This symposium focuses on the ethical questions raised by biotechnology. Biotechnology is the use of living organisms to provide goods and services, and has been essential to the development of civilisation for millenia. There are several key questions I want to answer in this paper. Firstly, does new biotechnology raise any different or novel issues that the old biotechnology did not? Secondly, how do people think about these issues and over the use of biotechnology, both in medicine and agriculture? What do they think about disease, and about nature and life? We could say bioethics is love of life, so our attitudes to life are an essential part of bioethics. Thirdly, from examining the reasoning that people use in making "bioethical" decisions, can we develop universal bioethics? The third question is the most controversial, and sensitive, and perhaps it is fitting to be discussed in Hong Kong, a cosmopolitan meeting point between European and Chinese culture.
The basic ideals of bioethical decision making are love (balancing risk of doing harm versus intended benefit); and balancing individual and/or familial autonomy versus social responsibility. The question of universal ethics rests on what we mean by the word "universal". Even within a single community one will find divisions on issues of bioethics, such as abortion, euthanasia and risk perceptions - so it is obvious not all people reach the same decisions. What I mean by universal is rather at the level of using the same ideals, but people may balance them differently to arrive at different decisions. Therefore, universal ethics does not mean identical decisions - but it does mean that the range of decisions in any one society are similar to those found across the whole world. It is also not the same as absolute ethics, saying that there is one correct ethical decision for a given set of circumstances.
The study of decision-making can and should be scientifically made, and is a question that we can answer from data and observations. Therefore in this paper I do not attempt to define an ethical or good decision. The correct "decision", if it does exist, is not necessarily the same as the majority decision. If people in different countries share the same thinking, and reasoning, then we could call this universalism, and it makes the possibility of universal ethics real. If they do not, then what we must aim for is cross-cultural understanding, perhaps with some degree of universalism. At the beginning I should make it quite plain that the use of surveys is only one part of the overall approach we can use to look at cultures, and that the data from the International Bioethics Survey I will describe is intended as a contribution to answering this question, it does not claim to have the whole picture. However, this data is, like all observations, a challenge to all of us to incorporate or explain into any description of the real world, and it cannot be ignored.
2. Biotechnology and bioethics as part of human heritage
Bioethics especially includes medical and environmental ethics. The word was mainly applied for issues of medical ethics in the 1970s and 1980s, but the 1960s and 1990s saw much more attention on environmental ethics. However, the concepts and issues of bioethics are much older, as we can see in the ethics formulated and debated in literature, art, music and the general cultural and religious traditions of our ancestors.
Life is diverse and complex and so are the issues that the manipulation of life and nature raises. To resolve these issues, and develop principles, we must involve anthropology, sociology, biology, religion, psychology, philosophy, and economics; we must combine the scientific rigour of biological data, with the values of religion and philosophy to develop a realistic world-view. Bioethics is therefore challenged to be a multi-sided and thoughtful approach to decision-making so that it may be relevant to all aspects of human life. Without combining both of these spheres of thought, natural science and values, we can never succeed to even approach a comprehensive ethics. However, bioethics is not just an academic endeavour or an applied part of philosophical ethics, it is rooted in the daily life and attitudes of all people, hence the title of my recent book, Bioethics for the People by the People (1).
The term bioethics should mean the study of life ethics, but it has often been viewed only as a part. The concern with medical ethics has meant that while many people, or committees, are called "bioethics" committees, they only consider medical ethics. Likewise, ecological and environmental ethics must include human-human interactions, as these interactions are one of the dominant ecological interactions in the world. Both extremes are incomplete perspectives. In the conclusion of an earlier book, Shaping Genes (2), I said that we have much to learn from the issues raised by genetic technology, not just the nature of our genes, but the nature of our thinking about what is important in life. New technology can be a catalyst for our thinking about these issues, and we can think of the examples like assisted reproductive technologies, organ transplantation, and genetics, which have been stimuli for research into bioethics in the last few decades.
