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In Uruguay, an ethic of care for the dying.

In Uruguay, an Ethic of Care for the Dying Perhaps the most striking point to be made about biomedical ethics in Uruguay is that there has been insufficient interest on the part of the medical community to engage in systematic reflection or to set up mechanisms for addressing ethical issues. For various reasons Uruguay underwent a process of secularization earlier than many European countries. The separation of the Catholic church and the state was formally instituted with the 1917 Constitution. Since that time ethical issues have been associated with "dogmatism" and "religion." From the end of the last century medicine in Uruguay, as in other countries, has been characterized by philosophical positivism. In this perspective, the "typical" Uruguayan physician has always maintained a humanistic attitude in certain recognized modalities in the physician-patient relationship. It is generally held that: * The patient deserves respect and consideration because he or she is a human being whom physicians are not permitted to manipulate. * The family is to be treated with deference. The physician seeks to accomplish the family's will whenever it does not come into conflict with his or her expert judgment. * It is the physician, however, who in the last instance resolves all issues concerning the patient's health care. The patient, for his or her part, trusts the physician to make all decisions in his or her best interest. * Uruguayan society attributes to the physician a paternal function that consists basically in curing the patient by the best available means and acting in his or her best interest. * The physician is aware also that patients expect a friendly and encouraging attitude on his part. Nonetheless, it is more or less tacitly acknowledged that a physician can withhold "sensitive" information from the patient, knowing that the latter will not insist on having treatment decisions explained in detail. These moral attitudes have been called into question by only a very limited minority among the 8,000 physicians who serve Uruguay's population of 3 million. Ethical issues not linked to the physician-patient relationship, or on which there is no positive law, are considered matters of personal moral philosophy and conceptually associated with religion. The most relevant issue of professional ethics in Uruguayan medicine in the past ten years has been that of physicians participating in torture at the service of the military dictatorship that ended in 1985. This led the Sindicato Medico del Uruguay (Uruguayan Medical Association) to create an ethics committee, whose activities to date have been restricted to this topic. To my knowledge as yet no hospital in the country has an ethics committee. Nonetheless, initiatives in the field of bioethics--although very confined--are not completely lacking in Uruguay. A small group of health professionals has sponsored courses and lectures by professors from other nations in bioethics at the Catholic University of Uruguay. Catholic physicians have organized activities, and chairpersons of some departments in the school of medicine at the Universidad Mayor de la Republica have initiated lectures and debates on bioethics. Yet in spite of this relative "poverty" of systematic reflection in our country, one is aware that there are conscientious physicians in Uruguay who are very interested in ethical issues. Through the scientific literature they receive they have access to their foreign colleagues' ethical reflections and are well informed. Ethics in the Care of the Dying In this context the fundamental relation between physician and dying patient is one of paternalism on the part of the physician and willingness to relinquish responsibility on the part of the patient. In a large majority of cases, physicians prefer not to inform the patient that his or her condition is actually terminal. …