Health and medicine in Brazil

A new path begins with the new management of the Conselho Federal de Medicina – CFM (Brazilian Federal Council of Medicine). An unprecedented phenomenon occurred in Brazil, in which colleagues, regardless of their affiliation with medical institutions, were elected by their peers in the hope that medicine will regain its prestige and dignity as the noble profession it has always been.

It is impossible to separate this political phenomenon from the change in the presidency of the Republic, in the ministries and in the ideological direction experienced for over 30 years in Brazil, which resulted in the proletarianization of medical work and the class being brought into disrepute.

Over the years, physicians have come to realize that politics is a concentrated economy, and that we will not get anywhere without caring about this aspect, even though the best surgical techniques and treatment excellence are learned in books, conferences, practical courses etc.

Health policies directly interfere in the life of everyone. The fundamentals for the protection of human and citizen dignity in the institutions of the judiciary, in the Brazilian Bar Association and in the Public Prosecution Service reflect citizens’ desire for the right to health due to failures of the executive branch. Regarding physicians, the Brazilian Civil Code¹ , the Consumer Protection Code² , the Child and Adolescent Statute³ , the Elderly Statute⁴ and ordinary laws have raised hopes for the right to health.

In turn, the CFM analyses the matters that regulate medical activity, adapting current demands to social reality, without neglecting the need to filter and score, in an ethical manner, all the questions that arise.

The distinguished doctor from Rio Grande do Sul, professor Dr. Mário Rigatto⁵ , author of the book "Médicos e sociedade" (Physicians and Society), published in 1976, was a visionary in this regard. He pointed out as achievements in the medical field in the twentieth century the preservation of healthy organisms (vaccines, antibiotics), the replacement of body parts (prostheses, transplants), weight loss drugs, hormones, birth control pills and fortifiers. For the twenty-first century, he suggested that the focus would be on preserving healthy organisms and that health would be much more in the hands of rulers, legislators, sociologists, and educators than in the hands of physicians. He also affirmed that medicine would have as key missions the prevention of cancer, mastering the aging process, improving the performance of brain and memory proteins, promoting discoveries in the field of genetics, and enabling intellectual optimization with computers. He also predicted that physicians would lose prestige. Protests, threats and political-ideological reforms could not avoid the paradox of the loss of social prestige and the financial success of the past.

Faith and belief are mystical factors that have been part of life and medical activity for many years. The resources of the doctor-patient relationship, such as warmth and sympathy, made physicians be treated as gods. But today perhaps the only physicians who still enchant are psychiatrists, because they work with values that are hard to measure.

If in 1969 we were already the country with the most medical schools in proportion to the population – according to World Health Organization (WHO) statistics of 1971, there were 90.8 million people in the country and 73 medical schools⁵ – let’s imagine the current situation, with 210 million people⁶ and 340 medical schools⁷ .

With the need to have physicians for everyone, professionals began to be "manufactured" in series, which saturated the market, diminished the resources to remunerate them and, consequently, devalued medicine and health professionals. The recruitment notices issued by Brazilian city councils and states began to offer demeaning remuneration to physicians, who were now funded by the government. The liberal profession began to be exercised as a civil service, levelling down the remuneration standard and removing the incentive for professional improvement. In the 1970s, 90% of physicians in the United Kingdom were general practitioners, disgruntled civil servants⁸ . The social trend was the same as that of the primary school teacher in Brazil: salaries became so negligible that interest in the profession began to wane.

Well, it seems that much of what was predicted by Professor Rigatto came to fruition in the most critical way, because, with the previous governments in Brazil, the idea of implementing public health policies to solve electoral problems continued. In 2013, Provisional Measure 621⁹ , instituted by President Dilma Rousseff, created the Mais Médicos Program, though which medical care for the most deprived population began to be provided by foreign graduates, without proving their technical capacity by the usual means of evaluation in force in the country. In the midst of all the chaos of an ever-underfunded universal health care system, physicians were paid less and less for their work and the care provided by them was commodified. As a result, patients’ respect and consideration for these professionals is rare today.

In 1948, the United Nations Universal Declaration of Human Rights ¹⁰ made health a primary right. Consequently, to meet this requirement, physicians should always be accessible to all. On the other hand, scientific techniques improved physicians’ efficiency but depersonalized them – the diagnostic processes simplified and commodified their professional activity.

