Cardenas D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):56-62.
Ethical aspects of the Cartagena Declaration
Aspectos éticos de la Declaración de Cartagena
Aspetos éticos da Declaração de Cartagena
Diana Cardenas1, Sonia Echeverri2
Received: September 25, 2019. Accepted: October 26, 2019.
https://doi.org/10.35454/rncm.v2supl1.032
1 Research Institute of Nutrition, Genetics and Metabolism, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia
2 Hospital Ethics Committee and Humanism and Bioethics Committee of the Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.
*Corresponding author: Diana Cardenas
dianacardenasbraz@gmail.com
Summary
Introduction: Nutritional care was recognized as a human right in the Cartagena Declaration on May 3, 2019. This article analyzes the Cartagena Declaration from the ethical approach.
Methodology: An analysis was made based on the four principle approach and on the principles of the UNESCO Declaration of Bioethics and Human Rights.
Results: it is recognized that the right to nutritional care implies feeding the sick person in conditions that respect their dignity, considering the vulnerability of the malnourished person or at risk of malnutrition and respecting the principles of bioethics. Therefore, the principles of autonomy, beneficence, non-maleficence and justice must be respected. Recognizing this right and the ethical basis of the Declaration does not imply that the obligation to feed all patients at any stage of life and at any cost is being accepted. On the contrary, recognizing this right implies from an ethical point of view that the best decision for the patient must be taken and this may include the decision not to feed.
Conclusion: The Cartagena Declaration has a fundamental structural ethical component which is based on the concepts of dignity and vulnerability, respect for autonomy, beneficence, non-maleficence and justice as a condition for the practice of clinical nutrition. In addition, it promotes the values of justice and equity in nutritional care.
Keywords: Human rights; Ethics; Bioethics; Malnutrition.
Resumen
Introducción: el cuidado nutricional fue reconocido como un derecho humano en la Declaración de Cartagena del 3 de mayo de 2019. Este artículo analiza la Declaración de Cartagena desde la perspectiva y fundamentación ética.
Metodología: se hace un análisis desde la ética teniendo en cuenta los principios de la bioética o “principialismo” y los de la Declaración de Bioética y Derechos Humanos de la UNESCO.
Resultados: se reconoce que el derecho al cuidado nutricional implica alimentar a la persona enferma en condiciones que respeten su dignidad, teniendo en cuenta la vulnerabilidad de la persona desnutrida o en riesgo de desnutrición y respetando los principios de la bioética. Por lo tanto, se deben respetar los principios de autonomía, beneficencia, no maleficencia y justicia. Reconocer este derecho y el fundamento ético de la Declaración no implica que se esté aceptando la obligación de alimentar a todos los pacientes en cualquier etapa de la vida y bajo cualquier costo. Por el contrario, reconocer este derecho implica desde el punto de vista ético, que se debe tomar la mejor decisión para el paciente y esto puede incluir la decisión de no alimentar.
Conclusión: la Declaración de Cartagena tiene un componente ético estructural fundamental el cual se basa en los conceptos de dignidad y vulnerabilidad, el respeto a la autonomía, la beneficencia, la no maleficencia y la justicia como condición para el ejercicio de la nutrición clínica. Además, promueve los valores de justicia y equidad en el cuidado nutricional.
Palabras clave: derechos humanos, ética, bioética, malnutrición.
Resumo
Introdução: o cuidado nutricional foi reconhecido como um direito humano na Declaração de Cartagena de 3 de maio de 2019. Este artigo analisa a Declaração de Cartagena sob a perspetiva e o fundamento ético.
Metodologia: é feita uma análise da ética, levando em consideração os princípios da bioética ou “principialismo” e os da Declaração da UNESCO de Bioética e Direitos Humanos.
