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NATIONAL BIOETHICS COMMISSION:ITS MANDATE AND APPROACH

Isabel Luengas1

Dafna Feinholz2

Guillermo Soberón3

he National Bioethics Commission (NBC) starts a new era through the

Presidential Decree issued on September 7,2005 that creates it as a deconcen-trated4 body, with technical and operative autonomy, and confers on it the mission to contribute to develop a bioethics culture in Mexico. As part of this task, defi ning and supporting the vision on which its tasks will rely is required, as well as the way in which it will carry out its actions to better respond to ethical concerns of the Mexican society.

YEAR 1 / NUMBER 2JULY / SEPTEMBER 2007

NATIONAL BIOETHICS COMMISSION:

NATIONAL BIOETHICS COMMISSION:ITS MANDATE AND APPROACH

D.R. Ministry of HealthNational Bioethics Commission

Carr. Picacho_Ajusco 154Colonia Jardines en la Montaña

Delgación Tlalpan14210

México D.F.

Design, layout and productionImpresos Santiago

Printed and Made in Mexico Intr

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1 Universidad Autónoma Metropolitana – Xo-chimilco.

2 Executive Director. National Bioethics Com-mission.

3 Chairman of the Board of the National Bio-ethics Commission.

Th e authors wish to express their gratitude to Dr. Rodolfo Vázquez, of the Instituto Tec-nológico Autónomo de México (ITAM) for the revision made to the paper and for his valuable and interesting comments and con-tributions to it.

4 On its way to become fully independent, it is not yet descentralized.

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Th is document has the following purposes:

• Identify the elements that have been important during the last four decades for the development of bioethics as a new and diff erent discipline of the medical ethics, from which it may have derived. Th is information will make it possible to build a doctrinaire body that guides and motivates the work of the National Bioethics Commission (NBC) at this present time.

• Disseminate the mission and the vision of the NBC, immersed in a very particular set of problems, as well as its immediate and long-term goals, its structure, and its working structures.

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TABLE OF CONTENTS

CHARACTERISTICS OF BIOETHICS5

THE NATIONAL BIOETHICS COMMISSION OF MEXICO27

REFERENCES41

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For a democratic society to achieve its development, it requires instances of commu-nication, dialogue, cooperation, and negotiation among diff erent groups and social players, and also between them and the State, to analyze and discuss the ethical, legal, and social problems that emerge from the intention to enforce Human Rights (HR) and from the prevalence of the outstanding contemporary progress achieved in science and technology, among other factors.

CHARACTERISTICSOF BIOETHICS

In the 60’s and 70’s of the last century, as a consequence of the HR implementa-tion, some facts occurred that caused a deep refl ection about the practical applica-tion of the new knowledge and the environmental care.

Th e concern for the ethical contents of the concrete and everyday life posed questions about personal autonomy and social justice, and also about the possibility of infl uencing on the physical, economic, social, and political environment, which took the form of students’ demonstrations that stated their disagreement with the status quo; of feminist movements that condemn, questioned and challenged the patriarchal structure of the society; and of ecological groups that raised their voice against the environmental degradation and misuse and abuse of the natural re-sources.

Based on this same approach, the movements of rights of the patients also enjoyed a boom. Th e publication of the Charter of these rights in the 70’s of the Twentieth Century represents a cornerstone in the history of health. Th ese move-ments contributed to transform the sanitary space. Th e satisfaction of the user with medical services as a criterion of the care quality and as an element to balance the power relationships between the health staff and the users, started democratizing the clinical relationship and, consequently, the consolidation of a process to a less authoritarian medical culture (1, 2) C

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Pluralism in the bioethical culture

Th e bioethical culture is focused on generating in the individuals and in society, the need of a conscious and growing moral development to deal in a rational and found-ed way with the situations of uncertainty that accompany the social development and the application of the scientifi c and technological advances. (3)

A bioethical culture implies the promotion of the participation of an increasing number of players in the orderly and rational discussion of topics, like the doctor-patient relationships, the public policies, the committees involved in the ethical as-pects of research, the genomic medicine, among others. It also tries to establish cri-teria and standards that express reconciliations between diff erent positions about these topics and that guide the decisions and concrete interventions in individuals under specifi c circumstances, taking care not to hurt individual sensitivities, but without leaving aside the greater social benefi t. (4)

It is necesarry to consider as a priority, those problems that aff ect individuals or groups who are in a disadvantaged position due to their economic, social or cultural characteristics.

Th e creation of a bioethical culture also means that a responsible attitude of the citizens, of the professionals, of the directors, and of the heads of states must be pro-moted also so that they consider the consequences of their actions and decisions; as well as the interest and commitment to respect the dignity, the autonomy, and the human rights of the people. Creating a bioethical culture means the establishment of a diff erent relationship among citizens organized in diff erent instances and the State, mediated by democracy, the law, responsibility, respect, and reason. (3)

In a democratic society, and consequently, plural, the existence of a single moral code accepted by the entire society is not acknowledged (moral monism). Th e voice of the unique and vertical society is replaced with the concept of the moral author-ity of the various players involved in a reality that concerns them, where they have to express their points of view to solve moral problems. Th is means a change to a paradigm characterized by the collective self-regulation and the secularization of the world. Th e discussion about the “quality of life” before the “sacred nature of life” acquires utmost importance because it is one of the elements that defi ne what is correct and incorrect in the medical decisions that have to be solved collectively. Th is questioning attempts to end up in provisional agreements that do not close the possibility of continuous discussion about the scientifi c advances and the so-cial and health needs. In this context, the deliberation processes emerge as a vital strategy in the search for self-regulation, which relies on the interpretation and de-

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liberation of values and rights, and not necessarily on reaching consensus. In this process, society tries to clarify, among other issues, the meaning of quality of life, death, and disease to defi ne with prudence and responsibility what is correct and incorrect under certain situations, considering the complexity of circumstances. As Adela Cortina states, (4) it is necessary to assume the type of society we live in; it is a society where neither the moral monism not the “moral polytheism” prevail (so diff erent codes that they do not share values and principles that make agreements possible), or even the “moral subjectivism” (the conviction that the moral issues are subjective and that inter-subjective agreements cannot be reached). Th ese are the elements that bioethics proposes for the discussion and the peaceful and respectful interaction of the diff erent points of view: everything immerse in a climate of toler-ance and plurality. (3, 4)

Considerations about ethics and bioethics

Ethics is the theory that makes it possible to explain, clarify, or research the moral reality, producing the corresponding concepts that explain the behavior of human beings in a society or community. (5) Ethics (6) studies, the moral practices, the moral emotions, the moral thoughts and judgments, and the moral standard as a whole. Ethics (5) as a theory does not identify itself with any particular morality; rather, it identifi es the principles that permit the explanation of the behavior in each group or society. In short, ethics is the theory and its object is morality on which it refl ects from a philosophical position. Ethics taken as moral philosophy, also refl ects on life and emerges as a vital practice.

However, applied ethics (5) studies the way the acts and the moral judgments are performed in concrete situations, whose references are established and socially accepted standards that defi ne the goodness or its absence in the moral facts. Stan-dards and practices can be studied independently, but they are closely linked indeed. A good example is professional ethics.

Th e creation of a bioethical culture implies the promotion of a responsible attitude and the consideration of the conse-quences that actions and decisions have.

To this regard, the question about the nature of man and the need to explain his work based on his obligations to others is a philosophical question that ethics C

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attempts to support. On the other hand, and consequently, ethics becomes a moral practice that has been commonly called praxis, once it has managed to give a reason to those legitimate motivations that approve or disapprove a behavior. In any of its expressions, ethics is always an issue that implies coherence. Its purpose it to repro-duce conditions for life and coexistence. (5)

Some important currents of thought have coined some terms to introduce cer-tain nuances in the comprehension of ethics as a study or discipline. For example, metaethics focuses on nature and on the essential foundations of moral concepts and judgments, as well as on studying diff erent cultures or groups and their values – how they are established – in order to characterize and compare the diff erent moral sys-tems, but without qualifying them.

