Bioethics of protection: fundamentals and perspective

Abstract

This article seeks to reflect on the perspective of bioethics of protection and explain its tools, by using a bibliographic survey based on the theorical marks of its main idealizers and the informative reading technique, which seeks to identify the thematic and the main ideas involved. To that end, we first present protection as a bioethical principle by going deeper into the origin, to the definition and the analysis of the terms “vulnerability”, “susceptibility” and “injury”. Then, we seek to present the bioethical approaches regarding the “principle of protection”. Finally, we argue that bioethics of protection works as a paradigm for the apprehension, analysis, and resolution of moral conflicts in public health, revealing itself a fundamental approach in this field, considering its challenge is facing the tension between the individual and the collective spheres.

Bioethical issues; Bioethics; Social vulnerability; Health care

Resumo

Este artigo busca promover uma reflexão sobre a perspectiva da bioética de proteção e explicitar suas ferramentas, por meio de levantamento bibliográfico ancorado nos marcos teóricos de seus principais idealizadores e da técnica de leitura informativa, que pretende identificar a temática e as principais ideias envolvidas. Para tanto, apresenta-se, inicialmente, a proteção como princípio bioético mediante um aprofundamento na origem, na definição e na análise dos termos “vulnerabilidade”, “suscetibilidade” e “vulneração”. Na sequência, busca-se apresentar as abordagens bioéticas voltadas ao “princípio de proteção”. Por fim, argumenta-se que a bioética de proteção funciona como paradigma para apreensão, análise e resolução de conflitos morais em saúde pública, revelando-se uma abordagem fundamental nesse campo, haja vista seu desafio de lidar com a tensão entre os âmbitos individual e coletivo.

Temas bioéticos; Bioética; Vulnerabilidade social; Atenção à saúde

Resumen

Este artículo pretende fomentar la reflexión sobre la perspectiva de la bioética de protección y explicar sus herramientas a partir de una recopilación bibliográfica realizada en los marcos teóricos de sus principales creadores y la técnica de lectura informativa, con el objetivo de identificar la temática y las ideas principales involucradas. Para ello, primero se presenta la protección como un principio bioético a través de un estudio en profundidad del origen, definición y análisis de los términos “vulnerabilidad”, “susceptibilidad” y “vulneración”. Después, se exponen los enfoques bioéticos relativos al “principio de protección”. Y, por último, se argumenta que la bioética de protección funciona como paradigma para aprehender, analizar y resolver los conflictos morales en salud pública, demostrando ser un abordaje fundamental en este campo teniendo en cuenta su desafío de lidiar con la tensión entre lo individual y lo colectivo.

Discusiones bioéticas; Bioética; Vulnerabilidad social; Atención a la salud

This study draws on the theoretical framework of the main creators of the concept of bioethics of protection and on research of our interest, found on the Brazilian Coordination for the Improvement of Higher Education Personnel (Capes), Virtual Health Library (BVS), SciELO, Google Scholar, and the Brazilian Digital Library of Theses and Dissertations (BDTD) databases. Material and information collection followed the four stages of the informative reading technique: 1) recognition/pre-reading; 2) selection; 3) criticism/reflection; and 4) interpretation¹ . This technique was applied to a bibliographical review of publications—especially papers, books, and scientific journals—related to bioethics of protection, using the keywords “bioethics of protection,” “vulnerability,” and “susceptibility.”

Next, we screened the material for relevant information to build an overview of the subject. After this first step, we undertook a more careful selection of information, followed by a critical and synthetic elaboration of content, aiming to provide a reflection on what the authors sought to claim. Finally, in the interpretive stage, we aimed to establish a correlation between the obtained contents by comparing and contrasting the meanings obtained from the statements supported by the authors.

