Death With Interruptions ” in the teaching of Ethics and Bioethics

The curriculum guidelines for undergraduate medical courses recommend that medical training should be humanistic, reflective, and ethical. Furthermore, medical professionals should be able to provide support in the process of death, with the evaluation of active methodologies for the teaching and learning of humanities, ethics, and bioethics a fundamental part of medical courses. The present study evaluates the use of the novel “Death with interruptions” as a teaching tool for ethics and bioethics, addressing individual and collective reflections when dealing with the theme of death. This is a descriptive study with a qualitative approach, analyzing the evaluation of a literary work by medical students from the Escola Bahiana de Medicina e Saúde Pública (the Bahia School of Medicine and Public Health). The study concluded that this instrument is recommended for the teaching of humanities, finding that its reading encouraged the development of subjective abilities in students to deal with situations related to death, respecting the principles of bioethics.


"Death With Interruptions" in the teaching of Ethics and Bioethics
The education of under graduated professionals in medicine, announced in current Curriculum Guidelines to under graduation course in medicine must be general, humanist, critic, reflexive and ethic, with social responsibility and commitment with the defense of citizenship, human dignity and integral health of human being 1 .It must also foster integrality and humanization of care through medical practice.
This reflexive capacity and ethical, psychological and humanistic comprehension of doctor-patient relationship, expected in professional education stage since it was set out the guidelines of 2001 2 , are still challenging to medical education.Its substantiation requires lots of effort from medicine schools, especially to develop efficient tools, both to implement this content and to assess its effective assimilation.
Considered applied ethics, bioethics deals with analyzing moral arguments in favor and against certain human practices that affect the quality of life and well-being of humankind and other human beings, as well as quality of the environment 3 .Every human being is capable of making moral judgments and it will be developed according to characteristics and interaction opportunities of subjects with their environment and stimulus to ethical reflections 4 .
The interaction conditions of individuals with their social environment (and opportunities provided by such social environment) are determinant to understand the results of this process.It places lots of responsibility to educational system, as it is its duty to educate health professionals in technical aspects, but also in moral and ethical ones.Therefore, it is essential to value the subjective and social dimension in all health attention practices 3 .Thus, the educational system contributes in an unequivocal way to the development process of moral and ethical competence of the individual, which must be explicitly approached in formal educative contexts 5 .
According to current requirements and necessities of medical education, pedagogical approaches of teaching-learning (or active methodologies) have been created as tools to reintegrate lost skills by the doctor in his historical path, qualifying him to intervene in contexts of uncertainties and complexities, such as those of current medicine 6 .A study conducted to characterize teaching bioethics to medicine students in São Paulo 7 demonstrated that activities related to this field are mostly developed as theoretical classes.It is possible this is one factors responsible for disinterest that under graduation students in medicine occasionally have for this curriculum component.
It was observed in the same study that to 54.3% of students the exposure of subjects related to bioethics during under graduation was insufficient or partially insufficient and to 84.6% of students such matters are important or very important to medical education 7 .It is emphasized in this difference between assessment of education in bioethics and perception of importance of such discussion, the urgent necessity of employing different techniques to approach students to applied ethics.

Literary works and teaching humanities
Literature can be an important learning resource of ethics and bioethics in medicine schools, as it instigates readings beyond the Code of Medical Ethics (CEM) 8 and that can influence the approach of ethical themes lived by students being educated.The doctor can increase his understanding of disease and suffering through reading.The careful examination of literary works can help under graduation students to apprehend human and ethical aspects of medicine 9 , as literature explores unique situations that can include conflicts of value.
Among literature properties applicable to clinical practice skills, it is highlighted: 1) Development of passive sympathy or emphatic (which transfers to doctor the perception of real necessity); 2) Assistance to conciliate emotions and conflicts involved in the disease process (especially to deal with losses); 3) Generation of questions about the meaning of life, tragedies coming from human relationships with great attention to moral questionings, which must be discussed in academic environment; and finally, 4) To be aware that even scientifically typified aspects manifest themselves in a unique way in individual patients.Therefore, novels, plays, poems and films can cause lots of impact on a student or doctor, assisting the development of his intuitive comprehension 9 .
The predominance of fragmented knowledge, generated by the classic model of curricular components, hinders the perception of integrality of human being, which include spheres of biological, psychological, cultural, social and spiritual health 10 .With the purpose of approaching future medicine professionals to some conflicts, reflections and http://dx.doi.org/10.1590/1983-80422018261235

