IV. LATIN AMERICA

This entry presents a historical panorama of biomedical ethics in Latin America, the name given to a linguistic and cultural community encompassing South America, Central America, Mexico, and part of the Caribbean. From political, economic, and social points of view, the Latin American nations are quite different, although at present they have underdevelopment in common.

Since bioethics as a discipline flourished first in the United States, it is useful to compare medical ethics in North America, with its predominantly Anglo and northern European culture, and in Latin America, pointing out the differences between the two traditions within the Western culture.

First, the Latin American tradition of medical ethics is described; next, the incipient bioethics movement in Latin America is considered; then the major bioethical problems of the region are noted; and finally, the challenge to Latin American bioethics is discussed.

The Latin American Tradition of Medical Ethics

When Spain and Portugal established colonies in the Americas, they brought with them the profound influence of the Roman Catholic Church, heir to that Western culture whose roots are Greek philosophy, Judaism, and Roman law. The Catholic tradition has in fact defined Latin American ethics and the Latin American ethos. First, Catholic moral theology built a system of medical ethics based on (1) natural-law theory as the basis of morality; (2) the principle of the sanctity of human life as a moral criterion; and (3) the commandment of love, or the virtue of charity, as the golden rule. Second, through their pastoral role and religious authority, priests reinforced the paternalistic medical ethos of the Hippocratic tradition. The paternalistic model of medical responsibility centered on the principle of beneficence (that benefit must be produced and harm avoided); the principle of autonomy is not taken into account. Beneficent paternalism has dominated the relationships between doctor and patient, and between medicine and society, in Latin America up to the present day.

As the cultures of northern and southern Europe evolved in the Americas, the differences between the two were accentuated. Modernity did not have the same secular, liberal, and pluralistic cast in Latin America as it did in North America. In Latin America, morality was not detached from metaphysics and religion; it did not establish a new basis in scientific and political rationalism, nor did it set itself up as critical and autonomous over against the natural and supernatural order of the medieval epoch.

Beginning in the eighteenth century, it is possible to contrast two ethics: the classical tradition of virtue, represented by the Mediterranean peoples (particularly the Italians and Spaniards), and the tradition in which principles are central, dominant in the English-and German-speaking countries (Mclntyre). In Latin America, the political paternalism of the ancien régime and the medical paternalism of the Hippocratic tradition go together; the result is a paternalistic model on both the individual-clinical and the social policy levels.

The ethics and ethos of Latin American medicine are expressed in professional codes of ethics and in health policy and legislation. The forebear of all these normative institutions was the protomédicato. Originating in the Roman Empire, the protomédicato was a tribunal of royal physicians (protomédicos) that granted professional licenses and acted as a judicial and legislative body in health matters. In the thirteenth century, Castile was one of the first kingdoms to establish legal regulations for medical practice and public health; examples of this were found in the School of Salerno, and the laws of Frederick II in Sicily (Mainetti, 1989). The protomédicato was transplanted from Spain to the Americas, where it endured until the period of independence (early nineteenth century), at which point medical instruction, practice, and policy began to be modernized.

In the twentieth century, professional associations and medical colleges in various countries began to formulate their own codes of ethics, in accordance with the deontological tradition that regulates the relationships of doctors among themselves, with the public, and with the state. One of the first such codes was drawn up in 1918 by Luis Razetti, a leading Venezuelan physician who specialized in medical deontology, under the influence of the French—an influence that was at that time very perceptible in Latin American society in general and in the medical culture in particular. This same code was later adopted in Colombia (1919) and in Peru (1920); it provided a basic model for other Latin American codes, which are essentially traditional guides for professional courtesy or etiquette, the relationships of physicians among themselves, with the patient, and with the state (León).

The medical codes promulgated in many Latin American countries are influenced by a variety of factors, among them biomedical progress, malpractice legislation, and the political changes throughout the region after decades of military rule. Brazil's Federal Code of Medical Ethics (1988), for example, incorporates concern about new problems like AIDS, and reformulates the rule of medical confidentiality. The Medical College of Chile has been very active since 1984, demonstrating its sensitivity to—among other issues—the participation of Chilean physicians in torture during the years of authoritarian rule that ended in 1984 (Mainetti, 1990).

