Alberto J. Muniagurria  Extract from the book Semiologia Clinica Tomo I

With the  advancement in the frontiers of science and technique both life and death could be modified. Knowledge of genetics, new diagnostic procedures through biotechnology, regulatory sciences and permanent advances in therapeutic fields, both physiological and pharmacological, and surgical interventionism, and in the field of mental processes, contributed their own , generating a changing, progressive, evolutionary and overcoming scenario on itself. In the past, the nature of diseases could not be modified in the actions of doctors, except for surgery that generally cut or removed diseased tissues. 

Another great change that developed in society, in the past two hundred years, were the advances that took place in respect for the rights of human beings and this had its impact on medicine, logically, especially in the areas of  relationship doctor with patient. . With the Declaration of the Rights of Man, in 1789 the right of people to decide their destiny for themselves arose. In reality, these ideas only knocked on the doors of medicine in 1970, according to Pellegrino, "..... it is only then that we begin to speak of autonomy" (1) or free will, that is, the ability to government of individuals, a quality inherent in rational beings that allows them to choose and act in a reasoned manner on their decisions. A growing rebellion had emerged in society towards authority and autocracy. This autonomy was reflected in what was known as  informed consent. (*).

Over the years, this document lost its original motive and became a mechanism for legal protection of doctors in medical malpractice issues. In this way, and progressively, the doctor / patient relationship went from being an episodically conflictive relationship to becoming an essentially conflictive relationship.

The health insurance systems and the progressive intervention of the State, with its regulatory, legal and judicial systems and thus also the participation of the different national, provincial and municipal entities, produced a change in the customs known as the doctor / patient relationship to be today a medical / patient // family / society reality.

From its origins, the doctor's task was oriented with an attitude of beneficence, (in the literal sense of the Latin voice bonum facere, to do good). Through the Hippocratic oath the professional acted mainly for the good of his patient. In general, the family also acts for the same reasons, and sometimes its right or autonomy applies, as does the patient, while society controls, audits and eventually judges in situations of conflict.

In other words, in the evolution of new circumstances, the doctor, historically accustomed to a single relationship with the patient, saw the incorporation of family members, health systems, their own interests, and educational needs into the bond. continues, and eventually to society with its laws and regulations.

Technical and scientific advances also influenced the development of new needs for healthcare environments, which were gradually incorporated. These new settings, appropriate to provide highly complex care, promoted areas of intensive care, coronary units and special care. These modifications contributed their own to separate or create distances between the doctor and the patient. All this movement reached its maximum expression in the United States during the 60s and 70s. The developing countries, in their healthcare centers, were building the same changes.

In 1920 voices were raised in the world that began to alert about the withdrawal of the doctor from his patients. These voices clearly raised the difficulties they observed in the healthcare area, as well as the disregard for clinically and clinically trained medical care, all of which occurred in both developed and developing countries, the so-called Third World.

The meeting of the World Health Organization in Russia in the town of Alma Ata proposed ... "essential medical health care must be offered within the reach of all individuals and families in the community, by means that are convenient for them acceptable, and at a cost that the community and the State can bear, with health education, prevention and promotion of this, nutrition, drinking water, maternal and child health care, family planning, treatment of endemic and traumatic diseases, as well as the supply of essential medicines ... "Health being a right, and defined as ..." a complete state of physical, mental and social well-being ... ". (5)

The primary health care was defined as a strategy for global health for 2000. The doctor, within that strategy, was the agent of change.

The levels of care proposed for contacts between individuals, the community and the health system were the following steps of action:

The individual and the family

The community The health agent First level of care (Basic Care) Second level of care (Intermediate step) Third level of care (High complexity)

In developed countries, where there are also problems in access to health,
Primary Medical Care was referred to as that which is exercised at the first level of care. It was considered as  a level of attention .

In these countries, the proposal was that care, at the first level, should start with medical professionals, and not with health agents, that is, that the doctor control the entrance to the health system, in charge of the first contact with the patient, .. "regardless of the state of physical, mental or social health of this" ...... With this objective in postgraduate careers, the proposal for a specialty in primary care, Family Physician, was promoted.

