Instituto de Bioética

During a highly contested process, abortion was partially decriminalised in Colombia in 2006 by the Constitutional Court: when the pregnancy threatens a woman's life or health, in cases of severe fetal malformations incompatible with life, and in cases of rape, incest or unwanted insemination. However, Colombian women still face obstacles to accessing abortion services. This is illustrated by 36 cases of women who in 2006-08 were denied the right to a lawful termination of pregnancy, or had unjustified obstacles put in their path which delayed the termination, which are analysed in this article. We argue that the obstacles resulted from fundamental disagreements about abortion and misunderstandings regarding the ethical, legal and medical requirements arising from the Court's decision. In order to avoid obstacles such as demands for a judge's authorisation, institutional claims of conscientious objection, rejection of a claim of rape, or refusal of health insurance coverage for a legal termination, which constitute discrimination against women, three main strategies are suggested: public ownership of the Court's decision by all Colombian citizens, a professional approach by those involved in the provision of services in line with the law, and monitoring of its implementation by governmental and non-governmental organisations.

Resumen: Tomar decisiones acertadas desde el punto de vista ético-moral en medicina es un asunto complejo y aprender a hacerlo debe constituir uno de los objetivos del entrenamiento médico. Una forma de contribuir a lograrlo es integrar una completa formación teórica en Ética Médica y Bioética con una verdadera correlación frente a lo vivido en la práctica clínica. Tener en cuenta lo que sienten y piensan los estudiantes al respecto es un buen referente para comenzar. En el presente artículo se presentan los resultados de un taller sobre el tema, llevado a cabo con estudiantes de medicina en Palabras clave: dilemas éticos, práctica clínica, currículo, educación médica Abstract: To take right decisions in medicine from an ethical-moral point of view is a complex matter and to learn to do it must constitute one of the goals of medical training. A way to contribute to achieve this is to integrate a complete theoretical training in Medical Ethics and Bioethics with a true correlation in clinical practice experience. To take into account what students think and feel about the issue is a good reference to start. In the present paper the results on a raise in the workshop development.

Ontological and ethical transformations in health care professions have deeply affected contemporary medical practice. In this scenario, the achievement of an adequate moral development should be a fundamental goal of medical education. We carried out a research aimed to characterize the moral reasoning of the medical students in the Xaverian University, Bogotá, Colombia. To do that, we analyzed the relation between five moral categories/ domains (altruism, contract-confidence-justice in the exchange, consciousness, decentering of self-interest, and role adoption) and four relevant bioethical categories (dignity, beneficence, confidentiality, and duty of care). In total 484 students participated, coming from each semester between first and tenth (Medicine academic program is divided into twelve semesters. Eleventh and twelfth ones correspond to a year of internship). Significant differences were found in four out of the five variables studied, with a significance level of .05. We ob...

Resumen: Tomar decisiones acertadas desde el punto de vista ético-moral en medicina es un asunto complejo y aprender a hacerlo debe constituir uno de los objetivos del entrenamiento médico. Una forma de contribuir a lograrlo es integrar una completa formación teórica en Ética Médica y Bioética con una verdadera correlación frente a lo vivido en la práctica clínica. Tener en cuenta lo que sienten y piensan los estudiantes al respecto es un buen referente para comenzar. En el presente artículo se presentan los resultados de un taller sobre el tema, llevado a cabo con estudiantes de medicina en Palabras clave: dilemas éticos, práctica clínica, currículo, educación médica Abstract: To take right decisions in medicine from an ethical-moral point of view is a complex matter and to learn to do it must constitute one of the goals of medical training. A way to contribute to achieve this is to integrate a complete theoretical training in Medical Ethics and Bioethics with a true correlation in clinical practice experience. To take into account what students think and feel about the issue is a good reference to start. In the present paper the results on a raise in the workshop development.

