Institutionalization of Bioethics in Mexico

Even though in 1927, Fritz Jahr invented the term bioethics,¹ this discipline development took place during the seventies, immersed in a context of a scientific and technological advancement not seen before, of demographic explosion and of an exponential destruction of biodiversity. Additionally, those were historical moments featured by the effervescence of social, political and moral transformations, striving to achieve equality, peace, and fraternity, and for justice.² It also was Van Rensselaer Potter, who in 1971 in his article, “Bioethics: the science of survival”, discussed the possibility to create a kind of wisdom that would teach “how to use the great amount of knowledge, that humankind has been acquiring, for the purpose of being able to build a bridge to the future. The aim of Bioethics would have been to work in favor of the survival of humankind, and of the environment from which, men depends on”.³

In that same year, with the founding of “The Kennedy Institute for the Study of Human Reproduction and Bioethics” at Georgetown University, it was when Bioethics began to be applied to the medical and biological fields due to the complex situations that scientific development brought with itself to clinical practice. Then, interdisciplinary groups of experts were formed, that with time were transformed into committees, councils and commissions, acquiring an institutional and national character. The United States and Europe were pioneers in the founding of those commissions, and their models were reproduced or retaken, by almost all the Countries, under various forms and strategies.⁴

After World War II in the United States, policies oriented to scientific work were generated, with their ethical implications derived from the use of human beings for research subject purposes. In 1974, by a USA Congress initiative, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created, in order to identify the ethical principals in research, and issue recommendations about their regulations at federal level. By 1979, the USS Department of Health, Education and Welfare, published the Belmont report, where the fundamental ethical principles in the use of human as research subjects are explained: respect, welfare and justice.⁵

The establishment of national bioethics commissions/committees around the world was strengthen by the Universal Declaration in Bioethics and Human Rights by UNESCO approved by the General Assembly in 2005,⁶ in which an integration of independent, multidisciplinary, pluralistic ethical committees were summoned. The diversity in which these commissions/committees in bioethics were formed is recognized by UNESCO as a reflex of the singularity of the culture, history and traditions of each country.⁷

The bases under which would later on allow the institutionalization of bioethics in Mexico, go back to the eighties of last century, when it begins to be considered as a field of knowledge, and the importance to analyze, the ethical aspects implicated in disciplines such as medicine, biology, law and natural resources management, is recognized. One of the first references found in “the studies plan of the National Open System of the middle upper education from the Public Education Ministry, where it was known as ecology and environmental preservation”.⁸

In the Article by Lizbeth Sagols: Traces of Bioethics in Mexico: the scope of secular philosophical perspectives, she performs a recount of the factors which explain the incorporation of bioethics in Mexico, that are a mirror of the socio-cultural development in the world, that in turn had an impact in our country. The first one of them was the awareness of various social groups about human rights, and in particular, the right to health and the right to a dignified treatment in medical care, which derived in the decision-making about their own body, specially, in face of events such as the beginning and end of life. Another relevant factor was, the worldwide diffusion of scientific discoveries in the communication media, such as the breakthrough in the decoding of the human genome and animal cloning, facts that demanded the attention of specialists in face of the opinions and doubts of society. And finally, “the awareness by the philosophers and humanists, as well as the physicians and scientists about their responsibility to analyze the bioethical questions and the need to provide criteria as clear and open as possible, in order to guide the society’s concerns”.⁹

The world recognition of bioethics, and the need for its implementation in Mexico, led to the fact that in 1989, the General Health Council would have led to the creation of a bioethics study group led by Manuel Velasco Suárez, an eminent physician from the State of Chiapas, and a strong promoter of strengthening the National Health System through the foundation of several institutions related to health and education, such as the Neurology and Neurosurgery National Institute, and the Autonomous University of Chiapas. On March 30, 1992, by Ministries agreement, the National Bioethics Commission was installed in the Council Room of the Health Ministry, with the presence of Dr. Jesús Kumate Rodríguez, head of the Health Ministry and Dr. Velasco Suárez, as an Executive Secretary.¹⁰

On October 23, 2000, in the Federation Official Gazette was published, the Presidential Agreement by which was created in a permanent character the National Commission on Bioethics. On September 7, 2005, by Presidential Decree, it was organized, as a decentralized body agency of the Health Ministry with a technical and operative autonomy, in order to promote the creation of a bioethics culture in Mexico, having among its powers, in order to fulfill such objective, the creation of the Bioethics State Commissions (CEB).

Conceived as collegiate bodies with an interinstitutional character, the Bioethics State Commissions support the National Commission’s mission, by means of the development of ethical norms and tutoring for the attention, research, legislation, public policy and academic teaching of bioethics as a subject matter, taking into consideration the social cultural context in which it is imbedded. Regarding the foregone, in order to respect the sovereignty of each one of the States, it was proposed that the operation of such Commissions would depend on the State Governments of each federative entity, through the corresponding Health Ministries, which would be in close communication with the National Commission. Due to the relevance acquired through time of the State Commissions on Bioethics, at the time of updating in 2017 the agreement of the National Commission,¹¹ it was ratified the momentum at the time of its creation, ensuring that advising and tutoring should be provided to their organization and for their functioning.

Structure and Development of the State Commissions on Bioethics

Even though the National Commission has among its goals to promote the forming of State Commissions on Bioethics, the support by the Health National Council from February 27, 2003 on has been fundamental. It is in the IX Ordinary Meeting, which took place in Monterrey Mexico, when it was established for the first time that each Federative Entity should create a Bioethics Commission. In March of 2004, the first State Commission on Bioethics was formed in the State of Morelos, having as an objective to promote the study and the observance of values and ethical principals in order to perform both the medical care as well as the research on health.

The Agreement by the National Health Council was ratified in 2011, 2013, 2014, and in March of 2018, during the XIX Ordinary Meeting, held in the State of Guerrero, when the importance of the creation of State Commissions on Bioethics was emphasized again, but also, the funding of resources for their operation, calling on the States’ Health Services Heads to ask for their support for the operational continuity. In that meeting it was established also, the commitment to generate collaboration links that will allow to include bioethics in the academic institutions, and with the Judicial Powers of each State with the support of the State Commissions on Bioethics.

The CEB evolution accounts for a gradual process of consolidation of bioethics in the various States that has been reinforced during the 2012 to 2018 period. Such process can be characterized, by two inter-related phases: the first one shows the continuity of the promotion work by the National Commission on Bioethics for the integration of the CEBs, giving as a result their presence by 2018 in 30 States. The second one, represented by the impulse of its strengthening, sustainability and continuity. That is to say, it is due to the support to their operations for the performing of training, diffusion and tutoring activities in each federative entity, regarding Bioethics as a subject matter, as well as the linkage with educational institutions and Bioethics related sectors, in order to stimulate development, in this subject matter.

The CEBs Creation was conceived as a strategy to entrench Bioethics studies in each region, by means of their liaison with organizations, academies, and civil society groups, having as an objective to position themselves as interconnecting spaces, among the federal, state and local levels, in these matters. In order to guide their formation and operability, The National Commission issued in 2011, The State Commissions on Bioethics Operational Guidelines; the second edition was published in 2015. In this last document were established as suggested functions the following ones: the implement of activities of the standardization, guidance, consultation, educational and information distribution types, which beginning in 2011, were led and oriented to the promotion of the registration of Hospital Committees on Bioethics, and Ethics Committees in Research¹² in all the federative entities, based and derived from the publishing in The Federation’s Official Gazette, about the modification made to the General Health Law, which establishes the obligation to form such committees, in accordance with the issuing of a Reform Decree to the General Health Law, by which Article 41 B is added, and Article 98 is modified.¹³

Work Scheme 1 Consolidation Process of the CEBs 

By creating the CEBs, it was under consideration, to include in its structure the figure of a Spokesperson’s Office integrated by members of several institutions kinship to Bioethics, such as the IMSS and/or ISSSTE State Delegations, The State’s Education Ministry, The State’s DIF, The State’s Human Rights Commission, The State’s Environmental Agency or Ministry, The State’s Council on Science and Technology, and also, the Public and Private Universities in each State. Their main purpose would be to act as a liaison between the institution they are representing and the CEB, in order to generate joint actions in Bioethics matters, as well as participate in technical information requests, and other situations that could affect the operability of The State’s Commission on Bioethics.

In order to integrate experiences of all the State’s Commissions on Bioethics, The National Commission initiated in 2005, the conduction of national meetings in Mexico City, that with time, they were acquiring a more specialized character, seeking to define key core subjects, the participation of national and international experts, and the approach to opportunity areas in the development of Bioethics subject matters in various States; by 2018, 12 meetings have been held. At the same time, since 2007 organizing meetings has been promoted in order to link CEBs from the four country regions: Northwest, Northeast, Center-South, and Southwest. By 2018, 12 meetings have been carried out, that have been held in the States of Tabasco, Guanajuato, Sonora -twice a State Venue-, Campeche, Oaxaca, San Luis Potosi, Puebla, Zacatecas, Tlaxcala, Coahuila, and Durango. Among the issues that were addressed, the following were emphasized: Health for Migrating Populations, Information Distribution on Bioethics Culture, Bioethics aspects on the Preventing and Pregnancy Care in teenagers, and the link strengthening between Bioethics and Society.

