Global Bioethics Initiatives

Prof. Dr. Walter Schweidler

Ruhr-Universität Bochum, Germany

GLOBAL BIOETHICS INITIATIVES

FROM THE EUROPEAN PERSPECTIVE

1. Is there a global bioethics?

There is some ambiguity in the title ”Global Bioethics Initiatives”. It can be understood as referring to global initiatives based on bioethical principles in order to analyze and hopefully solve problems caused by the current development in the biomedical field. Or it can mean that there is a worldwide movement based on some new kind of thinking called ”Global Bioethics”. I will stick to the first, the modest and pragmatic version. The second, the stronger version would presuppose that there is some closed system of bioethical thinking which would be able to give us complete orientation concerning bioethical problems. I think that such a view of ”Global Bioethics” has to be considered in a very critical way. Of course there are certain idealistic or utopian projects directed towards such an aim, e.g. Aldo Leopold’s ”Land Ethic” as an ”intuitive call for a new morality”[1] and other approaches which are more or less based on wishful thinking. But there is also a quite realistic understanding of what the term ”Global Bioethics” could mean, an understanding which would turn out to be much more problematic. It is based on the idea of the global establishment of a particular model of bioethics which has its origin in one particular part of the world. That is the model which Tristram Engelhardt called ”the American standard version of bioethics” and with reference to which he emphasized that ”there is no global bioethics”[2]. He characterized this ”American standard” model as follows: the model promises as the only ethically responsible way of dealing with human illness and suffering that the society would have to provide for all of its members the best possible care, equal care and the option to choose any medical treatment without runaway costs.[3] The simple reason why, according to Engelhardt, there is no global bioethics is that such a promise was and is dependent on the conditions of a booming economy and the financial resources of a welfare state in developed countries and therefore is not applicable to the rest of the world.[4]

Thus, what Engelhardt means by: ”There is no global bioethics”, is that the responsibility of dealing with bioethical problems must not be defined by equal standards of care for all members of mankind. ”The key is to articulate an inegalitarian ethos around an egalitarianism of altruism, rather than an egalitarianism of envy.”[5] In bioethics, we cannot promise and we cannot claim to do the best for everyone in the world, but only to act as good as possible. But the decisive question then is: What are the criteria for acting ”as good as possible”? What is meant by ”altruism”? I want to argue that it is exactly the difference in the answer to that question which constitutes a fundamental philosophical opposition in our current debates on bioethical questions and by which any attempt to cope rationally with the problem of ”global bioethics initiatives” in the pragmatic sense, i.e. with the problem of intercultural and international cooperation in the biomedical field, is threatened. The two different ways to answer the question of what is meant by ”altruism” are the utilitarian and the universalist way.

The utilitarian interpretation is that ”altruism” can only mean to do the best for as many persons in need of help as possible. While in the ”American standard model” the highest degree of care is promised to all potential patients, from a global perspective the subject of bioethical claims has to be restricted to the most persons possible – according to the classical utilitarian principle that to act morally means to maximize pleasure and minimize suffering for the largest amount of persons affected by one’s action. In view of this principle, bioethical altruism consists in the fight against suffering, and how many and which patients are going to profit from that fight is determined by the circumstances of the action, i.e. its place and time. The less developed a country and its society are, the more it will be necessary to restrict the degree of medical help to the most elementary forms of basic care for as many patients as possible. At least there is one perspective which leads us beyond this minimal condition: a limited number of patients will profit from ”certain centers of excellence to be maintained where critical care technologies can be nurtured so that as a country develops and increases its standards of care, it will have its home-grown critical care resources on which to draw”[6]. As the country becomes more developed, the number of patients who profit from the fight against suffering will be increased. Thus, for the utilitarian view of altruism, the difference between the ”American standard model” and the global development of bioethics is only a matter of degree: because the number of human beings who shall profit from the fight against suffering is dependent on a country’s degree of development, the most developed countries in the world can promise the highest medical standards not only for most but for all of their citizens.[7]

When I now turn to the universalist interpretation of the term ”altruism”, I will not at all deny the practical consequences of the differences between the degrees of social development in the world. It is certainly a rational and responsible strategy for a less developed country to guarantee a minimal level of basic care for as many of its citizens as possible and to concentrate on the establishment of some special centers of excellence in order to increase step by step its standards of medical supply for the whole population. My concern is a purely theoretical one; but nevertheless, as I hope to point out, the debate between utilitarianism and universalism has immense practical consequences.

