Anthropological Approaches to Bioethics

Today the field of bioethics is uniquely multidisciplinary, indeed it is perhaps best understood as a cultural space in which scholars from many fields interact, joined together by topical interests. However, anthropologists and other social scientists did not play a significant role in the initial development of the field (Fox).

In his analysis of medical ethics, Lieban (pp. 221-222) suggests two key reasons why anthropologists have been absent. First, given the strong history of cultural relativism in anthropology, studies of health and illness conducted by anthropologists have generally avoided what might be construed as ethnocentric value judgments about other systems. Anthropological focus on documentation and description— as opposed to normative analysis—excludes questions about what is morally "right" or "wrong" about particular health practices.

Second, medical anthropologists have often worked in non-Western settings where the technological challenges provided by contemporary biomedicine are less salient. In addition, Marshall (1992) suggests that bioethicists—unlike anthropologists—have concentrated their attention on the individual rational actor as the primary unit of analysis. Although in recent years bioethics scholars have begun to acknowledge the importance of social milieu—for example the role of family—in constructing individual choice and shaping decision options, anthropologists, in part because of their traditional subjects, have generally theorized a more complex self, viewing the individual as firmly embedded within a broader social and cultural context. The notion of autonomy, or respect for persons, which many acknowledge has been over-celebrated in bioethics clinical discourse, presumes an individuated self, set apart from the collective experience of family or community, and triumphant over other critical values. These explanations, however, represent fairly superficial explanations for the lack of anthropological representation within or interest in bioethics. In fact, the unwillingness of anthropologists to engage with ethics (and for philosophers to reach out to social scientists generally) reflects deep seated disciplinary boundaries and conflicting epistemologies (Edel and Edel).

The concept of culture is rarely a starting point in ethics; by contrast, pioneering discussions of comparative medical ethics by anthropologists emphasized the importance of a cultural foundation for framing ethical issues in healthcare. For example, Kundstadter addressed ethical challenges associated with development projects in Third World communities, noting the relevance and importance of cultural context for understanding moral dilemmas surrounding health and illness beliefs and healing roles. Practices such as treatment of less than perfect newborns cannot be adequately understood, much less judged, without detailed local knowledge. Approximately a decade later, Fabrega and Lieban examined the potential of "ethnoethics" for cross-cultural studies of the moral dimensions of health practices. A key starting point is the recognition of variation in the issues that different societies define as morally relevant or problematic. The role of healer is also critical, including the nature of interactions between healers and their patients, interactions among healers themselves, and finally, interactions between practitioners and the larger society.

As engagement with scholars working in healthcare ethics increased, anthropologists have questioned the fundamental schema underlying bioethics, urging greater attention to the lived experience of human suffering and to the social dynamics of local context (Muller; Koenig, 1996; Kleinman, 1995, 1999; Marshall and Koenig, 1996, 2000).

Cultural interpretation situates the moral dimensions of healthcare in local ethical practices and local notions of the good. This traditional anthropological orientation to ethics and morality is antithetical to the universalizing discourses of both basic science—which assumes that scientific principles and rules apply to human bodies in all times and places, and to the discourse of the philosophical traditions dominant in bioethics—which define a good ethical theory as one that can produce "objective" results that yield rational standards by which to judge actions, irrespective of their history or locality (Marshall and Koenig, 1996, 2000).

Medical anthropologist Arthur Kleinman (1995), in his critical analysis of the assumptions and theoretical foundations of bioethics, suggests that the new field is fundamentally ethnocentric, psychocentric, and medicocentric, and thus shares, rather than moves beyond, biomedicine's fundamental limitations. Kleinman argues that bioethics has failed to engage with the major non-Western moral traditions or to question the "orthodox sources of the self within the western philosophical tradition" (p. 1669). The medicocentrism inherent in bioethics constrains practitioner's ability to elicit a complex illness narrative despite the fact that bioethicists are charged with listening to patients and taking account of their perspective and preferences. Although Kleinman maintains optimism that bioethics may open up space in clinical practice for genuine moral reflection and debate, he remains concerned about the limitations of a bioethics devoid of attention to cultural locality: "In the end, then, ethics, once framed as models of moral reasoning championing the reflection and rational choice of autonomous individuals in quest of objective standards, risk irrelevance to the almost always uncertain circumstances and highly contextualized conditions of human experience" (1999, p. 72).

Anthropologists have the greatest potential to make significant contributions to the field of biomedical ethics in two domains: through studies of the cultural production of scientific and clinical knowledge and its translation into medical technology and healing practices, and, secondly, through analysis of the cultural construction of canons of medical morality, including the clinical practices of bioethics itself. Note that this contribution is not linked to the traditional role of anthropology in elucidating the cultural practices of exotic peoples. Ethnographic approaches to ethical questions help clarify the contextual features that are intrinsic to problematic moral issues that arise in medical and research settings throughout the world (Koenig, 1988, 1997; Hunt; Hogle; Rapp; Marshall and Koenig, 1996, 2001; Kleinman, Fox, and Brandt; Kaufman, 2000; Brodwin, 2000; Finkler; Farmer, 2003).

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