Vulnerability as conditio humana

Protection as a bioethical principle originally emerged in an approach to the conflict involved in the validity of biotechnoscience and biopolitics in public health² , based on the notion of vulnerability as a human condition. For bioethicists Kottow³ and Schramm⁴ , both human vulnerability and thriving stem from the fact that the human species is poorly provided with instincts and has an incomplete nature, which inspires the development and application of protective measures. According to Kottow³ , ⁵ , the vulnerability of citizens was already an object of concern for Hobbes since the protective function appears both in the adoption of the social contract by the state and in the rise of the common good in the figure of the sovereign. Later, and still according to the Chilean bioethicist³ , ⁵ , the Hobbesian conception was refined by Mill, who restricted state functions to guaranteeing individual rights and established protection as a fundamental state action insofar as politically legitimate and justifiable sovereignty should provide a minimum of security to its citizens² , ⁶ - ⁹ .

With the development of the modern state in the following centuries, and as societies became more complex, the vulnerability of citizens tended to extend beyond the fear of death or aggression. Consequently, further means of support and assistance were needed as the consolidation of the notion of protection became an ethical requirement⁵ . Thus, it is essential to understand how the notion of protection came to validate an ethical principle in Western societies.

Protection as an ethical principle

All human beings share common descriptive characteristics, such as vulnerability, integrity, and dignity. Although they are essentially descriptive rather than actually normative, Kottow³ states that they suffice to inspire the development of a bioethical principle of protection. It is worth remembering that such characteristics had already been proposed as ethical principles in the early 2000s by European ethics and, like the ethical principles influenced by the Belmont Report , contributed to the establishment of the bioethical horizon in the West. However, this study specifically addresses vulnerability and its relationship with the principle of protection.

Despite being considered a descriptive and universal characteristic of human beings, vulnerability is, among European ethical principles, the only one capable of adequately supporting the ethical prescription of protection as a principle³ . This statement can be better understood by establishing the distinction between “unharmed” human beings and those who find themselves “downgraded” by poverty, disease, discrimination, etc. or by suffering from other deprivations, that is, those who ceased to be vulnerable to reach another “existential level.” In fact, harmed individuals need more than generic protection and cry out for specific care and reparative measures implemented by bioethics as applied ethics³ , ⁶ , ⁷ , ¹⁰ .

At this point, it is essential to explain what is meant by vulnerability as a descriptive and universal human characteristic so we can better understand the ethical nature of the protective perspective which it inspires and its distinctive capacity to support the ethical prescription of protection as a principle.

Vulnerability

Humanity’s descriptive and normative characteristic

As seen so far, vulnerability, humanity’s descriptive characteristic, influenced the consolidation of protection as a fundamental institutional action and ethical requirement during the development of the modern state. In fact, vulnerability, like other European ethical principles, tends to guide ethical attitudes of respect and protection. However, this statement only becomes true when such principles undergo a categorical shift from the descriptive to the normative scope.

In other words, it can be said that vulnerability, integrity, and dignity are ethical principles used in an assertive language which becomes deontic when it describes particular conditions or characteristics and aims to represent moral requirements rather than anthropological characteristics (which they actually are). In such cases, it would be prudent to admit that these principles contain a normative element and, therefore, must be forcibly respected and protected. However, such an unqualified admission would allow any of them to be considered essential and protected without further ethical arguments, as in the typical example of the risk of racist assumptions claiming to have moral weight.

Thus, the possibility of indiscriminately considering human beings as vulnerable, and of this being an ethical principle, leads to a naturalistic fallacy. Vulnerability is, in effect, a human way of being and not an ethical dimension in itself. However, this particular condition obviously has a strong and legitimate claim to an ethical principle of protection³ .

Despite being a naturalistic fallacy, the category shift of the notion of vulnerability becomes less defensible when its meaning is expanded from a human trait to nonhuman animals and other living beings since it would then be difficult to understand how vulnerability would require indiscriminate protection of any form of life. In fact, vulnerability differs between human and other living beings in that the former are vulnerable due to the possibility of failing in the complex process of coming to be, whereas the latter are vulnerable at the level of the simpler and more radical dichotomy between being and ceasing to be. Owing to this difference, human vulnerability requires a type of active protection against negative forces and prevention of harm, whereas the biosphere must be protected via the choice of less drastic actions or of morally sustainable interference³ .

