Healthcare

Research

13 pages, 256 KiB

Open AccessArticle

Assisted Suicide for Irreversible Patients on Life Support? The Intricate Italian Journey Towards Conforming with the Legislation of Spain, Austria, and Portugal

by Gianluca Montanari Vergallo, Susanna Marinelli, Nicola Di Fazio, Simona Zaami and Paola Frati

Healthcare 2025, 13(8), 885; https://doi.org/10.3390/healthcare13080885 - 11 Apr 2025

Viewed by 284

Abstract

Background/Objectives: In 2019, the Italian Constitutional Court (ICC) stated that the principles of equality, dignity, and self-determination enshrined in the constitution require that assisted suicide be considered lawful under certain conditions, including that the patient is kept alive through life-sustaining treatments. In [...] Read more.

Background/Objectives: In 2019, the Italian Constitutional Court (ICC) stated that the principles of equality, dignity, and self-determination enshrined in the constitution require that assisted suicide be considered lawful under certain conditions, including that the patient is kept alive through life-sustaining treatments. In fact, since such patients could already die by refusing treatment, assisted suicide is ethical as it allows them to die more quickly and with dignity. The paper aims to analyze the requirement of life-sustaining treatments from a legal and comparative perspective. Methods: The authors performed the search on Italian legal databases as well as on Scopus and PubMed and by comparing Italian regulations with those of Spain, Portugal, and Austria, which are similar to the Italian one in their fundamentally restrictive nature. The authors have delved into the Italian legal system through an analytical method of interpretation of the normative texts and used the comparative method to investigate which of the legal systems considered is more permissive. Results: According to the ICC, continuing to prohibit assisted suicide for patients who do not require life-sustaining treatments is not discriminatory: these patients cannot be equated with others, as only in the former case does refusing treatment lead to death. From its personalist ethical framework, the ICC also rejected the claim that the patient’s self-determination is being infringed upon: self-determination must be balanced with the protection of life, which is a fundamental value. However, in 2024, the ICC clarified that life-sustaining treatments are not limited to those directly supporting vital functions through medical machines, but also include all treatments without which the person would die in a short time, such as manual bowel evacuation. Conclusions: The current Italian regulation seems inconsistent. It would be preferable to regulate assisted suicide by referencing the models of Spain, Portugal, and Austria. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

12 pages, 219 KiB

Open AccessArticle

Surveillance and Reporting of Hospital-Associated Infections—A Document Analysis of Romanian Healthcare Legislation Evolution over 20 Years

by Alexandru Coman, Dana Pop, Flaviu Muresan, Florin Oprescu and Shauna Fjaagesund

Healthcare 2025, 13(3), 229; https://doi.org/10.3390/healthcare13030229 - 24 Jan 2025

Viewed by 1003

Abstract

Background/Objectives: The objective of this study is to evaluate the evolution of Romanian legislation related to HAIs. The evolution of healthcare-associated infections (HAIs)’s definitions and surveillance frameworks in Romania reflects progressive advancement in diagnostic criteria, reporting, and prevention. Recent changes emphasize the need [...] Read more.

Background/Objectives: The objective of this study is to evaluate the evolution of Romanian legislation related to HAIs. The evolution of healthcare-associated infections (HAIs)’s definitions and surveillance frameworks in Romania reflects progressive advancement in diagnostic criteria, reporting, and prevention. Recent changes emphasize the need for accurate and centralized electronic reporting, inclusion of medico-social and palliative care institutions, and modernized hospital infrastructure standards. However, workforce deficits, insufficient infrastructure, and punitive sanctions remain barriers to effective implementation. Methods: This study analyzed publicly available Romanian legislative texts and their evolution, comparing definitions, diagnostic criteria, and surveillance structures. Key informant insights supplemented findings to contextualize legislative impacts. Legislative acts were reviewed sequentially to identify updates in regulatory frameworks and barriers to effective HAI management. Results: The legislative evolution demonstrates a shift from basic diagnostic criteria to a comprehensive surveillance framework aligned with European standards. However, challenges persist, including workforce capacity deficits, under-reporting due to fear of sanctions, and infrastructure inadequacies. The prevalence of HAIs remains largely under-reported (4.1%), with studies revealing rates well below the European average (7.1%). Manual and isolated reporting systems further hinder real-time surveillance and accuracy. Legislative advancements in Romania reflect progress in HAI management but highlight systemic barriers that impede effective implementation. Conclusions: Collaborative efforts across individual, organizational, and system levels are required to address workforce training, reduce under-reporting, and invest in infrastructure and electronic reporting systems. Promoting a blame-free organizational culture, combined with training, is essential to encourage behavior of accurate reporting and improve HAI prevention strategies. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

