What is an "Integrated Cross-Cultural approach to bioethics"?

- Frank J. Leavitt, Ph.D.

Jakobovits Center for Jewish Medical Ethics
Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva, ISRAEL 84105.

Eubios Ethics Institute Newsletter 2 (1992), 58-59.

The Eubios Ethics Newsletter has the stated goal of aiming at "an integrated and cross-cultural approach to bioethics". It is not immediately obvious just what such a goal amounts to. The purpose of this note is to try to stimulate some serious philosophical discussion of what is and should be involved in such an approach.

I think a cross-cultural approach to ethics would have to be something quite different from a universalist approach. By "universalism" I mean the naive view which says that all peoples can be expected to accept and live by the same set of ethical principles. Universalism seems to me naive because a kind of global pluralism seems to be not only the historical fact but also quite possibly the desirable situation.

In order to explain what I mean by "global pluralism" I want to distinguish it carefully from the idea of "pluralistic countries". A pluralistic country is one like the USA or Canada, where many different ethnic, religious, cultural and linguistic groups live together in one country. A "pluralistic globe", on the other hand, is a world which contains some pluralistic countries; but it also contains many countries in each of which a particular religious and cultural approach predominates. Thus a pluralistic country like the USA, but also a particularly Jewish country, like Israel, a particular Catholic country, like Ireland, and of course Japan with its own particular religious and cultural approach to life.

In such a world, the idea of "consensus" seems as naive and as unrealistic as does "universalism". A good example, in my opinion, of an unsuccessful attempt at consensus in bioethics was the Appleton Consensus (see J.M. Stanley, "The Appleton Consensus: suggested international guidelines for decisions to forego medical treatment", JME 15: 129-36). A cursory reading of the document gives the impression that something has been achieved in the way of broad agreement among people of different cultural and religious views. But that is only a superficial impression. The "dissents", which are printed at the end of the document (p. 134), present the strong stand of primarily Israeli physicians in favour of preserving life and against so-called mercy killing. The existence of such dissents suggests that international consensus in bioethics may be too much to hope for in the near future.

Although "universalism" and "consensus" are naive goals, an integrated cross-cultural approach may be something different if what is meant is to aim at international cooperation together with recognition and respect of differences. If such is to be a goal the first priority has to be given to distinguishing carefully between local issues and international ones. Questions having to do with whether to prefer socialism or a free-market economy in health services, for example, seem to me to be local problems which each country may solve according to its own religious, cultural and legal approach. Environmental and epidemiological issues, on the other hand, are clearly non-local and demand international cooperation. The great challenge is top see how ell countries, such as Israel and Japan, each of which has its own unique approach on life and ethics, a people which "shall dwell alone" (Numbers XXIII: 9) can achieve cooperation on bioethical issues of international importance, while recognizing and respecting one another's cultural and ethical uniqueness.

But let's not yield to the temptation to formulate platitudes while ignoring problems which may lead realistic thinkers to conclude that the idea of an "integrated global approach to bioethics" is a mere illusion.

One of the problems is a king of cultural imperialism which is being exercised by the English speaking world and which seems to be especially powerful in the bioethical fields. I do not deny the beauty of English literature or the ethical value of the contributions to democratic thinking by 17th century English Christian reformers like John Milton and John Locke, or by 18th century American revolutionaries like Thomas Jefferson. But the current international hegemony of the English language seems to be due less to considerations of literary beauty and moral profundity than to the financial might of American business and to real or pretended American military success.

Generalizations are often superficial and dangerous but if asked I would describe anglophone bioethics as characterized by a practice of taking ethical concepts out of their original - usually religious - contexts, emptying them of the original content and taking them to extremes. Thus, in the democratic thought, such as that of Locke, which grew out of the English Reformation, one's rights derived from one's duties. One has a right to do what is necessary to carrying out one's duties. And duties stem from Divine command. (I have gone some way towards explaining this in my "Inalienable Rights", Philosophy 67: 115-8). But since the American Revolution onwards, rights have increasingly been claimed to just about anything whatever. Thus it has been argued (George Annas, "Foreclosing the use of force: AC reversed", HCR (July/Aug. 1990), 27-9) that to force treatment on a woman in labour is to deprive her of "rights" in a way which is "counterproductive, unprincipled, sexist and repressive". In contrast, every Israeli mother whom I have asked has agreed that if an obstetrician and midwife agree that a caesarean is urgently needed to save mother or baby, and if the labouring woman refuses for what seem to be irrational reasons, she should be anaesthetized and operated on against her will. She will probably thank the physicians afterwards for having done so. (Statistically inclined researchers might want to check my claim empirically by questionnaire). Since such a view might be frowned upon by American bioethicists, for whom "autonomy" has become a holy incarnation, it is a healthy thing that there are around the world indigenous alternatives to anglophone bioethics.

