Ethics in palliative care : conceptions about the end of life

The purpose of this article is to highlight the importance of palliative care, as well as the practice of humanized care in the process of human terminality faced by patients who are out of a therapeutic possibility of cure. It was summarized the literature on concepts about such care, its historical trajectory of the Modern Hospice Movement, besides looking at death process and dying under the perspective of mourning phases, stimulating the reflection about bioethical dilemmas associated with aspects of human dignity. The narrative review undertaken emerges as a way to refer to gaps in the understanding of the subject, which requires a wider range of studies and research, especially given the importance of this knowledge for dignified care and a better quality of life for these patients. Regarding ethical issues, the challenge is to consider human dignity at the approach of death beyond the physical dimension of biological and medical perspective.


Ethics in palliative care: conceptions about the end of life
The Naturology as BA course in health, offers comprehensive care for human beings in their health-disease process.Uses complementary and integrative practices such as herbal medicine, hydrotherapy, trofoterapia, massage therapy, among others, with the intent to promote, maintain and restore health, quality of life.The course includes, in its principles, the systems view of life and the ancient philosophical foundations of traditional Chinese medicine and ayurveda medicine, and other perspectives, mostly focused on the ecology 1.2 .This study is contextualized in the formation of naturólogo, specifically the contents studied in graduation, with regard to the teaching of bioethics, ethics and deontology.
The moral formation of the individual has its peak in the family experiences, social and school, in childhood and youth 3 .In academic degree, the interpersonal relations of the school experience more influence on ethical formation of student than the actual insertion of autonomous disciplines of ethics, ethics and bioethics.Still, it is argued that autonomous disciplines or other content that teach ethics, ethics and bioethics can contribute to the training of professionals able to reflect critically on their practice.
It is important to understand the similarities and differences between the concepts of ethics, bioethics and ethics.One can understand ethics as a space for reflection about morality, considering ideal standards of what might be good for the individual and for society 4.5 .Bioethics can be understood as applied ethics, characterized by the systematic study of the moral dimensions, using a variety of principles and methodologies from the interdisciplinary context, thought from the society, culture and moral values of contemporary civilization 6,7 .The ethics, in turn, is the study of the set of moral standards compiled in the code of professional ethics, members of certain professional category must follow 8 .
Studies of ethical aspects of education in the health professions have shown the prevalence of traditional standards of education linked to the biomedical model, the study of ethics, at the expense of ethical and bioethical analysis of references.Although guided by individual clinical needs such molds do not strengthen the collective aspects from 3.9 -12 .Therefore, in education, bioethics can be considered a renewal movement, strengthening of ethics, as this field of study tends to translate moral philosophy to a language more available to those who work in various areas involving life on the planet facilitating its implementation.
The reflections of bioethics have been the path to enable ethical decision making in view of the emerging moral dilemmas, which flow from the technical and scientific progress.Still, problems remain in default of such developments and that have become commonplace, such as hunger, poverty, poor access to health, have been neglected in this study area 12 .It is also considered the fact that bioethics be field interdisciplinary, and there are different moral values in different cultures and societies, there are different analytical frameworks in bioethics able to solve the same problem.
In view of this, there is the need to address bioethics in the education professions, particularly in Brazil, for an approach to consider the reality of developing countries.In these countries, social inequality leaves people vulnerable, bad living conditions, without access to minimum conditions for, themselves, take care of themselves 13 .In the field of bioethics, are in current training grounded in social constituent, especially from the perspective Latin American [13][14][15][16][17] .For Vidal, it intends to contribute la construcción de una social bioethics, able to include en su análisis both a la mirada del clinic as a single human being, as it epidemiology usually llamada social perspective y la dimensión planetary global llamada también el integrating set of knowledge that ocupan of this field 16 .Hellmann and Verdi 17 call social bioethics the analytical framework that combines the approaches between schools of thought on bioethics that bring prospects able to discuss emerging ethical conflicts in the public health field and clinical practice -a practice thought of in terms of an extended clinic, highlighting the bioethics of protection, bioethics of intervention and everyday bioethics.As pointed Garrafa, social bioethics, to be effective, and willingness, persistence and academic preparation, requires a kind of programmatic militancy and historical coherence by the researcher 15 .
The focus of social bioethics is guided by the perspective that prioritizes the moral health actions decisions for the community in the face of a world that favors individual values.This current is main features of social justice, citizenship and the recognition of human rights; recognizes the existing moral pluralism in society and contextualizes the problems where they occur; values fairness and universal access to health and seeks to protect socially vulnerable population 14 .In this sense, there is the concern related to the professional training in the country, with regard to the solution of ethical dilemmas experienced daily by people.

