Original Article Culture and the principles of biomedical ethics Received: January 24, 2013; Revised: June 3, 2013 Kola Abimbola is Lecturer in Law and Forensic Science at the University of Leicester, UK. ABSTRACT This paper examines the roles of culture in the principles of biomedical ethics. Drawing on examples from African, Navajo and Western cultures, the paper maintains that various elements of culture are indispensable to the application of the principles of biomedical ethics. Journal of Commercial Biotechnology (2013) 19(3), 31–39. doi: 10.5912/jcb.598 Keywords: principlism; cultural goods of medicine; personhood; practical-beliefs; scientific methodology INTRODUCTION: CULTURE IN patient); and, justice (fairness is important in the allo- PRINCipLISM cation of resources— “give to each that which is her due”). Principlism is considered by many to be the Gold Standard for the resolution of biomedical ethical dilem- his paper maintains that the principles of bio- mas. This is because these four principles are claimed medical ethics are always culture specific in the to be culture free, universal, context independent, and sense that their validity, applicability and moral globally applicable. Tforce of persuasiveness is dependent upon the assump- Suppose, for example, that T, an unconscious 25 tion of a plethora of cultural categories. These categories year-old woman, was admitted to hospital after a car often operate tacitly as background assumptions in the accident. T is known to everyone in the local community architecture of reasoning, thereby giving the illusion that (including the attending doctor) as a devout Jehovah’s biomedical decision making on the basis of principles is Witness who has on many occasions preached against culture-free. blood transfusion. Her purse has a card that confirms Deontological ethics is one of the three main her objection to blood transfusions on religious grounds. approaches to biomedical ethics. It is an approach that Without blood transfusion the doctors cannot per- emphasizes principles, rules and duties as the basis of form the required surgery to save her life. However, her moral justification. Deontological ethics can be con- mother insists on blood transfusion. A utilitarian assess- trasted to virtue ethics (which emphasizes moral char- ment of this dilemma would look into the consequences acter as the basis for ethical decision-making) and of actions (or rules) to determine what the doctors ought consequentialism (which emphasizes the consequences to do to maximize wellbeing in this situation. A virtue of actions and rules). ethicist would appeal to character traits such as gener- Principlism is a deontological theory that relies osity, benevolence, or trust. A deontologist would base on the application of a set of four basic principles in her decision on a moral rule like “Do unto others as you the resolution of biomedical ethical dilemmas. These would be done by”, or the principle of autonomy which principles are: respect for autonomy (physicians should requires respecting T’s right to self-determination. respect the voluntary healthcare choices of rationally Suppose further that T was admitted at a hospital competent patients); nonmaleficence (physicians should somewhere in the Western world where the primary not needlessly intentionally inflict harm or injury); focus of biomedical ethics is on the application of these beneficence (health care should be of benefit to the four principles of principlism to the doctor-patient relationship. Since some of the physician’s main duties include respect for autonomy and the need to gain fully Correspondence: Kola Abimbola, University of Leicester, informed consent, the morally correct decision for the UK. Email: [email protected] JULY 2013 I VOLUME 19 I NUMBER 3 31 Western physician is to respect the implications of T’s adults, are perceived as metaphysical extensions of religious beliefs. their wards. Mother’s destiny is tied to daughter’s Suppose, however, that T had been admitted to a destiny. … Third, there is an expansive notion of hospital in a rural village in the Southwestern parts of the self, which makes the patient see her mother Nigeria. Suppose further that the physician is an indig- as part of her extended identity … There is an enous medical practitioner and that the hospital is enlarged notion of patient autonomy, which African-Western because it incorporates the best of both includes daughter and mother as one entity. It is worlds. The supposition is not so far-fetched. An exam- a notion that daughter, like mother, internalizes ple of one such fusion is the “Aro Village System” intro- and accepts. For if circumstances were to change duced by Professor Thomas Adeoye Lambo at the Aro and the mother becomes ill, the daughter will Psychiatric Hospital, Abeokuta, Nigeria: play the same role that the mother is now playing. It is a notion that is perhaps different from The world recognition of the hospital came about contemporary Western notion of self, but which is during the pioneering effort of Late Professor not thereby