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INTRODUCTION
The migratory flows that have characterized the last thirty years have led to an exponential increase in Italy of believers belonging to religions other than the Catholic one.
Compared to what happened in other European countries, immigration in Italy presents some peculiarities such as the short period in which it developed (about thirty years) and the great diversity of origin of the immigrants (over 200 countries from all continents). According to Fondazione Iniziative e Studi sulla Multietnicità (ISMU) calculations and estimates [1] on Istituto Nazionale di Statistica (ISTAT) data [2], the total number of foreigners regularly present in Italy on 1 January 2022 is 6,003,000 of which 5,194,000 residents, 303,000 non-residents (but with regular residence) and 506,000 irregular foreigners without a residence permit (estimated data).
The people who profess a religion other than Catholic Christianity in Italy are approximately 2.2 million Italians and 3.9 million foreigners. Among Italians, 82.1% are Christian (79.7% Catholic Christian), 16.2% atheist or agnostic and 1.7% profess other religions; mainly Islam, Buddhism, Hinduism and Judaism. Among foreigners, 51.8% are Christian (28.8% Orthodox, 17.7% Catholic), 33.3% Muslim, 4.5% are atheist or agnostic and the remaining share professes other religions; such as Hinduism, Buddhism and other oriental religions (Center for Studies on New Religions – Centro Studi sulle Nuove Religioni, CESNUR – elaboration based on the estimate of the 2022 Immigration Statistical Dossier) [3]. Religions followed by Italian citizens and immigrants are shown in Figure 1.
This found our institutions, and in particular public health, unprepared. The concepts of health and disease take on multiple meanings and values with a consequent plurality of behaviors, which must be constantly investigated and considered. In the case of disease, for example, there is substantial mistrust towards official medicine, especially on the part of groups of immigrants belonging to oriental religions or coming from African countries who continue to follow the traditional medicines of their own country or who associate them with prescribed therapies, resulting in problems regarding the effectiveness of the drug and interactions.
The rules dictated by religious faiths may concern the type of diet to follow, fasting periods but also the refusal of certain therapies and the type and composition of drugs that can be prescribed.
Sexuality, abortion and assisted fertilization follow precise rules dictated by the religion to which one belongs. There are also rules that the faithful must follow for organ donation, end-of-life rites, autopsies and burials.
In general, all the different religious confessions also present specific gender problems, complicated by the connection with the culture of the country of origin, which make the relationship with healthcare workers difficult and complicated.
Italy, later than other European states, is rapidly transforming into a multicultural and multi-religious society. Public health is called upon to provide a whole series of adequate responses to the new requests for assistance and care linked to individual cultural-religious specificities.
METHODS
This article analyzes in succession the general principles of the religious faiths present in Italy, focusing on the religious norms and the needs of patients who follow different religions, which have implications for our National Health Service (NHS). Judaism, Islam, Hinduism, Buddhism, Sikhism, the Orthodox Christian Churches and the Protestant Christian Churches were analyzed.
The study is based on bibliographic searches of studies published in Italian and English on the PubMed and Google Scholar databases and on publications available online.
PubMed and Google Scholar databases were searched until the 4th of June, 2023 (without starting date) to retrieve peer reviewed studies and grey literature relevant to the search question. Key words such as “religion”, “religious” “faith”, “health”, “disease”, “belonging”, “affiliation”, “behavior” and “well-being” and synonyms – plus the name of the most common religion faiths – were used with different combination with Boolean operators. Only studies published in Italian and English and publicly available were selected.
Bibliographic search and consultation with experts were used in order to capture information regarding the impact of different religious faiths on health.
