Bioethics, health and the Brazilian reality

Abstract

This article proposes a social, critical, active, humanistic, fair and effective approach to combat health system inequalities. In the Brazilian scenario. It seeks to discuss improvements to remedy the problems of this scenario from a sociological analysis with regard to social class issues. Health is addressed as an inalienable right of every citizen and justifying its inclusion, be it in the principles of universality, completeness and equity, proposing goals for a bioethics that thinks of sustainable developments, breaking away form everything that causes the imbalance in health assistance. The common good and the ethics of life are emphasized, highlighting the importance of solidarity and the pursuit of equality among human beings.

Bioethics; Health; Health equity-Civil society; Community participation; Human rights

Resumo

Este artigo propõe abordagem social, crítica, ativa, humanista, justa e eficaz no combate às desigualdades do sistema de saúde. Busca-se discutir formas de sanar os problemas da assistência no país a partir de análise sociológica que considera questões de classe. A saúde é aqui discutida como direito inalienável de todo cidadão, com base nos princípios da inclusão, universalidade, integralidade e equidade, propondo metas para uma bioética que rompa com as causas de desequilíbrio na assistência. São enfatizados o bem comum e a ética da vida, ressaltando a importância da solidariedade e da busca da igualdade entre os seres humanos.

Bioética; Saúde; Equidade em saúde-Sociedade civil; Participação da comunidade; Direitos humanos

Resumen

Este artículo propone un abordaje de tipo social, crítico, activo, humanista, justo y eficaz para combatir las desigualdades del sistema de salud. Se busca discutir formas de subsanar los problemas de la asistencia en el país a partir de un análisis sociológico que considere las cuestiones de clase. La salud es aquí abordada como un derecho inalienable de todo ciudadano, en base a los principios de inclusión, universalidad, integralidad y equidad, proponiendo metas para una bioética que rompa con las causas de desequilibrio en la asistencia. Se destacan el bien común y la ética de la vida, resaltando la importancia de la solidaridad y de la búsqueda de la igualdad entre los seres humanos.

Bioética; Salud; Equidad en salud-Sociedad civil; Participación de la comunidad; Derechos humanos

Goldim ¹ states that the term “bioethics” ( bio + ethik , indicating the union of biology and ethics) was first used by the German theologian Fritz Jahr in 1927 in an article for the journal Kosmos . The word comprises obligations of the ethical character of the human being, denoting a field of knowledge that reflects on life and death from debates on topics such as the extension of human existence, dignified death, euthanasia, interruption of assisted life, dysthanasia, kakothanasia and orthothanasia ¹ .

Bioethics has been echoed in theological and philosophical discussions, acquiring a multidisciplinary character by extending its debates to areas of law, social sciences, anthropology, psychology, etc. In the health sciences, the field has focused on medical staff conduct and physician-patient relationships. Subsequently, issues related to bioethics were also assimilated by public policies, economics and the sociological understanding of social exclusion ¹ .

Kovács ² emphasizes that the development of bioethics as a branch of scientific knowledge has been based on the tripod called by Pessini and Barchifontaine “bioethical trinity”, based on the ideals of autonomy, beneficence, and justice. Autonomy is defined by Ramos ³ as the right of human beings to self-govern, playing the leading role in health and disease. On the other hand, beneficence is associated with the promotion of well-being and the end of unnecessary suffering, while the principle of justice is based on equity, recognizing that all citizens must have their health demands met. Compliance with these precepts brings up complex issues such as euthanasia ³ .

Parizi ⁴ points out that bioethics advocates ethics applied to the analysis of the phenomena and living conditions of all beings, including the environment we inhabit, with the horizon of responsibility for current and future generations. Bioethics studies are based on moral and ethical values that need to be considered in the development of nations, respecting the social dimension in discussions about public health. Bioethics thus fulfills the role of grounding public policies focused on health, establishing norms for institutions, professionals, care procedures and decision making ⁴ .

