Bioethics: Principles and Challenges

Editorial

Bioethics is an interdisciplinary field of growing relevance, especially as continuous advances in science and medicine challenge established values, norms and practices, seeking to offer rigorous ethical guidelines to tackle complex issues associated with life, health and technology. Bioethics, a neologism combining the Greek words bios (life) and ethike (ethics), can be understood as the ethics of life. It is a systematic study of the moral dimensions of the life sciences and health care, using various ethical methodologies in an interdisciplinary context. Because it encompasses such vast content as life, bioethics is considered a study without borders. The term “bioethics” was coined by Van Rensselaer Potter (1911-2001) in 1971, in his article entitled “Bioethics, the science of survival”. Potter, a pioneer in this field, saw bioethics as a bridge between biological science and ethics [1].

The Second World War was a period of great atrocities and torture inflicted on human beings, such as the Eugenics Movement, the brainchild of Francis Galton, which aimed to find pure races. This movement was adopted by Hitler between 1939 and 1945, resulting in a relentless search for a pure race, which violated the dignity of many people and generated deep revulsion among human beings. Faced with the various abusive events that occurred in the 20th century during the Second World War, Potter formulated the term bioethics when he observed a risk to the survival of the ecosystem due to the separation of two areas of knowledge: the scientific and the humanistic. The distinction between ethical values and biological facts would endanger all human life on Earth, and the only way to avoid this situation, according to Potter’s (1971) definition, would be to build a “bridge” between the humanities and the biological sciences [1]. Bioethics, when considered beyond clinical ethical dilemmas, encompasses topics such as environmental, animal, work and science ethics. This open field allows for the discussion of relationships between sentient beings (and not just them), addressing fundamental issues that represent major contemporary crises. These issues can and should be discussed in an interdisciplinary way.

The same events that led Potter to create the term bioethics in 1971 also spurred the creation of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. This commission was dedicated to studying ethical criteria in research with human beings, with the aim of avoiding the abuses observed during the Second World War. Its conclusions were published on April 18, 1979, in the Belmont Report. This report established, for the first time, ethical principles to be obeyed in the USA when carrying out research, which should be taken into account when spending public funds, namely: the principles of respect for people (autonomy - the capacity for self-determination, for deciding on one’s own actions and life.), beneficence (Acting beneficently in favor of others; doing good; Maximizing benefits and minimizing risks; Duty to help others recognizing the moral value of others) and justice (establishes equity as a condition), as well as criteria for the application of these principles, such as informed consent and the analysis of risks and benefits in research [2].

Although it was published in 1979, the report was drawn up in 1978. Also in 1979, Tom L. Beauchamp and James F. Childress, in their book “Principles of Biomedical Ethics”, proposed principialism, adding the principle of non-maleficence (The health professional’s action should cause the least harm or damage to the patient’s health and reduce the adverse or undesirable effects of diagnostic and therapeutic actions) to the three previous principles (autonomy, beneficence and justice). These principles were intended to guide doctor-patient relationships and help resolve dilemmas encountered in clinical practice [2].

This combination came to be known as the “Principialist Theory”, which, despite being the most widely used today to help resolve bioethical dilemmas in clinical situations, received harsh criticism in the early 1990s for not being considered comprehensive enough; on the contrary, it reproduced a unilateral view, with the principle of autonomy maximized hierarchically in relation to the others as a kind of super- principle. The issue of autonomy requires multidimensional treatment, as exemplified by the issue of segments of the population qualified as vulnerable, who deserve essential care. As is well known, under conditions of vulnerability, the chances of autonomy decrease and the risks of these people becoming susceptible to accepting procedures that they would reject under normal conditions increase [3].

In this way, the traditional principles of bioethics have proved insufficient to resolve dilemmas in countries like Brazil, where conflict analysis often requires flexibility to adapt to the socio-cultural context. In addition, it is necessary to tackle macro-problems linked to the persistent social exclusion experienced in our country [3]. It was then observed that in addition to the four principles (autonomy, justice, beneficence and non-maleficence) which are considered rights and duties, we must also use some tools (references) such as dignity, solidarity, fraternity, confidentiality, privacy, vulnerability, responsibility, survival, prudence, otherness, altruism, integrity, equity and quality of life, which are not linearly linked to each other, but are free for bioethical interaction[2].

As a result, the need for social bioethics has been gaining prominence in Latin America. This perspective goes beyond the clinical sphere, addressing issues related to ethics in health institutions, public health, primary care, public policies and health system reforms. Above all, it is aspects of social justice that connect bioethics to biopolitics in these countries [4].

Based on a perspective that seeks to reduce social inequalities through interventionist practices, the current of intervention bioethics has emerged, which is concerned with discussing ethical conflicts and persistent problems, considering a holistic vision that goes beyond the concepts of principialist bioethics. Intervention bioethics plays a crucial role in the field of bioethics in Latin American countries, where social inequality is constantly on the rise. In Brazil, since the Health Reform, the formulation of health policies and the creation of the Single Health System (SUS) have been closely linked to intervention bioethics. This approach prioritizes, in the public and collective sphere, the development of policies that benefit the greatest possible number of people over prolonged periods, even if this may imply harm in some individual situations. In the private and individual sphere, the aim is to find viable solutions to locally identified conflicts. Intervention bioethics, appropriate to the Brazilian scenario, integrates the four basic principles of bioethics with reference tools, as well as the prevention of possible harm. Precaution in the face of the unknown, prudence in relation to technological advances and their application, and the protection of the most vulnerable are also fundamental [5].

Therefore, in countries with so many social inequalities such as Brazil, the current of interventionist bioethics is especially important to address these markers and ensure that health policies promote a fairer and more inclusive medical practice. Furthermore, as science is a social construction and therefore inevitably reflects ideas of gender and racial oppression, especially when discussing sexual and reproductive rights from the global south, the intersectional approach to bioethics must be considered [6]. Intersectionality highlights how axes of power, such as social class, gender and race, are interconnected in a complex and dynamic way, resulting in varied experiences of inequality and/or privilege [7]. Such intersecting historical oppressions cannot be neglected by a science that defends the diversity of life, so we must consider the anti-oppression, anti-capitalist, feminist and anti-racist perspectives in which bioethics is claimed as a field in dispute..