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Saúde e Sociedade

versão impressa ISSN 0104-1290versão On-line ISSN 1984-0470

Saude soc. vol.24  supl.1 São Paulo abr./jun. 2015 


Democratic education and its application to the health field

Fernando Lefevre1 

Ana Maria Cavalcanti Lefevre2 

Carla Cristina Tze Jú Cavalcanti3 

1Faculdade de Saúde Pública. Universidade de São Paulo. São Paulo, SP, Brasil. E-mail:

2Instituto de Pesquisa do Discurso do Sujeito Coletivo. São Paulo, SP, Brasil. E-mail:

3Programa de Pós-graduação em Saúde Pública. Departamento de Práticas de Saúde Pública. Faculdade de Saúde Pública. Universidade de São Paulo. São Paulo, SP, Brasil. E-mail:


This study presents the Democratic Education proposal applied to the field of health and public health. Whereas the practice of health and public health implicate a large extent of decision-making by individuals, the democratic education proposal seeks to highlight the necessarily ethical dimension involved in such a decision, which it is believed to always be considered as a free and autonomous option for individuals, who have conditions to exercise this freedom. However, so this situation can effectively happen, it is necessary to question whether valid and intrinsically ethical behaviors are always those based, grounded in science and technology. In this context, the main task of the educator who works in the health area shall be to offer all conditions so this freedom of decision-making can be effectively exercised by the individuals. Hence, it is essential to consider diversity and differences, which are uncontested attributes of contemporaneity.

Key words: Education; Decision-making; Ethics; Personal Autonomy


Apresenta-se neste trabalho a proposta de Educação Democrática aplicada ao campo da saúde e da saúde coletiva. Considerando que a prática da saúde e da saúde coletiva implicam em uma larga medida em tomada de decisões pelos indivíduos, a proposta da educação democrática busca dar relevo à dimensão necessariamente ética envolvida em tal tomada de decisão, que, acredita-se, deve ser sempre considerada como uma opção livre e autônoma dos indivíduos, que possuem condições para poderem exercer essa liberdade. Mas para que esta situação possa acontecer efetivamente, faz-se necessário questionar se os comportamentos válidos e intrinsecamente éticos são sempre aqueles baseados, fundamentados na ciência e na tecnologia. Neste quadro a tarefa magna do educador que atua na área da saúde consistirá em oferecer todas as condições para que tal liberdade de decisão possa ser efetivamente exercida pelos indivíduos. Para isso é indispensável considerar a diversidade e a diferença, incontestes atributos da contemporaneidade.

Palavras-Chave: Educação; Tomada de Decisão; Ética; Autonomia Pessoal.


With regard to Internet and Globalization, Castells (2003) says:

The third major challenge is the establishment of information processing capacity and knowledge generation in each of us - and in particular in every child. I do not mean, of course, the guidelines in the use of Internet in its evolving forms (this is assumed). I mean education. But in its widest, fundamental sense; that is, the acquisition of the intellectual ability of learning to learn throughout life, obtaining information that is stored digitally, recombining it and using it to produce knowledge for any purpose we have in mind. This simple statement puts on the line all the educational system developed during the Industrial Age. There is no restructuring more fundamental than this one and very few countries and institutions are truly facing it, because before we start changing technology, rebuilding schools, and updating teachers, we need a new pedagogy based on interactivity, on personality and on the development of autonomous ability to learn and think and, at the same time, strengthening the character and reinforcing the personality. And this is a land unmapped. (Castells, 2003, page 227. Free translation.)

It is in this ideological framework we will try to discuss the problematics of what we are calling Democratic Education and its application to the health field and to the public health.

Democratic Education, health, and decision-making

The Democratic Education proposal that is presented here is part of the field of Education in general, following a traditional perspective of this field associated with, among others, the ideas of emancipation, autonomy, respect for differences and horizontality of the agents involved in educational interactions.

With regard to its application to the health area, Democratic Education is part of the works that makes the criticism of Health Education, which is seen as an authoritarian practice of seeking compliance or merely obedience to the dominant medical and sanitary requirements.

