- Hans-Martin Sass, M.D., Ph.D.,
Zentrum Medizinische Ethik, Ruhr Universitaet
Postfach 102148, D-44780, Bochum, GERMANY
Eubios Journal of Asian and International Bioethics 14 (2004), 12-22.
Medical ethics, however, in form of physician's professional ethics is much older and may trace its roots of combining privileged knowledge with protecting the profession and providing quality control in service, of mating ethics with expertise, back to the days of the Yellow Emperor in China, of Hippocrates in Greece and even earlier. But the human need to be healthy, for health care and health care competence in health protection and health promotion and in fighting disease, pain and premature death is even older than the professionalization of medicinal knowledge.
Health and health care are a basic human precondition and need to live, to survive, to live a good live. Bioethics and biomedicine in this broadest sense as a human need and vision has been there since prehistoric times, based on a moral and human pre-theoretical and pre-professional 'a priori' [Sass 1986] of what Macer has termed 'love of life'[Macer 1998]. This quest for health care and health competence as a basic human and civil right is based on the existential and basic human and civil need for maintaining and promoting health.
In the course of cultural history individuals, communities, and cultures have developed different principles and virtues as orientational tools and have constructed different rooms and houses for understanding life and death, suffering, justice and injustice in mythological, religious and philosophical models and for encouraging the protection and cultivation of love of live, liberty, security, humaneness, and solidarity in determining the just course of individual and collective actions. Reference to harmony or struggle-for-life in nature, references to mythological figures, revelations and commandments by God or goddesses, insights gained in meditation or value-based discourses and dialogues, contracts negotiated, laws given or voted on, rules indoctrinated and enforced have served as tools for orientation and predetermining actions. Competing models of supporting and guiding moral norms and behavior and of competing visions of the good and love of life are abundant. Will the recent vision of a 'common morality' provide a common house for all and a global system of reference for orientation and moral action, not only in bioethics?
Are we facing ideological battles between the disciples of autonomy, community, and paternalism or battles between those relying on compassion and those favoring analytical reasoning? Is modern autonomy-based bioethics and its focus on the individual person a forerunner or follow-up of a last and final stretch of globalizing values and principles developed in Europe during the times of enlightment by philosophers like Voltaire, Rousseau, Locke, Hume, Kant and Hegel over community-based or family-based norms and virtues in other cultures? Or is it the consequent and necessary implementation of a vision of liberty and justice for everyone, in particular for those who had been deprived of human dignity, respect, rights and freedom such as women, slaves, ethnic or religious minorities, and thus rightly criticizing, deconstructing and replacing traditional cultural networks and responsibility structures? Is the growing interest in communitarian models of culture and commitment, also the moral and cultural recognition of human interaction with and dependance on nature in highly individualized and industrialized cultures and societies such as those in Western Europe and North America an indication that rationalization, individualization, economization of each and everything, including issues of life, health and disease, suffering and pain, measurement of qualities in personal achievement, recognition and satisfaction, a first indication that European cultural development and globalization has gone too far and misguided and stretched human desire for love of life, fulfillment of life, and in measuring the options and limits in defining and achieving good personal and collective quality of life? But then: does not paternalism represent exploitation and abuse of kings and priests, community elders and clan leaders over the 'others', rule of men over women in male dominated cultures and laws, rule of masters over slaves, rule of the powerful over the powerless?
A timely crosscultural moral debate on some of these conflicting positions and visions needs to reflect on (1) different systems of reference in orientation and (2) different frameworks for health care ethics, (3) basic pre-theoretical moral intuitions and rules active or dormant in most cultures and conflict solutions for conflicting values and accepting dissent on visions and values as orientational and practical tools in bioethics conflict solution on the personal, familial, communitarian and global level.
Cultural Tools and Rooms For Orientation and Action
We humans use and process natural materials such as soil, timber, and crude oil to protect us from the dangers of raw nature; we build houses, cultivate gardens and farms, breed animals and plants in the support, enrichment and cultivation of our life and survival, life and good lives of our families, and communities. But we have also developed different tools to understand and cultivate nature and ourselves and to build cultures and civilizations: orientational tools, reasoned equipment of principles, maxims, rules, regulations, also metaphysical rooms such as philosophical worldviews and religions and cultural traditions to orient ourselves in the physical and in the human world, to predetermine and to review actions taken by us and others. Over the centuries, different cultures far away from each other have developed different tools and build different houses for interpretation and orientation, for guiding their visions, hopes and fears, and for predetermining and reviewing action.
NATURE: CRUEL OR EXEMPLARY HARMONY? Many cultures have used heaven and earth as reference poles to picture physical and metaphysical landscapes for human orientation and action. While in most cultures heaven and earth complement and interact with each other, together providing harmony and guidance in Chinese reasoning, others in Iranian and European tradition interpret this world as the great battleground between the sons of the and good against the sons of darkness and evil, a concept originally formed in Persia with long lasting influence on the traditions of the Middle East and Europe. Whatever the structural differences in these orientational houses, it seems that goals were similar: to provide a house for understanding the world and oneself, to differentiate between good and evil, to position the individual within a community, to define humaneness, love and nobleness, and to express visions and goals for individual and collective action.
A pre-established heavenly harmony ('daode' in early Chinese terms; 'logos' in European Platonic reasoning) predetermines requirements for good human behavior and virtues ('de' virtues such as 'ren' humaneness and 'lunli' interpersonal relations in Chinese [Qiu 1988:278f]), 'solidarity' and 'respect for each other' and each other's position in society in European natural law tradition [Sass 1986]). We find similar references to pre-established exemplary harmony in the different shades of love, good people are educated and cultivated to practice: spousal love ('fuqi enai'), filial love ('xiao'), neighborly and patriot love or loyalty ('zhong') [Qiu 1991; Tai, Tsai 2003]. In more personal terms monotheistic religions have encouraged people to 'love God and love your neighbor' or (better:) 'love God by loving and doing good to your neighbor', in particular to the poor, the sick, the frail and those who cannot help themselves. As the Jewish prophets, Jesus, and the prophet Mohammed said: this is the simple, central, and clear message and God's command. In Confucius' 'Analects' we find the same golden rule 'do not do to others what you would not desire yourself' or 'help others to get what you have got' [Qiu 1988:298]. When Mohist, a contemporary of Confucius formulated 'a person with humaneness loves himself as well as others not as a means for use, unlike loving a horse' [Qiu 1988:288], such a definition is quite close to the Kantian categorical imperative requesting not to use fellow humans exclusive as a means to an end, always also as ends in themselves. In secular terminology European post-enlightment the three principles of the French revolution 'egalite, liberte, fraternity' express a similar request for kindness or humaneness ('ren') to each and every human being, including the kindness to tolerate other people's visions and principles and to enjoy one's own.
Of course, emphasis on individual autonomy or family or community are different in many traditions and may change over time within traditions. But we find the principle of solidarity in worldviews as different as Jewish, Christian, and Islamic religion, Buddhist, Confucian, and Taoist reasoning, socialist Weltanschauung, and even in Kropotkin's anarchist philosophy of 'Mutual Aid'. Its seems to be worth mentioning that reference to pre-established exemplary heavenly or natural harmony occurs in times of social and cultural turmoil and insecurity, such as in the times of Confucius or the late Hellenistic area, when the Greek 'Peri tou Cosmou' author recommended to understand relations between sun, moon, and stars as an exemplary model for human society. While these references address something very basic in human nature, they also tend to be easy instruments for the protection of inflexible social systems, hierarchies or dictatorships from improving human rights, equality, humaneness and compassion. Most Asian houses seem to use orientational tools and materials in the context of nature interpreted to be harmonious and of guidance in doing good or, as Menzi (390-305 BC) in his arguments against Gaozi in 'being compassionate and act humanely as this is innate in everybody's heart'; European philosopher Rousseau would agree. But strong cultural trends in Europe understood and understand culture as a cultivating tool for raw and cruel nature, While Asian tradition seems to base individual virtues and moral principles within the service and relation to communities, European visions of human values and cultures quite often fight against the orientational prisons of hierarchical powers of churches and feudal oppressors, against societal structures they felt were not their own, too suppressive and counterproductive to being good and doing good. But then, also in European natural law traditions, we have the vision that the world of the sun, moon, and stars should be regarded as a sample of good and harmonious relations between humans of various age, sex, gifts, and social positions. As natural law traditions tend to protect conservative social and cultural settings, the positions fighting for humaneness and compassion, and personal liberty and security against oppressive powers, have the options to either interpret actual situations as an aberration from nature or to define culture as a means to overcome raw nature, Both strategies can be found in either of the traditions one of the European positions, the 'natura naturata' tradition of cultivating rather than dominating raw nature seems to be dominant in many Asian worldviews.
Buddhist views on the relationship of the individual to the world are centered around a personal challenge of individual heritage and individual responsibility for lifestyle. The precise percentage of inherited challenge and lifestyle challenge cannot be known to the individual, therefore in a model of interrelated forces of 'dependant origination' failure and sickness may not be blamed fatalistically on genetic or social heritage. In order to live a good and liberating life and to be as healthy as the 'kamma' allows, one needs 'to practice morality (sila), mental discipline (samadhi) and Wisdom (panna)'[Ratanakul 1999:19]
CULTURAL TRADITIONS: SUPPRESSING, LIBERATING, OR IRRELEVANT? As it would be wrong to not differentiate between different ethics teachings and practices within large cultural traditions, we must also be aware that traditions may become just ceremonial and etiquette and lack the power to determine and guide real-life actions. It needs to be studied how strong Christian traditions in Europe and Confucian traditions in China really are after centuries of rationalistic and emancipatorial humanistic critique of church hierarchical dominance in Europe and of two generations of egalitarian communist doctrine in revolutionizing cultural traditions in family and community ethics in China. Cultural history is full of examples that reference to nature can go both ways, understanding nature either as an exemplary model of harmony or as cruel and in need to be overcome and cultivated. Similarly, reference to and protection of 'culture' has been used as an old que protecting bad habits, suppression and exploitation, but also as a tool in promoting good and doing good and well. The fight against the suppressive powers of cultures and traditions and the liberating use and empowerment of culture and tradition are the two edges of culture everywhere and at all times.
Applications of cultural and moral traditions in actual moral conflict solution can be strongly authoritative and exhortative to individuals and communities, regulative and informative in drafting regulation and advising legislation, educative, discursive and adjuvantive in actual case management and scenario assessment [Sass 1994A). Traditions never provide ready-made recipes to be used inflexibly without careful assessment of the technical, cultural, and ethical variables which make a situation and without identifying priority stakeholders, their responsibilities, values and wishes. Some traditions are more elaborate metaphysically, more shiny in appearance and ceremonies, supported by more people than others or older than others. As far as the transfer from orientation to action is concerned, the only thing that counts is the motivation and real-life application of theories, beliefs and principles in concrete situations as Jesus had tried to explain the parable of the 'Good Samaritan'[Sass 2003A]; Deng Xiao Peng expressed the same insight similarly when he said that it does not matter whether cats are white, black or checkered, as long as they catch mice well.
A CULTURAL AND MORAL TEST: TREATMENT OF MORAL STRANGERS. In the coming age of increased globalization and migration, a traditional challenge in all cultures becomes even more pressing: the moral recognition and treatment of the 'stranger' as a fellow human, the ethnic stranger or the moral stranger. Tribal and ethnically and orientationally closed societies have particular problems in recognizing the 'other' as of equal dignity and of equal right. Jesus, Deng Xiao Ping, Kropotkin, Spinoza and Locke present strong arguments, that respect for human dignity includes the respect for human diversity, personal abilities and disabilities, and conceptual differences and dissenting positions on deep philosophical and religious convictions. They also hold that actions count independently of how shiny, golden, bizarre, strange or crude the ideas or visions are, they are based on.
After centuries of ideological battles, including the slaughter of 'infidels', torture of Christian believers by Christians believing in other Christian dogmas, and persecuting ethnic or moral strangers or excluding them from society, European thinkers like Spinoza, Locke and Voltaire proposed tolerance as a moral and cultural principle of highest authority in the respect of the dignity of the individual human conscience and of personal moral and religious visions and values. Similarly, the respect for the individual fate and challenge [kamma] in Indian tradition and for compassion and humaneness [ren] in most Asian traditions wwas a strong force to accept differences in orientation and to tolerate differences in lifestyle. Daoist, Buddhist, and Hinduist models of harmony, compassion and personal moral challenges do not seem to differ much from the mainstream of monotheistic orientation among Jews, Christians and Muslims in making it culturally and morally mandatory to serve the poor and sick, to be pious by being compassionate. Terrorism and political or economic domination always has used and abused religious and other orientational tools for the exploitation and destruction of the 'stranger', the 'other', the 'infidel'. The concept of humaneness, compassion, and nobleness would fail if we would even start thinking about applying it only more or less arbitrarily to selected groups of fellow humans or our own moral communities and friends, or we would not make a difference between ideological strangers and moral strangers, and between different cultures on one side and of enemies of cultures on the other. Appealing not only to his Jewish fellow-believers, but to an already religiously pluralistic European cultural scene, enlightened Jewish rabbi and philosopher Moses Mendelsohn put it this way: 'Brethren, if you want true peacefulness in God (Gottseligkeit), let us not lie about consensus when plurality seems to have been the plan and the goal of providence. No one among us reasons and feels precisely the same way the fellow-human does. Why do we hide from each other in masquerades (Mummerei) in the most important issues of our lives, as God not without reason has given each of us his/her own image and face [Mendelsohn 1819:201].
Principles, Virtues and Moral Agents in Health Care Cultures
Orientational tools in health care ethics, as in most areas of complex professional and personal decision making and risk management, do come in packages as no single one principle or virtue will be able to guide alone in each and every situation. Compassion without skill is weak and powerless; skill without compassion is senseless and aimless. Expertise without ethics is blind; ethics without expertise is blunt. Different public and professional cultures in the care for health use different systems and packages of reference: principles, virtues, checklists, and interactive models.
PRINCIPLES FOR PHYSICIANS: The 'autonomy, nonmaleficence, beneficence, justice' "package" of principles does not cover the entire spectrum of physician's and researcher's responsibility, it is an add-on module for ethics review and quality assurance in addition to technical rules and standards to be implemented in research and patient care. Implementation of moral principles would be of no use neither in research nor in patient care, if scientific and technical standards in patient treatment and clinical research were sloppy, below standard, incompetently used and not reviewed by highest standards of quality control. But as a module for guiding and reviewing health care, patient care and clinical research, for educating health care professionals and administrators, politicians and insurance experts this package, indeed, represents essential features of what has been called 'common morality' applied in the fields of professional medical research and treatment.
Similar packages have been developed, in part in cultural opposition to what has been called 'common morality'. Rentdorff et al.  proposed the package set of 'autonomy, dignity, integrity, vulnerability' as a truly European package and recommend it over the so-called 'Georgetown mantra' for teaching, guiding and reviewing patient care. Developed not just for clinical research in the first place, it nevertheless can also be used in research as the four original principles of the 'Belmont Report' can and are used in patient care as well.
For an Asian audience Tai  has proposed a package set of 'ahimsa (nonmaleficence), compassion, respect, righteousness, dharma (responsibility)'. From a cross-cultural view, there does not seem to be any essential difference between these packages, as they only slightly differ in setting priorities among principles which have to be weighted anyway in each situation differently according to the case. But different words and terms are of different validity and authority in different traditions; therefore it is not a 'fight over words' when Europeans or Asians choose different terms in packaging principles for physician's ethics. Actually, it would be best to use those terms which would rest on the broadest possible general cultural and professional cultural fundament.
It is urgent and worthwhile to start a project to review the same clinical cases and research protocols competitively with each of these and other packages in order to find out about their utility in teaching, guiding and reviewing. Such an empirical research project on the cultural and attitudinal relevance of principles in medical ethics has not yet been done and only the 'autonomy, nonmaleficence, beneficence, justice' set so far has been proven empirically to be an important add-on module.
VIRTUES FOR PHYSICIANS: While principles address obligations and rules to be followed whether or not one feels these rules are adequate or correct, the appeal to virtues solicits personal commitment and compassion. Whenever there are coherent professional cultures, the call for the virtuous professional, in this case the virtuous physician is a much stronger call. Kant made the distinction between 'duties based on rule' (Rechtspflichten) and 'duties based on virtue' (Tugendpflichten); respecting traffic rules and principles of medical research does not require compassion or even the recognition that those rules and principles are necessary. They need to be respected as what they are: rules of professional conduct, expected by consumers and patients and the public, and eventually enforced by professional self-regulation or oversight authorities. Tai's  package already is one of virtues rather than principles. So is a package of virtues of 'dharma': 'love, trust, righteousness, compassion, tolerance, fairness, forgiveness, beneficence, sacrifice, concern for the weak', proposed by Indian lawyer and physician Kishore , and requiring moral values of 'justice, equality, autonomy, benignancy, altruism, human solidarity, respect for the dead, respect for other forms of life, preservation of life'. From a cross-cultural point of view, it is interesting to find included in Kishore's two sets the four principles of the 'Georgetown mantra' included, but not argued for based on Western reasoning.
One of the blueprints of physician's virtue theory is Confucian physician Yang Chuan's virtue package integrating ethics and expertise and trusting only those physicians 'who have the heart of of humaneness and compassion, are clever and wise, sincere and honest' [Qiu 1988:285f]. For Western humanist and Christian traditions Pellegrino and Thomasma [1988:205f] require for the post-Hippocratic physician 'place the good of the patient at the center, possess and maintain competence in knowledge and skill, recognize limitations, respect values and beliefs, care for all independent of their ability to pay, assist patients to make choices, hold in confidence, never participate in killing, fulfill obligations to society, practice what you preach, teach and believe'. Understandable and acceptable by Westerners and Asians alike would be a set of virtues published by the Ministry of Health of the Peoples Republic of China which includes 'healing the wounded, rescue the dying, and practice socialist humanitarianism; keep the interests of the patient in your mind and try everything to relieve patient suffering; show respect for the patient's dignity and rights and treat all patients alike whatever their nationality, race, sex, occupation, social position and economic status is, .. be honest in performing medical practice, keep secrets related to the patient's illness, be rigorous in learning and practicing, education on medical ethics and the development of medical ethics must be part of managing and evaluating hospitals' [Zeyi 1989:16f].
PRINCIPLES AND VIRTUES FOR PATIENTS AND THE LAY: As health, the protection and promotion of health and the fight of disease, the alleviation of pain and suffering is a very personal matter of life, good life and survival, since prehistoric times certain principles and virtues for prudent reduction of health risk have been part of family and community tradition and teaching. Health competence and health care literacy had been essential for survival and living a good life when medical expertise was low and available only to few privileged few. In Western tradition the so-called 'res non naturales', i.e. variable conditions for and in life which were not depending on the unpredictable powers of cruel and raw nature such as the avoidance of extremes and of stress, golden rules, personal harmony and harmonious relations in family and society formed the center core of these virtues and principles, many of them forgotten in modern sickness treatment systems promoting a repair mentality together with excellent modern high-tech disease management.
According to Ratanakul [1999:19-23], 'Buddhism advises those who want to be healthy to practice morality (sila), mental discipline (samathi) and wisdom (panna) in the Noble Eightfold Path'. 'Individual kamma', i.e. personal fate and fortune, depends on causations, some beyond the reach of humans, many not such as good exercise, proper nutrition, lifestyles, personal decisions and attitudes, also unhealthy environments and working conditions. Unwholesome states of mind such as greed (lobha), hatred (dosa), anger tendencies for aggression and possession tend to cause mental and/or physical harm and disease.
The following seven virtue rules for the healthy lay of Dr. Friedrich Hoffmann, a Christian physician and pharmacist in the European Age of Reason represent the Western tradition of the 'res non naturales', i.e. of those factors and conditions humans are in part in control of. But they are easily understandable in the Daoist, Hinduist, or Buddhist culture; they are actually understandable and practicable as common-sense health risk competence and common-sense morality for everyone: '(1) Stay away from everything which is unnatural.- (2) Be careful with changes as routine often becomes our second nature.- (3) Be happy and balanced, that is the best remedy.- (4) Stay in clean air, well tempered, as long as possible.- (5) Buy the best nutrition which goes easily in out of the body.- (6) Choose foods according to your bodily activity and relaxation.- (7) When you love health, run away from physicians and from all drugs' [Mueller 1991:260]. While not part of the 'res non naturales' set, a healthy distrust of the limited knowledge and of the often unlimited hunger for money by doctors has been present in other cultures as well, in this case recommended by a superior doctor and pharmacist. A similar action guide is used to promote Johns Hopkins' 2003 www.hopkinsafter50.com website and a subscription to a 'Medical Letter Health after 50' journal:'Get moving; don't smoke; follow a healthy diet; use supplements wisely; drink enough water; avoid excessive exposure to the sun; reduce stress; challenge your mind; limit alcohol consumption; cultivate satisfying relationships; consider preventive medicine'. Given the common-sense culture and ethics of lay health protection and promotion, it is not surprising that the 2003 Chinese bestseller 'Let Health be your Companion' by Dr. Hong Zhaoguang does not have any different advise to give than Dr. Hoffmann, the Hippocratic dietary and lifestyle rules or those given by Indian or Chinese doctors concerned about promoting lay people's health competence and health care culture [for details see www.health-literacy.org]. But it is surprising that bioethics in most cultural settings so far has not made the ethics of de-professionlized and de-medicalized lay health care and its partial disconnect from the medicalized culture of modern disease management by highly specialized experts a more focused topic in research and teaching.
While not well taught in many low-literacy cultures and forgotten in many cultures enjoying a successful disease-management system, lay health literacy and the ethos of health care and health promotion competence has found a powerful medium and tool in internet-based information and communication. E-health sites for general and specialized health care information and advice are abundant, become more and more popular, widely unregulated, more and more widely traveled, and so far outside of established medical systems. These new media for communication and cooperation, also for compassion and consolation, will make ethical issues of lay health care competence a prime and not yet recognized issue and challenge in medical ethics. The unfolding partly deprofessionalization of privileged medical knowledge is a cultural and moral gain for the individual and for a cultivated and health-competent culture [Sass 2003C; also www.health-literacy.org].
CULTURES OF INTERACTIVE HEALTH CARE PRINCIPLES AND VIRTUES: Neither physician's ethics nor patient's or citizen's health care ethics are independently and separately capable of caring for health and fighting disease; they have to interact and have to be complementary. Confucian physician philosopher Gong Tingxian was the first proposing interactive rules for physicians and patients [Qiu 1988:300]. He calls on physicians to provide their medical service within the framework of philosophy and humaneness and on the patients to choose enlightened physicians only, to comply, to trust and to be grateful. I have used the model of Gong Tingxian to propose post-Hippocratic interactive rules for modern citizens and physicians [published in EJAIB 1994; 4(1+2) and many other languages; Sass 1994].
In interactive sets, principles such as compliance and non-compliance or non-harm and beneficence have to be balanced in individual cases and in different scenarios every time anew. For the lay person, I see the maxims of self-determination (autonomy) and compliance in dialectical and differential tension and in need to be balanced, also the goals of quality of life and length of life in as far as certain forms of enjoying life might not be healthy nor contribute to a long life. On the side of the physician, I see the respect for the autonomy of the patient and the professional obligation to request compliance in need to be balanced in a process of prudent and honest decision making, also the traditional tension between doing the patient good without harm as a side-effect of treatment or medication. No stakeholder can resolve the tensions and probable imbalances between principles, maxims and goals alone, they have to interact on the basis of trust, of communication-in-trust and cooperation-in-trust, in caring for health as in all other endeavors when experts and lay customers have to cooperate and to communicate goals, means, and procedures [Sass 1994B].
Interactive maxims and action guides do not need to be general; they can be quite specific and address very specific situations such as dealing with inherited genetic disorders. Elsewhere Kielstein [2002:640] and I have discussed interactive maxims for carriers of ADPKD (polycystic kidney disease) and their counselors and physicians, covering presymptomatic as well as dialysis-dependent carriers: 'Three maxims for the carrier of genetic kidney disease: 1. Accept your abilities and disabilities and define for yourself within your individual possibilities and challenges your personal parameters for quality of life, personal fulfillment, role in family, among friends, and in public recognition.- 2. Be health-literate and health-responsible in compliance with medical advice and your personal life goals.- 3. Define your individual morale of responsible parenthood in making reproductive choices and your responsibility towards family and pedigree who might or might not be carriers.- Three maxims for the expert in nephrology: 1. Inform, educate and advice your counselee or patient as a person and a fellow human; do not just treat her or his disease.- 2. Assist lay persons in guiding them to make educated health-literate personal choices in lifestyle, work, and social activities.- 3. Fully and clearly inform counselees and patients about genetic risk in reproduction and towards their family and pedigree, but do not get involved in their personal life, values and decisions.'
In many situations, the integrated trust-based interaction of experts and patients and their families is not enough, if not supported by culture and societal traditions. Many cultures, e.g. in particular those in Asia, enjoy a strong tradition in honoring parents, elders, and old age. But a global cultural trend towards youth, young life, physical fitness, and being young might undermine, weaken or even render those century-old traditions irrelevant. Therefore sets of action guides and virtues need also to address and include issues of societal ethics, developing cultural trends and changing attitudes; this needs to be reflected in integrated action oriented virtue sets in geriatric care addressing not only the elderly and their caretakers but also society in general [Sass 2002B]; similarly health advice on issues such as HIV, smoking, and personal hygiene needs to address cultural trends and attitudes supporting lifestyle cultures, not just medical aspects. Cultural traditions are never self understanding, they need nurturing by teaching, role models examples and action-oriented implementation.
Interaction between customers and providers in health care and health care guidance becomes additionally important as modern medicine can more than just care for the sick and the frail; predictive and preventive medicine allows for protecting and even improving health. Health enhancement and anti-aging, millennium old dreams of humankind, can be achieved to a certain degree and at various costs and risks today. Enhancement issues together with those of lay health care ethics have not yet become a prime focus in contemporary bioethics. Dormant cultural traditions in lay health education and competence and physician's obligations to advice and assist in health care protection and, if possible, promotion or even enhancement have not yet been re-activated and re-evaluated. Different cultural traditions might react differently to the challenge of health protection, health enhancement and anti-aging. In general, as far as the professions of the healing arts and medicine are concerned, there seems to be the need either for an enframing culture of fiduciary relationship around a partnership or stakeholder relation between physicians, nurses, patients, healthy and sick people and their families, or an enframing partnership-stakeholder relationship within which extreme cases retreating to more paternalistic/ maternalistic models of care for the suffering and helpless is called for by the virtue of compassion.
Not only for reasons of competence-based self-determination in matters of protection and promotion of health as a human and civil right, but also because predictive and preventive medicine has made such a enormous progress that lay persons can with or without help of experts take care and responsibility for their health better than ever, lay health literacy promotion has to become a central focus in future cross-cultural and global bioethics. Health literacy promotion as a priority will help many people in poor countries more and quicker than the build-up of a hospital structure based on Western models; and the healthy as well as the sick in rich countries will be allowed to take the protection and promotion of their health in many areas into their own hands.
ETHICS AND CULTURES IN CONCEPTUALIZING HEALTH AND HEALTH CARE: The cultural understanding and concept of health will have to change accordingly. Health cannot simply be understood anymore as 'a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity', as the WHO defines it, rather as a process of challenge and response, a process of balancing, which needs understanding, protection, and management by the individual person. Health is not just a status; rather the balanced result of health-literate and risk-competent care of one's own physical, emotional, and social wellbeing and wellfeeling, achieved in competent understanding, modification and enhancement of individual genetic, social and environmental properties, with the support of health care professionals and through equal access health care services, including information, predictive and preventive medicine. The WHO definition of health seems to have outlived its usefulness as we need a re-evaluation and a re-prioritizing of traditional principles of care, confidentiality, beneficence, informed consent, and harm within physician's ethics and in lay health care competence and ethics.
Long neglected patient's ethics and health care ethics of the lay has to become a prime topic for bioethics research, education and application in the clinical, primary care and public health care settings. Also, we will have to focus on modified principles in medical such as duty to inform, duty to be told and to know, health education, health literacy, health care competence, informed request, informed contract, and the ethics of data availability [HUGO 2003; Sass 2002A]. These new challenges to health care and medical research are challenges for better education of experts and lay citizens and communities. New models of communication-in-trust and cooperation-in-trust between the experts and the lay need to be developed as, in the words of Ni Peimin, health care is 'not a matter of biology alone', but 'a never ending journey towards the highest perfection of human being' [Ni 1999:42]. Such a notion of caring for health was not only part of the Confucian tradition; there is a long tradition of dietetics, i.e. lay prudence in healthy lifestyle in European thought [Hartmann 2003]. Those concepts and maxims seem to have been lost in most modern systems of disease management and been replaced by an unfortunate repair mentality in health care matters. As the call for promoting lay health competence becomes more pressing today for the reasons mentioned but only just starting to become a focus of research, quality assurance, and teaching [see www.health-literacy.org].
STAKEHOLDER CULTURES AND ETHICS IN MODERN HEALTH CARE: There are more stakeholders in modern disease management and health care than just individual doctors and individual patients or their families. Actually, very rarely do we still find the century-old model of one-to-one physician-patient interaction. Builders, enablers, providers and stakeholders in modern health care include institutions such as hospitals and nursing homes, administrators, regulators, insurers and politicians setting up the framework and defining the acceptable standards of information, treatment, and reimbursement. Medical ethics is implemented or not implemented in a corporate and institutional setting within which the individual physician, patient and advice-seeker is just one small subject and object. But as Sun Si Miao, the revered father of Chinese medicine is reported to have been said 'a superior doctor takes care of the state; an average doctor takes care of the sick person; a inferior doctor takes care of disease symptoms' [Qiu 1988; Ni 1999], the call for making public health including a priority in health education and promotion is not new, nor is the notion that public health and public health care education, protection and promotion gives all citizens a more competent and self-determined decision making role in the care for their health.
Efficient health care is more than high quality of medical intervention and expertise by individual doctors; high percentages of GNP allocated to disease management, or paying medical treatment for the needy. Health care is about being able to care for one's own health with more or less support of professionals. As far as education and competence in health care matters is concerned, rich as well as poor countries have neglected to enable their citizens to make health risk avoidance and health care decisions on their own. Rarely is the promotion of health literacy and health care competence found in any basic package of privately or publicly funded insurance schemes. This neglect is not caused by a lack of funds, but by a lack of recognizing the civil right to care for one's health and to be given the opportunities to do so in an educated and risk competent way. Health information and education have to be recognized as basic human and civil rights.
Radical changes in existing systems of providing and insuring health care need to be supported by changing attitudes, first among those who structure systems, legislators and regulators, by those who provide and implement health care, disease management and financial services, and then by citizens capable of taking care of their health. This requires a new focus on different cultures in corporate ethics, institutional ethics and the ethics of health care policy, areas not yet a prime issue in bioethics debate. If, e.g. the restructuring of a health care system such as the one in Hongkong does not take into account traditional professional and lay cultures in dealing with health and disease, then theoretical philosophical and ethical deliberations on cultural roots in health care have shown their irrelevance and historic value only; a recent special issue of the 'Journal of Medicine and Philosophy' [1999; 24(6)] has among its six articles none which addresses specific Asian principles, virtues or traditions in health care. Such a finding calls on research and teaching in culturally sensitive medical ethics to reflect on its relevance in a developing global world of corporate and institutional disease management.
Changes in real-life disease management and health care and promotion, short of a civil rebellion enforced and supported by e-health information and guidance, will need to come from the big and powerful payers in the field, corporations, institutions, insurances. Recently, I have these challenges to corporate and institutional expertise and ethics and have proposed eight interactive maxims in health care for the players [Sass 2003C:566], of which I quote the first three for each: 'For politicians and regulators: (1) Base policy on solidarity, responsibility, subsidiarity. (2) Make solidarity the fundamental principle to pay for basic education, basic personal services and pain management. (3) Cover individual risk profiles by basic insurance.- For insurance professionals: (1) Offer insurance for people as partners, not for profit alone. (2) Provide basic insurance for costs of health education, acute intervention, chronic illness and pain management. (3) Solidarity requires that individual differences in health risk profiles be included in basic insurance.- For the lay person: (1) Find truly educated and trustworthy health care experts. (2) Develop health care competence and responsibility. (3) Make extended use of predictive and preventive services.- For the health professional: (1) Treat people as fellow humans, not just their symptoms. (2). Assist clients and patient to develop health risk competence. (3) Integrate the 'clinical status' and the 'value status' of your patient into differential ethics, diagnosis and prognosis.' While these maxims need detailed discussion and eventually cultural modifications, there integrated combination shows the interrelatedness of genuine clinical bedside ethics and care with the wider ethical framework of institutionalized and regulated health care systems.
Cultures In Accepting Dissent And In Forming Consensus
In the course of cultural history, different strategies were used to form consensus and what was understood as a coherent commonly shared culture: teaching and preaching, torture and indoctrination, burning or slaughtering of the infidel, the moral or religious stranger. All cultural and religious traditions have their share in means of promoting culture and stabilizing society and state, now widely understood as inhumane, non-compassionate, non-respectful to the dignity of a fellow-human's conscience and conviction, values and visions. Hangmen, pistols and torture chambers might prolong the existence of unjust societies; terrorists might undermine the trust in free and open societies. But terrorists and tyrants are not promoters of culture, they are strangers to any kind of culture, to morality, and to conscientious religious or philosophical references to harmony, a will of God, a love for life, or a peaceful society. Terrorists and tyrants are not only strangers to culture and ethics, they are their enemies.
Daoist visions of harmony in nature include the understanding that things are different and people are different, in their fate, their abilities and disabilities. Buddhist and Hinduist reasoning have great understanding and compassion with individual fate and individual challenge to meet one's own destiny. Monotheistic religions of Mideast descent and with a missionary ethos have learned it the hard way by prosecuting and slaughtering each other, that the love of God is best expressed (and actually required by God) by loving one's neighbor, in particular those who need love and support most, the poor, the sick, the desperate, the neglected, discriminated and forgotten.
REASONABLE AND MANDATORY MORAL AND CULTURAL CONSENSUS: There are definitely many, quantitavely probably most, areas of everyday life where consensus in regard to the best or preferred moral action and responsibility can reasonably be expected and in most cases even need to be made mandatory by law and supported by attitude and public culture. The tables of 'universal human rights', expressed supported and enforced by civil right legislation belong in this category. This would include all so-called negative rights such as the right not be tortured, raped, exploited, misled, misinformed, left alone in misery, sickness or despair, left hungry and thirsty, discriminated against based on race, gender, color of skin or belief. References I gave earlier support such a cross-cultural integrated list of priorities for each civilized tradition and culture. But also a small list of positive human and civil rights can be put together based on essential human and civil needs, including the need and vision for harmony in family, community, society and humankind, golden rules of different type, respect for fellow-humans and their dignity including respect for the dignity of their visions and values, beliefs and commitments. Some of these beliefs commitments do look strange to others, who are moral and cultural strangers to those traditions: a commitment not to eat pork or shellfish by Jews and Muslims, not to eat beef by Hindus, not to eat any animal protein by vegetarians, not to support or even eat genetically modified foods, not to receive or donate blood even not for saving life the Jehovah's Witness religious community. Most of us, and even most of our governments, have developed cultural sensitivity to recognize and to tolerate such 'strange' convictions shared only by minorities. Labeling of foodstuff takes care of minority convictions and allows them to avoid these foods. The right of competent adults to refuse blood donations even for saving their lives is respected in respect for the dignity of their personal values against the cultural and professional traditions of saving life. It would be a cultural wrong and an uncivilized and immoral act to forcefeed Hindi with beef or Jews with shellfish; it would be a crime against the religious belief, shared only by a very few, to infuse blood into their bodies against their will. It would be a moral wrong to abort a fetus from a women against their will or to kill a terminally ill person (euphemistically called 'euthanize'] against that persons will.
DISSENT AND TOLERANCE IN RESPECT FOR THE DIGNITY OF VALUES AND VISIONS: But would it also be a moral wrong to refuse active compassionate killing of a terminally ill suffering competent person, if such a wish is made reasonably clear and supported by that person's values and visions? Would it be morally wrong to refuse the termination of pregnancy to a competent woman asking for abortion and giving reasons based on her religious or philosophical beliefs? Would it be wrong to withheld donated blood in life-saving situations from a patient, even though the cultural and moral majority in such a society does not approve for various reasons such a transfer? Rousseau, at the height of European emancipatorial discourses on rights and wrongs and the limits of majority rule suggested to differentiate between the 'volente generale' (a general and inalienable human interest) and the 'volente des tous' (the will of the majority, even a 100% vote) and hold the thesis that there are issues which cannot be decided by majority vote if there are no escape clauses or toleration of dissenting positions. These are situations where we have a serious and true moral conflict, as the request for euthanasia or abortion cannot easily be considered as to be morally inferior than the alternatives, given that these beliefs, values and visions are genuine and firmly believed.
There are convictions we have learned to tolerate even though we do not share them: Did Jesus rise from the grave or walk on water; did the prophet Mohammed ride to heaven on his horse; is the holy trinity of the Christian God 'one person in three' or 'three persons in one'? These and other issues fought over for centuries are irrelevant to most, but not to the believers on either one of the debating sides. Early solution in Europe to these and other controversial issues included the conflict-reducing maxim of 'cujus regio, ejus religio', i.e. sovereign rulers were given the powers to decide about right and wrong while in best case scenarios the individual constituent allowed to emigrate into another country. In Europe, a continent sharing a common cultural and religious tradition, we have the same situation today in regard to bioethical issues such as embryonic stem cell research, reprogramming of human cells, abortion, euthanasia requested by competent adults. What superseded the 'the ruler decides about right or wrong in belief and conviction' by a truly tolerant and pluralistic view on many religious issues hotly debated in former centuries is still withhold from European citizens by their respective government, who by slim margins vote in either direction on laws guiding and threatening the moral intuitions of their citizens, but in most cases allow for rich people to get medical services in other European countries of different law. Thus, biopolitics takes bioethics and individual morality hostage, actually exploits bioethical controversies for party politics and ideological pressure groups. A biopolitical rule recognizing the true basis of bioethical disputes and different religious, moral and philosophical convictions among reasonable and responsible adult citizens should, contrary to its actual strategy, follow the rule of humaneness and respect for citizen's moral intuitions and convictions: Whenever and as long as philosophers, theologians, politicians and pressure groups fight over principles, theories and rules for action, the preferred course of biopolitical action should be to refrain from legislative action by majority vote and make sure that the primary moral agent, i.e. the person closest to the moral challenge, be given the right to follow her or his conscience and calling, and that individuals, families, neighborhoods and moral communities be given access to information and advice for making responsible and well reasoned choices of their own.
CONTROVERSIES OVER THE BEGINNING AND END OF MORAL RECOGNITION OF HUMAN LIFE. The moral recognition and legal protection of unborn human life and suffering human life at its end has found different answers in different traditions over time and among different schools of thought. Even long religious traditions have changed assessment, preaching and instruction. Thomas Morus, a saint of the Roman Catholic church former Lord Chancellor of Great Britain and a Christian martyr once hold the thesis that clinging unto life and using all available means of intensive medicine to prolong life in a terminal situation would be the attitude of a non-believer in an afterlife and the more appropriate attitude of a true believer would be to accept the advice of a pries and to ask for being poisoned in priest-assisted and -recommended euthanasia; no official church teaching would support Saint Thomas argumentation today.
In Europe, other positions pushed for by the Roman Catholic hierarchy, such as the teaching that the fertilized human egg is animated, i.e. has a soul and represents the image of God, from the beginning, are not that old and have not much footing in Christian dogmatic; for centuries church teaching and church law taught that the fetus initially is passively conceived and only later after 40 or 80 days animated, i.e. given a soul, by God [Sass 1991]. Recent church teaching repeat the doctrine that only marital intercourse possible resulting in pregnancy is not against God's will and that the use of any form of contraception or sexual acts which reasonably could not result in pregnancy are sinful, perverse and immoral. Preaching these and other doctrines to church choirs and to those within the religious and moral community of a religious denomination is the right of each and every moral community, as long as community members are not indoctrinated by force and others are not hurt by actions resulting from such teaching. But it is another thing to introduce those teachings into the lobby halls of biopolitics and to influence legislation and regulation. While brain-dead criteria were formulated in Western cultures based on philosophical and religious cultures of differentiating between the mortal body and immortal soul (supposed to be associated one way or the other with cortical functioning), cultures favoring a holistic compassionate understanding of life have difficulties to accept such a dualistic rational argument, and subsequently are reluctant to accept definitions of death of breathing bodies with dysfunctional brain or 'cadaver' organ donation; others do not accept living organ donation as unnatural.
The principle of tolerance and the respect for the dignity of personal beliefs and informed individual moral intuitions, when introduced into biopolitics, would require that national legislation pays respect most, even bizarre forms of individual and community beliefs , such as in the case of respecting the beliefs of Jehovah's Witnesses that sharing blood, even in life-saving situations, is a sin. It was Voltaire, cynical and sharp European educator and rationalist, who proposed to consider only two humans rights, interrelated to each other: the human right to make mistakes and, subsequently, the human right to be forgiven. Values have consequences, and consequences have to be accepted by individual persons, as anonymous institutions or governments will accept the moral and other cost of previous and actual mistakes.
As issues such abortion, euthanasia, stem cell medical research and the development of medical treatment have to be dealt with by oversight quality control bodies and governments, conscience clauses for conscientious objectors need to be included and implemented. A framework for regulating and legislating morally controversial issues should accept that dissenting positions are not immoral, but are based on other moral and cultural priorities. As to the end and the beginning of human life a liberal framework would have to look into beliefs and convictions shared by most but not all citizens and then allow for individuals to opt out of the belief of the moral majority, based on their personal values, visions and belief and accepting moral risk associated with such decisions themselves without burdening others. A universal culturally sensitive 'protection of human life formula' could state that the human person and human dignity is inviolable from the beginning to the end, defining the beginning as (a) fertilization, (b) nidation, (c) formation of the primitive strike, (d) beginning of the formation of the neocortex, (e) viability, (f) birth, and defining the end as ceasing of (a) cardiovascular functioning, (b) neocortical functioning, (c) neocortical and brainstem functioning, (d) cadaveric rigidity. In order to provide moral guidance and legal clarification, legislation or regulation or professional rules of conduct could favor one of these states of evolutionary development of human life over others, but need to allow competent adult citizens to opt for other definitions based on their personal values and visions. Of course, no health care expert should be forced to provide services she or he assess as to be wrong or questionable. Governments and moral communities should inform and educate citizens on cultural, moral and religious implications of different views represented not only globally but also within pluralistic societies; governments should offer free consultation on these and other crucial moral and cultural issues in order to help their citizens to make informed and well reasoned decisions based on their own conscience and moral responsibility [Sass 1994].
The freedom of moral choice for citizens is one of the most fundamental pillars of open and free societies rich and strong in the diversity of values and cultural attitudes. Such freedom needs to include the refusal of certain foods based on religious or cultural convictions, but also the refusal of medical interventions which run contrary to one's values, such as organ acceptance or donation, or medication which has been developed based on procedures not accepted by an individual, such as remedies based on embryonic stem cell research or pills containing components from pork or beef.
NO-TOLERANCE PRINCIPLES IN HUMAN RIGHT ABUSE. As many cultural traditions are somewhat odd, but mostly harmless to those involved and not hurting others, such as circumcision of male babies in certain cultures and religions, the responsibility of continuing or discarding such practices easily could be left to those moral and cultural communities. But other traditions such as female genital mutilation (euphemistically called 'female circumcision') would not qualify for tolerance, as those procedures are painful and done by force, and have in many cases a lifelong impact on personal and sexual development, happiness and health.
Keeping fellow-humans as slaves or slave-like conditions violates universal human and civil rights, so does the withholding of equal rights on the basis of race, gender, handicap or social status. Physician's professional cultures and ethics over centuries and in all continents have hold that the withholding of health care and health care from certain groups of people would be a violation of their professional standard and culture, also the exploitation of patients for sexual or financial gain. Slaves have been used in human experimentation; the last century has seen unspeakable crimes in using fellow humans as guinea pigs in biological and chemical warfare research, torture and pain studies, and in questionable clinical research; governments have been ambiguous in recognizing and persecuting those crimes and in preventing unacceptable research on humans in the future [Sass 2003A; 2002A].
Also, cowardly killing innocent people and terrorizing fellow humans cannot and should not be accepted because all humans, whatever differences exist, share the same dignity and right. Terrorists and torturers are not moral and cultural strangers; they are enemies of each and every kind of morality and culture. They are immoral and uncivilized people, sick in their mind; individuals and communities have the right to defend themselves and those in their care against them. Sea pirates over the centuries and modern age terrorists, often supported by immoral rulers and governments, violate the very basis and vision of humankind, humaneness, and human dignity, no matter whether they are in their vicious craft just for money or for sick religious or ideological beliefs. It has been and will be a challenge to tolerance, humaneness and cross-cultural communication and cooperation to define the line between fellow humans of strange morality and those of immorality.
When terrorists and torturers use religious or humanist language to promote their goals and hide their truly immoral and uncivilized intentions, then those believing in those religious traditions abused religious or philosophical traditions have to speak out, otherwise they and their respective system of belief will make themselves accomplices in those crimes and should be regarded as those. It is a challenge for Western and Eastern cultures and traditions alike to draw the line between the enemies of culture and morality, often wolves disguised in sheepskin, and the many different faces within cultures, some more mainstream, some bizarre, some fashionable and of short life, others dormant or not yet fully translated into the opportunities and challenges of the new world of global communication, competition, and cooperation.
RICHNESS OF CULTURAL AND MORAL CONVERGENCE AND COMPETITION: Cultural diversity, debate, and competition is a sign of life and of rich life; so is dissent in moral intuitions, values and visions; cultural uniformity probably is boring, non-creative and probably leads into uncultivated globalized uniformity. It was Spinoza, a mystic and philosopher of Jewish tradition, but discriminated against by his hometown synagogue, who in the middle of cultural and religious transitions and modifications in Europe at the end of the seventeenth called for religious and cultural diversity and for the promotion individual culture and morality.
In his 'Tractato Theologico-Politicus', 1670, he suggested that peace and the fabric of society would not fall apart when individual freedom and liberty would be granted; rather peace, respect for persons, and civilized life would fall apart if individuals would not be allowed to be the prime moral agents. At the other side of the globe the similar insight of Lao Tzu was already well known 'the more taboos and inhibitations there are in the world, the poorer the people become' and 'the more articulate the laws and ordinances, the more thieves and robbers arise [no 57], circumventing or exploiting these rules.
Will Western and Asian cultures and moralities converge, compete or conflict? Urgent human rights issues and empirical evidence from all sources of cultural history suggest that traditions and cultures need to merge and converge in their support, protection, and promotion of basic human and civil rights, reasonable and necessary health care and health care promotion, and in the development and recognition of essential principles and virtues in caring for health by experts and by the lay. But cultural history and the respect for human dignity expressed in the dignity of conflicting intuitions and visions on issues as such as embryonic stemcells and other forms of unborn human life, the dignified end of human life and of the probability of an afterlife or a continued circle of transformation of forms of life, also suggest that individuals and their moral and cultural communities should be given the right to follow their conscience. Global trends towards regulation and bureaucratization may take on dimension of threat to ethics and morality, replacing conscience and compassion by rule recognition and acceptance, rendering cultural and moral traditions together with personal virtues and visions irrelevant. Cultural traditions and professional cultures are a common global heritage, expressed in diversity and creativity, nobleness and humaneness. Some cultures and modes of reasoning in bioethics seem to represent a stronger analytical and rational way of reasoning in principles, educated by traditions in Roman law, Aristotelian, Cartesian, and Kantian thinking, others emphasize more strongly a less rationalistic and more compassionate attitude with less clear instructional characteristics. Both cultures will need to listen to each other and to recognize the rich tradition of the other side. Also, bioethicist been educated by books and writing books will need to communicate and cooperate in trust with those who educate themselves on the bedside and implement principles and virtues in treating patients. Bioethics, in Western as well as in Asian culture, still is an unfinished business. Thus, conflicting positions and visions in bioethics will be able to use different cultural experiences and traditions of moral intuition in a communication-in-trust and cooperation-in-trust attitude for the sake of the patient and of those who suffer and are in need of help and support of life and support of love of life.
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