Abstract

Introduction

The multiplicity of methodologies in the teaching of Ethics, Bioethics and Deontology are growingly attracting attention in the scope of scientific productions in parallel to the intellectual production of the learning contents¹1 Paiva LM, Guilhem D, Sousa ALL. O Ensino da bioética na graduação do profissional de saúde. Medicina (Ribeirao Preto). 2014; 47(4):357-69.. Currently, in a much more comprehensive way, it is possible to understand that the method used in the teaching-learning process has similar relevance as the object of study and has a decisive power in transformative learning, in other words, teachers who recognize the dialogical perspective of teaching have a more advanced view of the teaching-learning process²2 Freire P. Pedagogia do oprimido. 17a ed. Rio de Janeiro: Paz e Terra; 1987..

In view of the various ethical problems and the growing use of technology in the Health Sciences area, there is an urgent need for training that is not only centered on isolated disciplines with no communication between them, as they are insufficient to deal with the problems that health professionals face on a daily basis³3 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48.^,44 Costa IKF, Costa IKF, Dantas RAN, Dantas DV, Nascimento JCP, Costa RAGF, et al. Utilização da tecnologia no ensino a distância em suporte básico de vida. Rev Bras Inov Tecnol Saude. 2018; 8(2):11.. Moreover, the vertical transmission of knowledge (teacher to student), the overvaluation of technical training and the theoretical baggage dissociated from the social context of action configure a traditional teaching model still present in Health training¹1 Paiva LM, Guilhem D, Sousa ALL. O Ensino da bioética na graduação do profissional de saúde. Medicina (Ribeirao Preto). 2014; 47(4):357-69.^,33 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48..

From these situations, it is recognized the need to propose discussions about new practices and pedagogical models that stimulate the reconstruction of the social role of Higher Education Institutions (HEIs), as shapers of ethical, critical and reflective professionals, in order to act under the logic of quality care in health work, adopting such innovations, also called active methodologies¹1 Paiva LM, Guilhem D, Sousa ALL. O Ensino da bioética na graduação do profissional de saúde. Medicina (Ribeirao Preto). 2014; 47(4):357-69.^,55 Hellmann F, Verdi MIM. Ética, bioética e deontologia no ensino da naturologia no Brasil. Rev Bioet. 2014; 22(3):529-39.^,66 Ferreira HM, Ramos LH. Diretrizes curriculares para o ensino da ética na graduação em enfermagem. Acta Paul Enferm. 2006; 19(3):328-31.. In this way, the student is the protagonist of his learning, called upon to participate by discussing problems, leaving a passive position, merely receiving information and developing his individual competencies⁷7 Lovato FL, Michelotti A, Loreto ELS. Metodologias ativas de aprendizagem: uma breve revisão. Acta Sci. 2018; 20(2):154-71.

8 Mitre SM, Siqueira-Batista R, Girardi-de-Mendonça JM, Morais-Pinto NM, Meirelles CAB, Pinto-Porto C, et al. Metodologias ativas de ensino-aprendizagem na formação profissional em saúde: debates atuais. Cienc Saude Colet. 2008; 13 Suppl 2:2133-44.^-99 Borges TS, Alencar G. Metodologias ativas na promoção da formação crítica do estudante: o uso das metodologias ativas como recurso didático na formação crítica do estudante do ensino superior. Cairu Rev. 2014; 3(4):119-43..

These teaching-learning methodologies, although they share the same assumption of joint participation between teacher and student, are not always uniform from the theoretical and methodological point of view, so that one can observe several models and strategies of constitution in the different educational levels¹1 Paiva LM, Guilhem D, Sousa ALL. O Ensino da bioética na graduação do profissional de saúde. Medicina (Ribeirao Preto). 2014; 47(4):357-69..

Thus, this study aims to understand the use of teaching-learning methodologies for ethics, bioethics, and deontology in the context of higher education in the health professions in the last decade.

Methodology

This is an integrative literature review, a methodology capable of summarizing results in a comprehensive and ordered manner, with the possibility of including studies with diversified methodologies simultaneously, providing a synthesis of the production of knowledge on the subject in its entirety¹⁰10 Ercole FF, Melo LS, Alcoforado CLGC. Revisão integrativa versus revisão sistemática. REME Rev Min Enferm. 2014; 18(1):9-12.^–1212 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008; 17(4):758-64..

The guiding question “What methodologies have been used in teaching Ethics, Bioethics and Deontology in the last decade in health care?” used the PECO strategy (acronym for: population, exposure, control and endpoint/outcome)¹³13 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009; 339:b2535.^,1414 Morgan RL, Whaley P, Thayer KA, Schünemann HJ. Identifying the PECO: a framework for formulating good questions to explore the association of environmental and other exposures with health outcomes. Environ Int. 2018; 121(1):1027-31..

