rMH 40, 2018, 73-74
The need for security is something that has been accompanying mankind since its very origins. The constant search for food stability and protection from inclement weather was, and for many still is, the driving force of the great migrations that have always characterized the history of humankind. With the advent of the so-called “welfare society”, this need for security and – perhaps – this thirst for “certainty” instead of diminishing, as one might have guessed, started to undergo a steady and progressive growth. In certain sectors of activity, risk reduction and control have become over time the main concern and even the ultimate goal of most operators, particularly in the health sector. Now, if on the one hand this commitment to risk reduction, taking into account what is at stake (i.e. citizens’ health), finds its logical confirmation, on the other the risk of finding a way out by taking refuge behind a myriad of protocols, guidelines and algorithms is actually real and concrete. Where and how to give space to the uniqueness that characterizes each individual and, therefore, makes a relationship between two individuals even more unique (in our case, the patient and his/her carer)? Where and how to include and consider everyone’s background of experience and vicissitudes, to integrate the latter into clinical reasoning? How to reconcile the necessary consideration of the principles of “clinical evidence” without putting aside or denying one’s own wealth of experiences, narratives and sometimes even emotions that inevitably permeate therapeutic choices?
rMH 40, 2018, 75-79
Uncertainty and guidelines in clinical practice
Uncertainty is intrinsic to the practice of medicine, and physicians have to cope with uncertainty, making decisions without adequate information. A probabilistic approach allows managing uncertainty and making decisions under uncertainty. The best choice should enable to reduce the consequences of errors, even if some errors should actually be regarded as inevitable. Over the last two decades, Evidence Based Medicine (EBM) contributed to make medical practice more scientific, as clinical epidemiology became a basic science for clinical medicine. The traditional hierarchical structure of medicine was hindered, and endorsing clinical decisions with the best available evidence became a moral obligation. Clinical practice guidelines (CPGS) multiplied after the birth and introduction of ebm and contributed to the shift from opinion-based medicine to evidence- based medicine. cpgs have the potential to reduce inappropriate practice variation, enhance translation of research into practice and improve healthcare quality and safety. However, the limitations of cpgs are well recognized: they most often cite low-quality evidence due to the actual absence of high-quality evidence. Randomized clinical trials, the best evidence on which cpgs are mainly based, are not always able to properly answer many clinical questions. Possible conflict of interest of cpg authors remains a major problem and undermines the reliability and trustworthiness of CPGS.
rMH 40, 2018, 80-83
Restraint in medicine between risk and safety
Restraint practice must be rejected as a caregiving philosophy, although partial limiting systems of motor activity are likely to be allowed, provided that they are adopted for well-defined reasons and, in any case, limited to the strictly necessary time frame. Ultimately, this practice must remain an individual prescriptive act at the end of a path that, starting from the patient’s assessment, has previously considered all possible alternatives. The decision must be oriented to the patient’s presumable will and interest and not necessarily to the most indicated therapy from the medical point of view. In the event of inability to discern, the therapeutic representative must be consulted and, more generally, the involvement of the patient’s family members is very important. Furthermore, its use must be strictly recorded and documented on the caregiving plan. The ethical conflict that arises in situations of confrontation between the respect for the patient’s autonomy and freedom on the one hand and his/her safety on the other, can only be solved by assuming a responsibility and, therefore, a risk based on reflections and a working methodology that, while taking up legal rules, cannot be limited only to their respect. Staff training and clinical research in this area must be increasingly promoted.
Raffaella Ada Colombo
rMH 40, 2018, 84-88
Restraint in psychiatry: a psychoanalytic reading
When it comes to respecting the international, federal and cantonal legal framework, restrictive measures affecting freedom require a review of daily health practice. Since June 2014 now, the psychiatric clinic of Cantone Ticino has eliminated physical restraint following a decade of long work, aimed at overcoming this freedom-restricting measure while introducing an intensive 1:1 caring, as already implemented in the Anglo-Saxon countries (one-to-one). The brief psychoanalytic reflection is aimed at investigating the meaning of acting in a clear asymmetry of the act, focusing on what is contained in the intersubjective relationship: the symbolic language and the body image. The symbolic language needs to be re-evaluated, listened to and re-read in the light of the intersubjective relationship, given that its encroachment on the field of consciousness is experienced as a kind of uneasiness and extraneousness. Entering also the body space of the Other in order to limit his autonomy means touching both the subjective dimension of the body scheme and of the body image, which has come into being through the dyadic interaction of care between mother and child: as a matter of fact, the identity of the Other always places us in front of the ethical dimension of doing and being there for the Other. Finally, there is a mention and re-examination of a medieval healing event occurred in 1169 at the hands of Hildegard von Bingen, a Benedictine and Saint. The story has it that she took care of a possessed young woman by implementing a treatment method that we could consider pre-modern.
rMH 40, 2018, 89-94
Medical risk, protection measures and legislative perspectives
In relation to the risk, safety and responsibility of the treatment, the civil court recalls the principles that govern the doctor-patient relationship and the responsibility resulting from the fault of the former from the civil law viewpoint. Starting from the legal qualification of the therapeutic relationship, it highlights the main obligations of the doctor, namely the duty of diligence and the duty to inform the patient and obtain his previous consent. Particular attention is paid to the doctor’s duty to inform about the risk and the need to obtain an express and free consent from the patient, under pain of implementation of his responsibility. It highlights the methods of obtaining the consent in the event that the patient is incapable of discernment, a major under general guardianship or a minor. In particular, it indicates when it is necessary to refer to the Protection Authority in order that the latter designates a representative guardian, and identifies the powers that this Authority has and will have in the future to intervene, if necessary also ex officio, to protect the patient’s rights and healthcare. The conclusions focus on the reform of the general part of the Code of Obligations (project co 2020), which proposes to introduce a general liability clause for risk (objective strict liability, irrespective of the fault, in which the simple fact of causing damage by means of a source of risk gives rise to the obligation to compensate) as well as on the conditions and some possible consequences of its application to medical art.
rMH 40, 2018, 95-103
Risk and need
Chance and need are unavoidable elements of the scientific vision of biology and of natural sciences as a whole. In human sciences, there is an age-old struggle between determinism and free will, the prerequisite for the assumption of responsibility on the part of the individual. This situation is illustrated with examples derived from clinical and forensic psychiatry, with the formulation of a hypothesis that goes beyond this historical contrast. In medicine, we speak, for example, of “risk factors”, meaning by that those parameters or behaviours that influence the possibility of developing a certain pathology. So, within certain
limits, we have the opportunity to influence them in our favour by changing our own behaviour. These are choices that – when placed in front of risk – we are called to make freely. Since, however, at the end of the day we will all die, limiting and counteracting the risk factors turns out to be, ultimately, a mere elusive, dilatory activity, in which our freedom lies in an attempt to avoid dying of a certain pathology rather than another cause. It could be a better investment if we used our freedom to widen as much as possible those dimensions in which aesthetic, intellectual and emotional faculties, alongside ethical values that are predominantly, if not specifically, human, are realized in an intense and differentiated way. This is the task not only of the individual, but also of society as a whole, if it really intends to be deemed a civilized one.