Bioética y asistencia de la salud

Latin American Bioethics: intangible outline of the continent’s reality

Bioética latino-americana: intangível contorno da realidade continente

Latin American Bioethics

1. Where is Latin America?

At first glance, as the name suggests, one could delineate Latin American bioethics as a field of study developed in a specific geographic locus: Latin America. This definition, which touches on the obvious and slides into redundancy, fails to elucidate, even minimally, the subject because it faces a prior issue: there is no agreement on what would be the place of which and for which we speak when referring to “Latin America”.

Applying common sense, this would be the part of the continent composed of South and Central America and Mexico, encompassing the former Iberian colonies, which spanned almost the entire continent since the last decade of the fifteenth century (Atualidades Latinas, 2016). Other definitions circumscribe Latin America to countries whose language originated from the Romance languages, specifically Spanish, Portuguese and French, which, strictly speaking, would also extend the definition to the northern hemisphere. On the other hand, ECLAC, one of five regional commissions of the United Nations, dissociates Latin America from the Caribbean, as evidenced by its name: Economic Commission for Latin America and the Caribbean (Cepal, 2016). This disassociation emphasizes the English, French and Dutch languages that, in addition to Spanish, were officially adopted in some of the countries of the region, as well as the cultural differences resulting from their insular condition and colonization. In general, it is noted that there is no consensus regarding the definition.

Despite the apparent distinctions and dissension that this may cause, one can find common ground in the definition: “Latin America” is characterized in terms of location, culture and ideology by colonizers, alluding to the people who stormed the continent 500 years ago, and to the origin of their language. Thus, one can understand that within the definition there is an intrinsic element of domination. This a priori denied the autonomous existence of others, the people who inhabited the continent, thereby depriving them of their identity and giving their territory a name that refers to the process of colonization. Therefore, in other words, Latin America would be the portion of land between the Pacific and Atlantic oceans, both in the Southern and Northern Hemispheres, that were conquered and dominated from the late fifteenth century by the Spanish, Portuguese, French and Dutch, who imprinted their brand of domination on local culture.

But there is, in this broader context, one aspect that transgresses the Cartesian organization of space. This element is symbolically so powerful that it moves even the geographical landmarks, transferring to the Tropic of Cancer the function of the Equator, and restricting North America only to what is above that line, that is, countries whose colonization included people of other ethnic backgrounds, especially Saxon and French. Thus, according to this perspective, which challenges, imposes itself and models even the discourse of Latin American culture, the North of the Americas is composed of the United States and Canada, excluding all other countries above the Equator, including, Venezuela, Colombia, the Guianas, Suriname, all Central America, the Caribbean, Mexico and parts of Brazil, which are now considered as belonging to the south.

The differences brought about by migratory flows originating from other parts of Europe, have proved particularly influential in the far North of the Hemisphere. While the French presence was being consolidated in large part of Canada and in the South of the US in the society of plantations, the various waves of migrants from continental Europe and of English origin, were in search of land and religious freedom. This created the foundation of the rift that not only severed and ranked “natives” and “settlers”, but also opposed the settlers themselves, separating them by ethnic origin to which hierarchal elements of cultural order are attributed. Added to this dichotomous construction of reality were the subsequent territorial conquests by the United States in the war against Mexico (Mendes, 2005). The conflict, which occurred between 1846 and 1848, reduced the Mexican territories to less than half (Ham & Maya, 2001 Conclusiones § 2) and consolidated the territorial expansion of the –united– states that formed the USA, emphasizing through the same process the symbolic section that built the asymmetry of otherness between the Saxons or French and “Latino” colonizers:

The first is called cultural asymmetric opposition, which occurs when Latin America is defined by the absence or denial of habits, customs and institutions assigned to the American collective self. Through it America perceives itself as Protestant, universal and democratic, while perceiving Latin America as an Other who is Catholic, particularistic and authoritarian. The second is a time-based asymmetric opposition that occurs when Latin America is defined by the lack of synchrony with the historical present of the collective American self, that is, by a historical inability. This means that while the American self-image is modern, progressive and developed, in other words, it is as an agent of its own history, Latin America is defined as primitive, traditional, backward or underdeveloped. Finally, we have the racial asymmetric opposition that occurs when the other is defined by the lack or incompleteness of the physical and/or psychological characteristics attributed to the self. In this case, America defines itself as white and Anglo-Saxon, while Latin America is represented by non-white and those of mixed race (Feres 2004, §4).

