Bioethical contributions in health conflict situations

This is our last issue of 2021 – a year of many efforts against the COVID-19 pandemic, vaccination, and many important reflections.

This editorial begins with a topic that has been widely discussed, as it involves bioethical issues: an analysis of the pandemic and bioethical considerations about early treatment. Without polemicizing and adopting the Opinion of the Brazilian Federal Council of Medicine (CFM) 4/2020¹ , it is not about supporting or not the use of any medication, but about the bioethical pillar of physician and patient autonomy, especially when the principles of beneficence and non-maleficence are observed. That is, a true “therapeutic alliance” between physician and patient should be implemented to always comply with the guidelines provided by evidence-based medicine.

Ferreira² points out that before the pandemic, the world had already been facing humanitarian and environmental crises, social injustices, emigration, suffering, and death. The pandemic, the epidemiological insecurity, the limitation of liberties, the loss of dignity of many, the low investment in public health, and the reappearance of diseases considered eradicated due to the lack of vaccination, have only maximized the existing problems and exposed the wounds of the weakened public health.

We must consider that COVID-19 is a disease less than two years old, for which no country in the world was prepared. After all, the declaration of Public Health Emergency of International Concern occurred in January 2020, and the pandemic was recognized in March 2020. Since then, we saw many studies try to solve the problem and prevent mysthanasia, including research on drugs and vaccines. In the context of comprehensive health care, the early approach and use of medications in the early phase of the disease were understood as a possible attempt to provide off label treatment to minimize the effects of the pandemic. In such cases, both physician and patient needed to be informed of their choices³ .

Patient autonomy is a recurring topic, now considering the advance directives of will, which, according to Monteiro and Silva⁴ , are an instrument to guarantee to patients their right to decide about health care at the end of life. It is an important tool that helps end-of-life medical decision-making, which deserves to be the object of consensus between physicians, patients, and society. Advance directives represent the possibility for patients to make health choices for and by themselves when they are objectively unable of expressing their will.

The evolution of medicine has forced the Law and other disciplines to evolve in order to regulate technological advances. Law plays a key role in ensuring that these advances can be used legally⁵ .

Death remains a source of distress and concern for humanity, but it is part of the social phenomena that must be experienced by all, albeit in different ways. Advance directives of will – via living will or health care power of attorney – are the patient’s response to the great technological advances in medicine and to more aggressive medical treatments whose benefits are debatable. The goal is to avoid dysthanasia.

In Brazil, advance directives gained relevance and greater visibility after Resolution 1,995/2012⁶ , whose article 2 mentions that, concerning decisions on care and treatment of patients unable to communicate or express their will freely and independently, the physician will consider the advance directives.

Another theme addressed in this issue is pediatric palliative care, which, according to the World Health Organization (WHO), prevents, identifies and treats chronic, progressive, and advanced diseases in children, considering the families and multidisciplinary teams that participate in this care⁷ .

According to Iglesias, Zollner, and Constantino⁸ , pediatric palliative care differs from adult care. The number of children who die is small, many children survive to adulthood, and the care necessarily involves the family, lasting several months or even many years. Thus, pediatric palliative care encompasses the physical, spiritual, religious, psychological, and social aspects, according to family values, which is why it is multidisciplinary, global, and systematic. The goal is that children with life-threatening pathologies never lack love and comfort.

The current characterization of conscientious objection will also be cause for reflection since its application generates many controversies. In the case of legal abortion, for example, which in Brazil is allowed in three circumstances (pregnancy caused by rape, risk of death for the mother, and anencephaly cases), when a physician claims conscientious objection, considering a legally permitted procedure, they must justify such refusal and refer the patient to another professional⁹ .

Conscientious objection remains a way of protecting the diversity of cultures, beliefs, values, and individual convictions present in a plural and tolerant society. It is a physician’s right and an imperative of conscience, and must be used with great personal integrity. The subject is not only related to the medical profession, but also involves religious and ethical beliefs and aspects, relating both to women’s autonomy and to the autonomy of each physician. Given this complexity, the topic should be integrated in the medical school curriculum.