The study also made use of targeted interviews on health issues of the national representatives of the religious faiths that make up the Interreligious Table of Rome. The Interreligious Table of Rome brings together national representatives of 8 different religious confessions (Buddhism, Reformed Christianity, Judaism, Hinduism, Islam, Orthodoxy, Seventh-day Adventist Church and Italian Buddhist Institute Soka Gakkai). As an official body of the Municipality of Rome, from 1998 to 2011, it promoted interventions aimed at intercultural and interreligious education with respect for differences, in schools, universities and municipalities in the Roman territory. As a Cultural Association since 2011, it collaborates with local hospitals and healthcare companies in the creation of information and training projects aimed at healthcare workers involved in welcoming the sick, as a consultant for the processes of adapting care and assistance procedures in healthcare facilities.
The questions that guided the discussion with the religious representatives focused on any critical issues perceived by the religious representatives in the protection of health, in reference to topics such as the health of women and minors, the organization of health services and the relationship with the sanitary system.
In February 2023, 8 different in person focus groups, moderated by a researcher of the Center for Global Health Research and Studies of Università Cattolica del Sacro Cuore, Rome, Italy, were organised consulting one by one the different religious representatives. The focus groups lasted 90 minutes each. Key question leading the discussion with religious representatives was “are there any critical issues perceived by faithful of religion you represent in terms of health protection and healthcare?”. Moreover, the key question was further detailed with specific questions regarding any possible barriers encountered with reference to gender issues, children assistance, medicines uptake, healthcare services organisation. At the end of the meeting, the guiding questions were sent to the religious representatives that were also given the opportunity to add additional elements after further reflection.
RELIGIOUS FAITHS
This part will analyze the basic principles of the different religions currently present in Italy and the religious norms that follow their adherents, delving into all the problems and critical issues that NHS practitioners necessarily need to be aware of and deal with.
Judaism
There are approximately 13 million Jews in the world and they live mainly in Israel and the United States. The number of faithful in Italy is 37,000 (less than 2% of the national population) and the vast majority are Italian citizens [3].
In Judaism, illness is considered as a failure to comply with divine provisions and therefore is a consequence of the person’s lack of caution in prevention and treatment, it must be accepted as part of one’s nature and as evidence sent by God [4].
Observant Jews follow a particular diet called Kosher: they can eat ruminant animals such as cows, calves, sheep, goats (artiodactyl mammals with the hoof divided into two parts), poultry such as chickens, fish with scales and fins. Slaughter must be carried out by a qualified and trained person in order to follow the dictates of the Torah. Milk and dairy products cannot be consumed together with meat and poultry [5].
During the Jewish Passover (lasting 8 days, normally in April) the intake of leavened foods is prohibited and bread is replaced with unleavened bread. This celebration is very heartfelt. The patient may request that relatives bring particular foods, in particular for the traditional dinner which takes place on the first and second evening of Easter.
Kippur, the Day of Atonement (between September and October), is dedicated to fasting and prayer.
For Jews, male circumcision is mandatory. It is linked to the pact stipulated between God and Abraham (Genesis 17.10-14), of which circumcision becomes the physical sign that is repeated throughout the generations. Circumcision is performed on babies as young as 8 days old. In the Jewish community, ritual circumcisions are performed in compliance with medical-health protocols and in safe conditions, therefore Jewish newborns can be circumcised in Jewish community facilities. Law 101 of 1989, which approved the agreement between Italy and the Italian Jewish communities, recognized the conformity of the practice of Jewish circumcision with the principles of our legal system [6].
Saturday is a public holiday for Jews. Sabbath begins from sunset on Friday and lasts until Saturday evening. Patients may wish to light two lights at the beginning of the Sabbath and celebrate its beginning with kosher wine or grape juice and bread, and they may ask relatives to provide it. It is forbidden to work on Saturdays, this category also includes non-urgent surgical interventions. In case of hospital discharge on a Saturday, the patient must be able to stay until the evening (even without a bed). The same rules apply on other public holidays.
Judaism forces men to procreate and not waste semen, while women can use contraceptives. Among the contraceptive methods currently in use, the pill is considered the best aid because it interferes less with normal sexual intercourse.
Abortion is not permitted, but if it is intended to protect the physical or mental health of the woman, which could be damaged by a pregnancy, it may be permitted [7].
