Bioethics as a Western Culture-Bound Syndrome

Abstract

In this article I argue that the four guiding principles of medical ethics—autonomy, beneficence, non-maleficence, and justice—reflect the values of western culture, but do not necessarily apply outside of it. Western medical practitioners faced with the care of nonwestern patients need to examine their own prejudices in order to accept, not merely tolerate, other values. Acceptance of the other requires that the doctor welcome the patient as one welcomes a guest, openly and equally, with a willingness to listen and to be changed by the encounter. It is through the nurture of trusting relationships that ethical dilemmas in clinical medicine may be resolved, without recourse to the colonial moral hegemony of the principlist approach.

Notes

1. Raymond Cohen, Negotiating across Cultures (Washington, DC: United States Institute of Peace Press, 1991).

2. R. M. Veatch, Cross Cultural Perspectives in Medical Ethics, 2d ed. (Sudbury, MA: Jones & Bartlett, 2000); P. Stephenson, “Expanding Notions of Culture for Cross-Cultural Ethics in Health and Medicine,” in A Cross-Cultural Dialogue on Health Care Ethics, ed. Harold Coward and Pinit Ratanakul (Waterloo, Canada: Wilfrid Laurier University Press, 1999), 68–92.

3. Tom Beauchamp and James Childress, Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001).

4. Nathaniel Comfort, “Cultural Darwinism,” The European Legacy 13.5 (2008): 623.

5. Azgad Gold, “Physicians’ ‘Right of Conscience’—Beyond Politics,” Journal of Law Medicine and Ethics 38 (2010): 134–42.

6. Michel Foucault, The Birth of the Clinic, trans. A. M. Sheridan-Smith (London: Tavistock, 1973).

7. Ivan Illich, Medical Nemesis (London: Calder & Boyars, 1975).

8. Naomi Klein, The Shock Doctrine: The Rise of Disaster Capitalism (London: Penguin, 2008).

9. Ruth Shalit, “When We Were Philosopher Kings,” The New Republic, 28 April 1997.

10. Richard Wilkinson and Kate Pickett, The Spirit Level: Why Equality Is Better for Everyone (Harmondsworth: Penguin, 2010).

11. Karl Popper, The Open Society and Its Enemies (London: Routledge & Kegan Paul, 1945).

12. Jonathan Sacks, The Dignity of Difference (London: Continuum, 2002).

13. Cecil Helman, Culture Health and Illness (Bristol: John Wright, 1984).

14. Richard Wilkinson and Michael Marmot, Social Determinants of Health, 2d ed. (Copenhagen: World Health Organisation, 2006).

15. Aron Antonovsky, Health, Stress and Coping (San Francisco, CA: Jossey-Bass, 1979). Salvatore Maddi and Suzanne Kobasa, The Hardy Executive: Health under Stress, 2d ed. (Chicago, IL: Irwin Professional Publishers, 1984).

16. Heather Widdows, “Is Global Ethics Moral Neo-Colonialism? An Investigation of the Issue in the Context of Bioethics,” Bioethics 21.6 (2007): 305–15. doi:10.1111/j.1467-8519.2007.00558.x.

17. Immanuel Kant, “The Moral Law,” in Groundwork of the Metaphysics of Morals, trans. H. J. Paton (London: Hutchinson, 1953).

18. Martin Buber, I and Thou, trans. R. G. Smith (Edinburgh: T & T Clark, 1937).

19. The classic exposition of this idea is found in Jacques Derrida's in memoriam speech at Levinas's funeral in 1995, published as Adieu à Emmanuel Levinas (Paris, Editions Galilée, 1997).

20. Michael Balint, The Doctor, the Patient and His Illness, 2d ed. (Edinburgh: Churchill Livingstone, 2000).

21. Paul Ricoeur, The Conflict of Interpretations, ed. Don Ihde, trans. Willis Domingo et al. (London: Continuum, 2004).

22. Jürgen Habermas, The Theory of Communicative Action: Reason and the Rationalization of Society, trans. Thomas McCarthy (London: Polity Press, 1986).

23. John Launer, Narrative-Based Primary Care (Oxford: Radcliffe Medical Press, 2002); Kathryn M. Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton, NJ: Princeton University Press, 1991).

24. Carol Gilligan, In a Different Voice: Psychological Theory and Women's Development (Cambridge, MA: Harvard University Press, 1982). Helga Kuhse, Caring: Nurses, Women and Ethics (Oxford: Basil Blackwell, 1997).

25. Avi Sagi, “Between Ethics of Compassion and Ethics of Justice,” in Albert Camus and the Philosophy of the Absurd (New York: Rodopi, 2000), 159–72. I thank the author for introducing me to this concept.

26. Emmanuel Levinas, “Useless Suffering,” Giornale di Metafisica 4 (1982): 13–26.

27. Jerusalem Talmud, Tractate Nedarim, chap.4, 38c (Venice edition).

28. J. G. Scott et al. “Healing Relationships and the Existential Philosophy of Martin Buber,” Philosophy, Ethics and Humanities in Medicine 4 (2009): 11, doi:10.1186/1747-5341-4-11. This is one recent attempt to apply the philosophies of Buber and Levinas to medicine, and it proposes that the asymmetrical I-It relationships of medicine, the bio-science and the detached clinical reflection that William Osler called Aequanimitas, form an essential pre-requisite for the I-Thou bipolar relationship to develop, in which the doctor can experience as well as understand the effect of the relationship on the patient. Levinas seems to go further still, to turn the asymmetry on its head, making the patient the truly powerful agent in the relationship, for if I am the host in the host-guest relationship, it is the Other who makes the demands on me to serve him, thus defining my humanity. The healing relationship is a special case, however, for it is the patient's medical needs that drive the demands that he makes on me, so that the patient as Other becomes at one and the same time my master and also my beneficiary. See also Alfred Tauber, Confessions of a Medicine Man (Cambridge, MA: MIT Press, 1999).

29. Eirini Rari and Veronique Fournier, “Strengths and Limitations of Considering Patients as Ethics ‘Actors’ Equal to Doctors: Reflections on the Patients’ Position in a French Clinical Ethics Consultation Setting,” Clinical Ethics 4 (2009): 152–55, DOI:10.1258/ce.2009.009021.

30. Michael A. Weingarten, Changing Health and Changing Culture: The Yemenite Jews in Israel (Westport, CT: Praeger, 1992).

31. M. Reif, H. Zakut, and Michael A. Weingarten, “Illness and Treatment Perceptions of Ethiopian Immigrants and Their Doctors in Israel,” American Journal of Public Health 89 (1999): 1814–18.