Resultados: a Declaração de Cartagena tem como fundamento ético os princípios da Declaração da UNESCO de Bioética e Direitos Humanos. Reconhece-se que o direito ao cuidado nutricional implica alimentar a pessoa doente em condições que respeitem sua dignidade, levando em consideração a vulnerabilidade da pessoa desnutrida ou em risco de desnutrição e respeitando os princípios da bioética.
Portanto, os princípios de autonomia, beneficência, não maleficência e justiça devem ser respeitados. O reconhecimento deste direito e da base ética da Declaração não implica que a obrigação de alimentar todos os pacientes em qualquer fase da vida e a qualquer custo seja aceite. Pelo contrário, reconhecer esse direito implica, do ponto de vista ético, que a melhor decisão para o paciente deve ser tomada e isso pode incluir a decisão de não alimentar.
Conclusão: a Declaração de Cartagena possui um componente ético estrutural fundamental, baseado nos conceitos de dignidade e vulnerabilidade, respeito à autonomia, beneficência, não maleficência e justiça como condição para a prática da nutrição clínica. Além disso, promove os valores de justiça e equidade no cuidado nutricional.
Palavras-chave: direitos humanos, ética, bioética, desnutrição.
Introduction
On May 3, 2019, in the city of Cartagena, Colombia, the 16 associations, societies and schools that comprise the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE), after signing the Cartagena Declaration, committed themselves to defend the right to nutritional care and to fight against malnutrition. The Cartagena Declaration seeks through its thirteen principles to provide a frame of reference to promote the development of nutritional care in the clinical setting that allows all sick people to receive nutritional therapy in conditions of dignity. It also works as an instrument for the societies that are members of FELANPE and all the institutions that work in favor of nutritional care to promote, through governments, the formulation of policies and legislations in the field of clinical nutrition. It is a non-binding instrument, i.e. one that does not legally bind, but has an undeniable moral strength which commits the parties to join efforts in this common fight. Knowing its ethical foundations is key to the implementation of the declaration’s principles, the development of the implementation program and the formulation of policies in clinical nutrition. The objective of this article is to carry out an analysis on the ethical aspects and principles that lay the foundations for the Cartagena Declaration.
Methods
Ethics is a branch of philosophy whose objective is to carry out an intellectual analysis of the human moral dimension in all its complexity (1). Ethics has to do with principles that allow us to make decisions about what is morally right and wrong. It refers to a judgment of behaviors, good or bad. Bioethics is part of ethics and its objective is to reflect on and provide answers to the ethical problems and questions or dilemmas introduced by the advances in science and technology, including decision-making in the field of healthcare. This article analyzes the ethical foundation of the Cartagena Declaration taking into account the principles of bioethics (autonomy, beneficence, nonmaleficence, and justice) as well as the principles established in UNESCO’s Universal Declaration on Bioethics and Human Rights signed by 191 countries in the city of Paris on October 19, 2005 (DUBDH)(2).
Results - Analysis
Artificial nutrition is considered to be a great advance in 20th century medicine, because thanks to the administration of nutrients through enteral or parenteral routes today we can feed sick people who require it, and have an impact on malnutrition, outcomes and quality of life. However, this advance leads to ethical questioning in particular situations such as palliative care and the end of life, cancer, patients with advanced Alzheimer’s, patients in intensive care, etc.(3). The difficulties in decision-making and ethical dilemmas in this field arise mainly due to a lack of clarity on the role of artificial nutrition. It is a medical therapy that has to have an indication, a precise therapeutic objective, and must have the patient’s, their family’s, or their legal representative’s consent. Like every medical therapy, artificial nutrition has precise medical indications but can also have side effects and complications that can be more important than the possible benefit and can cause harm to the patient. This is why the decision of withholding or withdrawing nutritional therapy in specific situations must be made after an analysis of each case and after an interdisciplinary consultation with the treating medical team and the family.
