Abstract

Introduction

Educating health professionals to be qualified to act in a humane way and in consonance with the principles and guidelines of Brazil’s Healthcare System is a contemporary challenge both to the field of Health and to the field of Higher Education. This challenge has become even more complex in view of the diagnosis of crisis in these two fields⁵5. Ministério da Saúde. Ministério da Educação (BR). Pró-saúde: programa nacional de reorientação da formação profissional em saúde [Internet]. Brasília (DF): Ministério da Saúde; 2005 [acesso 2014 Jun 26]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pro_saude_cgtes.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,66. Feuerwerker LCM, Sena R. A construção de novos modelos acadêmicos, de atenção à saúde e de participação social. In: Almeida M, Feuerwerker LCM, Llanos CM, organizadores. A educação dos profissionais da saúde na América Latina: teoria e prática de um movimento de mudança. São Paulo: Hucitec; 1999. p. 47-82.. In the field of health, the crisis is caused by the contradiction between the dominant model, which is biomedical, centered on the technical fight against the disease – a model that has been presenting signs of exhaustion -, and the model of social construction of health, grounded on health construction practices.

The biomedical model originates from a concept of health as absence of disease. It proposes the provision of care for the patient in view of his/her individual and biological aspects, centered on the hospital, on the hegemony of medical specialties, on the intensive use of technology, and emphasizing the recovery of the ill individual. The model of social construction of health, in turn, is supported by the strengthening of care and by the increasing autonomy of populations in relation to health. The crisis in the field of health is revealed, above all, by the incapacity of the majority of societies to promote and protect collective health, and such incapacity is related to the inefficacy and inefficiency of the care systems and of the predominant care model, to the structural difficulties to finance them, and to the population’s growing dissatisfaction with their relation to the services and health professionals⁶6. Feuerwerker LCM, Sena R. A construção de novos modelos acadêmicos, de atenção à saúde e de participação social. In: Almeida M, Feuerwerker LCM, Llanos CM, organizadores. A educação dos profissionais da saúde na América Latina: teoria e prática de um movimento de mudança. São Paulo: Hucitec; 1999. p. 47-82.. Pinheiro and Ceccim (2006)⁷7. Pinheiro R, Ceccim RB. Experienciação, formação, cuidado e conhecimento em saúde: articulando concepções, percepções e sensações para efetivar o ensino da integralidade. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: IMS/UERJ, Cepesq, Abrasco; 2006. p. 13-35. corroborate this perspective when they state that the urgent need to transform health education derives, among other factors,

In education, the crisis is revealed by the opposition between the traditional hegemonic conception and the critical reflective conception. The former is expressed through the pedagogy of transmission, the pedagogical practice centered on the teacher and on the curriculum, and through the acquisition of knowledge in a way that is not connected with reality. The latter, in turn, is sustained by knowledge construction based on the problematization of reality, by the articulation between theory and practice, and by the student’s active participation in the teaching-learning process. Furthermore, it is possible to identify a philosophical crisis influencing and being related to the crises mentioned above: the Cartesian model of science has separated all the sensitive qualities from the world, because in order to know the true being of the universe, it would be necessary to abandon all sensations and impressions, desires and affections – everything that is presented as subjective and that, allegedly, does not allow the formation of rigorous and universal scientific propositions⁶6. Feuerwerker LCM, Sena R. A construção de novos modelos acadêmicos, de atenção à saúde e de participação social. In: Almeida M, Feuerwerker LCM, Llanos CM, organizadores. A educação dos profissionais da saúde na América Latina: teoria e prática de um movimento de mudança. São Paulo: Hucitec; 1999. p. 47-82..

On the one hand, there is the recognition that Cartesian science and the biomedical paradigm have promoted many technical advances in relation to health, mainly in medicine, which are reflected on the populations’ increased life expectancy. On the other hand, it is necessary to recognize that they have also generated an excessive distance between professionals and population, which produces the growing dissatisfaction that is revealed on a daily basis, the sad and widely reported cases of negligence, lack of expertise and imprudence, and accusations of omission of help and indifference concerning the suffering of people who receive care from these professionals. Last but not least, there are many cases of mental suffering among health professionals, whose etiology is related to a dehumanizing labor experience.

