ETHICS OF CARE IN PUBLIC HEALTH EDUCATIVE ACTIONS

Eva Neri Rubim Pedro, Fernanda Beheregaray Cabral, Juliana Silveira Colomé, Marta Cocco, Rafael Marcelo Soder, Maria da Graça Oliveira Crossetti

1 INTRODUCTION

This paper features a critical approach on the ethical aspects of care in the context of educative actions in the field of public health. For such purpose, one highlights the practice of nursing professionals from reflections and inquiries regarding the ethical dimension of care within the community. Relating the ethical aspects of care with educative actions in public health is justified by the fact that, many times, these activities are pervaded by ethical dilemmas inherent to situations of interpersonal relationships. Besides, this reflection is regulated by the affinity and interest of this paper’s authors who have somehow already performed in this area.

Thinking over ethics in the community health care acquires relevance in the sense that it allows a new glance at the commitment of the social actors in health educative actions and, specifically, of the nursing professionals as a social occupation. So, in the relations between the subjects, at this moment understood as nurses and patients, it is taken into consideration their knowledge, beliefs, habits and values making it easier, in such a way, the discovery of a community identity that searches for the construction of a social identity.

Upon referring to nursing as a social practice, currently conceived beyond its technical dimension as the performance of technical procedures, the focus of care is addressed to the inter-relationships of each practice range with the remaining ones, be it in the production of knowledge, in the social, economical and political reproduction and in the insertion of the subjects, what characterizes the social dimension of the subject of study.

Herein, public health appears by addressing a plural set of knowledge involving all of the basic health subjects of study like social sciences, epidemiology, planning and administration besides the specific ones that comprise fields of knowledge on health care. The areas that are aggregated to this field search at working the health problem in a sphere of social action, therefore, the community sphere that is understood as a field of organization of social practices considering that the object of performance does not concentrate itself in the biological field anymore but, instead, in the social realm1.

Nowadays, one perceives that health professionals, in general, and nursing in particular, have experienced, more and more, the need of developing health educative actions based on the concept of promoting health as defined by the Letter of Ottawa that mentions the community qualification in order to work for the improvement of its quality of life and health, including more participation in the control of this process and intensifying the responsibility for and rights of the patients and of the community regarding their own health2.

Within this context, Nursing stands out as one of the main fields that compose the health work acting in a constructive and effective way in public health because it makes possible a process of interaction among the subjects allowing the share of life experiences, knowledge and feelings whose essence and performance specificity is the care of the human being, both the individual and the community one. Therefore, it is up to nursing playing the role of the facilitating and mobilizing agent by utilizing an understandable and simple language that is adequate to the reality knowing the needs of the patients in the health-disease-care process in order to perform interventions that search for the improvement of their life conditions3.

To summarize, considering nursing as a practice that articulates with several social segments, one perceives that such practice needs the knowledge that emerges from the community in order to strengthen actions based on ethical principles and such issues shall be discussed in the topic dedicated to the ethical dimension of care. Next, health educative actions will be presented as well as the nursing work approached as a process that appears as a set of relations of empathy, ties, acceptance and responsibility.

2 HEALTH EDUCATIVE ACTIONS AND NURSING 

The health educative actions, understood as strategies to strengthen the Sistema Único de Saúde (SUS) – Brazilian Public Health System, and to provide equable, universal and egalitarian access to the patients of the health services can also be considered as a mode of care able to help and to qualify the subjects as to knowing their health needs, at identifying the problems of their communities and to stimulating the set up of critical and participative attitudes that signalize the family and community well-being.

In this sense, it is evidenced the need of thinking health education under the perspective of social participation by understanding that the true educative practices only take place among social subjects and of considering these actions as strategies for the construction of active subjects that move in the direction of a releasing life project4.

