Critical analysis of the bioethics, work and health interface

Abstract

With the current Brazilian labor counter-reforms, the topic becomes more present in political discussions. In this context, bioethics can help to understand the limits and possibilities of the current social scenario. Thus, this study analyzes the interface between bioethics, healthcare and work, as well as its relevance as a research topic. We chose the reflexive essay format and divided the text into three parts. The first addresses the work in healthcare and its ethical aspects, the second presents the relation between bioethics and this type of work considering mainly its performance, and the third addresses the bioethical-work relationship through the criticism of morals and the laws in capitalism. Finally, we make a brief suggestion on how to base this topic from the point of view of expanding its scope from a critical perspective.

Bioethics; Work; Ethics; Civil rights; Comment

Resumo

Com as contrarreformas trabalhistas em curso no Brasil, o trabalho retoma sua centralidade. Nesse contexto, no que se refere ao setor de saúde, a bioética pode ser uma aliada para compreender limites e possibilidades do atual cenário social. Assim, este estudo analisa criticamente a interface entre bioética, saúde e trabalho, pensando sua atualidade como tema de pesquisa. Optou-se pelo formato ensaístico-reflexivo, com texto em três partes. A primeira trata do trabalho em saúde e de seus predicados éticos; a segunda apresenta mais diretamente a relação entre esse trabalho e a bioética, detendo-se sobre a questão do desempenho; e a terceira resgata a raiz da relação bioética-trabalho por meio da crítica à moral e à forma jurídica enraizadas no modo de produção capitalista. Por fim, lança-se brevíssima sugestão sobre como pautar este tema criticamente, de modo a ampliar seu escopo.

Bioética; Trabalho; Ética; Direitos civis; Comentário

Resumen

Con las contrarreformas laborales en marcha en Brasil, el trabajo retoma su centralidad. En ese contexto, en lo que se refiere al sector de salud, la bioética puede ser una aliada para comprender límites y posibilidades del actual escenario social. Así, este estudio analiza críticamente la interfaz bioética, salud y trabajo, pensando su actualidad como tema de investigación. Se optó por un formato ensayístico-reflexivo dividido en tres partes. La primera trata del trabajo en salud y sus predicados éticos; la segunda presenta más directamente la relación entre ese trabajo y la bioética, deteniéndose en la cuestión del desempeño; y la tercera rescata la raíz de la relación bioética-trabajo mediante una crítica a la moral y a la forma jurídica enraizadas en el modo de producción capitalista. Finalmente, se hace una brevísima sugerencia sobre cómo basar este tema para ampliar su alcance desde una perspectiva crítica.

Bioética; Trabajo; Ética; Derechos civiles; Comentario

Bioethics has been little requested in scientific research on problems regarding the work environment. However, with the labor counter-reform underway in Brazil, anchored in the neoliberal advance throughout the world¹ , labor becomes more present in health discussions. In this context, bioethics may help to understand some issues by discussing the social context.

In the history of capitalism and, more recently, neoliberalism, work is no more linked to human emancipation, being increasingly in the hands of super plunderers who do not hesitate to reinforce slave labor. Exploitation based on the deregulation of labor relations and successive threats to the workers’ right are only legal expressions of this social relationship. This issue can be addressed by bioethics, as long as this field assumes a philosophical position away from metaphysical speculations and exposes the materiality of the problem.

The labor world gathers a wide range of economic production activities. With the development of capitalism, the act of producing has changed profoundly, from advances in the service sector to the “intensive” technology sectors, used in all spheres of social relations, even in the most intangible ones. In this context, healthcare – a sector with a high level of intangibility – is not exempt from the changes required by productive restructuring² , even in the public sector³ .

In health and other areas, whether in private or public sphere (but above all in the latter), legal relations tend to benefit management to the detriment of the worker, hampering the work itself and, therefore, undermining the right to health in its broad sense⁴ . For this reason, a criticism of the legal norms – and, more deeply, the nature of Law – can lead to the roots of the problem.

