The bioethics of intervention in the context of contemporary Latin American thought

This article highlights the process of construction, maturation and consolidation of a bioethics of intervention (BI) as a liberating bioethical proposal. Toward that end, it considers the main indicator of that characteristic to be its anti-systemic perspective, as manifested by its manifest political option and by epistemic insurgence against the epistemological domination of the bioethical knowledge produced in the countries located in the center of the capitalist world system. Because of its Latin American trademark, its ideological profile and its influence in the field of knowledge of bioethics, BI is presented as one of the most important theories of contemporary Latin American thinking, and is seen as the main novelty after the theory of dependence , the theory of the oppressed, the theology of liberation and the coloniality of power.

The bioethics of intervention in the context of contemporary Latin American thinking http://dx.doi.org/10.1590/1983-80422015232066 "Does Latin America exist?" And if it exists, does it have its own school of thought? These two critical questions have been the subject of much discussion among researchers from different areas of knowledge in the region and beyond. The first question is taken from the title of a text written by Darcy Ribeiro in 1976. After describing the historical process and analyzing the consequences of the violence of the colonial era, which imposed the perverse domination of capital on the peoples of the continent, the Brazilian anthropologist stated, in response, that the existence of the continent was based on the condition of it being "a great motherland for all of us". She went on to say that "Latin America has always existed, under the banner of utopia. I am convinced that this utopia has a location and a place. It is here 1 .
However, in attempting to avoid the predominance of "Latinnis", important Latin American thinkers -such as José Martí and José Carlos Mariátegui -have used other nomenclatures, such as "America, Our America", "Indo-America", "Ibero-America" and, more recently, "Abya Ayala", an expression taken from the Kuna language, which may be translated as "living land", "mature land", or "land in bloom". In this context -as a political option -indigenous movements came to use "Abya Ayala" to describe the region, as a substitute for the name "Latin America". Despite these questions and their multiple answers, there is a certain consensus regarding the "invention of Latin America", a term which arose following the usurping of the name "America" by the USA, in the 19 th century. Before this, the term "America" was used to describe the whole continent, as defined by the map of the German cartographer Martin Waldseemüller, produced in 1507.
In any case, Latin American thinkers have gone to considerable lengths to produce their own school of thought. If not all were able to separate themselves from the Eurocentric colonial epistemological legacy, others, with varying degrees of radicalism, successfully managed to break free from these epistemological chains. Evidently, a number of cultural, socioeconomic and political factors contributed to their doing so, which influenced the ideological choice, and place of declaration, of each protagonist. To our understanding, when faced with the historic imperative, Latin American thought is obliged to reflect on the reality of domination and underdevelopment to which the continent has been submitted, deriving from this concept the necessity of a practical approach capable of altering this condition, which was imposed by the colonial system. However, it should be recognized that, since the beginning of European colonization, epistemological domination inflicted Latin American thought to a long period of submission at the hands of the epistemological doctrines of the countries of the northern hemisphere, beginning with the Scholastic Period (predominantly from the XVI to the XVIII century), followed by the Enlightenment (the end of the XVIII and the beginning of the XIX century -in the case of Brazil, coinciding with the end of the colonial period) and Positivism (beginning in the XIX century). Liberal ideas also had a decisive influence on the political thought of the region, strengthening the political disputes between the defenders of republicanism and constitutionalism, such as in the case of Mexico and Brazil, in which the republican forces defeated the imperialist pretentions of Maximiliano (1867) in the former and brought about the coup d'état of Dom Pedro II (1889) in the latter.
With the processes of political independence at the beginning of the XIX century, nationalism emerged, connected with the appearance of new national states in the region. At the end of the XIX century, Marxist ideas, together with anarchy, began to spread throughout the region, growing in strength at the beginning of the following century. At this time they began to occupy an important role in the resistance movement in Latin America, which included the workers' strikes which were starting to take place in the main urban centers.
Despite the multiple strategies of the colonization of thought in Latin America, it is worth noting the presence of dissident thinkers throughout the history of the region. Such thinkers had stirred, since the beginning of the European presence during the colonial era, reflections of resistance to the dominant perspective, and included individuals both native to the continent and Europeans that sought to distance themselves from the Eurocentric strategy of thought production and its conceptual guidelines. These reflections took the form of collective expression -such as the ideas described in the Mayan work, "Popol Vuh" -to individual expression, from thinkers such as Felipe Waman Puma de Ayala and Bartolomé de Las Casas, to mention just two well-known names, who are unfortunately little discussed, or even neglected, by Brazilian intellectuals.
