O preventivismo e os homossexuais no contexto da ditadura militar brasileira: uma análise a partir das contribuições de Sérgio Arouca / Preventivism and homosexuals in the context of the Brazilian military dictatorship: An analysis based on Sérgio Aroucas contributions / El preventivismo y los homosexuales en el contexto de la dictadura militar brasileña: un análisis a partir de las contribuciones de Sérgio Arouca

No Brasil, a reforma da escola médica ancorada na medicina preventiva difundiu-se, em grande medida, durante a ditadura militar (1964-1985). O projeto preventivista é investigado aqui para além de uma reorganização curricular, estando imbuído de um papel social e político evidenciado, especificamente, pelo modo como caracterizou os homossexuais na ditadura militar. Foram analisadas publicações do "Jornal do Brasil" sobre congressos científicos que tematizaram o preventivismo no combate aos comportamentos desviantes na juventude, com destaque ao homossexualismo. A tese de Sérgio Arouca estruturou as principais discussões presentes e embasou a análise das publicações coletadas. Como resultado, os homossexuais, tidos como degenerados desde o século XIX, foram descritos como ameaças patológicas à família, à moral e à segurança nacional, sendo necessária a sua profilaxia a partir de recomendações médico-preventivas no ambiente escolar e familiar e da repressão política direta do Estado.(AU)

In Brazil, the medical school reform grounded on preventive medicine was disseminated, to a large extent, during the military dictatorship (1964-1985). The preventivist project is investigated here beyond a curricular reorganization, as it had a social and political role. This role was clearly visible, specifically, in the way in which it characterized homosexuals in the military dictatorship. We analyzed publications of the newspaper "Jornal do Brasil" about scientific conferences that focused on preventivism in the fight against youth's deviant behaviors, emphasizing homosexuality. Sérgio Arouca's doctoral dissertation structured the main discussions and grounded the analysis of the collected publications. As a result, homosexuals, seen as degenerate since the 19th century, were described as pathological threats to the family, morals and national security; thus, prophylaxis was necessary through medical-preventive recommendations in the school and family environments and through the State's direct political repression.(AU)

En Brasil, la reforma de la escuela médica anclada en la medicina preventiva se difundió, en gran medida, durante la dictadura militar (1964-1985). El proyecto preventivista se investiga aquí más allá de una reorganización curricular, incorporando un papel social y político. Este evidenciado, específicamente, por el modo en que caracterizó a los homosexuales en la dictadura militar. Se analizaron publicaciones del "Jornal do Brasil" sobre congresos científicos que tuvieron como tema el preventivismo en el combate a los comportamientos desviantes en la juventud con destaque para la homosexualidad. La tesis de Sérgio Arouca estructuró las principales discusiones presentes y sirvió de base al análisis de las publicaciones colectadas. Como resultado, los homosexuales, considerados como degenerados desde el siglo XIX se describieron como amenazas patológicas a la familia, a la moral y a la seguridad nacional, siendo necesaria su profilaxis por medio de recomendaciones médico-preventivas en el ambiente escolar y familiar y de la represión política directa del Estado.(AU)

Twentieth-century science education and 21st-century genetic engineering technologies: A toxic mix.

I challenge the "convenient consensus" that He Jiankui is a "bad apple" in order to consider alternative explanations for why He may have ventured down the ill-considered path in his research that he did. The answer I want to proffer is that He was ill-equipped by his education and training in biomedical research to appropriately weigh the competing goods he encountered and thus was not able to be swayed by the clear guidance that basic ethical considerations would have provided. If true, this shows us why, much as we would like to take solace in him being a bad apple, we should be prompted by this episode to focus instead on systems level contributors to He's decisions that, if left unaddressed, will surely lead to similarly reckless episodes by other researchers in the future.

How to distinguish medicalization from over-medicalization?

Is medicalization always harmful? When does medicine overstep its proper boundaries? The aim of this article is to outline the pragmatic criteria for distinguishing between medicalization and over-medicalization. The consequences of considering a phenomenon to be a medical problem may take radically different forms depending on whether the problem in question is correctly or incorrectly perceived as a medical issue. Neither indiscriminate acceptance of medicalization of subsequent areas of human existence, nor criticizing new medicalization cases just because they are medicalization can be justified. The article: (i) identifies various consequences of both well-founded medicalization and over-medicalization; (ii) demonstrates that the issue of defining appropriate limits of medicine cannot be solved by creating an optimum model of health; (iii) proposes four guiding questions to help distinguish medicalization from over-medicalization. The article should foster a normative analysis of the phenomenon of medicalization and contribute to the bioethical reflection on the boundaries of medicine.

Analysing the ethics of breast cancer overdiagnosis: a pathogenic vulnerability.