Research
"Death With Interruptions" in the teaching of Ethics and Bioethics perceptions capable of making his attention more humanized, this work intends to evaluate the book "Death with Interruptions" by José Saramago 11 .The objective is verifying the applicability of literary work to teach the content of humanities, ethics, bioethics and their principles in medical course.
Azeredo, Rocha and Carvalho 12 conducted a study with the purpose of analyzing how much the under graduation prepares medicine students to deal with death.They claimed that although the theoretical approach about death is a discussed theme in their education, the way such knowledge is transmitted does not include the multiple senses the subject awakes in students, not even in doctors themselves.Upon such observation, it is assumed there is still a lack of effective methods that attempt to respond to this necessity of cognitive development of student about such content.
However, no proposed method can exhaust all questionings of students and doctors about death, especially because the theme is unknowable and it recurs to existential reflections that will be observed in a different way in each moment of life.Thus, it is required to provide more safety through previous approaches before the future professional faces in practice an incapacitating inability to handle such situations, which are often lived in health care.

The dialogue of Saramago with death
Perhaps for being an incontestable and inevitable fact, the finitude of human life causes lots of fear in most people of contemporary Western society 13 .Death is something constant that is expressed in an overwhelming way in the routine of health professionals.Therefore, the National Curricular Guidelines of under graduation course in medicine 2 define that the comprehension not only biological, but also social of the phenomenon is among specific competences and skills that the doctor must acquire during his education to qualify him to follow up the death process.
Upon approaching the necessity of death to renew and perpetuate life in his novel, José Saramago 11 disclosed the tragedy that would follow the absence of end.In the plot, people stop dying in a certain country from a certain day and it is explored the consequences of this fact to population, society and services.The personification of death and use of metaphors and ironies by the author enable to handle the subject through magical realism, which leads the reader to deep reflections, inviting him to re-signify such moment.This reflexive process can approach the future doctor to dimensions that characterize human life in its essential equality (born, suffer and die).
Saramago enables a certain "dialogue with death" which is a break of taboo to current Western society, where the development of medicine has provided the cure to more and more diseases, with consequent increase of life expectancy.To a medicine student, death brings feelings of frustration and incapacity 13 , since, as a result of main aspects of his education, he is much more open to biological concept of death than required philosophical reflections to preparation of its acceptance.In Saramago's work 11 , whilst the absence of death shows the collapse of political, social and religious structures, its return makes all alive people uneasy, as it remembers that it is enough an individual to exist to be subject to such conclusion.Such death embodied in a feminine figure, which experiences passion and compassion for a man, on the other hand, the image of life, leaves the message that only love to life can change death, but not even it will be enough to avoid it.
Finally, the work invites the medicine student to reflect about the respect to life 14 , stimulating him to admit his limits.Such appeal enables to understand and avoid attempting to preserve life at any cost, as it happens when medical practice incurs in curative therapeutic obstinacy, prolonging too much the patient's suffering, rather than providing some relief by employing palliative care.

Method
It is a descriptive study with qualitative analysis.The research was developed at Escola Bahiana de Medicina e Saúde Pública (EBMSP), in Salvador, Bahia, from collection of assessments made by medicine students.It was applied the qualitative technique of thematic analysis from blind reading with random numeric identification of participant students.The target population of this study was formed by students of first year who studied the curricular component Ethics and Bioethics at EBMSP in 2014.

