Dignity, patient’s autonomy and mental illness

Eduardo Henr ique Rodrigues de Almeida

Abstract

Human dignity, intrinsicall y li nked to autono my, is vulnerable in situation s of seve re mental disor der, either to participate in medical or to participate of therapeutic decision s. The author discuss es the con cept of dignity, the principle of autono my and the infor med con sent, and, by rev iewing the li teratur e, sugg ests that ethical action is the con stant exercise to identify when and ho w it is easier to disregard dignity and avoid doing it. He con cludes by stress ing that to deny autono my to others, simply because on e is in a position to do so is to respect his dignity. Att ention shou ld be paid to the fact that paternali sm and are no t always goo d solution s for the mentall y ill.

Key words: Personal autonomy. . Vulnerability. . Mental health. Mental competence .

Man is he and his circumstances

Ortega y Gasset

How to deal with autonomy issue when one deals with subjects who were destitute of all and any possibility of its

Eduar do Henr ique Rodrigues use if they are labeled mentally ill? In view of this limitation, de Almeida apparently insurmountable, this work proposes to discuss two essential Physician by the Federal University of Minas Gerais aspects: mentally ill patients’ capability to exercise their autonomies in (UFMG) Medical School, specialized in Labor Medicine, face of therapeutical possibilities, and the inclusion of these in medical Medical Clinic, and research groups, under the risk of abuse for being a vulnerable group . Gastroenterology, working in his doctoral degree in Bioethics at Reflection will point still toward the issue of treatment access, the University of Porto Medical considering mentally ill who are without access to appropriate School, Portugal, medical expert at Social Security INSS/MPS ) in therapeutics would not have their autonomy affected in double . Belo Horizon te, Minas Gerais, Brazil

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Dignity : principle that defines human Dignity is a quality inherent to all human being beings, as moral beings, and just to these, for

being completely inseparable of autonomy for AThe notion of dignity as intrinsic and the exercise of practical reason . À As they common feature to every human being exert autonomously their practical is relatively recent. History shows that reason, human beings build different human being’s primacy was not personalities, each absolutely individual extended always to all humans. Slavery and irreplaceable . Consequently, dignity demonstrates this, reigning both in would be inseparable from autonomy to exert practical Oriental civilizations and in classic reason, and for this reason is that just humans dresses European Antiquity, as well as up on dignity . persecutions promoted by the Holy Inquisition, in which discrimination was The great legacy of Kantian thought for human notorious and, usually, accepted rights philosophy is the equity in attribution of dignity. pacifically by legislators, historians, Considering that freedom in the exercise of the religious people, and philosopher at the practical reason is the sole requirement in order to a time . being dresses himself up on dignity, and that all humans enjoy this autonomy, one has that human The notion of human being’s dignity condition is the physical support needed and rests in his real being and in his sufficient to dignity, independently of any type of capability of being able to be, not been social recognition . For Kant, human being is an restricted just to what effectively one absolute value, an end in itself, because is gifted does out of this capability. Thus, one with reason. His autonomy, for being rational, is considers it as inherent attribute . Human the root of dignity, as it is what makes Man an dignity is, then, the acknowledgement of a value; end in himself 2. is a moral principle based in the usefulness of the human being, and not in his use as a means . Principle of autonomy This notion, since it is proper of human Etymologically, the word autonomy derives from condition, is considered also as inalienable autos, self, and nomos, law . One of the that cannot be taken away or suppressed 1. theoretical basis for ellaboration of the Equity among human being in attribution principle of autonomy derives from John of dignity bases the philosophy of Stuart Mill’s thought , for whom the individual human rights. It is from this value that is sovereign over himself, his body and mind. basic human rights derive . But, in Kantian view, autonomy is the power of the self over oneself – the freedom -, exerted ÉIt is usual to see the first enunciation of the dignity principle attributed to Imma nuel Kant, for who dignity is a value that covers all that which there is not price, that is, it is passable to be replaced by an equivalent . In Kantian thought ,