Another important notion is what is known as normative ethics. From this per-spective, ethics establishes behavior standards about what is correct and incorrect and proposes parameters about the way we should live based on specifi c philosophi-cal theories. Another way to call this way of understanding ethics is deontology.

Finally, we must also refer to applied ethics, a branch of ethics that has achieved signifi cant development in the second half of the Twentieth Century and that re-fers to the application of the normative theories to the resolution of practical moral problems.

Based on these concepts, bioethics is conceived by many as the subset of the ap-plied ethics that refers to the human acts involved in everything that has to do with the vital phenomena (6). However, some authors, like Rodolfo Vazquez, (7) advocate that bioethics deserves its own place because it is responsible for studying and regu-lating the human acts involved in all the vital phenomena, with its own dynamics, positioned in an intermediate place between philosophy and science.

Bioethics, on the other hand, is a recent discipline that resulted from diff erent historic processes. Th e term was coined by the oncologist Van Rensselaer Potter in 1971 in a paper called Bioethics: the Science of Survival (8), where he said that the bio-logical knowledge should approach the knowledge of the systems of human values to launch a culture of survival, and to establish a bridge to the future for human-kind. However, the immediate development of the discipline in a specifi c institute was carried out by André Hellegers, when he founded a bioethics center in the Jesuit Georgetown University, in Washington, D.C. Th ere he gave a diff erent interpreta-tion to what was proposed by Potter when he defi ned bioethics as part of an ancient subject –a branch of the classical applied ethics–, whose task was to solve the con-crete moral problems in the biomedical fi eld through the valid application of already

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existing and valid ethical principles. Th is is the conception that has prevailed, more oriented to the medical work. (9)

According to the Encyclopedia of Bioethics, bioethics is “the systematic study of the human behavior in the fi eld of sciences of life and health care, examined in the light of moral values and principles. […] Bioethics is the systematic refl ection about the moral problems in the biomedical practices and in the health sciences.” (10)

Bioethics is an international movement that has achieved considerable recog-nition because it promotes the ethical refl ection about a myriad or problems (en-vironment, quality of life, cost of sanitary interventions, sanitary justice, human genome, etc.). Some authors defi ne the discipline as the analysis of the ethical prob-lems caused by the modern sciences of life, that provides methods to approach this analysis and to solve problems, and it also makes attempts to support the standards. Likewise, it provides criteria and procedures to make decisions based on dialogue and rational arguments. It is an instance of practical judgment exercised in concrete circumstances and to which a practical objective is assigned through diff erent forms of institutionalization. (11,12)

Other authors use diff erent expressions to defi ne the fi eld of action of this dis-cipline. J. Ladrière (2000) states that it is a “rational practice that sets in motion a piece of knowledge, an experience and a normative competency, all at the same time, in a particular context of action defi ned by the prefi x ‘bio’. [...] Biotechnology poses challenges that require analysis and proposals, whose answers cannot be only laws or standards; they imply essentially social and attitudinal modifi cations”. (13)

Victoria Camps, (14), on the other hand, considers that “Bioethics is essentially a process and a discovery. […] A process through which we attempt to make a reality of human rights and of that common morality that is our subsoil, even if we are not always capable of verbalizing it”. Fernando Lolas (15) asserts that eventually bioeth-ics is, mainly, dialogue.

In fact, morality is undergoing a transformation because of the substantial changes that have occurred in the use of science and technology, and of the new ways of living (sexuality, relationships between generations, couple and social re-lationships, etc.). Th ese situations pose new ethical challenges that must be dealt with and morality has to adapt to them by developing socially acceptable ethical references to face them. In this process, the defi nition is given of the characteristics that the new morality will have so that these transformations can be better delt with. Th e feeling of void, the lack of accurate ethical references when a diff erent ethical model is built, has enabled the development of bioethics by considering the concerns of the society and incorporating various positions and points of view to fa- C

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vor a morality with the characteristics required by a democratic society. At the same time, however, this process has radicalized some traditional positions.

Bioethics orients the refl ection and contextualizes the human problems in a dif-ferent way; thus, its need to incorporate multiple cultures, interdisciplinarity, and the methods of its topic areas. It is not only philosophy, but it is based on philo-sophical approaches; it is not law, but it incorporates it; it is not medical deontology, but it enriches it; it does not intend to provide unique answers but to reach transi-tory agreements that adapt to the social reality; it is characterized by permanent re-fl ection. Th ese special features allow bioethics to extend to the political arena from what is vital, giving a new meaning to morality.

Diego Gracia (1) states that the term bioethics is a neologism introduced in Eng-lish, whose success has been proportional to its own lack of defi nition. It is precisely the ambiguity of the term that has favored very diff erent interpretations and appli-cations, depending on the profession or the ideology.

What has been explained above leads to diff erent interpretations of bioethics approached from diff erent perspectives: (1)

• Th e physicians saw in bioethics the new face of the classical medical ethics or professional deontology.

• Th e biologists and ecologists considered that this discipline obeyed to a new creation of awareness of the advanced societies about the future of life, consid-ering the continuous environmental aggressions.

• Th e ethics of theological roots – Jew, Christian, and Muslim – believed that they saw in the new word the expression of their criterion of sanctity of life.

• Th e secular ethics – particularly the utilitarists, made it a synonym of quality of life.

Despite all this – or maybe because all of this – bioethics has been acquiring an important doctrinal body in recent years, making of it one of the most developed branches of ethics. (2)

Bioethics is the systematic study of the human behavior in the fi eld of the sciences of life and health care, examined in the light of the moral values and principles.

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For Rodolfo Vazquez, (7) “bioethics has become a multidisciplinary discourse where psychologists, geneticists, biologists, chemists, sociologists, anthropologists, jurists come together. It has also become a philosophical discipline on its own. Th is dual affi liation, on the one hand, through the convergence of diff erent scientifi c approximations and, on the other, as a strictly philosophical speculation, has led to question the possible relations between ones and another: either bioethics is the result of contributions of diff erent fi elds of philosophy and philosophy does not play a fundamental role, or bioethics is a fi eld of philosophy that resorts to its own methodological and conceptual resources, dismissing the problems proposed by the scientifi c knowledge”.

As has been mentioned before, this author proposes an intermediate position where bioethics is not placed exclusively in philosophy or exclusively in science, but that it creates a space and becomes autonomous knowledge.

In other words, bioethics is an interdisciplinary discipline or fi eld of specialists and a social and cultural movement of citizens at the same time, because it refers to the morality of the new ways to be born, die, heal, and care.

In order to advance in the discussion, it is important to mention fi rst what bio-ethics is not:

• It is not limited to the classical medical deontology. • It is not confessional ethics that is only useful to defend wholeheartedly pre-

established religious values. • It does not off er a series of simplistic recipes, rigidly pre-established values, or

formulas that clearly indicate what is good and what is bad. • It does not consist either of a set of commandments or of absolute prohibi-

tions. • It is not a set of subjective and relative statements.

Among the characteristics of contemporary bioethics, the following attributes can be highlighted: (16)

• It is secular because it looks for rational agreements among people of diff erent religious affi liations or atheists. It is tolerant.

• It is pluralist. It recognizes and promotes diversity and tries to reach reason-able agreements among diff erent postures in a discussion that arises from minimum points shared. It recognizes plurality not only as a fact but as a value. C

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• It is autonomous as a discipline and recognizes the same self-regulation capac-ity for the human beings.

• It is rational, philosophical and discursive. Th e ethical reality is not known a priori, but through the refl ection of the consequences that decisions have.

• It is universal. Th e decisions must go beyond the moral conventionalism be-cause the desire is to achieve responsible decisions via the inter-subjective agreement, but based on objective agreements of minimum starting points, like human rights.

• It is interdisciplinary because it includes philosophical, scientifi c, social, an-thropological, psychological, technical, legal related to health care, and health research.

• Plays a mediatory role because it promotes reasoned and rational mechanisms to fi nd ways that favor coexistence and help to make diffi cult decisions and solve confl icts.

• It is regulatory or procedural because it makes use of protocols, procedures, collegial bodies.

