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1
Psychologist. Masters degree ABSTRACT Based on the Brazilian context, this paper addresses medical power in terms
student, postgraduate program
in Preventive Medicine, School of the current conflicts in the intersubjective relationships that doctors establish in their
of Medicine, Universidade de work, conflicts considered here as a product of a crisis of trust connected to recent his-
So Paulo (USP). Scholarship
torical transformations in the medical practice. Reading these conflicts as questions of
recipient, Coordenao de
Aperfeioamento de Pessoal de an ethical and moral order, we use Hanna Arendts theoretical formulations to further
Nivel Superior (CAPES), Brazil. analyze this crisis of trust. In this way, utilizing the concepts of crisis, tradition,
yuri.azeredo@gmail.com
power, authority, and natality, we search for new meanings regarding these con-
2
Physician. PhD in Medicine. flicts, enabling new paths and solutions that avoid nostalgia for the past.
Professor, Department of
Preventive Medicine, School KEY WORDS Power, Professional; Humanization of Assistance; Ethics, Medical;
of Medicine, Universidade de Humanities.
So Paulo (USP). Researcher
1A, Conselho Nacional de
Desenvolvimento Cientfico RESUMEN Basados en el contexto brasileo, en este artculo abordamos el poder
e Tecnolgico (CNPq), Brazil
liliabli@usp.br mdico en trminos de los actuales conflictos en las relaciones intersubjetivas que el
mdico establece en su trabajo, conflictos considerados aqu como producto de una
crisis de confianza vinculada a los recientes cambios histricos de la prctica mdica.
Al interpretar esos conflictos como cuestiones de orden tico y moral, recurrimos a las
formulaciones tericas de Hannah Arendt para analizar con mayor profundidad dicha
crisis de confianza. De este modo, a partir de los conceptos arendtianos de crisis,
tradicin, poder, autoridad y natalidad, realizamos una lectura con nuevos
significados de estos conflictos, que posibiliten futuros caminos y nuevas soluciones que
eviten una nostalgia del pasado.
PALABRAS CLAVES Poder Profesional; Humanizacin de la Atencin; tica Mdica;
Humanidades.
this formulation derived from the great value Such configuration gives rise to a change
ascribed to scientific knowledge and techno- in the intersubjective realm by which the
logical resources that had become an asset means become ends in themselves, altering
in itself during modernity. the meaning of the relationship among indi-
Pragmatism demanded from doctors a viduals: doctors no longer interact with pa-
double technical action: on the one hand, tients, but the technical resources are now at
to use technical knowledge when pertinent, the service of such interaction. The doctor is
and on the other hand, to use a practical now a means for the interaction between
knowledge of the profession, that is, the patients and medical technology. Likewise,
rich experience acquired by each of them the patients have become means for the
individually and by doctors as a whole in doctors in their interaction with knowledge
similar cases, without scientific grounding for science and its discoveries and also
the action. It was for this reason that during means for doctors interaction with the cor-
modernity medicine positions itself as the porate mechanisms that are inherent to the
science and art of healing. exercise of their profession.
Furthermore, as stated by Schraiber,(2) When doctors and patients are instru-
when science is used as the application of mentalized to become a means for a spe-
universal knowledge to specific cases, espe- cific end, it is worth remembering that the
cially because medical practice is conducted hegemony of the systematic utilitarianism of
in the form of individual consultations (which modernity, imposing its logic of means and
coincides with the liberal practice in the pri- ends on all the categories of life, brings with
vate consulting room), the complexity of cli- it important consequences. Among them, the
nical judgement increases. This is in addition impossibility of understanding the difference
to the need of doctors to decide how to adapt between utility and full meaning, which we
the use of the universal knowledge to the con- express linguistically by making a distinction
tingencies of a particular case, that is, the ex- between in order to and for the sake of.(24
tent and appropriateness of this use, given the p.191)
Thus, everything is placed in the chain
specific peculiarities of the case in question. of means and ends, and, as a consequence
We highlight here not only the reflexive everything becomes a means to a specific end
character that was demanded of medical and will only be the reason for something, or
judgement but also the fact that for this same for the sake of something. This option allows
reason the doctor was who symbolized utility (what something is for and what pur-
medicine, in evident contrast with current pose it serves) to suppress the meaning (what
references. it is), the consequence of which is explained
by Arendt In order to has become for the
sake of; in other words, utility established as
CONTEMPORARY REFERENCES meaning generates meaninglessness.(24 p.192)
With this we do not intend to advocate
for the abolition of technological resources in
If not the doctor, what is the reference health, as if our goal were the restitution of
of medicine? We may answer: technology; traditional medicine. In this sense, we agree
medical teams or the great institutions with Ayres(25) in the conceptualization of care
such as hospitals, which are the home to as the assistential act that expands and flexibi-
technology; or health insurance and social lizes the normativity of the application of the
security organizations, which give access technosciences; a normativity that arises from
to technology. Technologies are today the constitution of the body as an abstract and
the references of medicine and symbolize generic entity in the sciences, in its techno-
it. Therefore, they generate professional logical products and in procedure protocols.
