Reflections on bioethics: consolidation of
the principle of autonomy and legal aspects
Re fle xõ e s e m b io é tic a: c o nso lid aç ão
d o p rinc íp io d a auto no mia e asp e c to s le g ais
1 Departam en to de Medicin a Legal, Ética M éd ica e Med icin a Social e d o Trabalh o, Facu ld ad e d e Med icin a, Un iversid ad e d e São Pau lo.
Ru a Teod oro Sam p aio 115, São Pau lo, SP
05405-000, Brasil. M arco Segre 1,2
Abst ract Th e a u t h or h igh ligh t s t h e im p ort a n ce of em ot ion s in a ll et h ica l reflect ion s. He d e-scribes th e m ost com m on p osition s of eth icists em p loyin g d u ties an d righ ts as th e basis for eth i-cal th ou gh t. Th e au th or, goes to Freu d ian th eory as v iew ed by th e u tilitarian s, statin g th at th e ‘qu est for p leasu re’ is n ot n ecessarily egocen tric, esp ecially for ad u lts. For exam p le, th e feelin g of solid arity em erges ‘from th e in sid e ou t’, m ak in g irrelevan t all th e em p h asis laid on obed ien ce to d u ty (from th e ou tsid e in ). Th e article qu estion s th e essen ce of Kan tian th eory, based exclu sively on ‘reason’ w ith d isregard for feelin gs, by establish in g w h at h e con sid ers a ‘p ositivist’ view of ra-tion al th ou gh t. It em p h asizes th e p rin cip le of au ton om y, w h ich it seen as basically op p osin g th e p rin cip les of ben eficen ce an d fairn ess. It is p rop osed t h at t h e lat t er sh ou ld be seen as w h at h e calls h eteron om y (a con cep t d ifferen t from th at of th e ration al eth icists). In th eory, au ton om y is n ot assign ed to an yon e on th e basis of an ex tern al assessm en t. An y in terven tion in in d iv id u al au ton om y m u st be m ad e (by th e in terven or) w h en it becom es im p erative in th e d efen se of social or cu ltu ral valu es. Th e article d istin gu ish es betw een eth ics an d m orals) an d states th at th e sole accep table eth ical p rin cip le is th at eth ics (th eoretically) h as n o p rin cip le.
Key words Bioeth ics; Social Valu es; Morals; Legislation
Resumo O au tor d estaca a im p ortân cia d as em oções em tod as as reflex ões éticas. Descreve as p osições m ais com u n s d os eticistas, qu e em p regam d everes e d ireitos com o base p ara o p en sa-m en to ético. O au tor refere-se à teoria freu d ian a, sob o en foqu e d ad o p elos u tilitaristas, ao afir-m ar qu e a “bu sca d o p razer”n ão é n ecessariaafir-m en te egocên trica, esp ecialafir-m en te p ara os ad u ltos. Por exem p lo, o sen tim en to d e solid aried ad e em erge d e “d en tro p ara fora”, torn an d o irrelevan te tod a ên fase colocad a n a obed iên cia ao d ever. O artigo qu estion a a essên cia d a teoria Kan tian a – basead a exclu sivam en te n a razão, d escon sid eran d o os sen tim en tos –, ao estabelecer o qu e ele en -cara com o u m a v isão p ositiv ista d o p en sam en to racion al. En fatiz a o p rin cíp io d e au ton om ia, qu e é visto com o basicam en te se op on d o aos p rin cíp ios d a ben eficên cia e d a ju stiça. Na teoria, a au ton om ia n ão é atribu íd a a n in gu ém , ten d o com o base u m a avaliação ex tern a. Qu alqu er in -terven ção n a au ton om ia in d ivid u al p recisa ser feita (p elo in -terven tor) qu an d o se torn a im p era-tiva a d efesa d e valores sociais ou cu ltu rais. O artigo d istin gu e ética d e m oral e estabelece qu e o ú n ico p rin cíp io ético aceitável é o d e qu e a ética (teoricam en te) n ão p ossu i p rin cíp ios.
Introduction
We c o u ld n o t st a r t t h is p a p e r o n b io e t h ic s, b a se d o n t h e fu ll a cce p t a n ce o f t h e co n ce p t o f a u t o n o m y, wit h o u t q u o t in g Pe lle gr in o (1990: 379-389): “Th e p h ilosop h ical roots. Th e p rin
ci-p le of au ton om y h as several sou rces in m oral p h ilosop h y. On e is Lock e’s Se c o n d Tre a t ise o n Gove r n m e n t, w h ich h eld M an in th e n atu ral
state to be free an d equ al su ch th at n o on e m igh t h ave sovereign ty over an oth er excep t th rou gh a social con tract en tered in to freely. Lock e’s argu -m en ts gave rise to th e n otion of ‘n egative righ ts’, or th e righ ts of a person n ot to be in terfered w ith by oth ers. Th ese n egative righ ts h ave becom e th e fou n dation of liberal dem ocracy for m an y.
A secon d p ow erfu l an d in flu en tial p h ilo-sop h ical m oral claim to au ton om y is p rop osed in Kan t ’sGro u n d wo rk fo r t h e Me t a p h ysic s o f Mo ra ls (...). Kan t argu es th at freed om is essen -tial to all m orality, th at it is iden tical to au ton o-m y, an d th at au ton oo-m y is ‘t h e gro u n d o f t h e d ign it y o f h u m a n n a t u re a n d o f e ve r y ra t io n a l n a tu re’.Kan t com bin es th e idea of a ration al be-in g w ith dign ity as follow s: ‘(...)a ra tio n a l b ein g h im se lf m u st b e t h e gro u n d fo r a ll m a xim s o f a c t io n , n e ve r m e re ly a s a m e a n s, b u t a s a su p re m e co n d itio n re strictin g th e u se o f e ve r y m e a n s, t h a t is, a lwa ys a lso a s a n e n d’. He goes
on ,‘An d t h e d ign it y o f m a n co n sist s p re cise ly in h is ca p a city to m a ke u n iversa l la w, a lth o u gh o n ly o n t h e co n d it io n o f b e in g h im se lf su b je ct to th e la w h e m a kes.’
A th ird sou rce for a m oral claim to au ton o-m y is Joh n S. Mill’s essayOn Lib erty. Mill asserts th at th e on ly restrain t to liberty is h arm to oth ers, n ot h arm to on eself. Th e latter n otion , com -bin ed w ith Lock e’s idea of n egative righ ts, is th e m ain lin k betw een th e p h ilosop h ical n otion of au ton om y an d th e legal n otion of p rivacy. Th is lin k is h igh ly in flu en tial in th e Am erican cou rt system . It is th e prin ciple gen erally u sed to solve con flicts abou t w h o sh ou ld m ak e th e fin al deci-sion in accep tin g or rejectin g m ed ical treat-m en t. It is also th e d otreat-m in an t con cep t in th e rep ort of th e Presid en t ’s Com m ission on w ith -h oldin g an d w it-h draw in g life-su stain in g treat-m en t” (Pelegrin o, 1990:381-382).
