BIOETHICS AND THE TERMINAL PATIENT IN MEXICO

INTRODUCTION

The situation that the Mexican Government has in front of its people is interesting, because for it is not important, only at election’s time. The health sector in Mexico leaves a lot to be desired, as much in public as in private, to talk about public sector is talking about a trip of horror for the patient, since it’s driven by a hungry syndicalism of power and money where the less important is the health in themselves and thereby, less the patient, in the private the business between insurers and doctors is round-trip, since the patient doesn’t look like a person otherwise like a customer, clarifying not in all cases but in the most.

We are not against that the medicine sells, because after all we live in a capitalist world, but is true the medicine has ethics and it is known like bioethics, that in this country is not known, it is different, in this context we will get to our study the terminal patient.

The terminal patient is an important part in the study for the bioethics, since it gives beginning and end to the person’s dignity as such. The bioethics is the ethics applied to the medicine, but from therapeutic point of view ethics is like the congruence in the person, or of a system.

The terminal patient in addition to fight, to feel and to cope with his illness, has to confront a system of negligent health in a lot of senses, where the relation medical-patient many of the times doesn’t exist or it’s not enough, the palliative medicine and the psychiatric and psychological attention as much to the patient like the family, it’s very little or void, since, appointments that it’s granted to them are very lengthy, regarding the forecast of the patient, thanks to the Mexican law that simply doesn’t chase social welfare, but yes the political proselytism.

The bioethics in this country is one of the few things that matter least, since, there’s very little knowledge in the population, and to Mexican Government doesn’t interest to spread it out for its town.

In this investigation we’ll go on board from the point of view of the terminal patient and the absence of bioethics in this country.

CONTEXT

The concept of terminal patient, we define it as the one it can be applicable like to people that suffer any pathology that is found in final stage of his life without possibilities of recuperation, either because the specific cure is not known to the condition that had or because the state advanced of disease doesn’t enable any improvement at all.

The notion of terminal patient implies a great level of complexity, since it involves the idea of death and a life coming to an end.

But, what is a terminal illness? It’s that one in that the patient no longer has any possibility of getting better, since solution isn’t known or because the condition doesn’t represent possible retroversion, in the terminal illness show up a series of characteristics that presents an advanced, progressive, incurable disease, the lack from reasonable possibilities of response to the specific treatment, the presence of numerous problems or intense, multiple, multifactorial and changing symptoms, a great emotional impact in patient, family and therapeutic team, very pertaining to the presence, explicit or no, of death, a forecast of lower life to 6 months.

Diseases like these can take a patient to make terminal; cancer, AIDS, motor neuron diseases, specific organic failure (kidney, heart, liver etc.)...  They keep these characteristics, in bigger or smaller measure, in the final stages of disease.

In this context play a role very important the alleviative medicine and the thanatology.

The mission of the alleviative medicine is helping the patients with serious or terminal disease to feel good and to accept her process of life and death, treat symptoms, side effects of disease and the treatments. Have impact on all the spaces of life and of the life of the members of the family.  As well as the family confronts stress during a disease that can provoke fear, anxiety, despair or depression.

The thanatology is death's scientific knowledge, its rites and significance conceived like professional discipline, which integrates the person as a biological, social and spiritual being to live in plenitude, is just like the thanatology is defined. A most concrete definition is regarding it as the study of the life that includes death. Of the Greek origin “thanatos” (death) and “logy” (study or treaty), the objective of the thanatology is providing to the patient with a disease in terminal stage and to theirs families professional help.

But, what does a dignified death? The quality of life during this final stage, the adequate attention, the help to solve problems, to die surrounded of affectionate people, not to be object of experimentation, to respect and to give the patient pleasure, to present real options for his present-day situation, not to give false expectations.

Kübler Ross has conceived death like “a passage toward another kind of life”, described that the terminal patient spend by 4 stages, many of them in their phase of agony and previous to death:

Denial: Deny reality looking for other options or looking for evidences that show the diagnosis that they receive is an error and consequently they want to change doctor.

Wrath: The patient revolts against reality.

Pact: Assumes his condition.

Depression: Appear when the patient is conscious that all phases fail and that disease obeys its course toward the ending.