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by the mediation of a law (nomos) that reason education or if he lives deprived of public order. imposes on itself. Moral occurs from this self-imposition. Equally, primary health care is a condition to Therefore, according to this proposition, autonomy and exercise autonomy 4. freedom are solidarian concepts, but not coincident. Whoever does evil acts freely, but without autonomy, The 5, which established the one submits freely to that part of his being that bases for adequacy of research ethics in the effectively is not free of his instincts, passions, United States (USA), designed autonomy as weakness, interests, and fears 3 , forgetting both law Principle of Respect for People. In this and its reflection in moral conscience . perspective, it proposed that autonomy incorporates, at least, two ethical An autonomous person is an individual convictions : the first one, that individuals capable to deliberate on his personal should be treated as autonomous agents; objectives and to act toward this the second one, that people with decreased deliberation, considering moral values from autonomy should be protected . Thus, one the context in which he is inserted. An divides the issue in two separate moral autonomous individual acts freely in requirements : that of recognition of autonomy, accordance to his own plan, in and that of protecting those with decreased analogous way to an independent autonomy . country that manages its territory and establishes its policies . To r espect Respect f or people with autonomy is to valuate consideration about decreased autonomy opinions and choices, avoiding, in the same way, the obstructions of autonomous subject’s action, Ar isto tle and Saint Augustine admitted the except if they are clearly harmful to others . distinction between things, animals, and human being 2 . Departing from premises coming from To show lack of respect toward an distinct conceptions of the world, both autonomous agent would be to not consider his recognized in human beings unique qualities judgments, to deny the individual freedom to act based that distinguished them from the others. on them or to omit needed information in order to a Currently, one considers that the fundamental judgment can be made when there are not convincing difference between human being and the other reasons for it. Ch arlesworth goes beyond and he animals is not in affectivity, but rather in the introduces the social perspective in defining capability to think symbolically, to represent individual’s autonomy, pointing that this may lead to and to project contents of conscience, using the own notion of citizenship . And he states that them in creation of human culture 6. nobody has the capacity to develop personal Consequently, conscience, is one of the freedom and feeling autonomous if he capabilities of human cognition, it is valuated as anguished by poverty, deprived of basic essential component of that which characterizes humanity – as one gets from Kant’s reasoning .

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According to this formulation, conscience the inter-relational process in society . could be classified as the a priori for the Thus , considering this, how do we exercise of practical reason. Associated to attribute this same humanity to those notions of autonomy and dignity, its existence who are deprived of this relational would constitute, therefore, in prerequisite to existence, of this materialization of qualify humans as moral beings. Thus, it would themselves while persons, either be only in consequence of it that these would be because they never had it, as the case embodied of dignity. But, if it is conscience that of the newly born, or because they fundaments dignity, autonomy, and freedom, have lost it in consequence of health how can we classify those mentally conditions ? incompetent or those who, in reason of their age or health condition, are taken as incapable EmIn reply to such paradox, one may argue to exert their autonomy ? Would they stop that the prerequisite of conscience and, being humans because they are deprived of consequently, the attributes of dignity and moral full use of their mental faculties ? Departing autonomy should be understood as inherent to from such premise, both very young human species, biological characteristics of the children and the sick destitute of full use of Homo sapiens, independently of their their conscience could not be classified as manifestation in plenitude in each specific human being . humanly dignified 2. That is , human dignity would be an attribute of the potential human for the exercise of practical reason . The deadlock generated by unilinear One may conceive that, in this perspective, even application of this rationale, which those deprived of full use of reason may be associates mistakenly humanity to entitle to it, being, thus, carriers of the same reason, establishing that the first is a essential dignity, as well as the same intrinsic function of the second, deepens itself and inalienable rights than the others right . when one analyzes closely the issue . If conscience can be associated to a biological However , seif this perspective allows to expand basis, related to cognition capability, and if this is humanity’s classification, untying it from the effective what differentiates and qualifies humanity, use of reason, and relating it to the potential for the allowing to presuppose human dignity, the practical exercise of this use, the same does not apply insane or terminal sick person, who is to the notion of autonomy, which cannot be considered unconscious or in persistent vegetative state, just as inherent possibility, but only as effective would not have the right to the same dignity as a capacity, materialized in moral choices of the social life . healthy person, and in full use of his faculties . The concept of autonomy, particularly in Moreover, the merely biological body may mental health realm, seems to be be taken even as an abstraction, in as recovered by inaccurate meanings 2, much as we are a lived-body, a personal- which may be exemplified in the body, which becomes human in consequence of requirement of informed consent, in the