The title of this book is Changing Nature's Course - this is something people have done ever since they began agriculture, began to block a river for irrigation, began to develop medicines, began to live in houses and to learn how to use fire. It is very attractive to think that biotechnology is new, but has been presenting ethical challenges for millenia, whether it be euthanasia, or how much land should be left for the animals to feed on. Human encounter's with the environment, the "bios", life, have always raised ethical issues. Even more issues have been raised by human encounters with each other, which is where the boundary between bioethics and ethics disappears.
Society does not need new ethics to cope with the impact of genetic technology. There is no inherent clash between genetics and human values as some books, including one under the title Genethics (3), would like to have us believe. Almost all of the issues raised by application of genetics are not novel (2, 4). What is needed is a revival and renewed discussion of ethical values by all members of the community as society interacts with technology. Also we need globalisation of the sphere of this discussion as the world becomes smaller and as it becomes easier for people to exploit the absence of controls in neighbouring countries. The pace and magnitude of change has become greater, for example, we now discuss global eco-engineering rather than only national agricultural policy. Likewise in medicine, the sequencing of the human genome may not create new or more difficult ethical dilemmas, but the sheer number of disease-related genes identified is making the number of such dilemmas greater. Life will become more complex, even the supposedly simple case of imposing higher insurance fees on smokers will become more cloudy should we find strong genetic determinants for drug addiction, to add to the environmental determinants we already know.
One of the issues people like to raise as new is germ-line or heritable genetic engineering, and they may say "never touch the germ-line". Although many may like to say this, perhaps to naively reassure the public that they have nothing to worry about, the issue of human germ-line genetic manipulation is certainly not resolved. There are some who want a ban on germ-line manipulation, but the somatic cell/germ-line division is less important than the therapy/cosmetic border. In the easy cases of severe disease, safe and inexpensive germ-line gene therapy can make sense, the same genetic sense that tells us not for sisters and brothers to marry each other. Eugenic ideas were debated long before genetic engineering, in both philosophy (e.g. Plato) and religion (e.g. Jewish marriage laws) (2). We should encourage discussion of these complex issues, extending our discussions from the debates of old, and in the real world, never say never (4).
3. International Bioethics Survey and cross-cultural bioethics
In every country individual's are facing personal choices in the use of biotechnology and countries are debating policy to regulate such choices. International society is also facing many policy choices for the adoption of new technology. There are many questions being raised about the future consequences that the genetic revolution will bring, especially the social attitude changes that result from the choices that persons make. Bioethics is the study of decision-making in questions of life, as discussed above; Balancing the ideals of: "do good" and "do no harm"; and respecting both "autonomy" and "justice". Do individual people and families in different countries actually make decisions by balancing these ideas, and do so differently? We need to look at the degree of similarity and differences, to determine what level of universalism is possible.
At present many countries have their own standards, some of which are based on false assumptions of cultural uniqueness (5). These standards may be challenged by this data. While it is important to adopt standards that are suitable to each society, such standards should be based on the views of individuals in the society and be realistic. If people are the same then the same standards of bioethics may be applied - Universal bioethics, while respecting the freedom of informed choice and responsibilities to society.
How can we answer the question of cultural similarities? In addition to using our widely open eyes and ears to observe, we can also gain data from opinion surveys. Mail response opinion surveys about bioethical reasoning of public, high school teachers, and medical students in Australia, Hong Kong, India;, Israel, Japan;, New Zealand, the Philippines, Russia, Singapore, and Thailand, were conducted with numerous collaborators in 1993 (1). These surveys included open response questions on the images of life and nature, and questions relevant to agricultural, environmental and medical biotechnology issues. Open response questions are preferable to fixed response surveys which "lead" the respondent to a particular answer, and the results can differ significantly (1, 6). The native language of the country was used, and the response rates for the questionnaires ranged from 14-90% for different samples. Full details of the results, including collaborators, interpretations, and open responses are elsewhere (1). Public questionnaires were distributed by hand into letter boxes chosen at random in different areas of Japan, New Zealand, and Australia. Mail response using enclosed stamped and addressed envelopes was requested. Mail response has one advantage over interviews in that lengthier comments were written to the free response questions and at other points in the questionnaire. The samples from New Zealand (N=329), Australia (N=201) and Japan (N=352) were representative of the general population, while the samples from India (N=568), Israel (N=50), Russia (N=446) and Thailand (N=550) had higher education than the general population, as they included not only public samples but also academics. Comparisons to surveys from North America and Europe was also made.