Telemedicine, which exists in many countries, with different forms and regulations, needs to be adequately regulated in Brazil and the risks to physicians’ responsibility should also be assessed. Telemedicine should be another tool to optimize work, without replacing face to face medical consultations and always counting on physicians at both ends of the service. This is because, according to the new Code of Medical Ethics, Resolution 2,217/2018¹¹ of the Federal Council of Medicine , it is still forbidden for physicians, according to article 37, to prescribe treatments without physical examination of the patient.

In the midst of the mass media era, the limitation of medical advertising for ethical reasons and the invasion of other professions in the field of medicine has become a reality. For some years we have been counting on Law 12,842/2013¹² , also known as the Medical Act Law, which defines the competence of the professional. Even with this law, we suffer constant attacks from other health professions, with resolutions from their respective professional councils often constituting an illegal exercise of medicine.

In parallel with this, the Conselho Federal de Odontologia – CFO (Federal Council of Dentistry) has issued two bombastic resolutions: CFO Resolution 198/2019¹³ , which recognizes orofacial harmonization as a dental specialty, and CFO Resolution 196/2019¹⁴ , which now allows dentists to publish, on social networks, photographs of the "before and after" of their facial interventions, as long as patients provide authorization. This constitutes an illegal exercise of medicine, contrary to Decree 4,113/1942¹⁵ that is currently in force and regulates medical prerogatives and advertising, both for the medical profession and for the dental profession.

According to Gracindo¹⁶ , in today’s society, there is a "fever" of selfies and a desire for aesthetic transformation, and the excessive use of social networks, together with the immediacy of publications, increases the demand for plastic surgery and aesthetic procedures. The obsession with beauty, youth, and looking like celebrities leads many people to unnecessary risks, even contraindicated procedures that should be dismissed by professionals due to the possibility of medical malpractice lawsuits. The desire for recognition, fame and power and the feeling that improving looks will bring success gives the beauty industry great power.

According to Weber¹⁷ , diseases such as body dysmorphic disorder (BDD) in both sexes and muscle dysmorphia, which affects mainly men, are increasingly common in the population, increasing dissatisfaction with the aesthetic procedures performed and contributing to more anxiety and depression cases.

According to Watts¹⁸ , medicine bravely continues to excel worldwide – there have never been so many people who care about health. There is also an increase in people’s longevity, making it necessary to consider the years of life gained compared to the expected years of active life, in which rates of chronic disability and elderly institutionalisation tend not to be very high.

Gene therapy remains part of the human genome research project. Considering that some people react better to certain types of medication, we can indicate more effective medications from genetic prediction, even considering that diseases are often caused by the interaction between genetics and environment.

Monoclonal antibodies, for example, may be used to inhibit tumour growth. Similarly, precise robotic surgery with microincisions and stem cell therapy are advancing and are already being used in some large hospital centres. Because of medicine’s ability to adapt to changing circumstances, the ethically unthinkable may become acceptable in medicine when its implementation causes broad benefit to individuals and the community.

In this social and cultural context, in which, at the same time that we have great discoveries and technological innovations and continue to have to resolve ethical issues, we started the new management of Revista Bioética , trying to raise current issues that mirror our reality and their implications in the context of bioethics.