Resumen: La Bioética tiene como reto argumentar en un contexto de multiplicidad de voces éticas. El mundo de hoy está constituido por «amigos» y «extraños» morales, al decir de T. Engelhardt, lo que torna difícil la búsqueda de autoridad moral con base en un mismo contenido. La Bioética debe proponer interpretaciones y noemas para la acción en diversos escenarios: justicia sanitaria, investigación clínica, biodiversidad, genética, entre otros. Siendo éste el reto de la Bioética, resulta útil distinguir, según ha expuesto J. Habermas, lo pragmático, lo ético y lo moral como diferentes usos de la Razón Práctica. Se trata de un lenguaje que pertenece a la tradición kantiana, de la cual hoy todos formamos parte cuando se hace filosofía sobre lo moral. A pesar de que T. Engelhardt no cree en la Teoría de la Acción Comunicativa de Habermas como solución al problema moral contemporáneo, el lenguaje de este último puede ser clave para el ámbito de la Bioética.

Resumen
La filosofía de la medicina es un interesante campo de estudios que se ocupa de temas y problemas filosóficamente
relevantes en la práctica e investigación en medicina. Sin embargo, a pesar de que en otras latitudes la
filosofía de la medicina goza de reconocimiento, en Colombia ha recibido poca atención, en particular porque
el auge de la bioética ha opacado otro tipo de reflexiones sobre el quehacer médico. En este artículo, partiendo
de una mirada general sobre la formación del campo, se argumenta que una filosofía crítica de la medicina
debe ser promovida como reflexión amplia y crítica sobre la génesis y posibles salidas a la crisis que el sistema
de salud y las profesiones de la salud han experimentado en Colombia en las últimas dos décadas. Esta filosofía
crítica de la medicina ha de contribuir entonces a formar médicos y profesionales de la salud para ser capaces
de transformar el éthos de sus propias profesiones y el de los servicios de salud.

Palabras clave: filosofía de la medicina, educación médica, bioética.

Abstract
Philosophy of Medicine is an interesting field of study concerned with issues and problems that are philosophically
relevant in practice and research in Medicine. However, although Philosophy of Medicine enjoys recognition in
other latitudes, in Colombia it has received little attention, in particular, because of the rise of bioethics, which
has overshadowed other kinds of reflections on the medical task. In this paper, departing from an overview about
the formation of the field, it is argued that a Critical Philosophy of Medicine should be promoted as a deep and
critical reflection on the genesis and possible way outs to the crisis that the healthcare system and the medical
profession have experienced in Colombia in the last two decades. A Critical Philosophy of Medicine must then
contribute to training physicians and health professionals to be able to transform the ethos of their professions
as well as of the health care services.

Keywords: philosophy of medicine, medical education, bioethics.

Resumen
En el debate global sobre la eutanasia el caso de Colombia, que la despenalizó en 1997, no suele ser discutido en profundidad. En este artículo se examinan el contexto socio-político y jurídico que permitió que la Corte Constitucional en 1997 a despenalizar el homicidio por piedad, los retos que implicó para la sociedad colombiana y los requisitos establecidos por esta corte en 2014 para hacer efectivo el derecho a la eutanasia. Al final se ofrecen algunas consideraciones críticas sobre el debate alrededor de la eutanasia en Colombia.

Palabras clave: eutanasia; Colombia; morir con dignidad; pluralismo; respeto por la autonomía.

Abstract
In the global debate on euthanasia the case of Colombia, which decriminalised it in 1997, is barely discussed. In this article it is examined the socio-political and legal context in which the Constitutional Court decriminalised mercy killing in 1997, the challenges this decision meant for the Colombian society and the requirements this Court set in 2014 to guarantee the right to euthanasia. At the end, some critical considerations around the euthanasia debate in Colombia are offered.

Keywords: euthanasia; Colombia; die with dignity; pluralism; respect for autonomy.

