Citizen constitution and social representations: reflecting about health care models

Abstracts

Este artigo apresenta uma reflexão sobre o significado dos termos cidadania e saúde, abordando a Teoria das Representações Sociais como estratégia para implementação e avaliação dos modelos de assistência a saúde no Brasil. Na primeira parte, traçamos um breve histórico sobre a concepção de cidadania; na segunda, tratamos dos princípios de liberdade e igualdade pautados no pensamento de Kant; na terceira, evidenciamos a saúde como um direito do cidadão e um dever do estado; por fim, destacamos a Teoria das Representações Sociais como estratégia para avaliar e implementar os serviços de saúde prestados ao cidadão pelos modelos assistenciais de saúde em vigor no Brasil.

Enfermagem; Direito a saúde; Política de saúde; Sistema Único de Saúde

THEORETICAL STUDY

Citizen constitution and social representations: reflecting about health care models^*

Constitución ciudadana y representaciones sociales: una reflexión sobre modelos de atención de la salud

Sílvio Éder Dias da Silva^I; Flávia Regina Souza Ramos^II; Cleusa Rios Martins^III; Maria Itayra Padilha^IV; Esleane Vilela Vasconcelos^V

^IM.Sc. in Nursing, Anna Nery School of Nursing, Federal University of Rio de Janeiro. Ph.D. Student, DINTER Program at Federal University of Santa Catarina and Federal University of Paraná. Assistant Professor at School of Nursing, Federal University of Pará. Member of the Study Group on the History of Nursing and Health Knowledge and of the Research Group: Nursing Education, Policies and Technology in Amazônia. Belém, PA, Brazil. [e-mail]

^IIPh.D. in Nursing Philosophy. Associate Professor, Nursing Department, Federal University of Santa Catarina. CNPq Researcher. Florianópolis, SC, Brazil. [e-mail]

^IIIPh.D. in Nursing Philosophy. Voluntary Professor, Nursing Department, Federal University of Santa Catarina. Florianópolis, SC, Brazil. [e-mail]/[e-mail]

^IVPh.D. in Nursing. Associate Professor, Nursing Department, Federal University of Santa Catarina. Florianópolis, SC, Brazil. Leader of the Study Group on the History of Nursing and Health Knowledge. CNPq Researcher. Florianópolis, SC, Brazil. [e-mail]

^VSurgical and ICU Nursing Specialist. Assistant Nurse, Eye Bank at Hospital Ophir Loyola and State Cancer Care Coordination, State Public Health Secretary of Pará. Belém, PA, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This article presents a reflection on the meaning of the terms citizenship and health, addressing the Theory of Social Representations as a strategy for implementing and evaluating health care models in Brazil. First, a brief history about the concept of citizenship is presented; then the article addresses the principles of freedom and equality according to Kant; the third section of the article shows that health is as a right of the citizen and a duty of the state. Finally, the Theory of Social Representations is emphasized as a strategy to evaluate and implement the health services provided to citizens by the current health care models in Brazil.

Key words: Nursing. Right to health. Health policy. Single Health System.

RESUMEN

Este artículo expone una reflexión sobre el significado del término ciudadanía, salud y la Teoría de las Representaciones Sociales como una estrategia para la implementación y evaluación de los modelos de atención a la salud en Brasil. En la primera parte, trazamos un breve resumen histórico sobre la concepción de ciudadanía; en la segunda parte, abordamos los principios de libertad e igualdad pautados en el pensamiento de Kant; en la tercera, dejamos evidenciado que la salud es un derecho del ciudadano y un deber del estado y, por fin, destacamos la Teoría de las Representaciones Sociales como una estrategia para evaluar e implementar los servicios de salud prestados al ciudadano por los modelos de atención a la salud vigentes en Brasil.

Descriptores: Enfermería. Derecho a la salud. Política de salud. Sistema Único de Salud.

INTRODUCTION

Unveiling the conception of citizenship - a short dialogue

In 1988, the constitution of the Democratic State of the Federative Republic of Brazil was ratified and called the Citizen Constitution⁽¹⁾. Since then, another concept has appeared in the Brazilian social context - citizenship. This reflection aims to discuss the meaning of the term citizenship and its connection with the Theory of Social Representation, as this theory is seen as an essential element to understand the practices of the social groups it is applied to, and thus enhance interventions that are put in practice based on their consensual knowledge.