Ethics in palliative care: conceptions about the end of life
This research aims, therefore, to discuss, by the look of social bioethics, how to setup the inclusion of ethics, bioethics and ethics as autonomous subjects or as taught within the upper Naturology education in Brazil, especially in relation to benchmarks theoretical studies that support academic.

Methodological approach
This is a study of qualitative descriptive approach, carried out in two stages: first, through document analysis; the second in field research.This study was conducted at two universities that offer courses Naturology, one located in Santa Catarina and another in São Paulo.
Participants answered two courses inclusion criteria: recognition by the Ministry of Education and coordinator accepted to participate in it, allowing access to the necessary documentation.The research was subject six teachers that teach in these universities, who answered the other two inclusion criteria: be teaching the Naturology course for a year or more and teach courses in ethics, bioethics and / or ethics, or disciplines that include such content on the menu.
Information was collected on two occasions in 2008.In the first, we proceeded to the analysis of the six lesson plans found explicitly contained in its menu the study of ethics, bioethics and / or ethics.In the second phase, interviews were conducted with six teachers responsible for providing such content selected, three subjects of each of the two Naturology courses.We used semi-structured interview technique, guided by a script topics that questioned the characteristics of the subjects, which were used as benchmarks and was systematized the teaching-learning process.
To address the data from documents and interviews, we used content analysis 18 , enabling the organization of findings into four categories given a posteriori, which were discussed in the light of social bioethics.
The national ethical standards in research involving human subjects were considered in the design and development of the study, and their respective research project was approved by the Research Ethics Committee of the Federal University of Santa Catarina (UFSC).To maintain the anonymity of the participant.

Results and discussion
The results and discussion from the collected data is presented below in four categories that emerged from this research: 1) general characteristics of the subjects who study ethics, bioethics and ethics; 2) bioethics in the course of Naturology: themes and references; 3) theoretical approaches to ethics studied in Naturology; 4) study of ethics in teaching Naturology.

