Journey of struggle: kalothanasia and the hospice way of dying.

The purpose of this article is to characterize the notion of a "good death" both historically and conceptually, grounding the philosophy of the modern hospice movement. This concept encompasses elements originating in ancient societies, such as peasant societies, where death was prepared for and shared socially, with ethical and aesthetic elements originating from Ancient Greece. These Greek elements emerged from a "journey of struggle" and can be recognized in the current day as a journey to cope with illness. From this conceptualization emerged a category of "good death" (kalothanasia), adding to the expertise of advocates of the modern hospice movement, who seek to revive a process of dying that is socially ritualized. However, this is challenging in the setting of a medical practice that is constantly incorporating new technology, in accordance with its present bio-techno-scientific paradigm, and in a medical scenario that identifies itself with the continued and persistent use of new technologies.

How might Levinas' concept of the other's priority and Derrida's unconditional hospitality contribute to the philosophy of the modern hospice movement?

Hospitality is commonly referred as one of the meanings of hospes, the Latin word which is also the root of hospice. This article explores the semantics of the word hospice - the seal of identity of modern hospice movement - and attempts to integrate the meaning of hospitality into the modern hospice movement, understood as unconditional reception. Therefore, the article analyzes the concept of unconditional hospitality, developed by Jacques Derrida and that of ethical responsibility proposed by Emmanuel Levinas based on the phenomenological experience of the other. From this point of view, these two concepts tie in with the meaning of hospice, bringing substantial grounding elements to the hospice movement for the construction of a protective ethos.

Bioethics of protection: a proposal for the moral problems of developing countries?

Bioethics of protection is a tool which appeared in the scope of the applied ethics in Latin America, related initially to the existing moral conflicts in Public Health, approached from the dialogue with the consecrated tools of the bioethics, but enrolled in the context of the praxis of the Latin American actors, who, even though they have proper problems, share many of those of the globalized world, of the planet. To the traditional descriptive and normative functions of the applied ethics, the bioethics of protection proposes an additional function consisting in the "protection" with priority of individuals and harmed groups, in order to permit them to develop, if possible, their capabilities, necessary to their empowerment, i.e. necessary to a decent life in a conflagrated world, and, possibly, searching for rational and/or reasonable solutions. The bioethics of protection is not applied, therefore, to those affected that are able to live a decent life with their own means or those offered by effective institutions. This implies, beyond education and adequate health services, the recognition of the differences in the cultures, cosmovisions and habits as common patrimony of the Humanity.

Abordagens à covid-19: bioética, empatia e a perspectiva de Spinoza / Approaches to COVID-19: bioethics, empathy and the Spinozian perspective / Abordar la COVID-19: bioética, empatía y la perspectiva de Spinoza

Resumo A covid-19 é uma crise sanitária e humanitária inscrita entre as maiores pandemias que a humanidade já conheceu. Este artigo destaca o caráter de sindemia que essa pandemia assumiu ao encontrar populações com maior vulnerabilidade econômica, social e ambiental. Diante desses contextos, intenta-se refletir, ontologicamente, sobre o ser humano e como o aprimoramento moral pode tornar-se um processo facilitador de diálogos empáticos, que gerem soluções solidárias nacionais e transnacionais durante crises pandêmicas. Serão considerados os conceitos de sindemia, bioética, ontologia, aprimoramento moral, processo facilitador, diálogo, dialética, empatia, conatus , afetos, apetite, desejo e continuum e suas potencialidades para reduzir danos durante a pandemia de covid-19. Por fim, este trabalho será concluído com um breve olhar a partir da perspectiva racionalista de Spinoza.

Abstract COVID-19 is a sanitary and humanitarian crisis featured among the greatest pandemics humanity has ever known. This article highlights its syndemic character, taken on by encountering populations with greater economic, social, and environmental vulnerability. Before such contexts, the essay proposes an ontological reflection about the human being and how moral enhancement can facilitate empathetic dialogues that generate national and international solidary solutions during pandemic crises. For this purpose, it draws upon the concepts of syndemic, bioethics, ontology, moral enhancement, facilitator, dialogue, dialectics, empathy, conatus , affections, appetite, desire, and continuum and their potential for reducing harm during COVID-19. Finally, this paper will conclude with a brief discussion based on Spinoza's rationalist perspective.