Pe lle gr in o (1990:383) c o n c lu d e s: “Fin ally,
th e prevailin g em ph asis on au ton om y gen erates a cu lt of m oral privacy, atom ism , an d in dividu -alism th at is in sen sitive to th e fact th at h u m an s are m em bers of a m oral com m u n ity. W h en au -ton om y becom es absolu te, each p erson is a m oral atom w h o asserts h is or h er righ ts in d e-pen den tly an d even again st th e claim s of th e so-cial en tity to w h ich h e or sh e belon gs. Con flicts betw een th e righ ts of a com m u n ity an d th e
righ ts of its in d ivid u al m em bers raise seriou s qu estion s of econ om ic an d social ju stice th at d em an d a better balan ce betw een au ton om y an d th e com m on good n ow prevailin g. Man y of th e m oral sh ortcom in gs of th e con cep t an d p rin cip le of au ton om y are am eliorated if w e look to th e m ore fu n d am en tal con cep t of in -tegrity of person s – of w h ich au ton om y is a par-tial, bu t n ot a fu ll, expression .”
We d o n o t a gree with th e h o n o ra b le p ro fes-so r o f th e Ken n ed y In stitu te wh o co n sid ers th e a c c e p t a n c e o f a u t o n o m y a s a m o ra l gu id e, a t re n d t owa rd s t h e a c kn owle d gm e n t o f m in i-m a lisi-m a s a i-m o ra l gu id e (Pe lle grin o, 1990). We b e lie ve t h e re a re n o c o n d it io n s fo r t h e e xis-ten ce o f a u n iversa l m o ra l gu id e. Co n so lid a ted m o ra ls m a y o n ly e xist fo r d iffe re n t co m m u n i-t ie s o r b y im p o sii-t io n o f a u i-t h o r ii-t ie s (re ligio u s, p o lit ica l, e t c.) o r b y a d e m o cra t ic n e go t ia t io n b e t we e n t h e d iffe re n t gro u p s (b e lie fs) t h a t m a ke u p so cie t y. We wo u ld a lso like t o q u o t e a p a ssa ge fo u n d in a n a rt icle re ce n t ly p u b lish e d o n th e p rin cip le o f a u to n o m y (Segre, 1995).
At p re se n t, th e co n ce p t o f a u to n o m y is se l-d o m fu lly u n l-d e rst o o l-d , a lt h o u gh co n t in u o u sly referred to in cou rt p roceed in gs (p a rticu la rly in th e USA a n d Ca n a d a , from wh ere it p rop a ga ted to th e rest of th e world , alm ost always related to co m p la in t s file d b y p a t ie n t s a n d in vo lvin g in -d em n ities for wh a t th ey con si-d er u n a u th orize-d m ed ica l a cts)(Bea u ch a m p & Ch ild ress, 1989).
We a re d e a lin g wit h a co n ce p t wh ich is a b -st ra ct . We a re q u it e ju -st ifie d in sa yin g t h a t a c-kn owled gm en t o f a u to n o m y m a y exten d to th e c h ild , t h e in sa n e (d e vo id o f re a so n ), o r t o t h e ir ra t io n a l b e in g. It sh o u ld b e n o t e d t h a t o u r id ea of a u ton om y covers wh a t Pellegrin o (1990) ca lls ‘in tegrity’. Su ch a u to n o m y co u ld o bvio u s-ly n o t b e im p lem en ted in a so ciety wh ere th ere a re le gitim a te in d ivid u a l a n d so cia l righ ts gov-e r n gov-e d b y r u lgov-e s, b u t t h gov-e u n d gov-e r st a n d in g o f t h is con cep tu a l a sp ect is im p orta n t. Wh en we ju d ge th e a b ility of p erson s to m a n ifest th em selves or a c t in t h is o r t h a t wa y a n d we in t e r ve n e c o n -t ra r y -t o -t h e ir will, a -t -t h a -t ve r y m o m e n -t we a re vio la tin g th eir a u to n o m y (Pellegrin o, 1990).
Ac c e p t in g t h is vie w, we fin d t h a t a p h ysi-cia n’s in terven tion in th e p a tien t’s con d ition or, in a b ro a d er sen se, in ter ven tio n b y h ea lth p ro -fe ssio n a ls in ge n e ra l, ca n o n ly a cce p t e d fro m t h e a u t o n o m ist’s p o in t o f vie w wh e n p a t ie n t s a sk fo r h elp.
co n flicts with th e cu ltu ra l sta n d a rd s o f a co m -m u n ity).
Ou r p o sit io n is c o n t ra r y t o t h a t o f m o st e th icists, wh o co n sid e r a u to n o m y a righ t to b e gra n t e d t o t h o se m a t u re e n o u gh t o e xe rc ise self-d eterm in a tio n . However, in o u r o p in io n , it is p recisely wh en we ju d ge su ch ‘m a tu rity’ th a t we vio la te th e p rin cip le o f a u to n o m y.
To th e a llega tio n th a t d ru g u se, religio u s fa n a ticism , o r a b ra in tu m o r a re o b sta cle s to a u -t o n o m y -t o s-t a r -t wi-t h , we re p ly -t h a -t we a re a ll certa in ly su b ject to a wid e va riety of con d ition -in g factors for ou r own resp ective con d u cts a n d t h u s fo r o u r re sp e c t ive re a lit ie s (t h a t is wh a t co u n ts, th a t a u to n o m y m u st a t lea st b e u n d er-stood ).
We in sist o n ch a ra ct e r izin g o u r co n ce p t o f a u t o n o m y. Au t o n o m y is n o t a ssign e d t o a n y-o n e : i.e., we a d m it th a t e ve r y p e rsy-o n h a s h is y-o r h e r own . Co n d itio n in g o f p e rso n a lity ce rta in ly exists in everyon e, an d relates to cu ltu ral, p h ys-ica l, p sych o lo gys-ica l, gen etic, a n d n o so lo gic fa c-t o rs. Bu c-t wic-t h in c-t h is vie w o f e a ch p e rso n ‘fro m t h e in sid e o u t’ (i.e., n o t a ju d gm e n t b y t h ird p a r t ie s), e a c h in d ivid u a l m a y c o n sid e r h im / h erself sovereign wh en exercisin g som e kin d of self-d eterm in a tio n .
