Professional Documents
Culture Documents
Biotica
e
Robert M. Veatch
textos
Chanceler:
Dom Dadeus Grings
Reitor:
Ir. Norberto Francisco Rauch
Conselho Editorial:
Antoninho Muza Naime
Antonio Mario Pascual Bianchi
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Diretor da EDIPUCRS:
Antoninho Muza Naime
Sobre
Biotica
e
Robert M. Veatch
textos
Organizador:
Joaquim Clotet
EDIPUCRS
1 edio: 2001
Capa: AGEXPP FAMECOS PUCRS
Preparao de originais: Eurico Saldanha de Lemos
Reviso: Marlia Gerhardt de Oliveira
Editorao e composio:
Suliani Editografia Ltda.
Impresso e acabamento: Grfica EPEC
V394
Sobre biotica e Robert M. Veatch: textos / organizado por Joaquim Clotet. Porto Alegre: EDIPUCRS, 2001.
43 p.
ISBN: 8574302414
1. tica Mdica 2. Veatch, Robert M. Crtica e Interpretao 3. Veatch, Robert M. Textos 4. Biotica I. Clotet, Joaquim
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Sumrio
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15
21
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O professor Robert M. Veatch americano e tem 62 anos de idade. Graduouse em Farmcia, em 1961, pela Purdue University e fez seu Mestrado em
Farmacologia na Universidade da Califrnia, no ano seguinte. Em 1963 e 1964,
trabalhou na Universidade de Ibadan, na Nigria. Voltando para os Estados
Unidos, foi para Boston continuar sua psgraduao, primeiro na Harvard
Divinity School (B.D.) e, posteriormente, na Harvard University, onde estudou
Religio e Sociedade, com nfase em tica Mdica, alcanando seu ttulo de
Doutor em Filosofia, em 1971. Em 1999, recebeu o ttulo honorrio de Doutor
em Humanidades na Creighton University.
O Dr. Veatch possui extensa experincia profissional, tendo sido
professor na Harvard University Divinity School, de 1968 a 1970, e,
posteriormente, na Columbia University, de 1971 a 1972. Em 1970, foi trabalhar
no Hastings Center, onde permaneceu at 1979, integrando vrios grupos de
pesquisa, principalmente sobre os temas da Morte e o Morrer, tica e Polticas
de Sade.
Em 1979, transferiu-se para a Georgetown University, onde continua a
lecionar at hoje. Nesta Universidade, tem trs reas de atuao: professor
de Filosofia, Professor Adjunto dos Departamentos de Medicina Comunitria e
da Famlia e do Departamento de Ginecologia e Obstetrcia, alm de professor
de tica Mdica junto ao Kennedy Institute of Ethics, do qual foi Diretor entre os
anos de 1989 e 1996.
Na atualidade, o prof. Veatch editor de trs peridicos: The Kennedy
Institute of Ethics Journal, The Journal of Medicine and Philosophy e IRB: a
Review of Human Subjects Research. J fez parte do conselho editorial de
Uma boa coletnea de sua obra pode ser encontrada nas bibliotecas
Central e da Faculdade de Medicina da PUCRS, que disponibilizam aos leitores
os seguintes ttulos:
Medical Ethics. Jones & Bartlet Publishers, 1989.
The patient-physician relation: the patient as partner. Bloomington:
Indiana University Press, 1991.
Ethical questions in dentistry. Quintessence Publish. Co., 1993.
Cross-cultural perspectives in medical ethics. 2. ed. Jones &
Bartlett, 2000.
Source book in Medical Ethics: a documentary history. Georgetown
University Press, 1998.
Transpantation Ethics. Georgetown University Press, 2000.
Ethical issues in death and dying. 2. ed. Prentice Hall, 1997.
The basics of Bioethics. Prentice-Hall, 1999.
Medical codes and oaths. In: Reich, W. T. Encyclopedia of Bioethics.
v. 3, Simon & Schuster MacMillan, 1995, p. 1419-1435.
Population policies strategies of fertility control. In: Reich, W. T.