As at the beginning of colonization, there is evidence over the following 500 years of the existence of works by Latin American authors, which diverged from European critical thought and created their own theories, taking as a reference the context of the region. This allowed moments of epistemic resistance, as we will now describe.

The political-epistemic insurgence of Latin America
The much vaunted "development" of Latin America in the 1950s, deepened, rather than reduced inequality, causing a greater concentration of wealth, increased levels of poverty and reinforcing the imperialist position of the USA over the countries of Latin America. The politics of development resulted, simultaneously and collaboratively, in the establishment of totalitarian regimes through military coups and dictatorships, supported and backed by the USA under the guise of the Cold War and as part of its international economic policy.
At the same time the triumph of the Cuban Revolution (1959) and the emergence of liberation movements such as the Sandinista National Liberation Front (FSLN) in Nicaragua, founded in 1961 -fed the idea of utopia, stimulating revolutionary thought and inviting engagement, principally among young people, with the social struggle, aiming to think about a political program for the articulation and liberation of the continent. Che Guevara became an icon, inspiring ideas of liberation not just in the region but throughout the world. As well as confronting the local dictatorships, various segments of society pushed to give their struggle a wider political dimension that was both anti-imperialist and anti-colonialist.
In this context, as expressions of Latin American thought, there emerged at the time (the 1960s and 1970s): the dependency theory, whose most prominent authors were Celso Furtado, Raúl Prebish and Theotônio dos Santos; the pedagogy of the oppressed, of which Paulo Freire was the main formative thinker; and liberation theology, in which area the theologists Gustavo Gutiérrez and Leonardo Boff first emerged. These three contemporary proposals, irrespective of their conceptual differences and capacity to mobilize the "masses", began the process of epistemic and political insurgency in the region which would subsequently be continued in the 1990s, in the form of decolonial thought, linked to the theory of coloniality of power, created by the Peruvian sociologist Aníbal Quijano.
The word "insurgence" here does not carry the classical political meaning of "insurrection/ rebellion", which implies the use of force (armed insurgence), but instead the idea described by Ca-therine Walsh, according to which an epistemic insurgence is understood as a constant process of construction of new strategies and different forms of praxis, or in other words, the creation of joint mechanisms of thought, reflection and action, when faced with dominant epistemologies. This epistemic insurgence contributes to a rethinking of theoretic and political perspectives and paradigms. Allied to political insurgence, it has helped to trace new pathways both for indigenous peoples and Afro-descendants and the population as a whole. We can take as an example the recent experiences of Bolivia and Ecuador, both of which created a decolonial horizon by diverging from what we traditionally understand as the State, as well as the logic and meanings that have informed such an understanding 2 . It was the experience of refounding the State, transforming its uni-national and monocultural nature (Nation-state) into something pluri-national and pluri-cultural (a pluralist, community based State), which led to substantial alterations to the constitutions of Bolivia and Ecuador, which were respectively approved in 2008 and 2009.
In an important article in which she analyzes the thinking of Quijano, the anthropologist Rita Segato makes the following statement: In a century of societal disciplines, only four theories originating on Latin American soil crossed, in an opposing direction, the great frontier, that is to say, the frontier that divides the world between the geopolitics of North and South, to make an impact and become part of global thought […] they are: Liberation Theology, the Pedagogy of the Oppressed, the Theory of Marginality, which fractures the Dependency Theory and, most recently, the perspective of the Coloniality of Power 3 . Two years before writing this article, during a meeting with a research group about bioethical pluralism, of which she was coordinator, Segato externalized the idea that, after the theory of coloniality formulated by Aníbal Quijano, intervention bioethics represents the most significant development in the field of Latin American thought. Recently, when we returned to ask her about the subject, she reaffirmed this belief, while recognizing that the theory remains in construction, and, therefore requires further exploration and experimentation in the deliberative practice of bioethics, through concrete cases.
