This is the final chapter. Thus far, I have written about Japan as an example. However, when we shift to a global perspective on bioethics, what do we discover from this analysis? I hope to clarify this and the intent of this book once again at the end.

11.1 The UNESCO International Bioethics Committee

As a member of the International Bioethics Committee (IBC), I have had many opportunities to observe discussion at UNESCO meetings. Almost without exception, these situations tend to leave me feeling that advocacy for universal human rights was being presented superficially. UNESCO’s the Universal Declaration on Bioethics and Human Rights (2005) states the following:

Recognizing that ethical issues raised by the rapid advances in science and their technological applications should be examined with due respect to the dignity of the human person and universal respect for, and observance of, human rights and fundamental freedoms. (Author emphasis)

Meanwhile, the preamble to the UNESCO Constitution (1945) that serves as the premise of the Declaration states the following:

That the great and terrible war which has now ended was a war made possible by the denial of the democratic principles of the dignity, equality and mutual respect of men, and by the propagation, in their place, through ignorance and prejudice, of the doctrine of the inequality of men and races….

That the wide diffusion of culture, and the education of humanity for justice and liberty and peace are indispensable to the dignity of man and constitute a sacred duty which all the nations must fulfil in a spirit of mutual assistance and concern… (Author emphasis)

The use of Western expressions of human rights and justice at UNESCO conferences may not necessarily reflect the thinking of persons from African and Asian countries (at the very least, myself). While I value the activities of UNESCO, I do question the suitability of the methods and terminology used to achieve their goals.

I also question the future validity of this document. The Universal Declaration on Bioethics and Human Rights was created by a sub-organization of the UN, an organization created by countries representing the victors of World War II. To what extent is this declaration useful in the global development of bioethics? Is it truly capable of serving as a guideline?

The Preface of the Handbook of Global Bioethics (2014) states the following [1]:

Preface

A landmark in the early stage of global bioethics was the Universal Declaration of Bioethics and Human Rights, adopted by all member states of UNESCO (United Nations Educational Scientific and Cultural Organization), in 2005. This political and legal document presents the first general framework of ethical principles for global bioethics that covers all cultures and countries. It has been used as the major reference document for this Handbook. (Author emphasis)

A reading of the Preface signals some disquiet. Namely, the assumption that the Universal Declaration on Bioethics and Human rights should serve without question as a framework for “global bioethics.”

Let me describe an experience I had while attending a UNESCO IBC conference. Although I was an individual committee member, I was also representing Japan. I had to make a courtesy call to the Japanese embassy in Paris and had dinner with the ambassador and governmental officials, where the ambassador and I exchanged opinions on current bioethical topics. After the dinner, the Foreign Ministry officials said something to the effect of “Dr. Akabayashi, tomorrow’s conference topics have nothing to do with Japan, so you do not need to say anything, and if you do, you do not need to temper your words.” Most bioethics topics require a global perspective, and thus, even if the topic do not directly relate to Japan, input from a Japanese perspective is still required. I was disappointed by this official’s stance (i.e., “I’m not interested, because it’s not my problem”), but also came to question the mission of the UNESCO IBC conference.

11.2 International Health (Global Health)

I wrote a commentary on a paper published by a researcher and activist from Africa who condemned her country’s traditional practice of female genital mutilation (FGM) (Fig. 11.1) [2]. In my commentary, I mentioned that “it was time for (the author’s) governments to intervene, and to establish clear policies on this issue.” However, I also noted in my conclusion that before we criticize others, we must take a careful look at our own cultural practices.

Fig. 11.1
figure 1

FGM

Full size image

I have to confess that I am still not sure of the significance of discussing this issue as a researcher living in a different culture. What is the rationale for discussing these issues from outside? I agree with what Lane and Rubinstein stated in their previous discussion that:

the method for moving beyond the impasse between cultural relativism and moral universals requires the careful, honest, and respectful conduct of conversations within our own society and between and among groups with different cultural suppositions.

Some of the strongest critics to FGM are from so-called developed civilised countries. But how do such critics confront problems within their countries, such as serious issues in reproductive health/rights and child abuse? Before judging others, we should spend some more time understanding the flaws in our own culture.

As another example of a global health issue, I often bring up the case described below in my international health bioethics class [3]. After introducing the background facts, I usually set up small discussion groups.

Case 18: Health Care Access & the Poor

Mrs. E is a 16-year-old female who is 39 weeks pregnant and lives in a small, poor village with a population of 200, roughly 400 km away from the nearest city (20 h by car). She lives with her family—a 17-year-old sister, her 22-year-old husband, and his parents. One morning, Mrs. E is found on the floor having a seizure and is later brought to the village’s health center, which is run by Nurse P. Mrs. E’s blood pressure measures 205/135 and protein is detected in her urine. She is diagnosed with severe eclampsia. According to Nurse P, the likelihood of mortality for Mrs. E and her baby is extremely high if nothing is done within the next 48 h. However, the family have neither a car nor enough money to pay for a ride to the city to seek proper treatment.