Health and public health, to a large extent, involve decision-making by the various social actors involved. From the point of view of health professionals, such decisions involve aspects such as: whether or not to pay attention to patients' stories; whether or not to offer alternative treatment and so on. From the point of view of patients: whether or not to treat themselves; whether or not to comply with the medical prescription; whether or not to use condoms during sexual intercourse; to smoke or not; to use drugs or not; to get depressed or face their problems.

Therefore, to analyze the decision-making issue is central to health and public health, even more when Education is involved, since Education is surely related to Decision-Making.

Decision-making has to do with Ethics to the extent it necessarily involves the tension between Autonomy x Heteronomy.

This tension is intensified when it comes to health because, as the technical area hegemonizes the health field, the heteronomy tends to prevail in the relationship among individuals and technicians (Silva, 2011), to the extent that the power is concentrated on the sanitary authority, de jure holder of the technical knowledge.

A paradox is reached at this point (sometimes a very real one for those who work in the field), which is that the major task of Education in the health and public health field consists of making the individuals able to "make the heteronomous decision" of always obeying the technical authority, and the Health Educators are positively assessed when they can effectively comply with this arduous mission, producing compliance.

Our Democratic Education proposal to the health and public health field is made when this framework is critically considered.

Concept of Education

Before discussing what we understand by democratic education, it should be noted a significant difference between what we understand by education in order to distinguish it from other pedagogical practices (Cambi, 1999).

We understand that education is a process that concerns the development of autonomy; therefore, it necessarily involves an ethical perspective. Hence, from our point of view, it is never an action, whatever it may be, on the other person; nobody educates anybody, as said by Paulo Freire (Vasconcelos, 2006); education is a responsibility of the individuals, who educate themselves in contact with the world.

The educated (by themselves, in contact with the world) is the one, as said by Castells (2003), who has learned to think, to make decisions, to assume a personal point of view (even if the decision is not to decide) based on information and on available knowledge.

People whether learn or not to educate themselves from their contact with the world and from a variety of forms of obtaining information and knowledge in these contacts.

The educator is not the one who educates the other, but the one who allows and facilitates the other to educate themselves.

An effectively educational practice consists, therefore, in a deliberate action in order to promote and facilitate the development of a thinking and decision-making autonomy in the individuals.

This concept of education surely does not exclude the fact that individuals can and certainly must be informed, instructed, trained, qualified, empowered. Thus such individuals will be able to understand and/or do something (fly an airplane, properly signal an offside in a soccer game, conducting a surgery, properly use a condom to protect oneself from STDs). The acquisition of skills is obviously necessary for the human life reproduction in society.

But then there will not necessarily be education if we understand that education concerns autonomous decision-making, conscious adoption of one's own point of views. Therefore, transmission of information is necessary, but not enough for the occurrence of education.

It is not, however, a querelle de mots or "words dispute"; nothing prevents that one resolves to call 'education' the transmission of information, the instruction, the training, the qualification, the school education, etc. What is important is to distinguish these processes from those involving the ability of autonomous decision-making or the informed adoption of point of views.

Our democratic education proposal concerns specifically situations, circumstances, processes and moments in which autonomous decision-making or adoption of own point of views are involved.

Practice of Democratic education

Democratic education and rescue of diversity and plurality

In the context above mentioned, the democratic education practice expects the educator or the educational body to deliver search and presentation of as much as possible of the diversity and plurality of point of views or perspectives involved in this specific issue, trying not to favor any of them.

The Democratic Education is committed to the diversity, to the difference (Mantoan, 2013) and to the plurality since significant thinkers of the present time (Giddens, 1991; Castels, 2003; Bauman, 1998) consider such features as defining traits of contemporaneity.

In the democratic education there is no point of view or perspective that is considered true a priori: the truth is not in the content, but in the process, in the discussion, in the dialog.

It stems from the assumption that in the short, medium or long term, the result of Education, i.e., the decision, the autonomous adherence to a perspective, the voluntary adoption of a point of view, will be always responsibility of the pupil, and the final decision they make will be even better if grounded in wide and diversified information.