• It is applied since it deals with real, daily, and concrete problems.

Fundamental aspects in the construction of bioethics

Bioethics has had an accelerated development in the last thirty-fi ve years, as it rep-resents an ethical vision of our commitment with life, the way we would like it to occur, with possibilities of well-being and development for each and every one of the inhabitants of the planet human and non-human alike) and with a better future for all. Diff erent elements, which are mentioned below, enrich it and direct it to its own goals. Th erefore, it assumes a prudent position that maintains it linked to them, preserving its autonomy and features that confer on it its own characteristics.

Human rights and bioethics

Th e Universal Declaration of Human Rights defi ned the most complete ethical proj-ect that humankind has, being common to human beings; the essence of these rights is human dignity, concept that has its roots in ancient Greece, in the natural law. Since then, it has been built and expanded until our times to respond to the needs

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of each society. Th ere it not a unique approach either from the philosophical point of view to the concept of dignity.

Juliana Gonzalez (17) summarizes the evolution of this concept: in the Greco-Roman tradition, the dignitas is conceived as moral or social value; for Christians, human dignity is universal and derives from the divine intervention in the creation of man in God’s own image; during the Renaissance it was interpreted as the free-dom and humanity of man; for Kant, the human dignity is conceived as autonomy, inherent end, respect to the humanity of all men and their universality.

In the current bioethical debate, the topic of dignity also emerges with diff erent perspectives; there are some who state that human dignity is precisely that attribute that human beings have defi ned as inherent in human life, based on the fact that man is an end by himself. And there are others who state that dignity is the capabil-ity man has to organize his life rationally based on his goals, and that it has to be supported by the conditions established by science for its development. Th erefore, dignity cannot be considered an underlying attribute that emerges from an issue that is conferred on him randomly (DNA), like gender or color of the eyes. (7, 18)

It is important to distinguish the moral use of the term “dignity” in everyday language, where the attribution of certain virtues to a person grant him some digni-ty, that is, dignity understood as kindness, or cases when a certain social or political status grant individuals a grade of dignity consistent with their economic, social, la-bor, political position. Th is conception of what is “dignifi ed” is not what represents one of the essential bases for any bioethical discourse; on the contrary, these are the discriminatory expressions, contrary to the essence of human dignity. (19)

Dignity corresponds to all human beings, regardless of the specifi c diff erences that exist between the members of the diff erent societies. To this regard, dignity is understood as an attribute that imposes morality limits or conditions to put an end to violence, discrimination, abuse of power, among others, because it considers that human beings are valuable and worthy of being protected and taken care of. In any case, human rights have emerged and have been established as an objective agree-ment of the framework that establishes the conditions for the defi nition, defense, and promotion of a dignifi ed life and of the dignity of life, facilitating the operativ-ization of the concept of dignity.

However, considering the current conditions of the planet, what one could ob-serve is that the human rights of the fi rst generation were insuffi cient to deal with the problems humankind face. Th erefore, this ethical framework was expanded and the second and third generation rights emerged: the former concerning the social, economic, and cultural rights; the latter, the collective rights and the rights of peo- C

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ples. (19) Even then, it was necessary to specify the particularly confl icting and vul-nerability conditions for large human groups. Th is is how the rights during armed confl icts were defi ned for refugees and stateless people. (19, 20)

Worth of mention is that human rights are progressive, irreversible, and must be maximized, and that there are several international agreements that the States, among them the Mexican nation, have signed Th us, our governments are obliged to comply with them, but also with their implementation and promotion.

Th e growing international interest to respect human rights demands a more responsible and committed attitude of authorities and citizens in the surveillance and promotion of them; (18) recent evidence of it is that UNESCO approved unani-mously in October 2005 the Universal Declaration of Bioethics and Human Rights.

Scientifi c and technological advances

We live in the era of information explosion. Th e second half of the Twentieth Centu-ry, witnessed a vigorous contribution to knowledge that exceeded all expectations. In the biological fi eld, the trigger was the discovery of the deoxyribonucleic acid structure by Watson and Crick in 1953. (21) Genetic engineering and the human genome clarifi cation followed. A great part of the knowledge generated is translated into technological innovations that give way to new interventions in health care, with the consequent birth of diagnostic means and therapeutic resources. Obvious-ly, this implies some risks for individuals. Th e scientifi c research conquers frontiers and, in parallel, poses bioethical problems. In addition to biotechnology, which accu-mulates more and more applications of a biological nature for health care, informa-tion technology and telecommunications have made quantum leaps that contribute to the vertiginous progress generating new bioethical problems as well. (22)

Bioethics had a dramatic boost in the second half of the Twentieth Century thanks to the technological and scientifi c advances that started creating possibili-ties to extend life, avoid death, and revisit the defi nition of life and death. Th is led to the refl ection about what is good and correct of many diagnostic and therapeutic interventions, never imagined before, and whose results for individuals as well as for society had to be assessed from an ethical standpoint.

Th ese developments are so dramatic that some Latin American philosophers have called them the “biotechnoscientifi c paradigm”, defi ned as “the competency to adapt living systems and human nature to the desires and projects useful to relieve suff ering, impede preventable diseases, improve one’s quality of life, program the

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quality of life of the descendants and prepare for the end of life [...]” (1) It is valid here to remember “that the world is transformed through human actions, and that it would be suicidal and unethical to fail to adapt to the changes that the human be-ings are capable of generating”. (23)

Although disturbing, the new possibilities of interventions in health care can represent great health benefi ts and the well-being of broad social sectors, which otherwise, would have no alternative. Th ey can certainly enhance the quality of life of the citizens and save fi nancial resources for the health systems.

Th us, health research would have to be oriented mainly to the search of alterna-tives for frequent health problems that affl ict the majority, so that the results yield an immediate improvement of the quality of life of the population. Nevertheless, in this process the autonomy, the freedom, and the dignity of people subject to it must be respected. Th e background about abuses that vulnerable populations have suf-fered, like those seen in the Nazi Germany, gave way to the fi rst international agree-ments about the ethical principles that should be considered in biomedical research, which were included fi st In the Nueremberg Code. Later, what happened in Tuska-gee, Alabama, started the debate in the United States of America on what principles should guide medical and behavioral research. So it was in 1972, in the Belmont Re-port, (25) where justice, respect, benefi cence and non-malefi cence were identifi ed as the principles that must orient research and medical care. Later on, bodies like theCouncil for International Organizations of Medical Sciences (CIOMS) (26) prepared the standards in force to perform studies in human subjects. At present, these stan-dards represent the ethical or bioethical and technical framework that contains the scientifi c work in the world.

Human rights are progressive, irreversible, and must be maximized; to ensure that they are respected, the States, like the Mexican nation, have signed international agreements.

Health and bioethics

Under the Human Rights framework, some governments, have established health protection as a constitutional right, like the Mexican State, who do so in 1983(27). Th is means that the States are obliged to defi ne public policies and to provide in-creasing resources to prevent, take care of and preserve health. Consistent with that C

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determination, in 2003 Mexico gave a crucial and very important step when it es-tablished a national health insurance system the so-called Popular Health Insurance (Seguro Popular). Th is insurance represents the fi nancial guarantee to ensure the health care of those who do not have a formal labor relationship and that protects them in case they incur “catastrophic expenses”. Th us, this is an attempt to over-come the lack of fairness and equal rights who have affl icted the National Health System for so long.

Eminent matters in the bioethical discussion are the changes that have occurred in medicine, considering that its goals are born, to a great extent, from its inter-action with society. Th e application of biotechnology has implied a revolution in medicine, and society has to adapt to these circumstances. Many people feel that it questions the already known forms of life and, therefore, ethics and morality.

In the light of this innovating scenario, new proposals concerning the goals of medicine have emerged, for example, those submitted by a leading international institution in bioethics, the New York Hastings Center. In the paper Th e Goals of Medicine. Setting New Priorities (28), it proposes that medicine has to focus on:

a) Disease prevention and health promotion. b) Pain and suff ering relief. c) Healing and care of terminal patients. d) Early death prevention and assistance in dying

Th is is how, the development of bioethics in the fi eld of medical care and bio-medical research and in the practice and research of public health is justifi ed.