As we h a ve a lrea d y sa id , th e a b ove id eologi-ca l p osition d oes n ot m ea n th a t ou r con d u ct a s h ea lth p rofession a ls sh ou ld n ecessa rily ch a n ge wit h re ga rd t o sp e c ific c o n d it io n s wh ic h we will d escrib e b elow u sin g som e of th e followin g e xa m p le s: c h ild re n’s a u t o n o m y; a u t o n o m y in m e n t a l h e a lt h ; a u t o n o m y a n d b lo o d t ra n sfu -sio n s; a u t o n o m y a n d va ccin a t io n ca m p a ign s; a u to n o m y a n d su b sta n ce a b u se legisla tio n (in -cr im in a t io n o f su b st a n ce a b u se rs); a u t o n o m y a n d steriliza tio n o r tra n ssexu a l su rgery; a u to n -om y an d d rivin g u n d er th e in flu en ce of alcoh ol. A p a t e r n a list ic a p p ro a c h is u su a lly t a ke n wit h re ga rd t o c h ild re n’s a u t o n o m y. Th e re is t h u s a c o n sc io u s vio la t io n o f t h e ir a u t o n o m y wh ich is so cia lly a ssu m ed a n d a ccep ted .
We sa y ch ild re n a n d n o t m in o rs so t h a t n o le ga l a ge lim it is c o n st r u e d in t h is sit u a t io n . Th e c h ild is o n ly t a ke n in t o c o n sid e ra t io n a s so m e o n e wh o, u n d e r c e r t a in c irc u m st a n c e s, n e e d s p ro t e ct io n . Th is is a so cia l a t t it u d e a lso fo u n d a m o n g o th e r sp e cie s, wh e re it is re ga rd e d a s in st in c t ive. Th e m o t h e r ‘p ro t e c t s’, c o n -d u cts, a n -d co n sta n tly vio la tes th e a u to n o m y o f h er offsp rin g: th ey wou ld d ie oth erwise. Un fotu n a tely, m istrea tm en t of ch ild ren by th eir p a ren ts or gu a rd ia n s is oftren d isgu ised by fa lse p a tern a lism . Th e sa m e o ften o ccu rs with ch ild la -b o r (e ve n in so m e ille ga l a n d c r im in a l a c t ivi-t ie s). Op p re ssio n in sid e ivi-t h e fa m ily, e sp e cia lly p syc h o lo gic a l, is m o re n o t ic e a b le in c e r t a in
cu ltu re s a n d co n so lid a te s th e a b o m in a b le vio -la t io n o f a u t o n o m y, e sp e cia lly if it is im p o se d with ‘sweet ta lk’ (b ra in wa sh in g). A go o d exa m -p le, in t h is ca se, is t h e re ligio u s in st r u ct io n o f ch ild ren . We co n ten d th a t even th e o ld a n d ‘a f-fe ct io n a t e’ p h ra se, “Drin k you r m ilk , ch ild , it’s
good for you,” sa ys m u ch m ore a b ou t th e m oth -e r’s p u r su it o f sa t isfa c t io n (sin c -e t h is r-e li-e v-e s h e r wo rr y a b o u t t h e b a b y’s n u t rit io n ) t h a n h e r co m p lia n ce with th e b a by’s n eed s a t th a t given m om en t.
Et h ic s vis-à-vis p syc h ia t r ic p a t ie n t s d e se r ve s a sp e c ia l a p p ro a c h a n d e m p h a sis re ga rd in g th e tra d itio n a l (a n d b la m e wo rth y) p o -sit io n t a ke n b y h e a lt h p ro fe ssio n a ls a s fa r a s th ese ‘sick p erson s’ a re con cern ed . Let u s reca ll th a t th e co n cep t o f d isea se o r illn ess is a sta tis-t ic a l c o n c e p tis-t . ‘Sic k’ p e r so n s a re o n e s wh o se ch a ra ct e r ist ics (p h ysica l, fu n ct io n a l, p sych o -lo gic a l, a ffe c t ive, so c io c u lt u ra l, e t c.) e xc lu d e t h e m fro m t h e st a t ist ic a l c u r ve s o f n o r m a lc y (Segre & Ferra z, 1997).
Fo r exa m p le, th e fa ct th a t a d isea se lea d s to d e a t h sh o u ld n o t b e u se d t o d e fin e it , b e ca u se e ve r y livin g b e in g w a s b o r n o n e d a y a n d w ill d ie so m e o th e r. Th e sa m e re a so n in g a p p lie s to th e fa ct th a t d ise a se p ro d u ce s p a in , im m o b ility, o r a n y o th er m o rp h o lo gica l, p h ysica l, o r so -cia l ch a n ge, b eca u se o n e ca n feel p a in with o u t b e in g d e fin e d a s sick o r d isp la y b e h a vio r t h a t is a b s o lu t e ly in c o m p a t ib le w it h t h e c u lt u r a l e n viro n m e n t in wh ich o n e live s with o u t b e in g s ic k. Th e o n ly c o m m o n t r a it in a ll t h e s e ‘d is -e a s-e s’ is d -e via tio n fro m n o rm a lcy (a sta tistica l criterio n ).
In p sych ia tr y it b e co m e s still m o re d ifficu lt t o d e fin e d ise a se s (a lt h o u gh st a t ist ica l crit e ria a re a ccep ted to d em a rca te th em ). Va ria tio n s in th e p sych ologica l sp h ere a re essen tia lly su b jec-tive. An y in ter ven tio n in su ch va ria tio n s th a t is co n tra ry to th e in d ivid u a l’s will is a vio la tio n o f a u to n o m y. If we in vo ke th e well-kn own d efin tion of h ea lth u sed by th e World Hea lth Orga n iza t io n – p h ysica l, m e n t a l, a n d so cia l we ll b e -in g – we n ot on ly corrob ora te a ll th e a b ove, b u t a re a lso rem in d ed o f th e co n fin em en t o f p o liti-ca l d issid e n t s t o p sych ia t r ic h o sp it a ls in t h e ir resp ective co u n tries.
t h o se ‘d iffe re n t’ p e o p le p la c e t h e p h ysic a l o r m o ra l in tegrity o f th e o th er m em b ers o f a so ci-e ty a t risk. Wci-e th in k th a t it is ci-e xtrci-e m ci-e ly im p o r-t a n r-t wh e n we in r-t e r ve n e wir-t h p syc h o p a r-t h s (p re fe ra b ly in a m in im u m o f sit u a t io n s) – n o t to su ga rco a t th e b itte r p ill o f th e ra p e u tics, b u t t o cle a rly a ssu m e t h e p sych ia t r ist’s ro le o f ‘so -cia l d efen d er’.
