Introducing a 'Thin Theory' for Cross-Cultural Hermeneutics in Medical Ethics. Reflections from the Research Project Biomedicine and Ethics in China
- Ole Doering, Ph.D.
Institute of Asian Affairs at Hamburg
Baumchaussee 32, D-20148 Hamburg, Germany
Eubios Journal of Asian and International Bioethics 11 (2001), 146-152.
1 Historical Background
The history of this research project dates back to 1995. Only a few Europeans had begun to realize that countries in the so-called 'East' were taking up the challenges of globalization in all related fields and that attempts to understanding and co-operation were due. At that time, the Dr. Helmut Storz Foundation and the Institute of Asian Affairs (Hamburg), invited me to explore the situation of medical ethics in China, with a focus on human genetics.
Since then, the focus has been systematically broadened, so that it is now covering the entire range of biomedical ethics. Also the discussion of values has been enlarged to cover fundamental, systematic and practical questions of the relationship between culture, progress and ethics. In the course of this work, numerous articles and three books have been published (the majority in German, but quite a few in English) (1), more are in the pipeline (2). This project is now covering the region, between Japan and Malaysia, Beijing and Taiwan, including research fieldwork, attending and organizing conferences and building up a network of colleagues and friends in bioethics. In the Summer of 2001, the formal explorative stage of this project will be finished. Together with colleagues and friends, I am now trying to introduce the research issues of Cross-Cultural Bioethics as a regular field of research and debate in Germany, with the international scope constantly in mind.
I took the opportunity of the TRT5 discussion to give an account of some implications this project seems to have for the theory and practice of bioethics. This paper attempts to continue and update this line of thinking. I am convinced that the theme of cultures and their influence on the justification of values and practices, as frequently as it is quoted in our discussions, is yet likewise poorly prepared for building a meaningful debate about cultures and medical ethics (3). From my own experience as a Sinologist, (that is a Cultural Scientist), it has been irritating to watch established academic concepts of culture degenerate and disintegrate inasmuch as I came closer to study real cultures and the dynamic generation of values and cross-cultural understanding (4).
2 The first encounter
What I met in China was the very beginning of a real discourse in bioethics. A small but active and ambitious group of scholars had begun since the 1980s to explore the impact of bioethics in the transforming society of China (5). Like in many other countries, biotechnological advances had stimulated, structured and facilitated this debate. In fact, I actually met two groups who were already working together. One group were bio-scientists who worked for the Chinese Human Genome Project and had already established a sub-section on the related ethical, legal and social implications of this project. The other group were connected with the National Program in Bioethics at the Chinese Academy of Social Sciences. In addition, a voice from philosophers in Taiwan, which now sharpens its profile, had begun to revisit concepts from ancient Chinese ethics schools and to relate them to contemporary problems in bioethics, and to feed them into the debate (6).
The young debate had to face challenges on many fronts at the same time. First, the range of politically tolerated freedom to discuss was unclear, making it a matter of courage and wisdom to openly engage in bioethics discussions, especially in those related to state policies (e.g., family planning, eugenics). Second, the obviously favoured biotechnological sciences had to carry ethics on their back, so as to link progress in one field to advances in the other, reserving a sphere of protection from attempts to interfere with bioethics. Third, the entire infrastructure had (and still largely has) to be build up, on the micro-levels of hospital management as well as nation-wide, including facilities and hardware as well as education, a state of legal rights and regulations, funding, communication, and others, starting on the post-Cultural-Revolution level in most places (7). Fourth, considerable international concern about the particular situation of human rights in the medical field and the readiness of Chinese colleagues to acknowledge basic standards in medical research and clinical practice, had to be answered (8). This bore a double impact on domestic attempts to excuse misconduct on grounds of cultural relativism, and on the self-granted license of international companies to suspend the standards in Asia that are valid in their own countries. Fifth, and probably most importantly, efforts in bioethics had to be integrated into the complete rebuilding of the Chinese health care system. Last but not least, bioethics is a difficult discipline in her own right, and especially so if her proponents aspire for finding an original assessment which still accommodates to international standards. China, different from many other places in the world with similar problems, has inherited a rich host of skills and resources waiting to be exploited by bioethics work, and it has just opened the box wherein it barely survived over a long time.
I felt excited about the deep earnestness of the dedication and concern and the high ethos I met in China, which embodied, to my understanding, all virtues that make the soil of an ethical medicine. I was shocked by the extreme degree of inadequacy, of the means to improve the situation as well as by the poor responsibility awareness among decision makers and the general public. Also I was intrigued by the obvious structural similarities of bioethical problems in China and those I knew from my own country, in many respects, though obviously on a much lower level of wealth and stability. Especially so, the dominant position of ideological, utilitarian, selfish, and badly informed approaches to bioethical problems, seems to be a lamentable situation that ethicists share. I had a strong sense that it was vitally important to build understanding and to co-operate, not only for me as a foreign visitor, but primarily for the prospects of the Chinese debate to unfold and develop. In particular, the efforts to educate the public and the educators themselves on a proper level of the state-of-the-art may be the key to the successful self-strengthening and rehabilitation of China. After discussing the Chinese situation from a variety of different experts' perspectives over the years, I am more than ever convinced that China offers a chance for bioethics to revise herself and become real global. The bioethical problems of China are bioethical problems of humankind.
