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Acupuntura na Enfermagem brasileira: dimensão ético-legal

Acupuncture in Brazilian Nursing Practice: Ethical and legaldimensions

Leonice Fumiko Sato Kurebayashi1, Taka Oguisso2, GenivalFernandes de Freitas3

ABSTRACTThe objective of this study was to reflect on the legal and ethical aspects for the practice of acupuncture by nurses in Brazil. There is a needfor nurses to be involved on a task force to create legal regulations and establish the scope of practice of acupuncture. This will prevent therestriction of the practice of acupuncture only to a specific health care professional group.Keywords: Acupuncture/legislation & jurisprudence; Acupuncture/ethics; Acupuncture therapy/ethics; Complementary therapies/legisla-tion & jurisprudence; Complementary therapies/ethics

RESUMOEstudo que teve como objetivo contribuir para a reflexão acerca da prática profissional da acupuntura pelo enfermeiro, contemplando asdimensões ético-legais do exercício dessa atividade. Concluiu-se que a participação da enfermagem na regulamentação legal para a atividadede acupuntura é urgente e necessária, para estabelecer seus limites e abrangência, sem, contudo, limitar-se a uma determinada categoriaprofissional.Descritores: Acupuntura/legislação & jurisprudência; Acupuntura/ética;Terapia por acupuntura/ética; Terapias complementares/legislação& jurisprudência; Terapias complementares/ética

RESUMENSe trata de un estudio que tuvo como objetivo contribuir a la reflexión respecto a la práctica profesional de la acupuntura del enfermero,contemplando las dimensiones ético-legales del ejercicio de esa actividad. Se concluye que la participación de la enfermería en la reglamentaciónlegal para la actividad de la acupuntura es urgente y necesaria, para establecer sus límites y lo que abarca, sin, con todo, limitarse a unadeterminada categoría profesional.Descriptores: Acupuntura/legislación & jurisprudencia; Acupuntura/ética; Terapia por acupuntura/ética; Terapias complementarias/legislación & jurisprudência; Terapias complementarias/ética

Corresponding Author: Leonice Fumiko Sato KurebayashiR. Capote Valente, 879 - Apto 22 - Jd. América - São PauloCep: 05409-002. E-mail: fumie_ibez@yahoo.com.br

Received article 25/02/2008 and accepted 25/08/2008

Acta Paul Enferm 2009;22(2):210-12.

1 Master in Nursing of the Programa de Pós-graduação da Escola de Enfermagem da Universidade de São Paulo - USP � São Paulo, (SP), Brazil. Nurse andacupuncturist. Member of the Nursing Legislation History and Research Group Universidade de São Paulo - USP.2 Lawyer, Professor of the Escola de Enfermagem da Universidade de São Paulo - USP -São Paulo, (SP), Brazil.3 Lawyer, Professor of the Escola de Enfermagem da Universidade de São Paulo - USP -São Paulo, (SP), Brazil.

Acupuntura en la Enfermería Brasileña: dimensión ético-legal

Acta Paul Enferm 2009;22(2):210-12.

211Acupuncture in Brazilian Nursing Practice: Ethical and legal dimensions

INTRODUCTION

Acupuncture, currently practiced in many westerncountries, originated in China, thousands of years ago(1).The World Health Organization (WHO) allows andencourages its use by member countries, and a documententitled �WHO Traditional Medicine (TM) Strategy, 2002-2005� was created, aiming to develop TM implementationpolicies and establishing safety, efficacy, quality, rationaluse and access requirements(2). In eastern countries,acupuncture has been practiced by technical professionals,eastern doctors, and western doctors specialized inTraditional Chinese Medicine (TCM). Regulations on thepractice of acupuncture have been occurring in manycountries. However, the professional profile of thoseallowed to practice it varies and oftentimes the first andmain requirement is that the professional has to havegraduated in western medicine. In Brazil, acupuncture hasbeen defended as a medical specialty by the Conselho Federalde Medicina (CFM � Federal Medical Council). However,it was accepted as a specialty in the sphere of Councilsfrom other health professional categories. Acupuncturehas been practiced by acupuncturists with foreignqualification, professionals qualified by short andprofessional courses other than university courses in Brazil,and acupuncture technicians and specialists, arousingethical-legal dilemmas concerning who has the right topractice this therapy in the country.

Historically, in terms of legal aspects, in 1982, theMinistry of Labor and Employment created theClassificação Brasileira de Ocupações (Brazilian Classificationof Occupations), including the occupation ofacupuncturist. Subsequently, a new version was made, bymeans of Decree nº 397/2002, describing the professionof acupuncturist as independent from other professionalcategories, including the medical one, under register nº3221-5(3).

