Brazilian bioethicists and the principles of universality and integrality in the National Health System

PROCEDIMENTOS METODOLÓGICOS: Estudo exploratório qualitativo, realizado com 20 professores universitários de bioética atuantes no campo das ciências da saúde, com funções de diretores e ex-diretores da Sociedade Brasileira de Bioética e de diretorias regionais, no período de julho de 2007 a julho de 2008. Foram realizadas entrevistas semi-estruturadas, com perguntas abertas, sendo realizada análise de conteúdo.

Health systems are the product of a country's economic and social conditions.Their organization and functioning includes various inductive factors, such as pressure from the different social actors involved in these health systems.However, the prevalent ideology and ethical values in society are fundamental factors for health systems guidance and resource allocation.
In Brazil, the Federal Constitution of 1988 considers health as a social right and the duty of the State.The public health area falls under the protection of the National Health System (Sistema Único de Saúde -SUS) and substitutes the previous system that was based on the notion of work, when, by law, only registered workers were entitled to medical and hospital care.The universal health system was established by the current Constitutional Charter.In addition to the principle of universality of access, the Charter introduced an innovation when, in Article 198 II, it also inserted the principle of integrality -"integral care, with priority for preventive activities, without prejudicing care services".Among the different concepts, one of the understandings of health integrality 7 refers to the responses of the health system to the individual and collective health needs of a preventive and care nature.
These principles have been defended and questioned by various social forces.In practice, according to Mendes,8 Brazil is facing a dilemma in terms of consolidating the current segmented system (SUS and the supplementary medical-dental care system) or moving towards universalization of the public system.Bioethics, especially in Brazil, has been guided by themes related to health policies and systems 2,3,13 and, as Drane & Pessini 1 state, bioethicists have progressively taken over the role of providing advice to legislators and managers when it comes to proposing public policies.
Considering that these economic, administrative and political policies involve underlying ethical issues, the objective of this study was to understand the meanings attributed by Brazilian bioethicists to the principles of universality and integrality in the Brazilian health system.

METHOdOlOgICAl PROCEduRES
An exploratory qualitative research with analyticaldescriptive orientation was carried out.The qualitative

INTROduCTION
a Research "The ethical principle of distributive justice and its application in the public health system in the view of Brazilian bioethicists", carried out by the Faculdade de Saúde Pública, USP, coordinated by Fortes PAC and funded by the National Council for Scientific and Technological Development.
approach was chosen for its potential to understand cultural values.The data analyzed were obtained from a larger study.a A convenience sample was constructed, comprising directors and former directors of the Brazilian Bioethics Society and of some of its departments (period between 2005 and 2008): Rio de Janeiro, Pernambuco and São Paulo, Southeastern, Northeastern and Southeastern regions, respectively.All participants had scientific bioethics production, in accordance with a consultation carried out in the database of the Lattes Platform, of the National Council for Scientific and Technological Development (CNPq).The Society, which was set up in 1995, currently brings together most of the Brazilian bioethicists.Its purpose is to unite people with different university backgrounds, who are interested in encouraging discussion and the diffusion of bioethics.The categories of professional background became more diversified when the sample was expanded to incorporate professionals from the field of medicine, dentistry, nursing, anthropology and theology.Saturation criteria was considered for limiting the number of interiewees. 9Semistructured interviews were carried out between July 2007 and July 2008.The interviews, which were conducted by the researcher himself, were recorded on magnetic tape and subsequently fully transcribed.The responses of three of those taking part were obtained in writing after the form had been sent to them by Internet, because of the difficulty of arranging an interview.
In order to find out the meaning of the theme given by the social actors surveyed, all of them had previously received a script with the following open questions: A) If Brazil were to carry out constitutional reform, what position would you adopt with regard to the principle "Health is a right of all and a duty of the State?" Explain.B) Knowing that there are insufficient funds to cover all health needs B.1.Which should be prioritized?C) Can or should some health needs be left without any service?
The replies were grouped into two analytical categories: "the principle of the universality of the health services system" and "the principle of integrality in the health system".Some of the key-expressions that consist in "literal transcriptions of part of the statements, which allow the essential discursive content to be taken from the segments into which the statement is divided" will be presented. 6he study was approved by the Research Ethics Committee of the Faculdade de Saúde Pública, Universidade de São Paulo.All participants signed the consent form and were guaranteed the right to refusal, anonymity and the confidentiality, in accordance with Resolution CNS 196/96.

ANAlySIS OF RESulTS ANd dISCuSSION
The principle of universality of the health services' system Most of the bioethicists interviewed were emphatically in favor of maintaining the principle of universality, defending the constitutional principle that the National Health System was a major social victory and that the State is responsible for guaranteeing that everybody has access to care and the possibility of living in a healthy environment.But, they remember that since funds are scarce they must be allocated in a prudent and reasonable way.Also in defense of universality, there was explicit opposition to focusing policies that are restricted to the most underprivileged layers of society.
"In this sense, I think that this right should be guaranteed to everybody; it should not be exclusively for the poor.Everybody's paying taxes, so everybody should have access to a quality system."(E15) On the other hand, even though they were in a minority, there were those who argued against maintaining the constitutional principle of universality.These particular participants argued that, in the absence of the possibility of covering all needs, decisions must be taken, for example, excluding those who have the material and economic conditions to look after themselves and their health.These should access supplementary medical care systems.

