Teaching Bioethics in Two Cultures, Thailand and USA

- Ann Lewis Boyd, Ph.D.
Hood College, Frederick, Md. USA
Email: boyd@hood.edu

and Ole Doering, Ph.D.
Institute for Asian Affairs, Hamburg, Germany
Email: odring@aol.com
Eubios Journal of Asian and International Bioethics 11 (2001), 184-9.


Introduction

The cross-cultural nature of bioethical debate has greater clarity after reflecting upon the contrasts between teaching Bioethics in Thailand and in the United States. The Bioethics courses had different curricular goals, for students at different levels of education. The course in the United States was part of an undergraduate liberal arts set of electives to fulfill a Science, Society and Technology requirement whereas, the Mahidol University course was a requirement in a doctoral program in Religious Studies. Each course was designed using a case study approach to test the Socratic method within a cross cultural context. This paper scrutinizes the responses of two groups of students: thirty-three undergraduate students at Hood College in the United States, and eleven doctoral students at Mahidol University in Thailand.

The undergraduate students at Hood College may elect the course to fulfill one of the liberal arts requirements in Science Society and Technology, thus, the students come from numerous disciplinary majors. Furthermore, the students are religiously and ethnically diverse, (20% are international students, and 40% are ethnic minorities, religions indicated include protestant, Roman Catholic, Buddhist, Hindu, and none, with more than 50% protestant). The Hood course is taught each year to undergraduate students, usually with 30-40 in the class, and the contact hours are approximately 48 hours (equivalent to a 3 credit course). The sample responses were taken from one section (one class of undergraduates) taught immediately after returning from Thailand, so numerous classes at Hood are not being compared to one class, rather, a one: one comparison is being made at similar time.

In Thailand, the eleven graduate students had each earned a master's degree in either philosophy or religion prior to admission, were taking courses in a "foreign language", English, and were either Buddhist or Moslem adherents. The pluralistic nature of each class offered an opportunity to assess the Socratic Method in a cross-cultural context, using cases selected from bioethics journals. Ann Boyd taught a standard 3 credit graduate course which met twice a week for 2 hours each meeting extended over 12 weeks. It was wanted to test the western standards of Utilitarian and Respect for Persons to see how religion majors native to Eastern philosophy would translate, reject, or adapt these thoughts relative to their more familiar Buddhist and Muslin perspectives. The 11 students were in the first semester of a new Ph.D. program in Religious studies and had previous undergraduate and graduate education in religion, including western religions and philosophies. Since these two standards are often cited in international ethics discussions, it is important to understand how someone from another culture or philosophy will interpret them.

Students in each course were required to evaluate the cases using contemporary versions of either deontological or consequentialist ethics representing the Categorical Imperative of Immanuel Kant (Kant, [1785] 1964) and the Utilitarianism of John Stuart Mill (Cohen, 1961, Mill, 1861). These two moral theories were tested by analytical reasoning through a series of case studies that represented the major contemporary issues in bioethics. These theories were selected because they are currently very influential in bioethics dialogues, conference proceedings, and publications. The aim was to assist students in understanding and recognizing these moral theories applied to modern medical cases, within an international context, as well as to identify for themselves the strengths and weaknesses of each standard; it was not to convert or install a prescriptive ethical standard for their lives. Emphasis was put on the application of standard-based normative and metaethical thought to a wide range of topics, including issues in death and dying, resource allocation, universal health care, organ transplantation, futile care, euthanasia; genetic technologies; global epidemics such as Acquired Immunodeficiency Syndrome (AIDS), and reproductive technologies.

