of these concerns by illustrating how different methods in clinical ethics would be used when considering a real case. The goal is not to establish the best model on a theoretical level, but to learn from actual practice in order to see if there are common elements in the different methods, and to validate their pertinence to clinical ethics consultation. (shrink)

Research integrity (RI) is defined as adherence to ethical principles, deontological duties, and professional standards necessary for responsible conduct of scientific research. Early training on RI, especially for early-career researchers, could be useful to help develop good standards of conduct and prevent research misconduct (RM).The aim of this study is to assess the effectiveness of a training course on RI, by mapping the attitudes of early-career researchers on this topic through a questionnaire built upon the revised version of the Scientific (...) Misconduct Questionnaire and administered to all participants at the beginning and at the end of the course.Results show that after the course, participants reporting a high understanding of the rules and procedures related to RM significantly increased (pre-course: 38.5%, post-course: 61.5%), together with the percentage of those reporting a lack of awareness on the extent of misconduct (pre-course: 46.2%, post-course: 69.2%), and of those who believe that the lack of research ethics consultation services strongly affects RM (pre-course: 15.4%, post-course: 61.5%). Early-career researchers agree on the importance to share with peers and superiors any ethical concern that may arise in research, and to create a work environment that fosters RI awareness.As a whole, results suggest the effectiveness of the course. Institutions should introduce RI training for early-career researchers, together with research methodology, integrity and ethics consultation services to support them. Senior scientists should promote RI into their research practices, and should stimulate engagement in peer-to-peer dialogue to develop good practices based on RI principles. (shrink)

Nowadays, the concepts of soldier and war have changed due to terrorism and the war on terrorism. According to the literature, to prevent terrorism, it is possible to use more violence, but how can we grant the safety of many versus the dignity of a few? In Israel, in order to protect civilians against possible terrorist attacks, Palestinian ambulances that would reach the Israeli hospitals must be quickly controlled. However, many times, at the checkpoint, patients have to wait for an (...) Israeli vehicle that will take them to Israel. This procedure causes many delays in medical emergency. How to avoid that terrorists may receive better care than Palestinian civilians may just because they are already on the Israeli side of the Separation Wall? How is it possible to ensure the life and safety of many, without denying the right to healthcare to somebody? How to decide when the State requirements conflict with traditional medical duties? Is it acceptable to provide health care to a terrorist? What should be done when it is uncertain whether the ambulance transports weapons besides patients? These questions call upon the core role of the doctor and of the medical profession: taking care of all sick persons. The care is the starting point of ethics. If we do not care about other human beings we do not have a real moral comprehension of any human ideal or action. For this reason we can say that the care is the premise of morality. The rights of all citizens, including the claim to public security, grounds on the care for each individual who needs help. (shrink)

Patient-and-family-centered care (PFCC) is critical in end-of-life (EOL) settings. PFCC serves to develop and implement patient care plans within the context of unique family situations. Key components of PFCC include collaboration and communication among patients, family members and healthcare professionals (HCP). Ethical challenges arise when the burdens (e.g., economic, psychosocial, physical) of family members and significant others do not align with patients’ wishes. This study aims to describe the concept of vulnerability and the ethical challenges faced by HCPs in these (...) circumstances. Further, it assesses the contribution of clinical ethics consultation (CEC) in assisting HCPs to face these difficult ethical conundrums. Two clinical cases are analyzed using the Circle Method of CEC. The first regards the difficulty faced by the doctor in justifying treatments previously agreed upon between the patient and his/her friends. The second regards the patient’s concern about being a burden on their family. Family burdens in EOL settings challenge PFCC in that patient autonomy may be disregarded. This compromises shared decision-making between the patient, family and HCPs as a core component of PFCC. In their ability to promote a collaborative approach, CECs may assist in the successful implementation of PFCC. (shrink)

Between December 2020 and March 2021, the US Food and Drug Administration and the European Medicines Agency issued Emergency Use Authorizations and Conditional Marketing Authorizations for the distribution of the first COVID-19 vaccines. Although these vaccines were thoroughly assessed before their approval, regulators required companies to continue ongoing placebo-controlled clinical trials in order to gather further reliable scientific information on their safety and efficacy, as well as to start new studies to evaluate additional candidates. The aim of this paper is (...) to present and discuss the ethical issues raised by the tension between the need to continue these types of clinical trials and the obligations related to the protection of the rights and well-being of research participants. Specifically, we question whether—how, and to what extent—fundamental principles governing research involving human beings can be applied to the current pandemic situation. We argue that continuing ongoing placebo-controlled clinical trials can be considered ethically justifiable only if all participants are adequately informed of any developments that may affect their willingness to remain enrolled, including the current situation of resource scarcity and the prioritization criteria established for vaccination. However, we also argue that currently approved vaccines, which are considered safe and effective enough to be administered to millions of people as part of the vaccination campaign, necessarily represent the “best proven intervention” currently available and, therefore, should be used as comparators in future studies instead of placebo. (shrink)

In order to fully understand the ethical, cultural, and political debate that moves around the papillomavirus vaccine, a bit of attention has to be paid to its history.In 2006 the first advertisements for Gardasil, the commercial name of the vaccine, started to appear in the United States. Merck pharmaceutical was the main dealer. Their “One Less” campaign was characterized by adolescent girls staring into the camera and saying, “I’m one less,” declaring their intention to be vaccinated against the human papillomavirus, (...) and to be one less victim of cervical cancer; all it would take was three injections over six months. A few months after the appearance of the advertisement, the HPV matter took another turn when Texas Governor Rick Perry decided to issue an executive order mandating vaccination of all sixth-grade girls in the state. Texas, a state with a conservative political culture and well-organized anti-vaccination movement, bypassed the legislature, overturned Perry’s order .. (shrink)

BackgroundMedia have increasingly reported on the difficulties associated with end-of-life decision-making in patients with Disorders of Consciousness (DOC), contextualizing such dilemma in detailed accounts of the patient’s life. Two of the first stories debated in the scientific community were those related to the cases of two women, one American, the other Italian, who captured attention of millions of people in the first years of this third millennium.MethodsMuch has been written about the challenges of surrogate decision-making for patients in DOC, but (...) less has been written comparing these challenges across legal systems and cultures. In our paper, we propose a systematic analysis of the final legal documents written by the American and Italian Courts in relation to the two cases, developing our discussion around three areas: the level of certainty/reliability of diagnosis and prognosis, the reconstruction of self-expression, time of illness and time of care. They are examples of the typical issues discussed by legal authors and allow us to understand the link and the difference between the legal and ethical perspectives.ResultsThe legal approach to the two cases has some common elements: the need to be certain about the diagnosis and prognosis and the fact that the clinical criteria are necessary in determining the most appropriate treatments, although these criteria are not sufficient unless they are supplemented by the patient’s will. The issue of relations takes on importance both from a legal and an ethical point of view, but from two different perspectives. While ethics safeguards relationships by guaranteeing their differences and makes them reconcilable, law safeguards relationships by guaranteeing the cold forms of respect, equality, impartiality, symmetry, reciprocity, and irreversibility. In this perspective, the link between the time of care and the decision of the family members assumes importance.ConclusionsThe most interesting point that emerges from our analysis is the issue of relationships and how they affect decisions, both from a legal and ethical point of view. For this reason, during the patients’ hospitalization, it is necessary to identify ways in which they might give their opinion about the moral issues underlying their choices. (shrink)