BIOETHICS ASPECTS IN THE ABBREVIATION OF LIFE: A REVIEW

Danielle Oliveira Maciel 1 , Bruna Roberta Paixão dos Santos 1 , Lucas Ribeiro Brito 1 , Maryllia Suellem Almeida Cesario 1 , Celyce Agrassar da Silva 1 , Mariana Zuleica Corrêa Massoud 1 , Arthur dos Santos Baia 1 , Suzanne Camila Ferreira de Ferreira 1 , Brenda Franklin 1 , Maria de Nazareth de Lima Carneiro 1 , João Gabriel Pinto Gursen de Souza 1 , Elza Sara Maues Pena 1 and Marcos Valério Santos da Silva 2 . 1. Resident in Critical Patient Care, Federal University of Pará. Belém, PA, Brazil. 2. PhD in Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, University of São Paulo. Professor at the Federal University of Pará and Multiprofessional Residency in Critical Patient Care. Belém, PA, Brazil. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

It can be affirmed that Brazilian law attributed to human life a higher value if compared to the other protected goods (Rocha, 2014). In the Brazilian constitutional scope, art. 5º expressly guarantees the fundamental right to inviolability of life, and does the same throughout the Magna Carta, that is, it protects life, but in an implicit way. It is interesting to cite, especially, the murderous willfulness, since it is in him that the practice of euthanasia fits when perpetrated. In this way, the one who, at the request of an incurable patient, causes him / her to die, will respond for the crime of willful homicide, which is when the agent wanted the result or assumed the risk of producing it. The penalty for this practice of 6 to 20 years' imprisonment, according to the Decree-law No. 2,848, of December 7, 1940, Brazilian Penal Code.
It can establish an association between suicide and euthanasia with regard to the desire to die, an attempt to plan death to mitigate suffering. However, assisted suicide consists of assisting people who can not consolidate the act alone. The aid may consist of prescribing lethal doses of drugs, assisting in the intake process or venous pathways, and also aiding and encouraging suicide (Kovács, 2013).
In assisted suicide, death does not derive directly from the action of another person, who requires and withdraws its own life is the terminally ill patient after consciously requesting the assistance of another person (Rocha, 2014;Martinez and Bersot, 2016).
According to art. 122 of Brazilian Penal Code, because life is an inviolable legal good, the one who provides assistance to the suicide will be held responsible for the crime of inducement, instigation or suicide aid, the penalty may be 1 to 6 years of imprisonment (Rocha, 2014).
Because they are considered crimes in Brazil, subjects such as euthanasia and assisted suicide are little discussed in institutions and among health professionals. However, to discuss and ponder the morality of the abbreviation of life, properly demarcating the concepts favorable and contrary to its realization, becomes essential for a broader exercise of citizenship (Siqueira-batista and Schramm, 2005).
In this context, the present study aims to verify in the literature studies that address the bioethical aspects in the abbreviation of life based on euthanasia and assisted suicide.

Methods:-
It is an integrative review of the literature, based on the bioethical aspects involved in the abbreviation of life. Articles written in Portuguese and English, available in full, were published by April 2016. As search sources, Lilacs and Medline virtual databases were consulted from the Virtual Health Library. The following words were addressed as descriptors: euthanasia, assisted suicide and bioethics, interconnected by the Boolean operator "AND". Thus, at the end of the search, 1039 articles were found, 114 using the descriptors "euthanasia and suicide and bioethics", 167 with the descriptors "assisted suicide and bioethics" and 758 with the descriptors "euthanasia and bioethics".
Articles in other languages, articles involving animals and those that did not address the proposed theme were excluded. Thus, after applying the search filters, which were: "limit" (except animals), "language" (English and Portuguese) and "type of document" (article), were obtained in total 652 articles. Removing the duplicate articles, among the tools used the EndNote® system, the result of 495 articles was reached. Among those, the ones in which the complete text was not available were removed, resulting in 59 articles.
And ultimately, two independent authors selected the appropriate studies to be included in the present review from reading the titles and abstracts. Finally, 24 articles, published in the period from 1987 to 2015, were included, being current articles, quantitative, literature review and case study or experience.

Results:-
The approach of the subjects euthanasia and assisted suicide aroused interest and served as a stimulus for the elaboration of this study. However, it is important to note that the scientific production on euthanasia and assisted suicide is very broad, whether national or international. However, the focus of this study is to use these concepts in 1674 order to analyze the bioethical aspects involved in these behaviors. The application of filters and selection of articles reached a quantitative of 24 selected articles.
From the Virtual Health Library virtual databases were consulted, such as Lilacs and Medline, and it is possible to observe that most of the studies are found in the Lilacs database (54%).
There was a significant diversity in the magazines and newspapers that published on euthanasia, assisted suicide and bioethics. The -Journal of Medical Ethics‖ and the -Bioethics Journal‖ were the ones that presented the most publications on the topics considering the period of analysis, with 7 (seven) and 6 (six) published articles, respectively, followed by -the Brazilian Journal of Medical Education‖ and the periodics -Ciência & Collective Health‖ and the -Canadian Medical Association Journal‖, all with 2 (two) articles, plus other journals that addressed these issues.
Regarding the type of study applied, 40% of the selected articles (n = 10) were current articles and the others about literature review, experience report and quantitative research. Another variable identified was the language, with most articles being 52% (n = 13) published in Portuguese. In relation to the year of publication, the greatest number of articles published occurred in 2014 (19.0%).
The description of the studies can be found in Table I.