Encyclopedia of Bioethics. v. 4, Simon & Schuster MacMillan, 1995, p.
2011-2017
10
place of medical ethics. The terms are now used almost interchangeably (p. 6).
Contudo, numa linguagem ou contexto mais esclarecido j no bem assim.
A tica aplicada de grande interesse para o autor. Os problemas ticos
decorrentes do exerccio e aplicao das cincias da sade, medicina,
odontologia e enfermagem, entre outras, so temas relevantes em nossa
sociedade. Ethics is becoming a discipline that is applied to real world problems
such as medicine. Applied ethics takes various rules and principles and integrates
them with detailed knowledge of the relevant facts and customs of a particular
sphere of life such as politics or race relations or the work place. This volume
explores the application of ethics to the sphere of medicine (p. 6).
Pela exposio e comentrios do autor sobre a origem dos problemas
ticos da medicina, o seu posicionamento filosfico moral ou tico no tem a
sua origem nem o seu fundamento na tica deontolgica profissional,
geralmente expressa pelos cdigos de tica profissional.
A presena do fator religioso na sua teoria e reflexo permite afirmar
que ele um elemento indissocivel do seu modo de conceber e interpretar a
tica. Ethics is a branch of the disciplines that deal with basic questions of
meaning and value: of philosophy and theology (p. 3).
O seu interesse pela justia, em geral, e pela justia social, em
particular, especialmente no que se refere alocao e distribuio de recursos
para a sade, revela-se como um dos temas preferidos pelo autor e que est
presente em muitos dos seus trabalhos.
Estes so alguns aspectos que pautam a tica mdica de Robert M.
Veatch.
Estariam
faltando,
no
entanto,
algumas
caractersticas
mais
11
Sobre
Cross Cultural Perspectives
in Medical Ethics: Readings,
de Robert M. Veatch e colaboradores
MARCOS NESTROVSKI
encontra
mais
questes
filosficas
bsicas
que
afrontam
controvrsias emergentes.
Qualquer um que venha a enfrentar dvidas em tica mdica est
situado, ao menos implicitamente, dentro de algum sistema fundamental.
Esta rica e expandida coleo poder servir tanto como texto ou
como referncia para quem se envolva seriamente numa apreciao integral
de casos mdicos.
A obra aqui apreciada se compe de quatro partes.
Na primeira, Veatch apresenta um apanhado sobre o que se constituiu,
at hoje, nas diversas latitudes e cortes histricos, a profisso mdica,
outras
culturas,
crenas
religiosas,
conceitos
polticos,
O texto que segue resume as idias de Robert Veatch presentes em captulos dos
seus livros citados nas referncias bibliogrficas. Vale ressaltar que ele escreve
com muita freqncia sobre este tema, sendo autor de um livro especifico (Death,
dying..., 1989) de grande importncia para os estudiosos no assunto.
PERSPECTIVA HISTRICA
O tema da morte, segundo Veatch, muito tem despertado o interesse
em diferentes pocas, com enfoques diversos, por estudiosos e profissionais
de mltiplas reas. Dessa forma, se nos reportarmos ao perodo da
Antigidade clssica, veremos que os gregos se preocupavam com o
sentido da vida, porm preocupavam-se muito mais com o que ocorria aps
a morte. Tanto era importante o significado da existncia da vida aps a
morte, que Aristteles e Plato descreveram decises de terminar a vida em
algumas situaes, como, por exemplo, no caso de crianas malformadas.
No entanto, no juramento de Hipcrates h uma censura eutansia ativa
quando dito eu no darei uma droga fatal, mesmo que o paciente pea e
nem farei sugesto para que isso ocorra.
No sculo XX, ocorre um fenmeno mdico novo que o grande
esforo para preservar a vida, o que Darrel Amndsen descreve como o dever
sem razes clssicas.
morte
cardiorrespiratria.
Quando
Christian
Barnard
executa
este
da
vida.
Para
um
paciente
de
posse
de
sua
regulamentos
denominados
Baby
Doe
preconizam
que
REFERNCIAS BIBLIOGRFICAS
BEAUCHAMP, I.; VEATCH, R. M. Ethical issues in death and dying. Upper
Saddle River (NJ): Prentice Hall, 1996.