Furthermore, it is worth remembering that anthropological vulnerability in modern culture has undergone a conceptual shift to economic and psychosocial contexts and medical and legal domains. This means that one no longer deals with universal vulnerability but rather with the contingent dimension of deprivation, poverty, disease, and suffering conditions, which requires a distinct and more specific response. Such circumstances involve human beings who are necessarily in an existential situation which goes beyond their original vulnerability.

In other words, there is a great difference in understanding vulnerability as a human condition of fragility when this concept tends toward a kind of reductionism which eliminates any and all pre-existing conditions of vulnerability. Therefore, although it is correct to say that vulnerability involves suffering and deprivation, if the fundamental and accidental are also included, the concept loses its anthropological nature and ceases to address a strictly human form of existence. In fact, the anthropological conception of vulnerability harks back to the universal characteristic of human beings, although an additional characterization of man is still required, one capable of describing those who are destitute and degraded in relation to normality, which can be remedied by the idea of susceptibility³ .

Susceptibility

As a way of being harmed

If vulnerability is a universal descriptive characteristic of human beings, it is hardly an appropriate description of accidental anomalies which affect the lives of many people. Therefore, a second and more specific definition is needed to address situations in which individuals suffer certain harm and lose their supposed original integrity. In a setting in which they become victims of possible ills and shortcomings, such individuals reach a state of vulnerability which can be called susceptibility, indicating both a process of deprivation and an increase in the likelihood of suffering further harm. Moreover, such harm may shift affected individuals from the dimension of vulnerability to that of actual vulnerated beings² , ⁴ , ⁸ .

Regarding this, Kottow³ seeks to undo the possible semantic confusions between the terms “vulnerable” and “vulnerated” and chooses to replace the latter with “susceptible.” According to the bioethicist, susceptible individuals suffer from a double injustice, or rather, they are affected by a condition of double jeopardy comprising the high risks of developing health problems and of suffering greater harm if their health is compromised. Thus, this state of injured integrity is obviously distinct from the concept of vulnerability, which is why the concept of “susceptibility” is introduced. The claim here is that vulnerability is an essential attribute of the human species, whereas susceptibility is an accidental and specific condition to be diagnosed and treated since susceptible individuals are already harmed to some extent, that is, they have been shifted from individual integrity to injured individuality.

This lexical distinction is especially important because decisions in the sphere of vulnerability must resort to the ethical support of the principle of justice, whereas injured individuals require care, recovery, and reparative treatment, ensured a priori by the principle of protection. Therefore, the link between ethical protection prescriptions derived from vulnerability differs in nature from both the diagnosis of a condition of susceptibility and the ensuing ethical requirement to first eliminate deprivation and the harm resulting from such susceptibility³ , ⁶ , ⁷ .

Finally, it is important to understand that vulnerability and susceptibility are different conditions and therefore require different approaches since the former tends to be addressed by equitable protective action for all members of a given society via the principle of justice. Susceptibility, in turn, supposes a certain state of deprivation which can only be mitigated or neutralized by compensatory measures guided by the principle of protection, measures which must specifically seek to actively fight a given deprivation⁵ - ⁸ .

Limits and alternatives in destitution scenarios

Undeniably, the distinction between vulnerability and susceptibility has greatly contributed to the bioethical discourse, with possible impacts on the description, analysis, and design of solutions for contemporary ethical conflicts, especially in developing countries. However, the asymmetry between citizens in those countries can also expose situations of lack of resources such that actual living conditions would escape the conceptual tool of susceptibility, leading to a tendency to categorize such cases as “only” susceptible.