The state's responsibility for healthcare has constitutional status in Latin American countries (Pan American Health Organization, 1989). The right to healthcare is included among social and economic rights. The first nation to incorporate the right to healthcare in its constitution was Chile, in 1925, followed by Bolivia, Cuba, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, Paraguay, Peru, Uruguay, and Venezuela. The responsibility of the state for health planning is legislated by many Latin American countries, which provide for universal access to essential medical services and a national healthcare system that is either free or based on co-payments, but with limited coverage. In Latin American government, health policy generally demonstrates a significant gap between principle and practice: between justice, which theoretically endorses the equal right to health care, and actual practice in societies that, owing to their social and economic development, are not able to guarantee that this and other rights will be respected.

Codes of ethics and health legislation are based on a moral view that is both dogmatic (codified and legalistic, in contrast with philosophic, analytic, and critical) and authoritarian (based on professional authority, which is partly religious and partly governmental, rather than civic or democratic). The Latin American tradition of medical ethics can be defined as naturalistic, paternalistic, dogmatic, and authoritarian. The new Latin American medical ethics, represented by bioethics, has developed in contrast with this older tradition.

The Bioethics Movement in Latin America

The bioethics revolution that has occurred in the industrialized nations has arisen both from the scientific and technological progress of biomedicine and from the liberal and pluralistic character of those nations. By contrast, in the developing Latin American countries bioethical interests correspond more to those of a low-technology society and a tradition of confessional morality (Mainetti, 1988). Bioethics, based on the principles of beneficence, autonomy, and justice, may be seen as civic morality to which the parties to an increasingly conflictual relationship—physician, patient, and society—appeal. Or bioethics may be seen as medical culture, expressed in the "introduction of the moral subject into medicine," the promotion of the rational, free agent in the therapeutic relationship. It is fair to say, however, that bioethics has barely arrived in Latin America in either guise.

Latin American bioethics evolved over a period of thirty years, in three decade-long stages, commencing in the 1970s: reception, assimilation, and re-creation. Public and academic interest in bioethical topics appeared in the 1980s with the proliferation of new medical technologies, such as those used in intensive care units, transplants, and assisted reproduction, and with the appearance of democratic governments in the region. On the one hand, legal intervention in medical cases increased, due perhaps to the distances created between the professional and the patient by specialization. Malpractice and a patient's rights movement in Latin America imitated the early history of U.S. bioethics. On the other hand, there was an academic rehabilitation of practical, moral, and political philosophy as they could be applied to medicine. This development was in keeping with the kind of ideological pluralism and consensus formation that has characterized bioethics as a discipline in the United States.

The academic and professional development of bioethics in Latin America has been a process of incorporating the U.S. model in stages. As the twentieth century neared its end, the institutionalization of the discipline as expressed in the creation of research centers, professorships at universities, ethics committees at hospitals, and national commissions on bioethics could not be said to be significant. Nor had the three main functions of bioethical studies been carried out. These are the educational function (deontology and legal medicine still stand for ethics at medical schools); the consultative function (clinical and healthcare ethics are not practiced in hospitals and other healthcare facilities); and the political function (groups of experts have not formed to advise public institutions on biomedical norms). Bioethics is also just beginning to capture the attention of the public and the media.

Among the groups active on the Latin American bioethics scene, several deserve mention: the Instituto de Humanidades Médicas y Centro de Bioética of the Fundación Mainetti (Institute for the Medical Humanities and Center for Bioethics of the Mainetti Foundation) in La Plata, Argentina, and the Instituto Colombiano de Estudios Bioéticos (Colombian Institute for Bioethical Studies) in Bogotá, Colombia. The former, established in 1972, combines the European and Anglo-American traditions of medical humanism, serving as a model and resource center for other countries in the region, particularly through its Escuela Latinoamericana de Bioética (Latin American School of Bioethics, ELABE), directed by Juan Carlos Tealdi. The latter, founded in 1985 by Fernando Sánchez Torres, former dean of the National University of Colombia, together with the ASCOFAME (Colombian Association of Medical Faculties) with its Center for Medical Ethics, directed by Alfonso Llano Escobar, S.J., and the Colombian School of Medicine and its Health Care Ethics Committee, also lead in the process of renovating medical ethics in the region.