The Ministry of Health presented the Política Nacionalda Medicina Natural e Práticas Complementares (National Policyon Natural Medicine and Complementary Therapies) tothe Sistema Único de Saúde (Unified Health System) inFebruary 2005, aiming to implement experiences that havealready been developed in the public health system ofmany cities and states, with emphasis on TCM/Acupuncture(4). It should be emphasized, however, thatin spite of the advances in acupuncture implementationin the public health system, its practice has been restrictedto the medical profession, dentistry and veterinary, withoutthe participation of other professional categories(5).

In Nursing, ethical questions have led to criticalreflections on values, freedom of action, and conscience,in terms of professional principles and foundations,involving judgments, beliefs and convictions(6). In thissense, there are ethical-legal questions about the practice

of acupuncture in Nursing. Moreover, nurses need toparticipate in the process of regulation of acupunctureas profession and its practice as a specialty, at the risk ofbeing prevented from practicing it. Thus, this study aimedto contribute to the reflection on the professional practiceof acupuncture by the nurse, considering its ethical-legaldimensions.

ETHICAL-LEGAL ASPECTS OF THEPRACTICE OF ACUPUNCTURE BY NURSES

In the nursing profession, it is not enough to betechnically prepared. Learning about current ethical, legaland technical aspects is what the nurse�s conduct shouldbe founded on. In this way, they can have a critical andreflective approach to the dilemmas that involve theirroutine practice, based on legal norms and ethical-deontological principles(7). In the sphere of debates aboutacupuncture as a nursing practice, the Conselho Federal deEnfermagem (COFEN �Federal Nursing Council)recognized acupuncture as a specialty by Resolution nº197/97(8). The COFEN establishes and regulates thepractice of nursing and, since its creation, in accordancewith Law nº 5.905/1973, it has been the institution withlegislative competence for nursing, according toresolutions �that have the force of law (even though theyare not laws)�(6). They show validity and efficacy, as theydo not oppose the Lei do Exercício Profissional de Enfermagem(LEPE nº 7.488/1986 � Law of Professional NursingPractice), establishing acupuncture as a specialty.

In this perspective, the LEPE/1986, in article 11,section 1, establishes that the nurse is exclusivelyresponsible for: �higher technical complexity care, whichrequires scientific knowledge and the ability to makeimmediate decisions�. The above mentioned law is inconcordance with the Código de Ética dos Profissionais deEnfermagem (CEPE � Nursing Professionals� Code ofEthics), in article 17, which foresees, as a nurse�s ethical-moral obligation, the assessment of technical (to knowhow to do safely, technical mastery and ability) and legalcompetences (those foreseen by law), and only assume aresponsibility when being capable of performing it safelyfor oneself and for the client. They must aim to achievemaximum benefits and minimize risks or harm to theclients cared for. Thus, it is understood that nursingprofessionals� ethics has the following guiding values forperformance: competence, justice, responsibility andhonesty, assuring that clients will be provided care freefrom flaws or errors caused by lack of expertise,negligence or imprudence(6).

As a result, it could be asked why a nurse would notbe fit to practice acupuncture. Why should it be anexclusive medical practice, if it was refused and despisedby these professionals until a short time ago and it is now

212 Kurebayashi LFS, Oguisso T, Freitas GF.

Acta Paul Enferm 2009;22(2):210-12.

REFERENCES

1. São Paulo (Cidade). Prefeitura do Município de São Paulo.Secretaria Municipal de Saúde. Caderno Temático da MedicinaTradicional Chinesa [Internet]. São Paulo; 2002. [citado 2006Out 16]. Disponível em: http://ww2.prefeitura.sp.gov.br//arquivos/secretarias/saude/areas_tematicas/0047/MTC_CadernoTematico.pdf

2. Organização Mundial de Saúde. Novas Diretrizes daOrganização Mundial de Saúde (OMS) para fomentar o usoadequado das Medicinas Tradicionais [Internet]. Genebra;2004. [citado 2006 Ago 10]. Disponível em: http://www.who.int/mediacentre/news/releases/2004/pr44/es.

