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This paper grapples with the issue of naked statistical evidence in general and the reference class problem (RCP) in particular. By analysing the reasoning patterns underlying the RCP, I will show, first, that the RCP rests on theoretical presuppositions which we are by no means willing to accept. Such a presupposition is the wholesale approach in decision-making. Secondly, I will show that the very effort to increase the level of precision to a maximum so that a reference class contains a single member only is theoretically inconsistent insofar, as it deprives reference classes of their general (and thus scientific) character. Thereupon, I will argue, thirdly, that the decision to enact a specific evidence rule is a political one and reflects deep moral and jurisprudential values, not scientific propositions. Such a value is personal autonomy, which I go on to illuminate briefly. Whether the trier of fact will treat cases in a wholesale approach or not depends on constitutional arrangements and legal values putting emphasis on the individual and the latter’s dignity.

The Italian law 217/2019 on "Informed consent and advance directives" is an important step forward in the redefinition of patient-doctor relationships. The law points out the principles of the decisional autonomy and freedom of the patient to choose the treatment options. However, it is underestimated and largely unapplied by the Italian cardiologists. The main elements of patient-doctor communication are present in the law. The most important is the time devoted to the patient-doctor relationship, necessary to ease the disease awareness. This time is clearly emphasized in the law, but the healthcare institutions did not arrange for the appropriate organizational procedures. Through the advance directives (ADs) the patients may express their own wishes about healthcare treatments, as well as their consent or refusal regarding the diagnostic or therapeutical doctors' suggestions, allowing their respect in case they become incompetent. This right is supported by the patients' designation of a healthcare proxy, who can interact for them with the healthcare team. However, after 6 years since the law enactment, only 0.4% of the Italian citizens signed ADs, due to insufficient information and organization by the healthcare authorities. In the Law, the advance care planning is closely related to ADs. In this process, the adults can understand and share their personal values, life goals and preferences, in order to define the potential future medical care and to discuss all the issues with family and physicians. These processes can be integrated in a broader shared decision-making, a strong tool of the patient-doctor alliance.

. Proposal for informed consent for the 'differentiated autonomy' experiment. Differentiated regional autonomy means the power given to the 15 ordinary Regions - the 5 special Regions are excluded - to obtain regulatory and management competences in areas that are today regulated and administered by the State. Although differentiated autonomy is bad for the entire country - which risks losing its ability to implement economic, social, environmental, and cultural policies at a national level - there is no doubt that the Southern Regions will pay the heaviest price for its implementation, since they are already far behind and penalised compared to the North, with a worsening of all the health parameters, such as: reduction in life expectancy, increase in avoidable mortality, increase in mortality, increase in trips of hope to seek treatment in the North, and more. But the North will also have its problems, with poorer areas even within the richest regions and in the urban peripheries. And if the idea of solidarity, contained in the Constitution, is rejected, it is easy to move from competition to conflict, not only between North and South but also within the Regions.

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There is a relevant gap between the medicine learned on books and the clinical practice made of suffering humans facing us. Guidelines recommendations don't usually cover this aspect. The Slow Medicine movement, born in 2011, stands as a model a sober respectful and right healthcare. Everyone is entitled to express himself freely: a respectful medicine receives worths, choices and tendencies of the patient in every moment of his life. The keystone of slow decisions is to respect patient's freedom and autonomy, and to recognize his ability to make decisions even if he is elderly and frail. Listening to a patient's biography and welcoming his personal needs and expectations allows the physician to spread comfort, trust and gratification.

The Italian law 219/2017, enacted on January 31, 2018, regulates patients' informed consent, personalized care planning and advance directives. The law provides for patient's self-determination in all phases of life. This also applies to patients suffering from chronic, progressive, terminal disease such as heart failure. In fact, the clinical and psychosocial trajectory for heart failure patients demands an interdisciplinary, systemic approach. Advance directives should be tailor-made to patient's needs and dynamically updated through the course of the disease according to patient's and family informed and shared decision-making. Healthcare professionals will require education and training to stay up to the task both clinically, psychologically and emotionally.

Increased life expectancy rates in people with a stoma prompt the need to gain a better understanding of what are the concerns and the strategies of adaptation in this population in the long term to provide appropriate guidance and ongoing care. Therefore, the aim of this study is to explore the experiences and perceptions of people living with a colostomy for at least 20 years with regard to body changes and how these influence stoma care. This is phenomenological study. Five main themes were identified following data analyses: 1) accepting the stoma and living one's life almost fully; 2) changes; 3) practices to which I owe the recovery of my autonomy; 4) we are in need: before, during and after; 5) most people don't know. After many years, interviewees did not report significant changes in the way they had to manage their stoma and activities of daily living. Participants underlined how their healthcare needs continue throughout their lives, thus outlining the key role they attribute to nurses, stoma therapy services and associations of people with a stoma.

