Schramm and Kottow’s bioethics of protection: principles, scopes and conversations

Abstract

The bioethics of protection is a theoretical-practical ethics proposed from the recognition of the insufficiencies of principialism for the approach of conflicts in the field of public health, an area to which originally the efforts of the nascent bioethical current were oriented. The basic rights of certain beings and populations are threatened by the expansion of globalization and social inequality and, in response to this context, the bioethics of protection aims to support them until they can autonomously seek quality of life (whenever possible). Based on these preliminary considerations, this article, this paper seeks to elucidate historical aspects, conceptual elements and the current scope of the bioethics of protection, outlining possible relations with other bioethical currents, such as care ethics and (bio)ethics for all beings, as a way to support reflection on current ethical conflicts in the sphere of health, lato sensu , and public health, stricto sensu .

Bioethics; Public health; Protection

Resumo

A bioética da proteção é uma ética teórico-prática proposta a partir do reconhecimento das limitações do principialismo para a abordagem de conflitos do campo da saúde pública, área à qual – originalmente – foram orientados os esforços da nascente corrente bioética. Com a crescente globalização e a desigualdade social, há seres e populações cujos direitos básicos estão ameaçados e, em resposta a tal contexto, a bioética da proteção visa oferecer-lhes amparo, até que sejam capazes de buscar sua qualidade de vida de modo autônomo (sempre que possível). Com base nessas preliminares considerações, este artigo busca elucidar os aspectos históricos, os elementos conceituais e o alcance atual da bioética da proteção, esboçando possíveis articulações com outras correntes bioéticas, como a ética do cuidado e a (bio)ética para todos os seres, como forma de subsidiar a reflexão sobre os conflitos éticos atuais na esfera da saúde, lato sensu , e da saúde pública, stricto sensu .

Bioética; Saúde pública; Proteção

Resumen

La bioética de protección constituye una ética teórico-práctica propuesta a partir del reconocimiento de que el principialismo no basta para abordar los conflictos en el campo de la salud pública, área en que originalmente se centró los esfuerzos de la reciente corriente bioética. Con la creciente globalización y las desigualdades sociales, existen seres y poblaciones que tienen amenazados sus derechos básicos, por lo que la bioética de protección pretende ofrecerles amparo hasta que puedan ser capaces de buscar su calidad de vida de manera autónoma (siempre que posible). Con base en estas consideraciones preliminares, este artículo pretende aclarar los aspectos históricos, los elementos conceptuales y el alcance actual de la bioética de protección, realizando posibles articulaciones con otras corrientes bioéticas, como la ética del cuidado y la (bio)ética para todos los seres, con el fin de fomentar la reflexión sobre los actuales conflictos éticos en el ámbito de la salud, lato sensu , y la salud pública, estricto sensu .

Bioética; Salud pública; Protección

Technological advances – particularly in biotechnosciences – and globalization have created an extremely favorable context for the emergence of bioethical conflicts in public health. To discuss these issues, different models of bioethical approaches have been proposed. Currently, the most used model is principlism, formulated by Beauchamp and Childress¹ , ² .

Schramm and Kottow² highlight the limitations of such a framework for the production of adequate responses to bioethical conflicts related to public health, as this field is not only oriented to the relationship between the health professional and the patient, unlike traditional clinical biomedicine ² , but it also globally addresses population/collective issues. In fact, public health has a scope that the principlism model is unable to satisfactorily address. Therefore, Schramm and Kottow² , based on this recognition, developed bioethics of protection, a model that seeks solutions to existing conflicts in public health, respecting its singularities and magnitudes.

Bioethics of protection is a practical ethics which originally emerged due to the need to respond to public health conflicts and research with human beings, aiming to protect vulnerable and susceptible individuals and populations. Schramm³ , ⁴ defines as “vulnerable” or “affected” beings or populations those who have incapabilities prohibiting them to face helplessness by themselves, as they need protection to face adversities. The author considers that vulnerability is inherent in those who are alive, that is, it is a universal characteristic that cannot be protected ³ . “Susceptibility,” or “secondary vulnerability,” refers to those who become vulnerable, that is, those who can be affected and unable to fulfil their potential for a life with quality and dignity³ .

