Brazilian bioethicists and the ethics of universality and integrality in the national Health System


Bioeticistas brasileros y los principios de la universalidad y de la integración en el SUS



Paulo Antonio de Carvalho Fortes

Departamento de prática de saúde Pública. Universidade de saúde Pública. Universidade de elas Paulo. São Paulo, SP, Brasil





OBJECTIVE: to understand the meanings attributed by Brazilian bioethicists to ns principles that universality e integrality in ns Brazilian público health system.

Você está assistindo: O que é universalidade no sus

METHODOLOGICAL PROCEDURES: naquela qualitative and exploratory research was carried fora with 20 Bioethics professors in ns field of publicamente health from July 2007 come July 2008. Participants to be directors e former director of the Brazilian Bioethics Society and of its local departments. Semi-structured interviews with open concerns were conducted and followed by contente analysis.ANALYSIS that RESULTS: com regard to a principle of a universal accessibility of Brazilians come the público system, most of interviewees were in favor of preserving it. However, there to be divergences of ns principle of integrality, with the majority being inclined come restrict it.CONCLUSIONS: Bioethicists hold a plurality of convencional values e difficulties come morally decisão on what would certainly be der fair health system.

Descriptors: Bioethics. Solitary Health System. Comprehensive Health Care. Universal Access to Health treatment Services. Qualitative Research.


OBJETIVO: Comprender sobrenome sentidos que sobrenome bioeticistas brasileros atribuyen der los principios de la universalidad y de la integración en el sistema público de salud brasilero.PROCEDIMIENTOS METODOLÓGICOS: Estudio exploratorio cualitativo, executar con 20 profesores universitarios de bioética actuantes en el área de leitura ciencias de la salud, con funciones de directores y exdirectores de la Sociedad Brasilera de Bioética y de directorias regionales, en el cerca de de apontado de 2007 a julio de 2008. Fueron realizadas entrevista semi-estructuradas, con preguntas abiertas, siendo realizado análisis de contenido.ANÁLISIS DE RESULTADOS: Con respecto ovo principio de la universalidad de acceso de sobrenome ciudadanos brasileros naquela un sistema público, las manifestaciones de eles entrevistados se ubicaron mayoritariamente en profissional de su mantenimiento. Aún así, con relación al principio de la integración, las divergencias fueron manifestadas, deseando la mayoría en restringirlo.CONCLUSIONES: sobrenome bioeticistas relatan pluralismo de valores morales y dificultades en decidir moralmente acima de lo o que sería un sistema de salud justo.




Health systems ~ ~ the product of der country"s economic e social conditions. Your organization and functioning contains various inductive factors, such together pressure from the different sociedade actors affiliated in these health systems. However, a prevalent ideology and ethical values in society ~ ~ fundamental factors ao health equipment guidance and resource allocation.

In Brazil, the comunidade Constitution of 1988 considers health as a social right e the duty of ns State. The público health área falls under ns protection the the nacional Health system (Sistema Único de saúde -SUS) e substitutes a previous system that was based on ns notion of work, when, by law, apenas um registered workers were entitled to medical and hospital care.

The universal health sistema was developed by ns current constitutional Charter. In enhancement to a principle of universality of access, ns Charter introduced technology when, in short article 198 II, it also inserted a principle the integrality - "integral care, com priority for preventive activities, there is no prejudicing care services".

Among ns different concepts, one of ns understandings of health and wellness integrality7 advert to ns responses of the health sistema to a individual and collective health and wellness needs of naquela preventive and care nature.

These principles have been defended e questioned by various social forces. In practice, according to Mendes,8 Brazil is facing a dilemma in terms of consolidating a current segmented sistema (SUS and the supplementary medical-dental treatment system) or relocating towards universalization that the publicamente system. Bioethics, specifically in Brazil, has been guided through themes related to health policies e systems2,3,13 and, together Drane & Pessini1 state, bioethicists have progressively taken over ns role of offering advice come legislators e managers once it involves proposing público policies.

Considering that these economic, administrative e political policies involve underlying moral issues, ns objective the this pesquisar was come understand the meanings meeting by Brazilian bioethicists to a principles the universality e integrality in the Brazilian health and wellness system.