This lack of resources which characterizes poverty points to a deprivation of the conditions which are minimally necessary for a dignified existence, such as freedom, well-being, education, and health, among others. Thus, these needs cannot be adequately met in these contexts and individuals often find themselves unprotected for generations, constituting deprivation at an existential level. To poverty is added inequality, that is, the social gap between the richest and poorest citizens in addition to exclusion. The latter has a prospective character, as it is linked to traits such as cumulative disadvantages, loose social ties, and loss of status quo. From the synergy between poverty, inequality, and exclusion emerge contexts of social inequity commonly found in Brazil and other countries in which the unfair distribution of resources is widespread, and the poorest social groups tend to have lower life expectancies, stay sick longer, and suffer greater restrictions¹¹ .

A context in which the effects of poverty, inequality, and exclusion mark the daily deprivation of populations needs a conceptual tool which is both more sensitive than susceptibility and capable of detecting the complexity of the phenomena of inequity and destitution. In fact, the extreme realities of susceptibility require more specific bioethical tools which enable a more manifest, accurate, practical, and conceptual approach to destitution conditions⁷ . It is in this context that the notion of “vulneration” emerges¹² .

Vulneration

The existential condition of potentiality restriction

Vulneration comprises situations in which an individual or community is incapable of self-defense due to reasons beyond their control, such as unfavorable living conditions, negligence, and/or abandonment by institutions. These situations call for the development and execution of protective actions that make it possible to restore the lost vulnerability⁷ , ¹⁰ . In other words, vulneration is the existential condition of those subjected to harm and deficiencies which are a priori effective, such as those situations often found in the daily deprivation of populations and individuals beset by inequality or destitution⁷ .

Indeed, the acknowledgment of a further existential level of deprivation is one of the most important contributions of the Brazilian approach to bioethics, insofar as the establishment of a conceptual and pragmatic difference between vulnerability and vulneration necessarily impacts the bioethical discourse. In this perspective, Schramm⁷ supports the subdivision of the notion of vulnerability into two categories, namely: a conception which is similar to the notion developed by Kottow³ , ⁵ , that is, “primary vulnerability” or “vulnerability in general,” related to the ontological condition which characterizes every living organism, which makes it a conception beyond the scope of human life and, due to its extension and complexity, outside the possibility of effective protective actions; and “secondary vulnerability” or susceptibility, which is also semantically similar to that developed by the Chilean bioethicist.

However, those who are, in a broad sense, directly affected and harmed, that is, living in an existential condition of deprivation of potentialities or capacities required to ensure a minimally dignified life, are inserted in a third category. This means that there must be a distinction between those who are susceptible and those who are truly vulnerated, that is, those who are a priori downgraded and those already affected or harmed as a result of adverse situations. Moreover, the former can also become vulnerated at any time⁷ .

Thus, protection should not focus on individuals and communities which can deal with unfavorable living conditions by their own means or with the help of institutions but rather on those who lack sufficient resources, whether personal or institutional, to escape vulneration. Hence, protection is the sine qua non condition for the vulnerated to be able to a posteriori develop the skills required to lead a minimum decent life⁷ .

Therefore, the bioethical debate must address health problems outside the scope of traditional bioethics, especially in so-called developing countries, in which privation and social injustice expose the population to inequitable conditions which go beyond universal vulnerability and, therefore, must be explained by a bioethics focused on social responsibility and on the protective function which is at the heart of the modern state: bioethics of protection (BP)⁷ .

Bioethics of protection

Initially conceived as “ethics of protection,” BP was developed as an attempt to apply the theoretical and practical framework of traditional bioethics to moral conflicts in public health, as in cases of social exclusion. It is specifically concerned with the issue of human vulneration and is, therefore, a bioethical and biopolitical project⁶ , ¹⁰ .

