Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy

Most contemporary bioethicists believe that Western bioethical principles, such as the principle of autonomy, are universally binding wherever bioethics is found. According to these bioethicists, these principles may be subject to culturally-conditioned further interpretations for their application in different nations or regions, but an 'abstract content' of each principle remains unchanged, which provides 'an objective basis for moral judgment and international law'. This essay intends to demonstrate that this is not the case. Taking the principle of autonomy as an example, this essay argues that there is no such shared 'abstract content' between the Western bioethical principle of autonomy and the East Asian bioethical principle of autonomy. Other things being equal, the Western principle of autonomy demands self-determination, assumes a subjective conception of the good and promotes the value of individual independence, whilst the East Asian principle of autonomy requires family-determination, presupposes an objective conception of the good and upholds the value of harmonious dependence. They differ from each other in the most general sense and basic moral requirement.     

Bioethics and conflicts of interest

Bioethics has been subject to considerable social criticism in recent years. One criticism that has caused particular discomfort in the bioethics community is that bioethicists, because of the way their work is funded, are involved in profound conflicts of interest that undermine their title to be considered independent moral commentators on developments in biomedicine and biotechnology. This criticism draws its force from the assumption that bioethics is, or ought to be, a type of normative social criticism. Versions of this criticism come from both the political left and right. For instance, such criticisms include allegations that bioethics is inherently socially conservative, that it is inherently “pro-technology”, that it lays spurious claims to moral and social authority and expertise, that its focus on autonomy links it to neoliberal theories of choice, and that it is an ideological mystification of real social relationships and political power. This commentary paper analyses the problem of bioethical conflict of interest, and argues that the types of conflict of interest facing bioethics are inherent to the role of “public intellectual” that bioethicists generally wish to assume. The paper defends this conception of the role of the bioethicist, arguing that bioethicists should be interested and openly so.     

Autonomy, interdependence, and assisted suicide: respecting boundaries/crossing lines

Western philosophy has been powerfully influenced by a paradigm of personal agency that is linked to an individualistic conception of autonomy. This essay contrasts this conception with an alternative understanding that recognizes a social component built into the very meaning of autonomy. After reviewing feminist critiques of the dominant conception of autonomy, I develop the broad outlines of a relational view and apply this reconceptualization to a concrete situation in order to show how this altered view reconfigures understanding of the participants' relationships and each of their personal perspectives. The situation chosen, physician-assisted suicide, is intended principally to illustrate one respect in which a relational conception of autonomy reframes a controversial moral issue and reveals perspectives toward it that are likely to be obscured when autonomy is viewed through the lens of the dominant individualistic conception. My principal aim is to show that when autonomy is understood relationally, respecting others' autonomy is likely to be a far more complex issue than is apparent within the standard conception, both for those with professional responsibilities and often for personal intimates as well.     

UNDIGNIFIED BIOETHICS

The concept of dignity is pervasive in bioethics. However, some bioethicists have argued that it is useless on three grounds: that it is indeterminate; that it is reactionary; and that it is redundant. In response, a number of defences of dignity have recently emerged. All of these defences claim that when dignity is suitably clarified, it can be of great use in helping us tackle bioethical controversies. This paper rejects such defences of dignity. It outlines the four most plausible conceptions of dignity: dignity as virtuous behaviour; dignity as inherent moral worth; Kantian dignity; and dignity as species integrity. It argues that while each conception is coherent, each is also fundamentally flawed. As such, the paper argues for a bioethics without dignity: an ‘undignified bioethics.’     