Other influential moral theories were discussed as contrasting approaches to ethical reasoning, including Egoism, Casuistry, Virtue Ethics, and Principlism (Singer, 1993; Denise and Peterfreund, 1992; Harris, 1997). Neither intuitionism nor relativism was encouraged in order to test the Socratic Method. Relativism rejects the idea of universally valid principles and asserts that all moral principles are valid only in relation to culture, collective or communal values, or individual choice. Whereas principles become meaningful only as being related to some context etc, the point is that relativism claims that good action is not good because it is good but because it is adopted as being good by a certain group - genesis overwhelms reasonable argument, thereby denying consequentially any normative standard, including ethical but also scientific standards in general. We just do not relate to a tertium comparationis. Ironically, by the same token, relativism must postulate smaller and smaller units of "community" as soon as internal conflicts arise which can not be solved by means of any overarching principle. In a similar way intuitionism rests on the individual perspective for any given case or ethical challenge and intuitionism is related to relativism - it may be a misunderstanding of the subjective character of our individual moral reasoning as an epistemic fact; it fails to account for the necessity to provide universally binding rules and a communicable - thus rational way to understand and apply them. It confuses subjectivity of apprehension, which can be autonomous, with heteronomic intuition which can't, therefore, it was not encouraged. It is often the case however, that a person may apply an intuitive solution to a case, then try to frame the argument in the standard based reasoning. Thereby intuition is transformed to a rational/reason-guided subjective conception. The experience necessary to tease issues and concepts from scientific facts in order to defend the ethical judgement achieved using a Respect for Persons or Utilitarian ethical standard. It was rather intended that deliberative dialogue be a means to reaching a consensus statement of what was a preferable moral action to each model situation. It was feared that deliberative dialogue would be subverted by a relativistic claim merely-as every perspective must also be individual to be moral/ethical. What could the alternative be other than irresolvable conflict? This would be a case for higher-order consensus and exploring the respective impact on the debated issue.

Socratic Method

The "Socratic" method derived much influence from Oriental and Greek philosophy and has continued to influence ethical debate because it serves the purpose of moral teaching universally. The Bioethics course objectives were to enhance the ability to critically analyze a specific case and to reach consensus on an ethical action or rule for action appropriate for the case through a process of deliberative dialogue reflective of the Socratic Method. This method is used in philosophical or pedagogical situations in order to help 'experts' in any field become aware of their professional or, in this context not only limitations, but also their underlying moral assumptions, which regularly deserve to be enlightened. This method tries to disinterestedly pursue 'truth', or progress in understanding, through analytical question-answer dialogues, whereby a self-professed expert's over confident claim to knowledge is subverted. The intent is to clear the mind for the subsequent development of more adequate views. According to Socrates/Plato, the precondition for such views are already "hidden" inside the mind but must be brought to daylight, as illustrated by the Cave parable and the philosophers job as a "midwife." Many people would claim to be experts, if not in general morals or ethics, at least in their own ethical autonomy, thus, ethics is a natural candidate field for exploring the capacity of the Socratic method. Bioethics in particular, with its cluster of expert's perspectives and unique problem situations, is a most suitable example.

Each class was assigned several cases ranging from the simple (involving individual choice) to the more complex (situations involving competing and compelling claims in the larger society). The cases illustrated contemporary topics in Bioethics, such as AIDS vaccine trials in an international context, genetic medicine, and issues surrounding life and death. Facts relevant to each issue were presented using assignments from the current literature clearly identifying the scientific content and the philosophical issues. The intention was to stress the metaethical question_why a prescribed rule or action is good_over the normative ethics of what a person should do: it was not intended to mold students into responders to situations according to the perspective of the instructor. Metaethics and normative ethics do not contradict one another, but together form a systematic body of understanding and acting, allowing again for new reflection and understanding and acting, and so on. This may appear repetitive, rather, it is intended to be a tool of reflection. The systematic framework gives students a stage, or a conceptual tool kit, to provide a creative tension between what they already do understand (and desire) as good on the one hand, and what they may find out to be even more appropriate, according to their own ethical intuition, but informed and reshaped with the help from new facts and diverse perspectives. This system logically requires that one understand what it is that is pursued as 'good and right', and how and why an action hence deserves to be called right or wrong. It does not say that it is more valuable to think than to act, but that we should at any time act according to our best available insight. We should understand better how we act and act better according to what we think. This systematic integration of metaethics and normative ethics further allows one to assess and evaluate ethical principles, and to put them into practice. In this light, a principle-based ethics is not principlistic but beneficent. Beneficence is achieved through constructing a thought pattern that begins with what is good and proceeds to find a maxim for acting in accordance with that concept of good. Ethics without principles is logically impossible and achieves nothing - it does not even manage to describe any ethical concept. The issue is not whether to refer to principles or not, but how to make sense of them in the most appropriate manner.

