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Rev. Latino-Am. Enfermagem vol.14 no.3 Ribeirão Preto May/June 2006
The use of medicinal plants as a therapeutical resource: from the influences of the professional formation to the ethical and legal implications of its applicability as an extension of nursing care practice
El uso de plantas medicinales como recurso terapéutico: de las influencias de la formación profesional a las implicaciones éticas y legales de su aplicabilidad como extensión de la práctica de cuidar de la enfermera
Neide Aparecida Titonelli AlvimI; Márcia de Assunção FerreiraI; Ivone Evangelista CabralI; Antonio José de Almeida FilhoI
IPhD in Nursing, Adjunct Professor, Anna Nery School of Nursing, Federal University of Rio de Janeiro, e-mail: firstname.lastname@example.org, email@example.com, firstname.lastname@example.org, email@example.com
This qualitative research aimed to analyze the biomedical influence in the context of nurses' formation and professional activities; to reflect about ethical and legal implications of using medicinal plants in nursing care; to argue about the need to configure and delimit this resource as a legitimate instrument for expanding nursing care practice. We used the creative-sensible method and developed dynamics with a group of nurses to produce data, analyzed in the categories "the biomedical influence in the academic-professional orientation of nursing" and "ethical and legal implications in the applicability of medicinal plants in care". Results indicated the need to advance in studies on the nursing diagnosis that implies the prescription of medicinal plants, so that the client is well taken care of by nurses, thus legitimizing it as an extension of their professional practice. Not as an exclusive territory, but as shared and interdisciplinary health care action.
Descriptors: nursing; nursing care; plants, medicinal
Esta investigación cualitativa buscó analizar la influencia biomédica en el contexto de formación y actuación profesional de los enfermeros; reflejar sobre las implicaciones éticas y legales del uso de plantas medicinales en la enfermería; discutir la necesidad de configuración y delimitación de este recurso como instrumento legítimo de extensión de la práctica de enfermería. Fue utilizado el método creativo-sensible y el desarrollo de dinámicas junto con un grupo de enfermeras para producir los datos de la investigación, analizados en las categorías "la influencia biomédica en la orientación académico-profesional de enfermería" y "las implicaciones éticas y legales en la aplicabilidad de plantas medicinales en el cuidado". Los resultados señalaran la necesidad de avanzar en los estudios sobre la diagnosis de enfermería que implica en prescribir plantas medicinales para que el cliente sea bien cuidado por la enfermera y, así, se pueda legitimarla como extensión de su práctica. No como territorio exclusivo, sino como la acción compartida e interdisciplinar en el cuidado de salud.
Descriptores: enfermería; atención de enfermería; plantas medicinales
Discussing the use of medicinal plants in nursing care involves various overlapping aspects. Some of these often impede professional practice and are restricted to impasses, that is, when conventional, technicist and allopathic practices do not find an immediate exit for solving certain health problems.
In academic teaching, the scientific ideology that has impregnated nursing education since the birth of professional nursing in Brazil until today is based on the rationality of the biomedical model. And, in professional activities, what happens is that nurses tend to reproduce this model uncritically, often ignoring other possibilities of manifesting health knowledge, such as those resulting from popular knowledge.
We believe that these issues difficult the applicability of natural (or non-conventional) therapies by nurses, such as medicinal plants, impeding a broader discussion on the ethical and legal aspects that permeate this applicability. What normally happens are parallel or isolated discussions that attend to particular interests and, therefore, are not strong enough to be treated at the level of the Law of Professional Exercise and the Deontological Code of Nursing, which would allow them to sustain changes that could guarantee these therapies as legitimate nursing practices.
In view of the above, this study aimed to: analyze the biomedical influence in the context of nurses' formation and professional activities; reflect about ethical and legal implications of using medicinal plants in nursing care; and argue about the need to configure and delimit this resource as a legitimate instrument for expanding nursing care practice.
The therapeutic use of medicinal plants in human health is an ancient practice, historically constructed on the common-sense knowledge that articulates culture and health, since these aspects do not occur isolatedly, but are inserted in a certain historical context. Despite considerable advances in phytotherapy, as plants used for therapeutic purposes are called in academic language, they often continue being used for health promotion and recovery on the mere base of popular culture.
