Rivista per le Medical Humanities

Pietro Snider
rMH 49, 2021, 14-19

The nature of consciousness: limits of knowledge and clinical practice

By briefly reviewing some of the issues set out as part of the philosophy of mind, the author argues that phenomenal consciousness entails an ontologically subjective mode of existence and that, logically speaking, it is not possible to know for certain whether or how another being is conscious. This argument has an impact on those who are involved in clinical practice working in contact with people with conscience-related disorders. The author thus invites those who work in this field to keep in mind that, however well established, practical and functional the protocols and clinical scales used to quantify a person’s degree of consciousness may be, these data should never be construed as objective evidence or a direct, faithful and irrefutable expression of the subjective reality of the person they refer to, but only as mere indicators. He also argues that becoming aware that no objective data on consciousness is sufficient to provide us with certain knowledge of third parties’ conscious states allows us to make use of the information available with the right sagacity, decide and act taking into account the intrinsic limits of what can be known and communicated about someone else’s experience. This makes it possible to observe, whenever appropriate, a precautionary principle by adopting decisions and behaviours which – having previously been duly weighed up – prove justified and ethical, and also respectful of the subjective dimension of other people’s conscience.

Carlo Calanchini
rMH 49, 2021, 20-25

Consciousness and its alterations: psychiatric-forensic aspects

After a historical digression, which leads from the pre-Socratics to current neuroscience, the article focuses on the psychiatric-forensic aspects, with particular reference to the alterations of consciousness which, in this framework, takes on the double meaning of “consciousness in the neurological sense” and “moral conscience” (cf. German, “Bewusstsein” und “Gewissen”, respectively). The questions that the law raises are so complex that they sometimes lead different judicial experts to reach divergent conclusions. The two basic questions concern, respectively: 1. the existence of a mental disorder (and, in this case, of which one); 2. incapacity and diminished imputability. (At the time of the events – taking into account and despite this mental disorder –, was the accused totally capable, only partially capable or totally incapable of judging their illicit nature or to act according to this judgment?). The core concept is that of “mental disorder”, namely a momentary alteration of a subject’s habitual condition due to multiple causes which are not all frankly pathological. Once the “mental disorder” has been excluded or identified, it is still a question of assessing whether there is a causal link between the latter and the crimes that were committed and whether it determined a diminished imputability (or even a unimputability). Now, the task of assessing the responsibility of the accused strongly involves the responsibility of the expert, who is required to carry out his task acting according to what he knows and thinks is right. The article is accompanied by examples, very different from each other, which draw on information that was disclosed by the press at the time.

Silvia Inglese
Andrea Lavazza
rMH 49, 2021, 26-34

The value of phenomenal consciousness

Only quite recently has phenomenal consciousness drawn the attention of scientific investigation. However, it plays a key role in end-of-life bioethical issues. What we mean to do in this article is try to set phenomenal consciousness in its appropriate context within the contemporary debate as well as explaining what it means “to give the impression of being oneself” in the framework of certain diseases. Furthermore, we propose cas- es of alexithymia and depression along with artistic abilities that manifest themselves in some people affected by dementia as particular and scarcely investigated examples of altered states of consciousness. In so doing, we mean to emphasise the value of phenomenal consciousness in a bioethical context that tends to belittle phenomenal consciousness as such, clinging instead to other criteria for decisions concerning patients in severely altered states of consciousness. Ours is an open conclusion, although we suggest that a non-criterialist approach could actu- ally be a promising path.   

Bernard Baertschi
rMH 49, 2021, 35-43

Vegetative states and minimally conscious state: some ethical questions

It is the duty of medicine to treat patients with the purpose of improving their health or quality of life in due respect of their will. This is not always an easy task, but for patients with disorders of consciousness (DOC) it is a real challenge, as they cannot communicate their wishes and their neurological state is not clear. Some of them are in a vegetative state (VS), others in a minimally conscious state (MCS). The state of mind of doc patients depends on their neurological state: Are these patients still living? Are they still conscious? Are they still persons, i.e. rational and autonomous beings? The answer to this question is not always clear, and physicians as well as nurses are sometimes hesitating and even induced to take wrong choices, as shown by some studies and famous cases. In order to avoid making mistakes while respecting these patients’ will as much as possible, it would be an important step forward succeed in communicating with them. Using brain imaging, fmri for instance, is particularly helpful, as shown by Owen and Monti. However, communication with DOC patients remains fragile and does not consist of a genuine dialogue between them and the people who care for them. Consequently, taking a decision on whether to stop or continue the ongoing treatment, which still relies on quality-of-life assessment, is not easy, as studies have shown that people with various handicaps consider their quality of life to be higher than judged by healthy people (this is referred to as the “paradox of handicap”).