Research on dead human bodies: African perspectives on moral status

A useful concept that can be invoked to resolve complex bioethical issues is that of moral status (or, human dignity). In this article, we apply this concept to dead human bodies in order to support our view that research on such bodies is permissible. Instead of drawing from salient Western theories of human dignity that account for it by appeals to autonomy or rationality, we will base our investigation on emerging conceptions in African theories of moral status as articulated by Thaddeus Metz and Munamato Chemhuru. Our conclusion is that neither of these theories of moral status, one secular, and the other religious, can accommodate the intuition that we have direct duties of respect towards such bodies because, in relation to Metz's conception, they lack the capacity to enter into social relationships while on Chemhuru's conception, dead bodies appear not to have any meaningful purpose within the hierarchy that captures the ontological systems that determine such status. Consequently, we argue that our analysis provides support for the use of unclaimed cadavers in training and research in medical institutions.     

Hard times, hard choices: founding bioethics today

The discussions of these past twenty years have significantly improved our knowledge about the foundation of bioethics and the meaning of the four bioethical principles with concern to at least three different points: that they are organised hierarchically, and therefore not "prima facie" of the same level; that they have exceptions, and consequently lack of absolute character; and that they are neither strictly deontological nor purely teleological. The only absolute principle of moral life can be the abstract and unconcrete respect of human beings. But when determining the material content of this respect, principles become contingent and relative. Therefore, moral reasoning must have necessarily no less than three moments, one absolute but merely formal, namely respect for all human beings, and the other two relative and material. The first material moment is comprised of the four bioethical principles, divided into two levels, one private, including the principles of autonomy and beneficence, and the other one public, including those of nonmaleficence and justice. The second material moment deals with specific cases, and requires analysis of their context, including their circumstances and consequences. Only when following these steps, and therefore balancing principlism and contextualism, can moral reasoning be correct and complete.     

HARD TIMES, HARD CHOICES: FOUNDING BIOETHICS TODAY

The discussions of these past twenty years have significantly improved our knowledge about the foundation of bioethics and the meaning of the four bioethical principles with concern to at least three different points: that they are organised hierarchically, and therefore not "prima facie" of the same level; that they have exceptions, and consequently lack of absolute character; and that they are neither strictly deontological nor purely teleological. The only absolute principle of moral life can be the abstract and unconcrete respect of human beings. But when determining the material content of this respect, principles become contingent and relative. Therefore, moral reasoning must have necessarily no less than three moments, one absolute but merely formal, namely respect for all human beings, and the other two relative and material. The first material moment is comprised of the four bioethical principles, divided into two levels, one private, including the principles of autonomy and beneficence, and the other one public, including those of nonmaleficence and justice. The second material moment deals with specific cases, and requires analysis of their context, including their circumstances and consequences. Only when following these steps, and therefore balancing principlism and contextualism, can moral reasoning be correct and complete.     

Rights of and duties to non-consenting patients--informed refusal in the developing world

The principle of informed refusal poses a specific problem when it is invoked by a pregnant woman who, in spite of having accepted her pregnancy, refuses the diagnostic and/or therapeutic measures that would ensure the well-being of her endangered fetus. Guidelines issued by professional bodies in the developed world are conflicting: either they allow autonomy and informed consent to be overruled to the benefit of the fetus, or they recommend the full respect of these principles. A number of medical ethicists advocate the overruling of alleged irrational or unreasonable refusal for the benefit of the fetus. The present essay supports the view of fetal rights to health and to life based on the principle that an 'accepted' fetus is a 'third person'. In developing countries, however, the implementation of the latter principle is likely to be in conflict with a 'communitarian' perception of the individual -- in this case, the pregnant woman. Within the scope of the limitations to the right to autonomy of J.S. Mill's 'harm principle', the South African Patients' Charter makes provision for informed refusal. The fact that, in practice, it is not implemented illustrates the well-known difficulty of applying Western bioethical principles in real life in the developing world.     