Also according to Carvalho, bioethics is based on the transparency of information, the recognition of diverse interests, respect for differences, mediation of conflicts, the formulation, and reformulation of agreements, considering that many truths are transitory (…) [due to] the inequalities, diversity, and complexity of contemporary life ⁵ .

The Brazilian Federal Constitution ⁶ establishes health as a social right. However, in the current scenario, the State lacks the commitment to the development of humanized care, so that universal access to this right can overcome inequalities. Thus, intervention bioethics seeks to demonstrate the importance of investments and government actions that prioritize health care for socially disadvantaged classes. To this end, it assumes utilitarian and solidary precepts, in view of the benefit of society as a whole ⁶ . This article discusses the inequalities of the Brazilian health system based on this bioethics aimed at the most disadvantaged: social classes of lower economic power and groups kept in marginality (the illiterate, the LGBT, and the mentally ill, to name a few). The discussion addresses the principles of equity and solidarity based on the provisions of the Brazilian Federal Constitution of 1988 ⁶ . From this perspective, solidarity is linked between states, individuals, families, groups, and communities seeking state-guaranteed health policy improvements for the entire population, as recommended by the Universal Declaration on Bioethics and Human Rights ⁷ .

Garrafa and Porto ⁸ indicate that in Brazil and other Latin American countries, since the 1990s, the principle of equity has been the basis for social discussions and the measurement of conflicts in health care. The authors point out that, by answering questions related to the current scenario of globalization, the critical aspect called “intervention bioethics” contributes to establishing the principle of equity as the basis of health policies and reducing inequalities generated by the hegemonic mode of production.

Another important point was to identify unique elements on the horizon of bioethics, grounded in the complex scenario of the socioeconomic, political and historical reality of a nation affected by global factors that cannot be overlooked. Addressing issues such as equity of rights and sense of citizenship responds not only to scientific need but also configures especially challenging research objects that further broaden the interdisciplinarity of bioethics.

Methods

This is an exploratory study ⁹ which, from a given population or phenomenon, identifies relationships between variables. Although they are initiatives in new fields of knowledge, many of these investigations use specific techniques to gather information. Here, for example, social inequality rates in the brazilian health sector were considered.

The data collection technique used was bibliographic research, which gathers, analyzes and discusses information from previously published documents. In this case, journals indexed in the Literatura Latino-Americana e do Caribe em Ciências da Saúde - Latin American and Caribbean Health Sciences Literature (Lilacs), the Biblioteca Virtual em Saúde - Virtual Health Library (BVS) and the Scientific Electronic Library Online (SciELO) databases, as well as books on bioethics.

In the way it addresses the proposed problem, the study can be classified as qualitative ⁹ , as it seeks meanings from the perception of phenomena, considering the context and the philosophical and social issues involved. In this sense, we analyzed texts by authors who establish active bioethics to address aspects of social inequality, focusing on the reality of the country and the power of justice as a bridge to the future of health.

Qualitative research aims to go beyond the appearance of phenomena, focusing on topics such as the origin of bioethics, humanization in health, the struggle for human rights and the relationship between social classes. Such an approach starts from observation and develops from the particular meaning to the general ¹⁰ , allowing to delve into bioethics and public health issues.

Social inequality and health

Cotta and collaborators ¹¹ state that the health condition of individuals is directly related to life trajectory and context, considering economic, political and technological variables that permeate the social fabric. Similarly, Barata ¹² emphasizes that structural conditions of social inequality also condition epidemiological profiles. Therefore, certain forms of social organization tend to generate healthier or less healthy contexts, and it is essential to consider society as a whole to understand the health situation.

In terms of economy. Brazil has the 9th economy with its gross domestic product on global terms, being the first in Latin America according to an international relations research institute ¹³ . Already in the ranking of human development index (HDI), with respect to the global term, in the Latin American continent Brazil is behind neighboring countries such as Argentina, Chile and etc. Brazil reaches 755.00 stagnant according to United Nations Development Program (UNDP) ¹⁴ .