The state of evolution of attitudes in a sample of 142 Medical Students at the Pontificia Universidad Javeriana in Bogota (at the beginning, middle and ending of their studies) in the field of Human Research Ethics (HRE) is analytically described. A complex scale of attitudes was used, with three components: affective, beliefs-related and behavioral, further divided into three theoretical categories taken from Bioethics: Subject-End/means-Dignity, Benefit and Justice. The relationship between the current medical education process and the attitudes regarding HRE in the sample are analyzed. A small trend towards progress in all categories and in all components of attitudes throughout medical education is described; neither the Benefit nor the Subject-End/means/Dignity categories evolve in a significant way; some significant differences were observed in the Justice category (beliefs and behavioral) and in the Subject-End/means-Dignity category (beliefs component). The results allow for asking about the role of formation and evolution of those attitudes throughout the academic process. In conclusion, attitudes seem to be progressing relatively, without a decisive evolution

La historia de la medicina ha estado íntimamente relacionada con la historia del cuerpo. Hoy vemos que anatomía, sexo/género, cultura, necesidades sociales, biotecnología y economía han llegado a confluir en este complejo escenario de prácticas y discursos que es la medicina contemporánea. El fenómeno de 'la medicalización de la vida' ha sido visto como un signo del poder del discurso médico en la sociedad. Ahora, sin embargo, la propia medicina es el objetivo de nuevos desplazamientos del poder. En este sentido, profundizar en el análisis del nacimiento y desarrollo de la bioética y el derecho médico en el contexto de lo que M. Foucault denominara biopolítica sigue siendo una tarea aún por completarse. En el caso latinoamericano este análisis es relevante en aras de evitar que los nuevos discursos normativos alrededor de la práctica médica sean elementos de subyugación y no de liberación y dignificación. Palabras clave: anatomía-bioética-biopolítica-tecnolujo-cuerpomedicalización-sexo/género.

Tradicionalmente o aborto na Colômbia tem sido um tema sensível e bastante controvertido no cenário público. Ainda que a Corte Constitucional descriminalizou o aborto em 2006 em três circunstâncias específi cas, a sociedade colombiana permanece polarizada ao redor da moralidade do aborto. Entretanto, esta decisão da Corte é uma oportunidade para ver como ética, política e direito podem ser em verdade combinados. De fato, diferencia cada campo e reconhece suas posibilidades pode ser a chave para conviver pacifi camente, inclusive ainda que nas últimas os desacordos éticos não podem resolver-se completamente. Abortion has traditionally been a deeply controversial and sensitive public issue in Colombia. Although the Constitutional Court decriminalised abortion in 2006 in three specifi c circumstances, Colombian society is still polarized around the morality of abortion. However, the Court's decision is an opportunity to see how ethics, politics, and law can be rightly combined. Indeed, to differentiate each fi eld and to recognize their possibilities may be the key to coexisting peacefully even if ethical disagreements cannot be completely solved.

El tema de la violencia en Colombia es de tanta importancia en nuestro país que ningún espacio académico, incluyendo la Bioética, escapa de ocuparse de él. Aparece, entonces, la pregunta ¿cómo podría la Bioética aportar a la paz en Colombia? Su respuesta implica, entre otras, el importante papel que ella podría jugar en la superación de la injusticia social, uno de los elementos que tienden a perpetuar la violencia. En el caso de la Bioética Clínica, este papel puede cumplirse mediante la promoción de una conciencia crítica en los profesionales de la salud, cuando ella hace parte del proceso de su formación. La Bioética Clínica no puede terminar convertida en una jerga pseudofilosófica o pseudocientífica, con lo cual sólo estaría ayudando a perpetuar situaciones de injusticia, caldo de cultivo para la permanencia de diferentes violencias, particularmente en países como Colombia.

Este artículo presenta la "Escala C de Razonamiento Moral" referida a la caracterización del razonamiento moral en estudiantes de Medicina, la cual fue validada mediante un modelo cuantitativo, que implicó inicialmente un análisis de medianas de ítems provenientes de dos escalas previas ("Escalas A y B"), el cual estableció la distribución de las frecuencias y la inferencia acerca de la competencia de discriminación poblacional; posteriormente se realizó un procedimiento de consistencia ítem y muestra total, a través, del coefi ciente de probabilidad, ji-cuadrado, con un valor igual o menor a 0.05, (H 1 de elección), el cual determinó si el ítem correspondiente era elegible para hacer parte estructural de la "Escala C". El instrumento fue construido por los grupos de investigación, "