In view of the challenge of constructing a professional action that is increasingly permeated by solidarity and ethics in the area of health, we propose, in this article, the possibility of reflecting on alternatives to the philosophical crisis that affects health and education in order to revive a broad and integral perspective of the health and disease process in the educational processes. This perspective should include sensitive qualities (sensations, impressions, desires, affections) and the understanding that they compose an integral panorama of life. This is about reviving the holistic view that used to be present in the Greek Hippocratic medicine, but was progressively left aside because it was considered a source of mistakes by the Cartesian thought and, consequently, by the biomedical knowledge.

When we revisit the Greek Hippocratic medicine, it is interesting to highlight its holistic character, which advocates that professionals must approach the patient as a whole. This holism was rooted in cultural values that were much disseminated in the Greek society⁸8. Bynum W. História da Medicina. Souto Maior F, tradutora. Porto Alegre: L± 2011., among which friendship stands out. Thus, the question that guides the outline that we attempted to give to this article is: How can frank speech and friendship be configured as pedagogical and philosophical principles in the educational process of health professionals?

Employing the hermeneutic tradition, we highlight that the concepts of frank speech and friendship that we intend to adopt in this discussion are of Greco-Roman origin and were reconstructed by Michel Foucault in the analyses he developed in the courses he gave at the Collège de France from 1976 to 1984. In this period, the author enters into the third domain of his work (the domain of the constitution of the “subject”) and develops concepts like ascesis, conversion, parrhesia and friendship, notions that are, sometimes, neglected, as they were not approached in a systematic way in his last and incomplete work, The History of Sexuality⁹9. Freitas AS. A parresía pedagógica e o êthos da educação como psicagogia. Rev Bras Educ [Internet]. 2013 [acesso 2014 Jun 26]; 18(53):325-493. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-24782013000200005 Doi: 10.1590/S1413-24782013000200005.
http://www.scielo.br/scielo.php?script=s... ^,1010. Ortega F. Amizade e estética da existência em Foucault. Rio de Janeiro: Graal; 1999..

It is important to emphasize that the publication of these courses and the understanding of the philosophical and pedagogical potential of these concepts have stimulated a new reception of Foucault’s ideas in the field of education⁹9. Freitas AS. A parresía pedagógica e o êthos da educação como psicagogia. Rev Bras Educ [Internet]. 2013 [acesso 2014 Jun 26]; 18(53):325-493. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-24782013000200005 Doi: 10.1590/S1413-24782013000200005.
http://www.scielo.br/scielo.php?script=s... and health professionals’ education^(bb The term parrhesia can be found in the Pubmed database. It is possible to find, in this database, nine references related to the uses of parrhesia in health professionals’ education. Given the limit of number of words for this article, it was not possible to add, to the present work, the discussions held about the theme in these publications. This will be accomplished in future studies related to this theme.⁾. From Foucault’s late thought, it is possible to “see clearly the birth of a reflection on the methods, knowledge and exercises that are necessary to impel a formative dynamics directed at the ethical discourse-action” ⁹9. Freitas AS. A parresía pedagógica e o êthos da educação como psicagogia. Rev Bras Educ [Internet]. 2013 [acesso 2014 Jun 26]; 18(53):325-493. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-24782013000200005 Doi: 10.1590/S1413-24782013000200005.
http://www.scielo.br/scielo.php?script=s... . For this reason, we have elected this stage of Foucault’s thought, highlighting the relationship that is established between friendship and parrhesia (true speech, frank speech) in the direction of conscience. According to Foucault⁴4. Foucault M. A hermenêutica do sujeito. São Paulo: Martins Fontes; 2004.,

To reflect on how friendship and parrhesia can become a pedagogical and philosophical foundation in the process of health professionals’ education, the discussion is divided into three parts. In the first part, we reconstruct the tension that exists between the healthcare models still in force: the traditional biomedical model and the model of social construction of health. The latter has originated the concern about the reorientation process of health professionals’ education. In the second part, we ground a philosophical perspective in the hermeneutic tradition, which sheds light on the possibility of amplifying university education in general, and health professionals’ education in particular, using, mainly, Hans-Georg Gadamer’s thought and the relation that is established to Hippocratic medicine. Finally, in the third part, we debate, also in a hermeneutic perspective, although different from Gadamer’s, how friendship and parrhesia, as presented in Michel Foucault’s thought, can become a pedagogical and philosophical foundation for health professionals’ education.

