Rivista per le Medical Humanities

rMH 27, 2014, 11-15

Citizenship: from the theory to the practice of health and social factors

This article aims at introducing the dossier on citizenship, connecting the theoretical concept of citizenship (under a sociopolitical approach) with welfare and, in particular, with health and social health system aspects. In doing so, the development of the vast amount of scientific studies is briefly mentioned, from Marshall on, and how the social aspects related to this dossier come to the fore in the debate between liberal theory and republicanism. The articles in the dossier are then introduced using a quote from Plato’s The Republic. The classical philosopher and politician already cope through topics that are still current, such as how to properly treat in a balance between individualism and collectivity, or how to access care with health and social issues all included in the articles of the dossier.

Gilles Ferréol
François Vedelago
rMH 27, 2014, 16-23

Inciting citizenship and healthcare practices

After having demonstrated the extent in use of the concept of citizenship, in order to today qualify the bonds between individuals and the welfare state, we will describe how social citizenship is the result of a sociopolitical construction, a type of hybridization between the questions expressed and the incitements of public devices, staged in contemporary debates so as to build consensus regarding the tendencies and goals of the health system. The speeches related to this citizenship, to individualization, and to autonomy create an imaginary patient, as many managers or experts would desire, but that is in opposition or in contradiction with the past, characterized by a relationship of dependency by the actors in healthcare and by very strong expectations with respect to health.

Mara Tognetti Bordogna
rMH 27, 2014, 24-29

The case of immigrants

The issue of health inequalities is becoming more and more central, since they are growing, in general, and are also increasing and differentiating in the presence of immigrant individuals. This question then takes on importance, since it challenges the universal right to health and healthcare for citizens, hindering the process of inclusion of immigrants. In our contribution, we will particularly focus on the inequalities in accessing healthcare services.

Francine Rosenbaum
rMH 27, 2014, 30-36

The acceptance of immigrant families in healthcare

The article presents some reflections relevant to the impact that the current dominant thought regarding citizenship has on the acceptance of immigrants who employ these services. This addresses operators who are involved in the care of individuals with different cultural origins and who speak languages different from those we are familiar with. Starting off from a clinical history, the author illustrates the changes introduced in the practice of weaving the therapeutic bond with immigrant families, a bond that stimulates the operator on an emotional, pragmatic, theoretical, institutional, political, and ethical level. Therefore, the contribution aims at illustrating the failure of our current model of assimilationist acceptance, abusively called integration.

Maria Grazia Soldati
rMH 27, 2014, 37-41

The invisible cure: cultural differences and policies of recognition

Keeping in mind the “ethnic” aspect in healthcare seems natural if one recognizes how much the geographical, cultural, and linguistic origin of individuals affects the way they live and represent their own existence. If we consider the ease of access and treatment of the immigrant population in the health and welfare systems, then it is evident that it can occur more effectively if oriented from an “ethno-clinic”, a methodological approach that stems from the interaction between the narration of the history of life and cultural mediation. This is a work practice based on the knowledge and active use of cultural differences in the acceptance and care of immigrants, while still achieving a citizenship policy based on recognition.

Vincenzo D'Angelo
rMH 27, 2014, 42-48

A right to health: for citizens, users, or consumers?

Is a right to health still a matter for citizens or only for patients/ users and consumers? The issues taken into consideration in the article relate to the interweaving between exercising citizenship and the right to health and healthcare. A citizen is not simply one who exercises civil, economic, or social liberties, a citizen is not only one who participates in the decision and the destiny of a civil or political community through the full enjoyment of political rights. Instead, a citizen is also one who, through his own actions, makes the social order in which he moves legitimate and qualifies himself as an actor of his own making, that is, responsible for whom he is and what he wants to be. Today, health is no longer “just” a right, but it is a particularly important social value, as well as an economic market of great importance, which deals with a very complex and singular “good”, due to the great emotional component that characterizes it. The phenomenon of the medicalization of life and of human enhancement makes it difficult to distinguish between what is relevant to healthcare work and what should instead be ascribed to the social problems that characterize our society and our time. In this plot, the theme that emerges is whether citizens/individuals are still able to identify themselves as such in relating to caring for their health, or are they increasingly relegated to the role of user/patient or, more so, should they play their game as a consumer, in this case, of products and services related to healthcare. 

