Global Bioethics and Culture in a Pluralistic World:How does Culture influence Bioethics in Africa?
- *Corresponding Author:
- Dr. Felix N Chukwuneke
College of Medicine, University of Nigeria Teaching Hospital, Enugu, 400 001, Nigeria.
E-mail: [email protected]
Bioethics principles and practice can be influenced by different cultural background. This is because the four globally accepted bioethics principles are often based on basic ethical codes such as autonomy, beneficence, nonmaleficence and justice. Beneficence/nonmaleficence requires us to maximize possible benefits, while minimizing possible harms and consequently secure the wellâÂÂbeing of others by refraining from harming them. Autonomy gives individuals the right to selfâÂÂactualization and decisionâÂÂmaking, while justice is concerned with the fair selection and distribution of the burdens and benefits of research among participants. Applications of these principles in cultural settings vary more often from one cultural perspective to the other because of the different understanding and practices of “what is good.” The proponents of global ethics may argue that these principles should be universally generalizable and acceptable, but this is not possible because of the existing cultural diversities. In the African setâÂÂup, despite the existence of major common cultural practices, there are other norms and practices, which differ from one society to the other within the communities. Therefore, the word “global” bioethics may not be applicable generally in practice except if it can account for the structural dynamics and cultural differences within the complex societies in which we live in. However, the extent to which cultural diversity should be permitted to influence bioethical judgments in Africa, which at present is burdened with many diseases, should be of concern to researchers, ethicist and medical experts taking into considerations the constantly transforming global society. This topic examines the cultural influence on principles and practice of bioethics in Africa.
Africa, Culture, Global bioethics
We live in a society that functions with a system of morals establishing what is right or wrong. Every community is governed by moral codes such as laws, tradition and culture, government policies, and human relationships. A society without these moral indices will automatically slide down to the abyss of failure and total collapse. To live and understand the importance of human values within which the society can live and operate in a harmonious state, every society has its own moral code that governs the action of individual in the community. Such norms and practices passed from generation to generation becomes a culture and could be based on the collective responsibility of the people in the community without which there will be anarchy. The African culture, for example, is based on moral principles and values, which are the ethical responsibility of the community. Bioethics in the real sense cannot function where there is no culture. Most culture is based on the principles of the “golden rules” do unto others what you will like them do unto you. This is the basis for bioethics because bioethical judgments are value-based in nature.  Values, however, are part of cultures and are dependent on, and influenced by other parts of cultures. Culture itself is a way of life of a group of people - the behavior, belief, values and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next. Culture thus influences a peoples belief, behavior and understanding of circumstances around them such as illnesses/diseases.  Bioethics has been used in the last 20-year to describe the investigation and study of ways in which decisions in medicine and science touch upon our health and lives and our society and environment. Perhaps the most striking development in the study of ethics during the second half of the 20th century has been a growing interest among philosophers in applied ethics, and that includes the application of normative theories to practical moral issues such as racial and sexual equality, human rights, and justice and respect for human life. Within the latter half of the 30-year history of bioethics, there has been an increasing pressure to address bioethical issues globally. Bioethics is not traditionally a theory-based enterprise, rather the focus has been problem related. According to Takala,  the introduction of the four ethical principles in the global perspective, has, however, become more important given way to probably the best known, theory of bioethics presented by Tom Beauchamp and James Childress in their Principles of Biomedical Ethics in 1979. This theory is known as the “four principles” or the “Georgetown mantra” approach or “mid-level principlism.” It is an attempt to create a global framework for bioethics on the four principles – autonomy, justice, beneficence, and nonmaleficence. These bioethics principles are concerned with questions about basic human values such as the rights to life and health, and the rightness or wrongness of certain developments in healthcare institutions, life technology, medicine, the health professions and about society’s responsibility for the life and health of its members. The four principles, though based on Western bioethics framework have been widely criticized.  In Africa, these four principles are quite familiar, but their applications in moral issues are quite different from western bioethics perspective because of different understanding that is influenced by cultural practice.
Method of Literature Research
We carried out internet search of articles, conference proceedings and textbooks on African culture and bioethics published anywhere without limitation of time span and language using Google, Google Scholar, Pub-Med, African Journal Online, Medknow, Hinari and NIH.gov. In addition to electronic publications, we also searched for journals and textbooks on culture and bioethics from the University libraries of University of Nigeria Enugu Campus (2012), Johns Hopkins University Baltimore and Kennedy Institute of Bioethics both in USA (2008), University of Pretoria and University of KwaZulu-Natal both in South Africa (2008). The search engines yielded 12 relevant articles which, in addition to the authors’ knowledge in bioethics supported the logic argument as presented in the article.
Global Bioethics and Culture
Can there be a universal “global” bioethics?
How can a global bioethics account for profound and constantly transforming sources of cultural differences?
To what extent should cultural diversity be permitted to influence bioethical judgments in our society?
Any need for African bioethics framework since Africa cannot leave in isolation against the rest of the world?
