Journal of Health & Culture

ISSN:2458-8113

Issue 1

Contributions and ambiguities in Islamic research research in Islamic ambiguities and Contributions contexts: in Muslim conducted research ethics and the review literature of a thematic Mehrunisha Suleman diseases mental on court records Ottoman A review of Nil Sarı Volume 1 Volume

June 2016 Journal of & Culture Health Migration and health in medical education: health in medical and education: Migration Central Europe from report in progress a work Frank Kressing Cultural dimensions of bios and bioethics and bios of dimensions Cultural Sass Hans-Martin The self-image of transident women since 1945 since women of transident The self-image PrüllLivia

Journal of Health & Culture June 2016 / Volume 1 / Issue 1

Journal of Health & Culture

J Health Cult June 2016 Volume 1 Issue 1

ISSN:2458-8113

Journal of Health & Culture June 2016 Volume 1 Issue 1

Editors-in-chief Rainer Brömer (Istanbul, TR) M. Kemal Temel (Istanbul, TR) Editors Hakan Ertin (Istanbul, TR), İlhan İlkılıç (Istanbul, TR), Hajo Zeeb (Bremen, DE)

Advisory Board Editorial Launching a new academic journal in this age of proliferating Journal of Health & Culture publications requires some justification, or at the very least a brief explanation. Health and illness are an intrinsic element of culture, and June 2016 . Volume 1 . Issue 1 in an increasingly globalized world, health concerns and approaches to healthcare are inextricably linked with the often radically different Owner cultures of patients, clinicians, and researchers. While modern medical Ahmet Özdemir, applications have not least contributed to a significant increase in life on behalf of Hayat Sağlık ve Sosyal Hizmetler Vakfı expectancy, concomitantly new complex problems have arisen from Managing Editor developments such as the use of modern technologies at the beginning Hakan Ertin and end of life, reproductive medicine, organ transplantation, or the decoding of the human genome and subsequent genomic intervention. Editors-in-chief Mustafa Kemal Temel Considering that these interventions are being used in a globalized Rainer Brömer world, the ensuing problems are of lasting intimate concern to members of all the various cultural spheres found around the globe and Editors accordingly call for culturally appropriate ethical sensitivity towards Hakan Ertin the ever-changing normative and ontological aspects of health and İlhan İlkılıç Hajo Zeeb illness. In today’s world, efforts to ease inevitable tensions and potential conflicts of interest require the input of the humanities more than Design ever. Of particular relevance in this regard are studies and analyses by Ahmet Yumbul scholars and scientists from different parts of the globe working within

Printing–Binding cognate disciplines. On behalf of the Beşikçizade Center for Medical Pınarbaş Matbaacılık Ltd. Şti. Humanities (Beşikçizade Tıp ve İnsani Bilimler Merkezi—BETİM), 0212 544 58 77 we intend to provide a forum for an interdisciplinary discussion of health-related issues and encourage exchange and interaction between Contact researchers involved in these fields. This journal, associated with Küçükmühendis Sk 7, 34096 Istanbul TURKEY +90 (212) 588 2545 +90 (212) 632 8579 the Istanbul Faculty of Medicine through four of its editors who are members of the school’s Department for History of Medicine and Ethics invites contributions from the humanities and human sciences investigating the interaction between health and illness concepts and ISSN 2458-8113 the notion of culture. In creating this platform, we aim at filling a significant gap in the international academic landscape.

Published biannually. While our journal is open to all social and human sciences and Authors are responsible for the content of the humanities related to culture, we want to accentuate the relevance of articles published in this journal. three disciplines in particular, namely, medical history, epidemiology, © Copyright reserved by the publisher. and medical ethics. Background for this emphasis is a project that Quotes can be used provided full reference is given. some of the editors embarked upon in 2009, leading to an ongoing international cooperation. In that year, under the roof of the medical faculty of Mainz University in Germany, researchers from the department for history, philosophy, and ethics of medicine and the department of epidemiology came together and approached colleagues working in equivalent fields at Istanbul University in cultures. On the way, medical humanities have Turkey, submitting a specific concept for a program evolved in various ways, making use of a variety of of collaboration. As a result, over the last six years disciplines while establishing themselves as a new, four international symposia under the main heading albeit somewhat undisciplined discipline.3 From the of “Health, Culture and the Human Body” have been outset, medical humanities have been encompassing organized: the first one in Mainz, then two rounds bioethics as well (Cole et al. 2015, pp. 255–7). In recent at Istanbul University’s Department for History of years, the moral relevance of medical humanities has 1 Medicine and Ethics in collaboration with BETİM; been more thoroughly examined (Marshall 2007, p. this year’s host in September will be Bremen University 139), and especially the awareness of the narrative jointly with the Leibniz Institute for Prevention nature of bioethical casuistry should not be neglected Research and Epidemiology in Bremen (Germany). (Chambers 2016). Medical humanities’ growth on At each of these symposia, specifically chosen topics different soils requires specific forms of cultivation, from within the field of healthcare have been or are given that the cultural framework for the experience being addressed from at least three disciplinary of illness and the delivery of healthcare differs very perspectives in different countries. The birth of this journal cannot be thought without taking into account significantly between cultures and changes over the international cooperation that has gone on for the time, though not necessarily in the same direction past seven years. One of the editors’ main interests is in every society. Translating applications developed to understand how concepts and practices are being within the humanities is not least a challenging applied outside their context of development: In how linguistic endeavor: Even if we just look at the Turkish far are those transfers successful and what are the translation of the term, using “human sciences” for processes of transformation involved.2 “humanities,” we get an idea about the ambiguities involved in moving between different cultures; a An important intellectual inspiration for us has more specific term such as “medical humanities” is been the medical humanities approach, developed even harder to express in other languages without from tentative beginnings since the 1930s (Bleakley & Jones 2014). During the past four decades, medical changing its semantic implications fundamentally— humanities have been contributing towards bridging thus, Germans speak about “history, philosophy, and 4 the gap between healthcare providers’ professionalism ethics of medicine,” while in the French-speaking 5 and the human experience of disease, both on the side world, the loan-words “les medical humanities” is of the patient and among members of the healthcare used alongside the literal translation les humanités team themselves. First emerging in the English- médicales. With all its important contributions to the speaking world, the field of medical humanities has interaction of health and culture, we also acknowledge gradually grown to encompass large swaths of the that medical humanities have come in for criticism globe, using many languages, developing in many from some quarters (Petersen et al. 2008).

1 Proceedings of the first two events have been collected in İlkılıç et al. (2014). 3 Defining the field of medical humanities is not within the scope of 2 For example, the Principles of Biomedical Ethics (Beauchamp & Chil- this editorial. Recently, Bleakley (2014, p. 17) speaks of “four con- dress 1979) originated from a particular liberal discourse in the US tested and fragmented fields,” including “[t]he humanities studying after the scandalous Tuskegee syphilis experiments exposed in 1972. medicine,” “medicine as art,” “[a]rts for health,” and “[a]rts thera- When teaching these principles in a rather more communitarian so- pies.” ciety four decades later, how can we expect them to resonate in the 4 Geschichte, Theorie und Ethik der Medizin, conveniently abbreviated same way with the audience as they do in today’s US, where the book into GTE. is now being used in the 7th edition (2013)? 5 Mainly in Switzerland. The papers included in this first issue of the new equitable treatment for all members of a varied society, journal mostly have been selected from among the taking into account their specific needs but avoiding presentations given at the third conference on “Health, stereotyping what are in fact complex groups of people Culture and the Human Body” held in Istanbul in at risk of being stigmatized as being society’s “other.” September 2014. The range of topics and approaches Associations and institutions in Germany dealing exhibited in these contributions provides the readers with medical education and ethics have set up specific with a first general overview of the field. working groups elaborating specific proposals for curricula enhancing the capacity for medical diversity Medical historian Livia Prüll combines a historical management. and an autobiographical approach to track the unfolding of transident life histories during the Mehrunisha Suleman presents the results of an past century, comparing the transition history of extensive literature review studying the importance Roberta Cowell in the mid-20th century with her of Islam in bioethics, identifying a number of own experiences at the beginning of the 21st century. dominant themes in the current debate. Recent years Medical scientists in the 19th century began in earnest have seen a significant growth in interdisciplinarity to study “sexual intermediaries,” seen as pathologies between religious scholars and biomedical scientists, of human development. While physicians and increasingly engaging with and learning from one psychoanalysts like Harry Benjamin after World War another. Current developments in biomedical research, II began to de-pathologize the status of transident such as reproductive technologies (including cloning) persons, emphasizing society’s responsibility for and organ transplantation, are attracting the attention “transsexuals,” structural conditions in the healthcare of theologians, while many Muslim scientists and system paradoxically require the classification of trans clinicians themselves are eager to understand religious identity as a pathology in order to allow insurances to positions towards their professional activities when cover the costs involved in medical interventions. dealing with patients or human embryos or single cells. Hans-Martin Sass examines the cultural founda- Mental health also played an important role in tions of bioethics, rooted in various ancient traditions more distant history. The changing attitude towards from the Mediterranean to the Chinese Sea. Based on the “insane” in the Ottoman Empire is illustrated Kant’s “categorical imperative,” itself heir to millennial by medical historian Nil Sarı, who presents a series intuitions, in 1926 a German pastor, Fritz Jahr, devel- of court cases dealing with complaints against and oped the notion of a “bioethical imperative,” using appeals from mentally disturbed individuals recorded findings from contemporary biological sciences. Jahr between the 17th and the 19th century (the section insists that “every living being” should be respected Discussion and Conclusion translated from Turkish as an “end-in-itself” and “if possible” be treated as into English by editor M. Kemal Temel). While family such. Now, ninety years later, reflecting moral rights and social environment bore an important share of the of non-human animals and plants, especially in medi- responsibility for the well-being of the affected persons, cal research and treatment, has gained even greater Sarı shows that the introduction of central legislation relevance, and all societies, inevitably involved in deal- in 1876, based on the French law, led to a rapid decline ing with living beings in production and consumption, in the sense of duty towards the “insane,” while the rate are still in need to work out their attitudes towards the of institutionalization soared accordingly. general realm of the living. Cultural philosophy, (auto)biography, institutional Frank Kressing emphasizes the role of cultural history, pedagogy, and interdisciplinary bioethics competence in the education of medical doctors. From are just some of the approaches required for a the background of the healthcare situation in Germany, comprehensive study of health and culture. As a country with a significant migrant population, we are living in an age when sociocultural as well Kressing argues that awareness of the dynamic process as biomedical changes are rapidly accelerating, a of cultural development is essential if we are to ensure thorough investigation of the ensuing tensions appears all the more essential. While the basic issues regarding References health and illness may be the same all around the Beauchamp TL, Childress JF (1979), Principles of Biomedical Ethics world, different cultures have responded differently (New York: Oxford University Press). throughout history, and the solutions to universal Bates V, Bleakley A, Goodman S, eds. (2014), Medicine, Health and the problems are not always universal: Every society Arts: Approaches to the Medical Humanities (London: Routledge). needs to make its own decisions, while transnational Bleakley A (2014): “Towards a ‘critical medical humanities’,” in Bates et interconnectedness requires mutual attention and al., eds., pp. 17–26. respect. Research banned in one region can easily Bleakley A, Jones T (2014), “A timeline of the medical humanities,” in be outsourced to some countries with less strict Bates et al., eds., pp. 280–4. regulations, but the outcomes may well affect the entire biosphere of the globe. Treatment disallowed in one Chambers T (2016), The Fiction of Bioethics: Cases as literary texts (London: Routledge, first published 1999). country can be purchased in another one where a ban either does not exist or is not being enforced. Cole TR, Carlin NS, Carson RA (2015), Medical Humanities: An Introduction (New York: Cambridge University Press). The essential tension between universalism and Marshall MF (2007), “ASBH and moral tolerance,” in The Ethics of particularism cannot be avoided in our world that Bioethics: Mapping the moral landscape, ed. Eckenwiler LA, Cohn does not recognize the luxury of “splendid isolation.” FG (Baltimore: Johns Hopkins University Press, pp. 134–43). The Journal of Health and Culture is intended to offer İlkılıç İ, Ertin H, Brömer R, Zeeb H, eds. (2014), Health, Culture and an interdisciplinary platform for intercultural debates the Human Body: Epidemiology, Ethics and History of Medicine, among equals in the health sciences—a Habermasian Perspectives from Turkey and Central Europe (Istanbul: Beşikçizade ideal not easily realized, to be sure, but one that may Center for Medical Humanities). still be useful to pursue as the ideal that it is. Therefore, Petersen A, Bleakley A, Brömer R, Marshall R (2008), “The medical the editors invite anyone researching the interaction humanities today: humane health care or tool of governance?” between health and culture anywhere in the world to Journal of Medical Humanities 29(1), 1–4. contribute the fruits of their labor –empirical as well as conceptual results– to the growing discourse that is supporting the creation of healthcare provision to be optimally suited to the needs of specific users, given that most of them inevitably do not share the tacit cultural assumptions of their doctors who have undergone many years of special “rites of admission” to the medical community, conditioning their way of thinking and acting. Papers from any disciplinary background relevant to medical and healthcare humanities will be considered for publication, while perspectives transcending disciplinary boundaries are particularly encouraged.

The Editors

CONTENTS

The self-image of transident women since 1945 10 Livia Prüll

Cultural dimensions of bios and bioethics 24 Hans-Martin Sass

Migration and health in medical education: 36 a work in progress report from Central Europe Frank Kressing

Contributions and ambiguities in Islamic research 44 ethics and research conducted in Muslim contexts: a thematic review of the literature Mehrunisha Suleman

A review of Ottoman court records on mental diseases 56 Nil Sarı Journal of Health & Culture Original Article

The self-image of transident women since 1945

Livia Prüll

Institute of History, Theory and Ethics of Medicine, Johannes Gutenberg University of Mainz

Abstract Correspondence to: Prof. Dr. Livia Prüll This paper discusses the experiences of trans* people from historical and sociopolitical per- Institut für Geschichte, Theorie spectives, going chronologically back to the post-1945 era. Medical history may help us ex- und Ethik der Medizin, Johannes- Gutenberg-Universität Mainz, Am plain ethical problems in medicine that we are facing today. The basis of our account is the Pulverturm 13, D-55131 Mainz, individual, the woman with trans*-identity; and we will ask how she is handling her identity. Germany [email protected] This is a key point in explaining a phenomenon which even today is not treated as adequately and appropriately as it should be. In this paper we will correlate the biographical experiences with the emergence of the transident self-image. First we will have a look at two transident lives, of Roberta Cowell (1917–2011) and myself, and then, building on these, we will address the concept of trans*-identity, its character, realization, and applications, and the self-image of transident women. Furthermore we will see how medicine is viewing and reacting to these processes. Keywords: transident women; trans* people; trans*-identity; Roberta Cowell; transsexuality

12 J Health Cult 2016;1(1) Prüll The self-image of transident women since 1945

Introduction out that my own biography has many similarities with Cowell’s. Furthermore, for reasons of confidentiality, I am writing this paper as a double-composite being. it is easier to talk about oneself than about any other On the one hand, I am trans*sexual myself, and on the fellow transident. other hand I am a scholar working academically on the topic. This position is comparable to the one oc- In the second section, I will use both biographical cupied by women writing on the history of feminism, examples to deduce the concept of trans*-identity. In having a specific access to the topic. Of course, this the third part, I will again use this concept to elaborate circumstance has an impact on the paper. On the one the necessary steps to deal with trans* persons today. hand, I will talk about my own biography; on the other hand, I will consider the context of history of medicine Two transident lives and medical ethics. The aim is to explain the history Roberta Cowell (1917–2011) of trans* people in West Germany after 1945, while at the same time a solution for handling trans*-identity Roberta Cowell (1917–2011) was born as Robert Cow- in our times should be worked out. ell, the son of a high-ranking officer and military surgeon in the British army, Sir Ernest Marshall Cowell. Before starting, I would like to make three prelimi- Her childhood was without greater disturbances. After nary remarks regarding the title of the paper: Firstly, her school time, she started studying aviation engi- when talking about trans* women, I am doing this on neering in 1933 and tried to become a member of the behalf of the faithful scholar, because the examples I Royal Air Force in 1936, but she had to terminate this am discussing are two trans* women. But all my results career because she suffered from air sickness. There- are also applicable to trans* men and even intersexual fore, she took up studying engineering at University persons. Secondly, the self-image of the trans* women College London in 1936 and started car racing in the is suggesting a focus on the individual experiences of very same year. In 1939, she owned three cars and had trans* people. But for me, this is only the starting point already earned several prizes. In 1940, she tried again to explain trans*-identity as such and then to deduce to join the Royal Air Force, this time with success. Af- an adequate way of dealing with trans* people. Thirdly, ter a period of training, she served between 1942 and the paper focuses –especially regarding legal aspects– 1945, and between 1944 and 1945 she was a PoW in on the situation in (West) Germany. This is owed to the Germany. currently ongoing debates there. But the basic ques- After World War II, Cowell kept herself afloat with tions and the possibilities suggested to cope with these some minor commercial activities and then returned questions are also applicable and being seriously dis- to car racing, this time on an international level, cussed in other societies. founding her own racing team in 1946 (Bouzanquet First, I will discuss the self-image of the trans* 2009). However, she experienced a psychic break- woman using two examples. The first one is the life of down, struggling with a severe identity crisis. She suf- the English racing driver and pilot ace Robert Cow- fered from depression, and in 1948 got divorced from ell (1917–2011). In 1952, she underwent sexual reas- her wife, whom she had married in 1941, and then signment surgery; she is believed to be the first trans* consulted two psychotherapists. The second therapist woman in England to have undergone reassignment enabled her to experience the unconscious female side surgery as well as having obtained an official change of of her character, which had been suppressed during marital status. Whereas this example tackles the 1950s her previous life. Starting in 1950, Cowell took estro- and the desperate efforts of trans* people to claim their gens, but she continued to live as man. Michael Dillon, rights and their acceptance, the second example deals her endocrinologist, who argued for the possibility with our current situation. I would like to write about that everybody should choose his or her own sex, un- myself, thus being able to discuss the contemporary dertook an orchiectomy, which at the time was illegal context in a different culture. Interestingly, it turns (Kennedy 2007, pp. 90–2). Furthermore, a gynecolo-

J Health Cult 2016;1(1) 13 Journal of Health & Culture Original Article gist certified Cowell to be “intersexual,” because in that through male behavior—car racing and flying. Even- period in Britain, this was the only chance officially to tually, her inner desperation caused her to see psy- change one’s marital status. Finally in 1951, surgeon Sir chotherapists, who she initially –if one believes in her Harold Gillies performed sexual reassignment surgery, autobiographical notes– consulted without any further which until then he had only tried in corpses (Ken- plans and prejudices. The following quotation shows nedy 2007, pp. 97–9; Cowell 1954a; Cowell 1954b). her process of self-definition and self-finding, which felt to be a painfully long process: While her car racing team and the textile com- pany did not yield a profit, it was, above all, her bi- “I had to acknowledge the extent of my physical ography that saved her financially. In 1954, an article abnormalities then, and I finally stopped fighting about Cowell was published in Picture Post (Picture against my femininity. I became a feminised male, Post 1954). In the same year, she published a book then a boyish woman, and finally a feminine woman. entitled Roberta Cowell’s Story, an Autobiography. The It is extremely difficult for me to realise now that I latter was remarkable because, according to her state- was once a Spitfire pilot with a liking for pretty girls” ments, trans* people also could have a heterosexual (Cowell 1954a, p. 4). orientation, whereas in contemporary discussions The second point is her self-image which she con- trans*sexuality was strongly associated with homosex- ceived eventually. This self-image was born out of her uality (Cowell 1954a). In 1954, the work was translated own experiences but also shaped by the ideas about into German (Cowell 1954b). In the same year, on the womanhood popular at that time. The psychotherapists occasion of this publication, the German magazine and the other medical specialists she visited convinced Der Stern began to publish its own series on Cowell’s her that she actually had always been a woman and, in life. This series elicited numerous letters from readers, fact, had never been a man. The supposed discovery demonstrating how much attention was paid to the that her organic matrix was female was supported by phenomenon of trans*sexuality (Cowell 1954c). contemporary notions of a dichotomous, twofold clas- Nevertheless, her further life was not very happy. sical gender model. In 1970, Cowell even claimed to be She continued car racing, and the purchase of an air- intersexual with XXY chromosomes. This would have plane did not pay off but rather plunged her into debt. justified her sexual reassignment and allowed her to In addition, she had problems finding a job. She re- label men with the ordinary XY genotype who under- tired into private life and died very lonely in Hampton went surgical operations as freaks. Because these men near London in 2011 (Bell 2013). in her view were in fact not women, their reassignment was inacceptable to her (Bateman 1972). In this These are the essential steps of her biography. Two case however, given that she had two children, it re- important points are remarkable. The first one is the mains unclear how Cowell could have been fertile. Yet long and painful process of her self-discovery. Cowell in our context, it is not relevant to ask whether she was was not one of those trans*sexuals who know about intersexual or whether she was a “real” woman. Rather, their identity from early childhood and enjoy playing what remains the most important point for us is her with dolls and wearing their grandmothers’ clothes. self-definition. Her way of defining herself shows how Only since about 1946, Cowell had the intense feeling convinced she was to be psychically and physically a that something was amiss with her, without any pre- “real woman.” She had already arrived at this point in cise knowledge about the origins of these impressions. the course of her assignment process in the 1950s, as Her emerging erotic feelings toward men, in addition the following quotation shows: to her lack of interest in male clothing, disturbed her. She was not keen to be attractive and turned up in “By now I had accepted the fact that nature had worn-out shirts and trousers. All the time, she was in originally intended me to be female, but for the pur- search for new activities, not being satisfied with her pose of some grim joke, had supplied me with male life. These problems were being compensated by her organs. Although I was tremendously upset and em-

14 J Health Cult 2016;1(1) Prüll The self-image of transident women since 1945

barrassed when I realised this, it explained a great me forcefully in the changing room of the gym, which deal about my nature and character that had always I could barely prevent. been a puzzle” (Cowell 1954a, p. 106). After graduating in history, medicine, and philoso- Cowell fulfils all conditions of an unambiguous phy, I went to Berlin, where I started to buy women’s gender assignment, which had to be considered in the clothing, e.g., high-heeled shoes and tights. I went 1950s. This gender assignment was a specific combina- through the Grunewald in Berlin in women’s clothing, tion of organic basis and social behavior. For example, painted my nails, and shaved my legs. Yet, I was still Cowell discovered in herself a maternal instinct, and not certain that I had a trans*-identity. A mixture of she learned cooking and baking to fulfil all criteria of repression and lack of understanding led me to inter- the Western European post-war housewife (Herzog pret this behavior of mine as neurotic and as a com- 2005; Herzog 2007; Eder 2009; Steinbacher 2011). pensation of being away from my hometown. During the following years, I had no trans*-exacer- Livia Prüll (1961—) bations; I focused very much on working my way into I was born in 1961. My father was a psychiatrist and the history of medicine; but the topic actually never neurologist. He was quite authoritarian and merito- vanished—I still had my hidden chest containing cratic, something I felt above all, being the eldest child. women’s clothing. The problem was that I could not My mother was a medical technical assistant. She was talk about this situation because I felt awkward. But very caring, but she was very keen on socially adjusted also in these times, although I was busy with my work, behavior. This was the atmosphere in which I grew up. I did not feel satisfied, or even happy, and kept looking for something else until in August 2010 I detected that My trans*-life has been shaped by the development I was trans*. of two different strands. The first one is characterized by the feeling of belonging to the other sex and feel- Before I come back to this point, I need to intro- ing an incongruence between body and psyche. In the duce the second strand of my life, which included the same way as Cowell, I had a good childhood. How- desperate effort to develop and confirm my masculin- ever, I soon detected that something was wrong with ity. Even when in elementary school, I used to draw me, as I did not feel comfortable with my classmates heroes. During adolescence, I was obsessed with scale and thought that I did not belong to them. During the models of tanks and fighter planes in huge numbers. first decade of my life, I developed the feeling of an- I collected steel helmets from World War II and mili- other identity. I had problems when playing, having tary medals. I ordered war games from the US that en- the intense feeling of being a girl. There was a mixture abled me to replay World War II battles on my desktop. of passion and pain that I could not accept; I needed While my classmates were having a good time with hours to free myself from these feelings. This phenom- their girlfriends, I was assembling models of tanks. (I enon continued well into my adult life when I again had my first girlfriend at the age of 22.) When I was had the intense feeling of being a woman and felt the 18, I decided sign up as a volunteer for the German urgent compulsion to wear women’s clothing, for ex- Army and applied to a rocket battalion, begging to be ample. Again I needed hours to suppress these emo- recruited. Unfortunately, I was rejected, which was tions, of which I felt ashamed. frustrating for me. Then, as a student, I used a chest expander to work out my muscles. I received reactions During adolescence, I tried to change my ap- such as, “My god, this is not you.” On the other hand, pearance into a woman, using appropriate tools and nobody could tell me who I was—or who I am. facilities. At this time, I also had a disturbed body perception, having problems to show myself naked to This second strand is important insofar as it has to other boys—something we were supposed to do in the do with the discovery of my trans*-identity. In August school showers after physical education lessons. On 2010, I came across a commentary that potential trans* one occasion, three of my classmates tried to undress women very often compensate their identity with ef-