20 pages, 611 KiB

Open AccessArticle

Towards a European End-of-Life Regulation: A Necessary Analysis

by Francesco Orsini, Andrea Cioffi, Luigi Cipolloni, Maria Antonella Bosco, Chiara Fabrello, Camilla Cecannecchia and Stefania De Simone

Healthcare 2025, 13(2), 130; https://doi.org/10.3390/healthcare13020130 - 11 Jan 2025

Cited by 1 | Viewed by 1296

Abstract

Background/Objectives: Biomedical progress has extended the lifespan of patients with incurable diseases, sparking debates about their desire to live under certain conditions. This study examines the ethical and legal challenges surrounding end-of-life issues in Europe, including informed consent, the refusal of treatment, the [...] Read more.

Background/Objectives: Biomedical progress has extended the lifespan of patients with incurable diseases, sparking debates about their desire to live under certain conditions. This study examines the ethical and legal challenges surrounding end-of-life issues in Europe, including informed consent, the refusal of treatment, the right to health, self-determination, advance directives, assisted suicide, and euthanasia. European countries exhibit different interpretations and regulations of these practices, leading to patient “migrations” seeking favorable legal environments. Methods: This study analyzes end-of-life legislation across European countries in a comparative and qualitative way, highlighting differences, commonalities, and the potential for uniform regulation. The data were collected from the literature published between 2000 and 2024, focusing on the EU member states, Switzerland, and the United Kingdom. Results: The examination of the norms governing end-of-life practices in various European countries revealed significant differences in legislative frameworks, reflecting diverse cultural, ethical, and legal perspectives. These variations have led to patient migrations in search of suitable legal environments to end their lives with dignity. Conclusions: This study highlights the need for a harmonized approach to end-of-life legislation in Europe to ensure equitable access to end-of-life care and to uphold human dignity. Continuous legal updates and comparative studies are essential to balance medical advancements with ethical considerations. The findings emphasize the importance of autonomy and self-determination, which are fundamental human rights that should be respected in the context of end-of-life decisions. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

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10 pages, 240 KiB

Open AccessArticle

Exploring the Connections between Medical Rehabilitation, Faith and Spirituality

by Laszlo Irsay, Viorela Mihaela Ciortea, Theodor Popa, Madalina Gabriela Iliescu and Alina Deniza Ciubean

Healthcare 2024, 12(12), 1202; https://doi.org/10.3390/healthcare12121202 - 15 Jun 2024

Viewed by 1567

Abstract

(1) Background: Patients who undergo a medical rehabilitation treatment are often facing a physical, emotional and spiritual crisis, mostly due to pain, loss of limb functionality, the memory of the pre-disease days or questions about their role and value in life. Most of [...] Read more.

(1) Background: Patients who undergo a medical rehabilitation treatment are often facing a physical, emotional and spiritual crisis, mostly due to pain, loss of limb functionality, the memory of the pre-disease days or questions about their role and value in life. Most of the time, the physician does not have the ability to deal with these issues or to provide the expected responses. The aim of this study was to analyze the patient’s perception on spirituality and faith while going through a medical rehabilitation program. (2) Methods: The current study included 173 patients treated in the Rehabilitation Department of the Clinical Rehabilitation Hospital in Cluj-Napoca, Romania. Of them, 91 comprised the study group and were assessed in 2023, while 82 comprised the control group and were assessed in 2007. All patients answered a 34-item questionnaire designed by the authors regarding the role of religion, spirituality and prayer in their post-disease life. (3) Results: The results show that 99% of the patients assessed believe in God, 80% pray every day, 50% have less pain after praying and 44% trust their priest the same as they trust their doctor. When comparing groups, results from 2023 show that more patients pray every day, while fewer are afraid of dying, think their disease is serious or wish for the medical team to pray with them, compared to 2007. (4) Conclusions: The physician should not neglect the faith of the patient and should use it to achieve a better rehabilitation outcome. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