Giona Mattei
rMH 27, 2014, 49-55

Citizenship and the new reason of the world

Citizenship, meant as the possibility of the participation and integration of individuals in the social, cultural, and political life of a society in a given historical period, has suffered a profound change in recent decades. The ideal of the era of the society of production was that of integrating each individual (through work and a predetermined, long-lasting social identity) in the development of their society. As good citizens, it was necessary to participate in the economic, social, and civic progress of the nation-state. The neo-liberal globalization, the “new reason of the world”, puts a strain on this model of citizenship. The new “common good” is now the free market, in its being the occasion of the production of wealth, utility, and common welfare. Access to the social game is no longer through work but through consumption and the duty of every citizen towards becoming an entrepreneur of oneself within multiple lifestyles and identity choices that are offered by the market. This new model of integration produces new forms of social marginalization. Those who do not make it become waste and risk no longer having citizenship within the new social order. In this process, the bodies of those discarded individuals are administered, managed, and controlled.

Giovanni Boniolo
Giuseppe Schiavone
rMH 27, 2014, 85-89

Deliberation and bioethics

Throughout the last forty years, a consistent politico-philosophical knowledge has been built upon the intuition that aggregative forms of democracy do not fare quite as well as we should demand of them when it comes to radical moral disagreement. This knowledge goes by the name of deliberative democracy. Despite some early suggestions that this approach could and ought to be profitably applied to policy-making bioethical issues, few explicit attempts at directly implementing it to such purpose have been made so far. In this contribution, we make the case that more effective attempts need to be taken to this end. First we set out – both historically and theoretically – the framework for our account of deliberative bioethics. Secondly, we further suggest a limited class of methodological, procedural requirements that instantiate the features of an actual implementation of such a framework. Finally, we provide a set of reasons grounding the proposal of a committed effort to the development of more democratic and more deliberative bioethics. 

Samia Hurst Majno
rMH 27, 2014, 90-97

Between fairness and prosperity, difficult decisions exist

Between fairness and prosperity, difficulties exist on several levels. Doing the most good can, in health care systems, as well as in our ethical life, more generally, mean acting in a way that is more efficient but less fair. Ensuring fairness is itself more difficult than we might like. Some of the reasons are theoretical: different views of fairness can yield different conclusions. Other reasons are practical: our biases and social arrangements make fair treatment of some populations more difficult. It can seem paradoxical that issues of fairness are discussed to a greater degree in conditions of prosperity. Prosperity, after all, makes better treatment available to all, and this could lead to fairness issues becoming less rather than more salient. Greater prosperity, however, also makes questions regarding appropriate limits more apparent: medicine practiced in deep scarcity simply does all it can, and it is with greater material security that questions regarding doing too much are more likely to arise. Fair access seems more feasible in times of prosperity, making the lack of it appear to be a greater wrong. Prosperity also has effects on health and its distribution, as populations exchange diseases associated with clear environmental risks, such as lack of access to clean water or adequate food, with diseases often associated with “lifestyle choices”, such as tobacco smoking or unhealthy rather than insufficient food. Although the latter set of pathologies also has strong environmental factors, this aspect is less visible. This leads to a shift towards considering individuals responsible for their disorders. In turn, this shift can make claims for fair treatment and solidarity more fragile. Finally, some aspects of prosperity are directly dependent on a form of “consumption of health” associated with behaviors such as fragilizing employment or selling products that are deleterious to the health of consumers. Political choices regarding health can place us in a tension between prosperity and justice at each of these levels.

Jean Martin
Simone Romagnoli
rMH 27, 2014, 98-102

Faced with limited resources

This presentation deals with ethical decision-making in a context of resource limitation when adopting an analytical approach and a particular perspective. It discusses the determination of specific factors characterizing the issue and gives relevant examples in the work of the Swiss National Advisory Commission on Biomedical Ethics. Concrete situations show that ethical decision-making, when confronted with resource limitation (and resources are practically always limited), generally faces challenges regarding social justice and risks of discrimination.

Melania Borgo
Mario Picozzi
rMH 27, 2014, 107-114

European codes of ethics and organ transplants

Only a few decades after the first transplant from man-to-man, almost all the desired results have been achieved: the chance of survival is increased, and the lives of thousands of patients have improved. Yet, still today, there are people who die waiting for a neworgan. What should be done? Is it possible to find shared guidelines about transplantation, if not globally, at least on a European level? Analyzing the twenty-seven medical codes of ethics of the member states of the European Union, it is possible to see that only seventeen codes include at least an article or an explicit reference to transplantation. Furthermore, only two issues are examined by almost all the codes: the need for precise and correct information, not only to the receiving or potential donors, but also to living donors (the weaker subjects), and the gratuitousness of the gift. Moreover, all the codes share the idea that the gift must be free. Therefore, at the moment, in the European codes, there are too few common themes and too many states that make no mention about transplantation. Furthermore, there are no references regarding new techniques, nor are there references to less common forms of transplantation, such as living donor, Samaritan donation, and cross-over. The ethical issues are still too debated to hypothesize guidelines shared by all twenty-seven eumember states. In fact, first of all, each state should consider all of the options to find those that better adapt to the laws and the traditions.