J Health Cult 2016;1(1) 15 Journal of Health & Culture Original Article forts to hide behind masculine behavior. This insight week—or twice, or three times, or more; but it can also caused a breakdown of the most important supporting be bodily sexual reassignment without changing the column of my repression. I knew within minutes that I public appearance or, conversely, changing the public was trans*, and I read that it was important to act out appearance without bodily sexual reassignment, or and adhere to one’s own identity. I have been coached both changing the public appearance and undergo- by a specialist since April 2012, taking hormones since ing bodily sexual reassignment. A trans*-life could be January 2013, and I have been living as a woman since maintained with the feeling to be a “real woman” or 1 March 2014. –as is more frequent today– as a trans* woman. That is, trans*sexuality is only one option to realize the When we compare my story with that of Cow- trans*-identity. There are also quite different solutions ell, we can see that similar to Cowell’s case there is a for the self-image, too. The question is not whether to compensation of the trans*-identity with strong ef- become a woman or not. On the contrary, it is impor- forts to emphasize masculinity. Furthermore, there is tant for the individual to find her own way to realize a no awareness of the phenomenon early in childhood. trans*-life for an entire lifetime and at the same time Moreover, the eventual discovery was a painful pro- to remain an active member of society, working and cess after a long period of uncertainty. caring for a family. This self-image can be developed There are, however, differences regarding the out- only by the person her- or himself, although support come, in the self-image developed by Cowell and by may be needed. Both of the cases presented above in- myself. In contrast to Cowell, I do not feel as a “bio- dicate that solutions can be very different. It is a long logical woman”, but as a trans* woman. This means and uneven process fraught with any number of pecu- that I do not fight my masculinity, that I accept it as liarities, shaped by reflections on one’s own situation one part of mine—something that in my view is typical and efforts to find the right way to go into the public as for most trans* people today. Of course, I try to appear a woman (Born 2014). as a woman as well as possible, but I have no problem with my bodily traits that allow me to be identified as Cross-dressing Trans*sexuality a trans* woman. Figure 1. The spectrum of realizing the trans*-identity. These two biographical sketches with their self- imagery give us a basis to construct the concept of It is important to consider now that trans*-identity trans*-identity. covers an extreme variety, which in principle can also be found in nature in general, regarding both sexes. The concept of trans*-identity Organic beings are not machines. Sex and sexual life The character of the concept are products of different factors and are so complex that it is simply not possible to find the Platonic real- On the following pages, we will focus on two ques- ization of “feminine” and “masculine.” “Sex” and “gen- tions: How can we explain these two different exam- der” are not stable categories, but fluid stages of transi- ples of self-identification? And which basic ideas on tion (Planert 2000; Hirschauer 2004; Schnier 2012). In trans*-identity derive from them? this sense, no pathological structure of trans*-identity The concept is very helpful in this pursuit. One could be found until today. Therefore, the phenom- important finding is that the life of a trans*person is enon is no disease, no “gender identity disorder” (Ge- characterized by uncertainties and breaks. There is no schlechtsidentitätsstörung), as German psychiatry still straight line toward a sex change process on the basis claims (Lieb et al. 2012). By contrast, it is an identity of a binary gender model. Moreover, it is important of its own, a variety of gender identity (Geschlechts- that every person in question finds their own way of identitätsvariante), and it is a challenge to explore the living on a broad scale of different solutions to real- character of this identity and develop a way to live with ize a trans*-life. This could be cross-dressing once a it. Only if a person does not accept to live with this

16 J Health Cult 2016;1(1) Prüll The self-image of transident women since 1945 identity, she will get ill. Medical help therefore is most- identity– was written in 1910; it contains the following ly needed for difficulties caused by the (social) envi- statement: ronment. Primarily, this identity is not a disease, but “Regarding the cases themselves, it should be re- a phenomenon that needs to be sorted out in its char- marked that I have followed up most of them for acter individually (Rauchfleisch 2014, pp. 14–27). This many years, some for 10 or 12 years and longer...” condition is comparable to the phenomenon of a situs (Hirschfeld 1910; quoted in Herrn 2005, p. 54). inversus in anatomy, where the locations of unpaired organs are switched between the left and right sides of For Hirschfeld, these “transvestites” included different the body. This situation does not represent a disease, “intermediate stages” (Zwischenstufen): hermaphrodites, but a variety; and the same is true for trans*-identity. homosexuals, and several types of heterosexual people. Furthermore, Hirschfeld pointed out that persons being The concept is old, having been developed by differ- supervised by him were integrated into society and that ent researchers since about 1900. This was only a side- they were keen to keep this status. Hirschfeld described line of sexual science, drowned not least by the rise of this insistence in one of his studies: National Socialism, and it came back to Germany only in the 1960s. One of the most prominent representatives “Among 16 male transvestites, 9 are married, 7 fa- today is Udo Rauchfleisch, a psychoanalyst from Basel, thers, 2 of them even have married twice out of love; Switzerland. What these scientists did was simply taking and the 7 singles, too, ejaculate normally [which their time to listen to their clients’ stories. means on a heterosexual basis and not as homosexuals]; the female case is also married, menstru- The realization of the concept ates regularly and has given birth” (Hirschfeld 1910; quoted in Herrn 2005, p. 59). The biographies of Cowell and Prüll are delivering defining factors of the trans*-life. In a similar way, We can see that Hirschfeld describes basic features these were already delineated by researchers around of the concept of trans*-identity, a term that was to be the year 1900 through differentiated talks with their coined decades later: the complexity of the different respective clients. These scientists thereby developed biographical accounts, the consensus of the transident an alternative strand to the dominant worldview of persons regarding their wish to integrate themselves psychiatry which was mainly shaped by visions about into society, and even a certain depathologization. In trans*sexuality. The key focus of these other scientists 1910, Hirschfeld used the term “transvestitism,” and was talking to their patients. The researchers heard in 1923 he spoke of trans*sexualism (Hirschfeld 1910; about ambivalences and various difficulties to handle quoted in Herrn 2005, p. 19). With his “Institute of Sex- the trans*-life. These life events were accepted as they ology” founded in Berlin in 1919, Hirschfeld set up the stood; the researchers did not try to define the phe- first institute of this kind in the world. It was successful nomenon with typical psychiatric nosological catego- not only in research, but also through life coaching of ries. Moreover, they tried hard to work out the unique trans* people. The worldview of the respective persons character of each client’s life story, then being able to needed to be taken into consideration. Hirschfeld de- find an adequate way of communicating and dealing veloped his theoretical notions on the basis of careful with the transident person. observations (Herrn 2005, p. 53–72). This was a long story, which can only be outlined in Yet in 1931, Hirschfeld’s activities came to an the following paragraphs. One prominent person re- abrupt end as he became a victim of the national so- presenting early research on trans*-identity was Mag- cialist anti-Semitic attacks. In the same year, he em- nus Hirschfeld (1868–1935). He spent his career in barked on a journey around the world, but he did not Berlin and belonged to the founding fathers of sexol- return to Germany for safety reasons. His Institute in ogy. His decisive publication on transvestitism –a term Berlin was destroyed by party men and sympathizers that at the time included the phenomenon of trans*- of the Nazi government in 1933. In 1935, Hirschfeld died in Nice. His theories were now followed mainly

J Health Cult 2016;1(1) 17 Journal of Health & Culture Original Article in the US, which had been one station of his jour- tor of Hirschfeld’s basic ideas that were then reimport- ney. In 1907, Hirschfeld had made the acquaintance ed into West Germany during the 1960s. At first, Ben- of the American psychoanalyst Harry Benjamin jamin’s influence was limited because trans*sexuality (1885–1986), with whom he had maintained contact had been pathologized by German medicine since ever since. Benjamin took up Hirschfeld’s theories about 1800. and included them into his own theoretical approach What was the basis for these conditions? The regarding trans*-identity after World War II. Similar bourgeois program to order the world during the 19th to Hirschfeld, Benjamin differentiated between dif- century was the decisive background movement. The ferent types of the phenomenon, which he termed erection of bureaucracy to structure social life was transsexuality; his classification of his clients shifted accompanied by ordering nature and mankind. This between the “principally psychogenic transvestite” process was supported by contemporary medicine, and the “psychosomatic transsexualist” (Herrn 2005, which undertook the breath-taking step to link re- pp. 219–20; Benjamin 1954). Although paternalistic in search into the organic matrix of the human with her his diction, similar to Hirschfeld, Benjamin was pri- psychic constitution and her social behavior. In this marily approachable for his patients. His theories were sense, the Italian forensic medicine pioneer Cesare also based on observation of his transident clients and Lombroso (1836–1909) could postulate the theory on conversations with them. Benjamin questioned the that criminals could be recognized from their physiog- meaning of psychotherapy and appealed to society’s nomy: Specified attributes such as a receding forehead responsibility for transident persons: or sunken eyes were signs of degeneration and delin- “Transvestism may be successfully handled by psy- quency (Mosse 1990). Exactly on this basis, medicine chotherapy if the patient desires a cure. Otherwise it dealt with sexes when erecting the “bourgeois order of can only be treated by treating society and our legal sexes” (Honegger 1991; Schössler 2008): Woman and statutes with their interpretations” (Benjamin 1954, man were allocated to a specific typology, in which p. 52). body and soul, a specific organism and a specific social behavior corresponded to each other. Trans*sexuals Eventually, the increased collaboration and partici- and transvestites did not fit into this scheme and were pation of the clients were in the focus of his main work assigned to the group of degenerated and pathologi- The Transsexual Phenomenon, published in 1966: cal individuals. One of the most well-known represen- “More power, therefore, to those brave and true sci- tatives of this medical approach was the psychiatrist entists, surgeons, and doctors who let the patient’s Richard von Krafft-Ebing (1840–1902) from Graz. In interest and their own conscience be their sole his main study Psychopathia sexualis (1886), he con- guides” (Benjamin 1966, p. IX). structed categories of deviant behavior on the basis of Right from the start, Benjamin was aware that he an analysis of apparently natural human sexual prac- would incur difficulties with his publication, because tice (Krafft-Ebing 1868). In 1870, the Berlin psychia- he pointed out the mismanagement and unsuccessful trist Carl Westphal (1833–1890) invented the term of therapeutic efforts in contemporary medicine: “contrary sex-sensation” (conträre Geschlechtsempfin- dung). Wearing clothes of the opposite sex was inter- “I have seen too many transsexual patients to let preted as an unambiguous indication of a “pathologi- their picture and their suffering be obscured by un- cal condition” (Herrn 2005, p. 26). informed albeit honest opposition. Furthermore, I felt that after fifty years in the practice of medicine, The sign of being pathological has been attached and in the evening of life, I need not be too con- to trans* people since then, while routinely applicable cerned with a disapproval that touches much more methods of treatment have been developed only since on morals than on science” (Benjamin 1966, p. IX). the 1960s. Surgical reassignment was then successively improved and introduced as a routine measure, in addi- This made itself felt when Benjamin became a vec- tion to psychotherapeutic care. Benjamin’s influence in

18 J Health Cult 2016;1(1) Prüll The self-image of transident women since 1945 this sense cannot been underestimated. He had a huge image and feeling of a person regarding her sex. These influence on sexologists Hans Giese (1920–1970) and disciplines push their clients into a patient career, re- Volkmar Sigusch (Sigusch 1995; Stryker 2008). But the quiring an admission of being ill in order to have the socio-critical aspects of Benjamin’s theories faded into official change of sex granted (Güldenring 2013). Dur- the background, as transident clients were not treated ing the 1980s, trans*sexual people saw the TSG as a as a variety of regular conditions. In contrast, they success, since the pathologization was seen as a step were seen as deviant and as carriers of a personality towards defining their status and put an end to lawless- disorder. In the 1970s, psychiatrists, psychotherapists ness and disregard for the respective persons. Patholo- and sexologists detected the underlying trans*sexual gization was and is necessary for medical insurance person as a patient. The problem was and is that the companies, given that the agreement to cover the costs therapist’s view remain restricted to those wanting to for medical interventions remains linked to the status “become a woman.” The broad range of trans* people, of being a patient. especially cross-dressers and their problems, remained But in last consequence, this solution remained to be seen as non-existent. The restricted horizon of fragile, because even intense discussions could not pre- the psychiatrists was focused on the inspection of the vent the failure of coordination and systematization of trans*sexual person. Possible changes and shifts in therapeutic efforts, nor was it achieved to base psychi- their life, even transition between woman and man, atric measures on scientific evidence (Haupt 2012, p. was not considered. In this sense, the treatment was 24). All shortcomings and failures regarding the han- concentrated on the “sex-identity-disorder,” with the dling of transident people were brought to the pub- aim to assign a person permanently as woman or man, lic’s attention by the sexologist Volkmar Sigusch, who backed by 19th-century visions of reordering the role sought to initiate changes with his book Geschlechts- of gender and sexes. Psychiatrists tried hard to squeeze wechsel [Sex Change] (1995). But his initiative was not trans*-identity into their own nosology instead of ac- realized in German psychiatry, which in principle still knowledging the phenomenon with its multitude of orients itself toward the guidelines described earlier. expressions—thus avoiding to accept that there is no The term trans*-identity is almost absent from recent reason for pathologization (Haupt 2012, pp. 22–30). German textbooks on psychiatry or sexology. In spite The Trans*sexual Act (Transsexuellengesetz, TSG), of all the efforts to go ahead with respective clients coming into effect in Germany in 1980, was helpful in and to achieve a better understanding, the main line this sense. It conclusively regulated the official change of strategy is bound to the idea of finding some sort of given name (“small solution”) and/or the marital of diagnosis and thereby to pathologize these persons. status (“big solution”). Prerequisite was and is answer- Under the heading trans*sexualism or trans*sexuality, ing three questions: Is the person in question trans*/ there is an attempt to treat a “gender identity-disorder” trans*sexual? Has she or he had the imperative idea to (Beier et al. 2005; Berger 2012; Tölle & Windgassen live in the respective sex for three years? Is this a per- 2012; Lieb et al. 2012). This demonstrates how unre- manent condition? Until February 2011, surgical reas- alistic the approach of the specialists dealing with the signment was necessary for both solutions, until the phenomenon is, since they concentrate only on the Federal Republic’s Constitutional Court declared this minority of trans* persons who attain full sexual as- prerequisite as inhumane. Nevertheless, from 1980 signment, thus being unable to understand the full im- until today, two psychiatric references are needed to pact of the phenomenon. Only clients undergoing full accept the changes officially. Setting aside the point sexual assignment are “healed,” and “cross-dressing” that the need for permanence contradicts our basic is thought to be a “perversion.” A moderate handling knowledge about the concept of trans*-identity, even of trans*-identity is described with skepticism: “Many the psychiatric references mean to pathologize and authors are pleading for a ‘de-pathologization’ of trans- stigmatize the person in question. Psychiatry and re- sexuality” (Lieb et al. 2012, p. 325). Even Sigusch, who lated disciplines presume the right to judge the self- invoked a decisive turn in psychiatric therapy with his

J Health Cult 2016;1(1) 19 Journal of Health & Culture Original Article statements, for a long time reduced the phenomenon Final remarks: two biographies and the conse- to “transsexuality” (Sigusch 2005). At the same time, quences for dealing with trans* people today insurance companies have not abandoned the formula The self-image of the transident woman and the ap- to couple the decision for payment of medical inter- plication of the concept of trans*-identity vention with the necessity to label the respective problem as “pathological” (Güldenring 2013, p. 165). After the description and analysis of the history of the concept and its consistent and still developing affirma- Decisive impulses to revive the idea of trans*-iden- tion, we come back to the two biographies outlined in tity and the renewed framing of this theory for a prac- part two. Taking another look, we will ask now about tical contemporary application go back to the first de- the validity of the concept in the light of the perspec- cade of our century and are connected with the name tives we can find in both trans*-lives. of Udo Rauchfleisch. For about ten years, dealing with trans* persons has undergone tremendous changes. In First of all, I will return to the dependency on the the sense of the basic ideas of the concept (as outlined historical period in performing the own (hidden) above), Rauchfleisch calls explicitly for a de-pathologi- identity. Cowell and Prüll, respectively, detected and zation of the persons in question and thus also argues realized their identities in a different historical context against the TSG and its recent application (Rauch- regarding gender role performance and gender assort- fleisch 2014, pp. 14–27, 206–7; Haupt 2012). On this ment. Cowell experienced this process in an atmo- path, today we come back to the ideas of Hirschfeld sphere of a rigid demand for living a classical 19th-cen- and Harry Benjamin’s influences on his work. Similar tury bourgeois family life with a clear-cut idea how to to these preceding approaches, Rauchfleisch integrates play the role of the housewife. The self-identity inter- impulses given by self-help groups and concentrates pretation as a “real wife” chosen by Cowell was in this on the trans*-subject herself: sense a tribute to the strict binary characterization of the organic and social realization of women and men “Since then, I’ve seen approximately a hundred during a historic period when Western societies were transsexual clients on the occasion of medical assess- seeking a socio-political stabilization after the crisis ments, later on also during the therapeutic prepara- of war. Although this interpretation of being a “real tion of surgical reassignment and in cases of crisis woman” is still chosen today by some trans* women, intervention, problem clarifications and subsequent for reasons that cannot be discussed here, the tempta- psychotherapies. In this course, I’ve detected that tion to adhere to it during the 1950s was much great- the so-called ‘transsexual personality’ does not exist. er than today. In contrast, when Prüll chose another More and more I’ve made the experience, above all variant, it did not happen by chance. Since the 1990s, during the last ten years, that there is a huge num- gender diversity became very fashionable in the natu- ber of totally different personalities with deviating ral and human sciences. With her “cyborg manifesto,” biographical developments, hidden under the title Donna Haraway undermined strict and rigid lines of ‘transsexuality’” (Rauchfleisch 2009). argument in the feminist movement, culminating at Again and again, Rauchfleisch had met transident the end of the 1970s: The “cyborg” as a hybrid subject persons who “did show absolutely no signs of psy- now served as a model for the ideal type of a wom- chopathology and –in contrast– had a huge psychic an, which was able to carry the combination of dif- stability.” These persons demonstrated a tremendous ferent motions and attitudes—“progressive” ideas on capability to cope with burdens as psychic disturbanc- women’s rights as well as more “conservative” lifestyle es, which were mainly caused not by their identity, options. Thus, Haraway called for tolerance among but mostly by “difficult conditions of their lives” that women as well as for accepting more difficult types of trans* persons are often confronted with (Rauchfleisch “mixed” beings in general. In this sense, her student 2014, pp. 7–8). Sandy Stone, a transident woman, responded to attacks brought forward in the book by radical feminist Janice

20 J Health Cult 2016;1(1) Prüll The self-image of transident women since 1945

Raymond, Transsexual Empire (1979). Stone wrote her developed their self-identity this way. In the center is Posttranssexual Manifesto in which she argued that the transident being herself, whose path is influenced trans* people should not hide and disappear among by coaching, but who in the end decides for herself. the members of the reassigned sex. By contrast, they Therefore, we can understand Rauchfleisch’s call for should show their trans*-body engravings and make accepting the wish of the trans* person to organize them “readable” with the aim of promoting acceptance herself and to maintain her own decision-making on in society. With these ideas, a development was set in questions concerning her life. motion that found its contemporary climax in Europe with the song contest success of the transgender Con- Dealing with transident people today chita Wurst in 2014. Today, it is easier to admit openly On the preceding pages, we have shown in the context to being a trans* man or a trans* woman than in the of the respective historical background how biogra- time of Cowell. Therefore, Prüll’s own decision to live phies of transident people can enable us to construct as a trans* woman is backed by contemporary notions the concept of trans*-identity. If we now take this con- on the subject. cept as a valid basis to deal with trans* people, we need Of course, it is important to consider also the simi- to draw consequences for further decision-making larities of both biographies. First of all, there is the and action. We can identify the following aspects: difficult decision-making regarding the realization of 1. Trans*-identity and trans*sexuality are not path- the own identity, which is definitely not standardized. ological conditions. They are not disturbances Rather, this is a complicated process of evaluating and but variants. We know that conditions of sexual- deciding about one’s own position on a scale between ity and gender are extremely complicated systems, rare cross-dressing and a fully implemented life in the depending on a number of different psychological new gender/sex role. The mechanism leading to the and bodily factors, and the Platonic idea of man development of a new self-identity is of importance. and woman are constructs of bourgeois 19th-cen- This can be described as an interchange between dif- tury society and especially its medicine. If there ferent levels of action (see Figure 2). are disease symptoms, they are due to two factors: First, there are problems with the social environment, caused by resistance of relatives, friends or other people to the person’s reassignment. Second, transident persons, too, can be affected by psychiatric diseases, but on average these occur at the same rate as in the general population. This means that psychiatric diseases have nothing to do with trans*-identity itself (Rauchfleisch 2007; Rauch- fleisch 2014). 2. Since “intermediate stages” of gender are not Figure 2. The development of the self-image in a transident person. pathological, the binary gender model must be rejected as providing absolute categories of gender In the case of Cowell as well as Prüll’s, the clari- assignment. The challenge for a trans* person is fication of how to go ahead is influenced very much not necessarily to become a “real” woman or man, by supportive individuals. Information given is linked but to find an orientation on a broad scale of op- with self-reflection as well as “trying” to keep up the tions towards the best way to lead the individual appearance of a woman in private and in public. The life and to remain or to become a fully accepted triangular relationship between these different ac- and functioning member of society. tivities is decisive for circular decision-making, self- organization and self-interpretation. Both persons

J Health Cult 2016;1(1) 21 Journal of Health & Culture Original Article

3. Therefore, transident people are not patients or and gender, the impact of bodily conditions and clients of psychiatrists, whose help can only be im- feelings as well as the respective individual’s ex- portant in two cases: First, they could be a coach periences are complicated processes that can be for coping with questions of leading the trans*-life, evaluated only by the person him- or herself. which is important for such a person in order to Therefore, it is a presumption for psychiatrists to orient herself in a world still dominated by a binary claim decision-making in this area. Psychiatrists gender role model. One prerequisite is of course should give up their role as referees in the frame that the psychiatrist is trained to guide trans* peo- of the Trans*sexual Act (Güldenring 2013, p. 173; ple and has specialist knowledge on the subject. It Rauchfleisch 2014, pp. 206–7). should be mentioned here that all helpers of trans* The free choice of sex registration should be ac- people should work together more closely and also companied by administrative changes in official regu- keep contact with different institutions and with lations of marital status, since it should be assured that self-help groups caring for the interests of those this registration can be changed freely. There are no people. Second, the psychiatrist’s role could be to arguments against such a step. One can be sure that treat psychiatric disturbances caused by secondary only persons who definitely want to do so will under- influences on the respective person or genuine psy- take the measure. Since the change is an official pro- chiatric diseases. cedure, suspicions of false intent are not appropriate. 4. If there are no medical counterarguments, trans* Cases of psychiatric reasons for sex change, e.g. delu- people should get free access to hormones, they sional wishes to belong to the other sex, should also themselves should decide whether they need sex not count as arguments against changes of marital reg- reassignment surgery or not. Since trans*-identity ulations. First of all, these cases are rare, and secondly, is not a pathological condition, the assent of the even if the applications are successful, there is no dam- psychiatrist is not necessary. Of course, advice of age to the health of the persons in questions and there an endocrinologist or a surgeon is needed for deci- is no violation of the interests of any other persons. sion-making to avoid health risks and damages. If Finally, in this context it is important to think there are serious doubts regarding the existence of about a general reform of sex registration in official a trans*-identity, further advice should be given by documents. As has become clear when looking at the appropriately educated colleagues. cases of New Zealand and Australia, the entry speci- 5. Insurances should pay for trans* people even fying the person’s sex is not necessary to prove their if their status is not pathological. This should be identity, and no international problems are caused. comparable to the financial support for pregnant There are no legal arguments which give definitive evi- women, who are also not sick in general. Although dence of any disadvantages. Reasons for keeping the the discussion in Germany is difficult, there is no old regulations are only based on traditional family alternative to taking these steps, as it is indispens- policy-making and bound to respective theories. able to depathologize the transident person. The This paper intended to explain how it is possible times are gone when the Trans*sexual Act with its to derive a concept of trans*-identity from different pathologization was seen as a success, because at biographies—individual experiences and the “cre- least some attention was paid to the specific situa- ation” of a personal identity. In this way, a theory was tion of trans* persons. rediscovered and revived, a theory that had been lost 6. Trans* people should choose the official sex en- until recent time due to the centuries-long dominance try they want. There are no arguments against the of psychopathological approaches. In the last conse- free choice of sex. The Trans*sexual Act should quence, the main aim is to enable trans* persons to live be abandoned for the reasons given above (Gül- in a congruence of psychic and bodily sex. This feeling denring 2013, p. 161). The development of sex of congruence is taken for granted by the majority of