However, it is worth noting that despite the various scenarios where health de-velops, when individuals are vulnerable or sick, they wish to be taken care of in a place that is safe, with technical excellence, respect, warmth, confi dence and reli-ability, solidarity, and dignity. Th is means that medical care has to redefi ne its work in the framework of a society governed by the law, without leaving aside the best of its clinical tradition. Th ese concerns are retaken by bioethics in a very relevant way, because it is one of the sensitive issues of society.

Th e emerging diseases are potential sources of bioethical problems. AIDS, which appeared in 1981, soon went from a bioethical issue that generated a lot of interest to a serious public health problem, and later on, to a serious and extended social problem. Th e emergence of AIDS has been accompanied by strong stigmatization of moral proportions to those affl icted by it. Discriminatory behaviors have been visible by the medical staff towards patients and this disease also revealed the inad-

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equate care in the biosafety measures; it unveiled the subordination of the well-be-ing of patients to the economic interests of Global Corporations who, arguing cost problems, delayed the control and safety measures in blood transfusions. (29) Th e treatment received by the HIV / AIDS patients has lead to their response to defend their rights, not only limited to the medical arena, but also to the labor, educational, political, and religious environments, among others. (30)

Besides, AIDS questioned the moral discourse about sexuality in the light of reality of the sexual behavior and opened the discussion about the right to be dif-ferent, without being this an excuse for social exclusion or discrimination. Bioethics incorporates in its concerns the way medical care is off ered and provides elements so that the sanitary health care staff is educated in a culture of respect and rights, free of discrimination. (31)

Among the contributions of bioethics to the public health arena, the following can be mentioned: (32)

• Change of paradigm in the social relationships, characterized by the democrati-zation of the health arena and the strengthening of a culture of rights, which meant opening this space to plurality and to interdisciplinary practices. (1, 2)

• Change in the relationships of power, based on the management of the body, sexuality, life, and death. Now, public health decisions are increasingly in the hands of the aff ected person and are no longer made by the individuals supposedly qualifi ed to do so: physicians, heads of state, priests, judges, etc. (1, 2)

• Change of paternalism for the co-responsibility in the clinical relationship (physi-cian – patient relationship). Communication and dialogue among people with the same moral category prevails, that is, with the same capacity (with the suffi cient competency) and rights, where the patient or: health service user makes decisions about his reality, his body, and his health, based on his project of life. (1, 2).

• Change of authoritarism for collective self-regulation. It is characterized by a pro-cess of social participation where the opinions are compared, and minimum, temporary agreements are established, for the collective health regulation. (4, 14)

• Deliberation is used as a dialogue and decision making method. Th is rational pro-cess becomes essential for self-regulation, and also to clarify the various inter-pretations of the principles and rights, which does not necessarily mean that consensus has been achieved. However, the deliberation extends the personal C

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moral vision of the participants and of the society by identifying the points of coincidence and of disagreement and the capacity to reach provisional agree-ments. (1, 4, 14)

• Strengthening of the democratic and plural processes, because the wish is to fi nd ways to achieve the rapprochement between varied positions. Th e intention is that not everybody thinks in the same way, which would be unfortunate since it would impoverish society, but that dialogue is accepted and agreements are reached from diff erent rationales and values. (3).

Poverty and bioethics

Some countries have developed bioethics in a very signifi cant way and stay in the forefront about its orientation and development. Internationally, however, ethical concerns are not the same. Th e lost decade of the 1980’s left the developing coun-tries, particularly in Latin America, in a situation of social and economic backward-ness, when compared with previous decades and the world. With a growing increase of poverty and of social polarization, benefactor States showed the limitations of this model to generate the necessary social well-being that made it possible to ar-rive at other levels of development and quality of life. Health and other indicators of progress were seriously impacted by the economic crisis, particularly in the rural world: maternal mortality rates increased, just to mention one sensitive indicator. Faced with the weight of foreign debt and the decreasing capacity of competition, both Latin America and other regions with similar underdevelopment levels, had to deal with the global economy at a disadvantaged position Th e main ethical concerns for the region focused on survival and on equitable justice, very diff erent priorities from those of the wealthy countries, where the worries were oriented towards au-tonomy, respect, and freedom. Many of the cultural traditions of Latin Americans are characterized by a community character ‘comunitarian perspective which along with socioeconomic and cultural diversity, emphatically explain the way to approach moral considerations.

Th e emerging diseases are potential sources of bioethical problems.

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Th is is why in Latin America, in general, and in Mexico, in particular, it is of utmost importance to stress the development of bioethics with social vocation that deals with the circumstances, the demands, the challenges, and the dilemmas gener-ated by the economic – cultural polarization of our society and by the huge impact that high poverty rates have on most of the Mexican population. Consequently, giv-ing priority to the attention of these disadvantaged groups will be possible.

Bioethics off ers and requires common grounds to incorporate diff erent perspec-tives and discuss the current ethical concerns, and who also defi ne proposals and fi elds of development. Hence, the importance of including in the common bioethi-cal discourses, both the perspective of Latin America and of other regions and social groups and avoiding marginal discourses. Some philosophers state that although in past decades concerns of bioethics were oriented to autonomy, in coming years justice will have to set the tone, and the Latin American countries will have a lot to contribute. (23)

Environment and bioethics

Increasing concern exists to strengthen the respect to environmental care and of other living beings and organisms, as a priority responsibility for the preservation and maintenance of the planet and humankind. Th e environmental degradation caused by the irrational exploitation of natural resources, and its consequences on climate changes and on the loss of non-renewable natural resources, along with nat-ural catastrophes and their costs related to economic and human resources, have shown the need to off er a better future to the generations to come. Bioethics has underscored the environmental awareness of the planet. (34)

As a result of these concerns, the moral horizon of human beings has expanded, exceeding what was known as moral in the vicinity (only among moral beings). In the framework of these concerns, a highly signifi cant requirement is to educate the government and the citizens in a new way of thinking and in a diff erent way to act before the environment, with greater responsibility to achieve sustainable develop-ment, capable of off ering resources to the present and future generations. Th e birth of environmental awareness in the civil society, as well as in international agencies devoted to this purpose, is seen in diff erent fora, agreements and conventions, like the Kyoto protocol, which tries to infl uence on more precise regulations and laws in the diff erent countries. (34)

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Globalization and bioethics

Th e Universal Declaration of Bioethics and Human Rights of the UNESCO, adopted in October 2005 by acclaim shows the growing interest at an international level to reinforce the vision of bioethics in order to cover diff erent confl icts that arise from the life sciences health and environmental care in the context of human rights. It also indicates that bioethics has revisited the contents of these social concerns, has given them a disciplinary structure, and has favored a space for discussion and con-tribution of a new ethical vision that goes beyond health care in health services (1)

Faced with the deepening of social injustice, as a consequence of the globaliza-tion processes, what is required is an ethics that goes beyond the gains seen as the essential objective of profi table ethics, that regulates the greed of the transnational capital, and that restricts the consequences of an economy based exclusively on the benefi t of a few; an ethics that is interested in favoring greater wealth and its better distribution. Th at is, the orientation of globalization in terms of authentic and sus-tainable human development anchored in the respect for human rights (35)

Concerning this issue, Nations would have to incorporate the notion of justice globalization – understood as the minimum essential required by individuals to de-velop their human capabilities. Th erefore, we have to consider that the reduction of the economic gap between countries is a topic relevant to all, within the logic of distributive justice. It is important to remember Amartya Sen, (36) who advocates in favor of the global responsibility of the world; he proclaims the unsustainable aspect of the developmet of developed countries faced with the underdevelopment of the underdeveloped countries: he invokes the international eff orts being carried out in this matter, like the Global Compact launched by the UN and the proposals contained in the document of the Millennium Development Goals of this same or-ganization, among which mention is made of “fostering a world association for de-velopment”. Objective eight outlines the following aspects: that the poor countriescreate plans to reduce their problems and the rich countries reduce tariff s, increase the assistance to the poor, increase working positions for young people, increase ac-cess to medications, and reduce the digital gap. (36)

Th e socioeconomic globalization has to go hand in hand with a second order of globalization, which occurs in the fi eld of culture and morality. However, globalized ethics cannot be understood in the traditional sense, as the basis of customs, but consistent with the ends: that is, ethics that outlines rights and obligations in the relationships between cultures, without the oppression of the ethics that support the morality of each of them. Th e intention is to avoid a global morality imposed as

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the only possibility that proposes culturally abstract, dissociated and decontextual-ized principles, which go against the visions and ways of living of the majority of the inhabitants of the planet. (35) Th e global ethics aims at a common ground and at the obligations that both individuals and governments have with the planet and with humankind in general, with the present inhabitants and with the future gen-erations as well.