A relevant fact, which has promoted the functioning of Bioethics in the federative entities, is the entry inclusion of Bioethics in The Health Sector Programme 2013-2018,¹⁴ published by The Ministry of Health in 2014, where it is instructed to set Bioethics as a Management and Development policy of the Universal Health National System. Accordingly, The National Commission on Bioethics, establishes its Specific Action Programme, a Strategy for the Promotion and Application of Bioethics Knowledge with a Global Perspective, being one of the processes to be highlighted, the consolidation of the institutional infrastructure in bioethics in the country, a fact that has allowed to call upon the Heads of the State Health Services to collaborate in the development of bioethics in Mexico through the integration of the State Commission on Bioethics.

Contingencies in the creation of the State Commissions on Bioethics

The Article Advancement and Challenges of the State Commissions on Bioethics in Mexico,¹⁵ presents an approximation to the operative development showing the main problems that have arisen up until 2016, being one of the significant subjects the resources allocation for its functioning. Even though the CEBs have been getting support, in either operational personnel, working space or budget exclusively for the bioethics activities, one of the issues that still represents a challenge, is to guarantee it continuity. In addition, it is in spite of its permanence, that it is established in an official document,¹⁶ which originates them, its functioning tends to become unstable due to the changes in government and of Health State Services Head, creating working procedures, which are not well defined, and a continuous personnel rotation.

In accordance with the foundation decree of each CEB, it is possible to see that in 26 State Commission on Bioethics, the president is also the Head of the Health State Services, except in Colima, Sonora, Zacatecas and Mexico City. At the time of analyzing the way each one of them operates, during 2018, it was identified that some of them depend directly from the office of the Head of the Health State Services in Mexico City, the State of Mexico, Nayarit, Oaxaca, Sonora, Tlaxcala, Yucatán, Zacatecas, and others are located in the Ministries Departments related to quality, teaching, research, liaison and social participation, among others -Aguascalientes, Baja California, Campeche, Chiapas, Chihuahua, Coahuila, Colima, Durango, Guanajuato, Guerrero, Hidalgo, Jalisco, Michoacán, Morelos, Nuevo León, Puebla, Querétaro, Quintana Roo, San Luis Potosí, Tabasco, Tamaulipas, Veracruz-.

All the above is remarkable because, even though the insertion of the bioethics is carried out through the areas that have a direct linkage with the theme, shows that CEB’s operation is not solid because it lacks an exclusive support for the performance of its activities, giving as a result a different functioning in each State, a situation that should become normal, above all, by accomplishing the goal of establishing 32 State Commissions on Bioethics. Thereon, an important factor is the institutional resistance to incorporate the bioethics perspective, in the medical care and research establishments, through the functioning of the CEBs, but also, by means of the integration of the Hospital Committees on Bioethics, and of the Ethics Committees in research. Due to these last facts, a large part of the activities, which are developed at the State Commissions on Bioethics, are focused on letting know what bioethics is, its application, and what it has given to the health system.

In the creation of the State Commission on Bioethics, multiple factors are involved which make difficult its consolidation, as the political will in each state, the importance given to the insertion of bioethics as an answer to the problems presented in health care and in medical research, the assignment of resources to other areas which are considered of greater priority, and of significant way, the difficulty placed by some sectors of society, in the analysis of issues which are considered controversial; for example, the dilemmas at the beginning or the end of life such as abortion or the notion of dignified death, subjects in which different aspects intervene such as cultural, political and religious ones, which are considered in the bioethics analysis in order to reach points of agreement among the various social actors involved.

Problems such as the previous are similar to the ones found by Eduardo Rodriguez and co-workers,¹⁷ who state that in Latin America there are not many, the countries that have been able to adopt a suitable model for the cultural context, -being this, one of the motivations to create the State Commissions in Bioethics in Mexico- for there exists other priorities to take care of, such as poverty, the access to health services, and because regulations on scientific work are issued by government agencies such as the Councils or National Commissions for Science and Technology. There are other difficulties such as the low level of social representation, the problem that represents to reach a true independence, the implementation of a job more political than ethical, and the commercialism of the biomedical and biotechnological applications in each country.