22 J Health Cult 2016;1(1) Prüll The self-image of transident women since 1945 people. Why is it so difficult for societies to concede Cowell R (1954b), Ich war ein Mann—Die vollständige Au- this option to trans* persons? Whoever asks how to tobiographie einer ungewöhnlichen Frau (Vienna: Paul deal with those people, eventually –if not intention- Zsolnay Verlag). ally– raises the topic of how to deal with all those who Cowell R (1954c), “Ich war ein Mann,” Der Stern 12, 4–6 & are “other” and who do not fit into the scheme of the 50–1; 13, 10–1 & 42–3; 14, 11–2; 15, 13–4 & 50; 17, 28. Eder FX (2009), “‘Liberalisierung’ und Kommerzialisierung average citizen. This means that to ask about trans* des Sex nach 1945,” in Kultur der Begierde: eine Geschich- people also means to ask about the social conditions te der Sexualität, 2nd ed. (Munich: Verlag C. H. Beck, pp. of people of other ethnic origin, other skin color, other 211–41). religion, or those being physically and mentally handi- Güldenring A (2013), “Zur ‘Psychodiagnostik von Ge- capped and, last but not least, about the situation of schlechtsidentität’ im Rahmen des Transsexuellengeset- women in general. Thus, the question of social interac- zes,” Zeitschrift für Sexualforschung 26, 160–74. tion with everyone in any of those categories is a chal- Haupt H (2012), Die Pathologisierung transsexueller Men- lenge for the democratization of the respective society. schen beenden! (Altdorf, Uri/CH: Sozial Psychiatrischer Dienst Uri, pp. 22–30), available at http://www.spduri. ch/fileadmin/dateien/downloads/Die__Pathologisie- References rung_transsexueller_Menschen_beenden.pdf, accessed 25 April 2016. Bateman M (12 March 1972), “Atticus,” The Sunday Times, Herrn R (2005), Schnittmuster des Geschlechts: Transvesti- retrieved from http://www.lizhodgkinson.com/lh/ tismus und Transsexualität in der frühen Sexualwissen- pages/journalismArticle/interview_with_transsexu- schaft (Giessen: Psychosozial-Verlag). al_roberta_betty_cowell, accessed 29 September 2014. Herzog D (2005), Die Politisierung der Lust: Sexualität in der Beier KM, Bosinski HAG, Loewit K (2005), Sexualmedi- deutschen Geschichte des zwanzigsten Jahrhunderts (Mu- zin: Grundlagen und Praxis, 2nd ed. (Munich: Urban & nich: Siedler Verlag). Fischer, pp. 365–412). Herzog D (2007), “Memory, morality, and the sexual lib- Bell M (27 October 2013), “‘It’s easier to change a body than eralization of West Germany,” in Conflict, Catastrophe to change a mind’: the extraordinary life and lonely death and Continuity: Essays on Modern German History, ed. of Roberta Cowell,” The Independent, available at http:// Biess F, Rosemann M, Schissler H (New York: Berghahn independent.co.uk/news/people/profiles/its-easier-to- Books, pp. 273–96). change-a-body-than-to-change-a-mind-the-extraordi- Hirschauer S (2004), “Social studies of sexual difference: Ge- nary-life-and-lonely-death-of-roberta-cowell-8899823. schlechtsdifferenzierung in wissenschaftlichem Wissen,” html, accessed 9 September 2014. in Gender Studies: Wissenschaftstheorien und Gesell- Benjamin H (1954), “Transsexualism and transvestism as schaftskritik, ed. Steffen TF, Rosenthal C, Väth A (Würz- psycho-somatic and somato-psychic syndromes,” re- burg: Königshausen & Neumann, pp. 19–41). published in The Transgender Studies Reader, vol. I, ed. Hirschfeld M (1910), Die Transvestiten: eine Untersuchung Stryker S, Whittle S (New York: Routledge, 2006, pp. über den erotischen Verkleidungstrieb (Berlin: Alfred 45–52). Pulvermacher), quoted in Herrn R (2005), Schnittmuster Benjamin H (1966), The Transsexual Phenomenon (Boston: des Geschlechts: Transvestitismus und Transsexualität in Human Outreach & Achievement Institute, p. IX). der frühen Sexualwissenschaft (Giessen: Psychosozial- Berger M (2012), Psychische Erkrankungen: Klinik und The- Verlag, pp. 19, 54, 59). rapie, 4th ed. (Munich: Urban & Fischer). Honegger C (1991), Die Ordnung der Geschlechter: Die Wis- Born J (2014), “Free Gender: Ein autobiographisch gefärbter senschaften vom Menschen und das Weib,(Frankfurt a. Essay von Jacqueline Born,” in Transsexualität– M.: Campus Verlag). Transidentität: Begutachtung, Begleitung, Therapie by Kennedy P (2007), The First Man-Made Man: The Story of Rauchfleisch U, th4 ed. (Göttingen: Vandenhoeck & Two Sex Changes, One Love Affair, and a Twentieth-Cen- Ruprecht, pp. 179–94). tury Medical Revolution (New York: Bloomsbury). Bouzanquet JF (2009), Fast Ladies: Female Racing Drivers Krafft-Ebing Richard (1868), Psychopathia sexualis: eine 1888–1970 (Dorchester: Veloce Publishing). klinisch forensische Studie (Stuttgart: Ferdinand Enke). Cowell R (1954a), Roberta Cowell’s Story, an Autobiography Lieb K, Frauenknecht S, Brunnhuber S (2012), Intensivkurs (New York: British Book Centre).

J Health Cult 2016;1(1) 23 Journal of Health & Culture Original Article

Psychiatrie und Psychotherapie, 7th ed. (Munich: Else- Schnier V (2012), Gender-Kompetenz als Schlüsselqualifika- vier). tion für die Erwachsenenbildung: Theoretische Hinter- Mosse GL (1990), Die Geschichte des Rassismus in Europa gründe und praktische Umsetzungsprozesse (Berlin: Bu- (Frankfurt a. M.: Fischer). drich UniPress). Picture Post (1954), retrieved from http://www.gettyimages. Schössler F (2008), Einführung in die Gender Studies (Berlin: de/detail/3134980, accessed 9 September 2014. Akademie Verlag). Planert U (2000), “Der dreifache Körper des Volkes: Sexu- Sigusch V (1995), Geschlechtswechsel (Hamburg: Rotbuch- alität, Biopolitik und die Wissenschaften vom Leben,” Verlag). Geschichte und Gesellschaft 26, 539–76. Sigusch V (2005), Praktische Sexualmedizin: eine Einführung Rauchfleisch U (2007), “Diskriminierung Transsexueller,” (Cologne: Deutscher Ärzte-Verlag). in Was ist krank? Stigmatisierung und Diskriminierung Steinbacher S (2011), Wie der Sex nach Deutschland kam: der in Medizin und Psychotherapie, ed. Steeger F (Giessen: Kampf um Sittlichkeit und Anstand in der frühen Bundes- Psychosozial-Verlag, pp. 189–96). republik (Munich: Siedler Verlag). Rauchfleisch U (2009), Transsexualität–Transidentität: Be- Stryker S (2008), Transgender History (Berkeley: Seal Press). gutachtung, Begleitung, Therapie, 2nd ed. (Göttingen: Tölle R, Windgassen K (2012), Psychiatrie: einschließlich Psy- Vandenhoeck & Ruprecht, p. 8, translated in the text by chotherapie, 16th ed. (Heidelberg: Springer). Prüll). Rauchfleisch U (2014), Transsexualität–Transidentität: Be- gutachtung, Begleitung, Therapie, 4th ed. (Göttingen: Van- denhoeck & Ruprecht).

24 J Health Cult 2016;1(1)

Journal of Health & Culture Original Article

Cultural dimensions of bios and bioethics*

Hans-Martin Sass

Professor Emeritus at Ruhr University; Senior Research Scholar Emeritus at Kennedy Institute of Ethics, Georgetown University

Abstract Correspondence to: Prof. Dr. Hans-Martin Sass Humanity has made its existence comfortable in the life world, bios, by cultivating nature Zentrum für Medizinische Ethik and society, in an inseparable connection of living and non-living, bodily and virtual com- e.V., Ruhr-Universität Bochum, Universitätsstr. 150 NABF 04/297, ponents. Humankind is characterized by what we can call 6 C properties: communication D-44780 Bochum, Germany and cooperation, competence and compassion, competition and cultivation. Together, they [email protected] provide our species with the capability for survival and development. While humans are capable of doing good as well as doing bad, an extension of Kant’s categorical imperative to encompass all the living, as Fritz Jahr demanded with his “bioethical imperative,” can help us find a way to avoid main dangers to our survival, such as biological, electric, confidence, revolt and repression risk. Keywords: 6 C properties; Behemoth; bioculturology; bioethical imperative; bios; Fritz Jahr; Leviathan; risk

* I would like to thank Tuba Erkoc for her critical comments on an earlier draft of this paper.

26 J Health Cult 2016;1(1) Sass Cultural dimensions of bios and bioethics

Introduction: cultures and cultivations of bios er seeds fell on dry and stony land, where they grew initially but then did not have enough water and soil Bios is a Greek word meaning life. Cultivation refers to and died; other seeds fell under the bushes where they the ways in which we humans make the cruel nature were overwhelmed by those bushes and could not de- our home through agriculture as well as social and po- velop either; again, other seed fell on good land and litical cultures. Cultures are the products of cultivation bore fruit and harvest thirty times or even a hundred and vary depending on countries, people, necessities, times (Matthew 13:1–13). When his disciples asked opportunities, visions, and times. All bios is inter- him why he did not directly speak to the people about connected: I have a father and a mother; my physical the kingdom of heaven, compassion and culture, Jesus life is interconnected with over a hundred trillion of answered that he did not want to give an agricultural microbes in and on my body without which I could lecture while the people would not understand more neither live nor digest or protect myself from disease direct lectures or sermons on ethical, bioethical, social and from pathogens (Mondat et al. 2013). Individual and cultural challenges. life is finite; species life goes on for a very long time. Individual bios cannot live without other species in The Greek word bios represents a broad concept biotopes and environments. My physical, emotional, of the Chinese sheng ming [ ], meaning zest of life, spiritual, economic, and cultural and political life is joie de vivre, Lebenslust; Henry Bergson introduced the interconnected with my nutrition, my friends and term élan vital in order to underline the difference be- neighbors, my workspace, the culture I grow up in and tween invariable and static durée and life as living (Berg- in which I thrive and develop or lose myself with inter- son 1907); Darwin assigned the zest and determination acting influence from other lives in my biological and for life and survival to all forms of life when discussing social environment, with my geographical space and the “struggle for life” (Darwin 1859; cf. Engels 2012). my cyberspace. Biology studies my interrelations with Bios –life– does not only include the bodies of natural nature. Sociology, political science, and cultural, reli- beings and biotopes, but also the “body politics” of our gious, social and art history assess my interrelations in cultures and human communities; and here we have to society with fellow humans, human traditions, collec- include the bodies and lives of corporations, institu- tive beliefs and values, my private, social, and business tions, cultures, societies, as communities located geo- life. Biological and social sciences are both sciences graphically or in cyberspace and biotope. For thousands of the bios-in-interaction and of the bios-in-interde- of years, most people lived in small villages or in small pendence. Therefore, codes of ethics need to correlate cities surrounded by protecting walls; now many of us between partners in cooperation.1 Only such a broad live in high-rise buildings and super-big cities, sharing understanding of the science of bios will allow for a non-geographical cyberspaces of different kind. Most of solid concept of bioethics and its mission. our elderly people have experience with both types of small geographical communities and also cyberspace There is an old Chinese saying: “Heaven and man communities; how will our children and our grand- are an integral one. As a result they are in constant children be formed by the living environments around pursuit of harmony between humanity and nature” them (Sass 2012a; Sass 2014)? (Yue 2006). In the Western tradition, Jesus probably was the first bioculturologist, as he explained failures Modern societies are symbiotic living creatures of and successes in human life and culture in the par- natural persons, natural communities such as families, able of a farmer who sowed seeds into the land; some clans and villages or neighborhoods, and economic seeds fell on the road and were eaten by the birds; oth- and legal persons such as enterprises, institutions, bureaucracies, and similar cyberspace-based persons, communities, and powers. They all want to live well, 1 For interactive codes of conduct in the physician–patient interaction, see Sass (1994). For internet-based e-health communi- to grow, and to sustain their lives and networks; this cation, see Sass (2006a, pp. 62ff, 274ff), for public health ethics desire might lead to cooperation and support, network Sass (2006a, pp. 146–8, 378–80), and for health care policy Sass (2006a, pp. 187–9, 428–30). building, favoritism, mutual aid and help, but also to

J Health Cult 2016;1(1) 27 Journal of Health & Culture Original Article corruption and exploitation in the interest of survival beneficial knowledge.” Knowledge is a double-edged and protecting or even expanding one’s biotope and sword. Poison can kill a person, but in the right dos- influence. These tendencies of different players can age it can heal. Cain murdered his brother Abel with and do lead to dysfunctional bodies and biotopes (Fu- an axe, but axes can be and have been used for culti- kuyama 2014). vating woodlands and building houses, for defending the family against animal and human aggressors. Ein- We humans, on and off, destroy our complex po- stein’s theories and its applications gave rise to nuclear litical, cultural, social and economic communities, as energy and medical technology saving lives, but also we do these days in many Muslim and other countries, allowed for atomic and nuclear bombs to be built with a phenomenon for which we may use terms such as the purpose of mass killings and mass pollution of the “culture collapse disorder,” “social disease,” or “politi- environment. All new wisdom and technologies may cal and societal sickness,” expressing discontent, hate, enable spin-off or double-purpose applications and ideology, terror—either based on internal “metabolic” potentially devilish technologies harming, killing, or disharmony or on “infections” from the outside. Be- eradicating individuals and communities.4 cause we humans lack specific highly developed senses and survival instincts such as dogs and bats possess,2 The inseparable interrelatedness of (biological) na- in their stead we have to use six basic and species-spe- ture and (human) culture has always been recognized cific human properties separately or in coordination: by religions and cultural traditions over the millennia, “communication and cooperation, competence and and these religions and traditions have called for the compassion, competition and cultivation.” We find respect and protection of non-human forms of live.5 A these 6 C properties in all successful human endeav- truly biological and bioethical argument would follow ors and in traditional religions and communities, and Socrates, who once argued against Euthyphron that the they are the only ones we have.3 They have also been Gods did not create the virtue of piety, rather that they called values or virtues or principles, agreed upon or appreciate it because it is good and natural in itself. In- revealed or given by the Gods as commandments or deed, a look at the multitude of religions and societies instructions. In the Muslim hadith tradition (al-Tir- proves the concrete and real existence of these 6 C prop- midhi, Hadith 422) we read: “God, His angels and all erties, leading to successful, long, and cultivated life in those in Heavens and Earth, even ants in their hills and most of them. We humans have used these properties fish in the water, call down blessings on those who in- to build houses, roads, gardens, cities, farms, and facto- struct others in beneficial knowledge.” If the prophet ries, economic and social networks, both geographically lived today, he might have added “also the Googlers and in cyberspace. We have used them to cultivate cruel on the Internet and the bloggers in cyberspace should natural environments, to build peaceful and harmoni- call down blessings on those who instruct others in ous communities, to help and teach one another, and

2 Other species live in the same geographical spaces as we humans 4 We humans have bred livestock, plants and trees for millennia; do, but they perceive and live their bios worlds differently. Bees most recently we have developed the ability directly to intervene live in complex and highly structured social and biological com- into DNA and RNA as the bases of life. Scientists routinely cut, munities, but sometimes they suddenly abandon their hives, a splice, and rearrange natural DNA in order to modify bacteria, phenomenon described as “colony collapse disorder.” Dogs ori- plants and animals, to develop “designer” microbes and en- ent themselves olfactorily, bats acoustically, humans in com- zymes, to create “in-vitro-flesh,” “cultured meat,” and “transgen- munication and cooperation, in competence and compassion, ic,” “non-sentient” or otherwise “enhanced” animals to be used in competition and cultivation. Corals build reefs; beavers build for improved medical research or food production; a conference dams; birds build nests; ants and bees build states; humans build on the “Ethics on In-vitro Flesh and Enhanced Animals” was houses and streets, the Silk Road and the Internet, the auto- held on 18–19 September 2014 and sponsored by the Wellcome bahns, the airways. Cyberspace locations and environments have Trust. modified geographical distances, bridged differences, enhanced 5 In 1986, the Assisi Declaration and the Windsor Declaration communication and cooperation, yet also allowed for more and initiated by Prince Philip, Duke of Edinburgh, respectively col- different forms of deceit, harm and exploitation. lected 5 and 11 contemporary documents from various world 3 For earlier C models, cf. Sass (2008; 2011; 2012b). Influenced by religions and traditions expressing and confirming their ongoing Fritz Jahr, I have added “competition” to the five C’s presented in call and support for the respect of non-human forms of life and those earlier papers. the environments; cf. Palmer & Finlay (2003).

28 J Health Cult 2016;1(1) Sass Cultural dimensions of bios and bioethics to build sustainable social and natural environments. laede, imo omnes, quantum potes juva,” i.e.‚ “do not However, we also have used these properties to destroy, hurt anyone, but help everyone as far as you possibly to harm, and to kill people, natural and social environ- can” (Jahr 2013, p. 77). For Jahr, the Bioethical Impera- ments, communities and cultures. tive serves as a Golden Rule that can be found in many successful traditions; his article Wissenschaft vom Integrating ethics and sciences and guiding actions Leben und Sittenlehre (1926), in which he presents the Bioethical Imperative for the first time, has the subtitle Because we have the choice to “be good” or to “be bad” “old knowledge in new clothing” (Jahr 2013, p. 17). in dealing with one another and with our environment, it is good and helpful to have guidance, recom- Warren Reich, editor of the first editions of the mendations, commandments, laws, and regulations Encyclopedia of Bioethics, defines bioethics as “the regarding what to do and what not to do. Those laws, systematic study of human conduct in the area of the regulations and recommendations have been given by life sciences and the personal, professional, and public divine authorities, by political leaders, or by mutual moral commitment and conduct towards all forms of consent within communities. In 1785, Immanuel Kant life, in as far as this conduct is examined in the light of demanded that the Categorical Imperative to “act in values and principles” (Reich 1995; cf. Reich 1994). As such a way that you treat humanity, whether in your to further differentiating such a broad vision of bioeth- own person or in the person of any other, never merely ics, Reich recommends to use “the term bioethics in its as a means to an end, but always at the same time as original, global sense, as referring to the ethics of the an end in itself” (Kant 1785), based on the dignity of a life sciences and health care; and then use adjectives to “moral law,” be recognized “categorically” without ex- specify particular areas of concern with bioethics. For emption. In 1926, Fritz Jahr extended the Categorical example, one might speak of medical bioethics, envi- Imperative to an all-encompassing Bioethics Impera- ronmental bioethics, clinical bioethics, or nursing bio- tive to “respect every living being in general as an end ethics without implying any particular approach” by in itself and treat it, if possible, as such” (Jahr 2013, p. using these terms (Reich 1995, p. 21). Kimura (1986) 21).6 The Bioethical Imperative is based on compas- refers to the rise of bioethics in the USA and opens the sion out of a “categorical” respect for the vulnerability, concept to Asian traditions: “Bioethics is a totally new dignity and interrelatedness of all forms of life, making form of discipline which goes beyond the notion of “hypothetical,” i.e., weighted and balanced assessments interdisciplinary studies; it is suprainterdisciplinary; and decisions depending on situations and challenges. it is deprofessionalizing medicine; it is a civil action Jahr refers to Karl Christian Krause when arguing “that movement. A new value of solidarity with all forms of they all, plants, animals and also humans, are equal in life (a traditional Confucian concept) will have to lead rights, each according to the necessary requirement to us into the new millenium.” Zhai Xiaomei referred to reach their destination” (Krause 1874). Jahr finds sup- Confucius’ “he er bu tong” as an example of true har- port for his model of bioethics in comparative studies mony and culture and suggests that “bioethics, health- in physiology and psychology on plants, animals and care ethics, healthcare law and regulations all over the humans (Jahr 2013, pp. 17ff; 23ff; 77ff. Cf. Bregenzer world –in China and elsewhere– should and must be 1894; Eisler 1909; Francé 1909). He coins the term in ‘in harmony but not identical’; ‘in harmony as well as analogy to the term bio-psychic, introduced and used diversified’” (Lúnyǔ 13:23, quoted in Mei 2011). Re- by Eisler to describe the conglomerate of new “bio- cently a new science has been generated, “bio-geron- logical factors” (Jahr 2013, p. 18; Eisler 1910, p. 190; tology” (combining the Greek terms bios and geron cf. Sass 1997). Jahr quotes Schopenhauer’s “neminem [old]), studying and evaluating the impact of science on influencing the process of aging by means of medical, mental, and physical efforts in antiaging, a new 6 For compassion as a transcultural value and principle, see Boyd et al. (1998); for a description of how reciprocal relationships in field definitely of interest for biocultural studies (Ehni families and businesses create those “systems,” see Weissman 2014, p. 279; cf. Medawar 1952). Van Rensselaer Pot- (2014).

J Health Cult 2016;1(1) 29 Journal of Health & Culture Original Article ter (1971) defines bioethics in Bioethics, the Science of condominium complex or in my geographical neigh- Survival as a “morality based on beliefs that we have borhood. Personal experience and scientific research about the relation between humans and biological sys- validate the fact that the world of my “bios” and simi- tems within us and around us” (Potter 2012, p. 150). lar worlds of others include the new non-geographical Unfortunately, Jahr’s broad concept of bioethics of was environments of the internet as real, not just virtual unknown before 2007, and Potter’s similarly farsighted worlds of success, happiness, satisfaction, failure, dis- concept had been forgotten during the last 30 years; appointment, trust and distrust. thus, its scope was narrowed to medical ethics, often confusingly even using the term “bioethics” as if be- The body politics: Leviathan wins over Behemoth ing identical to “medical ethics” in publications, in For over 3500 years, Mediterranean and European my- research, and even when naming institutes or confer- thologies have narrated the competition between the ences on medical ethics “bioethics institute” or “bio- land creature Behemoth and the water creature Levia- ethics conference.” than (Schmitt 1942);7 the land creature ruling the lands Recently, Ante Covic (2005) presented the most with great and small walls, through towers, armies, inclusive and comprehensive term “integrative bioeth- cities and rural areas; the water creatures dominating ics” in order to underline the integratedness of diverse the flowing streams, waters and oceans by streams of forms of life and living-togetherness. Methodologi- information, commodities, monies, and networks of cally, such an inclusive term will prove to be very use- ideas, propaganda and fashions. The winner in global ful to compare and to integrate analytical tools from political and cultural life in the 21st century might be various disciplines in biology and sociology for the the Leviathan, jumping over great and small walls of benefit of those areas of science, technology, and pro- all kinds and great and small political, social, econom- duction where these methods have not yet been used. ic, and cultural mountains using the new liquid bodies Recognizing the vital role of human-human, human- of audio and visual information, of travel and trade. nature, and human-culture interactions and interrela- Here are a few case studies: 300 years ago, in tions, I want to go one step further and follow Foucault 1714/18, the Muslim Ottoman Empire attacked the and Kelsen in also including the lives of institutions, Christian Habsburg Empire, but was defeated by the corporations, and other social networks into the field Austrian Prince Eugen in a number of battles. Today, focused on by bioethics, to encompass environmental in 2014, young German boys and girls in remote and networks and biotopes in the concept of integrated sleepy villages learn about extreme versions of Islam, bioethics (Kelsen 1945; Foucault 2004; Foucault 2014; become fanatic, travel to Muslim countries in the Sass 1991; Sass 2013). These human species-specific 6 Middle East with t-shirt and backpack and behead C capacities are flexible enough to go into both direc- other Muslims. The first battle in 1716 was the fight tions, to “do good” or to “do bad;” therefore, a critical between two Behemoths on land, the battle of today is analysis and a strong commitment to implementing the battle of the Leviathan against the Behemoths on the Bioethics Imperative are indispensable for further- land and in cyberspace. On September 11, 2001, the ing human culture and flourishing. We also need to in- widely unknown little Leviathan Al Kaida attacked the clude non-geographic environments into the concept most powerful Behemoth, the USA, and the Behemoth of integrated bios. For millennia, humans interacted declared war against this ever growing Leviathan. The with angels, devils, good and bad spirits; today we have events in Syria, Kurdistan and Turkey since 2014 have added real personal, business and professional interac- also had Leviathanian feedbacks in European cities tions and communities in digitally-based cyberspace such as Hamburg, Paris, and London, where various clouds. I communicate and cooperate with colleagues, fanatic Muslim factions, for example, fight one another business partners, and friends in cyberspace, and I have friends in the internet clouds that are closer and more intimate to me than some of the neighbors in my 7 See also Hobbes (1651; 1668); for today’s discussions using the Leviathan image, see Nasr (2001); Preble & Mueller (2014).