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clinic , what requires rational capability to – exactly the resources for information processing understand information and from them to make that are affected in mental disorders . decisions – skill that the mentally disabled do not have or have it severely compromised 7. The presumed Psychiatric patients may (or not) find themselves incapability of the mentally ill to exert their clinically deterred to consent in sovereign autonomy in view of therapeutical possibilities, manner, given that there is the possibility that the and participation in medical research groups disorder affecting them makes it difficult or deters would turn them into a group particularly the use of one or more cognition attributes . It vulnerable to abuse . occurs, equally, with the immature or those who, for other health reasons, become incapable to make The fundament of the informed consent choices or to make decisions. As people, even if in medical doctrine consists in understanding that such conditions, must be treated as human decision-making on health is a sort of sef- beings, that is, carriers of inherent dignity determination. The right to informed consent is that confers to all and anyone, simply not just a political or legal requirement, linked to because they are people, one can one the most fundamental ethical principles of conceive that this includes the right of not contemporary society, namely autonomy and been discriminated . respect for the individual. The exercise of this right departs from the premise that patient has However, even respecting the prerogative of the capacity to make decisions, to understand every individual be equal in rights, not all of the nature and implications of options presented them have the capability to self-determine in the to him, and making free choices. However, as same measure . Generally , this capability discussed, other elements are indispensable for matures during individual’s life, and some people conscious choices beyond understanding of lose it totally or partially due to illnesses, mental alternatives, mere conceptual items that need to disorders or circumstances that severely restrict be valuated 8. freedom. Given this differential in the capability for the exercise of autonomy, it becomes necessary to Autono my of patient with consider, in these cases, the principles of and mental illness equity as well, that is, it is indispensable to bear in

mind that relevant differences that may affect According to Eike-Henn er 8, mental p rocess es autonomous choices should be pondered for behind behavior derive from cognitive effective application of justice. There should be and, capability. Cognition is the act or knowledge therefore, one must seek for a way to ensure the process, involving attention, perception, right to self-determination in the absence of decision- memory, reasoning, opinion, imagination, making capability. thought, and language.

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Eike-Henn er 8 warns for the mistake that it would be Arrangements among people in the context to treat incompetent person in the same way that one of social contracts may turn feasible the would treat any individual, what he understands as increase in quality of life and, consequently, in punish him for its incompetence . Thus , he teaches, autonomy also 9. even in his incompetence there must be a way to understand and respect his autonomy. Similarly, the According to Santos et all 2, it seems that the respect for the immature and for the incapable may nodal point is in defining what can be understood require his protection as they mature or while they are as autonomy, both for us and for the psychiatric incapable . clientele. According to these authors, autonomy production may be characterized in two paths: i) Someone with decreased autonomy is, at least in abandonment of expectation of solubility and some aspect, controlled by others or incapable to efficacy by comparing with our own performance; deliberate and act based in his wishes and plans. and ii) creation of other possibilities of life from this Mental incapability limits autonomy in the same way other subjectivity standard . Directly relating to this that coercitive institutionalization does with prisoners . issue, one should discuss the possibility to rethink Pee l 9 admits that in psychiatry many patients are the cure process in psychiatry, departing from the considered incompetent in consequence of their clinical idea of possible autonomy . Thus, the polemics condition. Thus, formal falls back into between autonomy and tutorship enters in beneficence to decide how they should be treated . scene as well.

