Respect for cultural diversity in bioethics is an ethical imperative

Abstract

The field of bioethics continues to struggle with the problem of cultural diversity: can universal principles guide ethical decision making, regardless of the culture in which those decisions take place? Or should bioethical principles be derived from the moral traditions of local cultures? Ten Have and Gordijn (2011) and Bracanovic (2011) defend the universalist position, arguing that respect for cultural diversity in matters ethical will lead to a dangerous cultural relativity where vulnerable patients and research subjects will be harmed. We challenge the premises of moral universalism, showing how this approach imports and imposes moral notions of Western society and leads to harm in non-western cultures.

Cultural diversity is something that decision makers in bioethical contexts—doctors, nurses, members of bioethical committees, policy makers etc.— should try to understand and, when possible, respect. This respect, however, is not and cannot become the central pillar of bioethics, not only because such respect is faced with serious empirical and conceptual constraints in both theory and practice, but also because it jeopardizes the normative role of bioethics and thus undermines its very foundations and raison d’être. – T. Bracanovic

Imagine this: you are driving a large Cadillac limousine along a road passing through paddy fields in rural Bangladesh. On the way, you arrive at a village bazaar and find it difficult to navigate through the crowds in the marketplace. How would you understand this situation? Will you blame the crowds in the village bazaar? (Why can’t they put the market on a side street?) Or would you question the wisdom of travelling by limousine in a rural setting? Those who believe that cultural diversity places multiple “constraints” on bioethics and that certain abstract principles of ethics can be applied universally (ten Have and Gordijn, 2011; Bracanovic, 2011), will curse the thick crowd in the village bazaar rather than question the utility of a limousine as a suitable vehicle for rural travel.

We understand that bioethics is not a limousine. While the work of bioethics is not like driving a car, and the complexity of cross-cultural bioethics is not the same as navigating through a crowded village bazaar, nevertheless our metaphor is useful for understanding the problems facing contemporary mainstream bioethics in the globalized world. In our article “Bioethical concerns are global, bioethics is Western” (Chattopadhyay and De Vries, 2008) we argued that systems of bioethics should be suited to, and situated in, local culture. Ten Have and Gordijn (2011) took us to task claiming that we are perpetrating a point of view about bioethics that is “fallacious and even unjust.” In a separate paper, Bracanovic (2011) claims that “respect for cultural diversity,” is “untenable and misleading,” and poses “a series of conceptual and empirical constraints” to bioethics discourse. Bracanovic believes that the “cultural turn” in bioethics “ignores the typically normative role of bioethics and thus threatens to undermine its very foundations.” Like ten Have and Gordijn, Bracanovic supports the universalist approach to bioethics.

We, like our colleagues, are laborers in the field of bioethics; like them we seek to protect and promote the welfare of those touched by biomedicine. The question is, “How can this best be done?” We believe that respect for cultural diversity is an ethical imperative and the most appropriate way forward for “global bioethics.” In what follows we show that the application of “universal” principles does not promote respect and justice in medicine and medical research and can, in fact, cause real harm to persons.

Hidden in plain view: moral imperialism of Western bioethics

Ten Have and Gordijn (2011) deny that contemporary mainstream bioethics has a Western bias – they argue that bioethics as practiced in the West is simply the most recent incarnation of “ideas of personal and political rights” that have long existed in other cultures (p. 2). One need not look far, however, to confirm the Western bias of bioethics. At the now well-known conference, “The birth of bioethics” (held at the University of Washington at Seattle in 1992), participants concluded that bioethics was “a response to the effects that technological medicine has on the relation between patients, and physicians and between medicine and society” (Jonsen, 1998, p. 382). Assembled in the North American socio-cultural context and using the raw materials of Western moral philosophy, bioethics developed with a “primarily Anglo-American cultural ethos” (Myser, 2011) and dealt mainly with problems initiated by advancements in, and applications of, modern science and technology in healthcare. Bioethics thus originated as a product of, and a check on, Western biomedicine (Chattopadhyay and de Vries, 2008). As long as the work of bioethics was confined to white Western societies, this orientation posed few problems. But as bioethics moved into other cultures – both within and outside of the Western world (for example, the Navajo reservation and countries like Japan and China) – the field was forced to grapple with issues presented by diverse cultures, diverse moral traditions, and healing systems other than Western biomedicine.