Based on the revival of the concept of ethics in the sense of “shelter,” “refuge,” and “protection,” BP brings a critical view of the reductionism of the bioethical discourse sustained by a principlist interpretation which still predominates, and aims to shed light on health issues which traditional bioethics had, until then, failed to address² , ⁴ , ⁷ - ¹⁰ , ¹³ , ¹⁴ . In fact, although the link between state and protection had existed since the dawn of modernity, bioethics had not yet incorporated protection as a principle in its discourse. It was based on the notion of state responsibility and the revival of its protective role that researchers Schramm and Kottow² turned to authors acknowledged for addressing the issue of responsibility interconnected with ethics, such as Hans Jonas and Emmanuel Lévinas⁶ - ⁹ , ¹³ .

So, what distinguishes the principle of responsibility in Jonas and Lévinas from the principle of protection conceived by Schramm and Kottow? In short, Jonas’s principle of ontic responsibility implies the existence of a “being” which cannot be reduced to an “entity.” In other words, it is understood that the former remains sui generis , escaping objectification into something determined and specific, which seems to render the recipient of Jonasian responsibility meaningless, making its use in the institutional context to tend toward paternalism.

Moreover, attributing this type of responsibility is hardly operational since it is hard to identify the moral agent. As for Lévinas, applying the principle of diaconic responsibility to institutions and collectivities forces unconditional solidarity with others to subordinate the “self” to the other in such a way that the moral agent fades away, emptying and confounding them with the recipient of responsibility. Therefore, the Levinian principle of responsibility is also unsuitable for the public policy sphere, as it places the moral agent in an asymmetrical relationship of subordination and non-reciprocity with the moral patient² , ¹³ , ¹⁵ .

It was mainly due to these operational difficulties (and to try and avoid them) that Schramm and Kottow² envisaged the principle of protection. For this purpose, this principle was designed based on three main characteristics:

1. Gratuity or the free offer of protective action by the state or another body, the moral patient being free to accept it or not, which would restore responsibility toward the Other ( diakonia ) and, prima facie , respect for autonomy, in addition to avoiding paternalism;

2. Bonding , which makes protective action an irrefutable commitment for the protective body once recipients freely accept it, which is also provided for by diakonia ;

3. Coverage, the effective treatment of those affected in legitimate situations of susceptibility or vulneration² , ¹³ .

Based on these characteristics, Schramm and Kottow² understand that protection implies guaranteeing the provision of morally legitimate needs, which limits unconditional diakonia so that individuals may acquire goods or meet interests of their life project other than those related to their basic needs but which depend on them for their attainment, such as health, education, security, and housing, among others which are considered indispensable and must be guaranteed by protective bodies¹³ .

At this point, it is important to consider the fact that, since BP is a Latin American theory, it turns to a socioeconomic context whose populations are marked by very asymmetrical social and economic relations, which makes it essential to consider inequity in the decision-making process of public health issues. Therefore, this process must start out from the assumption that the term “protection” refers to the main function of the ethos , that is, to protect vulnerated individuals or populations from inequity and poverty. In fact, protection of the vulnerated should guide actions as a moral norm, which means that the asymmetry of relations should be the ultimate focus of bioethical analysis⁶ - ¹⁰ , ¹⁴ .

As for the expression “bioethics of protection,” it is understood that its constituting terms converge in one sense and diverge in another. In effect, the words “bioethics” and “protection” are united in the bioethical commitment to developing minimally reasonable, fair, normative, and pragmatic solutions to global problems, aiming to protect a particular individual or collectivity, given that both terms originally comprise the functions of harboring and establishing rules of coexistence. On the other hand, the terms “bioethics” and “protection” must necessarily be separated and differentiated so that they are not, above all, confused by the divergence between their semantic fields since not all bioethics is bioethics of protection and not all means of protection are means of bioethical protection ¹⁶ .