Tension between the healthcare models still in force and the concern about the reorientation process of health professionals’ education

The set of problems that originates the reflection proposed in this article is represented by the current tension between the traditional biomedical model and the model of social construction of health, which demands that the education of the professionals who work in this area should be reoriented. The model of health and medicine targeted at the provision of care for diseases in the individual and biological level, centered on the hospital, on medical specialties and on the intensive use of technology, is called biomedical or Flexnerian model, in reference to the Flexner Report, published in 1911. The report founded the reform of the schools of medicine in the United States and Canada. This model structured social security healthcare in the 1940s and 1950s, and guided the organization of university hospitals or teaching hospitals¹¹11. Silva Júnior AG, Alves CA. Modelos assistenciais em Saúde: desafios e perspectivas. In: Morosini MVGC, Corbo ADA, organizadores. Modelos de atenção e a saúde da família. Rio de Janeiro: EPSJV, Fiocruz; 2007. p. 27-42.. The biomedical model gives little relevance to the psychosocial context of phenomena, which are extremely important for a full and adequate understanding of individuals, their health and their diseases. As the consequence of an educational process anchored on this model, a posture of negligence of psychosocial aspects, both of the health professionals and of the individuals they assist, has been constructed¹²12. De Marco MA. Do modelo biomédico ao modelo biopsicossocial: um projeto de educação permanente. Rev Bras Educ Med [Internet]. 2006 [acesso 2014 Jun 28]; 30(1):60-72. Disponível em: http://www.scielo.br/pdf/rbem/v30n1/v30n1a10.pdf Doi: 10.1590/S0100-55022006000100010.
http://www.scielo.br/pdf/rbem/v30n1/v30n... . Due to this, the professional education and healthcare that are based on this model have been increasingly criticized. One example is the criticism made by Barros¹³13. Barros JA. Pensando o processo saúde doença: a que responde o modelo biomédico? Saude Soc [Internet]. 2002 [acesso 2014 Jun 28]; 11(1):67-84. Disponí-vel em: http://www.scielo.br/pdf/sausoc/v11n1/08.pdf Doi: 10.1590/S0104-12902002000100008.
http://www.scielo.br/pdf/sausoc/v11n1/08... :

The belief that the biomedical model is the only one that is capable of fully meeting the health demands has been showing signs of exhaustion. Moreover, the health demands have been increasingly extrapolating the reductionist perspective of health as absence of disease. Therefore, in order to create alternatives to think about health in a broader way, from the 1970s onwards, the model of social construction of health has been established in the international debates as an alternative proposal to the biomedical model, emphasizing the rational use of technologies in healthcare and efficient management. In this model, the centrality of promotion, protection, recovery and production of healthcare generates the need of transformations in the professional education process¹¹11. Silva Júnior AG, Alves CA. Modelos assistenciais em Saúde: desafios e perspectivas. In: Morosini MVGC, Corbo ADA, organizadores. Modelos de atenção e a saúde da família. Rio de Janeiro: EPSJV, Fiocruz; 2007. p. 27-42..

Concerning the trend of perspective in the field of health in Brazil, it is possible to observe

In this sense, strengthening a vigorous articulation between educational institutions and the public health service is a permanent challenge. It is necessary to correct the mismatch between the orientation of health professionals’ education and the principles, guidelines and needs of the SUS.

The national consensus about the need to reorient the model of health professionals’ education¹⁴14. Ministério da Saúde. Ministério da Educação (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial [Internet]. Brasília (DF): Ministério da Saúde; 2007 [acesso 26 Jun 2014]. Disponível em: http://www.prosaude.org/publicacoes/pro_saude1.pdf
http://www.prosaude.org/publicacoes/pro_...

15. Ceccim RB. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Cad Saude Publica [Internet]. 2009 [acesso 2015 Nov 8]; 25(10):2299-300. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2009001000021&lng=pt&nrm=iso&tlng=pt Doi: 10.1590/S0102-311X2009001000021.
http://www.scielo.br/scielo.php?script=s...

