THE USE OF MEDI CI N AL PLAN TS AS A THERAPEUTI CAL RESOURCE: FROM THE
I N FLUEN CES OF THE PROFESSI ON AL FORMATI ON TO THE ETHI CAL AN D LEGAL
I MPLI CATI ONS OF I TS APPLI CABI LI TY AS AN EXTENSI ON OF NURSI NG CARE PRACTI CE
Neide Apar ecida Tit onelli Alv im1 Már cia de Assu n ção Fer r eir a1 I v on e Ev an gelist a Cabr al1 Ant onio José de Alm eida Filho1
Alv im NAT, Fer r eira MA, Cabr al I E, Alm eida Filho AJ. The use of m edicinal plant s as a t her apeut ical r esour ce: fr om t he influences of t he pr ofessional for m at ion t o t he et hical and legal im plicat ions of it s applicabilit y as an ex t ension of nur sing car e pr act ice. Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 316- 23.
This qualit at ive r esear ch aim ed t o analyze t he biom edical influence in t he cont ext of nur ses’ for m at ion and pr ofessional act iv it ies; t o r eflect about et hical and legal im plicat ions of using m edicinal plant s in nur sing car e; t o ar gue about t he need t o configur e and delim it t his r esour ce as a legit im at e inst r um ent for ex panding nur sing car e pr act ice. We used t he cr eat iv e- sensible m et hod and dev eloped dy nam ics w it h a gr oup of nur ses t o pr oduce dat a, analy zed in t he cat egor ies “ t he biom edical influence in t he academ ic- pr ofessional or ient at ion of nur sing” and “ et hical and legal im plicat ions in t he applicabilit y of m edicinal plant s in car e” . Result s indicat ed t he need t o advance in st udies on t he nur sing diagnosis t hat im plies t he pr escr ipt ion of m edicinal plant s, so t hat t he client is w ell t aken car e of by nur ses, t hus legit im izing it as an ext ension of t heir pr ofessional pr act ice. Not as an ex clusiv e t er r it or y , but as shar ed and int er disciplinar y healt h car e act ion.
DESCRI PTORS: nur sing; nur sing car e; plant s, m edicinal
EL USO DE PLANTAS MEDI CI NALES COMO RECURSO TERAPÉUTI CO: DE LAS I NFLUENCI AS
DE LA FORMACI ÓN PROFESI ONAL A LAS I MPLI CACI ONES ÉTI CAS Y LEGALES DE SU
APLI CABI LI DAD COMO EXTENSI ÓN DE LA PRÁCTI CA DE CUI DAR DE LA ENFERMERA
Est a in v est igación cu alit at iv a b u scó an alizar la in f lu en cia biom éd ica en el con t ex t o d e f or m ación y act u ación pr ofesion al de los en fer m er os; r eflej ar sobr e las im plicacion es ét icas y legales del u so de plan t as m edicinales en la enferm ería; discut ir la necesidad de configuración y delim it ación de est e recurso com o inst rum ent o legít im o de ext ensión de la pr áct ica de enfer m er ía. Fue ut ilizado el m ét odo cr eat ivo- sensible y el desar r ollo de din ám icas j u n t o con u n gr u po de en f er m er as par a pr odu cir los dat os de la in v est igación , an alizados en las cat egor ías «la influencia biom édica en la or ient ación académ ico- pr ofesional de enfer m er ía» y «las im plicaciones ét icas y legales en la aplicabilidad de plant as m edicinales en el cuidado». Los result ados señalaran la necesidad de avanzar en los est udios sobr e la diagnosis de enfer m er ía que im plica en pr escr ibir plant as m edicinales par a que el client e sea bien cuidado por la enferm era y, así, se pueda legit im arla com o ext ensión de su práct ica. No com o t er r it or io exclusivo, sino com o la acción com par t ida e int er disciplinar en el cuidado de salud.
DESCRI PTORES: en f er m er ía; at en ción de en f er m er ía; plan t as m edicin ales
O USO DE PLANTAS MEDI CI NAI S COMO RECURSO TERAPÊUTI CO: DAS I NFLUÊNCI AS DA
FORMAÇÃO PROFI SSI ONAL ÀS I MPLI CAÇÕES ÉTI CAS E LEGAI S DE SUA APLI CABI LI DADE
COMO EXTENSÃO DA PRÁTI CA DE CUI DAR REALI ZADA PELA ENFERMEI RA
Pesqu isa qu alit at iv a qu e bu scou an alisar a in flu ên cia biom édica n o con t ex t o de for m ação e at u ação pr ofissional dos enfer m eir os; r eflet ir sobr e as im plicações ét icas e legais do em pr ego de plant as m edicinais no cuidado de enfer m agem ; discut ir a necessidade de configur ação e delim it ação desse r ecur so com o inst r um ent o legít im o de ex t ensão da pr át ica de cuidar r ealizada pela enfer m agem . Ut ilizou- se o m ét odo cr iat iv o- sensív el e o desenvolvim ent o de dinâm icas j unt o a um grupo de enferm eiras para produzir dados, analisados nas cat egorias “ a influência biom édica na or ient ação acadêm ico- pr ofissional da enfer m agem ” e “ im plicações ét icas e legais na aplicabilidade de plant as m edicinais no cuidado” . Os r esult ados apont ar am a necessidade de se av ançar nos est udos sobre o diagnóst ico de enferm agem que im pliquem prescrição de plant as m edicinais para que o client e sej a d ev id am en t e cu id ad o p ela en f er m eir a e, assim , se p ossa leg it im á- la com o ex t en são d e su a p r át ica profissional. Não com o t errit ório exclusivo, m as com o ação com part ilhada e int erdisciplinar no cuidado à saúde.
DESCRI TORES: en f er m agem ; cu idados de en f er m agem ; plan t as m edicin ais
1 PhD in Nursing, Adj unct Professor, Anna Nery School of Nursing, Federal University of Rio de Janeiro, e- m ail: t it onelli@t erra.com .br, m arciam at [email protected] .br, icabral@super ig.com .br, aj afilho@t erra.com .br
I NTRODUCTI ON
D
iscu ssin g t h e u se of m ed icin al p lan t s in n u r sin g car e in v olv es v ar iou s ov er lap p in g asp ect s. Som e of t hese oft en im pede pr ofessional pr act ice and are rest rict ed t o im passes, t hat is, w hen convent ional, t ech n i ci st a n d a l l o p a t h i c p r a ct i ces d o n o t f i n d a n im m ediat e ex it for solv ing cer t ain healt h pr oblem s.I n academ ic t eaching, t he scient ific ideology t hat has im pregnat ed nur sing educat ion since t he bir t h of pr ofessional nur sing in Br azil unt il t oday is based on t h e r at ion alit y of t h e biom edical m odel. An d, in pr of ession al act iv it ies, w h at h appen s is t h at n u r ses t e n d t o r e p r o d u c e t h i s m o d e l u n c r i t i c a l l y, o f t e n i g n o r i n g o t h e r p o ssi b i l i t i e s o f m a n i f e st i n g h e a l t h k n o w l ed g e, su ch a s t h o se r esu l t i n g f r o m p o p u l a r k n ow led g e.