behaviors that emphasize these references by Expansion and flexibilization here not only
stressing the loss of the old references. mean the treatment of the body and diseases
upon the consumption of diagnostic tests and For professionals there was also, in their
the possibility of accessing the technological occupational imaginary, a construction re-
equipment available in hospitals. In such a garding safety, though different from the
relationship, doctors are mere intermediaries. previous one, which moves in this same di-
This is also due to the transformation in the rection. Analyzing this movement is key to
significance and the exercise of responsible our understanding of how the bonds of trust
medical practice. The reference models for in the physician-patient relationship were
the latter have also changed, as will be dis- built during liberal medicine and why, due
cussed later; however we will now analyze to the change occurring during technological
another qualifier/attribute of medical practice: medicine, those bonds were breached and
the fact that it is a complex act that also implies this tradition in the relationships was lost.
making decisions, which are always risky. In liberal medicine this construction is
Clinical decisions imply risks based on based on the fact that physicians believe in
uncertainties, because they are concerned their own judgment, that is, they believed
with probabilistic knowledge related to vital themselves totally able to properly articulate
events, and, therefore with fluctuations with the scientific aspect with their practical
respect to the expected result. However, experience, and the iconic figure of the
in addition to these uncertainties, there are doctor became reinforced as a reference of a
others that have to do with the social strata sound and safe intervention. Therefore, they
themselves and subjective aspects that are were always professionally available to ac-
coterminous with the natural characteristics company their patients during the interven-
of these events, which complicate our topic tions, closely following every case they had,
of discussion even further. Although it may and if the decided therapy needed to be
seem that the clinical decision is related to the modified, they admitted the possibility and
diseases, in fact, the intervention is conducted the need for such a revision.
on the diseased: the development of the con- Trust in the liberal practice was con-
crete therapeutic decision depends on the structed on the basis of such moral behavior
patients biopsychosocial factors. It is worth in the profession. Trust was based on the
noting Freidsons(8) interesting reflection disposition to think, judge and accompany
on the topic with regard to the following the case. These aspects have currently
contrasting argument: medical practice is been transformed, whether for resorting
permeated by uncertainty; however, what almost automatically to technology, as a
prevails in the social imaginary is the ref- sort of fixed and a priori judgment, or for
erence to a safe intervention, because it is the great change in contemporary corporate
scientifically substantiated. The construction medicine regarding the possibilities of case
of scientific knowledge is based on the es- follow-up and interpersonal relationships,
tablishment of universal concepts regarding given the fact that in corporate medicine
the function of the body, the mind and physicians lose control of the clients and
disease. The place of medical decisions lies of the equipment with which they work.
in the space between the universal character According to Arendt,(24) Galileos discovery
of science and the uniqueness of the case that the Earth revolves around the sun and
that is being considered. The direct appli- not the other way round, elevated man-
cation of the universal concepts of science made instruments to a position in which
through its technological and pharmaceu- the traditional understanding of truth was
tical devices is one of the main changes in transformed, establishing a generalized
medicine, from liberal to technological, and distrust of the human senses in relation to
may be understood as one of the reasons for the search of truth. In modernity, the dis-
the perception, among physicians and pa- trust of medical judgment seems to grow
tients, that they are becoming mere interme- in proportion to the development of the in-
diaries for these relationships. struments that aid in professional judgment,
This work received financial support from Coor- 12. Bourdieu P. Razes prticas: sobre a teoria
denao de Aperfeioamento de Pessoal de Nivel da ao. 9a ed. So Paulo: Papirus Editora; 2008.
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fellowship, and from Conselho Nacional de Des-
medicine. New York: Basic Books; 1982.
envolvimento Cientfico e Tecnolgico (CNPq),
through research fellowship No. 306881/2013-6.
14. Ayres JRCM. Sujeito, intersubjetividade e
prticas de sade. Cincia & Sade Coletiva.
2001;6(1):63-72.
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CITATION
Azeredo YN, Schraiber LB. Medical power and the crisis in bonds of trust within contemporary medicine Salud Co-
lectiva. 2016;12(1):9-21.
http://dx.doi.org/10.18294/sc.2016.864