Student samples were chosen from selected medical schools (Australia (N=110);, Japan (N=435), New Zealand (N=96), the Philippines (N=164)), a medical laboratory course (Hong Kong (N=105)) and biology students (India (N=325), Singapore (N=250); and Thailand (N=290)). Students were generally similar to the public within each country, with most questions being age independent (1). The high school teacher surveys were national, using randomly selected biology and social studies teachers, in Japan (N=560 biology; N=383 social), New Zealand (N=206 biology; N=98 social) and Australia (N=245 biology; N=115 social). The funding for these surveys comes from the Eubios Ethics Institute, with some assistance from the ELSI group of the Ministry of Education, Science and Culture Human Genome Project, and The University of Tsukuba. The high school samples in Japan are partly funded by the Ministry of Education as part of a longer term project to develop high school materials to teach about bioethical issues in the biology and social studies classes.
Space does not permit the reproduction of the results here, however, some relevant features are useful for this discussion, and are presented here. In all countries there was a positive view of science and technology, it was perceived as increasing the quality of life by majority in all countries, with India being the most negative. However less than 10% in all countries saw it as doing more harm than good. When asked about specific developments of technology, including in vitro fertilisation, computers, pesticides, nuclear power, biotechnology and genetic engineering, both benefits and risks were cited by many respondents. People do show the ability to balance benefits and risks of science and technology (1, 6). People do not have a simplistic view of science and technology, and can often perceive both benefits and risks. This is necessary for bioethics, the balancing of good and harm, and I have called this some indicator of the bioethical maturity of a society (7).
Consistent with North American surveys, in all the countries in this survey, plant-plant gene transfers were most acceptable, with animal-animal next, and animal-plant or human-animal gene transfers were least acceptable. A variety of reasons were cited, as was the case in questions about the concerns of consuming products made from genetic engineering. When specific details of an application were given there was generally greater acceptance, suggesting people have some discretion. It also suggests that if details are given the public will show greater acceptance of an application, especially for human gene therapy.
Approval of pubic medical funding for prenatal genetic testing is high in all countries surveyed. In all countries except the Philippines there was about 80% support for making prenatal genetic screening available under government funded medicine, with 2-12% rejection, and about 70% said that they would personally use it. The level of personal rejection of genetic screening in the United States was similarly high to in the Philippines, being among the more negative of countries (32% said they would not use, while 53-64% would use; compared to 15-18% against in Australasia and Japan, and 61-69% saying they would use). Education does not seem to be an issue, consistent with results finding no difference in Japan between public, students, high school teachers and academics in my survey in 1991 (6).
The major reasons cited in the open responses for and against genetic testing are most revealing and were similar in all countries. One difference was in Japan there were less economic reasons given like it would "save the country's health care system money". People in Japan may not think deeply about the economic costs of health care, and it will be interesting to see whether this attitude changes as a result of the recession and of the growing health costs and aging population. It may be that the economic recession in New Zealand and Australia, and the general hard times in some other countries, has forced people to think in terms of saving money - it is also true that if taxes are high people have had to face the fact, taxes are redistribution of wealth according to the ethical principle of justice.
Other reasons for genetic screening included saving the fetus; parents' convenience and more positive support for a right to chose and decision to abort. Only 1-2% in Japan said the fetus had a right to life; 3-4% in Australia and 4-8% in New Zealand. In Asia there is more blame and shame for the birth of a handicapped child than in Western societies. This will be affected by genetic knowledge, but until education reaches more people it will be more than just bad luck in the minds of many Asian families, rather it will include guilt or shame. However, social acceptance of genetic testing is the high in all countries, and the reasons given are rather similar. Not all the reasons are known in these responses to a paper questionnaire, other responses may be the secrets of people's hearts, but the general nature of the comments suggests that it is a reasonable approximate. There is much greater diversity of reasoning within any one country than the differences between any two countries. This survey focused on the public attitude, and also general student attitude. The public is the user of genetic counseling, and if non-directive counseling is practiced than their attitude will be more important than the attitudes of genetic counselors. The results allow us to form a better picture of the real situation, and on the ideas that people may use in genetic counseling.