We b e l i e v e t h a t t h e se i ssu e s d i f f i cu l t t h e applicabilit y of nat ural ( or non- convent ional) t her apies b y n u r se s, su ch a s m e d i ci n a l p l a n t s, i m p e d i n g a br oader discu ssion on t h e et h ical an d legal aspect s t hat perm eat e t his applicabilit y. What nor m ally happens ar e p ar al l el o r i so l at ed d i scu ssi o n s t h at at t en d t o p ar t i cu l ar i n t er est s an d , t h er ef or e, ar e n ot st r on g e n o u g h t o b e t r e a t e d a t t h e l e v e l o f t h e La w o f Pr ofession al Ex er cise an d t h e Deon t ological Code of Nur sing, w hich w ould allow t hem t o sust ain changes t h at cou ld g u ar an t ee t h ese t h er ap ies as leg it im at e n u r sin g pr act ices.
I n v iew of t h e abov e, t h is st u dy aim ed t o: an aly ze t h e b iom ed ical in f lu en ce in t h e con t ex t of n u r ses’ for m at ion an d pr ofession al act iv it ies; r eflect about et hical and legal im plicat ions of using m edicinal plant s in nur sing car e; and ar gue about t he need t o con f ig u r e an d d elim it t h is r esou r ce as a leg it im at e inst r um ent for ex panding nur sing car e pr act ice.
LI TERATURE REVI EW
Th e t h er ap eu t ic u se of m ed icin al p lan t s in h u m a n h e a l t h i s a n a n ci e n t p r a ct i ce , h i st o r i ca l l y con st r u ct ed on t h e com m on - sen se k n ow led g e t h at ar t iculat es cult ur e and healt h, since t hese aspect s do n o t o ccu r i so l at ed l y, b u t ar e i n ser t ed i n a cer t ai n h ist or ical con t ex t . Despit e con sider able adv an ces in phyt ot herapy, as plant s used for t herapeut ic pur poses ar e called in academ ic language, t hey oft en cont inue being used for healt h pr om ot ion and r ecover y on t he m er e base of popular cult ur e.
I n t h e p r i m i t i v e a g e , m a n k i n d t u r n e d t o nat ure t o find solut ions for different kinds of desolat ing h a r m , w h e t h e r s p i r i t u a l o r p h y s i c a l . W i s e m e n , con sid er ed in t er m ed iar ies b et w een m en an d g od s, w er e r espon sible for h ealin g t h e sick , j oin in g m agic an d r eligion w it h t h e em pir ical k n ow ledge of h ealt h p r a c t i c e s , s u c h a s t h e u s e o f m e d i c i n a l p l a n t s . An t iq u it y b r ou g h t t h e st ar t of an ot h er f ocu s w h en , b ased on Hip p ocr at ic t h in k in g , w h ich est ab lish ed a r elat ion bet w een people’s env ir onm ent and lifest y le, h ealin g p r ocesses w er e n o l on g er con si d er ed on ly fr om a spir it ual and m y st ical per spect iv e.
Or iginally consider ed a nat ur al phenom enon, t he origin of diseases st art ed t o be st udied scient ifically. On t he sam e occasion, t he or ient al syst em developed in line w it h t he logic t hat t he organism w as a part of t he universe( 1). Thus, dur ing Ant iquit y, alt hough guided by differ en t cu lt u r al con t ex t s, h ealt h in t h e w est er n an d east er n sy st em w as b ased on h olism , t h at is, t r eat m en t sh ou ld act on t h e or g an ism as a w h ole, in t eg r at ed w it h t h e Un iv er se ( m acr ocosm ) , in st ead o f j u st el i m i n a t i n g t h e l o ca l l y m a n i f est ed d i sea se sy m p t o m s.
I n t h e Middle Ages, in t er est in t h e m at er ial w or ld r et u r n ed an d m an st ar t ed t o b e seen as t h e cent r e of t he univ er se, as opposed t o t he div ine and t he supernat ural. This w as follow ed by t he ‘int ellect ual revolut ion’, w hen im port ant philosophical and scient ific c o n q u e s t s w e r e a c h i e v e d . Th e X V It h a n d X V I It h cent ur ies m ar ked t he appear ance of a new par adigm , st ar t in g w it h t h e Scien t if ic Rev olu t ion . Scien ce w as r educed t o m at hem at ical and quant ifiable phenom ena. This ent ailed t he inst allat ion of a healt h m odel in w hich t he holist ic concept ion of t he Univ er se w as r eplaced b y t h e i d e a o f a m a ch i n e w o r l d . Th i s ch a n g e i n par adigm fav or ed capit alist pr oduct ion t o t he ex t ent t h at , af t er t h e I n d u st r ial Rev olu t ion in t h e XVI I I t h cent ury, science w as charged w it h great responsibilit y for m aint aining m an’s act ive labor for ce, guar ant eeing f act or ies’ pr odu ct ion .
of t h e Car t esian p ar ad ig m , w h ich f u lly at t en d ed t o t he int erest s of t he capit alist product ion m ode( 1). The k now ledge and t her apeut ics t hat w er e for m er ly used in h u m an h ealt h , su ch as m ed icin al p lan t s, am on g ot her popular pr act ices, w er e m ar ginalized due t o t he lack of a scient ific base.