By recognizing the right to nutritional care as a human right, the Cartagena Declaration is promoting a commitment and a very important ethical responsibility for all of the scientific societies or persons who push and defend it. It must be made clear that this does not mean that the obligation to feed every person under any circumstance or during every stage of life, including the terminal phase, is being defended. On the contrary, recognizing this right implies, from the ethical point of view, that an agreement must be reached together with the patient and their family, on the best decision for the patient, and this includes the option of not feeding. Therefore, the feeding of the sick person must be promoted under conditions that respect their dignity, taking into account and respecting the principles of bioethics.
UNESCO’s Universal Declaration on Bioethics and Human Rights
The Cartagena Declaration is based on the respect for the principles established in the UDBHR(2) . It is an ethical reference that encompasses matters related to medicine, life sciences, and the use of technology associated to human beings, taking into account the ethical, social, legal and environmental dimensions.
The UDBHR aims to provide a universal structure of principles and procedures to guide States in the formulation of policies, laws and diverse tools applied to the field of bioethics. It is an instrument whose central axis is the respect for human dignity, human rights and is based on 15 principles (Table 1).
The Cartagena Declaration recognizes and applies them in the field of clinical nutrition, so that Principle 5 “Ethical principles and values in clinical nutrition”, states:
“It is important to emphasize that nutritional therapy (oral, enteral and parenteral nutrition) is considered a great scientific and technological advance that has allowed any sick person to be fed and to improve clinical outcomes, quality of life and impact on health costs. It is recognized that with these advances bioethical issues arise that may have repercussions on individuals, families and groups or communities. These issues should be analysed within the framework of the principles set out in UNESCO’s UDBHR, in particular the universal principles of equality, justice and equity, non-discrimination and non-stigmatization, nonmaleficence, autonomy, beneficence and respect for human vulnerability and personal integrity.”
Table 1. Principles of the UDBHR, UNESCO 2005
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Human dignity
Respect for the person’s dignity is the cornerstone upon which the values of both the UDBHR and the Cartagena Declaration are based, and it is also the guiding thread of their statements.
The concept of human dignity and respect for human rights are closely related. The approach based on human rights allows the identification of priorities and objectives in order to fight against malnutrition and implement an optimal nutritional care for everyone. It also allows to understand that human dignity is a central axis in the ethical foundation of feeding the sick person. The notion of human dignity from its philosophical dimension means, according to Immanuel Kant, the fact that the person should never be treated as a means, but rather as an end in itself. People do not have a price, they have dignity (4). Dignity refers to a quality that would be linked to the very essence of each human being, which would explain the reason why this quality has to be equal for everyone and not admit levels, degrees or exceptions. In this sense, it means that all human beings deserve unconditional respect, regardless of their age, physical or mental health, gender identity or sexual orientation, religion, social status or ethnical origin.
The first principle of the Cartagena Declaration is focused exclusively on recognizing the importance of feeding the sick person in conditions of dignity. The respect for human dignity, understood as a person’s right to be treated ethically, to be valued and respected for who they are, is attained when by feeding the sick person (by means of nutritional therapy), their individual autonomy, religious beliefs and sociocultural environment are considered. This implies recognizing the intrinsic value of each human being, as well as the respect for integrity, and the diversity of moral, social and cultural values during the stages of the nutritional care process.
The absence of an optimal nutritional care can threaten human dignity. But prolonging nutritional therapy beyond what’s medically necessary, might also be considered as a lack of respect for human dignity since the person’s physical integrity would be harmed. Hence, it must be considered that nutritional therapy is a medical treatment, sick people have the right and the autonomy to refuse it, and healthcare personnel have the obligation to accept this decision and not perform futile actions.
The vulnerability of the malnourished patient
The notion of vulnerability is central to the ethical component of clinical nutrition. The Cartagena Declaration states:
“It is recognized that patients at risk or in a state of malnutrition are a group considered ethically vulnerable. Vulnerability is an inescapable dimension of human beings and the configuration of social relations. Considering the vulnerability of the malnourished patient implies recognizing that individuals may at some point lack the capacity and means to feed themselves and, therefore, it is necessary for this need to be met by professionals in clinical nutrition. Malnutrition implies physical, psychological and social deterioration (with the risk of losing one’s life and the possibility of losing one’s autonomy).”