In the search phase the descriptors “teaching” and “health” and “ethics” or “bioethics” or “deontology” were applied, in the search in titles, abstracts and subjects, as presented in Chart 1. Data were collected using five informational resources: electronic health database (Latin American and Caribbean Literature on Health Sciences - LILACS), electronic database in the area of Education (Educational Resources Information Centre – ERIC), portal PubMed (Medical Literature Analysis and Retrieval System Online – MEDLINE), digital library (Scientific Electronic Library Online – SciELO) and Google Scholar. Inclusion criteria were: original article, full text, published between 2010 and August 2020, and no language restrictions.

Initially, the titles and abstracts were analyzed from the criteria pre-established for the screening stage, involving thematic compatibility with the teaching of ethics, bioethics, and deontology. In the last step, reading the articles in their entirety, the eligibility criterion was the need to present methodologies for teaching Ethics, Bioethics and Deontology, in order to answer the guiding question of this integrative review. The studies found were imported into the Zotero reference manager (version 5.0.93).

The data extraction phase was organized following a pre-established instrument, automatically recorded in a spreadsheet independently by the researchers. The process allowed the identification of the authors, year of publication, country of origin, study design, population characteristics, and teaching methodologies. Extraction by reviewers followed the same logistics described above.

The synthesis of this integrative review was described from the grouping of teaching methodologies related to categories, aiming at better ordering and discussion of the data, and is presented in order of frequency.

Results

A total of 398 studies were identified which, after exclusion of duplicates, resulted in the screening of 373 articles. The analysis of titles and titles- abstracts, allowed the reading in full of 92 researches that, by the eligibility criteria, excluded 58 studies, as shown in Figure 1.

The bibliographic survey resulted in a final sample of 34 articles (Table 2). In the results, initially, the characterization of the review studies will be presented regarding the data found, the description of the population studied, distributed among undergraduates, graduate students, professionals and professors, and later, the categorization of the teaching methodologies for ethics, bioethics and deontology

The country with the most publications was Brazil with 17 (50%), followed by the United States of America (USA) with six (17.6%), India and the United Kingdom with two (5.8%) each, and the other countries appeared in the table with one article (2.9%). The periods presenting higher number of publications were: 2013 with eight (23.52%), 2014 with six (17.6%) and 2017 with four (11.7%). Regarding the approach used, the predominant type of study was qualitative 15 (44.1%), followed by quantitative studies with 10 (29.4%), quali-quantitative with three (8.8%), and experience reports with six (17.6%). A large part of the sample, more specifically 15 publications (44.1%), was composed of studies that analyzed training processes in Ethics, Bioethics and Deontology, nor analytically or comparatively addressing teaching methodologies, but addressing and describing the topic in their content, which justifies their inclusion according to the criteria of this integrative review.

The main focus of studies on Ethics, Bioethics and Deontology is concentrated on the Undergraduate teaching process with 24 publications (70.5%), of which Medicine with 13 (38.2%), Nursing with seven (20.5%), have the largest number of related studies, in addition, the other mentioned Undergraduate courses have one article each (2.94%). The graduate level, with five (14.7%), represented the second largest number of studies, followed by the category of professionals and technicians with three (8.8%), with emphasis on nurses with the largest number of specific articles. Four studies (11.7%) addressed teachers, through studies that, for the most part, did not specify which area they taught, with the exception of one, which included Medicine faculty members. The total number of studies in the analyses above exceeds 100%, since the same article could address different levels of training and profession.

The studies were classified into two categories presented in order of decreasing frequency in relation to the total number of articles:

a) Active methodologies with 33 studies (97.5%), subdivided into casuistry with 16 publications (47%), Art-based methods with 14 publications (41.1%) and problem-based learning - problematization methodology with five publications (14.7%); (b) traditional model with eight studies (23.5%);

In this analysis, it is also possible to observe that the sum exceeds the total number of articles, a fact explained because the same study could address different teaching methodologies.

Discussion

Contextualizing the Teaching of Ethics, Bioethics and Deontology

The scientific literature that analyzes the learning processes of the themes discussed here indicates the preponderance of the traditional teaching model associated with biomedical and strictly deontological practices, to the detriment of ethics and bioethical reflection in the observation of reality⁵5 Hellmann F, Verdi MIM. Ética, bioética e deontologia no ensino da naturologia no Brasil. Rev Bioet. 2014; 22(3):529-39.^,1515 Dantas F, Sousa EG. Ensino da deontologia, ética médica e bioética nas escolas médicas Brasileiras: uma revisão sistemática. Rev Bras Educ Med. 2008; 32(4):507-17.