2014
Brazil The euthanasia is considered na illegal practice according to national legislation and goes against the medicine principles, since the professionals in this field are trained to work for the maintenance of life.
Siqueira-Batista R, Schramm FR. Euthanasia and the paradoxes of autonomy.

2008
Brazil The main paradoxes of this concept are then presented in the fields of philosophy, biology, psychoanalysis and politics, expounding several of the theoretical difficulties to be faced in order to make its applicability possible within the scope of decisions relating to the termination of life. Holm S. The WMA on medical ethics-some critical comments.

2006
United Kingdom The manual covers a wide range of ethical issues in medicine, but much of the focus is on the interaction between the physician and other individual agents, for example, patients and other healthcare professionals. Morais IM. Personal autonomy and death.

2010
Brazil Understanding the dying process will help professionals to support patients in their death and to respect their dignity. Brassington

2000
England Professionals' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics.

Discussion:-
The bioethical debate on the subject of abbreviation of life should be discussed by health teams, since the ability to work these issues as cooperative members rather than adversaries will determine much about the health system's ability to respect the dignity and autonomy of those who seek help and comfort when faced with serious illness and imminent death. It is important to develop a better communication among the main actors in these issues, such as doctors, other health professionals, lawyers, in order to reflect on the various situations that involve disruption of life (Crispell and Gomez, 1987).
The topic of euthanasia and assisted suicide has seen notable increase in advertising over the last 20 years, especially among medical experts. In the teaching of courses in the area of health, the subject has great repercussion and some recent studies have found that the curriculum can influence ethical values of the students during the academic formation, concomitantly with the clinical practice (Pinheiro et al., 2011).
Some authors emphasize the need in the educational formation of a student: that of educating affectivity. They should not be disregarded. To educate would imply to teach beyond theoretical concepts, favoring attitudes and affectivities, making professionals more humanized referring to the cinema as a resource (Dantas et al., 2011).
Death in the humanized aspect is seen as significant in existence, and should be treated with humility and respect, welcoming patients and their families, excluding the treatment of banishment to the subject. Discussion based on the need to place in the process of death the person in the center, not feeling of belonging. Instigating the rapprochement and respect with this process of finitude (Kóvacs, 2014).
Some authors like Sundstrom and collaborators bring the opinion of the bioethical philosopher Peter Singer, who argues that it is appropriate to morally judge the life of individuals without a good expectation and, therefore, to shorten their lives. However, Sundstrom points to this statement as intriguing and that Singer's argument is flawed intellectually and / or ethically, for there is a vast difference between improving life and destroying it (Sundstrom, 1995).
Differences are placed between assisted suicide and euthanasia. Assisted suicide occurs when the action is voluntary, when there is consent of the patient, that is, it is the response to the expressed will of the patient. While euthanasia is the act performed in a non-voluntary way, when life is shortened without knowing the patient's will (Morais, 2010). Another author presents the two themes as synonyms, indicating them as a voluntary and autonomous refusal to continue living. Death would be a desire in an unsustainable life (Floriani, 2013).