The cross-cultural encounters of bioethics raised a number of questions. Can and should Western bioethical theories and methods be applied to Ayurveda, Acupuncture, Unani-tibb, Navajo medicine, or any other indigenous traditional system of medicine? How does ethics, as a branch of Western philosophy, relate to dharma, or to Eastern philosophical systems and worldviews? Is mainstream Western secular bioethics sensitive to the moral aspirations and needs of the citizens of non-Western societies? How does an individual-centered, rights-based bioethics resonate with the cultural ethos of traditional societies? These questions are inevitable when diverse cultures and moral traditions share a common world, but they are barely considered and poorly addressed when Western bioethics travels abroad.

We are not the first scholars to use the term “Western” to characterize mainstream secular bioethics and to point out its limited vision. In his 1997 book, Japanese and Western bioethics: studies in moral diversity, Kazumasa Hoshino wrote:

There are many subtle and overt racial, national, social, cultural and religious differences among divergent societies, such as Japan and the United States. Such differences may explain the difficulties that the Japanese and other cultures have in accepting many Western principles of bioethics. It may, in fact, be unethical to force people living in very different societies to accept Western bioethics.

Engelhardt and Rasmussen (2002) criticize fellow American bioethicists for their denial of moral diversity and nearly obsessive desire to find a “common morality.” Referring to scholarly meetings on bioethics attended by the Americans and Japanese, they write:

It was clear that the Americans…and Japanese saw issues of bioethics from radically different perspectives … The response on the part of most of the American bioethicists was again to assure … that the bioethics they (the Americans) were expounding reflected the common morality of mankind, whether or not the Japanese recognized this to be the case.

In his book Bioethics – Asian perspectives: quest for moral diversity, Ren-Zong Qiu (2004) observes:

The desire to solve global problems or issues by coordinated efforts made by all peoples and all countries in the world is understandable. However, these coordinated efforts have to be and only can be achieved by consensus between them … The final answer cannot be deduced from an overarching universal ethics or global bioethics invented by some genius philosopher or leading figure, and any such inventor may not impose his solution on other people. Nothing could prevent this kind of imposition from leading to the kind of ethical imperialism that some bioethicists in developing countries understandably worry about.

Not surprisingly, those in the developing world declared, more than 10 years ago, that we should move ‘Beyond a Western Bioethics’ (Alora and Lumitao, 2001). This call was echoed by both Western and non-Western bioethicists. Myser (2003) described the defining feature of mainstream bioethics – a “normativity of whiteness” – that Arekapudi and Wynia (2003) declared to be “unbearable.” Burton (2007) addressed the issue asked “why bioethics cannot figure out what to do with race.” A recent anthology, Bioethics Around the Globe (Myser, 2011), reconfirms that the dominant socio-cultural-moral construct known as Western bioethics as exported to developing and/or Eastern countries does not encompass the belief-systems, cultural norms and moral values of people located outside of the moral tradition that evolved in white, Western societies.

Morality is not mathematics

In criticizing our position, ten Have and Gordijn (2011, p. 2) state that the “genesis of an activity is not identical to its validity,” and thus, they assert, bioethical ideas developed in the West can be used elsewhere. In order to illustrate their point they note: “Our number system is inherited from the Arab culture. We are not accusing the Arabs of colonialism since they have imposed their number system on us” (p. 2) Is this an apt analogy? We think not. Not only does this analogy blur the distinction between imposition (bioethics) and gradual adoption (Arabic numbers), it makes an odd equation between morality and mathematics. Can a complex and rich concept like morality be compared with an abstract system of written numbers? Nearly all people would agree that the number “911” means a discrete number of things one more than “910” and one less than “912”, but can we find the same sort of agreement about the meaning of justice? The morality/math analogy falls apart completely when you let culture in. Nine hundred eleven may be just a number, but when you say “9/11” it means much more than a discrete number to people in certain societies. Furthermore, the question here is not about whether the “colonized” are accusing the “colonizers” for the “imposition” of their moral system. The question is whether the imposition of Western moral theories and methods in non-Western cultures (which Ten Have and Gordijn indirectly accept) is appropriate and ethically justifiable. We point out in our earlier article: “Bioethics … is Western not because it originated in the United States or has its roots in the West, but because of the way it is theorized, structured, formulated, and practiced” (Chattopadhyay and De Vries, 2008, p. 107, emphasis added).