In the United States, the process was complicated. Faced with the possible health plan promoted by the government of President Clinton that promised access to health for all citizens, millions of dollars were mobilized to create advertising aimed at convincing the electorate that the plan had "... socializing aspirations and created an affront to the Darwinian principle that every American has the right to live without state aid. "(6). The American people have a deep-rooted culture of self-effort. According to Kumar Sen, the Nobel Prize in Economics "... is a basic factor that enables them to be self-sufficient." (7). Only in 2010 in the presidency of Barak Obama, the project resumed, and general assistance was approved as a right of the Americans. President Donald Trump, took the project back.

In years before the 70-80s, the training of doctors was carried out in hospital wards. The outpatient care space became an important place for medical training, Ambulatory Medicine was ranked. Along the same path, the different specialty societies rehabilitated their role in Primary Care.

The model of doctor was oriented, in the new curricula of schools, to be more concerned with his patient than with the techniques or knowledge acquired. The aim was to work in the environment of the disease, with an educational and preventive attitude. Thus, the ambulatory and home care scenario was rescued.

All these proposals and changes were developed in Argentina. In the 90s the government launched the PMO (Compulsory Medical Program) programs. The new trends aimed to fill an empty space and make it hierarchical. The goal was to bring the doctor closer to his patient. That the doctor attend to the problems of his patient, rather than showing a reactive attitude to the pathologies that he presented, which was the norm in the training programs of yesteryear. Comprehensive, continuous, comprehensive care, with the professional acting as coordinator of the patient, male or female, child or older adult, "... throughout their life from birth to old age if possible".

The changes were happening so that the different levels, officials and professional associations, return to the style of a doctor that presents the profile of high scientific training, comprehensive management of family and community group problems. A primary care strategy was promoted, which does not mean primitive or second-class care aimed at a single model of rural or peri-urban population, but rather as the gateway to health, with universal accessibility to different levels of care when circumstances proper to the needs so require. A general training medical model was promoted, scientifically equipped for preventive and curative comprehensive care, typical of the first level of care, and trained to interact appropriately with the rest of the levels.

This demanded - and demands - to know the reality of the environment, to recognize the different regional characteristics, the prevailing pathologies, with profound contrasts in needs, demographic and socio-economic-cultural variations that vary from rural to urban, emergency towns, etc.

The different levels and lifestyles require diversified health services that are in a position to respond to the healthcare demand that ranges from the social pathology of poverty to those of the developed world. From cholera to hypercholesterolemia. Today the biggest problem of malnutrition is obesity. These changes impose an elasticity in the education and training models that do not ignore the realities or the wishes of each professional, but neither those of the environment where they must carry out their work. What seemed linear and of simple definition became something more complex. From the origins, focused on the care of patients' physical ailments, teaching and research, it became a new, broader role,

The challenge of the Foundation is to support the University Center to build a comprehensive doctor not loaded with information, such as Funes el memorioso, a character from Borges, who was not capable of conceiving or building new ideas, since he was only capable of remembering and reciting.

Paraphrasing Dr. Juan Manuel González, a distinguished professor of Semiology. "Knowledge is not the same as being informed. Information must be indispensable to face problems, cover them and embark on their resolution. The doctor must present a morality in accordance with the Hippocratic ideas of the profession in balance with the essentially changing needs of society "

Origin and Evolution of Bioethics

Dr. James F. Drane Rusell B. Roth Professor of Clinical Bioethics Edinboro, University of Pennsylvania (Emeritus) Introduction It is difficult to pinpoint the origin of a historical period, a cultural movement, or even an academic discipline. Most of the times the beginnings are too far and end up being lost in the past. Even when many years have not yet passed since the start of something new, the events that gave rise to it can be diverse, and distinguishing a first step is always problematic. Talking about the origin of bioethics inevitably means speculating. Speculation begins with the attempt to define the term

bioethics. In a very preliminary way, we can say that bioethics consists of the systematic study of moral behavior in the life sciences. It can be maintained that bioethics is a new and truly emblematic discipline of our era. No other discipline or field of study more accurately reflects our contemporaneity. Medicine and life sciences are in our era what religion with its promises of salvation was in the Middle Ages. A matter of great concern to the majority of our contemporaries, an enormous amount of social resources is devoted to them. The field of bioethics encompasses the many ethical dilemmas generated by bioscientific research and its medical applications. It is a paradigmatic discipline because such dilemmas compel all of us to face the essential problems of life and death: who are we? Why are we here? What are family, integrity, identity, kinship, freedom, love or community?