JONSTEN, R.; VEATCH; R. M.; WALTERS, L. Source book in bioethics: a
historical perspective. Washington D.C.: Georgetown Univ., 2000.
VEATCH, R. M. Death, dying and the biological revolution: our last quest for
responsibility. New York: Vail-Ballou Press, 1989.
ABSTRACT
Principle-based medical ethics has dominated the Western discussion of
ethics in health care for the past 20 years. It has recently been challenged by
other approaches including casuistry, virtue theory, feminist theory, care theory,
and what is sometimes called deductivism. This lecture will attempt to spell out
what is at stake and offer a partial defense of principle-based theories (or
principlism) from its critics.
A full ethical analysis of a clinical ethical problem can be seen as taking
places at four levels. At the level of the individual case4, claims about rules and
rights, the normative level, and the metaethical level. Religious and secular
ethics differs primarily at the metaethical level-the level of the meaning and
justification of ethical claims. Much of the action in medical ethics in the past 30
years has taken place at the level of normative theory. lt is here that broad,
abstract systems for making ethical decisions are developed. Normative theory
deals with three general questions: the principles of right action, the theory of
good character traits (virtue theory), and the theory of what counts as a benefit
or a harm (axiology). At a more concrete and specific level, statements of moral
rules or moral rights can be seen as being derived from normative theory. Codes
of professional ethics, patients bills of rights, and religious codifications of
proper moral conduct (such as the Vatican declarations and Talmudic laws) are
expressed at this level. Finally, there are judgments at the level of the individual
case-the choices the clinician and others must make at the bedside.
After outlining and explaining this four-level scheme, the lecture wilI
present the major controversies within the part of normative theory called
principlism Most medical professional ethics (including Hippocratic ethics) has
been
consequentialist.
They
focus
exclusively
on
producing
good
consequences and avoiding harmful ones. Hippocratic ethics shares this feature
with classical utilitarianism, but the latter includes the consequences for all
parties while Hippocratic ethics requires the physician to focus exclusively on the
single, isolated patient. That may be part of why the Hippocratic ethic is so
morally deficient that it is increasingly seen as irrelevant. Roman Catholic
medical ethics also has consequentialist features, but in quite different ways.
Other medical ethics focus on moral duties that purport to be obligations
independent of consequences. Much of the challenge to Hippocratic ethics has
come from this group of theories-either secular liberal rights-based theories or from
Protestant and Jewish religious ethics. That is part of why religious ethicists were at
the forefront of the attack on Hippocratism in the last decades of the twentieth
century. While some rights-based ethics remained focused on the rights of the
individual patient, others functioned at a more social level-replacing the social utility
principle with the principle of justice thus providing a way of addressing resource
allocation without simply trying to maximize net good consequences.
In addition to the conflicts within principlism, principle-based approaches
to medical ethics have been challenged from the outside. Other normative-level
theories (virtue theory and axiology) have been pitted against principle-based
approaches. Virtue-based approaches, for example, have been touted as a
return to concern about the good character of health professionals in contrast to
more concern about right action. Narrative theory, feminist theory, and care
theory are all best understood as, at least in part, efforts to promote the virtues.
Some of the challenges come from other levels of ethical analysis. Proponents
of codes and bills of rights favor attempting to reach societal agreement about
lists of rules or rights rather than dealing with more abstract principles or virtues.
Casuistry urges a return to the priority of the most concrete level, the level of the
individual case. Deductivism, on the other hand, claims that principlism is not
abstract enough. It wants to start at the most general level of theory and derive
principles of rules more systematically than some principle-based approaches.
The lecture will show that not all principle-based approaches suffer from
these criticisms and that at least one version of principlism survives unscathed.
Increasingly, these competing approaches are reaching an accommodation.
Principles remain at a central spot in biomedical ethical theory.
