Copyright © 2017 Lucio Mango, et al.
The authors have declared that no competing interests exist.
"The doctor relieves the sufferings respecting the life and dignity of the person, without discrimination of any kind, in peace and in war "European Charter of medical ethics, Kos June 2011
“Ethics is the reflection according to which every person is considering its own behavior, to see if what he does is what they should do and what is right. All human beings must be equal in their right to protection of health, understood as the overall well-being, physical and mental, regardless of age, sex, ethnicity, religion, nationality, social status, ideology... Medicine is a great vehicle of peace, able to look beyond the differences and to reconvert, overcoming, conflicts” 1 .
The fundamental purpose of ethics is the affirmation of the good, the just, the virtue, the freedom and the duty in reference to man, not only seen in his individuality, but, more importantly, in the community.
How many forms of ethics exist? Over the centuries, at least three morals have succeeded:
1. The Christian, based on the goodness of intention, on good conscience and forgiveness for the bad consequences
2. The rational moral of Kant, who considers man always as a purpose and never as a means
The ethics of responsibility, in which everyone is responsible for the foreseeable consequences of their work
There are some, however, who advocate "the ethics of the circumstances" where the rules are modulated in accordance with the conveniences and skill; it is a perverse concept, act only to justify changing attitudes over time depending on utility and personal advantage.
Today, the relationship between ethics and medicine is very topical, not so much for the many stresses that come from the chronicle, but above all because it is an integral part of our work. It is not therefore a "fashion", but a "way of being"
According to Jeremy Bentham2, the moral philosopher who first defined the daily work as "an ethical system in which prevails the idea of duty on that of law or utility," ethics has collected the most expressive name of deontology. It is therefore superfluous to say that our work must always be based on the strict observance of the Deontological Code and that each of our choices must be aimed at the supreme interest of the patient.
"Being a man is, exactly, to be responsible" says Antoine de Saint-Exupery in his "The Little Prince".3But are we truly responsible for our work? The rigor of the profession is no longer in the hands of the physician, although the Medical Ethics Code reads: "I swear to entrust my reputation only to my professional skills and my moral qualities"4.
Many actors are involved in a considerable extent, ranging from politicians to managers, through medical directors, departmental directors, presiding directors, and a host of office managers with all decision-making power over medical activity.
“In the doctor-patient relationship are interposed an infinity of other professionals who should work in harmony with each other for proper "clinical governance", but rarely actually interact in a synergistic way, most often representing an endless series of obstacles, often difficult to overcome. We are strongly influenced by the medical-political relationship, with the latter heavily affecting the ethic of daily behavior” 5 .
Professor Elio Sgreccia, Director of the Bioethics Center of the Catholic University, states: “If traditional ethics has not been always easy acceptance in medicine, at least in part it is also due to the fact that ethics has often been conceived as a set of abstract principles and outer man and not as the value itself of the person or set of personal values: it is also due to the fact that the synthesis between ethics and health promotion has often been done improperly or inadequately”6.
The technological and instrumental temptations have distracted the attention of operators from the sick person to the same machine, so depersonalizing assistance and greatly diminishing the significance of the therapeutic relationship with the patient. And yet in the impact on society, medicine has to deal with limited funds that are asked to be fairly distributed within healthcare plans, and this calls for a fair model of equity, in turn an expression of a precise vision of man.
It is not questionable ethics of an appropriate allocation of resources in the health care system. The common goal is to establish macro- and micro-allocation of resources: the part of gross domestic product (GDP) to be assigned to the system, and its distribution between the need to preserve public interest and proven effective, effective treatment of disease, the area where it is realistically possible to take care of health as well as of illness, organization of services, all for the purpose of proper use of procedures and access of citizens to them.
At a macro-allocation level, appropriate investment in the healthcare system must be appropriately distributed among its various sub-funds, not excluding those where effective interventions high cost and low economic profitability, and taking into account the critical importance of the human resource and the correct balance between the various professional figures, including medical staff, non-medical healthcare staff and administrative staff. When assessing the utility of services, the individual needs of the people to whom they are addressed should be as far as possible; for access to services the criterion of diagnostic-therapeutic proportionality must be valid and for hospitalization the medical one, with the responsibility to apply it correctly. In any case, the principle of fairness must be respected.
