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A bill against rights

Italy's Senate has approved a bill that ignores patients' wishes and the country's own constitution.

On 26 March, the Italian Senate approved a bill that would give physicians in the country the right to override the living wills of people who are in a persistent vegetative state, and to try to keep the patients alive through artificial nutrition.

The measure has caused intense controversy. Many countries have laws, or established codes of medical practice, that protect the expressed wishes of an individual to decline treatment if they become severely incapacitated and incapable of communicating. In most US states, for example, a doctor must negotiate with relatives via an ethics committee if he or she believes that a patient incapacitated in this way could benefit from additional treatment. The Italian bill, however, which is now being discussed in the lower house of parliament, the Chamber of Deputies, explicitly allows physicians to overrule such living wills. It also declares that artificial nutrition — which requires a feeding tube to be implanted into the stomach — is not a clinical intervention.

Curiously, the proposed law applies only to patients in the type of prolonged, deep coma known as a persistent vegetative state, and not to those with other, similarly incapacitating illnesses. This is because the bill has been prompted by the recent and much-publicized death of Eluana Englaro, who spent 17 years in a vegetative state after a car accident at the age of 21. Her father, arguing that his daughter had voiced a desire to be allowed to die if incapacitated, had pressed her reluctant doctors to cease artificial feeding. He eventually took legal action, winning in one court after the next in fighting off all the doctors' appeals. In February, he finally had her moved to a hospital that was prepared to remove the feeding tube. Prime Minister Silvio Berlusconi issued an emergency decree to block the process, but the Italian president refused to sign it. The constitutional crisis was averted when Englaro died on 9 February.

Surveys have indicated that a large majority of Italians do not support the idea that living wills could be ignored. But most relevant scientific societies have been quiet. The Federation of Italian Physicians published only a mild statement, after the Senate vote, suggesting that it should have been consulted.

As tragic as Englaro's situation was, media-fuelled emotion is not a good basis for lawmaking. The Italian constitution says that no one can be forced to undergo medical treatment without his or her approval. The Chamber of Deputies must now ensure that the bill is imbued with a suitable level of scientific and legal sophistication, and that it meets this constitutional provision. Discussion needs to embrace the requested wider consultation with the medical community and provisions should be made for care-givers' conscientious objection. But a physician whose conscience precludes his or her personally removing a feeding tube should not have the last say in the life or death of a patient whose wishes are clearly stated.

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A bill against rights. Nature 458, 550 (2009). https://doi.org/10.1038/458550a

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