In Jewish tradition, the fetus is protected from the moment of conception, but its right does not prevail over that of the mother to life [4].
There are no limitations regarding the taking of drugs, organ transplants and transfusions.
Fundamental to Judaism is the centrality of human life. Life is considered inviolable, which is why euthanasia is prohibited [8].
The autopsy is considered an act of disfigurement and any improper use of the body is expressly prohibited. An autopsy may only be permitted in exceptional cases, for example when it is requested by the criminal court when there is uncertainty about the cause of death.
Before burial, the body must be subjected to a washing ritual, which serves to honor the deceased by removing any type of dirt or bad smell. Cremation is prohibited by Jewish law.
Islam
Islam is the world’s second largest religion after Christianity, with followers equal to a quarter of the world’s population. There are over two billion Muslims in the world. Over fifty countries have Muslim-majority populations, including 22 nations in the Middle East, while other groups of believers are clustered in minority communities in nations on nearly every continent.
In Italy there are approximately two million three hundred thousand Muslims of which 528,000 Italian citizens, the majority of whom are of foreign origin who have acquired citizenship over the years and 1,769,000 resident foreign citizens [3].
According to Islam, God is believed to have created human beings and given them their bodies as gifts to be cared for. Therefore, keeping one’s body healthy is important and sick people are expected to look for solutions to restore their physical and mental well-being [9].
Islam has generally encouraged the use of science and biomedicine to alleviate suffering, with Muslim patients seeking medical solutions to their health problems.
Muslims are required to follow a diet, similar to the Jewish Kosher diet, which involves the consumption of foods considered legal (halal), foods subjected to a specific ritual. It is not permitted to eat pork and animals that have not been slaughtered according to Islamic custom; alcohol is strictly prohibited. If halal meals are not available, kosher Jewish meals or vegetarian meals are acceptable. Utensils used in the preparation of non-halal foods should not be used to prepare meals intended for a Muslim patient [9].
Medicines containing alcohol or derived from non-halal animal products are prohibited by the Islamic religion.
Ramadan is the holy month of fasting, dedicated to prayer, meditation and self-discipline. Fasting is an obligation for all healthy adult practicing Muslims. Fasting is one of the five duties of the Islamic faith. During Ramadan, Muslims do not ingest food or liquids, including water, between sunrise and sunset. During this month, medications taken orally, auricularly or nasally, suppositories or inhalations are not permitted because they could interrupt the fast. The patient can only perform certain treatments or take defined medications (drugs absorbed through the skin, injections and gargles, as long as no liquids are ingested). Minors, the elderly, the sick and women who are breastfeeding or pregnant are exempt from fasting. Women during their menstrual cycle and people traveling are exempted only temporarily [10].
Male circumcision, although not mentioned in the Quran, and therefore not obligatory, is practiced almost universally by Muslim males. Islam bases the practice of circumcision on the seventeenth chapter of Genesis, the same biblical chapter referenced by the Jews. For Muslims, circumcision is a matter of cleanliness, purification and self-control. It can be done from after birth up to about fifteen years of age. Unlike Jews, Muslims do not have an agreement with the Italian state. This is mainly due to the lack of a hierarchical clerical structure as well as the lack of a single representation of the different Muslim communities present in Italy [11].
The Italian regional health system does not guarantee the possibility of carrying out non-therapeutic circumcision in a homogeneous way throughout the national territory. In most regions the surgery can only be done privately. The cost, which can vary between 2,000 and 4,000 euros, can be prohibitive for an immigrant family. Often, Muslim immigrant communities, are forced to resort to unqualified personnel, without adequate medical training and in hygienically unsafe environments, putting the very lives of children at risk [6].
Muslim patients from some countries generally do not accept being examined or treated by doctors or other healthcare personnel who are not of the same gender. Women in particular may be less willing to see a male doctor. In addition to the refusal to be assisted by male healthcare personnel, there is the use of delegation to the male companion (father, husband, brother) both for the listing of symptoms and for the approval of therapeutic prescriptions.