The origins of citizenship go back to Greece, where the first conception of city emerged, the Greek polis. This first urban organization comprised free individuals, with political participation in the ruling democracy, whose rights and duties should be discussed in public. The practical aspect of this concept was forgotten during the feudal regimen, due to the predominance of rural feuds ruled by a lord who was fully entitled to the lands. As capitalism emerged, evidenced by the ascent of the bourgeoisie, the principles of citizenship were recovered as a way to structure social life among men in the new emerging urban centers. During the French revolution, the constitutional letters appeared that opposed the discriminatory standard of the feudal regimen and the dictatorial monarchy. This moment represents the emergence of the state of rights, which establishes, even if by law, equal rights for all men⁽¹⁾.

The researchers perceive the need to understand a country's Constitution as a way to set limits on the governing people's power, besides the rights and duties citizens should follow. This document values non-violent citizenship, considering all men as free beings who should follow its legislative guidelines, recommending individual freedom.

Citizenship is based on the principle that all human beings are equal by law, without any discrimination of race, belief or color, with authority on their body and life, right to a harmonious payment to handle their own life, besides the rights to education, health, housing and leisure⁽¹⁾. Another relevant aspect of citizenship refers to the law all citizens have to follow, which is managed by the State. The latter can be understood as a community's coercive organization, with three conceptions: the organicist (the state is independent from and precedes the subject), the contractualist (sees the state as the individual's creation) and the formalist (the state is a legal formation). The first two conceptions alternated in the history of social thinking, while the latter is linked to the modern period⁽²⁾.

The law can be conceived as a rule that detains need, which can be described in two ways: first, the impossibility or improbability that a fact occurs differently; or a coercive force that guarantees the accomplishment of the rule⁽²⁾. In other words, the law is something citizens should follow, as it evidences their rights and duties.

Civil rights can be understood as a technique that came about to favor human coexistence, as a series of rules and standards aimed at determining men's mutual behavior. This right evolved in philosophical and legal terms, with four intermingling conceptions: the first considers it positive, when various societies acknowledge it jointly; the second considered it a moral-based element and, therefore, a reduced or imperfect form of morality; the third reduces it to force, i.e. a politically organized historical reality, and the fourth considers it a social technique⁽²⁾.

Citizens have three modes of rights: civil rights, referring to individual mastery of one's body; social rights, related to attendance to basic human needs; and political rights, which are man's rights on his life⁽¹⁾. Reciprocity among men, as well as the right to agree with other people's rights, are the only way life can be understood in its full sense - that of citizenship.

PURPOSE

Based on this context, the purpose of this study is to reflect on Social Representations Theory as a strategy to put in practice and assess health care models in Brazil.

The principles of freedom and equal citizenship: contributions by Immanuel Kant

This section focuses on the fundamentals of freedom and equality defended by Kant. Although citizenship was already linked with other philosophers in the previous section, a specific section is needed to present this thinker's contribution to the theme. Texts like Perpetual Peace and Critique of Practical Reason permitted the conceptual understanding of citizenship for current times.

Kant was born in Königsberg, in Eastern Prussia, on April 22nd 1724, in a poor Protestant family. His studies concentrated on philosophy, starting with his free-lectureship degree in 1755, and when he published his work Perpetual Peace in 1795. In that work, he evidenced that a republican constitution should adopt the freedom of a society's members as one of its principles, characterized by all members' dependence as subjects mediated by the law of equality as citizens⁽³⁾.

In Critique of Practical Reason, Kant considers that the function of reason is to prescribe moral law to human beings' will. He evidences that this law does not derive from experience, but represents an a priori condition of will and starts to rule and standardize human beings' life, surpassing their will⁽⁴⁾. Kant's thinking develops the principles of equality and freedom and consolidates the question of power linked with the people. The State is intimately associated with the acts of man, who starts to be understood as a member of a civil society and called citizen⁽⁵⁾.

Freedom defined that man, as a rational beings, detains a will that conditions his way of acting, which should be submitted to moral law though. A rational being would always act according to reason but, as man is part of the sensitive and intelligible world, he is submitted to the prescriptive law of reason. Reason contains the idea of freedom, which contains the law of the intelligible world. Hence, all rational beings have to know the laws of the intelligible world as imperatives, and his resulting actions as duties⁽⁶⁾.

