Research Fellow, Institute of Philosophy, Russian Academy of Sciences, Moscow, RUSSIA
While the developed countries, becoming more rich, are looking for new ways of stabilisation and are experimenting in different forms of integration-the majority of developing countries (which accounts for two-thirds of the world population) has found itself in a very complicated, ambivalent situation. While in practice using many things derived from achievements of western civilization, they simultaneously continue to meet difficulties of their former outsider's position. This ambivalence can be explained by the traditional position of their obvious, and to some extent predicted, "balancing acts" between poles of wealth and destitution, modernism and conservatism, traditional religions and secularism etc. We shall consider how this phenomenon can be interpreted in bioethics, considering statistics and concrete facts.
Bioethics remained in the developing countries for a long time an outlying area of the moral sciences and biomedical practices. Now it is a well-known research trend, which helps to solve concrete professional problems. It considers the conflict between knowledge and values, which appear in the course of development of biomedical ideas and technologies like genetic engineering, euthanasia, transplantation of organs, reproduction technologies etc. These situations are directly connected with realisation of the main human rights to live and have health protection. Bioethics initiates professional and social discussion on ethical aspects of the difficult biomedical problems and situations.
The simultaneous orientation of bioethics towards the biological nature of human beings and general cultural values, allows bioethics to overcome professional, national, partly confessional and other particularism, to be a real high-principled basis for intercultural dialogue. As professional medical ethics regulating human rights in the situations "doctor-patient", "donor-recipient" etc., and as a platform for dialogue in the dynamic context of the developing countries, bioethics is of practical interest for all strata of society and institutes of the developing world.
Bioethics and demographic statistics
In order to form an adequate estimation of the prospects of bioethics in the developing countries, one should consider the world demographic situation of the decade, as one can often hear the statements that the problems of these countries are connected with uncontrolled birth rate. By statistics the world population increased to 5.1 billion people by 1990, the number of people in the developing countries accounting for 77% of the total (in the least developed countries live 450 million people). For every child in a developed country in 1990 there were 7 children in the developing countries. The comparison of initial and subsequent living conditions presented in the report by the Executive Committee of the World Health Organisation speaks for itself (I).
"Whom fortune will smile upon"
A girl born in 1990 in one of the rich countries has every ground to live to the age of 81. While growing up she will be provided with normal food and living conditions, education and modern medical service by the state and the family. She will have complete course of vaccination against all childhood diseases. At the age of 20 the girl will marry and have one or two children who will be born in a maternity hospital after regular prenatal medical observations. In the middle age her health will be mostly endangered by an accident at home or in a car, or a very serious influenza epidemic. When elderly, she is endangered by cardiovascular disease or cancer, though, there is great opportunity she will control first attacks of the disease due to excellent medical service and rehabilitation measures. In her old age, she will be guarantied medical and social services for an average cost of one thousand dollars yearly. 17 million children born in 1990 in the developed countries (that is 1/8 of the world population increment) will very likely share the living conditions of this lucky little girl.
"One who is the last"
A girl born in one of the poorest countries on the same day has an opportunity in fact, to live to the age of 43. Her parents, as usual, are not healthy, therefore there is great possibility that she is born premature. Every fifth child in the country does not live to the age of one year, and every third one dies before the age of five. The girl will not receive proper homecare and insanitary living conditions can easily cause intestinal diseases, cholera and tuberculosis. She has just one chance in five to learn to read and write. In the age of 10 she can be given in marriage and she can have more than 10 children (if one of the deliveries does not end in her death by not using the sterilized birth adjuvant). Three or four of them will die before the age of five, because she will not be able to provide proper care while pregnant and afterwards (obstetrical aid, vaccination, medical service for the growing child). Her life will be accompanied with danger of being infected through dirty water or insects. In order to support her family, she will have to carry out hard physical work. If she manages to live till she is grey-headed, that is extremely seldom, she will get cancer or cardiovascular disease and she will die very quickly without necessary medical aid. It was noticed that, among the developing countries' population, the index of oncological and cardiovascular diseases is low, mainly due to the fact that people there do not live to the age of the most of these diseases. Her country can spend less than one dollar a year to maintain her health in her old age. 20 million children born in 1990 in the developing countries will have exactly these living conditions, the other 120 million will have a little more hope.