According to Mendes (Mendes, 2005), Schoultz believes that “the belief in Latin American inferiority is the essential core of US policy towards Latin America, because it determines the precise steps that the United States takes to protect their interests in the region” (Schoultz, 2000, 13-14). Thus it is clear that the definition of North and South is not geographical, but ideological, forged for economic reasons, applied by political tools and supported by cultural prejudices designed for the purpose of domination.

As a result of this essential definition, Latin American bioethics would simply be a theoretical model forged in this geographical area, which stretches between Mexico and Patagonia, permeated by common linguistic elements that originated from the Iberian colonization process. But, as one can clearly see, although this delimitation may indicate the area one refers to, it does not help in the understanding about whom one speaks or regarding what one has to say. And, if the location of the speech is created from the symbolic marks that sever and rank, who talks about Latin America is the other, raised by the “self” to a superior position, in flagrant disparity to “us”. Both “I” and “we” were symbolically or economically dominated by the other, the one who creates and highlights differences to mark their “right” to rule and our essential duty of subordination.

2. Who is Latin-America?

If the idea of Latin America refers to the colonizer and their ideation of space, to understand who or what is spoken in Latin American bioethics it is necessary to first distinguish who were these colonizers, where did they come from, where did they arrive, and how they exercised the process of domination over the peoples they encountered on the continent. They are the role-players entering the plot of continental history to create the conflict of otherness. There are reports that, under papal arbitration, the Spanish and Portuguese divided the lands overseas that were soon to be coveted by the French, Dutch and English, who temporarily or permanently appropriated some portions of these landholdings.

At the time, neither the meridians nor the equator had been delineated, and it was the Treaty of Tordesillas that mapped out what today is understood as the Americas, defining the owners of the land. The Portuguese domination focused on a small part of what is now the coast of Brazil, while the Spanish territory extended to most of the Americas, covering what today constitutes the United States (US), Central America, the Caribbean and South America. Due to the continental dimension of their territory, the meagre communication and transport resources of that time, and the extractive aims of the crown, Spain failed to explore or colonize a considerable part of the land they considered to be their right, especially the more extensive territories such as the Northern part of the continent.

In the Northern Hemisphere, Spain was able to found colonies in areas we now consider as Central America and the Caribbean: Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Antigua and Barbados, Cuba, Hispaniola (Dominican Republic and Haiti), Jamaica and Puerto Rico, besides Florida, Louisiana, California, Oregon, Texas, New Mexico, Arizona, Nevada, Utah and parts of Colorado, Kansas and Oklahoma (Olimpio & Sampaio, 2006, 2). In the Southern Hemisphere, the Spanish crown initially established the Vice-royalty of Peru, to explore the Andean silver mines, subdividing it later into two other administrative areas, focused on the Caribbean and the River Plate regions.

Covering almost the entire continent, the Spanish colonizer’s control stretched from coast to coast in the Pacific, from Alaska to Patagonia, and, in the Atlantic coast, from the Southern region of the US to the mouth of the River Plate, with the exception of the Brazilian coast, which was under Portuguese domain. Despite the inequality of their territorial extent, the purposes of Iberian domination, whether Spanish or Portuguese, differed little in the new world, being primarily focused on the exploitation of natural and human resources for the parent country. Such unity of purpose became similar to colonial enterprise in the territories that are now considered Latin America, which was characterized by the dispossession of lives and the elimination of the culture of indigenous peoples. This main objective, however, was reflected in the different ways that the multitude of cultures wove the substrate of domination.