Visiting the sick is an important task in the life of a Muslim, so Muslim patients may receive a large number of visits.
Muslims are allowed to use temporary contraceptives, while permanent contraceptive methods (such as vasectomies and tubal closures) are only permitted if the woman’s health is at risk.
Assisted reproduction is allowed, however there are some techniques and practices that are not allowed such as using a sperm donor and cryopreserved sperm after the death of the husband (donor).
A fetus is considered alive after 120 days of gestation, therefore abortion after 120 days of gestation is not permitted unless the pregnancy poses a serious threat to the mother’s life, or in the case of fetal anomalies.
Muslims believe that death is predestined by God, therefore they accept both death and illness as a natural path of life. Islam does not accept treatment aimed at prolonging the final stages of a terminal illness. Under these circumstances it is permissible to shut down life support systems. Islam considers human life sacred, so suicide and euthanasia are prohibited; however, if a patient finds himself in a condition in which he has no life expectancy, he is allowed to stop medical treatment.
In the event of the patient’s death, relatives may want the face (or entire body) to be turned towards Mecca and for the entire body to be covered with cloth and handled as little as possible by healthcare workers. Burial should be carried out as soon as possible after death, sometimes relatives request that burial take place on the same day as death. Islam prohibits the disfigurement of corpses and, for these reasons, some Muslims reject autopsies even though some Muslims (Shiites) favor organ donation and transplantation [9, 12].
When healthcare providers interact with a Muslim patient, they should follow certain recommendations whenever possible [12]. Islamic prayer times may interfere with healthcare facility meal times and special arrangements may be necessary. Before praying, Muslims must wash themselves with water; prayers are recited facing Mecca and performed on a prayer rug, but in case of illness they can be performed in bed or sitting. For those who are not physically confined to bed, you may need a clean, quiet space to pray.
If the staff were to carry out the cleaning, it is a gesture of courtesy to ask the patient himself to move the sacred text which is only touched in a state of ritual purity.
Muslims prefer to use the right hand for eating and drinking. A water container should be placed next to the Muslim patient for washing hands after each meal. Islam places great importance on personal hygiene (washing with water after urination or defecation, removing hair from the pubic area and armpits, keeping nostrils and nails clean) [12].
Hinduism
Hinduism is a religion of Indian origin and, with almost a billion practitioners, it is the third largest religious community in the world, after Christianity and Islam. Hindus are mainly found in India, Nepal and Bali. There are over a billion Hindus in the world. In Italy there are two hundred and twenty-two thousand Hindus, of which 55,000 Italian citizens and 167,000 resident immigrants [3].
It is difficult to define guidelines for healthcare workers because the term Hinduism does not mean a single religious structure, but a myriad of faiths, cultures and philosophies, sometimes even theologically distant from each other, but with common convergent principles. These differences are found in ritual and religious practices. A preliminary interview with the patient and family members is advisable to learn about the religious tradition and related observances.
According to the Hindus, the state of health is a state of balance of vital energies, it is not just one or more organs of the body that become ill, but there is an imbalance of the vital force which alters the functioning of one or more organs, in attempt to re-establish one’s balance. Health is a piece within a complex system of relationships with the environment, emotions and feelings.
The relationship with the family unit is very important, it has a central role in the life of a Hindu, for this reason the visits could be very crowded [13].
The diet includes a ban on the consumption of beef. Many followers of Hindu religions are vegetarians and generally tend to avoid the consumption of milk, meat and eggs.
Hindu women wish to be cared for, bathed only by women and may wish to be examined by a doctor of the same sex. Hindu women are generally reluctant to go to the doctor and be examined and, if pregnant, only go to the doctor close to giving birth [14]. The Hindu woman is reluctant to show parts of her body so it is advisable to limit the affected area as much as possible and carry out the visit in the presence of her husband or another family member. Married women wear necklaces, bracelets or toe rings which have a very sacred value, they should never be taken off without their consent. The same goes for the sacred thread that some men wear around their chest.
