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| J R Soc Med. 2001 November; 94(11): 592–594. | PMCID: PMC1282251 |
Copyright © 2001, The Royal Society of Medicine Medical ethics in a multicultural society Leight Turner, PhDBiomedical Ethics Unit, Department of Social Studies of Medicine, Faculty
of Medicine, McGill University, 3690 Peel Street, Montreal, Quebec,
Canada |
Contemporary research and teaching in medical ethics is unduly influenced
by the imagery of stability, order and uniformity. Many commentators presume
the existence of a placid social order and pay little regard to differences in
understandings of birth, illness, suffering, death and the nature of healing.
Moral philosophers such as John Rawls and Norman Daniels, for example, argue
that with the existence of an ‘overlapping consensus,’ morality is
in a state of ‘side reflective
equilibrium’ 1.
Tom Beauchamp and James Childress, two of the earliest proponents of the
‘principlist’ approach to bioethics, take this
view 2, as do
advocates of case-based moral reasoning (casuistry) such as Albert Jonsen and
Stephen Toulmin 3.
Notwithstanding methodological differences in the manner these philosophers
address practical ethical issues in medicine and healthcare, all of them
presume the existence of a stable, settled moral order. ‘Society’
is discussed in monolithic terms, and both principlists and casuists pay
remarkably little attention to the role of religion and culture or ethnicity
in shaping understandings of such topics as abortion, physician-assisted
suicide, prenatal genetic testing, stem-cell research or the withdrawal of
treatment in end-of-life care. Relying upon philosphical approaches that
presume the existence of shared principles and moral paradigms, contemporary
ethicists commonly neglect to address important differences in the moral
understandings of particular religious communities and ethnic
groups 4. The notion
of ‘common morality’ tends to obfuscate the complex realities of
providing medical care in multicultural, multifaith
societies 5. In
pluralistic settings, different interpretive communities can exist, with
distinctive understandings of what constitutes moral conduct, forms of
evidence and reasoned
arguments 6. In
short, commentators on the ethics of medicine and healthcare greatly
over-simplify their task by presuming widespread social support for norms and
practices that are in reality subject to vigorous dispute. Let us consider the position of a physician or nurse in London, New York,
Sydney or Toronto, where patients come from diverse cultural and religious
backgrounds. Some patients wish to receive detailed information about their
diagnosis, prognosis, and treatment options. Other patients follow a different
cultural script, expecting family members to make important health-related
decisions and shield them from ‘bad news’. Some patients, fearful
that they will become captive to sophisticated medical technologies, prepare
advance directives refusing various possible medical interventions. Others,
perhaps because of deep religious belief, want ‘everything done’,
and insist on cardiopulmonary resuscitation even in circumstances deemed
medically futile by healthcare providers. Some families seek to practise their
religious traditions by asking physicians to circumcise their male
children—an act that other groups see as child abuse and a violation of
human rights. Members of some right-to-die organizations insist that
compassionate healthcare providers and legislators would permit
physician-assisted suicide, whereas members of many Jewish, Muslim and
Christian religious communities declare that legalization of
physician-assisted suicide would seriously devalue human life. To contribute
usefully to contemporary debates, ethicists need to better address the
multiethnic, multifaith character of contemporary social
settings7. They need
to recognize the existence of a plurality of ‘communities of
interpretation’ and ‘local moral
worlds’8. |
FROM THE LAYER CAKE TO THE WEB In the field's early years—at least in the North American
context—the imagery of the layer cake model of moral reasoning permeated
discussions of medical ethics. This model was most persuasively articulated in
successive versions of Beauchamp and Childress' Principles of Biomedical
Ethics, which popularized the notion that from moral theories can be
derived moral principles and rules that can then be utilized at progressively
more refined levels of
specification9.
Working in a deductive manner, the ethicist proceeds down the layer cake from
moral theories to mid-level principles that are applied to cases of various
sorts. While Beauchamp and Childress never presented the layer cake as the
sole model for the process of moral reasoning, this deductivist approach came
to serve as a major tool of bioethicists. But the layer cake is now yielding
to a different image—that of the ‘web’ of wide reflective
equilibrium or common
morality10. The
image of the web reflects the notion that no singular theory or principle can
serve as an adequate foundation for moral reasoning in all instances. The increased predominance of the web model of moral reasoning reflects the
détente now being established between
principlists and casuists. The decade following publication of Albert Jonsen
and Stephen Toulmin's The Abuse of Casuistry witnessed a lengthy
debate between the supposedly deductivist claims of principlists and the more
inductivist case-oriented
approach3. However,
the differences separating these approaches have seemed ever less important.
Contemporary casuists and principlists emphasize the extent to which the
exploration of moral issues in medicine and healthcare requires attentiveness
to common morality. According to casuists and principlists, common morality encompasses a
shared body of rules, rights, maxims, obligations and mores that constitute
the fabric of everyday moral life. Eschewing universalistic foundations for
moral reasoning in favour of a historically informed understanding of basic
paradigms, the common-morality approach assumes the existence of a stable,
shared, comprehensive moral order. Whether such a model of wide reflective
equilibrium existed in particular times—for example in regions of
medieval Europe or in the USA of the 1950s—is a matter of
dispute11.
Certainly, the contemporary multiethnic, multifaith scene to be found in most
of the major urban centres of the world is not to be characterized by images
of order, stability and
uniformity12. In
the clinical setting, some of the relevant differences concern sexual
relations and kinship patterns, perceptions of modes of healing, dietary
preferences and moral norms. The notion of a single web of moral reasoning
fails to capture the different understandings of morality and medicine. |
THE MULTIPLICITY OF MORAL WORLDS In turning from images of the layer cake to the rhetoric of the web,
philosophers have paid too little attention to multiplicity and
variability13. For
example, in the latest edition of Beauchamp and Childress' Principles of
Biomedical
Ethics2
‘mid-level’ principles are deemed to encapsulate the common sense
wisdom of a host of alternative moral visions and theories. Common morality
resides at the convergence of diverse theories, norms and moral traditions.