"Death With Interruptions" in the teaching of Ethics and Bioethics
The sampling selection was made from organizational criteria of the own subject.In every semester, a medicine class formed by approximately one hundred students is divided in two halves and each one is subject to work with a different literary work.The chosen class to develop the research was the one designed, by alphabetic order, to read the book "Death with Interruptions", with subsequent assessment of subject with regard to theme of work.The sampling size was 47 medicine students, who carried out the assessment and accepted to participate in the study through signature of free and informed consent document.
The reading of material together with access to theoretical bases that grounded the construction of knowledge of those students enabled to identify the benefits brought by content of curricular component associated with interpretative proposal of chosen book 11 .The approached themes included: Human finitude and fear of death by medicine student; its re-signification from the perspective of absence of death in society; technical-scientific advancements and use of technology in favor of life and palliative care and conflict matters about euthanasia, orthotanasia and dysthanasia.
All subjects were permeated by concepts of principle bioethics (autonomy, justice, beneficence, no maleficence) and the importance of approaching these themes to the student was also questioned.The instrument used in the research to collect and analyze data was the own assessment of Ethics and Bioethics curricular component.The questionnaire, formed by five discursive questions, required that the student showed his reflection grounded on theoretical content of the subject, interpretation of literary work and from intimacy of each one.
To analyze the discursive questions it was employed a qualitative technique of thematic analysis, formulated in three stages (Figure 1): Pre analysis, exploration of material and interpretation of results.On the other hand, such stage was divided in floating reading -defined by careful examination of material where the studied universe reached exhaustion, representation, homogeneity, and relevance -and formulation of hypothesis and objectives.When it comes to exploration of material, it was classified thematic units intending to reach a better understanding of results.Upon interpretation of results, last stage, it was also obtained the frequency of data.

Results and discussion
The results obtained in data collection disclosed interpretative relationships set out by students when requested to show their reflections about the five themes suggested in the assessment after reading the book: 1) Human finitude and importance of having in medical practice; 2) Social, economic and cultural implications of inexistence of death; 3) Setting out a relationship between life and death after reading the work; 4) Current medicine and advanced techniques related to death; 5) Importance of theme in medical education.

Human finitude and importance of thematic in medical practice
Kübler-Ross 15 , in "On Death and Dying", state that, with fast advancement of technique and http://dx.doi.org/10.1590/1983-80422018261235

Research
"Death With Interruptions" in the teaching of Ethics and Bioethics scientific advancements, people became capable of developing new qualities and weapons of mass destruction, having to defend themselves in different ways from fear of death against the growing incapacity to predict it.In societies where death is seen as taboo, always associated with a tragic or bad event, there is no space to imagine natural death in youth or even in advanced age.
The discussions about the phenomenon are considered morbid.On the one hand, the subject is avoided.On the other hand, the mass media bomb people on a daily basis with images of horror and death in news broadcasting, documentaries and fiction.The consequences are growing fear of death, increase in psychosomatic diseases, loneliness, isolation and emotional problems due to difficulty to deal with death and dying and the necessity of avoiding this reflection at all costs.
The proposal to read Saramago's book was followed by a questioning about the phenomenon of death.The students answered about human finitude developing relevant reflections, demonstrating that it is necessary and important to think about the end of existence.This process can help professionals to see death as a natural event (even though it is a reality hard to face), which can, on the other hand, facilitate the contact with this fact without considering life banal.
Most students answered there was a necessity of understanding death as something natural and intrinsic to human life and other species and that the disappearance of death in Saramago's book demonstrated how necessary it is in maintenance of societies when it comes to political, economic and cultural aspects.The second most frequent speech showed that the reflection about human finitude is important so that professionals are able to deal with processes of disease and death of their patients, following them up in the best way possible.
The third greatest share of students with common approaches wrote that death, since it is inevitable during medical practice, must be reflected in its ethical and psychological aspects by medicine student.Some of those speeches are transcribed below, identified by numbers, which show other approaches: "The view of death since childhood as a great taboo and scary perpetuates fear of dying in Western culture whilst it places in medicine the responsibility of removing such fear" (e41); "Death is so present in medical practice to the extent of hardening and making many doctors indifferent, being important to recover such theme in different moments of professional life" (e46).
There was a significant number of students who wrote that avoiding death at any cost, for considering it a failure, takes quality of life out of focus of medical attention, no longer creating favorable and cozy conditions to the inevitable process of human finitude.Other interviewees complemented this reasoning reporting the necessity of showing to medicine student that death is merciless, so that it is not educated doctors who think they are omnipotent and constantly frustrated with reality.
Two participants identified the role of death in primary and subjective decisions, as well as in routine actions, pushed by fear of dying and wish to continue living.They observed that in medical practice death is considered an enemy and most of behaviors are justified or grounded on avoiding it.An important reflection was that death, mystified as a great evil of society is questioned in the novel, as well as the role of hero-doctor, always beating it.It was also remembered that the fear of death by medicine student, as well as difficulty to handle the subject, cause from psychological discomfort to psychological health disturbances, such as depression.
Finally, many students stated to have started to acknowledge after reading the book that death can be a relief to suffering to many people, when it is seen under the perspective that the author brought to discussion.They noticed that the comprehension of finitude became less painful than seeking eternity of life, as it is not enough to live to be healthy, bringing about the importance of palliative care.

Social, economic and cultural implications of inexistence of death
Not everything is happy, but besides those who laugh there will always be those who cry, sometimes, as in this case, for the same reasons.Important professional sectors, seriously concerned with the situation, already started to direct to interested parties the expression of their dissatisfaction 16 .
In this brief excerpt of book 11 , according to Ferreira 17 , it can be detected in the beginning of http://dx.doi.org/10.1590/1983-80422018261235

Research
"Death With Interruptions" in the teaching of Ethics and Bioethics narration of every calamity that occurs in the country where people do not die and whose society the government cannot afford.To Tofalini 18 , everyone in this book face the reality of death and do not know what to do.Wish it does not return, that it is eliminated of life, means to take on all consequences generated by sudden possession of their own and collective destination.On the other hand, want it to return to its duties developed since the creation of species is placing himself in the death row and wait for the remaining time to the conclusion.Thus, the dream of immortality generates a relative euphoria, which is later shown as a terrible mistake.
Almost half of students identified that the literary work shows the dependency that different sectors of society have of death.In the book, its absence causes social, collective and individual problems and moral values start to be inverted.Consequently, the dehumanization of society starts to happen, where people care less about each other and start being treated as a burden.There is public and private economic imbalance due to retirements, pensions and bankruptcy of funeral services and life insurances.
Those transformations also extend to cultural sphere, with the disbelief about the resurrection dogma set out by the church, which grounds religious beliefs.Due to such unexpected situation, it was even attempted to bury dogs, as a desperate way to reorganize the logics of human civilization without death.Upon the absence of death there was chaos in social organization of the imaginary country, with increased necessity of medicines in the attempt to give some quality of life to dying people, an exaggerated demand of hospital beds and endless suffering of patients and relatives.Many people had to face the difficult decision of finishing this pain through alternative means, such as "Maphia", which brought people to die out of that border.
According to other students, there was also the impasse between the euphoria of infinite life and wish to end suffering, exemplified by ethical conflict of adherence or aversion to "Maphia".Those two positions evidenced the weight of immortality in human society, recovering reflections about euthanasia.The students considered that Saramago advocates being careful with what is wished and demystified the glory of eternal life, bringing about the disorder and confusion resulting from absence of death.
Three students considered that the absence of death could cause from the break of economy to cultivation of negative feelings and agony by a society that is not renewed.They also believe that difficulties of health care would be multiplied and families would be tired and discouraged to take care of somebody who never improves or gets free from pain.At least two interviewed students considered that, in similar circumstances to the book, current medicine must more than ever to have a more human attitude, without obstinacy of cure in order to avoid death, but with a doctor-patient relationship grounded on dialogue, compassion and respect to assure the challenge that would remain: To provide quality of life to those patients.
A considerable amount of students wrote that overcrowded nursing homes, hospitals and precarious existence does not end or recover good health, left doctors puzzled.They remembered that such incapacity wrongfully emerges when palliative care is indicated.They also stated that the inflicted suffering leads to perception that death is sometimes comfort, liberation and, thus, necessary.There were many reflections about how the inexistence of death would imbalance the entire capitalist order of current society, as there are many sectors that profit from death or its imminence.To them, being immortal would not be beneficial to societies grounded on cycle of life and death.Furthermore, they believe that we would be vulnerable to scarcity of resources and, especially, that the absence of fear of death would encourage many harmful attitudes and irresponsible behaviors.
The main connection with current society remembered by many students was that, within our health system, where there is no adequate infrastructure, it is not even necessary that death no longer exists to families pass through chaos of lack of access to treatments or care in hospital bed.The inexistence of death would merely worsen the chaotic situation that already exists.

