By: Will Naso, B.A. student at Davidson College and Vann Fellow at Mayo Clinic
As the advent of new technologies shrinks the world, cross-cultural interaction is guaranteed in modern society. Within the world of medicine, physicians are becoming more globally aware, whether through the growing medical tourism industry, the popularity of international education, or the mixing of cultures due to increased global migration [1, 2]. What does this mean for the development of a globalized bioethics? As bioethical research has evolved, the flow of knowledge has steadily moved from developed nations to developing, or more basically, from the ‘West’ to the ‘East . Claire Hooker and Estelle Noonan argue that this imbalance of information is marginalizing ‘Eastern’ religious, philosophical, and ethical traditions in lieu of the supposedly more reputable Anglophone theories .
This piece seeks to outline the role that philosophical foundations play in the establishment of modern bioethics, outlining the major philosophical and religious teachings that have shaped various Asian cultures and their relevance to the field of bioethics. The practicality of balancing personal ethics in cross-cultural settings will be briefly discussed, concluding with a prospective consideration of pathways for reconciling conflicting ideologies with the ultimate goal of a globalized field of bioethics.
Confucian teachings underpin much of modern medical ethics in East Asia through the emphasis of the fundamental human virtue ren. There are varying translations of ren, but essentially, it encompasses the ideas of compassion, purity, and plurality [3, p. 196]. Within historical Chinese medical texts, the emphasis on compassion and purity are clearly outlined within the physician’s duties. Sun Szu-Miao, the pioneer Chinese bioethicist, echoed the idea of ren in his 7th century text, A Great Physician’s Manual, “to be compassionate is the first requirement of a physician” [4, p. 65]. Using this compassion, the physician acted to maintain health and purity through the balancing of an individual’s qi. Qi, while difficult to translate, ultimately embodies the life force of the universe – spiritual, physical, and moral. Good health, therefore, is defined “in Chinese medicine…as the harmonious state of the bodily qi” [3, p. 196).
The sense of plurality embodied within ren can be found in the origination of the word itself, composed of “the element[s] ‘person’ and the number ‘two,’” [3, p. 196] there is an implied interconnectedness between individuals; one cannot be complete without another. This is further revealed through the 5 basic Confucian relationships that are necessary for achieving ideal moral status – “between ruler and subject, father and son, elder and younger brother, husband and wife, and between friends” [4, p. 65]. The weight Confucian ethics places on relationships creates an especially relevant ethical dilemma when compared to ‘Western’ modes of medical decision making.
When an individual becomes ill, it is the responsibility of the family to both decide on treatment and to endure any emotional or financial distress that may come of the illness. As Fan articulates:
This familial pattern of medical decision making is not seen as depriving the patient of a right to make decisions for himself or herself. Rather, the family is appreciated for removing burdens from the sick, including the burden of listening to and discussing the patient’s condition and clinical care with the physician [3, pp. 197-8].
Western ideas of patient-centric autonomous and informed decision making diverges from traditional Confucian teachings that focus on the importance familial directives and physician paternalism. Paternalism, which ‘Western’ ethics typically view as negative, is often invoked to prevent distress when delivering bad news to patients or families [5, p. 2]. In practice, contemporary bioethics in China and other parts of East Asia often depart from principles of individual autonomy, deferring instead to familial or physician wishes/advice.
Within the Hindu religion lies a rich history of interconnectedness between medicine, ethics, and religion. Both religion and ethics fall within the concept of dharma, emphasizing the fluid overlapping of mind, body, and the environment. The predominant practical application of dharma comes through sāmānya, the five core principles laid down by Manu of “nonviolence, truthfulness, nonstealing, purity, and restraining of sense organs (ahismā, satya, asteya, sauca, indriyānigrahah)” [6, p. 178]. These principles underpin what it takes for one to achieve a truly moral and virtuous life. Collectivism, as described in an article by Kane cited by Young, is ingrained in Hinduism within the teaching that, for an individual to satisfy one’s “inner person,” it is imperative that they develop and cultivate sāmānya, not for their own benefit, but in recognition that each person is “immanent in every individual as said in the word ‘tat tvam-asi ’ [that art thou]” [6, p. 179).
