Rivista per le Medical Humanities

Mattia Lepori
rMH 36, 2017, 11-12

The limits of healthcare beyond borders and boundaries

What does it mean to practice medicine in a poor country, with limited logistics facilities and poor diagnostic means, without laboratories, without x-ray machines or other paraclinical investigative techniques? The author, a specialist in internal and emergency medicine from Ticino, reflects on the theme of the limits in healthcare based on his own experience as a doctor in a fishing village in Senegal, where he noted that, along with practical and material limits, there were also limits in communication, as well as the centrality of the human dimension. The conclusion drawn was that the commitment as a care provider, since they are human beings who take care of others, must be maintained regardless of the logistic and material conditions where they are called upon to operate, in order to guarantee each patient the right to treatment, unquestionably. The experience of working in an environment with much higher limits than those with which one is usually confronted is also instructive towards thinking out ones activity differently: from this encounter, both sides have the opportunity to become enriched. 

Piermario Maffei
rMH 36, 2017, 13-16

Limit and omnipotence: reflections in relation to the care-healing dynamic

The human being, as a landscape, can be seen as the dynamic and functional interaction of various organs. Such a scena - rio can be further extended to a dimension that is broader than the biological one, including the psychic and relational sphere. Therefore, the doors to the borders open, intended at various levels. Among these is the one between two individuals, with the exchanges that occur within the doctor- patient relationship. Other boundaries and thresholds are represented by various super-specializations, improved in their skills in a manner that is so focused as to risk losing the big picture. Man’s identity is defined, case by case, in a complex interaction between internal components and the outside world, towards the structuring of what the ego is. During the course of a lifetime, this reaches states of relative equilibrium that are more or less stable, depending on the circumstances. Illness is a limit that disturbs the landscape by introducing a new scenario, with the need to adapt to it. Adapting can be seen as accommodating the limit, understanding it and accepting it, as an indispensable step towards managing and reducing its power, until it is integrated. Therefore, a conflict opens between the power itself and impotence, both of the patient, as well as the physician who is committed to curing the patient. This takes place in a complex interaction between the emotional and psychological components of both. In the integration process, we go from giving up an illusion of omnipotence, but without giving up the possibility of a cure. One can then access the concept of relative power with regard to the illness, where there is no possibility of a complete recovery. 

Tanja Fusi-Schmidhauser
rMH 36, 2017, 17-19

Palliative care for patients and care providers: what boundaries, limits, and thresholds?

The World Health Organization (who) publishes annual data regarding the causes of global mortality. In recent years, vascular, oncological, and respiratory diseases have had more prominent roles than other diseases. These chronic-progressive disorders not only imply an increased risk of mortality, but also of morbidity. Patients with these diseases are exposed to suffering that is not only physical, accentuated in the last year of life. During this time span, the needs of the individual, and family who takes care of the sick individual, increase and affect various spheres and dimensions of the human being. In this difficult and complex context, palliative treatments work through an approach that aims to enhance the quality of life of these patients and their families by taking on an holistic view of suffering. For those who carry out their work in this area, it is inevitable to confront oneself with multiple limits, dictated by the disease and by the time that passes. However, it is also a moment where thresholds may be crossed, in order to support and care for patients and their loved ones, while respecting their biographies, their needs, and their expectations.

Nicola Grignoli
rMH 36, 2017, 20-25

On the threshold of pain

This paper aims to explore several areas of inter-subjectivity that are open to expression and the treatment of pain. With a patient who is in pain, both acute and chronic, the nurse, the doctor, the healthcare assistant, and the psychologist are confronted with the enigma of subjective perception and with the problem of the externalization of an internal state that affects, and inevitably interrogates. Pain is one of the first symptoms that is manifested and expressed by the person who is suffering and conducts the patient’s experience threshold. Pain leads those who suffer to fully expose their own fragility by requesting help. To answer this, we must try to understand how pain is perceived, what sense is attributed to it, and then approach the patient, while remaining attentive to his/her dignity. This requires one to take small steps through the door of the hospital room, as well as the figured threshold of the interiority and, consequently, the intimacy of the patient, entering into a relationship with him/her.

Mattia Antonini
rMH 36, 2017, 26-29

"Here you're even allowed to say nothing"

At a time when the boundaries of intimacy seem to redefine themselves through social media, and that space of secrecy is in crisis, paradoxically, psychological consultations where everything can be said become the place of where a limit is discovered, where the opportunity and the same method of exposing oneself is questioned. The author questions the opportunity to take on, in some situations, a therapeutic stand that supports the adolescent patient by containing the expression when it becomes confused and hasty. The rediscovery of a certain modesty, understood as a dynamic subjectivizing tension between the unconscious desire to expose oneself and the fear of it, may constitute a fundamental step in the treatment process. The case of a fifteen year old youth with a self-harming behavior is presented and serves as a support for theoretical reflections and allows to demonstrate how psychotherapy in the situation can aim, not so much at the unveiling of unconscious meanings, but towards achieving transparency of the self, as the construction a limit and the recognition and acceptance of the opacity of the mind, which never lets itself become entirely known nor uttered. 