Relationship between life and death after reading the book
To Peiruque 19 , using sheer fantasy, the novel confirms that affirming life is necessarily integrating it to death whilst also refuses it (in a paradoxical and healthy way at the same time) as refusing means enjoying live.To Tofalini 18 , the suspension of deaths in the narration, in an opposite way, does not bring "Death With Interruptions" in the teaching of Ethics and Bioethics tranquility, quietness or serenity.On the contrary, the characters face many problems and do not find feasible solutions to them.What can be observed is increased greediness, hate, interests and lack of noble feelings.
The most established relationship between life and death by the students is that death constitutes an intrinsic cycle to life, essential to balanced work of any society.The second most frequent relationship is complementarity, as death validates life, gives meaning to it and warns people to live in the best way possible in a finite term, being a limit for such statement.Moreover, it brings about essential values to coexistence and personal development, such as love, gratitude, respect and care for human beings.Others also added that absence of death would lead to loss of purpose of existence and development of life, as what drives people, such as dreams, acting well and seeking plenitude in life is only possible and urgent with the value of finitude brought by death.
Another rather frequent relationship set out by the students was the interdependence between life and death.But some people defended that the book showed the necessity of death to renew the generations, evidenced in the relief brought by its return in Saramago`s work.One of them even brought another literary reference about the theme: "Machado de Assis said that it is necessary to die to be born again" (e17).Some students set out a paradoxical relationship between life and death.Whilst the former would be an active and participating state; the second would mostly occur in a passive way, forcing human beings to an acceptation process that is more difficult when naturalness of death is not understood, a situation worsened by permanence of memories and missing upon the absence of loved ones.Other students also defined death as extension of life, which during it creates conditions to naturalized process of acceptance.On the other hand, the latter facilitates the enjoyment of each stage of human development and preparation to deal with finitude.A student concludes: "(…) upon multiple relationships that can be set out between life and death, depending on cultural beliefs, values and acceptance of finitude, it must be attributed to ourselves the most comforting meaning of this reflection, as death is still the greatest mystery of life" (e46).

Current medicine and advanced techniques related to death
The advancement in all fields of knowledge is notorious and undeniable.However, regardless of technological development, it seems that death did not acquire more dignity or peace.Perhaps the acceleration of interdiction process of death is associated with the displacement of place of death from home to hospitals, where nowadays people get sick and die and to which it was directed matters related to such act, which used to be socially shared 20 .With such change of scenery, the doctor started having the necessity of routinely deal with death and dying.Human beings, deprived of power over death, could not learn how to deal with the limits of their desired omnipotence 21 .About such aspect, most research subjects answered that the advanced techniques of current medicine and technical-scientific advancement in health area became "fighters" of death.This is because they seek the cure of disease at the expense of any other interpretation that the individual might have about health and ignore death as a natural process.Such attitude generates futile treatments to terminal patients and it often also feeds patients and relatives with a false hope of life.
Another considerable part of interviewees stated that, due to technological competition, the advancements became determinants about death.Despite the positive side, it is not always beneficial or even comfortable to the patient to live under such care, which can result in dysthanasia, being even similar to therapeutic obstinacy.Many students believe that applicability of technicalscientific advancement in health causes many ethical conflicts about euthanasia, dysthanasia and orthanasia, which shows the importance of doctor being ready to consider his actions according to ethical principles of beneficence, no maleficence, autonomy and justice.Some students came to the conclusion that biopharmaceutical industry and hospital technology make the death process much less abrupt nowadays.Such extension, associated with prevention steps, community health and change of habits made death more and more distant.Therefore, it is difficult to accept it naturally and it increases both pain and disgust.Thus, they highlight the importance of palliative steps and assurance to integral health to patients whose life is conditioned to such new therapeutics.

"Death With Interruptions" in the teaching of Ethics and Bioethics
Two students emphasize the trend of medical education overcome the Flexnerian model, which significantly hinders the struggle with death by the doctor.They defend that, even with all theories and techniques, it is required to employ bioethical principles to guide their behavior and relationship with the patient and peers.To conclude the reflections that stood out about this theme, a student stated: "It is developed scientific techniques in a progressive way to improve curative methods of diseases, but it does not appear in the same speed, or does not have the same emphasis, studies about how to deal with death, reducing suffering, among other more human matters in health course" (e27).

