Bioethical approach: production of nursing knowledge in Brazil

Abstract

This article seeks to contribute to critical reflections on the production of nursing knowledge with a bioethical focus in Brazilian publications. This is a literature review conducted by searching the SciELO platform using the descriptors “nursing,” “bioethics” and “ethics,” including articles published between 1999 and 2019. As a result, 43 articles were identified and, after applying inclusion and exclusion criteria, 16 were selected, approaching teaching ethics/bioethics for the nursing course, followed by intensive care/or terminality, organ donation and health care/action/care. A transition in the emerging themes was observed considering the historical context over the years and the interest in the area.

Keywords:
Nursing; Bioethics; Ethics in nursing

Resumo

Este artigo busca contribuir para o processo de reflexão crítica sobre a produção do conhecimento em enfermagem com enfoque bioético em publicações brasileiras. Trata-se de revisão bibliográfica realizada por meio de buscas na SciELO utilizando os descritores “enfermagem”, “bioética” e “ética”, incluindo artigos publicados entre 1999 e 2019. Como resultado, identificaram-se 43 artigos e, após aplicar critérios de inclusão e exclusão, foram selecionados 16 trabalhos, cujos temas eram ensino da ética/bioética para o curso de enfermagem, seguido por terapia intensiva/ou terminalidade, doação de órgãos e atendimento/ação/cuidar em saúde. Verificou-se transição entre os temas emergentes considerando o contexto histórico no decorrer dos anos e o interesse da área.

Palavras-chave:
Enfermagem; Bioética; Ética em enfermagem

Resumen

Este artículo pretende contribuir a la reflexión crítica sobre la producción de conocimiento en enfermería con enfoque bioético en las publicaciones brasileñas. Se trata de una revisión bibliográfica realizada en SciELO utilizando los descriptores “enfermagem”, “bioética” y “ética” para artículos publicados entre 1999 y 2019. Los resultados identificaron 43 artículos y, después de aplicar los criterios de inclusión y exclusión, se seleccionaron 16 trabajos que abordaron temas como la enseñanza de la ética/bioética en la carrera de enfermería, los cuidados intensivos/fin de la vida, la donación de órganos y la atención/acción/cuidado en salud. Hubo una transición entre los temas emergentes considerando el contexto histórico a lo largo de los años y el interés del área.

Palabras clave:
Enfermería; Bioética; Ética de enfermería

In the 1970s particularly, bioethics emerged as an academic and scientific reformulation of what was previously addressed in a separate or unconnected manner: biology (bios/facts) and the humanities (ethics/human values). In this sense, Zoboli ¹ viewed bioethics as a bridge to interconnect these domains of human knowledge. Therefore, this field relates to examining, in a multidisciplinary approach, human behavior in the area of life and health sciences according to moral values and principles.

Bioethics also emerges as an important sphere of reflection and practice in nursing, specifically addressing human issues in their ethical dimension. This enables contributions and expands the reflection of ethical behavior in healthcare activities, shifting the focus from the individual towards discussions about social responsibility, human rights and citizenship ².

Construction of knowledge in the field of nursing has advanced, especially with regard to the reproduction of new models and criticism of old ones. It is understood, above all, that this construction aims at its own knowledge as a modern science, socially recognized and legitimized with its own epistemology, methods, autonomy and a widespread field of activity. One can therefore say that these are integral elements of a heterogeneous professional body whose actions should converge towards the well-being of the patient. With these changes emerged the need to study and solve problems based on bioethics ³,⁴.

Nursing has historically experienced different stages, ranging from the practical training of nurses in patient care, with behavior based on standards and minimal theoretical preparation, to the search for systematic, technical and scientific knowledge. Currently, new technologies point to the training of nurses who are increasingly critical and committed to the work environment, driven by attitudes and, especially, autonomy ³.

