Discussions on bioethics in medical journals of Paraná, Brazil (1970-2005)

Abstract

This article analyzes the discourses that enunciate bioethics in the medical field of Paraná between 1970 and 2005, identifying authors and meanings attributed to the term. This is a historiographical research on Arquivos journal, published by the Paraná Regional Medical Council since 1983, and Revista Médica do Paraná, published by the Medical Association of Paraná since 1931. The documentary corpus was analyzed from the perspective of cultural history. Bioethics was first mentioned in the journal Arquivos in 1988, in an article on brain death, and later in Revista Médica do Paraná, in 1996, in an article on the principles of bioethics, in an article on the principles of bioethics, both written by physicians and professors. Journals are educational devices, as they disseminate ethical and bioethical ideas of the medical class that have the potential to reverberate within the society and change behaviors. The bioethics listed in the sources is closely aligned with principlism and medical ethics.

Bioethics; Periodical; Address

Resumo

Este artigo analisa os discursos enunciadores da bioética na área médica do Paraná entre 1970 e 2005, identificando autores e sentidos atribuídos ao termo. Trata-se de pesquisa historiográfica sobre a revista Arquivos, publicada pelo Conselho Regional de Medicina do Paraná desde 1983, e a Revista Médica do Paraná, publicada pela Associação Médica do Paraná desde 1931. O corpus documental foi analisado a partir da perspectiva da história cultural. A bioética foi mencionada pela primeira vez na revista Arquivos em 1988, em artigo sobre morte cerebral, e depois na Revista Médica do Paraná, em 1996, em artigo sobre princípios da bioética, ambos escritos por médicos e professores. Os periódicos são dispositivos educacionais, pois divulgam ideário ético e bioético da classe médica que pode reverberar na sociedade e mudar comportamentos. A bioética enunciada nas fontes mostra proximidade com o principialismo e a ética médica.

Bioética; Publicação periódica; Discurso

Resumen

En este artículo, se analizan cuáles son los discursos enunciados de la bioética en el área médica de Paraná entre 1970 y 2005, identificándose los autores y el sentido atribuido al término. Es una investigación historiográfica sobre la revista Arquivos, publicada por el Consejo Regional de Medicina de Paraná desde 1983, y la Revista Médica do Paraná, publicada por la Asociación Médica de Paraná desde 1931. El corpus documental se analizó desde la perspectiva de la historia cultural. La bioética fue mencionada por primera vez en la revista Arquivos en 1988, en un artículo sobre la muerte cerebral, y en la Revista Médica do Paraná, en 1996, en un artículo sobre los principios de la bioética, ambos escritos por médicos y profesores. Los periódicos son dispositivos educativos, ya que divulgan un ideario ético y bioético de la clase médica que puede reverberar en la sociedad y cambiar comportamientos. La bioética enunciada en las fuentes muestra la cercanía con el principialismo y la ética médica.

Bioética; Publicación periódica; Discurso

Based on a historiographical approach, this article analyzes the first speeches and authors who announced bioethics in the medical field of Paraná. The time frame from 1970 to 2005 was delimited by the introduction of the term “bioethics” in the book “Bioethics: bridge to the future”, published by Potter ¹ in 1971, and by the Universal Declaration on Bioethics and Human Rights (UDBHR) ². In historiographical research, sources are the raw material for investigation ³. In this case, they bring traces that allow the acknowledgment of the ethical and bioethical ideas that the medical profession intended to disseminate in Brazil, particularly in Paraná’s society ⁴.

The documentary sources are Revista Médica do Paraná ⁵, published by the Medical Association of Paraná (AMP) since 1931, and Arquivos ⁶, a journal by the Paraná Regional Medical Council (CRM/PR) edited since 1983, which allow the understanding of the ethical discourse and medical practices trajectory. To revisit collections is to investigate memories selected by institutions and the way they positioned themselves in the face of ethical and social issues of their time ⁷. According to the analytical perspective, journals cannot be considered impartial, as they reflect the institutional discourse and respective intentions. They also serve as educational tools, as their reading may produce knowledge and trigger behavioral changes ⁸.

