Congenital syphilis and treatment refusal by pregnant women: a bioethical and legal analysis

Menezes, Gabriela Rodrigues de; Rosa Filho, Ailton Marques; Queiroz, Ana Paula Dossi de Guimarães e

doi:10.1590/1983-803420233010EN

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Research • Rev. Bioét. 31 • 2023 • https://doi.org/10.1590/1983-803420233010EN copy

Congenital syphilis and treatment refusal by pregnant women: a bioethical and legal analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Despite public policies, congenital syphilis infection remains a reality in the health system routine. Moreover, its epidemiological rates continue to be relevant and worrisome despite widespread and effective preventive methods, highly cost-effective treatments available in the Unified Health System, and high-coverage pre-natal care. A major obstacle to eradicating this scenario is treatment refusal by the progenitor. Important questions regarding medical responsibility in relation to refusal, the pregnant woman’s responsibility towards the unborn child, and the legal implications involved arise from this context. This article seeks to answer these questions and their legal and bioethical repercussions.

Fetus; Syphilis, congenital; Maternal-fetal relations; Treatment adherence and compliance; Patient rights

Rights of unborn children
Document	Theme	Description
Civil Code (Law 10,406/2002)	Civil rights	Art. 2	A person’s civil personality begins upon live birth; but the law safeguards, from conception, the rights of unborn children ⁴⁷47. Brasil. Lei nº 10.406, de 10 de janeiro de 2002. Institui o Código Civil. Diário Oficial da União [Internet]. Brasília, p. 1, 11 jan 2002 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3RjBU2z https://bit.ly/3RjBU2z... .
Constitution of the Federative Republic of Brazil, 1988.	Right to dignity	Art. 1	The federative republic of Brazil, formed by the indissoluble union of the states, municipalities and the federal district, constitutes a Democratic State under the rule of law and is founded on: (…) III – the dignity of the human person ⁴⁶46. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3Bcb8SS https://bit.ly/3Bcb8SS... .
	Right to life, physical integrity, image, honor and privacy	Art. 5	Everyone is equal before the Law, without distinction of any kind, ensuring to Brazilians and foreigners residing in the country the inviolability of the right to life, freedom, equality, security and property, in the following terms: (…) III – no one shall be subjected to torture or to inhuman or degrading treatment; (…) ⁴⁶46. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3Bcb8SS https://bit.ly/3Bcb8SS...
	Right to health	Art. 6	Education, health, food, work, housing, transportation, leisure, security, social security, protection of maternity and childhood, assistance to the helpless are social rights, as per this Constitution ⁴⁶46. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3Bcb8SS https://bit.ly/3Bcb8SS... .
	Right to health	Art. 196	Health is a right of all citizens and a duty of the State, guaranteed by means of social and economic policies that aim at reducing the risk of diseases and other problems, and aim at providing universal and egalitarian access to actions and services for health promotion, protection and recovery ⁴⁶46. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3Bcb8SS https://bit.ly/3Bcb8SS... .
	Right to life, health, dignity and physical integrity	Art. 227	It is the duty of the family, society and the State to ensure children and adolescents, with absolute priority, the right to life, health, food, education, leisure, professional qualification, culture, dignity, respect, freedom, as well as family and community life, and to safeguard them from all forms of neglect, discrimination, exploitation, violence, cruelty and oppression ⁴⁶46. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3Bcb8SS https://bit.ly/3Bcb8SS... .
Statute of Children and Adolescents (Law 8,069/1990)	Right to life, health, and physical integrity	Art. 7	Children and adolescents have the right to protection of life and health, through the implementation of public social policies that allow for healthy and harmonious birth and development, in dignified conditions of existence ⁴⁸48. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. Brasília, p. 13563, 16 jul 1990 [acesso 11 jan 2023]. Disponível: https://bit.ly/3jidOZi https://bit.ly/3jidOZi... .