From the universalist viewpoint, bioethical ”altruism” is not grounded in our task to fight against suffering but in the natural desire of every human being to have a life free from illness and suffering. The difference may appear to be academic, but it is decisive for any ethical approach to the problems of global bioethics. The universalist argument against utilitarianism is that we simply never know exactly the final balance of pain and pleasure which will be the result of our actions. An operation by which a doctor saves a patient’s life does not become an evil act if the patient afterwards fathers a child who becomes a mass murderer, although the pain and pleasure-balance of the world would have been better if the patient had died. The question if the doctor’s help for a patient is right or not finally does not depend on the question if it diminishes the amount of suffering in the world; it is right because medical help belongs to the natural conditions of human existence.

Without going into the deeper regions of the philosophical struggle between universalism and utilitarianism I think that one central argument for the defense of the universalist view of bioethics is simply that otherwise we could not understand the nature of the medical profession itself. The ”Islamic Code of Medical Ethics” given by the Islamic Organization of Medical Sciences” in 1981 explicitly emphasizes that ”in this respect the medical profession is unique. It shall never yield to social pressures motivated by enmity or feud be it personal, political or military”, and that he or she who has to fulfill the tasks of this profession will be ”never taking justice as its goal but mercy”[8]. If doctors declare: ” we devote our lives in serving mankind, poor or rich, literate or illiterate, Muslim or non-Muslim, black or white…”[9], then they cannot do this on the basis of a scientific prognosis that their acting will probably maximize pleasure and minimize pain on earth. They are and they can be certain that doing a good doctor’s job is serving mankind, because ”mankind” is a certain condition of cultural transformation of natural structures whose essential feature is that members of the human race who have the relevant knowledge devote their lives to help others for whom they are responsible. We could never answer the question whether in the end the existence of mankind will create more pleasure or more pain on earth, but we also do not need to answer this silly question because pleasure is not good in itself and pain is not bad in itself.[10] If pain was something intrinsically bad, we would be obliged to eliminate all human beings whose lives will certainly contain more states of pain than such of pleasure. Of course: To harm human beings, to make them suffer, is normally intrinsically bad, but not because suffering is intrinsically bad but because human beings by their nature do not want to suffer and because it is good to respect the human nature and bad to act against it.

Because human nature is common to all members of mankind, for the universalist view the horizon under which it is constitutive for our responsibility in the bioethical as in any field of moral relevance can never shift from the category of all to that of most human beings. The decisive point for the interpretation of altruism is not what we have to do but why it has to be done. Of course a doctor cannot help every human being; but he can help a patient because that patient is a human being and because as every human being he or she does not want to suffer. It has always been the general idea of universalism that morally relevant actions are actions in which by the way we treat one or some of its members we represent our responsibility to the whole of mankind.[11] A mother who in a situation of emergency saves her child first before trying to help other children is justified not because she would suffer more from her child’s than from the death of the others but because the relation between parents and children constitutes duties and obligations which are decisive for the existence of humanity. Mankind would not exist, if there would not be the elementary structures of help and solidarity which determine who is responsible for whom and for whom whose needs are more relevant than those of others. If we want to act in a responsible way it is never enough ”to do something good” in the abstract sense of performing actions of a good type, but it is always necessary to obey the demands of concrete relationships and situations in which we have to act. Given these elementary structures of obligation, responsible action in its necessarily limited horizon is the indirect fulfillment of our relation to mankind as a whole. ”Treat with respect due to the aged your own family’s elderly, so that you become able to treat the elderly in other families alike. Treat with affection due to infants the minors in your own family, so that you become able to treat the infants in other families alike”[12], we read in Mengzi. To act according to the moral demands resulting from the natural structures of humanity: this is the universalist alternative to the utilitarian principle of maximizing pleasure and minimizing pain.