“Bioethics of protection” can also be understood as an expression which indicates the issues to be faced while pointing to the tensions inherent in the actual terminology. Thus, it is important to emphasize that BP should not become a kind of magic solution to all moral problems, or rather, its field of application must be defined so that constructed answers neither prove frustrating as tools of intelligibility and resolution of moral conflicts in practices which involve living beings nor are confused with any kind of paternalism. In fac, this bioethical approach aims to avoid being overly generic to the point of referring to an “ethics of life,” but rather to be quite precise without being reductionist since it enables the focus on the potential irreversibility of human actions on organisms, which implies considering that life, at first sight, must be protected⁷ , ¹⁰ , ¹³ .

Furthermore, the actual coiners of the expression BP are not in total agreement as to its use, although they do concur that it focuses on health justice, scarce resource situations, and morality in public health. According to Schramm¹⁰ , the Chilean author Kottow considers this nomenclature unsatisfactory, given its inability to recognize bioethics as applied ethics persistently immersed in asymmetries between agents and the affected ¹⁷ , which would be solved by a more fitting use of the term “bioethical protection” since the latter refers to the need to protect bioethics so it can reflect more freely on human práxis .

Schramm disagrees with this position, assuming that the problems Kottow raises are already addressed in the expression BP. In fact, for the Brazilian bioethicist, BP is, above all, a proposal of práxis which encompasses action in the face of inequalities in the horizon of its original proposal, in which the context of poverty and the condition of vulnerability and susceptibility of individuals and populations are already respectively implied and included. Thus, the idea of a real and a priori asymmetry of empowerment between agents and moral patients is inherent to BP assumptions, which this would justify and legitimize the offer of necessary protection without entailing, as seen above, some form of paternalism¹⁰ .

It is also worth mentioning that there are two ways of thinking about BP, a stricter and a broader sense. Stricty speaking, BP aims to support individuals and communities who are considered sufficiently incompetent or incapable of reasonably and fairly realizing their life projects. In this precise view, it can be understood as a manifestation of the culture of human rights. On the other hand, in its broader sense, BP deals with the survival of the human species, assuming the existence of collective and ecological interests which individual interests or private groups are incapable of addressing, aiming to ensure the necessary conditions for anthropogenesis ⁶ - ⁸ , ¹⁰ , ¹² .

In both forms, BP has a common denominator, which is the principle of quality of life. This makes it possible to understand public health as the set of disciplines and practices whose main goal is the study and protection of the health of human populations in their natural, social, and cultural contexts ¹⁸ . Thus, health promotion (with a focus on lifestyles) and disease prevention (with the management of health risks) become two inseparable aspects of protection which include both facets of protective practice, the former considered positive and the latter, negative. "Negative protection" is understood as the set of preventive practices against illness and threats to the quality of life of a given individual or human group, and “positive protection” involves various practices aimed at human self-development and autonomy⁶ .

Regarding its method, BP can be understood as a transdisciplinary toolbox capable of dealing with the morality of health practices, insofar as it encourages the interaction of distinct but not separate kinds of knowledge, such as public health⁶ . To this end, the tools used intend to solve problems arising from today’s moral conflicts between individuals, besides serving a threefold function, namely:

1. Descriptive , by rationally and impartially portraying conflicts, which means that they also have a critical character;

2. Normative , insofar as they seek to resolve moral conflicts, classifying and prescribing appropriate behaviors and excluding incorrect ones;

3. Protective , given that the interconnection between the two previous functions focuses on concrete contexts, aiming to provide sufficient means to support those involved and guarantee that each life project is compatible with others¹³ , ¹⁹ .

Another important point to consider is the fact that the theory conceived by Schramm⁷ establishes a lexical priority for the vulnerated, which makes it indispensable to a priori apply the value of equity as a means of achieving equality and thus concretely respecting the principle of justice. Thus, BP aims to understand, describe, and solve conflicts of interest between those who lack competence and need protection and those who, on the contrary, are able to realize their life project⁷ , ¹⁰ .

