The recent acquittal of Mr Ezio Forzatti, charged with wilful murder for having disconnected his wife, who was in a state of come, from her respirator in the Monza Hospital, has given rise to a number of problems of a juridical, clinical and ethical nature. Among the many complex aspects of this story, one thing appears particularly striking: as it had already happened in England and in the U.S.A., also in Italy bioethical issues risk being actually solved through court rulings, according to a definition which is alien to the European jurisprudence system. While we are waiting to hear the grounds of the judgement which has led to the acquittal of Mr Ezio Forzatti, a number of interpretation lines have materialised: some have seen in this ruling a justification for euthanasia (or mercy killing), others, on the other hand, have deemed it as an acknowledgement of the right to interrupt life-prolonging therapy (the Italian expression for this literally translates as ‘therapeutic doggedness’).
The ridge separating euthanasia from life-prolonging therapy has involved the concept of “previously announced directives”, since Mr Forzatti has often stated that his act complied with his wife’s convictions, which would not have allowed for this type of treatment. Now, reference to what is defined as Living Will, or Testament de vie, which has been translated into Italian in different ways, as “biological will” or, more appropriately, as “previously announced directives”, appears to involve a concurrence between those who are in favour of euthanasia and those who, on the other hand, are against it.
And on this concurrence we now need to ponder, in order to understand the meaning and the value of this legal tool which, following the above mentioned case, is called upon as the resolution of the ethical and medical conflict separating the two fronts, supporters and opposers of euthanasia. The Patient’s Autonomy and the Doctor’s Duty An equanimous evaluation of the proposal to introduce “previously announced directives” also in Italy, must first of all take into account a number of factors which risk jeopardising the meaning of this concept. Indeed, on one side, we cannot overlook the fact that the “previously announced directives” concept emerged within the movements that were in favour of euthanasia and was often supported by financial requirements.
In fact, it might be worthwhile considering the words written, in this regard, by the philosopher David Lamb: “Over the last few years, the medical category and, for various reasons, that of administrators, who are aware of healthcare budget restrictions, have seen the wave of arguments in support of patients’ autonomy with a friendly eye. This is part of the new civic custom, comprising the proliferation of a whole range of documents inspired by the principle of consumers’ supremacy. But the autonomy concept was originally mentioned in support of the right to say “enough”, and the media, together with the community of bioethicians, have fought a battle to protect the patient’s right to refuse life-prolonging therapy. In addition, autonomy has been deceitfully appealed to with the purpose of legitimising the judgement whereby certain people “would be better dead than alive” (whatever is in store for us with death, this is not a state which we are in a position to describe as better rather than worse for us) and therefore the appeal to autonomy has helped to cloud the issue as to the distinction between assisted suicide and legitimate right to reject an invasive therapy by terminal patients”. (D. Lamb, The Ethics of Life Frontiers. Euthanasia and Life-Prolonging Therapy. Published in Italian by Il Mulino, Bologna 1998, 134 pages).
Once these connections have been clarified, however, we should ask ourselves whether the previously announced directives should also be accepted by those who are definitely against both euthanasia and assisted suicide. Undoubtedly, the techniques employed to postpone death create the problem of having to identify the moral “limit” that lies with the doctor’s responsibilities, whilst fully respecting the terminal patient’s dignity: indeed, this is how the Italian expression “therapeutic doggedness” was coined. Furthermore, reference to the patient’s autonomy may be accepted as a value to be respected, but one needs to take into account that this autonomy is often influenced by the “fear” of death and by the difficulty to decide in advance (maybe when one is still in good health) which treatment one would be willing to undergo in the event of terminal illness.
The idea of not wanting to be ‘at the mercy’ of the doctor’s power to decide (so to speak) (expressed through the refusal of the so called “medical paternalism”) cannot even be converted into some sort of contract-like relationship between doctor and patient, in that there still are a number of duties deriving from the medical profession itself. Indeed, David Lamb has coined the expression moderate paternalism (expressing the so-called therapeutic alliance) to describe the virtuous relationship between doctor and patient. In fact, in therapeutic decisions, it is important that the disproportion between the doctor’s duties and the patient’s requirements finds a point of contact and balance in the mutual acknowledgement of the equal dignity of the parties involved.
The patient’s autonomy must harmonise with the doctor’s autonomy, and this is achievable by referring to a few basic ethical criteria.
The safeguard of the patient’s physical life and personal integrity remains, within the therapeutic relationship, an ethical and practical criterion which cannot be simply accepted or refused, in that it represents the specific nature of this relationship.
On one side, the previously announced directives appear to reconfirm the complex terms of this relationship in the cases in which interpersonal communication is no longer possible, but on the other side they risk jeopardising first-aid interventions and involve the risk of converting the refusal of life-prolonging therapy into actual therapeutic abandonment.
Indeed, it is not always easy to make a diagnosis in an emergency situation: saving a person’s life cannot be an “optional” choice, influenced by certain quality-of-life criteria or by directives which are unable to predict the clinical-condition variables.
Furthermore, we cannot underestimate the possibility that this legal tool may end up by gradually reducing the doctor’s sense of responsibility, who may be converted into a plain executor of the patient’s will. Besides, once the previously announced directives have been legalised, there would inevitably arise a discriminatory situation between subscribers and non-subscribers: in the absence of an express request by the patient, the doctor would be entitled to act according to his own decisions, which may lead us back to medical paternalism! And which would the basic criteria be?
A careful analysis of the issues related to the resort to previously announced directives would allow us to state that they represent, as it often happens, an equivocal – or even wrong – answer to a very serious question. If we really want to avoid trying to keep a patient alive at all costs, because we feel it is ethically reprehensible and clinically useless, we must be brave enough to forbid it always and in any case. Choosing this path means making a difficult and demanding decision, in that it involves the process of certain general criteria capable of leading the doctor’s action and forming his ethical and professional conscience.
Undoubtedly, we need to overcome both a certain intellectual indolence, and a certain reticence in reminding the doctor that his work involves certain ethical limitations, which need to be set forth in the most objective way and which, in any case, involve the direct responsibility of the doctor himself. If, as many people claim, previously announced directives are not a means for legalising euthanasia, and are not a way of leaving the patient even more alone in his/hers own decisions when death is approaching, then we need to clearly set forth in which cases the doctor is to interrupt his activity or even not intervene, so as to avoid a prolongation of the death process whose causes derive directly from the patient’s clinical situation.
It certainly is not easy to take this path, which appears very close to that of passive euthanasia, because for a long time we have indulged in the illusion that we could control, through our technology, the death event, but this is the only path which allows us to fully respect the human dignity condition and its limitedness.
Only by starting to carefully reflect on the theme of “therapeutic doggedness” shall we be able to avoid, or reduce, the arbitrariness that still characterises certain medical interventions and be able to practically prevent the introduction of certain euthanasic practices. Of course, we must be aware that there will still be many painful and difficult situations to be dealt with, we shall still have the task of having to take care of people who are in a persistently vegetative state, but we shall be better prepared to face them, and also to avoid needlessly bringing them about.
Psychological and physical pain, as well as death, will continue to be our fellow-travellers, but we shall be more aware of how to avoid becoming their direct accomplices.

Adriano Pessina
Cattedra di Bioetica
Università Cattolica di Milano

Translated by interpres sas