Contributions to public health by the field of bioethics
In order to adequately understand contemporary bioethics and its relationship to public health, it is appropriate to trace the field's roots. Although its origin is formally recognized in the work of Potter and Hellegers, one can reasonably situate the emergence of the reflections leading to the field of bioethics within the sphere of concerns and repercussions of research involving human beings and events more closely associated with clinical medicine, like the episode involving the creation of the Life or Death Committee, in Seattle, Washington, related to the choice of patients to be included in a renal dialysis program. In both cases the direct relationship to public health was already evident. The focus on clinical aspects in the usual analyses of these episodes may only be the result of an extemporaneous understanding of public health itself, as a field of knowledge and practices demarcated by the narrow confines of epidemiology, transmissible diseases, and preventive medicine. To the contrary, such historical milestones (among others) highlight the relevance of bioethical analysis of public health problems, in this case policymaking and health services management.
The cross-disciplinary conformation and social recognition ascribed to bioethics occurred from a perspective that is much closer to the holistic concept proposed by Potter, although the principlist model developed by the Kennedy Institute of Ethics prevails in the analyses applied to clinical practice and research. It can be conceptualized as the systematic study of the moral dimensions of the life sciences and health care, employing a variety of methodologies. As applied ethics, bioethics has two indissoluble dimensions, descriptive and normative. That is, it is concerned with analyzing the moral arguments for and against certain human practices that affect the quality of life and well-being of humans and other living beings and the quality of their environments, and with basing decisions on these analyses. Considering specifically (but not exclusively) the field of public health, protection has been proposed as the underlying principle for analyses and decisions. This conception is consistent with the Universal Declaration on Bioethics and Human Rights (UNESCO).
Taking as reference the core of public health, "support for health systems, elaboration of policies, and construction of models; production of explanations for health/disease/intervention processes; and, (...), the production of [health] promotion and disease prevention practices" (Ciênc Saúde Coletiva 2000; 5:219-30), one can properly state that bioethics, with its theories and methods, has contributed and continues to contribute to the development of this field, with the analysis and proposal of solutions to the moral problems inherent to collective health practices. However, in Brazil and much of Latin America as a whole, this should not become a problem, to the extent that collective health also sees itself as an inter- and cross-disciplinary field.
Equal consideration for individual and collective interests, or the individual and collective good, is one of the public health challenges to which bioethics can make a significant contribution. The challenge is not to impose restrictions on individual freedoms, but to focus the public policymaking on collective interests, painstakingly based on the ethical point of view. Our recent history has shown that dialogue and the constant quest for understanding open the way for shaping a more just health system and its practices.
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil