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Health care for terminal patients: between medical practices and religious beliefs1

The new Brazilian Code of Medical Ethics, which became effective as of April 13, 2010, addresses terminal and irreversible clinical situations. In such cases, doctors are advised to provide appropriate palliative care for patients under their responsibility instead of performing unnecessary diagnostic and therapeutic procedures. The Code’s process of approval is examined in this article, as well as the changes occurred in Brazil within a few decades regarding health care for clinical profiles considered as terminal or out of the therapeutic chances of cure. Although the terms orthothanasia, dysthanasia and euthanasia are not used in the new Code of Medical Ethics, they are addressed in this article together with the different points of view of religious groups on the process of dying. A “good death”, with dignity, or the production of a humanized death has received the attention of palliative caregivers, who postulate the need to provide spiritual assistance to ill patients and their families. Surveys with palliative care teams and the medical ethics new code’s text are the background for the debate over the dilemmas faced by all those practically involved in the process of dying. Finally, focus is placed on the doctor/patient/family relationship in this recent kind of care, because such interaction is intertwined with power relations, where different values and religious beliefs can be seen.


document ruling doctors' ethical conduct results from criticism
to an markedly curative model, where death was -and still is, at times -seen as failure by health professionals (HERZLICH, 1993).
Determining the end of life -and how it should happendepends on historical, social and cultural context. Living/dying have always been influenced by laws and religious values.
Nowadays, it depends on the debate and the standardization that builds near the fine line dividing being alive from being dead. In the modern western society, two spheres influence the definition of the beginning and the end of life: the scientific and the religious spheres. The former has been associated, since the 18th century (FOUCAULT, 1994), with the statute of producing "truths", guiding the creation of criteria for the person's conditional existence. As regards the second sphere, in each context positions and demands of religious groups emerge, in view of new possibilities to intervene in the beginning and the end of life and to decide over them.
Since the beginning of this century, practices such as euthanasia and the interruption of fluids, food and/ or treatment have caused increasing controversy in many countries as the claims to make those procedures legal grow (MENEZES, 2009). In Brazil, there are groups both for and against the formulation of norms and laws, as was the case of the new Code of Medical Ethics.
This article aims to examine the process whose result was the formulation of the standards which refer to the condition of terminal patients, and the recent type of care provided in this situation. Surveys conducted in public units of palliative health care and interviews with doctors devoted to palliative care 2 have contributed to the debate on the practical dilemmas faced by all the people involved in the process of dying. The Code of Medical Ethics was chosen as a reference to examine these issues not only because it is the document that regulates and sanctions the medical conduct, but also due to the fact that the Brazilian Medical Council plays an extremely important political role in Brazilian society. As stated on the website of the Council, it is about "defending people's health and the doctors' interests" 3 . Moreover, it is common knowledge that creating and approving standards which refer to life and death are not only based on technical criteria, but also influenced by religious values and beliefs. Another aspect is the centrality of the forms of knowledge related to the health-illness process, to the medical institutions, and to health professionals in the modern western culture 4 . In other words, one can observe the increasing importance of this reference in people's everyday life, in the views and the habits concerning oneself's care.

Death and dying in modern western society
The process which originated the increasing penetration of referents arising from biomedical knowledge into everyday life -designated as medicalization of society -was and has been investigated by several authors, among which one can highlight the pioneering studies by Michel Foucault (1979Foucault ( , 1994, Philippe Ariès (1981Ariès ( , 2003 and Norbert Elias (2001).
Published from the 1960s onwards, these studies analyze the emergence of the general hospital and the concurrent transformation in knowledge that established the anatomoclinical rationality, which came to structure modern medicine.
Before the 18th century, hospitals were essentially institutions assisting the poor, managed by religious denominations, with no resemblance to contemporary hospital medicine (FOUCAULT, 1979). Hospitals not only offered shelter to the poor and the socially excluded but also protected other people from contamination danger. They were places associated with assistance, separation and exclusion. It should be noted that members of the clergy relied on other people's help, especially women's, to care for the poor admitted into hospital in order to save their souls. Those helpers were people considered to be sinners; they did not aim to cure the ill, but to save themselves on the day of the Last Judgment.
At the end of the 18th century, pathogenic elements are reorganized, and medicine starts to produce a scientific speech about the individual, his health and illness. Hence, the origins of the medicalized hospital lie in the adjustment of two closely connected processes: care shifts from clergymen to doctors, and the disciplinarization of the institutional space shows in specific architecture and functioning, so as to become itself a means of intervention upon in the ill patient.
An important character has emerged from the core of this type of intervention: the hospital doctor. Trust in this social actor by groups, communities or societies is the result of a long process that took place in the modern western culture. According to Daniel (1999), trustworthyness acts as a mediator not only in the doctor-patient relationship, but also in the articulation between a professional category and society.
From the 18th century, the definition of life and death was incorporated into the medical knowledge grounded in science, and in biology, in particular. At least ideally, secularization and medicalization of society (MENEZES, 2004) shifted the definition and the determination of the limits between life and death from religion to science. The organization of a highly rationalized logical structure to produce "truths" about the universe became the prominent axis (FOUCAULT, 1994;CAMARGO Jr., 2003). Thus, illness and death started to be considered natural events, caused by recognizable diseases.
The end of life was reconstructed and resignified: from a spiritual passage to a medical phenomenon (WALTER, 1996).
Biomedical knowledge became the hegemonic reference as regards health and, at the same time, hope while coping with dying. As a result, hope was medicalized and secularized.
As medicine and medical doctors became crucial to manage illness and dying, new standards had to be formulated, especially with the advent of innovative medical technologies geared towards creating, prolonging or maintaining life.
During the 20th century, particularly the second half of it, new equipment was manufactured -for example, mechanical ventilators -presenting new ways to intervene in the body. In In addition to brain death, another condition is required, as During the 20th century, the technical progress of medicine managed to reduce some mortality rates, especially child and neonatal rates -and extend life expectancy, thus changing the way death was dealt with. Concurrently, by adopting prevention measures and exerting social control of health and illness, medicine itself played a major role in keeping death away from individuals' consciousness. The awareness of some natural processes' inexorability is then softened by a notion that somehow they can be controlled.
Several authors (GLASER, et al., 1965(GLASER, et al., , 1968KÜBLER-ROSS, 1969;SUDNOW, 1967)  Rather than silenced, hidden or denied, the concept of dying started to be debated. The diffusion of this new form of care for terminally ill people, at the beginning of the epidemics, was partially due to the ones having AIDS: politically, ideologically and socially committed young people from social classes with great visibility. It should be noted that in 1986 the World Health Organization published the manual Cancer pain relief and palliative care report, which was translated into nineteen languages and distributed in several countries. This manual echoed the concern with the comfort and well-being of terminally ill cancer patients.
Basically, the palliative care team aims to assist the moribund until the end of his life, by minimizing his discomfort and by providing spiritual and emotional support to his family.
In other words, palliative health professionals advocate good death and believe that the dying person should have control over the dying process, that is, he/she should be able to make Palliative care teams believe it is crucial for the ill to rescue pending material, relationship and spiritual issues so that they can have a good death. Palliative ideas prescribe a path to be followed towards a good death. Practical decisions have to be made concerning retirement, pension or will. Quarrels with friends and/or relatives have to be resolved, preferably with forgiveness for wrongdoings being achieved. Finally, the ill person should let go the life and the people he is related to , so as to focus on another type of existence, at another level. Some palliative health professionals believe that spirits aid in the process of dying, along the journey towards another