30 J Health Cult 2016;1(1) Sass Cultural dimensions of bios and bioethics in the streets of the European Behemoth countries, of teach predetermined subjective disposition … Meth- which they are a part. Recently, this liquid air-and- odologically it is not acceptable to present only what is water dragon has conquered lands in Syria and Iraq suitable and to suppress unsuitable facts, or to deny or and given birth to the new Behemoth of a radical Mus- to manipulate them at will… The benefits and short- lim Caliphate that exercises dominance over land and comings of different opinions and attitudes must be people. Behemoth and Leviathan interact with each discussed (neither through a rosy glass, nor through other; our dreams, visions, ideas are of Leviathanian a black one)… Instead of presenting biased character nature, but they need to be embodied in the lands of formation, students should be given the opportunity the Behemoth for the realized and lived happiness of to form their own opinion, respectively objective in- people and communities. In the interpretation of the formation should be given, so they may form their book of “Job,” both are created by God to be the most own character at a later date” (Jahr 2013, pp. 61ff). powerful creatures on land and in water; those among Of course, being a realist and pioneer in establish- the powerful who fool around with the Leviathan ing a broadly-based model for the ethics of bios in aca- “are afraid: because of his crashings they are beside demia and in real life, Jahr recognized the biological themselves” (Job 41:25). Both creatures can be either and cultural importance of self-interest in the struggle peaceful or disastrous, and the potentials of our hu- for life and success, describing an “opposition and alli- man 6 C capacities might reflect these flexibilities of ance in social life” between egoisms and altruism (Jahr cultivating and destroying. The “body politics” of the 2013, pp. 51–7): “Egoistic mentality as a natural phe- Behemoth and the Leviathan are different from my nomenon is also a basic human right. If such a right body, where organs such as liver and lung are fully in- is used reasonably (natural and healthy lifestyle, espe- tegrated for a healthy and enjoyable life. Humans are cially in regard to nutrition, dressing, living and work- social beings, but they are not just part of something ing conditions, also in a regulated and sufficient pay, bigger and more complete; as nationalistic fascism not to forget also in the struggle for survival which can used to say: “You are nothing, your volk is everything.” be regulated largely in justice and fairness), then it will Territorial borders are no more a barrier for the long be effective in wide circles and is –at least in its conse- breath and wide reach of the Leviathan. Aristotle dif- quences– altruistic” (Jahr 2013, p. 56). This interrelat- ferentiated between six forms of society, with dictator- edness of egoism and altruism was the internal metab- ship and anarchism being the extremes. Depending on olism of the Behemoth yesterday and will govern the the specific culture and tradition of a given society, the Leviathan and the rivalry between the two tomorrow. optimal interrelation between individual and society would be between those extremes and everything liv- Risks in modern biocultures ing be in flux, change and development. Karl Popper and Michael Foucault have warned about the growing We have come a long way from the earliest information powers of the “enemies” of the open society and the on the developing body politics over the last ten thou- dominating power of the corps-état; much earlier al- sand years. For millennia we have been quite familiar ready Edmund Burke and Arnold Ruge had cautioned with traditional nature-based risk to bios and to hu- against developing powers of socialism and national- man individual and social life in particular. Social life ism in Europe (Burke 1790; Ruge 1846; Popper 1945; unfolded in a circular way based on the seasons and Foucault 2004). They all reasoned in terms of land, not the teachings of the old generations to the new ones; in terms of water. the wisdom of the great-grandfather und the great- grandmother were good also for the following genera- Protestant pastor Fritz Jahr was an educator with tions; modern technologies since the 18th century and teaching experience who in 1930 wrote a courageous global interaction based on modern technologies and article on “Character Dictate or Freedom of Thought” the clash and interaction of lifestyles and civilizations in an educational journal, giving out a public warn- have changed societies and cultures into progressive ing about growing political ideological terror: “Do not or regressive dynamics and developed new forms of

J Health Cult 2016;1(1) 31 Journal of Health & Culture Original Article interaction among individuals, communities, corpora- narios of new biological, digital, financial, and human tions and states in intertwined geo-space/cyber-space risks and potential catastrophes for the 21th century: biotopes (Lent 2014). These new amalgamated hu- global pandemic, electromagnetic pulse, global loss of man-made forms of life have provided new risks such trust in paper-based values, global potential for revolt as powers struggles, wars, exploitation, and techni- and/or repression: cal disasters. Some of these new human-caused risks, (1) Biological risk: Half a dozen people attending such as the dependency of urban mega-life on electric- a family reunion in Hong Kong unfortunately become ity and digital communication and cooperation that infected with a new strain of an H1 virus; they leave could be destroyed by terrorists or by state-based ter- the festivities and fly to various destinations in Eu- ror, could lead into most severe catastrophes. System rope, Asia and America where they unknowingly in- failure in medieval cities was related to the seasons, to fect more people, who then themselves infect others, fire and to loss of harvest; system failure in modern causing a global pandemic. This scenario can be used mega-cities and in global commerce and trade will be as well by half a dozen suicidal criminals who infect based on infrastructure failure of electricity and digital themselves with a naturally occurring or specifically technology or their potential catastrophic use.8 manufactured microbe and fly to one or more coun- As far as risk to life and enjoyment and cultivation tries in order infect strategically, during the incubation of life are concerned, human-based and human-creat- period and before their own death, as many people as ed forms of life make life safer and more comfortable possible by visiting sports events, riding the subway, by building, heating and cooling houses, providing or going to movie theaters (Sass 2009; cf. Sass 1987; safe and sufficient food through agro-technology, wir- Sass 2006b; Hoffman 2009). The infrastructure of the ing the globe with electricity and radiation waves of technological society will remain intact, but it will be- various length for energy, light, communication, coop- come difficult to find competent people to use it; non- eration, and further cultivation of our lives. To avoid human life will not be targeted, and a new form of in- nature-based risk, we humans are far too powerless, tegrated bios will prosper. as we cannot influence the seasons, the sun and the (2) Electric risk: A digital global meltdown, mak- moon, earthquakes and tsunamis; but we have experi- ing electricity-based information and communication ence of how to protect ourselves from those events by processing and controlling obsolete, can be caused just not living in the harshest environments, by provid- by severe, however rare, electromagnetic winds from ing enough food supply for winter seasons, by wearing the sun [EMP], but can also be triggered by states or clothing appropriate for the season, by building safe groups of criminals using strong magnetic radiation. and stable houses. Human-based risk, however, such A device similar to a hydrogen bomb exploded over as war, discontent in society, greed, error and terror, at Southern China or over the East coast of the USA in times have been successfully mitigated and eventually high air or on a harmless fishing trailer emitting strong avoided by prudent bioethics developed over the mil- gamma radiation may render the digital infrastructure lennia, the instruments for which are the 6 C human of Istanbul or the Ruhr region in Germany or the area capacities mentioned earlier, often also called virtues, of New York useless. Such an event would affect the values, or principles. Here are just four different sce- entire electric grid, microchips in phones, cars, super- markets, elevators, all forms of digital communication 8 The Greek term kata-strophe means downturn, fiasco, overturn; the catastrophe can be unexpected, expected or expectable; in and cooperation, including those of the police, mili- the Greek tragedy we can differentiate between three stages of a tary and rescue forces and the media.9 People will die fiasco: protasis as the introduction of the variables in the scene and the persons, catharsis as the high point of development and potential catastrophe, then the epitasis as the result and follow- up. Today we face a new tension between the powerful global 9 A USA 2008 EMP Congress Commission estimated that 90% of bodies of markets of values and valuables, of communication the US population would die within twelve months after a total and cooperation on one side and the priority of traditional po- loss of electricity from starvation, disease or societal breakdown litical power based on police, military and national law residing (Woolsey & Pry 2014); cf. Pry (2013); Metatech Corporation in nation states. (2010).

32 J Health Cult 2016;1(1) Sass Cultural dimensions of bios and bioethics in their high-rise buildings, or might kill one another ATM machine at my supermarket will be out of cash; over food and water; cars will stop driving, planes will the gas station and the supermarket will not accept my fall out of the sky; people will be clueless as to what has credit card anymore; everything is in order, values are caused the breakdown of civilization. Different other “there,” but trust is “gone.” This super colossus was not attacks on utility infrastructures have occurred and of gold or even bronze, it just was made of paper and very likely will occur again, destroying water dams, based on trust, when a kick against its feet of clay made power grids, pumping stations, al kind of control sys- it break down for a long time. tems, and annihilating all sorts of private intellectual (4) Revolt and repression risk: When Karl Marx in and real property. A highly complex and most com- 1848 researched human masses as a powerful force for fortable modern bioculture is revealed to be standing changing social and political environments, he pointed on “feet of clay,” as it is literally “built on (silicon) sand.” at the exploited proletarians of the European industrial (3) Confidence risk: Trade and commerce are get- revolution of his times; today he would identify the ting more and more integrated and thus can be prey unhappy and frustrated segments of populations in to unintentional or deliberate attacks on basic trust transition from traditional to modern societies, such in trade and finance; we experienced an uninten- as the youth in the so-called Arab Spring and its coun- tional meltdown of financial markets in 2008, and terrevolutions, global fashions of modes of rebellion only concerted efforts to rescue the very institutions against traditions from the past but also reactionary that had caused the meltdown prevented an interna- revolts against the fast moving developments of global tional catastrophe for economy and business life. To- integration and the loss of traditional points of orien- day, individual computer hackers or state-supported tation in religion and culture leading to uncertainty criminals can create total havoc in the fully integrated and disorientation of many young people and result- commercial life of the planet. Inadequate or corrupted ing in a rebirth of religious and cultural extremism dangerous legislation still allows for banks and other and backward-oriented narrow-mindedness. There speculators to buy and manipulate commodities of all have been many studies on discontent in culture and sorts; high-frequency trading [HFT] has not proven changes, destructions, and reconstructions brought to be economically necessary or beneficial; govern- about by rebellions. The new century provides differ- ments print paper money without control; unknown ent reasons for rebellion and discontent and allows for or undisclosed leverage of market players, predatory many new different forms of protest. At the same time, lending, deregulation, computer-driven interconnec- political dictators and strong social or business forces tion and trading create fragile, brittle business archi- may use the same new information, communication, tectures of yet unknown proportions (Ingham 2004; and cooperation technologies for microscopic invasion Roeder 2011; Wray 2012; Barth et al. 2012; Calomiris of privacy, for indoctrination and introjection, in order & Haber 2014; Wolf 2014). We have speed limits on to promote their own selfish interests of power.10 These highways and streets for individual drivers, but there new environments of information, communication, are no speed limits for trading commodities or deriva- and cooperation based in cyberspace can work both tive products for the “big players.” I am not aware of ways, in favor of further liberation and the develop- tough and convincing proactive measures by states ment of civil societies or in favor of state-controlled or and businesses to avoid such a global catastrophe ren- business-controlled masses, in favor of better transpar- dering digital-based or paper-based assets worthless. Take this case: A crazy person or group or government 10 In his famous lectures on “biopower” at the College de France in 1978, Michael Foucault discussed the use of information and in- throws 200 or 300 trillion US $ Treasury Bills on the doctrination methodology by nation states in Europe since the 18th European markets, real and for cash only, not as deri- century: “when discipline is the technology deployed to make individuals behave, to be productive workers, biopolitics is deployed vates, not as futures; not much trade will occur; the US to manage population; for example to ensure a healthy workforce” markets will not open, nor will the Asian bourses; my (Foucault 2003). He traces the model of biopolitics back to the Gre- co-Roman and medieval emperors and kings; nowadays he might bank around the corner will close the next day and the recognize the power of the radio, television and the internet for even more successful forms of domination and indoctrination.

J Health Cult 2016;1(1) 33 Journal of Health & Culture Original Article ency or in favor of even more successful corruption and tegrated geographical and non-geographical worlds of exploitation—similar to the double-purpose or spin-off today; but they were also instrumental in degrading use of old technology. These are just four among many and destroying natural and social habitats. However, more modern scenarios of potentially catastrophic di- we humans have no other instruments than those that mensions, individually or in combination. brought us here, to win the future or to lose it. And there will be different solutions to avoid risk and to Bioethics as a guide for culture and survival protect and even further cultivate our natural and social environments. In 1819, devout Jewish believer and How will we and can we manage risks and avoid or enlightened philosopher Moses Mendelsohn argued survive catastrophes to all of life in the 21st century? in regard to religious fighting: “Brethren, if you want Van Rensselaer Potter defined bioethics as the sci- true peacefulness in God, let us not lie about consen- ence and art of survival, and Fritz Jahr explained sus when plurality seemed to have been the plan and how self-interest (egoism) and care for others (altru- the goal of providence. No one among us reasons and ism) are two sides of the same coin. But this should feels precisely the same way the fellow human does. not be new to us, as many cultures and religions have Why do we hide from each other in masquerades in made compassion and reciprocity for culture and cul- the most important issues of our lives, as God not tivation and the “love of your neighbor” a superior or without reason has given each of us his/her own im- divine mandate. The Prophet Micah summarizes the age and face” (Mendelssohn 1819, p. 201). Very close entire Jewish law in two commandments: “Love God to the Jewish philosopher Mendelsohn is the Muslim and love your neighbor as you love yourself;” and Je- lawyer and scholar Abu Hanifa, founder of the influen- sus followed Micah with the same message. The Mus- tial Muslim Hanafi Law School, in quoting the Prophet lim tradition specifies the help to one’s brother even Mohamed, who recommended debate to solve social in extreme situations: “It is right to help him when and interreligious controversies: “Differences of opin- he is oppressed, but how should we help him, when ion in the congregation must be considered as a special he is an oppressor?” The answer given by the Prophet grace of Allah.” As we already have different faces, hair, was “by preventing him from oppressing others” (Al- skin color, bodies, and brains, why should our cultures Bukhari, Hadith 3:624). A recent review of Buddhist and societies be uniform as those of the bees and ants bioethics holds: “Modern biologists understand that probably are. If we have different opinions, we have to human nature –our genome– is the accumulated re- talk. World history shows us quite a number of suc- sult of organic experience gathered over hundreds of cessful and relatively long-sustained cultures and com- millions of years, during which some manifestations of munities from which we can learn bioethical cultiva- life (bodies) were more successful than others in pro- tion and biocultural survival. jecting themselves (their genes) into the future. As this process continued, the eventual results were ourselves, German biologist and maritime researcher Karl along with all other beings. We and our living cousins August Möbius coined the term “bio-cenosis” in 1877 are thus the result of innumerable prior beings and will from the Greek terms bios (life) and koinōsis (min- in turn be the cause of others in the future” (Barash gling/sharing), to describe ecosystems as bionic com- 2014, p. 95). Such modern scientific insight into inter- munities containing “mutually dependent species relatedness could as well quote the 2500 year old Vedic and individuals, the variety and number of which are saying “tat tvam asi” (“this is also you”), i.e., you are determined by the average external living conditions also this animal, plant, environment, growing or suf- and sustained in an appropriate area by means of re- fering living being. production” (Möbius 1877), using the symbiotic life of oysters in the North Sea as an example.11 In 1852, The good use of the 6 C human capacities –which we may also call virtues– has played a role in all religions and traditions of the world. These capacities have 11 Francé RH, often called the “father of sustainable agriculture” used the term Biozönose in Die Welt als Erleben: Grundriss einer been instrumental in building the modern, highly in- objektiven Philosophie (1923, pp. 96ff) in order to explain the

34 J Health Cult 2016;1(1) Sass Cultural dimensions of bios and bioethics

Czar Nikolas I used biomedical terminology to de- vidual humans, have the power to be good or bad, but scribe “the sick man at the Bosporus,” i.e., the dying at an enormous scale. As the history of human culture Ottoman Empire. Today, millennia-old societies such and ingenuity shows, the prudent use of the 6 C virtues as Iraq and Syria are disintegrating as they might be and principles of communication and cooperation, of infected by some sort of “cancer” or “auto-immune competence and compassion, of competition and cul- disorder.” Societies unwilling or incapable to adapt to tivation has been a great success. Transnationally and the modern world have been called “sclerotic;” there transculturally, we need just these 6 C properties to are other coronary or infectious diseases, dementia, protect and to cultivate human lives and cultures. In hypertension, diabetes, arteriosclerosis in modern so- his bioethical “last will,” Van Rensselaer Potter, one of cieties and cultures, in businesses, corporations and the fathers of modern bioethics, wrote: “Global Bioeth- communities; but there can also be “preventive care,” ics must evolve into a politically energized and socially fitness training and the support of happiness in the concerned Bioethics Worldwide: Global Bioethics for the cultural and social biotopes of economy and politics, 21st century calls for Peoplecare with Healthcare and in clans, communities, healthy and growing countries Earthcare with Animalcare” (Potter 2012, p. 153). and weak and disintegrating societies. Successful biocenosis can occur in a small pond of fish, plants, and algae, but also in large socio-cultural lakes or oceans of References people, cultures, and politics. Using the terminology Barash DP (2014), Buddhist Biology: Ancient Eastern Wis- dom Meets Modern Western Science (Oxford: Oxford of biology, biocenosis, or biomedicine thus might help University Press). us to understand better the social and political devel- Barth JR, Caprio G, Levine R (2012), Guardians of Finance: opments of and in living cultural, social and political Making Regulators Work for Us (Cambridge, MA: MIT bodies, business corporations, local clans, and cyber- Press). space communities. Bioculturology, indeed, is a new Bergson H (1907), L’évolution créatrice (Paris: F. Alcan). methodological and conceptual approach for the 21th Bregenzer J (1894), Thier-Ethik (Bamberg: Buchner). century, one of the many fields of bioethics, and very Boyd A, Ratanakul P, Deepudong A (1998), “Compassion as much needed and hopefully successful in looking at common ground,” Eubios Journal of Asian and Interna- important challenges, opportunities and risks in ways tional Bioethics 8, 34–7. never applied before. Burke E (1790), Reflections on the Revolution in France, and on the Proceedings in Certain Societies in London Relative We humans and our societies and cultures are an to That Event, in a Letter Intended to Have Been Sent to a integrated part of the worlds of bios, and therefore we Gentleman in Paris (London: J. Dodsley). need bio-ethics, (1) because in comparison to other Calomiris CW, Haber SH (2014), Fragile by Design: The species we lack a firm and inflexible instinctive drive Political Origins of Banking Crises and Scarce Credit to do the “right thing” at the right time, (2) because we (Princeton, NJ: Princeton University Press). have the liberties either to “do right” or to “do wrong” Covic A (2005), “Der Aufbau eines Referenzzentrums für and potentially harm ourselves, our fellow humans, Bioethik in Südosteuropa,” in Integrative Bioethik, ed. and our various environments, (3) because we want to Covic A, Hoffmann ST (St. Augustin: Academia-Verlag, be happy and healthy in sustainable civilized and cul- pp. 261–74). tivated geographical and non-geographical surround- Dartnell L (2014), The Knowledge: How to Rebuild Civiliza- tion in the Aftermath of a Cataclysm (London: Penguin). ings. The Behemoths and Leviathans, just as we indi- Darwin C (1859), On the Origin of Species by Means of Natu- ral Selection, or the Preservation of Favored Races in the phenomenon that each “individual” is in regular relationships with its biotope, striving and tending towards epharmony [“jedes Struggle of Life (London: John Murray). ‘Ich’ mit seiner Umwelt in gesetzmäßigen Beziehungen steht, Ehni HJ (2014) Ethik der Biogerontologie (Wiesbaden: welche nach einer Epharmonie tendieren”], and that biological Springer). biocenosis thus is a particular aspect of the general tendency towards balance [“die biologische Biozönose also eine Teilerschei- Eisler R (1909), Das Wirken der Seele: Ideen zu einer or- nung der allgemeinen Gleichgewichtstendenz des ‘Bios’”]; cf. Eisler ganischen Psychologie (Leipzig: A. Kröner). (1910, note 1 on p. 226).

J Health Cult 2016;1(1) 35 Journal of Health & Culture Original Article

Eisler R (1910), Wörterbuch der philosophischen Begriffe, vol. Mei ZX (2011), “Diversified and in harmony, but not identi- 1, 3rd ed. (Berlin: E. S. Mittler & Sohn). cal: harmonizing international guidelines with cultural Engels EM (2012), “The importance of Charles Darwin’s values and national traditions,” Asian Bioethics Review theory for Fritz Jahr’s conception of bioethics,” in Fritz 3(1), 31–5. Jahr and the Foundations of Global Bioethics: The Future Mendelssohn M (1819), Moses Mendelssohn’s Sammtliche of Integrative Bioethics, ed. Muzur A, Sass HM (Munster: Werke. Fünfter Band. Enthält: Jerusalem oder über re- LIT, pp. 97–119). ligiöse Macht und Judentum (Ofen: Burian’sche Buch- Foucault M (2003), Society must be defended: Lectures at the handlung). Collège de France, 1975–1976, trans. Macey D (London: Metatech Corporation for Oak Ridge National Laboratory Picador). (2010), “Appendix: E1 HEMP Myths,” in Report Meta- Foucault M (2004), Naissance de la biopolitique: cours au R-320: The Early-Time (E1) High-Altitude Electromagnet- Collège de France (1978–1979) (Paris: EHESS/Seuil/Gal- ic Pulse (HEMP) and Its Impact on the U.S. Power Grid limard). (Oak Ridge, TN: Oak Ridge National Laboratory). Foucault M (2014), Du Gouvernement des vivants: cours au Mondat S, de Wouters T, Doré J, Lepage P (2013), “The hu- Collège de France (1979–1980) (Paris: EHESS/Seuil/Gal- man gut microbiome and its dysfunctions,” Digestive limard). Diseases 31(3–4), 278–85. Francé RH (1909), Pflanzenpsychologie als Arbeitshypothese Möbius K (1877), Die Auster und die Austernwirtschaft (Ber- der Pflanzenphysiologie (Stuttgart: Franckh’sche Verlag- lin: Wiegand, Hempel & Parey), Eng. trans. H. J. Rice shandlung). (1883), “The oyster and oyster-culture,” in US Commis- Francé RH (1923), Die Welt als Erleben: Grundriss einer ob- sion of Fish and Fisheries, Report of the Commissioner jektiven Philosophie (Dresden: Huhle). for 1880, part VIII (Washington, DC: US Government Fukuyama F (2014), “America in decay: the sources of politi- Printing Office, pp. 683–751). cal dysfunction,” Foreign Affairs 93(5), 5–26. Nasr SVR (2001), The Islamic Leviathan: Islam and the Mak- Hobbes T (1651), Leviathan or the matter, form and power of ing of State Power (New York: Oxford University Press). commonwealth, ecclesiastical and civil, ed. Macpherson Palmer M, Finlay V (2003), Faith in Conservation: New CB (Harmondsworth: Penguin, 1968). Approaches to Religions (Washington, DC: The World Hobbes T (1668), Behemoth: or the Long Parliament, ed. Bank), available at http://siteresources.worldbank.org/ Tönnies F (London: Simpkin & Marshall, 1889). EXTDEVDIALOGUE/Resources/Faith_conservation. Hoffman DE (2009), The Dead Hand: The Untold Story of pdf, accessed 2 May 2016. the Cold War Arms Race and its Dangerous Legacy (New Popper K (1945), The Open Society and its Enemies (London: York: Doubleday). Routledge). Ingham G (2004), The Nature of Money (Cambridge: Polity). Potter VR (1971), “Bioethics, the science of survival,” in Bio- Jahr F (2013), Essays in Bioethics 1924–1948, ed. & trans. ethics: Bridge to the Future (Englewood Cliffs, NJ: Pren- Miller IM, Sass HM (Munster: LIT). tice Hall). Kant I (1785), Grundlegung zur Metaphysik der Sitten, AA IV Potter VR (2012), “The intellectual ‘last will’ of the first glob- (Berlin: Deutsche Akademie der Wissenschaften). al bioethicist,” in Fritz Jahr and the Foundations of Global Kelsen H (1945), General Theory of Law and State, trans. Bioethics: The Future of Integrative Bioethics, ed. Muzur Anders Wedberg (Cambridge, MA: Harvard University A, Sass HM (Munster: LIT, pp. 149–58). Press; reprinted Clark, NJ: Law Book Exchange, 2009). Preble CA, Mueller J, eds. (2014), In a dangerous world? Kimura R (1986), “Bioethik als metainterdisziplinäre Diszi- Threat perception and US National Security (Washington, plin,” Mensch, Medizin, Gesellschaft, 11, 247–53. DC: Cato Institute Press). Krause KCF (1874), Das System der Rechtsphilosophie: Vor- Pry PV (2013), Electric Armageddon: Civil-Military Pre- lesungen für Gebildete aus allen Ständen, ed. Röder KDA paredness for an Electromagnetic Pulse Catastrophe (Cre- (Leipzig: F. A. Brockhaus). ateSpace Independent Publishing Platform). Lent A (2014), “The Power to create,”Royal Society of Arts Reich W (1994), “The word ‘bioethics’: its birth and legacies Journal 2, 10–13. of those who shaped it,” Kennedy Institute of Ethics Jour- Medawar PB (1952), An Unsolved Problem of Biology: An In- nal 4(4), 319–36. augural Lecture Delivered at University College, 6 Decem- Reich W (1995), “The word ‘bioethics’: the struggle over its ber 1951 (London: HK Lewis). earliest meanings,” Kennedy Institute of Ethics Journal

36 J Health Cult 2016;1(1) Sass Cultural dimensions of bios and bioethics

5(1), 19–34. Sass HM (2011), “Cultivating and harmonizing virtues and Roeder M (2011), The Big Mo: Why Momentum now rules principles,” Asian Bioethics Review 3(1), 36–47. our World. (London: Virgin Books). Sass HM (2012a), “Ludwig Feuerbach über virtuelle Realität Ruge A (1846), Zwei Jahre in Paris: Studien und Erinnerun- im Internet,” Aufklärung und Kritik 19(2), 29–37. gen (Leipzig: Wilhelm Jurany). Sass HM (2012b), “The ‘5-C model’ for guiding science and Sass HM (1987), “Philosophical and moral aspects of ma- technology: a précis of reasonable Moral Practice amidst nipulation and risk,” Swiss Biotech 5(2a), 50–6. a diversity of worldviews,” Synesis: A Journal of Science, Sass HM (1991), “Professional organizations and profession- Ethics, and Policy 3(1), G52–G59. al ethics,” in Ethics, Trust, and the Professions: Philosophi- Sass HM (2013), “The clinic as a good corporate neighbor,” cal and Cultural Aspects, ed. Pellegrino ED, Veatch RM, Croatian Medical Journal 54(1), 78–82. Langan JP (Washington, DC: Georgetown University Sass HM (2014), “An early Hegelian vision of the Internet. Press, pp. 263–84). Ernst Kapp’s 1845 philosophy of cultivating space and Sass HM (1994), “Formulating Global Post-Hippocratic time,” in Jahrbuch für Hegelforschung 15–17, ed. Schnei- Health Care Virtues,” European Philosophy of Medicine der H (St. Augustin: Academia-Verlag, pp. 11–34). and Health Care 2(1), 6–10, Japanese trans. in (1994) Schmitt C (1942), Land und Meer: eine weltgeschichtliche Be- Journal of Health Care, Medicine and Community 5, 3–6, trachtung (Leipzig: Reclam). Cantonese trans. in (1994) Newsletter (Centre for Ap- Weissman D (2014), Zone Morality (Berlin: Walter de plied Ethics, Hong Kong Baptist University) 2(1), 8–15, Gruyter). Italian trans. in (1995) Kos 118, 46–51, French trans. in Wolf M (2014), “Shaping globalization,” Finance & Develop- (1995) Journal International de Bioéthique 6(1), 5–7. ment 51(3), 22–5. Sass HM (1997), “Fritz Jahr’s 1927 concept of bioethics,” Woolsey RJ, Pry PV (12 August 2014), “The growing threat Kennedy Institute of Ethics Journal 17(4), 279–95. from an EMP Attack,” The Wall Street Journal, available Sass HM (2006a), Bioethics and Biopolitics (Xi’an: The Fourth at http://www.wsj.com/articles/james-woolsey-and- Military Medical University Press). peter-vincent-pry-the-growing-threat-from-an-emp- Sass HM (2006b), “Crisis Management in Public Health Eth- attack-1407885281, accessed 4 May 2016. ics,” Chinese Medical Ethics 1, 16–21 [in Chinese]. Wray LR (2012), Modern Money Theory: A Primer on Mac- Sass HM (2008), “Asian and other ways of bioethics: commu- roeconomics for Sovereign Monetary Systems (London: nity, compassion, competence, cultivation,” Formosan Palgrave Macmillan). Journal of Medical Humanities 9(1&2), 5–12. Yue P (27 July 2006), “Humanity and nature need to exist Sass HM (2009), Ethische Risiken und Prioritäten bei Pan- in harmony,” China Daily, available at http://www.china- demien, Medizinethische Materialien 181 (Bochum: daily.com.cn/opinion/2006-07/27/content_650584.htm, Zentrum für Medizinische Ethik e. V.). accessed 2 May 2016.

