Journal of Medical Ethics and History of Medicine Respect for cultural diversity and the empirical turn in bioethics: a plea for caution Karori Mbugua University of Nairobi, Nairobi, Kenya. *Corresponding author: Karori Mbugua Address: University of Nairobi, Nairobi, Kenya. Postal Box: 30197-00100 Email: Karorim@yahoo.co.uk Received: 23 Nov 2011 Accepted: 27 Dec 2011 Published: 07 Feb 2012 J Med Ethics Hist Med. 2012; 5:1. http://journals.tums.ac.ir/abs/20181 © 2012 Karori Mbugua; licensee Tehran Univ. Med. Sci. Abstract Keywords: Ethics, Cultural sensitivity, Empirical bioethics, Ethical relativism, Naturalistic fallacy. Introduction Over the last twenty years a number of scholars have been calling for a bioethics that is culturally sensitive. Many have been critical of traditional bioethics, arguing that it is dominated by the principles and methods of Anglo-American philosophy which are too abstract and insensitive to social and cultural realities (1). At the same time, there has been a trend to make bioethics more relevant to real life cases by incorporating the methods of the social sciences (2). This is what is popularly referred to as the empirical turn in bioethics. My argument is that although these trends in bioethics have their own merits, if overemphasized and not properly conceptualized, they can easily undermine the normativity of bioethics by reducing it to a social science. Bioethicists must endeavor to provide judgments of how things ‘ought to be’ and not simply describe how things ‘are’. It is useful to note that the issues discussed in this paper are part of a wider contro- versy concerning the universality of human rights. Indeed, like in the field of bioethics, similar calls have been made for human rights to be culturally relevant and sensitive to context (3). The cultural turn in bioethics As I have already pointed out, over the past twenty years there have been incessant calls for bioethics to be more sensitive to culture and social context. What has motivated these calls is the realization that all individuals see the world through the filtered eyes of their own culture. Consequently, any attempt to impose moral In the last two decades, there have been numerous calls for a culturally sensitive bioethics. At the same time, bioethicists have become increasingly involved in empirical research, which is a sign of dissatisfaction with the analytic methods of traditional bioethics. In this article, I will argue that although these developments have broadened and enriched the field of bioethics, they can easily be construed to be an endorsement of ethical relativism, especially by those not well grounded in academic moral philosophy. I maintain that bioethicists must resist the temptation of moving too quickly from cultural relativism to ethical relativism and from empirical findings to normative conclusions. Indeed, anyone who reasons in this way is guilty of the naturalistic fallacy. I conclude by saying that properly conceptualized, empirical research and sensitivity to cultural diversity should give rise to objective rational discourse and criticism and not indiscriminate tolerance of every possible moral practice. Bioethics must remain a normative discipline that is characterized by rigorous argumentation. J Med Ethics Hist Med 2012, 5:1 Karori Mbugua Page 2 of 5 (page number not for citation purposes) principles based on Anglo-American philosophy to people with different cultural perceptions is unjust and amounts to cultural imperialism. The main criticism leveled against traditional bioethics is that it ignores the role of social and cultural factors in the ethical-decision making process. A number of scholars, especially those from the developing countries, see the globalization of bioethics as a form of neocolonialism and an attempt by the developed world agencies to advance their biomedical agenda on resource poor nations. These critics have gone on to call for a truly global bioethics that acknowledges the existence of alternative ethical frameworks (4). One of the earliest advocates of a culturally sensitive bioethics was Richard Lieban. He coined the term ethnoethics to refer to the examination of ethical issues in biomedicine in non-western cultures. He described ethnoethics in the following way: “This would include moral norms and issues in health care as understood and responded to by members of these societies. Ethnoethics should be informative not only about cross-cultural variation in ethical principles of medicine, but also about variations in issues which in different societies become defined as morally relevant or problematic. Ethnoethical information should contribute to the discourse of medical ethics, not only by illuminat- ing culturally distinctive moral views and prob- lems, but also by