For respectful care

Physicians face daily conflicts and moral dilemmas that they often cannot handle. In light of this, this article presents the proposal for special philosophical bioethics, founded on the contributions of Darlei Dall’Agnol to the philosophical debate in Bioethics, which are based on respectful care, as well as the importance of this new concept for the relationship between doctor and patient, according to the metaethical concept of moral cognitivism , of Wittgensteinian inspiration. However, it is worth noting that the four practical rules of medicine ( veracity, privacy, confidentiality and fidelity ), cannot account for conflicts and moral dilemmas that doctors face in the daily exercise of their profession. Therefore, we argue that it is imperative that these professionals have a moral training based on practical wisdom, integrating the principle of care with the principle of respect in a single concept, called respectful care , as a fundamental human attitude to the healthy relationship between doctor-patient.

Bioethics was conceived, since the origin of the term in the 1920s, as a practical wisdom bound up with human action with relation to the different forms of life on earth 1 . In "Principles of Biomedical Ethics," bioethicists Tom Beauchamp and James Childress 2 present the four principles that currently validate clinical practice: respect for autonomy, beneficence, non-maleficence and justice. These principles are supplemented by four practical rules (veracity, privacy, confidentiality and fidelity) 2 that guide the relationship between health professionals and patients. These rules, however, fail to account for the conflicts and moral dilemmas faced by these professionals in the exercise of their profession.
From a new philosophical concept in bioethics, developed by Darlei Dall'Agnol 3 , it is argued that, in addition to the four practical rules aimed at the doctor-patient relationship in Brazil, it is imperative that these professionals have ethical standards based on practical wisdom.
Firstly, we will present the four practical rules that guide the relationship between doctors and patients, taking into account the reality of these professionals in the country, based on the study of the Código de Ética Médica (Code of Medical Ethics) 4 ; then we will presente the idea of practical wisdom as philosophical bioethics, based on the contributions of Dall'Agnol 5 , in order to add this idea to the current debate in the field, taking into account the notion of respectful care, and its importance for the relationship between health professionals and patients, having as epistemological basis the concept of moral cognitivism.

The relationship between doctors and patients
Considering some important aspects of the Código de Ética Médica -CEM (Code of Medical Ethic), four practical rules that guide this relationship will be presented: veracity, privacy, confidentiality and fidelity. Some conflicts and moral dilemmas that these health professionals face in the exercise of their profession will also be pointed out.

Veracity
In telling the truth to the patient about his or her actual health situation, the medical professional contributes greatly to establish a relationship of trust, sincerity, and transparency with this individual, facilitating diagnoses, prognoses, and the therapeutic procedures necessary for treatment and cure. In Latin-culture countries, family relationships are more collective and supportive among members, which differentiates them from Anglo-Saxon countries such as the United States, for example, of more individualistic formation and where the patient's autonomy prevails. In this way, the patient has priority in accessing information and can decide whether to share it with others 6 .
In the case of Brazil, doctors often prefer to report diagnoses and prognoses first to family members and then to the sick person. It is important to clarify, however, that the CEM specifies that the physician can not fail to inform the patient about diagnosis, prognosis, risks and treatment goals, except when direct communication can cause harm. In this case, the physician must notify the legal representative 4 .
Regarding doctors' obligations to their colleagues, the CEM explains that it is the duty of the physician to report acts that contradict the ethical postulates to the ethics committee of the institution in which he or she carries out his or her professional work and, if necessary, the physician might report unethical acts to the Conselho Regional de Medicina (Regional Council of Medicine) 7 . In other words, it is the moral duty of the physician to be honest and transparent, denouncing cases of negligence that violate the rules of the code during the exercise of the profession, in order to preserve the good image and trust of society in the medical institution as well as the credibility of colleagues.
In the United States, for example, medical errors, most of the time, are surrounded by a wall of silence. The bonds of professional loyalty, emphasised in the Hippocratic tradition and medical ethics, represent enormous barriers in this case. However, we believe that, in practice, the Brazilian reality is not so different from the American one. There are many cases of medical malpractice in the country that only become known when divulged by the press. Finally, the doctor's ethical dilemma is not between whether or not to reveal the patient's diagnosis, or any other meaningful information, but rather how and when to communicate information 4 . The reciprocal guarantee of truthtelling and non-deception is one of the basic principles of the relationship between health professionals and patients.