Hoping to establish the sympathy/meaningfulness/understanding of a standard- or principle-based theory in ethical reasoning, students were asked to write an essay on the topic, 'What is Good?' The process of determining what is good and why it is good is the purpose of ethics. Student responses to the metaethical question varied, from quotations of sacred texts, to philosophical and religious authorities, to personal experience. One student framed her essay around the concept that 'God is Good', whereas another began with 'Enlightenment is Good', and yet another explored the idea, 'Chocolate is Good'. The variety of responses brings to mind the words ascribed to Socrates in the Euthyphro: 'Are things good because we desire them, or should we desire them because they are good?' One might imagine that it would be more Socrates' style to say that what we truly, and not just in reality, desire is desirable because it is the good, and that the truly good is what we truly desire, not any formula or doctrine. This leads to the important ethical and methodological difference between appealing to authorities, or sacred words, or formulas, or other positive sources, and using a rational argument (Freeman and Appel, 1952).

Working within a set of moral theories, students learned to analyze and judge an action, consider the meaning and moral significance of the action, and reflect how well the theory leads to attainment of the ultimate good. Because students came with a wide diversity of values, use of an ethical standard as a starting point helped create a sense of common ground, a pre-existing definition of the good upon which to base a reasoned argument. The fact that these definitions and metaethical concepts may be limited or preliminary did not undermine this function, because the issue of interest was not to find some 'absolute truth' but learning how to proceed in reflection and understanding of how to deal with medical ethics' cases properly. A useful ethical theory should accordingly encourage attention to the facts, interpretation of the facts, consequences, obligations, rights, and conceptual issues, because the skillful and enlightened application of these insights counts.

Philosophically, it may be that no single theory can claim absolute authority over all others. This dilemma was discussed after each student attempted to work within the range of theories adopted. It was hoped that students would ask what theory one should use and how one would choose because this interest would indicate that the Socratic method was in place. In both classes, the question was raised "can we combine these theories and use a non-consequentialist means-end standard in combination with the consequentialist calculus of the most good overall?" This question was especially welcome in that it indicated that a student was thinking independently, rather than shaping the argument to fit the frame of a deontological or utilitarian standard and indicated that the Socratic method was in place.

Praxis

During the semester, students wrote six case analyses and engaged classmates in dialogue about the most ethical response to each case. The class was divided into groups, each group working from the philosophical basis of either Respect for Persons moral standard, or Utilitarian moral standard. Following discussion among those writing from the same moral standard for each case, one reported to the class their consensus opinion if one was reached, and, if not, why not. Subsequently the two groups could continue debate about whether one or the other, or neither, of these moral standards provided a frame for decision making about the case at hand. In this way, the rules for proposed actions were compared and contrasted among the two theories, illuminating some of the limitations and strengths of each standard. It became apparent through the progression of increasingly complex and compelling cases, that students found neither moral standard easy to use in cases of distributive justice, issues highlighting more need than resources to meet them. In the later part of the semester, students are allowed the freedom to choose one moral theory and test it in another case analysis.

Respect for Persons, or deontological ethics hold that an action being intrinsically right or wrong can not be defined in terms/in the light of the consequences. Students found the maxim difficult to create and frequently too broad to be useful or too narrow to guide further actions. Thus creation of the maxim revealed to students their need to delve deeply into the issues and the recto ratio of their asserted moral claim. This result is however, in accordance with the categorical imperative. It is the point of maxim-ethics not to tell which maxims, interests, concrete actions one should do, but leave the generation of the will to each person's heteronomic personality. The model is evaluation: there is something submitted (a maxim), disregarding who submits, and this maxim can be either permissive, or nonpermissive: a subordinated imperative, the function of reason, demands that actions and maxims be coherent. Actions as actions can not be evaluated by the categorical imperative, only actions as expressions of some person's will to do X or Y can. If one would ordain people a certain will or self-determination, it would deprive people of freedom, autonomy and dignity. Only external practical rules can be ordained that is a matter of hypothetical imperatives. In other words: free humans are only in need of constraints (cultivation), because everything else is already part of their nature. The most frequent complaint about deontological ethics was the discovery that duties conflict, even when actual duties and prima facie duties are sufficiently differentiated. This observation points towards the important fact that deontological ethics, at least of a Kantian kind, in order to avoid lethal clashes of duties, depend on interpretation and the acknowledgement of a not-positive meta-principle, out of epistemological and systematical ethical reasons. Simply to quote some principle does not help (Denise and Peterfreund, 1992; Singer, 1993).