Ten Have and Gordijn go on to claim that our “argument is also unjust. It is ‘doublespeak’ to justify conditions and circumstances that are reproachable from the point of view of universal values. ‘Asian values’ for example have often been promoted to justify authoritarian regimes.”

This allegation of “doublespeak” is also odd. Of course we do not condone the use of ethical systems to justify moral wrongs. Likewise, we expect that our critics would not condone the use of Western values and ideas to justify the use of force, violence, and torture. Recall that slavery and genocide of indigenous populations are part of the history of the Western civilization¹ and were often justified by well-reasoned ethical ideas. Respect for religious values does not mean support or justification for terrorism in the service of religion, and respect for cultural diversity does not imply support for wrongdoings including, for example, violence against women, or corruption “justified” as part of culture. The fact that “Asian values” have been “promoted to justify authoritarian regimes” in some quarters does not mean “Asian values” are necessarily flawed, dangerous or evil.

Western bioethics faces enigma of culture

In our everyday lives, we celebrate diversity – in colorful clothes, delicious food, varied job skills, and a plethora of literary traditions. Diversity is an undeniable reality of our life on this earth – we share the planet with more than 6 billion people who speak over 6000 languages, live in about 200 countries, and belong to a number of religious and/or spiritual traditions. The Universal Declaration on Cultural Diversity describes cultural diversity as “the common heritage of humanity…necessary for humankind as biodiversity is for nature” and claims that its defense is an “ethical imperative that cannot be separated from respect for the dignity of the individual” (UNESCO 2002, emphasis added).

Nonetheless, for some Western bioethicists, culture appears to be an enigmatic puzzle. Sometimes it is seen a barrier that needs to be overcome to provide “scientific” health care and at other times, as argued by Bracanovic, it poses “constraints” to “normative role of bioethics.” But cultural diversity is something that cannot be denied or opposed: it is simply a fact of life in our world.

Why then is this “cultural turn” in bioethics so problematic? Taking a clue from our story of the Cadillac in rural Bangladesh, we think it is because the limousine (the philosophical framework of decontextualized Western bioethics) is facing hitherto unknown and difficult challenges of the thick context of village bazaar (non-Western cultures) and finding it almost impossible to move ahead. Instead of finding the lacunae in contemporary bioethical theories and methods, instead of “problematizing” the inability of Western bioethics to recognize and fruitfully engage with diverse cultures and moral traditions, Bracanovic chooses the easy, but wrong, way out. Much like the “blaming the bazaar” he finds the problem to be “respect for cultural diversity” in bioethics.

Perhaps typical for some Western bioethicists, ten Have, Gordijn, and Bracanovic do not (and perhaps cannot) see the ground below their feet: that is, the cultural contexts where their ethical reflection and analysis are grounded. The vantage points from where they observe, judge “others” and make “normative analysis” are never brought to focus or even questioned. Bracanovic’s own culturally conditioned and grounded ethics appears to him as “typically normative.” The moral traditions and ethical worldviews that guide “others” in different settings - for example, Hindus, Sikhs, Jehovah’s Witnesses, and Inuit (“Eskimos”) - are either “atypical” or not “normative” enough: they belong to the other less morally developed worlds of “cultural diversity.” Interestingly, the culturally embedded Western philosophical worldviews of universalists – local in nature - become the vision for the global ethics.

Bracanovic bases his critique of cultural diversity on the difficulty of defining culture. There are, of course, disagreements about the precise definition of culture – as Bracanovic points out. But, there is also disagreement about the precise definition of bioethics, a fact that does not bother Bracanovic. One of us (RdV) interviewed a number of leading figures in the field of bioethics and nearly all had great difficulty in giving a precise definition of bioethics: it is fair to say that were as many definitions of bioethics as there were persons interviewed. The definition of bioethics itself – using Bracanovic’s term - is “plagued by vagueness”, but that cannot be the reason to suggest that bioethical enterprise be abandoned. Just as we do not require a precise definition of beauty in order to value, admire, or create an artful painting, we do not need a precise definition of culture or bioethics to make sound moral judgments in the face of cultural diversity.