It is noteworthy that both individual conflicts – such as those resulting from doctor-patient, parent-child relationships – and issues concerning public health – such as sanitary measures for affected (or vulnerable) populations – can be addressed in terms of bioethics of protection. It should be noted that, according to Schramm⁴ , seeking to avoid an “authoritarian” stance, a rational and impartial analysis must be carried out, including the decision-making competence of the subject/population. Hence, avoiding the adoption of a paternalistic stance⁴ .

Based on these preliminary considerations, the objective of this article is to approach bioethics of protection, explain its principles, describe its scope and applicability in the field of public health, and analyze its convergences and dialogues with the ethics of care and (bio)ethics for all beings .

Principle of protection

Principlism, as aforementioned, is the first bioethical model to be organized as such and, probably for this reason, the most used up to date² . This framework is based on four principles: respect for autonomy, nonmaleficence, beneficence, and justice. The principle of respect for autonomy refers to the right to choose, and presupposes that the individual makes decisions based on the exercise of their self-determination, which must be respected; nonmaleficence establishes that health professionals do not intentionally cause harm to patients; beneficence indicates that professionals must promote well-being and act for the benefit of those who are sick; and justice is related to equity, allocation of resources, and the need to receive benefits or financial assistance according to their particular situations¹ .

Schramm and Kottow² point out that these principles respond to conflicts present in the field of biomedicine such as the doctor-patient relationship or the health professional-user relationship. However, they are insufficient in terms of public health. The authors argue that the reduction of bioethical issues – pertaining to public health – to biomedical ethics can cause two main problems: 1) the neglect of specific public health issues, such as disease prevention for populations and the promotion of health and environmental quality; 2) the reduction of conflicts only to the scope of clinical bioethics, disregarding the fact that not all conflicts of clinical biomedicine are relevant to the scope of public health² . The latter is marked by conflicts of greater magnitude, comprising vulnerable and susceptible populations, mainly requiring sanitary measures, which cannot be contemplated by the four principles of Beauchamp and Childress¹ , ² . After this conclusion, Schramm and Kottow² analyzed other principles, seeking to find one that addressed the aforementioned conflicts, considering solidarity and responsibility.

The principle of solidarity transforms the vision of the collective into the perspective of joining forces. Equality is included in this principle, claimed as the synthesis of efforts and protection² . Likewise, Garrafa and Soares state that an ethics of solidarity can be motivated by initiatives of public preferences – in addition to individual and private ones – aiming at reducing social asymmetries and improving the quality of life, as well as empowering the underprivileged population to seek their citizen emancipation⁵ .

It is also noteworthy that the principle of responsibility is based on the response of the affected person, that is, something needed by a certain subject in a vulnerable situation must be done. According to this principle, the applied ethics assigns responsibility to individuals, considering that every decision is made by a moral agent who is responsible for it. This principle is an imperative of existence² , ⁶ , ⁷ , as it would be the first ethical and responsible attitude toward the future⁶ . The ontic responsibility, a concept coined by Hans Jonas, refers to an ethics related to the totality of the being, concerned with the future condition of quality of life on Earth. The authors criticize this principle by enumerating three arguments:

1. The “being” referred to by Jonas is metaphysical, there is nothing or anyone capable of taking responsibility for all beings and populations in situations of vulnerability, even if considering public agencies; to believe that a generic being would be able to take responsibility for all those affected (individuals and populations) in the world becomes utopian;

2. Jonas applies the principle in situations of uncertainty related to technological development and possible decrease in quality of life; when seeking to stop technological advances, drastic consequences can be generated for the population such as unemployment, decrease in health resources, and, consequently, even greater lack of protection for the most vulnerable; and

3. The authors question the reliability of data obtained from clinical biomedicine and their applicability to public health² , ⁷ . They emphasize that the principle of caring, or diaconal responsibility, coined by Emanuel Levinas, is related to the “you” and the “other.” Similar to Jonas, Levinas also understands that a moral agent is responsible for their actions and must always bear the consequences, corresponding to the protection of an “other” being⁷:

It is precisely in the otherness, which infinitely comprises a great time in an insurmountable in-between. The one is for the other a being that detaches oneself, without becoming contemporary with the other, without being able to place oneself at its side in a synthesis, exposing oneself as a topic, one-for-the-other as a guardian-of-its-own-brother, as a responsible-for-the-other⁸ .