The procedures of historiographical research demonstrate how subjects and institutions that represent the medical profession in Paraná conceived their ways of discussing ethical issues. The historical look at the production of institutional discourses reveals practices and arts of medical and ethical practices ⁹ in each period ¹⁰. To visit institutional collections is to handle their history, a memory that materialized in the speeches presented to society through journals. “Discourse” is understood as a culturally constructed representation of reality, as well as the formation of speaking subjects within a given context ¹¹,¹².

Cultural history ³,⁷,⁹,¹⁰ guides the analysis of the corpus of this research. The documentary sources shed light upon the institutional production of narratives on ethics and bioethics in Paraná ⁸,¹¹,¹², and their authors are subjects with recognized authority in the elaboration of real speeches ¹³-¹⁵.

Elements of the history of bioethics

The term “bio-ethik” has been outlined in 1927 by Paul Max Fritz Jahr within an imperative context of respect for all living beings ¹⁶,¹⁷. In the 1920s gained strength sanitary and eugenic theses for improvement of the conditions of the population in several countries. In Brazil, specifically in Paraná, positive eugenics was widely accepted by physicians. Together with proposals from the sanitary movement, the formulation of national health policies was advocated, supporting medical-governmental actions aimed at developing the Brazilian citizen ¹⁸,¹⁹.

In the following decades, the world would experience many atrocities and human rights violations, especially those related to World War II. In response to those inhuman acts, the Nüremberg Code ²⁰ was approved in 1947. A year later, the Universal Declaration of Human Rights (UDHR) ²¹ was enacted and established dignity as the foundation of human life, and in 1964 the World Medical Association approved the Declaration of Helsinki ²², which introduced ethical parameters in human subject research ²³.

In the 1970s, Potter ¹ presented neologism “bioethics” as an interdisciplinary field of study – a way of emphasizing two components to achieve new wisdom, that is, biological knowledge and human values, using the metaphor of the bridge between human sciences and biotechnological knowledge. His conceptual proposal had little repercussion in both areas in that decade.

However, the term was redefined as pertaining to ethics in medical practice, adopted by André Hellegers and his colleagues at the Kennedy Institute of Ethics to reflect on the ethical implications of new knowledge in biosciences ²⁴. In 1978, the Belmont Report ²⁵ was released as a reaction to the scandals caused by medical experiments involving human beings in the United States (USA). Thus, bioethics was associated with ethics in biomedical research, with the prevalence of a principled conception, that is, it was based on four principles: beneficence, non- -maleficence, autonomy, and justice ²⁴,²⁶.

The concept of bioethics is not monolithic and concerns systematic, plural, interdisciplinary study, involving theoretical and practical moral issues raised by medicine and life sciences, while applied to human beings and their relationship with the biosphere ²⁷. In 2005, this field was recognized as related to human rights in the UDBHR ².

More recently in Latin America, the theoretical- -practical body of bioethics has also started to discuss the socioeconomic situation, covering the many social inequalities, the lack of access to health services, the struggle for a more just and equitable society. Thus, the theoretical contributions of protective bioethics, intervention bioethics ²⁸-³¹, and referential theory in this area ³² are imperative, as they encompass human rights inter and transdisciplinarily in social, environmental, and coexistence aspects considering the complexity of current ethical issues.

In the face of new ethical controversy in human subject research, the International Bioethics Committee prepared the UDBHR ² and the Universal Declaration of the Human Genome and Human Rights ³³ with the enactment of the United Nations Educational, Scientific and Cultural Organization. These supranational documents set universal standards on rights, freedom, ethics, and human dignity in the spirit of universal pluralism ³⁴. UDBHR deals with ethical issues in studies involving human beings, taking social, legal, and environmental dimensions into consideration.