Operation and interinstitutional links in Bioethics

Due to the important work performed by the CEBs in the promotion of the creation and registration of Hospital Committees on Bioethics and the Ethics Committees in Research, one of the main activities is the attention to requests of consultancies and the participation in sessions where cases with bioethics dilemmas are addressed, as well as the provision and bestow of training workshops on the functioning of such committees, but also, that promote Bioethics at the Educational Sector, Judicial,( and Civil Society Organization Institutions (Graphic 1). In order to address the requests for consultancies, they have a protocol that considers the use of e-mail, telephone, social networks, and the implementation of an orientation guide in a presence based form. The contact information can be obtained from the web page of the National Commission, or on the website of some State Health Ministries: -Aguascalientes, Coahuila, Puebla, Nayarit, Tlaxcala, Veracruz, and Guanajuato-.

Source: Survey on the operational assessment of CEBs 2017, CONBIOETICA

Graphic 1 Institutions that request consultancy to the CEBs 

One of the most important jobs of the State Commissions on Bioethics is the identification of relevant issues, which would motivate the performing of academic activities and information diffusion, in which decision makers, medical professionals, researchers, and society in general would participate. When inquiring about those relevant themes,¹⁸ it was identified the operation of the Hospital Bioethics Committees and Ethics Committees in Research, specifically aspects of its integration, functioning and analysis of the cases, as well as the application of the informed consent in the research protocols. In a relevant way, were mentioned issues that agree with those of national interest as the pregnancy in teenagers, abortion, maternal death, obstetric violence, anticipated will, differences between a dignified death and euthanasia, palliative care, organ transplant and corps donation, childhood obesity, subrogated maternity, Jehovah’s Witnesses blood transfusions, and protection of biological samples. Such themes must be analyzed with the support of alternative sources such as statistical data in health, subject matters as well as in epidemic ones, also those researchers of social profile, to report the multiplicity of approaches and socio cultural meanings that in each federative entity could be determining its incidence.

As the State Commissions in Bioethics are consolidating their operation, the diffusion of information work, which they perform, acquires a higher impact, because not only it is targeted to health and research professionals, but to society in general. The printed material is the most used diffusion media, such as posters, flyers; articles published in newspapers and magazines both of dissemination and specialized magazines. Furthermore, audiovisual resources such as informative capsules of radio and television are used, and the management of the web page and/or social networks where training events, and national and international notes on bioethics subjects or related ones are promoted.

In the State Commissions on Bioethics operability, the interinstitutional liaison is fundamental, due to fact that it promotes the holding of collaboration agreements, which allow the support management, to carry out courses, workshops, seminars, diploma courses, Master´s and Ph.D. programs, as well as the insertion of Bioethics in the Curricula of Bachelor’s Degree Programs, linked and related to Life Sciences and Medicine, as well as in other knowledge areas related to this subject matter, such as Law.

The Bioethics perspective as a methodological support tool in the analysis of cases related to sentences issued by justice providers is fundamental, for it provides thoughts and reflections that contribute to warrantee respect for dignity and also, for human rights. Moreover, strengthens the approach of the agencies in charge of ensuring the application of the law within a frame where justice would be impartial, and where science developments, and the benefits given by medical science and technology would be set in a democratic framework. It is in such a way that, in order to impulse this subject matter application in the judicial field, and provide an integrated and updated global vision of the Bioethics issues linked with law, such as the right to intimacy, privacy and the protection of personal data, the informed consent, the bioethical and judicial dilemmas on palliative care, the bioethical and judicial issues involved in the assisted human reproduction techniques, The National Commission on Bioethics signed in April 2016 a collaboration agreement with the Mexican United States Superior Courts of Justice where it is foreseen the celebration of specific instruments, before the authorities of each one of the regions of the States’Powers.

In agreement of the above stated, The Health National Counsel, established in March 2018, as part of the agreement regarding the State Commission on Bioethics, to promote collaboration links with the Judicial Powers of The States, recognizing the importance of favoring the experiences interchange between the health and law fields, and provide to law enforcement and judicial providers in Mexico, useful tools to issue declarations strictly attached to human rights in cases which present bioethical implications.

The State Commissions on Bioethics have strengthen their action field, by administering covenants with the Superior Courts of Justice of Nayarit, Campeche, Oaxaca and Tlaxcala, entities where seminars in bioethics have been carried out aimed at judges, magistrates, academicians and law scholars, where subject matters are reviewed such as the bioethics backgrounds, such concepts as morale, ethics, human dignity, palliative care, national and international legislation on research matters, the protection of personal data, sexual and reproductive rights, among others.