Whether eugenic views of improved genes and health for individuals, a positive view in itself, can be separated from the negative eugenic social forces of conformity, and discrimination against people with disease, is a question only time will truly answer. At the end of 1993, a proposal in China for a "eugenics and health protection" law that would ban the marriage of people with undesirable genes (8), is another argument supporting the view that economic forces are the major factor in determining the social consequences of genetic testing. The results of a survey in China among medical staff (9) suggests that many people will support the concept, though perhaps less would support the compulsory nature of the law. About 10% of the respondents in this survey in Russia, and many in India also, gave eugenic reasons for support of genetic screening, more than in the other countries (1).
There is clear support for attempting to do good, and no apparent public rejection of therapy altering genes. About three quarters of all samples supported for personal use of gene therapy, with slightly higher support for children's use of gene therapy. The major reasons were to save life and increase the quality of life. Few people gave a reasons like "improving genes". About 5-7% rejected gene therapy considering it to be playing God, or unnatural. There was very little concern about eugenics (0.5-2%), confirming the results of a different open question in 1991 (1, 6, 10).
Another question about gene therapy shows people do have significant discretion over therapeutic and cosmetic applications of gene therapy. This is encouraging for ethicists, and a similar discretion was shown in a question about use of genetic engineering to make a sports fish, compared to a disease-resistant crop. There is extremely high support for use of gene therapy to cure disease, both as somatic cell or germ-line, and high support as an AIDS vaccine. There is rejection of enhancement genetic engineering in all samples, another indicator of bioethical maturity. However, the success of cosmetic surgery suggests that once it is possible the 20-30% who accept genetic engineering to improve intelligence, may do so in practice. Whether this is acceptable is a much bigger question and may require stricter control than today's cosmetics as heritable changes affect future generations.
Attitudes to disease are central to how much people will want to "treat" someone, or return to "normal". The results of questions of knowledge of someone with a genetic disease or mental disease, showed some interesting geographical differences in the number of people who said that they knew someone with a genetic or mental disease. If they said yes, they were also asked to openly cite what disease, which was also interesting to see their perceptions of what is genetic or mental disease. Open comments about people suffering with diseases including muscular dystrophy, schizophrenia or AIDS were also included. Most people expressed sadness or compassion, but a number of people rejected those with HIV or said it was their own fault. However, there were more comments suggesting people are the same, no matter what disease they have, in Australasia. Only 2% admired people with muscular dystrophy, though for other diseases no one expressed admiration. For mental disease, such as depression, more people considered the diseases their own fault, in all countries. People were more afraid of people with neurosis.
Confidentiality is a consequence of respecting autonomy. Respect for privacy of genetic information was similar between Asians and Australians. People in all countries are similarly positive about sharing information with a spouse, with 85-98% saying that a spouse deserved to know if someone was the carrier of a defective gene or had a genetic disease, with 88-98% saying the same for HIV. About 90% of the people in Japan, Singapore or the Philippines said that the immediate family deserved to know, more than in Thailand (83%) or Hong Kong (76%), and less in India and Australasia (74%), USA (70%) or India (67%). The difference in the family result may represent attitudes to family involvement in disease and how much disease is seen as a family problem. Both genetic disease and HIV had similar results. A family in all countries may support a sick person, but it is interesting to see where the balance between individuals and families is; which is the basic unit of autonomy.
A difference was that 58% of people in the USA said that insurers deserve to know the information about genetic disease, much more than in the other countries (Australia, New Zealand, Russia 37-39%). Less people in Japan (18%) and Israel (6%) say the information about genetic disease or HIV should be shared with them. Although there are many bioethicists in the USA, the public apparently does not value privacy as much as in some other countries. Sharing information with employers was rejected most in Australasia and Japan (only 20% agreed), but it was still accepted by a third in most other countries.