We co n ten d th a t in b lo o d tra n sfu sio n s, ju st like in a n y oth er trea tm en t, th e p a tien t’s refu sa l m u st b e a ccep ted if h e h a s d isp la yed in fo rm ed kn owle d ge o f t h e r isks h e r u n s if t h e t ra n sfu -sio n is n o t p erfo rm ed .
Re t u r n in g t o p re vio u s e xa m p le s, t h e re a re c o m m e n t s o n a u t o n o m y wit h re ga rd t o e u th a n a sia , o rga n d o n a tio n , th e Bra zilia n legisla tio n o n su b sta n ce a b u se (with rega rd to th e in -c r im in a t io n o f su b st a n -c e u se r s), st e r iliza t io n o r se x- ch a n ge su rge r y, a n d u se o f sa fe t y b e lt s in m o to r veh icles. On th e o th er h a n d , th ere a re p e r t in e n t co n sid e ra t io n s re la t e d t o a u t o n o m y in va ccin a tio n ca m p a ign s a n d d rivin g a m o to r veh icle u n d er th e in flu en ce o f a lco h o l.
Th e se a re ju st a fe w e xa m p le s o f sit u a t io n s t h a t c a n b e c la ssifie d in t wo gro u p s: t h o se in wh ic h vio la t io n o f a u t o n o m y d o e s n o t p la c e o th e r p e o p le a t risk (e u th a n a sia , vo lu n ta r y o r-ga n d on a tion , p erson a l u se of d ru gs, a n d steril-iza t io n o r t ra n sse xu a l su rge r y a t t h e p a t ie n t’s req u est) a n d o th ers in wh ich th e n o n -vio la tio n o f a u t o n o m y (o r fa ilu re t o re st r ic t so m e o n e’s in d ivid u a l fre e d o m ) im p lie s re a l r isk t o t h e c o m m u n it y (e.g., re fu sa l t o a c c e p t a va c c in e d u rin g a n ep id em ic, o r d ru n ken d rivin g)
We d o n o t in t e n d t o d isc u ss e a c h o f t h e se e ve n ts n ow (a lth o u gh we will b e d o in g so la te r fo r t ra n sse xu a l su rge r y), b e ca u se ju st like e u -t h a n a sia (a ssis-t e d su icid e ) o r o rga n d o n a -t io n , e a ch o f t h e m in it se lf wo u ld su ffice fo r a n e n -tire p a p er. Th e p u rp o se o f th is a rticle is lim ited t o t h e t h e o re t ica l ch a ra ct e riza t io n o f t h e p rin -cip le o f a u to n o m y.
It st a n d s t o re a so n , h owe ve r, t h a t t h e re a re (a n d a lwa ys will b e ) situ a tio n s in wh ich p u b lic we b e in g m a y ove r la p wit h in d ivid u a l we llb ein g. Vio la tio n o f a u to n o m y is a d m issillb le u n -d e r t h e se circu m st a n ce s. Allow m e t o e xp la in b etter. If we see n o rea son to op p ose su rgery to d e ve lo p a n eovagin ain a m a le t ra n sse xu a l a t h is own req u est (i.e., in a p erson h avin g th e sou l o f o n e sex a n d th e b o d y o f th e o th er, a cco rd in g to Prof. An tôn io Ch a ves, Dea n of th e Un iversity o f Sã o Pa u lo La w Sc h o o l) o r t o p re ve n t a wo m a n wh o d o e s n o t wa n t t o h a ve c h ild re n from h a vin g a tu b a l liga tion , or if we con sid er it a re a l o u t ra ge a ga in st h u m a n fre e d o m t o p u n -ish so m e o n e fo r ‘sn o r t in g c o ke’ o r ‘sm o kin g p o t’, we reco gn ize a s fa ir th a t p eo p le sh o u ld b e
c o m p e lle d t o t a ke va c c in e s a ga in st p o lio, fo r exa m p le, d u rin g a n ep id em ic o f su ch a d isea se o r t h a t t h e y sh o u ld b e fo rb id d e n fro m d r ivin g u n d e r t h e in flu e n ce o f a lco h o l. Th e co lle ct ive we ll- b e in g ju st ifie s, vio la t io n o f a u t o n o m y in th ese ca ses. Th e sa m e wa s n o t tru e fo r th e o th -er situ a tio n s to wh ich we ref-erred .
Also, fu r t h e r cla r ifyin g t h e b io e t h ica l co n -ce p t, we h a ve a d o p te d a s o u r stra te gy fo r e th i-c a l re fle i-c t io n t h e fo llowin g p a ssa ge fro m t h e c h a p t e r o n t h e Defin ition of Bioeth ics an d its Relation to Eth ics, Deon tology an d Diceology
(Segre, 1995:28-29):
“As w e h ave already m en tion ed, ou r con cept
of bioeth ics h ad tw o p rim ary objectives. Th e first w as an attem p t to d efin e th e scop e of th is stu dy by ou tlin in g th e m ajor issu es. Th e secon d w as to create a m eth od com p risin g th e p sych o-an alytic experien ce for assessin g all su ch issu es. We agree w ith Beau ch am p s & Ch ild ress (1989) regardin g th eir criteria for acceptan ce of a th eo-retical con stru ction in eth ics. Th ey do n ot reject an y of th e great lin es of eth ical th in k in g over tim e, from w h ich th ey derive w h at th ey con sider p ositive asp ects rath er th an in valid atin g th em becau se of op in ion s w ith w h ich th ey d isagree. How ever, th ey d em an d th at all su ch lin es of th ou gh t com p ly w ith certain p rerequ isites, n am ely: 1) clarity; 2) coh eren ce; 3) scop e; sim -p licity; 5) ex -p lan atory -p ow er; 6) -p ow er to for-m u late ju stification s; 7) in n ovative p ow er; an d 8) practicability.
Based on th ese assu m ption s, th e au th ors an alyzed u tilitarian ism (Ben th am an d Mill), Kan -tism , th e eth ics of virtu es, liberal in dividu alism , com m u n itarian ism , an d eth ics, based on ‘p rin -cip les of com m on m orality’, ‘eth ics w h ich tak es in to accou n t th e em otion al in volvem en t’(eth ics of care, w h ich com es closer to p sych oan alytical eth ics, bu t w h ich does n ot reject th e p rem ises of com m u n itarian ism an d liberalism ), an d fin ally attem p ted to reach a con vergen ce of all th ese th eories.
Regard in g th e eth ics of care, in itially p ro-p osed by ro-p sych ologist Carol Gilligan an d ph ilosoph er An n ette Bau er, w e sh ou ld poin t ou t th at it is th eoretically opposed to su ch position s as th ose of Plato an d Kan t, w h o refer to in clin a-tion s, em oa-tion s, feelin gs, an d passion s as obsta-cles to ‘m oral ju d gm en t’; th ey con ten d th at ac-tion s based on feelin gs su ch as love, solid arity, an d p assion m ay be ‘good ’, bu t n ot ‘m orally good’, becau se th ey lack a cogn itive stru ctu re.