I n t er m s of Br azil, t h ese t r an sfor m at ion s in t h e w or ld of scien ce an d econ om ics h appen ed at a lat er st age, w hich collabor at ed w it h t he hegem ony of p op u lar h ealt h p r act ices u n t il t h e b eg in n in g of t h is c e n t u r y, w h e n i t s t a r t e d t o b e b r o k e n b y t h e inst it ut ionalizat ion of healt h ser v ices and t he ar r iv al of allop at hy, con sid er ed essen t ial f or t h e em er g in g for m of pr oduct ion( 2). Unt il t hen, t he popular use of m e d i c i n a l p l a n t s , a s s o c i a t e d w i t h o t h e r n a t u r a l r esou r ces, w as p r ed om in an t in t h e h ealin g p r ocess of m an y diseases t h at affect ed people’s h ealt h . Th e c o u n t r y ’ s e s s e n t i a l l y r u r a l e c o n o m y w a s d o u b l y favorable t o t he use of t hese resour ces, as t he r egion n o t o n l y p r o m o t e d i t s d e v e l o p m e n t ( d u e t o t h e pr act icalit y of close cont act w it h t he land) , but t hese also appear ed as t he only t r eat m ent alt er nat iv e.
I n t he init ial fr am ew or k of t hese t w o event s -t he ins-t i-t u-t ionaliza-t ion of heal-t h and -t he appear ance of allopat hy ; and for ced by t he t r ansfor m at ions t hat r esu lt ed fr om t h e n ew cu lt u r al or der est ablish ed by t h e m ou ld s of cap it alist in d u st r ial p r od u ct ion , n on -con v en t ion al h ealt h p r act ices, esp ecially m ed icin al plant s, st ar t ed t o lose pr est ige, as t hey w er e not par t o f sp e ci a l i ze d k n o w l e d g e , p r o v e d b y t h e l o g i c o f science. Ever yt hing t hat w as not obj ect ified, explained a n d d e m o n s t r a t e d s c i e n t i f i c a l l y w a s g r a d u a l l y d iscar d ed b ot h as k n ow led g e an d as p r act ice. Th e hegem onic m edical k now ledge r uled, per secut ing and pr ohibit ing non- official pr act ices, char lat ans, bleeder s a n d s o m a n y o t h e r p e r s o n s f r o m t h e p e o p l e , con sider in g t h em in capable of ex er cisin g t h e ar t of h e a l i n g a n d i m p o si n g t h e so ci a l r e co g n i t i o n a n d v alu at ion of m edical k n ow ledge.
Un d er t h e a u sp i ces o f ca p i t a l i st i d eo l o g y, h ealt h pr ofession als’ t r ain in g an d act ion s st ood ou t , w h ich ar e st ill gu ided t oday by t h e biom edical car e m odel and by allopat hic pract ice. Healt h professionals st ar t ed t o act on an d look closer in t o scien t ific an d rat ional know ledge, and less int o it s polit ical and social r o o t s. Th u s, “ o f f i ci al m ed i ci n e, l eg i t i m i zed b y t h e can o n s o f sci en ce, t o o k p o ssessi o n o f t h e p eo p l e’ e m p i r i ca l h e a l t h k n o w l e d g e a n d t u r n e d i t i n t o a biologist ic an d m edical k n ow ledge, t h u s con st it u t in g a n e w f o r m o f k n o w l e d g e ”( 3 ). I n t h i s c o n t e x t ,
Professional Nursing appeared, in accordance w it h t he Nigh t in gale sy st em , at a t im e w h en t h e biom edical m odel becam e incr easingly defined and t he efficiency o f m e d i c i n e w a s s u p p o r t e d b y t e c h n o l o g i c a l dev elopm en t an d m edicalizat ion .
How ever, since t he 1980’s and 1990’s, in view of sev er al p olit ical, econ om ic an d h ealt h ch an g es, som e popular pr act ices, including t he t her apeut ic use of m edicinal plant s, st art ed t o be rescued in scient ific m eans, not in t he sense of an opposit ion t o allopat hy, but as com plem ent s t o est ablished healt h pr act ices. Am on g t h e m ot iv es f or t h is r ecov er y, w e h ig h lig h t t h e lack of su ccess of t h e biologist ic m edical m odel for t reat ing diseases; t he iat rogenic effect s associat ed w it h t h e h ig h cost of cer t ain allop at h ic d r u g s; t h e scien t if ically p r ov en ef f icacy of som e p lan t s; alon g w it h respect and valuat ion of cult ur al aspect s t hat ar e clear ly pr esent in t he cont ex t of t hese pr act ices.
Hence, despit e t he cont inuous hegem ony of allopat hy, ack n ow ledged as scien t if ic an d a m edical prerogat ive but , in view of social, et hical, polit ical and e co n o m i c t r a n sf o r m a t i o n s t h a t d i r e ct l y i n f l u e n ce people’s h ealt h an d, con sequ en t ly, car e m odels, t h e t herapeut ic use of m edicinal plant s in care, w hich used t o be at t h e m ar gin of h ealt h in st it u t ion s, is t oday m oving beyond t hese bar r ier s and t r ying t o legit im ize it self in t his m eans. That is w hy it is necessar y and im port ant t o reflect on t heir applicabilit y, in academ ic f or m at ion as w ell as p r of ession al n u r sin g p r act ice, w i t h p a r t i cu l a r a t t e n t i o n t o i t s e t h i ca l a n d l e g a l i m p l i cat i o n s. We co n si d er t h e h y p o t h esi s t h at t h e t her apeut ic use of plant s can be com bined w it h w hat n u r s i n g t h i n k s a n d d o e s , e n t a i l i n g , a p r i o r i , a concept ion of t he hum an being as a w hole.
METHODOLOGY
Th i s s t u d y i s p a r t o f t h e r e s e a r c h “ Fundam ent al Nur sing and it s Links w it h Nat ur al Healt h Pr a c t i c e s : t h e Ex a m p l e o f Li v i n g Ph a r m a c i e s ” , appr ov ed by t h e Resear ch Et h ics Com m it t ee of t h e Collect iv e Healt h Gr ou p at t h e Feder al Un iv er sit y of Rio de Janeir o, in line w it h Resolut ion 196/ 96 by t he Nat ional Healt h Council, w hich est ablishes St andar ds for Resear ch I n v olv in g Hu m an Bein gs.
t his paper, w e chose t he dat a pr oduced in t he dynam ics ‘Calen d ar ’ an d ‘Bod y - Kn ow led g e’.
We used a differ ent gr oup and r esear cher for e a c h d y n a m i c s e s s i o n . Th e g r o u p s c o n s i s t e d o f p r o f e ssi o n a l n u r se s w h o w e r e a ct i v e i n d i f f e r e n t scen ar ios, as w ell as n u r ses t each in g at pu blic an d p r iv at e u n iv er sit ies, t ot alin g f if t een p ar t icip an t s f or t he t w o sessions. They par t icipat ed aft er signing t he Fr ee an d I n for m ed Con sen t Ter m .
