- Frank J. Leavitt, Ph.D.
Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, 84105 Beer-Sheva, Israel
In the last issue of EJAIB, Gerhold K. Becker wrote on a "productive tension" between universalism and tribalism (1). Becker mentioned me in connection with these terms, but really anthropologists have discussed universalism and tribalism for some time. And the philosopher, Karl Popper, wrote at length on tribalism, using the concept pejoratively to suggest "the emphasis on the supreme importance of the tribe without which the individual is nothing at all." (2, Vol. I, p. 9), as well as a society with "tribal taboos" and "tribal exclusiveness" (2, Vol. II, p. 22) and a "closed society" (2, Vol. I, p. 172). Although Popper was an erudite philosopher of science, I do not know how deeply he studied the tribal cultures, especially Judaism (2, Vol. II, p. 22), which he attacked. And I have suggested the phrase "enlightened tribalism" to characterize a bioethic which respects the unique culture of each people in its own land, while recognizing individual rights, the epistemic autonomy of individuals to seek truth and health open mindedly, and the "pursuit of harmony" with the bioethics of other cultures, as Prof. Sakamoto emphasized (3).
Reading the three articles in this issue, one strongly senses Becker's "productive tension". Arda and Pelin discuss bioethical developments within Turkey's unique culture (4) and in the context of the secularization which Atatčrk (1881-1938) introduced. They say that between 2000 BC to 1500 AD, the Turkish landscape was "the centre of the world scene". Perhaps it is legitimate to say this because the geometry of the surface of a globe, as with an infinite universe, gives every point an equal right to be called the "centre". But although Arda and Pelin's perspective is local, they make some important points for universal bioethics: especially the matter of ethical sensitization of medical students: a matter which is much harder than it may look. The approach in Beer Sheva, in contrast, includes rigourous pre-admission interviews to try to admit only students who are already to some degree ethically sensitive.
Segota's paper (5) also takes a local point of view, discussing Croatia's first "autonomous medical ethical codex". Segota makes a very important point about the affirmation of the right of an individual physician to refuse to do an abortion if it contradicts his or her conscience. Although abortion may sometimes be medically or ethically indicated, we cannot allow the Western dogma of "abortion on demand" to turn medical staff into technicians with no conscience of their own. This point, which also applies to disconnecting life support systems, is also important in nursing ethics, which must recognize the obligation of a nurse to refuse a doctor's order if it contradicts her conscience or professional knowledge.
In contrast to the local perspectives of Arda & Pelin and of Segota, Judge Byk's (6) stance is more universalist discussing legislation across Europe. He is also aware of Becker's "productive tension" calling for a "clearer view" of which areas of common interest should be dealt with internationally and those which should be left entirely to the decision of the country concerned." None of us has put enough work into this question. Our discussions are too general and philosophical. Specifically what issues should be universal? Obviously infectious disease vectors, which know no borders, and the global ecosystem, are universal matters. But what else? And what can be left for local, tribal bioethics? Can any ecology really be local? Are customs like clitorectomy local or universal matters? Should the definition of death (brainstem? cortex? heartbeat?) be a local, tribal matter, or are universal values, like the prohibition of murder, involved? We have to get down to details to make progress on these questions. And Byk's "three pillars" should help us along.
Assessing new technologies, as Byk recognizes, is a very difficult matter. What longitudinal studies are really being done, for example, on children of IVF? And until such studies are carried out (which will take at least fifty years) how can we decide whether such technologies are ethical?
Many more points in these three articles deserve discussion, and I hope readers will comment. Lest my commentary get too long, I'll conclude with a remark on an uneasy feeling I had during the process of reviewing Professor Segota's paper. I think some of the most important things in bioethics are being left unsaid. Segota lives in one of the world's crisis spots: Croatia. I also live in a crisis spot: Kiriat Arba, Hebron. And although I would like to keep my bioethics in the ivory tower, it is really inseparable from the tumultuous world in which we live.
In fact, I first started studying medical ethics at the Hadassah Medical Centre library in Jerusalem when I was recovering several years ago from having my head and jaws broken by a stone thrown at me as I drove home from work. And as I worked on Segota's paper, I wondered what he has to contend with trying to do scientific, scholarly and medical work in today's Croatia. I think we hesitate to bring local and sometimes violent events into our bioethical writings because we do not want to turn scholarly journals into platforms for our personal political opinions, and we would like to maintain an air of detached scholarship. But really, we bioethicists living in crisis areas ought to bring some real questions out into the open. What are our medical obligations to the other party in a violent conflict? What (as I discuss in a team-taught medical school course in crisis intervention) can the concept of "patient autonomy" really mean if the patient is in emotional breakdown? Can peace be achieved before "the end of days" or is it just a dream like "the eradication of infections disease"? Bioethicists in crisis spots, like Croatia and Hebron (this also includes those who were involved in helping survivors of the Kobe earthquake) must find a way to discuss these and similar questions openly. Perhaps once our other projects are underway, we should consider an international workshop on Bioethics in Crisis Locations.
1. Becker G.K. "Asian and western ethics: Some remarks on a productive tension", EJAIB 5: 31-33.
2. Popper K.R. The Open Society and it's Enemies, Princeton University Press, 1962 (Fifth ed., rev. 1966. Paperback, 1977). Two volumes.
3.Sakamoto H. "New initiatives in east Asian bioethics", EJAIB 5:30.
4. Arda B & Pelin SS. "Bioethics in Turkey in 1995", EJAIB 5: 64-5.
5. Segota I. "Physicians and ethics in Croatia", EJAIB 5:62-4.
6. Byk C. "Juridicial politics and bioethics: The three pillars of biomedical legislative wisdom", EJAIB 5: 59-61.