1677
Euthanasia can only be considered as voluntary and that when executed involuntarily it would be a homicide. In this way, euthanasia would be the request of a person to accelerate his life that is at the end. If the person's request for someone else to help end its life, regardless of terminal illnesses, it would be assisted suicide. The authors argue that these actions can only be performed when all alternatives for solving the health problem have been exhausted and must be requested by a competent and spontaneous patient (Floriani and Schramm, 2008).
The legalization of physician-assisted suicide is recent. The state of Oregon, USA, is the only one to authorize such an act by a medical professional, with legalization being carried out in 1998. The Netherlands being the first country to recognize assisted suicide, Belgium (Floriani and Schramm, 2008).
Assisted suicide is closely linked to death, deciding for it and no longer for life. Bound, then, choice and death. Autonomy derives from the Greek dialect autos meaning itself, by itself and nomus meaning usage, law of sharing.
In view of this, autonomy is called for what is the competence of each human, its own laws. Thus, each human being has the ability to choose what is good for itself (Morais, 2010).
Assisted suicide involves the choice of anticipating death with the help of other people. The individual chooses death when it realizes it has lost control. This moment being when the subject feels devalued and incapable.In addition to the physical, involving psychological and spiritual issues .
According to the philosopher Immanuel Kant's doctrines, suicide and, implicitly, assisted suicide are misconduct, which violate the moral law. Kantian thought shows us that prohibiting the execution of euthanasia and suicide is a form of respect for people. Therefore, when the two types of death occur, there is impairment of the personality. However, Kant's ideas are inaccurate to conclude that assisted suicide and euthanasia are contrary to morality (Brassington, 2006).
Corroborating with Kant's ideas, the author Rocha (2013) reports that it is a mistake to argue in favor of euthanasia or assisted suicide based on the suffering of the patient. This, in a way, de-responsibilities health professionals in palliative care. In addition, this practice, coupled with patient vulnerability, may influence you to believe that these abbreviations of life are the only alternatives for relieving your pain and distress.
It is worth noting that in the popular sense palliative care is linked to religious people who aim at the care and wellbeing of the end of life, referring to euthanasia directed at atheistic thinking (Pessini, 2010 Some authors present a framework for end-of-life care. This structure has three main elements: control of symptoms such as pain, use of treatments for a sustainable life, and support to patients and their families. This information can be used by physicians to increase the quality of care (Singer, 1998).
The discussion of euthanasia and assisted suicide brought with it the problem of abstraction. If society legalizes these practices of abbreviation of life, it does not mean that there will be an overcoming of abstraction, but substitution for another involved in the question of the right to self-determination of people (Callahan, 1996).
Disputes between ethical and unethical conduct are not resolved by philosophical arguments, since a position can be attacked, but it can hardly be overcome in its entirety (Long, 1988). In this sense, Dickenson (2000) questions whether it is feasible to use the health technologies from the constant scientific creations to revive a terminal patient of an incurable disease. He reports that some authors recommend that professionals should not differentiate withdrawal and conservation of treatment, when the latter provides maintenance of vegetative state, for example.
The euthanasia to be mentioned disturbs the human being, reaching its omnipotence beyond human, but professional, due to being stimulated in the health area to take care of life, and to fight for this. According to the authors, it is perceived in nursing students that their conceptions and opinions on the theme are influenced by family experiences and their social and cultural formative spaces (Oliveira et al., 2014).

1678
Death is seen as a process that demands respect, and should be valued until its natural end. However, what is happening today is the institutionalization of death, separating it from everyday life and causing people to die away from their loved ones and in an unfamiliar environment. The interference of technical and scientific progress in the forms of treatment in the final stages of life only increases the cost and suffering not only of the patient, but also of his family, without giving greater benefits (Giron and Waterkemper, 2006).
As for patient consent, euthanasia can be classified as voluntary, non-voluntary and involuntary. The volunteer occurs when the patient expresses his desire to die, while the non-volunteer refers to situations in which the patient's opinion is not known. The involuntary, in turn, happens against the will of the latter, associating more intensely with the willful homicide (Morais, 2010). It is of great importance, however, to note that in the literature there are several classifications of euthanasia, with considerable divergence.
The principle of respect for autonomy has provided support to cogent bioethical arguments in defense of euthanasia (Siqueira-batista and Schramm, 2005). In this context, it is necessary to respect the freedom of choice of the man who suffers, that is, his competence to decide, autonomously, what he considers important to live his life, including in this experience the process of dying, according to his values and interests.
Thus, according to Antiquity -Hellenic spirit and Christianity -and full bloom in the Aufklärung, respect for autonomy presupposes that each individual has the right to dispose of his life in the way that suits him best, opting for euthanasia in the exhaustion of his forces, When its very existence becomes subjectively unbearable: In this sense, it can be said that in case of conflict of interests and rights, the right of self-determination has a lexical priority over other rights in the context of decisions concerning life and Death of its owner, that is, the person is in principle more qualified to evaluate and decide the course of his life (Schramm, 2001).

Conclusion:-
The articles examined in this study reflected on bioethical dilemmas: euthanasia and assisted suicide. In this approach, Bioethics, as a field of reflection, promotes a better orientation to situations that generate the dilemmas. It was observed that, in Brazil, the legal system is contrary to the practice of euthanasia and assisted suicide, because they are considered a crime according to criminal law. However, this theme has been debated among the most diverse social actors such as philosophers, religious, professionals in the area of Health and Law Given the complexity of the topic, this paper does not intend to exhaust the discussion. On the contrary, it aims to stimulate the deepening of the theme, considering its social importance, besides fomenting debates, critical reflections, mainly among health professionals, who are closely involved in the care process, in the situations between life and death, comfort and suffering.
Because these practices are considered illegal in the country, and knowing the diversity of opinions among authors on the subject, the interest in palliative care increases, as an alternative to minimize suffering and promote patient well-being, giving a more harmonious death process. Thus, ortho-thasia fits into this line of care as a possibility for patients with terminal illnesses, with intense physical and psychological suffering.
Considering the dilemmas and discussions about euthanasia and assisted suicide, being taboos in Brazilian society, due to cultural and religious issues, the practice of palliative care arise as an attempt to answer these questions.