General characteristics of the disciplines of ethics, bioethics and ethics
The study of ethics, bioethics and ethics was presented herein How Three Contents enrolled sob guardianship the one-discipline, sometimes How Syllabus of different disciplines, an example of philosophy, bringing in its syllabus the study of ethics.IN ONE of Universities, bioethics was crafted in Exclusive ea Ethics discipline appeared, we both courses in the disciplines alluding Therapeutic Techniques.General shape, Objectives described nos education plans analyzed expressed the intention of the Academic develop the ability to understand, evaluate and make decisions in view of the conceptual aspects of issues related to ethics and bioethics, aiming good Professional Practice.
To analyze these aspects, we attempted to discuss elements How: position of the subjects in the curriculum degree; workload; Training of Teachers of these disciplines; Methodology Employed not teaching-learning process.
As subjects of ethics and bioethics que nos appeared pedagogic projects were given early in the course of Naturalogy, specifically in the Second and Fourth semesters.To Morano 3 , the period more suitable for subjects with that feature are as initial stages of education, opinion that meet the curricular courses analyzed Grid.It should be noted, however, that the teaching of ethics and bioethics tend to be more fruitful if not restricted to make disciplines home course, but was taught Also transdisciplinary and transversal along graduation, as pointed by Siqueira 19 .
As to the workload of general subjects What were engaged directly from the study of ethics, bioethics and ethics, It ranged from 30 to 60 class hours.Dantas and Sousa 9 show that in 2001, 74% of Medical schools offered courses this nature with Ethics in palliative care: conceptions about the end of life a workload of 60 hours up, being most at 30 hours, what indicates the meager institutional involvement in strengthening and teaching these three areas .This finding corroborates as statements made by Carvalho and Ceccin 20 by pointing the nonsense in Relation to Distribution of hours of courses In teaching courses in superior health, as Which focus on Technical Training, at the expense of dedicated training pair understanding complexity make health issue.Therefore, one of the teachers respondents expressed his concern, pointing out the need to count with Less hair, double hours for ethics and bioethics disciplines if the course would nedd to go through revision.
To contribute to the Education, not only a workload of disciplines makes relevant, but also the education of professors.In this sense, Figueiredo, Garrafa and Portillo 10 , in a study on bioethics teaching in the area of Health Sciences in Brazil, mention a little training of faculty, as well as the surveys to measure who those professionals are.Referring to the medical school, Rego 11 points a crescent number of new colleges, que hire teachers and outdated, many times, not preparated for the teaching of ethics.However, this was not a reality found among those responsible teachers for the disciplines of ethics and bioethics in Naturalogy Course: The three teachers all these disciplines were doctoral and masters were taking graduates areas of Humanities, in particular, a philosophy and as Social Sciences.The other three were graduate classes and had Specialization courses in health.Some respondents reported that they sought improvement through participation in congresses, and one of them was a member of an association in the area of bioethics.
The teachers interviewed were asked about the teaching strategies used.It was noted that, in the teaching of ethics and bioethics in the course of Naturology, they were diverse.Remarkable, in order of frequency, the exhibition-dialogued classes, the use of seminars, the use of case studies and simulated jury: The diversification of methods is important not only because it can extend the learning alternatives, as well as expand the possibilities that it may be implemented, overcoming potential difficulties of students 21 .
It can be considered the lecture as traditional teaching method.The three teachers interviewed said they used examples from everyday life and encourage the participation of the academic in class, trying asks him orally about their opinions and experiences, so that the learning process to become dialogical and attractive.The use of seminars in the teaching-learning process was identified by two teachers.This technique was usually for the last days of school.In one case, the teacher suggested the topics to be addressed; on the other, the students were responsible for looking for ethical issues in the context of Naturology, which should be discussed according to the theories studied during the course.
The case study was the third most used method.Draws attention to the methodology of one of the teachers interviewed: the first part of the lesson was presented in the exhibition-dialogic class, a theoretical framework of analysis in ethics / bioethics, on which the students had already read a text-base.In the second half of the class was made an assessment that consisted of the application of this theory to a real case, featuring thus a case study to which they assign a final assessment of note in the discipline.
The case study was the third most used method.Draws attention to the methodology of one of the teachers interviewed: the first part of the lesson was presented in the exhibition-dialogic class, a theoretical framework of analysis in ethics / bioethics, on which the students had already read a text-base.In the second half of the class was made an assessment that consisted of the application of this theory to a real case, featuring thus a case study to which they assign a final assessment of note in the discipline.
Another teaching methodology, as reported in one of the teachers was the debate among students on a topic in question, and this presents a kind of simulated jury.In this case, the teacher was responsible for choosing the discussion, abortion or euthanasia generally, and mediate the discussions.The teams were divided in such a way that a group of students would position for, for example, euthanasia, and another group took the opposite position, stating its position, always focusing the currents discussed in the discipline or other, which the students were tasked to locate.
It is considered that, in the course of Naturology, diversification of teaching-learning methodologies in the field of ethics and bioethics brings dynamic classes and increases the pace and motivation towards learning.This may be related to the profile of qualified teachers to teach such classes.

The unfavorable characteristic ethics and bioethics
Ethics in palliative care: conceptions about the end of life teaching is in its reduced workload on both courses analyzed and also the limited approach of themes related to public health and ethical problems experienced in daily work.