In the primitive age, mankind turned to nature to find solutions for different kinds of desolating harm, whether spiritual or physical. Wise men, considered intermediaries between men and gods, were responsible for healing the sick, joining magic and religion with the empirical knowledge of health practices, such as the use of medicinal plants. Antiquity brought the start of another focus when, based on Hippocratic thinking, which established a relation between people's environment and lifestyle, healing processes were no longer considered only from a spiritual and mystical perspective.
Originally considered a natural phenomenon, the origin of diseases started to be studied scientifically. On the same occasion, the oriental system developed in line with the logic that the organism was a part of the universe(1). Thus, during Antiquity, although guided by different cultural contexts, health in the western and eastern system was based on holism, that is, treatment should act on the organism as a whole, integrated with the Universe (macrocosm), instead of just eliminating the locally manifested disease symptoms.
In the Middle Ages, interest in the material world returned and man started to be seen as the centre of the universe, as opposed to the divine and the supernatural. This was followed by the 'intellectual revolution', when important philosophical and scientific conquests were achieved. The XVIth and XVIIth centuries marked the appearance of a new paradigm, starting with the Scientific Revolution. Science was reduced to mathematical and quantifiable phenomena. This entailed the installation of a health model in which the holistic conception of the Universe was replaced by the idea of a machine world. This change in paradigm favored capitalist production to the extent that, after the Industrial Revolution in the XVIIIth century, science was charged with great responsibility for maintaining man's active labor force, guaranteeing factories' production.
The consolidation of positivism in the late XIXth century and early XXth century brought a rupture with metaphysical knowledge and emphasis on the development of experimental research. Scientists' attention turned towards the parts of the human body and health care started to follow the Cartesian and mechanistic directions that continued in the Contemporary Age, in which health was considered from a biological viewpoint as the absence of illnesses. The biomedical health model was installed on the basis of the Cartesian paradigm, which fully attended to the interests of the capitalist production mode(1). The knowledge and therapeutics that were formerly used in human health, such as medicinal plants, among other popular practices, were marginalized due to the lack of a scientific base.
In terms of Brazil, these transformations in the world of science and economics happened at a later stage, which collaborated with the hegemony of popular health practices until the beginning of this century, when it started to be broken by the institutionalization of health services and the arrival of allopathy, considered essential for the emerging form of production(2). Until then, the popular use of medicinal plants, associated with other natural resources, was predominant in the healing process of many diseases that affected people's health. The country's essentially rural economy was doubly favorable to the use of these resources, as the region not only promoted its development (due to the practicality of close contact with the land), but these also appeared as the only treatment alternative.
In the initial framework of these two events - the institutionalization of health and the appearance of allopathy; and forced by the transformations that resulted from the new cultural order established by the moulds of capitalist industrial production, non-conventional health practices, especially medicinal plants, started to lose prestige, as they were not part of specialized knowledge, proved by the logic of science. Everything that was not objectified, explained and demonstrated scientifically was gradually discarded both as knowledge and as practice. The hegemonic medical knowledge ruled, persecuting and prohibiting non-official practices, charlatans, bleeders and so many other persons from the people, considering them incapable of exercising the art of healing and imposing the social recognition and valuation of medical knowledge.
Under the auspices of capitalist ideology, health professionals' training and actions stood out, which are still guided today by the biomedical care model and by allopathic practice. Health professionals started to act on and look closer into scientific and rational knowledge, and less into its political and social roots. Thus, "official medicine, legitimized by the canons of science, took possession of the people' empirical health knowledge and turned it into a biologistic and medical knowledge, thus constituting a new form of knowledge"(3). In this context, Professional Nursing appeared, in accordance with the Nightingale system, at a time when the biomedical model became increasingly defined and the efficiency of medicine was supported by technological development and medicalization.