helping to provide a more realistic and knowledgeable basis for the explora- tion of cross-cultural ethical similarities (5).” Murove (6) and Ogundiran (7) have separately complained about the Western domination of contemporary bioethics. They have gone on to call for the evolution of an authentic African bioethics, one that benefits from other cultural influences yet not overshadowed by them. Expressing similar sentiments, Tai and Lin (8) have called for a truly Asian bioethics, which is based on the traditions and culture of the Asian people. Taking the principle of informed consent as an example, the two authors have argued that applying this principle to research involving human subjects in the Asian context without consulting the family would be inappropriate because of the high value that Asians place on community shared decisions. But De Castro (9) has cautioned that any attempt to assert Asian bioethics must recognize that, even within Asia, different bioethical perspec- tives exist and it would therefore be wrong to lump all Asian people together as if Asia is a homogene- ous society. An understanding of the cultural beliefs of oth- ers and how they are influenced by them is especially important in clinical practice. Learning how different cultures define and understand health, illness, pain and even death can go a long way in helping resolve the many ethical dilemmas that healthcare providers routinely encounter. Such an understanding will also translate into improved clinical management (10, 11, 12). From the foregoing it is clear that there is an urgent need to recognize that different cultures have different practices and values and we should take this into account when evaluating them. However, as we shall see later, this does not mean that we cannot make important judgments about particular cultural practices. The empirical turn in bioethics Calls for a culturally sensitive bioethics have coincided with what is now described as the ‘empirical turn’ in bioethics. As with the calls for a culturally sensitive bioethics, the empirical turn in bioethics has come about as a result the traditional bioethics’ preoccupation with conceptual analysis, which many critics claim has led to a disconnect between theory and practice.While this turn has its own merits, when accompanied by calls to take cross-cultural moral differences seriously, it can undermine our confidence in the normative analytic methods of bioethics. A quantitative analysis of peer reviewed medical ethics journals in the field of bioethics in the period 1990-2003 showed that the proportion of empirical research in bioethics rose in these journals from 5.4% in 1990 to 15.4% in 2003 (2). A more recent study carried out in Turkey showed a sharp increase in empirical studies in Turkish medical ethics literature during the period 1994-2009 (13). This turn in bioethics has come as a response to the social science critique of traditional bioethics, with some commentators dismissing it as too abstract and naïve. As John Irves forcefully puts it ‘philosophers must get out of the Platonic ivory tower, and acknowledge that ethics is about people, not just good arguments. It is about encounter with experience and using those encounters to inform one’s philosophy’ (14) The Wellcome Trust of the United Kingdom has described this approach to bioethics as an ‘abstract exercise carried on over sherry in the tutorial rooms of ivory towers’ (15). It is noteworthy that this trust has been at the fore- front of funding empirical studies in bioethics. The value of empirical research to bioethics is not in dispute. This turn has been well received because it has enriched the field of bioethics in a number of ways. Mildred Solomon has identified three different ways in which empirical research can be used in bioethics. Firstly, empirical studies can help facilitate the move from ethical analysis to ethically justifiable behavior; secondly empirical data can be used to enhance ethical analysis and justification (this involves testing consequentialist claims), and thirdly it can be used to identify and document new moral dilemmas (16). However, it J Med Ethics Hist Med 2012, 5:1 Karori Mbugua Page 3 of 5 (page number not for citation purposes) must be emphasized that empirical data per se does not determine what is right or wrong although it might be relevant in making such a determination. But it could be argued that this approach to bioethics is not entirely new. According to sociologist Adam Hedgecoe those who are interest- ed in incorporating the empirical element into their work do not need to invent a new discipline. Such a discipline already exists in the form of medical sociology. As he forcefully puts it: ‘if medical ethicists are interested in the lived experience of the social