Acceptance: During this stage you are solving several processes, problems or situations that help the patient accept his condition.

Then categorically talking we’re in the face of a mourning, but a mourning takes place not only for the death of a loved one, losses constitute a phenomenon a lot ampler, and for better or worse, general and lose not only by death but also being abandoned, changing and moving on.

One of the most important points inside the thanatology is its Autonomy's principle allows the individual taking his own decisions related with the process of dying. The person’s dignity is understood only through respect for freedom.

For instance, they can get certain actions, from the realization of testaments, inheritances, responsibilities, or early wills where the biolaw would enter in your care.

To be in the terminal stage of a disease is definitely one of the most difficult situations that a human being can face, but depends on each individual the way in which effectively it’s done: Some lose every hope, while other ones devote themselves to faith and get ready at least spiritually of better way to receive the final stage.

Well, we’ve observed and analyzed the context of the terminal patient in general, now we’ll focus on Mexico.

THE TERMINAL PATIENT IN MEXICO

We will begin giving a brief context of the Mexican system of health, to give us an idea as this is linked to the terminal patient.

The bioethics has collected academic autonomy and social diffusion, when human and the ethical requirements derived of her protection have discussed problems related with the origin and end of life.

The fundamental value of life orders unavailability and the sacredness of the same. The right to life is the first right and it´s fundamental (without being absolute), because without it everybody else (including freedom) are non-existent. The respect to life, as well as its defense and promotion, both of others as their own, represent a human being's ethical important mandate that we have to respect always. It is the most sacred thing that we have; the life of each is unique, unrepeatable, irreplaceable, unbreakable. Such respect to the human life is understood in all his stages of manifestation, from the moment of conception (fertilization) until the last moment (total brain death).

Like already have mentioned it the terminal patient in Mexico besides dealing with his disease he faces to the negligence's system, a system known as social security, that would have like objective organizing the right to the health, the medical attendance, the protection of livelihoods and the necessary social services for the individual and collective well-being of the workers, as well as the granting of the pensions guaranteed by the State.

With a series of reforms done to the law, not seen by the patient's interest if not for political ideologies and corruption in the system, it seems that the individual's integrity is not important in Mexico and a lot less human rights.

The social security in Mexico counted itself like a paternalistic vision on behalf of the State in protecting her citizens, giving as such a welfare state that is the main objective of this system and takes us to the following issue:

Does exist the welfare state in Mexico?

We would begin by analyzing that the welfare state is an ideal model where the State assumes the primary responsibility of the well-being of his citizens, as we mention it previously, in theory and under the constitutional Mexican frame, it exists, but, really the Mexican State actually has been defender of the famous welfare state in our lives as Mexicans?

So remarking that we have made us this question many times during last years, when we're observing several reforms in the Mexican Social Insurance Institute's Law, the Institute of social security for the government employees, and in the bankrupt reach of the popular insurance.

The social security system in Mexico, is riddled with bureaucracy, syndicalism and negligence, acts as the burning of a nursery, where children die or as the constant negligence on the part of its staff, as well as the black market transplant organs, organized crime creating tertiary hospitals where money is laundered, and taxes are not paid, because the system is built for that.

Social security refers to the well-being pertaining to the social protection or the coverage of the needs socially recognized, like the poverty, the old age, the disabilities, the unemployment, families with children, that is to say, for there to be a welfare state.

The bioethics, understand it like the ethics applied for to all the sciences in this case the ethics applied for would be social security saying from other way, dressing with dignity to this branch of science as a human.

The abyss we propose is that in a country that feels of first world, with politicians and lawmakers mediocre, it gives horrible attentions tasteless to the people.

Leaving much to be desired in the welfare state of the State.

Understanding that the state of the well-being is an ideal model where the State assumes the primary responsibility of the well-being of his citizens. This responsibility is comprehensive, because they’re considered all the aspects of the well-being; A security system, is not enough it’s universal, because it covers every person, which gives positive rights legislation.

The welfare state refers to the provision of welfare services for the State.

Actually, the citizen is victim of your own leaders that suffer from power, where the welfare state has become a permanent- wealth stadium for them and its heirs that unfortunately has become in alms of life, for the citizens.