16 Finkler M, Ramos FRS. La dimensión ética de la educación superior en odontología: un estudio en Brasil. Bordón Rev Pedag. 2017; 69(4):35-49.^-1717 Figueiredo AM, Garrafa V, Portillo JAC. Ensino da bioética na área das ciências da saúde no Brasil: estudo de revisão sistemática. Rev Int Interdisciplin Interthesis. 2008; 5(2):47-72.. In addition, it is necessary to dissociate the bioethics and deontology subjects, traditionally linked in the curriculum, because they cause distortions in the concepts and understanding of the students in relation to their contents¹⁸18 Biondo CS, Rosa RS, Ferraz MOA, Yarid SD. Perspectivas do conhecimento da bioética pelos acadêmicos de saúde para atuação profissional. Enferm Actual Costa Rica. 2018; (35):63-74.^,1919 Finkler M, Negreiros DP. Formação x educação, deontologia x ética: repensando conceitos, reposicionando docentes. Rev ABENO. 2018; 18(2):37-44..

In general terns, ethics provides potential reflection on morality, based on models that seek the best for the subjects and for the collectivity⁵5 Hellmann F, Verdi MIM. Ética, bioética e deontologia no ensino da naturologia no Brasil. Rev Bioet. 2014; 22(3):529-39.^,2020 Figueiredo AM. Ética: origens e distinção da moral. Saude Etica Justiça. 2008; 13(1):1-9. Doi: https://doi.org/10.11606/issn.2317-2770.v13i1p1-9.
https://doi.org/10.11606/issn.2317-2770.... ^,2121 Marcondes D. Textos básicos de ética: de Platão à Foucault. Rio de Janeiro: Zahar; 2007.. The normative dimension of ethics, which originates its prescriptive sense, is related to the gathering of values and duties in a systematic way, following the example of religious dogmatism or even the creation of professional codes of ethics. This sense can be considered the embryo of the “theory of duty and obligation”, which contemporary moral philosophy calls deontology⁵5 Hellmann F, Verdi MIM. Ética, bioética e deontologia no ensino da naturologia no Brasil. Rev Bioet. 2014; 22(3):529-39.^,1515 Dantas F, Sousa EG. Ensino da deontologia, ética médica e bioética nas escolas médicas Brasileiras: uma revisão sistemática. Rev Bras Educ Med. 2008; 32(4):507-17.^,2121 Marcondes D. Textos básicos de ética: de Platão à Foucault. Rio de Janeiro: Zahar; 2007..

Thus, it may be understood that ethics, as an expanded concept, acts in the interrelation between prescription, by defining the behavioral norms of specific groups²²22 Barton WE, Barton GM. Ethics and law in mental health administration. New-York: International Universities Press; 1984., and reflection, when critical thinking and decision making are required, and can be understood contextually, being subject to the social modifications arising from the man-environment relationship²³23 Carneiro LA, Porto CC, Duarte SBR, Chaveiro N, Barbosa MA. O ensino da ética nos cursos de graduação da área de saúde. Rev Bras Educ Med. 2010; 34(3):412-21.. Specifically in the area of health, bioethics serves as a tool that studies questions concerning human life in the field of ethics⁶6 Ferreira HM, Ramos LH. Diretrizes curriculares para o ensino da ética na graduação em enfermagem. Acta Paul Enferm. 2006; 19(3):328-31.^,2424 Segre M. Definição de bioética e sua relação com a ética, deontologia e diceologia. In: Segre M, Cohen C, organizadores. Bioética. São Paulo: Editora da Universidade de São Paulo; 1999. p. 23-9..

It is emphasized that training in the health area sometimes contributes to the trivialization process of these concepts (ethics, bioethics and deontology), when it minimizes the critical work to a merely prescriptive application¹⁶16 Finkler M, Ramos FRS. La dimensión ética de la educación superior en odontología: un estudio en Brasil. Bordón Rev Pedag. 2017; 69(4):35-49.^,1919 Finkler M, Negreiros DP. Formação x educação, deontologia x ética: repensando conceitos, reposicionando docentes. Rev ABENO. 2018; 18(2):37-44.. The teaching of ethics and bioethics in health care, associates the practice of care with the recognition of rights as citizens, so that if this education is minimized or suppressed, the training contributes to the dehumanization of assistance, absence of empathy and precariousness of care¹⁹19 Finkler M, Negreiros DP. Formação x educação, deontologia x ética: repensando conceitos, reposicionando docentes. Rev ABENO. 2018; 18(2):37-44.^,2525 Cunha LL, Pires FS, Finkler M, Warmling CM. Bioética do cuidado na clínica de ensino: aprendendo com pacientes. Rev ABENO. 2021; 21(1):1229. Doi: https://doi.org/10.30979/rev.abeno.v21i1.1229.
https://doi.org/10.30979/rev.abeno.v21i1... .