world of modern medicine, an obvious solution would be to read some medical sociology rather than look towards developing a new disci- pline’ (17). Hedgcoe is right. Sociology and anthropology have a history of investigating bioethical subjects which are not always recognized by mainstream bioethics (see for example Fox (18) and Edel (19). However, the two disciplines i.e. sociology and anthropology do not have ethics as their primary focus. It is therefore still necessary to incorporate an empirical component into mainstream bioethics. The lure of ethical relativism Although both cultural sensitivity and empirical research can enrich bioethical debate, they can be harmful to the extent that they can be used to shield certain harmful but well entrenched cultural practices from external criticism. Indeed the greatest challenge facing bioethicists today is how to produce a bioethics that is both sensitive to culture and lived experience and yet critically normative. We should be worried about cultural relativism because in the past some people have equated it with ethical relativism, which is the claim that morality is relative to one’s culture. Those who argue in this way are accused of deriving an “ought” from an “is” or deriving normative claims from factual claims.The naturalistic fallacy, as this error in reasoning is called, was first pointed out by David Hume (20) in the 18 th century and elaborated by George Edward Moore (21) in the 20th century. Moreover, ethical relativism and its prescription for tolerance conjure images of a world where any- thing goes. Just because cultures differ in their ethical judgments does not mean that they are justified in holding them or that we should tolerate those beliefs. The major advocates of ethical relativism were anthropologists who were heavily engaged in the study of indigenous cultures. However, one of the earliest defenders of moral relativism was the Greek philosopher Protagoras. Protagoras is reputed to have said that man is the measure of all things. He went on to suggest that morality is a matter of social convention and in not found in nature. More recently, varied versions of ethical relativism have been defended. For example, Brandt (22) defends the view that there are conflicting moral claims that are equally valid, while Hartman (23) defends what he calls norma- tive moral relativism, which is the claim that different people are subject to different moral demands. Wong (24) rejects the notion that there is one true morality and defends the view that there is a plurality of true moralities. In the area of anthropology the main defenders of ethical relativism are Benedict (25) and Her- skovits (26). After studying the cultural practices of different human communities they concluded that what is considered morally normal is culturally bound and historically defined and the western standards of morality should not be considered universal. They also called for toleration of cultural practices with which one may profoundly disagree. A major criticism of moral relativism is that even if different cultures practice different moral behaviors, they may nevertheless share the same underlying moral values. Furthermore, even if we accept that different societies have different moral beliefs, this does not warrant the conclusion that all moral codes are equally valid (27). The field of bioethics cannot survive without the belief that there are moral universals. The truth of the matter is that despite the exist- ence of significant cultural differences, there exist some core moral values that are shared by inhabit- ants of most human communities. Unfortunately, most people have tended to over-emphasize cultural differences at the expense of the similari- ties. Again consider the much debated concept of autonomy. Many authors have claimed that this concept is absent in both African and Asian cultures whose moral theories are communal in nature. But this view has been challenged by Agulanna (28). According to him, the idea that Africans value collective agreement over individual choice is grossly exaggerated. Along the same lines Metz (29, 30) has conclusively argued that just like utilitarianism and Kantianism, African ethics entails a right to autonomy and informed consent. Another argument against ethical relativism is the argument from moral progress. Throughout history cultures have been known to change their beliefs about what is right and wrong. But if the later beliefs are better than the earlier ones, it must be because they are closer to what is objectively right. Take the concept of autonomy again as an example. This concept, which is today very highly valued in Western culture, came about as a counter response to the paternalistic Hippocratic medicine, which had dominated Western