Kant understands freedom as the framework for law and right. The latter emerges at the moment when various individual liberties are harmonized in the social context. Law is a set of conditions under which one individual's judgment has to make an alliance with the other's, according to a universal law of freedom⁽⁵⁾. Freedom is subdivided into internal (moral) and external (legal), the former responsible for the genesis of moral obligation, and the latter for legal obligation, guaranteed by a system of coaction.

As a rational being, man detains a free judgment and can generate moral and amoral attitudes determined by his will. Therefore, he uses reasons to distinguish what is right from what is wrong, good from evil. When this form of freedom is suppressed, though, legal freedom has to establish criteria to condemn or approve a given conduct. The moral issue can be suppressed by the fact that it is internal to the individual, as the legal issue, being external, always protects the former⁽⁴⁾.

Right is defined as awareness of each human being's obligation by a law, based on an exterior coaction that makes it effective, but can coexist with each individual's freedom according to the universal laws in force in States of Rights⁽⁶⁾.

With regard to equality, Kant perceives it as a characteristic of any free man, as it is universal. This inaugurates the inclusive concept of equality, in which each human being has a social value, participating in the construction of rules and standards that regulate his existence. Kant also uses right to support equality, as it sets limits to freedom, under the condition that all beings are limited in the same way.

According to Kant, citizenship can be exercised in two ways: the passive way, in which the individual does not participate in the formulation of his rights and duties, preconized by the State. In the active way, individuals interact so as to organize the state, as well as to formulate laws they submit to, which can never go against the principles of citizens' freedom and equality.

In this section, Immanuel Kant's contribution to the genesis of the term citizenship was evidenced, which sets the rights and duties of the individual and the State. With regard to Brazil, Brazilian citizens' right to health is quite compromised by their governors. Health has to be understood as a right of citizens and a duty of the state.

HEALTH - A RIGHT OF CITIZENS AND A DUTY OF THE STATE

The notion of health has never been consensual or permanent. It can be affirmed that the first records go back to pre-Christian times. Hippocrates' medicine guides that health constitutes the balance between existing fluids or secretions in the body. This conception would influence medical practice for centuries, and a big change in the notion of health would only be observed during the Middle Ages, when nosology starts to get structured⁽⁷⁾.

From that point onwards, a disease category classified as acquired in the work environment appears, which inaugurates the inclusion of a social and non-organic fact in the genesis of a disease. This phenomenon represents a great advance in the health-disease domain, but reveals that investments in medicine focus on the disease, so that health can only be understood as the absence of disease. This allowed physicians to gain more knowledge on symptoms and their origins than on health-defining aspects, and also generated a health concept in function of disease.

A radical rupture in this structure would only occur when the World Health Organization (WHO) elaborated a new health concept, which broke with the notions of a basically organicist profile and added social and mental aspects. Health can be defined as a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity⁽⁸⁾. This definition by WHO is criticized because it does not manage to move beyond the sieve of biologistic knowledge and is extremely loaded with subjectivism, making it difficult to quantify as, in this paradigm, the quantitative view is considered a priority to approach health.

Health and disease conceptions are limited by the theoretical-conceptual development of science, and especially by ideological conditioning factors that turn certain conceptual options more reliable and potent than others. They are based on distinct theoretical and philosophical frameworks and causal models are expressed which, in turn, unfold into corresponding ways to record, measure, analyze, interpret and intervene. They picture the conceptual and methodological diversity resulting from transformations in the milestones of causal inference throughout the history of this knowledge's constitution - from magic-religious beliefs, through rational empiricism, until modern science⁽⁹⁾.

Nowadays, as a result of the multifaceted view on health, a range of knowledge is observed that is not always consensual, derives from different subject areas, which altered the nomenclature related to health, so that health-illness is understood as a dialectic process⁽¹⁰⁾. This led to an evolution in the understanding of health and illness whose change permitted the official end of the apparent dichotomy in classical terminology - health and illness. As a result of this change, it became understood as a single process, joining and irremediably interlacing health, illness, life and death, and became known as a health-disease process.

Great social value is attributed to health, as being healthy means being apt for work, while illness, like nowadays, becomes understood as a factor that compromises capitalist production in society, as it generates incapacity to work. Health should be covered in a broader way, not solely as aptitude for work, but as something fundamental for human life. It is right that allows citizens to enjoy life with peers, granting them tranquility in life.

