An undignified bioethics: there is no method in this madness

In a recent article, Alasdair Cochrane argues for the need to have an undignified bioethics. His is not, of course, a call to transform bioethics into an inelegant, pathetic discipline, or one failing to meet appropriate disciplinary standards. His is a call to simply eliminate the concept of human dignity from bioethical discourse. Here I argue that he fails to make his case. I first show that several of the flaws that Cochrane identifies are not flaws of the conceptions of dignity he discusses but rather flaws of his, often problematic, understanding of such conceptions. Second, I argue that Cochrane's case against the concept of human dignity goes too far. I thus show that were one to agree that these are indeed flaws that require that we discard our ethical concepts, then following Cochrane's recommendations would commit us not only to an undignified bioethics, i.e. a bioethics without dignity, but to a bioethics without much ethics at all.     

A method of Reflexive Balancing in a Pragmatic,Interdisciplinary and Reflexive Bioethics

In recent years there has been a wealth of literature arguing the need for empirical and interdisciplinary approaches to bioethics, based on the premise that an empirically informed ethical analysis is more grounded, contextually sensitive and therefore more relevant to clinical practice than an ‘abstract’ philosophical analysis. Bioethics has (arguably) always been an interdisciplinary field, and the rise of ‘empirical’ (bio)ethics need not be seen as an attempt to give a new name to the longstanding practice of interdisciplinary collaboration, but can perhaps best be understood as a substantive attempt to engage with the nature of that interdisciplinarity and to articulate the relationship between the many different disciplines (some of them empirical) that contribute to the field. It can also be described as an endeavour to explain how different disciplinary approaches can be integrated to effectively answer normative questions in bioethics, and fundamental to that endeavour is the need to think about how a robust methodology can be articulated that successfully marries apparently divergent epistemological and metaethical perspectives with method. This paper proposes ‘Reflexive Bioethics’ (RB) as a methodology for interdisciplinary and empirical bioethics, which utilizes a method of ‘Reflexive Balancing’ (RBL). RBL has been developed in response to criticisms of various forms of reflective equilibrium, and is built upon a pragmatic characterization of Bioethics and a ‘quasi‐moral foundationalism’, which allows RBL to avoid some of the difficulties associated with RE and yet retain the flexible egalitarianism that makes it intuitively appealing to many.     

Beyond the Sterility of a Distinct African Bioethics: Addressing the Conceptual Bioethics Lag in Africa

In the current debate on the future of bioethics in Africa, several authors have argued for a distinct communitarian African bioethics that can counter the dominancy of Western atomistic principlism in contemporary bioethics. In this article I examine this rather contentious argument and evaluate its validity and viability. Firstly, I trace the contextual origins of contemporary bioethics and highlight the rise and dominance of principlism. I particularly note that principlism was premised on a content‐thin notion of the common morality that is in need of enrichment. I also contend that bioethics is essentially two‐dimensional, being both conceptual and empirical, and indicate the lag in Africa with regard to conceptual bioethics. I then appeal for authentic engagement by 1) African health care professionals, 2) African health care training institutions, 3) Africa's bioethics development partners, and 4) African bioethicists and philosophers, towards addressing this critical lag. I underline the need to maintain the essential universality of bioethics as a discipline. I particularly argue against the pursuit of a distinct African bioethics, as it appears to be rooted in sterile African ethno‐philosophy. Rather, African bioethicists and philosophers would do well to elucidate the universalisability of insights from traditional African thought, for the benefit of bioethics as a whole. Thus we must engage beyond the sterility of a distinct African bioethics ‐ authentically reflecting on the essentially universal contemporary bioethical concerns ‐ to effectively articulate a viable trajectory for bioethics in Africa.     

Finding A Seat at the Table Together: Recommendations for Improving Collaboration between Social Work and Bioethics

Social work and bioethics are fields deeply committed to cross‐disciplinary collaboration to do their respective work. While scholars and practitioners from both fields share a commitment to social justice and to respecting the dignity, integrity and the worth of all persons, the overlap between the fields, including shared values, has received little attention. The purpose of this article is to describe the ways in which greater collaboration between the two fields can broaden their scope, enrich their scholarship, and better ground their practice. We describe the potential for realizing such benefits in two areas – health care ethics consultation and social inequalities in health – arguing that the fields both complement and challenge one another, making them ideal partners for the interdisciplinary inquiry and problem‐solving so often called for today in health and health care.     

GLOBAL BIOETHICS: UTOPIA OR REALITY?