Social security it aims to protect people, of the contingencies, diseases and accidents, be or no of work, cessation, unemployment, maternity, temporary and partial inability, invalidity, old age, marriage, death and any other risk that can be object of social prevention, as well as of the loads derived of the home life and the needs of house, recreation that every human being has, contemplated in the article 4 four of the Constitution of the Mexican United States.

Social Security must ensure that people who are in temporary or permanent inability to earn an income, or that they should assume exceptional financial responsibilities, may follow satisfying their needs, providing them, for that purpose, financial resources or determined services. (9)

The right to the social security has a constitutional ground that is located on the fourth paragraph of article 4 of the Constitution of the Mexican United States which is quoted below:

   “Everyone has the right to health protection. The law will define the rules and forms for access to health services and establish the concurrence of the federation and the states in matters of public health, according to established in the section XVI of Article 73 seventy-three of this constitution” (13)

In the article 123 of the same Constitution, in its two sections: A and B abounds about social security of Mexicans.

The expedition of a law for the Creation of an organism integrated by federal governments, workers and employers is considered a social benefit, that he manages the resources of the National Housing Fund.

This law will regulate the forms and procedures under which employees can purchase the aforementioned property habitation.

So says paragraph XXIX which literally says.- Is public utility the Social Insurance Law, and it will understand disability insurances, of old age, of life, of involuntary cessation of the work, of diseases and accidents, of daycare services and any other, aimed at the protection and welfare of workers, peasants, no employees and other social sectors and their families. "(10)

Claims for the working class took shape from the Constitution of 1917.

The Article 123 establishes, between other measures, responsibilities of the bosses in industrial injuries and occupational diseases, as well as the obligation to observe the legal principles about hygiene and safety.

The aforementioned fractions are the more redeemable and fundamental of the social-security right.

In the course of time the Social Insurance Law, was reformed several times, but the most significant was in 1997 year to privatize the system of pensions, actually we observe that the law is becoming a ghost of what it was in your underlying principles of Social Insurance, and it is there where the Bioderecho's mother, I consider, it's the social-security right, its origin and its motive would be health and the welfare state of the workers.

We would begin by analyzing that the welfare state is an ideal model where the State assumes the primary responsibility of the well-being of his citizens.

In theory and under our constitutional frame, exists, but actually, Has the Mexican State actually been a defender of the so famous welfare state in our lives as Mexicans?.

We notice that the issue here we have prepared it during these last years when observing several reforms in the Social Insurance Law and in the bankrupt the Popular Security's reach.

But that’s the Popular Insurance according to Government of the republic:

    “The Popular Insurance of Health is the instrument to meet the challenge set out in the 2001-2007 National Health Program, offering an option of public insurance on the subject of health to the families and the citizens that for their labor and socioeconomic condition are not rightful claimants of the institutions of social security.”(11)

But in this sense Government of the republic mixes up the term of social work with insurance topic, and we observe in our juridical literature that is not the same and we analyze it as follows:

  “Article 3.- For the effects of this Law, understanding as social assistance the set of actions to modify and improve the social circumstances that impede the development of the individual as well as physical, mental and social protection of people in need, helplessness physical and mental handicap, until their incorporation into a full and productive life. Social assistance includes promotion, forecasting, prevention, protection and rehabilitation.” (12)

Unfortunately, our governments together with the legislators have made these two so solidary concepts and where social security goes hand in hand with social assistance, a paradise of lies.

To begin, the popular insurance term is a misused word since in the insurance, the organization that aims to manage the State, as we already observe the word insurance is in theory and practice an institution of social security, not only of social assistance.

As we know when talking of Social Insurance we’re talking about one of the institutions that supposedly is responsible for providing social security and entered a comparative terms where, the institutions of social security bring a pension system (bad in IMSS case) which they call cash benefits and the other benefits in kind, would be known as hospital care, that in the case of popular insurance does not handle in a matter of cash benefits.

That's why federal Government is pretending a fictitious social security system providing a poor reflection of social assistance, because they don't have many of the medicines.