Privacy
The privacy rule is characterised by the limited and restricted access of the health professional to the information and privacy of the patient or research participant. Thus, in this relationship, privacy exists when respecting the right of the patient to stay away or stay alone, that is, the patient has the right not to be accompanied without his or her authorisation.
Regarding the violation of the privacy of patients participating in research in university hospitals, the CEM is very clear when it obliges the researcher to obtain from the patient or his / her legal representative the free and informed consent term for conducting research involving human beings, after due explanations about the nature and consequences of the research 8 . It is therefore essential that these participants are aware of the study procedures, as their integrity is at stake.
One of the important points that involve the right of privacy of the patient is the conduct of clinical examinations required by the doctors. The CEM 4 , in this sense, clarifies that it is up to the doctor to respect the modesty of the person who is under his or her professional care. However, this means that the health professional can never invade the patient's private space, that is, his or her body. In this case, it is common for women to feel embarrassed and refuse to undergo gynaecological exams, especially the Pap smear test used to detect cervical cancer.
It is also common that some men over 50 years of age, for cultural reasons, refuse to take rectal examination to detect prostate cancer. Given this situation, what should the health professional do? The doctor obviously should not invade the privacy of the patient's body. However, this does not exempt the doctor from the responsibility of informing the patient of the risks of avoiding these preventive examinations. According to the CEM 4 , it is the duty of the physician to clarify and inform the patient about the diagnosis, prognosis, risks and objectives of the clinical treatment.
It is important to make clear the difference between breach of privacy and breach of confidentiality. The first concerns unnecessary access or use of information without the proper authorisation of the individual. The breach of confidentiality occurs when a health professional discloses information provided to him or her in confidence. Thus, for example, a person violates the right of privacy when entering the registration room or the hospital institution database to access information on the patient's medical record. In this case, only the medical institution, to which the information is given in a confidential way, may be accused of violating the right of confidentiality.

Confidentiality
Confidentiality must exist when the patient reveals information to the health professional. The person to whom such information is disclosed promises not to disclose it to a third party without the patient's permission. In this case, there is only a violation of the right of confidentiality of A (patient), when B (health professional), to whom A has disclosed the information in confidence, does not protect the information or deliberately reveals it to C (a third party) without consent of A 2 .
In Brazil, when it comes to access to the patient's confidentiality, the CEM prohibits physicians from referring to identifiable clinical cases or exhibiting patients or their portraits in professional advertisements or in the divulgation of medical matters in the media in general, even with the patient authorisation 9 . Although legislation is very cautious about confidentiality, breach of confidentiality is very common -for example, when doctors or nurses make comments about patients in common areas of hospitals 6 . Given this, it is necessary to establish procedures to avoid that people without any involvement with the patient violate this right.
This violation also occurs when, for purposes of auditing or evaluation of the quality of care provided, the hospital administration unnecessarily exposes one or more patients, or when health professionals, for purposes of research activities, use data contained in medical records. This use should be safeguarded and allowed only for projects previously approved by the Comitê de Ética em Pesquisa -CEP (Research Ethics Committee), as long as the identification of patients, their initials and hospital records have been removed. The patient should not be identified in photographs or other images even in scientific publications 6 .
According to the CEM, physicians are not allowed to disclose confidential information obtained at the medical examination of workers, even at the request of managers of companies or institutions, unless the silence of the physician poses a risk to the health of employees or the community. Therefore, the doctor can not provide this type of information to the employer without the patient's authorisation.
The confidentiality rule can only be broken in special circumstances such as: 1) testimony in court, in situations provided by law; 2) communication to the competent authority of the occurrence of illness, child or adolescent abuse, abuse of spouse or elderly person and injury caused by firearm or other kind of weapon injury when there is reason to suspect that the injury has been caused by a criminal 6 .
In some situations, however, when taking into account the Brazilian legislation, it is not so simple to break the privacy rule. The CEM prohibits doctors from disclosing information about patients, even when it comes to facts of public knowledge or when the the patient have already passed away. Even in cases where the doctor is called to testify as witness, he or she must appear before the authority and declare his or her impediment. In addition, in the investigation of a suspected crime, the physician is prevented from revealing confidential information that may expose the patient to criminal prosecution 4 .