In this context, it is important to mention Decree 94,406/1987 ⁵, which governs the professional practice of nursing, and the Codes of Ethics of 1958 ⁶, 1975 ⁷ and 1993 ⁸. The first two codes reveal a metaphysical, abstract and spiritual trend. The 1993 Code, in turn, seeks to address values from a historical point of view, based on a process-based outlook. In addition, the verbs “to nurse” and “to care” are replaced by “to guide” and “to cooperate.” Thus, nurses cease to be mere task performers to be placed on an equal standing with the other members of the healthcare team, and must be as well informed as the other professionals ⁹.

Despite the advances and legal contributions, some professional responsibilities are viewed as burdens, commitments, obligations and duties. Legal responsibility concerns compliance with Decree 94,406/1987; ethical responsibility is often wrongly understood as compliance with the Code of Ethics for Nursing Professionals.

This is explained by the fact that ethics teaching in healthcare courses has been largely history-oriented, focusing on the legal aspect, related to the set of duties professionals should perform in their activities, that is, deontological ethics. This model has been challenged by increasingly broad discussions on the need of codes of conduct to keep in step with social changes ⁹–¹¹.

Thus emerges a professional discussion in which morality means obedience to the law. At this point, ethical issues arise linked to professional practice and the great responsibility of nurses, who should include consultation and prescription of nursing care among their specific duties. Direct nursing care, especially in fields that deal daily with critically ill patients and those of greater technical (or therapeutic) complexity, requires adequate knowledge and the ability to make immediate decisions, which were absent in previous legislation ⁹,¹⁰.

The literature in the field of nursing with a bioethical approach has grown over time. The study of the production of knowledge in nursing and bioethics is undoubtedly extremely important, as it provides a broad range for the selection of relevant and updated bibliographic sources, which contributes to making nursing more reflective, aware and grounded in ethical and moral principles in the exercise of its duties ¹².

Hence the great importance of promoting a discussion about the current challenges of nursing from the perspective of bioethics. This study aims to contribute to this reflection by charting and understanding the conceptual frameworks capable of elucidating the discussions on the ethical and humanistic stance that has guided nursing in Brazil. This article aims to bring contributions to the process of critical reflection in order to identify and describe the production of nursing knowledge in Brazil with a bioethical approach.

Method

This article used a narrative bibliographic review ¹³. The searches were undertaken in the SciELO database using jointly the descriptors “nursing,” “bioethics” and “ethics,” always including the Boolean operator “and.” Articles in Portuguese, English and Spanish language published between 1999 and 2019 were included.

The review was conducted according to the following steps: 1) formulation of the research question, hypothesis and objective; 2) definition of inclusion and exclusion criteria for articles; 3) definition of the information to be extracted from the selected articles; 4) discussion and presentation of results; and, lastly, 5) presentation of the review. To guide the literature review the following question was formulated: “what approach has been used in nursing articles addressing bioethics in Brazil in the last 20 years?”

To contextualize the selected study period, spanning from January 1999 to December 2019, it is important to highlight that prior to the 1970s, researchers were occupied with topics that included professional practice and drafting of the Nursing Code of Ethics and Deontology ¹⁴ in Brazil. The year 1999 was chosen for being a five-year mark after the publication of Ordinance 1,721/1994 of the Brazilian Ministry of Education (MEC) ¹⁵, which provided new curriculum guidelines for undergraduate nursing courses. Subsequently, Ordinance 1,518/2000 ¹⁶ integrated bioethics to the teaching of ethics ¹⁷.

As previously mentioned, the inclusion criteria for the articles were: articles found in the selected database, published in Brazilian journals in Portuguese, English and Spanish, from 1999 to 2019. The exclusion criteria, in turn, were: books, articles not fully available for free, review articles (due to not drawing on primary data), and articles that did not address the researched subjects.

The articles found and selected were analyzed quantitatively and qualitatively to verify the main approach of bioethical discussions in nursing. Data were collected from the selection of articles, based on titles and then abstracts. The selected articles were read in full, and the following information was extracted: year, author, subject, study, theoretical concept, journal, objective, conclusion, study topic and type of research. The information was tabulated for analysis and to write the review.