3 Culture as a Conundrum
I am far from claiming that 'culture' is a myth, (though many ways to use this term are mythological). Also, it must be emphasized, it is important and legitimate to refer to cultures in order to identify stakes and legitimate normative claims, (though some notorious references to 'culture' have been clearly instrumental and abusive). The point is that bioethics has given us an exemplary opportunity and urge to revisit our understanding of culture and to reconsider our habitual understanding of this concept, which is rather outdated and shallow. Basically, we are using 'culture' either in order to address the totality of some human expressions, or creations, in the sense of feature sections or folklore. Or we use it to distinguish something as 'produced' from what is 'given' by nature, both related to creativity and sometimes also to values, moral and ethical claims. The distinction in the latter sense is currently re-invoked as a criterion for the patenting of bio-products. One commonly accepted principle for the admission of items to the patenting process is that this item can not be found in the biosphere, but has been produced as an invention by humans. In other words, nature shall not be patented. Only if 'work', in the sense of John Locke (9), has been invested in the first place, namely if it is (becoming) a cultural item, it may be legally owned and traded. This is a rather timely facet of culture in bioethics which makes it clear that the subject is not doomed to the ivory tower.
However, the meaning of culture remains opaque. Sometimes, 'culture' is referred to as a symbol for what we assume is original, unique, precious and worthy of protection and preservation. But why and how does culture relate to values at all, what makes culture so venerable; and even more importantly, how can one reasonably justify normative claims from culture? Is there anything intrinsically valuable to be found (or postulated) in the essence of culture? There are those cultural achievements we can be inter-subjectively proud of, such as the invention of medicine and ethics, as functions of humaneness and sympathy. There are others the value of which depends more on subjective affirmation or on special historical circumstances, such as certain legal provisions or medical models. And there are those we fail to have the slightest bit of appreciation for, such as female circumcision or feet binding, although they certainly are part of given cultures. Finally, some cultural achievements are simply forgotten.
It is a fact that some cultural phenomena are outrageous. This fact is owing to the history and genesis of culture, that is the realm of contingency. In this realm, we can at best depart from ambivalent situations, making efforts to improve ourselves and our world, and bring our real cultures closer to the ideal of a humane culture. By no means are those phenomena ethically prescriptive. At best they can help us to better understand, how we want our cultures to become. According to my understanding, the question of culture as normative is similar to the claim that life has an intrinsic value. I do not believe that we can have any 'true' opinion about them. However, we can imagine how our lives would look like without the common sense that culture should be valuable and that life should not be understood as subject to random powers only. And we can imagine how our lives and cultures ought to look like. Most of us would prefer to shape a world in which morals and ethics can in principle become meaningful rather than a world in which they can not. This assumption allows us to leave absolute goods (the truth, the good) being what they may be, and rest on the acknowledgement of improvement as a reasonable, desirable and meaningful goal, and as a heuristic basis.
From here, as from our provisional common ground, we can face the other side of ethics, that is, practice and the role of the actor. In this light, I found the most useful definition of culture, in terms of clarity and of comprehensiveness as well as for being unbiased, to be the following. Culture is a totality of the products of human spiritual activity, endowed with an intrinsic value, at least for certain people and under certain circumstances.
According to the preliminary results from this project this concept can be identified as an implicit common sense assumption underlying most arguments. It is obvious that this concept of culture does not support claims in medical ethics, which point out the mere fact that a norm has actually been expressed by a certain culture. From such a broad and abstract definition of culture, we gain a conceptual frame for as many different cultural contents as possible, as it serves as a heuristic reference for the purpose of integrating different approaches systematically. We are now able to integrate all sorts of culture into normative contexts all over the world, be it in the macro-perspective of humanity as a whole; or be it within the micro-perspective of a certain community. Yet this advantage has to be balanced by clear-cut restrictions of the possible normative content of culture. There is no justifiable ethical claim to normative power over others if it is only grounded in cultural belonging, without additional normative arguments. The measure for normative claims can only be the validity of the respective arguments. If we adopt a certain norm, it must be because it is understood as a good - maybe the best achievable norm, not only because it is a norm with roots in a certain traditional setting. On the other hand, it is obvious that the context of application is an important part of the arguments under consideration. The mere context, however, can inform relativistic norms only, whenever we fail to acknowledge the possibility and the value of some universal principles. Hence, culture can be used as both, a reservoir for stimulating ideas for our problems and an open window to the future.
So far, I have introduced a descriptive definition of culture. This definition can be used in understanding the term 'culture' as suitable for bioethics in cross-cultural hermeneutics, that is, in a sense of being ethically indetermined. This descriptive sense can be accommodated to the prescriptive dimensions of culture and bioethics, which are already part of the discourse, and not part of its basis. It makes the discussion more intelligible and more controversial if we expressly acknowledge the prescriptive concepts involved, too. In this regard, an old and yet rarely quoted source in bioethics may help to facilitate the debate. That is, the interpretation of culture as submitted by Albert Schweitzer, about 80 years ago, not only offers a rarely tested input to global bioethics, but surprisingly at the same time resembles a Confucian understanding of culture (wen) (10), which makes it a favourable reference for the hermeneutics of cross-cultural bioethics.