14 pages, 245 KiB

Open AccessArticle

Attitude of the Lithuanian Public toward Medical Assistance in Dying: A Cross-Sectional Study

by Benedikt Bachmetjev, Artur Airapetian and Rolandas Zablockis

Healthcare 2024, 12(6), 626; https://doi.org/10.3390/healthcare12060626 - 10 Mar 2024

Cited by 4 | Viewed by 1650

Abstract

Euthanasia and assisted suicide, involving the intentional termination of a patient’s life, are subjects of global debate influenced by cultural, ethical, and religious beliefs. This study explored the attitudes of the general public toward euthanasia, finding varying levels of support. A cross-sectional study [...] Read more.

Euthanasia and assisted suicide, involving the intentional termination of a patient’s life, are subjects of global debate influenced by cultural, ethical, and religious beliefs. This study explored the attitudes of the general public toward euthanasia, finding varying levels of support. A cross-sectional study was conducted. This research specifically evaluated the perspectives of 5804 Lithuanian residents using a survey distributed through social media, which presented medical scenarios on life-preserving interventions. Analysis indicated that gender, religion, experience in caring for patients in a terminal condition, education, and age significantly influenced the attitudes of the respondents toward end-of-life decisions. Specifically, factors like being non-religious or having less experience in caring for the terminally ill correlated with a more positive opinion regarding euthanasia and other forms of medical assistance in dying. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

Review

Jump to: Research, Other

13 pages, 608 KiB

Open AccessReview

Moral Distress of Nurses Working in Paediatric Healthcare Settings

by Ana Cristina Ribeiro Miranda, Sara Duarte Fernandes, Sílvia Ramos, Elisabete Nunes, Janaína Fabri and Sílvia Caldeira

Healthcare 2024, 12(13), 1364; https://doi.org/10.3390/healthcare12131364 - 8 Jul 2024

Cited by 2 | Viewed by 2728

Abstract

This scoping review aims to map the evidence on moral distress of nurses working in paediatric healthcare settings from homecare to hospital. It was conducted according to the Joanna Briggs Institute. International databases were searched according to the specific thesaurus and free search [...] Read more.

This scoping review aims to map the evidence on moral distress of nurses working in paediatric healthcare settings from homecare to hospital. It was conducted according to the Joanna Briggs Institute. International databases were searched according to the specific thesaurus and free search terms. Independent screening and analysis were conducted using Rayyan QCRI. This review considered a total of 54 studies, including quantitative and qualitative studies, systematic reviews, and grey literature; English and Portuguese languages were included. Moral distress is a phenomenon discussed in nursing literature and in the paediatric context but is considered absent from discussion in clinical practice. It is caused by disproportionate care associated with overtreatment. Nurses can present a variety of symptoms, characterising moral distress as a highly subjective experience. The paediatric contexts of practice should promote a healthy ethical climate and work towards a moral community built with peer support, education, communication, leadership, and management involvement. Moral distress is still a complex and challenging multidimensional concept, and the aim should be to promote a culture of prevention of the devastating consequences of moral distress and work towards moral resilience. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

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14 pages, 499 KiB

Open AccessReview

Conscientious Objection and Other Motivations for Refusal to Treat in Hastened Death: A Systematic Review

by Madalena Martins-Vale, Helena P. Pereira, Sílvia Marina and Miguel Ricou

Healthcare 2023, 11(15), 2127; https://doi.org/10.3390/healthcare11152127 - 26 Jul 2023

Cited by 3 | Viewed by 3017

Abstract

Background: Conscientious objection (CO) in the context of health care arises when a health care professional (HCP) refuses to participate in a certain procedure because it is not compatible with their ethical or moral principles. Refusal to treat in health care includes, in [...] Read more.