Importance of thematic in medical education
The contact with death encourages reflections about the own fragility and finitude of life, in addition to expression of different emotional attitudes in those who observe it.Among commonly evoked feelings in medicine students upon facing those situations are distress, anxiety, fear, loneliness and failure 22 .In a study about psychological aspects of fears os medicine students, Castro 21 reports many defense mechanisms incorporated during medical education in order to avoid suffering that is often handled, which involve distance from patient, dissociation between disease and individual, humor and banalization of death.
A study conducted with students of more advanced semesters and under graduated doctors disclosed that most participants do not feel prepared to deal with death, claiming they do not have a proper approach of humanities in the academic period about this fact.Most of them report not having received enough theoretical-practical education during under graduation to deal with patients in terminal stage 23 .
The students who participated in the study submitted here claimed that approaching death in medical study is important so that it does not become something scary, synonym of blame or sensation of unfulfilled duty when future professionals face the limits of their behaviors.At the same time, students must be prepared to handle the finitude of life with seriousness, effort and care in their profession, in other words, to do what is within the reach of both technology and ethics.
Nowadays, medicine colleges have directed their teaching to anatomic knowledge and cure of diseases in order to qualify students to understand physiological, pathological and therapeutic processes so that, upon facing the risk of death, they can use their knowledge and save lives.Nevertheless, the subjective approach of death is a subject that is still insufficient, reflecting in the way of treating patients and relatives and contributing to use defense and escape strategies by the professional.Three students claimed that approaching the thematic of death during medicine course provides a more humanistic education and enables the doctor to treat the patient and follow him up in this process, removing the focus of disease as enemy.
There was an important reflection during the study: The medicine student needs to consider death also as a relief and release of suffering, which finishes a cycle in a natural way.An expressive amount of students pointed out the fact that the performance of medical professionals can be harmed by not understanding death as a natural process.It is essential to their education to develop resilience "without losing tenderness" to better handle the impotence that human finitude brings.
Many students agreed that the reflection about death in medical education is important to develop a reflection about ethical conflicts that involve the theme, for instance, euthanasia and dysthanasia.It is also crucial to understand death as a process that cannot be avoided, but that can be differently followed up with the humanization of each medical act.Finally, one of students also considered the impact that approaching death by teaching humanities have to health and development of student in the course: "The education of doctors must include the study of people as a biological-psychological-social beings.Thus, it is required to implement curricular components that involve different aspects of medical psychology and ethics, assuring that such stimulus occurs throughout academic education in different ways and according to the demand of each period" (e13).

Final considerations
From qualitative analysis of procedural assessments of medicine students of EBMSP who read the book "Death with Interruptions" 11 , it is possible to infer that using this book as a teaching http://dx.doi.org/10.1590/1983-80422018261235

Research
"Death With Interruptions" in the teaching of Ethics and Bioethics instrument was relevant to approach ethics and bioethics.With such tool, there were significant reflections about human finitude and contact with death, theme of Saramago's work.Reading the book by students showed the possibility of re-signifying the taboo of death in Western society, to which health professionals are routinely exposed.Such resignification helps to notice death and accept it as a natural and intrinsic process and even complementary to the meaning of life.
In view of positive result, we, consequently, assess that literary works favor the reflection about ethical themes, encouraging the interpretative capacity connected to theoretical knowledge of its principles.In addition to re-signify other important concepts involved in ethical conflicts (such as euthanasia, dysthanasia and orthanasia), reading literary works with similar thematic, as Saramago's book, can cause emphathy and generate discussions about humanities in medicine, which actively prepare the student to deal with death process and other situations, such as palliative care.
Although the reading experience is individual and do not assure to set out relationships between values of intimacy of students and knowledge to which they have access and domain, it is recommended, from this study, to read "Death with Interruptions" 11 as a valuable tool to reflection about the theme of humanities in medicine course.This recommendation is grounded on the capacity of the book to generate and develop important philosophical and critical conclusions to teach humanities, as idealized to medical education by curricular guidelines.Due to students` answers and depth of arguments, which would hardly be reached only with theoretical classes, the study also opens possibilities of investment in researches of this type, seeking other works as active methodology of teachinglearning of ethics and bioethics in medicine course.

Figure 1 .
Figure 1.Schematic representation of stages of qualitative technique of employed thematic analysis.