'But, what is culture? The ethical completion of the individual as well as of the society must be regarded as the essence of culture. At the same time, each spiritual and material progress bears cultural significance. The will to culture hence is the will to universal progress, which is aware of ethics as the highest value.' (11). It is obvious from his life as well as from his words that Schweitzer had a culture of humankind in mind, not the horizons of any regional or moral tradition. Hereby, the ambivalent descriptive understanding of culture, as it is, can be confronted with a related prescriptive concept, i.e. with how it shall become. Whereas the former is of academic interest, the latter is of supreme practical import. The first task of prescriptive culture is the easiest part, namely to integrate the descriptive parts most accurately and systematically. The second part is even more painful, that is, to cultivate our understandings and practices of culture so that they may justly claim normative power through the discourse, and defend this claim and argue for it publicly.
It does not withstand the internal diversity of culture that we see ourselves as taking part in the process of making the culture of our times together with that of humankind. We are active agents, proponents and players in the continuous and (as long as there are humans) endless process of the building and transformation of culture. We can not simply describe the situation of bioethical cultures as if we were objective observers without some impact on the situation of bioethics (which may ideally be true in the academic frame). We already understand (at least parts and aspects of) the criteria for normative assessment, as soon as we begin to make culture, that is, by being social entities. Here, science is no safe ground for convenient and unconcerned deliberation. As agents we are without exception responsible for the practical meaning and outcome of our bioethics. If we appreciate that there can be no absolute judgements, we understand that we always lack certainty but know that we must make decisions at the same time (not only find out how one should make them). Therefore, we ought to acknowledge that cross-cultural bioethicists move on a slope, which is not less slippery and even more dangerous than the ones we are used to worry about on the consequentialist level. The only way to deal with such a situation is, again figuratively speaking, to continue moving, and to watch out were we are heading, trying to adjust our actual orientation to the point we would like to approach. Although every existing culture is morally heterogeneous, each one includes a grain of ethical evaluation and greater moral sketch, as a meeting point for different prescriptive assessments, that attempts to express itself through moral, legal, political, or ethical judgements. The resulting complexity of this encounter itself gives rise to fundamental considerations, which amount to an intrinsic imperative of bioethics to transcend disciplines and cultures, and to concentrate on the reasonable and communicable rules of developing ethics, instead of the ambiguous rules of cultural genesis. In other words, continuing to slide, with no basic agreement on the general direction, we can be sure to end up in rather ridiculous and dangerous ways of behaviour.
On the other hand, a well considered approach to a culture of bioethics provides the means for everybody to understand, not only the ways of the other, but, (with the help from changing perspectives), even one's own ways and arguments better or more comprehensively than before. Through a cross-cultural culture of bioethics, we can clarify and strengthen our arguments, and at the same time co-operate in adjusting the general practice. We need everyone's serious determination to listen, consider and argue with utmost sympathy and attention, to accept the others in their unique struggle for insight. Yet we need to agree on the overall direction. To give an example, bioethics for humankind should decide whether we want to argue for a medical system that is based on the market forces and technology, or rather aspire for a humane, just and fair basic health situation, on a common level, all over the world. Interestingly, transforming China is right now confronted with exactly this situation of general decision making, between a guided and a libertarian approach. This makes bioethics in China, and in other developing countries, different from bioethics in the so-called developed countries that have in fact largely adopted the market option. This decision, (as a practical and not as a theoretical decision), is not as easy to make as our moral sense may suggest. In terms of practice, we can decide, for instance, whether we want to ask people in the European Union who now have a high standard in medicine, to give some of the related resources away, in the name of an abstract notion of solidarity with other people. The consequences, such as drastic reduction of expensive diagnoses and treatment available in Europe, and the related adverse effects on research and entrepreneurial interest, will make this option hard to bear for many, especially among the powerful who take advantage out of the situation as it is now. On the other hand, it is obvious that the current situation favours unethical features of our system, with a bias against the underprivileged, and favouring economic reasoning instead of humane care, more and more even inside the communities of 'developed' countries. It is obvious that a globalized world can not peacefully house both scenarios under the same roof over the long run. A decision must be made by bioethics. Do we want to maintain the potential freedom and possible effectiveness of argument, and not simply let the 'market' take its course? (12)
If we aspire for peaceful and constructive co-operation in bioethics across cultures, there is no other reasonable choice but to acknowledge that our diversity as bioethicists of particular, individual and mutually related cultures belong together under the umbrella of the culture of humankind. This assumption bears significant consequences for bioethics, on the status of her propositions and on the methods to develop her as a humane science.