Based on these premises, the aim of this article is to reflect on the healthcare work from the bioethics perspective, in a moment when flexibilization of labor rights is advancing in Brazil – an even more serious advance for the health sector, given the human cost of the process. For this purpose, we divided this reflective and interpretive essay into three sections: the first addresses the healthcare work and its ethical aspects; the second presents the bioethical approach, showing the plurality and challenges of discussions on the subject; and the third section focus on the roots of the relationship between bioethics and labor and on criticizing the moral and legal system founded in the capitalist mode of production.

Healthcare work and ethical aspects

The work-healthcare relationship is defined by the impact of economic interests on the human body. In this interface, a recurring question has prompted the discussion: to what extent is the imposed economic order ethically tolerable, in terms of resistance and adaptation of the human organism? In addition to the economic and biological perspective⁵ , bioethics can be a fruitful field for a broad understanding of the possibilities and limits of such discussion.

There are many ways to understand work. However, regardless of the epistemological perspective, and especially in times of crisis in human relationships⁶ , it will always be the structuring factor of relations, no matter how much one tries to hide it. Here we rely on the understanding of healthcare work by Mendes-Gonçalves⁷ , who considers it a process whose purpose is to meet the essential needs of populations. These would be basically the reduction of epidemiological indices, which to a large extent depends on the expanded understanding of healthcare, focused on social aspects, beyond the mere encounter between professional and patient.

In the public sector, the assessment of workers from a narrow perspective makes them victims of external intentions and managers who judge their work based on what they understand as a product. The result is a disregard of healthcare work teleology in its critical sense and the mechanization that turns individuals into consumers of doctors’ consultations. When healthcare work is considered in such limited terms, the ethical aspects of the bioethics-healthcare work interface become restricted to the sphere of morality, with the polarization between “good” (when the expected product is obtained) and “bad” (expected production fell short). For this reason, the ethical discussion must focus on the contemporary transformations of work, relativizing and facing the concepts of “harmony” and “social order” for coexistence⁸ , ⁹ in order to emphasize ideas of struggle, conflict, change and, of course, social overcoming.

Work can be both a social bond linked to liberation and achievement as a source of oppression and alienation of human beings¹⁰ . In the prevailing macroeconomic logic, which implies power relations¹¹ in the social division of labor and class cleavage, the exploitation and devaluation of labor assumes sophisticated forms, beyond the deregulation and loss of rights, under an idea of “flexibility” that undermines these bonds¹² . This devaluation of work weakens its moral function¹³ and, to understand this from a bioethical perspective, we must go beyond deontology, emphasizing the current conditions of labor relations – disciplining, insecure and threatening – to which workers are subject.

The impossibility of dealing, individually or collectively, with situations that threaten positivist morality (produced/not produced) or questioning the purpose of this production generates moral suffering in the worker¹⁴ and the degradation caused by working conditions. At this point, a tolerance pact is established with this type of violence (symbolic and material), silencing the collective and gradually weakening and destabilizing the worker, who little by little loses self-esteem and starts to doubt himself and even feels like a liar, since he is often discredited by his peers. Thus, his defenses are destroyed and his self-confidence broken, making it difficult or even preventing the exercise of a professional activity, in a situation that reflects on the family and social sphere¹⁵ .

By its own nature, healthcare work is even more vulnerable to moral threats, since it occurs through living work in the act ¹⁶ . However, such living work continuously deals with instruments, standards and equipment, with the interaction of different types of technology. These interactions shape the production of care, which should be based more on the subjective interaction between professional and user than on the mere application of protocols and rules¹⁷ - ¹⁹ .

All work is mediated by technologies and depends on their behavior. This relationship can be more or less creative, with focus on relationships or on logical processes of rigid instrumentation (such as machinery and equipment). In the medical work, for example, we can point out three elements that show the technological arsenal linked to professional performance: instruments (hard technologies), technical knowledge (hard-soft technologies) and intersubjective relationships (soft technologies). The physician can use and combine these three types to treat patients. Therefore, if the predominance of a more instrumental, less free logic is possible, the opposite can also occur if human relations become the focus in work relations.

Working conditions have an impact on the ethical problems experienced by workers, in a system of determinations so multiple that it makes it difficult to approach the topic with analytical precision. Therefore, we must keep the focus on the interactions in the natural social environment, with its laws and rules, always considering culture, customs and power relations. Moreover, the researcher cannot ignore the particular macroeconomic logic that determines these relations²⁰ - ²³ .