morally deficient. (Gbadegesin, 2007, Thomas Adeoye Lambo (CON) when he started p.40-41.) way back in 1960, the “ARO VILLAGE SYSTEM” of treating the mentally ill. The thrust of this Since some of the indigenous physician’s main duties system was a community participatory system include respect for autonomy (Mother’s destiny is tied to of treatment of the mentally ill that involved daughter’s destiny in the sense that daughter is the meta- the psychiatric professionals, the relatives of the physical extension of mother; hence the individual here patients and the co-tenants, neighbours and the is a “mother-daughter” dualism) and the need to gain community where the patients were admitted. fully informed consent before treatment (in this mother- This treatment paradigm was achieved by daughter dualism, the voice of the entity is currently that creating “Aro Village System” a few kilometers of mother), the morally correct decision for the physician from Aro Hospital where patients were admitted is to respect the decisions of the mother. into “normal” houses where there were other In what follows, I highlight the ways in which cul- tenants alongside their relatives. The principle of ture shapes, influence and directs biomedical decision the village system was subsequently adapted all making on the basis of the four principles of biomedical over the world and virtually opened the hitherto ethics. locked gates of psychiatric hospitals. (http:// neuroaro.com/history Last viewed 28 September 2012) THE COMMON/UNIVERSAL MORALITY AND ITS IMPLICATIONS So, suppose that T had been rushed to the emer- FOR PRINCipLISM gency unit of Aro Psychiatric Hospital, where fully trained Western and indigenous Yoruba physicians One recent development in biomedical ethics is the idea are on call. As Gbadegesin (2007) has observed, in this of “common morality.” Tom Beauchamp and James alternative Yoruba Western-indigenous world, parents Childress, two of the most influential defenders of prin- often serve as surrogates for their children (including ciplism, use this notion as the starting point of their adult children); just as children could serve as surrogates position. I will make use of Beauchamp and Childress’ for their parents. As such, T in the West is more likely version of common morality and principlism in my cri- than T in South-Western Nigeria to have her wishes of tique of the claim that the principles of biomedical ethics no blood transfusion respected. Does this mean that the are culture-free. principles of biomedical ethics are not respected in the The central claim of the idea of a common moral- Yoruba indigenous-Western world? Gbadegesin makes ity is that all humans — at least all morally conscious some important observations: humans — have a “pretheoretical” awareness of certain moral norms. According to this view, every normal (i.e., First, it is clear that … in traditional African cognitively competent) human has an intuitive abil- health care systems … family members assume the ity that endows them with pretheoretical moral know- role of health care givers, acting as de facto nurses, ledge such as: it is wrong to lie, kill or break promises. physician’s assistants, medication dispensers, and These intuitive insights are empirical in the sense that so on. This is usually in addition to their roles as they are, as a matter of fact, relied on in moral judg- family members … Second, it is important to note ments. Moreover, they are universal in the sense that that family members, especially parents even of all thoughtful and rational persons have an intuitive 32 JOURNAL OF COMMERCIAL BIOTECHNOLOGY HTTP://WWW.COMMERCIALBIOTECHNOLOGY.COM awareness of their moral force of appeal. Hence, failure morality, and of the four principles, which to act in accordance with these pretheoretical insights are supposedly derived from them. “Our generates feelings of remorse, moral criticism, and moral common-morality theory does not hold rebuke. Particular moralities, according to Beauchamp that customary moralities qualify as and Childress, are not universal. They are content-rich, part of common morality. An important and are made-up of the concrete norms, ideals aspira- function of the general norms in the tions and attitudes of specific/individual cultures. common morality is to provide a basis Beauchamp and Childress’ version of common for the evaluation and criticism of groups morality and principlism commit them to the following or communities whose customary moral claims: viewpoints are in some respect deficient. Criticisms of those customs and attitudes i. … [T]he common morality is a product are warranted to maintain fidelity to of human experience and history and is common morality.” (2009, p. 387.) a universally shared product. The origin of the common morality is no different Since the pretheoretical assumptions of the com- from the origin of the norms of particular mon morality are “abstract, universal, and content thin” morality in that both are learned and (2009, p.5), the four principles of biomedical ethics transmitted in communities.