From Segato's perspective, we understand the intervention bioethics that has emerged in the Latin American scene in the last five decades to be the fifth theoretical proposition -after liberation theology, pedagogy of the oppressed, dependency theory and the coloniality of power theory -to carry a regional identity and the identity of its social setting and place of origin. In addition, from the periphery of the capitalist world system, intervention bioethics intends -like the four theories that preceded it -to break regional boundaries and to establish itself as a liberating bioethical perspective, rebelling against the imposition of bioethical knowledge produced in core countries, in order to definitively consolidate its process of epistemological territorialization. It should be noted that the concept of world-system used here is taken from the theoretical works of the sociologists Immanuel Maurice Wallerstein 4 and Giovanni Arrighi 5 , according to which the world-system logic of the global economy has several political centers, with centralized division of labor, and which operates in different cultures. Therefore, our theoretical framework for the analysis of international relations is the world-system, not the nation-state, as in the liberal approach.

Intervention Bioethics
In an article published in 2011, Porto and Garrafa associate the characteristics of Brazilian bioethics with the movement for health reform in Brazil, which began in the late 1970s 6 . Such an association is justified, principally, by the recognition and valorization of the social dimension for the analysis and understanding of the relationship between health and disease, as well as its importance in the process of discussion, formulation and implementation of public health policies.
In Brazil, the linking of bioethics with the struggle in the field of public health applies, evidently, to the very genesis of intervention bioethics, whose main advocate, Volnei Garrafa, was politically and intellectually involved in demonstrations to defend public health from the very outset of the movement. One of the author's key works is the book "Against the monopoly of health" 7 , widely read at the time by intellectuals, trade unionists and students of the left wing of the Brazilian health system, and which is considered the precursor of health reform in the late 1980s.
In this sense, the works of Garrafa, "The Dimension of Ethics in Public Health" 8 "Bioethics, health and citizenship" 9 and "Ethics and public health: the issue of equity and a proposal for hard bioethics for peripheral countries" 10 , published between 1995 and 1999, a period which represents the beginning of the development of bioethics in Brazil, can be considered historiographical landmar-ks of the seminal identity of intervention bioethics. This is due to their theoretical and political links with public health, originating from a concern for health demands, based on a theme of persistent and emerging situations. Persistent situations relate to the old, chronic ethical demands of the population, such as social exclusion, hunger, abortion and euthanasia. Emerging situations, meanwhile, stem from technological advances, such as those associated with genetic engineering, organ trafficking, organ transplantation, and predictive medicine and genetically modified organisms.
These three articles by Garrafa represented a transition that led to the 2000 conference Hard Bioethics: a peripheral perspective to traditional bioethical theories 11 , and the article "Bioethics, power and injustice: for intervention bioethics" 12 , a joint work by Garrafa and Porto, published in 2002. We can therefore define the period between 1995 and 2002 as corresponding to the gestational stage of intervention bioethics. It is also worth noting that 1995 was the year the Brazilian Society of Bioethics (SBB) was founded, a fact which symbolically represents the birth of bioethics in the country.
However, whether from a theoretical perspective or a political point of view, it would be lax to relate the proposal of intervention bioethics only to the influences of the health movement, specifically those of Brazilian health reform. Nevertheless, we are aware that in Brazil this social process assumed a militant identity, to the extent that it was even given the name the "health movement" by some researchers.
While we recognize the political and emotional proximity between Brazilian health reform and intervention bioethics, there is a great distance between the two in terms of the breadth of purpose that was gradually taking shape with the construction of the bioethical proposal. The first is focused on the idea of emancipation in the context of the formulation, implementation and monitoring of public policies, particularly health policies, even if this means some reform to the scope of the State, through focusing on a specific country. The second proposal is presented as a proposal for liberation, which takes into account the unjust relationships between the North and the South, as evidenced by social inequalities that distinguish core countries from the peripheral countries.
According to Porto, intervention bioethics can be taken as an "ethical basis for an abstract and imaginary model of the ideal society, and as utopian socialism" 13 . With this assertion, the author justifies describing intervention bioethics as "utopia", while making it clear that, for her, the word is not synonymous with unattainable ideals, but with a mobilizing force for building concrete, attainable and achievable historical projects, which is why, when considering the ten years of intervention bioethics, the term "retrospective of a utopia" is used, which gives a sense of concreteness to the proposal.
We are therefore faced with a liberating utopian framework that translates into an everyday bioethics based on the ethics of liberation, as defined by Dussel: The Ethics of Liberation does not seek to be an ethics for a minority, nor only for exceptional times of conflict or revolution. It inspires instead to be an ethics of everyday life, from the perspective and in the interests of the immense majority of humanity excluded from globalization throughout the world where the current historical "normality" prevails 14 . Assuming a position of politicization from moral conflicts, intervention bioethics argues that the first concern of bioethics originating from poor countries is confronting persistent ethical dilemmas. For this reason, it chooses the most fragile band of society and aims to fight against all forms of oppression and to promote justice, based on the principle of equity 12 .