4 Methods in Cross-Cultural Bioethics
4.1 Integrating and Engaging Perspectives
Advances in the field of biomedicine have been plenty. The diversity of attempts to answer the resulting challenges can not be successful if they fail to join capacities and approaches, and to engage in a meaningful constructive discourse, transcending disciplines, cultures and nations. We should seek for comprehensive approaches of humanity to regulate biomedicine on a global scale. This is not an easy task if we consider the given differences of "languages", (in terms of mother tongues, cultural preconceptions, academic concepts, terminology and methodologies, and individual languages). This makes it a fundamental requirement to address the issue of multiple languages and perspectives, and their inter-action. Our point of departure resembles a Babylonic multitude. Hence arrangements are required so as to avoid the probable destruction of our well-intended efforts to help humanity by improving medicine, owing to failures in understanding. In order to orchestrate the voices we should first introduce them, namely the respective perspectives, purposes, major concepts and methods. To do that we should use a language as plain, simple and lucid as possible. If we accept English as our lingua franca, we should make sure that it does not become an obstacle. The language should be treated as a tool to facilitate communication, not as a challenge to artistic skills of cultivated scholarship in the first place. Also it will be wise to identify and avoid ideosynchratic preoccupations with particular bioethical contents that are part of a highly educated language. In this light, I agree, as far as it goes without creating new barriers for understanding, with Frank Yeruham Leavitt's suggestion to recognize English as the international language in bioethics, out of pragmatic reasons, and at the same time to tolerate the fact that it may fail to meet the standards of 'good English' (13). Such a policy may be hard to stand for everyone who loves his mother tongue, as well as for those who feel they should protect English from distortion and abuse. However, in the name of forbearance and fairness, (would you make the same efforts to learn Chinese, e.g., as you expect Chinese colleagues to make in learning 'good' English?), I propose that we mould it jointly to become a means to express and communicate most accurately what we want to discuss in bioethics.
The well considered integration of multidisciplinary and cross-cultural efforts on all relevant levels of scientific, cultural and ethical understanding and their interplay is a new and exciting approach. Our capacities can be united and become available for the sake of ourselves, our fellow humans and for future generations. We should not predict the outcome but rather concentrate on the reasonable methods and rules of the discourse. Currently we are missing common rules and standards because our resources of experience in fair global bioethics are insufficient. It is therefore timely to create situations, which bring together as many qualified perspectives as possible to a forum. Perspectives in this sense are mainly the multiple related scientific disciplines, different social groups and stakeholders, different nationalities especially from countries with an unequal state of development, different walks of life, professionals (nurses, clinicians, lawyers, administrators), genders, generations, interests, claims and tongues. In short, everyone with an independent and reasonable claim in morals and ethics should be admitted in principle, because they may contribute the precious insight from their unique moral experience and reflection. In order to compensate for the gross disproportion of relevant perspectives from developing countries no effort should be spared to include and even, for a while, over-represent such perspectives in the discourse. However, given the some times awkward political situation in some developing countries, which may lead to interference of secondary interests, it should be confirmed that neither rank nor formal position but only the quality of argument decide about admission. Also a well considered approach will make sure that the fruits of related efforts in bioethics in the advanced countries are not wasted but systematically considered and integrated. To some extent, the integration of perspectives in cross-cultural bioethics constitutes an originally democratic procedure.
Of course, more perspectives and contributions do not automatically add up to 'more truth' or more understanding. This would be a misguiding adoption of the narrow rationality of the market. Ethics can not but qualify all contributions in the light of counter-factual propositions and the demand that they propel our ethical understanding and practice. Some principles must be acknowledged in the first place. For instance, whenever an action is going to interfere with the integrity, life or wellbeing of somebody, (e.g. abortion, or withdrawal of treatment), the invading actor should be required to defend his claim by proving that this is a legitimate action. He shall submit this argument to a fair procedure of decision making, which, after open discussion, will either confirm or reject it. This refers to empirical action as well as to moral and ethical arguments. Hence, each contribution to the cross-cultural discourse in bioethics must, first, be relevant and, second, be constructive in aiming at this goal. Thereby bioethics can be successful in introducing a greater variety of aspects of reality and examples of valid argument from a standpoint of ethical culture.
The totality of ethically relevant capacities goes far beyond the mere aggregate of individual contributions. It also keeps the attention of the agents continuously alert and never self-satisfied so that we do not yield in our efforts to improvement. A colourful bouquet of issues and perspectives can thereby be arranged, which makes discussants listen and speak to each other. Simple as this seems, everyone who has attended scientific discussions knows that this is not the regular experience in all conferences. In fact, cross-cultural bioethics might inspire our ways of scientific communication; or, it might just re-emphasize the Humboldtian approach of a unified science. To be sure, this is only a first step, dedicated to rearranging the fundaments upon which to build a new discourse, and to respond to the problems resulting from the ongoing diversification of sciences. We need a common framework in order to maintain meaningful and peaceful lives. As cross-cultural bioethicists, we are still in the constitutive stage of bioethics as a scientific field, with a regular curriculum and systematic standards. It remains an insoluble problematic fact that the objects of this study are intricate parts of empirical reality and, on the other hand, they can only be discussed ethically through deontological concepts. Within such a setting, participants are challenged to communicate beyond accustomed spheres of apperception, with professional and human curiosity and the maxim in mind that, 'it must be possible to understand the other because he talks reasonably', as bridge building devices. The very engagement in such a quest is a virtuous effort in its own right. It can be regarded as our plain ethical duty.
4.2 The Imperative of Practice
In cross-cultural bioethics we need a sound theory, because lives, well-being and dignity are at stake, and we shall not spare capacities to serve them. However, most important is the focus on practice. Bioethics must aim to improve, that is to change, practice. We can succeed in this task only when we begin to appreciate the real situation of practice as it is, in the first place. We can only change the given practice, not a world that does not exist. For example, some bioethicists talk about "Asian values", or "Eastern versus Western" approaches to bioethics, or 'Confucian' versus "enlightenment" cultures, and so on (14). I have never found any of those macro-concepts helpful in promoting our understanding of cultures and values. On the other hand, there has been a lot of fuzz about empty, false or distorted ideas as to how culture influences the making and interpretation of values. In situations of decision making those concepts are hardly ever informative. For the sake of the argument we may grant the (flawed) assumption that "Asians" cherish their families higher than "Westerners". What might a doctor in Shanghai, for example, hope to learn from the alleged fact that the family is of a comparatively high value, if only one person can in fact legally sign an informed consent form, and collision of interest must be avoided? In practice, either the affected person (patient) himself, or a guardian is required to sign in all countries I have studied. Everywhere, if there is an ethical or moral rational for norms in clinical practice or medical research at all, it is to protect and benefit the patient. The actual ways in which families and communities are typically involved in decision making may differ from place to place, but this can not be adequately be expressed in macro-cultural terms.