Regarding the diaconal responsibility, Levinas refers to it as the responsibility toward the “other,” which can be considered “too strong”:

Indeed, Lévinas gives as an example the case of the helpless “other” who urges me to assume an unconditional responsibility, which leads us to a kind of solidarity in which the “I” is totally subordinated to the “other,” theoretically, until the “I” disappears. Subsequently, the “I” disappears, being confused with the “other,” or being subsumed by the latter, which is at least implausible outside of a “strong” relationship such as, for example, a romantic relationship⁹ .

The aforementioned condition makes it impossible to apply this principle to public health as it places managers in a situation of asymmetry with the population. This makes the “other” to be protected based on a perception of who will protect, rather than a reciprocal relationship. Therefore, Schramm and Kottow² suggest the principle of protection as the one permeating decisions in a more committed and feasible way² , ⁷ . This, in fact, is founded on state protection to the physical and patrimonial integrity of citizens. According to the authors, the principle of protection has guided public actions, both political and sanitary, since the emergence of public health in the 18^thcentury² .

We understand protection as the attitude of providing protection or meeting essential needs, that is, those that must be satisfied so that the affected person can meet other needs or other interests¹⁰ .

Schramm and Kottow² present three conditions for applying the principle of protection: 1) gratuitousness , guaranteeing that there is no a priori commitment to provide protection; 2) bonding , stating that, after the decision to protect, there must be a commitment to the affected person; and 3) meeting the needs of the person. It should be noted that, contrary to the principle of beneficence, of principlism, the principle of protection guarantees the benefit to the affected person from the decision of the very affected person, with the objective of not adopting a paternalistic stance.

The authors argue, in fact, that the principle of protection is ideal to permeate actions regarding public health, as the sanitary measures taken by managers must be identified based on an ethical assessment, considering what really affects the population. This assessment must meet the following conditions: 1) the principle of protection should be applied in cases in which essential needs are the general agreement; 2) when there is agreement that the sanitary measures are reasonable to solve the sanitary problem; and 3) when approved, the principle of protection should not be revoked, assuming that actions are planned so there are no negative effects that invalidate it² .

Thus, the principle of protection becomes highly recommended for actions in public health due to the need to identify who will implement the action, who is affected, and what action is proposed. The action is presumed to be based on the need expressed by the affected person to avoid a paternalistic stance. Sanitary measures deemed essential must be implemented – which the affected beings and populations would not be able to do so without this protection – in such a way that, therefore, they can seek other goods⁷ , ⁹ .

Bioethics of protection

Before presenting this framework, it is necessary to define some important concepts: 1) vulnerability, which concerns inherent risks – for example, to human beings – which exist due to the fact of being alive; 2) vulneration, which refers to the already existing damage, that is, vulnerable beings or populations already find it difficult to maintain their quality of life without assistance; and 3) susceptibility, which concerns the risk of beings and populations becoming vulnerable, that is, they have the capacity to maintain their quality of life, but they may lose it at some point³ .

Bioethics of protection is a “practical ethics,” that is, it aims to resolve conflicts of interest and values, whose original proposition – as noted – concerns the attempt to resolve moral conflicts in public health and in research involving human beings⁴ . Indeed, according to Schramm:

(…) the bioethics of protection is an applied ethics that refers to human practices that can have significant irreversible effects on living beings and, mainly, on individuals and human populations, considered in their bioecological, technoscientific, and sociocultural contexts, taking into account the conflicts of interests and values that emerge from such practices and that, to deal with such conflicts, a) is focused on describing and understanding them in the most rational and impartial way possible; b) is concerned with solving them, proposing the tools that can be considered, by any rational and reasonable moral agent, more adequate to proscribe the behaviors considered incorrect and dictate those considered correct; and c) which, thanks to the correct dialogue between (a) and (b), provides the means capable of sufficiently protecting those involved in such conflicts, guaranteeing each life project compatible with the others⁴ .

