As a secular, rational endeavor, bioethics resists the religious. But, interestingly, in its efforts to establish its place in medicine and the life sciences, bioethics calls on proselytizing methods commonly associated with religious missionizing. Like Christian missionaries who left Europe and North America to witness to peoples in other lands, bioethicists are now bringing the gospel – the “good news” – to those in low and middle income countries.
The Christian gospel is the New Testament story of salvation found in the birth, death, and resurrection of Jesus Christ. The gospel of bioethics is “good clinical practice”, the Belmont Report,Footnote 18 and the Declaration of Helsinki.Footnote 19 Both missionaries and bioethicists may object to this comparison. Missionaries will point out that they are devoted to a spiritual task, not to the secular work of developing regulations and guidelines for the practice of medicine and medical research. For their part, bioethicists will likely resent being described with a term associated—in their minds, at least—with those who destroyed local cultures and paved the way for colonial abuses. These objections are, of course, based on stereotypes. Not all missionaries are tools of imperialistic nations, and most do more than care for the souls of those they minister to. And while it is true that bioethicists help to create and write regulations, their ultimate goal is to protect patients and research subjects from harm and exploitation.
Nevertheless, the metaphor of missionary work is useful for understanding how bioethics has insinuated itself in the developing world, making visible interesting similarities in the work of missionaries and bioethicists. For instance, it is clear that bioethicists have followed—consciously or unconsciously—one important example from the missionary movement. Like missionaries before them, bioethicists are shifting from “imported” to “indigenous” evangelization.Footnote 20 Beginning in the mid-nineteenth century and throughout the twentieth century, missionaries faced resistance from their host countries. In some places, most notably China, missionaries were expelled; in other places, missionaries were increasingly regarded as colonialists. Mission organizations responded to this turn of events with the notion of “indigenization.” No longer would missionaries from the West be exported to other countries. Instead, citizens from those countries would be brought to the West and trained to situate the missionary message in the local culture. This meant translating the gospel into local languages, using local organizational forms in the creation of churches and adapting local customs to the teaching of the gospel. Over time, indigenization came to be called “contextualization”, and it was described as an effort to protect, and be relevant in, local culture.
Although they do not use the term, those in the West who wish to bring the benefit of bioethics to the developing world have seen the value of indigenization. Indigenization is a solution to what Solomon describes as the “export problem” of Western bioethics—a problem that is unavoidable when bioethics, a creation of Western culture, collides with the systems of ethics found in local, non-Western cultures.Footnote 21 Pursuing the indigenization solution, bioethicists from the developing world are currently being trained in the United States (via the Fogarty International Center of the National Institutes of HealthFootnote 22), Europe (via the Erasmus Mundus Masters program in bioethicsFootnote 23), and the United Kingdom (via The Wellcome TrustFootnote 24). Having learned the language and logic of Western bioethics, trainees return to their home countries to spread the “gospel”.
What do we know about the “success” of the indigenization of bioethics? Research addressing and/or evaluating these specific training programs has been scant, and the descriptions and evaluations that do exist tend to be programmatic (i.e., “Did we meet the goals of the funder?”) rather than critical and reflective (“Have our bioethics programs helped local norms and values to be realized?”).
From Noble Intent to Unwitting Harm
For the most part, the desire to spread the gospel, Christian or bioethical, begins with noble intent—the goal is to bring the benefits of developments in one part of the world to another part of the world where those benefits are not experienced or understood. Those benefits may be eschatological or existential, but in either case, the motivation is to proffer aid and share lessons learned. But, as we have seen in some of the transactions between missionaries/bioethicists and the people they serve, noble intent is not sufficient to bring good results. An imbalance in power between would-be helpers and those to be helped creates a one-way flow of influence from “missionaries” to “locals” that not only diminishes the possibility of mutual enrichment, but also creates the possibility of unwitting harm.
An evaluation of a research ethics training workshop at a Nigerian university implicitly illustrates the problem of one-way flow of influence. The authors begin their report by noting that “training in research ethics affords scientists, especially those from developing countries, the opportunity to contribute to ever increasing international debates on ethical issues. . .” Indeed, “international debates on ethical issues” should be informed by insights of those in the developing world. But just a few pages later, we learn what the program actually accomplished: “Post-training improvements were found in participants’ knowledge of the principles of research, the application of these principles, the international regulations, and the operations of an IRB”.Footnote 25 Measured by its own evaluation metric, this program was focused on teaching Nigerians the wisdom of Western bioethics (“principles, the international regulations, and the operations of an IRB”), not on seeking wisdom from the traditions of Nigeria.