The problems with which bioethics deals are the focus of our literature and our legal system. They are the subject of news and editorial comments. Churches and universities deal with them because they interest both young and old. People want to understand what is right to do in front of a newborn with serious malformations or a dying old relative, since everyone is born and dies, and almost all families have some problem related to one or the other end of life. This extraordinarily expansive field of study and research began to be cultivated in developed countries. It was born relatively soon, when the growing biosciences began to pose a great number of new ethical problems. But those same problems now exist everywhere.

Today, the life science events that fueled bioethics in developed countries also occur in developing countries. Medical centers equipped with the most modern and sophisticated technologies can be found in any of the main cities in the world. People everywhere face the same ethical problems related to experimentation on human subjects. Today, European, Latin American or Japanese journalists attach as much importance to the ethical problems posed by medicine as their colleagues in the United States. Likewise, physicians in other countries are as aware as Americans of the need to understand the ethical problems associated with their practices and to update their professional codes. Now that the government is directly involved in regulating healthcare, domestic and foreign politicians are faced with difficult ethical choices and questions of justice. Bioethics, which in just a few decades has become a world-class concern, will continue to reflect the ethos of our bioscientific civilization for the remainder of this century and the next.

Given the critical place that it occupies in contemporary societies, the field of bioethics has experienced a meteoric development in the last three decades. First, bioethics centers, institutes, commissions and councils were created in the United States and Canada. Soon after, the European nations and the European Community created their own initiatives. After spending a season in the United States, Canada or Europe, Japanese and Southeast Asian scholars returned to their countries to lead the creation of institutes of bioethics. Bioethics congresses have been held in Eastern Europe, where work is already underway to create bioethics centers. Even in the newly independent republics of the former Soviet Union and in the emerging nations of the former. Yugoslavia is already organizing bioethics congresses and planning the creation of bioethics institutes. International exchanges have begun, and the field of bioethics has already begun to change as a result of efforts made to establish international agreements. The originally dominant North American style of doing bioethics is also changing due to the influence of the European, Asian and Latin American perspectives.

Contemporary bioethics: initial phase

In its early stages, bioethics dealt with ethical issues generated by medicine. At first, the term bioethics was almost synonymous with research ethics and clinical ethics (eg the Nazi experiments and the case of Karen Ann Quinlan). Subsequently, the focus of attention was expanded to include other aspects of medicine, and later all biosciences. However, research ethics and clinical ethics continue to occupy a central place in this now larger field. Although it is very difficult to accurately identify the beginning of bioethics, several events can be distinguished that played an important role in its rapid rise.

In the late nineteenth and early nineteenth centuries, German medicine provided the model for modern medicine. German medicine was closely related to laboratory science, so clinical medicine had to test the effectiveness of its interventions through rigorous experiments that necessarily involved the use of human subjects. Abuses of human beings in medical research sparked the first modern ethical crisis and the first calls for a new medical ethic. The Nuremberg Code responded with what would become one of the foundations of this new ethic: the requirement to obtain the informed consent of the participants.

The voluntary consentof the human subject is absolutely essential. This means that the person concerned must have the legal capacity to consent; he must be able to choose freely, without the intervention of any element of force, fraud, deceit, coercion, abuse of power or any other form of obligation or coercion; and you must have sufficient knowledge and understanding of the elements of the problem at hand to be able to make an informed and intelligent decision. This last element requires that before accepting an affirmative decision of the subject of experimentation, he is informed of the nature, duration and purpose of the experiment; the method and means to be used for its realization; all reasonably foreseeable drawbacks and risks;

Violation of traditional medical ethical criteria by Nazi medicine sparked widespread moral outrage. People who were used as experimental subjects believed that their doctors were doing something beneficial to them. Vulnerable, weak and needy human beings were treated inhumanely, and some of them even died. These events created the need to establish new ethical criteria, which rapidly expanded from medical experimentation to clinical practice, where vulnerable patients also need protection. The requirement of proportionality between benefits and risks, the disclosure of the latter to patients and the obtaining of voluntary consent became as important in clinical practice as in experimentation.