Social security is a duty that we have with other ones inside the society; It’s an human expression in order to take care of each other when we finished the productive age or some accident or disease forbids us to fend for ourselves. (13)

In this context we fall like an example, in the Bioethics Committees of hospitals, these committees are only in theory, because the IMSS law doesn't stipulate that have, neither in the ISSSTE or ISSFAM law, then entered in the conclusion that the committees are gaps in the Mexican legal framework.

Every Bioethics’ Committee is responsible for systematically and steadily of the ethical dimension of a) the health sciences, b) the life sciences c) innovative health policies. Theoretically this committee is composed of various experts, has multidisciplinary character and its members adopt different approaches with the intention of resolving issues and problems of bioethics policy, in particular moral quandaries related to bioethics. Moreover, in addition to  become more sensitive to ethical quandaries, the members of these committees acquired over the time, the knowledge and abilities necessary to approach the problems more effectively, to the point that often are the way to solve quandaries whose arrangement seemed impossible to the beginning, but what happens in our country, not only have been politicized.

Simply doesn’t exist because at least they should have taken a formal Bioethics' course, the General Health’s Law stipulates that there should be in each hospital must have an investigation with at least one ethics committee and another scientist.

Under the circumstances, here we see that the social security or bioethics are essential parts for a good development in the protection of the health of citizens, and therefore the regulatory framework would be the Biolaw together with the right to social security.(14)

THE PATIENT'S CROSSING THE MEXICAN HEALTH SYSTEM.

Well, now we're going to give an overview of several patients, either at terminal stage, and other diseases, these are some of their testimonies:

“ I left my job like always, in a hurry, suddenly I felt as my forces disappeared and I lost consciousness, I woke up after a while in a medical care center of the cross, there, quickly made me several analyzes and they said I was sick and to go to my family care clinic, because they were declared incompetent to the situation, as one of their diagnosis without basis was that I had an urinary infection, of a doctor who has not degreed and that they have him working there I don't know why, maybe for some political issues.

So I decided going to my family clinic where I belong, but what worried me was not my health, if not the way that would react in my work that they fire me, since my boss has me with the lowest salary in front of the social insurance institution, sometimes I labored twelve hours and my salary is the only thing that I have, in order to keep me.

Then I got to my clinic, since 5 in the morning the people get to leave their health cards at the table of reception out of their corresponding doctor's office to be attended for the doctor, it was a seemingly endless wait, and in the best case it can occupy the morning, I decided to wait since I had no scheduled appointment and decided to wait for the medical assistant, between so much people I was sleeping when suddenly appears three hours after putting makeup on and eating and I said her that if please programed me an appointment because I felt so bad, for my misfortune she told me that she didn’t have appointment up within a month, that she couldn’t help me, that  went for urgencies.

Desperate I went urgencies because my pain was intermittent, they examined me and make me analyzes, but they just returned me on to my doctor's office to get appointment again, I did it within a month and in urgencies only prescribed me paracetamol.

I returned to work next day, for this the night before I hadn't slept absolutely at all, and on the way to the work I fainted again, they knocked at the ambulance but this time they transferred me a private hospital, a familiar, decided to pay the account for the attention in urgencies, he spend almost all his fortnight and the analysis neither say it was unplayable, so he decided to help me paying, they did me the analysis and I saw a specialist and he told me that I had a very advanced cancer and that the chemotherapies' round cost as much as my house that I'm finishing to paying by a credit.

So I decided to go already with all my analysis to my appointment in order that they were moving me of a third level hospital, to my surprise the doctor was new and newly-arrived with a specialty in family doctor since the one that I had before was general, and they transferred me to a third level hospital to take my treatment.”

In Mexico we observe this crossing in most of the patients, another one, rightful claimant, he wants to know about the advancement of an injury in the arm that he had incapacitated since three weeks.

“ I arrived since 6 in the morning only to see that the row of people with injuries or in waiting for result of analysis that was growing up and growing up, but any reception clerks or doctor was arriving to the reception.

But as in every rule, always there's an exception: In one of the doctor's offices, doctor appeared, exactly at 6:12 hours, before the reception clerk, and he began to attend whom already expected him punctually ”

At the end they attended the patient until 11:30 to tell him that he was on with inability and that he should have gone with a traumatologist to take care of specialized way his injury; they programed to him the appointment for the day May 8 in the General Hospital.