Summarizing the contents of the Italian Constitutional Court's judgment n. 242/2019 on the non-liability in medical-assisted suicide, the author looks at how the new scenarios thus opened might undermine the safety and dignity of the most fragile and vulnerable people. He voices his concerns on the shifting relationship between doctors and patients and on the delegitimization of medical ethics that must instead continue to illuminate, with its guiding principles, professional behavior., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The aging of the population is a reality common to the entire Western world, while the time available and human resources are limited. According to many experts, the new robotic technologies could help meet the care needs of the elderly, at home and in hospitals and nursing homes. In particular, care robotics could foster their autonomy and provide support to operators in the sector. The robots also invite us to reflect on how we want to be, what kind of people we want to become, since we are launching ourselves into ever more intimate relationships with machines and less and less towards rights and respect for real people.

The high rates of psychological distress, disability and/or chronic illness reported among children, adolescents and young adults, are a recent stimulus for the development and evaluation of new initiatives. Adventure therapy, realized through sailing navigation or stay in the mountains are effective strategies to raise the welfare of the beneficiaries, implementing self-esteem, autonomy and social skills. A "Nave Italia" model is described and prospects for development in a sector not yet capable to produce high quality research and training, according to traditional gold standard criteria by medical research, are discussed.

The Italian Parliament has recently approved the Law n. 219/2017 concerning "Rules on informed consent and advance directives". The manuscript points out the main key points of the new law, in order to clarify the role of the advance directives and to provide clear operational guidelines for healthcare personnel. Taking into consideration the Italian deontological and juridical context, along with the main jurisprudential judgements, the law has been analysed. The Authors discussed the new rules and the bioethical issues also in relation to the provisions stated by the Convention on Human Rights and Biomedicine (Convention of Oviedo). The new law deals with relevant issues that were confined to jurisprudential rulings so far, such as the informed consent, the withdrawal/withholding of medical treatment (including artificial nutrition and hydration), the content of medical information, including the modalities, the medical responsibility and, finally, the value of advance directives. In the Authors' opinion this law provides essential rules to expressly strengthen the patients' autonomy, eliminating the juridical uncertainty on many central issues (such us, for example, the refusal of life-sustainment treatments) that have been the subject of contradictory judgments ruled by the Italian Courts. Nevertheless, advance directives should be regarded as a dynamic tools of relationship between physicians and assisted person and, thus, as an essential integrant part of the advance care planning. The education of health professionals and citizens about end of life issues is the basis for the successful implementation of this legislation.

The literature highlights the importance of involving the patient as a partner of care, using a patient-centered approach aimed at improving a process of share decision-making. However, there are clinical situations in which a shared decision-making process is difficult and its actual achievement is even more complex, as in the case of end-of-life decisions, in which a decision about death is a tremendous weight for both patients and their caregivers. In such situations, we wonder what kind of position physicians should assume in order to be patient-centered but also to reduce the patient suffering. Our proposal is to assume the perspective of palliative paternalism: doctors should provide a communication approach that determines the appropriate level of patient/parent autonomy in the process of decision making. In other words, doctors are required to share the information with patients, according to their desires, possibilities and resources, and to facilitate a share-decision making process. However, when the time of the decision comes, physicians should take full responsibility for giving voice to the patient's choices, putting them in action in his/her end of life and raising patients and their caregivers from the burden linked to the actual implementation of the decision.

Over the last twenty years we have witnessed a growing focus on the rights of the ill people. The debate on informed consent and a new redefinition of the therapeutic relationship is constantly evolving. With this article, we propose a critical literature review of the so-called "Ulysses contract" or "psychiatric advance directives". It refers to the will that a subject expresses in writing, or orally, about the treatments he or she wishes or does not wish to be subject to if the time comes when it may be impossible to express his/her consent. This can especially occur in those with psychiatric disorders with serious clinical involvement and remitting-relapse (typically bipolar disorder, but also chronic delusional disorders and schizophrenia). In this context, the question is whether during intercritical periods the patient may or may not leave instructions to their care-givers. This aspect opens up to a series of interdisciplinary problems. In this article, we want to show the complexity of this debate from a clinical, ethical, legal and psychodynamic point of view, emphasizing the strengths and the major criticisms of the psychiatric advance directives for each area.