The news that some Nazi doctors had behaved in a grossly immoral manner during World War II was followed in the United States by the revelation of a series of similar moral violations (Willow Brook School, New York Jewish Hospital, and the Study on Tuskegee syphilis). In 1996 Henry K. Beecher, a Harvard physician, published an article in The New England Journal of Medicine exposing a whole series of unethical behaviors common in medical research. (2) Beecher's article on abuse of human subjects by American doctors was widely disseminated and contributed substantially to stoking the public interest in reviewing medical ethics. The ethical flaws associated with the research prompted the creation of a new field of study that would later be called bioethics.

The imperative of scientific progress is present in all places where contemporary medicine is practiced. Since the authority of physicians tends to be greater in other countries than in the United States, conditions exist for similar ethical failures in those countries. Only well-developed and widely disseminated bioethics can prevent the ethical tragedies associated with experimentation from occurring. No society can afford to leave the task of balancing patient rights with the need for scientific progress to medical scientists. Criteria must be developed to regulate research in human subjects in all places where modern medicine is practiced, both in large medical centers in the developed world and in small community hospitals in developing countries, where drugs are also tested and other types of experiments are carried out. The research led to changes in medical ethics, and national and international health organizations took an interest in education and later with the supervision of medical professionals.

Bioethics and government participation

After World War II, developed nations invested a lot of effort and a lot of money in the field of medicine. Consequently, greater attention had to be paid to the ethical issues that inevitably accompanied medical advances. In the United States, the Public Health Service (SSP), an agency of what would later be called the Department of Health and Human Services, was given the responsibility to protect the rights and well-being of research subjects. In the 1960s, the SSP established ethical criteria for conducting research on humans. In the 1970s, the National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research was created. The members of this commission worked for four years and made 125 recommendations to improve the protection of the rights and well-being of research subjects. Likewise, the commission published the Belmont Report. In this report, the basic ethical principles (respect, charity, justice) that should guide the treatment with patients and research subjects were identified. Subsequently, and under the auspices of the same SSP, the federal government continued to update the regulations and require guarantees of compliance with ethical criteria from any group that was conducting research on human beings. Through its financial support for medical research projects, the United States government became a source of bioethical guidelines and rules. He created commissions that served to ethically substantiate the new ethical approach to medical practice. The United States government played a fundamental role in the development of modern bioethics.

Once the work of the National Commission was completed, the United States government continued to participate in the development of bioethics, now through the Presidential Commission for the Study of Ethical Problems in Biomedical Research. This commission was created in the 1980s with the mandate to prepare reports for the President, Congress and other relevant government departments. Such reports were to guide politicians in legislative development. In addition, his work provided guidance to health professionals and educators and to the general public. The Presidential Commission published 11 volumes, 9 reports, a guide for local committees responsible for supervising the conduct of research on human subjects and the minutes of a workshop on the reporting of irregularities in the research by the researchers themselves or any other person related to the research team or institution where it is taking place. The work of this government commission has had an enormous influence on North American bioethics. The commission's work list gives an idea of ​​the enormous development of bioethics during its first decades: Compensation for research damage; Rejection of life support treatments; Definition of death; Implementation of regulations on research in human beings; Medical decision making; Protection of human subjects; Detection and advice of genetic alterations; Ensuring access to health care; __ lifetime; The complaint of irregularities in biomedical research (by the researchers themselves or any other person related to the research team or the institution where it is being carried out.

Bioethics and medical technology

Government investments in medical science resulted in a whole host of new medical technologies and therapeutic interventions. The relationship between science and medicine that had begun in the late nineteenth century began to bear fruit in the form of new drugs, hermodialysis machines, organ transplant techniques, life support systems, artificial feeding techniques, intensive care units, saving surgical interventions, etc. However, with each new advance, new ethical problems appeared. In the 1960s, an ethics committee in Washington state attempted to make ethically justifiable decisions about who should have access to a hemodialysis machine when this scarce technology could not be offered to everyone. Modern bioethics is not interested solely in medical research on human subjects and the humanity of medical interventions. Since its inception, it has been concerned with the participation of patients and communities in decision-making on socio-economic issues, such as the distribution of scarce resources.

