Excepciones a la obligación a retener y de ingresar a cuenta

Considering how bioethicists address bioethical issues in Colombia, F. Suárez, a lecturer in genetics and bioethics, ironically asked in 2007: “Where is bioethics?” (Suárez, 2007).

205

Spanish acronym for Asociación Colombiana de Empresas de Medicina Integral [Colombian Association of Health Companies].

135 From the start Colombian bioethicists have discussed the same classical issues as their colleagues in the US, i.e. mainly the ethical implications of new biotechnologies. Accordingly Colombian bioethical literature mostly discusses informed consent, embryo research, genetic engineering, principlism and so on. Some bioethicists who have tried to enhance the scope of the field have added issues particularly relevant to Colombia such as violence, human rights abuse, armed conflict, illegal drugs and multiculturalism. After a critical review of this literature, particularly what it has been published by the most important journals in the field in Colombia such as the Colombian Journal of Bioethics206 and the Latin American Journal of Bioethics,207 I would like to make two observations. First, although the American principlist model is constantly criticised, it is nevertheless the „lingua franca‟ spoken by the vast majority of Colombian bioethicists. The attempts to create alternatives to such a model remain generally too theoretical, ideology-laden and bureaucracy-driven. Second, the analyses of the Colombian bioethics regarding the transformation of the healthcare system and the medical ethos in relation to neoliberal rationalities have largely remained limited to truisms. This trend has shown the detachedness from the actual socio- political, cultural and economic conditions of Colombia that mirror the Colombian bioethical establishment.

In 2007, for example, in the panel Violence and Bioethics at the Third International Congress of Scientific Research Ethics in Bogotá, I presented a paper where I criticised the pseudo-scientific and pseudo-philosophical language used by many bioethicists to address ethical issues that have arisen in the biomedical scenario. Such a language has contributed to camouflage forms of social injustice and structural problems as „ethical dilemmas‟. In this paper I argued that it was necessary to revise the role that the so-called clinical bioethics is playing in the current clinical scenario (Díaz Amado, 2007b). Unfortunately, in Colombia clinical bioethics is frequently reduced to a set of „technicalities‟ to solve „ethical dilemmas‟ and doctors are misled to believe that by dealing with such technicalities they have done their duty towards a „good medicine‟. But in this way fundamental reflections, for instance, about the nature of their own profession and the new relationships between medicine and society in the context of the medical industrial complex and neoliberal rationalities are not possible. In other words, in the way the bioethical discourse has taken over the biomedical scenario, the possibility of emancipatory and critical discourses has been drastically reduced.

206

Revista Colombiana de Bioética.

207

136 Another example is the first „designer baby‟ in Colombia in 2006. After a tutela (writ) one judge ruled that a healthcare insurance company should provide the assisted reproductive technology required to guarantee a couple a healthy embryo as the bone marrow donor to their first child who suffered from Fanconi anaemia. Apart from a laconic headline in a Colombian newspaper,208 this case passed unnoticed by bioethicists. The Colombian bioethics establishment remained virtually silent about this. The ethical assessment of reproductive technologies,209 as it happens with many other issues like genetics, availability of prescription drugs and policies on science and technology is discussed in an abstract way or with little reference to actual medical practice. Moreover, empirical research in bioethics remains largely undeveloped, with only a few exceptions. In contrast, issues highly moralised or deeply linked to religious beliefs have traditionally drawn the attention of bioethicists, such as abortion or euthanasia. But regarding the healthcare reform and its recent crisis, no one in the Colombian bioethics community has yet offered a comprehensive analysis. To carry out this analysis I consider two perspectives. On the one hand the question of how bioethics has been used by healthcare professionals, particularly by doctors, as a theoretical and conceptual tool in their daily practice. On the other hand the question whether bioethics has been able to critically examine both the healthcare reform and the simultaneous transformation of the medical ethos. The same detachedness of the Colombian bioethical establishment from the particular conditions of the country occurs in relation to other issues: embryo research, reproductive medicine, medical tourism, commodification of health and medical education, healthcare system corruption, bad quality medical attention, doctors exploitation, healthcare insurance companies abuses, pharmaceutical companies‟ influence on health policies and so on. All of these issues remained largely unanalysed from a bioethical perspective and the few analyses that have been carried out by Colombian bioethicists are, to a large extent, incomplete, inadequate and full of commonplaces.