Furthermore, one can never stress enough the danger of bioethical approaches based on a principle of protection sliding into paternalistic discourse and practice. The fact that there is no protection without a protective body fails to necessarily imply that protective actions automatically entail paternalism. In other words, protecting does not mean expanding inequalities, as typically paternalistic actions do by preventing individuals from deciding for themselves, but rather it means providing sufficient means for recipients to become aware of their contingent realities and be capable of deciding according to their legitimate interests and with the greatest possible freedom, exercising their right to autonomy² , ⁹ , ¹⁰ , ¹⁴ , ²⁰ .

At this point, it is worth introducing one of the main criticisms of BP, namely the issue of the limits between the possibility of protecting individuals and their competence to protect themselves, or rather, the problem of freedom to exercise autonomy within the rules of coexistence in a given society. This is due to the current trend of increasing individual responsibility in public health, that is, to subsume the moral agent into the moral patient, making the actor and the recipient of a certain behavior indistinguishable⁷ , ²¹ , ²² .

We may view this as both a theoretical and practical issue. Theoretical because it relates to the logical relation between protection and autonomy and to the balance which should exist in cases where these two principles clash. Practical because it involves its field of application and concerns the use of BP only for the vulnerated or, in a broader sense, the vulnerable at most. However, whatever the action scope of BP, it is worth stressing its need to be rid of both paternalism and the blaming of moral patients via the following arguments:

1. Its tools are only applied with populations of susceptible and vulnerated individuals who are unable to make decisions on their own, and not those who are merely vulnerable;

2. Protection must not be imposed but necessarily offered to recipients;

3. The principle of protection necessarily implies the duty of effectiveness in health interventions, even if this means restricting individual autonomy to favor the quality of life of a given group⁶ , ⁷ .

Therefore, it is possible to infer that the term “protection” implies the responsibility of moral agents and the pragmatic effectiveness of their respective actions, attested by their effects. In this context, BP proves to be an important analytical and pragmatic tool of applied ethics, capable of analyzing and mitigating conflicts, as well as resolving them, aiming at the quality of life and well-being of recipients of public policies⁶ , ⁸ , ¹³ . However, there are exceptions to the overall application of BP, such as protection of the social body against internal and external threats, exemplified in the use of coercive measures imposed on individuals or groups of a given population during epidemics which threaten to significantly affect population health, as well illustrated by the guidelines adopted by the World Health Organization (WHO) and countries affected by the COVID-19 pandemic. In other words, public health protection presumes the legitimation of certain forms of restriction of individual autonomy when based on the priority of social over individual rights⁶ , ²² .

One must also know who are these vulnerated individuals or populations. Implementing protective actions always run an effective risk of stigmatization, paternalism or authoritarianism, as there is the possibility of unduly disregarding multiculturalism, moral plurality, and differences in contemporary societies⁷ , ²⁰ . Therefore, contrary to Jonas’ ontic responsibility and Lévinas’ diakonia , the principle of protection is operational because it requires specifying what must be protected, who must protect what, and to whom protection is intended⁸ , ¹³ . Consequently, one of the main functions of BP is to oppose the trend to massify and standardize health policy procedures, resisting those which promote the restriction of the autonomy and singularity of individuals, disregarding their particular ways of living⁹ .

Thus, in considering health and the exercise of individual freedoms as fundamental conditions for quality of life, it can be inferred that BP deals with protection at two levels (or in a twofold sense) since it intends to ensure access to a reasonable standard of healthcare available to all and which is also compatible with the possibility of individual development of human capabilities unable of harming others. Thus, protecting everyone’s health fails to exclude the need to guarantee the protection of everyone’s fundamental freedoms. It is up to BP, therefore, to understand and critically analyze conflicts in these circumstances to provide relevant arguments supporting the legitimacy of the prescription or proscription of individual actions, establishing points of convergence between social justice and individual freedoms²² .