Another patient, attended to go on with the treatment of an asthmatic crisis that suffered five days ago. In his case, the visit to the clinic lasted for five hours approximately.

Since 5 in the morning he installed in the clinic to place his health card and in spite of being the second in the row, his consultation took place over past 9 in the morning, where they were given him a quick review, consult that consisted with Dr. sitting in her desk in front of her computer, with an occasional look to the patient, questioning him about how he was felt during the weekend and how does he feeling at his treatment.

Once he finished, she gave him an appointment for the following week and she prescribed to him some medications that he had to recibe in the pharmacy, medications that would help him to avoid a crisis of health again, but he found out that there was no medication and he had to buy it.

In the emergency's area only there are two family doctor's offices and one in urgencies, which is why the infrastructure is not enough to take care of the request of patients.

In other case a termianl patient with colon's cancer, had been to the hospital more of 52 of weeks, her situation was critical, the bureaucratic system doesn't admit that be patients with more of 52 weeks to hospitalized and they have to registrer him/her, in order to deposit him again, and that's what happened she was discharged her with a colostomy and parenteral nutrition, the patient that it lasts in your house a week suffers a relapse and he/she re-enters.

The emotional load for the patient is strong, and to him services of treatment or thanatology, for him and his family.

In this same case, the relatives that accompany it and go looking after sleep on the floor don't have peace, and they have to fight with a deficient security system, where, they demand them entrance card to see their patient awarded by them.

The waiting is long and the patient is just about to die the attending doctor gives the news of a very hard way and without humanity, it seems that the bioethics, doesn't exist, in the system a relative dies, between everything, they are not offered to psychological attention, and if they want to make it, they have to ask for appointment, and to do the crossing.

It's sad, observing as the patient is treated like an object, the system treats him as a thing and sees him like a package in a bed.

LEGAL FRAME OF THE TERMINAL PATIENT

In the General Health Law, mark the key aspects, observing:

Article 166 Encores 3. The sick patients persons in terminal situation have the following rights:  Receiving comprehensive medical attention; To be admitted in the health institutions when he requires medical attention; To voluntarily leave the institution of health in which is hospitalized, from conformity to the applicable dispositions; Receiving a worthy, respectful and professional deal trying preserving his quality of life; Receiving clear, opportune and enough information about the conditions and effects of his disease and the types of treatments which he can choose according to the disease that he suffers; Giving his informed consent in writing for the application or no of treatments, medications and palliative cares suitable to his diseases, needs and quality of life; Ask the doctor to administer medication to mitigate the pain; Give up, leave or refuse at any time to receive or continue treatment to consider extraordinary; Choose to receive palliative care in a particular home; Designate a family member, legal representative or a trusted person for the case that with the advance of the disease, be prevented from expressing his will, do it on his behalf; To receive spiritual services, when requested by him, his family, legal representative or person of trust; and other laws indicate.

It is interesting as the article of the Law is very clear however it doesn't perform literally, the patient is not cared with personalized attention, if he is seen only like a number or like a disease.

We will continue describing the Law.

Article 166 Encores 4. Every grown-up, in full use of his mental faculties, can, at any time and regardless of her state of health, leaving his will in writing in front of two witnesses, to receive or not any treatment, in the case he got to suffer a disease and being in terminal situation and don't be possible for him to manifest said will. The aforementioned document will be able to be revoked at any time.

To be valid layout will referred to in the preceding paragraph, it shall adhere to the provisions of this Act and other applicable provisions.

This article is null since in secondary laws it doesn't protect before who neither how we could talk about a public notary but his scope is municipal and not federal, the only one is the public hall but he specializes in mercantile stuff only, it seems that we're jumping gap in gap in Mexico.

Article 166 Encores 8. If the sick person in terminal situation is a minor, or he finds  incapacitated to express his will, the decisions derived of the rights indicated in this title, will be assumed by the parents or tutor and in lack of these his legal representative, person of his confidence of legal age or judge in accordance with the applicable dispositions.

Interesting but this fastens to that justice is prompt and expeditious, thing that in paper, sounds good but in practice judge's resolution can take long long time, for the case that the terminal patient in most instances has died.