Breast cancer screening aims to help women by early identification and treatment of cancers that might otherwise be life-threatening. However, breast cancer screening also leads to the detection of some cancers that, if left undetected and untreated, would not have damaged the health of the women concerned. At the time of diagnosis, harmless cancers cannot be identified as non-threatening, therefore women are offered invasive breast cancer treatment. This phenomenon of identifying (and treating) non-harmful cancers is called overdiagnosis. Overdiagnosis is morally problematic as it leads to overall patient harm rather than benefit. Further, breast cancer screening is offered in a context that exaggerates cancer risk and screening benefit, minimises risk of harm and impedes informed choice. These factors combine to create pathogenic vulnerability. That is, breast cancer screening exacerbates rather than reduces women's vulnerability and undermines women's agency. This paper provides an original way of conceptualising agency-supporting responses to the harms of breast cancer overdiagnosis through application of the concept of pathogenic vulnerability.

On the personal utility of Alzheimer's disease-related biomarker testing in the research context.

Many healthy volunteers choose to take part in Alzheimer's disease (AD) prevention studies because they want to know whether they will develop dementia-and what they can do to reduce their risk-and are therefore interested in learning the results of AD biomarker tests. Proponents of AD biomarker disclosure often refer to the personal utility of AD biomarkers, claiming that research participants will be able to use AD biomarker information for personal purposes, such as planning ahead or making important life decisions. In this paper, the claim that AD biomarkers have personal utility for asymptomatic individuals is critically assessed. It demonstrates that in the absence of clinical validity, AD biomarkers cannot have personal utility and do not serve research participants' autonomy. Over the next few years, many research groups will be confronted with participants' preferences to learn the results of AD biomarker tests. When researchers choose to make results available upon explicit request, they should ensure adequate information provision and education, notably on the uncertain clinical significance of AD biomarker information. Routine disclosure of AD biomarkers to cognitively unimpaired individuals in research settings cannot be justified with an appeal to the personal utility of AD biomarker information.

A mobile revolution for healthcare? Setting the agenda for bioethics.

Mobile health (mHealth) is rapidly being implemented and changing our ways of doing, understanding and organising healthcare. mHealth includes wearable devices as well as apps that track fitness, offer wellness programmes or provide tools to manage chronic conditions. According to industry and policy makers, these systems offer efficient and cost-effective solutions for disease prevention and self-management. While this development raises many ethically relevant questions, so far mHealth has received only little attention in medical ethics. This paper provides an overview of bioethical issues raised by mHealth and aims to draw scholarly attention to the ethical significance of its promises and challenges. We show that the overly positive promises of mHealth need to be nuanced and their desirability critically assessed. Finally, we offer suggestions to bioethicists to engage with this emerging trend in healthcare to develop mHealth to its best potential in a morally sound way.

The Ethics of General Population Preventive Genomic Sequencing: Rights and Social Justice.

Advances in DNA sequencing technology open new possibilities for public health genomics, especially in the form of general population preventive genomic sequencing (PGS). Such screening programs would sit at the intersection of public health and preventive health care, and thereby at once invite and resist the use of clinical ethics and public health ethics frameworks. Despite their differences, these ethics frameworks traditionally share a central concern for individual rights. We examine two putative individual rights-the right not to know, and the child's right to an open future-frequently invoked in discussions of predictive genetic testing, in order to explore their potential contribution to evaluating this new practice. Ultimately, we conclude that traditional clinical and public health ethics frameworks, and these two rights in particular, should be complemented by a social justice perspective in order adequately to characterize the ethical dimensions of general population PGS programs.

Left Of Bang Interventions in Trauma: ethical implications for military medical prophylaxis.

Advances in medical capability should be accompanied by discussion of their ethical implications. In the military medical context there is a growing interest in developing prophylactic interventions that will mitigate the effects of trauma and improve survival. The ethics of this novel capability are currently unexplored. This paper describes the concept of trauma prophylaxis (Left Of Bang Interventions in Trauma) and outlines some of the ethical issues that need to be considered, including within concept development, research and implementation. Trauma prophylaxis can be divided into interventions that do not (type 1) and those that do (type 2) have medical enhancement as an unintended side effect of their prophylactic action. We conclude that type 1 interventions have much in common with established military medical prophylaxis, and the potentially enhancing qualities of type 2 interventions raise different issues. We welcome further debate on both interventions.

The ethics of creating genetically modified children using genome editing.

PURPOSE OF REVIEW: To review the recent ethical, legal, and social issues surrounding human reproduction involving germline genome editing. RECENT FINDINGS: Genome editing techniques, such as CRISPR/Cas9, have facilitated genetic modification in human embryos. The most likely purpose of germline genome editing is the prevention of serious genetic disease in offspring. However, complex issues still remain, including irremediable risks to fetuses and future generations, the role of women, the availability of alternatives, long-term follow-up, health insurance coverage, misuse for human enhancement, and the potential effects on adoption. Further discussions, a broad consensus, and appropriate regulations are required before human germline genome editing is introduced into the global society. SUMMARY: Before germline genome editing is used for disease prevention, a broad consensus must be formed by carefully discussing its ethical, legal, and social issues.