Arguing from a natural law perspective, Boyle points out:
…fragmentation of the pursuits of health around the world implies that no authority within any health care or biomedical community such as a medical association or expert group [can] qualify as having global bioethical authority. . . [U]ntil the world is much more integrated and unified, there will be no properly bioethical legislature or Supreme Court for the whole world.Footnote 26
We know that religious, legal, psychological, historical, and ethical differences have an impact on bioethical views both within and between countriesFootnote 27 but this seemingly obvious fact gets lost in many ethics training programs in developing countries. Benatar, a bioethicist from South Africa, chides those from the West who would “improve” the ethics of countries in the developing world:
What should be avoided is the previous colonial mentality of wanting to study and improve others while oblivious of the need to address the more sophisticated and covert faults of Western researchers’ own societies. The desire to improve the behavior of others should also be associated with awareness that one’s own exemplary moral behavior might be more effective in promoting ethical behavior and respect for human rights than […] attempts to change the cultural attitudes of others while neglecting our own adverse cultural attitudes.Footnote 28
The Inside View of Indigenization: Bioethicists-in-Training Speak
Interviews with 21 trainees at a European-based bioethics program, described elsewhere,Footnote 29 shed light on several important things about efforts to indigenize bioethics. Here I briefly review three of these: (1) problems with the sources of, and models of, ethical reasoning; (2) a lack of fit between the ethical issues taught in classes and the ethical problems in the students’ home countries; and (3) the motivation(s) for establishing Western bioethics in the developing world.
Sources and Models of Ethical Reasoning
A majority of the students in this training program came from parts of the world where Christianity was not the dominant religion. And yet, in Europe, reasoning about ethical issues is deeply rooted in the Christian tradition and Christian scholarship of the West. Students were aware of this and felt a degree of disconnect with their own histories. A student from China pointed out:
“…if I want to accept all of the theologies and, too, the methods for the bioethics for Chinese people, it’s a little bit difficult …in China, we have different religions…and very few people believe in God…they are not Christian…so they have no sort of knowledge about Christian history, about Jesus, so you know, a lot of bioethics, methods, and theories came from Jesus…”
Students admitted that much of their own exposure to ethics and bioethics, before their arrival in Europe, came from the West. This is to be expected, given that the overwhelming majority of published knowledge about ethics—in books, reference works, and on the Internet—comes from Europe and North America.
One student pointed out that training in the Western way of bioethics is “interesting,” but the model of ethical reasoning that is almost universally taught—principlism—is not an easy fit in most developing countries.
Based on the well-known four principles—autonomy, beneficence, nonmaleficence, and justice—principlism is easily taught and applied to a wide variety of ethical dilemmas, at least in societies where these principles fit seamlessly with cultural values. It can be argued that the four principles are sufficiently abstract allowing them to float above, and yet account for, the peculiarities of culture. This line of argument suggests that regardless of our cultural differences, we all can agree that nonmaleficence is a good thing. But, of course, we must hasten to add that what you and I call “harm” may vary. And the same can be said of autonomy: in the United States, autonomy is conceived in a radically individualist manner, but in other cultures we can adjust the idea to incorporate more familial and communal ideas of autonomy. In the atomistic United States, a free and independent individual should (must?) determine her care, whereas in more communal societies, autonomous decisions occur in consultation with, or by decision of, recognized authorities.
Ultimately, this argument is specious. Pushed too far in this direction the principles become meaningless. Can we really speak of autonomy if others make a treatment decision for an adult woman? Bioethics students from the developing world saw several problems with the principlist approach they were learning. Not surprisingly, the principle of autonomy was identified as most problematic. Many of the students saw a disjuncture between their cultural values and the individualism implicit in autonomy. A student from a Muslim country noted: “…in [Islam]…justice [is more important] than autonomy…Islam said first your neighborhood…not first yourself.”
Another discussed a Buddhist view:
“…[an author I am reading] argues that in Buddhism you have no concept of autonomy. …She said that the central concept is compassion, and it emphasized paternalism. So for myself, this is what I think for myself, compassionate paternalism, it’s not that bad.”
From India:
“[In rural India] their idea of autonomy is totally different, like they’re not, even for signing our hospital admission sheet, it is not a patient or immediate person, it is…the family [that] was signing for that patient, even for admission, even for taking out of the hospital, it’s not the patient who is signing…we are not thinking the autonomy of the person, we are thinking about the collective autonomy of the whole family.”