The presentation of diversity and difference by the democratic educator can happen in distinct forms: among others, by making available to the interlocutor the several theoretical perspectives involving the theme, diversified bibliographic references, examples or illustrations and by conducting research to survey the various types of Social Representation involving the theme, and by translating the results for educational programs.

Democratic education, research of Social Representation, and Discourse of the Collective Subject

The Democratic Education proposal find important ground support in Social Representation Theory (Jodelet, 1989) since such theoretical perspective has the presence, in all social formations, as one of its basic propositions and even more in contemporary, of distinct and varied ideational schemes socially shared.

The social representation research that seeks to rescue such ideational schemes is a very useful tool for democratic education because it allows the arising of the diversity of point of views existing on the theme researched, in a given historical moment and in a given socio-cultural space.

Clearly, such research has to be done in order to facilitate the rescue of diversity and difference. Accordingly, a number of requirements must be considered: careful choice of stakeholders, i.e., of the populations object involved with the theme, definition of the appropriate tools to collect quantitative and qualitative data, social representation data processing with clear distinction between the obtained collective thoughts and the interpretations of their meanings by researchers (Lefevre; Lefevre, 2010a), etc.

As a quali-quantitative technique built to rescue social representations in all its diversity, through testimonials and other verbal materials (Lefevre; Lefevre, 2010b), the Collective Subject Discourse presents itself as a facilitating tool of the Democratic Education.

Considering this general framework of diversity, social representation research should seek to describe what the collective subject thinks about a given topic in a given socio-cultural space.

This task involves the rescue of distinct speeches that enunciate different perspectives, attitudes, beliefs, professed opinions by the collective subject, that is, by the set of actors or social agents involved in this specific theme.

The rescue through empirical research of these speeches implies the adoption of methodologies, techniques, strategies and instruments of nature both qualitatively and quantitatively.

By qualitatively we mean presenting and marking in the most detailed and clear way as possible the external differences between the speeches, and internally, the stories, contents, and arguments present in each.

The Discourse of the Collective Subject seeks to preserve the qualitative and discursive nature of Social Representations present in a given population, to the extent that, through always open questions, it seeks to enable responses in which representations are found in the form of testimonials; such testimonials are then individually processed in order to detect the Central Ideas or positions with their corresponding Key Expressions, i.e., contents, arguments and stories. Each testimonial is featured this way and the testimonials that show similar semantic positions are grouped in major categories. Finally, for each major category expressing a particular opinion or representation, Discourses of the Collective Subject are drawn in the first person singular with the present contents and arguments in each of the individual statements that have similar meanings, aiming that each DCS expresses a "collective story" about the surveyed topic.

By quantitatively, in turn, we mean the way in which the Discourse of the Collective Subject is made, with the help of the Qualiquantisof software to describe in details the distribution of these "collective stories" among the surveyed populations considering several attributes present in these populations, e.g. demographic.

An example of democratic education: the Programa Di@seguinte (Morning-@fter Program)

Di@Seguinte2 is a multimedia educational program designed with the results of the survey "Gravidez na Adolescência e Pílula do Dia Seguinte. Desvelando seus sentidos entre adolescentes e profissionais de saúde" (Teenage Pregnancy and Morning-After pill. Unveiling its meanings between teenagers and health professionals), project CNPq 550763/2007-4, developed from 2007 to 2010 in São Paulo, with 300 female and male teenagers, alongside 70 health professionals from PMSP (Municipality of São Paulo) responsible for health programs designed for young and teenagers.

The survey aimed to portray the Social Representations of teenagers and professionals from 6 cases or stories, each one related to one particular aspect of the problematics associated to sexuality and usage of morning-after pill.

The answers of the young and the professionals were processed with Qualiquantisoft, in the end achieving an expressive number of Discourses of the Collective Subject (DCSs) that portrait in a very detailed and diversified way the opinion categories of this collectivity on this specific theme.

The multimedia, designed with the DCSs of the surveyed young, is mainly intended to young people and it is available as from 2011 at the website, free of charge.