In real life, if no ethical but economic or ideological reasoning prevails, the power of stakeholder values or policy makers overrules the ethical purpose of medicine, thereby pointing at the fact that the overall situation requires most radical changes, from an ethical perspective, but no glorification on grounds of culture. Instead of indulging in esoteric praise for the precious essence of a culture, it is much more adequate and intelligible, for instance, to give sound advice to the nursing team, as a reference for their decision making. It is trivial that such advice must respect the specific interests and values at stake in the given situation, in order to be sound. Also, some proponents of cultural values simply confuse the levels of debate, in this case the value of family, with the concepts to honour them, the provisions to institutionalize them, and the socio-economic or political ways to practice them. There may be fairly different procedures in applying this principle, but to conclude from such descriptive structural differences to a comparison of their respective value, it is a far cry. Therefore, ideological biases (e.g. bio-reductionism) are as bad equipment as bad science (e.g. eugenics) and methodological distortions (e.g. cultural determinism and essentialism), if we really care to improve practice. A sound theory will take care to integrate lessons from practice and refine itself constantly. It will not ordain what is right and what shall be done in the name of a culture, but will enable us to make an original contribution to culture. In short, it is not a myth, but adequate treatment and cure, that benefits the patient. For all that we have learned and know from the past, medical decisions must be made now, which is the moment where Is and Ought become amalgamated, as elements of living culture. The one who interferes for medical reasons is functioning as a catalyst of medical culture. He is the accountable agent and must personally stand in for his responsibility, not hide behind anonymous authorities. This is particularly significant in cases where myths can be instrumentalized for purposes different from the real determination of medicine, that is, the patient's wellbeing.
Also, the deep problems of theoretical meta-ethics with their related philosophical elaborates should not bother bioethics too much. Coming from philosophy in the old fashioned scholastic sense myself, I suggest that it is appropriate if bioethics just learns one simple lesson from her. In the names of both, Socrates and Confucius, remain humble and scrupulous as to all you believe to know and understand!
In the course of this research project, (especially during the Shanghai Symposium and the Xi'an Workshop), it has become more and more obvious to me that bioethics can be meaningful only if it is richly supplied with most accurate practical data and descriptions, as narratives of medical reality in terms of ethical understanding. One useful tool in this regard is the discussion of real and virtual cases in medical practice, involving a multitude of relevant perspectives. By identifying the interests, values and legitimate claims of actual people in concrete clinical situations, we can get an unbiased picture of the actors, values, interests, problems and responsibilities, together with their embedding culture. Thereby we may substantialize the empirical fundament of a cross-cultural bioethics and prepare the stage for an informed discourse of scientific bioethics. Only after going through this stage of empirical examination we would be entitled to revisit macro-concepts of culture and values in medicine, which can be easily anticipated to be different from the one's we hear about these days.
5 Towards a "Thin Theory"
Practice is rich enough to puzzle, challenge and frustrate us as well as to supply relevant information. The related theory of cross-cultural bioethics ought to be slim and plain. It only needs to be based on few, well considered assumptions, which ought to be clearly phrased and well reasoned. The main objective of such a theory should be to keep the discussion and assessment on course, allowing the discourse to develop itself and to stimulate it, neither should it inhibit its course nor lure us into gross aberration. I would like to suggest that one means to translate this intention into practice is to avoid highly connotative, ambiguous, biased, preoccupied and controversial terminology, but speak as simple and plain as possible. For example, it has been pretty hard for myself to accommodate to the fact that, in the English speaking world, the meaning of 'autonomy' is categorically different from the Kantian concept (15), even in most cases with explicit reference to Kant. Here, we should avoid this term and talk about self-legislation (in a moral or in a legal sense respectively) when we mean it, self-determination when we mean it, self-expression when we mean it, and so on. Similarly, if we take a term such as, "well-bear" (Yousheng) out of its Chinese context, and translate it as "eugenics" (16), the implications are most unwelcome, especially in the political and legal dimensions of bioethics. The same applies to "peaceful death" (Anlesi). It will only create misunderstandings if we translate it by the notoriously doubtful term "euthanasia".
On the other hand, there are those terms that are quite useful in designating the underlying principle, that it is reasonable to do good, such as "dignity". Although the actual meaning of this term may differ from one perspective and situation another, it can serve as a point of reference (a regulative idea) in our discourse. It indicates for everyone that something is valuable and worthy of protection in itself without further qualifications, as long as the letters of the given positive interpretations are not confused with the underlying intention. Those terms which help to conceptualize the structure of a deontological frame of reference in assessing our actions are necessary for a theory of bioethics. However, they should not be confused with legal, moral or empirical terms.