With regard to the health concept in Brazil, the law considers it a duty of the State that took form when the Unified Health System (SUS) was established, which is a health management system whose principles were put in practice by the 1988 Constitution. The SUS started to establish health care in an equalitarian and comprehensive way.

This ideal is truthfully represented in the Brazilian Constitution of 1988, which contains an inedited specific section on health, presenting it as a right of the citizen and a duty of the State. From that moment onwards, the notion of social insurance, predominant in the 1920's, was transferred to social security, which starts to comprise an integrated set of actions, taken on the initiative of Public Powers and society, aimed at guaranteeing the rights to health, social security and social care⁽¹¹⁾. Citizens gain full access to health services, independently of their income, thus setting a new standard of citizenship.

Despite different types of criticism against the SUS, the system continues in its attempts to construct a universal care service at the periphery of capitalism, in a populous country marked by social inequality⁽¹²⁾. This reality evidences a perhaps unique case around the world, seeking health as one of the various facets of citizenship - health in an equalitarian and comprehensive way for citizens.

The SUS innovatively presents a tactic to achieve a health service for the Brazilian population. This system can already be considered equalitarian as it offers citizens high-complexity services like organ transplantation, independently of their social position, race and belief. Its practice, however, needs to value the consensual knowledge of the social groups it aims to deliver care to, that is, to put in practice programs based on the knowledge of the target population. Therefore, knowledge is needed on the community's naïve or popular knowledge on the health-disease context one intends to intervene in, and the theory of social representations (TSR) should be used to unveil it.

SOCIAL REPRESENTATIONS, HEALTH AND CITIZENSHIP - THINKING GUIDED BY CONSENSUAL KNOWLEDGE

The theory of social representations (TSR) started in France in the 1950, when the researcher Serge Moscovici attempted to understand how society at that time understood psychoanalysis, a new science. Based on this study, he managed to understand how a scientific object becomes common sense. This fact was published in his work Psychoanalysis, its image and its public, which granted him the title of father of social representations⁽¹³⁾.

The existence of two described knowledge types can be identified in TSR - the reified and the consensual. They have the same value although the first is identified as authentic in the scientific context. But consensual knowledge permits individuals and their group to take a stand towards a new situation, which the group element inserts in their cognitive, imprints personal knowledge and shares it with the group he belongs to⁽¹³⁾. This perspective shows that the function of social representations is to interpret the surrounding reality, guiding people's attitudes and those of the group they belong to. A social representation is present in the imaginary, reflecting in a certain group's behaviors regarding a psychosocial object.

An object is psychosocial when it is part of the individual's cognitive, who shares it with the group he belongs to. Therefore, health, like illness, is a legitimate object to use TSR, as it is present in the daily lives of the different groups that make up society.

A given social group's social representation is manifested through its behavior towards a psychosocial object, that is, a form of practical knowledge. It should be mentioned that a representation differs from an opinion, as the latter is solely manifested in an individual's report, but is absent from his attitudes and practices. Knowing social groups' practice regarding a given psychosocial object, such as health, is relevant to find out how these groups' behave towards the research object.

When addressing citizens' health, this automatically leads to the Unified Health System (SUS), as a policy that should permit universal access to both basic and the most complex care. Its goals are to: deliver care to the population based on the health promotion model, which implies actions to put an end to or control the causes of illnesses; to protect the population's health by using specific actions to maintain its health state: and to develop actions to recover health so as to avoid deaths and sequelae in people who have already been affected by disease processes⁽¹⁴⁾.

To fully achieve the abovementioned objectives, the use of social representations is emphasized as a theoretical construct that favors knowledge on the phenomenon that affects a specific population. In Brazil, various health care models are in force, but all of them have been and are elaborated in a vertical way for individuals. This makes them inadequate, as they were put in practice without respecting the particularities of the target population. To allow a program to truly respond to a community's health needs, it becomes relevant to get to know it, that is, first, this community should be studied, its habits and customs should be known, after which the service can be structured.

Studies using TSR have frequently focused on health, demonstrating that this practical nature is relevant to understand the different contexts involving health care models in Brazil. The establishment of programs aimed at health prevention and promotion in a given community should consider the practical knowledge of this population group the health service was put in practice for, besides respecting its beliefs and cultural taboos, which is why the service can be characterized as more adequate to deliver citizen health care.

