Bioethics – A Fundamental Reflection

Bioethics proposes reflecting on and discussing the developments in technology and their use in favor of the human being so as to assist humanity in participating with positive awareness in the process of biological evolution and cultural development [1]. Based on solid principles, bioethics leads to the consideration of issues that affect not only the human being as the subject of a health treatment, but an entire society, such as in the use of stem cells. This is why professionals and researchers should be familiar with the principles that govern such a discipline. It should be emphasized that the use of these principles is of extreme importance in facing the ethical issues common to clinical practice. Furthermore, the understanding and internalization of the principles of bioethics enable health professionals to accept their patients as humans who are capable of understanding and deciding about their treatment and/or issues involving their community, allowing and providing tools for health professionals to deal with the ethical/bioethical issues of professional life.


INTRODUCTION
Bioethics proposes reflecting on and discussing the developments in technology and their use in favor of the human being so as to assist humanity in participating with positive awareness in the process of biological evolution and cultural development [1]. Based on solid principles, bioethics leads to the consideration of issues that affect not only the human being as the subject of a health treatment, but an entire society, such as in the use of stem cells. This is why professionals and researchers should be familiar with the principles that govern such a discipline. It should be emphasized that the use of these principles is of extreme importance in facing the ethical issues common to clinical practice. Furthermore, the understanding and internalization of the principles of bioethics enable health professionals to accept their patients as humans who are capable of understanding and deciding about their treatment and/or issues involving their community, allowing and providing tools for health professionals to deal with the ethical/bioethical issues of professional life.
These principles were initially proposed by the Belmont Report (1978) to guide research with human beings and, subsequently, Beauchamps and Childress proposed its application to all health practices [2].

The Principles of Bioethics
The principle of beneficence: to foster the improvement of the patient has always been the most important in healthcare. This principle proposes to always do what is good for the patient, assiduously avoiding harm and, in cases in which it is inevitable, that it be significantly less than the good that the treatment provides so as to justify it.
The principle of autonomy: to remind us that people have "freedom of choice" over their own bodies. Autonomy is the ability of a person to manage his own will, free from the influence of other people. It is important to point out that to achieve this condition, it is indispensable to make the person aware of the risks, advantages, benefits, and disadvantages to which he or she is being exposed, as well as the type and conditions of treatment; that is, the patient must have all the information necessary to make an informed decision, to which his or her personal values and beliefs will also be added. This is the only way in which the principle of autonomy will be fully met.
The principle of justice: this refers to equality of treatment and the fair distribution of possibilities among the members of a society without any kind of discrimination or distinction. To this concept the concept of fairness is added, which gives each person what is due according to their needs. Since each person is different and therefore has different needs, when it comes to the search for justice they shall be treated so that their needs be met and thus, equal to the others' rights and opportunities.
Healthcare professionals, by training, have a higher technical knowledge than their patients, which gives them the role of disseminating information, always making sure that the patient who is under their care understands his or her health situation and the possible treatment options, while having their autonomy respected [2][3][4][5].
The patient is a unique person and must be considered holistically. Therefore, health professionals need a solid ethical base to face the various ethical dilemmas of their professional activities, always focused on the patient and their complexity. This review was propelled by the importance of professional behavior based on the principles of bioethics in order to respect the dignity of the human being.

MATERIALS AND METHODS
This literature review was carried out surveying the theme of Bioethics in Dentistry as it has been studied over the last five years (2012 to 2016) by means of articles published in English, Spanish, and Portuguese. To this end a search was performed using the following descriptors in Science and Health (DeCS): "dentistry" and "bioethic" in these databases: Virtual Health Library (BVS) -Brazilian Bibliography of Dentistry (BBO); Latin American and Caribbean Health Sciences (LILACS); Scientific Electronic Library Online (SciELO), at the National Library of Medicine (MEDLINE), and SCOPUS. No essays, dissertations, theses, book chapters, and articles published before the date established for this literature review were considered.

RESULTS AND DISCUSSION
Based on the methodology and after evaluating abstracts, considering the proposed inclusion criteria, 15 indexed articles were considered for the purpose of this systematic literature review, distributed according to Table 1. In these articles, the unifying concern among authors that stimulated the research and publication in the scientific milieu was education in bioethics. Most of the articles reviewed deal with the teaching of bioethics and its importance for the training of ethical professionals who are aware of its importance in society. The need for dissemination of information on health practices and proposals promoting integration provides the patient with the opportunity to interact with his treatment and/or scientific research and become an active decision-making agent with autonomy and social responsibility; this meets what is expected in health relationships according to the precepts of bioethics. Those authors emphasize the importance of undergraduate courses in the training of ethics and bioethics of their students. The concern regarding the form and contents of Bioethics led Junqueira et al. [6] to evaluate records of undergraduate students in dentistry as to their perceptions of the activities developed at one state college in Brazil. That evaluation, according to those authors helped teachers to improve their teaching decisions. The study of bioethics should be continued and included in the subjects of training in order to maintain an ethical assessment of the behavior facing the issues of each subject. This led Barrios et al. [3] to propose the inclusion of bioethics content as a transversal theme in the course units of a college in Venezuela. Also, in an effort to establish bioethics as a constant norm of behavior and analysis, Cuitino [7] emphasized that the residence program can provide experience, knowledge, and learning for health professionals, providing a more humanistic and critical training, focused on understanding and respecting others.
Considering the need to know about the historical events that led the world to reflect on ethics in research and in healthcare, as well as the content of the ethical and deontological aspects of health professions taught in a school