In other words, the debate around ethics and bioethics under the light of deontological codes makes problematization unfeasible to the detriment of normative characteristics, a situation that diminishes the space and visibility for reflection, reinforcing the need to link deontology to references in the social and human sciences²⁵25 Cunha LL, Pires FS, Finkler M, Warmling CM. Bioética do cuidado na clínica de ensino: aprendendo com pacientes. Rev ABENO. 2021; 21(1):1229. Doi: https://doi.org/10.30979/rev.abeno.v21i1.1229.
https://doi.org/10.30979/rev.abeno.v21i1... . Moreover, an important opportunity to contribute to the moral and political formation of the undergraduate is lost by focusing on the conception of the known, of what is safe, “correct” and uncritical from the point of view of the rules or even by the incessant search for the convergence of thoughts¹⁹19 Finkler M, Negreiros DP. Formação x educação, deontologia x ética: repensando conceitos, reposicionando docentes. Rev ABENO. 2018; 18(2):37-44..

Essential theoretical assumptions for the teaching of ethics, bioethics, and deontology are brought up in this discussion in order to propose a basic curricular contribution to training. Firstly, transdisciplinary teaching is highlighted as an axis of fundamental importance for educational practice, as it represents, a priori, social and collective interest. Just like Ethics, transdisciplinarity is organized from the co-participation of all, so that every teacher ends up becoming a Bioethics teacher³3 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48.^,2626 Simón-Lorda P, Barrio-Cantalejo IM, Peinado-Gorlat P. Content of public health ethics postgraduate courses in the United States. J Bioeth Inq. 2015; 12(3):409-17. Doi: https://dx.doi.org/10.1007/s11673-015-9608-x.
https://doi.org/10.1007/s11673-015-9608-...

27 Ferrari AG, Silva CM, Siqueira JE. Ensino de bioética nas escolas de medicina da América Latina. Rev Bioet. 2018; 26(2):228-34.

28 Menezes MM, Maia LC, Abreu MHNG, Sampaio CA, Costa SM. Percepções sobre o ensino de ética na medicina: estudo qualitativo. Rev Bioet. 2019; 27(2):341-9.^-2929 Burgatti JC, Bracialli LAD, Oliveira MAC. Problemas éticos vivenciados no estágio curricular supervisionado em enfermagem de um currículo integrado. Rev Esc Enferm USP. 2013; 47(4):937-42..

Studies defend that teaching should crosscut in the process of subjects’ formation, so that the topic should be included in the curricula since its conception in an orderly and continuous manner³3 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48.^,66 Ferreira HM, Ramos LH. Diretrizes curriculares para o ensino da ética na graduação em enfermagem. Acta Paul Enferm. 2006; 19(3):328-31.^,3030 Santos AFN, Montezeli JH, Gastaldi AB, Garanhani ML, Milhorini CR. A bioética como tema transversal na formação do enfermeiro em um currículo integrado: análise documental. Braz J Develop. 2020; 6(1):2463-77..

Another theoretical assumption highlighted as essential in the training process in the themes studied is interdisciplinarity²⁸28 Menezes MM, Maia LC, Abreu MHNG, Sampaio CA, Costa SM. Percepções sobre o ensino de ética na medicina: estudo qualitativo. Rev Bioet. 2019; 27(2):341-9.^,3131 Schwartzman UP, Martins VCS, Ferreira LS, Garrafa V. Interdisciplinaridade: referencial indispensável ao processo de ensino-aprendizagem da bioética. Rev Bioet. 2017; 25(3):536-43.^,3232 Campos Daniel J, Dias Reis Pessalacia J, Leite de Andrade AF. Interdisciplinary debate in the teaching-learning process on bioethics: academic health experiences. Invest Educ Enferm. 2016; 34(2):288-96., which leads us to think about the need to rethink the practices, postures and concepts of teachers³3 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48. and overcome the barriers presented by the students who, even though they have greater possibilities to experience this conciliation between theory and practice, are still unable to exercise it, for lack of maturity, dedication, among others³³33 Vendrusculo AP, Fillipin NT, Cunha TF, Schetinger MRC. Interdisciplinaridade na percepção de docentes de ensino superior. Rev Educ UNIPAR. 2019; 19(2):291-312..