Considering other controversial subjects, we can mention the medically assisted reproduction and the fact that sexual orientation, marital status or cis/trans status should only exceptionally serve as legitimate arguments for conscientious objection¹⁰ , since no form of discrimination based on such attributes is appropriate.

Bioethical paradigms are also cause of reflection, especially regarding the principlist theory, which includes respect for autonomy as a new principle of medical ethics. Beauchamp and Childress¹¹ proposed a new ethical theory that only applied the principles to conflicting situations in the physician-patient relationship. According to Dejeanne¹² , besides the principle of autonomy, which is joined by beneficence, non-maleficence, and justice, the Kantian ethical principle of autonomy of the will should be taken as the determining moral philosophical foundation to discuss bioethical issues.

The article “Vade mecum about dying and death” reflects on the representations of death in different cultures and religions. The representations of death and dying have undergone significant changes over time and space. Since the second half of the 20th century, death has ceased to be familiar and has become something that postmodern society does not feel able to deal with, since it does not admit death as part of the life cycle¹³ .

Another topic addressed in this issue is ecology. The text “The new climate regime of the Anthropocene and Gaia” comments on the moment we live in, based on Latour’s reflections, who challenges the Darwinian theory that only living beings adapt to the environment¹⁴ . According to Latour, the planet is also a living organism, subject to change, which interacts with living beings.

In fact, parallel to bioethics, environmental ethics has also become the focus of attention of scientists and public policy makers – nationally and internationally –, and is today a central concern, especially of younger generations. This is due to the progressive social awareness regarding the importance of the environment and biodiversity, as well as of the responsibility to leave future generations a truly sustainable planet.

Another article in this issue addresses joint custody in light of on bioethics and biolaw. According to Strong¹⁵ , since the dawn of humanity, the family has always been a social group that ensured the survival of our species. Bioethics, for being multidisciplinary, can assess the family in contemporary times from a privileged perspective. In this time of rapid changes, we must respect the family as a living organism based on human rights, with reciprocal duties and rights, thus reducing social vulnerability. Family is the core element of humanity, and the protection of children – always considering their best interest – is both a power and a duty.

Finally, an article on denial of discrimination and stigma according to bioethics analyzes and discusses these topics considering the role of the State in developing anti-discrimination and anti-stigmatization public policies. According to the Universal Declaration on Bioethics and Human Rights ¹⁶ , no individual or group should be discriminated against or stigmatized for any reason. Any kind of stigma or discrimination violates the dignity and human rights and fundamental freedoms of the individual.

According to Godoi and Garrafa¹⁷ , recurrent human rights violations, discrimination, and prejudice due to ethnicity, sexual orientation, or health issues require uncompromising defense of bioethics, for they increase vulnerability. This is a highly pertinent and essential topic to bioethics.

This issue also has several other interesting topics in the area of research. Enjoy your reading!