Another issue of ethics is who should make decisions, and who do people trust. A question on the level of trust that people had in authorities who were making a statement about the safety of a product of biotechnology, for example a new drug, revealed differences between countries in who was most trusted. There was most trust in the government in Hong Kong and Singapore, and least in Australasia, Japan, Russia, USA and Europe. Despite the lower trust shown in the government in Russia, they had a level of trust in medical doctors. The result is most striking when we compare it to Japan, in which doctors were not trusted. In fact it appears Japanese do not trust anyone very much, but the biggest difference with the other countries was that doctors and university professors were mistrusted, especially so by medical students. Whereas Russians show great trust in doctors, and a high level of trust in professors and environmental groups. Companies were least trusted everywhere.
We need to build a bioethics which includes the views of all people's of the world. Not only from the United States (we should not say American, as the USA is only one country of the Americas), neither only European. Also Europe itself is extremely diverse. We need to add Asian and African perspectives. Similar concepts, such as love, social harmony, relationships with the environment are found in the thinking of many regions, both today and in the past. Open questions about the image of "life" or "nature" were included in the International Bioethics Survey. The responses from people in all countries revealed many similarities, and also that there is similar diversity in all countries. These open comments are published in English in the book, Bioethics for the People by the People, and they add further data to the debate.
In bioethics we should use not only the data of our own interpretations, but rather look for any other data that can aid us in understanding the real situation. Academics may often have abstract ideas, we need to come back to earth and look at reality. The data from surveys, and observations, reveals that there are fundamental similarities in reasoning by individuals in different countries, despite diversity in social systems and even greater diversity in legal approaches to bioethics. I call this the universal bioethics approach. This is different in focus from the approach of regionalisation of bioethics, for example into Asian bioethics. However, both universal or regional desire understanding of local cultures, and should want to recognise the contribution of different peoples to bioethics. In fact we cannot really develop a complete bioethics without including this contribution. Even in Europe, there is a lot of debate about the autonomy, or ego. In Europe they add more emphasis to solidarity. Also in the USA, we can see some shift towards recognising our duties to other people more. Let me move onto further background for universal bioethics.
4. Universal ethics and our common biotechnological heritage
Any ethical approach must consider the biological, social and spiritual heritage and origins of humanity (1). All human beings are found as members of some society, all accommodate some individualism within a social niche. All societies have some biotechnological and agricultural basis to provide food and clothing, which has allowed civilisation to occur. The common biological origin and common needs, material, social order, and spiritual, mean that it should not be surprising that a common ethics exists.
All living organisms are biological beings, and share a common and intertwined biological heritage. Humans are members of the species Homo sapiens, one of the millions of species alive on the planet Earth. The method of our creation appears to be via a process of evolution, like all life on this planet. This is most consistent with the data we have. There is no conflict between a belief in the creation of the world by God and the theory of evolution. The suggestion that there was a conflict was generated by scientists who wanted to replace the church as the respected authority of human society, something that they have achieved to some extent. Scientists used the theory and the opposition to it to create an image of a "conflict" between science and religion which has been very harmful ever since. As a more scientific world view has been adopted many people continue to think there is a conflict.
People have minds which search for knowledge, and we can understand more and more of the world. A primitive picture of God is to use "God" to explain things we do not know, this could be called "god of the gaps", we use "God" to explain what we do not yet understand. However, whatever we know of the world we should be appreciative of our existence. Whether the world was created by pure chance or was created with a purpose, is a nonscientific question, a question which no one can ever prove or disprove. The conflict between science and religion led to the view that scientific questions (those that can be disproved by experiments) are higher than nonscientific questions (those not open to proof). However, love, relationships, religions, are not open to experiments - but are more important for most people's lives. Most questions of bioethics are similar, but we need to value both types of questions.
The biological data tells us that all human beings have the same basic set of genes, the variation found in any one population covers almost all of the total variation, and that humans share a common African ancestor. All peoples suffer from genetic diseases and variation. The genetic factors of human beings are being scientifically determined, and we must await the results of the human genome diversity project, and the identification of the function of human genes to get more detailed answers. Changes in DNA sequences have also been used to trace the way that different organisms evolve, called phylogenetic trees. We can compare the DNA of species alive today, and investigate trends in the sequence change, and we can also look at DNA from past organisms which is a more direct measure of the change over time. We could conclude, the most consistent explanation of sequence comparisons is that all organisms are related, and when combined with behavioural studies, we can see some behaviour relevant to ethics is found in other social animals.