When addressing scientific practice in Brazil, the role of the National Health Council (CNS), which supervises, assesses, and monitors public health policies and guidelines for studies with human beings ³⁵, should be considered. In the 1990s, CNS created the National Research Ethics Commission (Conep) and approved CNS Resolution 196/1996 ³⁶, repealed by CNS Resolution 466/2012 ³⁷, with guidelines and rules for this type of research.

CNS Resolution 466/2012 ³⁷ reaffirms the respect for human dignity present in the UDHR ²¹, the Declaration of Helsinki ²², UDBHR ², and other documents of the United Nations. It incorporates the bioethics references – autonomy, non-maleficence, beneficence, justice (equity) –, which ensure the rights and duties of all study participants, the responsibilities of the scientific community and the State, among others ²⁷,³⁶. Therefore, these official documents ¹³,³⁸ guide ethics in medical research and practice.

Results and analysis

Writing the history of statements on bioethics based on journals published by institutions representing the medical class in Paraná is a challenging task. Engendered by investigations, the historiographic operation revealed discourses that first introduced the bioethics in the state. It is worth noting that historiographical research does not seek to establish general rules but to understand contexts, reinterpret facts, situations from the past and produce narratives with criteria of veracity and plausibility. Diving into the records and handling such documents is to look for traces of the history of medicine and bioethics in Paraná ⁴,¹⁰.

In addition to representing the medical class of Paraná, the documentary sources of this research were selected for their social credibility ⁵,⁶. The analysis of the corpus is guided by cultural history, which has been consolidated since the 1990s ³,⁴,⁷,¹⁰. It is up to the researcher to investigate the sources in search of traces that reveal the investigated object, as well as to compare them with other documents to determine the veracity of the uncovered facts ³,⁴.

The results reveal the meanings of the speeches, places of speech, and the subjects’ authority in affirming principles of truthfulness. The relevance of the medical power present in this research is discussed by Foucault from the perspective of the subjects’ social position ¹², manifesting itself in the creation of control and surveillance mechanisms ¹¹,¹³. The institutions’ discursive productions ⁹ highlight their position regarding social and ethical issues of their time, as well as the way they built memories ⁴.

This study followed three steps: 1) subject definition, questions, and search for theoretical and empirical sources; 2) choice of descriptors (Graphs 1 and 2) for searches in institutional, physical or online collections, and beginning of systematic reading of all copies published within the chosen period – articles that listed the term “bioethics” or indications of references in this field were copied and organized in tables including authorship, date, and subject; and 3) collation of results with other documents on research regulations involving human beings, attributing meaning to the findings by theoretical analysis anchored in cultural history ³,⁷.

As the AMP did not own copies of Revista Médica do Paraná, we have visited Biblioteca Pública do Paraná and Biblioteca do Setor de Ciências da Saúde at Universidade Federal do Paraná. The journal was first published in 1931 and is still in circulation today, with many changes to cover and internal layouts, article presentation, as well as their content. CRM/PR makes Arquivos journal, first published in 1983, available through its online institutional page. In both publications the authors are physicians, researchers, and college professors, that is, subjects whose knowledge goes beyond doctor’s offices and hospitals, reaching classrooms and society in Paraná.

Although the specific time frame ranges from 1970 to 2005, the presentation of historical references from Revista Médica do Paraná since the beginning of its publication was considered relevant. In the 1930s and 1940s, the journal ran articles with a hygienist bias, with a predominance of health education (Graph 1). At that time, physicians engaged in the eugenic social project, which was part of a building project for the Brazilian nation ³⁹. This was the place of speech from which the medical profession built its discourse ¹¹.