Abreu 10 sustained that, in these terms, Both Abreu and Santos et all studies sustain that autonomy may be included in the axis every care implies in some level of tutorship, as every dependence-independence. The higher assistance service with protector character has the tutor independence level, greater the probability function. According to these authors, a possible of autonomy, but in conditions of partial conception for autonomy would to think it as a moment dependence, the subject still may have his in which a subject starts to live with his problems in a autonomy preserved, depending of social way requiring less assistance devices from the service arrangements that he is capable to itself . Thus, caberiait would be psychiatric establish . The binomial dependence- intitution’s competence to work as intermediary autonomy should not be considered, in space, a passage place, in the ratio that it would principle, as a contradiction, but rather as enable users to increase their contracting power. non excludent opposition . It is less important, in this sense, to create and impose autonomy criteria for this clientele, but to observe what would be the place occupied by this issue inside the new perspective of caring

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for insanity, as institution that conceives Regarding informed consent, the document and promotes care for their users 2. specifies: consent [should be ] freely gotten, without threats or undue persuasion, after In view of the discomfort awaken by the high risk of appropriate clarification with suitable and abuse in the relations between society and its insane, intelligible information, in form and language Basaglia 11 contested medical culture traditional understandable to user 13 . Thus, Brazil started posture that changed the individual and his to be formally committed with ethical body into mere objects of clinical intervention . imperative of humanization of mental health NoIn the field of relations between society care, and with recognition of citizenship and insanity, he assumed a critical stand rights of people with mental disorders. toward classic and hospital psychiatry, because it centers in isolation principle of In the Brazilian Psychiatric Reform the insane (internship as treatment context and of implementation of open model), therefore, being excluding and assistance centers, Santos et all 2 consider repressive . This kind of contestation of that autonomy is important from the stand confinement regime for carriers of mental disorders point of resolution capacity of service, as one gave start to the movement that was known as the believes that improvement of users come from Psychiatric Reform 12. the highest possible level of autonomy, enabled by the new anti-asylum approach . In order to align itself to the international effort toward According to this approach, it is not the subject that implanting psychiatric reform, the Federal Council of must adequate to clinical proposal, but rather the Medicine (CFM) approved Resolution no. 1,407/94, opposite, it is the service that must be able to absorb adopting the principles that the United Nations users’ specific demands, what requires the most diverse Organization (UNO) issued in the general tactics. However, authors admit that in the protected assembly undertaken in December 17, 1991 : field of the clinic, it is possible already that these the principles for protection of people with mental subjects transit and are able even, in certain way, to disorders, and for improvement of mental health establish social bonds, but it in the space of the polis care . The UN document, among other rights that barriers remains almost unchanged 2 . and safeguards, integrally incorporated by CFM, has references to psychiatric Moura Fé 14 speculates been possible that the treatment defining that treatment and care to trend to consider natural the treatment of the each user will be based in a plan individually mentally ill against their wills or opinions, has prescribed, discussed with him, regularly relationship with two prejudices that were reviewed, modified whenever necessary, and established in regard to patients: their administered by qualified professional dangerousness and incurability. personnel 13.

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He adds that the frequent use of physical or chemical (present skill) may be in question as it deals with contention suits to hide the quantitative or qualitative minors, prisoners, for been carriers of cognitive scarcity of health area personnel, that is, to mask the deficits, mental illness, or intoxicated. Sometimes, lack of patients’ health care, what he considers as one we suspend autonomy of such patients, but we of the dramatic and revolting features of asylums, do it rarely in favor of another ethical principle, which should be denounced always . beneficence, the non-maleficence, or justice 17. Attempts to extend application of the autonomy OAuthor reminds, still, that there are principle, for the author, to children and mentally tests attempting to evaluate the incapacitated configure distortion ( overuse ). rationality of patient’s choice in accepting or refusing treatment or Research involving vulnerable certain forms of treatment, as well as groups