Although this bioethical matrix was established just over fifteen years ago -taking the genesis of the theory to be the IV Argentine Congress of Bioethics in the city of Mar del Plata in 1988, when it was announced by Garrafa and called "hard bioethics" -it has already amassed a significant theoretical body of work. This output is the result, above all, of the efforts of its main formulators, as well as the contribution of sympathizers and supporters of the proposal, especially the graduates of fifteen specialized courses in bioethics that have taken place annually since 1998 at the UNESCO Bioethics Chair at the Universidade de Brasília (UnB) and the stricto sensu (masters and doctorate) Graduate Program developed from 2008 by the same institution, as well as Latin American bioethicists.
Among the bibliographic production of its most prominent authors, we can highlight the following articles: Ethics and public health: the issue of equity and a proposed hard bioethics for peripheral countries 10 ; Hard Bioethics: a peripheral perspective to traditional bioethical theories 11 ; Bioethics, power and injustice: for intervention ethics 12 ; Intervention bioethics: a proposal for peripheral countries in the context of power and injustice 15 ; Gender, race and intervention bioethics 16 ; Intervention bioethics: considerations of the market economy 17 ; From a 'bioethics of principles' to a critical and socially committed 'intervention bioethics' 18 ; Social Inclusion in the political context of bioethics 19 ; Bioethics of intervention and access to healthcare and medicine 20 ; The influence of health reform in the construction of Brazilian bioethics 6 ; Expansion and politicization of the international concept of bioethics 21 . In addition to these articles the following chapters of books and other publications are worthy of attention: "Intervention Bioethics: retrospective of a utopia" 13 ; "Multi-inter-transdisciplinarity, complexity and concrete totality in bioethics" 22 ; "Mercosur Regional Bioethics Convention: a proposal of the UNESCO Chair in Bioethics at UNB" 23 and "Intervention Bioethics" 24 .
This list of studies does not include the entire production of Garrafa and Porto during the period 1999-2012, but is an authoritative selection, based on the importance of its content and its symbolism and history in the consolidation of the epistemological proposal of intervention bioethics. Intervention bioethics is considered an autonomous area, different from other areas of bioethics, including even the Latin Americans. It stands out from, for example, two proposals that are particularly well grounded in the Brazilian context -protection bioethics 25 and bioethics linked to liberation theology 26 -although it maintains ideological and emotional ties to these areas, which allows the opportunity of dialogically interacting with them.
However, it is important to point out that other contributions have added to this repertoire, with a view to confirming the epistemological paradigm of intervention bioethics, which enables it to serve as an instrument of denunciation and discussion of situations of injustice, and contribute to the search for alternatives. Among such works, we can recommend: Intervention bioethics: an epistemological proposal and a necessity for societies with vulnerable social groups 27 ; Intervention bioethics: approximation to human rights and empowerment 28 ; Bioethics teaching: a brief analysis of the first decade of the specialization course of the UNESCO Chair in Bioethics at UNB 29 ; For an uncolonized life: dialogue between intervention bioethics and coloniality 30 ; Intervention bioethics and social justice: views from the south 31 .
Returning to the theoretical overview performed by Porto of the ten years of intervention bioethics, this important work provides support for our view that intervention bioethics is one of the key new developments in Latin American thought, following the emergence of the coloniality of power, which was preceded by the dependency theory, the pedagogy of the oppressed and liberation theology. Therefore, we are concerned with the conclusive manner in which the author formulates the analytical epitome of this new epistemological proposal in the field of bioethics: Summing up this retrospective, I believe that intervention bioethics politicized bioethics, awakening bioethicists to the presuppositions of Health Reform and indicating that conflicts in Health, which originate in the social dimension, are par excellence topics of applied ethics. It stimulated awareness of the fact that body and mind are one, aiming to overcome the Cartesian paradigm. It showed that each person is in fact an actor in society and must act to regulate the dynamics of social inter-relations based on the principles of justice, guided by human rights, according to collective needs 32 .
While three objectives achieved by bioethics intervention during its first decade of existence can be identified in these words, the manner in which these are ordered may give the impression that the second and third goals are complementary to the first, in other words, that the politicization of bioethics is based on the assumptions of health reform and the social dimension of health. This may suggest a reductionism of intervention bioethics, which proposes a wide interventional perspective, far beyond health issues. However, as we believe that Porto did not intend to suggest this meaning -on the contrary, she aimed to register the "realization of utopia" of intervention bioethics in all its political (practical) and ideological (theoretical) amplitude -we will use her arguments to validate our statement about the extent of this bioethical area, which the author has helped, along with Garrafa, to bring to life.