Interdisciplinarity provides the interlocution of knowledge and the socialization of knowledge and takes place between different fields of practice³⁴34 Pereira MLAS, Pereira MHQ, Teles BKA, Carvalho RB, Oliveira ERA. Interdisciplinaridade em Saúde Coletiva: construção de um recurso didático no campo da prática profissional. Rev Bras Educ Saude. 2019; 9(4):77-83.. The purely deontological, prescriptive, and theoretical methodologies need critical reflections to break with the traditional model and incorporate into their pedagogical practice, interdisciplinary and transversal assumptions³3 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48.^,3535 Lacerda FCB, Santos LM, Lacerda FCB, Santos LM. Integralidade na formação do ensino superior: metodologias ativas de aprendizagem. Aval Rev Aval Educ Super. 2018; 23(3):611-27..

Another important aspect to be questioned is focused on the application of the traditional teaching method. If we understand ethics not only as a set of moral values, but also as an exercise of skills and attitudes, its construction would be more related to experience than to the transmission of content per se¹⁹19 Finkler M, Negreiros DP. Formação x educação, deontologia x ética: repensando conceitos, reposicionando docentes. Rev ABENO. 2018; 18(2):37-44.^,3535 Lacerda FCB, Santos LM, Lacerda FCB, Santos LM. Integralidade na formação do ensino superior: metodologias ativas de aprendizagem. Aval Rev Aval Educ Super. 2018; 23(3):611-27.^,3636 Granzott RBG, Silva K, Dornelas R, Domenis DR. Metodologias ativas e as práticas de ensino na comunidade: sua importância na formação do fonoaudiólogo. Disturb Comun. 2015; 27(2):369-74.. Thus, it would be incompatible with this traditional teaching proposal that, historically, centralizes the teacher as the absolute holder of knowledge, sustained by the retention of information, rigid systems, isolated disciplines and evaluations by memorization, that is, it hinders the possibility of developing critical sense derived from the professional reality³⁷37 Dias ES, Jesus CVF. Aplicação de metodologias ativas no processo de ensino em enfermagem: revisão integrativa. Rev Saude Desenvolv. 2021; 15(21):19-31.^–3939 Marques LMNSR. As metodologias ativas como estratégias para desenvolver a educação em valores na graduação em enfermagem. Esc Anna Nery. 2018; 22(3):e20180023.. Thus, in order to deepen the concepts previously demonstrated in the results and discussion, the two categories of analysis will be presented individually, discussing them with other publications in the literature that address the theme.

Active methodologies

The concept of active methodologies is not configured as a specific way of teaching, but rather as an educational conception that encourages teaching-learning relationships in a critical and reflective way⁷7 Lovato FL, Michelotti A, Loreto ELS. Metodologias ativas de aprendizagem: uma breve revisão. Acta Sci. 2018; 20(2):154-71.

8 Mitre SM, Siqueira-Batista R, Girardi-de-Mendonça JM, Morais-Pinto NM, Meirelles CAB, Pinto-Porto C, et al. Metodologias ativas de ensino-aprendizagem na formação profissional em saúde: debates atuais. Cienc Saude Colet. 2008; 13 Suppl 2:2133-44.^-99 Borges TS, Alencar G. Metodologias ativas na promoção da formação crítica do estudante: o uso das metodologias ativas como recurso didático na formação crítica do estudante do ensino superior. Cairu Rev. 2014; 3(4):119-43.^,4040 Sobral FR, Campos CJG. Utilização de metodologia ativa no ensino e assistência de enfermagem na produção nacional: revisão integrativa. Rev Esc Enferm USP. 2012; 46(1):208-18.. From this principle, some articles made links of the concept to the teaching of Ethics, Bioethics and Deontology, highlighting it through research as to its applicability in practice.