According to Campello and collaborators ¹⁵ , despite the income inequality that worsened as a result of the historical oppression demarcated by the military dictatorship, there were improvements and social policies in the other subsequent governments from 2002 to 2015. There are more recent data that in 2015 the Gini coefficient decreased from 59.3 to 49.0 i.e. there was a significant decrease in income disparity compared to other less-developed nations, the level of absolute inequality is still large. This is where the 2030 agenda seeks ways to remedy global poverty. Only the billionaires in the Brazilian social strata hold the equivalent of the total income of the 50% less favored ¹⁵ .

About education, which is the key to improving our development index, points out that higher education is in a scenario of social elitization. Where the rich have quality education and the poor suffer for quality education ¹⁵ . Indeed, the state must seek and develop improvements to remedy these misfortunes.

Still on Health continues its socioeconomic reflection of social inequalities by the fact that Campello and collaborators ¹⁵ point out: The disorderly growth of cities, lack of sanitation and quality water, living and working conditions, food, education, ethnic/racial issues, aspects that have been seen earlier in this paper as dimensions of inequality are strong Social Determinants of Health ¹⁶ .

But the big problem, thanks to social health policies, has been decreasing from 2002 to 2015, that is, more recent data indicate that primary care, which was 31.8% before in 2002, in 2015, to be 63.2%. Concerning these administrative issues, improvements are being made, especially in previously vulnerable regions such as the north and northeast ¹⁵ . Research points out that factors such as these programs helped to remedy this social retardation, such as:

Initiatives such as the Programa Mais Médicos (More Physicians Program), the Núcleos de Apoio à Saúde da Família - Nasf (Family Health Support Centers), Street Offices, River Basic Health Units, Mobile Oral Health Units, the National Policy for Integral Health of the Black Population, among others, added to the network expansion and the increase of attendances in the Sistema Único de Saúde - SUS (Unified Health System) ¹⁷ .

The statistics still indicate a very unequal rate in Brazilian health, but we cannot keep silent in the face of these moral deviations and we must always look for ways to claim our rights in collusion with social justice. Continuing on the subject explaining social inequalities in health, based only on statistics, the country’s situation lives in poverty, colluding with great injustice and inequality, with a significant degree of income concentration and great inequities in terms of economic and social inclusion of a great part of the population. This inequality, present in Brazil and several countries in Africa and Latin America, has historical and cultural causes that go back to colonization, whose model of pure and simple extraction of wealth ignored the sharing of benefits.

This situation is aggravated by globalization, which leads colonized countries to a new form of dependence on the great powers. In addition to the perverse distribution of wealth among nations, the imposition of rich countries’ models of life and behavior also contributes to the exclusion of highly discriminated portions of the population, depriving them of quality educational background, better working conditions, income and the possibility of consumption. This whole scenario converges on the growing limitation of social and human rights ¹⁸ , ¹⁹ .

The social rights of the disadvantaged are not considered a priority ²⁰ . Hence, impoverishment and disease, as Magalhães, Burlandy and Senna ²¹ point out, end up feeding in a true endless cycle. Therefore, the correlation between poverty and other variables that create oppression and suffering is known: illness, illiteracy, violence, poor basic sanitation and difficulty in accessing health services.

It should be noted that although the most delicate and complex demands (transplants, organ procurement and distribution, high-cost medicines, etc.) are almost completely covered by the health system, access to these services is much more difficult for the poor, which, unlike the wealthier social strata, has no private service. Poor income distribution, due to the lack of commitment from the State, contributes to the rendering of increasingly precarious services, infrastructure problems, lack of supplies, equipment and medicines, unworthy working conditions and low salaries, with absenteeism and overburden of professionals, making health care even more problematic.

Problems such as unemployment and poor quality of food also affect health, among many other factors that make up the social exclusion of a significant portion of the population. This relationship is confirmed by the study by Bagrichevsky and collaboratos ²² , which shows how indices of greater health vulnerability underlie the social pyramid.

