- Ole Doering, Ph.D. Zentrum Medizinische Ethik Ruhr Universitaet Postfach 102148 D-44780, Bochum, GERMANY Email: firstname.lastname@example.org
This new book, which assorts the fruits from the IV Asian Bioethics Conference in Seoul, can be recommended for indicating a new phase in the development of a global bioethics. With her fourth conference's site, the ABA has not only symbolically returned to the Asian mainland. After two interesting meetings in Japan, (in Kobe, in co-operation with the UNESCO in 1997, and in Tokyo, in association with the IAB's Fourth Congress in 1998), which succeeded the founding conference in Beijing in 1995, bioethicists from Asia have moulded their profile as being independent from international institutional support (Leavitt 2002: 212). It will now be easier for the established ethicists in the Western-European and Northern American mainstream to appreciate the contributions from Asia.
What does this mean to appreciate? Is a global bioethics confronted with new, surprising, or even strange answers and approaches to the puzzles of the ethics of life and death, challenging the frontiers of acceptance of science from Asia? Some culturalistic enthusiasts have put forward such expectations in the past, in Asia, Europe and America. After several years of organized bioethics in Asia, have we seen radically new understandings of humanity emerging, which would contradict moral intuitions of people in other places? Obviously, this is hardly the case. Yu Kam Por (in this conference) has impressively pointed out the similarities in approaches from different regions of the world in laying the grounds for ethicists to improve the real ethical situation according to their respective conditions. In a sense, this was just another conference in bioethics, discussing a variety of serious concerns from different perspectives. From a sober view, the odds are less dramatic, less metaphysical, but more constructive and down to earth, and in no ways less exciting.
Controversy is in many details of language, mores, education, socialization, assessments, forms of thinking, etc., but not in the fact that we originate from different environments. Our discussions seem to indicate that the project of an Asian Bioethics is in the first place an open-minded, well informed and sophisticated engagement in real issues of bioethics. The discussions in this conference take the entire range of individual, communal, regional and global ramifications into account, while, for practicability's sake, most focus on the level of engagement that actually seems to matter. It is less preoccupied with the implications of belonging to a certain tradition than concerned about moral and ethical issues, which might but need not invoke such considerations.
Such an interest in matters that matter encourages bioethics to explore more thoroughly the substance of what it is that needs to be discussed and evaluated. For example, how far can we really achieve an understanding in ethics by studying biology? How can bioethics learn from those lessons in critical sociology and anthropology that in particular deal with the problematic "cultures" of science and medical sociology? For example, in "experimental medicine (...) where the distinctly modern tension between the claims of scientific medicine and those of the individual patient come into their sometimes complementary, sometimes antagonistic, but not easily dissolvable relationship" (Rabinow 1996: 159), there is a great need for independent responsible and accountable decision making skills as well as for empathy and an aptitude for teamwork. Given that it is the common aim of bioethicists to make our lives more healthy, (whatever this means, cf. Kleinmann 1988: 3-11 and 1995), and that we are all confronted with, (tentatively), the same structure of problems. How can bioethics help people to engage in a fair relationship and make the best decision? Being versed in handling the relevant scientific, legal and administrative protocols does not suffice. Likewise, to offer an ethical vision that ultimately leaves moral responsibility in matters of distributional justice to "a lottery" does not appear "ingenious" (Peter Singer, in this conference) to me but rather as a lack of courage and intellectual creativity in ethics. Telling people that they belong to an "Asian culture" is not likely to help anyone much either. Here, the conference drafted a richly featured sketch of perspectives, including self-critical science (Lee Pil Ryul), informed consent (Zhai Xiaomei), levels of risk-assessment (Lei Ruipeng), the conundrum of fuzzy laws (Alireza Bagheri), and others. It addressed institutional issues, especially the importance and problems of IRB's (Park and Kim, Nurten Aksoy, Nei and Yeh, Niu Huei-Chih). It was clarified that an ethically sensitive discussion of the situation of dying patients reinforces concern about the situation of poor or neglected people in general (Yang Hsiu-I, Hamano Kenzo, in this conference). Legal and economic strata of ethics do not have much to say here. Instead, we learned about the social and political power of good moral examples from cases of AIDS-activism in Thailand (Pinit Ratanakul), and the quandary of using "exemplary" behaviour as a moral incentive to encourage "selfless" action in organ donation or euthanasia (Leonardo de Castro). This plenitude of the real and sometimes contradictory situations and approaches represents a wealth of moral and intellectual resources Asian bioethicists offer humanity to cope with our new and not so new problems. It is their genuine ethical concern rather than being "Asian" which glues them together.