Resumen La COVID-19 es una crisis sanitaria y humanitaria que está entre las más grandes pandemias que afectó la humanidad. Este artículo destaca la sindemia que asumió esta pandemia al encontrar poblaciones más vulnerables económica, social y ambientalmente. En este contexto, se pretende reflexionar, ontológicamente, sobre el ser humano y cómo la superación moral puede convertirse en un proceso facilitador de diálogos empáticos, que genera soluciones solidarias nacionales y transnacionales durante las crisis pandémicas. Se consideran los conceptos de sindemia, bioética, ontología, superación moral, proceso facilitador, diálogo, dialéctica, empatía, conatus , afectos, apetito, deseo y continuum y su potencial para reducir los daños durante la pandemia de la COVID-19. Por último, se harán breves consideraciones finales desde la perspectiva racionalista de Spinoza.

[Moral and operational challenges for the inclusion of palliative care in primary health care]. / Desafios morais e operacionais da inclusão dos cuidados paliativos na rede de atenção básica.

Palliative care, a model in end-of-life care, is currently undergoing expansion in Brazil. This article emphasizes the need to implement palliative care in primary health care, with an important role in end-of-life care, especially in areas without specialized palliative-care teams. The article discusses key aspects in the organization of this treatment modality and analyzes how palliative care could and should be implemented within primary health care in Brazil. The article describes several challenges for health teams to provide such care, related to the primary caregiver, inherent ethical conflicts, and human resource allocation.

Bioethics of protection: a health practice evaluation tool? / A bioética de proteção: uma ferramenta para a avaliação das práticas sanitárias?

Bioethics of protection (BP) was proposed in the early 21st century in bioethics, built in Latin America following attempts by researchers to work on the possibilities of public health policies being morally legitimate, socially fair (equitable) and respectful of human rights, after noting the limits of traditional bioethical tools, essentially implemented in and restricted to interpersonal conflicts between moral agents and patients involved in the practice of biomedicine. Methodologically, BP tries to negotiate distinct problematic disciplinary realms that are, however, interlinked through interdisciplinary dialogue and common concern with the quality of life of the human population, considered in its natural, technological, social and cultural contexts: Public Health, concerned with the health and well-being of individuals and populations; Bioethics, concerned primarily with the moral legitimacy of practices that affect their quality of life; Biopolitics, concerned with the social effects of health policies.

The Exercise of Autonomy by Older Cancer Patients in Palliative Care: The Biotechnoscientific and Biopolitical Paradigms and the Bioethics of Protection.

Toward the end of life, older cancer patients with terminal illness often prefer palliative over life-extending care and also prefer to die at home. However, care planning is not always consistent with patients' preferences. In this article, discussions will be centered on patients' autonomy of exercising control over their bodies within the current biotechnoscientific paradigm and in the context of population aging. More specifically, the biopolitical strategy of medicine in the context of hospital-centered health care control and of the frail condition of cancer patients in the intensive care unit will be considered in terms of the bioethics of protection. This ethical principle may provide support to these patients by ensuring that they receive appropriate treatment of pain and other physical, psychosocial, and spiritual problems in an attempt to focus attention on the values of the ill person rather than limiting it to the illness.

Bioética de proteção: fundamentos e perspectiva / Bioethics of protection: fundamentals and perspective / Bioética de protección: fundamentos y perspectiva

Resumo Este artigo busca promover uma reflexão sobre a perspectiva da bioética de proteção e explicitar suas ferramentas, por meio de levantamento bibliográfico ancorado nos marcos teóricos de seus principais idealizadores e da técnica de leitura informativa, que pretende identificar a temática e as principais ideias envolvidas. Para tanto, apresenta-se, inicialmente, a proteção como princípio bioético mediante um aprofundamento na origem, na definição e na análise dos termos "vulnerabilidade", "suscetibilidade" e "vulneração". Na sequência, busca-se apresentar as abordagens bioéticas voltadas ao "princípio de proteção". Por fim, argumenta-se que a bioética de proteção funciona como paradigma para apreensão, análise e resolução de conflitos morais em saúde pública, revelando-se uma abordagem fundamental nesse campo, haja vista seu desafio de lidar com a tensão entre os âmbitos individual e coletivo.