It creates educational situations capable of providing the learner’s critical thinking, simultaneously with reality, besides enabling means to carry out research on problems and solutions, to recognize and have the most adequate hypothetical designs for the conjuncture, guaranteeing the use of these propositions in practice. It is worth pointing out that the teacher is not the only determinant for the successful execution of learning, with the student having an active and decisive role in this process, corroborating the reflexive conception of ethics¹1 Paiva LM, Guilhem D, Sousa ALL. O Ensino da bioética na graduação do profissional de saúde. Medicina (Ribeirao Preto). 2014; 47(4):357-69.^,2323 Carneiro LA, Porto CC, Duarte SBR, Chaveiro N, Barbosa MA. O ensino da ética nos cursos de graduação da área de saúde. Rev Bras Educ Med. 2010; 34(3):412-21.^,3535 Lacerda FCB, Santos LM, Lacerda FCB, Santos LM. Integralidade na formação do ensino superior: metodologias ativas de aprendizagem. Aval Rev Aval Educ Super. 2018; 23(3):611-27.^,4040 Sobral FR, Campos CJG. Utilização de metodologia ativa no ensino e assistência de enfermagem na produção nacional: revisão integrativa. Rev Esc Enferm USP. 2012; 46(1):208-18., In this sense, the use of casuistry, art, and problematization has proven to be a great alternative to encourage this participation, both in the construction of collective discussion spaces, and in breaking away from the traditional teaching model, as we see below.

Use of casuistry

Most of the articles in this integrative review addressed, analyzed or compared the application of case studies in the teaching of Ethics, Bioethics and Deontology. Historically, the casuistic paradigm emerges in the 16th and 17th centuries, as a response to the moral problems of the modern world and its transitions, analyzing concrete circumstances and proposing comparative solutions with cases already experienced⁴¹41 Jonsen AR, Toulmin S, Toulmin SE. The abuse of casuistry: a history of moral reasoning. Berkeley: University of California Press; 1988.

42 Junges JR. Bioética como casuística e como hermenêutica. Rev Bras Bioet. 2005; 1(1):41.^-4343 Leite DAA, Pessalacia JDR, Braga PP, Rates CMP, Azevedo C, Zoboli ELCP. Uso da casuística no processo ensino-aprendizagem de bioética em saúde. Rev Bioet. 2017; 25(1):82-8., following the paradigms of Problem-Based Learning and Problematization Methodology, which will be presented and discussed further below⁴⁰40 Sobral FR, Campos CJG. Utilização de metodologia ativa no ensino e assistência de enfermagem na produção nacional: revisão integrativa. Rev Esc Enferm USP. 2012; 46(1):208-18.^,4444 Villanueva P. Aprendizaje basado en problemas: un enfoque innovador en el currículo de fonoaudiología. Rev Chil Fonoaudiol. 2006; 7(1):63-75..

The main difference in the casuistic perspective in comparison with applied ethics lies in the fact that the former prioritizes practice over theoretical references, while the latter proposes a theoretical advance that justifies and/or criticizes the choices of individuals⁴²42 Junges JR. Bioética como casuística e como hermenêutica. Rev Bras Bioet. 2005; 1(1):41.^,4545 Jonsen AR. Razonamiento casuístico en la ética médica. Dilemata. 2016; (20):114.. In general, casuistry serves as a starting point for the construction of new theoretical paradigms and the articulation of possible reformulations of principles, a proposal that is not compatible with the mere reproducibility of content in the traditional teaching model or in the application of strictly prescriptive ethics³⁷37 Dias ES, Jesus CVF. Aplicação de metodologias ativas no processo de ensino em enfermagem: revisão integrativa. Rev Saude Desenvolv. 2021; 15(21):19-31.

38 Alarcon MFS, Galdino MJQ, Martins JT, Prezzoto KH, Komatsu RS. Percepção de graduandos de enfermagem sobre a Aprendizagem Baseada em Problemas. Rev Enferm UFSM. 2018; 8(3):489-503.^-3939 Marques LMNSR. As metodologias ativas como estratégias para desenvolver a educação em valores na graduação em enfermagem. Esc Anna Nery. 2018; 22(3):e20180023.^,4242 Junges JR. Bioética como casuística e como hermenêutica. Rev Bras Bioet. 2005; 1(1):41.^,4646 Cudney P. What really separates casuistry from principlism in biomedical ethics. Theor Med Bioeth. 2014; 35(3):205-29..

As a teaching model, the casuistic involves the students in an active and critical way, so to confronting their ideas and positions through reflections derived from practice, demonstrating greater effects in comparison with traditional classes, since it proposes reflection on values, culture and decision-making in a real context³3 Amorim KPC, Araújo EM. Formação ética e humana no curso de medicina da UFRN: uma análise crítica. Rev Bras Educ Med. 2013; 37(1):138-48.^,4242 Junges JR. Bioética como casuística e como hermenêutica. Rev Bras Bioet. 2005; 1(1):41.^,4747 Loike JD, Rush BS, Schweber A, Fischbach RL. Lessons learned from undergraduate students in designing a science-based course in bioethics. CBE Life Sci Educ. 2013; 12(4):701-10..