Pessini and Barchifontaine ²³ , in the book “Reflexão ao redor da desigualdade na saúde” (“Reflection around health inequality”), reflect that given the health situation in Brazil, it is difficult to develop bioethics (life ethics) at all levels of life for all citizens taking into account its three basic principles. Indeed, how can we bring the idea of autonomy and integrity to those who never had to feel like being autonomous to manage even their hunger? It is embarrassing to speak of the integrity of the body to a body whose malnutrition and diseases of poverty have already disregarded their dignity to the extent that they are not their being. Did the discourse of the principle of beneficence make sense to those who benefit from nothing?

It is somewhat comforting to know that every doctor should result in some form of benefit to the patient. But if the patient cannot even see a doctor, how to bring protection to the principle of charity into their daily lives? Any country that respects its people does so through the principle of justice: everyone must have equal access to the benefits of medicine. Resources for health should be distributed according to the criterion of justice so that many in situations of inequality benefit ²³ . In Brazil, and Latin America, is the cry for justice in the lives of millions of socially wronged people not more convincing than the theoretical formulation of bioethics based on the principle of autonomy?

In this sense, we understand that, today, it is more important to transfer information and educate the population to health than just to assist them, in effect, the informed and educated citizen will become their own health agent, also aware that health is a right, not a favor, as the national culture has distorted. This is a political and cultural change, which is, therefore, difficult, but which, if implemented, will provide a significant advance in health and quality of life.

The deep analysis of the Brazilian social inequality. Historically produced, iniquities are most pronounced in countries whose colonization was based on the domination of native peoples and slavery. In the most vulnerable social extracts (blacks, browns and indigenous people, especially those who live in rural areas) inequalities are even more persistent. This asymmetric process has damaged access to education and the economic dimension, generating social vulnerability that spans generations.

According to Costa and Lionço ²⁴ , to face these adversities it is important to identify and define the demands of the health sector, living up to the principle of equity. The Sistema Único de Saúde – SUS (Unified Health System) should promote constant improvement of professionals to meet the health care needs of the population, considering the deep economic impoverishment and social disparity that unfortunately permeate the Brazilian daily life.

Solidarity in bioethics

According to Pessini, solidarity as a concept, a value, and an idea, played an important role in the fields of sociology and social philosophy from the late nineteenth century but was largely ignored in bioethics until the early years of this century ²⁵ . The difficulty with the concept can be explained by acculturation: bioethics was born in the United States from an individualistic perspective, given the progress of technology and science, assuming a principled character, based on autonomy, beneficence, non-maleficence, and justice. However, in Latin America, the bioethical perspective tends to be humanistic and communitarian, more interested in the socio-economic reality.

The questioning of the principlist model by researchers from the South (Africa, Asia, and Latin America), as well as the emphasis on more humanized treatments based on socio-political judgments, have brought the category of solidarity to the center of current bioethical concerns. Several authors and scholarly publications with a communitarian approach have greatly assisted this movement.

Pessini and Barchifontaine ²⁶ indicate that, despite the scarcity of use of the term “solidarity” in bioethics, this scenario is gradually changing with the insertion of the concept in meetings of experts. In this context, “solidarity” represents respect for the human person and understanding of the situation in which the individual, community or community is in regard to justice, autonomy, legal norms, etc. This change is related to social and collective questions that highlight the need to go beyond the purely individual perspective, addressing social challenges, including the horizon of global phenomena.

Based on principles, bioethics prioritizes respect for the autonomy of the individual and the protection of their privacy ²⁶ . Considering the precautionary principle, the United Nations Educational, Scientific and Cultural Organization (Unesco) indicates that, in addition to preserve rights and respond to the needs of the individual in clinical practice and research, special attention should be given to public policies aimed at health, aiming at the aspirations of the community.

Solidarity in bioethical literature is associated with the public health perspective, which discusses the concept as humanitarian and collective, capable of justifying the responsibility of state authorities to ensure assistance to the population ²⁶ . From this perspective, the conception also relates to the notion of justice and equity, in aspects such as full access to services and adequate allocation of resources. Considering the global dimension, the idea reinforces the need to ensure health care for economically disadvantaged populations and poorer nations.

There are new areas of questioning in bioethics, and the concept of solidarity is relevant in this movement since it meets social concerns. While these themes once occupied a marginal position, they have now migrated to the center of the debate, mobilizing academic communities and health public policy actors from both civil society and governments ²⁷ .