its real capability to understand As reflect of Nazi that led to the Nuremberg information related to proposed trials, even today one recognizes that the tension between therapeutics . It is of special relevance to set if researchers’ intensions to produce scientific knowledge patient’s decision is rational, wise, or if it is and comply to ethical principles of protection to research compromised by his illness. However, in the end, it is participants is a space of continued risk . OsEthical the physician who defines if patient is competent or not transgression cases, occurred in the second half of the to decide if what he does should be considered wise, 20th Century, during undertaking of experiment in which 15 rational, or not – what sets under suspicion the participants were not considered, unfairly treated, pretention to grant him autonomy jeopardized in their interests or, even, mutilated and killed have stimulated continued monitoring of researches, as 16 In the opposite sense , Gessert argues that well as designing of guidelines for protection of excessive emphasis on patient’s autonomy participants in these experiments . results in feeling of abandonment by them and in frustration on physicians’ part. He highlights As Scott and Kim 18 highlight, science is not that in the past 50 years, the physician-patient merely a technical activity; it has ethical rules without relationship was changed from strong which could not even be qualified as science . paternalism to one that now strongly reflects Normally, ethical q uestionings in clinical 17 patient’s autonomy . And he goes on by research fall back into seven categories that stating that the right to autonomy makes define validation premises of the research: sense, and it is easierly advocated for lucid and well informed adults, but routinely we face patients whose competence (legal status), and capability

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1) to be social or scientifically useful ; 2) to Economic and gender inequalities, in have scientific validity ; 3) to have a fair the other hand, associate themselves selection of participants ; 4) to have a to vulnerability of the poorer, victimizing favorable risk-benefit ratio ; 5) to go through women – particularly, pregnant women independent review ; 6) to get informed consent, – and prisoners . A roll of all subjects in such which in Brazil corresponds to the expression situation, nevertheless, could be more free and clarified consent TCLE); and 7) comprehensive . show respect for potentially involved individuals. Vulnerable populations are inviting to trials exactly in Authors refer, still, that in research with virtue of their vulnerability, a condition that gives children the United States federal regulation potential for the risk of ethical transgression during data defines that these cannot be exposed to assessment phase . One cannot forget, minimum risk when research involves additionally, that compulsory intervention or procedure that does not have confinement practice is but a violation of a perspective of direct benefit to participants, rights . According to Kingdon et all 20 , such restricting participation of this group in the cases should be within the criminal experiments . However, there is not analogous judiciary scope . At this regard, the policy for incapable adults. The setting of European Council emphasizes that the acceptable risk-benefit limit is a social policy mental health system should not be more than scientific expertise . used for strictly custody reasons, even in situation of severe risk for third In this context, Schuklenk 19 states that people parties, without having therapeutical in disadvantage or vulnerable to harm and purposes 20. risks, independently of required conditions by determined , should be target of Independently of understanding and decision constant ethical concern . These are capability, free and clarified consent is required participants, for different reasons, already always as requisite for inclusion of socially marginalized and, therefore, participants in clinical trials. The Nuremberg susceptible to exploitation . Generally, Code establishes that volunta ry consent of they occupy an inequality place in power human participant is totally essential 21 relation with other people or, in some specific to carry out correct trials from ethical point of cases, they present different cognitive skills, view . Nevetheless , Schuklenk observed that this which makes them less capable and criterion – absolutely essential – would turn the autonomous. It is what happens, for example, undertaking of trials with participation of the with mental deficiency carriers. incapable mentally ill impossible . However, if we wish to contribute to improve the situation of those who suffer

