JPHI Journal of Public Health International 2641-4538 Open Access Pub United States JPHI-21-3861 10.14302/issn.2641-4538.jphi-21-3861 case-report To What Extent is it Possible to Respect the Principle of Autonomy in Pandemic Times? A New Approach to Bioethical Principles rethinking bioethical principles and public health Ivan Dieb Miziara 1 * Carmen Silvia Molleis Galego Miziara 2 Associate Professor – Head of Department – Department of Legal Medicine, Ethics and Social Medicine São Paulo University School of Medicine (São Paulo – Brazil) – Orcid Id: 0000-0001-7180-8873. Assistant Professor – Discipline of Legal Medicine and Bioethics – Abc School of Medicine (Santo André-Brazil) Orcid Id: 0000-0002-4266-0117 Corresponding author Sasho Stoleski 1 Institute of Occupational Health of R. Macedonia, WHO CC and Ga2len CC. Ivan Dieb Miziara, Associate Professor – Head Of Department - Department Of Legal Medicine, Ethics And Social Medicine – São Paulo University School Of Medicine (São Paulo – Brazil) Orcid Id: 0000-0001-7180-8873. miz@uol.com.br

The authors have declared that no competing interests exist.

 19 06 2021 4 1 21 23 06 06 2021 18 06 2021 19 06 2021 © 2021 Ivan Dieb Miziara, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This article is available from http://openaccesspub.org/jphi/article/1648

Based on two fictitious cases of disregard for the rules to prevent the spread of Sars-Cov-2 in which individuals claim that their autonomy has been disrespected, in Brazil, the authors ask to what extent individual autonomy must be strictly respected and propose a new approach to the bioethics principles, so that they are applied with a view to public health and the common good.

 Autonomy personal Bioethical issues Relational Autonomy Social Justice Introduction

Ethics applied to health practices have evolved over the centuries. Many factors contributed to the creation of Bioethics as a field of knowledge, a discipline involved with the evolution of Ethics in the cultural panorama of the end of the 20th century. These factors belong to several territories, including medical practice1.

By the middle of the last century, Medical Ethics was primarily limited to professional conduct. Codes of professional conduct established the ideal rules that governed members of the medical profession. In general, the character of these codes was, as Hippocrates ideas, eminently paternalistic2.

It became clear that a new philosophical field within the biomedical sciences was opened: that of Bioethics. The first to use the term “bioethics” was Van Rensselear Potter3 in an article and in his seminal book “Bioethics, Bridge to the Future”.

It is important to say, as stated by Racine4, that “Bioethics was initially and is still first and foremost an American intellectual and social production. A typically American way of dealing with the moral challenges of contemporary biomedical science and health care, especially with respect to the predominant value of autonomy.” In Brazil, culture of people has different perspectives, which oblige the adoption of new forms of moral and ethical analysis.

 Case Studies

Imagine the following (fictitious, based in real cases) situations

Case 1

Mr. CMJ, a 50-year-old welder and worker in an automobile factory, refuses to wear a surgical mask during his work, claiming that it disturbs his vision protected by goggles over his eyes. CMJ rebels against the supervisor of his section who wants to oblige him to comply with the rules of protection against the spread of the Sars-CoV-2 virus. CMJ also says he will not be vaccinated, because vaccines have serious side effects.

 Case 2

The police interrupt a clandestine party in a poor neighborhood in the city of São Paulo, where about 300 young people flocked to the funk sound, contradicting the curfew imposed by the State Government to prevent the spread of Sars-Cov-2 that has killed more than 400,000 people in Brazil so far. The 300 youths are taken to a nearby police station.

In both cases, CMJ and the 300 youths claim that their autonomy is being violated. That they have the right to come and go and that public health is not their concern.

 Individual Autonomy and Public Health Petrini et al.<xref ref-type="bibr" rid="ridm1843273012">5</xref> stated that

The delay in the bioethical investigation on public health and the apparent conflict between individual and public interests has led several authors to highlight the differences between classical bioethics and public health ethics, the latter focusing on collective aspects, such as the sharing of risks and benefits, the definition of socially acceptable levels of risk and the acceptability of compulsory interventions (screening, testing, vaccination, etc.)