Background: Conscientious objection (CO) in the context of health care arises when a health care professional (HCP) refuses to participate in a certain procedure because it is not compatible with their ethical or moral principles. Refusal to treat in health care includes, in addition to CO, other factors that may lead the HCP not to want to participate in a certain procedure. Therefore, we can say that CO is a form of refusal of treatment based on conscience. Hastened death has become an increasingly reality around the world, being a procedure in which not all HCPs are willing to participate. There are several factors that can condition the HCPs’ refusal to treat in this scenario. Methods: With the aim of identifying these factors, we performed a systematic review, following the PRISMA guidelines. On 1 October 2022, we searched for relevant articles on Pubmed, Web of Science and Scopus databases. Results: From an initial search of 693 articles, 12 were included in the final analysis. Several motivations that condition refusal to treat were identified, including legal, technical, social, and CO. Three main motivations for CO were also identified, namely religious, moral/secular, and emotional/psychological motivations. Conclusions: We must adopt an understanding approach respecting the position of each HCP, avoiding judgmental and discriminatory positions, although we must ensure also that patients have access to care. The identification of these motivations may permit solutions that, while protecting the HCPS’ position, may also mitigate potential problems concerning patients’ access to this type of procedure. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

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Other

Jump to: Research, Review

8 pages, 268 KiB

Open AccessOpinion

Legislation on Medical Assistance in Dying (MAID): Preliminary Consideration on the First Regional Law in Italy

by Lorenzo Blandi, Russell Tolentino, Giuseppe Basile, Livio Pietro Tronconi, Carlo Signorelli and Vittorio Bolcato

Healthcare 2025, 13(9), 1091; https://doi.org/10.3390/healthcare13091091 (registering DOI) - 7 May 2025

Abstract

Medical assistance in dying (MAID) remains a sensitive and evolving issue in Europe, frequently linked with discussions about human freedom, life dignity, and healthcare policy. While national consensus in Italy is absent, the Region of Tuscany has enacted Law No. 16/2025, which establishes [...] Read more.

Medical assistance in dying (MAID) remains a sensitive and evolving issue in Europe, frequently linked with discussions about human freedom, life dignity, and healthcare policy. While national consensus in Italy is absent, the Region of Tuscany has enacted Law No. 16/2025, which establishes a MAID procedure based on recent Constitutional Court rulings. The commentary aims to provide a preliminary analysis of the new law, addressing ethical, medico-legal, and social issues that emerge in relation to the Italian and global debate on the topic. The law establishes a three-stage process based on four eligibility criteria: irreversible disease, psycho-physical suffering, life-support dependence, and informed consent. However, Tuscany’s model poses medico-legal and ethical concerns, particularly about the boundaries of regional legislative competence, the duties of healthcare professionals, and the possibility of intra-national inequity or “health migration.” In addition, critical organisational implications derived from informed consent and lethal drug self-administration impede clinical implementation in some individuals with mental or neurological disorders. The lack of clarity in the different steps of the procedure, the uncertain supervision system, and the potential consequences for specific categories of vulnerable people underline the need for comprehensive national regulation. A future regulatory framework must balance procedural clarity with individual autonomy and equitable access, bringing Italy in line with larger European context for end-of-life care. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

20 pages, 1717 KiB

Open AccessSystematic Review

AI and Ethics: A Systematic Review of the Ethical Considerations of Large Language Model Use in Surgery Research

by Sophia M. Pressman, Sahar Borna, Cesar A. Gomez-Cabello, Syed A. Haider, Clifton Haider and Antonio J. Forte

Healthcare 2024, 12(8), 825; https://doi.org/10.3390/healthcare12080825 - 13 Apr 2024

Cited by 33 | Viewed by 11867

Abstract

Introduction: As large language models receive greater attention in medical research, the investigation of ethical considerations is warranted. This review aims to explore surgery literature to identify ethical concerns surrounding these artificial intelligence models and evaluate how autonomy, beneficence, nonmaleficence, and justice are [...] Read more.