3. Brasil. Ministério do Trabalho e Emprego. CBO - ClassificaçãoBrasileira de Ocupações. Portaria Nº 397 de 9 de outubro de2002. Aprova a Classificação Brasileira de Ocupações - CBO/2002, para uso em todo território nacional e autoriza a suapublicação [ Internet]. Brasília; 2002a. [citado 2007 Fev 25].Disponível em: http://www.mtecbo.gov.br/legislacao.asp

4. Brasil. Ministério da Saúde. Política Nacional de MedicinaNatural e Práticas Complementares (PMNPC) [Internet].Brasília (DF); 2005. [citado 2007 Fev 28]. Disponível em:h t tp ://bvsms. saude.g ov.br/bvs/pub l i cacoes/ResumoExecutivoMedNatPratCompl1402052.pdf

5. Kurebayashi LFS, Oguisso T, Campos PFS, Freitas GF.Acupuntura na enfermagem brasileira: uma história emconstrução. Rev Paul Enferm. 2007;26(2):127-33.

6. Freitas GF. Conceituação sobre direito e normas éticas elegais. In: Oguisso T, organizador. Trajetória histórica e legalda enfermagem. Barueri: Manole; 2005. p.159-72.

7. Fernandes MFP, Freitas GF. Fundamentos da ética. In:Oguisso T, Zoboli E, organizadores. Ética e bioética:desafios para a enfermagem e a saúde. Barueri: Manole;2006. p. 27-44

8. Conselho Federal de Enfermagem (COFEN). ResoluçãoCOFEN-197/97. Estabelece e reconhece as terapiasalternativas como especialidade e/ou qualificação doprofissional de enfermagem [Internet]. Brasília (DF); 1997.[citado 2006 Nov 20]. Disponível em: http://w w w . p o r t a l c o f e n . g o v . b r / 2 0 0 7 /materias.asp?ArticleID=7041&sectionID=34

9. Almeida Filho JCA. Regulamentação da profissão deacupunturista: ato médico ou corporativismo?[Dissertação]. Rio de Janeiro: Universidade Gama Filho;2003.

10. Brasil. Câmara dos Deputados. Projeto de Lei 7.703/2006 [ Internet]. Brasília: 2006. [citado 2007 Set 10].Disponível em: http://www.camara.gov.br/sileg/integras/442391.pdf

11. Conselho Regional de Medicina do Paraná. Arquivos [Internet] 2006 [citado 2006 Ago 10]. Disponível em: http://www.portalmedico.org.br/Regional/crmpr/revista/revista_arquivo842005.pdf

12. Brasil. Ministério da Saúde. Portaria nº 971 de 3 de maio de2006. Aprova a Política Nacional de Práticas Integrativas eComplementares (PNPIC) no Sitema Único de Saúde.Diário Oficial da União, Brasília, 4 Maio 2006. Seção 1,p.20.

claimed as their exclusivity? CFM resolutions, concerninghomeopathy and acupuncture, are the only �legalexceptions�, prohibiting the practice of these therapiesby non-doctors. However, it is worth emphasizing againthat such resolutions can only have �legal efficacy� withinthe limits of the category it is aimed at. Thus, it is notpossible for the CFM to expect its resolutions to havethe force of law, as this would go against the Constitutionitself(9).

The heated debate on what is called the Medical Act,in view of the Projeto de Lei do Senado nº 7703/2006 (PLS� Senate Bill nº 7703/2006), has become frequent amonghealth professionals. Acupuncture, as a medical specialtyin the western world, was only recognized by the CFM in1995, by Resolution CFM nº 1455/95, considering it tobe a medical act. In the analysis of constitutionality ofthe Medical Act, this Senate Bill, if approved, could leadto innumerable problems for professional acupuncturistsand health professionals that want to practice this therapy.If acupuncture is to be viewed as an exclusive medicalactivity, there can be violation of a right acquired,according to section 36 of article 5 of the Constitution,because it has already been recognized as a specialty by

nurses and other health professionals. The Ministry ofHealth Directive nº 971/2006 shows new paths toacupuncture, as it is included by the Sistema Único de Saúde(Unified Health System) as a practice of healthprofessionals who have completed a specializationcourse(12).

FINAL CONSIDERATIONS

In view of what has been presented here, it isunderstood that the challenge nurses are faced with istheir participation in the implementation of the practiceof acupuncture, whether as a profession or a specialtyof their professional category. The professional culturedepends largely on the interest and awareness of thosewho perform a profession and are involved with theknowing and practicing that characterize it. Consequently,it is essential to broaden conceptual horizons regardingthe benefits of acupuncture, extending this therapy tonurses in both public and private health institutions anduniversities, so that it becomes a shared and ethicalmultiprofessional practice, benefitting the Brazilianpopulation.