As Kramer and colleagues6 said, “Circumstances in which individual choices are overridden or liberty is restricted — vaccination mandates, for example — are controversial precisely because of the central place of autonomy in medical decision making.” As proposed by Kenny et al.7, in this context, “an inordinate focus on the urgent issues of emergency preparedness in pandemic and reliance on bioethical analysis steeped in the autonomy and individual rights tradition of health care do not serve adequately as the basis for an ethic of public health with its focus on populations and the common good.” So, we can ask: when individual attitudes compromise public health, must we respect his autonomy? Did we learn nothing from the predecessor pandemics of Covid-19? We have not learned any moral lessons with them?

Bioethics and Medical Paternalism

In its early days, Bioethics was based on the adoption of normative principles, a branch of the discipline known as “principlism”. This branch, advocated by Tom Beauchamp and James Childress, consisting of four principles: respect for autonomy, beneficence, non-maleficence, and justice1. 

As stated by Vaughn7, “autonomy is a person’s rational capacity for self-governance or self-determination. In bioethics, respect for patient´s autonomy is a fundamental standard that can be violated only for good reasons and with explicit justification.” 

So, respect for autonomy became the main ethical foundation on which clinical practice rests (an abandonment of paternalism in medicine) In this way, bioethical analysis is almost centered on the individual's perspective. Except for the principle of justice, public health is not taken into account.

Relational Principles: Practical Aspects

At this point, we believe it is morally correct to embrace the concept of relational autonomy proposed by Kenny et al.7

Relational autonomy embraces the fact that persons are inherently socially, politically, and economically situated beings. A relational approach to autonomy directs us to attend to the many and varied ways in which competing policy options affect the opportunities available to members of different social groups… and to make visible how the autonomy of some may come at the expense of others.

The same concept can be applied to all principles. For example, the concept of non-maleficence and beneficence must not be restricted to the interests of a single individual but must be extended to the entire population. It allows us to see that sometimes autonomy, beneficence, and non-maleficence are best promoted through social change rather than simply protecting individuals’ interests. The principle of justice can also be analyzed from this relational perspective. Powers and Faden9 say that social justice is “the foundational moral justification for public health”. In our understanding, the concept of social justice can also be based on a personal value that we can call “empathy”, which we can define as the ability of someone to put themselves in the other's place. Empathy is a cognitive skill that can be invoked10, so that it becomes a value not only individual but of an entire society.

Thus, we can remodel the principle of justice, to also shelter social justice, with the perspective of "empathy". That is, we analyze not only the inequalities in a population from the econometric point of view, but from an affective point of view, taking into account the empathy for the suffering of others.

 Conclusion

The Covid-19 pandemic brought new dilemmas to the ethical debate. It is also an opportunity for us to rethink and reshape bioethical principles, regarding the health of the community. For example, in both cases mentioned above, we believe that the conduct taken by the factory supervisor and the police were correct- even though disrespecting the individual autonomy of those involved.

This does not mean a return to medical paternalism in ancient times, nor, in our view, a restriction of individual freedoms. To the extent that behaviors that are harmful to society are being practiced, putting at risk even other countries by the spread of new strains of the virus, we believe that the interests and safety of the population from all over the world are above individual interests. After all, it is the life of all of us that is at stake - a game in which there may only be losers (like the 400,000 Brazilians so far).

JÁ Carrese Sugarman J The inescapable relevance of Bioethics for the Practicing Clinician 2006 Chest 130 1864 1872 Fitts W T Ravdin I S What Philadelphia physicians tell patients with cancer 1953 JAMA 153 901 904 Potter V R Bioethics, the science of survival 1970 Perspectives on Biology and Medicine 14 127 53 Racine E Do We – and Should We – Have a Canadian Bioethics? 2020 Can J Bioeth / Rev Can Bioeth 3 3 1 10 Petrini C Gainotti S Requena P Personalism for Public Health Ethics. Ann Ist Super Sanità 2010 46 2 204 209 Kramer D B Opel D J Parasidis E Mello M M Choices in a Crisis - Individual Preferences among SARS-CoV-2 Vaccines 2021 N Engl J Med. Epub ahead of print. Kenny N P Sherwin S B Baylis F E Re-visioning Public Health Ethics: A Relational Perspective 2010 Can J Public 101 1 9 11 Vaughn L Bioethics – Principles, Issues, and Cases 2010 New York: OxfordUniversityPress Powers M Faden R Social Justice: The Moral Foundations of Public Health and Health Policy 2006 New York: OxfordUniversitPress Thangarasu S Renganathan G Natarajan P Empathy Can Be Taught, and Patients Teach it Best 2021 Journal of Medical Education and Curricular Development 8 1 3