Bracanovic also points out that culture must not be considered in making moral decisions because “culture changes.” But of course morality also changes. Consider the major shift in moral outlook of the post-WWII world regarding the moral propriety of racism, colonization, and slavery. Not too long ago, many in the West (including philosophers) justified these practices as a way to “civilize” the “barbarians.” Few do today. Does this “negatively affect [the] capability [of bioethics] to change and adapt to new environmental circumstances” as Bracanovic claims?

Interestingly, Bracanovic uses the example of Hindu-Sikh religio-cultural tradition(s) to raise a problem about individual and family autonomy. He asks: “which element should have more weight in our decision-making: collective (family) decision-making or individual decision-making?” Notice: it is Bracanovic’s own cultural perspective (which he seems not to see) that drives him to prioritize one over the other. Thoroughly grounded in his tradition, he cannot conceive that an ethical decision can hold these two in tension when rendering a decision. Seen from the Hindu-Sikh religio-cultural point of view, the question is not just about choosing “either/or” – as Bracanovic asks – it is also about how to find the points of convergence, if not harmony, between the individual and collective.

Ten Have, Gordijn, and Bracanovic seem to be caught in the tension between two divergent compulsions at opposite ends - the need to argue for culture-free moral standards at one end and undeniable reality of socio-cultural context at the other. This queer half-denial-and-half-acceptance of culture reveals itself in perplexity, hesitation, dilemma, self-contradiction, and anxiety. For example, Bracanovic says:

Morality—as the human capacity to judge about right and wrong—is undoubtedly of social and cultural origins and it develops in each individual as he or she internalizes culturally transmitted values.

But then he asserts:

If standards of right and wrong lie outside biology, then they lie outside culture too…“identification of values with cultural facts and evaluation on the basis of cultural origins is …fallacious”

When morality is “undoubtedly of social and cultural origins,” how could the “standards of right and wrong” then “lie outside culture”, and why is “evaluation on the basis of cultural origins” then “fallacious”?

Ten Have and Gordijn admit (p. 2):

Taking seriously the bioethical questions and answers in different countries, cultures and religions implies not to impose a particular normative framework but to do as much justice as possible to the normative considerations and concerns existing in these different contexts.

But then they make a U-turn:

It is a kind of ‘moral protectionism’ to continue to regard basic ethical notions and human rights as “Western values” that cannot be exported to other cultures.

What does export of “Western values” to “other cultures” mean if it is not imposition of Western “normative framework”?

The concern with stereotyping a culture and ignoring individual differences reveals an anxiety about culture on the part of Western bioethicists. “If we treat culture seriously, won’t we end up stereotyping a particular culture or ignoring the differences that exist within cultures?” No. Taking culture seriously recognizes that people draw on several cultural traditions in making moral decisions. It also means that when people draw on other than Western moral traditions, it is inappropriate to declare those traditions wrong, misguided, or evil. Culture creates the broad “world” within which individuals live and make moral decisions. It is not necessary that individuals share all beliefs and values of a culture to belong to that culture.

Reducing cultural differences to the more familiar Western concept of individual differences – thus allowing them to be weighed by some delicate and abstract philosophical balance – is, in fact, denial of the cultural world an individual inhabits. An answer to Bracanovic’s western-colored question on the prioritization of the individual versus the collective can be found in the behavior of a conscientious and caring healthcare professional from a non-Western culture who practices medicine in the US, UK or other Western European country. These practitioners know – if not by training, then by experience - that a caregiver can act ethically but in different ways depending upon a patient’s situation in a specific socio-cultural context. The science and art of compassionate medicine (and cross-cultural bioethics) must address the medical-emotional-cultural needs of individual patients. An ethical doctor may place more weight on individual autonomy in one case and on family autonomy in another. In real life situations there is more than one way to do the right thing.