However, since the 1980's and 1990's, in view of several political, economic and health changes, some popular practices, including the therapeutic use of medicinal plants, started to be rescued in scientific means, not in the sense of an opposition to allopathy, but as complements to established health practices. Among the motives for this recovery, we highlight the lack of success of the biologistic medical model for treating diseases; the iatrogenic effects associated with the high cost of certain allopathic drugs; the scientifically proven efficacy of some plants; along with respect and valuation of cultural aspects that are clearly present in the context of these practices.
Hence, despite the continuous hegemony of allopathy, acknowledged as scientific and a medical prerogative but, in view of social, ethical, political and economic transformations that directly influence people's health and, consequently, care models, the therapeutic use of medicinal plants in care, which used to be at the margin of health institutions, is today moving beyond these barriers and trying to legitimize itself in this means. That is why it is necessary and important to reflect on their applicability, in academic formation as well as professional nursing practice, with particular attention to its ethical and legal implications. We consider the hypothesis that the therapeutic use of plants can be combined with what nursing thinks and does, entailing, a priori, a conception of the human being as a whole.
This study is part of the research "Fundamental Nursing and its Links with Natural Health Practices: the Example of Living Pharmacies", approved by the Research Ethics Committee of the Collective Health Group at the Federal University of Rio de Janeiro, in line with Resolution 196/96 by the National Health Council, which establishes Standards for Research Involving Human Beings.
We carried out a qualitative study and adopted the creative-sensible method(4) (CSM). Creativity and sensibility dynamics (CSD) were used for data production, analysis, discussion and validation. For this paper, we chose the data produced in the dynamics 'Calendar' and 'Body-Knowledge'.
We used a different group and researcher for each dynamic session. The groups consisted of professional nurses who were active in different scenarios, as well as nurses teaching at public and private universities, totaling fifteen participants for the two sessions. They participated after signing the Free and Informed Consent Term.
The dynamics were developed in a class room at a public university, duly prepared for developing the activities. Data were produced during two hours and thirty minutes. The nurses were identified through colors ('Body-Knowledge' dynamics) and plants ('Calendar' dynamics), which they chose for themselves.
Primary data sources were the participants' reports and artistic products generated in the context of the CSD. These revealed problem situations that allowed for the coding of two subjects for debate, according to the Freirian language that supported the data analysis used in the CSM, and which constituted the following categories: 1) The biomedical influence in the academic-professional orientation of nursing; and 2) Ethical and legal implications in the applicability of medicinal plants in care.
RESULTS AND DISCUSSION
The Biomedical Influence in the Academic-Professional Orientation of Nursing
In the dialogue that occurred as part of the 'Body-Knowledge' dynamics, Nurse Violet's discourse gave rise to the first subject for debate: "the biomedical influence in the academic-professional orientation of nursing". The discussion that resulted from this theme was that, at the heart of the academic world, the use of non-conventional health practices is mostly accompanied by pejorative connotations. This view is even maintained by some nursing students, who believe that the use of these practices does not guarantee "status" to the profession. Even when the teaching-learning experience permits students to experience the use of herbs in health care, students do not value this practice, because they do not consider it is scientific.
This is what the above mentioned nurse says when she remembered a curricular experience during her undergraduate courses, when she was a trainee at a health unit in Niterói: [...] I think my class was the last one at that unit... Because the students did not see this as productive, the fact of dealing with that thing of going out there into the garden, at the back of the unit, where you recognize the herbs and see how they are manipulated... That is not acknowledged as scientific knowledge, which includes the issue of status, of power. What happens is that, in undergraduate courses in general, natural care practices are used occasionally, and are not systemized in nursing teaching. As a rule, they are introduced as a teaching-learning experience so as to attend individually to the specific interests of faculty who study these practice, and not to a professional political project.
According to one of the participants, resistance against students' participation in experiences that include natural treatments during their intellectual (academic) training is accompanied by the perspective that it are nurses who know; this grants them the power of knowledge and, consequently, in their point of view, they possess a status and social recognition. These are professionals who possess technical and technological management, as nurse Violet concluded. In this respect, it cannot be denied that technical-scientific advances brought great accomplishments in the field of health. The development of the biomedical care model, whose influence rests on the Cartesian paradigm, contributed to medicine for the elimination or control of certain diseases, such as bacterial pathologies, diseases, for heart surgeries and organ transplants, among others.
