Contemporary clinical ethics was founded on principlism, and the four principles: respect for autonomy, nonmaleficence, beneficence and justice, remain dominant in medical ethics discourse and practice. These principles are held to be expansive enough to provide the basis for the ethical practice of medicine across cultures. Although principlism remains subject to critique and revision, the four-principle model continues to be taught and applied across the world. As the practice of medicine globalizes, it remains critical to examine the extent to which (...) both the four-principle framework, and individual principles among the four, suffice patients and practitioners in different social and cultural contexts. Using the four-principle model we analyze two accounts of surrogate decision making – one from the developed and one from the developing world – in which the clinician undertakes medical decision-making with apparently little input from the patient and/or family. The purpose of this analysis is to highlight challenges in assessing ethical behaviour according to the principlist model. We next describe cultural expectations and mores that inform both patient and clinician behaviors in these scenarios in order to argue that the principle of respect for persons informed by culture-specific ideas of personhood may offer an improved ethical construct for analyzing and guiding medical practice in a globalized and plural world. (shrink)

Background Respect for autonomy is a key principle in bioethics. However, respecting autonomy in practice is complex because most people define themselves and make decisions influenced by a complex network of social relationships. The extent to which individual autonomy operates for each partner within the context of decision-making within marital or similar relationships is largely unexplored. This paper explores issues related to decision-making by couples for health care and the circumstances under which such a practice should be respected as compatible (...) with autonomous decision-making. Discussion We discuss the concept of autonomy as it applies to persons and to actions, human interdependency and gender roles in decision-making, the dynamics and outcomes of couples’ joint decision-making, and the ethics of couples’ joint decision-making. We believe that the extent to which couples’ joint decision-making might be deemed ethically acceptable will vary depending on the context. Given that in many traditional marriages the woman is the less dominant partner, we consider a spectrum of scenarios of couples’ joint decision-making about a woman’s own health care that move from those that are acceptably autonomous to those that are not consistent with respecting the woman’s autonomous decision-making. To the extent that there is evidence that both members of a couple understand a decision, intend it, and that neither completely controls the other, couples’ joint decision-making should be viewed as consistent with the principle of respect for the woman’s autonomy. At the other end of the spectrum are decisions made by the man without the woman’s input, representing domination of one partner by the other. Conclusions We recommend viewing the dynamics of couples’ joint decision-making as existing on a continuum of degrees of autonomy. This continuum-based perspective implies that couples’ joint decision-making should not be taken at face value but should be assessed against the specific cultural, ethnic, and religious backgrounds and personal circumstances of the individuals in question. (shrink)

This paper explores the bioethical issues associated with the diagnosis and treatment of vulvar cancer for Indigenous women in East Arnhem Land, Northern Territory, Australia. Based on a qualitative study of a vulvar cancer cluster of Indigenous women, the article highlights four main topics of bioethical concern drawn from the findings: informed consent, removal of body parts, pain management, and issues at the interface of Indigenous and Western health care. The article seeks to make a contribution towards Indigenous health and (...) bioethics and bring to light areas of further research. (shrink)

In the field of bioethics, scholars have begun to consider carefully the impact of structural issues on global population health, including socioeconomic and political factors influencing the disproportionate burden of disease throughout the world. Human rights and social justice are key considerations for both population health and biomedical research. In this paper, I will briefly explore approaches to human rights in bioethics and review guidelines for ethical conduct in international health research, focusing specifically on health research conducted in resource-poor settings. (...) I will demonstrate the potential for addressing human rights considerations in international health research with special attention to the importance of collaborative partnerships, capacity building, and respect for cultural traditions. Strengthening professional knowledge about international research ethics increases awareness of ethical concerns associated with study design and informed consent among researchers working in resource-poor settings. But this is not enough. Technological and financial resources are also necessary to build capacity for local communities to ensure that research results are integrated into existing health systems. Problematic issues surrounding the application of ethical guidelines in resource-poor settings are embedded in social history, cultural context, and the global political economy. Resolving the moral complexities requires a commitment to engaged dialogue and action among investigators, funding agencies, policy makers, governmental institutions, and private industry. (shrink)

Turkey has a complex character, which has differences from the Western world or Eastern Asia as well as common points. Even after more than a century of efforts to modernise and integrate with the West, Turkish society has values that are different from those of the West, as well as having Western values. It is worth questioning whether ordinary Turkish people show an individualistic character. The principle of respect for individual autonomy arises from a perception of oneself as an individual, (...) and the person’s situation may affect the applicability of the principle. Patients who perceive themselves to be members of a community rather than free persons and who prefer to participate in the common decisions of the community and to consider the common interest and the common value system of the community concerning problems of their life rather than to decide as independent, rational individuals may not be competent to make an autonomous choice. Expectations that such patients will behave as autonomous individuals may be unjustified. The family, rather than the patient, may take a primary role in decisions. A flexible system considering cultural differences in the concept of autonomy may be more feasible than a system following strict universal norms. (shrink)

