Ethicists, doctors and triage decisions: who should decide? And on what basis?

We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level of evidence that healthcare professionals would rather not be left alone with their 'clinical judgments' to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the discussion of the care of critically ill patients with COVID-19 and has broader implications beyond the national context for the discussion of how to relieve moral distress in contexts of imbalances between healthcare resources and clinical needs of a population.

Brief Remarks on Engelhardt's After God.

>Engelhardt's After God gives a comprehensive perspective on the deepest and hardest issues in both moral philosophy and bioethics of our time. Although the book is an intelligent critique of contemporary moral philosophy in favor of a kind of traditionalism rooted in the perspective of the Orthodox Church, containing numerous forceful arguments, I ultimately disagree with Engelhardt on several main points stemming from his pessimistic view of our current culture and society. I have neither the pretense to open new perspectives, nor to put forward new arguments, and I am aware that I might be wrong. I simply want to present a different position on the quest for meaning.

The Italian reaction to the Giubilini and Minerva paper.

From 28 February to the end of March 2012, the Italian media reacted fiercely to the Giubilini and Minerva paper published in the Journal of Medical Ethics a few days earlier. The first article viewed the proposal as analogous to 'barbaric invasions', but in a first stage of the debate it could be seen as a case of the usual controversy between Catholics and secularists. Then emotive reactions prevailed and a flood of papers expressed strong opposition to 'infanticide'. The authors were even deemed insane; the fact that both are Italian certainly increased interest in the subject as well as surprise at their proposal, which some reckoned to be an insult to their 'national identity'. Even freedom of academic research and discussion was put in question, and defenders of free debate were accused of being supporters of the theory of infanticide.

Early pregnancy wastage: ethical considerations.

Information on early embryo wastage is relevant for debating the status of human embryos. Two main points of view confront each other. Theists hold that human embryos should be treated as human persons from the moment of conception because, even accepting that human beings are the fruit of evolution, they are part of a divine project. Without a developmental event prior to which the human embryo could not be considered a human being, embryos should be regarded as if they were human subjects. After all, if one believes in the resurrection of the dead, it makes no difference at what stage one's life ends. Secularists oppose the idea of granting absolute value to human life from its beginning because early human embryos lack individuality and sentience. Personifying embryos is morally absurd because it would mean that countless human beings never had even the slightest chance to express their potential and, in the light of this catastrophic loss, one would expect early pregnancy wastage to have become an important research priority; this is not the case. In practical terms, most Western countries have legalized first-trimester abortion, de facto giving embryos a lower status than that of full person.

The origins of human sexuality: procreation or recreation?

Human sexuality has multiple meanings, although reproduction is considered the focus of sexual activity. In spite of this, human sexuality began to lose its exclusive reproductive meaning very early in the evolution of the genus Homo and, with a concealed ovulation and a female accessible to the male during the entire menstrual cycle, the need became that of avoiding, rather than seeking conception during intercourse. The 'contraceptive revolutions' of the 20th century (sex without reproduction, reproduction without sex, reproduction in menopause and, one day, reproduction without gametes) are having a major impact on the lives of individual couples and women. At the same time, this tumultuous progress drew the attention of religious moralists, since ethics have always focused on sexuality and its moral regulation. Catholic ethicists have been at the forefront of the battle against 'dehumanizing' the reproductive process, whereas Judaism took a much more open position. Early Christian teaching on sexuality, focused on abstinence; this is because Christ himself defined celibacy as a better life choice for human beings. Drawing on this basis, early Church fathers developed the concept, upheld until the 20th century, that intercourse is totally justifiable only in order to procreate. Today, some cautious overtures are being made and the Church has recognized that sexuality can be expression of conjugal love independent from procreation.

Evaluation of hand function in patients with unilateral cerebral palsy who underwent multilevel functional surgery: a retrospective observational study.