The dynam ics w er e developed in a class r oom at a pu blic u n iv er sit y, du ly pr epar ed f or dev elopin g t he act iv it ies. Dat a w er e pr oduced dur ing t w o hour s and t hirt y m inut es. The nurses w er e ident ified t hrough c o l o r s ( ‘ B o d y - K n o w l e d g e ’ d y n a m i c s ) a n d p l a n t s ( ‘ Ca l e n d a r ’ d y n a m i c s ) , w h i c h t h e y c h o s e f o r t h em sel v es.
Pr im ar y dat a sou r ces w er e t h e par t icipan t s’ r epor t s and ar t ist ic pr oduct s gener at ed in t he cont ext of t h e CSD. Th ese r ev ealed pr oblem sit u at ion s t h at allow ed f or t h e cod in g of t w o su b j ect s f or d eb at e, accor ding t o t he Fr eir ian language t hat suppor t ed t he dat a analysis used in t he CSM, and w hich const it ut ed t he follow ing cat egor ies: 1) The biom edical influence in t h e academ ic- pr of ession al or ien t at ion of n u r sin g; and 2) Et hical and legal im plicat ions in t he applicabilit y of m edicinal plant s in car e.
RESULTS AND DI SCUSSI ON
The Biom edical I nfluence in t he Academ ic- Professional Or ient at ion of Nur sing
I n t he dialogue t hat occur r ed as par t of t he ‘Body - Know ledge’ dy nam ics, Nur se Violet ’s discour se g a v e r i s e t o t h e f i r s t s u b j e c t f o r d e b a t e : “ t h e b i o m ed i ca l i n f l u en ce i n t h e a cad em i c- p r o f essi o n a l or ien t at ion of n u r sin g”. Th e discu ssion t h at r esu lt ed fr om t his t hem e w as t hat , at t he hear t of t he academ ic w orld, t he use of non- convent ional healt h pract ices is m ost ly accom panied by pej or at iv e connot at ions. This v iew is ev en m ain t ain ed by som e n u r sin g st u den t s, w ho believ e t hat t he use of t hese pr act ices does not guar ant ee “ st at us” t o t he pr ofession. Ev en w hen t he t e a ch i n g - l e a r n i n g e x p e r i e n ce p e r m i t s st u d e n t s t o ex per ience t he use of her bs in healt h car e, st udent s d o n o t v a l u e t h i s p r a ct i ce , b e ca u se t h e y d o n o t consider it is scient ific.
This is w hat t he above m ent ioned nur se says w hen she r em em ber ed a cur r icular exper ience dur ing
her under gr aduat e cour ses, w hen she w as a t r ainee at a healt h unit in Nit erói: [ ...] I t hink m y class w as t he last one at t hat unit . . . Because t he st udent s did not see t his as
pr oduct ive, t he fact of dealing w it h t hat t hing of going out t her e
int o t he gar den, at t he back of t he unit , w her e you r ecognize t he
h e r b s a n d se e h o w t h e y a r e m a n i p u l a t e d . . . Th a t i s n o t
acknow ledged as scient ific know ledge, w hich includes t he issue
o f s t a t u s , o f p o w e r . W h a t h a p p e n s i s t h a t , i n u n d e r g r a d u a t e c o u r s e s i n g e n e r a l , n a t u r a l c a r e p r a c t i c e s a r e u s e d o c c a s i o n a l l y, a n d a r e n o t sy st em ized in n u r sin g t each in g. As a r u le, t h ey ar e in t r od u ced as a t each in g - lear n in g ex p er ien ce so as t o at t end individually t o t he specific int erest s of facult y w ho st udy t hese pr act ice, and not t o a pr ofessional polit ical pr oj ect .
A c c o r d i n g t o o n e o f t h e p a r t i c i p a n t s , r e s i s t a n c e a g a i n s t s t u d e n t s ’ p a r t i c i p a t i o n i n ex p er ien ces t h at in clu d e n at u r al t r eat m en t s d u r in g t heir int ellect ual ( academ ic) t r aining is accom panied by t he per spect ive t hat it ar e nur ses w ho k now ; t his g r a n t s t h e m t h e p o w e r o f k n o w l e d g e a n d , con sequ en t ly, in t h eir poin t of v iew, t h ey possess a st at us and social r ecognit ion. These ar e pr ofessionals who possess t echnical and t echnological m anagem ent, as nurse Violet concluded. I n t his r espect , it cannot be denied t h a t t e ch n i ca l - sci e n t i f i c a d v a n ce s b r o u g h t g r e a t a c c o m p l i s h m e n t s i n t h e f i e l d o f h e a l t h . Th e d ev elop m en t of t h e b iom ed ical car e m od el, w h ose influence rest s on t he Car t esian par adigm , cont ribut ed t o m edicin e for t h e elim in at ion or con t r ol of cer t ain diseases, such as bact er ial pat hologies, diseases, for hear t sur ger ies and or gan t r ansplant s, am ong ot her s. How ev er, in t he or ganizat ion of m oder n life, s o c i e t y i s c o n f r o n t e d w i t h v a r i o u s t h e o r e t i c a l -philosophical paradigm s. We ar e facing a huge paradox sin ce, at t h e sam e t im e as t h e t ech n ical- scien t if ic ev o l u t i o n b en ef i t ed so m e p o p u l at i o n seg m en t s b y st r u ct u r in g scien ce accor din g t o cer t ain pat t er n s of t r ut h, t he Car t esian m odel also t r ansfor m ed t hem int o a m echanized syst em , w it h closed and dist inct par t s( 1). I n t h i s an al y si s, i n v i ew o f co n st an t m u t at i o n s i n people’s liv es now aday s, t heir healt h is det er ior at ed, due t o social organizat ion and unlim it ed consum erism , am on g ot h er r eason s. I n t h e et h ical, p olit ical an d e co n o m i c sp h e r e , t o d ay, d i sco u r se h a s t u r n e d t o ou t sou r cin g an d econ om ic globalizat ion .
w it hout m easur e or cont r ol. I nadequat e and unhealt hy w ork condit ions, an increased num ber of occupat ional accid en t s, r ecession an d u n em p loy m en t h av e b een t h e cau se of d if f er en t p h y sical an d social d iseases an d h av e collab or at ed w it h t h e g r ow t h of v iolen ce rat es. Mor eov er, differ ent for m s of aggr ession t o t he en v ir on m en t ar e im p or t an t f act or s in t h is sy st em , w hich ar e m ost ly r esponsible for t he det er ior at ion of h u m an h ealt h . I t sh ou ld b e h ig h lig h t ed t h at h ealt h i n v o l v es v ar i o u s d i m en si o n s an d r esu l t s f r o m t h e i n t e r a ct i o n b e t w e e n d i f f e r e n t – p h y si ca l , so ci a l , hist or ical and cult ur al - com ponent s.