Abstract This article seeks to reflect on the perspective of bioethics of protection and explain its tools, by using a bibliographic survey based on the theorical marks of its main idealizers and the informative reading technique, which seeks to identify the thematic and the main ideas involved. To that end, we first present protection as a bioethical principle by going deeper into the origin, to the definition and the analysis of the terms "vulnerability", "susceptibility" and "injury". Then, we seek to present the bioethical approaches regarding the "principle of protection". Finally, we argue that bioethics of protection works as a paradigm for the apprehension, analysis, and resolution of moral conflicts in public health, revealing itself a fundamental approach in this field, considering its challenge is facing the tension between the individual and the collective spheres.

Resumen Este artículo pretende fomentar la reflexión sobre la perspectiva de la bioética de protección y explicar sus herramientas a partir de una recopilación bibliográfica realizada en los marcos teóricos de sus principales creadores y la técnica de lectura informativa, con el objetivo de identificar la temática y las ideas principales involucradas. Para ello, primero se presenta la protección como un principio bioético a través de un estudio en profundidad del origen, definición y análisis de los términos "vulnerabilidad", "susceptibilidad" y "vulneración". Después, se exponen los enfoques bioéticos relativos al "principio de protección". Y, por último, se argumenta que la bioética de protección funciona como paradigma para aprehender, analizar y resolver los conflictos morales en salud pública, demostrando ser un abordaje fundamental en este campo teniendo en cuenta su desafío de lidiar con la tensión entre lo individual y lo colectivo.

[Caregivers of elderly with advanced cancer: vulnerable actors]. / Cuidador do idoso com câncer avançado: um ator vulnerado.

Cancer presents high prevalence and mortality rates among elderly Brazilians, and family members provide meaningful care, especially during terminal illness. A literature review focused on the impact for families and the physical, psychological, social, and economic burden for family caregivers of seniors with advanced cancer, as well as related interventions. More studies are needed on family caregivers of elderly with advanced cancer in Brazil in order to develop programs to protect these important social actors.

[Medical care, organ and tissue transplants, and targeted policies]. / Atenção médica, transplante de órgão e tecidos e políticas de focalização.

This article reflects on the moral legitimacy of implementing public policies for targeting advanced medical care, specifically in the case of organ and tissue transplants. The article refers to two theoretical approaches: the theory of capabilities by Nussbaum and Sen and the bioethics of protection by Schramm and Kottow, considered complementary in this context. The article begins by characterizing the issue of resource scarcity in transplantation, as well as strategies to overcome this problem. Next, the capabilities approach and bioethics of protection are briefly presented. Finally, from the perspective of the above-mentioned ethical approaches, in situations of scarce health resources such as the Brazilian case, the author contends that it would be morally justified to adopt targeted policies in advanced medical care, including organ transplantation.

Internação em terapia intensiva: aspectos éticos da tomada de decisão / Intensive care hospitalization: ethical aspects of decision-making / Hospitalización en cuidados intensivos: aspectos éticos de la toma de decisiones

Resumo A escassez de recursos para ações de cuidado - questão extremamente relevante nos sistemas de saúde de acesso universal - tem motivado diversas situações em que é necessário estabelecer critérios de priorização, mormente no âmbito da regulação. Partindo de perspectiva bioética, este artigo visa discutir o processo decisório de médicos reguladores em situação envolvendo escassez de recurso - no caso, leitos de centro de tratamento intensivo. Trata-se de estudo teórico-reflexivo, empreendido a partir da análise ética de situação-problema fictícia envolvendo a escolha de paciente para tratamento intensivo em contexto de limitado número de vagas. O caso fictício apresentado foi apreciado a partir dos referenciais das correntes bioéticas principialista e utilitarista. A reflexão ressaltou que as decisões dessa natureza devem ser baseadas na profunda articulação entre critérios técnicos e éticos. Foi possível concluir que, na situação-problema analisada, a seleção aleatória seria a mais viável e mais justa do ponto de vista bioético.

Abstract Scarcity of resources in healthcare - an extremely relevant issue in universal healthcare systems - has motivated the emergence of several situations where one needs to establish prioritization criteria, especially within the scope of regulation. Based on a bioethical perspective, this article discuss the decision-making process of coordinating physicians in a situation involving scarcity of resources - in this case, intensive care unit beds. This is a reflective theoretical study, based on the ethical analysis of a hypothetical problem-situation involving the choice of patient for admission in this unit, in a context of a limited vacancies. The situation presented was assessed based on the principlist and utilitarian bioethical perspectives. The reflection emphasized that decisions of this nature must be based on a deep articulation between technical and ethical criteria. After the analysis, we concluded that random selection would be the most feasible and fairest from a bioethical point of view.