BACKGROUND: Hemiplegia is the most common form of cerebral palsy. Upper limb is generally more affected than lower one. Indeed, hemiplegic children can spontaneously acquire standing and walking ability, while manipulation remains uncertain, with severe limitations in activity and participation, which define a child's functional status (International Classification of Functioning [ICF]). Several non-surgical tools are currently available to approach upper limb impairments. Studies regarding upper limb multilevel surgery in Hemiplegic Cerebral Palsy are relatively few and inhomogeneous. AIM: The aim of this study is to propose a surgical approach based on upper limb functional level and manipulation strategy and establish whether multilevel surgery can improve segmental alignment, performance and capacity, that ICF defines as activities and participation qualifiers. DESIGN: This study is an observational retrospective study. SETTING: This study involves patients who referred to the Unit of Children Rehabilitation of S. Maria Nuova Institute for Research and Care, in Reggio Emilia (Italy), over a four-year period. POPULATION: Children affected by hemiplegic cerebral palsy who underwent upper limb multilevel surgery. METHODS: For each patient, we previously defined functional use of affected upper limb applying the House classification and the Ferrari one of manipulation pattern. Patients are divided into three groups: synergic hand (House 4, 5), imprisoned hand (House 3), excluded hand (House 0). We recorded goals achievement through Goal Attainment Scale and unimanual and bimanual abilities through Melbourne Assessment of Unilateral Upper Limb Function and through Assisting Hand Assessment respectively. RESULTS: We recorded 16 upper limb multilevel surgical interventions in 13 children and report their results. CONCLUSIONS: This study suggests that surgery can induce a segmental and/or aesthetic and/or a functional change depending on manipulation pattern. It also underlines the importance to analyze results in term of spontaneous manipulation abilities and daily use. CLINICAL REHABILITATION IMPACT: This study provides a preliminary guide to plan surgery in relation to segmental deformities and overall manipulation pattern and describes their feasible improvement measures. It also suggests the most useful tools to record goal achievements in modifying manipulation function. Further controlled, randomized and prospective studies are required to support this idea.

A secular perspective on 21st century ethics in human reproduction: why religious views and attitudes are becoming obsolete and possibly dangerous.

The application of reproductive technologies to humans has brought about a radical change in traditional perspectives about sexuality and reproduction. In the past, the field was surrounded by an aura of mystery, which allowed religion to grasp the subject firmly. Now an explosion of knowledge, and a new capacity to control all aspects of human reproduction are beginning to modify attitudes, so that the arenas of sexuality and reproduction are apparently undergoing a process of rapid secularization. As a result, religious solutions to reproductive problems are becoming obsolete and possibly dangerous, since they no longer adequately fulfill the needs of humanity in our modern era.

Italy: pluralism takes root.

KIE: Mori gives an overview of biomedical ethics in Italy in one of four Hastings Center Report country reports. Public policy on issues like in vitro fertilization, sterilization and abortion, passive euthanasia, and organ transplantation reflects the declining influence of the Catholic Church and the increasing cultural pluralism of Italian society. The government has appointed advisory bodies on reproductive technologies and AIDS to study the issues and make recommendations. Bills regulating technologies such as in vitro fertilization or liberalizing restrictive laws such as those on contraception are introduced regularly in Parliament, if not always enacted. Mori concludes that general interest in and formal study and discussion of biomedical ethics is increasing in Italy. He sees a danger that the field of bioethics will develop a dual identity, with little progress made in resolving the issues, unless serious dialogue between Catholics and non-Catholics increases.^ieng

Genetic selection and the status of the embryo.

In this paper I want to try to clarify the nature of the two different problems indicated in the title: there is a lively debate on whether or not genetic selection is a morally licit practice, and there are strong disagreements on whether or not the embryo is a person. I think that most of such controversies depend on confusions and/or unclearness about specific problems involved in each issue, I have no precise normative proposal on the morality of genetic selection, but I hope that my analysis will be helpful in avoiding some current confusions.

Fecundaçäo assistida e liberdade de procriaçäo / Assisted reproduction and procreative freedom

De acordo com uma opiniäo de senso comum, nos casos em que as pessoas se valem de alguma tecnologia de reproduçäo artificial a liberdade de procriaçäo deveria ser restrita. Visando examinar tal opiniäo o autor procura esclarecer o sentido de "liberdade de procriaçäo" em diferentes situaçöes, distinguindo dois tipos de "liberdade de procriaçäo": a liberdade negativa, referente à escolha de näo procriar, e a liberdade positiva, examinada em relaçäo à escolha de trazer um novo ser ao mundo. Após averiguar que no mundo ocidental contemporâneo a liberdade negativa é considerada um direito fundamental, o autor mostra que a mesma situaçäo implica também a liberdade positiva