I n v iew of t h ese con sid er at ion s an d in lin e w it h t he neo- liberal concept ion of t he current globalized e c o n o m y, m a n i s b e i n g u s e d a s a p r o d u c t i o n inst r um ent . Fr om a polit ical and social v iew point , he is cont r olled t o at t end t o t he needs of t he econom ic syst em , w hich affect s all of his relat ions w it h t he w orld. An o t h e r a s p e c t t o b e t a k e n i n t o a c c o u n t i s t h e “ at t r ib u t ion of b lam e t o t h e v ict im ”, in w h ich “ t h e individualizat ion of blam e r esult s in t he explicat ion of a collect iv e pr act ice ( ...) , for ex am ple, by ov er r at ing t h e p o p u l a t i o n ’ s s o c i o e c o n o m i c p r o b l e m s , t h u s j u st if y in g pr ecar iou s ser v ices”( 5 ).
I n t h i s co n t e x t , h e a l t h p r o f e ssi o n a l s a r e t rained t o deal w it h t his ideological st ruct ure, w hich is ca p a b l e o f r e co v e r i n g t h e a ct i v e l a b o r f o r ce t h a t reproduces w ork force, m ainly in view of t he challenge of t he infor m at ics r evolut ion t o hum an w or k. And t hat i s w h a t w e s e e i n t h e d i s c o u r s e o f n u r s e s w h o par t icipat ed in t he ‘Calendar 2’ dynam ics, t hat is, t hat ( academ ic) for m at ion is t ot ally biom edical: My academ ic for m at ion w as for r at ionalit y... And phyt ot her apy r eally did not
st an d a ch an ce ( Nu r se Bo l d o ); My f o r m at i o n w as t o t al l y biom edical ( Nur se Pink) .
Unt il t he ear ly 1980’s, t echniques t aught by m e a n s o f n o n - i n v a s i v e p r o c e d u r e s , s u c h a s t h e a p p l i c a t i o n o f c a t a p l a s m s , s u c k e r s , t h e r a p e u t i c m a ssa g e s, a m o n g o t h e r s, w e r e o f t e n l o st i n t h e hospit al sphere, giving room t o allopat hic pract ices( 3). So m e o f t h e s e t e c h n i q u e s o r p r o c e d u r e s f o l l o w guidelines t hat are sim ilar t o w hat is found in popular logic. How ever, it should be highlight ed t hat t her e exist s a dichot om y bet w een scient ific and popular ( com m on sense) k now ledge, and t hat “ w hen one is confr ont ed w it h t he ot her, at fir st sight , t hey seem t o be m oving in differ ent dir ect ions t hat do not m eet , leading t o a g r o w i n g d i st a n ce b e t w e e n b o t h ”( 4 ). Th e a ca d e m y t each es an d su st ain s t h e t each in g - lear n in g p r ocess on academ ic- scien t if ic k n ow ledge, becau se t h is h as
been pr ov ed by ex per im ent at ion and scient ific pr oofs an d ob j ect if ied t h r ou g h t ech n iq u e; con seq u en t ly, it st ar t s t o be adopt ed as a cr it er ion of t r ut h.
I n t h e d ialog ic m ov em en t t h at occu r r ed in t h e con t ex t of t h e t w o dy n am ics, w h en par t icipan t s an aly zed t h e biom edical in f lu en ce in t h e con t ex t of t heir for m at ion and pr ofessional act iv it ies, w hich led t h e m t o co n v e n t i o n a l p r a ct i ce s su st a i n e d b y t h i s m o d e l , t h e y a l s o r e f l e c t e d o n e t h i c a l a n d l e g a l im plicat ions inv olv ed in t he applicabilit y of m edicinal plant s in nur sing car e. Hence, t he second t hem e for debat e discu ssed t h ese im plicat ion s.
Et h ical an d Legal I m plicat ion s in t h e Applicabilit y of Medicinal Plant s in Car e
Let us t ake a look at t he r epor t of a par t icipant in ‘Body- Know ledge’, w hich cont r ibut ed t o a br oader d i scu ssi o n an d t h e ad d i t i o n o f o t h er el em en t s f o r r eflect ion and debat e: [ ...] dur ing m y t r aining, som e year s ago, I obser ved a ver y st r ong collocat ion in r elat ion t o et hics,
w hich em phasized t hat w e could not use t his so- called popular
know ledge, because t hat w ould go against pr ofessional et hics,
as t her e w as no scient ific pr oof for t his pr act ice. So, w hen t her e
was som eone orient ed t o t hese pract ices, t hat person was kind of
pur sued, kind of discr im inat ed and even cut ( Nur se Gr een) .
We k n o w t h a t t h e e t h i c a l d i m e n s i o n im pr egnat es all dim ensions of t he healt h sect or and is present in different professions and services in t his ar ea. How ever, t his k ind of decisions t ranscends t he sect or and affect s societ y as a w hole. I n t his sense, t he pluralit y of sit uat ions involving et hical fact ors needs t o b e t a k e n i n t o a c c o u n t . Th u s , t h e m i s s i o n o f b i oet h i cal com m i ssi on s “ i s n ot t o f i n d t h e m i r acl e solut ion, t he oppor t une solut ion for such conflict s; in pr in ciple, t h eir m ission is t o t u r n t h em ex plicit an d t hat is w hy it is good for t hem t o j oin per sonalit ies w it h subst ant ially differ ent opinions, m et aphysics and beliefs”. That is w hy, in bioet hics, w e ar e “ condem ned t o ar bit r ar y an d t r an sit or y com pr om ises”( 6 ). We see t he incor por at ion of know ledge inher it ed fr om popular cult ure int o academ ic form at ion as viable, w hich does not im pede pr ofessionals ( or fut ur e pr ofessionals) fr om const ant ly updat ing t heir t echnical skills in t he search f or n ew or r ecov er ed k n ow led g e. Af t er all, “ w e d o not have t he m essage. What w e can do is t o r aise t he pr oblem s, for m ulat e t he cont r adict ions, is t o pr opose pr ov ision al m or als”( 6 ).
part icipat ing in t his discussion process. This is because univ er sit ies, m ainly public inst it ut ions, ar e based on a t r ip le st r u ct u r e con st it u t ed b y t each in g , r esear ch a n d e x t e n s i o n . Th u s , t h e y a r e r e s p o n s i b l e f o r form alizing and st rengt hening bonds w it h civil societ y in t h e sear ch f or alt er n at iv es t h at can im pr ov e t h e populat ion’s qualit y of life and healt h.