Bioethics in Naturalogy course: themes and references
The second category of this research brings the discussion of issues and analysis of references studied in bioethics as an autonomous discipline or as thematic content in other subjects of Naturology graduation.The analysis of themes and references found in the two surveyed courses are presented together.It could be observed that, in the syllabus and in the speeches of teachers, the themes present in general, are the traditional bioethical debate: euthanasia, abortion, allocation of scarce resources to health, research with embryonic stem cells and those involving animals.
On the list of issues addressed by bioethics, Berlinguer 22 points out that the approach most prevalent in the field are the extreme situations or border, centered on technological advances, particularly in medicine and biology, and to give priority to return to the individual level.The author points out that the bioethical debate in general has overlooked problems that persist in society, which affect thousands of individuals every day, especially the most vulnerable.
The sought topics for students to debate on bioethics discipline, especially in seminars requested by the teachers turned up for the sustainability issues, research involving animals, problems in the therapeutic relationship, especially about the autonomy of the individual assisted.It highlights that beyond the traditional themes of bioethics, the students brought to the debate environment-related issues, while the ethical issues brought by the teachers were concentrated in extreme situations, such as euthanasia, stem cell research use although also would add other guidelines such as the ethical implications of the relationship between humans and animals (especifcity).
Note the lack of attention given to the discussions of topics that relate health and society.Health as a human right could be discussed topics such as health care for the vulnerable population and equal access, gender discussions, ethnicity and its relation to the welfare of individuals, groups and segments.In a society marked by social inequality, it is necessary emphasis on these issues.On this, one of the teachers reported: "One thing I'm thinking for the next semester is to bring social issues for discussion" (Lemon Balm).
The interface between ethics, economics and market appeared as a social issue discussed in a class at one of the courses analyzed.The conduct of this debate was made by the reflection on the current exacerbated commodification, he sees economics as the use of resources for the endless accumulation, and not as a study of the optimization of scarce resources due to the maintenance of life.
The discussion about the commodification of health was based on the work "human market" of Berlinguer and Garrafa 23 .It is noteworthy that, although the works of these authors appear in the syllabus of the two courses analyzed, this social vision of bioethics was used only one of the graduations.Based on the placement of a teacher, there is today a market society in health: "Health has also become a bargaining chip.The disease became a possibility of infinite accumulation.Do not work in the modern rationalist clinic, the notion of healing because healing would mean the cessation of profits "(Alecrim).These words refer to the need to design the health of dissociated form of the lucrative market and the prevailing logic of individualism in contemporary society, to meet the collective needs.
It is considered that the approach to this subject was conducted by social bioethics, reference able to collaborate in the reflections of ethical problems brought from the progress of science and those who stubbornly persist in default of such developments.Thus, in addition to electing topics for discussions in class, it is important to the presentation of different analytical frameworks to mark the decisions in view of the issues, as this would favor the reflective process in the formation of professional identity.The presentation of social bioethics in the course is not unanimous in disciplines involving the study of bioethics.The principialist approach of Beauchamp and Childress 24 , followed by practice ethical vision, Peter Singer 25 , are the two most discussed references to discuss bioethical issues in the course.
The principialism turns to biomedical ethics, in particular the clinical practice, and has Beauchamp and Childress 24 as exponents.The authors note that the common morality is possible to find basic principles for biomedical ethics and propose four principles as a way to guide the analysis of ethical problems: respect for autonomy, beneficence, non-maleficence and justice.There is no hierarchy between them, all are equally important; so there is room for mediation.