Unprecedented increase of the population of developing countries, generating numerous problems and the helpless measures taken by the governments, alarms the world community. But high birth rate itself is a result of many causes. At present, as well as in the days of Livingstone, there are no doctors in many villages and general medical education as well as special care, connected with the family planing, are at the lowest level. The problem is acute. Apart from humanistic reasons, urgent appeal to it is demanded by lamentable increase of population that turns various regions of the developing world into centres of infectious and social tension Of course it would be more rational to spend time and means of the world community for preventing the dangerous situation. One of the steps taken is intended to be a stable bioethical monitoring in the regions of the developing world. Adequate appreciation of the situation is constructed with bioethical conceptions of guarantied sanitary and medical service, just distribution of biomedical resources based on bioethical indices such as "mother and child health institutions", "social appreciation of new biomedical technologies", "programmes on special medical education" etc. At present the population of some developing countries has exceeded 100 million people, and the foremost leaders are China and India with about a billion each together they have a half of the developing countries population. The status of china, which reproduced ideology and economics of the socialist system for a long time is not typical for the developing countries. The status of India, on the contrary, can be considered as a model for studying the problems and prospects of bioethics in these countries.
India in the Mirror of Plurality
Sometimes they say of India: "There are so many gods, languages and films here, that all these words should be used in plural". These series can be continued by the statement that, there are still enough unresolved problems and enigmas in India. The future leadership of the country in the index of population determines the focus of attention of the demographers and sociologists, politicians and health policy makers, religion researchers and bioethical experts.
For a thousand years, India has been the country of classic, legalised and sacred inequality - everybody carrying the burden of their Karma. Caste institution strictly regulated human rights and duties, western culture and cult of individualism did not settle in India. Nevertheless half a century has not elapsed since India found independence, and the country has achieved remarkable progress in many fields, including realisation of human rights and liberty. At the same time, up to now, biomedical discrimination of the least socially protected people like invalids, the elderly, women and children is widespread. This is connected with a number of social causes and the practical inactivity of bioethical monitoring in the country. The following stories of the real life talk about these problems.
"Merchants from Agra"
Illegal trade of human organs for their transplantation is a rather old and a very profitable kind of illegal business, which is widespread in the majority of developing countries. Biomedical businessmen travel all over the remote villages and slums in search of donors. these businessmen announce old and uneducated people ill and in need of an urgent operation, which is done "gratis" a good trap for extracting healthy organs for illegal transplantation. Often such "mis-informed donors" are old and sick people, who are the last to discover fraud.
The matter of fraud by doctors and officials in the Institute for study on Leprosy in Agra shook India. There, several patients were promised gratis medical service and their kidneys were extracted by fraud for sale. The independent lawyer Sushil Kumar Verma, who had examined the incident, exposed more than 20 cases of such selling(2). In fact, the leper can be more easily convinced that an kidney-extraction operation is necessary, on being announced that an kidney-extraction operation is necessary, on being announced that his disease affected this organ. In the case of internal organs, extractions irrespective of the kind of real or fictitious disease according to the doctor's choice are totally unlimited. Absence of strict laws and practice of social protection of sick and old people, and the poor educational standard of patients, makes it possible to manipulate them with impunity.
As another example of biomedical manipulating people deprived of real social protection, we shall quote the practice of great affect in the sphere of prenatal diagnostics of the future child's sex(3). The fact that biomedical technology of embryo sex-testing has widely spread in India is, first of all, attributed to social reasons. birth of a girl in an Indian family is welcomed with less enthusiasm than that of a boy. The parents of a future wife, when time of bridal comes, will have to, beside payment of large sum of money, provide a house for the newly weds. It is clear that only well-to-do people can afford to bring up several girls, though traditionally Indian families are large. That is why when the embryo testing results promise a girl, pregnancy is usually terminated on the family's insistence. That is an anti-human act towards the woman, whose opinion is never listened to and that is a kind of "discrimination in a womb" towards a fetus. the Indian government, forced to act more effectively by women and social organisations, adopted a law banning the practice of amniocentesis for sex selection (embryo-testing) in 1991. The following story shows what it leads to.
"Lata and thousand others"
The 32 year-old Lata, the representative of the middle class Indian society, being in one of the Delhi private clinics, was forced to agree to abort a girl fetus under family pressure, because she already had two daughters. It is clear, that the fetus was killed not for medical reasons, but in accordance with traditional modus of life as the dowry for the third daughter could not be provided by the family. the illegal sex-testing of the future child cost Lata's family thrice as much as it had cost before the adoption of the law. Nevertheless, these procedures are actually carried out in all big cities of the country. Some medical centres publish the advertisements in newspapers on the pretext of testing for genetic diseases of the foetus. thousands of women, irrespective of religion and social distinctions are compelled by their families to take the test.
Prostitutes with poor economic and medical facilities are one of the major contributing factors in the spread of AIDS in developing nations. Of 88 reported deaths in India so far 27 have been of prostitutes. Jamila, a legal prostitute of Bombay, who intended to be a mother was infected by a client. Before delivery, she appealed for aid to a number of state maternity hospitals and everywhere she was refused. That was accounted for by a danger to medical staff and other patients. Thanks to the human attitude of two hospital nurses she gave birth to a child in one of the city's infectious hospitals, that as one can see, was accompanied with a double hazard of unspecialised and infectious hospital. The human fate is not the only thing that is shocking in Jamila's story, but also the fact that only in this infectious hospital they explained to the woman the real nature of her disease and the limits it put on her(4). the tragedy of this case is that it is typical of India and of the developing countries as a whole, where the absence of medical aid is often accompanied with the ignorance of people.