I frankly confess that I still have not learned what "Asia" could be, taken as a perspective in Bioethics. The assortment of different individual opinions, traditions, schools and practices appeals as a resource rather than suggesting that all authors adhere to a certain kind of view. Perhaps I have learned what contributions from different perspectives in Asia can pitch in to a kind of bioethics which is less burdened or restricted by apologetic, utilitarian or legal views chiefly designed to cater for the narrow demands of bio-politics. "Merely allocating money to support a growing community of professional ethicists and then parroting a few commonplaces about 'hard choices' will not do. It won't do for two reasons. First, it is certain to produce more procedural specialists and more moralism (...). Second, such a division of labour won't change the habits and practices of the scientists. The best among them perhaps will pledge three percent of their time to posing dilemmas and then get on with their scientific work exactly as before. That is to say, in a very precise manner - it won't have any ethical impact on them. One might well wonder what, if anything, is wrong with that? One way to approach that question is to ask how is it that scientists are not more theoretically curious about such matters?" (Rabinow 1996: 155). This development towards an instrumental bioethics is unavoidable and yet an imminent, indeed a vital, challenge for ethics. Every bioethicist can help to do a better job than the one criticized here by Rabinow.
In short, bioethics from Asia can contribute to the making of a new culture of "Bildung" (pursuit of knowledge), which has been expected to evolve together with the advancement of the sciences (Snow 1964). A philosophical ethics revitalises the scientists' curiosity about the meaning and impact of their work beyond the confinements of laboratories, just as it opens the minds of scholars in the humanities for the findings of science. Thereby, bioethics might help to reintegrate all avenues of science, driven by the greater vision of taking part in a scientific research programme (Lakatos 1978). It might achieve exactly this, if it does not content itself with following the established mainstreams - including the related concepts, procedures, institutions and priorities of any existing bioethics. Instead, bioethics in Asia is free to set out for a new agenda that is not preoccupied by somehow "being Asian" but by making good ethics in the fields of biomedicine. Whatever Asian essence there may be at work, it will surely make itself visible through such a course eventually.
An unbiased interest in the constructive meanings of culture(s) in bioethics takes into account the impact of social development, which is partly driven by economic, scientific and technological progress. Asian ethicists can take advantage of studying both their respective own situations and the history of relevant developments in other places, with special attention to the accompanying critical lessons that have been put on the record by social scientists and medical sociologists in particular. European and American colleagues did not have such favourable access to experiences, trial and error in implementing bioethics, before they decided which course to take or which way to let the winds blow in the forming of their systems. They find themselves stuck with partly advanced and partly outdated structures and institutions making it more difficult to cope with the exploding growth in science and technology from an ethical view. In this light, developing countries appear to have time on their side. There is no reason to want to become "like the West", perhaps but for the critical scholarship that lies largely besides the mainstream.
On the other hand, after times of "Asia watching", from a European view, Asia now offers many examples with an inkling of living history, reminding us of the long and arduous ways we had to go in order to overcome inhumane social, economic and political systems of the 19th century. Many Asian regions now rush through similar developments within only a minute of the time we have had. To scrutinize where bioethics came from might be helpful if we want to identify the major threads of social modernization and how to protect the world from a newly disguised, anonymous but refined despotism. There is much truth in observing that extreme individualism, just as collectivism, is an ethical deadlock, which jeopardizes society's health. However, the current challenge of "liberal eugenics" (Osamu Kanamori, in this conference) can only be managed on the basis of profound understanding of the reasons why and in what sense people pursue medical services, and which additional interests and powers are involved. Defining the overall objective of medicine makes this task assessable. I propose that still the first purpose of medicine is to seek health and relief from suffering, not to attempt to overcome nature. Ethics should encourage and enlighten, not confuse and deprive our minds and the capacity to moral judgement, respectively.