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from illnesses that imply in the ir incapability to not objective conditions always to guide choices . manifest free and clarified consent, it is necessary to carry out research Scott and Kim 18 highlight, on informed involving such universe of people 22 . It is consent in research, three essential elements : worth stressing, however, that suppressing participant’s i) individuals need to be clearly informed or his representative’s voluntary consent, even if in behalf about the purpose, methodology, risks, of possible benefit for carriers of such incapacitating benefits, and alternatives to research ; ii) illnesses, may be the first step to incur in serious risk of they need to have capability to make opening a fundamental ethical precedent, regarding decisions ; and iii ) to have the human rights assurance of clinical trials participants . poss ibility to make voluntary choice . The severe and incurable nature of many It was in consequence of this same neuropsychiatric disorders sets patients in consideration that the World position especially vulnerable for exploitation, Medical Association (WMA) adopted , and authors call attention for the need of future during initial formulation of the Helsinki studies, taking into account the concept of Declaration 23, the free and clarified vulnerability may be reasonably operational. consent by means of power of attorney They indicate that there is continued need as acceptable alternative for those research for research specifically focusing on the participants not apt to directly consent, which decision point to respond questionings should be represented by third parties 24. Even that arise throughout undertaking of if laudable WM A attempt to ensure to those research with partially capable or incapacitated their rights as research incapable people . participants, on should consider that consent gotten by means of power of attorney is AThe importance of this type of always problematic . Perhaps, the most research becomes clear when one important pondering to be made is about who realizes that from these initial should give legal consent . The general considerations arise a series of other mechanism adopted by society is the questionings, for example : how does delegation of the right of decision to incapability changes into capability ? How do someone who has the conditions to we adjust the intensity of the incapability decide and to ensure that the best evaluation process in accordance to the risk- choice is made . However, which values benefit ratio of proposed protocol ? How do should be taken into account on the part of we carry out the selection of the non-incapable the substitute ? When one deals with in a process that is ethical and efficient someone who has been competent in the procedurally ? What is the relation between past, the substitute has the parameter to capability to provide informed consent and suppose how the stakeholder would act to nominate a legitimate representative to probably and, then, to decide as if it was decide for replacement ? really him 8. But, as one knows, there are

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Another major consideration that evident that the involvement of this specific universe outstands from this discussion is to what of individuals is necessary for the study, but no direct end legal consent should be given, that is, benefit will arise for participants . in which research and in what conditions could it be accepted . In this case, difference Differently from research with adults without between therapeutic and non-therapeutic research cognitive restrictions, where free and is under stake 24 . The first ones confer direct benefits to clarified consent through power of attorney is research participants, and the second does not. By rare occurrence, research with mentally contemplating research participation incompetent people requires constant possibilities to include mentally incapable monitoring, continue communication individuals, the initial version of the Helsinki between participants in order to ensure that Declaration 23 allowed for carrying out the first one will be informed always and apt therapeutic research involving these to consent 25. people, as long as they are particularly beneficial especially to this group . Studies Finally, it is fit to highlight the legal aspects that may include psychiatric drugs trials, behavioral define incapability condition in the country and, therapies, or surgical interventions . consequently, decrease of autonomy . OThe Brazilian Civil Code, in its Article 4, Non-therapeutic researches, however, do not contribute in considers relatively incapable certain order to mentally incapable peope to change acts, or the way to exert them, the their clinic condition, thus, they can be exceptional, the habitual drunk, drug carried out with participation of adults addicts, and those that, due mental capable to consent, not demanding, deficiency, have reduced discerning, necessarily, the involvement of vulnerable and incapable to personally exert the populations . Regarding mentally incapable acts of civil life , those who, due to people, non-therapeutic researches may illness or mental deficiency, do not have include from efficacy tests of new need discerning to practice these acts, vaccines against HIV to risk evaluations and those who, even because of of the side effects of a new drug . This transitory cause, cannot express their type of research may encompass also will. Therefore, medical researches involving studies that seek specific data that do not such groups and carried out in the Brazilian directly benefit the universe of incapable territory need to consider the limits of law that, by people participating in the research . nature, are expressed in generic way when Researchers may get interested, for example, in referring, for example, to necessary discerning , understanding the incidence of hereditary dysfunctions issue of complex evaluation , subject always among mentally incapable people . In this case, it is to sound criticism . One gets out of this, once again, the necessity of following up

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case by case in studies undertaken with One must be attentive to the fact that paternalism and this kind of patient in order to the ethics of beneficence are not always good solutions for the experiment, and participants’ dignity be mentally ill and that, perhaps, State tutorship and respected effectively . medical control are much more at service of the

mentally ill contention, stigmatized or dangerous for Final considerations society, than seeking real comfort and treatment or him .