Our conviction is supported by the depth of Porto's analysis, which when performing the aforementioned overview considered the following issues: a) contexts, theoretical frameworks and benchmarks; b) self-criticism of the idea of intervention; c) criticisms of intervention bioethics. When considering each of these points, she was able to give convincing answers to both her own questions and those of others, and even provide exemplifications, including the sanctioning of the UNESCO Universal Declaration on Bioethics and Human Rights 33 , identified as an achievement of bioethics on a global scale, and which included an important contribution from the Brazilian Society of Bioethics and the UNESCO Latin American and Caribbean Bioethics Network. In the process, it included a valuable theoretical basis of intervention bioethics and the political engagement of its formulators, which for us is indicative of the incidence (intervention) and acceptance of this theoretical proposition and its impact beyond the borders of America Latin.
Garrafa, in his article "Expansion and politicization of the international bioethics concept", presented at the opening of the IX Brazilian Bioethics Congress in 2011 and published in 2012, strongly valued the significance of this achievement, placing it among the measures and changes needed to address old and new problems of bioethics. The first item of the article, to use the principles and references of the Universal Declaration on Bioethics and Human Rights, is particularly worthy of note 34 .
Recently, intervention bioethics advanced its proposal of liberation, establishing inter-epistemic dialogues, such as adding a decolonial feature, an argument made by Nascimento and Martorell 35 . Among other essential contributions to academic thought and decision-making considerations is bioethical pluralism. According to Segato 3 , bioethical pluralism goes beyond the plurality of doctrines, as Western bioethical thought postulates: he proposes identifying and analyzing other experiences and theories of ethical life that are not covered by the biopolitics of contemporary Western history, in other words, not remaining limited to the idea of a biologized and universalized humanity. Bioethical pluralism therefore seeks inspiration in legal pluralism, which posits different conceptions of justice and law, influencing different conflict resolution practices, such as those adopted by indigenous peoples.
The proposal of intervention bioethics, with its bold manner of exposing the overlap of political and social issues in order to ethically evaluate bioethical conflicts, does not only demand concrete interventions, but also requires that we observe the locus of our thought, in order to assess such conflicts. It therefore requires that the health sector is considered as one of a number of key fields, which, despite its importance, must be linked to an evaluation of the social conditions in which life is experienced in the various geopolitical regions of our planet. Therefore, in an inventive and decisive manner, intervention bioethics inserts health in the insurgent context of Latin American thought.

Final considerations
During the first decade of its existence, intervention bioethics has, based on its theoretical foundation and in collaboration with other Brazilian and Latin American forms of bioethics, internationally secured the acceptance of the political dimension in the formulation and practice of bioethics, establishing the human rights paradigm as a unifying axis of this dimension.
In proposing to be a bridge between subjects (citizens), society and the state, intervention bioethics assumes a strong social character. The term "intervention" in a broader historical perspective, was often associated with the intervention of a major power in economic and politically weak nation states. Although one should not succumb to this historically constructed pejorative labeling, nor can it be ignored. It may be then that the term "intervention bioethics" sounds strange to some at first. However, what is of genuine importance is the action, and how it manifests itself. For this reason, intervening action should always take place through dialogue with the people and institutions involved, whether the recipients or proposers of the action. Intervention, therefore, at least in this case, can ever be confused with interventionism.
Intervention bioethics conforms to a tried and tested bioethical paradigm, especially in the experimental field and at its most important center of diffusion: the UNESCO Chair of Bioethics and the Graduate Studies Program in Bioethics at the University of Brasilia. Therefore, we must consciously assume the responsibility and consequences of the process of production of bioethical knowledge, which is intended to operate in two dimensions: the epistemological and the political. In the epistemological framework, this occurs through criticism, deconstruction and reconstruction of knowledge, and in the political sphere, through critical reflection of the praxis of bioethics and the defense of practices that are committed to the transformation of an unjust social reality.
Intervention bioethics has come to occupy a position of relevance in the bioethics arena, and has become an important theory in current Latin American thought. It is through this epistemic openness that the proposal can further explore the basis of its epistemological territorialization, in constant liaison and interaction with the insurgent epistemologies of the south.