I n t h e sam e con t ex t , w h en con su lt in g t h e Et h ics Cod e of Nu r sin g Pr of ession als( 7 ), on t h e on e hand, w e obser ve t hat it does not cont ain any m ent ion w h a t so ev er a g a i n st n u r ses’ u si n g a n y a l t er n a t i v e pract ice in it self. On t he ot her, in chapt er I I I , Art . 17 and 18 - “About responsibilit ies” est ablish, respect ively, t hat t he nurse has t o: “ Judiciously assess her t echnical a n d l e g a l c o m p e t e n c y a n d o n l y a c c e p t t a s k s o r at t r ibut ions w hen ( s) he is capable of per for m ing t hem safely for him - / herself and for t he client s” and “ Keep t h e m s e l v e s u p d a t e d , e x p a n d i n g t h e i r t e c h n i c a l , scien t if ic an d cu lt u r al k n ow led g e t o b en ef it clien t s, societ y and t he developm ent of t he pr ofession”.
I n t hese ar t icles, special at t ent ion should be giv en t o aspect s r elat ed t o com pet ence and differ ent k n ow ledge for m s. Et h ical issu es sh ou ld be assessed in t he applicabilit y of m edicinal plant s by nur ses t oo. I n t his sense, in t he fir st place, t he academ y should w or r y about condit ions needed t o pr oduce know ledge abou t t h e u sed of m edicin al h er bs an d v alidat e t h e k n ow ledge t h at su st ain s it s u se by popu lar classes. To allow nur ses t o deliver car e by applying m edicinal h er bs, academ ic t r ain in g u r gen t ly n eeds t o su ppor t t his pr act ice t hr ough t he for m al inclusion of cont ent s an d p r act i cal ex p er i en ces i n t o u n d er g r ad u at e an d g r a d u a t e c u r r i c u l a , w h i c h c a n g r a n t n u r s e s t h e t echnical com pet ence r equir ed t o act in t his specific k n ow led g e ar ea.
I n t h i s r e sp e ct , i t sh o u l d b e a d d e d t h a t u n iv er sit y ed it or s h av e in clu d ed p u b licat ion s ab ou t t his subj ect in t heir cat alogues. Exam ples include t he Feder al Un iv er sit y of Cear á( 8 ) an d of Rio Gr an de do Sul( 9), w hich have published m at er ial t hat cont r ibut es t o t he st udy of plant s w it h t her apeut ic pr oper t ies. As t o scient ific nursing research about t he sam e subj ect , in r ecen t decades, st u dies h av e f ocu sed on clien t s’ as w ell as on nur sing pr ofessionals’ per spect iv es( 3,
10-13)
. Mor eov er, t he I NTERNET offer s access t o sev eral e x p e r i m e n t a l r e se a r ch g r o u p s i n t e r e st e d i n t h i s m a t t e r, m a n y o f w h i c h a r e e v e n a f f i l i a t e d w i t h a c a d e m i c p r o j e c t s i n p a r t n e r s h i p w i t h r e s e a r c h inst it ut es and t he user com m unit y.
Alt hough st ill incipient and not syst em at ically, st u d y p ar t icip an t s w h o g r ad u at ed f r om t h e secon d
half of t he 1980’s onw ar ds m ent ioned t hey r eceiv ed i n f o r m at i o n o n u si n g h er b s d u r i n g t h ei r acad em i c t r aining. This can be ex plained by t he fact t hat t his w a s a t i m e w h e n so m e n o n co n v e n t i o n a l h e a l t h t h er a p i es r ecei v ed g o v er n m en t a l su p p o r t a n d t h e sit uat ion st ar t ed t o giv e signs of change, w it h t hese t r eat m ent s being discussed as a possibilit y in healt h ca r e.
A s t o l e g a l s u p p o r t f o r t h e p r o f e s s i o n a l ex er cise of alt er n at iv e pr act ices, Resolu t ion 1 9 7 / 9 7 b y t h e Fed er al Nu r sin g Cou n cil( 1 4 ) “ est ab lish es an d ack n ow led g es Alt er n at iv e Th er ap ies as a sp ecialt y an d/ or qu alificat ion for t h e n u r sin g pr ofession al”. I n ou r v iew , t h is in dicat es t h at pr act icin g n u r sin g car e b y a p p l y i n g m ed i ci n a l p l a n t s i s su p p o r t ed b y t h e r egulat or y body of our pr ofession. How ev er, w e need t o be aw are t hat t his Resolut ion deals w it h “ alt er nat ive t h er ap ies”, w it h ou t sp ecif y in g w h at t h ese so- called
t her apies w ould be. This gives r oom t o const r uct and deconst r uct a classificat ion of t he count less pr act ices t hat ar e called alt er nat iv e t oday. I f m edicinal plant s ar e con sider ed as “ alt er n at iv e t h er apies”, in t h eor y, nur ses ar e suppor t ed; if not , t hey lose legal suppor t for pr ofessional car e w it h m edicinal plant s. We w ould be at t he m er cy of t he t r ansit or iness of t he t heor et ical-philosophical field in t he const r uct ion of concept s.