WHY MORAL PHILOSOPHERS ARE NOT AND SHOULD NOT BE MORAL EXPERTS

Professional philosophers are members of bioethical committees and regulatory bodies in areas of interest to bioethicists. This suggests they possess moral expertise even if they do not exercise it directly and without constraint. Moral expertise is defined, and four arguments given in support of scepticism about their possession of such expertise are considered and rejected: the existence of extreme disagreement between moral philosophers about moral matters; the lack of a means clearly to identify moral experts; that expertise cannot be claimed in that which lacks objectivity; and that ordinary people do not follow the advice of moral experts. I offer a better reason for scepticism grounded in the relation between moral philosophy and common‐sense morality: namely that modern moral philosophy views even a developed moral theory as ultimately anchored in common‐sense morality, that set of basic moral precepts which ordinary individuals have command of and use to regulate their own lives. Even if moral philosophers do nevertheless have a limited moral expertise, in that they alone can fully develop a set of moral judgments, I sketch reasons – grounded in the values of autonomy and of democracy – why moral philosophers should not wish non‐philosophers to defer to their putative expertise.     

Deciding on Death: Conventions and Contestations in the Context of Disability

Conflicts between bioethicists and disability theorists often arise over the permissibility of euthanasia and physician assisted suicide. Where mainstream bioethicists propose universalist guidelines that will direct action across a range of effectively disembodied situations, and take for granted that moral agency requires autonomy, feminist bioethicists demand a contextualisation of the circumstances under which moral decision making is conducted, and stress a more relational view of autonomy that does not require strict standards of independent agency. Nonetheless, neither traditional nor feminist perspectives have fully engaged with the critique of disabled people that they are consistently subjected to discriminatory, even life-threatening, practice and policy in biomedical and health care. The paper revisits some of the issues that drive the often highly polarised debate between bioethicists and disability theorists around the question of end of life decisions involving disabled people. While many bioethicists have doubtless been indifferent to the difference that disability makes, I am also concerned that the very proper demand of disability activists and theorists to scrutinise all end of life decisions for signs of discrimination and even violence has segued into something damagingly restrictive that silences internal dissension and stifles external debate. Given that euthanasia and physician assisted suicide may be issues where conventional argument on either side will founder on deeply felt convictions, I make the radical move to speculate on an entirely different, quasi-Deleuzian, approach to the value of life in order to shake up entrenched positions, and begin to think differently.     

Mental competence and long term care: an uncomfortable relationship

Competency is an important concept in medical ethics as well as in law. It refers to the moral principles of self-determination and autonomy, which are of central importance in the ethics of health care. These moral principles also prevail in nursing home care. Societal prejudice concerning nursing home patients suggests that the inhabitants of a nursing home are almost by definition incompetent. We assert that such prejudice rests on certain societal delusions and misinterpretations of incompetency five of which are subsequently analysed. Next we discuss the dominant conception of competency in terms of decisional capacity. This conception is predominantly oriented towards cognitive abilities and underplays affective capacities. We confront this dominant conception with an alternative proposal of competency in terms of 'the capacity to value', which--to our opinion--more properly reflects nursing home practice concerning questions of competency. Finally we address the limitations of any concept of competency or decisional capacity in relation to the moral issues of 'good care' for demented elderly. As an alternative we draw attention to the moral perspective of the 'ethics of care'.     

AFRICAN AND WESTERN MORAL THEORIES IN A BIOETHICAL CONTEXT

The field of bioethics is replete with applications of moral theories such as utilitarianism and Kantianism. For a given dilemma, even if it is not clear how one of these western philosophical principles of right (and wrong) action would resolve it, one can identify many of the considerations that each would conclude is relevant. The field is, in contrast, largely unaware of an African account of what all right (and wrong) actions have in common and of the sorts of factors that for it are germane to developing a sound response to a given bioethical problem. My aim is to help rectify this deficiency by first spelling out a moral theory grounded in the mores of many sub-Saharan peoples, and then applying it to some major bioethical issues, namely, the point of medical treatment, free and informed consent, standards of care and animal experimentation. For each of these four issues, I compare and contrast the implications of the African moral theory with utilitarianism and Kantianism, my overall purposes being to highlight respects in which the African moral theory is distinct and to demonstrate that the field should take it at least as seriously as it does the Western theories.     