Bioethics and healthcare work: plurality and performance

Before starting the proposed reflection, based on Berlinguer, we should point out that in several countries not only the relationship between bioethics and work is not addressed, but older and inhuman types of exploitation persist, such as slavery and servitude, (…) practices (…) morally overcome for centuries and declared illegal since the 1926 Slavery Convention ²⁴ .

Regarding the work-bioethics interface, we turn to Lins, Vasconcellos and Palacios²⁵ , who suggest this relationship is influenced by one of the most important milestones in the affirmation of citizenship: the Universal Declaration of Human Rights . Dated from 1948, the document defines work, in the article 23, § 1, as essential, explaining that everyone has the right to exercise and choose it freely, in fair and satisfactory conditions, being protected against unemployment²⁶ .

The reflection here presented starts from the crossing of two historical events, and considers that the correspondence between article 23 of the Universal Declaration of Human Rights ²⁶ and the four principles of Beauchamp and Childress’ theory²⁷ are not accidental. We can make the following association: everyone has the right to work and freely choose their profession (autonomy), the right to choose the field of action (justice), to have job satisfaction (beneficence) and, finally, to be protected against unemployment (no maleficence).

This analogy is essential for the discussion proposed, considering that, from a Marxist perspective²⁸ , one can question the liberal trend ethics of the very conception of “human rights”²⁹ . In the Universal Declaration , the worker seems to be within the scope of ideas, and not in the materiality of concrete life. Workers who are affected by pneumoconiosis, neurovegetative syndromes, silicosis and contamination by methylmercury or pesticides, did they “choose” their jobs? Whoever carries out activities with such risks certainly does not do so by free choice. The same can be said, for example, of domestic employment. Do young children dream of becoming a maid in the adult life? It is not about choice, but a question of lack of choice.

Regarding principialism, Schulte and Salamanca-Buentello³⁰ point out how work should follow the principles of autonomy, beneficence, non-maleficence, justice, privacy and respect. To this end, the authors report that employers must: 1) accurately present risks and dangers; 2) prevent them as much as possible; 3) communicate with workers; and 4) control risks so that employees can find them acceptable.

Under the same theoretical framework, Gattás, Segre and Wünsch Filho³¹ state that the discussion between bioethics and work traditionally highlights the conflict between rights, such as between the right to protection of employment and health, the right to information and privacy, or individual and collective rights. However, in practice, companies focus on the individual analysis of work, tending to make workers responsible for risky activities³² .

An example: even when employees use appropriate personal protective equipment (PPE), the short time to produce expected by employers forces them to neglect precautions, since the attention needed is not compatible with agility. Even though the manager must provide PPE and the worker must use it (so that both are responsible for risk management), the responsibilities are uneven. In a critical perspective, if the worker relapses and maximizes risks, the ethical analysis must consider the demands of a hyper-accelerated production that, if not met, will lead the professional to unemployment. This is what is expected from a critical bioethical analysis on working conditions.

What we want to demonstrate is that Beauchamp and Childress’ principles, known to be liberal, are not enough to analyze the current work processes, especially in the “Global South” countries, knowing that the field epistemology has significantly changed in the last 15 years. Conservative market-paradigms, based on conceptions of freedom that reinforce the individualization of social subjects, reinforce the oppressive and unequal perspective of work. Thus, we emphasize here Latin American bioethics³³ , which criticizes moral imperialism and coloniality (of knowledge, power and life itself).

In this field, we can mention Marxist authors such as Daniel Callahan³⁴ and Martha Nussbaum³⁵ , in the United States, or Lucien Sève³⁶ , in France, or the Italian Giovanni Berlinguer³⁷ – a classic reference that we cannot forget in our analysis. In Brazil, we have publications focused on Latin American bioethics, especially intervention bioethics³⁸ , which does not recognize the maximization of autonomy as a local principle, proposing notions such as “empowerment” or “liberation,” in the Freirian sense, indicating the workers’ power to combat the forces that devalue and oppress them. The Universal Declaration on Bioethics and Human Rights ³⁹ can be a reference in this analysis, considering articles 3 to 17, especially article 14 that deals with social responsibility and health.