Therefore, protection can have two meanings for Schramm⁴: 1) a “negative” one, concerning the support to problems inherent in human beings, such as illness, for example; and 2) a “positive” one, which promotes personal development, respecting autonomy. Thus, it should be considered a theoretical-practical tool in a double entendre, against threats and in favor of personal development⁴ . Health managers become responsible for the sanitary measures that must protect the population, and these managers must also be accountable for the results obtained from such measures. Therefore, the effectiveness of the adopted conducts becomes indispensable, including probable positive effects⁴ . Furthermore, still according to Schramm, bioethics of protection is in line with the Federal Constitution when referring to the principle of universality. However, the author contests the idea of equality, that is, that everyone should have equal rights, indicating as an alternative the concept of equity, as formulated by Aristotle, stating that equals should be treated equally and unequals, unequally:

(…) the same equality will be observed between the people and between the things involved, for just as the latter [the things involved] are related to each other, so are the former. If people are not equal, they will not receive equal things; but this gives rise to disputes and complaints (for instance, when equals have and receive unequal shares, or when unequals receive equal shares)¹³ .

In pluralistic societies, the same measure can infringe the fundamental rights of specific people and groups. These rights must be respected, except when they harm the common and social well-being⁴ , ⁹ .

Scopes of the bioethics of protection

Bioethics of protection – as aforementioned – is a theoretical-practical ethics⁴ . According to Schramm⁴ , protection is applied via councils (or ethics and bioethics committees and commissions), considering that such a proposal presupposes the idea of protecting the population against threats to their quality of life. To present the scope of bioethics of protection, we will show some practical examples in which it was applied for ethical reflection⁴ .

The moral conflicts involved in the unequal access to drinking water were analyzed by Pontes and Schramm⁷ in the light of bioethics of protection. The authors point out that developed countries provide, in most cases, universal access to drinking water. Nevertheless, in some underdeveloped nations there is no such access, leaving part of the population exposed to substantial health risks. The researchers emphasize that this fundamental right is a public health issue and the State, as its protector, must guarantee access to drinking water in adequate and sufficient amounts to ensure the basic needs of the population.

Moreover, Pontes and Schramm state that, to validate the protection offered by the State, situations of inequality of access must be recognized and public policies must be developed to solve it Hence, it is possible to understand that the population lacking access to drinking water is vulnerable, as it is affected by the lack of a fundamental right; and, therefore, they must be protected, making it possible to guarantee their fundamental rights⁷ .

Boy and Schramm¹⁴ presented the difficulties faced by individuals with rare genetic diseases – morbid conditions that have an incidence of less than 5 per 10 thousand inhabitants, which are chronic, degenerative, and debilitating and reduce life expectancy – with emphasis on lysosomal storage diseases (LSDs). Patients affected by these conditions seek access to the medicines required to treat such diseases but face logistical difficulties for this acquisition. The authors address, in their essay, the principle of protection, referring to patients with LSDs as a vulnerable population which needs to be protected by public health policies. Access to medicines becomes limited due to scarcity of resources; considering this, it is necessary to invest in programs aimed at public health, prevention, and promotion of quality of life for these patients¹⁴ .

The reflection on the legalization of illicit drugs from the perspective of bioethics of protection is presented by Pereira and collaborators¹⁵ . The authors reported that drug use can be considered a genuine “scapegoat” for more serious problems present in the lives of people affected by social inequality. Therefore, they claim that, based on bioethics of protection, attention should be directed to users of illicit drugs and their needs. Thus, the focus of the public authority would be vulnerable individuals, and not drug trafficking, as is currently the case. Pereira and collaborators¹⁵ also stress the reductionism in the polarization between legalizing and prohibiting, considering the vast cultural diversity and social inequality in the country. On bioethics of protection, the researchers state:

(…) this framework of bioethics can assist these professionals in making critical-reflective decisions to contribute to the construction of a more just and egalitarian society, with the implementation of social and health policies to promote the quality of life of vulnerable populations¹⁶ .

Silva and collaborators¹⁷ analyzed environmental permits demanded by large enterprises in the country and their consequences for the health of the population and the environment. In this investigation, they used bioethics of protection to show the need to empower communities in the face of threats to the quality of life and the environment. They add that bioethics is the ideal – theoretical and practical – tool to mediate moral conflicts related to this matter¹⁷ .