Bioethics cannot be universal because of the existence of different values/morals that vary from community to community and from different societies within the communities. It will therefore be difficult to globalize bioethics without considering cultural response to ethical issues because different cultures have different values and morals that guide them. For example “cause no harm” might mean different thing to different people. While certain culture, especially the western world will encourage and legalize abortion, Africans may look at it as grievous transgressions that must be resisted by all means. In Nigeria and especially in Igbo speaking tribe, we regard the time of conception as the beginning of personhood and any attempt to terminate the fetus at any stage is regarded as murder and will attract severe punishment. This is in contrast to Western culture where abortion is legalized. On the other hand, in the western world female circumcisions could be regarded as causing harm and unethical practice but in some African countries it may be seen as harmless practice. In fact in some African societies where circumcision is practiced at adulthood, many women look forward to it with enthusiasm as mark of maturity. Other cultures in the same African countries can equally frown at it as primitive and harmful act especially with the gradual transformation of the societal norms and habit to modernization. At present bioethics in its present form is rooted in and largely dominated by Western culture,  which often brings conflict of interest especially when there is international collaborative biomedical research. This is largely influenced by the Western technological advancement and creations of the developed world in comparison to the developing world. Global bioethics emphasis is on the autonomy, freedom, and moral inclination of the individual contrary to African conception.  Mainstream bioethical frameworks are not sufficiently sensitive to cultural realities in issues of health and health care in African setting. Unlike the Western world, in a cultural African setting, people do not just make their ethical decisions based on autonomy, justice beneficence, nonmaleficence, but also on cultural notions of personhood, health, illness, community, death, dying, and religious beliefs.  In Africa, the peculiarities of culture, ethnicity, and language differences are what make biomedical care and ethics a unique experience for individual. Consequently, the view in this connection is that bioethics should be, contextual, pluralistic and respect for cultural diversity.
Bioethics Principles in African Construct
Bioethics principles and framework in Africa though may take cognizance of the bioethics principles as postulated by Western philosophy but with different approach and practice.  This is because of the diversity in understanding of personhood and social interactions existing within the various communities in Africa that are different from what is seen in Western construct. Consequently, African bioethics by its application has its own framework based not entirely on the method of practice and application of what the western bioethics regard as global bioethics. The four bioethics principles; autonomy, justice, beneficence, and nonmaleficence if followed and obeyed is good. Generally speaking everybody will agree that autonomy is good, that justice is good, that it is good to do good, and that it is good not to inflict harm. However, what constitutes the good in various circumstances cannot be universalized because we have different understanding of what is “good” hence the need for African bioethics framework and principles.
African ethics places considerable value on conformity of the individual to the social group in order to preserve the unity of human relationship. It could be said that in a way African thought is, indeed, more concerned with the relationship than with the different entities which constitute the relationship.  For example in Africa, there is little or no individual autonomy as seen in the Western world but community autonomy. The idea of community autonomy, according to Black and Mooney  is that the community’s elected or appointed representative authority has the power to make choices. The community can draw upon its own values and goals in making decisions. The individual is important in moral deliberations, but references are made not only to the individual but also to the community. What are considered good are those things that enhance the welfare of the people. In other words, in issues concerning health research, the community, or its designated authority, determines the common needs and interests, what levels of morbidity and mortality are acceptable, and how to go about making public health changes. In Africa, the saying goes I am because we are, and since we are, therefore, I am.”  Ubuntu (spirit of togetherness and collective responsibility).
The idea of what constitute justice and how justice is maintained in Africa may not be entirely the same with Western bioethics framework. The notion of justice in African construct especially in health matters holds that, as a result, of common needs and interests, the community comes together to improve its aggregate health by reducing morbidity and mortality. This principle asks if the program meets public health goals and furthers the health of the population at large.  This justice framework in African construct is often regarded as Solidarity, which is derives from Bentham’s Principle of Utility which holds that in making ethical choices, the action taken should provide the greatest utility, in this case health, to the greatest number of people. The principle depends on the equity, community autonomy, and paternalism. Specifically, solidarity incorporates the notions of preventing bad health, promoting social justice, working with its community mandate.