Fidelity
Fidelity between doctor and patient is fiduciary, that is, is based on trust. The physician is the depositary of the patient's trust in this relationship. In addition, this issue is also important for the recovery of the health and well-being of the patient. It is worth noting that this model of fidelity is based more on the values of loyalty and trust than on being as good as one's word 2 .
The CEM, for example, prohibits doctors from leaving patients under their care. The abandonment would be considered a breach of said fidelity. The doctor can only waive health care service in the following cases: 1) when there are facts that, at the discretion of the physician, impair his or her relationship with the patient or the full performance of the professional's activity; and 2) for some fair reason. In these situations, the physician should always communicate the patient or his/her family members in advance 4 .
The doctor is obliged to respect the right of the patient or his / her legal representative to decide on the execution of diagnostic or therapeutic practices, except in case of imminent risk of death. In such cases, therefore, it is the professional's duty to save the patient's life 4 . For example, children whose parents are Jehovah's Witnesses, which religious beliefs prohibits blood transfusion. Even if the initial contract for health care has been established by a third party, in case of death risk, the doctor is responsible, above all, for the life of the child.
Thus, the obligations of the doctor and the hospital institution with the parents are easily overcome, since the professional can resort to a court of law, opposing the decisions of the parents that contravene the best treatment or endanger the integrity of their children. In the USA, the courts have allowed adult Jehovah's Witnesses to refuse blood transfusions for themselves, but the courts overruled the parental refusal of the treatment for their children.
Often, parents are accused of neglect of their children when they stop looking for treatments or do not allow the use of beneficial treatments recommended by doctors 2 . A situation that occurs with relative frequency in Brazil, for example, is that parents neglect their children in relation to preventative treatment with vaccines.
Moreover, in health care, health professionals often conflict with the policies and objectives of the institutions where they operate. A military doctor, for example, must submit to certain legal obligations of the Army, other than those accepted by the civilian physician. However, all physicians are required to refuse actions that violate human rights and canons of medical ethics.
The CEM also recognises that it is the moral duty of the physician to denounce practices that harm human dignity. In this case, the physician must denounce torture, degrading, inhuman or cruel practices and the physician must not perform those practices, be conniving with those who perform them or provide them with the means, instruments, substances or knowledge to facilitate those harmful practices 11 .
Economic interests involving health professionals, institutions and patients have led to serious ethical conflicts. In the USA, for example, a very disturbing discussion involves the creation of incentives by medical institutions and health plans for doctors to limit their care to patients 2 . In the Brazilian case doctors are denied the mercantilist practice of medicine 12 . However, it is observed that the practice of medicine in our country has become a very profitable activity, and this is largely due to the deficiencies and shortages of the public health system. Thanks to that, people faced with difficulties are increasingly turning to private health.
Finally, considering the above, it is evident that, for the medical professional, it is not so simple to follow norms and formal rules present in the professional codes of ethics, especially when it comes to the noble mission of caring for vulnerable patients. It is noted that health professionals, in the exercise of their professional activity, deal on a daily basis with conflicts and moral dilemmas that they can not solve immediately. Given this, it is indispensable to recognise that compliance with ethical rules and norms requires from the professional a type of practical knowledge, that is, a "know how", which would be based on the learning of moral rules and norms, having as a common core a new concept on the meta ethical foundations of a special bioethics of respectful care.

