Derechos de cobro cedidos a largo plazo (bursatilizaciones)

In 1991 the Latin American Federation for Bioethics101 (FELAIBE) was created in Caracas following an agreement between Pablo Pulido, a Venezuelan physician for the Pan American Federation of Medical Schools 102, José A. Mainetti for the Centre for Bioethics of the José María Mainetti Foundation103 and Alfonso Llano for the Centre for Medical Ethics104 of the Colombian Association of Faculties of Medicine 105 (ASCOFAME).106 FELAIBE embodies the ethos of the Latin American bioethics establishment: its role has been reduced to organising regional congresses,107 and power struggles over what group or ideology should be adopted in this federation are frequent. Moreover, a lack of clear policies to control the quality of academic work submitted to its congresses have contributed to turning FELAIBE into a bureaucratic apparatus that helps little to improve the quality of Latin American bioethics. In its beginnings FELAIBE was important for the socialisation of bioethics in the region. For example, more than 1500 people attended its second congress that took place in Bogota in 1998, which, according to its organiser A. Llano, helped to spread bioethics in the region, underlined the role of human dignity in ethical debates, and facilitated a dialogue between science and ethics, particularly at the level of those in charge of making decisions in society (Llano, 1998, p. x). But it seems that while attendance has decreased since then, mediocrity has increased and, moreover, right-wing groups have now taken over the federation, imposing a particular ideological agenda and restricting certain debates, e.g. on abortion, as was manifest in FELAIBE‟s latest congress, at Viña del Mar, Chile, in June 2011.108

Latin American bioethicists have a special predilection for a language full of neologisms, metaphors and baroque language. This linguistic „excess‟ sometimes complicates and obscures discussions. For this reason some bioethicists, e.g. G. Calderón (2010, p. 364), have called for avoiding the „pamphletism‟ and the „tropicalism‟ that has sometimes characterised

101

Federación Latinoamericana de Bioética. Its current president is F. Leon Correa.

102

Federación Panamericana de Facultades y Escuelas de Medicina.

103

Centro de Bioética de la Fundación José María Mainetti.

104

Centro para la Ética Médica.

105

Asociación Colombiana de Facultades de Medicina.

106

See: http://www.bioeticachile.cl/felaibe/quienes.html

107

Sao Paulo 1995, Bogotá 1998, Panamá 2000, Puerto Rico 2003, Argentina 2007 and 2009, and Chile 2011.

108

83 the bioethical discussions in the region. Moreover, for him, the sharp distinction that is usually made between American and Latin American bioethics should be avoided. Although issues like poverty and injustice are usually linked to the Third World, it is worthwhile bearing in mind that the First World also has “its own underdeveloped world within its borders.” However, it was Latin American bioethicists who promoted the inclusion of social problems, giving Latin American bioethics “a distinct openness not found in other bioethics” (Calderón, 2010, p. 360). Unfortunately, this understanding of bioethics has ended up facilitating in Latin America a „totalising‟ conception of bioethics: bioethics is about everything. This position causes serious issues. As I will show in the particular case of Colombia, bioethicists are able to demonstrate the „bioethical angle‟ of everything and therefore make virtually any situation or problem amenable to a „bioethical solution‟. Most importantly, I argue that this totalising nature of bioethics hides a „will to power‟, because this allows bioethicists to intervene at all levels, something of which even bioethicists themselves have remained unaware. Furthermore, what bioethicists see as a „bioethical solution‟ is just a renaming of social problems by using „bioethical labels‟ instead of properly addressing them in order to find a suitable solution.

F. Lolas urged bioethics to avoid being ideologically compromised and militant political activism. For him, some bioethicists in Latin America have flooded bioethics with outdated discourses like that about „imperialisms‟. He argues that “[t]here is, as has always been the case in Latin American initiatives, a picturesque group of pro-natives and another […] one of defenders of a third-world marginality, who purport to know and appreciate, and on behalf of which they disown, European or USA academic work, taking upon themselves the germs of irreversible alienation” (Lolas, 2004, p. 18). Lolas has warned of different dangers for bioethics in Latin America. He argues that there is a bioethics that can be characterised by its “superficiality, intellectual villainy, and academic banditry” (Lolas, 2008a, p. 133). Also for him, beyond “nominal questions”, in Latin America it is necessary to know what actually do those who suppose “do bioethics”, how they spend their time, what they want to achieve, and what their motivations are (Lolas, 2005b, p. 162). In short, for him there is a chapter yet to be written on the history of bioethics in Latin America: a chapter about the ethics that those who have called themselves bioethicists actually practise (Lolas, 2009, p. 8).

Lolas‟ critical stance is against the belligerent positions that some bioethicists, particularly in RedBioetica and the so-called Brazilian group, led by V. Garrafa, have adopted. When V.

84 Garrafa claimed in a recent publication that some conservative bioethicists in Latin America have used an alien mentality –Anglo-Saxon or Spanish – to analyse our conflicts, a trend that is expressed in academic meetings and publications (Garrafa, 2008c, p. xvii), the members of the Latin American bioethics community knew whom he was referring to: F. Lolas and his group in Chile. Against what he considers an undesirable „alien‟ approach in bioethics, Garrafa has promoted RedBioetica‟s approach that, according to him, seeks to analyse “bioethical problems [with] our own mentality and perspective” (Garrafa, 2008c, p. xviii).