In summary, BP can be interpreted as a paradigm for understanding and justifiably resolving moral conflicts in public health, drawing, to this end, on the description and analysis of those conflicts in the most rational and impartial way possible and seeking to resolve them in a normative manner, making use of tools which are able to organize appropriate behaviors and prohibit those deemed incorrect. Hence, by combining understanding, analysis, and conflict resolution based on the application of adequate and consistent tools, BP aims to ensure the achievement of individual life projects alongside the protection of all those involved. In this, it proves to be a key approach for public health in its challenge of dealing with tensions between the individual and collective spheres⁶ , ¹⁰ , ¹⁴ .

Final considerations

Bioethics can be understood as a solution produced by the challenges which emerge in the contexts of contemporary life, especially those related to biotechnological advances in health, social achievements, economic development, the phenomenon of globalization, the use of finite resources, and the understanding of life itself. In short, it intends to be a coherent response to the impacts of human existence on life on the planet and on itself.

Owing to its rational and pragmatic character, bioethics is also a tool whose development is guided by the construction of sufficiently cogent arguments for decision-making in different contexts. To this end, some bioethical trends base the justification of these resources on principles deemed fundamental for human life, such as vulnerability. Strictly speaking, vulnerabiliry—as seen above—is a descriptive characteristic of humanity which links notions such as incompleteness, becoming, and finitude, among others. Thus, protection as a consolidated need is considered an ethical requirement, that is, vulnerability implies the establishment of protection as a fundamental action of the modern state. Therefore, the idea of a principle of protection as a guideline to decision-making relates to the structuring of modern societies around the notion of vulnerability, hence its relation with the value of human life in contemporary times, which shows its relevance to bioethics.

However, since it is an attribute of the human species, vulnerability implies the generalizing trend of indiscriminate application of the principle of protection and the consequent loss of effectiveness of protective action. This is mainly due to the existence of individuals and population groups which are previously “injured” (according to the Latin root “ vulnus ” of “vulnerability”) and exposed to accidental and specific conditions which require other means of protection. Thus, at first, it is reasonable to say that protection presupposes actions which seek to reduce threats to human vulnerability when moral recipients are at the same “existential level.” However, such a position ignores the diversity of contingencies which affect individuals as mortal beings, and it is this interpretation which gives rise to BP, reaffirming protection as an ethical principle of conservation of life while shedding light on the degrading living conditions stemming from inequity and poverty.

Ultimately, BP promotes a shift from a focus on generalist and leveling actions supported by the principle of justice and aimed at the vulnerability of human groups to a concern with the development of actions guided by the principle of protection and specifically aimed at individuals or groups who are previously susceptible and vulnerated. The latter, in particular, lack specific capabilities and are thus unable to face the adverse situations in which they were thrown. Thus, as they are previously subjected to injury or concrete shortcomings which they are unable to face, BP advocates the need to develop and implement protective actions specifically aimed at the vulnerated, which can be understood as its ultimate goal and mission.

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• ¹¹
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• ¹³
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  Schramm FR. 2008. Op. cit. p. 13.
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  Schramm FR. 2011. Op. cit. p. 718-9.
• ¹⁸
  Schramm FR. 2011. Op. cit. p. 1536.
• ¹⁹
  Siqueira-Batista R, Schramm FR. A bioética de proteção e a compaixão laica: o debate moral sobre a eutanásia. Ciênc Saúde Colet [Internet]. 2009 [acesso 22 mar 2022];14(4):1241-50. DOI: 10.1590/S1413-81232009000400030
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• ²¹
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• ²²
  Gaudenzi P, Schramm FR. A transição paradigmática da saúde como um dever do cidadão: um olhar da bioética em Saúde Pública. Interface [Internet]. 2010 [acesso 22 mar 2022];14(33):243-55. DOI: 10.1590/S1414-32832010000200002

• This work includes part of the first author’s doctoral research and is the product of a bibliographic survey on bioethics of protection.

Publication Dates

• Publication in this collection
  01 Aug 2022
• Date of issue
  Apr-Jun 2022

History

• Received
  27 Aug 2020
• Reviewed
  22 Mar 2022
• Accepted
  13 Apr 2022