Controversy over orthothanasia
In curative medicine, when a patient is clinically diagnosed as "hopeless", the physician ceases both responsibility and efforts on him. The patient is merely the occupant of a bed.
The new assistance model, however, is about providing a "good death", or orthothanasia, seeking to avoid dysthanasia. After more than a month at the ICU, the patient's profile of dementia worsened, and her daughter questioned the doctor about the need to keep her mother at the unit. She was given the following answer: "Don't you wish your mother the best? We are offering her the most comprehensive type of health care!" The patient's daughter advocated she should be transferred to a room so that her family could be closer to her. The doctor insisted that the patient was receiving the most sophisticated and state-of-the-art treatment. Eventually, after four months at the ICU, the patient passed away. In an interview, her daughter explained: "It was all very difficult for me. I avoided being present in the physical therapy sessions because she moaned and cried a lot. After a while, she stopped reacting, but I reckon she was already half-conscious. There are very relevant current dilemmas posed by increased life expectancy, life support to premature and/ or underweight newborns, and the ongoing release of sophisticated equipment and technologies. Religious attitude is extremely important in Brazil, a "minimally religious" society (DROOGERS, 1987). Moral values and religious beliefs interfere in defining the boundaries between life and death, by influencing the proposition, acceptance or rejection of resolutions, standards and/or law bills. The Catholic Church and the American Medical-Spiritist Society are in favor of orthothanasia, which the latter considers a "method that enables disincarnation within the right time" 10 , while for the former it is licit choosing to withhold treatments that could only prolong life in a precarious, painful manner when inevitable death is imminent despite the means adopted to avoid it" 11 .
There is a crucial aspect in palliative care for terminally ill patients: the moral values and beliefs which are at stake in the evaluations made by all the parties involved. Thus, when examining each situation, one should take into account the complex nexus existing between the social actors and the shared meanings they produce.

Final remarks
The changes in the Brazilian Code of Medical Ethics mirror society's great concern with excessive medical power over the patient and his family. Reflection should be made on the complex interaction between doctor and patient, which contains issues regarding respect for life, death, pain, (lack of) hope, cure, salvation, dignity, choices, autonomy, among others, which are particularly relevant for the existence of any human being. In addition, we live in a culture which assigns great value to the physical reality of the world that can be understood by human reason. Such an elaboration lies in the basis of modern science emerging both as an idea and an instance which enunciates truth(s). In this sense, emphasis on the condition of a person's body reinforces his status in the modern western society. The privilege of individual choice, autonomy, access to the truth and the emphasis given to controlling all the stages in life -including the process of dying -highlights an ideology centered in the individual as a value (DUMONT, 1993). Health institutions and their professionals -or, in other words, the medical apparatus -are one of the pillars that support such ideology. In this panorama, all the subjects involved can produce different notions for person.
Given each case and context, it is necessary to reflect upon conceptions and values for person, body, life/death, autonomy, suffering, among other categories.
While a new professional field is formed towards caring for the dying, the religious sphere -or spirituality, in palliative terms -becomes the object of intervention by a health care team. How can we understand the incorporation of a sphere of life that did not previously belong to the domain of medicine? At a first glance, one could say that religion is apparently encompassing the sphere of medicine. However, from another perspective, one could affirm quite the opposite.
It is not about rendering the nexus between the two spheres as strictly hierarchical. Sharing interests between the two fields -apparently so disparate and seen as opposite poles -namely science (which is the basis of biomedicine) and religion (spirituality, religious ethos) reiterates the individual (value) and the need to construct him -during his life, while he is dying, and even after his death -a type of modeling that reaffirms the ideology of our western culture.
The new area of palliative care is disseminated by its proponents as a liberating discourse which can offer social acceptance of death and inclusion of the moribund, a character who used to be socially stigmatized. By proposing that some attention is given to spirituality, palliative care professionals introduced themselves as spokespeople for a social demand of opening new horizons. However, one can question whether or not such opening can be a sophisticated way of dying where the patient must fit into the proposed standards to achieve his "salvation" or, in other words, have access to a good death.
Undoubtedly, it is necessary to standardize/normalize and constantly update the current regulations on the conduct of health care professionals, as was the case with the Brazilian Os aspectos aqui abordados, acerca das normas, práticas e representações de vida, morte, autonomia e sofrimento, entre outros, indicam que as definições e determinações em torno dos limites de intervenção sobre a existência humana envolvem tensões e dilemas, que permanecem -e devem permanecer -na pauta de debates.