What global ethics with these characteristics proposed assumes is that princi-ples can be accepted and integrated as points of reference in the diff erent societies, but tailored to their core features. When people are convinced that its incorporation is convenient, the inclusion of these ideas does not become a foreign or imposed is-sue (alienation), but an act that endorses the autonomy and that allows a common language and goals as humankind: this can be illustrated adequately with the hu-man rights (19, 35)

Bioethics Methologies: decision making process

Consistent with its own principles and aimed at reaching intersubjective agree-ments, bioethics has two roads to approach the decision making and makes use of, among many options, of the deliberative method as an alternative to solve ethical problems that occur in the society. (37)

Th e bioethical deliberation does not attempt to solve confl icts through voting without dialogue; does not consist either of assessing the problems from the sub-jective positions of those interested and involved (or the committee members), be-cause a sum of subjectivities does not result in inter-subjectivity; the attempt is to get to the bottom of the principles and the values of the social ethics (civic) and assess, from them, the concrete issue. (3, 37)

Th e benefi ts of having a logical route are that it helps to clarify our beliefs, to question them and to fi nd new ones. A method with these characteristics allows the moral growth of those who carry it out, expanding their ethical horizon. It is neces-sary to consider, however, that in the grounds of morality, logical procedures are not suffi cient to make decisions because they stake the beliefs; besides, in the moral

Th ere is increasing interest in strengthening the respect of environmental care and of other living beings and organisms.

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judgment there can be qualitative arguments that may eventually tilt the balance to one side or another. (11, 37, 38)

To deliberate, certain skills and capabilities must be developed, such as:

a) express clearly the arguments that support one’s position; b) willingness to approach those who think diff erently; c) capacity to listen to and understand the points of view of others; and d) negotiation skills.

Deliberation is an art and training is required. (4, 37, 38, 39)It is worth remembering that the secular moral authority pertains to those that

agree to collaborate and reach consensus and a better social coexistence, without imposing a general ethics, as has been said, but building a model of moral assess-ment that favors the understanding of those involved in the problems and of those aff ected by the decisions derived from the deliberation – from justice - mainly in the case of decisions about issues of public standards and policies(37, 39)

Th e problem gets complicated when decisions have to be made to regulate issues on which there is no prior human experience and that, consequently, generate a lot of moral uncertainty (like the possible eff ects of the application of technology to medicine or the research of stem cells, to support the so-called therapeutic cloning, among others), and reach conclusions that are founded, inclusive, benefi cial, and prudent. Th e intention is to follow a route that makes it possible to identify ele-ments to issue a founded moral judgment. (37, 38)

Th ere are diff erent levels for the decisions made: (37, 38, 39)

• Th e facts and cases on which particular moral judgments are established (in this level, the context is a determining factor to establish a judgment because it is a well-defi ned situation).

• Th e particular rules and standards applicable to a certain class of cases or situ-ations.

• Th e general principles (the international agreements, the statements, the con-ventions, the codes, etc., would be in this level).

• Th e theories and systems of beliefs (the cosmovisions, the religions, the phi-losophies, or the scientifi c theories).

However, there are diff erent levels in which interventions are possible. All of them require that the situation under discussion is deeply understood: it is neces-

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sary to include the diff erent perspectives about them, imagine diff erent routes of action, and consider the consequences of the decisions made, at least those that can be foreseen in a given moment. It is also important to take into consideration that the more general the decision level is, the greater its social impact will be, determin-ing responsibilities of diff erent quality.

Th e deliberative method has its background in ancient Greece, where the phi-losopher established a dialogue with others by means of questions and answers he tried to base. At present, some philosophers with the vocation of interpreting and transmitting concepts invite the bioethicists to be articulators – facilitators – in the discussions and to stress those particularly dark points that need to be analyzed to reach a conclusion. (37, 39)

Th e deliberative method starts from the following assumptions: (1, 2, 3, 37, 38)

• Th at the opinion can be uncertain, but not irrational. • Th at diff erent opinions about the same problem can coexist. • Th at there can be diff erent perceptions of reality. • Th at perception is the guide for action. • Th at the deliberation does not exhaust reality • Th at there is unknown information. • Th at nobody has the absolute moral truth. • Th at the perspectives of those involved in the moral problems must be consid-

ered • Th at the deliberation process is important because it expands the points of

view of those involved, promoting individual and collective moral growth. In this method, it is not only important to reach a conclusion but the process itself.

• Th at the intention is to collaborate to fi nd agreements and solutions, rather than to confront irreconcilable positions or impose points of view.

• Th at the deliberative method is based on founded, reasoned, and rational dis-cussion.

In short, the deliberative method is based on argumentation, which is a founded reasoning process, where cooperative and respectful dialogue is established, with the aim of fi nding routes for the solution of moral problems.

Th e bioethical deliberation does not seek to solve confl icts through voting devoid of dialogue.

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In this method, the road is what matters, more than the solution. However, human rights are the framework for deliberation, because they off er support and establish limits to the solutions reached. Th us, for Diego Gracia (37) a decision made following the deliberative steps can aspire to be prudent and responsible. Th is is the type of decisions that can be reached, and not the total and radically correct.

In the solutions to the moral problems, a certain value can be violated or its scope be limited. Th e idea is to reach balance and opt for the least damage possible. Th is does not imply denial, instrumentalization or diff erential assessment of any of the human rights. It is an exercise where specifi c factors in a concrete situation are weighed. We must humbly accept that some moral problems have no solution. (11, 37)

In general terms, the moral judgments must be characterized for being: (11, 37, 39, 40).

• Coherent with the cultural references or with the system of beliefs or of knowl-edge where they are expressed.

• Balanced between the general and the particular judgments (in accordance with the level in question), on the one hand, and between the strong ideals and principles, on the other.

• Founded. • Inclusive. • Refl exive. • Prudent. • Benefi cent (oriented to the greatest social and human benefi t).

Th ere are elements, however, that can hinder the deliberation: (11, 37)

1. Th at there are no prior conditions (of respect for plurality, democracy, free-dom, and legality).

2. Th at it does not happen under the adequate circumstances: it must be per-formed without any haste and with knowledge of cause, because it is contrary to ignorance.

3. Th e psychological obstacles: unconsciously, we all want be right and total-ly right, If the reasons of the other are diff erent from ours, we live them as threats; each threat produces the need of protection against the anguish it generates. Some mechanisms of defense that are mobilized against anguish, described by Freud, are denial, aggression, imposition. (37)

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It is important to train the health care staff about the deliberative method andalso to introduce the patients and users within its scopes and limits. It is necessarythat the society as a whole is involved, in one way or another, so that dialogue andmoral growth are achieved.

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Th e National Bioethics Commission (NBC) is responsible for fostering the disci-pline in Mexico. Albeit only briefl y it is convenient to describe the trajectory it has followed, its mission, vision and tasks, as well as its infrastructure.

THE NATIONAL BIOETHICS

COMMISSION OF MEXICO

Th e course of the NBC

Based on the interest generated internationally in bioethics, the need to develop it in our country was acknowledged, particularly to deal with transcendent issues, such as biomedical research, health and environmental care.