Physicians have always accepted the moral responsibility that comes with exercising medical power over patients. Traditionally, medical ethics have expressed this responsibility in the form of ethical codes and treaties published by the medical associations themselves. Every socially authorized professional power, and especially the medical power, carries with it a public responsibility.The right to practice medicine implies both internal and external moral restrictions. As medical interventions became more powerful, ethical problems related to medical practice proliferated. The list of things that doctors could do for their patients kept increasing as the invasiveness of their interventions increased. Each intervention raised microproblems. The macro problems raised by the relationship between technology and human life also had to be addressed. In both developed and developing countries, doctors were pushed to update their ethical codes. At first, doctors did not play a very important role in the development of bioethics, but later they began to contribute to the field.

Scientific-technological medicine has brought medical treatments to public discussion forums. The practice of medicine shifted from the privacy of the patient's office or home to public hospitals, where responses to ethical problems had to be publicly justified. The technology of the next millennium will make current therapeutic interventions seem simple and primitive to us, but already in the first medical-technological advances, the driving force of the new interest in ethics and the emergence of this new discipline called bioethics can be identified.

Until the 1950s, the expression "Doctors know best ..." reflected the attitude of most people towards medicine and summarized the paternalism of traditional medical ethics. After the Nuremberg trials and with the growing influence of experimentation in the clinic, this old paternalistic ethic gradually gave way to different criteria of right and wrong. Other attitudes, different norms and new principles came together to create the germ of modern bioethics.

The role of non-governmental institutions

Bioethics did not develop solely on the basis of government initiatives. Non-governmental institutes and centers appeared here and there in response to new medical problems.

As early as the 1950s, the Institute of Religion at the Texas Medical Center in Houston began to study ethical problems in medicine. A group of religious thinkers interested in promoting the humanities in medical education formed the Society for Health and Human Values. The first medical humanities department, comprised of a faculty with a strong interest in medical ethics, was created in the 1960s at Pennsylvania State University Medical Center in Hershey, PA. The 1970s witnessed the appearance of the Hastings Center in Hastings, NY (in late 1969) and the Kennedy Institute of Ethics at Georgetown University (1971).All these initiatives tried to bring depth and rigor to the new discipline, now known as bioethics.

The Kennedy Institute, which adopted a university model, developed the National Reference Center for Bioethical Literature, which soon became the best library in the world on this rapidly expanding new discipline. Its academics, who hailed from many different disciplines, worked more or less independently and acted as professors in a bioethics doctoral program at Georgetown University. One of its earliest members, Warren Reich, a Catholic theologian, prepared the Encyclopedia of Bioethics, which soon became a leading reference source. Another of its members, Leroy Walters, a Protestant academic, started the annual publication of a Bioethics Bibliography and developed the Bioethics Line, a database accessible online.

The Hastings Center was started by Daniel Callahan, a lay Catholic with a background in philosophy and theology. At the Hastings Center, academics met to work both independently and in groups to develop strong policy recommendations on various bioethical issues. The Hastings Center continues to publish policy recommendations and monographs and influence government responses directly and indirectly. The Hastings Center Report, a bioethics journal founded in 1971, publishes articles on ethical issues in medicine, the life sciences, and the professions. It was the first bioethics journal and remains the most important in this field.

Since the establishment of these non-governmental bioethical institutes, literally hundreds of centers, programs, magazines and newsletters have appeared. The number of bioethics books and articles that appear each year is in the tens of thousands. In a short time, bioethics has become a major field of study. In 1987, the American Hospital Association published a list with 77 bioethics organizations. In 1994, the National Reference Center for Bioethical Literature at Georgetown University published an International Directory of Bioethical Organizations, which less than 5 years more trade and had more than doubled its number of entries. Since then, the number of tickets has doubled and today it already exceeds 500.

In the early 1970s and with the help of scholarships from the National Endowment for the Humanities, the Institute of Values ​​in Medicine and the Society for Human Values ​​and Medicine started a project aimed at promoting the study of bioethics in medical schools . Along with other members of these institutions, Dr. Edmund Pellegrino, a prominent physician and humanist, visited more than 80 medical schools to introduce their teachers and students to this new discipline and to prepare a bioethics education program for future generations of doctors. Dr. Pellegrino and his colleagues wanted to make sure that bioethics was going to move from texts, reports, and commissions to the clinical practice of ordinary doctors.