El "paciente sano": desafíos éticos de la medicina preventiva / The ethical challenge of "healthy patients"

This paper deals with the phenomenon of the "healthy patient", an ethical issue receiving increased attention at a global level. The genesis of this phenomenon rests in the contradiction between a higher availability of technical and scientific resources for prevention and, paradoxically, the tendency towards an accelerated classification of healthy people as being at risk of developing disease. This manuscript focus on the ethical implications of the "healthy patient", using a theoretical and philosophical approach. Therefore, this research aims to set forth the phenomenon of the "healthy patient" and its fundamental ethical problem, interpreting it as a contradiction between the perennial goal of medicine to maintain and promote health and the increasing use of technology. Thus, it can be hypothesized that the early classification of individuals as subjects at risk is a problem of time. Finally an interpretation from a philosophical point of view will be presented to offer a better understanding of the ethical problem of the "healthy patient" and to elucidate possible strategies of action for physicians and their patients.

[Exists an Obligation to be Healthy? Ethical Limits of Medical Prevention]. / Gibt es eine Pflicht zur Gesundheit? Zu den ethischen Grenzen medizinischer Prävention.

An obligation to be healthy in the sauce of a categorical imperative "You shall change your life!" (P. Sloterdijk) does not exist. There is however a moral responsibility to shape ones own life in such a way that the resulting potentials for development can be realized within one owns possibilities (I. Kant). The example of predictive medicine illustrates, why the right not to know can be a responsible way of self governance when dealing with the knowledge of modern biomedicine. This allows the setting of limits within prevention, which preserve the quality of life of the exposed as well as enabling the individual the "acceptance of self" (R. Guardini).

Empirical population and public health ethics: A review and critical analysis to advance robust empirical-normative inquiry.

The field of population and public health ethics (PPHE) has yet to fully embrace the generation of evidence as an important project. This article reviews the philosophical debates related to the 'empirical turn' in clinical bioethics, and critically analyses how PPHE has and can engage with the philosophical implications of generating empirical data within the task of normative inquiry. A set of five conceptual and theoretical issues pertaining to population health that are unresolved and could potentially benefit from empirical PPHE approaches to normative inquiry are discussed. Each issue differs from traditional empirical bioethical approaches, in that they emphasize (1) concerns related to the population, (2) 'upstream' policy-relevant health interventions - within and outside of the health care system and (3) the prevention of illness and disease. Within each theoretical issue, a conceptual example from population and public health approaches to HIV prevention and health promotion is interrogated. Based on the review and critical analysis, this article concludes that empirical-normative approaches to population and public health ethics would be most usefully pursued as an iterative project (rather than as a linear project), in which the normative informs the empirical questions to be asked and new empirical evidence constantly directs conceptualizations of what constitutes morally robust public health practices. Finally, a conceptualization of an empirical population and public health ethics is advanced in order to open up new interdisciplinary 'spaces', in which empirical and normative approaches to ethical inquiry are transparently (and ethically) integrated.

Participant selection for preventive Regenerative Medicine trials: ethical challenges of selecting individuals at risk.

The innovative field of Regenerative Medicine (RM) is expected to extend the possibilities of prevention or early treatment in healthcare. Increasingly, clinical trials will be developed for people at risk of disease to investigate these RM interventions. These individuals at risk are characterised by their susceptibility for developing clinically manifest disease in future due to the existence of degenerative abnormalities. So far, there has been little debate about the ethical appropriateness of including such individuals at risk in clinical trials. We discuss three main challenges of selecting this participant model for testing RM interventions: the challenge of achieving a proportional risk-benefit balance; complexities in the trial design in terms of follow-up and sample size; and the difficulty of obtaining informed consent due to the many uncertainties. We conclude that selecting the model is not ethically justifiable for first-in-man trials with RM interventions due to the high risks and uncertainties. However, the model can be ethically appropriate for testing the efficacy of RM interventions under the following conditions: interventions should be low risk; the degenerative abnormalities (and other risk factors) should be strongly related with disease within a short time frame; robust preclinical evidence of efficacy needs to be present; and the informed consent procedure should contain extra safeguards with regard to communication on uncertainties.

Integrating patient-centered care and clinical ethics into nutrition practice.

The purpose of this article is to present the application of patient-centered care and clinical ethics into nutrition practice, illustrate the process in a case study, and promote change in the current healthcare clinical ethics model. Nutrition support clinicians have an opportunity to add another dimension to their practice with the incorporation of patient-centered care and clinical ethics. This represents a culture change for healthcare professionals, including nutrition support clinicians, patients and their family. All of these individuals are stakeholders in the process and have the ability to modify the current healthcare system to improve communication and facilitate a change by humanizing nutrition support practice. Nutrition support is a medical, life-sustaining treatment, and the use of this therapy requires knowledge by the nutrition support clinician of patient-centered care concepts, preventive clinical ethics, religion/spirituality and cultural diversity, palliative care team role, and advance care planning. Integrating these into the practice of nutrition support is an innovative approach and results in new knowledge that requires a change in the culture of care and engagement and empowerment of the patient and their family in the process. This is more than a healthcare issue; it involves a social/family conversation movement that will be enhanced by the nutrition support clinician's participation.