Metathetical foundations of the special philosophical bioethics
Facing illness can be one of the most vulnerable moments of the human being. In other words, we feel particularly vulnerable when we become ill and need care and protection from others, especially as we depend on the treatment of professional medicine. And, in this relationship, it is imperative to consider, therefore, that attitudes of caring and respecting are ways of valuing human beings intrinsically 5 .
The act of caring is a way of preserving or providing well-being to the vulnerable patient. However, this attitude can degenerate into paternalism, when the caregiver imposes on the vulnerable person a certain procedure or conception of a good life, disregarding the patient's autonomy. Paradoxically, the act of respecting can also lead to negative attitudes. This happens, for example, when, in the name of respect for the autonomy of the vulnerable individual, it is sought not to interfere and protect the rights of the person. In this way, respect for the autonomy can result in indifference and individualism.
However, it is worth clarifying that "care" means "special attention," "good treatment," "special treatment," and therefore it is inherent in the word "respect." That is to say, in the vernacular, the combination of care and respect (respectful care) would have pleonastic sense. However, in the literature of biomedical ethics, the two terms represent the two traditions of principlism in bioethics; on the one hand, the Hippocratic tradition, in which "care" integrates the principles of beneficence and non maleficence and, on the other hand, the Kantian tradition, whose term "respect" unites the principles of respect for patient autonomy and justice.
Dall'Agnol 5 then tries to rethink the foundations of a new special philosophical bioethics, integrating these two terms of the principlist tradition in bioethics into a single concept, respectful care, as a fundamental and necessary human attitude for a healthy relationship between caregivers and vulnerable individuals.
True care presupposes sympathy, the human capacity to share joy or sadness, pain and suffering from others. It is, therefore, an immediate and involuntary feeling that arises from the intersubjective interactions of human beings. Sympathy, in turn, is always accompanied by empathy, which means to imagine yourself in the place of others. However, feelings of sympathy and empathy can compromise the human attitude of caring. Any health professional who cares for a patient in a hospital bed, and who is guided by anxiety in an attempt to restore the patient's health, can lead to mistakes. Given this, the feelings of sympathy and empathy must be tempered by reflection on what can actually be beneficial to the patient 13 .
Care presupposes identification with the object of attention, in view of the well-being of vulnerable individuals. However, in the relationship between doctors and patients, one should consider that health and well-being are important but not sufficient ingredients. What is needed above all are the intrinsic moral values of those who care for vulnerable people. An example of this is the doctor who seeks to improve the health and well-being of the patient in a hospital bed, recognising him/her as a subject endowed with intrinsic value 14 , with fundamental rights and as someone who needs special care.
Care and respect must be integrated into a single concept, "respectful care", in order to avoid paternalistic attitudes. This idea is the only moral attitude and new concept on the metathetical foundations of special philosophical bioethics, thought and applied as practical wisdom. Thus, reproducing Dall'Agnol in paraphrasing Kant, it is possible to affirm that care without respect is blind (that is, leads to paternalism); respect without care is empty (or rather leads to individualism) 15 .