The word vulnerable comes from the Latin vulnerabilis, formed by vulnus (wound) and the suffix abilis or -able which indicates possibility, that is, that can be wounded. Hence the word vulnerability in its common use means “capable of” being wounded. A vulnerable person is a person who can be hurt easily and who cannot defend themselves expeditiously. It is in this way the field of law considers vulnerable people, whom the State has the obligation of protecting to avoid, for example, them from becoming objects of research. In the ethical field, the notion of vulnerability is based on the Levinasian notion that suggests a non-intellectual morality whose origin is an individual’s vulnerability and subjectivity, defined by bodily sensitivity and not by conscience, or reason, or the rational deliberation of freedom(5). Thus, according to the ethics of vulnerability, the matter of respect for and the support of the vulnerable person goes beyond the protection of a category of individual and the difficult problem of informed consent (6). In these conditions, the respect for the person is not reduced to the assessment of their legal competence nor to the examination of their cognitive abilities. Likewise, the response to specific needs cannot turn into deciding for the other which would be a dismissal of their will. Furthermore, what situations of vulnerability highlight is the need of considering the fact that the person needs the other, needs medical care and health care structures, and the de facto reality that they wish to be considered a person, a human being whose dignity is intact despite being at risk of physical or cognitive aggression.
Therefore, the deepest ethical sense of vulnerability implies a commitment to responsibility towards others, the “care for others”(6). Vulnerability implies “the responsibility for the other” and that means we need the other. In the case of malnutrition, a malnourished patient is doubly vulnerable because on the one hand, their integrity is compromised, and on the other hand, they are fragile due to their relationship of dependence with the professional who must feed them artificially. Malnutrition implies, the same way the illness does, the loss of control over the body, of the vital processes that are necessary for health and of autonomy. In the case of malnutrition this is even more serious because its diagnosis is difficult due to the lack of consensus on its definition and the methods to determine it; in addition to the scarce action of doctors that can be due to insensitivity per se or due to lack of education on the subject of malnutrition and its consequences. Therefore, it is possible to consider that the malnourished patient is a doubly vulnerable patient. In particular situations, the person with disease-related malnutrition loses the ability to feed themselves. They are then dependent on a caregiver, on their technical and scientific qualifications, but also on their moral qualities to satisfy the medical treatment that is nutritional therapy.
The bioethical principles in the Declaration of Cartagena
Principlism, according to Tom Beauchamp and James Childress, is based on four principles: the respect for the person’s autonomy, the principle of nonmaleficence, the principle of beneficence and the principle of justice(7). These four principles constitute a common frame of reference for the analysis of bioethical problems.
Autonomy
Patients must be treated as autonomous agents, i.e. recognize their capacity to make independent and authentic decisions about how they want to be fed, whether they want to be fed or not, based on their knowledge, values and personal beliefs. Autonomy does not mean that a patient has the right to obtain any treatment they desire or request if this treatment in particular is not medically indicated. Autonomy can only be excercised after having gathered complete and appropriate information, as well as having understood it. The decision must be made without any kind of pressure or coercion.
These aspects are manifested in Principles # 1 and # 3 of the Cartagena Declaration. On the one hand, Principle 1 states that:
“It must be considered that nutritional therapy is a medical therapy, sick persons have the right and autonomy to refuse it and caregivers have the obligation to accept this decision.”
This is complemented by Principle # 3 which recognizes the importance of the patient’s empowerment to ensure truly autonomous decisions by the patient:
“Empowering patients and their families in the fight against malnutrition implies empowering them to think critically about this syndrome and its respective negative consequences, while allowing them to make autonomous and informed decisions, such as demanding nutritional care and complying with the suggested nutritional treatment.”