There is no official position on contraception, for Hindus life is extremely sacred, birth control is considered a practice not to be encouraged. The only accepted form of contraception is moderation in sexual activity.
Termination of pregnancy is not permitted except in cases where it poses a serious risk to the mother’s life.
As for drugs, natural ones are preferred, while those of animal origin are avoided.
There are conflicting opinions on transplantation and organ donation.
Hinduism encourages acceptance of pain and suffering (Hinduism and death with dignity: historical and contemporary cases) [15].
Hindus believe that the moment of death is determined by fate. The anxiety to prolong life as much as possible, denying imminent death is an undoubted consequence of the illusion of immortality, therefore they are not in favor of the long term use of life sustaining treatment [16].
Hindus believe that all living things, including animals, have a soul that transmigrates from one life to another. Consequently, they do not see death as the end of life but as a passage to rebirth, from one life to another [17].
An autopsy is usually not accepted and, if necessary, it is important to consult the family first.
Hindus practice cremation which according to their religion should take place immediately after death.
Buddhism
Buddhism originated in north-eastern India and then spread from India to central and south-eastern Asia, China, Korea and Japan and recently also to the West.
Buddhism is the fourth largest religion in the world with over 500 million followers. In Italy there are approximately three hundred and forty thousand Buddhists. Italian citizens of the Buddhist faith, including those who have acquired citizenship over the years, are 215,000, while resident Buddhist immigrants are 125,000 [3].
Buddhist women prefer to be visited and cared for by female healthcare personnel, while monks are prohibited from being cared for by personnel of the opposite sex. Often women only turn to health facilities at the end of their pregnancy.
There are no dietary restrictions due to religion, but many Buddhists are vegetarian or vegan.
According to Buddhist teachings, the value of life is sacred, taking life is the negative act par excellence, not only the life of man, but also that of other living beings must be respected.
Life begins at the very moment of conception. Therefore, the voluntary termination of pregnancy is in itself a very negative act. In some situations, for example in danger for the mother, in cases of physical violence or similar, the termination of the pregnancy may be permitted, but it is always the termination of a life. This has moral implications from the perspective of the woman’s karma.
Illness and suffering are an integral part of man’s life, and as such they must be realistically considered not a punishment for a fault committed, a misfortune, but a fact that must be addressed carefully from a therapeutic and psychological point of view. Any intervention and therapy aimed at improving the patient’s condition is accepted.
As regards the approaching moment of death, a treatment is strongly recommended that guarantees the patient maximum tranquility and serenity so as to be able to best prepare for the moment of passing away. However, Buddhism often opposes the use of opioid medications at the end of life due to the undesirable consequence of a reduced level of consciousness at the time of death.
From the Buddhist perspective, the patient in a persistent vegetative state is a living human being. Such a patient should not, in principle, be treated differently from any other patient. Therefore, euthanasia is not permitted [18].
Death is the fundamental act of life as it indicates the possibility of a positive rebirth. There is a lot of attention to the passage, which does not end with cardiac arrest, but requires more time to allow consciousness to move away from the body. Buddhists believe that the body is not immediately devoid of spirit after death. According to Tibetan tradition, the body should not be handled for 72 hours, and many Buddhist families may request that the body remain at their disposal for several hours after death to perform religious rites [19].
From this perspective, the autopsy is seen as a bloody act and is therefore accepted with great difficulty.
In Buddhism there are no injunctions for or against organ donation. Central to Buddhism is the desire to alleviate suffering, so organ donation can be seen as an act of generosity [19].
Sikhism
The Sikh religion, the fifth religion in the world by number of believers, was born in northern India in the Panjab. It has around 30 million believers distributed throughout the world, in Italy the number of believers is around 150/180 thousand [3].