Ranging from tribal societies to empires, marked by disparate social structures and symbolic systems, the differences in Native American societies and cultures make it difficult to identify a unique set of values and principles that can currently be considered a matrix for the construction of a common identity for Latin American bioethics. If there is any unity, it was built in response to the colonizer, as a reaction that was outlined in the escape attempts, rebellions and independence of the dominated peoples, manifested in nativist movements that marred the independence processes and the consolidation of national states throughout the region.

Therefore, considering the differences in native social and cultural foundations, on which the Iberian domination was set, one can draw an outline of what the peoples of the continent, with their in-built Latin culture, have to say: the reaffirmation of their indigenous identity, resumed from the clutches of the colonization process, and rebuilt from the rubble of the colonial enterprise. This discourse is expressed in ethical and bioethical terms through the construction of proposals aimed at reducing extreme social and economic inequality that still marks the reality of people living in the region. Given that this paper does not have space to list this extensive body of work, which is best represented in the Diccionario latinoamericano de bioética (Latin American Bioethics Dictionary – Tealdi, 2008, we present reference to some works and authors to illustrate this statement (Anjos, 2000; Bergel, 2006; Codina, 2007; Fortes, 2008; Garrafa, Oselka & Diniz, 1997, Junges, 2006; Kottow, 2011; Oliveira, 2003; Pfeiffer, 2006; Porto & Garrafa, 2005; Schramm, 2005; Tealdi, 2007).

Latin American bioethics also advocates the full inclusion of the guarantees inherent in human rights for all those who, since the invasion of the Americas, were repeatedly dispossessed of their territory. It defends the concrete life of people who, from the “invention” of Latin America, have been subsumed in their self-determination and social and economically relegated to be “next to the social scale, (to) real or sentimental standards of life” (Campos, n.d., 127).

3. What can we aim for?

Currently developed bioethical perspectives reflect the duplicity of locus as well as the cultural, economic and health differences between the realities of the North and South of the continent. The Biomedical Ethics Principles (Beauchamp & Childress, 2002), which consolidate the scope from bioethics to clinics, stand out as the epitome of what American bioethics represents. In the wake of this landmark the Declaration of Helsinki (Associação Médica Mundial, 1964), which transposes principlism to research, is also included.

Principlism revealed itself to be extremely effective. Consisting of the prima facie application of four parameters of conduct, three of which were already widely described and punctuated by the health profession’s codes of conduct, the proposal had a teaching tool for the application of a single innovative parameter in relation to the Hippocratic philosophy: respect for autonomy, which began to be mediated with the introduction of the consent form. Even compared to other coeval proposals that went beyond the biomedical field (Potter, 1971), the ease of understanding and applying the principlist proposal contributed to its rapid spread around the world, consolidating an univocal understanding of what Bioethics would be. In fact, it is still “reassuring” to apply such a recognized and effective theoretical proposal, which leads to the temptation to “forget” its limits and constraints.

While the principlist tools aimed at conflict resolution in clinics and research were firmly endorsed by health professionals, they were not able to equally grasp the complexity of the social dimension (Diniz, Guilhem & Garrafa, 1999). This characteristic manifests itself in the analysis of the health-disease process in any reality. It becomes even more visible in those contexts where extreme inequalities of power and access to citizenship determine the conditions of life and the health conditions of a significant portion of the population. It is especially in contexts such as these that respect for autonomy needs to go beyond offering the best therapeutic response or complying with standards of civility and courtesy. Extreme poverty, hunger, and diseases that could be avoided with prevention or access to treatment, are some of the topics that openly challenge the set of principlist tools, demonstrating that, even with the greatest goodwill, they are not able to respond to the complexity of health conflicts in the social dimension.

The difficulty inherent in the application of the principlist tool in the social dimension ended up conditioning two basic types of responses. Either the discourse of bioethics was restricted to conflicts in clinics and research, allowing for an accentuated reductionism of the characterization of “health” and its connections with bioethical reflection, or it sought to reveal the impasses in the social dimension of health with a set of such small and specific tools that inevitably it ended up wasting analytical efforts and generating heightened frustration. The fact that a health professional or team act according to the criteria that ensure beneficence; that their actions do not incur non-maleficence; that they meet the criteria of justice that prevail in their social context; and that they respect the patient’s autonomy and ability to choose, does not guarantee the elimination of social inequalities or lessen the injustices that affect the factors that lead to illness.