Beneficence
The principle of beneficence imposes the obligation of acting for the patient’s benefit. Caregivers must comply with professional obligations and standards. Each decision must be made at the individual level. Health professionals have the obligation of maximizing the potential benefits for their patients and simultaneously minimizing the potential harm for them.
This means that an adequate nutritional therapy must be provided in response to a medical indication and following the patient’s consent, the screening of malnutrition risk must be done using a validated tool that is adequate for all people that come into contact with health services. Nutritional assessment must be conducted on all subjects identified as being at risk by the nutritional risk detection. Monitoring of the nutritional therapy must be carried out on all patients.
Respect for the principle of beneficence in the Declaration is implicit in the preamble:
“Aware that adequate nutritional therapy can correct malnutrition, improve disease prognosis and quality of life, reduce comorbidities, mortality and health costs,”
And in Principle # 2 which recognizes that:
“Nutritional care is part of the patient’s overall care, and should therefore be an inherent component of their care.”
Nonmaleficence
The principle of nonmaleficence imposes the obligation not to inflict harm on others. Medical nutritional therapy must minimize possible harm. If the risk of administering nutritional therapy to a specific patient outweighs the potential benefits, then the caregivers have the obligation of not providing (withholding) said therapy. If the nutritional therapy is useless and it only prolongs suffering or is postponing death, it must be suspended. Additionally, respect for this principle implies avoiding the hospitalized patient’s prolonged and unnecessary fasting. Withholding or withdrawing nutritional therapy if it is considered useless: in a situation where it would only prolong suffering, or at the terminal stage of an incurable or untreatable disease, situations in which nutritional therapy would not be medically indicated.
Respect for this principle is recognized in the preamble of the Declaration of Cartagena:
“Aware that nutritional therapy may have side effects and low effectiveness in some patients such as those in a hypercatabolic state, or if not administered properly,”
Emphasis is also placed on not performing futile actions in Principle # 1:
“It must be considered that nutritional therapy is a medical therapy, sick persons have the right and autonomy to refuse it and caregivers have the obligation to accept this decision and not perform futile actions.”
Justice
The principle of justice refers to an equal access to healthcare for everyone. Limited resources, including the time that doctors and other healthcare professionals dedicate to their patients, must be allocated uniformly in order to achieve a true benefit for the patient. The resources must be allocated justly without any discrimination. This means that all patients must have the best nutritional care available. This implies that nutritional therapy must always be administered, like any other therapy, only when there is a medical indication. This is explicit in the preamble of the Cartagena Declaration:
“Aware of the need to seek, through the application of basic, clinical and public health sciences, increasingly effective nutritional solutions,”
And in Principle # 6 of the Declaration where emphasis is placed on the value-based approach in healthcare:
“Under this approach, the aim is to reorient health services to improve the satisfaction of people’s health needs, particularly nutritional care, while maintaining an optimal relationship with costs and outcomes.”
Principle # 11 acknowledges the importance of the values of justice and equity in nutritional care.
Table 2 shows the ethical contents of the Cartagena Declaration.
Conclusion
The Cartagena Declaration has a fundamental structural ethical component which is based on the concepts of dignity and vulnerability. The principles established by this Declaration recognize the importance of Principlism and promote the respect for autonomy, beneficence, nonmaleficence and justice as a condition for the practice of clinical nutrition. In addition, it promotes the values of justice and equity in nutritional care.
Table 2. Ethical Contents of the Declaration of Cartagena
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Ethical Foundation |
Declaration of Cartagena |
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Feed the ill person in conditions of dignity |
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Vulnerability of the person at risk of malnutrition or in a state of malnutrition |
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Respect for the principle of autonomy |
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Respect for the principle of beneficence |
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Respect for the principle of nonmaleficence |
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Respect for the principle of justice |
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Financing
This article was not financed.
Conflict of interests
The authors declare that they have no conflict of interest.
Author’s contributions
DC and SE designed the article. The authors declare that they read and approved the final manuscript.
References
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