The principle of integrality in the health system
As for the question of integrality, there were those who defended maintaining the constitutional principle and there were those against it; those who defended it were in a minority.Most of the interviewees criticized maintaining the principle of fully taking care of needs, because they considered it would be "difficult", "impossible", "illusory" or "utopian" for this to become a reality."I saw, for example, that in Canada -you notice that all health systems today, to a certain extent, are in crisis, precisely because of funding, because of costs.Today you realize that we have growing infinite needs and finite resources."(E9) It was also considered that taking care of collective needs should gain priority over individual needs.Procedures that fit the so-called "desire-driven medicine", such as cosmetic surgery and assisted reproduction techniques should be restricted.Moreover, one of the bioethicist interviewed said that the principle of integral care should be restricted for those who have access to supplementary systems of medical-dental care:

"Only those who can pay for procedures, i.e. who have health plans, should not have full access to all resources." (E19)
There are currently three health system models: the liberal model, the model based on being employed and the universal model.In the last two cases state authorities have a direct participation, through planning, management, regulation, control and direct funding.The history of health systems, as we understand it currently, is recent.The process for creating public instruments for protecting social risks, such as old age, disease, unemployment, maternity, disability and workrelated accidents started in the 19 th century. 4,5 Germany, in 1883, in response to claims and social pressures from worker sectors, a public social security system was set up, based on the compulsory contribution of workers and companies.The basic principle of this health system model is professional affiliation and solidarity between those who contribute to it, solidarity between generations and between the "healthy" and the "sick".In addition to Germany, this model was adopted in France, Austria, Belgium, the Netherlands, Japan and various countries in Latin America during the 20 th century.
However, in the second half of the 20 th century another social protection system model based on universality and the notion of the social right to health care came into the scene.In 1946, in Britain, right after the end of the Second World War, the National Health System law was enacted that was the result of conceits and principles established in 1943 in a report presented to the British parliament by Lord Beveridge's team.In 1948, the British National Health System was implemented. 5This public system covers all citizens and is not based on professional affiliation and its funding is guaranteed out of general taxes and independent of any welfare contributions.It incorporates the notion of right to free health.This system was subsequently adopted in Australia, New Zealand, Canada and Brazil.
In our research, most of interviewees were in favor of maintaining a universal system and opposed to the idea of focusing resources on people living in a less privileged situation.The notion of focusing resources is frequently related to undercurrents of egalitarian liberalism, which accepts actions that have consequences that are unequal for the various individuals involved only when they result in compensatory benefits for everyone, and particularly for the less privileged members of society.It could be said that they favor "positive discrimination", prioritizing the underprivileged, the excluded, the most vulnerable or those who are already suffering in some way. 11,12here were few discursive arguments that, invoking the scarcity of resources for guaranteeing that all can be cared for, understand that it is valid to direct resources exclusively to people who are unable to take care of their own health.Despite the fact that such discourses did not explicitly defend the liberal health system model, they indicate acceptance of a segmented system that differentiates customers according to their degree of satisfaction with their health needs, either with their own means or through forms of inclusion in formal employment, or through solidarity-based groups, like those that go to make up social securitybased systems.
Mendes 8 discusses the idea that, if the public system were oriented only towards underprivileged people, leaving aside the principle of universality, there would be more than enough resources for the poorest layers of society.In fact, by excluding that part of society with the greatest power of opinion and pressure on politicians and legislators, the system would be more vulnerable to obtain adequate resources due to the smaller potential for bringing social pressure of the underprivileged segments.
Therefore, questions may be asked about the bases and criteria for saying that someone is underprivileged or already suffering in some way and whether such criteria are economic, social, demographic, epidemiological or sanitary.Questions might be asked as to whether biological criteria and those related to pathological conditions resulting from disease should be taken into consideration.
If, on the one hand, the majority defended the principle of universality, maintenance of the constitutional principle of integrality was characterized by fairly divergent positions, with criticism as to its continuity predominating.The bioethicists interviewed took positions that ranged from defending maintenance of the principle, without change, to explicit manifestations from the majority of the need to reformulate it, by restricting resources for certain technical procedures, such as those related to "desire-driven medicine".
With regard to integral care for all users of a health system the World Health Organization recognizes that the various public health systems are unable to fully assume the needs of everybody.Even if this were possible, there would have to be a substantial increase in the funds invested in the health sector and in the basic causes responsible for most of the population's health condition. 15hutz 14 questions whether the maintenance of unrestricted care would not result in an increase in cases of social injustice, because with resource scarcity, instead of prioritizing the most underprivileged, it would serve the interests of the most organized groups that have the greatest lobbying power and greater access to the judiciary system.So, universal access to integral care would be a mere "image-objective" of the system, which is not borne out in the daily reality. 7en counties with structured universal systems, like the United Kingdom, Canada and Spain, restrict certain care being offered to all citizens, such as pharmaceutical help and dental care. 4r a discussion about the principle of integrality, Senate bill 219/2007 intends altering items in Law 8080/90, known as the Organic Health Law, which regulates the organization and functioning of the Brazilian National Health System.It intends limiting the pharmaceutical assistance supplied by the SUS.It argues that the interpretation of the concept of the integrality of pharmaceutical assistance refers to what is stated in the tables and in line with the therapeutic guidelines instituted by the federal manager of the SUS.
As for restrictions to integral care for health needs, Narvai & São Pedro 10 differentiate health problems arising from public health problems, since they understand that the latter correspond to the social representations of the needs of a group at a particular moment in time.It is up to the State to meet the needs arising from public health problems and not simply the individual health problems.For example, cosmetic problems might be considered to be individual health problems, above all in the psychical sphere, but would not be considered as a collective responsibility, involving public resources.

CONCluSIONS
The results of the research, principally with regard to integrality, show that bioethicists find it difficult to morally decide on what would be a fair health system.To build up the SUS, a truly deliberative process must be established that includes the various social players interested in the health system.A minimum basic ethical reference point for the organization and the functioning of the health system must be prepared, thus making it possible for the myriad ethical viewpoints to be manifest.