Ethics in palliative care: conceptions about the end of life
In turn, the ethical practice of Peter Singer 25 , though with shorter discussion in class compared to principialism, appeared as a reference in both Naturology courses analyzed.Basically, the author investigates the application of ethics in practical, utilitarian point of view, in particular issues such as abortion, euthanasia, treatment of women and ethnic minorities, environmental conservation, use of animals in research and production of food.
Both contributions of Beauchamp and Childress as the Singer are relevant to bioethics and should not be discarded, since the cultural diversity and moral plurality enrich the discussions of the field.However, taking into account the Brazilian social reality, it is possible to point out that the ethical reflection carried out by these authors tend to disregard the salient features of developing countries, such as urgent debate of generating social inequities of diseases that lead thousands people dying early, since these benchmarks are constructed mainly based on the Anglo-Saxon economic and socio-cultural reality: in American society in the first case and in the Australian in the second.
The principialist approach analyzes situations of clinical practice; However, in the case of public health, has insufficient responses to contextual debate in conflicts that require cultural relativism, and the marking of macro-social problems in Brazilian society.The maximum use of the principle of autonomy can still lead to an assessment that ignores the ethical directions to the common good collective 14.26 .
One of the teachers interviewed noted the concern about the discussion of autonomy in Brazilian society and warned that autonomy should be qualified because the social conditions that the country has, many tend to act not independently; and commented about principialist model of bioethics: "At issue today is whether these principles are sufficient or whether there should be other principles" (Cidreira).
The teacher concludes his thought affirming the need for other ways of thinking about bioethics, even defending the view that the principialist theory is still the main proposition underlying this field of study.Another respondent Vera says, is not limited to only present the principlism students: "I like to put different viewpoints.They see the principlist and see, in contrast, ethical practice of Peter Singer, who is an author who does not embrace principialism.My conduct in class is for them to see multiple perspectives.I do not mean for them to follow one.My idea is to present there are several chains, so that students, as professionals in the future know how to deal with them" (Capuchinha).
Present different perspectives on bioethics is a factor that enriches the academic training.Still, the short time for the discipline at the two universities as submitted by teachers, complicates the possibility to address other approaches in bioethics.For Naturology courses analyzed, ethical practice of Peter Singer, Australian, professor of philosophy in the United States, has been the second most discussed approach.Note that the utilitarian view this author of the reality of American and Australian societies, the latter being one of, if not the only economically developed society of the South.Thus, criticism of theories of this author must be accompanied by reflections in view the "import" of such a vision for the Brazilian social context, which requires proper context.
There are, at Singer's speech 25 , numerous discussions which the Naturology includes graduation, as the issue of food and food production, subject to which the author contributed.Anyway, bioethics conception of the author, and any other coming from foreign cultures should be appropriate and contextualized in the socioeconomic and cultural reality of the country.
It is, in general, that the issues addressed in bioethics classes allude almost exclusively to limit questions and that while they may present ecology issues, it is necessary to deal with socio-political themes.It was noted also that themes related to ethics and bioethics in the field of non-conventional health practices, as sets the Naturology were not properly addressed in the analyzed courses.Similarly, it is urgent that add references to social bioethics course Naturology, thus contributing to the reflexivity process in vocational training, process able to contemplate themes and references that may favor the formation of professionals committed to the society in which they live.

Theoretical ethics approaches studied in Naturology
In support of bioethics, is necessary to the ethical and philosophical approaches, as this field of knowledge feeds on concepts that are related to the interpretation and philosophical understanding of the human being and his life 27.This understanding is also present in the speech of a of teachers interviewed, stating that bioethics is "the practice of ethics, a perspective of ethics which applies emerging current issues to the theoretical bases" (Cidreira).
It is in this context that presents the third category, which includes the theoretical approaches in ethics, studied as an autonomous discipline or as Ethics in palliative care: conceptions about the end of life thematic content in other subjects of the course of Naturology.The relevance of the study of ethics in undergraduate debate, which probably extends to all other health graduate students in the words of interviewed teacher, is due to the fact that this kind of discussion allows the student to understand the world in which it operates, so that, to be in this world, be able to make choices consciously.For the teacher, the ethics of speech comes in the rapprochement between philosophy and life, and that's where "made the conscious man, with a capacity for reflection that turns all his thoughts in practice; therefore an action accompanied by consciousness, of reflection "(Alecrim).
The results show that while ethics is studied from different perspectives, three of them are the most worked in disciplines involving the theoretical study of ethics in the course of Naturology: the approach of duty, Immanuel Kant (1724-1804), then the proposal utilitarian ethics, John Stuart Mill (1806-1873), and the perspective of virtue, Aristotle (384-322 BC).
According to Kantian ethics, the individual must act morally by self-imposed moral standard, considered by the individual as correct.It is perspective that stands for freedom of the individual, respecting the duty and moral obligation to the exercise of freedom.Kant says that man must act out of respect for duty, seeking to transcend the inclinations and passions, guided especially by a categorical imperative, presented by the author as the maxim that the actions of an individual should be such that they become a law valid not only for themselves but for all other 28 .
John Stuart Mill advocated a utilitarian ethics, in which the utility is the guiding criterion for the choices of moral actions, aiming at the happiness of the greatest possible number of individuals.For the author, the pursuit of happiness requires the cultivation of virtue and the improvement of character.Thus, Mill's utilitarianism implies recognition of the relativity of moral norms 29 .
Classically, utilitarian ethics may tend not to establish grounds for individual rights, which must be protected.But it is worth remembering the contribution of this theory to social bioethics, as Bottle and Port 14 show the intervention of bioethics as utilitarian proposal, and consequentialist.The intervention bioethics has utilitarian and consequentialist philosophical foundation, defending as morally justifiable, inter alia: a) the public and collective field: a priority over public policy and decision-making as long as possible and that result in the best collective consequences 30 .However, an intervention for most should be such that it allows creating greater wel-fare for the whole community, not just favor certain majority group.Thus, the intervention will not fit as bioethics theory that can be used as a justification pretext of totalitarian or authoritarian regimes supported by the majority, nor any political movements able to oppress minorities 30.Note, therefore, that the proposal of contribution utilitarian for citizen academic training is given to the extent that the notion of majority is relativized and context, as does the intervention bioethics.
In turn, the ethics of Aristotle is centered on the character of the subjects manifested through the virtues, which can be acquired and developed by force of habit.The result would be the mean between two vices, between two contrary moral actions.Aristotle held that every action aims to an end and each end would be a human right, being the greatest of all happiness.From this point of view, ethics is closely related to the policy: aim for public happiness 31 .
Note that, in Kant, Aristotle and Mill, ethics has legislative nature, as it seeks to establish how is the action of individuals.Therefore, the three concepts contribute to the academic, personal and also for the students raise ethical reflections on the actions of professional practice and also about the very act of their lives.Similarly, are concepts that lead reflections of bioethics, because, as noted by Schramm 32, it is both descriptive and normative time.
In short, the three classical views of normative ethics presented here provide theories to guide the reflections on professional practices, as well as subsidies to encourage discussions of current ethical conflicts, emerging and persistent, problematized from the lived social reality and suffered today.