Eating disorders (and especially anorexia nervosa) are associated with severe disability, poor quality of life and high mortality rate. Anorexia nervosa ranks among the main causes of death among young women. Despite physical and psycho-social impairment, patients suffering from anorexia nervosa do not recognize low body weight and extreme calorie restriction as a clinical problem and are ambivalent towards treatment. Some patients with anorexia nervosa refuse treatments though presenting severe medical complications and having a high mortality risk. Hence the need to evaluate when it could be appropriate to prescribe a compulsory treatment in the more complex cases who refuse interventions, deemed necessary for them. To date, the compulsory treatment in anorexia nervosa is still under debate: some authors take into account the negative impact on the therapeutic relationship, other authors consider it as a compassionate treatment or as life-saving therapy. Indeed, compulsory treatment for eating disorders must always be weighed very carefully because it is considered by law as the highest form of restriction of personal freedom. Political Institutions must provide a clear framework for the society and for professionals, while the health care services must face the problem of the adequacy of available resources (not only in terms of hospital beds but also of skilled professionals) compared to patients' needs, considering the organization and the integration of clinical services dedicated to the treatment of eating disorders.

The article proposes a critical reflection on issues that appeal to the conscience clause as part of end of life care can produce and what can guarantee freedom of conscience, self-determination of those involved and respect for the dignity of the sick person. After a philosophical and normative analysis, the article is organized on the basis of two important documents for discussion: a position paper of Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) signed by several scientific societies "Grandi insufficienze d'organo end stage: cure intensive o cure palliative?" and the Design of Law currently being debated "Norme in materia di consenso informato e di disposizioni anticipate di trattamento". In particular, the conscience clause has been discussed in the light of advance care planning (ACP), which represents the instrument to guarantee the shared planning of care and the shared-decision making. In this context, recourse to the clause of conscience brings out critical ethical and deontological issues that the article discusses, using the position paper SIAARTI and the text of law currently being debated, both built on the assumptions of a shared care relationship, where patient has a key-role in medical decisions.

In the last decade an extensive debate on the topic of end of life decisions has developed in western countries, obtaining a worldwide media relevance. Philosophers, theologians, legal experts and doctors, focus their attention on the three thorny issues of the topic: forgoing treatments, euthanasia and assisted suicide. A thorough and respectful discussion on these issues should include all stakeholders - above all palliative care physicians - and should be encouraged in order to understand the views in favor or against the three practices, checking the different moral positions, and analyzing the cultural, social and legal aspects in the background on one hand, and, on the other, their impact on the health care systems. At present, in the fields of communications and politics, the debate related to the topic of these end of life practices is characterized by a confusion of terms and meanings. As an outcome, the term "euthanasia" is misused as a "container" including forgoing treatments, euthanasia and assisted suicide, while palliative sedation is wrongly considered as a procedure to cause death. This confusing approach does not permit to understand the real issues at the stake, keeping the debate at the tabloid level. Conversely, sharing the precise meaning of the words is the only way to provide tools to make rational, autonomous and responsible decisions, allowing individual informed choices in compliance with the principle of autonomy. This article is not aimed to take a moral stand in favor or against forgoing treatments, euthanasia and assisted suicide. Through an analysis based on scientific criteria, the authors firstly review the definitions of these three practices, examining the concepts enclosed in each term; secondly, they offer a glance on the legal approach to end of life issues in western countries; lastly, they investigate the relationship between these practices and palliative care culture in light of the medical societies official statements. The authors chosen to examine the topic of forgoing treatments, euthanasia and assisted suicide from a scientific point of view, because the clinical approach, taking into account the biological context of disease related to the human and social domains, seems to be able to better gather all the aspects of end of life practices, providing useful information to deal with them also in a philosophical or juridical perspective.

Medical futility refers to interventions that are unlikely to produce any significant benefit for the patient. Medical and technological resources allow many patients affected by advanced cardiovascular diseases to receive more aggressive and expensive treatments than ever before. This wide range of available options can frequently lead to the delay of complex end-of-life decisions, such as starting palliative care programs. Medical futility is a daily problem, with significant ethical implications and concerns about the respect of the main ethics points: non maleficence, patient's autonomy, and justice. This paper examines some considerations and applications of the concept of medical futility, particularly about the various definitions of futility, the complexities of management when care is considered futile and the ethical and clinical criteria to withdrawing or withholding aggressive treatments. The patient-centered care, based on physician-patient communication, seems to be the best approach to this problem, even with a patient with advanced heart disease. Finally, the increasing power of technology and its relationship with the current cultural values of the developed societies are outlined, particularly when end-of-life decisions are addressed.