Given this intertwining of religion and ethics, medicine falls neatly within traditional discourse, primarily through the concepts of karma and dosa or dhatus. The law of Karma is most simply summarized by the idea that one “[reaps] what one sows” [6, p. 178]. Consequently, to promote good health is inherently karmic for the maintenance of the body is vital for achieving enlightenment, social harmony, and moral superiority. Dhatus translates as the matter that holds the physical body in balance, eventually evolving into the concept of dosas or ‘faults.’ Thus, the objective of medicine was to balance the dosas within one’s body and overall promote good karma. This motif of balancing life and spirituality is foundational in modern Hindu influences on bioethics. Care for one’s physical dosas mirrors the moral balancing of one’s virtues or guna, thus emphasizing the connectivity between moral action and health [6, pp. 178-83].
In modern times, Hinduism relates to bioethics through the concepts of ahismā and satya (nonviolence and truthfulness, the first two principles within sāmānya) and tat tvam-asi (‘that art though’). Modern Indian medicine is transitioning towards a more principle-guided bioethical paradigm, applying practical doctrines of nonviolence and consent, but, as with ‘Western’ bioethics, there is often conflict between principles [6, p. 510]. The 2002 Indian Medical Council’s published Code of Ethics states that a physician “should neither exaggerate nor minimize the gravity of a patient’s condition” [7, p. 4] yet then goes on to outline the more paternalistic idea of satisfying best interests. A clear conflict arises here between ahismā and satya – should a physician convey the true severity of a patient’s illness if this knowledge may not be in the best interests of the patient? Furthermore, given an incidence of surrogate decision making, if a patient elects to defer to his family’s interests in choosing treatment, should a physician honor the wishes of the family over the best interests of the patient? With respect to the concept of tat tvam-asi or the idea that an individual is only one part of a collective, should a physician honor the family’s decision?
Buddhist traditions also have contributed to the fundamentals of ‘Eastern’ bioethics. Buddhism is expressed through the idea of transience; there is no true ‘Self;’ individuals exist among a collective, constantly seeking a state of enlightenment known as nirvāna. Within the three sects of, Theravāda, Mahāyāna, or Vajrayāna, the role of ethics varies slightly [6, p. 185].
In Theravāda Buddhism, the main religious teachings refer to the Buddha’s experiences in his pursuit of nirvāna. First are the Four Noble Truths and the Eight-fold Path. Within these teachings there are several important ethical considerations, the first of the Truths prescribes that ‘to live is to suffer.’ Individuals are in a constant state of non-existence marked by suffering, yet the Eight-fold Path, which includes aspects of “right views, resolve, speech, conduct, livelihood, effort, memory, and meditation,” represents a way to relieve this suffering and reach enlightenment [6, p. 186]. Alongside these teachings is the separation between good or “skillful” actions (known as punya or kuśala) and bad or “unskilled” actions (papa or akuśala) [6, p. 187]. Furthermore, there are the five “precepts” of Buddhism that are presented primarily for the common man in his pursuit of nirvāna – “not taking life, not stealing, not committing adultery, not lying, and not consuming intoxicants” [6, p. 187]. Finally, there is the idea of the soulless individual (anātman) which prompts questions of individual autonomy – if one is constantly in a state of transience with no “independent nature,” is real autonomy achievable [6, p.187]?