	Right to dignity	Art. 15	Children and adolescents have the right to freedom, respect and dignity as human persons in the process of development and as subjects of civil, human and social rights guaranteed in the Constitution and laws ⁴⁸48. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. Brasília, p. 13563, 16 jul 1990 [acesso 11 jan 2023]. Disponível: https://bit.ly/3jidOZi https://bit.ly/3jidOZi... .
	Right to physical integrity and image	Art. 17	The right to respect consists in the inviolability of the physical, psychological and moral integrity of children and adolescents, comprising the preservation of the image, identity, autonomy, values, ideas and beliefs, and personal spaces and objects ⁴⁸48. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. Brasília, p. 13563, 16 jul 1990 [acesso 11 jan 2023]. Disponível: https://bit.ly/3jidOZi https://bit.ly/3jidOZi... .
Medical responsibilities
Civil Code (Law 10,406/2002)	Civil duty	Art. 186	The person who, by voluntary action or omission, negligence or recklessness, violates the law and causes harm to others, even if only moral, commits an ilicit act ⁴⁷47. Brasil. Lei nº 10.406, de 10 de janeiro de 2002. Institui o Código Civil. Diário Oficial da União [Internet]. Brasília, p. 1, 11 jan 2002 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3RjBU2z https://bit.ly/3RjBU2z... .
Civil Code (Law 10,406/2002)	Civil duty	Art. 927	The person who, by an ilicit act (arts. 186 and 187), causes harm to others, is obliged to repair it ⁴⁷47. Brasil. Lei nº 10.406, de 10 de janeiro de 2002. Institui o Código Civil. Diário Oficial da União [Internet]. Brasília, p. 1, 11 jan 2002 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3RjBU2z https://bit.ly/3RjBU2z... .
Medical responsibilities
Code of Medical Ethics (CFM Resolution 2,217/2018)	Consent	Art. 22	Physicians are prohibited from: Abstaining from obtaining consent from the patient or their legal representative after clarifying to them the procedure to be performed, except in case of imminent risk of death ²²22. Conselho Federal de Medicina. Resolução CFM nº 2.217, de 27 de setembro de 2018. Aprova o Código de Ética Médica. Diário Oficial da União [Internet]. Brasília, nº 211, p. 179, 1 nov 2019 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3MbOz3i https://bit.ly/3MbOz3i... .
		Art. 31	Physicians are prohibited from: Disrespecting the right of the patient or their legal representative to freely decide on the execution of diagnostic or therapeutic practices, except in case of imminent risk of death ²²22. Conselho Federal de Medicina. Resolução CFM nº 2.217, de 27 de setembro de 2018. Aprova o Código de Ética Médica. Diário Oficial da União [Internet]. Brasília, nº 211, p. 179, 1 nov 2019 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3MbOz3i https://bit.ly/3MbOz3i... .
		Art. 36	Physicians are prohibited from: Abandoning patients under their care ²²22. Conselho Federal de Medicina. Resolução CFM nº 2.217, de 27 de setembro de 2018. Aprova o Código de Ética Médica. Diário Oficial da União [Internet]. Brasília, nº 211, p. 179, 1 nov 2019 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3MbOz3i https://bit.ly/3MbOz3i... .
CFM Resolution 2,232/2019	Treatment refusal	Art. 5	Treatment refusal should not be accepted by physicians when it characterizes abuse of rights. § 1 The following characterizes abuse of rights: I – Treatment refusal that endangers the health of third parties. II – Refusal of treatment for communicable disease or any other similar condition that exposes the population to risk of contamination ⁵²52. Conselho Federal de Medicina. Resolução nº 2.232, de 17 de julho de 2019. Estabelece normas éticas para a recusa terapêutica por pacientes e objeção de consciência na relação médico-paciente. Diário Oficial da União [Internet]. Brasília, nº 179, p. 113, 16 set 2019 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3DsbsOy https://bit.ly/3DsbsOy... .