This article discusses what 'global bioethics' means today and what features make bioethical research 'global'. The article provides a historical view of the development of the field of 'bioethics', from medical ethics to the wider study of bioethics in a global context. It critically examines the particular problems that 'global bioethics' research faces across cultural and political borders and suggests some solutions on how to move towards a more balanced and culturally less biased dialogue in the issues of bioethics. The main thesis is that we need to bring global and local aspects closer together, when looking for international guidelines, by paying more attention to particular cultures and local economic and social circumstances in reaching a shared understanding of the main values and principles of bioethics, and in building 'biodemocracy'.     

Developing Ethical Awareness in Global Health: Four Cases for Medical Educators

In recent years, the growth of interest in global health among medical students and residents has led to an abundance of short‐term training opportunities in low‐resource environments. Given the disparities in resources, needs and expectations between visitors and their hosts, these experiences can raise complex ethical concerns. Recent calls for best practices and ethical guidelines indicate a need for the development of ethical awareness among medical trainees, their sponsoring and host institutions, and supervising faculty. As a teaching tool to promote this awareness, we developed a scenario that captures many common ethical issues from four different perspectives. Each perspective is presented in case format followed by questions. Taken together, the four cases may be used to identify many of the elements of a well‐designed global health training experience.     

Research ethics capacity development in Africa: exploring a model for individual success

The Johns Hopkins-Fogarty African Bioethics Training Program (FABTP) has offered a fully-funded, one-year, non-degree training opportunity in research ethics to health professionals, ethics committee members, scholars, journalists and scientists from countries across sub-Saharan Africa. In the first 9 years of operation, 28 trainees from 13 African countries have trained with FABTP. Any capacity building investment requires periodic critical evaluation of the impact that training dollars produce. In this paper we describe and evaluate FABTP and the efforts of its trainees. Our data show that since 2001, the 28 former FABTP trainees have authored or co-authored 105 new bioethics-related publications; were awarded 33 bioethics-related grants; played key roles on 78 bioethics-related research studies; and participated in 198 bioethics workshops or conferences. Over the past nine years, trainees have collectively taught 48 separate courses related to bioethics and have given 170 presentations on various topics in the field. Many former trainees have pursued and completed doctoral degrees in bioethics; some have become editorial board members for bioethics journals. Female trainees were, on average, less experienced at matriculation and produced fewer post-training outputs than their male counterparts. More comprehensive studies are needed to determine the relationships between age, sex, previous experience and training program outputs.     

THE FUTURE OF BIOETHICS: THREE DOGMAS AND A CUP OF HEMLOCK

In this paper I argue that bioethics is in crisis and that it will not have a future unless it begins to embrace a more Socratic approach to its leading assumptions. The absence of a critical and sceptical spirit has resulted in little more than a dominant ideology. I focus on three key issues. First, that too often bioethics collapses into medical ethics. Second, that medical ethics itself is beset by a lack of self‐reflection that I characterize here as a commitment to three dogmas. Third, I offer a more positive perspective by suggesting how bioethics may benefit from looking towards public health ethics as a new source of inspiration and direction.     

NEW DIRECTIONS IN AFRICAN BIOETHICS: WAYS OF INCLUDING PUBLIC HEALTH CONCERNS IN THE BIOETHICS AGENDA

Research ethics is the most developed aspect of bioethics in Africa. Most African countries have set up Institutional Review Boards (IRBs) to provide guidelines for research and to comply with international norms. However, bioethics has not been responsive to local needs and values in the rest of the continent. A new direction is needed in African bioethics. This new direction promotes the development of a locally‐grounded bioethics, shaped by a dynamic understanding of local cultures and informed by structural and institutional problems that impact the public's health, as well as cognisant of the salient contribution of social sciences and social epidemiology which can bring a lasting impact on African local communities. In today's post‐Structural Adjustment Africa, where healthcare has been liberalized and its cost increased, a bioethics agenda that focuses essentially on disease management and clinical work remains blind in the face of a structural marginalization of the masses of poor. Instead, the multidimensional public health crisis, with which most African countries are confronted, calls for a bioethics agenda that focuses primarily, but not exclusively, on health promotion and advocacy. Such an approach to bioethics reckons with the macro‐determinants of health and well‐being and places clinical and research ethics in the broader context of population's health. The same approach underscores the need to become political, not only by addressing health policymaking processes and procedures, but also by becoming an advocacy forum that includes other constituencies equipped with the potentialities to impact the population's health.     