Utilitarian ethics rests on the premise that the most good overall is defensible and pragmatic. The greatest happiness principle of Bentham and Mill is defined as pleasure satisfaction, fulfillment of life potential, what everyone desires, and all persons are counted equally unless some qualitative values are defined in giving some differential weight to certain types of happiness. For example, pleasures of the intellect are considered more important than mere sensual pleasures. Happiness intends pleasure and the absence of pain. Therefore, actions are right as they promote happiness; wrong as they tend to produce the reverse of happiness because the only things desirable as ends for human beings is happiness and freedom from pain. The calculus can support actions that a Respect for Persons standard may deny in that no person can be a means or outside the universalism standards of the deontologist, but the most good overall understands that all persons will not receive everything equally. Therefore, the Utilitarian standard could in some sense be viewed as a risk-benefit analysis that imagines all possible good and bad outcomes to any one situation and seeks to determine a rule or action that produces the most good. Careful reading of the Utilitarianism essay of John Stuart Mill, adds that the most good overall is intended to be without doing harm, that it is beneficent (Mill, 1861). The happiness which forms the utilitarian standard of what is right in conduct is not the agent's own happiness but that of all concerned. Utilitarianism requires him to be as strictly impartial as a disinterested and benevolent spectator. "To do as you would be done by" or "to love your neighbor as yourself" constitute the ideal perfection of the classic utilitarian morality (Mill, 1861). Students, however tended to defend a moral claim using a quantitative justification of the "most good" without much attention to an inclusive "love of neighbor." Active participation in dialogue helped students recognize the injustice potentials within a strictly utilitarian calculus.

Participation in class discussion was imperative but some students needed more encouragement to articulate his/her position than others. The cases were discussed as described above, and at the close of the semester the ethical theories were evaluated for usefulness, plausibility, justification and consistency (Harris, 1997). The students were asked to test moral theories in the laboratory of human experience; through events in their personal lives, media stories, conversations with peers, to reflect about how one or any of these theories were helpful in acting according to their will. Such reflection may stimulate students to recognize a double operational basis for learning ethics: to be motivated to act morally and to understand what that demands. It proves that even moral intuition is not merely subjectivistic.

Medical ethics, therefore, can be described as a process, in learning as well as in theory and practice. This indicates that the meta-principle is applied, namely the imperative to systematic integration of different standpoints into the process of bioethics as it moves on in time. Utilitarian theories are criticized for their failure to ensure justice while maximizing good over evil, whereas, Deontological theories are counterpoised as a way of successfully dealing with this problem (Harris, 1997). Students seemed surprised that both standards could lead students to similar conclusions in a case, of individual judgment, or where beneficent outcomes were predictable and no person was clearly being used as a mere means. Thus it was clear that either standard could serve to guide critical thinking to a logical and intuitively acceptable conclusion.

Genetics: Case 1

The case describes a woman, 45 years of age, who has just been diagnosed with Huntington disease (HD): HD causes irreversible mental deterioration leading to death after several years of intense suffering. There is currently no treatment, and most patients with HD don't have symptoms until their fourth to sixth decade of life. By the time symptoms occur, most have completed childbearing and may have transmitted the gene to another generation. In this case, Mrs. S knows of no cases of HD in her family, but she has three children, ages sixteen, nineteen, and twenty- four. Her oldest daughter married last year and plans to have children. Mrs. S has three sisters and a brother, ages thirty-four, thirty-five, thirty-seven, and forty, who have eleven children ranging from 2 to 20 years of age. None of her siblings has any HD symptoms nor any idea that they may be at risk. The genetic counselor and the family doctor try to persuade Mrs. S. that it is her moral responsibility to tell her siblings and children of her diagnosis so that they can plan their lives with the knowledge that they are at 50-percent risk of developing HD, but she refuses. Mrs. S says she is ashamed of her condition and is afraid that her family will ostracize her or that her employer will fire her. Unless members of the family know they are at risk, they cannot request genetic testing. Furthermore, the test is more reliable if a sample of DNA is available from a family member with HD. Again, Mrs. S will not give permission to use her DNA or to tell her family (Crigger, 1993). What should the doctors do?