Therefore, if a developing country cannot avoid to provide unequal degrees of medical help for its population, we must not interpret this as following the utilitarian principle to minimize suffering as far as possible. By providing at least as many of its citizens as possible with medical care and perhaps some of them with a higher level of care than others the society in this country does acknowledge indirectly its obligation to improve the situation for all of its members. It is true that there are important regions on the globe which now do not have and will not have in the foreseeable future the resources to fulfil that obligation. The slogan ”There is no global bioethics” may be acceptable to describe that situation. But it is a dangerous slogan, if it is understood as the postulate that in less developed circumstances the medical profession would not have the same ethical dignity as everywhere else. All over the world the doctor’s work is dedicated to all human beings who need medical help. The nature of the medical profession is not defined by the aim to maximize pleasure and minimize pain as far as possible but by the obligation to help ill and suffering human beings. There may be no global bioethics, but there are universal bioethical principles which are constituted and defined by the relationship between doctor and patient which is one and the same all over the world.

If we did not have such universal principles, if we changed from the universalist to the utilitarian view that the doctor’s job is to devote his or her life to the lives of ”most” human beings or of ”as many as possible” of them in order to maximize pleasure and minimize pain, this would change the nature of the medical profession in three decisive dimensions:

-from the humanitarian to the national obligation: If a country’s society provides the financial support for the doctor’s education and career, why should it not have the power to decide who belongs to ”the most”, i.e. whom he has to serve and whom not? The doctor would become a civil servant who even would have to fulfill the requirements of inhumane and criminal regimes.

-From the ethical to the political claim: If the doctor is nothing but a civil servant, then the state’s political decision, e.g. on human cloning, on medically assisted death, on experiments with human beings etc., would determine the doctor’s tasks and duties, and even the definition who is a human being would become a political matter.

-From mercy to justice: Not help but administration would become the basis of the doctor’s profession. There are already tendencies to make e.g. organ donation a part of an assurance system. Whoever wants to benefit from it must be prepared to contribute to it, so that the doctor before helping a person in need would have to ask about his or her input to the pool the output of which he or she is controlling.

If we want to avoid these consequences, then we will have to see any global bioethics initiative in the light perhaps not of ”global bioethics” but of globally valid universal principles emerging from the nature of the relationship between doctor and patient. When we refer to these principles in bioethics we are not developing an ideal construct. In fact, the public debates on bioethical questions in the last decade and the – still few but important – legislative consequences which they have had in international politics cannot be understood without referring to such universal principles as the unavoidable criteria for responsible deliberation in this field. I want to exemplify this by a brief view on the first steps of the development of an international legal framework of dealing with bioethical conflicts which lately occurred mainly on the European level, but also on the level of the UN.

2. Universal principles of bioethics and their legislative implementation

If we want to formulate ethical principles we have to go back to the origin of the conflicts which make the ethical point of view necessary. Up to now I have only focused on the medical profession as the basis for the solution of such bioethical conflicts, not on their origin. Why do we need bioethics anyway?

The origin of the problems which bioethical principles have to face lies in the rapid development in the fields of biological research in general, of biotechnology and of biomedicine. This development has confronted us with new possibilities and challenges concerning the human life especially in three fundamental dimensions: its beginning, its end and its determination. Biological research and biotechnology have provided us with the ability to manipulate the genes, the cells and tissues of organisms including our own, the human organism. Biomedicine allows us to use these manipulative capacities to treat diseases and to help suffering patients in various ways which we never have had before. In this situation the practical relevance of the difference between the utilitarian and the universal view of bioethics becomes obvious. If maximizing pleasure and minimizing pain were the ethical basis of medical action then the capacities of organ transplantation would hardly raise significant ethical problems. The question whether the person from whom the desperately needed organs are taken is dead or not would not be decisive; the only question would be which one of the two persons, the one who receives the organ or the one whom it is taken from, would profit more from it in respect to his or her balance of pleasure and pain. The formation of embryos purely for the uses of research, for the gain of stem cells and for the breeding of tissue or organs would then hardly be morally problematic. And the worldwide refusal to allow the cloning of human beings could not be understood at all. The manipulation of germ cells in order to eliminate painful or undesirable qualities of whole generations would become our duty towards the future of mankind. When, as it is the case, in all these fields and in respect to these and similar options the conflicts and problems arise which make bioethics necessary, then the principles of this discipline cannot be essentially utilitarian. The origin of bioethical problems lies in the challenge which new biological, biotechnical and biomedical methods mean for the universal principles which are constitutive for the medicine’s responsibility towards all human beings – including the organ donor, the formed embryo, the foetus who is destructed for the aims of stem cell research, the (hypothetically) cloned person and future generations. Which of these principles are the most basic?