Bioethical reflection is often raised to qualify medical treatment in relation to the concept of "dignity" of the human being. In philosophy, the concept of human dignity is used to refer to the intrinsic value of every human being but it has been framed in many different ways depending on the theoretical matrix we refer to. According to Christian principles, the dignity of human beings resides on their being created in the image and likeness of God: hence, the holiness of life for the believer and the condemnation of all means of action intended to anticipate death from suicide to euthanasia. On the contrary, according to the liberal tradition, human dignity is especially expressed in the autonomy of every human being. The Italian and the German Constitutions recall the value of human dignity. In the article 32 of the Italian Constitution, the concept of dignity is taken into account when stating the autonomy of the individual decision-making about health treatment. This is confirmed by the Code of Medical Ethics (2014): the right to self-determination and the right of patients to decide for themselves in accordance with their own life plans, are at the core of the concept of "human dignity". For this reason, doctors should support and encourage the full right of every patient to be considered as an autonomous person until the end of life, affirming his dignity. The acronym ABCD (airway, breathing, circulation, drugs) synthetises the essentials of intensive care procedures in life-threatening events. The same acronym should guide our behavior in promoting dignity in clinical settings. Attitude: moving away from our certainties, to better understand the real nature of the sick person we are approaching. Behavior: always be inspired by kindness and respect. Compassion, that is, deep awareness of the suffering, coupled with the desire to bring relief. Dialogue, being open to know the human being "behind" disease. This approach, developed by Chochinov and called "Dignity in Care", promotes the expression of the dignity of people and allows them to operate, together with the healthcare team, the choices consistent with their own life plans to the end of life.

In this article, the author discusses the topic of mercy, trying to focus on the ethical-practical aspects in the health care relationship. The limits of the medical paternalism and of the health care model based on the person's autonomy are discussed in order to propose mercy as the new dimension of the health care alliance.

The advance directives (ADs) have been adopted in many countries to defend patients' autonomy. In Italy, in the past, this topic gave rise to a heated debate involving philosophers, theologians, and politicians. In 2009, the government presented a bill of law on ADs firmly criticized from a scientific, moral and juridical point of view because the bill's content is against the principles of Italian Constitution, Italian Code of Medical Ethics, Oviedo Convention, and official statements of many scientific societies. Although the bill has passed the Low Chamber it lies, even since, in the Senate, lacking in regard any agreement among the political parties. The purpose of this article is to highlight that, in our country, patients, relatives and doctors deserve a law not only related to the specific topic of ADs, but - as in other European countries (Germany, Spain, France, UK) - aimed to deal with the complex issue of end of life care as a whole. This law should take into account the sound evidence existing in regard to the four fundamental principles supporting the best scientific and ethical approaches to the end of life issues: shared decision making process between doctors and patients/relatives; rejection of dying process marked by the suffering; withholding/withdrawing futile treatments together with palliative sedation as two crucial contributions to suppress the patient suffering and pain; clear-cut difference between these clinical/ethical options and euthanasia. At the same time, this law should be able to provide physicians with a legal coverage to make all the clinical and ethical decisions more and more complex because of the continuous evolution of medical science on one hand, and the impressive development of biotechnology on the other hand.

Subjects with heart diseases at risk of sudden death may be free from symptoms and be able to perform high-level sports activities. Preparticipation screening helps to detect these diseases, reducing the risk of sudden death in athletes. Fortunately, sudden death in athletes is a rare event (1-2/100 000 in subjects aged <35 years). As a consequence, it is not clear whether extensive preparticipation screening is cost-effective. In Italy pre-participation screening is mandatory for both agonistic and nonagonistic sports, whereas in the United States it is not requested. In addition, many US authors suggest that compulsory medicine visits are in conflict with the freedom of any people to self-determine its own destiny. In the presence of heart disease, international guidelines exist that provide recommendations for sports eligibility. Although all of them are similar, US guidelines are more permissive. Guidelines are not laws. However, in case of legal disputes, they are taken into account and, hence, it is a good rule to know and follow them.