Within Mahāyāna and Vajrayāna, ethics presents as more of a tool for achieving enlightenment. Both sects emphasize the collective good and a need to ‘save’ all “sentient beings” before any one person can achieve nirvāna [6, p. 190]. Some similarities to utilitarianism arise here in that actions can be ethically permissible as long as they further the goal of salvation for the greatest number. Yet, rather than appealing to efficacy or productivity, Mahāyāna and Vajrayāna Buddhism stress compassion and, what Young terms, “radical altruism” [6, p. 190] as the basis for their desire to promote the salvation of all. While the teachings are largely spiritual (disease resulting from demonic influences, etc.), the foundational connection between spiritual and physical health are pivotal in the later development of modern bioethics [6, p. 193].
The role Buddhism plays in contemporary modern ethics is as complex as the religion itself. There is a general consensus that the first precept of not doing harm applies to the medical profession and professional ethics. Mahāyāna Buddhism especially highlights physicians’ obligation to do good considering the unique emphasis on altruism. However, when considering issues of individual autonomy, there is substantial debate. When considering the Buddhist belief of anātman, or the lack of a ‘Self’ or soul, it may seem that individual autonomy is entirely opposite of the religion. Extending this, one must also consider the precept of not lying and whether a physician should always convey to a patient the seriousness of his illness regardless of the harm that it may cause. Given Mahāyāna altruism, it would seem that the physician should lie in order to protect the patient and the family from harm, thus maximizing good [6, pp. 519-521].
PERSONAL VALUES IN CROSS-CULTURAL CARE
Within a diverse and multicultural world, how can a practitioner operating in a cross-cultural setting balance their own personal values and the values of their patient? Suppose a British physician encounters an Indian patient. The physician will likely have been classically trained, prone to personal values emphasizing respect for autonomy and individualism, while the patient may put stock in the Hindu traditions of collectivism. Should the physician force a decision upon the patient if they do not wish to be distressed by the burden? Tradition dictates that the family should undertake the task of deciding medical care as to relieve the afflicted from further pain.
In order to interact with such cultural divergence, physicians must be equipped with tools to respect and understand differing cultures of their patients. Denier and Gastmans propose a model for a Belgian healthcare organization through a unique interdisciplinary approach involving perspectives from relevant cultural and professional actors. Their model maintains the typical ‘Western’ patient-centric approach, but attempts to define it within a cross-cultural setting . They identify seven fundamental values necessary for ethical care as, “respect for the human person, commitment to dignity-enhancing care, autonomy as a relational value, the value of trust, mutual respect, preferential option for the most vulnerable, and equality of access for all” [8, p. 41). Uniquely, this framework seeks to take the “middle course between moral imperialism and ethical relativism” [8, p. 43]; it seeks to not impose ‘Western’ ethics upon patients, but also to not take the stance of ‘anything goes’.
There are several issues with this framework. Fundamentally, as Denier and Gastmans concede, their structure is undeniably built within an Anglophone perspective of ethical theory. The idea of person-centric care, as Chattopadhyay comments, is “distant, alien, and discordant” [9, p .7] to many ‘Eastern’ cultures. In fact, as we see in Buddhist cultures, the idea of ‘Self’ or personhood may be entirely incongruous with religious teachings. Furthermore, as Padela et al. argue, emphasizing autonomy of an individual in a collectivist culture removes the individual from a community, thus lessening their cultural autonomy . Referring to the hypothetical Indian patient/British doctor scenario, Denier and Gastman’s framework may leave the physician helpless in such a situation with potential conflicts in regards to “relational autonomy” and the idea of person-centric care.
The need for a reevaluation of modern bioethics is apparent through an increasingly diverse global society. The intermingling of traditional ‘Eastern’ and ‘Western’ cultures presents a new host of ethical dilemmas that common bioethics is unequipped to handle. As bioethics extends beyond the ‘Western’ world, it is clear that these principles may not stand the test of culture. Only through careful study, understanding, and true considerations of the cultural or religious origins of human behavior can bioethics truly shape and develop into a harmonic, globalized discipline.
Will Naso is pursuing his B.A. in Public Health at Davidson College through the Center for Interdisciplinary Studies. Throughout this summer, he has worked as a Vann Fellow at Mayo Clinic in Biomedical Ethics Research.
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