The right to health implies, among other things, that individuals and communities must be allowed to have a voice in decisions concerning the definition of their well-being. The article argues for a more active participation of ethnocultural minorities in healthcare decisions and highlights the relevance of strategies aimed at creating a bottom-up engagement of people and groups, as well as of measures aimed at a broader organizational flexibility, in order to meet migrants’ and minorities’ needs. Finally, the article clarifies that (...) these strategies are not simply the outcome of a welcoming attitude of the Western healthcare system but may be interpreted as a specific duty resulting from the notion of “particularly vulnerable groups,” as formulated by the ECtHR in its case law: when vulnerable groups are at stake, every decision about state actions and rules regarding healthcare should start from an a consideration of the specific conditions and needs of people belonging to vulnerable minority groups. (shrink)

If we want to take firm the importance of universal principles in Bioethics, but at the same time we want to take seriously the importance of cultural diversity and pluralism, it is necessary to adopt a multifaceted approach. In the article I argue that a possible way out is a sort of hermeneutic approach, in order to reduce the ambivalence that stems from the dual recognition of cultural diversity and universal value of human rights. Through this approach conflicting principles and (...) traditions can be harmonized within a common framework, at least to some extent. Such an approach, in my perspective, can be implemented as a strategy of interpretation, which can hold together different conceptions and common principles. (shrink)

ZusammenfassungKulturelle Zugehörigkeit und die Möglichkeit, diese auch in der Situation von Krankheit erleben zu können, wird als wesentliches Element kultursensibler Krankenversorgung gesehen. Hierfür scheint ein grundlegendes Verständnis kultureller Besonderheiten, wie auch die Reflexion auf die eigenen kulturellen Wurzeln besonders wichtig. Gleichzeitig besteht Konsens, dass kulturessentialistische Ansätze, die auf das Verbindende innerhalb einer Kultur in Abgrenzung zu anderen Kulturen rekurrieren, zu problematischen Vereinfachungen und stereotypen Zuschreibungen führen können. Vor diesem Hintergrund erscheinen Aussagen über Gruppen von Patienten mit ähnlichem kulturellen Hintergrund als (...) problematisch. Interkulturelle Bioethik bewegt sich in diesem Spannungsfeld, das sich auch auf theoretischer Ebene widerspiegelt: Aspekte wie Fremdheitserfahrungen und Missverständnisse werden im Kontext kultureller Verschiedenheit gedeutet. Der Beitrag geht der Frage nach, wie im Kontext von Medizin und Kultur Differenzen gesetzt und verstetigt werden und welche Rolle bioethisches Nachdenken dabei haben kann und soll. Aus der Perspektive der Ethik werden dabei zwei Aspekte besonders beleuchtet, zum einen, wie die bestehenden Differenzsetzungen strukturell verankert sind und mit Fragen von Macht und Interesse zusammenhängen. Hier wird untersucht, welche Fragen nach kultureller Identität insbesondere aus der Perspektive von Patienten hilfreich sind. Zum anderen wird in Bezug auf konkrete Handlungsfelder der Krankenversorgung untersucht, welche Ansätze einer kultursensiblen Ethik vor diesem Hintergrund gestärkt werden können, so dass im Alltag der Krankenversorgung ein Umgang mit Fragen von Kultur gefördert wird, der Raum für widersprüchliche Aspekte von kultureller Identität eröffnet. (shrink)

Background There has been debate on whether a global or unified field of bioethics exists. If bioethics is a unified global field, or at the very least a closely shared way of thinking, then we should expect bioethicists to behave the same way in their academic activities anywhere in the world. This paper investigates whether there is a 'global bioethics' in the sense of a unified academic community. Methods To address this question, we study the web-linking patterns of bioethics institutions, (...) the citation patterns of bioethics papers and the buying patterns of bioethics books. Results All three analyses indicate that there are geographical and institutional differences in the academic behavior of bioethicists and bioethics institutions. Conclusion These exploratory studies support the position that there is no unified global field of bioethics. This is a problem if the only reason is parochialism. But these regional differences are probably of less concern if one notices that bioethics comes in many not always mutually understandable dialects. (shrink)

Respect for autonomy is a key principle in bioethics. However, respecting autonomy in practice is complex because most people define themselves and make decisions influenced by a complex network of social relationships. The extent to which individual autonomy operates for each partner within the context of decision-making within marital or similar relationships is largely unexplored. This paper explores issues related to decision-making by couples for health care and the circumstances under which such a practice should be respected as compatible with (...) autonomous decision-making. We discuss the concept of autonomy as it applies to persons and to actions, human interdependency and gender roles in decision-making, the dynamics and outcomes of couples’ joint decision-making, and the ethics of couples’ joint decision-making. We believe that the extent to which couples’ joint decision-making might be deemed ethically acceptable will vary depending on the context. Given that in many traditional marriages the woman is the less dominant partner, we consider a spectrum of scenarios of couples’ joint decision-making about a woman’s own health care that move from those that are acceptably autonomous to those that are not consistent with respecting the woman’s autonomous decision-making. To the extent that there is evidence that both members of a couple understand a decision, intend it, and that neither completely controls the other, couples’ joint decision-making should be viewed as consistent with the principle of respect for the woman’s autonomy. At the other end of the spectrum are decisions made by the man without the woman’s input, representing domination of one partner by the other. We recommend viewing the dynamics of couples’ joint decision-making as existing on a continuum of degrees of autonomy. This continuum-based perspective implies that couples’ joint decision-making should not be taken at face value but should be assessed against the specific cultural, ethnic, and religious backgrounds and personal circumstances of the individuals in question. (shrink)

