SPECIAL ARTICLE   

Minerva Pediatrica 2002 February;54(1):63-74

Copyright © 2002 EDIZIONI MINERVA MEDICA

language: Italian

Professional autonomy in the choice and management of therapy. Medicolegal aspects

Bolino G., Alfano C.

Any discussion of the delicate subject of a doctor's autonomy in the choice and management of therapy entails addressing the intimate question of professional and ethical conduct. The professional freedom to choose which therapy to use continues to be the most quintessential expression of the medical professional and, in respect of the primary purpose of safeguarding health, must be aligned with: the choices of the informed patient or his/her legal representatives, existing guidelines and the equitable allocation of resources. On these grounds, the author sets out brief considerations regarding a number of issues frequently raised in the everyday work of the pediatrician and neonatologist: from the doctor's autonomy to adopt a diagnostic-therapeutic approach, with special reference to the prescription of drugs and the subtle differences compared to pharmacological trials, to the promotion and protection of breastfeeding, with explicit reference to the Ministry of Health's recent Circular no. 16 of 24.10.2000 (''Promotion and protection of breastfeeding'') which, following a cursory reading of the text, appears to highlight restrictions to the pediatrician's decision-making autonomy. Special emphasis is also given to the medicolegal problems of caring for high-risk neonates. The clinical practice of neonatology often places the doctor in ''critical'' decision-making situations, with far from negligible ethical and moral implications, not to mention juridical and forensic ones. The author sets out a number of decision-making parameters for use as guidelines: the statistical criterion, the legal criterion and the clinical criterion, the only one capable of adjusting to scientific progress and to the specific technical and professional resources of the medical centre where the doctor is required to intervene in order to preserve even the simple ''possibility'' of autonomous life for the fetus. From this point of view, the so-called chronological vitality and scientifically proven statistics form part of the numerous criteria available for clinical evaluation. If the clinical criterion is not met, namely if the product of conception is not vital and has never been fully alive in the biologically complete sense of the term, then the omission of therapeutic support is not particularly important in professional and juridical terms. On the contrary, it would show an obstinate persistence of therapy, which would be both ethically and professionally incorrect. Lastly, even during the final stages of life, the doctor must play a participatory role ‹ not only by providing palliative treatment but also, and above all, offering moral assistance ‹ to sanction the ineluctable end of the therapeutic alliance, that ''feeling together'' which is the most literal and profound meaning of the word ''consent'', indicating both ''information'' but to an even greater extent ''discussion'' and ''empathy'' with the patient and his/her family.