Art-based Methodology

This subcategory encompasses active methodologies that use alternative resources of Art in the teaching-learning process, therefore aiming at the interrelation between subjectivity and objectivity as possibilities for education, contradicting the passivity attributed to the student in the traditional model and the lack of interest in detriment of other forms of stimuli such as audio, video, internet, theater, among others⁴⁸48 Arveklev SH, Wigert H, Berg L, Burton B, Lepp M. The use and application of drama in nursing education: an integrative review of the literature. Nurse Educ Today. 2015; 35(7):e12-7.. It proposes such a meaningful experience, capable of making the learner give new meaning to his experiences, create and apply concepts, and understand the social representations around him³⁵35 Lacerda FCB, Santos LM, Lacerda FCB, Santos LM. Integralidade na formação do ensino superior: metodologias ativas de aprendizagem. Aval Rev Aval Educ Super. 2018; 23(3):611-27.^,4949 Vigotski L. Psicologia pedagógica. Schilling C, tradutor. Porto Alegre: Artmed; 2003..

Cinema emerges as an alternative for teaching Ethics, Bioethics and Deontology in studies that have demonstrated experiences in the application of videos, films and documentaries, highlighting the importance of recognizing the other, sharing affections, feelings, emotions and needs, to understand the importance of cinematographic language in the construction of the cognitive process and its relations with teaching⁵⁰50 Araujo AR, Voss RCR. Cinema em sala de aula identificação e projeção no ensino/aprendizagem da Língua Inglesa. Conexao Comun Cult. 2009; 8(15):119-30.

51 Dantas AA, Martins CH, Militão MSR. O cinema como instrumento cidático para a abordagem de problemas bioéticos: uma reflexão sobre a eutanásia. Rev Bras Educ Med. 2011; 35(1):69-76.

52 González Blasco P. É possível humanizar a Medicina? Reflexões a propósito do uso do Cinema na Educação Médica. Mundo Saude. 2010; 34(3):357-67.

53 Guilhem D, Diniz D, Zicker F. Pelas lentes do cinema: bioética e ética em pesquisa. Brasília: Editora UnB; 2007.^-5454 Kovalik AC, Campos LA, Zarpellon DC, Rocha JS, Pochapski MT, Santos FA. A ética em pesquisa com seres humanos pelas lentes do cinema. Rev ABENO. 2009; 9(1):34-8..

The dramatization, pointed as a strategy through the simulated jurisprudence and theater techniques, enhances the experiences, reflections and learning of content, providing satisfaction in acquiring knowledge by the experience of inter and intra group contact⁴⁸48 Arveklev SH, Wigert H, Berg L, Burton B, Lepp M. The use and application of drama in nursing education: an integrative review of the literature. Nurse Educ Today. 2015; 35(7):e12-7.^,5555 Bonamigo EL, Destefani AS. A dramatização como estratégia de ensino da comunicação de más notícias ao paciente durante a graduação médica. Rev Bioet. 2010; 18(3):725-42.^,5656 Coelho MP, Partelli ANM. Júri simulado no ensino da ética/bioética para a enfermagem. Rev Enferm UFPE. 2019; 13(2):499-510.. Another didactic resource mentioned in this subcategory was literature. The use of this methodology provides self-reflection, analysis of values, human relations, socio-political understanding, besides enabling the student to improve clinical skills (observation, imagination and linguistic fluency) rather than merely deontological approaches²⁵25 Cunha LL, Pires FS, Finkler M, Warmling CM. Bioética do cuidado na clínica de ensino: aprendendo com pacientes. Rev ABENO. 2021; 21(1):1229. Doi: https://doi.org/10.30979/rev.abeno.v21i1.1229.
https://doi.org/10.30979/rev.abeno.v21i1... ^,5757 Balbi L, Lins L, Menezes MS. A Literatura como estratégia para reflexões sobre humanismo e ética no curso médico: um estudo qualitativo. Rev Bras Educ Med. 2017; 41(1):152-61..