Other academic and professional associations have emerged in Latin American countries in recent years for the purpose of developing programs of bioethical studies: the Department of Bioethics of the Catholic University of Uruguay; the Sindicato Médico of Uruguay, a very important professional organization that appointed a bioethics commission; the Department of Bioethics of the Chilean Catholic University; and the Chilean Medical College, mentioned above. These associations work actively on deontological questions, and the Brazilian Association of Medical Ethics Teachers emphasizes bioethical issues.

The bioethics enterprise also can be evaluated by the number of people interested in the discipline; by courses, conferences, and other scientific activities; and by the publication of books and articles. The classic 1973 Latin American text on medical ethics, by Augusto León, was followed by several bioethics texts (Mainetti, 1988; Varga; Vélez Correa). According to a 1990 report issued by the Pan American Health Organization, conditions in Latin America were expected to encourage the development of programs to integrate medical ethics into the health system. This integration could occur along a broad spectrum ranging from legislation and public policies to academic curricula, and should include the revision of the ethics codes of established medical associations. To this end, the Latin American School of Bioethics has been coordinating a regional program of hospital ethics committees since 1989 (Tealdi and Mainetti). The growth of interest in bioethics justified a Latin American bioethics association to unite isolated efforts, and thus to offer a concerted response to the needs of the region. Meeting in La Plata, Argentina, in December 1991, representatives from several Latin American nations founded the Federaciòn Latinoamericana de Instituciones Bioéticas (Latin American Federatíon of Bioethics Institutions, FELAIBE).

In 1990 the Pan American Health Organization (PAHO) commissioned James Drane of the United States to produce a decisive report that reviewed the development of bioethics in Latin America and proposed several steps for the further regional development of the discipline (Drane and Fuenzalida). That same year, PAHO published a special issue on bioethics, edited by Susan Scholle Connor and Hernàn Fuenzalida-Puelma, formally introducing bioethics in Latin America. This was the first collection in which early authors in the field addressed diverse topics and set out different perspectives on the discipline. Finally, PAHO, a pioneer among international health organizations, created the Regional Program on Bioethics (1994) with headquarters in Santiago de Chile, but whose activities are decentralized in order to serve all the member countries of PAHO. This program—a comprehensive policy in bioethics and its associate disciplines—entered a new stage under the outstanding scholar Fernando Lolas Stepke's leadership (Programa Regional de Bioética, 2000).

Bioethics has become a field of new challenges in Latin America. A seeming uniformity hides a rich, heterogeneous set of activities. Not only European and Christian influences but also indigenous intellectual traditions are very important in the development of Latin American bioethics. It does not have its own philosophy, as Anglo-American bioethics is perceived to have, but it does have its own literature or narrative. The particular historical setting, cultural ethos, and social reality of Latin America could infuse new life into the global bioethics community. In this sense, a symptom of the new times is the fact that the Second Congress of the International Association of Bioethics took place in Buenos Aires, Argentina, in 1994, and the Sixth Congress was held in Brasilia, Brazil, in 2002. A "new Brazilian bioethics" or "hard bioethics," inspired by Brazil's contradictory social reality, began to flourish at the turn of the twentieth century, and explores alternative perspectives to traditional bioethical currents (Garrafa).

Bioethics first arrived in Latin America as a foreigner, and later underwent a transcultural shaping. Transplanted to a new habitat, bioethics took on its own distinctive character and voices and has become a strong intellectual and political enterprise (Lolas Stepke, 1994; 1998).