16. Portaria Interministerial nº 2.101, de 3 de novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde – para os cursos de graduação em Medicina, Enfermagem e Odontologia [Internet]. Diário Oficial da União. 4 Nov 2005; (212):111 [acesso 2014 Jun 26]. Disponível em http://portal.saude.gov.br/portal/arquivos/pdf/2101.pdf
http://portal.saude.gov.br/portal/arquiv... ^-1717. Stedile NLR, Friendlander MR. Metacognição e ensino de Enfermagem: uma combinação possível? Rev Latino-Am Enfermagem [Internet]. 2003 [acesso 2014 Jun 26]; 11(6):792-9. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-11692003000600014&script=sci_arttext Doi: 10.1590/S0104-11692003000600014.
http://www.scielo.br/scielo.php?pid=S010... has its greatest expression in the Programa Nacional de Reorientação da Formação Profissional em Saúde (PRÓ-SAÚDE – National Program for the Reorientation of Health Professional Education), designed by the Ministry of Health in partnership with the Ministry of Education and in cooperation with the Pan American Health Organization (PAHO). According to PRÓ-SAÚDE, the change in the educational process is centered on the shift of the reductionist understanding of health (as absence of disease in the biological level) towards a more comprehensive understanding of integral health, determined by economic, political, social, biological and cultural factors.

The intervention in the educational process constitutes, in the perspective of PRÓ-SAÚDE, the most adequate means to reach this change in the conception of health. To achieve this, it is necessary to shift the axis of education, which is currently centered on individual care provided at specialized units, to be in tune with the social needs, considering the economic, cultural and social dimensions in which the population lives and qualifying professionals for a generalist, humanistic and ethical approach, characterized by solidarity, to the determinants of the health-disease binomial⁵5. Ministério da Saúde. Ministério da Educação (BR). Pró-saúde: programa nacional de reorientação da formação profissional em saúde [Internet]. Brasília (DF): Ministério da Saúde; 2005 [acesso 2014 Jun 26]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pro_saude_cgtes.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,1414. Ministério da Saúde. Ministério da Educação (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial [Internet]. Brasília (DF): Ministério da Saúde; 2007 [acesso 26 Jun 2014]. Disponível em: http://www.prosaude.org/publicacoes/pro_saude1.pdf
http://www.prosaude.org/publicacoes/pro_... . Therefore, it is necessary to modify a formal educational process that does not give sufficient attention to the issue of health promotion and prevention of health problems, as it is usually fragmented and dissociated from the social context, and emphasizes technical excellence and specialized education. As for the pedagogical focus, it is frequently limited to traditional methodologies based on knowledge transmission, which do not focus on the critical education of the student. The interdisciplinary approach and working in multiprofessional teams are rarely explored by the educational institutions in undergraduate courses, and this is reproduced in the healthcare teams, resulting in the isolated action of each professional and in the overlap of care actions and their fragmentation¹⁴14. Ministério da Saúde. Ministério da Educação (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial [Internet]. Brasília (DF): Ministério da Saúde; 2007 [acesso 26 Jun 2014]. Disponível em: http://www.prosaude.org/publicacoes/pro_saude1.pdf
http://www.prosaude.org/publicacoes/pro_... .

Concerning the development of the proposal of PRÓ-SAÚDE, it is necessary to take into account the importance of the integrality of actions, as well as the individual and collective dimension, emphasizing the interdisciplinary approach, with a broad articulation between preventive and curative actions, and actions in the community, in the outpatient clinic, in teaching clinics and in the hospital sphere¹⁴14. Ministério da Saúde. Ministério da Educação (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial [Internet]. Brasília (DF): Ministério da Saúde; 2007 [acesso 26 Jun 2014]. Disponível em: http://www.prosaude.org/publicacoes/pro_saude1.pdf
http://www.prosaude.org/publicacoes/pro_... . Respecting the national guidelines approved by the Ministry of Education, the educational process must pay attention to the accelerated rhythm of knowledge evolution, to the change in the process of work in the field of health, and to the transformations in demographic and epidemiological aspects in the perspective of the balance between technical excellence (specialization, high technology, sophisticated premises and overvaluation of technical knowledge) and social relevance (equitable access, integral approach, ethical and humanistic orientation, and promotion of quality of life)¹⁴14. Ministério da Saúde. Ministério da Educação (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial [Internet]. Brasília (DF): Ministério da Saúde; 2007 [acesso 26 Jun 2014]. Disponível em: http://www.prosaude.org/publicacoes/pro_saude1.pdf
http://www.prosaude.org/publicacoes/pro_... .