Research Ethics Committees or Institutional Review Boards are rapidly becoming indispensable mechanisms in the overall workings of university institutions. In fact, the ethical dimension is an important aspect of research governance processes present in institutions of higher learning. However, it is often deemed that research in the social sciences do not require ethical appraisal or clearance, because of the alleged absence of harm in conducting such research. This is an erroneous and dangerous assumption given that research in social sciences poses (...) various and complex dilemmas related to ethics. The article aims to gauge the importance of ethical appraisal at a particular institution of higher learning’s Faculty of Humanities. This is done by scrutinising its defunct REC, and the views that Heads of Departments of the Faculty have of ethics in research and the need for ethical appraisal by this REC. Finally, some suggestions are made to proceed to review and restructure the current REC with the ultimate objective to make it functional again. It was found that the development and discussion around ethics in research and ethical appraisal are part of a much needed thrust to sensitise the entire Faculty and the institution on the widespread beneficial repercussions of ethical awareness in research and beyond. (shrink)

Moral theory is an important guide to bioethical decision-making, but it can confuse and mislead those who offer ethical advice to clinicians and researchers, delaying decisions that must be made in a timely fashion. In this paper I examine the ways moral theory can lead bioethicists astray. Absent a sensitivity to the empirical realities of ethical problems, moral theory 1) contributes to the disappearance of the persons caught in an ethical quandary, 2) focuses on the puzzle-solving rather than examining the (...) conditions that generate moral problems, and 3) universalizes ethical dilemmas, overlooking local processes for resolving moral questions. Taken together, empirically informed moral theory and theoretically informed empirical research can help bioethicists transcend the is/ought problem in ethical work. (shrink)

This paper presents an analysis of the applicability of a principalist approach for a global, or cross-cultural, bioethics. We focus especially on the principle of individual autonomy, a core value in ethical discourse. We echo some long-standing criticisms of other anthropologists, sociologists, and many medical ethicists that the individualistic approach to autonomy is a Euro-American value and cannot be ethically applied in all settings. As a remedy, we suggest an adaptation of Kleinman's Explanatory Model approach to questions of decisionmaking. We (...) argue that the analysis and resolution of ethical dilemmas might also benefit from forms of pedagogy that integrate anthropological and other social science perspectives, and the incorporation of ethnographic techniques in ethical practice. (shrink)

This paper presents a pedagogical framework for teaching cross-cultural clinical ethics. The approach, offered at the intersection of anthropology and bioethics, is innovative in that it takes on the “social sciences versus bioethics” debate that has been ongoing in North America for three decades. The argument is made that this debate is flawed on both sides and, moreover, that the application of cross-cultural thinking to clinical ethics requires using the tools of the social sciences within a principles-based framework for clinical (...) ethics. This paper introduces the curriculum and provides guidelines for how to teach cross-cultural clinical ethics. The learning points that are introduced emphasize culture in its relation to power and underscore the importance of viewing both biomedicine and bioethics as culturally constructed. (shrink)

A discussion of whiteness as an “ethos” or “relational category” in bioethics, drawing on examples from medical and historical research.

Humanitarian emergencies and natural disasters can overwhelm the capacity of local and national agencies to respond to the needs of affected populations. In such cases, international relief organizations are frequently involved in the provision of emergency assistance. Health care professionals play a key role in these interventions. This practice environment is significantly different from the context of health care delivery in the home countries of expatriate health care professionals. Clinicians who travel from a developed nation to a resource-poor setting where (...) a humanitarian crisis has occurred experience a shift of professional, social, cultural and regulatory environments. In this dissertation I examine the ethics of health care practice in humanitarian work. I evaluate the literature of global bioethics, global health ethics and the ethics of humanitarian assistance, and consider the contributions of various ethics frameworks and normative approaches. I also develop a set of questions to guide health care professionals as they address ethically complex issues arising in clinical practice during humanitarian crises. In the empirical component of this research program I use Interpretive Description methodology to examine the moral experience of health care professionals in humanitarian relief work, and clinician experiences of resources and constraints for addressing ethical issues in humanitarian settings. Building upon the inductively derived findings, I argue for strategies and approaches that humanitarian organizations, project teams, and health care professionals can adopt to respond to the ethics of this field of practice. I also provide a critical review of Interpretive Description methodology. The research presented in this dissertation makes an important contribution to the ethical analysis of health care practice in humanitarian work. (shrink)