However, in the organization of modern life, society is confronted with various theoretical-philosophical paradigms. We are facing a huge paradox since, at the same time as the technical-scientific evolution benefited some population segments by structuring science according to certain patterns of truth, the Cartesian model also transformed them into a mechanized system, with closed and distinct parts(1). In this analysis, in view of constant mutations in people's lives nowadays, their health is deteriorated, due to social organization and unlimited consumerism, among other reasons. In the ethical, political and economic sphere, today, discourse has turned to outsourcing and economic globalization.
Limitless competition in the labor market, emphasis on increased productivity in less time and on workers' technical efficacy, characteristic of neo-liberal policy, have led to a development standard without measure or control. Inadequate and unhealthy work conditions, an increased number of occupational accidents, recession and unemployment have been the cause of different physical and social diseases and have collaborated with the growth of violence rates. Moreover, different forms of aggression to the environment are important factors in this system, which are mostly responsible for the deterioration of human health. It should be highlighted that health involves various dimensions and results from the interaction between different - physical, social, historical and cultural - components.
In view of these considerations and in line with the neo-liberal conception of the current globalized economy, man is being used as a production instrument. From a political and social viewpoint, he is controlled to attend to the needs of the economic system, which affects all of his relations with the world. Another aspect to be taken into account is the "attribution of blame to the victim", in which "the individualization of blame results in the explication of a collective practice (...), for example, by overrating the population's socioeconomic problems, thus justifying precarious services"(5).
In this context, health professionals are trained to deal with this ideological structure, which is capable of recovering the active labor force that reproduces work force, mainly in view of the challenge of the informatics revolution to human work. And that is what we see in the discourse of nurses who participated in the 'Calendar 2' dynamics, that is, that (academic) formation is totally biomedical: My academic formation was for rationality... And phytotherapy really did not stand a chance (Nurse Boldo); My formation was totally biomedical (Nurse Pink).
Until the early 1980's, techniques taught by means of non-invasive procedures, such as the application of cataplasms, suckers, therapeutic massages, among others, were often lost in the hospital sphere, giving room to allopathic practices(3). Some of these techniques or procedures follow guidelines that are similar to what is found in popular logic. However, it should be highlighted that there exists a dichotomy between scientific and popular (common sense) knowledge, and that "when one is confronted with the other, at first sight, they seem to be moving in different directions that do not meet, leading to a growing distance between both"(4). The academy teaches and sustains the teaching-learning process on academic-scientific knowledge, because this has been proved by experimentation and scientific proofs and objectified through technique; consequently, it starts to be adopted as a criterion of truth.
In the dialogic movement that occurred in the context of the two dynamics, when participants analyzed the biomedical influence in the context of their formation and professional activities, which led them to conventional practices sustained by this model, they also reflected on ethical and legal implications involved in the applicability of medicinal plants in nursing care. Hence, the second theme for debate discussed these implications.
Ethical and Legal Implications in the Applicability of Medicinal Plants in Care
Let us take a look at the report of a participant in 'Body-Knowledge', which contributed to a broader discussion and the addition of other elements for reflection and debate: [...] during my training, some years ago, I observed a very strong collocation in relation to ethics, which emphasized that we could not use this so-called popular knowledge, because that would go against professional ethics, as there was no scientific proof for this practice. So, when there was someone oriented to these practices, that person was kind of pursued, kind of discriminated and even cut (Nurse Green).
We know that the ethical dimension impregnates all dimensions of the health sector and is present in different professions and services in this area. However, this kind of decisions transcends the sector and affects society as a whole. In this sense, the plurality of situations involving ethical factors needs to be taken into account. Thus, the mission of bioethical commissions "is not to find the miracle solution, the opportune solution for such conflicts; in principle, their mission is to turn them explicit and that is why it is good for them to join personalities with substantially different opinions, metaphysics and beliefs". That is why, in bioethics, we are "condemned to arbitrary and transitory compromises"(6). We see the incorporation of knowledge inherited from popular culture into academic formation as viable, which does not impede professionals (or future professionals) from constantly updating their technical skills in the search for new or recovered knowledge. After all, "we do not have the message. What we can do is to raise the problems, formulate the contradictions, is to propose provisional morals"(6).