On Taylor's justification of medical informed consent

In contemporary Western biomedical ethics, informed consent practices are commonly justified in terms of the intrinsic value of patient autonomy. James Stacey Taylor maintains that this conception of the moral grounding of medical informed consent is mistaken. On the basis of his reasoning to that effect, Taylor argues that medical informed consent is justified by the instrumental value of personal autonomy. In this article, I examine whether Taylor's justification of medical informed consent is plausible.     

An African theory of bioethics: reply to MacPherson and Macklin

In a prior issue of Developing World Bioethics, Cheryl Macpherson and Ruth Macklin critically engaged with an article of mine, where I articulated a moral theory grounded on indigenous values salient in the sub-Saharan region, and then applied it to four major issues in bioethics, comparing and contrasting its implications with those of the dominant Western moral theories, utilitarianism and Kantianism. In response to my essay, Macpherson and Macklin have posed questions about: whether philosophical justifications are something with which bioethicists ought to be concerned; why something counts as 'African'; how medicine is a moral enterprise; whether an individual right to informed consent is consistent with sub-Saharan values; and when thought experiments help to establish firm conclusions about moral status. These are important issues for the field, and I use this reply to take discussion of them a step or two farther, defending my initial article from Macpherson's and Macklin's critical questions and objections.     

Autonomy reconfigured: incorporating the role of the unconscious

The principle of respect for autonomy has served as a pillar of American bioethics. Through its application in response to physician paternalism and as the basis for informed consent, it has attained preeminent status in the discipline. New challenges in health care warrant a re-examination of the origins of our autonomy. Developmental psychology, cognitive neuroscience, and behavioral neurology all emphasize the intimate relationship between our cognitive and emotional development, and through this, our conscious and unconscious minds. Our intellectual, and particularly our moral development, are instilled in us by our moral mentors, and consequently by our community as a whole. Autonomy and community are therefore inextricably interlinked, and our emphasis on liberty, rights, and privacy without the inclusion of family, community, and social responsibility is biologically unsound. Appreciation of this reality should lead to a more balanced set of bioethical norms.     

Bioethics: An Export Product? Reflections on Hands-On Involvement in Exploring the “External” Validity of International Bioethical Declarations

As the technosciences, including genomics, develop into a global phenomenon, the question inevitably emerges whether and to what extent bioethics can and should become a globalised phenomenon as well. Could we somehow articulate a set of core principles or values that ought to be respected worldwide and that could serve as a universal guide or blueprint for bioethical regulations for embedding biotechnologies in various countries? This article considers one universal declaration, the UNESCO Declaration on Bioethics and Human Rights (2005a). General criticisms made in a recent special issue of Developing World Bioethics are that the concepts used in the Declaration are too general and vague to generate real commitment; that the so-called universal values are not universal; and, that UNESCO should not be engaged in producing such declarations which are the domain of professional bioethicists. This article considers these and other criticisms in detail and presents an example of an event in which the Declaration was used: the request by the Republic of Sakha, in Siberia, for a UNESCO delegation to advise on the initiation of a bioethics programme. The Declaration was intended to provide an adequate “framework of principles and procedures to guide states in the formulation of their legislation, policies and other instruments in the field of bioethics” (article 2a). The Declaration was produced, and principles agreed upon, in an interactive and deliberative manner with world-wide expert participation. We argue that the key issue is not whether the general principles can be exported worldwide (in principle they can), but rather how processes of implementation and institutionalisation should take shape in different social and cultural contexts. In particular, broader publics are not routinely involved in bioethical debate and policy-making processes worldwide.     