Bioethics is a fundamental discipline in order to address the problems derived from the transformations in the contemporary world. Therefore, it turns out relevant its teaching as a tool, which provides up-dated knowledge, and promotes reflection and deliberation skills, in order to understand the relationships between individuals, as well as their environment. A relevant element to consider, for providing an education in Bioethics position, is the increasing need of training medical professionals and medicine and health sciences students in Bioethics, as well as the members of the Hospitals Committees in Bioethics and Ethics Committees in research. In this scenario it is important to include the most important study centers at national and state levels, in order to include bioethics in the plans and educational programs in medical and health sciences, as well as in areas of related knowledge, promote knowledge and the application of international ethical standards, and scientific integrity criteria at universities and higher education institutions that perform research with human beings, and to impulse the creation of groups, in order to discuss relevant subject matters in bioethics that have a social impact.

As part of their liaison strategy with higher education institutions, the National Commission established a cooperation agreement with the National Association of Universities and Higher Education Institutions (ANUIES). In that agreement, it is considered to promote the participation of the State Commissions on Bioethics and the Regional Councils of the ANUIES. In this way, in October 2018, the Veracruz and Quintana Roo’s CEBs participate in the ordinary session of the South-Southeast Regional Council, and in November 2018 Nayarit’s CEB attends the ordinary session of the Center West Council; in those sessions the importance of Bioethics in the training on health of human resources is presented, calling for the strengthening the liaison between the CEBs and the ANUIES Councils of the various regions, where the most representative universities and educational institutions at state level are included.

Prospective of the State Commissions on Bioethics

The State Commissions on Bioethics present a sustained development, highlighting advances in its creation and functioning, for which currently only Southern Baja California and Sinaloa are pending in forming a CEB. Notwithstanding, given that the status of the CEBs is heterogeneous and conditioned upon the interest granted to bioethics, among the prospective actions to consolidate them, it is to guaranty the support of the State Health Ministries to achieve their operation and continuity in each one of the states, in fulfilling the National Council on Health Agreement.

Therefore, the sustainability caption must be highlighted as a topic which keeps representing and opportunity area because the majority of the State Commissions on Bioethics do not have an exclusive budgeting allowance, personnel fully dedicated to bioethics work, their own working space, as well as the lack of furniture and necessary working equipment, elements that would result in an ideal operation, and thus, in the observation of bioethics criteria in the care, teaching and research of health, having as an horizon the goal to offer health services with justice and social equity in each state of the Mexican Republic.

Equally important shall be to build specific instruments for determining the impact of the activities developed, and achieve a more detailed assessment of the advancement of bioethics in each state, and of how it is understood and applied, for which, it will be fundamental that the National Commission on Bioethics promotes the achievement of diffusion campaigns about the existence of the State Commissions on Bioethics, with the purpose that the population should know its relevance and demands its continuity in each federative entity.

Another aspect is the building of instruments that would allow the Bioethics work assessment in the State Field, in order to determine the effects and achieve a more detailed evaluation of their activities development, results that will allow a greater liaison with educational institutions, interested in this subject matter. Therefore, by achieving the goal of creating 32 State Commissions on Bioethics, the work shall be focalized in their operation, and on the impact of their existence in each State.

Other actions will imply to expand their scope of action, inasmuch as many times Bioethics application in the States materializes in the creation of Hospital Committees on Bioethics, and of Ethics Committees in Research, the Biggest Job of the State Commission on Bioethics, is to position the subject matter issue in such a form that it would be understood as an administration policy, and a priority in the health field´s human resources formation, as well as through its insertion in the educational field of different knowledge areas, representing an innovative model to entrench Bioethics in Mexico, within the framework of Federalism, and addressing the autonomy of each federative entity. In face of all the forgone, it is fundamental to continue with the performing of a thorough, exhaustive monitoring of all those issues that are worth of special attention by the CEB’s, and also of competent institutions and organizations (organisms), and proceed to their attention, pointing out their Bioethics implications.

There is no doubt that, the consolidation process of the State Commissions on Bioethics should be going to continue redefining themselves, being necessary the active participation of their members, the creation of more efficient and state of the art communication channels, and the generation of alliances among the different participants which will carry out the strengthening and the spreading out of Bioethics, both at a regional level, and at the whole Mexican society level too.