Between Relativism and Imperialism: Navigating Moral Diversity in Cross‐Cultural Bioethics

The need for explicit theoretical reflection on cross‐cultural bioethics continues to grow as the spread of communication technologies and increased human migration has made interactions between medical professionals and patients from different cultural backgrounds much more common. I claim that this need presents us with the following dilemma. On the one hand, we do not want to operate according to an imperialist ethical framework that denies and silences the legitimacy of cultural values other than our own. On the other hand, we do not want to backslide into a form of cultural relativism that is unable to critically appraise cultural practices that are harmful, unjust, or oppressive. I examine two prominent attempts – the principlism of Tom Beauchamp and James Childress and the Contractarianism of Robert Baker – to frame cross‐cultural bioethics between these two extremes and argue that both approaches have significant flaws. The principlist approach fails to provide a non‐question begging way to identify cross‐cultural norms that does not already assume the universal legitimacy of moral principles dominant in North American society. Baker's contractarianism cannot grapple with the realities of political power imbalances that often characterize cross‐cultural moral disputes. I suggest that a naturalized feminist framework, though not free of its own theoretical difficulties, provides the best alternative for approaching moral diversity respectfully and critically.     

WHO'S ARGUING? A CALL FOR REFLEXIVITY IN BIOETHICS

In this paper we set forth what we believe to be a relatively controversial argument, claiming that ‘bioethics’ needs to undergo a fundamental change in the way it is practised. This change, we argue, requires philosophical bioethicists to adopt reflexive practices when applying their analyses in public forums, acknowledging openly that bioethics is an embedded socio‐cultural practice, shaped by the ever‐changing intuitions of individual philosophers, which cannot be viewed as a detached intellectual endeavour. This said, we argue that in order to manage the personal, social and cultural embeddedness of bioethics, philosophical bioethicists should openly acknowledge how their practices are constructed and should, in their writing, explicitly deal with issues of bias and conflict of interest, just as empirical scientists are required to do.     

Lessons from Queer Bioethics: A Response to Timothy F. Murphy

‘Bioethics still has important work to do in helping to secure status equality for LGBT people’ writes Timothy F. Murphy in a recent Bioethics editorial. The focus of his piece, however, is much narrower than human rights, medical care for LGBT people, or ending the HIV/AIDS pandemic. Rather, he is primarily concerned with sexuality and gender identity, and the medical intersections thereof (i.e. DSM diagnosis; access to SrS or ARTs). It is the objective of this response to provide an alternate account of bioethics from a Queer perspective. I will situate Queer bioethics within Queer studies, and offer three ‘lessons’ that bioethics can derive from this perspective. These are not definitive rules for Queer bioethics, since it is a field which fundamentally opposes categorizations, favoring pastiche over principles. These lessons are exploratory examples, which both complement and contradict LGBT bioethics. My latter two lessons – on environmental bioethics and disability – overlap with some of Murphy's concerns, as well as other conceptions of LGBT bioethics. However, the first lesson takes an antithetical stance to Murphy's primary focus by resisting all forms of heteroconformity and disavowing reproduction as consonant with Queer objectives and theory. The first lesson, which doubles as a primer in Queer theory, does heavy philosophical lifting for the remainder of the essay. This response to Timothy F. Murphy, whose work is certainly a legacy in bioethics, reveals the multiplicity of discourses in LGBT/Queer studies, many of which are advantageous – even essential – to other disciplines like bioethics.     

Acceptance and Perception of Nigerian Patients to Medical Photography

The aim of the study was to determine the acceptance and perception of Nigerian patients to medical photography. A self‐administered questionnaire was distributed among Nigerian patients attending oral and maxillofacial surgery and plastic surgery clinics of 3 tertiary health institutions. Information requested included patients' opinion about consent process, capturing equipment, distribution and accessibility of medical photographs. The use of non‐identifiable medical photographs was more acceptable than identifiable to respondents for all purposes (P = 0.003). Most respondents were favourably disposed to photographs being taken for inclusion in the case note, but opposed to identifiable photographs being used for other purposes most especially in medical websites and medical journals. Female respondents preferred non‐identifiable medical photographs to identifiable ones (P = 0.001). Most respondents (78%) indicated that their consent be sought for each of the outline needs for medical photography. Half of the respondents indicated that identifiable photographs may have a negative effect on their persons; and the most commonly mentioned effects were social stigmatization, bad publicity and emotional/psychological effects. Most of the respondents preferred the use of hospital‐owned camera to personal camera/personal camera‐phone for their medical photographs. Most respondents (67.8%) indicated that they would like to be informed about the use of their photographs on every occasion, and 74% indicated that they would like to be informed of the specific journal in which their medical photographs are to be published. In conclusion, non‐identifiable rather than identifiable medical photography is acceptable to most patients in the studied Nigerian environment. The use of personal camera/personal camera‐phone should be discouraged as its acceptance by respondents is very low. Judicious use of medical photography is therefore advocated to avoid breach of principle of privacy and confidentiality in medical practice.     