J Health Cult 2016;1(1) 37 Journal of Health & Culture Original Article

Migration and health in medical education: a work in progress report from Central Europe

Frank Kressing

Institute of History, Philosophy, and Ethics of Medicine, Ulm University

Abstract Correspondence to: Dr. Frank Kressing According to different sources, the percentage of migrants in Germany amounts to between Institut für Geschichte, Theorie und 12 and 20% of the total population, meaning that between 9 and 15 million people have a Ethik der Medizin, Universität Ulm, Parkstraße 11, D-89073 Ulm, Germany foreign, “non-German” background. Naturally, the result is an increasing number of patients frank [email protected] with “foreign” background in clinics, surgeries, and hospitals, plus a growing number of patients from abroad who come to Germany in the course of “medical tourism,” seeking specific types of healthcare that are not available in their home countries. On the other hand, there is an increasing number of internationally composed teams of doctors and nurses, treating “foreign” and “domestic” patients alike, plus an increasing number of “international” students, achieving their degrees through medical teaching and training in Germany. Until the present day, however, challenges resulting from migration processes of patients and healthcare workers have been addressed only insufficiently. Despite obvious needs for an effective cultural diversity management in medical institutions, the education of medical students in central Europe still shows severe shortcomings in terms of intercultural awareness and practical skills in serving patients from different cultural, geographical, and religious backgrounds. Furthermore, presently existing medical curricula do not consider special needs in training international medical students. In this paper, we will first try to answer the question why medical diversity management should be a topic in a medical doctor’s education before offering some theoretical considerations concerning the term “culture;” and we will then turn to the state of affairs in migrants’ healthcare in central Europe, mainly in Germany. The question of so-called culture-bound syndromes shall be addressed and some stereotypes concerning migrants’ health pointed out before introducing working groups and committees dedicated to the spread of intercultural awareness in medical education. Keywords: cultural trap; medical diversity; foreign doctors; culture-bound syndrome; migrant patients

38 J Health Cult 2016;1(1) Kressing Migration and health in medical education: a work in progress report from Central Europe

Introduction an increasing number of “international” (again, foreign) students, achieving their degrees through medi- Migration –especially from Turkey, but also from oth- cal teaching and training in Germany. er Mediterranean and Middle Eastern as well as from Eastern European countries– has played a dominant Theoretical background: the “cultural trap” role in public debates of the last decades in German- speaking countries (Austria, Switzerland, and Germa- Relating to this setting of multiple intercultural en- ny). Until the present day, however, challenges result- counters, I would like to refer to what can be called ing from migration processes of patients and health- the “cultural trap” in medical diversity management care workers have been addressed only insufficiently. (Knipper 2014; Kressing 2014b), attempting to exam- Despite obvious needs for an effective cultural diver- ine the popular usage of labels such as “cultural diversity management in medical institutions, the educa- sity,” “ethnicity” and “cultural/religious identity” from tion of medical students in central Europe still shows a social/cultural sciences and humanities perspective, severe shortcomings in terms of intercultural aware- since the term culture is not always used in a very ness and practical skills in serving patients from differ- thoughtful manner and therefore deserves a thorough ent cultural, geographical, and religious backgrounds. examination (Wimmer 1996). According to Peters et Furthermore, presently existing medical curricula do al. (2014), an essentialist understanding of the term not consider special needs in training international culture needs to be avoided, since “culture” refers to medical students. To overcome these shortcomings, processes of internal and external ascription of iden- several working groups have been founded to establish tities, supporting the perception and handling of dif- and to improve culturally sensitive curricula in medi- ferences. Culture is usually applied according to the cal training. It is the goal of these committees to raise specific context; in the life of most migrants, multiple the awareness for the need of cultural diversity man- cultural identities prevail,1 and belonging to a specific agement in hospitals, clinics and surgeries, based on a nation, nationality, or ethnic, religious, or cultural profound theoretical framework in terms of ethnicity, group represents just one among several aspects of religious diversity, and the term “culture” itself. an individual person’s identity and biography (Borde 2005). Why should medical diversity management be a topic in medical doctors’ education? The state of affairs: inequities in migrants’ healthcare According to different sources, the percentage of migrants in Germany amounts to between 12 and 20% As several official reports by German healthcare of the total population, meaning that between 9 and authorities indicate (e.g., Statistisches Bundesamt 15 million people –out of a population of 81 million– 2013), challenges resulting from migration processes have a foreign, “non-German” background (Schenk et of patients and healthcare workers have –until the al. 2006; Razum et al. 2004; Razum et al. 2008; Razum present day– only insufficiently been addressed (David et al. 2009; Tivig & Hetze 2007). Naturally, the result et al. 1998; Mangiapane et al. 2013; Mashkoori et al. is an increasing number of patients with “foreign” 1998; Zeeb & Razum 2006). There is a lack of reliable background in clinics, surgeries, and hospitals, plus a data concerning the number of migrant patients in growing number of patients from abroad who come Germany, especially due to the fact that an exact to Germany in the course of “medical tourism,” seek- definition of immigration status in Germany does not ing specific types of healthcare that are not available in exist (Deutscher Ethikrat 2010). According to federal their home countries. German census authorities, the term “immigrant” refers to every person who settled in the present territory of On the other hand, there is an increasing number of internationally composed teams of doctors and nurses, 1 This is vividly illustrated by the Turkish-German cartoonist treating “foreign” and “domestic” patients alike, plus Muhsin Omurca’s character Kanakmän (“German during day- time, Turk at night”).

J Health Cult 2016;1(1) 39 Journal of Health & Culture Original Article

Germany after the year 1949, including the offspring for example kitchen or cleaning staff, for interpretation, of these persons, and all foreigners born in Germany which proves to be an obviously very insufficient proce- or persons having at least one parent of foreign dure. Instead, interpretation between different languag- origin (Statistisches Bundesamt 2013; Mikrozensus es in a hospital environment should not be restricted to Statistisches Bundesamt 2005).2 It turns out that an the word-to-word translation of medical diagnoses and unequal access to healthcare institutions –comparing therapy suggestions, but interpretation needs to be cul- “native Germans” to immigrants– still prevails. The turally adapted and sensitive—a demand that can only situation is especially difficult for refugees and other be met by qualified interpreters being familiar with the migrants with uncertain legal status of residence or the cultural background of the patient and German “main- so-called sans papiers, meaning people with undefined stream society” alike, but not by family members –who status of residence (Bergmann 2012; Bornschlegel often have a bias concerning the desirable treatment of 2013; Collatz et al. 1999; Thilke 2013). Although a high their peers– or some member of the patient’s linguistic percentage of healthcare workers –doctors and nurses community who –accidentally– happens to be within alike– come from abroad, most foreign doctors do not reach, but might speak a completely different dialect, come from the migrant patients’ countries of origin or might not be familiar with medical procedures, and heritage, so that a language barrier between “foreign” might belong to a completely different social stratum or MDs and patients may still exist and may be even segment of the respective society (Peitinger 2011; Pöch- worse than between migrant patients and “German” haker 2000; Saladin 2014). medical personnel (Razum et al. 2008). Culture-bound syndromes and stereotypes concern- Mental illnesses ing migrants’ health Concerning the realm of mental illnesses, there is The problem of adequate translation already addresses also an unfortunate lack of reliable data, but it is quite the need for respect toward non-Western explanatory obvious that even though migrants suffer from men- models regarding the origin of illnesses or diseases and tal complaints twice as often as the average German their possible cure or therapy (Greifeld 1995; Klein- population, they tend to be underrepresented in the mann and Benson 2006; Grützmann, Rose and Peters respective medical institutions. A high rate of suicides 2012). In this context, so-called culture-bound syn- in migrants is attested, especially in young females of dromes have to be mentioned, even though their im- Turkish origin, compared to the average in juveniles portance has often been exaggerated: Not all migrants, (Ärzte Zeitung 2012; Aichberger et al. 2010; Schouler- e.g., those from Middle Eastern countries, are pos- Ocak 1999; van Bergen et al. 2014). Overall, a striking sessed by jinn or struck by the evil eye. Furthermore, lack of medical diversity management can be attested in an act of intercultural medical othering (cf. Bunge to German healthcare institutions (Höhne & Schubert 2004; Herrmann 2000; Petersen 1995), medical staff 2007; Knipper & Bilgin 2009; Klein-Ellinghaus et al. may tend to construct typical illnesses that are presum- 2014), with the lack of qualified translation and inter- ably typical in migrants, such as morbus Bosphorus, the pretation facilities –for migrants with limited knowl- infamous mamma mia syndrome, Ganzkörperschmerz edge of German– being a crucial element (Migrant- (which means pain all over the whole body), or the Friendly Hospitals Project 2004). term Gastarbeiterulkus (migrant workers’ ulcus), referring to the higher incidence of ulcer in migrant In everyday clinical communication, healthcare workers. The well-attested emergence of stereotypes workers and patients often resort to ad hoc translators, concerning migrants’ health that developed from the 1970s onwards lead to a widespread stigmatization of 2 For the year 2008, the Federal Statistics Office and the Robert migrants’ illness perception and –in the author’s opin- Koch Institute claimed that 15.58 million foreigners lived in Germany. According to these official figures, 16% of them are of ion– often serves as a camouflage reflecting the inter- Turkish origin (Tivig & Hetze 2007; Höhne & Schubert 2007, pp. cultural helplessness of many healthcare workers. 103–25; Razum et al. 2008, p. 7).

40 J Health Cult 2016;1(1) Kressing Migration and health in medical education: a work in progress report from Central Europe

Working groups and committees fostering intercul- and respected, and professional interpreters have to tural awareness in medical education be established as standard in all hospitals (not ad hoc translators, e.g., kitchen or maintenance staff). Ac- Despite obvious needs for an effective cultural diver- cording to this paper, all professionals working in the sity management in medical institutions, the educa- healthcare sector, no matter whether they are actually tion of medical students in central Europe still shows dealing with patients or not, have an ethically ground- severe shortcomings in terms of intercultural aware- ed responsibility to work in favor of intercultural sen- ness and practical skills in serving patients from differ- sitivity and justice in the healthcare sector. Changes ent cultural, geographical, and religious backgrounds. in favor of culturally sensitive healthcare have to be Furthermore, presently existing medical curricula do implemented in the basic structure and at all levels of not consider special needs in training international the healthcare sector—this means also in the adminis- medical students. tration, monitoring and catering sectors of a hospital. To overcome these shortcomings, several work- Culturally sensitive healthcare has to respect different ing groups have been founded to establish and to im- outlooks, perspectives, identities and backgrounds of prove culturally sensitive curricula in medical train- all persons involved (patients, clinic staff, etc.). ing. One example is the Committee on Intercultural Coming to specific demands concerning medical and Global Health Issues within the Association for education, it has to pointed out that no checklist for Medical Education (Gesellschaft üf r medizinische Aus- appropriate intercultural behavior can be provided— bildung), established in September 2013; another one instead, a general commitment to culturally sensitive is the Working Group on Intercultural Awareness in healthcare for all patients is needed and has to be imple- Practical Medicine, which is also part of the German mented in doctors’ and nurses’ teaching and training. Academy for Ethics in Medicine (Akademie für Ethik Medical diversity management has to be a compulsory in der Medizin), founded in February 2011. It can be topic in MDs’ academic education, not just a voluntary said that non-governmental groups focusing on the subject, and teaching/training facilities in regard of cul- rise of intercultural awareness in medical practice – tural awareness have to be available for all healthcare and medical education– are presently “mushrooming” professionals—not just for medical doctors (cf. Coors et in Central Europe, mostly including members from al. 2014; Knipper et al. 2010; Peters et al. 2014). Germany, Austria, and Switzerland, expressing the need for definite improvements in this field, and es- Coming to the teaching and training for inter- tablishing a close link between intercultural awareness national, foreign students, previous experience has and global health issues, e.g., in the field of medical shown that especially students from Middle Eastern tourism. countries show significant problems to cope with conditions in Western medical schools, and that they fail Demands pertaining to medical diversity manage- far more often in exams than students of German or ment comparable “Western” background. In a literature review presented by Elzubeir et al. (2010),3 the authors What are specific demands put forward by these dif- indicate that the introduction of innovative medi- ferent committees and associations? To answer this cal curricula in a number of Arab countries, such as question, central demands from the paper “Recom- small-group, case-based, or problem-based learning, mendations in dealing with intercultural variety in the seems to contribute significantly to increase stress. healthcare sector” (Peters et al. 2014) shall be cited. Elaborating on such studies, the opinion shall be put This paper starts with a general commitment in favor forward that Middle Eastern students’ problem in cop- of healthcare equity, meaning (1) that equal access to ing with teaching conditions cannot be exclusively healthcare institutions is provided and guaranteed, and (2) that discrimination is avoided and forbidden. 3 This review article is based on studies dated from 1998 to 2009 Specific health needs of migrants have to be recognized and is largely restricted to Egypt, Saudi Arabia, and the United Arab Emirates.

J Health Cult 2016;1(1) 41 Journal of Health & Culture Original Article reduced to the language barrier. Instead, it has to be References assumed that culture-bound factors are also involved Aichberger MC, Schouler-Ocak M, Mundt A, Busch MA, (Kressing 2014a). Nickels E, Heimann HM, et al. (2010), “Depression in middle-aged and older first generation migrants in Eu- Therefore, intercultural awareness is nothing med- rope: results from the Survey of Health, Ageing and Re- ical students have to learn exclusively on the level of tirement in Europe,” European Psychiatry 25(8), 468–75. academic knowledge, but involves skills and attitudes Ärzte Zeitung (12 September 2012), available at http://www. that can be practiced with their “international,” “for- aerztezeitung.de/821501/psychisch-krank-migranten- eign” peers from the first class in university teaching besonders-gefaehrdet.html, accessed 28 April 2016. onward. Students from abroad should not be regarded Bergmann M (2012), “Begegnung mit einem tschetscheni- as a burden, but need to be perceived as an enrich- schen Kriegsflüchtling,” In Weiß 1, 15–23. ment for intercultural training, offering opportunities Borde T (2005), “Repräsentationen ethnischer Minderhei- to learn about specific culturally-bound images con- ten in Studien und Gesundheitsberichten: Erfordernis, Chancen und Nebenwirkungen,” in Kinder und Jugendli- cerning the role and identity of the physician and the che mit Migrationshintergrund: Lebenswelten, Gesundheit perception of disease and illness. und Krankheit, ed. Borde T, David M (Frankfurt a. M.: As many clinical examples show, conflicts between Mabuse, pp. 267–87). patients, doctors, nurses, and other medical staff of- Bornschlegel W (2013), “Gesetzlich vorgeschriebene unter- ten tend be labelled “ethnic” or “intercultural” as an lassene Hilfeleistung? Medizinische (Akut-)Versorgung excuse for lack of understanding and commitment in für Kinder und Jugendliche ohne Aufenthaltsstatus,” communicating between patients and healthcare staff Amatom: ein Magazin von kritischen Medizinstudieren- den 25, 12–3. (Imhof & Kressing 2014; Knecht 2008). Thus, the ref- Bunge C (2004), Zum Mythos des “Mittelmeer-Syndroms”–zur erence to the patient’s “foreign,” “exotic,” “unfamiliar” Bedeutung von Kultur und Migration auf das Schmerzer- culture hides the fact that an unbiased treatment of a leben und Schmerzverhalten (Berlin: Freie Universität). specific patient might not be in the intention of health- Collatz J, Winfried H, Ramazan S, eds. (1999), Begutachtung care workers or is regarded to be too difficult—inter- im interkulturellen Feld: zur Lage der Migranten und zur cultural problems might easily turn out to be problems Qualität ihrer sozialgerichtlichen und sozialmedizinischen of hierarchies or social difference (Peintinger 2011). Begutachtung in Deutschland (Berlin: VWB-Verlag). Coors M, Grützmann T, Peters T, eds. (2014), Interkulturali- Conclusion tät und Ethik: der Umgang mit Fremdheit in Medizin und Pflege (Göttingen: Edition Ruprecht). It can be said that in the light of intercultural encoun- David M, Pette GM, Kentenich H (1998), “Unterschiedliche ters, basic bioethical principles that ought to be applied Inanspruchnahme einer gynäkologischen Notfallambu- to all patients can be defined, e.g., precise anamnesis, lanz durch deutsche Patientinnen und Migrantinnen,” translating medical terms into colloquial language, Geburtshilfe und Frauenheilkunde 58(6), 319–23. patient’ information and education, informed consent Deutscher Ethikrat, ed. (2010), Tagungsdokumentation. Mi- and shared decision-making. Standards and rules of gration und Gesundheit. Kulturelle Vielfalt als Heraus- healthcare for international/”foreign” patients are ex- forderung für die medizinische Versorgung. Vorträge der actly the same as those for the treatment of “native,” Jahrestagung des Deutschen Ethikrates 2010, available at mainstream patients. Thus, intercultural sensitivity http://www.ethikrat.org/dateien/pdf/tagungsdokumen- becomes a testing ground for standards of healthcare tation-migration-und-gesundheit.pdf, accessed 28 April that have to be applied to all patients, and culturally 2016. sensitive healthcare allows health workers to show and Elzubeir MA, Elzubeir KE, Magzoub ME (2010), “Stress and coping strategies among Arab medical students: towards act out their mental and social potentials. Basically, a research agenda,” Education for Health 23(1), 1–16. dealing with intercultural patients is a phenomenon Greifeld K (1995), “Was ist ‘krank’? Wohlbefinden und of interaction requiring awareness—the same type of Mißbefinden im interkulturellen Vergleich,”Dr. med. awareness as the interaction with “average” patients. Mabuse: Zeitschrift für alle Gesundheitsberufe 96, 22–6.

42 J Health Cult 2016;1(1) Kressing Migration and health in medical education: a work in progress report from Central Europe

Grützmann T, Rose C, Peters T (2012), “Interkulturelle mann T, Peters T (Göttingen: Edition Ruprecht, pp. Kompetenz in der medizinischen Praxis,” Ethik in der 52–69). Medizin 24(4), 323–34. Kressing F (2014a), “Contested medical identities, migration Herrmann M (2000), “Kulturspezifische Krankheitskon- of health care providers and Middle Eastern students at zepte,” in Handbuch zum interkulturellen Arbeiten im Western universities,” in Health, Culture and the Human Gesundheitsamt, ed. Bundesweiter Arbeitskreis Migra- Body: Epidemiology, Ethics and History of Medicine, Per- tion und öffentliche Gesundheit unter Koordination der spectives from Turkey and Central Europe, ed. İlkılıç İ, Beauftragte der Bundesregierung für Ausländerfragen Ertin H, Brömer R, Zeeb H (Istanbul: Beşikçizade Cen- (Berlin: Beauftragte der Bundesregierung für Auslän- ter for Medical Humanities, pp. 113–24). derfragen, pp. 27–30). Kressing F (2014b), “Anmerkungen zur Ethik der Forschung Holenstein E (1998), “Ein Dutzend Daumenregeln zur Ver- an und mit ethnischen Minderheiten,” in Handbuch meidung interkultureller Missverständnisse,” in Kul- Ethik und Recht der Forschung am Menschen, ed. Lenk C, turphilosophische Perspektiven: Schulbeispiel Schweiz, Duttge G, Fangerau H (Dordrecht: Springer). Europäische Identität auf dem Prüfstand, Globale Ver- Mangiapane S, Rattay F, Riens B, Schulz M (2013), Versor- ständigungsmöglichkeiten, ed. Holenstein E (Frankfurt a. gungsatlas, ed. Fachbereich Regionalisierte Versorgungs- M.: Suhrkamp Verlag, pp. 288–312). analysen und Versorgungsatlas des Zentralinstituts für Höhne A, Schubert M (2007), “Vom Healthy Migrant-Effekt die Kassenärztliche Versorgung, available at http://www. zur gesundheitsbedingten Frühberentung: Erwerbsmin- versorgungsatlas.de/der-versorgungsatlas, accessed 15 derungsrenten bei Migranten in Deutschland,” DRV- March 2014. Schriften Band 55/2007, 103–25. Mashkoori K, Weth C, Gardemann C (1998), Zur Gesund- Imhof C, Kressing F (2014), “Die ethnische Verlagerung von heitssituation der Flüchtlingskinder in Münster: statis- ethischen Problem- und Konfliktfällen,” in Interkultu- tische und epidemiologische Darstellung einiger aus- ralität und Ethik: der Umgang mit Fremdheit in Medizin gewählter Gesundheitsindikatoren anläßlich einer Erhe- und Pflege, ed. Coors M, Grützmann T, Peters T (Göt- bung bei 178 Flüchtlingskindern unter 15 Jahren in allen tingen: Edition Ruprecht, pp. 70–80). städtischen Übergangseinrichtungen, Gesundheitsberich- Klein-Ellinghaus F, Brand T, Zeeb H (2014), “Needs and te der Stadt Münster 7 (Munster: Abteilung Kinder- und resources of Turkish-speaking relatives of dementia pa- Gesundheitspflege, Gesundheitsamt). tients: experiences from Bremen, Germany,” in Book of Migrant-Friendly Hospitals Project, European Commission Abstracts, Third International and Interdisciplinary Con- (2004), The Amsterdam declaration: towards migrant- ference Health Culture and the Human Body (Istanbul: friendly hospitals in an ethno-culturally diverse Europe, Beşikçizade Center for Medical Humanities), pp. 31–2. available at http://www.mfh-eu.net/public/files/europe- Kleinman A, Benson P (2006), “Anthropology in the clinic: an_recommendations/mfh_amsterdam_declara-tion_ the problem of cultural competency and how to fix it,” english.pdf, accessed 1 October 1 2012. PLOS Medicine 3(10), e294. Peintinger M, ed. (2011), Interkulturell kompetent: ein Knecht M (2008), “Jenseits von Kultur: Sozialanthropolo- Handbuch für Ärztinnen und Ärzte (Vienna: Facultas). gische Perspektiven auf Diversität, Handlungsfähigkeit Peters T, Grützmann T, Bruchhausen W, Coors M, Jacobs F, und Ethik im Umgang mit Patientenverfügungen,” Ethik Kaelin L, et al. (2014), “Grundsätze zum Umgang mit In- in der Medizin 20(3), 169–80. terkulturalität in Einrichtungen des Gesundheitswesens: Knipper M, Bilgin Y (2009), Migration und Gesundheit (Ber- Positionspapier der Arbeitsgruppe Interkulturalität in lin: Konrad-Adenauer-Stiftung e. V.), available at http:// der medizinischen Praxis in der Akademie für Ethik in www.kas.de/wf/doc/kas_16451-544-1-30.pdf, accessed der Medizin,” Ethik in der Medizin 26(1), 65–75. 16 June 2012. Petersen A (1995), “Somatisieren die Türken oder psycholo- Knipper M, Akıncı S, Soydan N (2010), “Culture and health- gisieren wir? Gedanken zur angeblichen Neigung der care in medical education: migrants’ health and beyond,” Türken zum Somatisieren,” Curare 18(2), 531–40. GMS Journal for Medical Education 27(3), 1–6. Pöchhaker F (2000), Dolmetschen: Konzeptuelle Grundlagen Knipper M (2014), “Vorsicht Kultur! Ethnologische Perspek- und deskriptive Untersuchungen (Tübingen: Stauffen- tiven auf Medizin, Migration und ethnisch-kulturelle burg). Vielfalt,” in Interkulturalität und Ethik: der Umgang mit Razum O, Geiger I, Zeeb H, Ronellenfitsch U (2004), “Ge- Fremdheit in Medizin und Pflege, ed. Coors M, Grütz- sundheitsversorgung von Migranten,” Deutsches Ärzte-

J Health Cult 2016;1(1) 43 Journal of Health & Culture Original Article

blatt 101(43), A 1–2 & A 2882–7. Statistisches Bundesamt (2013), Statistische Wochenberichte: Razum O, Zeeb H, Meesmann U, Schenk L, Bredorst M, Bevölkerung, Soziales und Arbeit: Monatszahlen (Wies- Brzoska P, et al. (2008), Schwerpunktbericht der Ge- baden: Statistisches Bundesamt). sundheitsberichterstattung des Bundes: Migration und Thilke K (2013), “Moderne Sklaverei und Gewalt gegen Mi- Gesundheit (Berlin: Robert Koch-Institut, Statistisches grantinnen,” Amatom: ein Magazin von kritischen Medi- Bundesamt), available at https://www.rki.de/DE/Cont- zinstudierenden 25, 14–5. ent/Gesundheitsmonitoring/Gesundheitsberichterstat- Tivig T, Hetze P, eds. (2007), Deutschland im Demografischen tung/GBEDownloadsT/migration.pdf?__blob=publica- Wandel (Rostock: Rostocker Zentrum zur Erforschung tionFile, accessed 29 April 2016. des Demografischen Wandels), available at http://www. Razum O, Spallek J (1 April 2009), “Definition von Migra- rostockerzentrum.de/Content/publikationen/Deutsch- tion und von der Zielgruppe ‘Migranten’,” available at land%20im%20Demografischen%20Wandel_2007.pdf, http://www.bpb.de/gesellschaft/migration/dossier-mi- accessed 30 April 2016. gration/57302/definition, accessed 5 March 2013. van Bergen D, Montesinos AH, Schouler-Ocak M, eds. Saladin P (2014), “Verankerung transkultureller Kompetenz (2014), Suicidal Behavior of Immigrants and Ethnic Mi- im Krankenhaus: eine Führungsaufgabe,” in Interkultu- norities in Europe (Göttingen: Hogrefe Verlag). ralität und Ethik: der Umgang mit Fremdheit in Medizin Wimmer A (1996), “Kultur: zur Reformulierung eines sozi- und Pflege, ed. Coors M, Grützmann T, Peters T (Göt- alanthropologischen Grundbegriffs,” Kölner Zeitschrift tingen: Edition Ruprecht, pp. 139–46). für Soziologie und Sozialpsychologie 48, 401–25. Schenk L, Bau AM, Borde T, Butler J, Lampert T, Neuhauser Zeeb H, Razum O (2006), “Epidemiologische Studien in der H, et al. (2006), “Mindestindikatorensatz zur Erfassung Migrationsforschung,” Bundesgesundheitsblatt – Gesund- des Migrationsstatus: Empfehlungen für die epidemi- heitsforschung – Gesundheitsschutz 49(9), 845–52. ologische Praxis,” Bundesgesundheitsblatt – Gesundheits- forschung – Gesundheitsschutz 49(9), 853–60. Schouler-Ocak M (1999), “Posttraumatische Belas- tungsstörung – Bedeutung in der Begutachtung im interkulturellen Feld,” in Begutachtung im interkulturellen Feld: zur Lage der Migranten und zur Qualität ihrer sozialgerichtlichen und sozialmedizinischen Begutachtung in Deutschland, ed. Collatz J, Hackhausen W, Salman R (Berlin: VWB-Verlag, pp. 233–42).