Pellegrino's efforts were aimed at promoting the relationship between medicine and the humanities. When it started, very few medical schools offered courses on human values ​​in medicine; When it ended, 10 more years of trade, practically all medical schools and many nursing schools offered courses in bioethics and other medical humanities. Those visits to medical schools and personal contact with their teachers led to a big change. After Pellegrino, bioethics ceased to be a mere academic discipline and became part of the daily practice of medicine. (3)

Government commissions, academic centers, and nongovernmental institutes combined contributed to the development of bioethics in the United States. Moved by their interest in bioethical problems, many professionals attended an increasing number of bioethical education institutes. The bioethics departments of the academic centers trained professionals to occupy teaching positions in this new field. Hospitals created professional opportunities for bioethicists, as they sometimes hired a bioethicist to act as an educator and consultant. The members of the bioethics committees that were beginning to be created in health centers needed education in a field that already had extensive literature. Attitudes of resistance and skepticism towards the humanities in scientific medicine gradually gave way to acceptance by university professors, students, and practicing professionals. The thousands of bioethics books and articles published annually (many of them now written by doctors) reflect on what this field has become over the past few decades.

Bioethics and the law

Bioethics is not just a new field of study. It is a subject on which the general public reads in the newspapers and sees things on television. Some famous cases, like that of Karen Ann Quinlan, are as well known as movie stars and eminent politicians. This wide public interest in such complex problems made politicians, legislators, and lawyers take an interest in them as well. The tendency in the United States to seek legal solutions to life's problems brought bioethics and law into immediate relationship.

When problems created by experimentation or clinical practice could not be resolved between the doctor, the patient, and their family, they were brought to court. The first legal cases involved tragic situations in dying patients. Families and hospital employees disagreed on the removal of life-support technologies, so the courts had to be brought to their resolution. These disputes attracted media attention and became headlines. People wanted to know more about these tragic cases that touched worrying present in any family. The court decisions in the most popular cases contained arguments that gave rise to other arguments. Subsequent court decisions ratified or invalidated the first ones,

The attention of the media and the interest of the public made bioethics become important for politicians, who understood the need to create laws to defend the rights of patients and their families in health centers. Currently, all North American states and provinces have laws that cover bioethical concerns. New cases and new laws keep politicians and judges active. Other nations are under the same pressures. Legislators and judges from other countries will look to the United States for experiences that can help them develop sound legislation.

In Europe and North America the law adopted many positions that came from ethics. For centuries, Catholic moral theology had held that patients had the right to refuse any treatment, even when it was necessary to sustain life, whether it was expensive, risky, expensive, or, in the language of theological ethics, "extraordinary." This position was maintained in statutory law and in legal cases. But this influence was reciprocal. Secular and religious bioethicists adopted criteria for decision-making that came from the law, eg subjective criteria (what the patient __ chose), surrogate judgments (what the patient would have chosen) and the best interest of the patient (what is considered medically best for the patient.)

The expansion of bioethics

In its initial stage, bioethics dealt with the ethical problems associated with medical research and practice, but it quickly expanded and also began to deal with social problems related to access to health care, animal welfare or conservation of the environment. Every bioscientific advance or change in the health system contributed to the expansion of bioethics.

The ethical problems with which bioethics began have not disappeared. Research, technology utilization, life and death issues, abortion and contraception are still an important part of bioethics. The problem of the distribution of health resources was already present in the initial stage of modern bioethics. In the 1960s, the first ethics commissions attempted to establish ethically justifiable criteria to regulate access to scarce medical technologies. Later, distribution issues expanded as states and governments struggled to decide how to distribute equitably. and just increasingly scarce medical resources.

Bioethics has undergone an incredible development parallel to that of the biomedical sciences. The original concerns of bioethics were expanding to include axiological problems in all health professions; nursing, paramedical professions, mental health, terminally ill centers, home health care, etc. A wide range of social problems were included under the term bioethics: public health, occupational health, international health, demographic control, women's problems, and concerns for the environment. Clinical topics have expanded to include issues related to reproductive technologies, transplants, genetics, cloning, and molecular biology. The connection between the concerns of contemporary bioethics and culture is obvious.