Gilligan in sists th at w e sh ou ld listen to th e voice of care (th e voice of th e ‘h ea rt’), m ore su it-in g to w om en , an d n ot on ly th e “voice of righ ts”, th e ‘vo ice o f d u t ie s’, an d th e ‘vo ice o f ju st ice’.
r igh t s b y u sin g a q u a si- le ga l t e r m in o lo gy a n d im p a rtia l p rin cip le s fo llowe d b y d isp a ssio n a te re fle ct io n , wh e re a s wo m e n t e n d t o t h e ‘e t h ics o f c a re’, b a se d o n re sp o n sib ilit y a n d a n in t e gra t e d n e t wo rk o f n e c e ssit ie s, c a re, a n d p re -ven tio n o f d a n gers.’
Th erefore, it is clear to u s an d th em th at bioeth ics is n ot m erely on e m ore lin e of eth ical th ou gh t, bu t an area of stu d y for w h ich w e are p rop osin g a m eth od ology (w h ich is close to th e eth ics of care: see A Ca re - Ba se d Ap p ro a c h t o Et h ics, by Alisa Casse, Ph D) w h ich assim ilates proposals ran gin g from th e ‘eth ics of virtu es’ex-p ou n ded by Pellegrin o to th e absolu tely legalist focu s th at can be u sed to solve m ajor p roblem s of h u m an coexisten ce” (Segre, 1995:28-29).
We a gre e wit h Ka n t (1964) t h a t a ll b e in gs with m in d s ca n b e rega rd ed a s fou n d ers of u n i-ve r sa l la w. Co n sid e r a n e t h ica l m o d e l wit h n o p re d e fin e d p a ra m e t e r s a s we a re p ro p o sin g. Im a gin e t h e a b st ra ct e xa m p le o f t h e first m a n livin g a lo n e o n th e p la n e t a n d gra d u a lly wo rk-in g o u t ru les fo r livrk-in g to geth er with o th er m en h e wo u ld m e e t . Th e y wo u ld u se t h e ‘p syc h e’, co n t in u o u sly fe d b y in d ivid u a l a n d co lle ct ive e xp e r ie n ce. We wo u ld a d m it t h a t t h is Ka n t ia n m a n a lso h a s wh a t we c a ll e m o t io n s (o r fe e l-in gs), l-in a d d it io n t o h is ra t io n a lit y (wh o se d iffe re n ce wit h re ga rd t o iffe e lin gs is, in o u r o p in io n , ju st it s gre a t e r u n ifo r m it y in va r io u s h u -m a n co -m -m u n it ie s, b e ca u se t h e a cq u ire d cu l-t u ra l c o m p o n e n l-t b e a r s m o re in flu e n c e o n il-t ) a n d t h e se a r t ificia lly co n ce ive d se gm e n t s in a p e r so n a l in t e ra c t io n b e t we e n t h e m in e ve r y th ou gh t a n d a ct.
Th e re is n o t h o u gh t d isc o n n e c t e d fro m e m o t io n s, co n t ra r y t o t h o se wh o co n t e n d t h a t ra tio n a lity a lwa ys p reva ils. An excessive a p p ea l t o re a so n a im s t o c o n c e a l fe e lin gs re ga rd in g ou rselves (as p sych oan alytical th eory an d p ra c-t ic e give a m p le p ro o f ). An d re a so n , wh ic h is m u ch m o re rela ted to o n e’s so cio cu ltu ra l en viro n m e n t (co n t ra r y t o e m o t io n s, wh ich a re b a -sica lly in t e r n a lize d ), is se e n a s ‘co m m o n t o a ll m e n’ (c o n sid e r in g a m a n d e vo id o f re a so n a s in sa n e) a n d is given a m a ss co n n o ta tio n wh ich satisfies th e in clin ation s to p ositivism th at p eo -p le h a ve to a grea ter o r lesser exten t.
Acco rd in g t o t h e p o in t o f vie w (a n d e t h ics) o f fu ll so cia l a n d in d ivid u a l re la t ivism (m e a n -in g t h e ‘ra d ica l’ t h e o re t ica l a cce p t a n ce o f t h e p r in c ip le o f a u t o n o m y) we c o n sid e r a c h o ic e m o re a u t o n o m o u s wh e n it is m a d e wit h t h e grea test p o ssib le kn owled ge o f o n e’s own em o -tio n s. Here we refer to th e co n cep t o f eth ics es-p o u se d b y Co h e n &ames-p; Se gre (1995), t h a t ‘e t h ica l-n ess’ is th e cap acity to p erceive ol-n e’s owl-n em o-tio n s by m a n a gin g co n flicts gen era ted by th em
th ro u gh a h ie ra rch ica l a rra n ge m e n t o f th e va l-u es th a t o rigin a te sl-u ch em o tio n s. Fo r exa m p le, if we d ecid e in fa vor of (or a ga in st) th e lega liza -t io n o f a b o r -t io n , we fa c e c o n flic -t in g fe e lin gs, on e of th em in h eren t in th e d estru ction of a life a n d a n o t h e r re la t e d t o c o m p lia n c e wit h t h e m o t h e r’s a u t o n o m y, wh ic h u n d e r c e r t a in c ir -c u m st a n -c e s (-c o n t ra r y t o m o ra l p re a -c h in g) is th e ‘n a tu ra l e n e m y’ o f th e fe tu s. Re ga rd in g th e a b ortion issu e, th ere a re oth er fa ctors to b e ta k-en in to a cco u n t (fo r exa m p le, d a m a ges ca u sed b y p e rfo rm in g a n ille ga l a b o rtio n ), b u t o u r b a -sic e t h ic a l p o sit io n re su lt s fro m c o n fro n t in g th e va lu e we a ssign to th e em b ryo’s life a n d th e m o th er’s a u to n o m y.