For Sikhs, hair (hair, beard and perineal hair for women) must not be removed from any part of the body without their consent. In the event that a patient’s life is in danger and in the event that urgent medical care is required (which cannot be carried out without their removal), medical care must be provided without hesitation. If a Sikh patient refuses medical treatment on the basis of his religious beliefs (because his hair cannot be shaved), these wishes must be listened to and the patient informed of the potential risks arising from such a decision is required to sign a document in which he assumes all responsibility [20].
Cleanliness is very important as Sikhs follow a ritual of cleanliness and prayer each morning and evening, that healthcare workers should try to respect.
Given that the religion prohibits alcohol consumption and smoking and that most Sikhs are vegetarians, some medicines may not be suitable because they contain alcohol or are derived from animals. Healthcare professionals should inform patients: about the pharmaceutical composition and the production process of the proposed medicinal product (for example whether the use of materials of animal origin is foreseen in the manufacture of the product).
Prayer is an integral part of their daily routine. Sikh patients may wish to have a prayer book with them during their hospital stay. The prayer book is usually covered with a piece of cloth and should be kept in a clean place at bed height. It is important to wash your hands before handling any prayer book.
For a Sikh, the family is fundamental, therefore the family unit must always be kept informed and represents an excellent interlocutor for the medical and paramedical staff, in fact many decisions regarding the patient’s health are made in agreement with the relatives.
Sikh patients prefer to be seen by healthcare professionals of the same sex and may request the presence of a family member during any clinical examination.
Healthcare professionals must ask permission from the patient or a family member before remove any article of faith; cut hair and hair from any part of the body; remove the turban [20].
Orthodox Christianity
The Orthodox Church does not have a single structure like the Catholic Church but is made up of local “autocephalous” Churches. An autocephalous church possesses the right to resolve all internal problems on its own authority and the ability to choose its own bishops, including the Patriarch, Archbishop or Metropolitan who heads the church. While each autocephalous church acts independently, they all remain in full sacramental and canonical communion with one another. The Orthodox currently number around 130 million and are widespread especially in Eastern Europe, the Balkan peninsula and the Middle East, but also in North Africa, Japan and North America. In Italy there are approximately two million Orthodox Christians: 400,000 Italians plus approximately 1,600,000 non-Italian citizens (resident immigrants), originating mainly from Romania, Ukraine and Moldavia [3].
The Orthodox Church considers human life and well-being as gifts from God, perceives the healing of physical illnesses by the doctor as also a divine action. Therefore, to achieve healing, most Orthodox Christians turn to both modern medicine and the spiritual resources of their ancient faith. The Orthodox Christian sees suffering as a consequence of man’s sinful condition which manifests itself in various ways: through human mortality, individual sin, and the evil prevalent in society and nature.
There are no restrictions on diet but the Orthodox fast for many days a year: every Wednesday and Friday, and at the start of Great Lent, and on Great Friday of Lent. Fasting consists of excluding alcohol, oil and animal proteins and consuming only bread, pasta, rice, olives, vegetables and fruit.
The Orthodox Church does not oppose the use of drugs and blood transfusions as therapeutic measures, and in the case of a dying patient, palliative care should be provided to relieve pain.
Orthodox Churches generally have a more nuanced position on contraception than the Catholic Church. However, artificial contraception is not seen as evil, but can be considered lawful under certain conditions within marriage (for example if the spouses have already had more children) [21].
Only the Ethiopian Orthodox Church, the Eritrean Orthodox Church and the Coptic Orthodox Church advise to perform male circumcision.
The Orthodox Church condemns euthanasia as a mortal sin. If the patient’s health condition is critical and there is no hope of recovery, interruption of life support systems may be allowed.
Once death has occurred, the presence of an Orthodox priest is necessary who, in addition to reciting prayers, will provide family members and/or medical personnel with information on the procedures to be performed. Since the faithful often ask the hospital to be able to place a candle near the patient’s bed in the last moments of life and since this need is often not permitted for safety reasons, the Orthodox priest is the only person able to mediate between the hospital norms and tradition.
Autopsies should only be performed if clearly necessary.