FROM INTEGRATIVE BIOETHICS TO PSEUDOSCIENCE

Integrative bioethics is a brand of bioethics conceived and propagated by a group of Croatian philosophers and other scholars. This article discusses and shows that the approach encounters several serious difficulties. In criticizing certain standard views on bioethics and in presenting their own, the advocates of integrative bioethics fall into various conceptual confusions and inconsistencies. Although presented as a project that promises to deal with moral dilemmas created by modern science and technology, integrative bioethics does not contain the slightest normativity or action‐guiding capacity. Portrayed as a scientific and interdisciplinary enterprise, integrative bioethics displays a large number of pseudoscientific features that throw into doubt its overall credibility.     

A call from justice to support the people in Gaza

Using Madison Powers and Ruth Faden's definition of ‘well‐being,’ the authors argue that Israel, the international community and public health practitioners have a justice‐based obligation to assist the Palestinian people in the Occupied Palestinian Territories. Focusing on Palestinians in Gaza, the authors first outline a normative framework of justice, as articulated by Powers and Faden. Following Powers and Faden's assumption that empirical assessments of justice can be made using the six dimensions of well‐being, the authors next present current data on the living conditions in Gaza and describe how these conditions prevent residents from achieving sufficient levels of well‐being. Using these indicators to demonstrate that Palestinians living in Gaza suffer deficiencies in these dimensions of well‐being, the authors present a strong argument from justice to assist the residents of Gaza. The medical, public health, and bioethics community cannot sit idle while injustice continues.     

BRAIN DEATH IN ISLAMIC ETHICO‐LEGAL DELIBERATION: CHALLENGES FOR APPLIED ISLAMIC BIOETHICS

Since the 1980s, Islamic scholars and medical experts have used the tools of Islamic law to formulate ethico‐legal opinions on brain death. These assessments have varied in their determinations and remain controversial. Some juridical councils such as the Organization of Islamic Conferences' Islamic Fiqh Academy (OIC‐IFA) equate brain death with cardiopulmonary death, while others such as the Islamic Organization of Medical Sciences (IOMS) analogize brain death to an intermediate state between life and death. Still other councils have repudiated the notion entirely. Similarly, the ethico‐legal assessments are not uniform in their acceptance of brain‐stem or whole‐brain criteria for death, and consequently their conceptualizations of, brain death. Within the medical literature, and in the statements of Muslim medical professional societies, brain death has been viewed as sanctioned by Islamic law with experts citing the aforementioned rulings. Furthermore, health policies around organ transplantation and end‐of‐life care within the Muslim world have been crafted with consideration of these representative religious determinations made by transnational, legally‐inclusive, and multidisciplinary councils. The determinations of these councils also have bearing upon Muslim clinicians and patients who encounter the challenges of brain death at the bedside. For those searching for ‘Islamically‐sanctioned’ responses that can inform their practice, both the OIC‐IFA and IOMS verdicts have palpable gaps in their assessments and remain clinically ambiguous. In this paper we analyze these verdicts from the perspective of applied Islamic bioethics and raise several questions that, if answered by future juridical councils, will better meet the needs of clinicians and bioethicists.     

Intergenerational healthcare inequities in developing countries

Concern about the rapid ageing of all societies reaches alarming proportions as healthcare inequities are steeply rising, prompting the elderly to live longer but subject to insufficient social protection and healthcare in the wake of dwindling public resources. The aged population of developing nations are facing additional hardships due to the growing gap between needs and the financial reductions of public institutions, retirement funds, and the trend towards privatization of essential services turned into commodities. Current approaches to allocation of insufficient resources without ageist discrimination are briefly discussed: individual self‐care aimed at successful, active and healthy ageing based on resourcefulness of the privileged elderly; utilitarian approaches founded on QALY and fair innings, and human rights focused on the plights of the elderly. These approaches cannot apply to resources poor nations, who need to engage in context‐bound bioethics dealing with the realities of their exposed ageing population. A developing world bioethics is needed to face the plights of the elderly in countries with low and middle‐income and insufficient social capital. Suggested are: 1) a phenomenological approach based on the interaction of bioethics and ethnology, furthering grass‐roots input from the elderly; 2) Create small communities –campus‐like boroughs– to simplify accessibility to social services and healthcare facilities, as an alternative to the high‐cost WHO proposal of age‐friendly large cities.