Knowing how to take care: a new epistemological basis for respectful care
In his work "Nicomachean Ethics", Aristotle 16 was the one who first tried to systematise the three Theoretical knowledge deals with "what is". In other words, through the exercise of theoretical reflection, human beings seek to understand and explain how things are. Technical or poietic knowledge deals with "doing", in the sense of human producing and operating in the world. This type of knowledge is characteristic of the technoscientific rationality, that is, the instrumental rationality, predominant today. Finally, practical knowledge deals with human action, that is, with the ethical and political action of the human being in the world. In this way, practical reason deals with the "must be", that is, with the ethical action of the human being. The focus of this discussion will be the practical knowledge as source of human action, from the point of view of a meta ethics inspired on Wittgenstein, as the epistemological basis for the respectful care indispensable in the relationship of the health professional and patient.
The human attitude of caring and respect, according to Dall'Agnol 5 , has moral connotation and presupposes a special kind of knowledge. For this, it is important to identify two kinds of knowledge in advance: "know that" and "know how". The "knowing" is traditionally defined as "true and justified belief", that is, it involves propositional attitude. That way, a person only knows if he/ she is able to justify why he/she knows. However, knowledge is not reduced simply to having a true and justified belief. Most important, above all, is knowing how to effectively do it. For this, it is necessary a "knowing how", or rather, a type of knowledge that involves mastery of acquired human skills and practices, for example, someone who knows how to play chess, swim, bike, cook, among other activities. For Dall'Agnol, "knowing how" has two meanings: the tacit and the explicit. In the tacit sense, it refers to the type of uncoded or implicit knowledge that occurs when someone masters an activity and does not know how to explain why he/ she knows that. Someone, for example, knows how to ride a bicycle or drive a car without reflecting on the norms and rules involved in this activity.
The "know how" in the explicit sense, in turn, involves acquired human skills to follow rules and normative principles, that is, procedural knowledge 13 . Because it is a type of knowledge acquired through the human capacity to follow normative standards and principles, we can say that, in this explicit sense, it is in a domain that is proper to morality. At this point, Dall'Agnol emphasises that explicit "knowing how" in the moral sense would be the basis for a new moral epistemology called "practical cognitivism": Practical cognitivism is the epistemic thesis that moral knowledge exists and that it is best understood in terms of knowing how and not only in terms of knowing that. The central idea is that the basis of a moral epistemology reveals that moral knowledge is primarily a problem of knowing how to follow normative standards 17 .
The practical cognitivist recognises, in this sense, that there is a "knowing that", that is, a propositional type of knowledge that can explain theoretically how to take good care of vulnerable individuals. For example, the health professional who cares for the sick person who is in the ICU can know and master very well theories, techniques and therapeutic procedures necessary for the palliative treatment of a terminally ill patient. However, propositional and procedural knowledge, as expressions of the domain of relevant technical skills, are not sufficient to deal with the conflicts and moral dilemmas that involve the human attitude of caring for vulnerable individuals.
There are two ways of knowing how to care for these individuals: 1) knowing how to take care in the normal sense and 2) knowing how to take care in the moral sense. The first involves the knowledge of techniques and procedures that health professionals must master and which, therefore, are necessary to restore the patient's health. However, they are not enough, since it is necessary to know how to take care of the patient in the moral sense. The criterion for this is the intrinsic moral valorisation of vulnerable individuals.

Final considerations
Practical rules work as "beacons" that guide the relationship between doctors and patients. However, the overcoming of conflicts and moral dilemmas that these professionals face on a daily basis, in the fulfilment of these rules, requires moral training. It is, therefore, a continuous activity of character formation of the human being in the sphere of the family as well as in the social life as a whole.
It is worth noting that this training process aims, above all, to prepare ethical citizens to act according to the principles of full citizenship, respect and care.
Thus, a child who has been educated in a family and social environment stimulated by selfishness and individualism, in which the human being is treated as a means to achieve desired ends, will not be prepared to evaluate norms and moral standards that will guide his/her professional life in the future.
In these conditions, a professional who has a good academic background in the medical field, that is, acquired medical practice skills, such as knowledge of theories, techniques and procedures necessary for the treatment and cure of patients, is not necessarily morally prepared to care for and respect vulnerable individuals.
In view of this, we consider that this new concept in philosophical bioethics, the "respectful care" developed by Dall'Agnol, is an interesting proposal for the valuation of fundamental presuppositions that guide the harmonious and peaceful coexistence between different forms of human life, such as "do no harm", "do not cause physical suffering", " do not kill, "and " do not offend. " Therefore, we believe that in addition to learning theories, techniques and procedures aimed at treating and healing patients, medical professionals must also learn how to care for and respect morally vulnerable individuals.
Once medical professionals are supported by commonly shared moral standards, they will know how to respect and care for patients. In this way, they will also contribute to building a more humane and supportive society, in which care and respect are integrated.