The Orthodox religion only provides for burial in the ground (inhumation) [21].
Protestantism
There is no “Protestant religion” as such. “Protestant” is a term that applies to various Christian groups that do not accept the authority of the Pope of Catholicism or the Patriarch of Orthodox Christianity [22, 23].
According to estimates by the Center for Studies on New Religions (CESNUR), in 2021 among Italian citizens (excluding foreign citizens resident in Italy) there were 383,100 Protestants, whose main Churches of belonging were: Pentecostal, Evangelical (Lutheran and Reformed), Waldensian, Baptist, Methodist, Seventh Day Adventist, Anglicans. Among foreigners, residents and irregulars, CESNUR estimates 224,400 units [3].
Protestant Christians have a different way of understanding the cause of illness, some see it as a consequence of personal behavior and an expression of guilt or shame, others see illness as a cause derived from situations over which they have no control, others as a punishment or personal test from God.
Since these ideas are often linked to personal experiences, it is appropriate for healthcare professionals to discuss them with the patient. For example, a small number of Protestants from a tradition that practices faith healing will be reluctant to trust today’s medical practices and may wish to be treated by faith healers in addition to the care provided by medical personnel.
There is no universal agreement between different Protestant groups regarding abortion [23].
Many Protestant groups affirm gender equality even though individual families may not practice it. Healthcare personnel may find themselves in situations where the males of the family are responsible for every decision regarding practical and therapeutic measures.
There are no specific diet-related prohibitions, however some Protestants may prefer to avoid the consumption of caffeine, meat, and alcohol. The Seventh-day Adventist Church, for example, shows particular attention to healthy and sober lifestyles. Adventists strictly follow a lacto-ovo-vegetarian diet. They refrain from eating meats such as pork, rabbit, horse and fish that do not have fins and scales. They also abstain from the use of alcohol, tobacco and any type of drug [24].
Most groups do not ban cremation. Some Protestant groups perform specific rituals and practices at the time of death, while others prefer that family, friends and their clergy be present to comfort the patient at this delicate time.
In general, Protestant groups do not prohibit organ and tissue donation, in fact most groups encourage it because it is a way of caring for others. Both blood transfusions and autopsies are permitted.
RELATIONSHIP BETWEEN STATE AND RELIGIOUS FAITHS IN ITALY
The Italian Constitution recognizes (article 19) the right to freely profess one’s religious faith and practice worship, excluding “rites contrary to good customs”, and prohibits regulatory limitations on ecclesiastical bodies, which can organize themselves according to their own statutes. Relations between the State and religious confessions other than the Catholic one, according to Article 8 of the Constitution, are regulated by law on the basis of agreements that must be stipulated with the relevant representatives [11]. The confessions with and without agreement are shown in Table 1. The Agreement with the State guarantees, among other things: spiritual assistance in compulsory institutions, such as the armed forces, places of health and penal institutions; the right not to make use of religious teaching; recognition of the civil effects of marriages celebrated before the ministers of worship of the respective religious confessions; the protection of places of worship and the valorization of assets relating to the historical and cultural heritage of each confession; free exercise of their ministry by ministers of religion; the recognition of the religious holidays of each religious confession.
In the case of the Confessions that have stipulated the Agreement, hospital spiritual assistance is entrusted to ministers of religion registered in the appropriate certified lists. They enjoy free access to institutions even on their own initiative, without time limitations; in any case the hospital is required to promptly communicate requests for assistance made by patients or their families.
For religions without convention the regulatory basis remains Royal Decree no. 289 of 1930, according to which ministers of religion admitted to the State can be authorized to frequent places of treatment, to provide religious assistance to patients who request it, by the administrative management of the institute itself (art. 5). For the latter, spiritual assistance is not always guaranteed.
THE INTERVIEWS: OTHER CRITICAL ISSUES
The interviews with the representatives of the religions of the “Interreligious Table of Rome” confirmed the critical issues previously listed for the individual religious faiths.