In comparison to the North American style of bioethics, Latin American bioethics takes a more theoretical and philosophical approach. As a search for a critical, radical and global bioethics, Latin American bioethics represents a global, "post-bioethical" age (Drane, 1998; Spinsanti). Although Latin American bioethics is far from being a unified theoretical system or a single coherent perspective, it represents the ethica spes of the new millennium.

Major Topics in Latin American Bioethics

Latin American countries share a concern about a number of problems with implications for both law and policy. A common sociocultural and public-health situation defines the Latin American biomedical ethos. Ethnomedical ethics ought to be an essential topic, because the health and disease conceptions, practices, and values, as well as the needs, of the native (precolonial) Latin American peoples are not properly understood by academic medicine and the health policy of the dominant culture. These peoples still await the fulfillment of the World Health Organization's proclamation calling for the integration of their healing arts into modern medicine. Among the most pressing bioethical issues facing Latin America are the following.

REPRODUCTIVE ETHICS. Both the prevention of human reproduction (contraception, sterilization, and abortion) and assisted human reproduction (reproductive technologies) are central issues for Latin American population policy. This policy is clearly linked to health and to religious, secular, and geopolitical factors. Underdevelopment and overpopulation form a vicious circle that distances societies more and more from the goal of sustainable development. The Catholic Church does not tolerate what it calls "artificial" control of fertility and condemns abortion, which is legally prohibited in most Latin American countries. To date neither public debate nor legislative reform has occurred, although the widespread and frequent practice of clandestine abortion effectively expresses Latin American governments' laissez-faire policies. The ethical complexity of assisted reproduction provokes polemics about the status of the embryo without leading to a declared war between "Catholics" and "secularists, " but this area requires legal regulation.

THE ETHICS OF DEATH AND DYING. In Latin America, death is not as medicalized nor is the medical profession as tormented about it as is the case in the First World. The technological assault on dying, the new danse macabre in the intensive care unit, does not offer the same sort of spectacle in Latin America as it does in the United States. Nevertheless, the contemporary "art of dying" is a challenge in Latin America, too, even if living wills, do-not-resuscitate orders (DNRs), the ethical principles of critical care medicine, and the pro-euthanasia movement have yet to become major issues. Palliative medicine, the hospice movement, and campaigns for death with dignity are the modern Latin American versions of ars moriendi. At the beginning of life, pediatrics ethics committees are improving regulations regarding the treatment of premature and disabled newborns. At the end of life, legislation authorizing removal and transplantation of organs has advanced markedly in many Latin American countries (Fuenzalida-Puelma).

RESEARCH ETHICS. Biomedical research in Latin America lacks both a legislative framework and an effective set of controls. Much research also lacks scientific validity and, motivated more by monetary interest than by interest in knowledge, overlooks patient's rights such as consent and confidentiality. Developing countries must create the scientific and financial conditions for research itself; they must also attract projects that involve international cooperation while avoiding the risks such cooperation often brings with it, including economic and human exploitation. Oversight committees are needed so that international standards, with criteria appropriate to the cultural modalities of each community, may be applied. U.S. standards of consent, for instance, cannot be implemented easily in the social conditions of developing countries (Levine). Questions that must be considered in the future include research priorities, allocation of resources for research, and access to new, experimental drugs. This last issue, which has an especially high profile because of the global AIDS crisis, now involves not only the right of patients to protection from possible ill effects but also their right to have access to such drugs, which may prolong or save their lives.

HEALTHCARE ETHICS. Health status in Latin America must be seen within a larger picture of underdevelopment, poverty, hunger, and economic crisis aggravated by the foreign debt of the region. Two global short-term goals set by the World Health Organization have not yet been reached in Latin America: Infant mortality has not been brought below 5 percent, and life expectancy has not risen beyond sixty-five years. Healthcare expenditures in Latin America did not exceed 5 percent of the gross national product in the 1970s and 1980s, compared with 10 percent for the so-called developed countries.

