“Cross-cultural bioethics” is becoming not only something of a buzzword but an entire sub-discipline in the area of contemporary bioethics. Globalisation and the increasingly multi-cultural nature of the modern state result in ethically pluralistic societies in which there is a growing awareness of and interest in alternative modes of ethical thought, as well as heightened potential for conflict between them. Consequently, scholars of bioethics are now beginning to recognise the importance of understanding, analysing and applying ethical principles derived from a variety of cultures. One particular distinction often emphasised in this regard is the divide between so-called Western and Eastern bioethics.
The questions with respect to such division are whether it is warranted, and if it is, what may be gained from first drawing and then crossing such a dividing line. The publication in 2007 of The Family, Medical Decision-Making and Biotechnology: Critical reflections on Asian moral perspectives, edited by Shui Chuen Lee, goes some way towards answering both of these. The existence of such a volume in itself clearly indicates and reinforces the idea that there is something distinctive about Asian ethical perspectives in comparison to Western bioethics; thus, the need to explore what this might be, while the inclusion of contributions from scholars versed in the various approaches highlights the tensions but also the similarities between what are often perceived as two discrete philosophical clades.
The main “Asian moral perspective” covered in the book is that stemming from Confucianism, probably the predominant East Asian philosophical approach. Topics spanned by the 17 papers include the role of the family versus the individual in medical decision-making, the use of reproductive technologies, embryonic stem cell research and the politics of health care. All of these issues are ethically contentious even within what might be regarded as the “Western” bioethical tradition; what this volume contributes to the discourse is another set of alternative approaches within which these problems may be framed and understood.
The focus of Chapters 2 to 6 is the concept of the family and its ontological significance as a central part of Confucian philosophy. Ruiping Fan provides an overview of Confucian familism and its implications for contemporary bioethical issues, including responsibility and decision-making in the health care context as well as the challenges posed by new reproductive technologies. Fan takes the view that “traditional Confucian bioethics is radically at odds with that of the dominant modern North American and Western European models”1 in that it contextualises the individual within the social and particularly the familial structure, leading to different models of ethical reasoning about these situations. Expositions on this theme are provided by Sheu and by Wear in their respective considerations of truth-telling in medicine. Erickson also contrasts Confucianism with what he terms “liberal secular individualism”2, originating in the Western world but spreading its influence through increasing globalisation. Instead of emphasising the East–West divide, however, he finds resonances between Confucian thought and Western alternatives to individualism such as Hegel's conception of human identity, in which family and community play a core role.
Fan, Ruiping, “Confucian Familism and its Bioethical Implications”. In S.C. Lee (ed.), The Family, Medical Decision-Making, and Biotechnology, 15–26, at p. 15.
Erickson, Stephen A. “Family Life, Bioethics and Confucianism”. In S.C. Lee (ed.), op cit., 47–58, at p 47.
In Chapter 7, Lee's re-evaluation of the autonomy concept draws together a number of theoretical perspectives from both East and West. Lee explores the way in which feminist ethical notions of relational autonomy, themselves developed in the West as a critique of “traditional” autonomy, intersect with Kantian and Confucian concepts of moral action to define a sphere of ethical relational autonomy that centres on but also extends beyond the family. This can be used to ground family models of medical decision-making.
Rei's analysis of the application of sex selection technology in the essentially patriarchal society of Taiwan (Chapter 8) provides both valuable insight in itself as well as a particularly pertinent comparison with bioethical discourse surrounding sex selection in Western societies, in which it is often argued that sex selection is a product of personal preference rather than entrenched sexism. The paper draws on extensive theoretical and empirical evidence across ethics, sociology and law to argue that regulation of sex selection in such a context poses a danger to women's bodily and reproductive autonomy. Even if choices are made on what we might regard as a less-than-morally-neutral basis, Rei suggests, the harm that is likely to ensue if such choices are precluded is a strong reason to allow them. Interestingly, sex selection is nominally banned in Taiwan, but it appears that this ban is leniently enforced if at all; some further commentary on the possibility for legislative change might have been apposite in light of the ethical analysis presented.
Leonardo De Castro, in Chapter 9, presents a different analysis of Confucian familism in bioethics. He examines the implications of modern biotechnology for both Western and Confucian notions of family and shows, using the case of organ donation, that rather than necessarily highlighting the differences between these approaches, these ethical challenges are resulting in convergence and a blurring of the boundaries between them.
Chapters 10 to 14 address the issue that, for Western bioethics, has perhaps come to be seen as publicly emblematic of the discipline: human embryonic stem cell research. Leaving aside ethical differences for the time being, it is widely apparent that Asian countries have in general adopted a more permissive approach to embryo research than their Western counterparts—a point demonstrated by Wong's comparison of stem cell research regulation in a number of East Asian countries (Chapter 12). The ethical basis of this difference is analysed by Fan (Chapter 10) and Lee (Chapter 11), who respectively provide a critique of Western liberal individualism, rather broadly conceived, and of Warren's account of embryos' moral status, as well as an exposition of the alternatives offered by Confucian philosophy. While Fan asserts that Western approaches are inadequately equipped to deal with the problem of embryo research, Lee takes a more balanced approach which draws on both perspectives to produce a subtler analysis. Engelhardt explores the roots of the Western–Confucian difference in Chapter 14, in which he identifies the influence of theological ethics on Western thinking about embryo research as a major point in this regard. Importantly, this also distinguishes between the Islamic approach of Near Asian countries, discussed by Aksoy et al in Chapter 13, and the Confucian East Asian perspective.