Representatives of Hindus, Buddhists and Muslims reiterated the problems relating to the relationship of immigrant faithful with social and healthcare personnel, the poor adherence to female cancer prevention campaigns and the poor access to gynecological visits and pre- and post-natal procedures. The representative of the Buddhist faith also underlined the difficulty of health integration of the Chinese community, essentially due to linguistic barriers.
Another critical issue noted is the lack of trust that Eastern faiths share in official medicine and the fact that immigrants often prefer to return to their country of origin to undergo treatments and surgeries. As regards Islam, it should be added that in the Italian school population there are very few girls originating from Bangladesh, precisely because some groups of immigrants, originating from Bangladesh, send their daughters to study in their country of origin.
Some religions such as Islam and Judaism, which give great importance to end-of-life rites, complain about the general impossibility of carrying them out in healthcare facilities.
All the representatives, both of the faiths affiliated with the State and those not affiliated with the State, underlined the difficulty of having their religious ministers access hospitals to assist their faithful, in addition to the lack of places in our hospital facilities dedicated to the prayer of patients hospitalized.
CONCLUSIONS
In this study we have considered the main needs of believers of religions other than the Catholic one who turn to healthcare, and we have tried to indicate the consequent behaviors that all healthcare workers should take into consideration to guarantee adequate assistance in structures of the Italian health services, as required by our Constitution.
The task of the NHS is to guarantee access to prevention, diagnosis and treatment services to every individual present on the national territory, without distinction of gender, religion or ethnicity. Religious beliefs influence choices regarding procreation, organ donation and transplantation, palliative care and end-of-life rituals; adherence to pharmacological prescriptions and dietary indications and different attitudes towards prevention. Structural change in society also requires change in the healthcare sector.
However, in the management of the doctor/patient relationship and in the assistance/care spaces there is still a general lack in the implementation of active practices and positive actions with respect to the need to guarantee adequate religious and spiritual support aimed at alleviating suffering, pain and illness, to promote individual well-being
It is often the citizens themselves, of faiths other than the Catholic religion, who report a certain inadequacy of health facilities in dealing, in the treatment and care sector, with specific needs relating to aspects of a cultural and religious nature, with the emergence of possible inequalities. Places of care and assistance are also called to be spaces of attention to intercultural dialogue and respect for religious differences. To support care processes it is also necessary to intervene on the quality and comfort of the hospital environment; propose adequate menus; ensure support for the spiritual and religious needs of all patients; facilitate the entry and presence of ministers of worship for the spiritual assistance of both the patient and his family, prepare spaces for the prayer needs of the faithful.
The change towards a multi-religious and multicultural society requires that healthcare workers equip themselves with new professional skills, suited to the health needs of citizens of other cultures and religions.
In conclusion, healthcare is called to renew itself and adapt to changes in needs and expectations that affect the population. This is why it is increasingly important to build a healthcare system based on integration, dignity and respect for the person as a whole.
It is therefore impossible to ignore adequate information/training courses on the fundamental principles, rules and observances dictated by the different religions followed by patients.
Figures and tables
Figure 1. Religions followed by Italian citizens and immigrants. Italian Catholics, Italian atheists and agnostics are not shown in the graph because the numbers are too high.
| Religious faiths that have entered into an Agreement with the Italian State |
| Waldensian Table Union of Italian Jewish communities Union of Seventh-day Adventist Christian Churches Assemblies of God in Italy Evangelical Baptist Christian Union of Italy Evangelical Lutheran Church in Italy Sacred Orthodox Archdiocese of Italy and Exarchate for Southern Europe The Church of Jesus Christ of Latter-day Saints Apostolic Church in Italy Italian Buddhist Union Italian Hindu Union Soka Gakkai Italian Buddhist Institute |
| Religious faiths that have not entered into an Agreement with the Italian State |
| Several independent Evangelical Churches Islam Jehovah’s Witnesses Romanian Orthodox Diocese of Italy Sikhism |
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