In response to this circumstance, that implodes the limits of clinics and extrapolates the capacity of health professionals to respond, Latin American bioethics and, specially, the different conceptions of Brazilian bioethics, are articulated in the defense of the expansion of the scope of action of the discipline, leaving the demarcated neighborhood of the biomedical field, which is consecrated by principlism, encompassing the social dimension in the bioethical analysis of conflicts in health. Without spurning principlism, but seeking to go beyond the analytical frameworks of the four principles, the different branches of Latin American bioethics and, specifically, of Brazilian bioethics (Siqueira, Porto & Fortes, 2007; Braz, Raggio & Junges, 2007) speak on behalf of the vulnerable (Diniz & Guilhem, 2000; Schramm, 2008) and adopt the references of human rights (Oliveira, 2010), considering the milestones outlined in treaties, conventions, conferences, statements and other anarchic instruments of international standardization1. Culminating this process, of recognizing the expanded scope of Brazilian and Latin American bioethics, is the Universal Declaration on Bioethics and Human Rights (UNESCO, 2005), which confirms the validity of providing a social dimension for the analysis of the field, making it an interdisciplinary debate and a plural proposition.

The different bioethical proposals that originated from Latin American countries bear the imprint of a social perspective, contemplating the historical, cultural, economic and social circumstances of peoples and territories of the region. In the case of Spanish-speaking countries, which make up most of South and Central America, this perspective is developed from proposals that were designed based on the theory of coloniality, which discusses the power relationships arising from the European domination process in Latin America and its consequent ramifications in terms of the construction of thoughts, ideas, concepts, categories, hierarchies and even of the logic structure that organizes the hegemonic and indigenous knowledge (Quijano, 2009; Mignolo 2000; Lander 2000; Colombres, 2004; Briones, 1998).

The perspective of coloniality highlights the cultural and structural specificity of the native peoples of South America advocating their right to an identity detached from the European model, as pointed out by the authors mentioned above, who are just a few names, among others, brought to illustrate this analytical theoretical perspective. For this line of thought, even the name “Latin America” would be an imposition that characterizes the native peoples according to the perspective and geography of the colonizer (Porto-Gonçalves & Quental, 2012). Although resounding in all groups, societies and cultures native to the Americas that seek to maintain the tangible and intangible heritage of their cultures and indigenous organizational forms (Bonilha, n.d.), the discourse of coloniality is especially poignant among the current Andean peoples, whose ancestral culture subsists and fights for recognition in the small communities throughout the Andes.

This is the case, for example, of the armed resistance fought for 20 years in the mountain areas of Southern and Central Peru, where more than 75% of the 69 thousand people killed had Quechua or other native languages as their mother tongue “the conflict seems to have exposed a central problem for the country, which is the indigenous issues and the multiple elements that permeate them, such as racism, social and economic marginalization, and the invisibility of indigenous peoples” (Fávari, 2015).

Although the perspective of coloniality condones bioethics gestated in Latin America, focusing its arguments on conflicts arising within the social dimension, particularly vulnerable groups and segments, it cannot be said that it equally condones the same world view regarding the value and meaning of human rights instruments as conceptual tools of applied ethics, capable of mediating and promoting dialogue between those who differ. Focused on social and cultural differences between these groups, and especially in relation to the surrounding society, some of these bioethical proposals, which were drafted based on the study of coloniality, consider the human rights instruments excessively universalist, which prevent the emergence of particular characteristics and go against the indigenous processes of cultural affirmation (Nascimento, 2012; Feitosa & Nascimento, 2015). However, it is worth noting that among the human rights are the cultural rights (ICESCR, 1966) that should be taken as an expression of “how individuals, groups, segments and populations want to be provided with economic and social rights to, simultaneously, eliminate inequalities without suppressing differences”(Porto, 2012, 122).