The most important strategic function of such a proposed theory is not to approach the truth, but to promote understanding. This is not a contradiction in terms, because we can imagine that understanding leads to "more truth" and depends on a common notion of truth, so that one step leads to the other. However, it spares us a lot of epistemological and metaphysical discussions, which are not relevant at this stage of cross-cultural bioethics.
Understanding, as the task of hermeneutics, can be defined as realizing what the other is saying, sympathizing with what he might want to say, and granting him the credit of presumed understandability. The related ethical and epistemological concepts are almost trivial. However, if we remind ourselves of the meaning of triviality, which in its archaic form designates a "commonplace", it becomes obvious that it must be on the edge to something we fundamentally share, so as to be suitable to fulfil its task as reflecting regulative ideas and heuristic principles. It is one of the methodological challenges of cross-cultural bioethics to establish common wisdom and shared rules, as meeting and starting points from where to depart on the voyage to mutual enrichment, understanding and ethical development.
As to the challenges for a theory in cross-cultural bioethics, it is crucial that we agree upon an adequate concept of science. It is an obvious consequence of the above described integrated approach that science in bioethics should be understood in a way that makes such an integration of diverse scientific disciplines possible and intelligible. Although the international debate habitually distinguishes between sciences, in the narrow sense of natural sciences, social sciences and the humanities, I propose that it is more helpful in bioethics to use the term "science" in the sense of "Wissenschaft", as the quest to knowledge and understanding. Thereby we acknowledge the fundamental postulate in all scientific approaches, namely the primate of reason, and we already integrate reason as a capacity to explore the thread, which binds theory and practice together.
The last but not the least important aspect of such a theory I would like to introduce here, (leaving it far from being completed), is that disciplines ought to systematically discuss and share their methodological and theoretical insight. It will be much easier that way, for example, to avoid misunderstanding owing to an ignorance of the shift of meaning, such as from "improvement" in the sense of repairing a defective part of an organism, or upgrading its function, to the sense of social or moral "improvement". This type of misunderstanding, as well as reductionism of various kinds, frequently include a failure to recognize their shift from is to ought, and from ought to is, respectively. Also, if we actively learn from each other, we might appreciate our own respective limits, and remain practical as well as humble.
6 Only Bioethics beyond Relativism can be Practical
In conclusion, cross-cultural bioethics is well advised to debate less on our conceptual and theoretical common ground but rather to pay more attention to improve the practical situations of medicine and health care, both in general and in diverse situations and contexts. Bioethics has a licence to be fundamentally pragmatic in practising humaneness. We can go quite a long way without academic niceties, but hard work must be done, if we wish to utilize the capacities of bioethics to become a major source of inspiration. The first step is still incomplete, namely to make bioethics a discipline of global understanding and discourse. A few rules, basic regulations, theoretical and methodological axioms suffice to form the base of such a discipline. If co-operation and communication are essential, then understanding is imperative, and we need a mode to assess how understanding in bioethics can be achieved. I believe that the old idea of a sound argument will do this work.
If a concept or an argument is regarded as convincing, it does not matter ethically, where it comes from. The geographical or other physical points of origination may be of historical, psychological and hermeneutic significance, depending on the given case. What matters in ethics as a meta-discipline transcending morals, customs and particular interests, (in order to make us able to address these levels on the basis of insight), is the force of the argument and the persuasiveness of the proposed concept. Both are certainly matters of interpretation, especially as to the meaning of rationality involved. As it has been frequently put forward by critics of universalism, the implications of rationality and its association with secular powers can be counter-effective in cross-cultural bioethics. However, we must not give up the principal acknowledgement of reasonable argument as a heuristic principle that drives and keeps it on the course of fairness, honesty and modesty. The best way to shelter minorities and diversity is to give them reasonable room for development and self-expression. If we universally acknowledge the dignity of every human being, we thereby rule out discrimination on grounds of difference. I suggest that reason is a less connotative term to refer to whenever we wish to refer to the human capacity to argue ethically.
1) Among the English publications are, Ole D_ring (ed.), Chinese Scientists and Responsibility: Ethical issues of Human Genetics in Chinese and International Contexts. Proceedings of the 'First International and Interdisciplinary Symposium on Aspects of Medical Ethics in China: Initiating the Debate', Hamburg, April 9-12, 1998 Mitteilungen des Instituts f_r Asienkunde Nr. 314, Hamburg, 1999; Ole D_ring and Chen Renbiao (ed.), Advances in Chinese Medical Ethics. Chinese and International Perspectives, Hamburg (Mitteilungen des Instituts f_r Asienkunde) 2001 (in print); "Human Genetics and Ethics in China" EJAIB 7 (1997): 130-131; 'Bioethics Goes China. The Second Sino-German Interdisciplinary Symposium about Medical Ethics in China: Medical Ethics in Clinical Medicine, Medical Theory and Research, and in Medical Education', Shanghai 19.-23. Oktober 1999', ASIEN (Juli 2000) 76: 57-58; 'Chinese Prospects in Global Medical Ethics: Enhancement or Emulation? The Second International Conference of Bioethics: Human Genome and Health Care', Chungli and Taipei, 26-30 June 2000', ASIEN (Oktober 2000) 77: 96-97; ''Bioethics in Asia \ Integrating Cultural Issues into Medical Ethics'. A Workshop at the Fifth World Congress of Bioethics, Ethics, Law and Policy, London, 22 September 2000', ASIEN (Januar 2001) 78: 121-122.