The scientific information that makes understanding a genetic trait and the technology that supports DNA diagnostic testing is complex and requires careful explanation. It is often necessary to reduce the science to a high school level to make clear the facts of a case. It cannot be assumed that students from diverse educational backgrounds will have current knowledge about DNA, genes, or testing, much less likely that they will know the details of more sophisticated technologies. Therefore, to process cases that deal with the appropriate and ethical use of technology, what the technique can do in a given case is an important factual point. The ethical issues frequently discussed in the current literature help to expose students to diverse positions from which new and creative thought can generate their individual case assessment and inform their collective dialogue. Therefore, detailed handouts are prepared about the scientific facts and selected literature is assigned for the ethical arguments for each topic in the course. To give students ethical concepts to consider in this case, several articles were assigned (Capron, 1991; Parens, 1995; Peters, 1995; Gardner, 1995; Pence, 1995; Munson and Davis, 1992).

Some students in each class said exposing a family member to an unknown genetic trait, that is to withhold information that is potentially important to an individual, in order to protect confidentiality is unjustified on the basis of doctor-patient relationship. As with infectious diseases that are reported according to law, the presence of a genetic trait that places someone at risk for a terminal or life-compromising condition must be shared with that person, in order to respect the dignity of that individual. Respect for Persons means-end standard would prohibit using a person as a mere means, and those using utilitarian calculus stated that the most good was also accomplished by telling patients the truth (not withholding information that is requested from individuals who have a right to know). Each class also stated that this case is important in understanding how conflicts can arise between doctor-patient relationships when there is more than one "patient" at issue. Furthermore, when a person is willing to withhold information from someone else and use the doctor to achieve this intention, the doctor becomes the means. In both classes, students report too much paternalism from the doctor, but admit that cases of this type make it easier to appreciate dilemmas physicians encounter where respecting the autonomy of every party is impractical or neigh to impossible. Even though it is important to protect the confidentiality of Mrs. S., the responsibility to do no harm ought to have trump status. In contrast, some students asserted that the doctor-patient relationship requires confidentiality, even if others are put at risk, because trust is essential to providing quality health care. Students seeking to find a compromise position suggested that, for the present, Mrs. S's wishes should be honored but that as her illness advanced, the opportunity would present itself for the doctors to give the family information that would neither dishonor Mrs. S. nor place others at risk. Students want to think about the practice of medicine, one patient at a time, and that each patient can be equally and justly served. A moral conundrum results when a patient's exercise of autonomy means potential harm for another.

One Hood Student commented: "Today in class, I wanted to rewrite my case study. Having group discussions really helps you to see different perspectives. After hearing from different people, I thought that I was very narrow minded in writing my case." Several students expressed amazement at the range of genetic technology and the future potential in medicine. One student said, " This genetic technology is amazing. I don't think we are ready for this power in the marketplace, but from a scientific standpoint it is cool. The potential for abuse is scary. This stuff is more dangerous than nukes. It allows us to define what humans are, rather than let nature do it. McBaby could be the new standard. Made to Order. If we look at the natural world around us, we see a diverse collection of species. There is even diversity within species. If we eliminate this diversity in humans, what becomes of us?

I don't know, maybe nothing. But the diversity around us tells me it serves a purpose. Have you ever wondered if our intelligence is what will render us extinct? Maybe genetic manipulation is the beginning. The point is that we have no idea what all this knowledge and technology will bring us. We need to find out. Let's use our labs instead of marketing agencies. We'll have plenty of time to use this, let's be sure we use it right'.