Statute of Children and Adolescents (Law 8,069/1990)	Follow-up for pregnant women	Art. 8	All women are guaranteed access to programs and policies for women’s health and reproductive planning and, pregnant women, adequate nutrition, humanized care for pregnancy, childbirth and the puerperium and comprehensive prenatal, perinatal and postnatal care within the scope of the Unified Health System. (…) § 9 Primary health care professionals will actively search for pregnant women who do not start or do not adhere to prenatal care, as well as puerperal women who do not adhere to postnatal care ⁴⁸48. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. Brasília, p. 13563, 16 jul 1990 [acesso 11 jan 2023]. Disponível: https://bit.ly/3jidOZi https://bit.ly/3jidOZi... .
Statute of Children and Adolescents (Law 8,069/1990)	Communication to responsible authorities	Art. 245	Physician, teacher or person responsible for health care and elementary school, preschool or daycare establishment failing to report to competent authority the cases of which they is aware, involving suspicion or confirmation of maltreatment against a child or adolescent: Penalty – fine of three to twenty reference salaries, applying double in case of recidivism ⁴⁸48. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. Brasília, p. 13563, 16 jul 1990 [acesso 11 jan 2023]. Disponível: https://bit.ly/3jidOZi https://bit.ly/3jidOZi... .
Responsibilities of pregnant women
Civil Code (Law 10,406/2002)	Civil duty	Art. 186	The person who, by voluntary action or omission, negligence or recklessness, violates the law and causes harm to others, even if only moral, commits an ilicit act ⁴⁷47. Brasil. Lei nº 10.406, de 10 de janeiro de 2002. Institui o Código Civil. Diário Oficial da União [Internet]. Brasília, p. 1, 11 jan 2002 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3RjBU2z https://bit.ly/3RjBU2z... .
Civil Code (Law 10,406/2002)	Civil duty	Art. 927	The person who, by an ilicit act (arts. 186 and 187), causes harm to others, is obliged to repair it ⁴⁷47. Brasil. Lei nº 10.406, de 10 de janeiro de 2002. Institui o Código Civil. Diário Oficial da União [Internet]. Brasília, p. 1, 11 jan 2002 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3RjBU2z https://bit.ly/3RjBU2z... .
Statute of Children and Adolescents (Law 8,069/1990)	Duty of care	Art. 4	It is the duty of the family, community, society in general and the government to ensure, with absolute priority, the enforcement of the rights to life, health, food, education, sport, leisure, professional qualification, culture, dignity, respect, freedom, and family and community life ⁴⁸48. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. Brasília, p. 13563, 16 jul 1990 [acesso 11 jan 2023]. Disponível: https://bit.ly/3jidOZi https://bit.ly/3jidOZi... .
Responsibilities of pregnant women
Criminal Code (Decree-Law 2,848/1940)	Exposure of unborn children to danger	Art. 132	To expose the life or health of others to direct and imminent danger: Penalty – imprisonment, from three months to one year, if the fact does not constitute a more serious crime ⁵⁴54. Brasil. Decreto-Lei nº 2.848, de 7 de dezembro de 1940. Código Penal. Diário Oficial da União [Internet]. Brasília, p. 23911, 31 dez 1940 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3FpmvYx https://bit.ly/3FpmvYx... .
Criminal Code (Decree-Law 2,848/1940)	Exposure of unborn children to danger	Art. 136	Expose to danger the life or health of a person under one’s authority, custody or surveillance, for the purpose of education, teaching, treatment or custody, either by depriving them of food or indispensable care, or by subjecting them to excessive or inadequate work, or by abusing means of correction or discipline: Penalty – imprisonment, from two months to one year, or fine ⁵⁴54. Brasil. Decreto-Lei nº 2.848, de 7 de dezembro de 1940. Código Penal. Diário Oficial da União [Internet]. Brasília, p. 23911, 31 dez 1940 [acesso 11 jan 2023]. Seção 1. Disponível: https://bit.ly/3FpmvYx https://bit.ly/3FpmvYx... .

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E-mail: bioetica@portalmedico.org.br

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[1] Correspondence: Gabriela Rodrigues de Menezes – Rua Olavo Bilac, 48, Cohab Aeroporto CEP 79240-000. Jardim/MS, Brasil.