Ta kin g a n o t h e r e xa m p le, n o t e h ow p e o p le b e h a ve re ga rd in g t h e d ile m m a cre a t e d b y t h e re q u e st fo r se x-ch a n ge su rge r y. Fo r e m o t io n a l re a so n s, m a n y p e o p le p o in t t o t h e im m o ra lit y o f t h e se in t e r ve n t io n s, c o n t e n d in g t h a t t h e y a re t h e d e sire o f a p e r so n wit h a m a le p h e n o -typ e (wh o cla im s to con sid er h im self a wom a n ) req u estin g th e a m p u ta tion of h is extern a l gen i-t a lia a n d i-t h e p ro d u ci-t io n o f a n eovagin a. Th e y cla im th a t th is is a p a th o lo gica l a sp ira tio n a n d e xp lic it ly re je c t a n y su rgic a l in t e r ve n t io n o n th e gro u n d s th a t it go es a ga in st n a tu re. Th e a t-t it-t u d e is ro o t-t e d in fe e lin gs, b e ca u se d o ze n s o f e q u a lly ‘u n n a t u ra l’ m e d ic a l p ra c t ic e s a re a c -ce p t e d wh ich a re ge a re d t o im p rovin g q u a lit y o f life fo r h u m a n s (p la st ic su rge r y, fo r e xa m -p le ). Th e re is n o re a so n t o d e n y t h e r igh t t o a b e t t e r life fo r t h o se wh o “h ave th e sou l of on e
sex an d th e body of an oth er”, in th e word s of ju -rist An tô n io Ch a ves (o ra l co m m u n ica tio n ).
If th e assu m p tion of eth ical, social, an d in d i-vid u a l rela tivism is a ccep ted (i.e., th a t th e o n ly e t h ic a l p r in c ip le is t h a t e t h ic s h a s n o p r in c i-p le), a n d if we a lso a ckn owled ge th e im i-p o rta n t ro le p la ye d b y e m o t io n s in t h e gro u n d wo rk o f a n eth ica l sta n ce (in th e d evelop m en t of a con -cep t of eth n icaln ess as a ‘con d ition for valu e h i-erarch y arran gem en ts’), we m u st agree th at ou r p ro p o sa l a b o u t th e co n cep t o f eth ics h a s th eo re t ica l gro u n d s, co n t ra r y t o Ka n t , wh o co n sid -ered ‘p assion s’ th e an tith esis of eth ical th ou gh t.
After a ll, n ot a ll h u m a n feelin gs a re d estru c-t ive c-t o so cia l co e xisc-t e n ce : love, so lid a r ic-t y, a n d resp ect fo r a u to n o m y co exist with h a tred , fea r, a n d en vy.
Re n own e d e t h icist En ge lh a rd t Jr. (1996:32-101) h a s t h e sa m e o p in io n a s o u r s wh e n h e re fe r s t o t h e re a so n s fo r t h e fa ilu re o f a ll a t t e m p t s t o ju st ify p r in cip le s: t h e a b so lu t e re la -tivity of good a n d evil, b oth from th e socia l a n d in d ivid u a l p o in ts o f view.
-t u re’, o r ra -t io n a li-t y le a d s -t o ‘b lin d a lle ys’ a n d ca n n o t wit h st a n d a skillfu l crit ica l a n a lysis. As h e p o in t s o u t , “In th e m agm a of p assion an d com p assion , eth ical th ou gh t in trod u ces its or-d er, bu t th e p rin cip les u p on w h ich th is oror-d er sh ou ld be based d o n ot d ep en d on reason , bu t on each person’s ch aracteristics. Facin g som eon e w h o p ores over sacred scrip tu res or bu ck les u n -d er au th oritarian ism , a free sou l w ill say th at th ere is on ly on e con dition th at m oves h im : h u -m an -m isery, expelled fro-m th e w orldly paradise th rou gh sh eer ven gean ce” (Sca rp e lli, 1991: 25) Here we fin d a ‘co n n ectio n’ with religio n m a d e b y t h e re n own e d It a lia n p h ilo so p h e r wh e n h e wr it e s a b o u t t h e Bib lic a l e xp u lsio n o f m a n fro m th e ‘wo rld ly p a ra d ise’.
Th e sa m e a u th o r p ro ceed s, “Sym path y gen
-erates resp ect an d toleran ce. Resp ect an d toler-an ce lead to au ton om y as th e cap acity to create ru les for on eself. Th e p rin cip le of au ton om y is th e k ey to u n lock bioeth ics an d is d ecisive for m an y issu es: eu th an asia, assisted fertiliz ation for a cou p le, organ d on ation , etc” (Sc a r p e lli, 1991:25).
Re t u r n in g t o t h e co n ce p t u a l d e ve lo p m e n t of eth ics, we va lu e th e sta tem en t by Hob b es a s-cr ib in g gre a t e r m o ra l we igh t t o “a p erson w h o k n ow s h e is h u n gry bu t h as th e ability to th in k w h eth er h e is goin g to eat or n ot” (Coh en & Ma r-colin o, 1995:54).
Th e criticism of th e u tilita ria n p h ilosop h ers (Be n t h a m , Mill, a n d Sid gwick), i.e., t h a t u t ili-t a r ia n ism is im m o ra l b e ca u se o f iili-t s h e d o n ism (o r q u e st fo r p le a su re ), is ch a lle n ge d b y o n e o f t h e t h re e h im se lf (Sid gwic k) wh e n h e st a t e s t h a t in d ivid u a l p le a su re is fe lt n o t o n ly b y t h e in d ivid u a l h im self, th u s a d m ittin g th a t th ere is p le a su re in givin g p le a su re t o so m e o n e e lse. Th is co n t e n t io n is b r illia n t ly co r ro b o ra t e d b y Fre u d wh o, in a n a lyzin g p e r so n a lit y d e ve lo p -m e n t (fro -m b ir t h t o a d u lt h o o d ) p rove s h ow m a n is p ro gressively so cia lized b y lea rn in g th e b e n e fit s o f a ffe c t ive in t e r re la t io n s. Ba se d o n Fre u d ’s st u d ie s, o n e c a n sa y t h a t t h e re is a n ‘e t h ic s o f b e in g’ a n d n o t ju st t h e ‘m o ra ls o f wh a t m u st b e’.
We a ls o b e lie ve t h a t t h e ‘p r in c ip le s’ a l-r e a d y t l-r a d it io n a lly l-re fe l-r l-re d t o a s ‘p l-r in c ip le s o f b io e t h ic s’, t h a t is, a u t o n o m y, b e n e fic e n c e, n o n - m a le fice n ce, a n d ju st ice, ca n a ct u a lly b e su m m ed u p in a u ton om y a n d h eteron om y (th e la tter n ot in th e Ka n tia n sen se of sovereign ty of ‘p a ssio n s’). As a m a tte r o f fa ct, th e y a re n o t re -a lly p r in c ip le s, b u t o n ly t wo fo r m s o f h u m -a n re la t io n sh ip s, in wh ic h t h e re will a lwa ys b e a grea ter or lesser d egree of in d ivid u a lity (a u ton -o m y) -o r c -o n st ra in t b y t h ird p a r t ie s a s t -o t h e wa y ea ch p erson th in ks a n d a cts (h eteron om y).