4.6. Clinical bioethics, committees, and national commissions

According to D. Gracia (1990), medical practice was for centuries a sort of dictatorship and the “pluralism, democracy, and civil and political human rights, [which can be seen as the] leading achievements of the modern era […] only reached medicine very recently” (p. 357). For him, bioethics and the rise of autonomy are parallel phenomena, representing the advent of „true ethics‟ in medicine. Accordingly, bioethics is promoted in Latin America as a way out of medical paternalism. In 1996 R. Macklin and F. Luna (1996) argued that in Latin America “medicine is still practiced in a paternalistic way. Patients rarely ask for information and physicians are not in the habit of providing it” (p. 140). For these authors, medical paternalism is reinforced by “the myth of illiteracy”, i.e. that patients are in principle uneducated, which is not only false, but also unjustifiably associated with mental incompetence (Luna, 2007, p. 282). For J. C. Tealdi (2009, p. 588) although Latin American medical ethics expressed the values of domination in its paternalism, it “has turned from deontology to bioethics” and according to him, bioethics is an opportunity to transform the field of medical ethics in this region through the inclusion of the language of human values.

Also in 1990, J. Drane contrasted the formalistic, theory-driven, and rule-dominated American clinical bioethics with the more humanistic European and Latin American approaches. He argues that while American medicine, culture, and society have led to a “technologized, secular and pluralistic” approach in bioethics, medical traditions in Europe and Latin America “are more humanistic [and] not so tied to deontological and utilitarian theories” (Drane, 1990, p. 401f). Drane furthermore emphasises the difference between the cultural backgrounds of the USA and Latin America (Drane, 1996). Drane argues that the bioethical issues linked to poverty in Latin America have been largely ignored by bioethicists in the USA and Europe. For him, a dialogue between different cultural approaches to

85 bioethics is not only possible, but also necessary since there are “common problems” in the field (Drane, 1996, pp. 559f).

Although ethical issues in clinical settings are widely discussed in the Latin American bioethics literature, issues related to public health and healthcare systems have received much less attention. In the last twenty years there has been a wave of neoliberal healthcare reform in Latin America, but there has been little space to analyse this phenomenon in the regional bioethical literature. Critical voices have attacked this silent complicity. A lack of opportunities and an effective social protection, particularly for the poor, are still common in the region, as is illustrated by the case of Chile (Olavarría, 2005, p. 47). Yet, as S. Litewka (2010, p. 149) has argued, Latin American bioethicists have been passive and even negligent in discussing the ethical issues raised by the neoliberal healthcare reforms in the region. For him, justice remains an abstraction among bioethicists, and the dominant bioethical discourse in Latin America, with its common phrases, e.g. that bioethics is the defence of life and repetition of the same rhetoric again and again, e.g. respect for human dignity and personal autonomy, has led to an “ethical atonia” (Litewka, 2010, p. 152).

At the same time, some bioethicists have talked of the necessity of implementing an „ethics culture‟ in the field of human research, i.e. the adherence to international norms such as the Council for International Organisations of Medical Sciences (CIOMS) guidelines and the Declaration of Helsinki (Rodríguez, E., 2005, p. 11). In this sense, the role of bioethical commissions and committees goes beyond the protection of research subjects. They are political bodies that can have enormous influence in institutions and channel different kinds of debates, for example, as Ulloa and Barrantes (2008, p. 204) have shown in the case of Nicaragua with the discussion on abortion. In a paper at the VI International Bioethics Association‟s Congress in Brasilia, 2002, I argued that clinical bioethics committees might play an important role in the positive transformation of healthcare institutions. Ethical committees are not only privileged to „approve research protocols‟ or „solve ethical dilemmas arisen in clinical practice‟, but also to „facilitate‟ self-reflection among healthcare professionals (Díaz Amado, 2002b). Unfortunately, the growing institutionalisation of ethical committees and bioethics in general has also meant a loss, to a certain extent, of their ability to criticise and/or denounce negative aspects, elements or circumstances in or around the biomedical field.

86 Bioethics commissions and committees are part of the „ethicalisation‟ of biomedical research in Latin America. The number, performance and quality of bioethics committees have been taken as an indicator of the development of bioethics (Zwareva, 2010, p. 90). In the last 20 years national commissions for bioethics and bioethics committees have spread across Latin America, where they have been enthusiastically welcomed as a mechanism to firmly establish bioethics in the region. They are seen as guarantors of ethical standards in biomedical research and clinical practice. However, it is important to recognise the power mechanisms which were involved in their creation and functioning. The literature on bioethics committees has mainly focused on the application of human research ethics norms, decision-making methods and the role of national commissions to provide guidelines (ethical and legal) on sensitive issues like embryo research, abortion, euthanasia and so on.

Moreover, as A. Bota (2003, p. 33) has argued, while bioethics promotes sophisticated mechanisms such as informed consent, basic problems (e.g. poverty, healthcare access, exploitation and the like) remain unsolved in Latin America. This paradox reveals that some issues are privileged while others are neglected. To deal with this situation, some bioethicists have suggested that the scope of bioethics should be expanded. Perhaps, but nevertheless it would be necessary to examine other possibilities, for example, that bioethics is in itself a kind of truth regime that determines what is ethically, politically and legally relevant to be discussed in and about the biomedical field. In order to see this dynamics, considering the Foucauldian approach in the analysis, as I explained in the previous chapters, might be a promising path. For instance, from a Foucauldian perspective, bioethics committees and national commissions embody a pastoral discourse as they are set up to protect patients and research subjects (Juritzen, et al., 2011, p. 644). This characteristic might partially explain why they have been so welcomed in contemporary societies in which the language of threats and risks has also had a great impact.