The expansion of bioethics to deal with the ethical dilemmas characteristic of modern culture provided crucial help to social leaders, both political and professional. But society and its leaders were not the only beneficiaries; ethics itself benefited from bioethics. In 1973 Stephen Toulmin argued that medical ethics had saved ethics in general from decline and oblivion. (4) The problems that medical ethics had to deal with not only renewed interest in ethics, but saved to the academic ethics of irrelevance created by an __ openly abstract, rationalist and linguistic. Philosophers, theologians, lawyers, doctors, and social scientists suddenly discovered that the ethical aspects of medicine and the life sciences were fascinating and began to study them.

The future of bioethics

Will bioethics continue to expand and have the same importance in the next century? A quick and clear answer to this question comes from considering two recent bioethical issues: the genome project and AIDS.

Once the human genome has been fully mapped and the information locked in the genes deciphered, new ethical problems will explode. This is already happening with each new discovery about the genetic basis of the disease. The information generated by genetic research has both ominous and hopeful potential. Banks of individual genetic information could be created. If they could access this information, government agencies, the police, employers, and insurance companies could literally divide people into categories and destroy human initiatives. Only through well thought-out ethical criteria and judiciously developed ethical policies could the worst outcomes imaginable be avoided.

The human genome project is the life science project of the 1990s, and can easily be compared to the project of physicists to unleash the power of the atom in the 1940s. The potential benefits are great, but the problems are associated ethics are not discussed and thought beforehand, human life tAs we know it today in a civilized, free and democratic society, it could be threatened. It is difficult to imagine the enormous number of ethical problems that can arise. but the ominous consequences of not addressing the bioethical dimensions of this project are even more ominous. Therefore, it is not surprising that part of the money allocated to the human genome project is dedicated to studying its bioethical aspects. The ethical questions raised by the advances in genetics are already present in the clinic, but nowhere with the intensity with which they will be developed once the new knowledge is converted into new treatments.

AIDS is another problem fraught with ethical dilemmas. As with many other diseases that doctors have struggled with over the years, attention must be paid to both its biological and bioethical aspects in order to wage an aggressive and effective campaign against AIDS. Good strategies are those that take into account from the beginning the scientific and ethical dimensions of the disease. Campaigns to protect the human rights and dignity of people infected with HIV and / or affected by AIDS have been added to commitments to find effective vaccines and treatments. Efforts to stem the spread of the epidemic combine with efforts to tackle discrimination against carriers of the virus at work, travel, housing,

Like the human genome project, AIDS shows the inevitability of bioethics in contemporary life, as well as the increasing complexity of this field. On a practical level, problems arise in various areas: confidentiality; distribution of resources; use of human subjects in experimentation; development of sanitary measures for schools, the workplace, prisons and society in general; educational campaigns; Privacy; detection campaigns; informed consent; And a long etcetera. No aspect of the AIDS epidemic is devoid of a bioethical dimension.

As far as we can see, bioethics expanding and having importance, since in addition to being inseparable from bioethics, the biological sciences will continue to play a critical role. All institutions will be required to establish ethical standards. Codes and laws will have to be constantly developed and updated, both nationally and internationally, as well as politically and professionally. Clinical professionals versed in bioethics will play new roles in the future. The discipline that emerged in the second half of the 20th century in the United States and Europe is now an international company, expanding more and more in Latin America and the East. It is hard to imagine that he will not continue accompanying us throughout the next millennium.

References
Código de Nüremberg. En: Levin R.J. Ethics and Regulation of Clinical Research, 2ª ed. New Haven: Yale University Press, 1988; 425.
Beecher HK. Ethics and Clinical Research. The New England Journal of Medicine 1996; 274: 1354-1360.
Pellegrino ED, McElhinney TK. Teaching Ethics, the Humanities, and Human Values in Medical Schools: A Ten-Year Overview. Washington, D.C.: Institute on Human Values in Medicine & Society for Health and Human Values.
Toulmin S. How Medicine Saved the Life of Ethics. Perspectives in Biology and Medicine S