Managing a difficult ethical and legal equilibrium in healthcare: assuring access to the basics while keeping up with innovation
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Edi o ial
Managing
a
di ficul
e hical
and
legal
equilib ium
in
heal hca e:
Assu ing
access
o
he
basics
while
keeping
up
wi h
inno a ion
A
ges ão
de
um
di ícil
equilíb io
é ico-legal
em
saúde:
assegu a
o
acesso
aos
cuidados
básicos
man endo
a
ino ac¸ão
The e
is
a
new
and
challenging
pa adigm
in
heal hca e
which
is
pe ading
he
sec o
and
con ains
an
appa en
in e nal
con-
flic .
On
one
side,
he
undamen al
human
igh
o
access
o
basic
heal hca e,
(see
a icle
25
o
he
Uni e sal
Decla a ion
o
Human
Righ s
–
UDHR1and
a icle
12
o
he
In e na ional
Co enan
on
Economic,
Social
and
Cul u al
Righ s
–
ICESCR2)
seems
o
become
mo e
and
mo e
di ficul
o
a ain
in
mos
pa s
o
he
wo ld,
including
he
so-called
Wes e n
de eloped
coun ies
whe e
a
financial
c isis,
which
s a ed
in
2008,
is
1A icle
25
o
he
UDHR
1.
E e yone
has
he
igh
o
a
s anda d
o
li ing
adequa e
o
he
heal h
and
well-being
o
himsel
and
o
his
amily,
including
ood,
clo hing,
housing
and
medical
ca e
and
necessa y
social
se ices,
and
he
igh
o
secu i y
in
he
e en
o
unemploymen ,
sickness,
disabili y,
widowhood,
old
age
o
o he
lack
o
li elihood
in
ci -
cums ances
beyond
his
con ol.
2.
Mo he hood
and
childhood
a e
en i led
o
special
ca e
and
assis-
ance.
All
child en,
whe he
bo n
in
o
ou
o
wedlock,
shall
enjoy
he
same
social
p o ec ion.
2A icle
12
o
he
ICESCR
1.
The
S a es
Pa ies
o
he
p esen
Co enan
ecognize
he
igh
o
e e yone
o
he
enjoymen
o
he
highes
a ainable
s anda d
o
physical
and
men al
heal h.
2.
The
s eps
o
be
aken
by
he
S a es
Pa ies
o
he
p esen
Co enan
o
achie e
he
ull
ealiza ion
o
his
igh
shall
include
hose
necessa y
o :
(a)
The
p o ision
o
he
educ ion
o
he
s illbi h- a e
and
o
in an
mo ali y
and
o
he
heal hy
de elopmen
o
he
child;
(b)
The
imp o emen
o
all
aspec s
o
en i onmen al
and
indus ial
hygiene;
(c)
The
p e en ion,
ea men
and
con ol
o
epidemic,
endemic,
occupa ional
and
o he
diseases;
(d)
The
c ea ion
o
condi ions
which
would
assu e
o
all
medical
se ice
and
medical
a en ion
in
he
e en
o
sickness.
ye
o
be
comple ely
esol ed.
On
he
o he
side,
he
mos
ad anced
and
expensi e
biomedical
echnologies
applied
o
p e en ion,
diagnosis
and
ea men
con inue
o
expand
in
e y
sophis ica ed
ways
and
he
igh
o
enjoy
he
benefi s
o
such
scien ific
p og ess
is
also
coined
as
a
undamen-
al
human
igh
(see
a icle
27
o
he
UDHR3and
a icle
15
o
he
ICESCR4).
This
ension
be ween
in es ing
in
g an ing
immedia e
access
o
basic
heal hca e
when
esou ces
a e
lacking
and
de eloping
no el
solu ions
ha
can
only
bene-
fi
a
ew
in
he
sho - e m
bu
p omise
o
o e
widesp ead
p og ess
la e ,
equi es
a ional
and
eflexi e
analysis
in
o de
3A icle
27
o
he
UDHR
1.
E e yone
has
he
igh
o
eely
pa icipa e
in
he
cul u al
li e
o
he
communi y,
o
enjoy
he
a s
and
o
sha e
in
scien ific
ad ance-
men
and
i s
benefi s.
2.
E e yone
has
he
igh
o
he
p o ec ion
o
he
mo al
and
ma e ial
in e es s
esul ing
om
any
scien ific,
li e a y
o
a is ic
p oduc ion
o
which
he
is
he
au ho .
4A icle
15
o
he
ICESCR
1.
The
S a es
Pa ies
o
he
p esen
Co enan
ecognize
he
igh
o
e e yone:
(a)
To
ake
pa
in
cul u al
li e;
(b)
To
enjoy
he
benefi s
o
scien ific
p og ess
and
i s
applica ions;
(c)
To
benefi
om
he
p o ec ion
o
he
mo al
and
ma e ial
in e -
es s
esul ing
om
any
scien ific,
li e a y
o
a is ic
p oduc ion
o
which
he
is
he
au ho .
2.
Shall
ake
he
s eps
necessa y
o
he
conse a ion,
he
de el-
opmen
and
he
di usion
o
science
and
cul u e.
3.
Unde ake
o
espec
he
eedom
indispensable
o
scien ific
esea ch
and
c ea i e
ac i i y.
4.
Recognize
he
benefi s
o
be
de i ed
om
he
encou agemen
and
de elopmen
o
in e na ional
con ac s
and
co-ope a ion
in
he
scien ific
and
cul u al
fields.
122
e
p
o
s
a
ú
d
e
p
ú
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2
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4;3
2(2):121–122
o
s ike
he
igh
balance
and
p io i iza ion.