However, the challenge seems to be how to find balance between technical excellence and social relevance, respecting the specificities of each area without losing the integral human dimension that is behind any health phenomenon. This challenge calls for reflection and corroborates Ceccim’s summons (2009)¹⁵15. Ceccim RB. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Cad Saude Publica [Internet]. 2009 [acesso 2015 Nov 8]; 25(10):2299-300. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2009001000021&lng=pt&nrm=iso&tlng=pt Doi: 10.1590/S0102-311X2009001000021.
http://www.scielo.br/scielo.php?script=s... when he states that:

In light of the challenge presented in the summons cited above, we believe in the potential of hermeneutics and parrhesia as forms of appreciation of experience and of relation to truth that respect the necessarily singular dimension of education without turning away from the universalizing objectives of the field of health, from its inevitable commitment to all individuals.

The philosophical hermeneutic perspective and the relation to Hippocratic medicine shedding light on the amplification of the educational process of health professionals

Gadamer¹⁸18. Gadamer HG. O caráter oculto da saúde. Petrópolis: Vozes; 2006., Nussbaum¹⁹19. Nussbaum M. Sin fines de lucro: por qué la democracia necesita de las humanidades. Buenos Aires: Katz Editores; 2010., Flickinger²⁰20. Flickinger HG. A caminho de uma pedagogia hermenêutica. Campinas: Autores Associados; 2010., and Dalbosco²¹21. Dalbosco CA. Universidade e formação profissional alargada: porque ainda humanidades. In: Bertolin JCG, Souza JCC, organizadores. Planejamento institucional de uma universidade comunitária: ideias, propostas e experiências na UPF. Passo Fundo: UPF; 2012. p. 24-35. warn us of the risks of technicism in the education of university students and also that democracy needs the humanities. The authors’ warning corroborates the perspectives that advocate closer relations between health professional education and what the SUS recommends, as proposed by PRÓ-SAÚDE.

Dalbosco²¹21. Dalbosco CA. Universidade e formação profissional alargada: porque ainda humanidades. In: Bertolin JCG, Souza JCC, organizadores. Planejamento institucional de uma universidade comunitária: ideias, propostas e experiências na UPF. Passo Fundo: UPF; 2012. p. 24-35. reveals a worldwide trend of higher education, marked by technicism and by the progressive reduction of knowledge to information, focusing on the education of professionals to meet the immediate demands of the labor market to the detriment of a broad cultural education. In this sense, the author warns us against the reduction in the role of the humanities in the education of the new generations of students, through the exclusion of humanistic disciplines from undergraduate curricula. Furthermore, he warns us against the double risk that this worldwide trend causes: reductionism in the idea of university as a center of knowledge production and socialization to the detriment of research and teaching, and a threat to the democratic conception of society.

Nussbaum¹⁹19. Nussbaum M. Sin fines de lucro: por qué la democracia necesita de las humanidades. Buenos Aires: Katz Editores; 2010. also analyzes the significant reduction in the number of humanistic disciplines in the professional education of the new generations and the fact that professionalizing teaching is insufficient in the preparation of the new generations for democracy. This happens mainly because it is the arts and literature, according to the author, that originate the imagination that enables students to develop their creative capacity and the interest in the other. Flickinger¹⁶16. Portaria Interministerial nº 2.101, de 3 de novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde – para os cursos de graduação em Medicina, Enfermagem e Odontologia [Internet]. Diário Oficial da União. 4 Nov 2005; (212):111 [acesso 2014 Jun 26]. Disponível em http://portal.saude.gov.br/portal/arquivos/pdf/2101.pdf
http://portal.saude.gov.br/portal/arquiv... also warns us of the loss of the notion of whole caused by specialization, but argues that wanting to revive the old stage of a unique view of human knowledge, and expect that it will be capable of integrating the diversity that exists today into the sciences, would be extremely naïve. He proposes the intensification of the debate about a possible reconstruction of bridges among disciplines.