Here is Israel we have a new country with ancient ethical traditions. I hope I shall not provoke too much disagreement from my colleagues if I say that the developing Israeli approach is based upon a Jewish tradition which emphasises family values of monogamy and children, a respect for nature and a commandment to save and protect life; but it recognises the need for sophisticated responses to the complex problems presented by new biotechnologies and it is making every effort to learn reflectively and critically from whatever ideas other cultures can offer.

It would be of benefit to us all if the Eubios Newsletter would publish more detailed reports of bioethical thinking in Japan.

Another indigenous approach to bioethics is, of course, that of the Dutch. But the recent, shocking reports (especially Carlos F. Gomez, Regulating Death: Euthanasia and the Case of the Netherlands, New York: The Free Press 1991; and various articles in the HCR (March-April 1992) which document case after case of the Dutch's failure to follow even their own extremely liberal guidelines, make the very idea of an "integrated global approach" sound like a mere slogan, especially when one notices that the Dutch may be setting the trend for some other Western countries. Can those for whom the duty to save life is paramount, like the Jews, Catholics, and Protestant sects more traditional than the Reformed Churches of the Netherlands (who seem to be cooperating with "bioethicists" on Dutch euthanasia; see ref.s to hospital chaplains in Gomez, pp. 67, 70, 79, 83, 86, 87; and M.A.M. Wachter, "Euthanasia in the Netherlands", HCR (March 1992), 23-30, especially the analysis on pp.27f.) maintain a dialogue with pro-euthanasia people which can amount to anything more than superficial, smiling academic politeness? In other words, don't vast and profound differences in moral outlook make the idea of "integrated cross-cultural" bioethics sound too idealistic and far-fetched to be taken seriously?

I will try to answer this question as an Israeli. But I hope that my answer will stimulate people from other countries, cultures and religions to contribute their own answers.

I shall not address myself to questions of the environment and large-scale epidemiology where international cooperation is obviously desirable. Nor shall I discuss matters such as local economic systems which need not concern other countries. My concern is only with such practices as Dutch euthanasia, whose practical effects are only local but whose moral importance should concern the entire human species.

The Jewish religion is extremely tolerant with respect to the belief's and practices of other nations. We see absolutely nothing wrong with a Japanese or an Irishman eating port or performing agricultural labour on the sabbath, for example, even though we may forbid these activities for ourselves. But we draw the line at behaviour which is extremely morally repulsive and which we believe God forbade not only to Jews but to all mankind through a series of commandments which he gave to Noah. Among these Commandments is the prohibition of murder. According to the laws of Judaism the laws of Moses apply just to Jews while the laws of Noah apply to all mankind.

Moses Maimonides (1135-1204), Israel's great physician, philosopher and rabbi, stressed the importance of actively working to get all mankind to obey these basic Commandments (Maimonides, Laws of Kings, VIII:10).

What this means for us is fairly clear when we are dealing with people within our own legal jurisdiction. We must take legal steps to prevent murder. The questions arise even it comes to acts of murder in other countries, especially when the people involved do not agree with our definition of "murder".

Again, the matter seems to be relatively clear-cut in a case of large-scale genocide. if military action is practically feasible I would not oppose going in and rescuing the victims of genocide. But euthanasia seems different from genocide, it is voluntary: done at the patient's request or at least with their consent.

or is ti? Gomez lists a number of involuntary cases, including one in which a two day old infant was put to death. And Keown (J. Keown, "On regulating death", HCR (March 1992), 39-43) has reported that a Royal Dutch Medical Association "discussion paper on handicapped neonates condoned their termination".

I am not in a position to judge the accuracy of these reports, but let us assume theoretically that there is a country which has gained, over several years, a reputation for toleration, democracy, ethics and culture, and where infanticide is being practiced on a serious scale with the approval of the national medical association and with at least the tacit consent of the country's jurists.

I shall not dwell on the question of whether such a situation differs morally from genocide. The question of what name to call something does not help much towards deciding what to do about it.

With respect to any country whose moral behaviour is not just different from our own but in our opinion, intolerable, I see no practical course of action other than a large scale campaign of persuasion and education. Such campaigns might benefit from temporary alliances between groups which share ethical stances on some issues while they may not do so on all or even many issues. For example, we Jews can and should be working together with Catholics and the more traditional Protestants on the matter of euthanasia, even though there are other bioethical issues on which we differ too fundamentally to allow for partnership. For example, while we agree with Catholics in disapproving of abortion, we are much more flexible than they are when the mother's physical or mental health is at stake.

I will sum up by returning to my opening question: What would an "integrated cross-cultural bioethics" amount to? In my opinion, it would involve at least sincere attempts to understand how different cultures think, cooperation amongst divergent culture which share specific moral values (even when they do not share others), and more of a voice in international bioethical discussion for the opinions of non-English speaking cultures. I have attempted to contribute to this as an Israeli (allowing of course that not all my compatriots will agree with me) and I hope others will do so from their own points of view.

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