Worried about the implications of cultural diversity, Bracanovic tries to reduce the richness of cultural differences to an abstract moral commonality (p. 233):

The practice of parricide and infanticide among Eskimos does not mean that human life is of no value to them; it only means that they, just as we do, take the quick and less painful death as preferable to slow and painful one and that they, just as we do, place community good above the individual good.

But in so doing he runs roughshod over empirical reality. He ignores real and significant cross-cultural differences on bioethical issues like doctor-family-patient relationships, healthcare policy, end-of-life care, organ transplantation, stem cell research, and traditional medicine (Alora and Lumitao, 2001; Chattopadhyay and Simon, 2008; Coward and Ratanakul, 1999; Engelhardt and Rasmussen, 2002; Hoshino, 1997; Qiu, 2004; Song, Koo and Macer 2003, Tangwa 2007). In fact, he misrepresents empirical reality: Do we in the West “place community good above the individual good” as he asserts? “We” in the Unites States have organized the healthcare system in a way that actively resists the common good.

Part of the problem that Western bioethics faces when dealing with cultural diversity stems from inclination to see “ethics” and “culture” as independent, separate and segregated domains of human experience. This creates an unfortunate schism between culture-oriented disciplines like anthropology and sociology and bioethics. The need to recognize that facts are value-laden and that values are fact-laden is long overdue:

Useful moral theory transcends the tired is/ought debate, abandoning insistence on developing moral ideas “from nowhere”, as if there is a place where moral theory can be created free from social influence on cultural values. Recognizing that ought’s are shaped by ises and ises are shaped by ought’s, will move us to more moral moral theories (De Vries, 2011)

Anti anti-relativism

Lurking at the core of Bracanovic’s arguments and ten Have and Gordijn’s disagreement with us is what they call “ethical relativism and particularism.” We find the export and uncritical application of individual-centered, rights-based Western bioethics in non-Western societies to be moral imperialism; they find our position – which they label ethical relativism – as problematic and argue for moral universals.

Ten Have, Gordijn and Bracanovic are what Clifford Geertz would call “anti-relativists.” In his important article – “Anti anti-relativism” – Geertz (1984) reassures the anti-relativists that they need not fear relativism,

because the moral and intellectual consequences that are commonly supposed to flow from relativism – subjectivism, nihilism, incoherence, Machiavellianism, ethical idiocy, esthetic blindness, and so on – do not in fact do so and the promised rewards of escaping its clutches, mostly having to do with pasteurized knowledge, are illusory (p. 263).

Geertz goes on to defend the value of anthropology in revealing the variation in the moral and political lives of humans:

[We anthropologists] have been the first to insist on a number of things: that the world does not divide into the pious and the superstitious; that there are sculptures in jungles and paintings in deserts; that political order is possible without centralized power and principled justice without codified rules; that the norms of reason were not fixed in Greece, the evolution of morality not consummated in England...Most important, we were the first to insist that we see the lives of others through lenses of our own grinding and that they look back on ours through ones of their own…The objection to anti-relativism is not that it rejects an it’s-all-how-you-look-at-it approach to knowledge or a when-in-Rome approach to morality, but that it imagines that they can only be defeated by placing morality beyond culture and knowledge beyond both…If we wanted home truths, we should have stayed at home (pp. 275-276)

Once you dispense with the unfounded fears of relativism, unavoidable questions remain: who decides what a “moral universal” is? How should we handle conscientious disagreements with so-called “universal” ethical principles?” It is important to note in this regard that a number of scholars – from East and West, North and South – have even questioned the supposed universality of the so-called Universal Declaration of Bioethics and Human Rights (Benatar, 2005; Chattopadhyay and de Vries, 2008; Macpherson, 2007; Rawlinson and Donchin, 2005).

Respect for cultural and moral diversity is an ethical imperative

In 1992, Barker (1992) observed:

“Bioethics is still largely entangled in asocial, acultural, and decontextualized philosophical, moral, and legal discourses. It has yet to investigate comprehensively the social and cultural realities that matter to diverse patient populaces”

The situation has improved since this lamentation. Despite strong resistance in many quarters, there is now little doubt that cultural norms, values, and belief systems play significant roles in ethical reflection and analysis. The question of whether culture matters in bioethics no longer evokes “Wow I didn’t know this” kind of response. It has been replaced by the second generation question of “In what ways and to what extent does culture matter in bioethics? Sadly, Bracanovic’s paper is a move backward – arguing against respect for cultural diversity - when bioethicists need to address the nature of a myriad of conceptual, analytic, and methodological questions that arise when diverse moral traditions share a common world.

