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• PHYSICAL ACTIVITY, HEALTH, AND BIOETHICAL PRINCIPLES: THE NEED FOR AN EXPANDED AND DECOLONIAL APPROACH
  Alexandre Palma, Giovana B Paiva, Mariane FS Araújo and Murilo M Vilaça
  Published on: 1 September 2021

• Published on: 1 September 2021

  PHYSICAL ACTIVITY, HEALTH, AND BIOETHICAL PRINCIPLES: THE NEED FOR AN EXPANDED AND DECOLONIAL APPROACH

  • Alexandre Palma, Professor Universidade Federal do Rio de Janeiro/ Physical Education and Sports School/ Rio de Janeiro/ Brazil
  • Other Contributors:
    • Giovana B Paiva, Physical Education Teacher
    • Mariane FS Araújo, Physical Education Teacher
    • Murilo M Vilaça, Professor

  Some decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
  The relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
  It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
  Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
  Regarding the expansion of the non-...

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  Some decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
  The relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
  It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
  Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
  Regarding the expansion of the non-maleficence principle, it has been shown that occupational physical activity can be harmful to one’s health, extending the physical activity paradox beyond the harmful effects of intensity. 4 This finding contradicts the idea that physical activity in its various dimensions is beneficial.
  Another point that deserves wide attention concerns inequalities and how they impact various aspects of individuals’ relationships with physical exercise. Various studies have indicated that the vulnerability of certain social groups—such as black people, people of low socioeconomic status, and women—interferes with the performance of leisure-time physical activities or even other behaviours considered as healthy 5–6. We view this as an affront to the principle of justice. Moreover, some researchers have disregarded such inequalities and reinforced blaming the individual for his or her ‘failure’ to engage in behaviour considered appropriate, even arguing that it leads to enormous economic costs to society. 7 This position clearly aligns with neoliberal precepts since it places the responsibility for taking care of oneself on the individual, thus removing it from the State. Why, in general, are women less involved with leisure-time physical activities than men? Why is the same true for black people? Why is physical inactivity lower among black women? How do violence, mobility, and urban planning impact physical activity? Are more impoverished people equally likely to have access to leisure-time physical activity? The possibility of exercising does not seem equal for everyone.
  Although we recognise that the focus of Pugh et al. 3 was correct medically, we consider that inequities interfere decisively in the possibility that any isolated measure effectively produces some benefit and/or avoids some harm. The principles of beneficence and non-maleficence may not be guaranteed if effective measures to combat inequities are not adopted. Regarding the context of peripheral countries, it is essential to consider adequate bioethical theories, rather than principlism. 8
  In particular, socially excluded people—because of their unequal position in society—may sometimes be unable to make autonomous decisions. The capacity to make decisions is in itself incomplete, relative, non-global, and determined by a series of changing contextual aspects.
  We also consider it necessary to question the supposed universality of bioethical principles since they are often presented within a colonialist perspective. This posture is reflected in individuals’ concepts of autonomy, which we believe should be decolonised. Decolonisation stimulates the debate about the knowledge and experiences of the community to reveal their richness. This process is in line with a vision of social justice: achieving health equity considering individual and collective empowerment. Therefore, taking advantage of the knowledge and perspectives of social groups to contribute to the development of specific interventions seems essential for yielding effective results.
  Finally, we highlight the insistence on considering the relationship between physical exercise and health as a problem that is only biomedical. The resulting discourses reinforce the idea of the medicalisation of exercise. Thus, the practitioner becomes a patient and the pleasure for the practice is always neglected.

  References
  1. Beauchamp TL, Childress JF. Principles of biomedical ethics. 8 ed. New York: Oxford University Press, 2019.
  2. Booth FW, Roberts CK, Laye MJ. Lack of Exercise Is a Major Cause of Chronic Diseases. Compr Physiol 2012; 2:1143-1211.
  3. Pugh J, Pugh C, Savulescu, J. Exercise prescription and the doctor’s duty of non-maleficence. Br J Sports Med 2017; 51:1555-1556.
  4. Holtermann A, Schnohr P, Nordestgaard BG, Jacob Louis Marott JL. The physical activity paradox in cardiovascular disease and all-cause mortality: the contemporary Copenhagen General Population Study with 104 046 adults. Eur Heart J 2021; 42:1499-1511.
  5. Brodersen NH, Steptoe A, Boniface DR, Wardle J. Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences. Br J Sports Med 2007; 41:140-144.
  6. Abichahine H, Veenstra G. Inter-categorical intersectionality and leisure-based physical activity in Canada. Health Promot Int 2017; 32:691-701.
  7. Allender S, Foster C, Scarborough P, Rayner M. The burden of physical activity-related ill health in the UK. J Epidemiol Community Health 2007; 61:344-348.
  8. Garrafa V, Porto D. Intervention bioethics: a proposal for peripheral countries in a context of power and Injustice. Bioethics 2003; 17: 399-416.

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  Conflict of Interest:
  None declared.

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