PRINCIPIALISMO E SUAS ALTERNATIVAS:
CONTROVRSIAS EM TEORIAS DE TICA MDICA
Nestes ltimos vinte anos, a tica Mdica baseada em Princpios que
tem predominado nas discusses sobre tica em cuidados com a sade, pelo
menos no Ocidente.
Agora, porm, tm aparecido contestaes, sob a forma de outras
abordagens, como a Teoria Casusta, a Feminista, a Teoria da Responsabilidade e
aquela que algumas vezes se costuma chamar de Dedutivismo.
Esta palestra vai tentar expressar o que est em jogo e apresentar uma
defesa em favor de teorias que se fundamentam em princpios (Principialismo).
A anlise tica completa de um problema clnico se estende por quatro
nveis: (1) o nvel do individual; (2) o nvel das reivindicaes sobre regras e
direitos; (3) o normativo; (4) o metatico.
tica religiosa e tica secular diferem basicamente no nvel metatico: o
nvel do significado e da justificao de reivindicaes ticas.
Muito do que se fez em tica mdica nos ltimos trinta anos foram no
nvel da Teoria Normativa. Foi a que se desenvolveram amplos e abstratos
sistemas para apoiar a tomada de decises ticas.
A teoria Normativa trabalha com trs questes genricas os princpios
da ao boa; a teoria dos bons traos de carter (teoria das virtudes); e a
teoria daquilo que conta como benfico ou como prejudicial (axiologia).
De forma mais concreta, mais especifica, afirmaes sobre regras
morais ou direitos morais podem ser consideradas como tendo origem na
Teoria Normativa.
Nesse nvel que se encontram os Cdigos de tica Profissionais, as
Declaraes de Direitos do Paciente e os cdigos religiosos sobre condutas morais
apropriadas (por exemplo, as declaraes do Vaticano e as leis Talmdicas).
Finalmente temos os juzos a serem feitos para atender casos
individuais, como as decises que mdicos e outros tm que tomar ao lado do
leito do paciente.
Depois de definir e explicar este esquema de quatro nveis, a palestra
ir expor as mais evidentes controvrsias naquela parte da Teoria Normativa
chamada de Principialismo.
Quase toda a tica da profisso mdica (incluindo a tica Hipocrtica)
tem sido conseqencialista. Seu interesse nico que se produzam
conseqncias benficas e que as ms sejam evitadas.
Esta faceta a tica Hipocrtica divide com o Utilitarismo Clssico,
porm, enquanto este abrange conseqncias para todos os envolvidos, a tica
Hipocrtica insiste em que os mdicos devam concentrar o foco de sua ateno
exclusivamente no paciente.
Talvez seja por isso que a tica Hipocrtica moralmente to
deficiente, a ponto de estar se tornando cada vez mais irrelevante.
A tica Mdica Catlica Romana tambm apresenta fortes traos
conseqencialista, mas de modos diferentes.
ABSTRACT
After considering an opening case, the concept of justice will be
contrasted with other kinds of ethical appeals. The Hippocratic ethic will be
characterized as an approach that deals only with benefit and harm to the
isolated patient, which, therefore, cannot deal with problems of justice and
resource allocation. Likewise, the focus on patient autonomy cannot either. For
an ethic to deal with social issues, some consideration of competing moral
claims must be provided.
Two major ethical systems for allocating scarce resources wiIl be
contrasted: one focusing on social utility (maximizing the aggregate net good
from available resources) and the other focusing on justice (striving to create an
end state pattern of distribution of the good). Although social utility is the darling
of the public health community and many health planners, it is flawed not only
because it requires comparison of incommensurable goods, but also because it
fails to take the distribution of goods into account. It fails to consider the needs
of the neediest.
The principle of justice provides an alternative. There are many different
patterns of distribution that justice might promote. Distribution according to need
is the most plausible. These are considered egalitarian theories of justice.
Among egalitarian theories two major alternatives must be considered.
The maximin theory of John Rawls would permit gross inequalities, but only if
they are necessary to benefit those who are worst off (by giving the elite an
incentive to help the worst off). True or radical egalitarianism strives for greater
equality of opportunity for equal outcomes (even if the worst off are not as well
off as they would be under the maximin approach).