There is a move in bioethics to bend over backwards to deny moral pluralism and save the idea of “universal” moral principles. Faced with a culture where a young woman allows her father make medical decisions for her, for example, members of this camp would argue that this is, in fact, an expression of autonomy(). In this case they would say the young woman has autonomously decided to give her autonomy to her father – a kind of “second order autonomy.” Thus, “we” in the west, and “those” in a non-western society, value autonomy equally. This is simply a word game – acrobatics of language. It does nothing to help us understand how moral decisions are actually made in real-life scenarios.

But “moral universals” – as decided in Washington D.C. or Paris – are more than just a game. Insistence on individualistic notions of autonomy results in the ritualistic use of written consent forms in illiterate communities. “Autonomy” is thus honored and upheld and the researchers have a written record of their compliance with research ethics committee regulations. But the subject of the research has no idea about what she agreed to. We have heard stories of people in illiterate communities showing up at hospitals with years-old consent forms believing that the form was some kind of admission ticket to medical care. The regulations were followed, “universal” principles honored, and the subjects were exploited.²

This clearly represents misuse of Western forms (in both senses of the word). There is a kind of ethnocentric universalism at work here. It is characterized by a remarkable disrespect, distrust, denial, and fear of non-Western approaches to moral decision-making. “If we honor Asian values are we not justifying authoritarian regimes?” Or, “If we honor African values, are we not justifying female circumcision?” Anti-relativist Western bioethicists cannot escape the belief that an individualized, individual rights-based approach to ethics is the most, if not only, moral approach. They believe that when more primitive societies evolve, they will see the light, turn from their communal ways and recognize the need for individual, first order autonomy. Perhaps it is hard for Western bioethicists to realize that over–emphasis on a “moral universal” like individual autonomy is, in reality, an assault on the matrix of relationships in which an individual is embedded and therefore also an assault to the ethos of family and community. And, the danger is real - when the notion of “duty-free human rights” permeates and virtually replaces ethics in public space, it creates a moral vacuum in the social psyche that allows for neglecting duty and, not surprisingly leads to bolstering a narrow self-interest incongruent with social responsibility and duty toward the vulnerable.

Human civilization will suffer irreparable loss if diversity is treated as a menace and cultures with all their treasures, including languages, literature, art, music, medicine, and moral visions, are restricted within narrow limits. Culture is broader than, and inclusive of, ethics. There can be no true respect for cultural diversity without accepting the possibility and reality of diverse moral worldviews; respect for cultural diversity means acknowledgment, appreciation and respect for diverse moral traditions. The alternative to respect for cultural and moral diversity is, either consciously or inadvertently, accepting or making the way for what could be termed cultural and moral genocide - annihilation of varieties of culture and moral visions of life and medicine that evolved over eons. Any bioethics worthy of the name needs to engage fruitfully and meaningfully with the diverse cultures and moral worldviews in the era of globalization. Ten Have, Gordijn and Bracanovic are wrong about moral pluralism and cultural diversity in bioethics. Respect for cultural diversity does not confound moral judgment; it is, in fact, an ethical imperative that cannot be compromised. And, moral genocide - by export and uncritical application of Western bioethical theories, methods and worldviews - is unacceptable.

We believe that challenge for the bioethicists in the twenty-first century is to explore the possibility of finding common grounds of morality across different cultures while acknowledging, and yes, respecting, cultural and moral diversity. Search for moral equivalent of “unity amidst diversity” is a quest of all humanity and yet to begin.

Epilogue: We have argued ten Have, Gordijn, and Bracanovic are wrong. In the Hindu spiritual tradition as espoused by Swami Vivekananda, they may be considered as not “wrong”, but on “lower plane of truth”. Readers will judge whether or not, we are, humbly speaking, “right” or on “higher plane of truth” in this aspect of bioethics.