Problem-based learning and problematization methodology

Active methodologies are based on problems⁷7 Lovato FL, Michelotti A, Loreto ELS. Metodologias ativas de aprendizagem: uma breve revisão. Acta Sci. 2018; 20(2):154-71.^,4040 Sobral FR, Campos CJG. Utilização de metodologia ativa no ensino e assistência de enfermagem na produção nacional: revisão integrativa. Rev Esc Enferm USP. 2012; 46(1):208-18., Its practices are commonly related to problem-based learning and problematization methodology. The former is related to tutorials presenting problems predetermined by the teacher in a fictitious way, that is, not always representing a concrete reality, as in the use of case studies and Art resources, for example⁴³43 Leite DAA, Pessalacia JDR, Braga PP, Rates CMP, Azevedo C, Zoboli ELCP. Uso da casuística no processo ensino-aprendizagem de bioética em saúde. Rev Bioet. 2017; 25(1):82-8.^,5656 Coelho MP, Partelli ANM. Júri simulado no ensino da ética/bioética para a enfermagem. Rev Enferm UFPE. 2019; 13(2):499-510.. It fulfills a curriculum that seeks the aptitude for professional exercise, with reflections either collective or individual⁵⁸58 Cyrino EG, Toralles-Pereira ML. Trabalhando com estratégias de ensino-aprendizado por descoberta na área da saúde: a problematização e a aprendizagem baseada em problemas. Cad Saude Publica. 2004; 20(3):780-8..

The problematization methodologies, on the other hand, are linked to unleash ways of education that dialogue, demystify and transform thought and society through reflections on real problems, which can also be presented by the casuistry, producing the construction of knowledge from significant experiences, a methodology that opposes the unidirectional proposals centered on the teachers’ knowledge²2 Freire P. Pedagogia do oprimido. 17a ed. Rio de Janeiro: Paz e Terra; 1987.^,5959 Freire P. Pedagogía de la autonomía: saberes necesarios para la práctica educativa. Tres Cantos: Siglo XXI; 1997.^,6060 Rodrigues RM, Caldeira S. Movimentos na educação superior, no ensino em saúde e na enfermagem. Rev Bras Enferm. 2008; 61(5):629-36..

Traditional model

The presence of the traditional model in the studies that evaluated training processes shows that even with the advent of research that proves the failure of this method, it is still of utmost importance to discuss the ways of training and qualifying, based on the assumptions of Ethics, Bioethics and Deontology⁶¹61 Urias GMPC, Azeredo LAS. Metodologias ativas nas aulas de administração financeira: alternativa ao método tradicional de ensino para o despertar da motivação intrínseca e o desenvolvimento da autonomia. Adm Ensino Pesqui. 2017; 18(1):39.^,6262 Benedetto MACD, Gallian DMC. Narrativas de estudantes de Medicina e Enfermagem: currículo oculto e desumanização em saúde. Interface (Botucatu). 2018; 22(67):1197-207. Doi: https://doi.org/10.1590/1807-57622017.0218.
https://doi.org/10.1590/1807-57622017.02... . In this sense, the articles that aimed to compare teaching methods came to the conclusion that innovative pedagogical practices, also called active methodologies, provide better results when compared to traditional lectures, strictly theoretical content, lecture classes and slide shows³⁵35 Lacerda FCB, Santos LM, Lacerda FCB, Santos LM. Integralidade na formação do ensino superior: metodologias ativas de aprendizagem. Aval Rev Aval Educ Super. 2018; 23(3):611-27.^,3636 Granzott RBG, Silva K, Dornelas R, Domenis DR. Metodologias ativas e as práticas de ensino na comunidade: sua importância na formação do fonoaudiólogo. Disturb Comun. 2015; 27(2):369-74..

Conclusion

Based on the present integrative review, it was possible to categorize two teaching methodologies (active and traditional) and three subcategories (casuistry, art and problems) presented in scientific productions of original articles, national and international, in the period from 2010 to August 2020.

The discussion of the literature presented indicates that the use of active methodologies has greater applicability and better results than the traditional model of teaching. Moreover, reflections based on problem situations (PBL and MP), methods based on Art and the casuistry used as an application tool in the learning practice, enable subjects to learn in a significant way. It also points out that the theoretical and methodological references demonstrated as indispensable were crosscutting and interdisciplinary in the curricula.

The selected sample identified that Brazil was the country that produced the most studies in the area of Ethics, Bioethics and Deontology, enabling reflections through qualitative designs, in the educational process at the Undergraduate level in Medicine and its relationship with the active methodologies and the traditional model. These configurations appeared to be different from the international publications.

The US studies prioritized the post-graduate population, in articles that analyzed training processes, through quali-quantitative research and experience reports. The European and Asian research are mostly experience reports at the Undergraduate level, the peculiarity lies in the fact that the Asian studies focused on studies that presented, in a larger number, art-based methodologies. Latin America, South America (with the exception of Brazil, already mentioned) and Australia presented qualitative and quantitative studies analyzing training in Ethics, Bioethics and Deontology, applying active methodologies.

Acknowledgments

To the Coordination of the Post-Graduate Program in Science Education (PPGEC) of the Federal University of Rio Grande do Sul (UFRGS), for the support offered in the publication of this study.

References

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