In view of the aforementioned studies, there are some examples in which bioethics of protection was applied to deliberate on moral conflicts in situations of social asymmetry, in which people and populations are affected by some threat that compromises their quality of life and must be protected by a moral agent – in these cases, public managers. In addition to the aforementioned situations, the perspective of protection in the context of the end of life ¹⁸ – deemed as a moment of extreme suffering in which there must be support for the subject who decides to die –, understanding compassion as a characteristic of bioethics of protection –, which introduced perspectives for the relation of this framework to the concepts of care and compassion.

Bioethics of protection, care, and laic compassion

As presented in the previous topics, bioethics of protection aims to protect vulnerable and susceptible beings and populations. This theory is important in situations of social asymmetry, in which there are individuals who are unable to protect themselves and need public policies so that they can carry their lives with quality and autonomy⁴ . Other bioethical concepts that can be related to the principle of protection are described as follows: 1) care, by Boff; and 2) laic compassion , by Siqueira-Batista. Both will be briefly discussed next.

Care can be characterized as courtesy, attention¹⁹ , ²⁰ . It is the essential way of being, that is, it is inherent in human beings. According to Boff, humans are not careful, they are care itself. Care has two basic meanings: the first represents solicitude, zeal, and attention; the second represents worry and uneasiness. Such meanings are associated and show that care will always be present in human beings because they will neither stop loving or caring for someone nor worrying about or being unease by a person’s affection²¹ . Indeed, the expression “being-in-the-world” means relating to the things of the world, being part of the construction of identity, of the consciousness of the very being¹⁹ , ²⁰ . Boff¹⁹ states that there are two ways of “being-in-the-world”: work and care.

“Being-in-the-world” through work refers to the intervention in the environment to adapt aiming at comfort – for instance, building a city or a machine. Boff emphasizes that, through work, the evolution that would probably not occur by nature itself is prolonged. In nature itself, work is also present, for example, in a plant or an animal which adapts to favor its growth and development. When encountering obstacles in this relationship with nature, human beings adopted a more “aggressive” posture – moving from a “relationship” to a “deep intervention” –, harming it. This way of being-in-the-world places humans in a superior position in relation to things for dominating them and making them available to their interests²¹ , ²² .

The way of being of care is a different modality, though not opposed to work. In this way of being of care, the relationship with nature is one of coexistence, not domination, in which its “voice” is respected, admitting that it sends messages of grandeur, beauty, perplexity, and strength. It is a relationship of equality, respecting nature, its “voice,” and its value.

The author states that all are interconnected, forming an organic unit¹⁹ . Furthermore, he also emphasizes that the two modalities – care and work – rather than opposing each other, complement each other, which presupposes the challenge of seeking a balance between them. The author also criticizes that contemporary society is subjected to a “work dictatorship,” in which being-in-the-world is no longer based on the relationship with nature, but rather with capital:

We must resume the reflection on the nature of essential care. The gateway cannot be the calculating, analytical, and objectivistic reason. It takes us to work-intervention-production and imprisons us there. So much so that machines and computers show, better than human beings, the operation of this type of reason-work²³ .

Boff explains the need to expand care, instead of work, in such a way that one can look at the world with more feeling, something that no machine would be able to do, as human beings are capable of contemplating the other with affection. Furthermore, he emphasizes that, accordingly, the feeling of abandonment and carelessness that affects poor, older, retired, or unemployed people can be fought, as social institutions are often less guided by human beings than by the economy (that is, an increase in capital and material goods, for example)¹⁹ .

Protection and care are also related to laic compassion , a key concept of (bio)ethics for all beings²⁴ , which, in its most recent version, claims that there is an essential equality between everything that exists²⁵ . It is a proposal under development, which recognizes the difficulties in distinguishing the borders between the living and the nonliving and proposes that the quiddity of all beings be recognized²⁶ . Therefore, it considers not only the totality and the relationship of these beings but also that they are all projections of a single totality – an idea similar to the Greek conception of physis ²⁷ – inserted in reality from a perspective of interdependence²⁸ ; in fact, all existing beings – living and nonliving – are interdependent²⁴ , ²⁵ .