Another considerable category of potential AIDS victims is the children. AIDS in children has become a real human and medical tragedy which is even more difficult to be controlled than AIDS in adults. During the 1980s, 200,000 children were infected with AIDS. The overwhelming majority live in the developing countries. In India 10 of every 100 AIDS-infected people are children. The main source for children's infection is regular blood transfusion, which is necessary in cases of various genetic anaemias, and contact of mother with foetus during pregnancy (5). An eleven year old inhabitant of Delhi Pankaj was born with thalassemia, a genetic disease ( one of hemoglobin abnormalities). The sick person would receive blood every fifteen days. It is unknown, in what period of his life treatment, the boy was infected. Now the boy is sick of AIDS, that is accompanied with tuberculosis. In accordance with the doctor's opinion he will live less than a year. The AIDS-infected and sick children endure their position of "social-outcasts" harder than the adults, since these really innocent victims of the disease, are unable to live alone.
The World Band has allocated US$85.5 million for AIDS control in India, 31 million was allotted to set up the social informing bureaus and to support the AIDS patients. Besides, the integrated and stable system of medical education and information, the social rehabilitation of the AIDS risk group is also very important. Speaking of the problems confronting biomedical practice in India, we observed a number of necessary medical and social measures, but theoretical concepts differ very much from real life. Access to basic health is still one of the most pressing issues facing a vast majority of people in developing countries. In the area of human experimentation there is a lack of safeguards for research subjects - women, children, and elderly people represent the most vulnerable populations and need special protective measures. Moreover, in the developing world, especially the social consequence of technological advances reveal clearly the dynamic interaction between science and values. The widespread misuse of biomedical techniques like amniocentesis for sex determination leading to female feticide, unscrupulous trading in human organs, and the unchecked spread of AIDS (especially among prostitutes) are dangerous signs of growing tension among nonprivileged sectors in the developing world. Informed consent, one of the ethical foundations of research with human subjects, is constantly violated in developing nations, supplanted by "misinformed consent", "forced consent", and "no-choice(nonvoluntary) consent".
The distortion of informed consent in developing nations is largely a function of the lack of education and people's failure (or inability) to participate in health policy matters. Beyond special educational necessary preconditions of the principle of informed consent is to function in its true spirit in developing nations. Ensuring that the fundamental rights of patients and research subjects are respected requires integrating several different approaches to address issues of how advanced technologies interact with existing cultural norms and social stratification in ways that can be undesirable. This calls for a dialogue that incorporates cross-cultural perspectives.
People in most developing countries have remained socially and culturally divided into different communities disunited by religion, language, caste and gender. The communal situation has taken a grave turn in most of these nations. A special feature of bioethical dilemmas in developing societies is the way personal views, developed within the framework of different religious faiths or other cultural traditions, can take the place of broader societal perspectives and goals. The inability to differentiate the often dichotomous and dynamic relationship between personal and social outlook give rise considerable tension, especially around issues central to bioethics. Yet at the same time, the deep influence of bioethical issues on people's lives and beliefs is reshaping the correlation between the personal and the social to become more flexible. Especially, in the context of the developing world, the ambivalent character of bioethical values is transforming the supposedly fixed relation between, for example, unanimity and consensus, universalism and pluralism, an ethics of virtue and an ethics of principles, and the religious versus secular foundation of ethics, to a more dynamic and interactive one. The reshaping of rigid patriarchal culture, recognition of human rights, demand to stop state patronage to different religions and widespread use of amniocentesis tests irrespective of class, caste and religious beliefs are a few indicators of dynamic change in outlook in developing nations. The distinction between the personal and social is seen not to be an example of a double standard, but to reflect the dynamic nature of formulation.
The dynamic correlation of these factors and intercultural and religious tolerance as a humanist norm demands urgent attention for a holistic approach to the bioethical dimensions of underdevelopment in developing countries without forgetting common sense to preserve useful traditional values.
1. World Health Organization. Implementation of the global strategy for health for all by the year 2000, second evaluation and eight report on the world health situation. 26 November, 1991.
2. Arvind N. Das. Leprosy Institute selling patients organs. The Times of India 16 Jan. 1992.
3. Vibhuti Patel. Sex-determination and sex preselection tests in India: Recent techniques in femicide. Reproductive and Genetic Engineering Journal 2 (2): 11-119, 1989.
4. Sonora Jha Nambiar, Nurses deliver HIV patient's baby. The Times of India 5 Jan. 1993.
5. Sukhmani Singh. AIDS in the age of Innocence. The Illustrated Weekly of India Sept. 5-11, 1992.