Resumen La escasez de recursos para las acciones de atención -tema de extrema relevancia en los sistemas de salud con acceso universal- ha motivado varias situaciones en las que es necesario establecer criterios de priorización, especialmente en el ámbito de la regulación médica de las urgencias. Desde una perspectiva bioética, este artículo tiene como objetivo discutir el proceso de toma de decisiones de los médicos reguladores en situaciones de escasez de recursos (en este caso, camas de unidades de cuidados intensivos). Se trata de un estudio teórico-reflexivo, realizado a partir del análisis ético de una situación-problema ficticia que implica la elección de un paciente para tratamiento intensivo en el contexto de un número limitado de vacantes. Se apreció el caso ficticio a partir de los referenciales de las corrientes bioética principialista y utilitarista. La reflexión destacó que las decisiones de esta naturaleza deben basarse en la articulación profunda entre criterios técnicos y éticos. Se pudo concluir que, en la situación-problema analizada, la selección aleatoria sería la más viable y justa desde el punto de vista bioético.

[Conversations on the "good death": the bioethical debate on euthanasia]. / Conversações sobre a "boa morte": o debate bioético acerca da eutanásia.

Despite extensive current debate on euthanasia, many open and apparently unsolvable issues persist, awaiting a better conceptual treatment. The area includes "prejudices and fundamentalisms" in relation to the theme, still viewed as taboo by a major share of society, specifically in the case of Brazil, while semantic imprecision in the term and argumentative tensions surround the issue, focusing on the principles of sacredness of life, quality of life, and autonomy and the so-called "slippery slope" argument. The purpose of the current essay is thus to serve as a sphere of inquiry concerning euthanasia, moving from historical antecedents towards a better solution to the problem and the demarcation of necessary future perspectives for enhanced understanding of the issue.

[Ethically conflicting situations experienced by medical students]. / Situações eticamente conflituosas vivenciadas por estudantes de medicina.

PURPOSE: To identify ethically conflicting situations experienced by medical students of UERJ and recommend new bioethic contents to be incorporated in the curriculum. METHODS: We have carried out an observational, cross sectional study with medical students in the last two years of the course, the period when the practice probation of interns occurs. The students had to fill out a questionnaire with personal data and open questions about conflicting situations from the point of view of ethics and how these situations had been solved, In addition there was a question about ethical issues which they would like to be included in the medical curriculum. RESULTS: Nearly seventy per cent of the students (n = 128) filled out the questionnaire and reported situations and suggestions involving a wide variety of ethical issues, which, in most cases, are not a part of the school curriculum. Conflicts were identified and suggestions were separated into three broad groups: medical learning situations; situations related to medical practice with the patients and situations which involved legal and political health care matters. CONCLUSION: It is fundamental that these contents be included in the medical curriculum thereby enabling future professionals to better face new challenges arising in health care for the population.

[Individual versus collective protection: bioethical analysis of the national program of mass child vaccination]. / Proteção individual versus proteção coletiva: análise bioética do programa nacional de vacinação infantil em massa.

Vaccination is considered one of the most efficient and cost-effective public health policies most used in the control and prevention of disease. However, it is also one of the most polemic and controversial biomedical techniques, making it difficult to avoid an ethical dilemma, especially when vaccination is compulsory for the entire population. Indeed, since vaccines are not totally effective and safe, there is an ethical conflict between the individual and the collective interest, because children effectively carry the burden of vaccination for the benefit of public health when they are affected with serious adverse reactions and do not benefit from the care that should be offered by the government. The objective of this article was to demonstrate that the tools of bioethics are relevant in this discussion to understand and analyze these dilemmas critically by providing convincing arguments to underpin the development of biopolitics that consider prevention not only rigorously, but also the joint responsibility of all as fundamental for individual and collective protection.

[Home care for the elderly: problem or solution?]. / Atendimento domiciliar ao idoso: problema ou solução?

Home care for the elderly has become an important health care tool in both developed and developing countries. However, several ethical, social, and operational concerns have received insufficient attention, and the Brazilian literature on this theme is limited. Starting with a bibliographic review on home care, this paper takes a bioethical approach to potential problems arising from this growing and important patient care modality. A broader ethical approach is needed to implement home care for the elderly, with policies to protect the patient, family, and caregiver, aimed at improving the quality of this program format.