For such purpose, there is a belief that the educative practices must consider the shared construction of knowledge that establishes the foundations of the awareness of people and that call them and the community as well to become protagonists. As a priority, such practices must reject individualist and authoritarian educative actions that, most of the time, are turned to the change of habits that have as reference a life style that is infinitely distant from the reality where the popular layers of the country are set.

However, it has been found out the existence of a great variety of health education practices, ranging from good to bad ones, from healthy to unhealthy ones, of both power promotion and submission practices, of liberation and of taming. So, health educative practices must promote the power of the subjects because the mediated knowledge helps them making decisions about their health by giving them the opportunity of exercising autonomy and self-government5.

Thus, health education should not be understood as a coercive measure of social control but as an instrument that allows the subjects to understand themselves as citizens while being participative social members and citizens with rights to adequate health and life conditions. Within this context, education is shaped as an instrument of social transformation and such reflections do not refer only to formal and institutionalized education but also to actions that propitiate the reformulation of habits and the acceptance of new values6.

Besides, from the moment when the subject acquires a broader investigative and critical view of the social phenomena and, particularly, of health issues of his/her community, it becomes possible acquiring an attitude of community commitment aimed at effectively calling the governmental responsibility as to initiatives that give the opportunity of enjoying the health sector as everybody’s true right.

Thus, the more the popular masses unveil the objective and challenging reality into which their changing action must fall the more they insert themselves in it critically speaking, and so, leadership and masses, co-intentioned as to reality, find themselves in a task where both are subjects in the act, not only to unveil that act and, so, knowing it critically in the act of recreating this knowledge. Thus, upon reaching such knowledge about the reality by means of reflection and action held in common, they find out themselves as their permanent re-makers and lead to citizenship attitudes7.

Based on these affirmations, nurses are considered permanent educators and, especially in the field of community nursing, their work reach the highest degree of range and responsibility since educating for health means making people capable of reaching a satisfactory level of health by themselves through an active participation in their community problems what leads to a reflexive and critical praxis of the reality8.

For such purpose, nurses and other health professionals, who perform activities in this area of care which is strongly stressed nowadays, need inputs on knowledge committed with reality and culture that do not impose to people changes in their way of thinking but that contribute to the expression of the subject in its totality, active before social issues and, consequently, capable of intervening and interfering on his daily life.

Promoting health implies performing in a creative and transforming manner by utilizing health educative practices as working tool, being such instrument a generator of changes provided that the health-disease-care process be understood in a broader way, i.e., including the social issue so that the patients understand their lives socially with the objective of perceiving adverse health situations by recognizing their own health problems as well as those of the communities.

3 ETHICAL DIMENSION OF CARE: THE NURSE’S ROLE 

Society has established the set of ethical values as patterns of behavior, of inter-subjective and inter-personal relations, of social behaviors that may guarantee the physical and psychic integrity of its members and the preservation of the social group. It also determines the moral values regarding good and bad, to what is allowed and what is forbidden, to right and wrong, to virtue and vice9.

The ethical dimension of care involves certain concepts that emerge through professional practice in the relations established in the community. Thus, moral and ethics are characterized as follows: (…) Moral derives from Latin mos or mores, “habit” or “habits”, in the sense of a set of acquired standards or rules or of a way of being conquered by man. Ethics comes from Greek ethos what means, similarly, “way of being” or “character” while being a way of life that is also acquired or conquered by man. Therefore, originally, ethos and mos as well as “character” and “habits” resemble in a way of behavior that does not correspond to a natural arrangement but that is acquired or conquered by habits10.

Taking care/care must be understood in a transpersonal manner, under a humanistic perspective, by relating the scientific knowledge with a broad awareness of the world and the ability of critical thinking11. In such a way, that this transpersonal care makes possible a higher involvement of people who engage themselves in the act of taking care and, so, that taking care in an expansive way reaches the promotion of the moral development that is considered indispensable in the daily work of nursing in the search of a humanistic praxis12.