medicine since the time of Hippocrates. The problem with ethical relativism is that it would make such moral progress impossible. Today cultural relativism has come to mean nothing more than the idea of tolerance. On the J Med Ethics Hist Med 2012, 5:1 Karori Mbugua Page 4 of 5 (page number not for citation purposes) face value this might be considered good but as Nafisi rightly pointed out such an attitude neutral- izes action instead of galvanizing it (31). Indeed, it is possible to practice cultural relativism as a social scientist and the same time maintain a commitment to moral objectivity. By reasoning and argument we can discover the true moral beliefs. Further- more, as Velasquez (32) has noted, moral disa- greements may be an indication that some people are more morally enlightened than others and we should not assume that if ethical truth exists, then everyone must know it. Empirical studies and bioethics’ normative mandate As they use empirical studies to enhance bioeth- ical discourse, bioethicists must ensure that bioethics does not become a chapter of sociology or anthropology. It must remain a second order activity. This in essence means that the cross- fertilization between ethics and the social sciences must be done with utmost care. The temptation to move from ‘is’ to ‘ought’ is very real. Most bioethicists don’t have a very good grounding in academic moral philosophy. And as David Benatar points out, ‘the field of bioethics today suffers from serious quality control prob- lems’. The reason for this is that although strictly speaking bioethics is a sub-branch of ethics (as its name suggests) which is in turn a branch of philosophy, many of the practitioners in this field are either social scientist, lawyers, health econo- mists, theologians and medical practitioners who are not well grounded in academic moral philoso- phy. Benatar’s further notes: “…there has been a proliferation of courses, diplomas and degrees in bioethics. As these courses are often aimed at those without philosophical training and lack the rigor and often duration of other courses of study, there are more and more people with formal and poor bioethics education. There is a whole enterprise of bioethics education that is creating “experts” if not instantly then certainly very quickly. In some cases, a brief course or a diploma is thought sufficient to transform a novice into a so called “ethicist”, “bioethicist” or, worse still, bioethics educator (33).” These kinds of bioethicists are vulnerable to the seductive lure of ethical relativism. Given that they do not have a good grounding in academic moral philosophy, they can easily be tempted to move too quickly from empirical findings to normative conclusions. But this is not to suggest that bioethics should be the exclusive domain of professional philoso- phers or that empirical research has no role to play in bioethics. On the contrary, non-philosophers and especially social scientists have a big role to play in bioethics because empirical findings are often used as premises in ethical arguments. Indeed, good studies in bioethics must be grounded on good empirical data and the philosopher has no choice but to either collaborate with the social scientist or be acquainted with social science methodologies so that she can at least read and interpret empirical data if not carry out the empirical research herself. Bioethicists will also need to know what counts as useful and relevant empirical data and where to find it. This is because the most useful and original empirical studies, as James DuBois recently pointed out, are not published in traditional bioethics journals. Bioethicists must therefore understand that ‘empirical data in bioethics are not data that determine what is right or wrong, but rather are relevant to that determination’ (34). Some of these data is to be found in non-bioethical journals. But as I pointed out previously, in order to avoid the compartmentalization of the empirical and the ethical, collaboration between philosophers and social scientists should be encouraged. What I am calling for is a moderate form of naturalism that does not threaten to undermine the normativity of bioethics. Eric Racine prefers to call it pragmatic or moderate naturalism (35). The worries I have raised regarding the relation- ship between facts and values; ethical theory and empirical data should not be viewed negatively by social scientists. As Chris Herrera has pointed out this tension should be viewed ‘as part of the normal inquiry in bioethics….’ (36). It is a reminder that bioethics is rooted in philosophy, which is a self- reflective discipline that questions its own methods. Indeed, the relationship between facts and values is a perennial problem of philosophy. Conclusion In this paper I have argued that although both the cultural and empirical turns in bioethics have enriched the field of bioethics, if not properly conceptualized and integrated with ethical theory, they can easily undermine bioethics’ normative mandate. This concern cannot be wished away or dismissed with a wave of the hand as it touches on the very essence of bioethics as a philosophical discipline. As they use empirical data and acknowledge that different cultures have different moral codes, bioethicists must be guided by the belief that objective moral values that transcend culture exist. This is the only way that bioethics as a discursive discipline can grow and flourish. It is also the only way that we can have moral progress. Bioethicists should debate and, if need be, reject those moral practices that defy rational justification. Page 5 of 5 (page number not for citation purposes) J Med Ethics Hist Med 2012, 5:1 Karori Mbugua References 1. Ryan MA. Beyond a western bioethics. Theol Stud 2004; 65(1): 158-77. 2. Borry P, Schotsmans P, Dierickx K. Empirical research in bioethics journals: a quantitative analysis. J Med Ethics 2006; 32: 240-5. 3. James SA. Reconciling international human rights and cultural relativism: the case of female circumcision. Bioethics 1994; 8(1): 1-26. 4. Mbugua K. Is there an African bioethics? Eubios J Asian Int Bioethics 2009; 19: 2-5. 5. Leiban RW. Medical anthropology and the comparative study of medical ethics. In: Weisz G. eds. Social Science Perspectives on Medical Ethics. Philadelphia: University of Pennsylvania Press; 1990, p. 221-40. 6. Murove FM. African bioethics: an exploratory discourse. J Stud Relig 2005; 18(1): 16-36, 7. Ogundiran TO. Enhancing the African Bioethics Initiative. BMC: Medical Education [on-line] 2004; 4(21) 8. Tai MC, Lin CS. Developing a culturally relevant bioethics for Asian people. J Med Ethics 2001; 27(1): 51–54. 9. De Castro L. Is there an Asian bioethics? Bioethics 1999; 13: 227-35. 10. Irvine R, Mchphee J, Kerridge IH. The challenge of cultural and ethical pluralism to medical practice. Med J Aust 2002; 176(4): 174-5. 11. Fiore RN. Ethics Culture and the Clinical Practice Ethics. Northeast Florida Medicine Supplement. 2008; 50(January): 33-36. 12. Zahedi F., Larijani B. Common principles and multiculturalism. J Med Ethics Hist Med 2009; 2:6. 13. Kadioglu FG, Kadioglu S. An overview of empirical ethics research in Turkish medical literature. Eubios J Asian Int Bioethics 2011; 21: 197-200. 14. Ives J. Encounters with experience: empirical bioethics and the future. Health Care Anal 2007; 16: 1-6. 15. Bennett R, Cribb A. The relevance of empirical research to bioethics: reviewing the debate. In: Hayry M, Takala T, eds. Scratching the Surface of Bioethics, Amsterdam: Rodopi; 2003, p. 9-18. 16. Solomon MZ. Realizing bioethics’ goals and practice: ten ways ‘is’ can help ought. Hastings Cent Rep 2005; 35(4): 40-7. 17. Hedgecoe A. Medical sociology and the redundancy of empirical ethics. In: Ashcroft RE, Dawson A, Draper H, eds. Principles of Health Care Ethics. Chichester: John Wiley and Sons; 2007, p. 167-75. 18. Fox R C. The Sociology of Medicine. New Jersey: Prentice Hall; 1989. 19. Edel A. Ethical Judgments: The Use of Science in Ethics. Glencoe: Free Press; 1955. 20. Hume D. A Treatise on Human Nature (1740). Oxford: Oxford University Press; 1983. 21. Moore G. E. Principia Ethica (1903). Cambridge: Cambridge University Press; 1975. 22. Brandt B. Ethical Theory. Englewood Cliffs: Prentice-Hall, Inc; 1959. 23. Harman G. Moral relativism defended. Philos Rev 1975; 84: 3-22. 24. Wong D. Moral Relativity. Berkeley, CA: University of California Press; 1984. 25. Benedict R. Patterns of Culture. New York: Penguin; 1934. 26. Herskovits M. Cultural Relativism. New York: Vintage Books; 1973. 27. Aramesh K. Cultural diversity and bioethics. Iran J Public Health 2008; 37(Suppl 1): 28-30. 28. Agulanna C. The requirement of informed consent research ethics. Eur J Sci Res 2010; 44(2): 204-19. 29. Metz T. African and Western moral Theories in Context. Dev World Bioethics 2010; 10(1): 49-58. 30. Metz T. An African Theory o Bioethics: Reply to Macpherson and Macklin. Dev World Bioethics 2010; 10(3): 158- 163. 31. Nafisi A. Liberal Education and the Republic of Imagination. Liberal Education. 2006; 92(3): 6-13. 32. Velasquez M. Philosophy. New Delhi: Wardsworth; 2007. 33. Benatar D. Bioethics and Health and Human Rights: A Critical Review. J Med Ethics 2006; 32: 17-20. 34. Du Bois J M. What Counts as Empirical Research in Bioethics and How do We Find the Stuff? Am J Bioethics 2009; 9(6): 70-72. 35. Racine E. Which Naturalism for Bioethics? A Defense of Moderate (Pragmatic) Naturalism, Bioethics 2008; 22(2): 92-100. 36. Herrera C. Is it Time for Bioethics to Go Empirical? Bioethics 2008; 22(3): 137-146.