As an example of this reality, the problem of alcoholism is mentioned. The Ministry of Health has made efforts to mitigate this public health problem. However, a non-governmental entity has dealt with the alcohol problem longer and with a much higher recovery ratio than other governmental institutions around the world - the Alcoholics Anonymous (A.A.). Based on this reflection, a study was performed to analyze the social representations of alcoholics attending A.A. meetings on alcoholism. It found that, when they started to attend A.A. meetings, the alcoholics started to represent alcohol as a causal agent of their disease, and no longer as social pleasure. This social representation favored the constitution of a new stereotype, i.e. that of an abstemious alcoholic, instead of that of a drunk, which in turn was relevant for a change in attitudes - to the attitude of keeping distance from alcoholic beverages⁽¹⁵⁾. This reality evidences the relevance of setting up an alcoholism prevention program that prioritizes the affected population, i.e. the alcoholics' consensual knowledge, making it more efficient and effective.

Health is seen as a right of the citizen. For a health service to exist, it needs to permit the population's participation, as that will provide an essential solidary interaction to achieve its social target, which is the population's wellbeing. The state can no longer be represented as a determining entity of power that lies beyond people's reach⁽¹⁶⁾. Therefore, health emancipation is needed as a right of citizens, so that the State needs to listen to their requests regarding to elaboration and supply of a given health service; that is the only way to truly achieve a democratic state.

Civil participation or social control is one of the SUS principles, which suggests the constitutional guarantee that the population, through the health councils, needs to participate in the elaboration process of health policies and control their execution, at all power levels⁽¹⁴⁾. With regard to the exercise of this right, however, in a way, it does not occur, as one very noteworthy point in health care practices in Brazil is the absolute predominance of reified knowledge. The consensual universe of the target population needs to be valued, as the interrelation between scholarly knowledge and common sense provides for a much more significant health care model, as it starts to value the persons it should take care of - the citizens.

CONCLUSION

In this paper, the intent was to clarify the formation of citizenship, ranging from its Greek origins to its emancipation through the ascent of the bourgeoisie. Next, some comments explained the foundations of freedom and equality according to Kant, addressing the relevance of that thinker's philosophical work for the formation of the principles of citizen and citizenship. With regard to health, it was evidenced as a responsibility of the State, in according with the 1988 Constitution, and a right of the citizen. Then, a short explanation on the SUS was included as a way to achieve equalitarian and universal access to health. It was also evidenced that this system is an attempt to oppose the great commercialization of health around the world.

TSR is a strategy to put in practice care models that value the communities they were created for, as they will center on the communities' daily reality. This reality will only be possible, however, through the valuation of the affected population's consensual knowledge, as this common sense favors the structuring of more efficient and effective intervention forms, as they are horizontal, thus respecting the cultural background of the social group under analysis.

It should be highlighted that, due to its practical and clarifying nature, the TSR can be understood as a way to approximate this health service, with respect to the valuation of consensual knowledge, to the target communities. One cannot talk about citizenship when health models are imposed which were created by a small group of technicians, to respond to such a diversified population demand. The cultural specificities of Brazilian social groups needs to be respected, as that is the only way to permit the achievement of the ultimate goal - citizen health.

Through this study, aspects of citizenship, health and the applicability of TSR were further elaborated to created or adapt a health service to a given target population. This can contribute to aspects that value popular knowledge presented in the daily reality health services attempt to intervene in. Viewpoints on the citizenship, health and TSR axis need to be broadened with a view to new perspectives to elaborate health services for citizens.

It should also be mentioned that this essay makes no claim on offering a proposal to solve such a severe public health problem in Brazil, which is the lack of health and respect for citizens. What it does offer is a way to perceive that one of the structures responsible for the establishment of full citizenship centers on Brazilian people's right to have access to health services.

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Correspondência:

Sílvio Éder Dias da Silva

Trav. 25 de Setembro, 1965 - Apto. 901

Ed. Monterrey - Marco

CEP 66093-005 - Belém, PA, Brasil

*

Extraído do trabalho de conclusão da disciplina "Filosofia da Ciência e da Saúde" do Curso de Doutorado do Convênio DINTER da Universidade Federal de Santa Catarina e Universidade Federal do Paraná, 2007.

Publication Dates

• Publication in this collection
  15 Dec 2010
• Date of issue
  Dec 2010

History

• Received
  09 Mar 2009
• Accepted
  18 Nov 2009