In this sense, one perceives taking care as a moral ideal of nursing and its essential feature concentrates in the preservation of human dignity by understanding the human value that involves knowledge, the actions and the results of the care13. Within this approach, the actions of taking care envisage the satisfaction of the patient’s needs, being such needs in the physical field understood as procedures, administration of medicaments and in the psychosocial field that correspond to the humanistic values of the cared human being.

Besides, acting ethically is an option since it is the fruit of the autonomy exercise so that free subjects, who perform their citizenship and search for the good through their acts, build ethical relations and attitudes14. On the other hand, ethical behavior is the expression of the day-to-day life, of the subject’s commitment with other people and of the ways whereby human beings relate among themselves. So, the moral consciousness does not only know these differences, but it also recognizes itself as capable of judging the value of behaviors and of acting in conformity with the ethical and moral values of society15.

            In the last years, many ethical issues have been discussed in society and, specifically, in the health field. Thinking on health ethics is seeing man, as a participant of political and social integrations, as the subject of a history and capable of opting for issues related to health, food, leisure, fair salaries, that is, everything that is related to the human life16. Therefore, thinking about ethics in nursing addresses to the reflection about practices developed by the nurses in the context of public health that, besides searching for the promotion and the protection of health, such practices also need to favor the development of educative practices that aim at the population’s quality of life.

The contemporaneous ethics of health care relates intrinsically to the idea of the subjects’ autonomy what means self-determination and self-government. It is the human being power of making decisions about his/her health, physical and psychic integrity, his/her social relations, that is, it refers to the capability of the person to decide what is “good” and what he/she considers adequate for himself/herself17.

Respect to autonomy is the recognition of the person’s right to having his/her opinions, making his/her choices and of acting based on his/her beliefs and personal values without interventions. Upon the Nursing practice, it is essential that the professionals understand the importance of such principle as “guidance” to all of the activity to be performed18. In this sense, in order to perform his/her autonomy, the patient needs to understand the health-disease-care process from the knowledge shared and worked by the health professional, in order to become possible that the decisions adequate to the patient’s needs be feasible19.

So, the respect to the human being autonomy requires that his/her consent be obtained or that his/her refusal be accepted before submitting him/her to diagnosis, preventive or therapy procedures. Therefore, among the patients’ rights that may be guaranteed in the health services there is the right to confidentiality of information provided to health professionals, meaning that the subjects themselves may decide what they want to keep under confidentiality and under control and to whom, when and where they will be revealed20.

The ethical relations of care in the daily routine of health educative actions imply human relationships and, consequently, complex relations tuned by empathy or not. In this manner, upon developing health educative actions, the nurse must do everything possible to preserve the individuality of each person who searches the health service by respecting his/her beliefs, habits, values and attitudes.

For such purpose, it is necessary that everyone be respected and welcome according to his/her needs what requires the construction of ties between the professional and the patient, regulated by ethics, respect and, above all, by confidentiality of the revealed information. In order to guarantee such propositions, the Nursing Ethical Code that has been revised by the Federal Nursing Council through the COFEN 240/2000 decree is aimed at regulating the nurse’s working process by guiding the actions of the nursing professionals and helping solving ethical conflicts in his/her praxis. Nursing professionals constantly face situations that require from them decision making in the realm of ethics and such situations involve a series of determinants comprising different people placing them before a varied range of attitudes16.

Human care comprises commitment and responsibility for being in the world what does not only mean making what pleases but also helping to build a society with foundations on moral principles21. Nevertheless, in spite of the ethical dimension of the nursing care being one of the fundamental elements of professional performance, one perceives that the concern regarding acting according to ethical principles is not common to all of its professionals because many nurses do not know or even ignore the principles of the ethical code in developing their working process.