Gadamer¹⁸18. Gadamer HG. O caráter oculto da saúde. Petrópolis: Vozes; 2006. discusses the theme of healthcare in the era of science and technique and argues that the mathematical-experimental thought has been imposed so strongly on the art of curing that it has become lost in the labyrinth of specialization. At the same time, the notion of whole has also been lost. “Unfortunately, we have to admit to ourselves that what followed the progress of science was a huge throwback in general healthcare and in disease prevention” ¹⁸18. Gadamer HG. O caráter oculto da saúde. Petrópolis: Vozes; 2006. (p.111). To recover the notion of whole, he proposes the construction of bridges between philosophy and practical medicine through the double face of theory and praxis. To the author, theory means contemplating, looking, recognizing what is or what is presented. In praxis, a permanent process of learning and self-correction is conducted, either with success or with failure. We must learn how to cross the division that exists between the theoretician, who knows about generalities, and the practitioner, who must act in the unique situation of the ill patient. This closeness between theory and praxis would be triggered by the discussion about the notion of whole, of totality, of balance, and of treatment as listening, dialog and careful look. According to the German philosopher, these are the elements that can oppose the instrumentalization of science in the area of health¹⁸18. Gadamer HG. O caráter oculto da saúde. Petrópolis: Vozes; 2006..

Gadamer highlights that we find a rich material in the Greek Hippocratic medicine that illustrates that all the climatic and environmental factors contribute to the concrete constitution of the being whose recovery is the focus. Thus, the context that surrounds the treated party allows to conclude that the nature of the whole encompasses the entire vital situation of the patient and even that of the doctor. Hence, medicine can be compared to true rhetoric. The physician, as much as the true speaker, must see the totality of nature. The speaker must find the right word by means of true judgement; likewise, the physician must see beyond the object of his knowledge and beyond what he is capable of doing, if he wants to be a true physician. His condition is an intermediate position, which is hard to maintain, between a professional presence far from the human and a commitment to the human. His state of physician is constituted by the fact that he needs trust and, at the same time, he has to limit his power. It is necessary to see beyond the case he is treating so that he can evaluate the human being in the whole of his vital situation. Therefore, the physician must reflect on his own activity and on what it causes in the patient. He must know when to withdraw, because he can neither make the patient depend on him nor unnecessarily prescribe conditions of life conduct that hinder the reestablishment of the patient’s vital balance¹⁸18. Gadamer HG. O caráter oculto da saúde. Petrópolis: Vozes; 2006..

When we highlight that the physician needs to reflect on his activity and on what it causes in the patient – and, meanwhile, understand that he can neither make the patient depend on him nor unnecessarily prescribe conditions of life conduct -, perhaps it is possible to suggest a common point between this Gadamerian perspective and friendship as parrhesia in Foucault, understanding education less as an art of governing or guiding and more as a force of sensitive affection of subjects. And, in this way, perhaps it is possible to propose friendship as parrhesia as a didactic, educational and philosophical foundation in the teaching of the disciplines in the area of health.

Friendship and parrhesia - the relation to health professionals’ education

The concept of friendship proposed in this discussion is of Greco-Roman origin and was reconstructed by Michel Foucault in his historical analyses developed in the courses he gave at the Collège de France (1976-1984). The relationship that is established between friendship and parrhesia stands out in this phase of the Foucauldian thought. In the courses he gave in 1983 and 1984 about the theme of parrhesia (true spokenness), Foucault emphasized the role of the friend, whose presence was fundamental to the success of this practice. To present oneself to the other’s judgement presupposed the trust of a personal relationship and a common relationship to the truth. In the other’s eyes, the esthetics of the very existence emerged and was, in this way, apprehensible, reflecting on the other¹⁰10. Ortega F. Amizade e estética da existência em Foucault. Rio de Janeiro: Graal; 1999.. However, this notion is not univocal in all the writings of Antiquity, and in order to extend the notion to other possible meanings of the term, we turn to Foucault²2. Foucault M. A coragem da verdade. São Paulo: Martins Fontes; 2011.:

Foucault²2. Foucault M. A coragem da verdade. São Paulo: Martins Fontes; 2011. argues that parrhesia is not a mere demonstration, although it implies demonstrating and using one’s strategies to perform it; also, it is not a rhetoric: on the contrary, perhaps it is its negative, as it does not use figures of thought, it is not an art of speaking; it is not a form of discussing, either, as it does not presuppose the prevalence of one discourse over another; and, what influences most directly the proposal of this essay, it is not a pedagogical technique, it is not a type of teaching; rather, “the truth is thrown at the face of the individual with whom the subject talks or to whom the subject addresses”²2. Foucault M. A coragem da verdade. São Paulo: Martins Fontes; 2011., in a way that may be considered anti-pedagogical. However, even though it is not a pedagogical practice, it aims at or achieves a transformation: of the subject that practices it and of the individual to whom the true speech is directed. It is not a teaching method; rather, it is an educational experience.

Parrhesia and its meanings of “saying everything”, “speaking freely”, “word freedom”, is a complex notion, as it represents, simultaneously, virtue, ability, obligation and technique, which must characterize the individual whose task is to guide other individuals in their constitution as moral subjects¹⁰10. Ortega F. Amizade e estética da existência em Foucault. Rio de Janeiro: Graal; 1999..

In the 1^st and 2^nd centuries of the current era – the historical moment on which Foucault concentrates his studies and in which he finds subsidies to the courses he gave between 1976 and 1984 -, care of self is intensified and the task of establishing a satisfactory relationship with the self becomes a social practice, triggering the emergence of schools and academies and encompassing many social relations (family relations, friendship relations). In the so-called “culture of self”, parrhesia occupies an outstanding place, for self-constitution as a moral subject requires the presence and the constant help of another individual that has the faculty of parrhesia: the parrhesiast or the person in whom one must look for shelter¹⁰10. Ortega F. Amizade e estética da existência em Foucault. Rio de Janeiro: Graal; 1999..

Ramirez²²22. Ramirez CEN. Foucault professor [Internet]. In: Trabalhos GTS 31ª Reunião Anual da ANPED; 2008; Caxambu, Brasil. Caxambu: ANPED; 2008 [acesso 2014 Jun 28]. Disponível em: http://31reuniao.anped.org.br/1trabalho/GT17-4152--Int.pdf
http://31reuniao.anped.org.br/1trabalho/... , in his work about Foucault’s side as a teacher, shows the existence of a close relationship between the philosophical practice of care of self - and parrhesia is one of its constituent elements - developed in the 1^st and 2^nd centuries, and pedagogical practice. Citing Potte-Boneville’s work about Foucault as a stoical master, Ramirez²²22. Ramirez CEN. Foucault professor [Internet]. In: Trabalhos GTS 31ª Reunião Anual da ANPED; 2008; Caxambu, Brasil. Caxambu: ANPED; 2008 [acesso 2014 Jun 28]. Disponível em: http://31reuniao.anped.org.br/1trabalho/GT17-4152--Int.pdf
http://31reuniao.anped.org.br/1trabalho/... reports that the teaching form (teaching understood as the teacher’s practice and public act) might be understood as parrhesia, as frank spokenness. Thus, teaching is enabling the other to emancipate himself from the very teaching relationship, an autonomy from the master’s discourse. This frank spokenness can be assumed as an exercise of self, an exercise of transformation, which would be characterized as a pedagogical attitude.