Tatiana Bragança de Azevedo Della Giustina – Editor-in-Chief

Referências

• ¹
  Brasil. Lei nº 10.406, de 10 de janeiro de 2002. Institui o Código Civil. Diário Oficial da União [Internet]. Brasília, 11 jan 2002 [acesso 30 out 2019]. Disponível: https://bit.ly/2ChSYjS
  » https://bit.ly/2ChSYjS
• ²
  Brasil. Lei nº 8.078, de 11 de setembro de 1990. Dispõe sobre a proteção do consumidor e dá outras providências. Diário Oficial da União [Internet]. Brasília, 12 set 1990 [acesso 30 out 2019]. Disponível: https://bit.ly/2pNdu98
  » https://bit.ly/2pNdu98
• ³
  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, 16 jul 1990 [acesso 30 out 2019]. Disponível: https://bit.ly/2qoDYhh
  » https://bit.ly/2qoDYhh
• ⁴
  Brasil. Lei nº 10.741, de 1º de outubro de 2003. Dispõe sobre o Estatuto do Idoso e dá outras providências. Diário Oficial da União [Internet]. Brasília, 3 out 2003 [acesso 30 out 2019]. Disponível: https://bit.ly/2Chlsu0
  » https://bit.ly/2Chlsu0
• ⁵
  Rigatto M. Médicos e sociedade. São Paulo: Byk-Procienx; 1976.
• ⁶
  Nitahara A. Estimativa da população do Brasil passa de 210 milhões, diz IBGE. Agência Brasil [Internet]. Economia; 28 ago 2019 [acesso 6 nov 2019]. Disponível: https://bit.ly/34CLJPG
  » https://bit.ly/34CLJPG
• ⁷
  Nassif ACN. Estatísticas Nacionais. Escolas Médicas do Brasil [Internet]. [s.d.] [acesso 6 nov 2019]. Disponível: https://bit.ly/2JZ1rwC
  » https://bit.ly/2JZ1rwC
• ⁸
  Tanaka OY, Oliveira VE. Reforma(s) e estruturação do Sistema de Saúde Britânico: lições para o SUS. Saúde Soc [Internet]. 2007 [acesso 30 out 2019];16(1):7-17. DOI: 10.1590/S0104-12902007000100002
• ⁹
  Brasil. Medida Provisória nº 621, de 8 de julho de 2013. Institui o Programa Mais Médicos e dá outras providências. Diário Oficial da União [Internet]. Brasília, 9 jul 2013 [acesso 30 out 2019]. Disponível: https://bit.ly/2JTCWAP
  » https://bit.ly/2JTCWAP
• ¹⁰
  Organização das Nações Unidas. Declaração universal dos direitos humanos [Internet]. Rio de Janeiro: Unic Rio; 2009 [acesso 30 out 2019]. Disponível: https://bit.ly/33lI9ca
  » https://bit.ly/33lI9ca
• ¹¹
  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, p. 179, 1º nov 2018 [acesso 30 out 2019]. Seção 1. Disponível: https://bit.ly/34A2GtX
  » https://bit.ly/34A2GtX
• ¹²
  Brasil. Lei nº 12.842, de 10 de julho de 2013. Dispõe sobre o exercício da medicina. Diário Oficial da União [Internet]. Brasília, 11 jul 2013 [acesso 30 out 2019]. Seção 1. Disponível: https://bit.ly/2WLd92P
  » https://bit.ly/2WLd92P
• ¹³
  Conselho Federal de Odontologia. Resolução CFO nº 198, de 29 de janeiro de 2019. Reconhece a harmonização orofacial como especialidade odontológica e dá outras providências. Diário Oficial da União [Internet]. Brasília, nº 22, p. 91, 31 jan 2019 [acesso 30 out 2019]. Seção 1. Disponível: https://bit.ly/2PR0Y36
  » https://bit.ly/2PR0Y36
• ¹⁴
  Conselho Federal de Odontologia. Resolução CFO nº 196, de 29 de janeiro de 2019. Autoriza a divulgação de autorretratos (selfie) e de imagens relativas ao diagnóstico e ao resultado final de tratamentos odontológicos e dá outras providências. Diário Oficial da União [Internet]. Brasília, nº 22, p. 91, 31 jan 2019 [acesso 30 out 2019]. Seção 1. Disponível: https://bit.ly/2reeeVf
  » https://bit.ly/2reeeVf
• ¹⁵
  Brasil. Câmara dos Deputados. Decreto-lei nº 4.113, de 14 de fevereiro de 1942. Regula a propaganda de médicos, cirurgiões, dentistas, parteiras, massagistas, enfermeiros, de casas de saúde e de estabelecimentos congêneres, e a de preparados farmacêuticos. Diário Oficial da União [Internet]. Rio de Janeiro, p. 2443, 18 fev 1942 [acesso 7 nov 2019]. Seção 1. Disponível: https://bit.ly/2pJSJeR
  » https://bit.ly/2pJSJeR
• ¹⁶
  Gracindo GCL. A moralidade das intervenções cirúrgicas com fins estéticos de acordo com a bioética principialista. Rev. bioét. (Impr.) [Internet]. 2015 [acesso 29 out 2019];23(3):524-34. DOI: 10.1590/1983-80422015233089
• ¹⁷
  Weber JBB. Estética e bioética. Rev AMRIGS [Internet]. 2011 [acesso 29 out 2019];55(3):302-5. Disponível: https://bit.ly/2NkPhAf
  » https://bit.ly/2NkPhAf
• ¹⁸
  Watts G. Olhando para o futuro revisitado. In: Porter R, ditor. Cambridge: história da medicina. Rio de janeiro: Revinter; 2008. p. 335-45.

Publication Dates

• Publication in this collection
  10 Jan 2020
• Date of issue
  Oct-Dec 2019