Portuguese Version

Year:  2004  Vol. 70   Ed. 5 - (0º)

Editorial

Pages: 578 to 579

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Bioethics: the change in ethical attitude

Author(s): Daniel Romero Muñoz

Hippocratic oath is a preciosity of human thought directed to the wellbeing of fellow humans. For the past 25 centuries, it has been the basis of the ethical attitude of physicians; however, in addition to marked medical and human development as a whole, a number of important social changes has deeply affected the relationship between physicians and patients, requiring adjustment to the moral stances of new patterns adopted by the society. In other words, Hippocratic oath was made by a physician and to a physician; at no point the text refers to patients' willingness or participation in decision-making. It has a paternalistic position of physicians towards the patients, not allowing the latter to be entitled to say what would be better for him/her. It reflects the time it was conceived, since ancient Greece contributed enormously to human evolution, but the ideas on human rights and fighting for the implementation of the society came much later. The French Revolution is a milestone to its effective development: from then on, citizens started to claim equal rights to all people before the eyes of the law, to be entitled to deciding what is the best for them and to unite for the common goal of all people. This revolution has taken place for some decades now and it has finally more directly affected medicine in past years. The ideas are structured in a new body of knowledge, giving rise to a new discipline: Bioethics.

The denomination was created by North-American oncologist Van Rensselaer Potter, who used it for the first time in his book: Bioethics: bridge to the future. The purpose of the book was to promote a new dialog between science and humanism, which seemed to be unable to communicate 1. Concerned about the ecological survival of the planet and the democratization of scientific knowledge, he wanted to create a discipline that covered biological knowledge (bios) and the system of human values (ethics) 2. His intention was to conceive a cultural matrix, a model of integrating thought 3, reason why the term bioethics emphasize both ingredients considered to be the most important to reach his goal: biological knowledge associated with human values 4. The importance of the futuristic approach by Potter is the idea that the constitution of ethics applied to life situations would be the way to preserve the human species. Moreover, survival would not require rigorous knowledge of the technique, but rather respect to human values 2.

This proposition of association between life sciences and ethics (aiming at the well being of human beings and animals and safeguarding the environment) is what maintains the spirit of bioethics to present.

The birth of bioethics was preceded by important transformations that had taken place in the social, political and technological scene in the 60's and 70's. On the one side, the significant technological development led to unexpected moral dilemmas related to biomedical practice (brain death, donation of organs to transplantation, test tube baby, disposal of embryos, etc). On the other hand, the 60's were also the years of civil rights, which have strengthened the onset of organized social movements, promoting heated debates about normative and applied ethics. Those different social actions advocated issues related to a diversity of opinions, about differences and moral pluralism 2.

Jonsen pointed out three facts that had predominant role in the consolidation of the discipline 5. The first one was the article published at Life magazine in 1962, which reported the history of the Seattle Committee, which had unexpectedly passed on the decision-making process to the public, upon delegating the selection criteria for medical services to the hands of small groups of people, all of them lay in medicine. The second event was Beecher's article, published in the New England Journal of Medicine, in 1966, in which upon analyzing the scientific research studies conducted in human beings and published in internationally awarded periodicals, about 12% of the medical papers had serious violations of ethics. The third event was the first cardiac transplantation, in which the main question was: How can Barnard guarantee that the donator was really dead before the transplantation started? This fact raised difficult-to-answer questions, such as "When shall someone be considered dead?", "If the brain is dead, is the person also dead?", etc.

Other events are remembered as extremely fundamental for the history of bioethics, such as the fight for patients' rights in the United States and the publication of the book Principles of Biomedical Ethics, in 1979, which consolidated the theoretical power of bioethics 6. The authors of the book stated that "it provides systematic analysis of the moral principles that should be applied to biomedicine" and suggested that four of them should be the basis of consistent bioethical theory:

1) Autonomy: corresponds to respecting the right people have to self-govern, which implies that all subjects should be seen as autonomic agents and those with compromised autonomy (socially vulnerable groups) should be protected from any type of abuse. From a practical perspective, it means that patients' wills should be a fundamental prerequisite in medical procedures.

2) 2) Beneficence: bonum facere (doing good), which dates back from Classical Ancient Times, from Hippocratic oath, emphasizing the need to always try to search for the wellbeing of the sick.

3) Nonmaleficence: it is the Hippocratic principle of non nocere (first of all, do not harm), which refers to caution of interventions.

4) Justice: it is the formal principal of equity, in which equal people should be treated equally, whereas unequal people should be treated unequally. What it means is that not everyone should receive the same, but rather that one should receive what is proportionally deserved and of right.

Bioethics, in our opinion, should not be seen as an end to classical medical ethics (especially because it has adopted its basic principles of beneficence and nonmaleficence), but as a result of the modern times and changes in physicians' stances, to better response to ethical challenges that we face as a result of social changes and progression of knowledge and technology.


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