Graph 1
Topics covered by Revista Médica do Paraná, 1949-2002

Medical research and experiments involving human beings during World War II, as well as the UDHR ²¹ or the Nüremberg Code ²⁰, were not featured in Revista Médica do Paraná. Considering that what is said, as well as what is not said are elements of the educational device ¹¹,¹², this absence allows us to believe there was a distancing from the institution regarding issues related to ethics proposed by supranational entities. Paradoxically, the subject of dignity and human rights sees its first publications, not explicitly ⁹, but composing the content of articles, revealing sensitivity to be built within the medical ideal.

Revista Médica do Paraná changed its profile from 1953. Among the subjects discussed, techniques and ethics of professional practice became prevalent, especially the Medical Code of Ethics ⁴⁰, demonstrating a change in ideas. Health education issues have become infrequent, which points to a new practice following the incorporation of medical ethics ⁹. There was an absence of ethical, social, and political discussions in the period from 1964 to 1985, in the face of cases of human rights violations in Brazil.

Social and medical situations involving children, young people or the elderly, as well as multidisciplinary teams, became an issue in the 1970s. This change in text content showcases the approximation between the professional and the problems in vogue in the country ⁹,¹¹,¹², highlighting ethical propositions acceptable to the medical profession and society. Graph 1 shows that the most popular subjects were human dignity, codes of ethics, and medical responsibility. Until the 1950s, the debate on social and health education prevailed, and later ethical discussions were incorporated concerning human rights.

The first mention of the term “bioethics” in Revista Médica do Paraná dates from 1996, in an article signed by physician and professor William Saad Hossne ⁴¹. He was one of the authors of Resolution CNS 196/1996, co-founder of the Brazilian Society of Bioethics and coordinator of Conep between 1996 and 2007, representing the authority of speech in medicine and bioethics. His article was published 25 years after medical ethics was associated with bioethics resulting from the perspective endorsed by Hellegers in the United States. This time-lapse demonstrates that bioethics reached the medical profession of Paraná with Resolution CNS 196/1996.

In the article, Hossne ⁴¹ presented the bases of the principialist theory (autonomy, beneficence, non-maleficence, and justice) ²⁴ regarding the doctor-patient relationship and discussed the institution’s responsibility and professional secrecy. On human subject research, he proposed the formation of hospital ethics commissions and pointed out the need for normative documents by the State.

AMP was introduced to Paraná’s society through Revista Médica do Paraná, initially via the doctor’s speech of social action through sanitarism with a hygienist bias, and later with the incorporation of the technical and ethical discourse on medical procedures and conduct. This demonstrates that institutions occupy a specific place of speech and present a discourse characterized by social recognition ¹²,³⁹.

The scope of the second source – CRM-PR’s Arquivos journal, launched in 1983 – has always been professional ethics. The journal published articles on ethics regarding human subject research and medical decisions, human rights, as well as other emerging social issues (Graph 2). With articles signed by Brazilian and foreign physicians, Arquivos has an important place in social speech, as it represents the professional class through the CRM-PR, which expresses its concerns towards such matters.

Graph 2
Subjects covered by Arquivos journal, 1984-1988

Graph 2 demonstrates the subjects most discussed by Arquivos were human rights, dignity, and human subject research, which highlights the institution’s ethical ideals, revealing its role within these discussions and the educational aspect for the medical profession.

The term “bioethics” has been first mentioned in 1988 in the article “Morte encefálica: meditações”, by Lincoln Brazil e Silva ⁴², a physician graduated from the University of São Paulo and specialized in clinical neurophysiology. The author addressed the difficulty of defining brain death and the patient’s right to a dignified end of life. He also mentioned social, legal, cultural, scientific, and ethical aspects regarding the concept of death, showing concern towards establishing a medical and legal basis to confirm death. He also questioned the possibility of the institution of selective death, biased by racism, or even the legalization of death in health care facilities. Silva mentions “bioethics” twice and relates it to the ethical dilemmas of conceptualizing death, pointing to the need for a normative instrument that brings security to professionals.

