Informed consent in Italy-traditional versus the law: a gordian knot.

BACKGROUND: Italian law no. 86 of 5 June 2012, which establishes a set of rules on the matter of breast implants, came into effect in July 2012. The law is at the center of a widespread and animated cultural debate that in recent years has been taking place in Italy. DISCUSSION: The fundamental prohibition imposed by the law concerns the age limit. Breast implants for exclusively aesthetic purposes are allowed only if the legal age (18 years) has been reached. This prohibition does not apply in cases of severe congenital malformations certified by a physician operating within the National Health Service or by a public health care institution. The legal imposition of an age limit raises a number of perplexities: one at a bioethical level and one that is strictly juridical. In fact, it is impossible to deal with this issue unless the wider debate concerning the self-determination and autonomy of underage patients in biomedical matters is considered. It appears, then, that the issue is again exclusively related to the peculiarity of cosmetic surgery, which when aimed at correcting "only" the pathologic experiences of self-image, does not acquire the dignity of therapy. If, however, the improvement of self-image serves to achieve a better psycho-emotional balance and favors the development of social relations undermined by evident physical defects, age restrictions can be disregarded. The authors believe the real risk is that the law imposed by the Italian state is based on assumptions and preformed value judgments. Furthermore, in the understanding of needs, legislation often is biased toward objective biophysical problems without attaching due importance to subjective psychological and social problems. While acknowledging the seriousness of the issue, the authors do not agree with the legislature's rigidity. However, plastic surgeons must form a plan for addressing the concerns about breast implants and evaluating whether they are appropriate for adolescents, taking into account the unique psychological and developmental considerations of adolescent cosmetic surgery patients. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Taking time: the tempo of psychoanalysis.

In this article the author argues that in order to be psychoanalysis, the 'here and now' technical approach needs to be firmly grounded theoretically and technically in a practice that includes the notion of reverie or its equivalent. The author has argued previously that the analyst's theory is the essential 'third' of the two-person analytic situation. She now suggests that it is specifically the theories of temporality and the attitude of 'evenly suspended attention' or its more contemporary development, 'reverie', that are the crucial aspects of that theory. She refers to these essential aspects as the 'theory in practice' in so far as they are more than a technical approach or a theory of practice but reflect directly a particular analyst's internalisation of the whole psychoanalytic theoretical corpus. While she believes this to be an essential component in any true psychoanalysis, in developing her argument the author looks at situations in which the analyst is particularly prone to forgo this temporal aspect, as is the case when patients show an absence of symbolic thinking within the analytic situation. In fact, with those patients reverie and the visual images it produces within the analyst's mind offer perhaps the only hope of a meeting ground between the concrete and the symbolic and the possibility of avoiding an impasse. Impasse, she suggests, has at its root the absence of reverie as a third and temporal element, inevitably giving rise to concrete thinking on the part of patient and analyst and so to a situation that cannot evolve.

Choosing reconstruction after mastectomy: a qualitative analysis.

PURPOSE/OBJECTIVES: To describe women's perspectives on factors that influenced their decision to have reconstructive surgery after a breast cancer diagnosis. DESIGN: Exploratory, descriptive, qualitative study. SETTING: A comprehensive cancer center in an urban setting. SAMPLE: Eleven women who underwent mastectomy and reconstruction. Six participants had autologous transverse rectus abdominis musculocutaneous-flap reconstruction, four had saline implants, and one had a silicone implant. All but one reconstruction was performed at the time of mastectomy. METHODS: Open-ended, face-to-face interviews using an interview guide were conducted within one month of reconstruction. One to two follow-up interviews were conducted approximately six months later. MAIN RESEARCH VARIABLES: Decision making about reconstruction, perceptions of information needs and sources, sources of support, and factors important to decision making. FINDINGS: The main theme identified was Getting My Life Back. The participants described this in terms of the themes of Information Seeking, Talking It Over, and Seeking Normality. The interactive skills of the healthcare provider played an important role in the women's decision making. CONCLUSIONS: Reconstruction minimized the negative consequences of breast cancer and its treatment for the women in the study. The decision-making process was aimed at getting the person's life back as close to what it was before the diagnosis as possible or improving it. The three themes of decision making are interactive in nature, with participants returning to information Seeking and Talking It Over as necessary to increasing their understanding and clarifying their "normality goals." IMPLICATIONS FOR NURSING PRACTICE: Healthcare professionals should determine how a woman wants to participate in decision making as well as the kind, amount, and sources of information the individual with breast cancer wants to have to make her decisions. Healthcare providers are key sources of information about treatment options, and they are critical to patient satisfaction with the decision-making process and with the final results of the surgical procedure. Family members, friends, and other women with breast cancer play a crucial role in talking it over.