Background: Job satisfaction and work ability are important in the nursing profession to ensure good working conditions and to reduce work-related diseases and illness. Psychosocial factors such as social support and decision latitude (autonomy) could have a role in cardiovascular diseases, low back pain, injuries and sick leave., Aim: To evaluate work ability, job satisfaction, psychosocial factors and diseases in 10 departments of the Monfalcone Hospital., Material and Methods: The Work Ability Index (WAI) questionnaire and Karasek Job Content Questionnaire with other questions related to working conditions and diseases were administered to 160 nurses working in 10 departments. The response rate was 90%. SPSS Statistic packaging was used for statistical analysis., Results: The study population had a mean age of 41.1 ± 7 years and the majority were female (81.25%). WAI gave a rating of over 37 points (good and excellent) for 86.4%, with an average of 39.9 ± 5.9 in women and 40.6 ± 6.4 in men. The WAI differences between the departments were significant with Medicine and Surgery showing lower values (p=0.012). WAI was significantly lower in subjects with sick leave higher than 10 days per year (p=0.000) and in subjects with cardiovascular diseases (p=0.031)., Conclusion: Our study showed very good working conditions for nurses. A follow-up of the analyzed population over time will add further information on this aspect.

Background: Past clinical research has provided varied and sometimes diverging descriptions of burnout., Objectives: As burnout is still prevalent in today's workplaces, actions are required mainly at the primary but also at the secondary and tertiary levels of prevention., Methods: In this literature review, the concept of burnout is reread through the lens of positive psychology and the most established theoretical models in the field., Results: A common view is seemingly emerging that characterizes burnout as a condition of alienation, loss of motivation and low autonomy resulting from an unbridgeable gap in the personal and/or organizational resources that one has to invest in building a stimulating and rewarding professional career, full of significant relationships that give meaningfulness to one's life project., Conclusions: Establishing clinical criteria for burnout, as it is the case in some European countries, couldfacilitate the identification of the syndrome and the estimation of its prevalence in Italian work organizations.

The risk of loss of essential elements of our professionalism, such as sense of duty, altruism and collegiality, contributes to the difficulties in the interplay between health services administration, health professionals and patients. It is not enough to increase salaries or change organization models. It is also insufficient a generic reference to the values of our profession, but it is mandatory to overcome the self-referencing attitude of health professions.

The 1853 Vaccination Act, adopted in England during XIX century, was the first law about compulsory vaccination in Europe. The Act caused a violent movement of opposition with the birth of Victorian anti-vaccination. The modern anti-vaccination movement was born in 1998 following a paper of Andrew Wakefield published in the Lancet. In this paper Wakefield illustrated a study of twenty patients and concluded that the administration of the MMR vaccine caused autism and some forms of colitis. The publication was later disowned by almost all authors. However the study of Wakefield caused a reduction of compliance to the anti-MMR vaccination in the United Kingdom, resulting in lower coverage and new outbreaks. The theorethical principles of anti-vaccinationists of 19th and 20th century were: the hypothesis that vaccines cause illnesses; the presence of toxic substances in the vaccine; the violation of freedom Personal and People's; the ineffectiveness of vaccinations. Moreover, anti-vaccinationists always refused the scientific methods and the peer-review of their scientific studies.

The study deals with the problems facing elderly patients in rehabilitation structures having to autonomously assume oral medication. Often, elderly people who were previously capable of doing so, become confused and disoriented when admitted to rehabilitation. This may be due to physical or mental deterioration subsequent to their recent pathological experience (e.g. Trauma, falls, surgery), to a lack of knowledge about their medication or to reduced motivation. Patients who do not regain their independence not only represent increased health expenditure but also an increase in the risks connected with erroneous self-medication.

In a traditional social setting, the entire family was involved when one of its members died; nowadays, this event has been transformed into a private affair. Medicine has alienated us at a time of family intimacy and death has become institutionalized in either a hospital or hospice environment. In a society whose values are changing , is it possible to restore respect and dignity to the final moments of life?. Sometimes life can be shortened or prolonged depending on the opinion of the medical staff, the equipment available in the hospital, the economic status of the family and their country of residence. How far should cure be taken when cure means forcing life to continue regardless of its quality : who chooses how and when to die?. Death is an inevitable aspect of human life and the medical community must accept this as part of their mission. Although intensive care is a precious tool, it may lead to paradoxal situations in which it is difficult to identify the exact moment when a human being becomes a corpse . When death is inevitable , it is no longer possibile to choose between life and death: the only choice left is how the patient chooses to die. The biological testament will be able to answer some of these questions and provide information making it possible to agree to or refuse further medical treatment.In the second part of this paper, that will be published later, the opinions of young people on this topic are will be reported together with those of the nurses whose institutional role is to divulge the necessary information.

The document deals with some ethical issues raised by the treatment of demented people. In particular the conceptual and empirical aspects of the assessment of awareness and competence of these patients are analysed, as well as the dilemmas related to the treatment of behavioral disorders.

Background: Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society., Objectives and Methods: The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders., Results: Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered., Conclusion: Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.