We re it e ra t e t h e t o t a l re la t ivism o f e t h ic a l t h o u gh t : la ws, m o ra l co d e s, a n d re ligio n s p la y th e req u ired ro le in regu la tin g so cia l co n vivia l-ity. However, it is in d isp en sa b le for th e p u rp ose s o f rose flose c t io n t h a t t h ose p ra gm a t ic c o n n o t a -tio n s o f a ll th e se in stru m e n ts b e ve r y cle a r. Fi-n a lly, it is im p o ssib le t o d e Fi-n y t h a t t h e re is a Fi-n e d u c a t io n a l m e a n in g in re gu la t io n s (le gisla tio n , m o ra ls, a n d religio n ), in tro jectin g th e n o -tio n o f ‘p ro h ib i-tio n’, wh ich en d u p s rein fo rcin g t h e su p e r-e go, t o wh ich Fre u d ia n t h e o r y it se lf assign s a relevan t role in th e ‘ego stru ctu re’.
By wa y of con clu sion , th e n otion of a u ton om y ca n o n ly b e u n d e rst o o d b a se d o n t h e co n c re t e m o d a lit ie s o f c o n st r u c t in g h u m a n su b -jectivity in its exp erien tia l in d ivid u a lity.
If a ll p e rce p t io n in vo lve s e a ch in d ivid u a l’s s u b je c t ivit y, i.e ., if t h e ‘re a l’ p h e n o m e n o n is d e scrib e d a s it is se e n a n d fe lt b y e a ch re sp e ctive ep istem ic su b ject, wh o is a lso a n em o tio n -a l su b ject, th en kn owled ge is -a lw-a ys em b o d ied in c o n c re t e su b je c t s a n d m a y p o t e n t ia lly b e sh a re d . Th u s, wh a t is ‘re a l’, wh ic h is a lwa ys a c o n st r u c t io n b y h u m a n (s), b e c o m e s a ‘c o m m o n (o r sh a red ) tra it’ a cco rd in g to th e p ercep -t io n o f m a n y in d ivid u a ls a n d -t h u s a c u l-t u ra l p h e n o m e n o n su sce p t ib le t o scie n t ific in ve st i-ga t io n . Pu t sim p ly, if o n e s ju m p s fro m a give n h e igh t a n d se e s a n d fe e ls t h a t o n e is fa llin g, a n d oth er p eop le witn essin g th e even t d escrib e it a s th e sa m e p h en om en on , for ea ch a n d every o n e o f t h e m t h e e ve n t / p h e n o m e n o n b e co m e s rea l. Un d er su ch circu m sta n ces, we will h a ve to in vestiga te th e ca u se o f fa lls, th ereb y d ed u cin g th e la ws o f gra vity.
If we a d m it th a t, th a n ks to ra tio n a l co m p e -ten ce, h u m a n th o u gh t ca n b e a u to n o m o u s (a lth o u gh n o t fu lly so, sin ce it is p resu m a b ly co n d it io n e d b y ge n e t ic in h e r it a n c e, c u lt u ra l fa c -t o rs, e d u ca -t io n , la n gu a ge, e -t c.), a n d -t h a -t b o -t h o u r th in kin g a n d feelin g a re th e o n ly th in gs ex-c lu sive t o e a ex-c h o n e o f u s, we re a lize t h a t t h e id e a o f a u to n o m y is a t th e ro o t o f lib e rty itse lf, a n id e a a n d a va lu e th a t b e lo n g to o u r m o d e rn a n d ‘in d ivid u a list’ cu lt u re. Th u s, t h e p ro b le m (b o t h e t h ica l a n d p o lit ica l) is h ow t o in t e gra t e ou rselves a s ‘we’ (wh ich d efin es th e self-u n d er-st a n d in g t h a t we h a ve o f a cu lt u ra l a n d so cia l co m m u n ity) with su p p o sed ly a lien d ifferen ces a s a wa y of p reservin g th e sp irit of tolera n ce for a n d e q u a l c o n sid e ra t io n o f d iffe re n t va lu e s, wh ic h a re a lso p a r t o f t h e c u lt u ra l le ga c y o f m o d ern ity.
labelt h o se wh o sh ow t h e y h a ve e xt ra p o la t e d th e criteria fo r n o rm a lcy. Alth o u gh o n e ca n n o t fa il to co n ced e th e p ra ctica l im p o rta n ce o f tra -d itio n s, re ligio n s, a n -d la ws fo r th e co e xiste n ce o f in d ivid u a ls, t h e y a ll, in p r in cip le, in d o ct r i-n a t e a i-n d i-n o r m a lize , w it h t h e ir c o i-n c e p t s o f ‘s in’, ‘m is d e m e a n o r’, a n d ‘a b n o r m a lit y’, a n d a re t h u s o p p o s e d t o ‘fre e w ill’, s e e n fu lly a s ‘le ga c y’ a n d wh ic h is a lso p a r t o f We st e r n (o r m od ern ) cu ltu ra l a n d p olitica l tra d ition (Bra sil, 1989a ).
Au to n o m y a s a n id ea l o n ly p a rtia lly p erm e-a t e s Bre-a zilie-a n le gisle-a t io n . It is e st e-a b lish e d in p rin cip le b y th e Fe d e ra l Co n stitu tio n , Article 5 (Bra sil, 1989a ), in keep in g with th e la ws o f o th -e r co u n tri-e s a n d b a s-e d in sp irit o n th -e Un iv-e rsa l De cla ra t io n o f t h e Righ t s o f Ma n (De ce m -b er 10, 1948), Articles I, II, a n d III (ONU, 1993), fro m wh ic h d e r ive su c h le ga l in st r u m e n t s a s t h e Bra zilia n St a t u t e fo r Ch ild re n a n d Ad o le s-cen ts (MS, 1991) (Article 7), Pen a l Co d e (Bra sil, 1989b ), Co d e o f Me d ic a l Et h ic s (Co u t in h o, 1989), Legisla tion on Orga n Tra n sp la n ts (Bra sil, 1997), a n d va r io u s r u lin gs b y t h e Bra zilia n Fe -d era l Bo a r-d o f Me-d icin e (CFM, 1992, 1994) a n -d th e Na tio n a l He a lth Co u n cil (CNS, 1997; Re so -lu çã o 196/ 96). A clo se e xa m in a tio n o f th is le g-isla tio n sh ows th a t its sco p e is restricted , if n o t clea rly in th e wo rd in g itself, certa in ly in its en -fo rce m e n t . Th e Co n st it u t io n gu a ra n t e e s e ve r y Bra zilia n cit ize n t h e r igh t t o life, b u t d o e s n o t m a ke e xp licit wh e t h e r life is a lso a d u t y. Th e re a re t h u s d ive rge n t in t e rp re t a t io n s co n ce r n in g th e m ora l va lid ity of ‘d esistin g from life a t on e’s own will’. Th e p re va ilin g vie w is t h a t life is a n in a lie n a b le go o d . Th u s, b a se d o n t h is re a d in g o f t h e Fe d e ra l Co n st it u t io n , Ar t icle 122 o f t h e Bra zilia n Pe n a l Co d e (Bra sil, 1989b :93) e st a b -lish e s sa n ct io n s a ga in st t h o se wh o “in d u ce or in stigate som eon e to com m it su icid e or assist h im in so d oin g.” No t e t h a t t h e co n ce p t o f life a s a n in a lie n a b le go o d h a s re su lt e d fro m t h e p ra gm a tism of sta tes th rou gh ou t h istory, in n ot a llowin g t h e ir su b je c t s t o d e p r ive t h e m o f a wo rk fo rce o r p o t e n t ia l gro u p d e fe n se. Th e issu e is t h e so ca lle d ‘co lle ct ive go o d ’, e xt ra p o -la t in g in d ivid u a l a u t o n o m y, a n e ve n t t h a t is su b lim a t e d b y m o st re ligio n s, wh ich co n sid e r su icid e a sin . Life b ecom es n ot on ly a righ t, b u t a n o b liga tio n .