2) In preparation are, To Educate the Educators. Challenges of Education in Medical Ethics in China, Hamburg 2001 (Proceedings of the 'Sino-German International Workshop about Ethics in Medical Education in China' Xi'an, September 18-19, 2000, briefly the Xi'an Workshop); and Cultural Issues in Medical Ethics. Asian Perspectives, Hamburg 2001.
3) Among the few authors who have included explorations of the meaning of culture in this field to some extent are Qiu Renzong ('Cultural and Ethical Dimensions of genetic Practices in China', in Ole D_ring (ed.), Chinese Scientists and Responsibility. Ethical Issues of Human Genetics in Chinese and International Contexts, Hamburg (Institut f_r Asienkunde) 1999, 213-238), Paul U. Unschuld (Medical Ethics in Imperial China, Berkeley, 1979), Robert Veatch (1989, Cross Cultural Perspectives in Medical Ethics: Readings, Boston: Jones and Bartlett), H. Tristram Engelhardt Jr. ('Bioethics in the Peopl'e Republic of China', Hastings Center Report 10 (2): 7-10), Lynn Payer (Medicine and Culture, New York (Owl Books) 1996), Hoshino (Kazumasa Hoshino (ed.), Japanese and Western Bioethics. Studies in Moral Diversity, Dordrecht (Kluwer) 1997), and, most visible, Darryl Macer in numerous activities and publications of Eubios Ethics Institute. The most outstanding systematic Chinese contribution in this regard has been made just recently by Nie Jingbao ('The Plurality of Chinese and American Medical Moralities: Toward an Interpretive Cross-Cultural Bioethics', KIEJ10 (2000), 239-260). Also, cf. Proceedings of the Second Asian Bioethics Seminar, _Global Bioethics from Asian Perspectives', 24-25 November, Nihon University, 1999, Tokyo, 2000. For a comparative approach, cf. 'Global Profession. Medical Values in China and the United States', Special Supplement, Hastings Center Report 30, no.4 (July-August 2000), edited by Stanley J. Reiser and Wang Debing.
4) I have published several papers on the hermeneutics of cross-culture medical ethics, including (among others) "Gedanken zur Interkulturellen Philosophie aus praktischer Perspektive" Studien zur interkulturellen Philosophie Bd.5 (1996), R.A. Mall / N. Schneider (Hg.): 251-258; "Zwischen Kulturalismus und Globalisierung - die Sinologie am Scheideweg?", in Chinawissenschaften-deutschsprachige Entwicklungen. Geschichte, Personen, Perspektiven, Helmut Martin und Christiane Hammer (Hg.), Mitteilungen des Instituts f_r Asienkunde Nr.303, Hamburg 1998: 63-80; "Hermeneutische Kompetenz in der Krise? Eine Vor_berlegung zum Ausgang der Asienwissenschaften aus ihrer selbstverschuldeten Unsichtbarkeit", in Asienkrise, Demokratie, Nationalismus. Neue Wechselwirkungen zwischen Politik und _konomie in Ostasien, Gudrun Wacker und Christoph M_ller-Hofstede (Hrsg.) BIOst, K_ln, 1999: 149-151
5) Cf. Qiu Renzong, 'Medical Ethics in China: Status Quo and Main Issues', in Ole D_ring (ed.), Chinese Scientists and Responsibility..., Hamburg, 1999: 24-32.
6) Cf. Lee Shui-chuen, 'A Confucian Concept of Personhood and Its Implication for Medical Ethics', in Ole D_ring and Chen Renbiao (ed.), Advances in Chinese Medical Ethics..., Hamburg 2001.
7) The situation of medical ethics in China and East Asia with a focus on diverse issues has been introduced to a German audience in the author's following book and articles. Technischer Fortschritt und kulturelle Werte in China: Humangenetik und Ethik in Taiwan, Hongkong und der Volksrepublik China (incl. English summary), Mitteilungen des Instituts f_r Asienkunde 280, Hamburg 1997; 'Bildung und Ethik. In der chinesischen Medizinethik zeigen sich die Grenzen der Planbarkeit von Initiative und Verantwortung durch den Staat.', China aktuell, Januar 2000 (01/00): 40-50; "Wandel und Selbstbesinnung: In China entwickelt sich eine medizinethische Debatte" China aktuell 10/97: 1012-1020; "Schwierigkeiten mit nackten Tatsache: Ostasiens Umgang mit der Sexualit_t", Neue Z_rcher Zeitung (international edition), 133, 12/13.6.1999: 53; 'Humangenetik und Ethik in China", Gen-Ethischer Informationsdienst 122 (Okt.97): 34-38; GID Berlin; "Bioethik in China" Dr.Med.Mabuse 115 (September 1998): 30-31; "Ge_ffnete Horizonte. China setzt auf die wirtschaftliche Kraft der _berseechinesen", Neue Z_rcher Zeitung (international edition) 229 (2./3. 10.1999): 52; "Shape and Perspectives of a Chinese Gen-ethics: The Contribution of Hong Kong", Proceedings of 1st Hong Kong Medical Genetics Conference 25-27 January 1997, published by the Hong Kong Society of Medical Genetics, S.T.S. Lam (ed.) Hong Kong 1998: 225-230; "Medizinethik als Schl_ssel f_r die Modernisierung Chinas?" in Biologie einer Ethik. Die Bioethik im Blickfeld der Globalisierung, Akademie f_r Wissenschaft und Klinik der Chinesischen Medizin und Dr. Jean Weinfeld - die werkstatt (Hrsg.), Berlin 1998: 47-61; He Lin and Ole D_ring, "Some Ethical Observations about the Protection and Exploitation of Genetic Resources in China", in Chinese Scientists and Responsibility, Ole D_ring (ed.) Mitteilungen des Instituts f_r Asienkunde Nr. 314, Hamburg, 1999: 169-176; "DNS Peking, DNS Schanghai. Planziel: China will Asiens gr__te Macht in der Biotechnologie und Genforschung werden", Frankfurter Allgemeine Zeitung, 25.5.2000
8) Cf. my "Grenzenlose Gemeinschaft: W_hlt China einen humangenetischen Sonderweg?", in Frankfurter Allgemeine Zeitung 49/1997.