In summary, the relationship between bioethics and healthcare work focuses on subjective processes related to the nature of the craft itself, which can be summarized in three aspects. The first is work ethics as a normative code that ensures and disciplines the workforce; the second (associated with the first) refers to the social recognition of the worker as a citizen; and the third addresses the possibilities of ethics, as a reflexive practice, to rise up against and criticize hegemonic parameters, contrasting currents of thought that restrict or increase the freedom and decision-making power of workers¹³ , ³⁰ .

An important contribution to the discussion in Brazil comes from the public health movement, which opposes the approach of the Economic-Industrial Complex in Health⁴⁰ , and helps us to better understand issues related to the worker’s location, the incorporation of technologies and the construction of the Unified Health System (SUS). The movement has questioned the dominant health paradigms, opposing the market logic to the logic of social needs, with an ethical debate aimed at mobilizing professionals to rethink care.

In imposing an increasingly fast pace of work, for example, private interests overlap public interests. The market’s health parameters create an idea of human beings, civilization and life, which demand an ethics to think new technological advances and ways of working. In Latin America, this debate has focused on issues of social vulnerability, human rights, power and justice¹⁴ .

Managerialism has been widely implemented in the public sector, and with this “performance” becomes an instrument of oppression of health workers. Work processes are increasingly subjected to productivism⁴¹: the order is to produce more (and more thoughtlessly) in less time, even without the necessary technological input, as the focus of the performance logic is on the goals achieved and the financial incentives, not on working conditions.

The performance discourse preaches the idea of exceeding expectations and rewarding the employee who produces more than the established goal, classifying results from the perspective of meritocracy. However, such management paradigm considers only productivity and the amount of work⁴² . Thus, although all work needs to be evaluated through a system that allows reviewing strategies and methods⁴³ , the logic of performance goes beyond ethical-moral limits.

This model, which goes beyond the absence of dialogue with unions and the intensification of exploitation⁴⁴ , generates moral problems by establishing a culture of unfair competition at work, with consequences for health care itself. Since 2011, when the performance measurement of teams and local health systems was legalized⁴⁵ , evaluations based on this logic have become the focus of management in public health services.

In the case of primary health care, such as the Family Health Strategy program, the teams, composed of at least one doctor, a nurse and a dentist, have specific processes for their assistance. However, several Brazilian cities use general performance measurement standards to assess these workers, disregarding the nature of their work.

For Junges and collaborators⁴⁶ , bioethics has already considered quite complex ethical problems in the hospital environment based on the traditional principles – autonomy, beneficence, non-maleficence and justice. However, they could not be used for primary health care, whose peculiar organization requires another type of analysis.

To investigate health work, we must see it in the light of the current performance evaluation paradigm, considering the ethical problems of this mode of production⁴⁷ . The discussion should always consider the risk that work may harm the lives of patients and health professionals, who suffer from stigmatization, prejudice and damage to self-esteem when trying to avoid the economic loss resulting from unemployment, and have their performance often evaluated by arbitrary parameters established by employers⁴⁸ . Thus, the debate must be deepened in order to build an applied, emancipatory ethics, based on reflective practice that respects differences and is open to otherness⁴⁹ .

The roots of bioethics-work interface

When addressing labor relations, the limits of liberal ethics⁵⁰ become evident, since it emphasizes a supposed freedom without equality in the material reality. These systems reiterate the capitalist mode of production by treating it as inevitable and, by pretending to be autonomous, they reinforce a certain idealism⁵¹ . However, if we recognize the importance of work in the constitution of the human being⁵² , we should admit that no form of idealism can be fully committed with the construction of a (bio)ethical thinking anchored in the empirical practice that could comprise working conditions in all its multiple expressions.