I n t h is d iscu ssion , w e in q u ir e w h et h er, b y p r escr ib in g h er b s, n u r ses ar e in f r in g in g t h e Law of Professional Exercise? Let us t ake a look at Art icle 48 in Chapt er V of t he Nur sing Et hics Code( 7). I t st at es t hat it is pr ohibit ed for nur ses t o “ pr escr ibe dr ugs or p r act ice su r g ical act s, ex cep t t h ose d et er m in ed b y cu r r en t legislat ion or in case of em er gen cy ”. Ar t icle 8 , se ct i o n I I , i t e m C, o f t h e La w o f Pr o f e ssi o n a l Ex e r c i s e( 1 5 ) m e n t i o n s t h a t i t i s t h e p a r t i c u l a r com pet ence of nur ses t o “ pr escr ibe dr ugs pr ev iously est ablished in public healt h pr ogr am s and in r out ines appr ov ed b y t h e h ealt h in st it u t ion ”. Bot h t h e Et h ics Cod e an d t h e Law of Pr of ession al Ex er cise r ef er t o “ dr ugs”, leav ing r oom for differ ent int er pr et at ions. I n o t h e r w o r d s, b y p r e scr i b i n g m e d i ci n a l h e r b s, a r e nur ses pr escr ibing dr ugs as m ent ioned by t hese t ext s? What k ind of dr ugs ar e bot h r efer r ing t o?
r e c u r s o , s o l u ç ã o ; a u x íl i o , a j u d a ; e m e n d a , cor r eção”( 1 6 ). Th u s, w e m ay con sider t h at t h e w or d “ r em éd io” in clu d es, b esid es “ m ed icam en t os”, ot h er r esour ces, such as people’s w ay of life, t heir beliefs, v alu es an d p op u lar car e p r act ices f or ex am p le. I n t h i s c a s e , n u r s e s u s e m a n y “ r e m é d i o s ” i n t h e i r p r act ice, as t h er e ar e cou n t less w ay s of h elp in g a clien t t o cop e w it h t h e p r ocess of liv in g an d b ein g healt hy, get t ing ill and dy ing.
We can also int er pr et t hat dr ugs ar e w hat is pr oduced by m ainly m ult inat ional phar m aceut ical, t hat is, allopat h ic in du st r ies; or, also, pr escr ibed n at u r al f o r m u l a e m a n i p u l a t e d i n p h a r m a ci e s; o r n a t u r a l f or m u lae pr odu ced by a labor at or y t h at det ain s t h e br ands. Thus, w e can consider all or par t of t hese as pr ohibit ed. These doubt s ar ise fr om t he fact t hat , in a way, w e are inclined t o consider as “ drug” w hat goes t hr ough t he pr ocess of pr ofessional pr epar at ion, t hat is, in labor at or ies an d ph ar m acies. An d w h at abou t nat ur al herbs? Would t hese be consider ed as t he dr ugs
m ent ioned in t he legal pr ohibit ion?
This sim ple r eflect ion in t he light of t he Law and Professional Et hics reveals a series of issues t hat , in our v iew, w eaken our pract ice and, consequent ly, ou r pr of ession al au t on om y * . Th ese am bigu it ies can det erm ine ( or not ) t he applicabilit y of m edicinal plant s in pr ofessional nur sing pr act ice. But it is par am ount t o con sider t h e an aly sis abou t t h e n eed t o con qu er spaces in pract ice t o allow us t o guarant ee t his pract ice by Law .
I n line w it h t hese reflect ions, w e believe t hat discou r se abou t t h e et h ical an d legal possibilit ies of incorporat ing m edicinal plant s int o daily nursing w ork s h o u l d n o t i m p e d e i t s a p p r o p r i a t i o n i n p u b l i c -pr ofessional -pr act ice. Any im pedim ent w ould suppor t t h e ex t er n alizat ion of acad em ic d og m as an d w ou ld st rengt hen it s adopt ion in privat e- hom e pract ice only. Today, scient ific pr oduct ion is available in nur sing t o d e m o n st r a t e t h e i m p o r t a n ce a n d a p p l i ca b i l i t y o f m edicinal plant s in healt h car e. How ev er, t her e is an ur gent need t o configur e and delim it t his pr act ice in t he sphere of nursing care. That is w hy t he specificit y of our pract ice, and part icularly our care, is based on t he est ablishm ent of nur sing diagnoses.
Th e car e p r escr ib ed b y n u r ses is aim ed at solving a nursing problem and, hence, is part of t heir pr ofessional spher e. Thus, if w e t hor oughly elabor at e t he concept s t hat guide our pr act ice ( our car e) and,
also, ad v an ce in d iag n ost ic st u d ies t h at im p ly t h e p r e scr i p t i o n o f m e d i ci n a l p l a n t s, w i t h a v i e w t o deliv er ing appr opr iat e nur sing car e t o client s, w e w ill b e b et t er eq u ip p ed t o leg it im at e t h is sp ace as an ex t en sion of pr ofession al n u r sin g pr act ice.
FI NAL CONSI DERATI ONS
We h av e sh o w n t h at t h e u se o f m ed i ci n al p l a n t s d o e s n o t h a v e sci e n t i f i c o r i g i n s, b u t i s a hist or ically legit im ized know ledge and pr act ice t hat is d i ssem i n at ed i n co m m o n sen se. No w ad ay s, m an y plant s are t he subj ect of scient ific st udies, conquering s p a c e i n t h e a c a d e m i c s p h e r e a n d i n h e a l t h pr of ession als’ act ion s, in clu din g n u r sin g, in spit e of t h e d om in an ce of t h e b iom ed ical m od el in scien ce const ruct ion, professional t raining and pract ice. I n t his sen se, t h er e ar e ex am p les of r esear ch f ocu sin g on t rials w it h m edicinal plant s for prevent ion and healing. Alt h ou g h b ased on av ailab le st u d ies an d em p ir ical observat ions about professional pract ice, t he level w e have reached bot h in t erm s of discussion and concret e pract ice is st ill insufficient t o guarant ee it s legit im acy, especially by nur ses, t o t he ext ent of t ur ning t he use of m edicinal plant s int o a concr et e pr act ice t hat can be applied in t he public- pr ofessional nur sing spher e. Th i s m ay b e d u e t o t h e n o n i n co r p o r at i o n o f t h i s know ledge int o t he t r aining cur r iculum , as m ent ioned above, giving r ise t o t he need t o configur e and delim it t h is pr act ice in car e, in clu din g r eflect ion s abou t t h e et h ical an d leg al im p licat ion s of it s ap p licab ilit y b y n u r sin g .
Th e n u r si n g p r o f essi o n u r g en t l y n eed s t o r eflect on t hese im plicat ions for nur sing car e, all t he m or e w h en m an y p r of ession als ar e d iscu ssin g an d t r y ing t o guar ant ee t he ex clusiv it y of k now ledge and pr act ices for t hem selves, const ant ly at t em pt ing t o get t he best par t . Thus, w hat w e ar e discussing her e is n ot st r ict ly t h e et h ical an d legal at t r ibu t ion s of t h e t h er ap eu t ic u se of p lan t s as t h e ex clu siv e t er r it or y f o r o n e o r a n o t h e r p r o f e ssi o n a l , b u t t h e n e e d t o dem ocr at ize and r elat iv ize t heir use as a shar ed and int erdisciplinary healt h care act ion and, in t he case of nur sing, as an ex t ension of t heir car e pr act ice.