The key issue is the relationship between ethics, economics and health economics. Because resources depend on the economy, the central question is whether ethics is alien or vice versa non-neutral with respect to it. When it comes to healthcare, the non-neutrality of ethics seems indisputable, but economic and ethical efficiency are inevitably in conflict. Is this conflict irremediable? It's more apparent than real, both because healthcare professionals were mostly careful to balance their activities to the benefit of patients with due attention to expenses and because, for the activity they are called to perform, they represent a qualified component of society, that wants to be fair. If there are difficulties, these are due to the separation of roles, to the fact that those who decide do not have direct contact with patients' needs, that the guidelines of clinical behaviors depend on the economic strategies they elaborate, and that, ultimately, it is not considered enough that it should be rather clinical protocols, diagnostic and therapeutic, to inspire economic strategies.
Another important theme is proposed by the indispensability of health research. The resources allocated to the healthcare system should be properly distributed among its various fields, and one of them must necessarily be the research, support to its operation and its continuous modernization.
This is an indisputable statement in principle, but involves the not easy problem of providing shared distribution criteria. This problem requires a complex reflection, of course scientific, but not only. You should say cultural in a broad sense, even philosophical, of moral and legal philosophy. Certainly epistemological, necessarily social and political. Meaning here research in the health system, not about the universal value of research as a human need of knowledge, therefore necessarily also of its finalization for health purposes.
Therefore there are two types of research, one of most immediate application, with direct effects on the quality of care and the organization and functioning of the system, and one more sophisticated. In the political and management culture, and in the same common psychology, it must be clear the idea that science and technology evolve together, but are not synonymous; that research into the health system does not only refer to the sophisticated and expensive technology; that technology is not just techniques but it is a reflection on the effectiveness and appropriateness of procedures in general, and therefore on the possibilities of simplifying them. Well-thought research, especially in the clinical field, is also research on technological simplification, with possible economic benefits, as well as reduced invasiveness, therefore humanitarian. It is known that the multiplication and refinement of instrumentation attracts operators, and that this attraction is not always useful for either the economy or, especially, the human quality of care.
The above mentioned also involves the evaluation of the relationship between ethics and rationality.
It should be remembered that ethics is the science of conduct that deals with the goals and the means adopted to reach them, deducting the one and the other from the right to protection of health (cf. art. 32 of the Italian Constitutioon7). This social right, as well as being a relationship between goals and means, it is also a moral reason, which recalls the principles of equity, equality, universality. The economic rationality and organizational efficiency (management) have, however, a very different reason, that is the result, influenced by the availability of resources.
The public health authority must therefore face a difficult challenge because it must simultaneously achieve three factors, the so-called "three E":
• Efficiency (understood as the maximum amount of healthcare provided with less resource use)
• Effectiveness (understood as health outcomes)
• Equity (understood as health protection in concrete cases)
The challenge is to combine efficiency and solidarity, effectiveness and equity, without subjecting solidarity to efficiency and ethical equity to effectiveness, giving preference to ethical and social purposes than economic means.
Organizational forms that provide healthcare services are articulated, as we know, in hospitals, departments, districts, services, skills integration, mobility, teamwork, and so on.
In this business framework the priority is not the government of spending, which must be attributed to its instrumental function, as instrumental is the company, but rather the pattern of consumption, which then determines the spending.
“In the face of an inevitable limitation of financial resources, it is not allowed to spend without limit, having regard only to needs, whatever its seriousness and urgency; on the contrary, it is necessary to tailor the spending to actual financial resources, which affect the amount and level of health services, to be determined after evaluation of priorities and compatibility and of course taking into account the fundamental need to protect the right to health”8.
On the issue of health priorities and financial compatibility, it seems necessary to point out the relationship between right (protected expectation) to health care and rationing (reduction) of financial resources based on the fundamental criterion of equity (fundamental justice).
The problem of priorities in health care can not be solved only with political and administrative choices (national and regional), but requires the synergy of three decision-making centers, which are health determinants:
• Politicians, who must ensure resources and efficiency compatible with solidarity
• Doctors, who they have judgments of effectiveness in the interventions
• Ethicists who are involved in ethical and health issues questions
Finally, it is necessary to overcome the wall of non-communication, still existing among healthcare professionals, with a new design, which can coordinate ethics and economic rationality, health needs and health resources in a coherent regulatory framework fair.