Although the need to recognize specific rights of social groups/segments, marked by color and gender, as well as those aimed to ensure guarantees to ethnic, religious and age groups, is undeniable, it will not be the simple negation of human rights from the perspective of coloniality, taken as an example of the hegemonic rhetoric and epistemology, that will increase the forum of these groups and segments to speak, or consolidate the power of native cultures. In a time of global communication, it is unrealistic to imagine the possibility of keeping people living in certain cultures isolated from the social environment, in a bell jar that would keep them “unpolluted”, away from the “danger” of cultural contagion. This difficulty allows the discourse of coloniality to be classified much more as a legitimate record of the manifestation of nonconformity in relation to power and to the hegemonic society, rather than as a pragmatic proposal for applied ethics.

On this point, it would not be too much to resume the proposition presented earlier regarding the importance of human rights as a horizon of common morality since the mid-twentieth century: “(...) I believe that human rights inaugurate an egalitarian view of the world, unprecedented in history. Before its conception, inequalities were naturalized and, in this context, the differences between people and cultures could be overshadowed and suppressed without the consciences of those exercising hegemonic power being troubled” (Porto, 2012, 121). Human rights present moral parameters agreed between national states. Even if the recommendations endorsed in those instruments are not yet applied to all human beings, as recommended by the international treaties themselves (among these the Universal Declaration of Human Rights – UN, 1948), the notion of equality of rights for all human beings is unprecedented in history and has the potential to stimulate effective equity.

Thus, trying to answer the fundamental question that prompted this digression – which characterizes Latin American bioethics – it can be said that it is configured around theoretical proposals aimed at promoting equality for people and cultures of the region. Even in cases where it is based on proposals that exalt the essential characteristics of groups and societies, such as the perspective of coloniality, the organization of Latin American bioethics is based on the egalitarian framework of human rights, because it was the emergence of this fundamental concept that led to the rise of the different local and regional perspectives, that point to and analyze inequities. By simply encompassing all human beings, the notion of human rights opens up the possibility of organizing the fight for the real consolidation of these guarantees and for the articulation of the discourses that demand recognition and respect for differences, which may gradually cease to be factors for discrimination, becoming inalienable elements of an identity.

4. Resuming the purpose?

Considering the selected aspects that circumscribe the idea of Latin American bioethics –location, history and culture– it is possible to characterize it as a proposition for applied ethics formulated in Latin America, preferably by and primarily for the Latin American peoples, taking into consideration the factors that determine and constrain culture, the living conditions, and the health situation of the populations of the region. However, this minimalist definition opens the possibility for the formulation of questions regarding each and every one of these parameters: “Should Latin American bioethics be considered only in and for Latin America?”, “Should it consider the influence of Iberian colonization as a common element of the domination and acculturation of native peoples?, “Must it take into account the cultural specificities of native peoples or could it be drawn from a common basis of human rights?”, “Would it be able to deconstruct the logic of coloniality or would it be just another instrument of hegemonic power?. Or even, “Could it provide conceptual tools that could act effectively in the resolution of social conflicts in health?”

I believe these questions and many others that can arise when trying to establish a concept of such a scale and scope will not be answered definitively, at least not for now. As we have seen, the difficulty of characterizing Latin American bioethics starts with the definition of the concept and spans issues that go beyond the analytical possibility of a conceptual framework that is, spatially and temporally, significantly defined for such a great diversity of peoples and cultures.

One can, for example, question the locus of this applied ethics because the world’s misery is not restricted to nor only concentrated in Latin America. One can also object that the woes of the population groups and peoples dispossessed of their rights, and even of their self-determination, are not limited to the effects of the Iberian colonialist enterprise on the original inhabitants of the region, to which even African natives, who were brought to the Americas against their will and used as the driving force of the economy, can be added. This adverse situation extends to the Northern Hemisphere, which was subject to other colonization policies, where both the original populations and the African descendants are, still today, an especially vulnerable population group.