The centrality of solidarity in bioethics brings up themes that transcend the individual perspective, with socio-political issues that include obligations and bonds of responsibility with each other. In view of the so-called “globalization”, which takes place without the prospect of social inclusion, solidarity must be highlighted, which encourages respect for human rights.

Social bioethics and health policies

In the book “Bioética cotidiana” (“Everyday Bioethics”), Giovanni Berlinguer ²⁸ draws the distinction between everyday and frontier bioethics. The aim is to bring this field of knowledge closer to everyday experience, as attention is still currently largely focused on extreme cases of life intervention that, before the recent development of the biomedical sciences, were impractical or even unthinkable (reproduction assisted, organ transplants, artificial survival, genetic mutations, breeding of new species).

The moral reflection on birth, gender relations, treatment of the sick, death, abortion, ethnic miscegenation, and interdependence between humans and other beings is ancient. Today these themes more or less consciously guide individual or social decisions and even advanced achievements of science. Thus, there are aspects of bioethics with distant roots, such as ideas and values that permeate reason and human behavior daily, and which deserve investigative attention from the perspective of the less fortunate.

Reflection on health policies in Brazil ²⁸ from daily bioethics can contribute to improving care. This implies an understanding of the term “health”, which cannot be defined simply as the absence of disease, as it is primarily the result of food, housing, education, income, environment, work, transportation, leisure, freedom, and access to care ²⁵ . In short, health is the product of objective conditions of existence, resulting from circumstances and relationships that humans establish among themselves and with nature through work.

Promoting health means guaranteeing rights and intervening in economic structures that perpetuate inequalities in the distribution of goods and services. Policies in this area should implement strategies that correct social imbalances. When examining the health situation in Brazil, we find several problems that derive from the living conditions of the population, inequalities generated by poor distribution of wealth and opportunities.

In Brazil, a few individuals have many rights, while many have almost none. The same happens with the distribution of income and public resources. There is great disparity between regions and cities in Brazil: child mortality, for example, is much higher in the Northeast compared to the South and Southeast. Individuals with higher wages live longer than those who earn only one minimum wage.

The economic crisis, recession, and negative growth in the country, coupled with the techno-structural trend of declining employment, are increasingly reducing the formal labor market, leading people to informality even in metropolitan areas. As for health, everyone knows that the industry is not doing well. Child mortality is still high. Newspapers and television daily report the chaos of health care: crowded hospitals, waiting lines and, especially for the elderly, the increase in monthly fees, which do not cover the treatment of various diseases. There are constant strikes by health workers for better wages and decent working conditions. Finally, cases of previously controlled diseases such as dengue, tuberculosis, diphtheria, meningitis, syphilis, etc. increase.

In full force of the 1988 Constitution, which guarantees the universal right to health, it appears that the expanded concept of care was not incorporated into political culture through governmental and social practices. Solidarity should be at the core of public policies, reflecting the concern of bioethics in guaranteeing citizenship rights to anyone and everyone. In its discussion of autonomy, privileging human values and dignity, bioethics can contribute to the search for improvements in health conditions.

Final considerations

The concern with the dignity of life, which underlies the arguments of this article, is the search for social equality, which in practice is achieved by solidarity. Thus, we sought to define what is meant by bioethics, with a valid approach for Brazil and Latin America: the approach of everyday bioethics, which values dignified life. From this perspective, we analyzed the 2014 Ministry of Health report, which demonstrated the relationship between social inequality and health.

Once the diagnosis was made, “the remedy” was proposed: to improve the SUS, putting into practice its ideals to alleviate the suffering of the people. In this process, it is concluded that the principles of daily bioethics should be applied, focusing on solidarity and dialogue with those responsible for public health so that we have policies developed based on the consensus that health (as well as education) must be a priority.

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Publication Dates

• Publication in this collection
  26 Sept 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  14 June 2018
• Reviewed
  30 Jan 2019
• Accepted
  26 Mar 2019