The study of ethics in teaching Naturology
The fourth and final category presented in the teaching-learning process in the course of Naturology are the reflections on ethics.It should be noted that while this degree is recognized by the Ministry of Education, the profession is not regulated in the country to date.So there are no Naturology advice, only associations.Similarly, there is a code of ethics of legally valid Naturology, only the codes offered by universities and existing Naturology associations.
In the absence of a code of professional ethics of naturólogo and proof of mailing a code of ethics provided the pedagogical design of the analyzed courses, one of the universities surveyed rode through team composed of five teachers, professional code of proposed the Naturology before starting the discipline that discuss this topic.Other Ethics in palliative care: conceptions about the end of life Travel studied showed no discussion of code of ethics in the education program, but this fact does not exclude the existence of the discussion of possible codes of ethics: in disciplines related to the study of natural practices, ethics was studied by means of codes taken from other professional groups.
In general, as the study of ethics in Naturology teaching, teachers of ethics and bioethics subjects were unanimous in considering the legal issues of the profession should be discussed during the stage, not in theoretical subjects, dedicated to ethical reflection .This concern of teachers with the humanistic academic meets the perception that, in itself, the mere uncritical obedience to ethical codes can not bring ethical reflections.
But, depending on how the discussion of professional ethics codes is conducted, codes of ethics can indeed be spaces for reflection.This observation is confirmed by the explicit teaching strategy in the story of a teacher: "[...] have some code of ethics that there are therapists because of naturólogo not yet exist.[...] We work in class one thing that I think has been effective.It is this: we see a code of ethics and locate what difficulties are gaps exist in these codes; and ask students to think about how they would do these codes to naturólogos "(Melissa).
The process of teaching and learning, presented in this case, invites the students to reflect on professional practice, more than simply "picking" standards.Another way in which ethics is presented to students is the discussion of actual cases experienced in Naturology stage from the reading of the proposed code of ethics to class.
No doubt the focus of Professional Ethics is essential to academic training, since it is related to the regulatory dimensions of professional practice 10 .But the different codes of ethics of various health professional categories are supported by all in the same conceptual basis, as respect for privacy and informed consent from the patient to perform the practices, setting up in patients obligations and rights of moral content, which makes it difficult to reflection, the processes of perceiving and autonomously feel the rights and obligations as such 8 .This difficulty in perception of rights and duties senses as such in the face of the community health needs can perhaps be exemplified in the deontological approach made by two other teachers in Naturology teaching.Both addressed in their classes, the study of the "code" of professional ethics as a way of distinguishing naturólogo the performance limit before the other health professions:

"So we see within the code of ethics is what I'll do is a specialty, if I could speak I do this [technique] or not [...]" (Camomila).
"What can I do within my code of ethics.[...] The Regional Council of Psychology often sees the naturólogo as a professional entering [...]  The position to which these words refer is the notion of "field" professional.Bourdieu 33, to define the concept of scientific field, which approaches the professional field, argues that the fields are constituted as spaces in which to configure the struggle for power.This is the arena of competitive struggle for a monopoly of scientific authority, defined by the technical capacity (authority) and social legitimacy (authorization) in the face of different forms of human knowledge.
In such cases, the deontological approach studied in Naturology courses has pointed to the discussion of professional space in society as a professional field.Even if one considers such a discussion in academic education in order to define the action of naturólogo, it is relevant to discuss the need for the Naturology constitute legitimate career defense of citizenship.
There are frequent power struggles of the professional categories in its own jurisdiction in society.What is perhaps unusual, but necessary, are the actions that seek to legitimize the social function of the professions that should be, above all, solidarity professions.As noted Morano 3 , health professionals use a body of knowledge that is cultural heritage of humanity, so that should not be the bookies accumulated knowledge, but only concerns them the expertise, the greater or lesser ability in implementing the use techniques and acquired knowledge.
There seems to be, in the teaching of Naturology, which may be extended to other grades: the concern to safeguard the unique knowledge as a professional category, which tends to expropriate the accumulated knowledge of mankind for millennia, such as configure the integrative practices and further, as a simple way of exercising power.Thus, more and more essential it is preparing learners in the sense that they understand the ethical implications of the use of knowledge 34 .
Constant reflection on the ethical codes of the professions is necessary in order that the professional practice to be able to contribute to a just society.Under the ethics education in Naturology, this Ethics in palliative care: conceptions about the end of life assumption is no different.Be attentive to the fact that in Brazil there is a "code" of ethics for naturólogo valid, and it is important that, to be designed, that code is also facing the challenges that are needed today to the collective health of the country.

Final considerations
The study of ethics, bioethics and ethics in academic education can become, depending on how it is directed, a mechanism that enables the formation of professionals committed to the society.In Brazil, reflections on bioethics and ethics, and also about ethics, require a socio-political perspective that goes beyond individual rights and is concerned about the collective good common, in order to contribute to the formation of critical professionals, able to consider social reality to offer humanized and quality care.In this sense, this study sought to present the bioethics teaching characteristics, ethics and deontology as autonomous disciplines and as content in teaching Naturology in Brazil, analyzed through the prism of a social bioethics.
We saw the need to increase the workload of these disciplines, especially bioethics, because it is applied ethics.It was noted the apparent academic preparation of teachers of ethics and bioethics course of Naturology, which proved to be committed to education, because in addition to diversify teaching strategies to facilitate academic learning, signaled their concerns with the formation of a professional able to reflect ethically on professional activity with a view to a better society.Still, it was observed that the study of bioethics in Naturology course is guided by foreign references -the principialism of Beauchamp and Childress and ethical practice of Peter Singer -which need to be contextualized in the Brazilian reality.It was noted that the topics covered in class focus on borderline issues, with insufficient attention given to the contents that refer to everyday issues, as well as the issues of Brazilian socio-political reality.The focus of social bioethics, had here as a link to the reflections of bioethics, was made in the teaching of Naturology, but in one class and only one of the courses analyzed.It is necessary, in education, emphasis on social focus of bioethics, because this perspective contributes to the formation of a professional citizen to favor the reflective process of building professional subjective identity.
The theoretical approaches to ethics studied in undergraduate staff are mainly the classical views of normative ethics of Kant, Mill and Aristotle, which contribute to the reflections on professional practices.The ethics, in turn, is designed in the course of Naturology, despite the absence of "code of ethics" for this profession.Therefore, attention should be paid to the ethical discussions are not taken as speech exclusively focused on the professional field, in order to exercise power in confrontation with society, but as a tool to propose critical reflections on the social practice of the profession.
In short, it is necessary that education in Naturology expand and contemplate themes and theoretical frameworks relevant to public health in view of emerging issues, the result of technological advances, without leaving aside the issues that persist in absentia these advances, as issues of gender, hunger and various types of social inequality present in human beings everyday.Thus it will be able to overcome the formation of focused almost exclusively for professional expertise and therefore restricted to a fragmented view of the world.