Pierluigi Quadri
rMH 49, 2021, 44-49

Decision-making capacity in relation to the degree of dementia

The ability to make decisions is a key prerequisite to allow individuals to decide for themselves. Assessing a person’s decision-making capacity always entails a tension between respect for the right to self-determination and the need for protection of those who, in terms of this capacity, appear particularly vulnerable. Hindering a person’s decision-making capacity also involves important consequences in legal and medical terms – just think, for instance, of the self-determination of one’s health. There are many clinical conditions that are likely to compromise the subject’s decision-making capacity to a greater or lesser extent, e.g.: outcomes from head trauma, psychiatric diseases, state of mental confusion, depression and dementias. The article, which deals precisely with the latter, also examines two clinical cases, namely: one concerning Alzheimer’s disease and a refusal of surgery, the other raising the issue of financial capacity in the presence of a frontotemporal dementia. In conclusion, it is emphasised that the clinician who works with patients with cognitive deficits should be comfortable with the complexity of the decision-making capacity assessment and the consequent implications of its conclusions. This is essential in order to guarantee the patient’s interests while ensuring him maximum autonomy.

Maria Cristina Ferrera
rMH 49, 2021, 71-77

While everything flows... Being a reflective team in an adolescent therapeutic community

Pre-established theory and knowledge are not enough for the educator who works in a socio-therapeutic community for adolescents to identify effective solutions to factual problems; he needs a practical decision-making capacity that enables him to learn from the experience of each individual situation. That is why it is crucial to question oneself about the processes that affect the elaboration of the responses to be put in place in the contests of care provided by the educator. Starting from John Dewey’s book How we think and focusing in particular on the concept of “Reflective practice” developed by Donald Schön, some dimensions concerning the reflexive processes present within the socio-therapeutic community for adolescents Arco, Centro Educativo Minorile (CEM) [Youth Education Centre] in Riva San Vitale were investigated by means of an analysis of the literature and through semi-structured interviews. In particular, the purpose of the investigation was to bring out and understand how the operators of the Centre implement (more or less consciously) reflective practice processes at the team level, such as to allow them to undergo ongoing “training” continuously through a reflection on the their daily work.

Giulia Binaghi
rMH 49, 2021, 78-82

Sometimes, when words fail, silence is equally good

The Associazione Malattie Genetiche Rare della Svizzera italiana [Rare Genetic Diseases Association of Southern Switzerland] (MGR) has been present in Ticino since 2013, offering various services to those suffering from diseases of this kind. His activity is extensive and is also characterised by intensive network work involving various professional figures. Despite such professional variety, the figure of the social educator is absent. Starting from this statement of fact, the study was aimed at investigating the experiences of people who attend the association, with the purpose of reflecting on the possible role of the social educator. For this reason, the stories of those who live constantly confronted with their health conditions were heard: these are the people who most of all can express their need in relation to daily life, both from a social and private point of view. The reflection on the role that the figure of the social educator could play, who could advantageously contribute to the multi-professional network that supports patients suffering from rare genetic diseases, is based precisely on their stories and on the ascertainment of their needs as emerged from the study.

Pierangela Mentasti
rMH 49, 2021, 83-88

The ergotherapeutic interview with people suffering from existential distress at the end of life

Holistic suffering affects the well-being and quality of life of peo- ple suffering from diseases with a negative prognosis who expe- rience the approach of death. The assessment and treatment
of holistic suffering require a multidimensional and personalised treatment programme to be put in place by the palliative care team. The patient’s spiritual health is seen as a priority. In initiat- ing an occupational intervention with these people, the ergo- therapist conducts an informal interview where he welcomes this suffering, favouring the spiritual dimension to activate the search for meaning in the patient. Adopting a dialogic approach is certainly a way to deal with these situations, but there are also more purely spiritual channels to achieve this goal, such as med- itation. Further investigation is needed to define which counsel- ling skills are effective in supporting patients in a path of aware- ness and transcendence of suffering and which paths are useful for training occupational therapists in contact with suffering.

Valentina Barbato
rMH 49, 2021, 89-95

The nurse's role in enhancing spirituality while accompanying the dying patient

Spirituality is a dimension inherent in every human being, which, if cultivated, can support the person in facing the uncertainties and challenges of life, more than ever in the event of severe diseases. In the nursing field particular attention is paid to the impact it can have with respect to care and to the function it can perform as a means of support. Spiritual affliction weakens the sick person to a considerable extent and carers are personally consulted in an attempt to give answers to the existential questions expressed. The dimension of spirituality can be an important healing tool capable of improving the person’s quality of life while being accompanied to cross the threshold of death. To this end it is useful for the nurse to know the different models for taking charge of the spiritual dimension, in order to be able to adopt suitable behaviours for the co-creation of a treatment path.

Brunello Rusca
rMH 49, 2021, 96-100

Behavioural economics and nudging in promoting organ donation in Switzerland

In 2019, the donation rate per million inhabitants in Switzerland reached 18.4. The Confederation hopes to increase this figure to 22, through the “More organs for transplant” action plan. The article aims at evaluating the possible beneficial effects of elements of behavioural economics and of the nudging strategy on possible Swiss organ donors. Through the study of the specialised scientific literature, it was possible to examine the elements that most influence human behaviour in the decision-making process, after which the different doctrinal approaches applicable to organ donation were illustrated. Subsequently, the reference context was thoroughly investigated, examining the various ethical, legal and cultural constraints present in the Swiss society which narrow the architecture of choices. The Swiss framework that emerged is strongly oriented towards protecting different individual opinions and freedoms. In all likelihood, the best feasible method is that of explicit consent, to be supported by a set of measures capable of protecting the citizens’ different sensitivities.