Ethical doctrines that aim at transforming and changing the world through ideas have limits, especially those based on liberalism. They are the deformed reflection of only one side of the real world, and precisely in the world where the relationship between people is subordinated to the law of value. In a critical Marxist perspective, bioethics is not dissociated from the emergence of sciences in general; it is not disconnected from culture and its forms. Therefore, the problem is not only theoretical, but essentially practical. After all, Marx understood that the reiterated discourse on “should be” did not include the comprehension of the “being” itself⁵³ . For this reason, Marxist ethics tries to face the profound changes in the conditions of existence – the impetuous development of science and technology, the contradictory phenomena of reality – redefining the values of real “human life”⁵⁴ .

Therefore, analyzing the relationship between (bio)ethics and work with principlist or even idealistic approaches could be too simple. The Marxist perspective of ethics would be more appropriate, defined by Barroco as a critical reflection and theoretical systematization guided by socio-historical assumptions and directed at emancipatory values ⁵⁵ . Therefore, we are aware of the ethics limits in a bourgeois society, but without denying that it can expand the critical social awareness that brings “being” and “should be” together.

With this, especially when discussing the bioethics-work relationship, we must view capitalism as a system with moral meaning. Although this feature is not exclusive to this mode of production, the fact is that, in this interface, capital becomes the center of criticism for not meeting the vital needs of the majority of humanity, proving itself incapable of providing material goods and social rights necessary for a dignified life to all individuals, which are enjoyed only by a privileged minority. On the contrary, capitalism keeps populations under subhuman conditions, denying basic rights such as food, housing, health, security, social protection and work⁵⁶ .

As Ingo Elbe⁵⁷ points out, work has legal character only under specific historical conditions. An infinite network of legal relationships – like a web and, why not, a trap – emerges as a result of the gigantic collection of goods. This is how legal subjectivity (free, equal and fully capable personality) is built as a principle of the legalization of human relations in the capitalist mode of production. For this reason, Marxist ethical thinking must criticize the prevailing moral values and their fixation in laws and regulations, since they reflect and reinforce exploitation⁵⁸ .

Valls⁵⁹ emphasizes that exploitation, especially today, takes on very subtle forms. Worldwide, it has assumed neo-colonial features, so that, in certain cases, bosses and workers from developed countries may share interests to the detriment of people in peripheral societies. Even in microeconomics, exploitation is no more seen as a policy but something supposedly organic, autonomous, intrinsic to a social order cleaved by classes in which the bourgeoisie (ruling class) uses the legal system for moral (and penal) coercion of those who sell their workforce.

In the established mode of production, human beings establish a relation to their work through commercialized products⁶⁰ . They do so out of habit, ignoring moral explanations of how and why they live this way. As Pachukanis states, man as a moral subject, that is, as a person equal to all others, is nothing more than a condition of exchange based on the law of value. Man as a subject of law, i.e., as an owner of rights, also represents this same condition. Finally, both determinations are closely linked to a third, in which man appears as a selfish economic subject ⁶¹ .

It is in this sense that Pachukanis points out selfishness, freedom and the supreme value of the person as the three principles of legal subjectivity, demonstrating the responsibility of law in sustaining capitalist sociability. These principles are linked to each other and express the same social relationship. For the author, the selfish subject, subject of law and moral person are the three fundamental masks through which man acts in the society that produces goods. Economies of value relationships offer a key to understanding the legal and moral structure not in terms of the concrete content of the legal or moral norm, but in the sense of the legal and moral form itself. The idea of supreme value and equality between human beings has a long history ⁶² .

The constitution of this Homo oeconomicus – with values coined in an supposed separation of economy from other elements of social life⁶³ , acting under his own laws – brings about coercion, which aims to guarantee insignificant social behaviors, which reproduce capitalist sociability as a “natural right.” However, Marx and Engels⁵² had already made it clear that economics is the social production of life in all its relations – material, legal-political, religious, philosophical and scientific – composing an indivisible totality.

As Pachukanis asserts, if human thought, over the centuries, has so persistently turned to the thesis of equality among people and elaborated it in a thousand ways, then it is clear that some objective relationship must be hidden behind this thesis. There is no doubt that the concept of moral person or equal person is an ideological construction and, as such, does not fit the reality ⁶⁴ . However, until Marx, no one had questioned the historical reasons for this precept of natural law.