Moreover, it would be incorrect to disregard the changes promoted by the contributions of information technology, which act directly on traditional forms of communication, radically changing the interpersonal contact processes and intercultural exchange. Except for those populations who remain really isolated, without any interchange with the surrounding world, the densification of contact altered the perception of space and the sense of time. It changed the proximity standards, establishing close relations even between strangers, while normalizing desires by inscribing them definitively in the context of the consumer society. This process, which is not restricted to real time distance communication, but also includes the transport of people and goods, tends to amalgamate peculiar aspects of regional cultures, diluting, mixing and reinventing their cultural traits.

Thus, more than defining a conceptual framework, establishing a regulatory unity or pointing a methodological tool to deal with otherness in the context of which is usually understood as Latin America, and with the kind of applied reflection that is intended in bioethics, the framework outlined in this paper points to the importance of thinking in terms of comprehensive ethics, detached as much as possible from particularistic labels and time-space limitations. A process that responds to contemporary challenges of increased contact between peoples and cultures and can generate a global, or better yet –planetary– bioethics (Fortes, Carvalho, Tittanegro, Pedalini & Sacardo, 2012; Cunha & Lorenzo, 2014), which takes into account the first three generations of human rights for all without forgetting the specific cultural identities of the myriad of peoples who inhabit our world. Finally, bioethics that starts from the utopian notion that all existing people, regardless of sex, gender, color, ethnicity, age, wealth or culture, should ensure life and quality of life are guaranteed.

Life is defined in existence itself. Quality of life is based on preventing any avoidable suffering, whether by suppressing hostility and processes of domination and subjection, or by providing access to the attributes that characterize the dignity of human life in society. Having education and health as a basis, dignity is also based on freedom of choice, which fosters the exercise of will and self-determination, and on social justice, which is demarcated by ensuring access to tangible and intangible assets and to the essential conditions for the maintenance of the person’s existence and their lives as members of a group, segment, people or population.

The possibility of sustaining life and existence, and ensuring quality of life for all people in any territory, country, state or nation can provide a new relational level for humanity. A level in which to be “human” underlies the dignity of persons, and their right to life and quality of life. A relational plane in which nationality, being male or female, straight or gay, religious or atheist, from the North or from the South, does not necessarily imply a power asymmetry and that differences can be taken for what they are: legitimate expressions of identity.


1Listed below are some international human rights instruments aimed at different groups and segments with their respective singularities. The recommendations of these instruments can work as parameters for bioethics that are socially orientated, comprehensive and committed to the respect of equality and differences as well as to the practice of equity: a) United Nations. [Internet]. International Covenant on Economic, Social and Cultural Rights (ICESCR). UN, 1966. [Accessed on the 12th May 2016]. Available in Portuguese at: http://www.planalto.gov.br/ccivil_03/decreto/1990-1994/d0591.htm b) United Nations. [Internet]. Vienna Declaration and Programme of Action of the 1993 World Conference on Human Rights. UN: Vienna; 1993. [Accessed on the 12th May 2016]. Available in Portuguese at: c) United Nations. [Internet]. Millennium Declaration. UN: New York, 2000. [Accessed on the 12th May 2016]. Available in Portuguese at: https://www.unric.org/html/portuguese/uninfo/DecdoMil.pdf d) United Nations. [Internet]. Beijing Platform for Action. UN: Beijing; 1995. [Accessed on the 12th May 2016]. Available in Portuguese at: http://www.unfpa.org.br/Arquivos/declaracao_beijing.pdf e) United Nations. [Internet]. UN Convention for the Elimination of all Forms of Discrimination against Women (CEDAW) UN; 1979 [accessed on the 12th May 2016]. Available in Portuguese at: http://www.pge.sp.gov.br/centrodeestudos/bibliotecavirtual/instrumentos/discrimulher.htm f) United Nations. [Internet]. World Conference against Racism, Racial Discrimination, Xenophobia and Related Intolerance. UN Durban; 2001. [Accessed on the 12th May 2016]. Available in Portuguese at: http://www.gddc.pt/direitos-humanos/Racismo.pdf g) United Nations. [Internet]. Report of the International Conference on Population and Development. UN: Cairo; 1994. [Accessed on the 12th May 2016]. Available in Portuguese at: http://www.unfpa.org.br/Arquivos/relatorio-cairo.pdf

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