However, despite their articulation of a common-morality model incorporating
mid-level principles, Beauchamp and Childress still do not fully acknowledge
the multiple ways in which particular principles can be understood and applied
within different settings. For example, ‘autonomy,’ as both a word
and a substantive principle, can assume quite different meanings. Antonella
Surbone, an Italian medical oncologist, writes, ‘In the Italian culture,
autonomy (autonomia) is often synonymous for isolation
(isolamento)... Protecting the ill family member from painful
information is seen as essential for keeping the family together and not
allowing the ill member to suffer
alone’14.
Likewise, questions of what constitutes beneficence, non-maleficence and
justice can be addressed in quite divergent manners, depending upon the manner
in which moral reasoning is informed by religious and cultural
norms15. The diversity of moral tongues can be recognized even within what is often
termed the western intellectual tradition. A philosophical and religious
tradition that includes not just Plato, Augustine, Aristotle, Aquinas,
Descartes, Kant, Bentham, Mill, Rawls, Nussbaum and Habermas, but also Seneca,
Vico, Herder, Nietszche, James and Berlin, is scarcely a seamless garment of
common sense or common morality. It is more of a patchwork quilt. |
THE NEED FOR NEW LABELS The motley character of this patchwork quilt or tangle of webs becomes even
more evident when one recognizes that the western philosophical tradition is
not the only starting-point for normative analyses. Many contemporary
bioethics textbooks assume that the most decisive moral battles are between
different schools of western moral philosophy. Students are given potted
summaries of Aristotle, Mill and Kant as though moral reflection in various
communities is completely uninformed by Hindu, Jewish, Roman Catholic,
Protestant, Muslim, Buddhist, Confucian, Shinto and Taoist interpretive
traditions. Unfortunately, a host of simplifying labels obscure the complexities of the
various cultural and religious traditions that shape moral reflection in
various settings. Terms such as Judaeo-Christian ethics or eastern and western
thought conceal far more than they reveal with their massive generalizations.
Just as it is one thing to be born in Pocatello, Idaho, and quite another
experience to be raised in Barcelona, Cape Town, Kyoto or Reykjavik, there is
good reason to differentiate between the ‘local moral worlds’
found within such regions as Thailand, South Korea, North Korea, Singapore,
Japan and
China8. |
CONTINUITIES AND CHANGES While differences within and amongst cultural and religious traditions need
to be recognized, we must not fall into the trap of fostering
‘frozen’ accounts of discrete, highly bounded moral traditions.
Take for example the city of Los Angeles—a key site for the observation
of globalization and the transnational flow of communities, where individuals
from different religious traditions and ethnic groups grapple with different
understandings of moral practice. Of course, these individuals do not just
transplant their ‘culture’ to Southern California or leave their
salient religious and cultural traditions behind when they immigrate to the
USA. Rather, ethnic traditions and religious practices are commonly
transformed in the new setting, just as the new locale is shaped by the
cultural traditions and mores of its immigrant communities. There is a process
of mutual influence and transformation. Innovative social and familial
arrangements, courtship patterns, culinary dishes, musical forms and dances
begin to emerge. Over time, these groups blend and blur, so that the citizens
of Los Angeles are not just multiethnic in the sense that individuals from
many different ethnic groups inhabit Los Angeles, but in the sense that
particular individuals live at the intersection of multiple strands of human
community, language and history. |
THE TRANSNATIONAL MOVEMENT OF INTERWEAVING TRADITIONS Through cultural exchange, dispersion and globalization urban centres such
as Paris, San Diego and Vancouver illustrate the growing porousness of
cultures and
nations16.
Increasingly, it will not make sense to think of culture as a sharply
demarcated body of knowledge or sets of practices expressed by the members of
discrete, isolated social
groups17. Rather,
recognition of the varieties of common sense and ways of worldmaking will
require attentiveness to flux, diversity and
heterogeneity18.
Increasingly, it will make little sense to think in terms of eastern and
western religions and philosophical traditions, or of ‘national’
culture. In an era of rapid globalization, boundaries and borders begin to
blur19. In such a
setting, it is misleading to think of ‘society’ existing in a
state of reflective equilibrium. Rather, we live in a time when competing
narratives bring different standards of reasoning, argumentation and evidence
to topics ranging from male circumcision to the definition of death. Anthropological and sociological approaches to social analysis can avoid
the most egregious weaknesses of approaches to bioethics that presume the
existence of a common morality. These more ethnographically attuned studies of
moral orders will not necessarily disavow all claims to a common
morality—or to minimal standards necessary for shared social
institutions and legal
frameworks20. While
the introduction of tools and approaches from anthropology, sociology and
ethnic studies into medical ethics risks accusations of ‘ethical
relativism,’ the current complacent emphasis upon the existence of a
common morality seems more appropriate to Enlightenment Scotland than to the
realities of contemporary multiethnic, multifaith, multicultural regions.
‘Commonsense’ moral philosophies of medical ethics must recognize
the multiplicity of modes of practical moral reasoning. The existing models of
moral reasoning in bioethics simply do not face the challenges that exist in
highly pluralistic social settings. Bioethics as a discipline will take an
important step when it stops presuming the existence of a stable, settled,
order and begins to acknowledge the multiplicity of moral worlds. |
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