44 J Health Cult 2016;1(1)

Journal of Health & Culture Original Article

Contributions and ambiguities in Islamic research ethics and research conducted in Muslim contexts: a thematic review of the literature

Mehrunisha Suleman

Ethox Centre, Nuffield Department of Population Health, Oxford University

Abstract Correspondence to: Mehrunisha Suleman Islam forms the second largest religious affiliation across the world and very little study has Nuffield Department of Population been done to explore its role in the context of research ethics. The majority of Muslims live in Health, University of Oxford, Richard Doll Building, Old Road Campus, the developing world and therefore can form a significant cohort for research as well as those Oxford OX3 7LF, UK who carry out research. Since Islam has generally encouraged the use of science, medicine [email protected] and biotechnology as solutions to human suffering, it would be useful to assess its influence on global and local (regional and national) ethical decision-making. This paper provides a thematic review of the literature related to Islamic research ethics and research conducted in Muslim contexts. PubMed was searched with a basic Boolean search strategy using key phrases: “(Islam OR Muslim) AND (ethics OR Bioethics) AND research.” A new database, the Islamic Medical and Scientific Ethics (IMSE) database developed by Georgetown Uni- versity, was also searched. Searching in both databases yielded 505 articles, which were then analyzed for relevance. The review revealed eight overarching themes in the literature relating to Islamic research ethics and research conducted in Muslim contexts. The themes include (i) ethical principles, (ii) complexity of the consent process involving married and single Muslim women, (iii) the consent of minors, (iv) retention of genetic material and tissue, (v) religio-ethical challenges raised by global pandemics such as HIV (vi) scholarly deliberations surrounding emerging medical technologies such as genetics and reproduction (vii) the emerging role of contextual scholars as authorities collaborating alongside Islamic textual scholars, and (viii) religious injunctions relevant to research. The literature as it relates to these themes is summarized in this review. Although the application of Islamic principles is varied and inconsistent, this review, revealing the importance of normative Islamic sources within the research ethics discourse in the Muslim context, emphasizes the role of religion and religious authority in underlining research priorities, guidelines and conduct. Muslim scientists, researchers, ethicists, theologians and legal scholars need to address the questions presented here using tools from within their own tradition to provide coherent guidelines to enable researchers to engage in moral reasoning that is congruent with their own religio- cultural values, while remaining consistent with the necessary international research governance standards. Keywords: Islamic research ethics; research in Muslim contexts; Boolean search

46 J Health Cult 2016;1(1) Suleman Islamic research ethics: a thematic review of the literature

Introduction existing research protocols to establish whether they allow for the necessary cultural diversity and therefore In recent years, biomedical research in developing enhance applicability. countries has been expanding, with important implications for the development of novel, lifesaving thera- It is also important to consider the role religious pies for pandemics such as HIV (Nuffield Council on views and values play in defining what counts as an Bioethics 2002). It has also been suggested that health ethical problem and what it means to be an ethical re- research conducted in developing countries may rep- searcher. The latter is critical in order to gain a deeper resent a valuable source of healthcare, be a means of understanding of the moral universe of researchers addressing conditions specifically affecting these areas, who consider themselves affiliated with a religious or as a vehicle for implementing such solutions whilst school of thought or the challenges researchers may building capacity in the form of infrastructure devel- face when working with a religious community. As opment and the training of local staff (Bhutta 2002). very little study has been done within this area, this review aims to elucidate some of the questions and chal- Biomedical advancement, however, has to be care- lenges that may occur when research is conducted in fully monitored with sufficient governance processes Muslim contexts and to analyze the role of normative to ensure there is no compromising ethical standards Islamic sources in the moral considerations pertaining (Lurie & Wolfe 1997). Recent work on global biomedi- to research. cal ethics has transformed dramatically, considering not only challenges in consent procedures (Freedman Another important consideration that needs to 1987), but also more subtle questions relating to ex- be made here is that, within the Muslim tradition, ploitation, the need for research to be responsive to lo- although the formulation of religio-ethical opinions cal population needs and the sustainability of research. has usually been perceived as the exclusive charge of This shift has occurred, as there is growing realization religious scholars, more recently physicians and scien- that some of the most contentious contemporary ethi- tists themselves have taken on this task. Studies have cal controversies are not related to informed consent shown that Muslim medical and scientific experts are but rather to the ethics of appropriate risk-benefit ra- keen to adopt the language of Islamic theology (Ghaly tios, exploitation and the value of research to the local 2013) and to draft Islamic legal rulings in an attempt community (Emanuel et al. 2000), where the endemic to answer emerging religio-ethical challenges. It may socioeconomic injustices also cannot be overlooked be pertinent to assess the nature of this emerging (Ijsselmuiden et al. 2010). multifaceted role of the Muslim physician/scientist/ researcher and the impact it may have on the global However, the field of global health research ethics health research ethics discourse. faces the continuing challenge of its application within ethnographically diverse settings. Although bioeth- Islam forms the second largest religious affiliation ics has increasingly developed a global consciousness, across the world and very little study has been done to universal principles to guide ethical decision-making explore its role in the context of research ethics. Cur- successfully, irrespective of cultural or religious con- rently there are 1.57 billion Muslims across the globe texts, are not available and may never be established accounting for just under a quarter of the world’s pop- (Ryan 2004; Chattopadhyay & De Vries 2012). Despite ulation (Sachedina & Ainuddin 2004). The majority the variety of work that has been accomplished thus of Muslims live in the developing world and therefore far (in deriving ethical principles, applying them and can form a significant cohort for research as well as reviewing them), some authors suggest that many re- those who carry out the research. Islam has generally searchers fail to take into consideration the pertinence encouraged the use of science, medicine and biotech- of religious pluralism, cultural differences and moral nology as solutions to human suffering and as such, it diversity which pervade different societies (Durante would be useful to assess its influence on local ethical 2009). They suggest that it may be necessary to assess decision-making (Inhorn 2003). Novel ethical dilem-

J Health Cult 2016;1(1) 47 Journal of Health & Culture Original Article mas that have been presented by the recent biomedical This paper provides a thematic review of the lit- advancements have functioned as a catalyst within the erature related to Islamic research ethics and research Islamic scholarly sphere, compelling religious experts conducted in Muslim contexts. into renewed and sustained discussions about these challenges and the need to present appropriate solu- Methods tions. Thus, it would be useful to capture the Islamic Although the literature review was largely descriptive, perspective on the complex questions posed by global with the aim of identifying emerging themes in the lit- health research. erature, a systematic approach was taken to find and “Islam” in this review refers to the religion, with its categorize the relevant literature. Two databases were normative sources the Qur’an (book of God) and Sun- used to undertake the search. PubMed was searched nah (teachings of the Prophet Muhammad). However, with a basic Boolean search strategy using key phras- the textual guidance needs to be considered alongside es: “(Islam OR Muslim) AND (ethics OR Bioethics) the contextual experiences of Muslims. Their lived ap- AND research.” A new database, the Islamic Medi- plication of the normative sources is a substrate for cal and Scientific Ethics (IMSE) database, developed the growing body of Islamic legal literature. Both the by Georgetown University, was also searched. The textual and lived experiences need to be considered in PubMed search yielded 157 articles and books. The order to understand better how Islam influences re- IMSE search yielded 348 articles, books and relevant search and how Muslims, who encounter research, ap- references. Items from both databases were then an- ply Islam’s teaching in their professional and personal alyzed for relevance by interrogation of the title and lives. abstract. Irrelevant articles were discarded from the

Figure 1. Literature search interrogation process.

48 J Health Cult 2016;1(1) Suleman Islamic research ethics: a thematic review of the literature search results. Full texts of the remaining articles and reasons for the lack of publications within this arena books were analyzed and again irrelevant results were may be the necessary intellectual catch-up by Muslim discarded from the search. Forty full texts were dis- scholars who have been preoccupied with the genera- carded as they were not relevant to Islam and Research tion of responses to specific biotechnologies. ethics. Figure 1 summarizes the results of the literature Another reason that has been suggested is that the searches and the interrogation process. output from Muslim scholarly meetings over the past two decades that are relevant to biomedical ethics are Results and Discussion yet to be collated or translated into English. Concerted Searching in both databases yielded 505 articles, which efforts are being made to invest both financially and were then analyzed for relevance by interrogation of intellectually in order to make such material available the title and abstract. One hundred and seventeen rel- to the English-speaking world (Ghaly 2013). Ghaly ar- evant articles were then extracted and their full texts gues that Muslim scholars during the 1990s collaborat- reviewed and analyzed. The ethical challenges of glob- ed with physicians and scientists in order to arrive at al health research, from an Islamic perspective and Islamic responses to the HIV/AIDS pandemic. These within Muslim contexts, fall into two broad categories: proceedings were intellectually robust and successful the ethical challenges of the topic under study, and the in their subsequent outputs. However, until recently, ethical challenges of the research design and conduct. the available literature in English on Islamic perspectives on HIV/AIDS has paid little attention to the con- Ethical challenges of the topic under study tent and output of these meetings (Atighetchi 2007). Most of the 117 relevant articles found were general discussions on bioethics with a mention and/or sub- Eight overarching themes within the literature section on research ethics. The major focus of these The review also revealed eight overarching themes in articles was on the Islamic responses to technological the literature relating to Islamic research ethics and advancements such as genetics, cloning, reproductive research conducted in Muslim contexts. The themes technologies and organ transplantation. From an Is- include (i) ethical principles, (ii) complexity of the lamic perspective and in Muslim contexts, before the consent processes involving married and single Mus- process of research can be morally interrogated, it is lim women, (iii) the consent of minors, (iv) retention imperative that the topic of research is sufficiently ana- of genetic material and tissue, (v) religio-ethical chal- lyzed. In Muslim countries, for example, before cer- lenges raised by global pandemics such as HIV, (vi) tain technologies are considered for context-specific scholarly deliberations surrounding emerging medical research trials, scholarly opinion may be needed in technologies such as genetics and reproduction, (vii) order to determine their appropriateness as a subject the emerging role of contextual scholars as authorities of study (Larijani et al. 2006; Zahedi & Larijani 2008). collaborating alongside Islamic textual scholars, and For example, Fadel (2010) reports that the internation- (viii) religious injunctions relevant to research. al guideline CIOMS, which has been adapted for use within the Muslim world, specifies that in an Islamic I. Principles of ethics country each IRB should include the opinion of a fiqh (Islamic jurisprudence) committee “to be certain that Of the articles that specifically consider research ethics the proposed study is within the guidelines of Islam.” principles, these largely reflect on Islamic laws and values in reference to existing secular ethical principles, Ethical challenges of research design and implemen- such as the four principles developed by Beauchamp tation and Childress (2001). Autonomy, for example, is discussed by numerous authors, some of whom accept it Of the 117 articles found relevant to research ethics, as a principle that was present within the Islamic tra- only 34 specifically focused on issues pertaining to the dition predating Beauchamp and Childress’s seminal design and conduct of healthcare research. One of the

J Health Cult 2016;1(1) 49 Journal of Health & Culture Original Article work (Aksoy & Tenik 2002), agreeing with the latter (Oguz 2003). The decision-making unit, or jama‘ah (a authors’ claim that autonomy is a universal principle group), is favored in Islam over an individual’s deci- shared and applied by different religio-cultural tradi- sion. This is not to mean that an individual’s view is tions. In another work, Aksoy explores the roots of not respected, it is to allow familial and community all four principles from within the Islamic tradition advice when making a decision and retaining their (Aksoy & Elmai 2002), arguing that these principles support through a favorable or unfavorable outcome. are “already being applied in Islamic traditional and The literature search and review reveal that there is cultural societies.” little material in English where Islamic legal thought However, many other authors argue that although is applied independently of existing guidelines, where Muslims may broadly share the four principles, how many authors have simply sought the “Islamic equiva- these are applied within the research context may vary. lents” of the four principles. One may argue that there For example, autonomy and the principle of informed may be little need for additional frameworks if those consent is a contentious issue within Islamic ethics. that exist allow researchers to answer emerging ethical Secular ethics is widely accepted as “rights-based” with questions (ten Have & Gordijn 2011). However, rather a strong emphasis on individual rights and freedoms. than trying to superimpose secular ethics within an Is- Autonomy and in turn informed consent are impor- lamic legal framework, it may be more valuable to de- tant corner stones of biomedical research, etched into rive principles from within the tradition. Authors have ethical guidelines to prevent the repetition of historical also argued that there exists a “Western bias” within atrocities. Many authors have considered autonomy contemporary mainstream bioethics (Chattopadhyay as the most important ethical principle (Engelhardt & De Vries 2012). Sachedina states “there is a critical 1986). need to understand moral epistemology in Islam before searching for equivalents of the secular bioethics In Islam, however, the emphasis is on the individ- in the Islamic legal texts” (Sachedina 2007). He makes ual’s duty to God, the community and him/herself. It a “strong case for distinctly Islamic and yet cross-cul- does not allow another person to infringe on an indi- turally communicable, principle-based deontological- vidual’s rights, unless absolutely necessary, and based teleological ethics that are operative within the Mus- on duties such as preserving life and avoiding harm. In lim socio-cultural context in assessing moral problems Islam, an individual’s freedom may be constrained if in Islamic biomedical ethics” (Sachedina 2006). it causes harm to others (Rathor et al. 2011). Defining harm may be based on the principle of maslaha (public Yet, one may consider that this is an intellectual in- good), where the risk-benefit ratio is used to ascertain teraction that is both necessary and inevitable. Many whether a decision would be in the public’s benefit Muslim practitioners train in the West and therefore overall. Thus, the literature highlights that different become familiar with Western and secular moral moral traditions may require us to do the same thing, principles. When practicing in the West or in Muslim in the end, yet it is very important to acknowledge and contexts, they may adapt these principles based on respect the different views, values and traditions that their environment or personal beliefs. It may not be exist globally. possible for them to divorce their intellectual and professional training of what is morally correct by simply Another important concept in Islam and within considering what “Islam would say.” Rather, what may Muslim committees is the sacred position of the fam- be necessary is a platform to discuss such intellectual ily. Thus, Muslims may not share the secular construct and practical interactions to enable Muslims to remain of autonomy and may prefer “collective autonomy,” cognizant of their training whilst having the moral re- where healthcare and health research decisions are sources to navigate through problems that are in har- made not only by the individual, but the entire family mony with their beliefs. unit. In some Muslim societies, this decision making process may even include religious leaders and friends

50 J Health Cult 2016;1(1) Suleman Islamic research ethics: a thematic review of the literature

Other ethical principles that are discussed in the sions with the male members of the household, where literature within Islamic research ethics or research such conversations may be necessary and common, or conducted in Muslim communities include: owner- does it cause them to withdraw further from access- ship of the body, justice, scientific validity, privacy in ing services? The ambiguity in the interpretation of the Islam, religio-ethical challenges involved in placebo- normative texts, however, reveals that more may be at controlled trials, religious responsibility for the en- play in determining the gender roles in Muslim com- rolled subject by the research sponsor and the poten- munities. It would require an empirical investigation tial for criminal charges in the case of harm, phase 1 to explore in which communities women are required trials and payment, and religio-ethical definitions of to seek permission and whether it is the religious texts benefits and risks. that influence these social norms or cultural traditions that are shared by other faith communities in the re- II. Complexity of the consent process involving mar- gion, and are therefore independent of religion. ried and single Muslim women III. Consent of minors The status of women is a commonly disputed area within Islam. Although equal in faith to men (Qur’an In most countries, the age at which children legally at- 16:97), women are offered the protection of men tain full age is at 18 years. However, papers have de- through their fathers, guardians or husbands (Qur’an scribed that according to Islamic law and the opinion 4:34). Application of the latter principle often leads to of several Muslim jurists, puberty marks the age at discordance within the Muslim community. For exam- which a child becomes an adult (Afifi 2007). On aver- ple, within research, some authors suggest that a mar- age, this may be considered at 15 years. Prior to puber- ried woman may only participate if she has first sought ty, the assent of the child would be necessary alongside the permission of her husband. A husband may not, parental consent. however, force his wife to participate in a trial (Afifi The IOMS guidelines also highlights that the con- 2007). Seeing it as a religious duty, women may consent of minors is an area where Islamic law differs sider their husband’s permission as imperative, and from CIOMS and many other international laws and such a decision may be described as her exercising her guidelines. However, no papers or guidelines describe second-order autonomy (Keyserlingk 1993). how researchers would implement such a ruling when Others have, however, argued that it is not in ac- conducting trials in Muslim contexts, nor is there any cordance with a woman’s human rights to have to seek documentation of how compliant Muslims are with her husband’s permission before participating in a trial this law. Empirical studies may provide an insight into (Fadel 2010). The latter consensus was established by this phenomenon and offer an exploration of the ap- the Islamic Organization of Medical Sciences (IOMS). plication of this law in Muslim contexts. However, the IOMS guideline (2005) added that “although not a requirement, it is preferable for a married IV. Islamic perspectives on retention of tissue samples woman to obtain her husband’s consent.” The latter is and genetic material ambiguous, however, with no details about which cir- Studies have been conducted to collate the Muslim cumstances a husband’s opinion would be necessary. public’s attitudes towards biomedical research in Saudi It would, therefore, be useful to know how Muslims Arabia. In particular, a study was carried out to cap- researchers, who use IOMS or other such resources as ture Muslim views on the storage and use of human a guide, implement this clause. tissue that carries genetic information, and the will- Another important ethical consideration is that ingness of participants to donate samples to biobanks women are often marginalized in communities and (al-Jumah 2011). The study revealed that almost 70 do not access healthcare. Does such a religious posi- percent of participants had a positive attitude towards tion, empower women to have the necessary discus- biomedical research and almost 80 percent were will-

J Health Cult 2016;1(1) 51 Journal of Health & Culture Original Article ing to donate excess surgical tissue for research. How- mon response from policy makers in Muslim coun- ever, participants were less willing to donate tissue or tries for HIV prevention had been a focus on absten- organs from a deceased relative. The latter views arise tion from illicit drugs and sexual practices. One of from religious injunctions regarding the respect that the key features of the discussions around HIV/AIDS must be shown to the deceased and that “our bodies were human rights issues, and scientists and physi- belong to God” (Hamdy 2012). cians questioned the consistency of the “not our problem” approach (Ghaly 2013). Increased awareness of Another study conducted in Egypt revealed that 66 the devastating effects of HIV/AIDS as well as the fact percent of individuals would donate their samples for that there is no inevitable relationship between having future research. However, those who agreed favored a AIDS and having committed illicit sexual and recre- consent process that limited future studies to the ill- ational practices challenged the common stereotypes ness that was currently being studied. Additionally, and taboos within the religious scholarly discourse. those who participated in the study expressed reluc- tance to having their blood samples exported out of More recently, in countries where HIV/AIDS is the Arab region. Factors that may account for such un- rapidly rising, such as Uganda (Farrell 2003), Sen- willingness may include issues around confidentiality, egal (Lagarde et al. 1998), and Indonesia (CDC 2003), lack of shared religious values or fear that oversight of Muslim scholars have taken a more flexible stance and samples may be more difficult once they are exported justified the use of condoms and clean needles as a (al-Jumah 2011). short-term means of ensuring the sanctity of life. The latter is mentioned in a Qur’anic verse (5:32) and un- V. Religio-ethical challenges raised by global pan- der a state of emergency overrides the discouragement demics such as HIV of condom use (Hasnain 2005). A recent subject of debate within Islamic medicine During the 1990s, the Islamic Medical Associa- and medical ethics is the HIV/AIDS pandemic. In tion of Uganda designed an HIV/AIDS prevention the 1990s, Muslim religious scholars, physicians and program where they conducted a baseline survey and scientists collaborated in order to construct Islamic implemented prevention activities within local Mus- responses to the ethical questions raised by the HIV/ lim communities. An education program employed AIDS pandemic. The first report of this exercise in col- trainers to educate thousands of religious leaders, lective legal reasoning (ijtihad jamai), has been made who in turn educated their communities about HIV/ by Ghaly (2013). AIDS. After two years, there was a significant increase in knowledge about HIV transmission, methods of Before such collaborative efforts, there was a dis- prevention and the risk associated with ablution of the connect between scholars of the text and those of con- dead and unsterile circumcision. More significantly, text. For example, one Muslim scholar described the there was a marked reduction in self-reported num- HIV/AIDS epidemic as: “A disease that Allah (God) bers of sexual partners among the respondents under has sent upon the infidel countries which made what 45 years. Additionally, there was a significant increase God has forbidden lawful and declared their rebel- in self-reported condom use among men in urban ar- lion against Allah by [committing] the unlawful sex- eas (Kagimu et al. 1998). A recent report highlights ual practices, viz., adultery and homosexuality. That is that there has been a marked decline of HIV/AIDS why Allah sent upon them this little force whose name incidence among the members of Uganda’s Muslim is the ‘AIDS virus,’ namely acquired immune deficien- community from 18% in the early nineties to 6% (Far- cy” (Ghaly 2013). rell 2003). However, Muslim countries that had previously The Ugandan example highlights the importance considered themselves protected from HIV/AIDS due of integrating HIV prevention and treatment strat- to religious and cultural norms realized they were fac- egies within existing social, cultural and religious ing a rapidly rising threat (Hasnain 2005). The com-

52 J Health Cult 2016;1(1) Suleman Islamic research ethics: a thematic review of the literature frameworks (Hasnain 2005). Additionally, successful to the debates that are playing out within the broader research of taboo subjects within the Muslim commu- field of bioethics. There may also be drive to develop nity requires appropriate education of local scholars responses that employ, more explicitly, an Islamic ap- and the public. Muslim responses to the HIV/AIDS proach. pandemic illustrate that successful collaboration can Genetic research, cloning and reproductive tech- yield population health benefits. Such religio-cultural nologies are also of particular interest within the Mus- adaptation has required extensive work by local and lim world due to the familial nature of the research. international health professionals with the religious Protection of progeny and paternity are key principles leaders as key collaborators to ensure public accep- in Islam (Kabir 2007), and so related fields of research tance and adoption of the prevention measures. and development feature highly within this literature Muslim communities rely on their faith leaders for search. guidance on what is Islamically considered as moral and/or legal practice. The Ugandan study highlights VII. Emerging role of contextual scholars as authori- the importance of engaging, educating, and training ties collaborating alongside Islamic textual scholars religious leaders about emerging global health chal- Traditionally, Islamic scholars have primarily held Is- lenges to enable them to arrive at an informed scholar- lamic legal authority. They are usually trained in semi- ly opinion that can then be disseminated and accepted naries and study the Qur’an, teachings of the Prophet by their community. and other relevant Islamic sciences to equip them with tools for answering emerging ethico-legal problems. VI. Scholarly deliberations surrounding emerging However, with the advancement of science and the medical technologies such as genetics and reproduc- subspecialization of knowledge, traditional Islamic tion scholars are becoming more distant from the language There is a vast number of articles in English and other and context of science. With the growing ethico-legal languages such as Arabic and Urdu focusing on genet- conundrums practitioners face in their work, physi- ics and reproduction. This may be a result of the grow- cians and scientists have taken on the task of famil- ing interest in the incidence of genetic diseases in the iarizing themselves with the Islamic legal tradition. Middle East, due to the prevalence of consanguineous Studies have shown that Muslim medical and scientific marriages within Arab Muslim populations (al-Hazmi experts are keen to adopt the language of Islamic the- 2004). Muslims believe in the importance of seeking ology (Ghaly 2013) and to draft Islamic legal rulings in cures for all diseases, and the benefit that is accrued order to bridge the communication gap between their through genetic research may outweigh the immediate profession and the traditional scholars. This is in an individual and societal cost (Fadel 2010). attempt to answer emerging religio-ethical challenges. Authors have called such collaborations between Another reason for the high number of such ar- “scholars of the text and context” as necessary to ad- ticles is that major scholarly efforts over the past dress communities’ emerging challenges (Ramadan two decades, within medical ethics, have focused on 2009). emerging technologies. This may be because advances in biotechnology have resulted in the subsequent eco- It may be pertinent to assess the nature of this nomic response of increased demand for such tech- emerging multifaceted role of the Muslim physician/ nologies. Scholars have thus prioritized mounting a scientist/researcher and the impact it may have on the reaction to this growing consumer market within the global health research ethics discourse. Is it possible medical field, whereas they have not yet fully grappled that, in time, such bilingual scholars will replace tra- with the equally pressing concerns relating to the de- ditional scholars? Or will traditional scholarship only sign and conduct of medical research. Another reason retain its relevance if it develops alongside technical may also be that Muslim scholars are simply adding knowledge?