Autonomy is the fundament of human It is up to everyone who assists these patients in any dignity of all rational being. It is in the way, and to those that have disposition to produce expression of his autonomy that human science in collaboration with these, to act with his being dignifies himself, while it may not consent, getting it in the manner that is possible, but (the autonomy) imposingly restricted assuring to seek for it with genuine effort and interest . under the pretext of replacing free will by that which one believes to be better or In view of a therapeutical or medical research proposal most appropriate . in which bioethical principles of self-determination and autonomy cannot be fully applicable, one must valuate, Vulnerable people, like the mentally disorder carrier, are particularly, the principles of beneficence and non- among the most subjected to abuse that violate this attribute maleficence . Psychiatric patients have the of his dignity . However, the limit between the right to benefit from innovation and withdrawal of power/autonomy, justifiable in research that, however, should be view of the clinical situation and the carried out only when is clear enough disrespectful imposition of force aiming at that direct benefit for the health of those assuring greater facility, precisely for those involved – contemplating, thus, the principle who have strength, is very thin . of justice and equity in access to new therapeutical possibilities. Ethical acting is, therefore, the constant exercise to identify, precisely, how and when is easier to disrespect dignity and to avoid doing it . Refraining to deny autonomy to others, because simply one is in position that allows him so, is to respect his dignity.

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Resumen

La dignidad, la autonom ía del paciente y la enfermedad mental

La dignidad humana, intr ínsecamente vinculada a la autonomía, es vulnerable en situaciones de trastorno mental grave, ya sea para participar en la investigaci ón médica o para proporcionar informaci ón sobre los requisitos del efecto terap éutico. El autor discute el concepto de dignidad, el principio de autonom ía y consentimiento informado, y mediante la revisió n de la literatura, sugiere que la acci ón ética es el ejercicio constante para identificar dónde y cómo es más fácil hacer caso omiso de la dignidad y evitar hacerlo. Concluye aseverando que negar autonom ía a otros, simplemente porque se está en posici ón que as ípermita, es no respetarle la dignidad. Debe prestarse atenci ón al hecho de que el paternalismo y la beneficencia no siempre son buenas soluciones para los enfermos mentales.

Palabras-clave: Autonom ía personal. Bioética. Vulnerabilidad. Consentimiento informado. Salud mental. Competencia mental.

Resumo

Dignidade, autonomia do paciente e doença mental

A dignidade humana, intrinsecamente vinculada à autonomia, fica comprometida em situa ções de dist úrbio mental grave, quer para participação em pesquisas médicas quer para opinar sobre as prescri ções de caráter terap êutico. O artigo discute o conceito de dignidade, o princ ípio da autonomia e o consentimento informado e, com base em revisão da literatura, preconiza que o agir ético é o constante exerc ício de identificar quando e como é mais fácil desrespeitar a dignidade e evitar faz ê-lo. Conclui asseverando que negar autonomia a outrem, porque simplesmente se está em posição que assim permite, é desrespeitar-lhe a dignidade. Deve-se atentar para o fato de que paternalismo e benefic ência nem sempre são boas solu ções para o doente mental.

Palavras-chave: Autonomia pessoal. Bioética. Vulnerabilidade. Consentimento livre e esclarecido. Sa úde mental. Compet ência mental .

References

1. Andorno R. Human dignity and human rights as a common ground for global ethics. J Med Philosophy 2009;34(3):223-40. 2. Santos NS, Almeida PF, Venâncio AT, Delgado PG. A autonomia do sujeito psic ótico no contexto da reforma psiquiátrica brasileira. Psicol Cienc Prof 2000;20(4):46-53.

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Received: 1.20.2010 Approved: 6.17.2010 Final approval: 7.9.2010

Contact

Eduardo Henrique Rodrigues de Almeida - [email protected]

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