Another common thread in our global village is the transformation, (or, more pessimistically: the disintegration), of the family (V. Manickavel, in this conference). This traditional nuclear unit of society is evidently in a process of change. In Europe the related socio-economic development has begun almost two centuries earlier than in East Asian countries. Being propelled by contradicting motifs, such as emancipation and alienation of the individuals, it is difficult to evaluate it in itself. Predicting its ultimate destination is impossible. Rather than engaging in moral laments, we should acknowledge the facts and reconfirm, perhaps even rebuild, the universal function of the family in a modern society. Ideally, the family used to be constructive in offering a protected sphere for social and moral learning (socialization), that would shield the vulnerable individual from other powers and authorities (state education, economic pressure). It also was instrumental in social, cultural and individual identity building. These strong points should be cherished. Given our human biological, psychological and intellectual dependence upon others and society, a kind of family, involving different sexes and different age groups as well as distinct individuals' roles, will continue to be part of the desirable human life. The point of concern about the family in medical ethics transcends questions of individual interests versus social power. It directly relates to the overall purpose of building the structures of a "good life". Bioethics should explore the possibilities for transforming the family into a living system that serves humanity under the conditions in the era of biomedicine. Again, the ethical question is not, whether either an individualistic or rather a communitarian approach should be adopted. We may expect bolder proposals from ethics. Countries with a relatively long history of departure from traditional family structures and, at the same time, reasonably healthy living conditions, could share their experiences from social experiments where people created new or revived old forms of communal life, adaptable for the moral and professional requirements of the present times. The question is, how to organize good ways of managing conflicts, which arise unavoidably from the interplay of individuals and communities, within and beyond the family (Henslin 1992, Edwards 2001).
Accordingly, the resolve to respect cultural issues in bioethics should facilitate and enhance the level of ethics in practice, rather than paralyze intellectual creativity. More contributions from bioethicists in Asia can stimulate participation of fresh perspectives, a wide variety of insights and capacities, engaged, first of all, in a practice-related discourse. The ultimate horizons of thinking can be deep and philosophical, even mystical, but they won't indulge in mere metaphysical speculations without a constructive practical sense. The living picture of Asian Bioethics, as drafted here in terms of a sketch from the IV Asian Bioethics Conference in Seoul, leaves room, perhaps for objections and for many interpretations and remaining puzzles of bioethics. As always, the future is uncharted territory. The development of bioethics in Asia cannot be predicted. In terms of the capacities of Asian bioethicists, I would like to conclude on an optimistic note. Master plans of any branch for ethical puzzles are outdated; claims to know what truth and good mean in action have been unveiled as hubris; principle-based and voluntary approaches to ethics are incompatible with the spirit of honesty, justice and a good life for all. Appreciating the real variety, the dramatic urgency and the basic level of bioethics' issues as presented here, this conference may strengthen independent and constructive critical thinking, inspired by ethics in the original sense.
Lee Edwards (ed.), The Global Economy: Changing Politics, Society, and Family, 2001.
James M. Henslin (ed.), Marriage and Family in a Changing Society, Free Press 1992.
Arthur Kleinmann, The Illness Narratives. Suffering, Healing and the Human Condition, New York (Basic Books) 1988.
Arthur Kleinmann, Writing at the Margin. Discourse between Anthropology and Medicine, Berkeley (University of California Press) 1995
Imre Lakatos, The Methodology of Scientific Research Programmes, ed. by John Worral and Gregory Currie, Cambridge (Cambridge University Press) 1978
Frank Leavitt, "Bioethical Transparency and Vegetarianism: Report as a Member of the Board of Directors of the International Association of Bioethics (IAB) and of the Asian Bioethics Association (ABA)", EJAIB 12 (6) Nov 2002: 212-214.
Paul Rabinow, Essays on the Anthropology of Reason, Princeton (Princeton University Press) 1996.
C.P. Snow, Two Cultures: And A Second Look, Cambridge 1964.