[Plato's philosophy and the bioethical debate on the end of life: intersections in public health]. / A filosofia de Platão e o debate bioético sobre o fim da vida: interseções no campo da Saúde Pública.

This article discusses bioethical aspects of medical futility, focusing on some of its intersections in public health. Starting from a demarcation of finitude in the core of the philosophical and bioethical debate on the end of life, we confront the contemporary criticism regarding medical futility with the ideas of Plato (427-347 B.C.), a philosopher who proposed significant considerations on numerous features of the medicine of his time. We thus explore novel theoretic references to guide the disputes related to this essential problem, the implications of which are decisive to health and life.

[The necessary frugality of the elderly]. / A necessária frugalidade dos idosos.

The purpose of this article is to reflect on the pertinence and moral legitimacy of basing the allocation of public resources for health on the age variable, considered from the perspective of the theory of "justice as equity" as formulated by John Rawls. After characterizing the problem of public resource allocation for health -- confronted with the challenge posed by population aging -- and briefly presenting the concept of equity adopted in this study, as well as discussing the approach by Norman Daniels and Daniel Callahan to resource allocation among different age groups, we conclude that basing resource allocation on the age variable may be considered ethically adequate if we conceive the individual's life as a limited cycle of existence formed by different stages (childhood, adolescence, maturity, old age, and death), during which the needs vary, such that the distribution of resources among different age groups should be based on an ethics of protection.

[The bioethics of protection and the state's role: moral problems in unequal access to drinking water]. / Bioética da proteção e papel do Estado: problemas morais no acesso desigual à água potável.

The aim of this study is to examine unequal access to drinking water as a public health problem in terms of normative and analytical tools in the bioethics of protection. Therefore, we analyze both the moral implications of unequal treatment of primary needs, such as situations of vulnerability and threat to population groups, and the public sector's responsibility in supplying safe water. In addition, solutions are proposed for the protection of public health and the promotion of legitimate personal development projects. The bioethics of protection reaffirms the state's role in maintaining the drinking water supply and recommends avoiding a policy of privatization of this public good, meanwhile justifying public policies to correct situations of social injustice.

[Plato and medicine]. / Platão e a medicina.

Medicine and philosophy are branches of knowledge that had decisive influence on each other in the time of Ancient Greece, shaping the development of both. A landmark of this interrelationship was the thought of the philosopher Plato (427-347 A. C.), considered the greatest thinker in Western tradition. The text discusses how Platonic reflection reached into the most varied aspects of medicine in the philosopher's days.

Saúde pública: biotecnociência, biopolítica e bioética / Public health: biotechnoscience, biopolitics, and bioethics

RESUMO O campo complexo da saúde pública pode ser visto como sendo atravessado pela seguinte polaridade: a) uma tendência totalizante de controle da sociedade tanto do ponto de vista biológico como econômico; b) uma tendência à individualização das práticas da medicina e da saúde pública baseada na liberdade e na responsabilização dos indivíduos pela sua saúde. Ademais, devido ao fato de o campo da saúde corresponder às atividades da biotecnociência e da biopolítica, e ser, portanto, atravessado por conflitos de interesses e de valores, entra em campo a bioética, cujo escopo principal no campo da saúde e do bem-estar individual e coletivo consiste em detectar, analisar e avaliar tais conflitos, propondo soluções que impliquem alguma forma de convergência entre agentes e pacientes morais envolvidos, e que vise, em última instância, à qualidade de vida dos afetados pelas políticas públicas e pela incorporação das ferramentas da biotecnociência.

ABSTRACT The complex field of public health can be seen as crossed by the following polarity: a) a totalizing tendency to control society, both biologically and economically; b) a tendency towards individualization of medical and public health practices, based on individuals' freedom and accountability for their own health. Furthermore, since the field of health has to do with biotechnoscientific and biopolitical activities, and is thus permeated by conflicts of interests and values, bioethics enters the scene because its main scope in the field of health and individual and collective welfare consists of detecting, analyzing, and assessing such conflicts, proposing solutions that involve some form of convergence between moral agents and patients, ultimately aiming at quality of life of those affected by public policies and the incorporation of the tools of biotechnoscience.