Inno a ion
is
indeed
undamen al
and
he e o e
he
unding
and
he
c e-
a ion
o
incen i es
o
public
and
p i a e
esea ch
canno
be
neglec ed,
o he wise
he
no el y
in
heal hca e
can
s agna e
and
wi h
i
he
endless
possibili ies
o
con inue
o
e ficien ly
minimize
human
su e ing.
Tha
ou come
is
undesi able
e en
o
hose
who
a e
mos
c i ical
o
he
way
heal hca e
esea ch
and
inno a ion
a e
cu en ly
designed,
financed
and
execu ed,
pa icula ly
conce ning
well
documen ed
une hical
p ac ices.
In
eali y,
he
in es men
in
inno a i e
leading
edge
heal hca e
echnology
can
also
con ibu e
o
he
ealiza-
ion
o
he
igh
o
access
heal hca e
by
imp o ing
he
accu acy
and
as
such
also
he
e ficiency
o
heal hca e
mea-
su es.
This
in es men
should
p oceed
in
andem
wi h
he
applica ion
o
cu en
know-how
o
b ing
heal hca e
o
he
egions
o
he
wo ld
whe e
i
is
cu en ly
inaccessible
and
whe e
human
su e ing
demands
u gen
amelio a ion.
The e-
o e,
a
a ional
sys em
mus
unde s and
ha
in es ing
in
he
u u e,
o
example
in
he
o m
o
genomic
echnolo-
gies
aimed
a
achie ing
e ec i e
pe sonalized
medicine,
does
no
ha e
o
collide
o
all
unde
he
immedia e
p emise
ha
e e y
human
li e
dese es
he
highes
a ain-
able
s a e
o
heal h
a
he
p esen
ime.
Ne e heless,
he
equi ed
ade-o s
o
pe ec
such
sys em
a e
nec-
essa ily
di ficul
o
find
and
equi e
pe manen
sc u iny
and
mul idisciplina y
e alua ion,
which
includes
neces-
sa y
inpu s
om
economics,
medicine,
science,
law
and
e hics.
This
issue
o
he
Po uguese
Re iew
o
Public
Heal h
p esen s
o iginal
a icles
ha
look
a
hese
wo
conflic ing
eali ies,
i.e.
he
di ficul y
o
a ioning
heal hca e
and
he
necessi y
o
main aining
a
s eady
pace
o
inno a ion,
h ough
he
lens
o
human
igh s,
e hics
and
heal h
law.
The
esul
may
be
a
somewha
“bipola ”
pic u e,
whe e
we
simul aneously
s i e
o
sea ch
o
solu ions
o
he
lack
o
essen ial
heal hca e
–
o
example
by
p o iding
he
bes
legal
and
e hical
answe s
o
ackle
inequi y
in
heal h
sys ems
–
and
on
he
o he
side,
con inue
o
mee
he
legal
and
e hical
challenges
b ough
by
he
ad ances
o
biomedical
science,
such
as
he
b each
o
he
igh s
o
p i acy
and
medical
confiden iali y.
The
same
philosophy
encompasses
he
ongoing
socie al
e o s
o
implemen
measu es
ha
can
expand
access
o
heal hca e
in
mo e
a o dable
ways
( .g.
gene ics)
and
also
o
p omo e
measu es
and
in e en ions
o
help
he
mos
ul-
ne able
( .g.
he
elde ly)
o
be e
manage
and
imp o e
hei
heal h.
The
analysis
p o ided
by
he
a icles
included
in
his
RPSP
issue
will
ce ainly
con ibu e
o
he
discussion
in oduced
abo e.
Howe e ,
i
will
no
o e
any
decisi e
o
final
solu ions
o
such
a
complex
ange
o
opics.
None heless,
one
idea
ha
sounds
mo e
like
an
impasse
han
a
conclusion
becomes
clea :
basic
heal hca e
is
a
p io i y
bu
he
con inui y
o
he
in es -
men
in
pa ien
sa e y,
heal h
p omo ion
and
inno a ion
in
heal h
canno
be
jeopa dized
unde
he
economic
p essu e.
This
equilib ium
is
indeed
di ficul
and
almos
impossible
o
manage,
bu
no
pa
o
i
should
comple ely
o e shadow
he
o he .
To
ou
assu ance,
while
ying
o
deal
wi h
he
mos
in ica e
issues
ha
con on
ou
socie ies,
he
bes
p ac ices
o en
esul
om
he
ension
be ween
di e en
and
some imes
conflic ing
pe spec i es
and
hei
espec i e
con ic ions.
Hope ully,
ha
will
also
be
he
case
wi h
he
eal-
iza ion
o
he
undamen al
human
igh s
discussed
abo e:
he
igh
o
access
imely,
accep able,
and
a o dable
heal h
ca e
o
app op ia e
quali y
and
he
igh
o
enjoy
he
benefi s
o
scien ific
p og ess
and
i s
applica ions.
Paula
Loba o
Fa ia∗,
João
V.
Co dei o
G upo
de
Disciplinas/Depa amen o
de
Ciências
Sociais
em
Saúde,
Escola
Nacional
de
Saúde
Pública,
Uni e sidade
No a
de
Lisboa,
Lisboa,
Po ugal
∗Co esponding
au ho .
E-mail
add ess:
pa.lob a [email protected]
(P.L.
Fa ia).
0870-9025/©
2014
Escola
Nacional
de
Saúde
Pública.
Published
by
Else ie
España,
S.L.U.
All
igh s
ese ed.
h p://dx.doi.o g/10.1016/j. psp.2014.11.001