Data collection aimed to respect ethical aspects, preserving the authors’ ideas, concepts and constructs. A further aim was to emphasize theoretical perspectives that emerged in the studies, that is, to understand trends and dilemmas and learn about the bioethical guidance given by nursing on patients, the relationships between professionals and society. For a better understanding of the results, after the articles had been read, the emerging themes in the studies were selected and an analysis of each article was undertaken, presented in a table and also descriptively.

Results

Based on the previously described search method, 43 published articles were found in the SciELO database. Of that total, only 16 were included, since they met all the methodological criteria for inclusion.

Regarding the journals in which they were published, four articles were in Acta Paulista de Enfermagem, two in Texto & Contexto: Enfermagem, two in Revista Latino-Americana de Enfermagem and four in Revista Brasileira de Enfermagem. In addition, one article was selected from each of the following journals: Revista Brasileira de Educação Médica, Revista Bioética, Revista da Escola de Enfermagem da USP and Saúde e Sociedade. As for the SciELO thematic area, 15 articles were classified as health sciences and one as human science. Regarding the year of publication, most articles were published in 2010 (six), followed by 2002 (two), 2013 (two), 2015 (two), 2005 (one), 2006 (one), 2007 (one) and 2011 (one).

The survey revealed a gradual increase in publications on the subject of bioethics in nursing found in SciELO, and this trend is corroborated by the number of publications in 2010 ⁹,¹⁰,¹²,¹⁸–²⁰. França and collaborators ²¹ reported the need to observe and disclose the recommendations for theses and publications provided in National Health Council (CNS) Resolution 196/1996 ²², which is currently already well disseminated, according to the results observed. In addition, there was a trend to evaluate the impact of Federal Council of Nursing (Cofen) Resolution 240/2000 ²³, ten years after its publication.

Most publications were linked to graduate programs, in master’s and doctoral courses, with theses and dissertations in the area ²¹. This is linked to the theoretical perspectives on which the authors base their arguments, although some do not emerge in the texts nominally. Among the main topics addressed, it was observed that ethics/bioethics teaching/education in nursing was the most frequent (seven articles), followed by minimal, intermediate and intensive nursing care (two articles), Family Health Strategy (ESF) (two articles) and, lastly, scientific production/thesis and educational health actions, with one article each (Chart 1).

Chart 1
Articles on bioethics and nursing selected in Brazilian journals between 1999 and 2019

Year	Author	Subject	Journal	Theoretical concepts
2002	Soares, Lunardi 24	Nursing care	Revista Brasileira de Enfermagem	Principlism/Foucault
2002	França and collaborators 21	Scientific production/theses	Revista Brasileira de Enfermagem	Aristotle/CNS*
2005	Koerich, Machado, Costa 2	Health action	Texto & Contexto: Enfermagem	Principlism
2006	Ferreira, Ramos 25	Teaching/education	Acta Paulista de Enfermagem	Principlism
2007	Zoboli 4	Family Health Strategy	Acta Paulista de Enfermagem	Principlism
2010	Oliveira, Silva 18	Nursing care	Acta Paulista de Enfermagem	Principlism
2010	Mascarenhas, Rosa 19	Teaching/education	Acta Paulista de Enfermagem	Principlism
2010	Mascarenhas, Rosa 12	Teaching/education	Texto & Contexto: Enfermagem	Principlism
2010	Carneiro and collaborators 10	Teaching/education	Revista Brasileira de Educação Médica	Aristotle/Principlism/legislation
2010	Vargas, Ramos 9	Intensive care	Revista Brasileira de Enfermagem	Foucault/Kant
2010	Coli, Anjos, Pereira 20	Intensive care	Revista Latino-Americana de Enfermagem	Principlism
2011	Pessalacia and collaborators 26	Teaching/education	Revista Brasileira de Enfermagem	Principlism
2013	Couto Filho and collaborators 27	Teaching/education	Revista Bioética	Principlism
2013	Burgatti, Barcialli, Oliveira 28	Teaching/education	Revista da Escola de Enfermagem da USP	Principlism
2015	Siqueira-Batista and collaborators 29	Family Health Strategy	Saúde e Sociedade	Aristotle/virtue
2015	Luz and collaborators 30	Nursing care	Revista Latino-Americana de Enfermagem	Principlism