An exploratory qualitative research with analytical-descriptive orientation foi ~ carried out. A qualitative approach ser estar chosen para its potential come understand cultural values. The encontro analyzed were obtained from a larger study.ª

A convenience sample was constructed, comprising directors e former directors of a Brazilian Bioethics Society e of several of its department (period between 2005 and 2008): rio de Janeiro, Pernambuco and São Paulo, Southeastern, Northeastern and Southeastern regions, respectively. All participants had actually scientific bioethics production, in accordance with naquela consultation carried lado de fora in the database of ns Lattes Platform, the the national Council porque o Scientific and Technological development (CNPq). A Society, which was set increase in 1995, at this time brings together most of the Brazilian bioethicists. Its function is to unite people com different university backgrounds, who ~ ~ interested in encouraging discussion e the diffusion the bioethics. Ns categories of experienced background became more diversified when ns sample foi ~ expanded to combine professionals são de the field of medicine, dentistry, nursing, anthropology and theology. Saturation criteria era considered para limiting the number of interiewees.9 Semistructured interviews were carried out between July 2007 e July 2008. A interviews, i m sorry were conducted by ns researcher himself, were recorded on magnetic tape e subsequently fully transcribed. Ns responses of three of those taking part were acquired in creating after a form had actually been sent to castle by Internet, because of ns difficulty of arranging one interview.

In order come find lado de fora the meaning of a theme given by the sociedade actors surveyed, all of them had actually previously received der script with the following open up questions:

A) If Brazil to be to carry lado de fora constitutional reform, what position would friend adopt with regard to the principle "Health is der right of todos and der duty of the State?" Explain. B) knowing that there are insufficient funds to cover tudo health needs B.1. Which should be prioritized? C) have the right to or should some health and wellness needs be left without any type of service?

The replies to be grouped into dois analytical categories: "the rule of ns universality of ns health services system" and "the rule of integrality in a health system". Some of a key-expressions that consist in "literal transcriptions of component of a statements, i beg your pardon allow a essential discursive contente to it is in taken a partir de the segments right into which the statement is divided" will be presented.6

The aprender was authorized by the research Ethics Committee that the faculdades de saúde Pública, universidade de elas Paulo. Todos participants signed ns consent form and were guaranteed the right to refusal, anonymity e the confidentiality, in accordance com Resolution CNS 196/96.



The rule of universality of ns health services" system

Most of ns bioethicists interviewed were emphatically in favor of maintaining the principle of universality, defending ns constitutional principle the the nacional Health sistema was der major social victory and that ns State is responsible porque o guaranteeing the everybody has accessibility to care e the opportunity of vida in der healthy environment. But, lock remember that since funds estão scarce they need to be allocated in der prudent e reasonable way.

Also in defense that universality, there was explicit the opposite to focusing policies that are restricted to ns most underprivileged layers of society.

"In this sense, i think the this right should be guaranteed to everybody; it must not be exclusively para the poor. Everybody"s payment taxes, for this reason everybody have to have accessibility to a quality system." (E15)

On ns other hand, even though they to be in naquela minority, there were those who argued versus maintaining ns constitutional rule of universality. These particular participants argued that, in a absence of ns possibility of covering tudo de needs, decisions have to be taken, ao example, not included those who have a material and economic problems to look at after themselves and their health. This should accessibility supplementary medical treatment systems.

The rule of integrality in ns health system

As for the inquiry of integrality, there to be those who defended maintaining a constitutional principle e there to be those against it; those quem defended it to be in a minority. Most of ns interviewees criticize maintaining the principle of completely taking care of needs, because they thought about it would certainly be "difficult", "impossible", "illusory" or "utopian" for this come become a reality.

"I saw, ao example, that in Canada - you an alert that tudo health systems today, to a certain extent, estão in crisis, precisely since of funding, because of costs. Today you establish that we have farming infinite needs e finite resources." (E9)

It was also taken into consideration that taking treatment of collective needs should get priority over distinguível needs. Steps that fit ns so-called "desire-driven medicine", such together cosmetic surgery e assisted reproduction methods should be restricted. Moreover, uma of ns bioethicist interviewed stated that the principle of integrante care should be restricted porque o those who have access to supplementary equipment of medical-dental care:

"Only those quem can pay ao procedures, i.e. Quem have health plans, should not have actually full accessibility to tudo resources." (E19)

There ser estar currently three health sistema models: the liberal model, ns model based upon being employed and the universal model. In the last dois cases state authorities have naquela direct participation, through planning, management, regulation, control e direct funding. A history of health and wellness systems, together we recognize it currently, is recent. A process ao creating publicamente instruments porque o protecting social risks, such together old age, disease, unemployment, maternity, disability and work-related mishaps started in the 19th century.4,5

In Germany, in 1883, in an answer to claims and social pressures from worker sectors, der public social security sistema was set up, based on a compulsory contribution of workers e companies. Ns basic principle of this health sistema model is experienced affiliation and solidarity in between those quem contribute to it, solidarity in between generations e between a "healthy" and the "sick". In enhancement to Germany, this model foi ~ adopted in France, Austria, Belgium, ns Netherlands, Japan e various nations in Latin américa during a 20th century.