Emerging ethical issues and human rights, in addition to the term “bioethics”, have been present on Arquivos’ publications since 1988. This reflects the country’s political moment, marked by re-democratization and the new Federal Constitution ⁴³. The journal, thus, reflected the necessary articulation for physicians to communicate with society and consider their patients as subjects of rights. Eugenics has been discussed in 1984 ⁴⁴, in an article on prenatal care for pregnant women at risk of giving birth to “children with serious defects”, but their approach to genetic selection was cautious, pointing to the need for ethical principles so as not to incur past mistakes.

The discussion of ethics in human subject research in this journal preceded the debate on bioethics. The Declaration of Helsinki ²² and the regulation of studies involving human subjects were discussed in two articles from 1986 ⁴⁵,⁴⁶, which similarly address the need for standards to safeguard the patient’s dignity, privacy, and well-being. The two provide evidence on the establishment of ethical parameters in this context, and refer to the question as referred by Foucault ¹¹: who exerts power over this regulation? It is the responsibility of the State to create norms and monitor ethical parameters for scientific research.

Despite the specificities of the analyzed journals, both published converging subjects with similar meanings. Chart 1 shows the contents and meanings attributed to each subject. Similarities and differences are observed regarding the concepts of social, ethical, and bioethical issues, showing that medical ethics temporally preceded bioethics in published articles.

Chart 1
Comparative and subject approaches by Revista Médica do Paraná and Arquivos journal

Revista Médica do Paraná (1932-2002)	Arquivos (1984-1988)
Patient autonomy: achieves relevance after 1953, with the publication of international normative documents on medical conduct and ethics in research. The patient’s decision regarding treatment is prioritized to the detriment of the professional’s will, if the patient’s life is not at risk as a result of this choice.	Patient autonomy and rights: it was widely discussed in the journal as a fundamental part of medical ethics. It is argued that only individuals who are aware of all stages and possible adversities should participate in research; “consent” is understood as “trust in the researcher’s discretion”.
Beneficence: respecting and doing good to the patient are guidelines for medical practice. Therefore, physicians are prohibited from carrying out procedures that harm their patients.	Beneficence: it is perceived as one of the guiding principles of medical practice. No action by the physician should harm his patients, but cherish their well-being, respecting human life and dignity.
Bioethics: in 1996 it is associated with the principles of beneficence, non-maleficence, justice, and autonomy, which may be used as guidance to the medical practice.	Bioethics: it is understood as an innovation in medicine, referring to the need for social, legal, and ethical standards to determine brain death. It could change conceptions and paradigms in which medicine was based in 1988.
Ethics committees or commissions: instances to resolve complex ethical issues, avoiding abuse in research involving human beings.	Ethics committees: they are associated with the need to regulate human subject research in Brazil, producing documents to support and standardize this type of study.
Human dignity: implicit in some articles, it is understood as a moral imperative that must be respected by medical practices.	Human dignity: widely disseminated, it is understood that it is the physician’s role to care for the well-being of the patient, respecting ethical, moral values, human rights, as well as local and international laws.
Human rights: they are presented in a tenuous way when dealing with patients’ rights, and mainly life.	Human rights: published in numerous articles, which include documents such as the UDHR and the Declaration of Helsinki in full, to reinforce their guiding role not only in the medical act but also in all daily practices.
Health education: much discussed in the first decades of publication, it covers topics such as hygiene and public health. It appears as an attempt to make the population aware of the importance of hygiene, and thus contribute to reducing the spread of diseases.	Health education and hygiene: they were not addressed by the journal.
Medical ethics: from 1953, it is perceived as a set of values and moral principles that must guide the physician in the life and exercise of his profession.	Medical ethics: frequently published subject. It is understood as the physician’s duty to act per moral and ethical values, as well as with current legislation. The professional must respect human dignity and the patient’s will while caring for their well-being.
Eugenics: approached from the hygienist and sanitary bias, with the engagement of physicians in the improvement of the life of the population. It was brought up in articles until the 1950s.	Eugenics: subject of a 1984 article warning about the risks of genetic selection. The text argues that eliminating genes can also mean eliminating people.
Human subject research: not addressed explicitly in the articles but approached in a tenuous way in the Medical Codes of Ethics.	Human subject research: a well-published subject, seeking international contributions and regulations to build national regulatory instruments and create Ethics Committees. It is the physician’s role, in his research, to care for the patient’s well-being, respecting ethical values, human rights, human dignity, and aiming at improvements that benefit the population.