Class associat ion s lik e t h e Br azilian Nu r sin g Asso ci a t i o n , t h e N u r si n g Un i o n a n d Pr o f e ssi o n a l
Nur sing Councils hav e a fundam ent al r ole t o play in t he fight t o delim it t he space of nursing in areas t hat a r e b u r n i n g w i t h c o h e r e n t a n d c o n s i s t e n t c a r e pr oposals in t he cur r ent healt h cont ex t .
Fin ally, in t h e con t ex t of t h e p r ob lem s t h e p o p u l a t i o n i s f a ce d w i t h a t d i f f e r e n t l e v e l s, f r o m
an ot h er per spect iv e, h igh er edu cat ion r ev eals w eak p o i n t s i n t e r m s o f k n o w l e d g e a r e a s r e l a t e d t o alt er n at iv e h ealt h issu es, for ex am ple, w h ich ar e at t he m ar gin of t he est ablished pow er, t hat is, at t he m ar g in of t h e ack n ow led g ed scien t if ic ch ar act er of t h e biom edical m odel.
Recebido em : 16.5.2005 Apr ovado em : 25.4.2006
REFERENCES
1 . Cap r a F. O p on t o d e m u t ação. São Pau lo ( SP) : Cu lt r ix ; 1 9 9 3 .
2 . Si n g er P, Cam p o s O, Ol i v ei r a EM. Pr ev en i r e cu r ar. O cont r ole social at r av és dos ser v iços de saúde. 3rd ed. Rio de Jan eir o ( RJ) : For en se Un iv er sit ár ia; 1 9 8 8 .
3 . Alv im NAT. Pr át icas e sab er es d as en f er m eir as sob r e o u so d e p lan t as m ed icin ais n a v id a d as en f er m eir as: u m a con st r u ção em esp ir al. [ d isser t ação] . Rio d e Jan eir o ( RJ) : Escola de En f er m agem An n a Ner y / UFRJ; 1 9 9 9 .
4 . Ca b r a l I E. O m ét o d o cr i a t i v o - sen sív el : a l t er n a t i v a d e pesquisa na enfer m agem . I n: Gaut hier JHM, Cabr al I E, Sant os I , Tavar es CMM, or gan izador es. Pesqu isa em en f er m agem : novas m et odologias aplicadas. Rio de Janeir o ( RJ) : Guanabar a Koog an ; 1 9 9 9 . p . 1 7 7 - 2 0 3 .
5 . Va l l a VV. A co n st r u çã o d esi g u a l d o co n h eci m en t o e o con t r ole social dos ser v iços pú blicos de edu cação e saú de. I n: Valla VV, St ot z EM, or ganizador es. Par t icipação popu lar, educação e saúde: t eor ia e pr át ica. Rio de Janeir o ( RJ) : Relum e-Du m ar á; 1 9 9 3 . p. 9 5 - 9 6 .
6 . Mor in E. Ciên cia com con sciên cia. 2 ª ed. Rio de Jan eir o ( RJ) : Ber t r an d Br asil; 1 9 9 8 . p. 1 3 2 - 3 3 .
7 . Con selh o Feder al de En f er m agem ( BR) . Código de ét ica dos pr ofissionais de enfer m agem . Br asília ( DF) : COFEn; 1993. p . 9 - 1 0 .
8 . Mat o s FJA. Far m áci as v i v as. Si st em a d e u t i l i zação d e p lan t as m ed icin ais p r oj et ad o p ar a p eq u en as com u n id ad es. 2ª ed. For t aleza ( CE) : Univer sidade Feder al do Cear á; 1994. 9. Mar t ins ER. Plant as m edicinais. Viçosa ( MG) : Univ er sidade Fed er al d e Viçosa; 1 9 9 4 .
1 0 . Mach ado ACC. A f it ot er apia com o u m a n ecessidade do cl i en t e. Um a p er sp ect i v a d e assi st ên ci a d e en f er m ag em . [ t ese] . Rio de Jan eir o ( RJ) : Escola de En f er m agem Alf r edo Pi n t o / UNI - RI O; 1 9 9 6 .
11. Medeir os LCM. As plant as m edicinais e a enfer m agem – a ar t e d e assist ir d e cu r ar, d e cu id ar e d e t r an sf or m ar os s a b e r e s . [ d i s s e r t a ç ã o ] . Ri o d e Ja n e i r o ( RJ) : Es c o l a d e En f er m agem An n a Ner y / UFRJ; 2 0 0 1 .
1 2 . Vi v ei r o s AA, Go u l ar t PF, Al v i m NAT. A i n f l u ên ci a d o s m eios sociocult ur al e cient ífico no uso de plant as m edicinais por est u dan t es u n iv er sit ár ios da ár ea da saú de. Esc. An n a Ner y Rev. En fer m agem 2 0 0 4 abr il; 8 ( 1 ) : 6 2 - 7 0 .
1 3 . Go u l a r t PF, Vi v e i r o s AA, Al v i m NAT. O d i á l o g o co m g est an t es sob r e p lan t as m ed icin ais: con t r ib u ições p ar a os cu i d a d o s b á si co s d e sa ú d e . Rev. Act a Sci e n t i a r u m 2 0 0 5 set em b r o ; 2 6 ( 1 ) : 2 8 7 - 9 4 .
1 4 . Con selh o Feder al de En fer m agem . Resolu ção COFEn n º 1 9 7 / 9 7 . Est ab el ece e r eco n h ece as Ter ap i as Al t er n at i v as co m o e sp e ci a l i d a d e e / o u q u a l i f i ca çã o d o p r o f i ssi o n a l d e enfer m agem . Br asília ( DF) : Conselho Feder al de Enfer m agem ; 1 9 9 7 .
1 5 . Lei n º 7 . 4 9 8 de 2 5 de j u n h o de 1 9 8 6 . Dispõe sobr e a r eg u lam en t ação d o ex er cício d a en f er m ag em e d á ou t r as pr ov idên cias. Diár io Oficial da Un ião 2 6 de j u n h o de 1 9 8 6 , Seção 1 , p . 9 2 7 3 - 5 .