9) Cf. John Locke, The Second Treatise of Government, ed. by Richard H. Cox, Arlington 1982.
10) C.f. Heiner Roetz, 'Aus Albert Schweitzers Nachlass: _Die Geschichte des indischen und chinesischen Denkens'', in: Helmut Martin und Christiane Hammer (ed.), Chinawissenschaften \ deutschsprachige Entwicklungen. Geschichte, Personen, Perspektiven; Hamburg (Mitteilungen des Instituts fur Asienkunde 303) 1999: 528-545.
11) Albert Schweitzer, Aus meinem Leben und Denken, Hamburg (Richard Meiner Verlag), 1932: 129. An article discussing hermeneutical issues together with some misunderstandings about cultural relativism in ethics is the author's 'Hermeneutic Dimensions of Global and East Asian Medical Ethics in the 21st Century', Proceedings of the Second Asian Bioethics Seminar, _Global Bioethics from Asian Perspectives', 24-25 November, Nihon University, 1999, Tokyo, 2000; see also my "Schlechte Aussichten f_r die Kulturwissenschaft? Eine Anmerkung zu einer Anmerkung von Karl-Heinz Pohl", ASIEN, (Juli 1999) 72: 76-78, and "Nach der Aufl_sung eines Mythos - auf zum n_chsten!? Statement des Moderators von Panel 7 'Asiatische Werte'", in Asienkrise, Demokratie, Nationalismus. Neue Wechselwirkungen zwischen Politik und _konomie in Ostasien, Gudrun Wacker und Christoph M_ller-Hofstede (Hrsg.) BIOst, K_ln 1999: 157-162. See also my book (with Anja Osiander) Zur Modernisierung der Ostasienforschung: Konzepte, Strukturen, Empfehlungen, Mitteilungen des Instituts f_r Asienkunde 305, Hamburg 1999.
12) Issues of globalization and just health care are explored in the author's "Bioethik versus Globalisierung - Perspektiven der Vereinbarkeit von Menschenw_rde und Biomedizin", in Walter Schweidler (Hrsg.) Werte im 21. Jahrhundert - Wer bestimmt die Richtung?, Schriftenreihe des Zei, Nomos-Verlag 2000
13) Cf. Frank Leavitt, 'Whose English language?', EJAIB 10 (2000), 185.
14) A paradigmatic example is Hyakudai Sakamoto, 'The Edmonton Lecture', reprinted in: Proceedings of the Second Asian Bioethics Seminar, Global Bioethics from Asian Perspectives II (24-25 November, 1999 Nihon University, Tokyo), Comprehensive Study on East Asian Culture Project, University Research Center, Nihon University, Tokyo 2000: 3-9
15) An attempt to come to terms with the deep ethical impact of this situation is offered by Ann Lewis Boyd, 'Anagogy of Autonomy', EJAIB 10 (4) July 2000: 113-119. See also Ann Lewis Boyd and Ole Doering, "Genetics and the Common Good", in Darryl Macer (ed.), Ethical Challenges as we approach the end of the Human Genome Project, Eubios Ethics Institute, Christchurch 2000: 9-20.
16) I have published extensively about the issue of eugenics in China. Cf. Ole Doering, "'Eugenik' und Verantwortung: Hintergr_nde und Auswirkungen des 'Gesetzes _ber die Gesundheitsf_rsorge f_r M_tter und Kinder'" in China aktuell August 1998 (08/98): 826-835; "China and Eugenics - Preliminary remarks concerning the structure and impact of a problem of International Bioethics", in Bioethics in Asia: Proceedings of the UNESCO Asian Bioethics Conference, 3-8 Nov 1997, Kobe and Fukui, Norio Fujiki&Darryl Macer (ed.), Eubios Ethics Institute, Christchurch 1998: 86-91; "Eugenics and China: Where is the Ethical Problem?" EJAIB 8 (July 1998): 114-115; "China: Suche nach neuen Perspektiven. Diplomatisches Geschick erm_glicht eine Diskussion um humangenetische Fragen" (Mit einer Chronologie der deutschen Diskussion des chinesischen "Gesetzes _ber die Gesundheitsf_rsorge f_r M_tter und Kinder" vom Juni 1995), Schwerpunkt: Forschung GmbH & Co. KG, Gen-Ethischer Informationsdienst (Dezember 1998) 130: 32-35
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