Laic compassion, which emerges from the composition between quiddity , totality, and interdependence, refers to the support to all beings – placing them on the same level, from the perspective of their origins –, without judgments. It is a movement of reception of an “I” by an “other,” in relation to the possible existing asymmetries¹⁸ , ²⁴ . Therefore, it is noteworthy, associated with Schramm’s protection, that:

(…) being compassionate does not mean adopting a paternalistic stance – that is, deliberately deciding what is best for others –, based on a mere feeling of pity or commiseration, but rather developing and practicing a broad respect for existence, insofar as what and who exists is welcomed²⁹ .

Accordingly, the characterization of laic compassion as piety is incorrect, as it is understood as the passive beneficence of someone in a position of superiority over an inferior individual. Laic compassion takes place between equals³⁰ . Hence:

(…) to act by laic compassion is, in fact, to protect the other – especially in situations of helplessness, in which their autonomy is very limited –, giving them conditions to exert a minimum of self-determination in relation to the (serious) decisions to be made³¹ .

Considering this, it is possible to observe fruitful associations between laic compassion , care, and the principle of protection. Everyone aims to achieve the provision of support to ensure the ability to face the challenges inherent in life, after promoting the real conditions for this to happen² , ⁴ , ¹⁸ , ¹⁹ , ²⁴ ; Boff¹⁹ describes the necessary relationship with the environment and nature, perceiving them as equals and emphasizing that, like human beings, nature also has a “voice” that must be heard. This statement corroborates the proposal presented in terms of (bio)ethics for all beings, by Siqueira-Batista¹⁸ , ²⁴ , when the author argues that all beings – living and nonliving – are part of a single totality³⁰ , ³² . Finally, the concept of laic compassion concerns care for the other, which is also provided for in bioethics of protection ³³

The present conjectures gain particular relevance when considering the current context of technological advance and globalization, marked by a prominent asymmetry of relationships, in which some beings and populations are in a position of superiority over others. Those in an inferior position are affected by this inequality, having difficulty guaranteeing their basic rights. The three theoretical proposals defend that there should be an affectionate look of unconditional hospitality towards the other³⁴ , offering them the guarantee of reducing inequality and, perhaps, the construction of a better world:

Let us say yes to those who arrive, before any determination, before any anticipation, before any identification, whether or not it is a foreigner, an immigrant, or an unexpected visitor, whether or not it is a citizen of another country, a human, an animal, or a divine being, one living or dead, male or female³⁵ .

The analysis of bioethical proposals allows the recognition that all three consider the moral relevance of all beings, proposing a much more respectful perspective of the world. The principles related to each model aim to reduce social asymmetry and “protect” those affected by this imbalance. Thus, it is possible to observe the existence of similarities that “dialogue” and complement each other, assisting in addressing bioethical conflicts related to the basic rights of vulnerable beings and populations.

Final considerations

Growing social inequality has produced a significant increase in injustices in different domains of contemporary reality² . Schramm and Kottow² perceived the need for a bioethical model which comprised public health, in view of the limitations of principlism for such an endeavor² , ⁴ . Therefore, bioethics of protection was conceived, a framework seeking to guide ethical discussions about globalization, ethics in research, public health, and end of life, among others² , ³ , ¹⁴ , ³⁶ . From this perspective, it is possible to highlight – as a synthesis of this essay – the importance of formulating public health policies and health measures based on bioethical principles oriented to the protection of vulnerable populations, which must be respected and have their basic rights guaranteed.

Theoretical associations were also mapped throughout this article. Indeed, similar to bioethics of protection, ethics of care and (bio)ethics for all beings also aim to “antagonize” the vulnerability of the “other,” based on the recognition of 1) interdependence – interconnection – and of 2) the totality of all beings. Accordingly, it became possible to propose that these bioethical models “dialogue” with each other¹⁸ , ¹⁹ , ²⁴ , ³⁰ , perhaps aiming at reducing social asymmetries and guaranteeing care for all beings , especially vulnerable ones, in such a way that these are able to manifest an existence – and a life, in the case of those who are born and die – of quality.

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Publication Dates

• Publication in this collection
  09 May 2022
• Date of issue
  Jan-Apr 2022

History

• Received
  16 Mar 2021
• Reviewed
  18 Feb 2022
• Accepted
  23 Feb 2022