If the moral person is the subject of the capitalist production, then the moral law will be the rule of this society, which inevitably gives it an antinomic character. On the one hand, it must be social and, as such, place itself above the individual personality. On the other hand, the possessor of goods has freedom (of appropriation and alienation) and, therefore, the relationship with his peers must be present in each one’s soul, as an eternal law. Nevertheless, the Kantian categorical imperative⁶⁵ brings together all these characteristics.

Despite the efforts of Kantians and Neokantians, Vázquez⁶⁶ recalls that there are particular morals, corresponding to each class, that coexist in the same society. For this reason, in the absence of real conditions for universal morality⁶⁵ , one cannot speak of a system valid for all times and societies. Attempts like the Kantian imperative end up expressing particular interests in an apparently universal form.

Ethical universalism, which considers all beings as belonging to the same belief system, with one and the same “soul,” was imposed by the commercial expansion that has intensified the market flow with foreigners. People from different cultures, with different customs, habits and values, were “elevated” to the “abstract equality” of the autonomous morality of commercial society to mitigate the losses of the property owner. In other words, what is behind such universalism is the love for “one’s own (goods)” and contempt for “others.”

In a society of private class interests, freedom is supposedly universal. Private property, desired but not accessible to all, is explained in terms of “personal will,” “talent” and “individual efforts,” values that are crystallized in legal norms. And then morality can only be built under the aegis of greed. For this reason, social life, even in its most elementary forms, appears as a sphere standardized by norms, and labor products, which function as materials of these norms, are not simply objects of use, but use values ⁶⁷ . The human being becomes an “end in itself,” the other side of the selfish economic subject.

Bornheim⁶⁸ highlights autonomy as the first and most decisive (bio)ethical principle that accommodates the bourgeois type, representing the modern individual as the center of the social process. The big bona fide capitalist, for example, can ruin the small one without usurping his absolute value. The proletarian is “equal in principle” to the capitalist, a concept that finds its expression in the “free” employment contract. And it is from this “materialized freedom” that the worker can easily die of hunger.

The exchange, that is, the circulation of goods, presupposes that the participants recognize each other as owners. But how those who have nothing could be recognized as owners? Demonstrating how important their workforce is in the act of exchanging. However, the idea that the more qualified the worker, the better his conditions, has proved to be an illusion. The relationship between qualification and better wages – presupposed by the transformation of the workforce into merchandise – has clearly been deteriorating.

All this shows that equality of exchange is illusory⁶⁹ , since the employment contract is based on the values of competition and performance, authorizing overexploitation. This is what expresses the categorical imperative, the ultimate representation of the ethical system of the commercial production society.

As Pachukanis proposes, moral conduct is opposed to legal conduct, which is characterized as such regardless of the reasons that generated it ⁷⁰ . In a very clear example, the debt will be paid because, in any case, the debtor was forced to pay it , or because the debtor feels morally obligated to do so ⁷⁰ . Thus, both morals and laws ratify the capitalist order; thus, external coercion (law), ideas (ethics) and their organization (system of norms) are fundamental aspects of the legal system.

Final considerations

Associated with the acceleration of work and the maximization of performance, the conflict between healthcare and work in the production of care is an ethical problem that tends to become more acute in our times. In this context, if bioethics does not engage in a critical shift regarding the capitalist mode of production and its legal form, it will lose the opportunity to improve emancipatory values.

When the legitimate objective of the State and corporations of increasing production clashes with the organization of work – especially in the area of health, which requires attention, calm, solidarity and humanization –, ethical issues emerge. At this moment, it is important to reflect critically, in order to point out solutions that avoid or reduce morally unacceptable risks, such as illness at work.

Investing in research on the relationship between bioethics and the labor world is important not only to create an area of convergence between knowledge, but also to fight injustices. We hope the proposals in this article will help those interested in forming a project agenda, fulfilling the objective of clarifying the aspects that such interface may take, in search of dialogue and solutions.

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Publication Dates

• Publication in this collection
  26 June 2020
• Date of issue
  Apr-Jun 2020

History

• Received
  7 Mar 2019
• Reviewed
  7 Oct 2019
• Accepted
  29 Mar 2020