Bioethics is presented in both journals as guiding ethics in medical practice, safeguarding patients’ rights, autonomy, and well-being with respect for human dignity. It can also be considered an ethical mechanism to resolve impasses linked to technoscientific advances due to its multidisciplinarity and interdisciplinarity ¹⁸,²².

The institutions researched have a specific enunciation place ⁴⁷, that is, they occupy socially representative positions so that the documents produced and disseminated are revealed as instruments of power, of “truth”, with historical and political significance ¹³-¹⁵. The results demonstrate how the institutions positioned themselves before society and presented a “horizon of expectation” to the target audience ⁴⁸,⁴⁹. The speeches reached physicians through the journals and reverberated in society with the incorporation of content and principles, changing behaviors and attitudes ⁸.

Through the published articles, the institutions strategically showed that professionals, in their daily work, needed to know ethical principles and research guidelines ⁹. These elements were incorporated into professional practice, specifically in the Code of Ethics and in the recognition of the rights of patients, study participants, and vulnerable subjects ²⁴,²⁸. Thus, the historical conditions for the rise of the bioethics discourse, the recognition of the subjects’ rights, and the ethical norms are related. This clarifies that the truth is centered on scientific discourse, on the institutions that produce it and is the subject of political debate ¹¹,¹².

Speeches on bioethics presented to the medical profession and the society of Paraná were written in two distinct historical moments, showcasing it as a theoretical and practical field, of a descriptive and prescriptive nature, whose object is ethical issues related to the health area, technologies, and human rights ⁵⁰.

Final considerations

This research investigated discourses on bioethics in Paraná between 1970 and 2005 in two medical journals, revealing their enunciators. Bioethics was published late in Paraná compared to the USA, being linked to ethical guidelines for human subject research. Arquivos journal was the first to publish an article containing the term (in 1988, in the Brazilian context of re-democratization), associating it with the need for regulations to determine brain death. Revista Médica do Paraná, in turn, presented the subject in 1996, addressing principialist bioethics during the process of standardizing research with human beings.

The institutions that publish these scientific journals have a place of speech legitimized by their social representation, disseminating ethical and bioethical ideas produced in a certain period. Therefore, the sources were essential tools in the theoretical and methodological construction of the research. The published speeches disseminated principles of bioethics, playing an educational role in disseminating them to the medical category and society in Paraná.

The authors of the articles are physicians and university professors and are in contact with other professionals in the field. They speak from the university, a place of great social prestige, and bring theoretical and technical innovations to their daily lives. As professors, they disseminate scientific knowledge that can influence professional behavior.

The bioethical ideas disclosed in the analyzed journals are associated with medical ethics and human subject research. Each journal chose a way to present the subject to society, highlighting some topics that were considered of interest to the medical profession. We emphasize the discourse of respect for human dignity and the recognition of subjects with rights, even though the ethical discussions of medical practice have preceded the statement of bioethics. This research contributes to building the history of bioethics in Paraná, and the traces located in the records allowed to indicate elements in the production of collective memory.

Acknowledgments

We would like to acknowledge Paula Manfredini, student of the undergraduate course in History at the Pontifical Catholic University of Paraná and introduction to scientific research with a scholarship from the Araucária Foundation, for her contribution in the preparation of the graphs.

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Publication Dates

• Publication in this collection
  30 Mar 2020
• Date of issue
  Jan-Mar 2020

History

• Received
  18 Mar 2019
• Reviewed
  10 July 2019
• Accepted
  17 July 2019