Social-science Perspectives on Bioethics: Predictive Genetic Testing (PGT) in Asia

In this essay, I indicate how social-science approaches can throw light on predictive genetic testing (PGT) in various societal contexts. In the first section, I discuss definitions of various forms of PGT, and point out their inherent ambiguity and inappropriateness when taken out of an ideal–typical context. In section two, I argue further that an ethics approach proceeding from the point of view of the abstract individual in a given society should be supplemented by an approach that regards bioethics as inherently ambiguous, contested, changeable and context-dependent. In the last section, I place these bioethical discussions of PGT in the context of Asian communities. Here, a critical view of what constitutes a community and culture proves necessary to understand the role of bioethical debates and the empirical manifestations of PGT in Asian societies. A discussion of the concepts of family and kinship in relation to PGT indicates that any bioethical analysis has to take into account that bioethical values are not just reflections of a cultural community, but embody both bioethical ideals and prevalent political rhetoric which is exhibited, propagated and manipulated by individuals and collectives for a variety of purposes. I end by summarising the contributions that social science could make to the understanding of the bioethics of PGT.     

Implications of Odera Oruka's ethics of consumerism for reducing globesity

In this paper, I advance Odera Oruka's insights on the ethics of consumerism in order to draw relevant implications of his thoughts on rethinking the problem of obesity. I argue that Oruka's ethics of consumerism and his right to human minimum theory entail some salient ideas that might serve as a better ethical model for reducing the global obesity prevalence. Though Oruka's African moral philosophy is yet to receive universal attention it arguably deserves, the interests of the international and ‘globesity’ community would be better served learning from the contributions of an African moral theory to contemporary bioethical discourse on obesity. Oruka's moral thoughts are by constitution, a deontological and cosmopolitan call for reducing hunger in globalized world, while also indirectly, addressing obesity of the poor. I show the limitations of his ethics of consumerism, and the shortcomings of such ethics in the context of obesity of the poor. Consequently, I develop a neo‐Orukan virtue based ethics that is worthy of attention in efforts towards addressing the obesity tide. No such perspective currently exists in the context of obesity; yet the exigent need for one is necessitated by the defects of the libertarian and harm principle approaches in Western bioethical discourse.     

A critique of the principle of ‘respect for autonomy’, grounded in African thought

I give an account how the principle of ‘respect for autonomy’ dominates the field of bioethics, and how it came to triumph over its competitors, ‘respect for persons’ and ‘respect for free power of choice’. I argue that ‘respect for autonomy’ is unsatisfactory as a basic principle of bioethics because it is grounded in too individualistic a worldview, citing concerns of African theorists and other communitarians who claim that the principle fails to acknowledge the fundamental importance of understanding persons within the nexus of their communal relationships. I defend the claim that ‘respect for persons’ is a more appropriate principle, as it is able to acknowledge both individual decision making and the essential relationality of persons. I acknowledge that my preference for ‘respect for persons’ is problematic because of the important debate around the definition of ‘personhood’ in bioethics discourse. Relying on Thaddeus Metz's conception of moral status, I propose a relational definition of personhood that distinguishes between persons with agency and persons without agency, arguing that we have different moral obligations to these distinct categories of persons. I claim that this conception of personhood is better able to accommodate our moral intuitions than conventional approaches, and that it is able to do so without being speciesist or question‐begging.     

IS GLOBAL ETHICS MORAL NEO‐COLONIALISM? AN INVESTIGATION OF THE ISSUE IN THE CONTEXT OF BIOETHICS

This paper considers the possibility and desirability of global ethics in light of the claim that ‘global ethics’ in any form is not global, but simply the imposition of one form of local ethics – Western ethics – and, as such, a form of moral neo‐colonialism. The claim that any form of global ethics is moral neo‐colonialism is outlined using the work of a group of ‘developing world bioethicists’ who are sceptical of the possibility of global ethics. The work of virtue ethicists is then introduced and compared to the position of the developing world bioethicists in order to show that the divide between ‘Western’ and ‘non‐Western’ ethics is exaggerated. The final section of the paper turns to the practical arena and considers the question of global ethics in light of practical issues in bioethics. The paper concludes that practical necessity is driving the creation of global ethics and thus the pertinent question is no longer ‘Whether global ethics?’, but ‘Why global ethics?’.