J Health Cult 2016;1(1) 53 Journal of Health & Culture Original Article

VIII. Religious injunctions relevant to research lim researchers/physicians when doing their work. The latter may comprise a mixture of secular and reli- The literature describes that the factors influencing gious thinking and principles. Both of these aspects of the design and implementation of research involving study will enable greater understanding of how Islam Muslim communities may also include those issues influences the expectations and experience of research pertaining to religious injunctions, such as: participants, the dilemmas and decisions of Muslim • Dietary restrictions such as fasting during the researchers and the lessons that can then be employed month of Ramadhan and the use of porcine-based by non-Muslim researchers medical products within a research study (Padela It is accepted that within Islamic jurisprudence, the 2013), or other illicit ingredients. numerous schools of thought, although rooted in the • Muslim attitudes towards a research study may same primary sources, may arrive at differing and of- also be affected by the proposed clinical environ- ten contradictory judgments. It is thus imperative not ment such as lack of modest hospital gowns as well simply to rely on the textual reasoning found in pub- as the gender of the researcher. Although excep- lished guidelines and literature but the contextual rea- tions are made within the context of an emergency, soning that is arrived at by researchers, scholars, and within the context of research, Muslims may prefer participants. This may allow identification of the un- researchers of the same gender especially if physi- derlying normative principles that are applied by Mus- cal examination or the discussion of sensitive sub- lim researchers. The literature search also reveals that jects is necessary (Inhorn 2003). the Islamic perspective on research ethics is a nascent area of intellectual discourse. Within it lies the exciting Future work: the need for a contextual study scope of unravelling the potential impact that is being The textual analysis completed thus far requires a made by researchers analyzing their biomedical con- complementary contextual study to answer the ques- text in light of an Islamic legal framework. Although tion about the role of Islam within research. There scholarly opinions have thus far focused on the religio- have been no empirical studies to date to assess the ethical challenges of emerging technologies, there is a “moral world” of the Muslim researcher. Although in- growing interest in further work within this field. ternational guidelines have been adapted to incorpo- The literature also reveals that there are many rate Islamic views, studies have shown that the latter moral concerns arising from the Islamic tradition and are of limited practical application within a “Muslim Muslim contexts that remain unanswered and require country” setting. As yet, it is unclear whether Muslim consideration. Conducting studies on humans raises researchers rely on such adapted guidelines or simply issues around the sanctity of life, stewardship of one’s use the existing international guidelines that are pres- body, seeking cures and enduring hardship. If Muslims ent. If the latter is true then it may be useful to assess consider being stewards of the valuable gift of life as how Muslim researchers employ “secular” guidelines well as their bodies, how do they reconcile the pos- within their local environment and whether they need sible opportunity to preserve life that may be offered to adapt them based on their faith and/or context. by a trial chemotherapy drug, whilst potentially open- In settings where non-Muslim researchers are ing the window of harm by scientific experimentation? working with a majority Muslim population, it may be What is considered an acceptable risk and an adequate valuable to assess whether they are able to apply re- benefit? If Islam promotes charity and public good, search protocols according to international guidelines, then why has the majority of the religio-ethical discus- verbatim, or whether adaptation is necessary based sions focused on emerging technologies that are avail- on local religious beliefs. For example, recruitment of able to the privileged few? How will the Muslim world, women may have to be done with the consent of her with its growing economies and resources, implement husband or male relative. Also, it would be valuable Islamic teachings whilst remaining competitive on the to assess the practical ethics struggles faced by Mus- global market? Inequalities in power, health, and re-

54 J Health Cult 2016;1(1) Suleman Islamic research ethics: a thematic review of the literature sources are rife in Muslim contexts all over the world. The literature highlights areas of religio-cultural Is it simply the case that religion is called upon when contention between what is expected according to relevant or does faith provide and necessitate the ap- global secular standards and what can be implemented plication of principles that may help address some on in a context where researchers’ and participants’ values the most profound questions presented by medical re- may require consideration. Further study is necessary search? Islam is mentioned as a reason for why certain on such areas of contention firstly to document sys- research is funded or rejected; it is called on to legiti- tematically where the conflicts may arise and secondly mize or prohibit certain technologies and practices. how then to ensure that participants’ interests and safety are upheld whilst balancing the professional and There is a scarcity of discussion around such im- personal considerations of the researcher. portant questions. Is the reason that Islamic scholars and Muslims feel these are sufficiently answered by A combination of empirical and normative study existing discussions within the secular guidelines and is necessary to provide further insight into the phe- literature? The themes discussed here, namely, female nomenon “Islamic research ethics” and to offer a more consent, tissue storage, genetic research and expert au- robust discourse from within the Islamic and Muslim thority, reveal that there is a need for Muslims to ac- ethics sphere. Muslim scientists, researchers, ethicists, quire their own resources of moral reasoning to enable theologians and legal scholars need to address the them to navigate through existing and emerging ethi- questions presented here using tools from within their cal questions that uphold both professional standards own tradition to provide coherent guidelines to enable and their own religio-cultural beliefs. The question, researchers to engage in moral reasoning that is con- however, is whether there are sufficient intellectual re- gruent with their own religio-cultural values, whilst sources and will to undertake the answering of such presiding within the necessary international gover- questions. nance standards.

Conclusion References This thematic review of the literature reveals the im- Afifi R (2007), “Biomedical research ethics: an Islamic view portance of normative Islamic sources within the re- part II,” International Journal of Surgery 5(6), 381–3. search ethics discourse in contexts where Muslims Aksoy S, Elmai A (2002), “The core concepts of the ‘four may be subjects of research and/or conducting re- principles of bioethics’ as found in Islamic tradition,” search. Although the application of Islamic principles Medicine and Law 21(2), 211–24. is varied and inconsistent, the review emphasizes the Aksoy S, Tenik A (2002), “The ‘four principles of bioeth- role of religion and religious authority in underlining ics’ as found in 13th century Muslim scholar Mawlana’s research priorities, guidelines, and conduct. teachings,” BMC Medical Ethics 3:4. al-Hazmi MA (2004), “Ethics of genetic counseling—basic This paper highlights a growing literature on Is- concepts and relevance to Islamic communities,” Annals lamic research ethics and research that is conducted in of Saudi Medicine 24(2), 84–92. Muslim communities. It also emphasizes that further al-Jumah M, Abolfotouh MA, Alabdulkareem IB, Balkhy discussion and debate are not only desirable but nec- HH, al-Jeraisy MI, al-Swaid AF, et al. (2011), “Public at- essary on the issues surrounding Islamic research eth- titude towards biomedical research at outpatient clinics ics and research that is conducted in Muslim contexts. of King Abdulaziz Medical City, Riyadh, Saudi Arabia,” This is because with the increasing volume of research Eastern Mediterranean Health Journal 17(6), 536–45. being conducted by and with Muslims who are largely Atighetchi D (2007), Islamic Bioethics: Problems and Perspec- tives (Dordrecht: Springer). conscious of their faith, there will be a growing need to Beauchamp TL, Childress JF (2001), Principles of Biomedical address issues pertaining to research that interact with Ethics (Oxford: Oxford University Press). their own religio-moral make up.

J Health Cult 2016;1(1) 55 Journal of Health & Culture Original Article

Bhutta Z (2002), “Ethics in international health research: a International Islamic Code for Medical and Health Ethics, perspective from the developing world,” Bulletin of the vol. 2, ed. al-Gendy AR, al-Awadi ARA (Kuwait: Islamic World Health Organization 80(2), 114–20. Organization for Medical Sciences, pp. 121–276). CDC—Centers for Disease Control National Prevention In- Kabir M, al-Zubair B (2007), “Who is a parent? Parenthood formation Network (2003), “Indonesia’s insulation from in Islamic ethics,” Journal of Medical Ethics 33(10), 605– HIV/AIDS wears thin,” excerpted from Deutsche Presse- 9. Agentur (19 June 2003), retrieved from http://thebody. Kagimu M, Marum E, Wabwire-Mangen F, Nakyanjo N, com/content/art28461.html, accessed 18 August 2015. Walakira Y, Hogle J (1998), “Evaluation of the effective- Chattopadhyay S, De Vries R (2012), “Respect for cultural ness of AIDS health education interventions in the Mus- diversity in bioethics is an ethical imperative,” Medicine, lim community in Uganda,” AIDS Education and Preven- Health Care, and Philosophy 16(4), 639–45. tion 10(3), 215–28. Durante C (2009), “Bioethics in a pluralistic society: bioethi- Keyserlingk EW (1993), “Ethics codes and guidelines for cal methodology in lieu of moral diversity,” Medicine, health care and research: can respect for autonomy be Health Care, and Philosophy 12(1), 35–47. a multi-cultural principle,” in Applied Ethics: A Reader, Emanuel E, Wendler D, Grady C (2000), “What makes clini- ed. Winkler ER, Coombs JR (Oxford: Blackwell, pp. cal research ethical?” Journal of American Medical Asso- 319–415). ciation 283(20), 2701–11. Lagarde E, Pison G, Enel C (1998), “Risk behaviours and Engelhardt HT (1986), The Foundations of Bioethics (Oxford: AIDS knowledge in a rural community of Senegal: re- Oxford University Press). lationship with sources of AIDS information,” Interna- Fadel HE (2010), “Ethics of clinical research: an Islamic per- tional Journal of Epidemiology 27(5), 890–6. spective,” Journal of the Islamic Medical Association of Larijani B, Zahedi F, Nouri M, Bagheri A, Heshmat R, Mote- North America 42(2), 59–69. vaseli E, et al. (2006), “Ethics committees and externally- Farrell M (2003), “Condoms and AIDS prevention: a com- sponsored research in Iran,” DARU Journal of Pharma- parison of three faith-based organizations in Uganda,” ceutical Sciences 14(Suppl. 1), 1–6. AIDS and Anthropology Bulletin 15, 3. Lurie P, Wolfe SM (1997), “Unethical trials of interventions Freedman B (1987), “Scientific value and validity as ethical to reduce perinatal transmission of the human immuno- requirements for research,” IRB: Ethics & Human Re- deficiency virus in developing countries,”New England search 9(6), 7–10. Journal of Medicine 337(12), 853–6. Ghaly M (2013), “Collective religio-scientific discussions on Nuffield Council on Bioethics (2002), The Ethics of Research Islam and HIV/AIDS: I. Biomedical scientists,” Zygon: Related to Healthcare in Developing Countries (London: Journal of Religion & Science 48(3), 671–708. Nuffield Council on Bioethics), available at http://nuff- Hamdy S (2012), Our Bodies Belong to God: Organ Trans- ieldbioethics.org/wp-content/uploads/2014/07/Ethics- plants, Islam, and the Struggle for Human Dignity in of-research-related-to-healthcare-in-developing-coun- Egypt (Berkeley: University of California Press). tries-I.pdf, accessed 18 August 2015. Hasnain M (2005), “Cultural approach to HIV/AIDS harm Oguz NY (2003), “Research ethics committees in developing reduction in Muslim countries,” Harm Reduction Journal countries and informed consent: with special reference 2:23. to Turkey,” Journal of Laboratory and Clinical Medicine Ijsselmuiden CB, Kass NE, Sewankambo KN, Lavery JV 141(5), 292–6. (2010), “Evolving values in ethics and global health re- Padela A (2013), “Islamic verdicts in health policy discourse: search,” Global Public Health 5(2), 154–63. porcine-based vaccines as a case study,” Zygon: Journal of IMSE—Islamic Medical and Scientific Ethics Database, Religion & Science 48(3), 655–70. http://imse.library.georgetown.edu, accessed 18 August Ramadan T (2009), Radical Reform: Islamic Ethics and Lib- 2015. eration (Oxford: Oxford University Press). Inhorn MC (2003), Local Babies, Global Science: Gender, Rathor MY, Rani MFA, Shah ASM, Leman WI, Akter SFU, Religion and In Vitro Fertilization in Egypt (New York: Omar AM (2011), “The principle of autonomy as related Routledge). to personal decision making concerning health and re- Islamic Organization for Medical Sciences (2005), “Inter- search from an ‘Islamic viewpoint’,” Journal of the Islamic national ethical guidelines for biomedical research in- Medical Association of North America 43(1), 27–34. volving human subjects ‘an Islamic perspective’,” in The

56 J Health Cult 2016;1(1) Suleman Islamic research ethics: a thematic review of the literature

Ryan MA (2004), “Beyond a Western bioethics?” Theological ten Have H, Gordijn B (2011), “Travelling bioethics,” Medi- Studies 65(1), 158–77 cine, Health Care, and Philosophy 14(1), 1–3. Sachedina A, Ainuddin N (2004), Islamic Biomedical Ethics: Zahedi F, Larijani B (2008), “National bioethical legislation Issues and Resources (Islamabad: COMSTECH). and guidelines for biomedical research in the Islamic Re- Sachedina A (2006), “No harm, no harassment: major prin- public of Iran,” Bulletin of the World Health Organization ciples of health care ethics in Islam,” in Handbook of 86(8), 630–4. Bioethics and Religion, ed. Guinn DE (Oxford: Oxford University Press). Sachedina A (2007), “The search for Islamic bioethics principles,” in Principles of Health Care Ethics, 2nd ed., ed. Ash- croft RE, Dawson A, Draper H, McMillan J (New York: John Wiley & Sons, pp. 117–25).

J Health Cult 2016;1(1) 57 Journal of Health & Culture Review

A review of Ottoman court records on mental diseases

Nil Sarı

Cerrahpaşa Medical School, Department of Medical Ethics and History

Abstract Correspondence to: Prof. Dr. Nil Sarı The Ottoman judges’ (kadı) registers are juridical texts. These court records reflect the reali- İ.Ü. Cerrahpaşa Tıp Fakültesi, Temel ties of everyday life in the Ottoman Empire. Such historical evidence of implemented deci- Bilimler Binası, Tıp Tarihi ve Etik Anabilim Dalı, 34098 İstanbul, Turkey sions reveals the attitudes and course of action that Ottoman society considered to be appro- [email protected] priate and just. Cases culled from several court registers kept in different cities shed light on the exercise of seeking legal counsel for mental patients. The court records, written in Otto- man Turkish, indicate that these cases were conducted with the participation of the judge, the plaintiff, the defendant, and relevant witnesses. Often the patient, a guardian (tutor, possibly from among the family members), relatives, neighbors, and other community members also appeared in court. When needed, expert opinion was taken into consideration in legal discussions, and physicians (as specialists for the determination of insanity) were consulted. As we can infer from the cases cited in this text, the underlying factor for the determination of insanity was mental incompetency. This paper reviews hospitalization, guardianship (vasilik/ vesayet), personal rights (hak ehliyeti–vücûb ehliyeti), competence to act (edâ ehliyeti / fiil ehliyeti), marriage and divorce, and some other legal proceedings regarding mental patients in the Ottoman Empire in the light of cases cited from the Ottoman court records. Finally, the first act on mental patients and mental hospitals in the Empire is discussed and findings are evaluated. Keywords: Ottoman Empire; juridical records; legal rights; mentally ill; social attitudes

58 J Health Cult 2016;1(1) Sarı A review of Ottoman court records on mental diseases

Introduction As we can infer from the cases cited in this text, the underlying factor for the determination of insan- The Ottoman judges’ (kadı) registers are juridical texts. ity was mental incompetency. The main criterion used These court records reflect the realities of everyday to judge someone to be insane was his/her inability to life in the Ottoman Empire. Such historical evidence reason. Lacking reason or deficiency in reasoning was of implemented decisions reveals the attitudes and expressed as lacking the temyiz kudreti, which means course of action that Ottoman society considered to be the power of discernment of the reasons and conse- appropriate and just. Cases culled from several court quences of actions (Dönmez 1993; Dönmez 2011). We registers kept in different cities shed light on the exer- come across expressions such as, “her reason is gone” cise of seeking legal counsel for mental patients (Bayat or “he lost his mind.” The mind (akıl) determines the 1992; Çetin et al. 2006).1 capacity of the human being to tell right from wrong These court records, written in Ottoman Turkish, and to act accordingly. The termakıl means reason, indicate that the cases were conducted with the par- intelligence, discernment, discretion, as well as com- ticipation of the judge, the plaintiff, the defendant, and prehension (idrak), perception and mental ability. In relevant witnesses. Often the patient, a guardian (tu- court registers, we come across expressions such as tor, possibly from among the family members), rela- yarım akıllı, meaning mentally weak, and akılda hiffet/ tives, neighbors, community members, and physicians hafiflik, meaning light-witted (see Case 5, 9, 11). This (the latter listed as specialists for the determination of notion is based on Islamic law, where it is the mind insanity) also appeared in the court. When needed, that renders the human being responsible and legally expert opinion was taken into consideration in legal liable. (Uzunpostalcı 2007; Yıldız 2009; Udeh 1990). discussions. According to the information we obtain from case The legal notion and definition of insanity applied reports, madness was recognized from its signs and in legal decisions in the canonical courts can be recon- symptoms, called eser-i cinnet. For example, the way structed from court registers. The wide range of men- of acting, mode of external conduct, behavior (etvâr tal disturbances mentioned in medical manuscripts and evzâ’), such as hitting or insulting other people, are not reflected in the court records (Sarı 1986). would be signs of madness. People’s testimony about While there were certain criteria used to judge insan- an individual’s state of mind, as a result of observing ity, decisions were highly flexible, on an ad hoc basis. A or experiencing an act of madness, was also taken into generic expression is used in lawsuits for various forms consideration. Attributing madness to oneself (kendü- of unusual behavior. In court cases, the terms cünûn or ye cünûniyet isnâd etmek) is also cited in court records. cinnet are frequently applied to denote madness. Al- However, a physician’s report was required for a defi- though the noun cinn, meaning genie, is the root of the nite diagnosis and a final decision about madness. term cinnet (Devellioğlu 2009), this meaning is not re- The distinction between permanent and intermit- flected in court registers, where the following expres- tent forms of mental disturbances was a significant cri- sions are used to define madness and the insane: terion for legal decisions. Confirmed permanent mad- • “cinnet getirmek”: displaying madness, go mad, ness is called cünûn-i mutbik. A judicial decision is to become insane required to confirm that a person is permanently mad • “cünûn ‘ârız olmak”: having signs of madness (cünûn-i mutbik). Intermittent or short-term madness • “cünûniyet müstevli olmak”: being possessed by presenting with lucid intervals is called cünûn-i gayr-i madness mutbik (non-permanent). Another term we encounter • “mecnûn”: the madman in court registers is cünûn-i müfîk, meaning reversible • “mecnûne”: the madwoman madness (Bilmen 1967; Dönmez 1993, p. 126; Udeh • “mecnûnü’l akîle”: one who has lost his mind 1990, pp. 171–2).

1 Different approaches in various Islamic sects are not discussed in this paper. The issues presented emphasize a common ground.

J Health Cult 2016;1(1) 59 Journal of Health & Culture Review

Cases charge from hospital. Below, a physician’s opinion is requested for a decision to discharge an offensive in- The following case is about a mother’s action for a judicial decision to confirm that her son is permanently, sane person from the hospital: i.e., irreversibly, mad. The court order conformed to a consensus of the community. Case 3 “Osman is chained up in the Sultan Ahmed Han Case 1 Hospital in Istanbul. His father-in-law Mehmed applied to the court, submitting a petition to take Os- “Ayşe, mother of İlyas, applied to the court and as- man home. The hospital’s head physician said, ‘It serted, ‘My son İlyas came to be mentally ill at three is not harmful for Osman in terms of treatment at years of age, after his father’s death. Gradually, his ill- home, provided he is chained.’ ness became more severe. He harms people because of his innate mental illness. Ask those present in the The person sent by the head physician and people court.’ She requested a decision about her son’s mad- of the community conveyed the head physician’s ness. decision to the court. Osman’s transfer to his home, his maintenance and treatment at home, while be- All those present said, ‘His insanity is of the perma- ing chained, were decreed” (Istanbul court records, nent type of madness (cünûn-ı mutbık). It has been 1766; Yılmaz 2006, pp. 315–6). 15 years since his mind did not come back…’

It was decided that İlyas was permanently insane.” When serious impairment was likely to occur to (Adana court records, 1744; Yılmaz 2006, p. 299). the patient without treatment, a decision for compulsory treatment was given in the patient’s best interest. Hospitalization of the insane In Case 4, a father requests hospitalization of his insane son for treatment: Lawsuits provide case studies related to mental patients concerning hospitalization, discharge from hos- Case 4 pital, and care at home. The duty of the court to protect both the individual and society reflects the paradoxical “A Christian named Hâsır applied to court. He wanted his son, who had attempted suicide, to be hospi- status of the insane. In the following case, a son op- talized. Hilmi Beşe, the guardian of Sultan Alâeddin poses his insane mother’s hospitalization that has been Hospital, was present at the hearing of the case. The requested by the community. As a result of the court father said, ‘My son Mirat, who is present here, has decision, the responsibility for the insane remains with symptoms of madness. He threw himself down a the family. well and in other dangerous places. I wish him to be handed over to Hilmi Beşe for treatment.’ Case 2 Madness was displayed in Mirat’s manners and be- “Many residents of the district came to court and havior. In addition, local residents confirmed Mirat’s said, ‘As Fâtıma has gone mad, she ought to be hos- insanity and also reported about him throwing him- pitalized and treated by administering syrup at the self into the well. Thereupon the father delivered hospital.’ Fâtıma Hatun, the insane mother of Ömer his son to the official Hilmi Beşe to be treated at the was also present, hearing the lawsuit. hospital” (Konya court records 1669; Yılmaz 2006, p. Ömer, son of Fâtıma said, ‘I will guard my mother 167). at home.’ Times of lucidity in intermittent and reversible With the decision of the court, Fâtıma was entrust- madness ed to her son Ömer.” (Konya court records, 1614; Yılmaz 2006, p. 117). Being deprived of reason, the deranged individual Need for medical knowledge and expertise is en- was unable to undertake judicial acts, but in periods countered in several cases of hospitalization and dis- of lucidity judicial functions were permitted. The law

60 J Health Cult 2016;1(1) Sarı A review of Ottoman court records on mental diseases allowed the insane to make their own will in the fol- is presumed to be competent (ehil). The law allowed lowing two cases (Case 5 and 16). Judges based their the insane the right to inherit property. However, this decision on the testimony of the insane women and right is to be exercised by the guardian (Bardakoğlu adult witnesses. 1994; Şentürk 2000). In the following case, guardianship of property is conferred to the mother of the in- Case 5 capacitated.

“Sâbire Hatûn was light-witted (‘hiffet’), and acts of madness appeared suddenly. She was said to be Case 6 insane (‘mecnûne’). Her brothers Yûsuf and Ivaz “The insane female Şerife is one of the three children wanted to be her guardians. After residents of the of the deceased knife maker Mustafa; and, like her community were questioned, Sâbire herself said, sister and brother, one of the heirs of the property ‘From time to time I go mad, and insanity (cünûn) transferred by inheritance. possesses me.’ The court has to choose and appoint a guardian who Many people in the community also said, ‘Sâbire is is to take the possession (‘zapt’) and the protection light-witted, she is suffering from reversible mad- of the property inherited from the father and to do ness (cünûn-i müfîka) and her foot and hand are what is needed. paralyzed (mefluce).’ Following the information given by some people Sâbire was handed over to her brothers Yûsuf and whose names were registered, it was evident that the Ivaz to be protected and controlled” (Konya court mother of the children, Hatice Hatun, being quali- records 1676; Yılmaz 2006, pp. 184–5). fied as necessary, was trustworthy and honest, capable to cope with trusteeship.