As an example of a democratic education proposal, Di@Seguinte program proposes an "horizontal" pedagogy, in which the teenager vision of the issue involving the usage of the morning-after pill appears alongside (and not submitted to) the sanitary vision of the problem, with dialogue or going against it.

At the end of the program, the young may (it is their right) continue with the same vision as before they accessed the program, even if such vision can be deemed wrong, from the perspective of the sanitary thought. But even then they will have had access to a plural set of information and in this sense the educational process will be democratic and ethical.

The program starts with a presentation by the research coordinator, describing the program's origin and its method of use.

Then a screen is opened, where the user can choose one of 6 stories. The story is presented (visually and orally) and then a version in "comic" format is presented with background music.

At the end of the comic version, the user is asked to choose answers from the surveyed teenager; such answers are visually and orally displayed and at the end of the answer the user can have access to the comments of each answer prepared by a health professional, who states its position as an expert against the option in the surveyed teenager answer.

An example of this dialogue below:

Case 3:

A female teenager has been dating, for a while, a young man. As they love each other very much, eventually they were unable to resist and went to bed. The next day, the girl was very nervous thinking she could have got pregnant; she, then, told her girlfriends and even her mother, and they recommended that she could take the morning-after pill. However, she decided not take the pill because she was a very religious person.

If this religious teenager went and asked you for advice, what would you say to her?

Below it is found one of the answers categories of the young girls expressed as DCS

She should take it to not get pregnant, because it could be an unwanted pregnancy and there was still time to stop, right? So I would tell her to take the pill because she would not be doing an abortion, she would be preventing herself from an unwanted child; because the pill, it is not killing a human being. It is simply preventing the ovulation from happening and you get pregnant. She is simply stopping the ovulation that will generate a real fetus, right? I would advise her to take the medicine to not get pregnant, because she would have to depend on her mother to help her to support the child. If she were dating or were making out for the first time with him, she shouldn't have gone to bed with him, she should take the pill since she regrets it and don't know for sure what she wants, because she is young, maybe not even finished school. So I would advise her to take the pill and obey her mother, because a child is not a joke, it is not like this, what "we do" and leave to the world. You have to raise, you have to learn, to live together with the child, because the consequences to the life of a woman who becomes a mother is totally different from a single person, who has more freedom to go out, to hang out, to have like a real free life.

Comments of the health professional

I see you have a mature outlook on this issue. It is important to know that emergency contraception is not abortifacient. I also think that teenagers who have this position could be multipliers of this information. I also agree that it is not worth sacrificing the future of everyone involved. It is best that everyone can prepare their future with studies and a good profession, gathering conditions to have a family.

The program also features a number of technical information relating to the morning-after pill and its use.

The goal of Di@Seguinte was to inform the young person about several aspects related to the morning-after pill as part of the teen pregnancy problem.

Its uniqueness lies in the fact of presenting to the ones who access the program the various possible positions against the use or non-use of MAP adopted by the young people surveyed, as well as a dialogue between lay and technical perspectives, as exemplified above.

The purpose of this form of presentation is to encourage the identification of the program user with either position or attitude towards the subject, and the access to other possible positions, as well as the confrontation with the technical position of the health professional.

On the Democratic Education proposal, the democratic has to do primarily with the democratization of information, proper and distinctive feature of the contemporaneity according to Castells (2003), among others, which the Di@Seguinte program tried to implement.

Such democratization implies that educational programs - primarily, but not only in the case of adult education - should strive for horizontality of the presented information, which means that all point of views on the subject in question are equally respected and respectable.

This informative horizontality is visible in Di@Seguinte to the extent that the method used for the rescue of Representations - the Discourse of the Collective Subject - enables the quantitative presence of different ideas and positions on the issue of Morning-After Pill, besides the qualitative factor, which is present in the speeches that develop and detail the contents of each of the different ideas.

Democratic Education also has to do, in the wake of the thought of Freire (1972), with the dialogue between different ideas, which also has an outstanding presence in Di@Seguinte when the program shows an "exchange of ideas" between each of the positions of the surveyed and the position of health professionals. This dialogue is also effective, albeit implicitly, by the mere presence of different positions present in the interviewees speeches, those which the program user can access.

