|
In the conference hall of Cassa di Risparmio di Cesena
(the Cesena Savings Bank), in a very pleasant environment, the round-table
discussion organised by Prof. Enzo Pretolani - university lecturer in
Bologna and chairman of the Ethical Committee of the Bufalini Hospital
in Cesena - has taken place on the subject “Impossible Medicine and
Sustainable Medicine”.
“What
will the future of medicine be?” was the issue the speakers faced during
a lively debate in which the audience also took an active part: there
was a large attendance which confirmed the great interest aroused by
these problems when dealt with positively and without demagogy.
The
long and detailed speech given by Prof. Pretolani introduced the chief
themes to be discussed.
We
are quoting here some passages from his speech: “The multifaceted world
of healthcare displays a number of paradoxes and contradictions, which
we shall try and analyse today.... One of these, which is really fundamental
for the future of healthcare, is the objective issue that, whilst the
availability of ever new and expensive diagnostic and therapeutic techniques
grows, at the same time, paradoxically, the discontent and complaints
of the population also increase, as well as the apprehension of the
financial, technical and political managers who run the healthcare system...
From a sustainable medicine we expect an active cultural role amongst
society and citizens, to lay bare the possible financial consequences
of a progressive technological dependence. We therefore need to devise
a drastic reallocation of resources, and related cost containment, in
order to ensure, not only for the present but also, and above all, for
the future, good medical care for everybody... Post-modern medicine
should indeed focus on individual health and well-being, but it should
allow for this to harmoniously fit in the broader social context in
which individuals live and act. In this regard, we cannot simply maintain
that in medicine progress may be unlimited, but we also need to take
the necessary steps to make this progress financially bearable... Exasperated
technological innovation has not only won over physicians but also the
general public to an orgy of technological (and not clinical!!) perfectionism,
almost as if a more extensive resort to technology could make recovery
easier and quicker. If we keep moving in this direction, the time will
come when many doctors will find their hands have atrophied since they
will no longer be needed to operate the machines (let alone touch or
palpate patients), since these machines will be operated by the human
voice if not by that of robots. ". Prof. Pretolani closed his speech
as follows: “An overall formula aimed at designing a sustainable medicine
for the future does not exist; we need to devise a healthcare whose
absolute priority is that of not neglecting anybody, by finding an intermediate
approach between two operating models, the one which privileges the
population in general and the one which cares for individual desires
and needs, without allowing the latter to become what we expect from
society. The logic of a market aiming at balancing available resources
and affordable expenses should take into account the fact that no society
can financially afford limitless progress, which would amongst other
things prejudice other fundamental sectors of modern and post-modern
life. Are we still in time to avoid burdening future generations with
the load of our recklessness and of out irresponsibility? Let us hope
so, but I am not that sure!!!”
Particular
interest was aroused by the presentation made by Prof. Giovanni Ceccarelli
- lecturer at the University of Pavia - whose theme was “A new discipline
to be included in the Future European Faculty of Medicine: Medical Market
and Promotion”. We are quoting here the salient points of his speech:
“In my time - the 50s - the list of disciplines provided for by the
Faculty of Medicine included “Medical Semeiotics”, which, even though
it was an optional subject, was regarded by us students as compulsory,
in view of its importance... In other words, it is the doctor who makes
the diagnosis and a doctor is such because he is able to diagnose disease...
A first blow to my firm convictions as a doctor, convictions I was rightly
proud of, came when I discovered that certain diagnoses changed over
time... I received a further blow when I realised that certain clinical
conditions remained always the same, but changed names over time...
Finally, a strange phenomenon leapt out at me during the early 90s:
because of my profession, I came in touch with an organisation which,
amongst other things, also deals in the production of statistics on
the diagnoses made by doctors as they compare with subsequent prescriptions,
by ordering them, for instance, in accordance to their frequency for
certain periods. So I became aware of the number of different diagnoses
made by my colleagues in Italy during the course of certain years; please
bear in mind that I am referring here not to diagnoses “announced” by
physicians but to diagnoses linked to drug prescriptions... The diagnosis
of depression ranked 32nd in 1984 and shared the 3rd position with diabetes
in 1993. At the time, I conjectured - although my hypothesis was rash
- that we were witnessing an “absurd wind”: up to 1987-88 anti-depressants
had basically remained those used in 1950 (imipramine, amitriptyline),
whose prices had also more or less remained the same as those of the
1950’s. But in 1987, for the first time after thirty years, the antidepressant
category had started to avail itself of new substances - selective inhibitors
of serotonin reuptake - which had new and updated activity mechanisms
and also new prices, which took into account the different times and
research requirements; these new prices enabled industry to shift the
attention on the “depression” disease, having available not only more
active molecules but also more profitable products. If I was right in
my hypothesis, the drug which “cured” depression was responsible for
the increase in the number of depression cases: in other words the drug
had created the disease market. So, if in this situation I invoke -
a bit provocatively - the introduction of a course of studies in “Drugs
and marketing promotion ” for future European doctors, my suggestion
may not be that out of place... But (how should I put it?) I refuse
to be included in the already large number of patients suffering from
depression: spes ultima dea [Hope, Last Goddess].
Just
as interesting was the address made by Avv. Antonella Monteleone, (who
is a member, together with Prof. Pretolani, of the Cesena Hospital Ethical
Committee) on “Ethical and Legal Behavioural Models for a New Healthcare
System”. Here are a few passages: “In my profession, on the occasion
of numerous criminal and/or civil proceedings against medical staff,
I have had the opportunity to acknowledge the enormous degree of expectations
which patients have towards doctors, or rather towards medicine, which
is viewed as an omnipotent discipline, which is above any possible mistake;
.. Over the last 15 years, there has certainly been an increase in the
demand for jurisdictional control over medicine, there has been an increase
in criminal cases against medical staff, also relating to offences prosecutable
upon official denunciation, and these figures have been mirrored by
an increase in civil litigations. As regards penal control, this is
magnified by the media which, in taking advantage of these situations,
tend to derive from individual cases of doctors’ mistakes conclusions
as to a general negative value of the so-called “malasanità” [bad healthcare].
...The judicial controlling system, which is strictly related to the
compensation expectations, has bureaucratised medicine, has levelled
out medical performance to a strict compliance with the necessary execution
of “due” practice, irrespective of actual therapeutic requirements.”
The closing speech was made by Prof. Fiorenzo Facchini, regular lecturer
of anthropology at Bologna University, who dealt with a particular aspect
of the debate, which is extremely topical today: “Biotechnologies and
Biomedicine. Will this Represent a Conflict or a Synergic Coexistence
in Tomorrow’s Medicine?” This is a theme which would require volumes
and which our journals have been dealing with for some time now. According
to Prof. Facchini, “The ethical principles regulating the employment
of the new biotechnologies must allow for respect for the person on
which the operation is performed and for this person’s rights, as well
as for the good of the people who may request it...These are the principles
which generate the criteria which should be taken into account in biomedicine
applications: respect for the person’s dignity, respect for human life,
relief from pain, rational employment of resources...” The editor of
Leadership Medica and Leader for chemist, Genina Iacobone, who chaired
the debate, stressed that discussing healthcare costs is very difficult,
since we usually know what the public expenditure for healthcare is
(as most taxes paid by citizens provide for a share which is meant for
healthcare), but we do not know the revenue. Furthermore, one of the
aspects we should be really focussing on relates to ethics amongst healthcare
workers; a professional code of conduct is essential in this field,
and is even more important than the debate relating to the legitimacy
of biotechnologies. (traduzione Interpres sas-Giussano)
|