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Page |3 of dentistry in Italy, Marinozzi et al. [2] wrote about an educational project concerning the historical origins of current norms in bioethics.
With the intention of verifying the ethical dimension in the training of health professionals, Finkler et al. [8] surveyed teachers and followed the academic activities of a group of undergraduate students in dentistry with emphasis in bioethics and stated that it is essential that teachers assume their role in the ethical dimension of professional training. The conventional educational model for health professionals does not favor their developing capabilities to deal with the ethical dilemmas they face in the course of their professional life. This fact stimulated Janakiram & Gardens [9] to assess, in an analytical study, the bioethical knowledge, practices, and attitudes among undergraduate and graduate students at colleges in India and pointed out that they were not prepared to face ethical dilemmas in clinical practice. Even so, students in the course of general medicine were more prepared than students of dentistry. The concern with the teaching and attitudes in bioethics can be seen in various countries, with the classrooms being the most appropriate place to develop awareness and to train more conscientious professionals preparing to enter health practice in times of great technological advancement.
The community as a whole must be included in the discussions of bioethical questions. In this realm, Naidoo & Virnillo [10] described a model of community of practice developed around ethics in health research, education, and clinical care. This proposal would rely on the collaboration and social presence of community members, health professionals, educators, ethicists, and policy makers to benefit the community, with approaches tailored to meet the health needs of a group with common interests, generating discussions to foster knowledge in providing effective healthcare and research ethics.
Sánchez et al. [11] conducted a descriptive study by means of content analysis in bioethics in order to know the perceptions of dental students in a school of dentistry in Brazil and observed that, fortunately, these students recognized the importance of bioethics in their formation. To monitor and implement activities for teaching about health is not enough; assessing the teaching of bioethics is as important as monitoring and working on the perspective of the students and encouraging their commitment and behavior in relation to bioethics, both in their learning process and in their professional life. In order to verify this commitment, Munoz et al. [12] proposed to understand, through discourse analysis, the bioethical commitment of dental students in the clinical teaching-learning process through documental analysis, non-participant observation, and semi-structured interview. The authors pointed out that there were several visions of teaching practices regarding bioethical commitment and emphasized the need to rethink them so as to contribute towards a professional training of real social commitment.
Currently, the dynamic dissemination of knowledge is a way to reach and sensitize young people, proposing to develop professional activities in the area of health with the use of electronic tools as well as new technologies to train professionals to offer complete care, respecting the dignity of the person and meeting the principles of bioethics. With this in mind, Warmling et al. [13] evaluated the virtual object of learning by analyzing ethical situations, produced and used as an innovative approach in the teaching of bioethics in courses in the area of health. They observed that the educational material allowed situations with possible bioethical conflicts to be analyzed, thereby demonstrating the possibility of interdisciplinarity, considering this experience important in the training of health professionals. The study points to bioethics as a crosscurriculum field in the health practices.
The patient-professional relationship should always be based on respect for the dignity of the person and for the possibility of ensuring that the patients be allowed to express their opinions about the direction of their treatment or of scientific research, including the community in the discussions of urgent bioethical issues.
With particular reference to the patientprofessional relationship, Chambers [14] evaluated the behavior of patients and dental surgeons involved in complex ethical issues and observed that the patients still expected a more active and resolute behavior from the professional. Maluf et al. [5] argued that the appropriate and legally accepted patientprofessional relationship is built bilaterally based on respect and shared decision making.
The professional must have the ability to understand the fragility and vulnerability of the patient and make an effort to enable the patient's decision-making and commitment to his health situation and recovery. With a focus on this premise and considering the subjectivity of pain, common in patients seeking dental treatments either as a symptom, fear, or experience, Te-kloot [15] proposed a reflection on the pain theme that, according to him, seems forgotten by technological development. Pain is also the reason patients seek health professionals to have their needs met since it causes them confusion, making them accept treatments and medications just to be rid of the unbearable discomfort. According to Ibarra [4], the paternal patient-professional relationship is no longer acceptable. The bioethical principles of autonomy, beneficence, and justice must be present in patient-professional relationships under any circumstances in order to be effective and valid. It is the responsibility of the professional to see to it that mutual decision making occurs in order to meet these premises.
More than implementing rules, it is necessary that health professionals include bioethics in their daily practice.
The evaluation of actions, knowledge, and constant studies and improvement are fundamentally important for the relationships in healthcare to be effective and to meet the principles of bioethics.