Although there is a plethora of medical students and an oversupply of physicians, approximately 75 percent of the population of Latin America does not receive medical attention. This dramatizes the gap between the proclaimed right to healthcare and the conditions necessary to exercise it. Primary care—including family planning, maternal and child care, immunization, health counseling and education, campaigns against tuberculosis, and treatment of infectious diseases—should be the goal of health policy in all developing nations. Healthcare policy must be focused on health as an indicator of development, oriented to the basic needs of the majority of the population, and designed to promote medical care based on criteria of equity, integration, participation, and efficiency (Pan American Health Organization, 1989).

Between 80 and 90 percent of the resources allocated to healthcare in Latin America is spent on secondary and tertiary care. "Bioethics in the time of cholera," to paraphrase the novelist Gabriel García Márquez—medical ethics faced with plagues like cholera and AIDS—sums up the challenge to healthcare ethics in Latin America.

ENVIRONMENTAL ETHICS. The environmental problems of Latin America are in part peculiar to the region and in part similar to those in western Europe and the United States. Overpopulated cities like Mexico City, Caracas, and São Paulo are more polluted than their European counterparts, and the Latin American urban crisis ranges from street cleaning to disposing of radioactive wastes from nuclear power plants.

In agricultural areas, the indiscriminate use of biocides contaminates crops and reduces the fertility of the soil. The extinction of animal and plant species produces imbalances in the ecosystem. Of worldwide importance is the devastation of the Amazon rainforest, the largest jungle in the world. An ecological reserve with an influence on world climate, the area has been deforested by 10 percent. It faces the prospect of destruction within half a century, for reasons not unrelated to the sizable foreign debt owed by Brazil.

Governments and publics in Latin America are just beginning to become conscious of the importance of the environment to human and animal health; to national, regional, and world economies; to the preservation of nature and of life itself. Some countries have environmental protection legislation, projects to protect or preserve natural resources, and active ecology movements. Bioethics, however, has yet to raise its voice in civic and public arenas with regard to environmental ethics (that is, ecological rights), a new type of third-generation human rights, and policies of sustainable development (Pan American Health Organization, 1987).

The Challenge of Bioethics for Latin America

Because of its humanistic medical tradition and the social conditions of developing countries, Latin America can offer a distinctive bioethics perspective. There are two dimensions to this perspective. First, a discipline established along European lines of the general philosophy or theory of medicine, with three main branches (medical anthropology, epistemology, and axiology), may be better equipped to transform academic, scientific medicine into a new humanistic biomedical paradigm (Mainetti, 1988). Such an approach would guard against the accusations often lodged against bioethics in the United States and Europe: that the discourse of bioethics only appears to humanize medicine while obscuring the real dehumanization of the system. For example, the bioethical discourse on autonomy may hide the depersonalization of medical care and its risks of iatrogenesis, exploitation of the body, and alienation of health. In response to the development of biomedicine in a technological era, bioethics may be able to play a more critical role, one that is less complacent or optimistic about progress.

Second, the Latin American reality of "bioethics in the time of cholera" requires an orientation toward social ethics, with an accent on the common welfare, the good society, and justice rather than on individual rights and personal virtues (the modern and classical traditions of morality, respectively). A macroethics of health or public health may be proposed as an alternative to the Anglo-American tradition of micro or clinical ethics. Greater emphasis can be placed on the social importance of medicine; as far as medical ethics is concerned, the great need in the developing countries is fairness in the allocation of resources and the distribution of health services. Latin America has not lost hope that it might be the continent of justice.

Several decades after its birth, bioethics in the United States is moving toward new intellectual models. This movement shows up in the revisionist-foundationalist debate within the discipline; the application of ethics to other discourses, including the political arena; the rediscovery of ethics of virtue; the return to what is experiential; and the cross-cultural and international dialogue. The bioethics revolution in North America and Europe—summarized in a high-technology bios and individualized ethos—must be complemented in Latin America by a humanistic bios and a communitarian ethos.

A promising outlook is emerging as the bioethics traditions and problematics of the two Americas move closer to one another. Perhaps in the context of the new world order and the beginning of the twenty-first century, bioethics—the bridge toward the future of humanity—will also be a bridge of inter-American cooperation and integration.

josÉ alberto mainetti (1995)

revised by author

translated by mary m. solberg

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