On the other hand, the nurse who works in the public health field also experiences facts and events plausible of intervention but that many times go beyond the limits of the ethical code of their occupation. For example, when he/she makes a home visit, often without noticing previously, this may cause embarrassment or exposition of facts from the private life of people who would not like to reveal them (family disintegration, alcoholism, unemployment, intra-family violence, addiction or traffic of drugs, exploration of infantile work, incest, among others) whose witnessing, in spite of requiring immediate intervention, results in an ethical dilemma.

The plurality of contexts where the nursing practice is inserted may be an element that makes the performance of the nurse in the community health difficult, because upon interacting with the community, he/she faces its specificities and diversities that, very often, do not favor an intervention proposal according to his/her moral and ethical limits. Considering other examples of ethical dilemmas, as regarding blood donation, how is the nurse going to approach a request of consent for such procedure in case the family of the patient who needs blood transfusion belongs to a religious faith that is radically against such procedure? How to instruct a mother to bathe her children daily in order to avoid numberless diseases if in the region where they live water is not available even to drink? How to guide a pregnant woman if she cannot afford buying the essential food for her to eat?

In view of such considerations, it has to be pointed out the dichotomy existing between thinking and doing, between good and bad, between what is considered right or wrong, healthy or not, be it from the scientific or from the popular knowledge, can go beyond the ethical conflicts and dilemmas of the professional praxis. So, the biggest ethical conflict seems to be the contradiction between the nursing commitment with promoting health in the community where he/she works, blaming the subject for the non-adoption of the guidelines “provided” by the health professionals, and the thoughtlessness of the misery and exclusion context where many people live in detriment of the little resolvability of the health actions and services proposed by vertical public policies which are frequently selective and discriminating.

 4 FINAL CONSIDERATIONS

Facing the demands of the new health model proposed by the Sistema Único de Saúde (SUS) – Brazilian Public Health System, the concep of health as a citizenship right must be guaranteed and legitimated by means of policies that aim at reducing exceptions and that assure the universal and equal access to actions and services for the promotion, protection and recovery of health. Within this context of changes, it is remarkable the importance of the performance of the nursing professionals who are committed both ethically and socially with the development of educative practices that aim at promoting health and quality of life.

This way, health education plays a relevant role for the reduction of social inequalities through the universalization and democratization of health actions, promotion of sustainable development and social inclusion and, yet, the improvement on the quality of life of the population by incorporating the guidelines of integrality and humanization of health care within the SUS range.

Within this perspective, the health educative process favors the development of autonomy and competence for the health care at the same time it meets social objectives, that is, health education does not play the role of replacing the structural changes needed to overcome social inequalities but, no doubt, it participates in the promotion of processes that, somehow, allow the subject to recognize himself/herself as agent of his/her own health in the search for a better quality of life.

In order to guarantee that the individuality of the human being be respected, it is needed to rescue the nursing ethical dimension in the daily health educative actions once the patient, being the subject and not the object of care anymore, needs to be cleared up and informed as to his/her rights, to his/her current health condition by involving him/her in the decisions that are pertinent to him/her, and by establishing actions and attitudes of respect and dialogue. Respect to the human being is one of the basic values of the modern society, based in the presupposition that each person must be seen as an end in himself/herself and not only as a mean22.

In this sense, care must be understood as a gradual process of exchange, involvement, presence, co-responsibility and help among the whole team with the patient by improving the assistance, the humanism and by appraising the professional ethics. Upon care, a commitment is established and it is represented by the moral and ethical performance of the nurse, working in an educative perspective of dialogue and inter-relation with the patients knowing how to live along with the existing differences and respecting the desires, wishes, values, habits and manners of the human being.

Therefore, the issue of nursing ethics needs a holistic view of the human being and from this perspective of performance it will allow the nurse to recognize his/her duties and responsibilities with the patients, leading the health educative actions in an ethical manner. So, it is up to these professionals to take over their commitment, while educators within this social reconstruction process, by struggling for the fulfillment of public health policies in order to overcome the assistance over-practices and to rescue quality in the attendance of the population by means of ethical, competent, responsible and humanized nursing care.

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