• ^*
  CNS: Brazilian National Health Council

Discussion

Specific themes emerged in the results according to the context and historical moment of the researchers, and recurring topics were grouped, contributing to the knowledge of the area under study. According to the data, bioethics is used in multiple senses and applications, from its most normative to its most reflective character, but also in virtue ethics, utilitarian ethics and principlism, in addition to the several philosophical schools whence ethics originate ²⁹.

Regarding the emerging themes, the main focus of the studies is bioethical principlism, a US paradigm stemming from the Belmont Report³¹ which, according to França and collaborators ²¹, provides the moral principles that should be applied in the biomedical field. Bioethical principlism has been adopted by both utilitarians and deontologists, since both types of theorists develop similar standards ²⁹. The bioethical principlism framework was disclosed and applied in the field of biomedicine, formulating a number problematizations related to individual rights and the provider-patient relationship in clinical practice, which resumes the discussions about communities and populations ⁴,³².

The findings make clear the consolidation of the contribution of principlism to bioethics. Most studies evidence the debate on the principles of autonomy, justice, beneficence and non-maleficence, enabling important advances to overcome specific conflicts through the systematization of knowledge relevant to the role of nurses in their professional field ³,¹⁸,²⁹.

Santiago and Palácios ¹⁷ stress that care for terminal patients and organ donation figure prominently among the most discussed topics on bioethics in the field of nursing. However, in the articles listed by this review, teaching/education in ethics/bioethics was the most prominent theme.

Luz and collaborators ³⁰ suggest that despite the existence of a positive attitude of providers and patients in relation to knowledge about ethical and bioethical aspects, there are still reports of lack of information and insecurity in complying with legislation, which often prevents individuals from making decisions with autonomy. Regarding nursing professionals in particular, there seems to be an interference of personal and ethical values in their practice, requiring improved capacity building and emotional maturity.

Regarding nurses’ attitude towards the intensive care unit (ICU), there was a trend to reflect on behavior in a context pervaded by the possibility of adopting wrong procedures. According to Vargas and Ramos ⁹, such mistakes should be corrected not only through knowledge or legislation but also through actual practice. Corroborating this position, Coli, Anjos and Pereira ²⁰ showed that nurses recognize the principles of autonomy, beneficence, non-maleficence and justice as important in intensive care.

Currently, there is great concern about changes that have occurred in working environments, especially in the use of new technologies previously inexistent and which today are indispensable to the care process ⁹. In the ICU, nurses often take on the responsibilities of other professionals in order to solve problems, facing important ethical issues ⁹. Another point of concern is the teaching of bioethics to healthcare providers, given that they daily face dilemmas and must make important decisions in a complex environment where all actions are questionable from an ethical point of view ²,²⁷,³⁰.

The most frequently published topic in the last 20 years available in the SciELO database has been teaching/education of ethics/bioethics in nursing, contributing to the development of reflection on philosophical and social aspects useful to the moral values of nursing students ²⁵. Despite the large number of studies on the subject, research with federal universities in Brazil showed that not all nursing courses offered bioethics in their curriculum. In addition, there is a lack of standardization regarding the offer of the subject, suggesting that professional training could be impaired ²⁴,²⁶.

It was evident that there is concern about the ethical education of nurses grounded in theory and philosophy in order to go beyond discussions restricted to the normative and deontological scope. Most publications suggest using active and transversal teaching strategies, with an approach to everyday practice ¹⁰,¹²,²⁵, highlighting the importance of coming closer to human sciences ¹⁰.