The HD case often evoked conflicting positions for action, providing an interesting, often difficult discussion about a common rule of action. The disagreement was important because through the process of searching for a rule that all can agree on, students learned to respect diverse values and opinions. In the process of deciding which ethical standard may be most appropriate in a given situation, students were encouraged to seek agreement where they could and maintain mutual respect when they could not. Inclusive dialogue invites all opinions to the collective discussion and provides a forum in which decisions may be legitimized. When consensus or compromise is reached through debate about the most good overall_for example, in the creation of a rule which can be applied universally_it is important that each student participate and state their views. Individual claims should be considered on their own merit in an atmosphere of compassion and tolerance, all participants open to a re-examination, and possible revision, of their own views. The deliberation does not seek consensus for the sake of peace but for the sake of finding terms that all participants can accept, even in disagreement (Gutmann and Thompson, 1997). It is important to note that neither consensus nor compromise in this sense necessarily compromises the ethical standard of Respect for Persons or Utilitarianism. To the contrary, the two moral standards become more intelligible and thus more powerful in practice. Truth, however, in ethics as everywhere, is not a matter of majorities or of agreement.

Moral Maturation

Verbalizing important concepts within a peer group is important because it helps the speaker achieve clarity about the issues and, through personal and collective process of deliberation, identify the points of conflict. Not everyone will agree on what constitutes the right or good action or why one action is more "ethical", better, or worse, than another, but the process through which we debate the reasons for an action is important. If each student merely wrote the case study from her or his individual perspective and no opportunity (forced at times) to debate were given prominence in the classroom, students would be deprived of the views of others as well as correction and response to their arguments. Moral maturation requires the ability to identify common ground because this requires people mature enough to face shortcomings on their own side and to open their minds for the normative claims of others, which in a sense, means to gain morality by losing a certain feature of identity; that is to change oneself due to the influence of others. This is ethically permissible if it is achieved by peaceful and informed argument, and not by enforced persuasion. It is different from refutation of one's argument, because it not only challenges and analyses one position and exposes it to different values, but proceeds with a purpose to enhance the ethical capability of all actors involved. Thereby it establishes an identity and personal self-esteem over time, through a process of moral maturation. Students learn to separate issues from concepts, and to determine who is affected by any proposed action. A decision that an action is moral or ethical should be deemed reasonable when viewed by those who are bound by the action and this is not sufficient condition but a necessary check. Finally, the challenge is to determine why and in what way the proposed action is permissible, impermissible or obligatory. To entrust moral/ethical capability to other members of the group and to accept the results of the discourse loyally, goes beyond the range of ethics: it is constitutive for an enlightened democratic culture.

Conflict resolution involves understanding an opponent's position and finding within the disagreement a common purpose or ground. Negotiating to arrive at one rule or action, even among theorists of similar ethical persuasions, views and perspectives, requires compromise, agreement, or changing perspective. If eight students are working on a case and the goal is to find one 'right' action, and each comes to the discussion with different answers, the process resulting in one final proposal to the class is often difficult and frustrating. Some students resorted to 'moral authority' and quoted sacred texts to prove the absolute correctness of their position. Others, proposing a completely different action, claimed equally high moral ground. In the complexity of issues, it is difficult to help students identify the best action for themselves and one another. It is an encouraging starting point for moral development if students understand that 'absolute moral authority' is a doubtful claim among humans. Fundamental concepts must be dissected from the human drama in such cases in order to deal with the ethical theory. The professor may need to redirect the discussion and lead students to the identification of issues and principles, while modeling respect for divergent viewpoints.

The increased understanding of two moral theories applied across a wide range of cases helps to broaden students' perspectives through Socratic debate. One should encourage students to weigh values different from their own, to recognize within each moral theory a devotion of purpose to the common good, and to respect the moral merit of contradicting, alien, unfamiliar, or partially dissonant values, respectively. This is perhaps the most dramatic change in students who take the cases and readings seriously, who really dig deep within their recto ratio to find the who, what, where, when, and why answers within these compelling and complex situations. The analysis teaches not only critical thinking but also tolerance for other opinions and values. Not every student will find a standard-based ethical theory consistently useful to justify an action among dissimilar cases. When students are from diverse cultural and religious traditions, the exposure to other values, views, and perspectives helps to identify common interests, common humanity, common human dignity, and the common good. It may even facilitate the shaping of different standpoints so as to enhance the level of discussion. The willingness to broaden one's horizons requires an open mind. It is not to coerce students into a change of mind; rather, it is to recognize the security of having a rational and logical defense for those values meaningful to them, and to respect those persons and cultures whose rational synthetic logic supports an opposing viewpoint. It is here that multinational cases are important: not just to expand students' exposure to diverse views within the same nation, but to enlarge their vision to worldwide perspectives through which their 'citizen of the world' view can enlarge and mature. It is likely that this exposure adds new aspects to one's moral reasoning, thereby challenging but possibly strengthening one's capability to argue. It is not expected that the process of deliberation will result in all values being made harmonious, rather that one will learn to recognize the merit in their opponents' claims. In defining and understanding the argument, one is open to resolution of the conflicts, willing to work together to seek a fuller understanding of the 'good' (Gutmann and Thompson, 1997). It is vital that the starting point is acknowledged as being open for unbiased development into all directions.

It is not sufficient to rest on the moral justification for an action in a medical context unless the scientific understanding supports the reasoned argument. The technology applied to medicine is increasing at an astonishing speed and the information available in the human genome project on human genes will open the market to testing, screening, and putative genetic therapies in the present era, not some imagined future. The knowledge necessary to make informed decisions about genetic medicine, means also understanding the basic scientific elements involved. Therefore, the information to increase scientific literacy is a natural byproduct of a course of interdisciplinary emphasis taught in a liberal arts context.

International testing of drugs and vaccines: case 2

A second case used in both Thailand and the United States describes the proposed clinical trial of a putative AIDS vaccine to be tested in human volunteers selected from drug rehabilitation clinics in Bangkok. This case has since been discussed widely in scientific and medical journals as an illustration of the competing and conflicting claims intrinsic to distributive justice and the allocation of scarce resources. Assigned reading material included original articles from the Bioethics literature (Forsberg, 1995; Powers, 1996; Lantos, 1996; Zaner, 1996; Levine, 1996; Bok, 1995).

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AIDS Vaccine Testing: Case 2

The World Health Organization estimates that 22.8 million persons are infected with Human Immunodeficiency Virus (HIV) which causes progressive failure of the immune system and the disease known as Acquired Immunodeficiency Syndrome (AIDS). Thailand is a nation with 60 million people and over 700,000 of them are HIV positive. The prevalence of heterosexual transmission with clade E HIV escalated from less than 1% to almost 40% among commercial sex workers in Bangkok and Chiang Mai within two years. The American and Thai armies have collaborated since 1961 to monitor infectious diseases in Southeast Asia. Serum samples are taken from all military conscripts each year. The analysis of these sera provide documentation of the HIV epidemic. The mobility of rural populations, based on economic and career needs, may remove them from the standard familial influences that dictate social behavior and expose them to new cultural and social norms, which, in turn, may affect their risk of exposure to HIV. Long term protection of future generations can best be achieved with a protective HIV vaccine. A clinical trial using a recombinant DNA vaccine is in developmental stages in Thailand. It is obvious from research on HIV that antibody alone does not entirely prevent virus infection or transmission to others. The vaccine scheduled for clinical trial in Bangkok is a recombinant DNA generated glycoprotein, gp120, the outermost surface protein on the intact virus and the most prominent viral antigen. The plan is to immunize persons with gp120, so that antibody to gp120 would protect the host from future exposure to infectious HIV. The virus clade in Thailand is E whereas the original rDNA gp120 was made against clade B, and there is little scientific support for cross-protection. The vaccine manufacturer will add clade E gp120 to the already prepared gp120-clade B. It is important to note that persons who are infected with HIV have antibody to gp120 and remain infected and infectious. There is scientific reason to question the efficacy of this vaccine and ethical concerns about the proposed clinical trial. Some scientists assert that the vaccine has merit and standard informed consent documents are being used to enroll persons in the clinical trial. The vaccine is scheduled to be given to selected persons from drug-rehabilitation clinics who will receive education about preventive behavior that should protect them from natural infection. Should the vaccine trial proceed as scheduled? Ought this vaccine to be used among drug users and persons known to have risk-behaviors, in order to determine whether the vaccine is effective? Who ought to be recruited for the vaccine trial (Boyd, et al., 1998; Boyd and Ratanakul, 1998).