In 1999, the Colombian physician and expert in health economics R. A. Castaño published

Medicine, Ethics and Health Care Reform, a book in which the language of principlism is

combined with the language of economy in order to „demonstrate‟ that the Colombian healthcare reform was „morally‟ necessary. He argued that medical practice had so far been

208

“A Woman Is Undergoing In-vitro Fertilisation Treatment to Save the Life of his Oldest Son.” El Tiempo, 24 March 2006.

209

This is a flourishing industry in Colombia, with several fertility centres, but so far bioethicists have given it virtually no attention.

137 guided by the principle of beneficence that advocates patients‟ welfare, but that this principle neglects issues of distributive justice. For Castaño, the basic conflicts between the medical profession and society nowadays can be reduced to two dilemmas: first, octors’ eneficence

v. social justice, and second, octors’ eneficence v. patients’ autonomy. Then, for him, a

new „social contract‟ with the medical profession was necessary. In this contract the medical profession should embrace new duties, particularly related to justice. Unfortunately, this argument has been used to justify the current model of healthcare and in the name of justice health insurance companies have implemented practices of intermediation, labour flexibilisation and health commodification. The approach of this author illustrates well how the principlist model has served to reinforce a truth regime facilitated by the rise of bioethics. According to this regime „ethics‟ in healthcare has ended up meaning an abstract conflict between principles called „a dilemma‟. This model has become canonical in talking about ethics within the medical scenario in Colombia. The Beauchamp and Childress principlist method became synonymous with ethical analysis in medicine. As a result, only what can be presented in terms of a dilemma is seen as an ethical problem. Then, there is a power effect of bioethics that should be recognised. On the one hand, the reduction of ethics in medicine to principlist dilemmas to be solved by a bioethics committee or by a bioethicist reveals a truth regime determining the morality of contemporary medical practice. On the other hand, with the help of bioethics certain contingencies have been transformed in natural and necessary scenarios or outcomes, for instance, the current model of healthcare and the current way of being a doctor remain taken for granted truths at the same time as bioethicists permanently invoke human dignity or individual autonomy in their „analyses‟.

By and large, the aforementioned journals of bioethics have published only a few articles that address ethical issues related to the healthcare reform.210 These articles show three main characteristics. First, they do not analyse in depth the relationship between healthcare system, socio-political conditions and the transformation of the Colombian medical ethos. Second, what is called in these articles a „bioethical perspective‟ is merely a set of additional paragraphs where the four principles are mentioned. In other words, they do not offer any

210

For example in the series Bios & Ethos, published by El Bosque University over almost ten years, between 1997 and 2007, there are only two articles (in the issue No. 25) that examine the healthcare reform, but from a bioethical perspective neither of them is a comprehensive and critical analysis of such a reform nor do they address properly the impact of it on medical practice. Thus, while the first article is just a list of common places about administrative, political, and economic aspects of the reform summarised (Rodríguez, C. E., 2006), the second one is an attempt to demonstrate that the healthcare reform failed to realise the concept of sanitary justice (Galvis, 2006).

138 original, innovative or critical perspective. And, third, when these articles seem to discuss the crisis of the Colombian medical ethos, they mainly express „a professional point of view‟, i.e. a medical ethics approach but using the language of American principlism. Hence, in Colombia it seems that any discourse is „bioethical‟ as long as it cites or appeals to the four principles. The approach of the Colombian bioethics establishment to the crisis of the medical ethos, in the context of the healthcare reform of 1993, first, has not been consistent with the dimensions of this crisis, second, has contributed to leave some structural problems unnoticed, and third, has reduced the philosophical reflection on medical practice to a game of balancing the four principles. In fact, the grandiloquent discourse of bioethics about personal autonomy and free choice fits well in the new neoliberal environment that characterises the current socio-political and economic life of the country. In this point, however, it is necessary to take into account the counterintuitive aspect of Foucault‟s position: freedom is not just a precious good or right that should have guaranteed to every human being in a modern liberal and democratic society, but rather a strategy to govern.