Guardianship (vasilik/vesayet) and personal rights The mother was chosen and appointed as the guard- (hak ehliyeti–vücûb ehliyeti): ian; and she undertook to carry out the necessary Lawsuits provide case studies related to the incapacita- duty” (Konya court records, 1816; Ünlü 2005). tion of a person on grounds of insanity. Assigning responsibility of care for an insane person and his or her In the following case, a trustee (kayyum) is ap- property to another person, i.e., guardianship, aimed pointed by court order to administer the estate of an at the protection of the insane as well as the protec- insane inheritor: tion of the community. Guardianship over an insane person is similar to curatorship. A curator (veli) is one Case 7 who is empowered to exercise the legal rights of an in- “The insane named Mustafa is the son of Mustafa capacitated person, such as a child. The notion of legal who is deceased. His father’s wife Kezban and his incapacity is based on the need for protection of the sister Hadice are also dead. The insane is heir of the defenseless. Whoever cares for the insane is expected decedents (‘soydan’) to the property left over from to act as a parent. The guardian vasi( ) must be mature, the deceased. in full possession of his/her mental faculties, of good The ‘kassâm’ who is in charge of distributing the in- repute and able to undertake the office. The guardian is herited estate and protecting the rights of children, appointed by the court with the approval of the judge chose and appointed the children’s relative Hasan (Bardakoğlu 2013). b. Halil as the trustee so as to control (‘zapt’) and protect the inherited share (‘hisse-i irsıyye’) of the Acts considered as “rights endowed to human be- insane. ings by God,” such as inheriting property, marriage and divorce are called hak ehliyeti, meaning personal People whose names were written down in the reg- rights. Madness does not eliminate these personal istry made it known that this person was good and beneficial in all aspects concerning the insane. rights. When personal right is considered, the insane

J Health Cult 2016;1(1) 61 Journal of Health & Culture Review

Upon this, the judge appointed Hasan as the trustee Then, Sinan said that he would bring his sister home, (‘kayyum’). attend to her treatment and control her; and his words were recorded in the register. He undertook (‘taahhüt’) to carry out the necessary service as required, in the appropriate way” (Tokat Five judges sealed the decision” (Konya court re- court records 1812; Hanilçe 2009). cords, 1673; Acartürk 2006).

The needs of insane who had no income were also Competence to act (edâ ehliyeti / fiil ehliyeti): an issue referred to the court. A guardian might ask Regarding Islamic jurisprudence, the basis of capacity for financial support. Below is a case where the elder to act is provided by the power of judgement / power son was appointed as guardian for his penniless insane of discernment (temyiz gücü). Mental illness removes mother: the power of judgment. The insane is incompetent in respect to the capacity to act (fiil ehliyeti). Therefore, Case 8 the insane does not have criminal liability. However, “It was reported by honest and credible people that the insane and/or the guardian are responsible/li- signs of madness appeared in the behavior of the able for damages caused due to madness. Compensa- woman Melek Hatun that year. It was necessary and tion for damage/harm given by a mentally ill person important to appoint a guardian to serve the inter- is paid from his/her own wealth. For indemnity debt ests of Melek Hatun. (tazmin borcu), the condition (şart) of competence to The elder son of Melek Hatun, es-Seyyid Mustafa act (fiil/edâ ehliyeti) is not demanded. Personal right Çelebi was said to be devout and honest. It was in- (hak ehliyeti) is sufficient. Although the insane can be dicated that he was capable of handling his mother’s considered liable (borçlu) for damage, the responsibil- guardianship. When the judge chose and appointed ity for payment of the debt from the insane person’s es-Seyyid Mustafa as the guardian, he accepted the property is incumbent upon the legal representative guardianship (‘vesayet’) and undertook to carry out (Bardakoğlu 1994; Dönmez 2011; Uzunpostalcı 2007). her affairs. However, Mustafa asked for ‘ten silver coins (akçes) alimony to be appreciated and assigned Reason or the ability to understand is the essential as a maintenance allowance for her garments and condition for the existence of all judicial actions, and other necessary expenses; and to be written as debt, this is presumed to be lacking in the insane. Mental in case required, on her husband Kara Mahmud Bey, illness removes the competence to act (fiil ehliyeti), who was in another country.’ thus legal liability. If a mental patient was deprived The names and seals of many people who witnessed of the power of discernment during the act subject the lawsuit were also registered” (Kayseri court re- to trial, then he/she was released from judicial action cords 1693; Yılmaz 2010). (Bardakoğlu 1994). Christian residents also applied to the Muslim Questioning a person’s sanity at the time of action court to ask for guardianship: is a matter of discussion. In the following case, qualified witnesses were called to testify to the insanity of Case 9 the individual:

“Many people came from the district to the court. They said, ‘The Christian woman named Şemam, Case 10 sister of Sinan, came to be light witted (aklına hif- “The head official lieutenant colonel of Karaman fet târî olup); however, her husband is not here and sent Abdullah Çavuş to the court of justice. He there is nobody to look after her. Şemam’s brother summoned Bektaş b. Mustafa, a resident of the Sinan should take his mentally ill sister to his home Debbağhane district, to the court. In the presence of and take care of her by administering medicine and Bektaş, he claimed, ‘Bektaş robs from the vineyard.’ control her.’ When it was said that the circumstances of the event

62 J Health Cult 2016;1(1) Sarı A review of Ottoman court records on mental diseases

be learned by questioning the people of the dis- has the right to ask the judge for a divorce (Atar 2007). trict, several people from the community present at In the following case, the marriage engagement of the court, whose names were registered, reported, ‘Bektaş’s mind suddenly turned mad (aklına cinnet a man who was proven to be mad at the time of mar- târî oldu); he is insane (mecnûn) .’ riage is annulled upon medical examination and the testimony of witnesses: Notable people (‘ayan’), teachers (‘müderris’) and sheiks put their seals under the words registered” Case 12 (Konya court records, 1673; Acartürk 2006). “Fatıma applied to the court and said, ‘At the time In the following case, a prisoner who got mad while when I married Mustafa ibn İbrahim, receiving 1001 being in prison was decided to be released: piasters (kuruş) dowry (başlık parası), making an engagement in the presence of witnesses, I did not Case 11 know that he was insane. Before entering the bridal “Scholars (‘ulema’) and dignitaries, who were inhab- chamber, it was understood that Mustafa was really itants of Lârende, came to the court and explained mad and, after being arrested, he was sent to the hos- 2 their intention: ‘Zeytuni Çavuş from Konya was put pital. As the fatwa I have necessitates, my request in prison by the order of the Sheikh al-Islam, so as to to cancel the marriage engagement was put into ef- th correct him, because he dared to make disapproved fect with my petition dated June 7 , 1897 [26 Mayıs behaviors. But, God save, he has got light witted 1313]. The written order emirnâme( ) of the country (aklına hiffet getirip) and become insane (mecnûn). doctor Sava Efendi, whom Mustafa was referred to, He is in a wretched condition; he deserves mercy in is attached to my claim. After Mustafa was arrested, all respects, he is worthy of affection.’ Mustafa’s neighbors informed the officials that he had been mad for 3–5 years. A new medical examination They requested and wished (‘niyaz’) him to be re- was performed and signs of madness were observed leased and expressed their wish emphatically in in Mustafa; it was confirmed that signs of madness backing him. were medically evident, hence from then on he should The court ruled to set Zeytunî Çavuş free from pris- not be left uncontrolled, and ought to be sent to the on” (Karaman court records, 1830; Gürbüz 2009). hospital for treatment, as he was not safe.’ The prayer leader (‘imam’), the headman (‘muhtar’), Marriage engagement and divorce the aldermen (‘ihtiyar heyeti’) and all the people of the district stated that Mustafa’s mind and com- According to Sharia, agreements made by the insane prehension were disordered, as he dared to hit this are illegal and business cannot be transacted with and that (person) and to do harm. Being so mad, he them. However, the insane can be bestowed in mar- would commit serious crimes, hence he needed to be riage by a guardian, being viewed from the personal sent to hospital. As it was clear that his wife (Fatıma) rights (hak ehliyeti) perspective (Karaman 1989). How- really should not be allowed to live with him, an in- ever, a guardian is expected to act responsibly toward sane, she asked for further action (‘icabının icrasını the insane and his property or else will be removed taleb ederim’). After Mustafa’s examination, it was for improper conduct. The duty of anyone knowing of apparent from his acts and behaviors and the state- the misconduct of a guardian is to inform the judge. ments of the said people of the community that he Guardianship can be declined with the acknowledge- was still mad. ment of the judge (Bardakoğlu 2013). On the other At the court, when confronted with the Konya Or- hand, insanity is a ground for divorce. A physician is phanage Director Hüseyin Efendi, who was the chosen required to decide in a given case whether or not a per- and appointed guardian of the insane, Fatıma Hatun son is insane. Medical proof of an individual’s insanity repeated what she had said, ‘Although I made a mar- at the time of engagement would invalidate the marriage engagement with Mustafa on the said date, he riage contract signed by an uninformed partner. If a partner was insane at the time of marriage, the spouse 2 Opinion on legal matter furnished by a mufti, on application.

J Health Cult 2016;1(1) 63 Journal of Health & Culture Review

was mad at the time of engagement. As the marriage Case 14 engagement of such a mad man would not be trustwor- “As the people of the district were helpless and des- thy, I request the termination of this marriage.’ perate, the mad woman (‘mecnûne’) Havva Hatûn The said guardian replied, ‘As the plaintiff explained was sentenced to exile (‘sürgün’) from Konya. The in detail, she denies the signature at the time of en- substitute judge of the township Lârende announced: gagement.’ ‘People of the district are exasperated by the acts of Havva Hatun, an insane female (mecnûne) inhab- Witnesses said, ‘We witness that Mustafa’s mind is itant of the city of Konya. They gave a petition for damaged (şuuru muhtel) and he has been perma- her to be exiled to another city. This time the insane nently mad (cünûn-ı mutbık) for a long time, and woman is exiled to Karaman. As you know, you must was the same during the plaintiff’s marriage.’ detain her in your town and make certain she stays They signed the registry” (Konya court records in one place. This is ordered by the council (dîvân) of 1897; Albayrak 2010). the Karaman province, the district (liva) of Akşehir In the case given below, the divorced husband pre- and Aksaray. When you receive the decree, act as necessary, refrain from opposition’” (Karaman court tending to have been mad was determined to have records, 1831; Gürbüz 2009). been sane at the time of divorce, which was confirmed consequently: On the other hand, a mad person could apply to court for a plea. In the case given below, a mad woman Case 13 seeks her right and opposes her exile to another city:

“Mihriye Hatun went to court and said, ‘Six months ago Ali divorced me in court. When I wanted to Case 15 marry another man, he came against it. He tries to “The insane woman Şerife Fâtıma Hâtûn, insisting prevent my marriage.’ on her request, was seeking her right against being Ali said, ‘I did divorce Mihriye in court on the date exiled. Şerife Fâtıma Hâtûn, presenting her trouble in question, yet I was mad at the time of divorce. As to the court, said, ‘I got mad, because fear of burning our divorce is wrong in this respect, I oppose it.’ prevails me.’

Mihriye Hatun said, ‘My husband was completely Upon the petition of the people of the community, sane during the divorce; he has a perfect mind for the court ordered her expulsion from the district. trade.’ She came to live in another place. However, she submitted a petition to live in her own house. This Certain people known for their justice were brought time, a suit was brought against the people who had to court and said, ‘Ali was completely sane and com- been present in court. Questioning the reasoning of prehending when he divorced his wife. However, we the court decision, a detailed investigation was re- are witnessing his intention to cancel the divorce.’ quested. Two men amongst the people said, ‘Fâtıma Their testimony was accepted. Permission and license is still mad (mecnûne) and we are not safe and not was given to Mihriye Hatun to marry the person she comfortable.’ intended” (Konya court records 1817; Ünlü 2005). As most of the people were silent, in order to be free from injustice and guardianship, she was referred Sentence exiling the mad from the city to the head physician to correct and investigate the situation. Then, Fatıma said, ‘My illness is not mad- Inhabitants of a community sometimes appealed to ness, I am suffering from anxiety.’ court complaining about and requesting the exile of a mad person who disturbed the community. The fol- Her expression was registered in the court, in front lowing case is about the complaints of local residents of the people.” (Istanbul court records, 1776; Yılmaz 2006, p. 350). regarding the unacceptably offensive behavior of a mad woman, leading to her exile from the district:

64 J Health Cult 2016;1(1) Sarı A review of Ottoman court records on mental diseases

The first act concerning mental patients and mental When we examine the court records, we see that hospitals the Ottoman law did not allow the punishment or im- prisonment of mental patients or their stigmatization as Though there were criteria used to judge insanity, ca- sinners. Yet it is hardly imaginable that in an era long nonical court decisions were highly flexible, on an ad before the introduction of today’s antipsychotics a men- hoc basis. Enacting laws in line with Westernization tal patient with uncontrollable aggression and a poten- gradually came to change the attitude and behavior of tial to harm others would not be subject to confinement. people towards the insane. Hospitalization of lunatics In such cases, however, a guardian would be assigned and bureaucratic procedures came to be much more to take responsibility for the patient, thus precluding a significant. On March 6th, 1876, the Regulation on forced hospitalization. It was preferred that the guard- Mental Hospitals (Bimarhanelere Dair Nizamname) ian be a family member of the patient. Besides the rights was passed. The regulation was adapted by Mongeri of the patient, the guardian was also responsible for the from the French law dating from 1853. The new legal safety of society and people close to the patient. arrangement led to a new system. The municipal police was held responsible for the hospitalization and Ottoman court records do not include any men- discharge of mental patients. Strict disciplinary police tion of genies (cinn) nor any trace suggesting the per- measures were foreseen according to the law. First, the spective of the “holy fool” (“deli velidir”). In court, all family was to restrict the mentally ill compulsorily at mental patients were referred to as mecnun, an umbrella home. Then, the family had to notify the government. term used to encompass all patients suffering from any The police and the family each had to appoint a physi- mental disorder, hence not using the names given to cian to examine the patient. Several documents were their illnesses in the medical literature of the time; the to be prepared and presented to the hospital. An ap- court would rule considering the medical, juridical, and plication was to be made to the ministry of law in Is- moral aspects of the case. When necessary, physicians tanbul or to the local government in other parts of the would be asked to provide an expert opinion. In resolv- country. After the law came into effect, social tolerance ing the cases brought to court, judges (kadı) would fol- for the mentally afflicted gradually disappeared. The low an approach based on judicious reasoning and rule population of mental hospitals increasingly soared. in accordance with the judicial and moral terms in the The family and the guardian’s responsibility for the in- Qur’an. If we look at the examples of court cases involv- sane declined rapidly. Issues related with the mentally ing mental patients presented in this paper, it can be ill came to be institutionalized. (Kara 2006; Sarı & Ak- suggested that the methods used in resolving these cases gün 2008). were quite ahead of their time. Today’s much debated ethical issues concerning Discussion and Conclusion mental patients’ basic rights, power of discernment, de- The rulings and judicial approaches observed in the gree of legal capacity, criminal liability, forced institu- cases brought to Ottoman courts directly reflect the tionalization and appointment of guardians (vasi tayini) moral values, attitudes and behaviors of the Ottoman could all constitute reasons to go to court in the Otto- state and society. Each court case helps us gain insight man Empire. The patient’s family, people in the patient’s into another value. If in addition to the cases presented neighborhood or others could appeal to the court to above we look at other examples, we can learn about seek a solution for related problems, and when they ap- other moral values. By examining these cases, we can peared in court, they could raise their pleas or defense also determine the fiqh-based criteria according to arguments within the limits drawn by fiqh. We also see which Ottoman court decisions were made and their that courts would allow patients to express and defend legitimacy defended. The primary criterion was the themselves. Depending on the case, the court would degree of the mental patient’s power of discernment sometimes accept the patient’s claims and sometimes (temyiz kudreti). rule in favor of society, taking into account public safety concerns.

J Health Cult 2016;1(1) 65 Journal of Health & Culture Review

State and society would consider persons with psy- References chiatric disorders as “patients.” The court was obligat- Acartürk F (2006), 1672–1673 Tarihlerinde Konya’nın Sos- ed to protect the mental patients’ rights. What rights yal ve Ekonomik Durumu (19 Nolu Konya Şeriyye Sici- these patients had and to what extent their freedoms line Göre) [master’s thesis] (Konya: Selçuk Üniversitesi could be acceptably restricted were discussed with Sosyal Bilimler Enstitüsü Tarih Anabilim Dalı Yeniçağ Tarihi Bilim Dalı). great scrutiny, and it was known that their imprison- Adana court records [Adana şer’iye sicili] (7 July 1744), no. ment would not be appropriate in the absence of crim- 17, s. 51, belge no. 100. inal liability. The pleas, defense arguments and rulings Albayrak H (2010), Konya Şer‘iyye Sicillerinden 130 Nolu expressed in courts were all processed in accordance Defterin Değerlendirilmesi [master’s thesis] (Istanbul: with these considerations. In resolving the conflicts Marmara Üniversitesi Sosyal Bilimler Enstitüsü İs- and incompatibilities between the third parties con- lam Tarihi ve Sanatları Anabilim Dalı İslam Tarihi ve cerned about their safety and the patient lacking the Sanatları Bilim Dalı). power of discernment, rights of the each of the affected Atar F (2007), “Nikâh,” Türkiye Diyanet Vakfı İslam An- parties, i.e., the mental patient, the patient’s family and siklopedisi, vol. 33 (Ankara: Türkiye Diyanet Vakfı, pp. society, were taken into consideration and balanced 112–7), available at http://www.islamansiklopedisi.info/ against one another. dia/pdf/c33/c330075.pdf, accessed 1 May 2016. Bardakoğlu A (2013), “Vesayet,” Türkiye Diyanet Vakfı İslâm We see that women sought their rights in the courts Ansiklopedisi, vol. 43 (Ankara: Türkiye Diyanet Vakfı, just as men, and non-Muslims appealed to Islamic pp. 66–70), available at http://islamansiklopedisi.info/ courts as Muslims did. The Islamic courts would base dia/pdf/c43/c430038.pdf, accessed 1 May 2016. their rulings on reasoning and judicial and moral prin- Bardakoğlu A (1994), “Ehliyet,” Türkiye Diyanet Vakfı İslâm ciples and not on the principles of faith stipulated in Ansiklopedisi, vol. 10 (Ankara: Türkiye Diyanet Vakfı, the Qur’an; this was why many people from different pp. 533–9), available at http://islamansiklopedisi.info/ religions appealed to these courts to seek their rights. dia/pdf/c10/c100451.pdf, accessed 1 May 2016. Bayat AH (1992), “Şer’iyye sicilleri ve tıp tarihimiz I: rıza The regulation concerning mental patients and senetleri,” Türk Dünyası Araştırmaları 79, 9–19. hospitals that was introduced in 1876 as part of the Bilmen ÖN (1967), Hukuk-ı İslamiye ve Istılahat-ı Fıkhiyye ongoing modernization and Westernization in the Kamusu, vol. I (Istanbul: Bilmen Yayınevi). Empire affected the attitudes and behaviors toward Bimarhanelere Dair Nizamname [Regulation on the Mental mental patients, leading to a decrease in the imple- Hospitals] (6 March 1876/1292—18 Safar 1293), [373] mentation of ethical approaches. Its provisions had a 52. restrictive effect on the tradition to treat each mental Çetin O, Hızlı M, Yediyıldız A (2006), “Osmanlı kadı si- patient according to the individual conditions in the cillerinin tıp tarihi araştırmalarındaki önemi,” in patient’s particular case. The regulation also began Osmanlılarda Sağlık I, ed. Yılmaz C, Yılmaz N (Istanbul: Biofarma Yayınları, pp. 321–33). to shape the society’s attitudes and behaviors toward Devellioğlu F (2009), Osmanlıca–Türkçe Ansiklopedik Lügat, mental patients. Its provisions introducing a code of 30th ed. (Ankara: Aydın Kitabevi). conduct fixed the freedoms of mental patients; eventu- Dönmez İK (1993), “Cünûn,” Türkiye Diyanet Vakfı İslam ally, it took precedence over the previous ethical ap- Ansiklopedisi, vol. 8 (Ankara: Türkiye Diyanet Vakfı, pp. proach that had been flexible enough to change in ac- 125–9), available at http://islamansiklopedisi.info/dia/ cordance with patients’ individual conditions as seen pdf/c08/c080095.pdf, accessed 1 May 2016. in the examples presented in this paper. While at first Dönmez İK (2011), “Temyiz,” Türkiye Diyanet Vakfı İslam glance a precise regulation for mental patients may Ansiklopedisi, vol. 40 (Ankara: Türkiye Diyanet Vakfı, seem appropriate, it actually cast a shadow over the pp. 437–9), available at http://islamansiklopedisi.info/ pursuit of moral and ethical values. dia/pdf/c40/c400253.pdf, accessed 1 May 2016.

66 J Health Cult 2016;1(1) Sarı A review of Ottoman court records on mental diseases

Gürbüz S (2009), 296 Numaralı Karaman Şer’iye Sicili Çer- Konya court records [Konya şer‘iyye sicili] (23 June 1897), çevesinde 1829–1832 Yılları Arasında Karamanda Sosyal, no. 130, 17-b-1, İdarî Ve Hukukî Hayat [master’s thesis] (Konya: Selçuk Sarı N (1986), “The classification of mental diseases in the Üniversitesi Sosyal Bilimler Enstitüsü Tarih Anabilim Ottoman medical manuscripts,” Tıp Tarihi Araştırmaları Dalı Yakınçağ Tarihi Bilim Dalı). 1, 105–12. Hanilçe M (2009), 16 Numaralı Tokat Şer‘iye Sicili’nin (M. Sarı N, Akgün B (2008), “Türk tarihinde psikiyatriye bakış,” 1810–1813) Transkripsiyonlu Metni ve Değerlendirilmesi in İ.Ü. Cerrahpaşa Tıp Fakültesi Sürekli Tıp Eğitimi [master’s thesis] (Tokat: Gaziosmanpaşa Üniversitesi Etkinlikleri Sempozyum Dizisi no. 62: Türkiye’de Sık Sosyal Bilimler Enstitüsü Tarih Anabilim Dalı Yeniçağ Karşılaşılan Psikiyatrik Hastalıklar (İstanbul: İ. Ü. Tarihi Bilim Dalı). Cerrahpaşa Tıp Fakültesi Sürekli Tıp Eğitimi Komisyo- Istanbul court records [İstanbul şer’iye sicili] (21 December nu, pp. 1–24), available at http://www.ctf.edu.tr/stek/ 1766), no. 29/2/4. pdfs/62/6201.pdf, accessed 2 May 2016. Istanbul court records [İstanbul şer‘iyye sicili] (27 December Şentürk R (2000), “İnsan hakları (İslam dünyasında),” Tür- 1776), no. 40/4/3. kiye Diyanet Vakfı İslâm Ansiklopedisi, vol. 22 (Ankara: Kara H (2006), “Osmanlı’nın mahalle sakinleri: mecnunlar, Türkiye Diyanet Vakfı, pp. 327–30), available at http:// deliler ve ölüler,” in Osmanlılarda Sağlık I, ed. Yılmaz C, islamansiklopedisi.info/dia/pdf/c22/c220202.pdf, ac- Yılmaz N (Istanbul: Biofarma Yayınları, pp. 197–205). cessed 1 May 2016. Karaman court records [Karaman şer’iye sicili] (11 August Tokat court records [Tokat şer‘iye sicili] (28 October 1812), 1830), no. 296, L.Ş.S/296-161.2. no. 16, 12/1. Karaman court records [Karaman şer’iye sicili] (16 June Udeh A (1990), Mukayeseli İslâm Hukuku ve Beşerî Hukuku 1831), no. 296, L.Ş.S/296-81.2. (Notlar İlaveli ve Türk Ceza Kanunu ile Karşılaştırmalı), Karaman H (1989), “Akid,” Türkiye Diyanet Vakfı İslam An- vol. 2, trans. Şafak A (Ankara: Rehber Yayınları, pp. siklopedisi, vol. 2 (Ankara: Türkiye Diyanet Vakfı, pp. 170–81). 251–6), available at http://islamansiklopedisi.info/dia/ Uzunpostalcı M (2007), “İslam hukukunda ehliyeti da- pdf/c02/c020227.pdf, accessed 1 May 2016. raltan veya ortadan kaldıran sebepler,” İslam Hukuku Kayseri court records [Kayseri şer’iyye sicili] (16 June 1693), Araştırmaları Dergisi 9, 67–100. no. 100/2, s. 122/123, belge no. 400. Ünlü N (2005), 70 Numaralı Konya Şer‘iyye Sicili (1814–1816 Konya court records [Konya şer’iye sicili] (5 December M./1230–1232 H.) [master’s thesis] (Elazığ: Fırat Üniver- 1614), no. 16–39. sitesi Sosyal Bilimler Enstitüsü Tarih Anabilim Dalı). Konya court records [Konya şer’iye sicili] (24 June 1669), no. Yıldız K (2009), “Sorumluluk,” Türkiye Diyanet Vakfı İslam s-236. Ansiklopedisi vol. 37 (Ankara: Türkiye Diyanet Vakfı, pp. Konya court records [Konya şer’iye sicili] (12 September 380–2), available at http://islamansiklopedisi.info/dia/ 1676), no. 24–211. pdf/c37/c370243.pdf, accessed 1 May 2016. Konya court records [Konya şer‘iyye sicili] (9 April 1816), Yılmaz C, Yılmaz N, eds. (2006), Osmanlılarda Sağlık II, no. 70, S.32/B.144. Arşiv Belgeleri (Istanbul: Biofarma Yayınları, pp. 117, Konya court records [Konya şeriyye sicili] (30 May 1673), 167, 184–5, 299, 315–6, 350, et passim). no. K.Ş.S /19 58-4 Yılmaz E (2010), 100/2 Numaralı Kayseri Şer’iyye Sicili Konya court records [Konya şeriyye sicili] (27 September (H.1104 / M.1692) Transkripsiyon ve Değerlendirmesi 1673), no. K.Ş.S /19 130-4. [master’s thesis] (Kayseri: Erciyes Üniversitesi Sosyal Konya court records [Konya şer‘iyye sicili] (20 June 1817), Bilimler Enstitüsü Tarih Anabilim Dalı Yeniçağ Tarihi no. 70, S.61/B.265. Bilim Dalı).

J Health Cult 2016;1(1) 67 ISSN:2458-8113

Issue 1

June 2016 Journal of & Culture Health The self-image of transident women since 1945 since women of transident The self-image PrüllLivia bioethics and bios of dimensions Cultural Sass Hans-Martin health in medical and education: Migration Central Europe from report in progress a work Frank Kressing

Journal of Health & Culture June 2016 / Volume 1 / Issue 1