As a result of this interest, in 1989 a study group on bioethics was established in the General Health Board (Consejo de Salubridad General CSG), which eventually and thanks to the initiative and interest of Dr. Manuel Velasco Suárez, Executive Secretary of the CSG —who was entrusted with the initial creation of a Commis-sion—, changed on March 30, 1992, to the National Bioethics Commission (NBC), through agreement of this entity.

Th e NBC was installed in the Antiguo Clautro de San Pablo, occupied by the Mexico City Juárez – Centro Hospital. Its mission and objectives were defi ned as follows:

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Th e better knowledge of the universal cultures, the reality about life protection, respect of human rights in terms of freedom, health, well-being, and exercise of solidarity for equity and justice. (41)

To comply with its objectives, the NBC made an analysis of human rights re-lated to health, social development, and individual and collective well-being; of the development of sciences of human reproduction and genetics, as well as the study and analysis of the ethical issues of biomedical and clinical research, the refi nementof the organ and tissue transplantation procedures, and the assistance to terminal patients.

In 1993, the rules of the Commission were created with the participation of twelve work committees, made up by professionals of diff erent disciplines, invited for this purpose Bioethics was disseminated and promoted with the publication of a Bulletin of the National Bioethics Commission, the organization of three international conferences (1994, 2000, and 2003), and seven domestic conferences (consecutive from 1997 to 2003), as well as multiple work meetings, sessions, conferences, and fora.

As a result of the recognition to its work and to the social importance of its tasks, on October 23, 2000, the NBC acquired its permanent status granted through Presidential Agreement providing it with more consistency. Th is new status allowed it to carry out broader actions for its projection in the public and private sectors. Under this new framework, its purpose was redefi ned as follows:

Th e objective of the National Bioethics Commission will be to promote the study and respect of ethical values and principles related to the exercise of the medical care and health research

Th is meant a change in the orientation of the Commission, more focused on the provision of medical services and research.

In this same Agreement, it was specifi ed that the NBC should be comprised of the heads of the main health institutions (SSA, IMSS, ISSSTE, etc.) and the National Medical Arbitration Commission, with the recommendation of including the deans of public and private universities and the Chairman of the National Science and Technology Council

Likewise, on October 23, 2000, the Offi cial Gazette published the Presidential Agreement for the establishment of the National Human Genome Commission (CO-NAGEN) to “coordinate public policies and actions of educational and health agen-cies and institutions” concerning the knowledge about the human genome, which is particularly relevant, as will be explained later on Dr. Guillermo Soberón was ap-pointed Executive Secretary of the CONAGEN.

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In March 2002, after the demise of Dr. Velasco Suarez, Dr. Fernando Cano Valle assumed the position of Executive Secretary until June 30, 2003. Th e management of Dr. Cano Valle was characterized by the promotion and establishment of some commissions in the federal states as well as of bioethics committees was reinforced in hospital, research and higher education institutions. Likewise, documents were drafted to serve as guide for human resources in health services to act ethically.

On February 27, 2003, at the initiative of the Commission, the National Health Board, made up by the Health Secretaries of the Federal Government and of the thirty-two states, agreed that “in each State a Bioethics Commission will be estab-lished”. Th e Bioethics Commissions of the States are instances of dissemination and support for the development of bioethics. Th ere are at present ten Bioethics Com-missions in states in the country: Baja California, Baja California

Sur, Guerrero, Jalisco, State of Mexico, Morelos, Nayarit, Nuevo León, Oaxaca, and Tlaxcala.

In October 2002, the Bioethics Code for Health Care Personnel was issued to

respond to what was established in the Presidential Agreement that stated: “Dis-seminate among the society and health professionals, technicians and assistants, the principles and values that must govern the exercise of their activity”, document that was submitted extensively to the consideration of diff erent instances to col-lect for two years diff erent opinions and look for consensus. Another dissemination strategy of the NBC was the edition of the journal Summa Bioética, specialized pub-lication, of which fi ve issues were prepared.

From July 1, 2003 to August 2004, Dr. Juan Garza Ramos was appointed to be in charge of the Commission. On July 20, 2004, the National Genomic Medicine In-stitute was created: for this reason, on August 2, 2004, the Presidential Agreement was issued through which the National Human Genome Commission (CONAGEN) was abolished. In this way, the refl ections about ethical issues of the human genome were to be assumed by the NBC.

In fact, the advances in the democratization process, the need to discuss old and new health-related moral problems, the application of technology and biomedical research, and the need to incorporate innovating approaches and arguments to ana-lyze the impact and scope of the work performed by the NBC, resulted in changes in its mission and its structure.

Th e objective of the National Bioethics Commission will be to promote the study and respect of ethical values and principles for the exercise of medical care and of health research.

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A new Presidential Decree of September 7, 2005 establishes the NBC as a non- concentrated body, hierarchically subordinated by function to the Health Ministry, with technical and operative autonomy. Dr. Guillermo Soberón Acevedo, who had led the CONAGEN, assumed the position of Executive Secretary of the NBC and became eventually the Chairman of the Board, appointed by the Health Minister.

Mission and vision of the NBC

In short, the mission of the NBC is to contribute to the development of a bioethical culture in Mexico.

In the Mexican society, diff erent ethical positions coexist, some of them based on strong traditions. Th is multiethnic and multicultural society requires a broad, comprehensive and inclusive ethical framework, where this social & cultural mo-saic is refl ected. Th e Mexican society is a morally pluralistic society, aware that it is possible to discover intersubjective agreements in the diversity of codes. Worth of mention is that the functions of culture, according to Luis Villoro, (42) are: satisfy needs, conform to desires and fulfi ll goals. Culture provides the contents to express emotions, desires, and ways of conceiving the world; it gives meaning to attitudes and behaviors; it outlines values; it allows preferences and choices of goals; it inte-grates the individuals; and it determines the criteria to fulfi ll these ends.

Th us, it is necessary to create appropriate spaces where dialogue and the willing-ness to approach others prevail to achieve a better social coexistence concerning the moral problems that are a reason of concern. Spaces that favor the construction of a bioethical culture that, in turn, becomes the support of new forms to legislate, to participate, and that enables a greater margin of social self-regulation. Th e intention is not to impose a unique, rigid, and homogeneous ethical framework that expresses the opinion and the vision of a few, but to fi nd points of confl uence from diff erent perspectives, accepted for diff erent reasons and values within the framework of the secular State. (3) Th is must be translated necessarily into a form of government that is more satisfactory from the ethical standpoint and into the moral progress of the society.

To contribute and establish a “bioethics culture in Mexico, the NBC has to to fos-ter an attitude of multidisciplinary and multisectorial refl ection, deliberation and discussion of the topics linked to human health, and develop ethical standards for health care, research and education. Part of its tasks are to collaborate in the estab-lishment of bridges of understanding among the diff erent social groups and players,

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promoting the autonomous, rational, secular, and respectful refl ection of the diver-sity on bioethical topics, based on the greatest social benefi t; the intention, conse-quently, is to expand the moral horizon..

In this sense, the mission of the NBC of promoting a bioethical culture will also serve to improve the coexistence and expand the social and individual awareness based on a vision of ethics toward life. Th e relevance of bioethics endorsing the so-cial practices is supported by the fact that it takes as reference the vital processes; that means that foundations of law should be more comprehensive towards the dif-ferent expressions of life and that its care and protection is fostered; it also means that respect of human rights is promoted, that the environment is taken care of, that the medical service and research look for the collective well-being; and that the autonomy of patients is strengthened when decisions are made, among others, Th is is to say that the society and the professionals should incorporate the bioethical vi-sion in their work.

Th e NBC has to make decisions, create and adopt, go in depth and communicate concepts and methods based on deliberation, that is, on the founded reasoning.

It is necessary to create appropriate spaces where dialogue and the willingness to approach others prevail to achieve a better social coexistence concerning the moral problems that are a reason of concern.

In short, promoting a bioethical culture in Mexico means a transformation and reorganization of the environment, from an ethical perspective of life, to solve the elementary and essential needs of human beings, as well as the symbolic represen-tations, the language, and the social relationships.