The university as a knowledge-producing center par excellence is ethically committed to participating in this discussion process. This is because universities, mainly public institutions, are based on a triple structure constituted by teaching, research and extension. Thus, they are responsible for formalizing and strengthening bonds with civil society in the search for alternatives that can improve the population's quality of life and health.
In the same context, when consulting the Ethics Code of Nursing Professionals(7), on the one hand, we observe that it does not contain any mention whatsoever against nurses' using any alternative practice in itself. On the other, in chapter III, Art. 17 and 18 - "About responsibilities" establish, respectively, that the nurse has to: "Judiciously assess her technical and legal competency and only accept tasks or attributions when (s)he is capable of performing them safely for him-/herself and for the clients" and "Keep themselves updated, expanding their technical, scientific and cultural knowledge to benefit clients, society and the development of the profession".
In these articles, special attention should be given to aspects related to competence and different knowledge forms. Ethical issues should be assessed in the applicability of medicinal plants by nurses too. In this sense, in the first place, the academy should worry about conditions needed to produce knowledge about the used of medicinal herbs and validate the knowledge that sustains its use by popular classes. To allow nurses to deliver care by applying medicinal herbs, academic training urgently needs to support this practice through the formal inclusion of contents and practical experiences into undergraduate and graduate curricula, which can grant nurses the technical competence required to act in this specific knowledge area.
In this respect, it should be added that university editors have included publications about this subject in their catalogues. Examples include the Federal University of Ceará(8) and of Rio Grande do Sul(9), which have published material that contributes to the study of plants with therapeutic properties. As to scientific nursing research about the same subject, in recent decades, studies have focused on clients' as well as on nursing professionals' perspectives(3, 10-13). Moreover, the INTERNET offers access to several experimental research groups interested in this matter, many of which are even affiliated with academic projects in partnership with research institutes and the user community.
Although still incipient and not systematically, study participants who graduated from the second half of the 1980's onwards mentioned they received information on using herbs during their academic training. This can be explained by the fact that this was a time when some non conventional health therapies received governmental support and the situation started to give signs of change, with these treatments being discussed as a possibility in health care.
As to legal support for the professional exercise of alternative practices, Resolution 197/97 by the Federal Nursing Council(14) "establishes and acknowledges Alternative Therapies as a specialty and/or qualification for the nursing professional". In our view, this indicates that practicing nursing care by applying medicinal plants is supported by the regulatory body of our profession. However, we need to be aware that this Resolution deals with "alternative therapies", without specifying what these so-called therapies would be. This gives room to construct and deconstruct a classification of the countless practices that are called alternative today. If medicinal plants are considered as "alternative therapies", in theory, nurses are supported; if not, they lose legal support for professional care with medicinal plants. We would be at the mercy of the transitoriness of the theoretical-philosophical field in the construction of concepts.
In this discussion, we inquire whether, by prescribing herbs, nurses are infringing the Law of Professional Exercise? Let us take a look at Article 48 in Chapter V of the Nursing Ethics Code(7). It states that it is prohibited for nurses to "prescribe drugs or practice surgical acts, except those determined by current legislation or in case of emergency". Article 8, section II, item C, of the Law of Professional Exercise(15) mentions that it is the particular competence of nurses to "prescribe drugs previously established in public health programs and in routines approved by the health institution". Both the Ethics Code and the Law of Professional Exercise refer to "drugs", leaving room for different interpretations. In other words, by prescribing medicinal herbs, are nurses prescribing drugs as mentioned by these texts? What kind of drugs are both referring to?
The Portuguese language dictionary can offer some help in answering this questions, as the definition of drug ("medicamento") is expanded when it incorporates the meaning of medicine ("remédio"): "medicamento" is a male noun that refers to "substância ou preparado que se utiliza como remédio"(16); and "remédio" is "aquilo que combate o mal ou a dor de; recurso, solução; auxílio, ajuda; emenda, correção"(16). Thus, we may consider that the word "remédio" includes, besides "medicamentos", other resources, such as people's way of life, their beliefs, values and popular care practices for example. In this case, nurses use many "remédios" in their practice, as there are countless ways of helping a client to cope with the process of living and being healthy, getting ill and dying.
We can also interpret that drugs are what is produced by mainly multinational pharmaceutical, that is, allopathic industries; or, also, prescribed natural formulae manipulated in pharmacies; or natural formulae produced by a laboratory that detains the brands. Thus, we can consider all or part of these as prohibited. These doubts arise from the fact that, in a way, we are inclined to consider as "drug" what goes through the process of professional preparation, that is, in laboratories and pharmacies. And what about natural herbs? Would these be considered as the drugs mentioned in the legal prohibition?
This simple reflection in the light of the Law and Professional Ethics reveals a series of issues that, in our view, weaken our practice and, consequently, our professional autonomy*. These ambiguities can determine (or not) the applicability of medicinal plants in professional nursing practice. But it is paramount to consider the analysis about the need to conquer spaces in practice to allow us to guarantee this practice by Law.
In line with these reflections, we believe that discourse about the ethical and legal possibilities of incorporating medicinal plants into daily nursing work should not impede its appropriation in public-professional practice. Any impediment would support the externalization of academic dogmas and would strengthen its adoption in private-home practice only. Today, scientific production is available in nursing to demonstrate the importance and applicability of medicinal plants in health care. However, there is an urgent need to configure and delimit this practice in the sphere of nursing care. That is why the specificity of our practice, and particularly our care, is based on the establishment of nursing diagnoses.
The care prescribed by nurses is aimed at solving a nursing problem and, hence, is part of their professional sphere. Thus, if we thoroughly elaborate the concepts that guide our practice (our care) and, also, advance in diagnostic studies that imply the prescription of medicinal plants, with a view to delivering appropriate nursing care to clients, we will be better equipped to legitimate this space as an extension of professional nursing practice.
We have shown that the use of medicinal plants does not have scientific origins, but is a historically legitimized knowledge and practice that is disseminated in common sense. Nowadays, many plants are the subject of scientific studies, conquering space in the academic sphere and in health professionals' actions, including nursing, in spite of the dominance of the biomedical model in science construction, professional training and practice. In this sense, there are examples of research focusing on trials with medicinal plants for prevention and healing. Although based on available studies and empirical observations about professional practice, the level we have reached both in terms of discussion and concrete practice is still insufficient to guarantee its legitimacy, especially by nurses, to the extent of turning the use of medicinal plants into a concrete practice that can be applied in the public-professional nursing sphere. This may be due to the non incorporation of this knowledge into the training curriculum, as mentioned above, giving rise to the need to configure and delimit this practice in care, including reflections about the ethical and legal implications of its applicability by nursing.
The nursing profession urgently needs to reflect on these implications for nursing care, all the more when many professionals are discussing and trying to guarantee the exclusivity of knowledge and practices for themselves, constantly attempting to get the best part. Thus, what we are discussing here is not strictly the ethical and legal attributions of the therapeutic use of plants as the exclusive territory for one or another professional, but the need to democratize and relativize their use as a shared and interdisciplinary health care action and, in the case of nursing, as an extension of their care practice.
Class associations like the Brazilian Nursing Association, the Nursing Union and Professional Nursing Councils have a fundamental role to play in the fight to delimit the space of nursing in areas that are burning with coherent and consistent care proposals in the current health context.
Finally, in the context of the problems the population is faced with at different levels, from another perspective, higher education reveals weak points in terms of knowledge areas related to alternative health issues, for example, which are at the margin of the established power, that is, at the margin of the acknowledged scientific character of the biomedical model.
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Recebido em: 16.5.2005
Aprovado em: 25.4.2006
* It should be reminded that this article did not aim to discuss the applicability of medicinal plants by other health professionals, including discourse about legal support, to the example of the Regional Council of Medicine, which has been publishing media reports that defend this practice as for medical professionals only and threaten other professionals with legal punishment.