Public policies, autonomy, interculturality and bioethical discussions

The pandemic continues to have a major impact on health and the world economy, raising constant questions to the health field and society. In this context, the role of the State in the adequate financing of health services is fundamental, for the iniquity of people’s living conditions means different repercussions caused by COVID-19. The lack of basic sanitation, for example, hinders – and in some cases prevents – taking preventive measures necessary to contain the disastrous effects of the pandemic.

Although the coronavirus infects all indistinctly, most of those affected live in informality, cannot escape agglomerations, lack the infrastructure to work from home while maintaining their income and lack a minimum basic income guaranteed by the government for their survival¹ . A comprehensive view of the model of society that is intended to be built for an effective fight against the COVID-19 pandemic is necessary. From the outset, everyone, without exception, must have access to basic humanitarian conditions and it is society’s responsibility to build a social welfare model in line with the modern democracies of the 21st century.

Given that the COVID-19 pandemic is an international problem, finding effective solutions for all peoples is a matter of global justice. The human development index, recommended by philosopher and economist Amartya Sen² , winner of the Nobel Prize in Economics in 1998, measures development and quality of life according to more than material criteria, since it also includes factors such as education, health, freedom and enjoyment of human rights. In this period of crisis, the importance of these issues is stressed, and global responses are necessary since public policies implementation should aim to correct distortions.

Another topic addressed is the advance medical directives (AMD) in patients with Alzheimer’s disease. The progressive aging of the worldwide population, starting on the 20th century, resulted in an increase in chronic, possibly disabling degenerative diseases, which often progress to dementia³ . This is another “pandemic” with which contemporary societies must learn to coexist, always respecting older people’s rights with affection and compassion.

In April 2012, the World Health Organization⁴ published a document that places dementia as a public health priority, considering the quality of life of people of advanced age. Studies project continued growth in the number of people with dementia, especially those over 85 years³ , but even if no treatment can deter or reverse the process of dementia, planning medical care is possible. The advancement of technologies in the medical area prolongs the lives of individuals but it is necessary to ensure their autonomy and self-determination before the most advanced phase of the disease, when the patient is no longer able to decide on their preferences, thus avoiding unacceptable treatments – within the values of each person³ .

AMDs minimize the incidence of mysthanasia, the miserable death faced by many older adults, who often not even have access to Brazil’s public hospitals. Likewise, they avoid dysthanasia, understood as postponement of death that often only prolongs suffering⁵ . Thus, in the form of a living will or healthcare power of attorney, AMDs also hold important positive externality in the strengthening of individual responsibility in making decisions to and for themselves and the collective responsibility to care for those who need it most.

Next, the indication of surgical management in cases of brainstem tumors, which represent 10% to 20% of central nervous system tumors in children, is discussed. In this group, the most frequent tumor is diffuse intrinsic glioma, diagnosed by magnetic resonance imaging or stereotactic biopsy, which accounts for 80% of cases and results in short survival and poor evolution. As the brain stem is vital for life and cannot be removed, surgery in these cases would be more harmful than beneficial and is generally not attempted, requiring ethical reflection on the topic⁶ .

The influence of ethical parameters in nursing practice was also addressed, considering that autonomy in the care of human beings in health is the right that guarantees decision-making based on information. This is the basis of the concept of free and informed consent to choose rationally and accept or not a certain treatment or procedure, being aware of its risks and benefits.

It is important to know the limitations of the work and the importance of nurse’s actions, who participates in the health team in the patient’s care process, recognizing that the autonomy of the professional never overlaps with that of a chronically injured patient⁷ . The understanding of these ethical principles in nursing practice has been, over the decades, an important factor not only of recognition of the profession, but also of creation of an identity of its own, always in defense of patients’ rights.

In a multicultural country such as Brazil, addressing the theme of bioethics and interculturality in indigenous health care is essential⁸ . The principle of autonomy has positive impacts on the physician-patient relationship and the balance between traditional medical paternalism and the indigenous patient’s culture is fundamental for symmetry. According to Bauman⁹ , even if human communities have particular cultures, this does not deny the existence of a culture of humanity.

Globalization has increasingly shown that, despite important cultural differences, civilization tends to be one, but respect for the self-determination of peoples and the affirmation of their cultural identity are factors that emerge from a new wave of globalization with a view to a more promising future for humanity. According to Brighenti¹⁰ , even when considering the “epistemicide” of indigenous practices and knowledge that occurred in Brazil – including that of territoriality –, intercultural bioethics in indigenous health care is possible. Such knowledge can be applied to other scenarios, where people from different cultures coexist.