Introduction: As large language models receive greater attention in medical research, the investigation of ethical considerations is warranted. This review aims to explore surgery literature to identify ethical concerns surrounding these artificial intelligence models and evaluate how autonomy, beneficence, nonmaleficence, and justice are represented within these ethical discussions to provide insights in order to guide further research and practice. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five electronic databases were searched in October 2023. Eligible studies included surgery-related articles that focused on large language models and contained adequate ethical discussion. Study details, including specialty and ethical concerns, were collected. Results: The literature search yielded 1179 articles, with 53 meeting the inclusion criteria. Plastic surgery, orthopedic surgery, and neurosurgery were the most represented surgical specialties. Autonomy was the most explicitly cited ethical principle. The most frequently discussed ethical concern was accuracy (n = 45, 84.9%), followed by bias, patient confidentiality, and responsibility. Conclusion: The ethical implications of using large language models in surgery are complex and evolving. The integration of these models into surgery necessitates continuous ethical discourse to ensure responsible and ethical use, balancing technological advancement with human dignity and safety. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

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16 pages, 1770 KiB

Open AccessSystematic Review

Factors of Hospital Ethical Climate among Hospital Nurses in Korea: A Systematic Review and Meta-Analysis

by Yoon Goo Noh and Se Young Kim

Healthcare 2024, 12(3), 372; https://doi.org/10.3390/healthcare12030372 - 1 Feb 2024

Cited by 5 | Viewed by 1936

Abstract

In the current healthcare landscape, nurses frequently encounter various ethical dilemmas, necessitating situation-specific ethical judgments. It is crucial to thoroughly understand the factors that shape the hospital ethical climate and the elements that are influenced by this climate. This study aims to identify [...] Read more.

In the current healthcare landscape, nurses frequently encounter various ethical dilemmas, necessitating situation-specific ethical judgments. It is crucial to thoroughly understand the factors that shape the hospital ethical climate and the elements that are influenced by this climate. This study aims to identify the variables associated with the hospital ethical climate perceived by Korean nurses. A literature search was conducted using the core database, and the effect sizes of relevant variables were analyzed using a comprehensive meta-analysis. The overall effect size analysis incorporated 56 variables, and a meta-analysis was performed on 7 variables. This study found correlations between ethical sensitivity (ESr = 0.48), moral distress (ESr = −0.30), empathy (ESr = 0.27), ethical leadership (ESr = 0.72), job satisfaction (ESr = 0.64), and intention to leave (ESr = −0.34) with the hospital ethical climate. Both personal and organizational attributes were moderately related to the hospital ethical climate. Enhancing the hospital ethical climate could positively affect both individuals and the organization. The protocol for this study has been registered with PROSPERO (CRD42022379812). Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

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10 pages, 254 KiB

Open AccessEssay

The Dilemma of Compulsory Vaccinations—Ethical and Legal Considerations

by Yael Sela, Keren Grinberg and Rachel Nissanholtz-Gannot

Healthcare 2023, 11(8), 1140; https://doi.org/10.3390/healthcare11081140 - 15 Apr 2023

Cited by 4 | Viewed by 4608

Abstract

The high childhood vaccination coverage in Israel leads to a low rate of morbidity from the diseases against which the vaccination in administered. However, during the COVID-19 pandemic, children’s immunization rates declined dramatically due to closures of schools and childcare services, lockdowns, and [...] Read more.

The high childhood vaccination coverage in Israel leads to a low rate of morbidity from the diseases against which the vaccination in administered. However, during the COVID-19 pandemic, children’s immunization rates declined dramatically due to closures of schools and childcare services, lockdowns, and guidelines for physical distancing. In addition, parents’ hesitancy, refusals, and delays in adhering to routine childhood immunizations seem to have increased during the pandemic. A decline in routine pediatric vaccine administration might indicate that the entire population faces increased risks for outbreaks of vaccine-preventable diseases. Throughout history, vaccines have raised questions about their safety, efficacy, and need among adults and parents who feared or hesitated to vaccinate their children. Objections derive from various ideological and religious reasons or concerns about the possible inherent dangers. Mistrust in the government and/or economic or political interests also raise concerns among parents. The importance of providing vaccines to maintain public health, as opposed to the autonomy of the individuals over their body and their children, raises ethical questions. In Israel, there is no legal obligation to get vaccinated. It is imperative to find a decisive solution to this situation without delay. Furthermore, where democratically one’s principles are sacred and where one’s autonomy over one’s body is also unquestionable, such a legal solution would not only be unacceptable but also rather impossible to enforce. It seems that some reasonable balance between the necessity to preserve public health and our democratic principles should apply. Full article

(This article belongs to the Special Issue Ethical Dilemmas and Moral Distress in Healthcare)

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