Two final issues need to be addressed to present a full theory of justice.
First, what is the relation of the principle of justice to other principles. Some
would completely subordinate justice to social utility. Others would claim that
competing principles ought to be balanced against each other so that neither
completely dominates. Still others might attempt to give justice an absolute
priority. I will advocate an approach that gives priority of justice over social utility,
but gives other ethical principles (such as autonomy and avoidance of killing) coequal status with justice. The result is that justice is one among several
principles that, jointly, take priority over social utility.
Second, we will complete the examination of justice and resource
allocation by asking what the role of the bedside clinician ought to be in
allocating resources. While some would urge the physician to abandon the
exclusive focus on the welfare of the patient, I will advocate giving the clinician
at the bedside an exemption from resource allocation so that he or she can fulfill
special duties to the patient. The corollary will be that, if the clinician does not
place limits on the use of scarce resources, then someone else wiIl. I will
suggest that the patient population (the citizenry) is in the best place to impose
those limits.
JUSTIA E ALOCAO DE RECURSOS
Para iniciar, vamos analisar um caso e a seguir, comparar o conceito de
Justia com outros conceitos ticos.
A tica Hipocrtica ser mostrada como o enfoque que se relaciona
apenas com o Beneficio ou o Prejuzo do paciente em si e que, portanto, no
tem condies de lidar com problemas de Justia e Alocao de Recursos. To
pouco apenas a Autonomia. Para que uma tica possa lidar com problemas
sociais necessrio considerar-se as reivindicaes morais em conflito.
Apresentaremos dois grandes Sistemas ticos em conflito para a
Alocao de Recursos Escassos: um, o da Utilidade Social (levar ao mximo a
diferena a favor dos benefcios conseguidos pelos recursos disponveis) e o
outro, centrado em Justia (esforando-se para criar, ao final, um padro estatal
na distribuio dos bens).
Mesmo sendo a menina dos olhos de quem lida com Sade Pblica e
de muitos planejadores da Sade, a Utilidade Social falha porque requer uma
comparao de benefcios incomensurveis e porque no leva em considerao
a distribuio destes mesmos benefcios.
Falha porque ignora as necessidades dos mais necessitados.
Uma alternativa Justia como Princpio pois pode promover diferentes
padres de distribuio. Distribuir conforme a necessidade o mais plausvel.
So teorias igualitrias de Justia.
Dentre essas, duas grandes alternativas tm que ser avaliadas.
A maximin, teoria defendida por John Rawls, admitindo grandes
desigualdades, mas s onde elas sejam necessrias para poder levar
benefcios aos mais carentes (ou seja, dando, aos mais afortunados, incentivos
para ajudar os carentes).
E o verdadeiro igualitarismo, radical, que se esfora em garantir
oportunidades iguais para situaes iguais (mesmo que os mais carentes no
fiquem to bem como poderiam ficar sob um enfoque maximin).
Finalmente, dois temas tm que ser abordados para a apresentao de
uma teoria geral de Justia.
Primeiro, qual a relao do Princpio de Justia com outros Princpios:
pois h quem julgue Utilidade Social prevalente; outros defendem um equilbrio
entre Princpios antagnicos para no venha a haver prevalncia de nenhum: e,
ainda, os que se batem por prioridade absoluta para Justia.
ABSTRACT
While some patients must struggle to get life-prolonging medical treatments
stopped, others are demanding such treatments even if their physicians believe the
treatments to be of no value. These interventions, sometimes called futile care,
pose new and complex problems in medical ethics. Examining several cases
involving such demands, two kinds of so-called futile care will be identified: care that
cannot produce the effect desired by the patient and care that will produce an effect
valued by the patient but seen as useless by the clinician. While physicians must
have the right to refuse to provide the first type, whether they have such a right in
the second case is more controversial.