Finally, the surveillance activity conducted by class councils is analyzed; their function is to ensure ethical and good professional practices for the protection of society. These entities are private entities¹¹ created as a result of the decentralization of State activities and arose from the need of the Federal Government to create legal entities to act in certain branches, such as the supervision of regulated professions¹² . Thus, the so-called police of the professions, which would be the responsibility of the public authorities, is delegated to professional orders that conduct the tasks typical of such authorities¹³ .

Since public systems are heavily regulated, orders and other professional entities have important professional self-regulation functions and must balance their invested regulatory powers in order to defend the interests of users and promote professional integrity.

These and other interesting research topics are available to readers for reflections.

Enjoy your reading!

Referências

• ¹
  Catão MO. A covid-19 no brasil e os grupos socialmente vulneráveis: do reconhecimento de necessidades à institucionalização de direitos. SciELO Preptints [Internet]. 2020 [acesso 20 ago 2021]. DOI: 10.1590/SciELOPreprints.508
  » https://doi.org/10.1590/SciELOPreprints.508
• ²
  Sen A. Desigualdade reexaminada. 2ª ed. Rio de Janeiro: Record; 2008.
• ³
  Burlá C, Rego G, Nunes R. Alzheimer, dementia and the living will: a proposal. Med Health Care Philos [Internet]. 2014 [acesso 20 ago 2021];17(3):389-95. DOI: 10.1007/s11019-014-9559-8
• ⁴
  World Health Organization. Dementia: a public health priority. WHO [Internet]. 2012 [acesso 20 ago 2021]. Disponível: https://bit.ly/3gwelm2
  » https://bit.ly/3gwelm2
• ⁵
  Alzheimer’s Disease International, McGill University. World Alzheimer Report 2021. Alzheimer´s Diseases International [Internet]. 2021 [acesso 20 ago 2021]. Disponível: https://bit.ly/3sKQune
  » https://bit.ly/3sKQune
• ⁶
  Reynolds R, Grant GA. General approaches and considerations for pediatric brain tumors. In: Winn HR, editor. Youmans neurological surgery. 6ª ed. Philadelphia: Elsevier; 2011. p. 2040-6.
• ⁷
  Santiago IS, Carvalho KK. Princípios da bioética e o cuidado na enfermagem [Internet]. In: Anais do 1º Congresso Internacional de Filosofia Moral e Política; 9-12 nov 2009; Pelotas. Pelotas: Universidade Federal de Pelotas; 2009 [acesso 20 ago 2021]. Disponível: https://bit.ly/38eLbD6
  » https://bit.ly/38eLbD6
• ⁸
  Santos ACG, Iamarino APM, Silva JB, Zollner ACR, Constantino CF. Considerações bioéticas sobre a relação médico-paciente indígena. Rev. bioét. (Impr.) [Internet]. 2017 [acesso 20 ago 2021];25(3):603-10. DOI: 10.1590/1983-80422017253217
• ⁹
  Bauman Z. Ensaios sobre o conceito de cultura. Rio de Janeiro: Zahar; 2012.
• ¹⁰
  Brighenti CA. Colonialidade do poder e a violência contra os povos indígenas. PerCursos [Internet]. 2016 [acesso 21 ago 2021];16(32):103-20. DOI: 10.5965/1984724616322015103
• ¹¹
  Medauar O. Direito administrativo moderno. 5ª ed. São Paulo: Revista dos Tribunais; 2001. p. 108.
• ¹²
  Santos AL, Jacobs E. Os conselhos de fiscalização de profissões regulamentadas. Jacobs [Internet]. 2020 [acesso 21 ago 2021]. Disponível: https://bit.ly/3gtZyYQ
  » https://bit.ly/3gtZyYQ
• ¹³
  Magami RT Jr. O poder de polícia (ou limitação administrativa à liberdade e à propriedade) como instrumento de desenvolvimento econômico e social. Jus.com.br [Internet]. 2016 [acesso 21 ago 2021]. Disponível: https://bit.ly/3ze59Kj
  » https://bit.ly/3ze59Kj

Publication Dates

• Publication in this collection
  18 Oct 2021
• Date of issue
  Jul-Sep 2021