The Democratic Education also regards listening to the other person, since the user of the programs that enable such proposal is implicitly taught to listen and respect the opposed thought, trying to understand its internal logic. As Bastos said (2009):

Listening is not a passive role; it sets the subject in motion, making them speak, facing their lack of knowledge, their questions about themselves and the world. Listening is active, you need to give consequences to it, like meeting the satisfaction and pleasure of new knowledge; new knowledge that places us before a reality in which we want to participate and in which we want to be entitled to have an active voice. Listening needs to be directed to the uniqueness of the subject, allowing them to express, speak and involve their desire (Bastos, 2009, page 94. Free translation).

All these attributes of Democratic Education are inputs for a better decision-making, the ultimate objective of educational activities in general and particularly in the health field.

Obstacles to the practice of democratic education

Many aspects of people's lives in contemporary social formations prevent or make it difficult the practice of democratic education.

The pursuit of identity

The identity achieved when one belongs to one or several groups (family, religions, politics, sports, work, etc.) is something we all seek and that everyone needs. The pursuit of identity is a clear obstacle to the practice of democratic education for it tends to lead the "identified" to defend or propose, in a non-critical way, ideas, beliefs, positions of their groups of belonging, failing to consider other perspectives.

Prevalence of Instrumental Rationality

Another obstacle to the democratic education is the field of Instrumental rationality in modern societies and cultures, dominated by a "know-how" ethic ( succeed in life, to make friends, to conquer women, to have extended orgasms, to succeed at work, to stay healthy throughout life, to be a productive researcher, etc.), since in such circumstances there is a clear impediment to critically considering the implications of the "solutions" proposed and even the very "problem" (is it obligatory to always "succeed in life" or "conquer women"?).

Hegemony of scientific knowledge

We live in societies completely grounded in science and technology or in the scientific-technological reason, which means that we tend to consider as inferior or wrong or fragmentary all other rationalities (mystical-religious, popular, common sense, etc.) and even as "irrationalities" everything that refers to the instinctual and supposedly departs from behaviors or conducts called "civilized".

In this context, derived from the Enlightenment proposal, education is precisely understood as the act of "enlightening the darkness of ignorance" or lead the "irrational", children, women, Africans, barbarians and other uneducated adults to the scientific-technological reason.

The Democratic Education proposal goes in the opposite direction from this trend, seeking to (re)direct to the main stage, without prior judgment, all rationalities or even the alleged "irrationalities", so that the pupil can freely make a choice.

The public policy issue

The educational activity, in many instances, involves educators as social actors linked to public health services, education, art, transportation, public safety, etc.

In this situation, the freedom of action of such actors is strongly limited to the extent that they are seen and see themselves as mere transmission links or operators or, at best, as adapters to local contexts of decisions previously defined in law, therefore mandatory.

For the Democratic Education proposal, the exit to such dilemma makes it necessary that the educator, agent of the public service, presents public policy not as something imposed or as an adherence object, but as something to be negotiated in an atmosphere of dialogue, in the context of a wide range of options to be equally considered and put into action.

By way of conclusion

Health and public health throws the ethical question of the necessary autonomy in decision-making into sharp relief, because they involve a great extent of the individuals decisions.

Educational practices in force in the sanitary field, however, most often consist of always making individuals make the decisions that the technique and the science recommend.

This type of education implies the use of all sorts of techniques and teaching strategies to make the pupil comply with the recommendations, adherence, consent (even the so-called "informed consent") leaving aside the question of autonomy, based on the (false) alleged thinking that behaviors grounded in science are always valid and intrinsically ethical.

The Democratic Education proposal goes in the opposite direction from the usual educational practices in the health field since it postulates that decision-making should always be a free and sovereign choice of the subject that makes the decision and that the main task of the educator is to offer all the conditions so such freedom can be effectively exercised.

Hence the commitment of this educational approach to the ideas of diversity, autonomy, difference and plurality, undisputed pillars of contemporaneity.


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Received: October 14, 2013; Revised: February 07, 2014; Accepted: May 15, 2014

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