However, in ns second fifty percent of ns 20th século another social protection sistema model based on universality and the notion of the social right come health care came into a scene. In 1946, in Britain, ideal after the fim of the Second world War, the national Health sistema law era enacted that was a result that conceits e principles established in 1943 in a report presented to the britânico parliament by lord Beveridge"s team. In 1948, the britânico National Health system was implemented.5 This público system covers all citizens e is not based on professional affiliation e its capital is guaranteed fora of visão global taxes e independent of any kind of welfare contributions. The incorporates ns notion of right to totally free health. This system was subsequently embraced in Australia, new Zealand, Canada e Brazil.

In our research, most of interviewees to be in doar of maintaining der universal system and opposed come the idea of focusing resources ~ above people vida in a less privileged situation. Ns notion of focusing resources is frequently related come undercurrents that egalitarian liberalism, i m sorry accepts actions that have aftermath that ~ ~ unequal for the various people involved só when they result in compensatory benefits porque o everyone, and particularly for the much less privileged members of society. It can be claimed that they favor "positive discrimination", prioritizing a underprivileged, ns excluded, ns most fragile or those who are already experiencing in part way.11,12

There were couple of discursive arguments that, invoking ns scarcity that resources for guaranteeing that tudo de can it is in cared for, know that that is precious to direct resources specifically to human being who estão unable to take care that their own health. Despite the fact the such discourses did no explicitly safeguard the liberal health system model, they suggest acceptance of naquela segmented sistema that differentiates customers de acordo com to their level of satisfaction com their health needs, either com their own way or through forms of consist of in formalmente employment, or v solidarity-based groups, choose those that go to do up social security-based systems.

Mendes8 discusses the idea that, if the público system were oriented só towards underprivileged people, leave aside a principle of universality, there would certainly be much more than sufficient resources para the poorest class of society. In fact, by not included that component of society with the greatest strength of opinion e pressure top top politicians and legislators, the sistema would be much more vulnerable to obtain adequate sources due to ns smaller potential for bringing social pressure of ns underprivileged segments.

Therefore, questions might be asked about ns bases e criteria para saying that someone is underprivileged or already suffering in part way e whether such criteria are economic, social, demographic, epidemiological or sanitary. Questions might be asked as to whether organic criteria e those regarded pathological problems resulting em ~ disease should be taken right into consideration.

If, top top the 1 hand, ns majority defended the principle of universality, maintenance of a constitutional principle of integrality ser estar characterized by fairly divergent positions, com criticism regarding its continuity predominating. The bioethicists interviewed take it positions the ranged são de defending maintain of the principle, without change, to explicit manifestations são de the bulk of ns need come reformulate it, by restricting resources ao certain technical procedures, such as those concerned "desire-driven medicine".

With to the to integral care for tudo users of a health system the mundo Health company recognizes that ns various publicamente health systems are unable to fully colocar the demands of everybody. Even if this to be possible, over there would need to be naquela substantial increase in ns funds invested in a health sector and in a basic reasons responsible porque o most of a population"s health condition.15

Schutz14 inquiries whether a maintenance that unrestricted care would not result in an increase in situations of sociedade injustice, because com resource scarcity, rather of prioritizing ns most underprivileged, the would cabe the understanding of the most organized groups that have a greatest lobbying power e greater accessibility to the judiciary system. So, universal access to integrante care would certainly be a mere "image-objective" of the system, i beg your pardon is no borne o fim in ns daily reality.7

Even counties com structured universal systems, like the United Kingdom, Canada e Spain, restrict details care being readily available to tudo citizens, such together pharmaceutical help e dental care.4

For a discussion about the principle the integrality, Senate invoice 219/2007 intends transforming items in legislation 8080/90, recognized as ns Organic health Law, i m sorry regulates the organization and functioning of ns Brazilian national Health System. The intends limiting the pharmaceutical ajuda supplied by ns SUS. It argues that a interpretation of a concept of a integrality that pharmaceutical ajuda refers to what is declared in the tables e in heat with the therapeutic indict instituted by the federal manager of a SUS.

As ao restrictions to completo care ao health needs, Narvai & elas Pedro10 distinguish health difficulties arising from public health problems, due to the fact that they understand that the latter correspond to the sociedade representations of a needs of der group at naquela particular moment in time. The is up to a State come meet the needs arising from public wellness problems and not merely the separado health problems. Porque o example, cosmetic problems can be thought about to be individual health problems, above all in a psychical sphere, but would not be taken into consideration as naquela collective responsibility, involving public resources.

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The outcomes of a research, principally com regard come integrality, show that bioethicists find it complicated to morally decidir on what would be der fair health system. To construct up the SUS, a truly deliberative process must be established that includes the various social players interested in ns health system. Der minimum basic ethical reference point ao the organization e the functioning of a health system must it is in prepared, thus making it possible para the myriad honest viewpoints to it is in manifest.



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Correspondence: paulo Antonio de Carvalho Fortes faculdades de saúde Pública, universidade de São paulo Av. Dr. Arnaldo 715 - Cerqueira Cesar 01246-904 elas Paulo, SP, brasil E-mail: pacfusp