Among treatments expected to produce outcomes valued by the patient (or
surrogate) but deemed useless by the clinician, two reasons can be given for limiting
access. The treatments consume scarce medical resources and they force clinicians
to practice medicine in ways that seem unprofessional or inappropriate to them. The
first reason is surely a legitimate basis for Iimiting access, but it is doubtful that the
bedside clinician should be the one setting such limits. If treatments must be
rationed, other people are in a better place to set the limits. Whether physicians
should have the authority to refuse to deliver treatments that they deem to constitute
unprofessional conduct depends on the circumstances.
The futility debate: who should set limits to useless health care? 31
This lecture will argue that health care professionals should have the
right to unilaterally refuse to deliver treatments they deem to serve no useful
purpose unless five conditions are met:
1. The treatment will increase the chance of extending life or providing
some other outcome deemed fundamental
2. There is an on-going patient/physician relation
3. The physician is capable of providing the service
4. There is equitable funding and no competition for scarce resources
5. No colleague who is capable is willing to take the case
If all of these conditions are met, it should be part of the medical
professionals responsibility to deliver the care even if he or she deems it
useless, inappropriate, or a violation of professional obligation, the physicians
covenantal commitment with the state should require that, in exchange for the
monopoly right to practice medicine, such services must be delivered in these
circumstances. In several of the most famous futile care cases all five of these
conditions were met and physicians were required-by law and ethics-to continue
treating even though doing so violated personal conscience.
FUTILIDADE CONTROVRSIAS:
QUEM DEVERIA IMPOR LIMITES AO TRATAMENTO INTIL
The futility debate: who should set limits to useless health care? 32
obrigam
os
profissionais
fazer
uma
medicina
improvisada
e inapropriada.
A primeira razo tem, seguramente, uma base legtima, mas, no que se
refere segunda, controvertido que o mdico que esteja atendendo um
doente venha a ser o prprio agente limitador. Se for preciso racionar um
tratamento, outras pessoas esto em melhor posio para determin-lo. S em
circunstncias especiais que o prprio mdico deveria ter essa autoridade
para recusar tratamento se este lhe parecesse uma conduta no-profissional.
Nessa palestra, discutiremos o direito do profissional em recusar tratamento que
ele julgue intil, por no apresentar as seguintes cinco condies:
1. O tratamento ir condicionar a possibilidade de prolongar a vida ou
de criar outra situao julgada fundamental;
2. Existe uma continuada relao mdico-paciente;
3. O mdico apto para tal servio;
4. Existe proviso eqitativa e ausncia de competio por
recursos escassos;
5. Nenhum outro colega habilitado queira assumir o caso.
Se todas essas condies estiverem presentes, passa a ser do mdico
a responsabilidade pelos cuidados necessrios, mesmo que ele os julgue
inefetivos, no apropriados, ou uma violao de sua conscincia profissional.
The futility debate: who should set limits to useless health care? 33
The futility debate: who should set limits to useless health care? 34
ABSTRACT
Clinicians wishing to recruit patients as subjects in clinical trial face a
dilemma: they are duty-bound to choose what is best for their patients, yet a
randomized trial exposes subjects to a therapy chosen at random.
Traditionally, this dilemma has been resolved by appeal to the equipoise
of individual clinicians or clinical community. An offer of randomization is moral if
the individual clinician (or better) the clinical community sees the risks and
benefits of the standard treatment and the experimental alternative as equally
attractive. However, we now realize that this justification fails because subjects
may hold rational preferences for one of the treatments even if the clinician or
the clinical community finds the two options equally attractive. This lecture will
propose the indifference of subjects as an alternative moral foundation for
justifying randomization. This means that even if the clinician or clinical
community is in equipoise, randomization is normally unethical if the potential
subject has a rational preference for one of the options. With certain exceptions,
patients should be given their preferred treatment when they have a rationally
formed preference. On the other hand, if after being adequately informed, the
subject is indifferent between the two options, randomization may be ethical
even if the clinician or clinical community are not in equipoise.
Conselho Fiscal:
Titulares: Carlos Fernando Francisconi
Jussara de Azambuja Loch
Marlia Gerhardt de Oliveira
Suplentes: Maria Estelita Gil
Helena Wilhelm de Oliveira
Nilce Maria Ferrari
38