Human beings are created in the midst of an intricate biodiversity, which is yet to be comprehended. The process or time scale over which all life was made is not so remarkable as the species and ecosystems that we have today, or those that we can see from the fossils. The debate over the method and time frame of evolution is likely to continue for a long time, and may not ever be resolved, but whatever view we hold we can marvel at the diversity of life. There are economic reasons to value biodiversity, but most people value it more because of more "religious" or experiential reasons, as shown in open questions about "nature", and "life" in the International Bioethics Survey (1).
Human beings are organised into societies, and our social groups include our spouse, children, relatives, neighbours, religious group, community, workplace, village, city, nation, and international partners. The social origins can be studied by sociology and history. Most societies we think of today as countries are modern artificial creations of historical and present political power systems. Perhaps the best example of the artificiality of the national borders is the division of Africa, an artefact of colonial power struggles between Britain, France and Germany. The attempt to stop further wars in Africa by the regional congress to stop further power struggles as tribal boundaries were separated is only a partial success, at best.
We could consider that wars are a sign that universalism is already lost, however, if we really look at origins of most wars they are caused not by clashes between ideologies and customs of ordinary people - most are caused by certain charismatic individuals who are seeking further power. They may draw upon the perceived differences between cultures, often generated with the help of the media. They utilise the sense of national identity that is attractive to one part of human beings - we all have an urge to be identified as a member of some community. Sometimes religious groupings are used, sometimes racial differences, and these are usually combined with ethnic differences and the promise of better economic conditions.
Language is central to social structure, and one of the contributing factors to conflict and mistrust. Linguistic trends are consistent with migrations of humans over the planet traced by genetics (11). Individual communication systems are found in other social mammals and birds, and they are used to discriminate between individuals. Some other behavioural systems may also be shared with other animals, which raises a number of ethical questions about the origin of love, altruism and selfishness, and our responsibilities in our encounters with animals (1).
The complete diversity of attitudes and characters of human individuals is represented in any one society, and shown by personal experience, or surveys. A failing of human thought is that people view their society as being different from another, with sweeping generalizations. We describe the English as conservative, the Australians as noisy, the Japanese as quiet. Such thinking is often tied to discrimination, for example men are..., and women are...; whites are..., blacks are..., and Asians are... . Such thinking, of "us" and "them" is a root of much disharmony in the world, and should be actively discarded from thought, not only because it has bad consequences but more importantly because it is a false positive.
We need to look at the world and ourselves. In many countries it is apparent when you walk in the street, or read the newspaper, that the country is mixed. Ever more than before, universally applicable ethical principles are necessary. Many immigrants from a range of countries have come to the new countries like Australasia or America, and to the centres of the old European Empires, especially Britain and France. The practises that immigrants are accustomed to differ from each other. Their religions may also be different, and certainly some social customs. The indigenous people in Australasia and America, and parts of Africa and Asia, have been suppressed and although they have been overrun by culture introduced from the immigrants countries, often a new culture has emerged. At first we may be surprised that so many Chinese in Hong Kong are Christians, but we must remember that Christianity has its origin in Asia, and Europeans were converted from their former beliefs, as with other religions and ideals. This continues to be a source of friction in some countries, because the groups may try to form an "us" and a "them".
One of the fundamental assumptions of bioethics is that all human beings have equal rights. There are universal human rights which should be protected, and recognised. We can argue for the foundation of human rights from secular philosophy or religion, and they have become enshrined in international law. Universal cross-cultural ethics should be developed to allow diverse views to be maintained even within a single community, as well as throughout the world in the global community. Even within a so-called homogeneous culture, such as Japan, there is a wide variety of individuals and universal ethics would promote choice. The view of life that people have is individual, despite the often assumed homogeneity.
Economic factors are an inseparable part of society, and trading between adjacent regions has been a major source of cultural mixing, today as in past centuries. The world has become smaller with modern trade and communications, and this is certainly one factor in the growing trend for internationalism. This is epitomised in GATT, signed in 1993. International economics helps break down geographical and linguistic barriers, though globally it has resulted in deepening divisions between rich and poor nations, another hurdle to the recognition that much of human heritage and much of ethics is universal. This is not to say that modern economics is bioethical, as it usually devalues the environment and social values central to bioethics.