African bioethics believes in the philosophy of “do good and cause no harm”. However, causing no harm may mean different thing to different society and people. While the use of stem cells or embryo for any form of clinical or research work is regarded as murder in most African society, the western world may see no problem with that as far the use is for the benefit to the society. In the same vein while they may frown at female circumcisions as harmful to the individual, the African perception look at it as beneficial to the individual and the community as well because to them the practice will among other things reduce social problems relating to female sexuality in the community. Bioethics framework in African context itself cannot be generalized because of the pluralistic African society. However, Africans still have the common principles of communal interest and as such the bioethics framework is entirely based on the general good of the community. The challenges now are that with the increasing and emerging new diseases, which Africans are at present burdened with such as HIV/AIDS, we have difficulty dealing with the new set of questions and ethical dilemmas arising from technology, biosciences and biomedical research. Cultural impacts on model of healthcare systems in Africa cannot be underestimated. Many African cultures have different understanding of the causes of disease which more often affect our public health system, policy and implementations. Some culture sees diseases and illness as spiritually determined while some see it, as a result, of unhealthy social interactions within our environment. Family values and communal living often deny individual ability to make a decision concerning his or her health matters. Most Africans, therefore, have different concerns and problems in the area of bioethics that require a framework that is congruent with their cultural realities  African bioethics framework focuses on the community good rather than individual, which is different from Western ethics that lays emphasis on the autonomy, freedom, and moral inclination of the individual. While Western ethics conceives the individual as an intellectual being, emphasizing the faculty of reason as the basic tenet in moral conduct, African ethics conceives the individual as an ethical entity.  Western ethics is driven by an attempt to sharply distinguish persons from the rest of the world, and then to identify the ways in which persons must be treated. The traditional African approach and bioethics framework is different on both counts. Because African continent cannot be isolated from the rest of the world, we should have a bioethics framework that is internally consistent based on basic moral sense with reference to worldview that will embrace a middle-ground to accommodate the pluralistic society that we live in today.
African and Global Bioethics: Facing the Future
Communal living respect for life, respect for personhood, solidarity and justice are the hallmark of African bioethics that is bioethics of common morality and not individual morality. It is based on human relationship in African culture, cultural reminiscence, norms and habit, tradition and custom. In Africa extended families are still the norm and, in fact, remain the backbone of the social system in Nigerian. Grandparents, cousins, aunts, uncles, sisters, brothers and in-laws all work as a unit through life. Family relationships are guided by hierarchy and seniority (Familismo). Individuals turn to members of the extended family for financial aid and guidance, and the family is expected to provide for the welfare of every member even in time of ill health. Therefore, individual that benefited from the family structure is expected to owe allegiance to the system in return and in certain situation, do not have autonomy to decide on his or her health matters without the family input.  However, in other to be relevant in the ever transforming global society, morality in the African society should start changing from the communalistic characteristic paradigm to personal morality. Africa cannot leave in isolation against the rest of the world irrespective of our cultural inclination as such a mid-level ground is needed. Africa should take a close look and adjust her construction on certain ethical principles such as autonomy that is based on consensus alone. Consensus need not be substantive, individual should be fully aware of their responsibility and obligations not only towards the family and community in general but also to oneself. Notwithstanding, it is a must for Africa to adapt a bioethics framework that takes cognizance of their cultural peculiarity and still become relevant in the global world. The global world should also not fail to recognize that the family and community are the most important aspects of one’s social identity in Africa and manifest at every facet of our life. Africa should in the same vein recognize the need for a middle-ground with global bioethics since the continent is at present burdened with many diseases that needed urgent intervention through biomedical research. Global bioethics, therefore, requires the acknowledgement of different cultural realities seen in different communities. Culture should therefore be respected without compromising key moral values, while conception of bioethics as dialogue process and not as set of principles that must be followed should be maintained.  With this and the contribution of African culture and value system at the back of our mind, it will be possible to formulate a common bioethical framework that could be shared by individuals and groups in a pluralistic society with cultural diversities. Thus providing the basis for a common bioethics principles and practice based on cultural diversities.
- Aramesh K. Cultural diversity and bioethics. A supplementary issue on Bioethics. Iranian J Publ Health 2008;37:28-30.
- Onuoha C. Bioethics Across Borders: An African Perspective. Uppsala Studies in Social Ethics 2007; 34:340 pp. Uppsala Sweden. ISBN 978-91-554-6869-9.
- Takala T. The right to genetic ignorance confirmed. Bioethics 1999;13:288-93.
- Mkhize N. Communal personhood and the principle of autonomy: The ethical challenges. Contin Med Educ 2006;24:26-9.
- Gbadagesin S. Bioethics and Culture. African Perspective. Bioethics 1993; Vol. 7: 257-262
- Takala T. Culture, health, and bioethics: At the Crossroads. Camb Q Healthc Ethics 2001;10:72-7.
- Tangwa GB. The traditional African perception of a person. Some implications for bioethics. Hastings Cent Rep 2000;30:39-43.
- Black M, Mooney G. Equity in health care from a communitarian standpoint. Health Care Anal 2002;10:193-208.
- Mbiti JS. African Religions and Philosophy. Nairobi: East African Educational Publishers Ltd., 1969. p. 108-9.
- Kass NE. An ethics framework for public health. Am J Public Health 2001;91:1776-82.
- Chukwuneke FN, Ezeonu CT, Onyire BN, Ezeonu PO. Culture and biomedical care in Africa: The influence of culture on biomedical care in a traditional African society, Nigeria, West Africa. Niger J Med 2012;21:331-3.
- Toldson IL, Toldson IA. Biomedical Ethics: An African centered perspective. Journal of Black Psychology 2001;27:401-423.