Theoretical Issues in Bioethics

An exciting area of anthropological and sociological research has focused on critiquing the field of bioethics by highlighting the social, political, and cultural dimensions of its theoretical frameworks and what bioethics construes as topics of interest and topics to silence, for example cultural relativism (Crigger, 1998; Kleinman, 1995a, 1995b; Marshall, 1992; Muller, 1994). Echoing concerns noted by Fox and Swazey (1984) of bioethics' "provincialism," Kleinman (1995a, 1995b) contends that bioethics is limited in orientation because it is ethnocentric, psychocentric, and medicocentric in its inattention to non-Western moral traditions. Much of the critique aims to uncover the Western cultural foundations of the normative philosophical principles contributing to bioethical discourse. Early bioethics philosophers contend that the principles of autonomy, beneficence, non-maleficence, and justice are universal concepts (Beauchamp & Childress, 1994). However, several U.S. studies show that, for example, expressions of "justice" in terms of allocating scarce medical resources in a rural primary care practice setting differ from practices in urban settings (Brown, 1994; Jecker & Berg, 1992). The contingencies of rural life that engender face-to-face, everyday interpersonal relations with health providers who must make allocative decisions reveal that justice is not a blinded, impersonal process, as many philosophers contend. The principle of respect for "autonomy"—self-rule or agency that is free from interference from others (Beauchamp & Childress, 1994)—has been the target of greatest criticism because it prioritizes a sense of personhood as the individual, which is clearly Western, particularly American in orientation (Fox & Swazey, 1984; Wolpe, 1998). When most cultures espouse a socio-centric conception of personhood as opposed to an ego-centric or indexical self (Gaines, 1982; Shweder & Bourne, 1982), the enduring preeminence of an individualistic approach to moral reasoning and medical decisions appears limited, since families play an important role or even greater role than the individual in care-taking and decision-making in the United States and cross-culturally (Kuczewski & Marshall, 2002). A noteworthy contribution toward this line of work examined preferences for autonomous decision-making among four different ethnic groups in the United States (Blackhall, Murphy, Frank, Michel, & Azen, 1995; Frank et al., 1998). Other bioethical constructs and assumptions that serve to buttress ethical arguments and health policies have also been subject to cultural analysis. For instance, while bioethics scholars presume that altruism drives people's decisions to donate their loved one's cadaveric organs, anthropological research shows that altruism plays little or no role in their decisions, but rather, decisions are made out of the personal desire to witness the loved one living on in another person, thus helping to make a devastating experience meaningful (Siminoff & Chillag, 1999). Moreover, concomitant to such challenges to the four principles is a growing recognition of other cultural norms that guide how people experience and resolve moral dilemmas and ethical issues, including the value of the community, respect for the elderly, or care (Das, 1999; Fox & Swazey, 1984; Gilligan, 1982; Kohn & McKechnie, 1999).

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