Referências

• ¹
  Conselho Federal de Medicina. Processo-Consulta CFM nº 8/2020 – Parecer CFM nº 4/2020 [Internet]. Brasília: CFM; 2020 [acesso 29 out 2021]. Disponível: https://bit.ly/3ks1X8w
  » https://bit.ly/3ks1X8w
• ²
  Ferreira S. Ética em tempos de covid-19. Resid Pediatr [Internet]. 2020 [acesso 31 out 2021];10(2):1-5. DOI: 10.25060/residpediatr-2020.v10n2-06
• ³
  Organização Pan-Americana da Saúde. Histórico da pandemia de covid-19 [Internet]. 2020 [acesso 1º nov 2021]. Disponível: https://bit.ly/3D5Qcfm
  » https://bit.ly/3D5Qcfm
• ⁴
  Monteiro RSF, Silva A Jr. Diretivas antecipadas de vontade: percurso histórico na América Latina. Rev. bioét. (Impr.) [Internet]. 2019 [acesso 1º nov 2021];27(1):86-97. DOI: 10.1590/1983-80422019271290
• ⁵
  Santos GS. Testamento vital e diretivas antecipadas de vontade [dissertação] [Internet]. Capão da Canoa: Universidade de Santa Cruz do Sul; 2016 [acesso 1º nov 2021]. Disponível: https://bit.ly/3Hf4EUP
  » https://bit.ly/3Hf4EUP
• ⁶
  Conselho Federal de Medicina. Resolução CFM nº 1.995, de 9 de agosto de 2012. Dispõe sobre as diretivas antecipadas de vontade dos pacientes. Diário Oficial da União [Internet]. Brasília, p. 269-70, 31 ago 2012 [acesso 29 out 2021]. Seção 1. Disponível: https://bit.ly/31S0stT
  » https://bit.ly/31S0stT
• ⁷
  Castro REV. Considerações sobre cuidados paliativos pediátricos. Pebmed [Internet]. 2019 [acesso 29 out 2021]. Disponível: https://bit.ly/30dJ3e6
  » https://bit.ly/30dJ3e6
• ⁸
  Iglesias SBO, Zollner ACR, Constantino CF. Cuidados paliativos pediátricos. Resid Pediatr [Internet]. 2016 [acesso 1º nov 2021];6(supl 1):46-54. Disponível: https://bit.ly/3F3p6pG
  » https://bit.ly/3F3p6pG
• ⁹
  Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de medicina. Rev Bras Educ Med [Internet]. 2016 [acesso 1º nov 2021];40(1):86-92. DOI: 10.1590/1981-52712015v40n1e02382014
• ¹⁰
  Mascarenhas IL, Costa APCA, Matos ACH. Direito médico à objeção de consciência e a recusa em realizar procedimentos de reprodução assistida em casais homossexuais: a discriminação travestida de direito. Civilística.com [Internet]. 2021 [acesso 1º nov 2021];10(2):1-24. Disponível: https://bit.ly/3c1I9UL
  » https://bit.ly/3c1I9UL
• ¹¹
  Beauchamp TL, Childress JF. Princípios de ética biomédica. São Paulo: Loyola; 2002.
• ¹²
  Dejeanne S. Os fundamentos da bioética e a teoria principialista. Thaumazein [Internet]. 2011 [acesso 1º nov 2021];4(7):32-45. Disponível: https://bit.ly/3ojVGNd
  » https://bit.ly/3ojVGNd
• ¹³
  Caputo RF. O homem e suas representações sobre a morte e o morrer: um percurso histórico. Revista Multidisciplinar Uniesp [Internet]. 2008 [acesso 1º nov 2021];6:73-80. Disponível: https://bit.ly/3kuvtdL
  » https://bit.ly/3kuvtdL
• ¹⁴
  Silva FS, Araújo A. Fazer-se terrano: por uma metafísica política de Gaia. Opinião Filosófica [Internet]. 2020 [acesso 1º nov 2021];11(3):1-8. DOI: 10.36592/opiniaofilosofica.v11.1000
• ¹⁵
  Strong MI. Reflexões bioéticas em situações de família: a guarda compartilhada dos filhos. Bioethikos [Internet]. 2010 [acesso 1º nov 2021];4(4):461-71. Disponível: https://bit.ly/3CaLH1E
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• ¹⁶
  Organização das Nações Unidas para a Educação, a Ciência e a Cultura. Declaração Universal sobre Bioética e Direitos Humanos [Internet]. Paris: Unesco; 2006 [acesso 4 abr 2021]. Disponível: https://bit.ly/3mZ1Wuh
  » https://bit.ly/3mZ1Wuh
• ¹⁷
  Godoi AMM, Garrafa V. Leitura bioética do princípio de não discriminação e não estigmatização. Saúde Soc [Internet]. 2014 [acesso 1º nov 2021];23(1):156-66. DOI: 10.1590/S0104-12902014000100012

Publication Dates

• Publication in this collection
  18 Mar 2022
• Date of issue
  Oct-Dec 2021