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Revista Brasileira de Enfermagem

Print version ISSN 0034-7167

Rev. bras. enferm. vol.66 no.4 Brasília July/Aug. 2013 



Statement of the Brazilian Nursing Association regarding the approval of the medical practice act



Ivone Evangelista Cabral

Federal University of Rio de Janeiro, Anna Nery School of Nursing, Maternal Child Nursing Department. Rio de Janeiro-RJ, Brazil. Brazilian Nursing Association (President), 2010-2013 term. Brasília-DF, Brazil



As soon as Brazilian Senate, on the night of June 18, 2013, approved the Bill nº 268, 2002, known as the Bill of Medical Act, the Brazilian Nursing Association (Associação Brasileira de Enfermagem - ABEn) expressed its rejection stance against a set of legal devices that considered, private to physicians, actions and procedures currently shared by different members of the multidisciplinary team in the Unified Health System (Sistema Único de Saúde - SUS). The entity recognizes as legitimate the right of physicians to have their own regulation of professional practice, similar to what already happens with nursing professional practioners (Federal Act 7,498, 1986).

In fact, physicians are one of the practioners who integrate a multiprofessional healthcare team; thus, it is unquestionable their importance to the functioning of public and private healthcare services. What has been questioned are the different views of how health care of population can be organized, according to the rules of a caring model that, in its nuclear aspect, is exclusively medical-centered, and closes strong medical corporate appeal. It is still considered, that, under the Act 12,842, 2013, there is an overestimation of hierarchical services, with greater importance for some activities over other ones.

The effectiveness of the Unified Health System (SUS) requires multidisciplinary teams, ability to work with the network of healthcare, taking both as a central place. What is questioned is the impossibility of only one practioner member of SUS to be really able to attend the entire healthcare needs of the human beings, with their distinctive demands of healthcare system during their life cycles.

The nosological diagnosis as a private decision of physicians disregards all historical construction of scientific knowledge about the health and disease process as universal and not tutored by only one healthcare practioner. At the same time, reinforces an exclusive dimension of the concept of disease, as belonging to the physician and not to the patient, and implies a legal uncertainty for the other members of the multiprofessional healthcare team, that would depend on reference and counter reference of physicians to start their own caring approaches.

Nowadays, the intense demands of SUS' users for healthcare have demonstrated the system inability to confront the problematic of health and disease of the Brazilian population. In a broad view, their biggest demands are more focused on the needs and social determinants of health than on the need for complex medical interventions managed at hospital basis. Over the past 25 years, since the implementation of the SUS in the country, has pointed out a changing epidemiological profile of morbidity and mortality, with includes communicable diseases and non-communicable chronic conditions that represents challenge to overcome. These issues have prompted the need to renegotiate caring models to face chronic conditions at primary healthcare services basis, resigned in a multidisciplinary and more horizontal practice

Understanding that disease is a social production leads treatment beyond the disease and the patient; it is also necessary to include family, social determinants, and community among others. In a broader perspective, the diagnosis is a result of clinical reasoning constructed by different healthcare professionals. That skill is learned by student during formal training at School, and continuously qualified as a professional at continuing education service. In this sense, elaborating a nosological diagnosis is not something of exclusive and unique domain of physicians.

In opposition to these new trends is established the new law of professional practice of medical, and its polemic effect over Brazilian healthcare system. In turn, ABEn, as a member of the National Health Council (CNS), and in the Coordination of the Intersectorial Committee for Human Resources, played an important role by articulating other entities, and preparing reasons for the approval of the Recommendation 10, 2013, by the plenary of the CNS, in favor of the partial veto of the Bill, known as Medical Act, by the President Dilma Rousseff. Also, ABEn, as a member of the National Forum of Healthcare Workers Entities (Fórum das Entidades Nacionais dos Trabalhadores da Área da Saúde - Fentas), have participated actively on the street movements, doing chorus to the mobilization "Dilma vetoes the Medical Act".

Thus, the veto of the items and paragraphs of the Senate Bill of Act 268-2002 addressing the hierarchical level of healthcare; the physician-centered model of care; the management of health services, the nosological diagnosis, and therapeutic prescription as private actions of physicians, were a courageous and wise decision of the President of Brazil, Dilma Rousseff. In our analysis, this was the most prudent way perceived by the President, for the effectiveness of teamwork, networking polyarchic assistance, directed by a health care model centered on multiprofessionality in order to serve the best interest of SUS' users under the perspective of universal healthcare system.

The 11th of July, 2013, aroused with the publication in the Official Diary (Diário Oficial da União nº 132, Seção I, página 6), of the Federal Act 12.842, that regulate the medical practice in Brazil, with ten vetoes of items and paragraphs. Among the vetoes, it should be highlighted those ones that could interfere, directly or indirectly, in numerous clinical protocols and programs implemented at the public and private services, linked or not to the SUS.

Particularly, in regard to the nursing professionals workers, more specifically to the nurses activities, it can be included a sort of nursing care that will be dependent on physician's prescription to be implemented, such as: a) formulation of nosological diagnosis and its respective therapeutic prescription; b) invasion of the epidermis and dermis with the use of chemicals or abrasive substance; c) execution of a set of procedures, like injections (subcutaneous, intradermal, intramuscular, and intravenous), catheterizations (pharyngeal, tracheal, esophageal, gastric, enteric, anal, bladder) and peripheral punctures (arterial and venous).

The reasons for the vetoes, also published in the DOU, were based on avoiding unnecessary damages to attend the population at SUS, either by exclusive character (Private) inherent in a set of actions (diagnosis, prescription and management service) and procedures, either by significant impact to public and private health services, the public health policies operationalized in the context of the NHS, such as the National Immunization Program happens in the environment of the campaigns and the rooms or vaccination clinics.

ABen recognizes that, as President Dilma Rousseff vetoed those devices, she advocated on behalf of Unified Health System and health as a national policy. So, the maintenance of the vetoes by National Congress is the next battle to face. ABEn continues to fight as member of the Mobilization Movement named MantenhAM-Oveto in order to the preservation of public SUS and multiprofessional model of care the Brazilian population.

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