The spiritual origins of humanity are less mixed than the social ones, and these have been used as transnational boundaries in the past, and also today. The Islamic countries, Catholic countries, and loosely-called Christian countries, are major regions of the world. Asia has more diversity of religion, for example, Buddhism in Sri Lanka is different from that in Japan. Within Asia there are also many Christians and Muslims, and most of the world's religions.
Despite the scientific world view that is prevalent among academics, most other people find religions to be a much more important source of guidance in life than science. In questions of ethics, this is true of most people. Any theory of bioethics that will be applied to peoples of the world must be acceptable to the common trends of major religious thought. This comparison is one purpose of the International Bioethics Survey. The countries chosen in the survey were chosen for two reasons, one being as representatives of the world, and the other in terms of convenience of access. Unfortunately there is no African or South American, nor Islamic country among the countries chosen. It is hoped that future studies will look at these questions in these and other countries also, as a test of the ideas discussed here. The countries chosen include India, a country of mixed religion and the major so-called "developing" country, though it has a biotechnological and social history much longer than most countries. Russia represents the former communist world, another possible dominant force in shaping opinion. The Philippines is a Catholic country. Thailand is a Buddhist country and represents South East Asia. New Zealand and Australia, with some comparisons to North America, and to past European surveys, represent Christian and Western countries. Hong Kong and Singapore represent the Chinese influence, and some comparison to mainland Chinese attitudes is also made. A small sample from Israel was also included, as one Middle Eastern country. In compiling the data from these different countries, and comparing to other published data, we can form a better global picture of the reasoning used by people, and whether there are religious differences. In many issues there were not.
We must also learn from traditions, these are another type of data we have. There are a variety of different ethical traditions, and it is essential to consider these for the development of universal bioethics. These traditions are also part of our social heritage, though most have a more spiritual base. These different traditions should be respected to make this universal bioethics also cross-cultural ethics; respected to the extent that they do not conflict with fundamental human rights.
5. Ethical progress
We can find many common features in surveys like those described here that are useful to develop universal ethics. The full results in the book Bioethics for the People by the People (1), include chapters from each region describing the background circumstances, examples of open comments and explanation of the categorisation. This provides some data that allows us to actually look at the bioethical decision-making of ordinary people, and to examine the question of the universality of responses to genetic disease, and biotechnology. This data finds most of the total diversity in all samples is found in any one country or group. In every society there are people who want to use new genetic techniques such as prenatal genetic screening, and there are some who reject the concept of selective abortion. In all societies we see high support for gene therapy, or making disease-resistant crops, as could be expected.
Attitudes to people suffering from disease may be affected by the use of genetic screening, but further studies over time will be needed to see whether there are significant attitude trends. In most countries the majority of respondents express sympathy, however, in practise we may not always see such an attitude. This type of study is one approach to address some of these questions. The results are also being used in an attempt to develop a method for assessing the general "bioethical maturity" of different societies, which includes the ability to balance benefit and risk; and discretion between enhancement and therapy; and the balance between autonomy and freedom/restriction.
The most important message of this survey is that people in different countries share very similar images of life and similar diversity of views on most of these issues of bioethics associated with genetics. The main difference may be in the acceptance of selective abortion, but even people saying they were very religious also supported this. Any universal ethics must include some respect for informed choices of people, and the range of choices people desire is transcultural. Policy should reflect the universality of diversity and reasoning.
The social consequences of biotechnology depend on the society that we make. Individuals in different countries share similar attitudes to these questions, but already the social systems in Asia and Oceania are different. Despite the similarity in the views of individuals, the social system in Japan and some other countries is constructed differently, and may not represent the views of the public (5). However, universal attitudes reviewed in some parts of the International Bioethics Survey, when compared to other international surveys, suggest that we have to reconsider our view that different social systems are the result of differences between peoples, in fact the different social systems may occasionally be used in attempts to establish differences. Universal bioethics already exists at the level of individual decision-making, and therefore it is certainly possible to develop social and educational systems to allow universal ethics at the higher level of social systems.
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