Th e approach of the NBC

Among the functions of the NBC are to call upon various social sectors to discuss relevant topics in an orderly way, with the purpose of clarifying the bioethical prob-lems presented, and identifying the diff erent points of view, indicating the routes to reach consensus and / or approaches. Th e intention is to fi nd bridges of under-standing, acceptable formulas for a coexistence that is tolerant and respectful of divergences, for the benefi t of the society. Attempts are made to promote an at-titude of multicultural, multidisciplinary and multisectorial attitude of refl ection, Th

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deliberation and discussion of relevant topics concerning the human life and that are of signifi cant concern to the society, in a climate of tolerance, plurality, and re-spect within the secular State. Eff orts are made to involve diff erent groups of the society in the development and surveillance of ethical standards in medical care and in health research.

In order to off er relevant and founded information to social institutions, groups and players interested, in a plural and secular environment, the NBC foresees the specifi c and plural identifi cation, systematization and discussion of topics that are of moral concern to the society, like cloning, abortion, euthanasia, confl icts in the clinical relationship (physician – patient relationship), among others.

It is necessary to create appropriate spaces where dialogue and the willingness to approach others prevail to achieve a better social coexistence concerning the mor-al problems of concern.

Another reason of concern for the NBC is that the health policies respond to a public ethics oriented by the national priorities that have more social impact; like-wise, that the resources available are used correctly in medical care and in research, and the most vulnerable population and at social disadvantage is protected.

Among the functions of the NBC are to achieve an impact on the health teaching and health care delivery through theoretical bioethical training and, especially, so that respect and technical excellence are included in the education of the profes- sionals in their daily work.

An agenda for the NBC: new and old sanitary challenges

Th e second article of the Presidential Decree of September 7, 2005 states that to comply with its objective the NBC shall:

I. Establish the public health policies linked to the bioethical topics. II. Act as a national consultation body on bioethical specifi c topics. III. Identify and systematize the elements that included in as well as those that

aff ect a bioethical issue in order to off er relevant information about them to institutions, social groups, or any other sector interested.

IV. Collaborate so that the health protection right is enforced in the health re-search topics, as well as in the medical care quality.

V. Promote debates about bioethical issues with the participation of the diff er-ent sectors of the society.

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VI. Promote the teaching of bioethics, particularly concerning medical care and health research.

VII. Promote the establishment of bioethical commissions in all the federal states.

VIII. Promote the organization and operation of hospital bioethical committees and research ethics committees in private and public health institutionswith the powers granted by the applicable legal provisions, and also to sup-port the training of these committee members.

IX. Establish and disseminate guidelines that must be considered by the bioeth-ics and ethics hospital committees in research for the development of their activities.

X. Organize and participate in research and teaching activities linked to its ob-ject.

XI. Give opinions about the health research protocols that are submitted to its consideration.

XII. Execute the collaboration agreements necessary for the fulfi llment of its ob-jective.

XIII. Foster the communication with universities, higher education institutions, academic and civil society groups linked to bioethical issues.

XIV. Promote the respect of bioethical criteria among the diff erent sectors in health-related issues in matters of food, water, environment, education, among others, and

XV. Th e other functions assigned by the Health Minister.

In order to orient the work of the NBC, some aspects that have to be considered in further depth have been identifi ed, as they act as benchmarks for the develop-ment of their work:

• Review the bioethical implications in the health policies, in research, and in the legislation in force related to current topics of interest, like cloning and organ transplantation, abortion, euthanasia, smoking, among others, to obtain an updated perspective of the bioethics in Mexico and identify the possible moral confl icts that arise in the application of the policies and legislation in force. Scientifi c research should be more oriented to the application in topics that are currently amidst extensive discussion, like stem cells, cloning, assisted repro-duction, organ transplantation, genomic medicine among others, that could represent tools to discover therapeutic opportunities for humankind and to Th

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deal with present and future health problems, with interventions compatible with the Mexican society. It is important to consider always that the benefi ts derived from research must be accessible not only for those who participate in it, but that the rest of the community must be considered. Besides, the inter-national collaboration topics must be established on an equitable, democratic fashion, respecting the unique ethical standards in any country where the re-search is conducted. Likewise, routes of action must be established in case con-fl icts of interest arise among the researchers, the fi nancing agencies, and the research subjects, among others. But mainly, mechanisms must be sought for the protection of the vulnerable groups that can be subject of research.

• Assess the priorities established to approach the health research problems, based on ethical principles, particularly the principle of justice, in order to improve the collective health and achieve the greatest social impact possible. Make eff orts so that the allocation of resources in research results in extensive benefi t, both to solve potential confl icts of interest among those involved in the research, and to protect those who participate in it, mainly the subjects of research.

• Take care of confi dentiality, especially the information contained in the clinical fi le and in the documents elaborated to obtain the informed consent, because confi dentiality is currently understood not only as a medical duty but also as a fundamental right of the patient and, in general, of the citizen. We have to insist on the care that must be taken in the management of the genetic data when it aff ects third parties and in the protection of minors. It is necessary to reiterate as well the protection that must be given to the information in the diff erent means to protect the privacy of citizens before medical insurance companies and potential employers, for example. It is necessary to reconcile with the Federal Information Access Institute (IFAI) the limits between trans-parency and confi dentiality.

• Insist on the respect to the rights of the patients in the health systems and on the need to inform and train the health staff with a bioethical vision that pro-vides them with elements to improve the treatment given to users and that promotes positive attitudes of the health care personnel based on this vision. Incorporate the living wills in the health decisions in the terminal patients.

• Defi ne the limits of the medical intervention, because particularly with the in-creasing incorporation of technology, the line is blurred between the good medical practice and therapeutic obstincy especially in terminal patients, y especially in terminal patients, yin the selection of patients for hemodialysis, the intervention in premature babies, the organ transplants, the palliative care or the assisted reproduction,

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among other cases. Moral confl icts arise among those involved, particularly when new ways of actions are sought preserving the dignity of the individuals but also oriented to the service providers in the decision making process and in public health.

• Follow the international biotechnological development and the subsequent bioethi-cal debates to support public health polices, based on understanding the predict-able consequences of these developments. Th erefore, the ongoing updating of the bioethical information and literature is required. Updated bioethics and the participation in domestic and international fora is essential to face this challenge.

• Bioethics and mental health. Mental health is an aspect of human health that does not always receive the attention required, even though it covers highly signifi cant problems, some of which reach dimensions that represent public health problems, like depression, other forms of psychiatric diseases, and many psychosocial disorders, among which addictions are found. Th e addic-tion rate has increased, it starts now at earlier ages and it aff ects young people who represent an important potential for the country.

Some of the addictions are socially accepted, entailing more diffi culties in terms of establishing limits for the abuse defi nition. Besides, they conceal and promote another very important phenomenon, namely, co-dependency. In the case of alcohol, for example, in addition to the direct health damage, its role as a causal agent of accidents is an important factor in the great increase of mor-bidity and mortality in this fi eld, particularly among males. Th e fi ght against smoking, on the other hand, shows some advances, but the ages when people start smoking have increased and its incidence is now felt among women; its eff ects in both genders at all ages cause disorders (COPD, emphysema, lung cancer, heart diseases) that are seen so frequently in our hospitals. Concern-ing drug dependency, we are losing ground in an extremely diffi cult battle: Mexico is no longer a country of drug transit It has become a production and consumption nation; the diversity of the drugs used has expanded and the synthetic drugs are gaining in relevance; the number of consumers of the so-called hard drugs is increasing; the trail of corruption produced by drug traf-fi cking is very serious and disseminates through high levels of the society.

Th ere are some bioethical issues that are still in need of clarifi cation and dissemination, for example, the application of profi ts generated by alcohol and tobacco consumption to health or social research, or treating drug addicts as criminals and not as patients; from the ethical point of view, it is important Th

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to include the topic in the refl ection of the freedom of the victims, because the harm on their health that hinders them from making autonomous decisions must be assessed as well. We have to move into realms where it is necessary to diff erentiate between a personal behavior and a compulsive, conditioned be-havior, when it is not determined by clear modifi cations in the neurobiologi-cal, psychological, and social conditions of the individual. Besides, concrete issues can be studied, on the one hand, like the substitution programs for opi-ate dependents, the inclusion of drugs that can cause dependency in the treat-ment of terminal patients and, on the other, more general aspects that focus the social debate on drugs, but from a bioethical perspective, that is, the ethi-cal analysis of consumption and the ethical analysis of control. Th e proposal of legalizing drug consumption must be discussed extensively because its ap-plication in some places has produced adverse eff ects.