The state of evolution of attitudes in a sample of 142 Medical Students at the Pontificia Universidad Javeriana in Bogota (at the beginning, middle and ending of their studies) in the field of Human Research Ethics (HRE) is analytically described. A complex scale of attitudes was used, with three components: affective, beliefs-related and behavioral, further divided into three theoretical categories taken from Bioethics: Subject-End/means-Dignity, Benefit and Justice. The relationship between the current medical education process and the attitudes regarding HRE in the sample are analyzed. A small trend towards progress in all categories and in all components of attitudes throughout medical education is described; neither the Benefit nor the Subject-End/means/Dignity categories evolve in a significant way; some significant differences were observed in the Justice category (beliefs and behavioral) and in the Subject-End/means-Dignity category (beliefs component). The results allow for asking about the role of formation and evolution of those attitudes throughout the academic process. In conclusion, attitudes seem to be progressing relatively, without a decisive evolution

Background: Cancer patients’ end-of-life care may involve complex decision-making processes. Colombia has regulations regarding palliative care and is the only Latin American country with legislation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals.Methods: Attending physicians of 261 cancer patients in participating hospitals answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was (partially) made with the intention or consideration that it may hasten the patient’s death. Results: Decisions to wi...

In the late 1960s and early 1970s bioethics was born in the USA and rapidly spread across the world. Bioethicists have traditionally argued that their discipline was the answer to the ethical challenges posed by the scientific and technological progress in biomedicine, although others have emphasised the abuses committed in biomedical human research and the dehumanisation of medicine. Notwithstanding the great excitement produced by the rise of the new field, its foundations, scope, and official historical accounts have been criticised. Calls to give bioethics better philosophical foundations –beyond the American principlism- and to broaden the field, particularly to include problems typical of the developing world such as poverty, exploitation and inequality have grown in the last twenty years. In Colombia, the idea that bioethics is an advocate of life, a discipline to protect life on earth from the dangers of an irresponsible scientific and technological advance as well as from a...

Eduardo Díaz Amado, MD, Fil., MA. Researcher and Lecturer, Instituto de Bioética, Universidad Javeriana, Bogotá, Colombia. This article was originally written while I was attending the master program in History and Philosophy of Science and Medicine, Durham University, UK, 2007/08. To be published in this journal some parts were updated or modifi ed. The views expressed in this paper are solely the responsibility of its author. Email: [email protected] ABORTO: INCONCLUSO DESDE EL PUNTO DE VISTA ÉTICO, FACTIBLE DESDE EL PUNTO DE VISTA LEGAL Y POLÍTICO

La historia de la medicina ha estado intimamente relacionada con la historia del cuerpo. Hoy vemos que anatomia, sexo/genero, cultura, necesidades sociales, biotecnologia y economia han llegado a confluir en este complejo escenario de practicas y discursos que es la medicina contemporanea. El fenomeno de ‘la medicalizacion de la vida’ ha sido visto como un signo del poder del discurso medico en la sociedad. Ahora, sin embargo, la propia medicina es el objetivo de nuevos desplazamientos del poder. En este sentido, profundizar en el analisis del nacimiento y desarrollo de la bioetica y el derecho medico en el contexto de lo que M. Foucault denominara biopolitica sigue siendo una tarea aun por completarse. En el caso latinoamericano este analisis es relevante en aras de evitar que los nuevos discursos normativos alrededor de la practica medica sean elementos de subyugacion y no de liberacion y dignificacion

Background: In Colombia, recent legislation regarding end-of-life decisions includes palliative sedation, advance directives and euthanasia. We analysed which aspects influence health professionals´ decisions regarding end-of-life medical decisions and care for cancer patients.Methods: Qualitative descriptive–exploratory study based on phenomenology using semi-structured interviews. We interviewed 28 oncologists, palliative care specialists, general practitioners and nurses from three major Colombian institutions, all involved in end-of-life care of cancer patients: Hospital Universitario San Ignacio and Instituto Nacional de Cancerología in Bogotá and Hospital Universitario San José in Popayan. Results: When making decisions regarding end-of-life care, professionals consider: 1. Patient’s clinical condition, cultural and social context, in particular treating indigenous patients requires special skills. 2. Professional conditions: training in palliative care and experience in dis...