Article 166 Encores 11. In cases of medical urgency, and there's incapability of the sick person in terminal situation to express his consent, and in the absence of relatives, legal representative, tutor or man of trust, the decision of applying a medical surgical procedure or necessary treatment, will pass for the specialist and or for the Bioethics Committee of the institution.

It sounds good it reads better, but a lot of hospitals in Mexico don't know what is bioethics and a lot less consider necessary Bioethics committee.

Although there is a difference between justice and right, many times the right, most of times in this country does not chase justice. So, that falls into a legality kind of barbarity, making of the statistics its social and lucrative intentions, taking away the basic principles of justice. It plead so for a Law not formalistic, no dogmatic, no anti-historic, but for a right inserted in his social changing reality, facing the future, that not only regulate situations now established, but also the new realities, in which there are no precedents. Here the judge, the operator of Law, in the case of the theme that develops, should to request the collaboration from other connected sciences to the theme, like biology, medicine and ethics, for recognize and establish together the principles and basic standards, that they allow combining the scientific investigation and its responsibility with the protection of human person and its dignity, that is specific tasks of ethics and the right, through the biolaw.

We are a town on growing, consolidation and in evolution, the impact of other cultures; that is learning to walk, to value and know ourselves; that we have negatives sides, and that we have to have more emotional intelligent, combining ethics and bioethics, although we are individualists. We are maturing before our difficulty of working as a team.

Like indicates to corporate level and having in our legal commercial frame a kind of society that is interested in associates, the limited-liability company.

The Bioethics is a basic answer based in the dignity of the town that taking it to a stricter sense brings a consolidation of the Mexican state like a humanly possible country, that the ideological barriers would not have grief neither glory, since they would look dim by a humanistic system bringing everything along to what aspirates the traditionalistic politics.

Politics misses all that the biopolitica would deem as interference and not like an innovative result that has persecuted Mexico during a lot of years.

The biopolitics, would brushed aside the class-conscious politics in which we are immersed and having been to us generations in our walking.

The Mexican politics is sick, is a patient in terminal state, damaging this country, and bringing with it in degenerate environmental and social of the town that lives like normality, and this brings it get to the medicine and the right between its feet.

It is not normal that a Latin American country, the average citizen cannot dedicate a profession that cost him years of study and this, are controlled by a corrupt unionism with nepotism, public transport and is an epidemic out of control by the death of people, that the police be a criminal with permission, that the media be the fourth political power, that kill students, kill children in a kindergarten in the state, that killed religious leaders and social idealists, that kill teachers, kill everything that has to do with the present of Mexico.

That's why to violence must dedicate ethics, and to politics Bioethics.

To the law, must be given justice and bioethics, and to the medicine, humanity and applied ethics and dignity to the terminal patient.

CONCLUSION

The terminal patient has been forgotten by this country and therefore the health system in Mexico, the patient, apart from your illness suffer a series of bureaucratic anomalies, medical malpractice, and labor movements, bioethics is the answer to give dignity to the patient.

Of legal way the biolaw would give legal respect and juridical certainty to the patient, the general law of health lacks secondary laws, and what's interesting is that to the politician, he doesn't matter because is in his own occupations, here the strange it's that the town doesn't react.

Today it is a big problem; the most insecure that exists, forgotten for the jurists of the absence of the suitable information, of the roots of the problematic.

In a country where the right to life is not contemplated in the constitution, where the Health Service is a business, where social security has become part of the capitalist system we couldn't expect more.

The bioethics committees in this country are scarce the bioethics is a someone else's theme, there is not source of job for a bioethicist, it's a strange race in this country, the human factor has been forgotten.

Do not forget that we can't take off this problem of thousands of forms of problems facing the country, since it’s art of forgetting of a country without conscience and that its story is largely invented by a corrupt political system where democracy was created in 1910 for the masses of illiterate and not to be held as such.

Where the authorities raze everything and the society is subdued and absorbed in alms of life.

Where a mother, a fundamental part of the system such as the country is full of corruption called terminal cancer patient.

Only a society committed can succeed, the human factor doesn't count in this, politicians are in their affairs, we lack of awareness and terminal patient died before being treated by doctors.

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