Th e ethical dilemmas generated in the mental health fi eld are very broad and complex and include such diff erent issues, like thought diffi culties in the application of the informed consent (either for research or for care or hospital admission) in people with hindered autonomy; it is not easy to make maximal-ist interpretations of freedom; there is always a chance for a glimpse of the “human being” that obliges us to consider the possibility of responsible acts in the sickest patients, and a particular analysis is required in each case. Th e new fi eld of neuroethics must be included here as well. Such is the need to include depression, schizophrenia, and gender violence, the dilemmas posed on the society of their high incidence and the low importance given to the severe consequences they have both for those who suff er them and for the society as a whole and the health systems. Th e dilemmas are present because it is necessary to establish the limits between the public and private realms to launch programs and actions at public policy levels and avoid the growth of these phenomena, whose causes are found, to a great extent, in the forms of socialization.

Psychiatric disorders and psychological diseases, as well as drug dependency and its health eff ects not only represent persistent problems, but also changes and new proposals that demand that everybody - politicians, professionals in the dif-

Th ere are some bioethical issues that are still in need of clarifi cation and dissemination, for example, the application of profi ts generated by alcohol and tobacco consumption to health or social research.

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ferent fi elds of intervention, researchers and social entities – performs an eff ort to refl ect on, comprehend, and question previous concepts and ideas to improve and achieve more eff ective actions in the future. Th e scant resources devoted to the care of psychic disorders and abuse of patients has been a constant situation in many countries.

Bioethics, as an element of morally plural and interdisciplinary refl ection, can-not be absent in this scenario. Its presence is required to collaborate in the eff orts to disseminate a culture of responsibility and of quality of life and contribute to inhibit values and principles in the society that relieve the vulnerability of some groups.

• Create awareness that poverty and its impact on health (expectation of life, mor-bidity and mortality in children, maternal mortality, among other indicators), particularly in groups at disadvantage, like indigenous ethnic groups, requires of innovations in the health protection strategies, especially in the public poli-cies, in order to generate better alternatives to fi ght it. To this regard, rein-forcing the commitment of conforming to the human rights already included in our Constitution, such as non-discrimination, the health protection right, education, among others, is required. It is necessary to consider the risks and the benefi ts, as well as the moral implications involved when adapting to new possibilities of life and death.

• Learning about population aging and its consequences on the quality of life for the increase of chronic-degenerative diseases and their eff ect on the increase of medical care costs, in order to foster the regulation and legislation to pro-tect the citizens in the fi nal stage of their life.

Operative structure of the NBC

Th e current structure of the NBC shows a new spirit and is the starting point to consolidate its capacity to face its responsibilities.

To meet its objectives, the Commission develops an organizative structure con-sistent with the underlying tasks entrusted to it. Among them, it proposes to im-prove and strengthen the bioethics culture promotion. Th e Commission has a Board that will characterize the bioethical issues in the general health policies and will orient the NBC work. As part of the Board, the Health Minister has invited dis-tinguished personalities of the civil society and the medical community, with vast knowledge about bioethics, and formed originally in diff erent disciplines: medicine, Th

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law, sociology, philosophy, psychology, so that this body has an interdisciplinary na-ture, balance of gender, and diversity in ideological perspectives. Th e fi rst Board was comprised of Drs. Maria Asunción Alvarez del Río, Roberto Javier Blancarte Pimen-tel, Ingrid Lilian Brena Sesma, Juliana Gonzalez Valenzuela, and Jose Kuthy Porter. Members of the Board are changed every for years; not all at the same time. As has been mentioned already, the Board is led by Guillermo Soberón Acevedo, acting as Chairman, and also appointed by the Health Minister. Th e NBC has an Executive Director, position held by Dr. Dafna Feinholz Klip, who directs the fundamental ac-tions directly through four technical and operative areas, each under one direction. Th ese areas are: the Center of Bioethical Knowledge (CECOBE), the Academic Plan-ning and Development area, the Infrastructure Strengthening area, and the Admin-istration and Organization area. Th ere are twelve assistant directions in charge of the priority theme areas that the Commission must approach, which are:

• Communication and Link with the Society • Information Technology • Human Genome • Public Policies • Human Resources education • Analysis and Evaluation • Bioethics Commissions of the Federal States • Research Ethics Committees and Hospital Bioethics Committees • Legal Issues • Human Resources and Organization • Financial Resource • Material Resources and General Services

Th e NBC will have a Center of Bioethical Knowledge (CECOBE) in charge of per-forming the collection, systematization, analysis, and dissemination of bioethical information produced at such high rates in this discipline. Th e CECOBE will be re-sponsible of the NBC Web site, it will have a library and a documentation center for the organization of the bibliographic and hemerographic site open to the members of the Commission, the professionals interested and, in general, all the members of the society. Th e advance of information technology and of telecommunications makes it possible to have the technology necessary to attain the ambitious purposes of the venture proposed.

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Th e Center will cover the broad spectrum of action of bioethics, that is, the phil-osophical, scientifi c, technical, legal aspects of health care and of health research, and will also have human resources training and professional formation, so urgently needed to promote the development of the discipline and its institutionalization. Th erefore, it will give special emphasis to the training of members of Research Eth-ics and Hospital Bioethics Committees. Th is Center will be established in Tlalpan, in the zone of the National Health Institutes so that, in an emblematic way, the mean-ing of bioethics is expressed as a primary reference in health care.

Th e operative areas that are directly related to the Commissions in the diff erent states, and also to the Hospital Bioethics Committees and the Research Ethics Com-mittees, will prepare a registry of them, will follow up on their activities and will establish national networks.

Th e national infrastructure strengthening strategy contemplates the reinforce-ment of the Bioethics Commissions in the federal states whose function is to rep-licate and extend the work of the National Commission in the legal frameworks in force in each state. Likewise, they must promote in all the public and private health institutions the organization and operation of Hospital Bioethics Committees and Research Ethics Committees, with the powers granted to them by the legal provi-sions applicable. Among other tasks they have are to support the training of the members of these committees; the establishment and dissemination of the guide-lines that the Hospital Bioethics Committees and the Research Ethics Committees must consider for the development of their activities and that are produced at the national level ; institutionalize the opinion about the health research protocols sub-mitted to its consideration, including those that involve the development of new medications and their correct use in the medical practice.

Th e teaching of bioethics must be promoted, particularly concerning medical care and health research, and also organize and participate in research and teaching activities linked to its objective. Th e Presidential Decree of September 7, 2005 con-tains the elements to establish the governance of the NBC in the harmonization of the work of the State and Federal District Bioethics Commissions and the operation of the Research Ethics and Hospital Bioethics Committees.

Among its objectives, the NBC proposes to improve and strengthen a national infrastructure that allows the bioethics culture promotion.Th

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Th e tasks of the Hospital Bioethics and the Research Ethics Committees must be clearly defi ned: the former are in charge of responding to the bioethical problems that arise from medical care, public health, teaching, while the latter have to do with research protocols and they are responsible for following up on the development of the research projects so that ethical issues are taken care of.

Th ere will be an Advisory Committee comprised of national and international experts, who will meet on a periodic basis and will be in touch with the base team to discuss and give their opinions about the tasks performed. Links and / or collabo-ration agreements will be established with educational and research institutions, international bodies, organizations of the civil society, and with other regional and international bioethics commissions and associations.

Finally, the NBC has projects of launching at least two periodic publications: a bulletin that explains the main activities performed and communicates topics of general interest in the bioethical world, and a journal Debate bioético, which will in-clude the bioethical analysis of topics of current interest and comments, aimed at achieving progress in a reasoned debate about these topics.

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