To Freitas⁹9. Freitas AS. A parresía pedagógica e o êthos da educação como psicagogia. Rev Bras Educ [Internet]. 2013 [acesso 2014 Jun 26]; 18(53):325-493. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-24782013000200005 Doi: 10.1590/S1413-24782013000200005.
http://www.scielo.br/scielo.php?script=s... , philosophical parrhesia, that is, philosophy practiced as care of self and as pedagogy (paideia), requires a specific way of putting discourse into action, in the bond between master and disciple, that demands not a rhetoric but an erotic. This happens because the question raised by pedagogy, exercised as psychogagy (way of conduction of the soul), is not simply that of the meaning of knowledge or the knowledge of meaning, but rather, the meaning of presence and the presence of meaning in the educational relationship between master and disciples. Thus, pedagogy as psychogagy corresponds to a practical-sensitive way of looking at and listening to the self and the other. As a psychogagy exercise, pedagogy is supported by practices that are directed to a subject in transformation, being fulfilled not so much as an art of governing or guiding, but rather as a force of sensitive affection of subjects. Therefore, as a practical-poetic activity, pedagogy would generate and disseminate discourses capable of mobilizing actions, stimulating an ethical deliberation around accepted conducts or conducts to be assumed by oneself^9.9. Freitas AS. A parresía pedagógica e o êthos da educação como psicagogia. Rev Bras Educ [Internet]. 2013 [acesso 2014 Jun 26]; 18(53):325-493. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-24782013000200005 Doi: 10.1590/S1413-24782013000200005.
http://www.scielo.br/scielo.php?script=s...

Thus, friendship as parrhesia, as a pedagogical and philosophical foundation in the education of health professionals, can allow that free spokenness, understood as ascesis of the self in the relationship between master and disciple, produces relations between professionals and population in which there is less government (in the sense of unnecessary prescription of conducts) and more force of sensitive affection. Educating professionals based on this foundation can contribute to a thought-action in the area of health that is increasingly democratic, integral and marked by solidarity.

Therefore, only friendship would support parrhesia: “this discourse through which the weak, despite his weakness, takes the risk of criticizing the strong for the injustice he has committed, this discourse is precisely called parrhesia”²2. Foucault M. A coragem da verdade. São Paulo: Martins Fontes; 2011.. That is: there is no parrhesia (true speech, frank spokenness, the courage of truth) without the presence of the other, of the friend, which presupposes trust and a relationship to the truth.

This true speech that, whenever necessary, assumes the risks of interrogating and confronting authority and institutional limitations²2. Foucault M. A coragem da verdade. São Paulo: Martins Fontes; 2011. would be, therefore, a fundamental element to the ethical-moral elevation of the health worker. Parrhesia, as a constitutive experience in the educational sphere, experienced in the friendship (φιλία) between masters and apprentices, might be transported to the subsequent labor activity, as ethical expression and conduct, by those who, in their health practices, assume the mission of guiding the fates of others.

Final remarks

A philosophical crisis has been influencing the crisis in the areas of health and education. On the one hand, the Cartesian model of science has brought great advances in terms of health, whose reflection can be seen in the longer human longevity. On the other hand, this model has been giving signs of exhaustion, which is evidenced particularly by the societies’ increasing incapacity to care adequately for their members’ health. Educating health professionals to face this incapacity is a challenge to both health and education. As alternatives to the traditional biomedical model in the area of health and to the traditional pedagogy of knowledge transmission in the area of education, alternative models have been proposed – models that consider the human being as an interconnected whole in his biological, cultural, social and psychological dimensions, connected with the environment. If Cartesian science has separated all the sensitive qualities from the world, it is necessary, now, to resume the debate about the importance of the presence of these qualities in the construction of more appropriate health and education models.

In the education of health professionals, the challenge seems to be finding a balance between technical excellence and social relevance. When we propose friendship and parrhesia as a pedagogical and philosophical foundation in the education of health professionals, we aim to provide elements to strengthen social relevance in the education of these professionals in order to shorten the distance between what happens in the relationship between teacher and student and what happens between professionals and population. The healthcare model that should guide the education of these professionals recommends precisely this. When frank spokenness between teacher and student is valued in the professionals’ educational process, and this practice or ascesis is understood as transformation of self, the discourse that demands the meaning of presence and the presence of meaning in the educational relationship between master and disciples is put into action. This enables the emergence of the possibility that there is less government (in the sense of authoritarian prescription of conducts) and more force of sensitive affection in the relations between professionals and population. This is the contribution that we intend to give to the challenge that is presented to the education of health professionals when we resort to the hermeneutic tradition, in Gadamer’s and Foucault’s thought, and to the Greek Hippocratic medicine. This intention does not end in this essay; rather, it constitutes the first step towards future reflections.

References

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