Student responses varied within each class, but overall, more Thai students thought the vaccine trial should proceed whereas the Hood students expressed more reluctance to support a vaccine clinical trial in Thailand. Perhaps this is not so much a surprise as it expresses the, maybe naive in a good sense, ethical principle that what is distant must be judged and handled with caution, because relevant information supposedly is lacking, which creates a danger of invasive behavior, in the best sense of the phrase 'this is not my business'. The proper action in this view is to start by asking the affected people. Thai students stated that the problem was very serious and that any effort to help was better than none at all. Hood College students expressed the concern that because the need was great, those being offered the vaccine might be coerced, or unduly influenced by cultural values. Perhaps social and critical awareness is much more familiar to undergraduate students in the United States than is common among the Thai's, because of their respective educational experiences and style of living. The first step is very easy again: ask the people affected about their risk assessment and develop a dialogue. Of particular concern was the possibility that persons in Thailand would be used as a mere means to an end; the end being the monetary value of the vaccine to manufacturers. This concern is well grounded as we have numerous examples of exploitation of persons in developing countries.

Students in both classes struggled to understand the science of AIDS, and to understand whether the proposed vaccine held scientific merit, as well as how the extreme seriousness of the epidemic influenced government and individual choice to participate. There was much discussion on how autonomy might be influenced by the nature of the epidemic. The diverse opinion among students was made more poignant by the fact that some had relatives or friends with AIDS. The emotion generated by a fatal infectious disease makes the logical and objective nature of discussion more difficult to maintain. It is here that the instructor must appear neutral, even when she may not be. Objectivity in teaching is essential if we are to encourage students to develop their autonomy and to mature morally. We cannot follow them into the future to help them decide the right or the good, but we can equip them to think and reason and debate, to listen, to participate, to care what is done among the myriad options of all that can possibly be.

Students in the process of evaluating the course commented on how much they learned about complex medical situations that they had never before considered; some reflected that they had increased their personal self-knowledge, and some said they had gained a better appreciation of other value systems. The majority of the students states they had a heightened self-confidence in deliberative dialogue and respect for pluralistic values: a better sense of what global citizenship means. "I would like to say that this class was very good because it has forced me to look at what I believe and why I believe it. The case studies I have written have forced me to really think and consider my life and inner perspectives in comparison to the life situations we explored. You have challenged us not to just spit out regurgitated information but to explore our own ideas and formulate opinions on our own. I admire your ability to provide us with the basic tools one needs to make ethical decisions and then allow us to make our own decisions or in other words practice our autonomy. The discussion based class really provided me with the time to think and reason through the many controversial issues we discussed."

Conclusion

A course in Bioethics is by nature interdisciplinary and international in context; therefore, whether the course is taught in Thailand or in the United States, a case analysis using the Socratic method is an appropriate pedagogy. Graduate and undergraduate students learn through a participatory and deliberative dialogue to critically evaluate contemporary issues. The common ground established by the use of moral theories provides a forum for open discussion. The comparison of strengths and weaknesses among various theories evolves from their usefulness and consistency when applied to a variety of cases. It is no simple matter of choice of theory or of right/wrong, but of a process of continuous debate, moral claims/synthesis, interpretation, negotiation and transformation. One thing evidenced here, at least, is that the Socratic method is very useful as a universal method for learning the practice of autonomy in medical ethics classes as well as in the world classroom of our daily lives.

The students at Hood represent diverse ethnic and religious backgrounds and there is an age range (22-52) in the class, although there are fewer students in the class over 25 than under. In Thailand all of the students were in the 3-5th decades of life. Life experience does influence how a person interprets ethical standards and principles. A direct study should be done to establish how age and life experience affects ethical reasoning and this was not an objective of this paper.

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