Graziano Ruggieri
rMH 36, 2017, 30-33

An encyclopedia of limits?

Medicine may help to better understand the limitations and restrictions that can afflict a human being in the later years of life, discovering content that, regarding “oldness”, were produced by literature, poetry, and especially philosophical reflection. If aging is, in some way, an objectified process, “oldness” is a biographical subjectivity where each of us lives that dimension and those elusive properties of human time of which we cannot know anything. In this sense, old age and oldness represent the two faces of the coin of the existence of the aged individual. Old age can also be taken hostage by the metric and the method of science, but the reflection made on oldness still strongly and concretely remains a prerogative of bolder and more demanding speculations of philosophy. Crossing the areas of humanistic production, the article leads to several encounters: from Ovid to Baricco, from Swift to Romains, from Leopardi to Ungaretti.

Mauro Manconi
rMH 36, 2017, 36-42

Beyond the vigil

Consciousness is the awareness of the self and the outside world. On the basis of anatomical and functional elements, consciousness is distinguished as a state or as vigilance and as content of consciousness, where the latter coincides with the awareness of being vigilant and, therefore, being able to relate with the outside. Although often in harmony, state and vigilance can dissociate. This occurs in pathological conditions, such as a vigil coma or in paraphysiological conditions, such as parasomnia or a dream. One experiences a physiological impairment of consciousness every day when in the phase of transition into the sleep. Pathological degrees of the suppression of consciousness are represented by stupor and by a coma. A vigil coma represents an example of discreet vigilance (state) when facing a virtually nil content of consciousness where the individual does not relate with the outside world. In fact, in several states of permanent coma, external stimuli can evoke the activation of brain areas through adequate stimulation, without any behavioral manifestation. This suggested the use of the expression “states of minimal consciousness” for those chronic conditions that were once improperly defined as “vegetative state”. Sleep is an ideal dimension for studying the dissociation of the state and represents a vital function, an active and heterogeneous phenomenon, comprised of phases that harmonically alternate and constitute its complex structure. Sleep is the nocturnal dimension where main processes of neuroplasticity are   needed, allowing for the expression of daytime consciousness.

Matteo Andreozzi
rMH 36, 2017, 43-49

Human limits, non-human boundaries

The main object of this article is environmental ethics, a philosophical discipline founded in the mid-70s in Anglo- Saxon countries, which aimed at collecting the rather prevailing challenge of putting under the lens of moral reflection all those actions related to a scope that is traditionally understood as non-moral, namely, the scope of relations between human moral agents and the non-human natural world. Within ethics, it has long been assumed that the status of “person” would identify all the stakeholders in the moral scenario. It is by essentially complicating this preconception that environmental ethics fits in. What, in general, the author tries to show in the article is the need to set limits to our actions in and on the natural world, extending the status of “moral patient” (referring to an entity that can be treated in a right or wrong manner by “moral agents”) beyond the ideal paradigm of human being and extending it to entities of a non-human nature.

Graziano Martignoni
rMH 36, 2017, 73-82

La bote outils of healthcare: entre, avec, limit, threshold, passivity, hospitality

In the technical era, “anthropological silence” dares to obscure the landscape of healthcare; care that is made up of rigor, but also, as Plato had already suggested, of “certain enchantments”. This obscuring starts off from a misunderstanding of what works with what it is: a misunderstanding that erases, or at least makes re-appropriation difficult for each of us – in sickness as well as during treatment – with regard to the concrete experience of the world and its telos. The paradigm of Humanities, which is at the heart of “clini - cal humanism”, is traversed by the dimension of the encounter. This is a multifaceted encounter: with one’s own inner world, with those who act as neighbors, and with the world, but also sometimes with what lies beyond. These are all forms of encounters that open pathways towards otherness, which is the foundation of one’s own identity. “Clinical humanism” is a witness – in theoretical practice, as well as “bedside” practice – of a knowledge of hearing before thinking, of invention and imagination before the project. Through a few guide-words, as if they were parts of an imaginary “boîte à outils”, this paper tries to depict the practicaltheoretical landscape of “clinical humanism”, which is the original and central nucleus of Medical Humanities.