Health care, rationing and responsibility are the subjects of the final three chapters. Teo (Chapter 15) compares and contrasts the Singapore system of compulsory family health insurance with Hong Kong's welfare-based model and argues that the former is in harmony with the main tenets of Confucian familism. A further exposition on this subject is provided by Ho's critique of this analysis in Chapter 17, which considers in addition the Confucian model of an ideal society and the ways in which the Singaporean model may not accord with this. Meanwhile, Yu argues in Chapter 16 that the Hong Kong Old Age Allowance policy, although it ensures care for the elderly, actually undermines the Confucian value of respect for elderly parents (xiao) because it transfers responsibility from the family to society at large.
Throughout this volume, the Confucianist approach is compared and contrasted with features of “Western bioethics”, in particular what has been characterised as the trend towards “[l]iberal individualist ethics” (Fan, p 134).
Confucian ethics is primarily virtue and duty-based, while the Western approach against which it is most commonly juxtaposed is a liberal, consequentialist one. This provides an important critical and analytical perspective not least because it adds texture to both approaches. If taken to an extreme, however, it might well commit (albeit in reverse) the crime of which Western attempts to incorporate Asian bioethical viewpoints are often guilty: that of assuming a single approach is representative of an entire society's or culture's thinking on bioethics. Deontological and virtue ethics approaches are also characteristic of some schools of Western philosophy, and to reduce “Western” bioethics merely to liberal consequentialism or “Eastern” bioethics to simple Confucianism is to flatten the complex contours of both into one-dimensionality.
This volume largely avoids both of these pitfalls by way of the scope and breadth of the contributions included: of particular note in this regard is Engelhardt's nuanced exploration of the individual and the family in both Eastern and Western contexts (Chapter 3), which acknowledges the extent of ethical pluralism in both cultures. Likewise the inclusion in this volume of a Central Asian perspective in the form of a commentary on Islamic bioethical perspectives (Chapter 13, Aksoy et al.) is also welcome, in part because it acknowledges that “Eastern” bioethics is not, any more than “Western” bioethics, a unitary school of philosophical thought.
What might be construed as a minor omission from such a collection is that there is little overt attention paid to Communist/Marxist approaches and their potential implications for bioethics, although the political dimensions of these philosophies have undoubtedly influenced socio-cultural attitudes towards such issues in some countries in both East and West.
Some features of Confucianism are presented that may be difficult to accept from a modern Western liberal perspective, or to reconcile with the principles of such an approach. For example, the definition of family excluding those individuals who do not fit within normative categories is contrary to many current critical perspectives, and the casting of individuals who do not fit within these definitions as somehow “deficient and ambiguous…falling short of realising that which is normatively human”3, if accepted, would have dire implications for Western ideals of equality and equal respect for persons. Similarly the idea that “[i]ndividuals do not count equally” would seem to be completely contrary to liberal egalitarian and utilitarian principles, for example the Benthamite maxim of each to count for one and none for more than one.
Fan, op. cit. at p 25
The contrasts observed between Confucian philosophy as a doctrine central to much of East Asian bioethics and the various philosophical attitudes analysed as representative of the West are instructive, but at times threaten to obscure the similarities.
The debate over decision-making in health care and the involvement of the family with reference to Confucian familism is recapitulated in practical and ethical conflicts that arise over some medical decisions in the West, for example genetic testing or HIV testing. There might well be something to be gained by considering a Confucian, family-centred approach to such decisions, given the extent to which the medical information and decisions involved affect family relations. If the tendency within the Western liberal perspective is to maintain an individualistic focus with respect to more conventional health care decisions perhaps it is because the effect such decisions have on others has not been fully recognised.
The debate over personal responsibility in health care is another example of overlap. The communitarian ethic that underlies Confucian philosophy is not so far from underlying continental European principles that ground some “Western” approaches, especially with respect to rationing and responsibility in health care; and even advocates of Western liberalism are beginning to question whether seemingly individual choices may in fact cause (albeit indirectly) harm to others and thus be subject to restrictions under the classically liberal harm principle. An interesting difference, however, is that although Confucianism supports a communitarian approach, its primary definition of community is a narrower one focused on family, as is illustrated by the Singapore health care model; concerns for an ideal society are a secondary consideration.
Overall, there is much to be gained from a comparative critique of Eastern and Western bioethics. One potential flaw in making such comparisons is the possible perception of Western liberal individualism and Confucianism as directly competing and mutually exclusive philosophical perspectives. The contributions in this book, however, stray only rarely into this territory. What this volume illustrates overall is instead that Western and Eastern philosophies, insofar as it is worth drawing this distinction, are multi-faceted but valid alternatives which can learn from and inform each other to produce a richer account of ethics.