Th is a p p ro a c h is p re se n t n o t o n ly in t h e legisla tion , b u t a lso in n u m erou s b ioeth ica l p o-sition s in wh ich th e p rin cip le of b en eficen ce or n o n -m a le fice n ce p re va ils ove r th e a u to n o m ist tren d .
Th e c o d e s o f e t h ic s o f h e a lt h p ro fe ssio n s, wh ile em p h a sizin g th e p a tien t’s righ t to a ccep t o r re fu se t re a t m e n t , e m p h a size sit u a t io n s o f
im m in en t risk to life, wh ich a llow p rofession a ls (in th e n a m e of th e p rin cip le of b en eficen ce) to in te r ve n e th e ra p e u tica lly, e ve n a ga in st th e p a -t ie n -t’s will. He a l-t h le gisla -t io n is n o d iffe re n -t with rega rd to in d ivid u a ls d isp la yin g a b n o rm a l b e h a vio r, m e d ic a lizin g t h e a p p ro a c h t o t h e m a n d in t e r ve n in g in t h e ir a u t o n o m y t h ro u gh co m p u lso r y in t e rn m e n t in p sych ia t ric in st it u -t io n s. On c e a ga in , -t h e n o -t io n o f a u -t o n o m y is se e n a s so m e t h in g t o b e gra n t e d t o t h o se sit u -a t e d wit h in t h e r-a n ge o f t h e st -a t ist ic -a l c u r ve t h a t is a rb it ra r ily d e fin e d a s ‘n o r m a l’ (t e n d in g t o r u le o u t in d ivid u a lit y), a n d n o t a s a c o n d i-tio n in h eren t to a ll livin g b ein gs.
Th e le gisla t io n p e r t a in in g t o ch ild re n a n d m in o rs d o es n o t ta ke a n a u to n o m ist a p p ro a ch . It re fle c t s a t re n d t h a t is p re se n t in b o t h h u -m a n s (a n d t o a n e ve n gre a t e r d e gre e in o t h e r a n im a l sp ecies) to p rotect th e offsp rin g a n d th e h e lp le ss in ge n e ra l (i.e., p a t e r n a lism ). Ot h e r p ieces of legisla tion th a t a re n ot a u ton om ist in -c lu d e Ar t i-c le 124 o f t h e Bra zilia n Pe n a l Co d e (Bra sil, 1989b :93), wh ic h p e n a lize s a m o t h e r wh o “p erform s an abortion on h erself” a n d th e p re va ilin g Su bstan ce Abu se Act (6368/ 76), p e -n a lizi-n g su b st a -n ce a b u se rs (Se gre & Ca r va lh o, 1978:97).
Ma n y ju rists give a n on -a u ton om ist rea d in g t o Ar t ic le 129 o f t h e Bra zilia n Pe n a l Co d e (Bra sil, 1989b ), wh ich cla ssifies a ll form s of su rgica l st e r iliza t io n b y p h ysicia n s a s se r io u s le sio n s. Se rio u s le sio n s (o r gra ve le sio n s a cco rd -in g t o t h e su b - c la ssific a t io n d ra ft e d b y ju r ist Ne lso n Hu n gr ia ) in c lu d e lo ss o f re p ro d u c t ive fu n ct io n (va se ct o m ie s, i.e., liga t io n o f t h e va s d eferen s in m en , an d tu b al ligation s in wom en ). Th e se ju r ist s d isre ga rd t h e p a t ie n t’s will, i.e., h is/ h e r a u to n o m y to o p t fo r th e lo ss o f a fu n c-tio n th a t h e/ sh e n o lo n ger wish es to reta in .
Th e sam e can b e said of ‘sex-ch an ge’ su rgery in Bra zil, i.e., t h e a t t e m p t t o m o r p h o lo gic a lly a d a p t th e gen ita ls o f in d ivid u a ls fro m o n e b io lo gica l gen d er to th a t wh ich th ey co n sid er rep -resen ta tive o f th eir p erso n a lities. Alth o u gh th e r u lin g wh ic h is a b o u t t o b e a p p rove d b y t h e Fe d e ra l Me d ic a l Bo a rd (CFM ) p ro p o se s t h a t su ch su rgeries b e a llowed exp erim en ta lly, th ere h a ve b e e n n u m e ro u s c a se s b ro u gh t a ga in st Bra zilia n su rge o n s wh o h a ve re m ove d t h e p e -n is a -n d testes o f m a le p a tie-n ts to p ro d u ce n
eo-vagin aso r re m ove d t h e ova rie s o f wo m e n a n d im p la n ted p en ile p ro sth eses.
p reced ed by th e ‘in form ed con sen t’ of th e in d i-vid u a l p a rticip a tin g in th e exp erim en t.
As a n o t h e r e xa m p le, t h e m a n d a t o r y u se o f sea t b elts in m o to r veh icles is a lso n o t a u to n o m ist , sin c e fa ilu re t o u se su c h sa fe t y e q u ip -m e n t e n t a ils a n in c re a se d r isk fo r t h e d r ive r s a n d p a ssen gers th em selves.
Fo rth co m in g is a th o ro u gh a n a lysis b y Segre a n d Sch ra m m of Bra zilia n legisla tion a n d ju risp ru d e n ce p e rt a in in g t o t h e id e a l o f a u t o n o -m y. Th is p a p er is -m erely a n ou tlin e of th e id eo-lo gica l co n ten t o f th is p ro p o sed resea rch .
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