Ethical Issues Here and There
Training in bioethics typically involves review of ethical theories (described above) and in-depth discussion of critical ethical issues. These discussions offer the opportunity to apply ethical theory to real-life situations, and allow students to practice the move from the theoretical to the applied. What are the ethical issues covered in coursework of students from the developing world? Here are two course descriptions from the curriculum of the students who were interviewed:
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Ethics of Reproductive Technologies: The aim of this course is to familiarize participants with an ethical approach of assisted reproduction. The goal is not only to essentially inform the participants about the latest developments and challenges in this area of medicine, but also to help them develop a critical and ethical clarification of this subject. This course works from an interdisciplinary (theological, legal, psychological, medical) perspective.
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Human Genetics and Medical Technology: The course aims to educate participants on a range of ethical subjects that currently are the focus of debate in genetics. Teaching will focus on the moral problems generated by the Human Genome Project, as well as the ethical boundaries in the clinical application of new knowledge in, for example, genetic counseling, genetic screening, gene therapy, and cloning. The implications of scientific progress for the image of the human being, as well as for modern culture, will also be studied.
This curriculum is not atypical. Review of the course requirements for those in the Johns Hopkins Fogarty African Bioethics Training Program reveals a few more relevant-sounding titles—for example, there is a “Short Course in International Research Ethics”—but course content is equally skewed toward Western ideas. The description of the International Research Ethics course reads: “Introduce trainees to the major principles and theories of Western bioethics, to U.S. and international guidelines that govern human participants research”.Footnote 30 An evaluation of the program suggests it has been empowering to students but, significantly, also indicates that the training is still too Western-centric, lacking in curricula more appropriate to developing countries.Footnote 31
Students in the European program noticed this lack of fit. At one point, students from the program approached the faculty about making the coursework more relevant to conditions in their home countries. As one student explains, they were rebuffed:
“… would you like to know what was a surprising thing for me? That when we were talking about adjusting this program to the need not just to talk about the [European] situation, but a little bit wider, and people from India were highly interested to talk about HIV…the reaction was, ‘but we are a European course.’”
Students also felt that the assigned readings were not aligned with what they would need to know when they returned home. One student talked about the need to learn the basics, even if she did not know “who Levinas is:”
“… for me, it is sometimes too much, too many terms, not the right context, and I will prefer to debate, to talk, to share something like that, because it is the way I learn better, rather than just to have a philosopher who is using a very specific language.”
Motivations: Why Teach Western Bioethics to Students from the Developing World?
Given the lack of fit between the content of training programs in bioethics and the bioethical situation and needs of countries in the developing world, it is reasonable to ask “Why do these programs exist?” The answer to that question is not simple. In our search for an answer, we look to both what we learned from students and to campaigns by for-profit organizations marketing their clinical trial services. In her explanation of the difference between medical ethics and bioethics, a student from India reveals an important motivation for the export of Western bioethics (emphasis added):
“Medical ethics was something like the ethics related to clinical care and the doctor, how we should be with patients and all that. That was what we were taught in medical school … But now because research is coming in a big way, especially with a lot of international collaborations, the U.S. ethos of bioethics is coming in a big way.”
This student understands the current situation. As Petryna has pointed out, the number of clinical trials in the developing world has grown markedly over the past 15 years, as pharmaceutical companies search for “naïve bodies” (bodies that are not under the influence of several drugs, as is the case in many Western nations), and more favorable ethical environments.Footnote 32
Students are aware of the need for better bioethics in the developing world. In their comments on the coming of the pharmaceutical industry to their countries, they demonstrate a mix of motives for learning the ways of Western bioethics: to protect the subjects of research but also to encourage economic development. This student from China was typical:
“No, just now, [we have] no formal [research ethics] committees [in China], no, so it’s a big problem. I think I like to come here and learn more knowledge about this field, I want to do some work in this field… at least I can help to organize the bioethical review communities in my universities, for our country…I know doctors, they do some clinical trials, they have no approval…they didn’t do the informed consent…they didn’t have the review…[from] the research review committees, so it’s a big problem, they do some trials, it’s not good.”
She goes on to discuss the director’s enthusiasm for having European-trained bioethicists in China:
“…my director, director of our institute, he’s very good person and he has a lot of ideas for the future development, and when he learned [that] I got [a] scholarship, and of the European community, and I can come to European countries to learn bioethics, he [was] very excited. He said, ‘ahh it’s good, it’s good for you and also for our institutions. I know in Europe the bioethics have a very good…they pay a lot of attention in this field and they have a lot of knowledge in this field and I think you can learn a lot of things there.’”
Similarly, a student from an Eastern European country noted:
“…we have several IRBs registered, just because let’s say our genetics center, probably 7, 8, 10 years ago, became interested to work with some French organization and they, one of the requirements was: ‘where was your IRB?’ So these people started to work on that…”