The teaching and study of ethics/bioethics to nursing students and professionals should be adequate to the demands of professional practice and grounded in a solid ethical-moral framework in order to review values and principles suited to reality ¹⁹,³³. This should not be restricted to deontological approaches, which aim at critical and moral reflection ¹², since nursing education faces the challenge of fulfilling its political and social function, preparing students to critically analyze the world, work and society ²⁵,³⁴.

Many studies confirm the effort to definitively include bioethics in the education of all healthcare providers, considering contemporary debates and new points of reference directed at issues in the area ⁶,¹⁹,²⁵,²⁷,³²,³⁴. In their study, Pessalacia and collaborators ²⁶ address the importance of the subject in education as recommended by the Brazilian curriculum guidelines for undergraduate nursing courses, which prioritize knowledge in ethics and bioethics for the comprehensive education of future professionals.

The studies also addressed nursing care with a focus on bioethics ²⁶, which champions the concept that caregivers must have more than technical and scientific knowledge and also show empathy and put themselves in others’ shoes. That goes beyond the duty of care, a practice taught throughout the history of nursing. The trend of principlism seems to have contributed to important advances in solving conflicts produced by the effect of inequalities in the scope of social and professional relationships, through the systematization of knowledge relevant to the profession with a focus on people ²⁷.

The essence of care is not related to the ability to use high technology and nursing practice is based on the nature of human relationships. This is not restricted to technical procedures but also involves human subjectivity, dilemmas related to finitude, pain and patient comfort ³⁰,³⁵.

Another trend observed was the study of bioethical problems from the perspective of Michael Foucault, which, according to Vargas and Ramos ⁹ and Soares and Lunardi ²⁴, focuses on people’s health as a responsibility of nursing, with the patient in the role of object of care. In addition, self-care is addressed as an ethical concern for the exercise of patient autonomy, since, in this viewpoint, self-care is a requirement for care for others ⁹,²⁴, This has consequences: producing and inducing the behaviors through which it will effectively influence the issue of autonomy in nursing practice/knowledge.

Studies on bioethics in nursing go beyond the theme of teaching and advance to other fields, addressing, for example, problems related to the ESF ⁴,²⁹. At the same time, consistent and comprehensive research on the beginning and end of life is scarce and hardly encouraged. In this context, principlism is not sufficient to respond and propose solutions to all situations, given the complex composition between clinical and public health concepts, theories and methods ¹⁸,²⁹.

It is important to emphasize and consolidate the confluence of issues that require greater unification between medical and nursing knowledge. Thus, each area can preserve its ethical and bioethical context yet converge to a common point: reflection on transcendental interprofessional actions and their impact on the patient’s quality of life. Therefore, it is up to medicine—whose professionals are placed in a higher social position—to meet more often with nursing, not only during shift hours or scheduled meetings, but in the understanding that seeking to enhance the production of nursing knowledge can greatly contribute to building respect and appreciation between the professions ³⁶.

Final considerations

This review showed that there is continuity in studies on bioethics in the field of nursing, especially in ethics/bioethics teaching, ICU and end of life. To those were added issues such as the ESF, which differs organically from the commonly addressed hegemonic hospital model, and nursing behavior/care. Moreover, codes of professional ethics, professional practice laws and CNS resolutions on research with humans contributed to the construction of current knowledge, proving that such discussions should also be expanded.

The dearth of studies in many thematic areas is evident, given the changes in higher education and in the field of science and technology, which deserves more attention with regard to bioethical aspects. It is clear that principlism is currently used to guide behavior and decisions related to moral conflicts in nursing and increasingly discussed in the actions and decisions of those professionals.

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Publication Dates

• Publication in this collection
  28 Nov 2022
• Date of issue
  Jul-Sep 2022

History

• Received
  28 Sept 2020
• Reviewed
  27 May 2022
• Accepted
  30 May 2022