What Each Person Has to Say

Mrs. E: I just want my baby to be saved; I don’t care if I die. Just save my baby.

Mr. E: Please save her and our baby. I’m willing to sell my kidney to save them.

Sister: I would even work in a brothel to make enough money to pay for their treatment.

Mr. E’s parents: This has happened many times in the past in our village; it’s sad but there is really nothing we can do about it.

Nurse P: I saw a similar case just last month. The girl ended up dying from severe sepsis during labor. It would be great to help Mrs. E and get her to the city for proper care.

Case Questions

  1. 1.

    Suppose you are a health care professional:

    What do you think Nurse P should do to help Mrs. E and her family?

  2. 2.

    Suppose you are a policymaker in your country:

    What policy would you propose to improve health care access in your country?

Photo 11.1
figure a

What to do, midwife Maude Callen?

Full size image

Given the inherent complexities of the case, my class often end without any concrete conclusions. When handling more clearly defined topics such as abortion, surrogate childbirth, or euthanasia, the class discussions are fairly lively. However, when discussing this case, many students seem to be unable to find words to resolve the issues. Nonetheless, this experience pushes students challenging them to think from the relevant perspectives. The same is required in our discussion of global issues, particularly for topics related to health care disparities or, more directly, to distributive justice.

When I was working with Services for the Health in Asian and African Regions (SHARE), I participated in a project undertaken by the Japan International Cooperation Agency (JICA) from Japan’s Ministry of Foreign Affairs. We conducted field research on medical care policies in three African nations and offered detailed suggestions to the respective governments regarding Official Development Assistance (ODA). This project provided many opportunities to interview top governmental officials from each African country. However, one conclusion I came to, not only during the interviews with these officials, but also in my conversations with ambassadors and employees at Japanese embassies, was that regardless of how much ODA support was offered to LMICs by Japan, this funding would end up in the pockets of the supported country’s government and intermediate organizations. Essentially, the funding was unlikely to reach the actual individuals in need.

When a professor from Thailand came to work in the Department of International Health Studies at the University of Tokyo, School of Medicine, I asked him: “Do you have any ideas about what would help support SHARE?” Without hesitation, this he responded, “Democratization!” I responded, “Would democracy be spread more readily by international health activity or ODA acts? What do you perceive as democracy? Do you see any limitations to democracy?” I received no reply from him.

Instead, this professor put a stop to the continuation of a US-Japan collaborative comparative research study on research ethics I (an assistant professor at the time) was conducting, refused to approve any opportunities for me to publish any papers, and our data from that study remains buried. Does democracy as defined by those from Thailand not allow for freedom of speech (which is allowed even by the Japanese Constitution)?

Having survived two World Wars and the Cold War, the mission of democracy no longer has any challenging force to keep it accountable. Meanwhile, the definition of democracy has become somewhat cloudy. As history reveals, many forms of democracy have existed, and include “democracy” as defined by the Thai people, Japanese, and many others. However, even the imprecise concept of “democracy” seems to be the current mainstream ideal. Given this reality, I believe that all we humans can do now is to see how far we can go with “revised” democracy. Democracy originated in ancient Greece and ancient Rome and boasts a long history of over 2000 years. If we intend to keep democracy alive by the year 3000, what can we do today to revise this ideology, and what does that even look like?

11.3 Van Rensselaer Potter, Inventor of Bioethics, his Acceptable Survival, and Anthropocentrism

In this chapter, I use the term “survival” frequently. I am drawing on of the concept of survival as coined by Van Rensselaer Potter, the Father of Bioethics. This also represents a return to the origin of bioethics. Potter [4,5,6] comments on five different forms of survival: “mere,” “miserable,” “idealistic,” “irresponsible,” and “acceptable.” For example, “mere” survival implies food, shelter, and reproductive maintenance, but no progress beyond a more or less steady state. It implies no libraries, no written history, no cities, and no agriculture for urban support—essentially a “hunting and gathering” society. Potter’s examples of this are the Inuit on the shores of the Arctic Ocean and the indigenous peoples of the Kalahari Desert in South Africa.

Potter proposes “acceptable survival” as the goal of global bioethics, defining it as “a long-term concept [1980] with a moral constraint: worldwide human dignity, human rights, human health, and a moral constraint on human fertility.”

In response to the query “(a)cceptable survival for whom and acceptable to whom?” he notes that acceptable survival for all the world’s people and acceptable to a universal sense of what is morally right and good and to what will realistically continue in the long term.

While Potter’s argument considers the survival of the entire planet, it only incorporates perspectives from a portion of the West. If “mere survival” is excluded, then what will happen to the Inuit and Kalahari indigenous peoples? As Potter himself indicates in the same article, anthropologists would state that “to be a hunter and gatherer wasn’t bad after all.” Therefore, this perspective must require our respect. If we refer to them as “all the world’s people,” then are we claiming that if humanity does not seek acceptable survival for Inuit and Kalahari indigenous peoples as well, then will the human race will not survive to the year 3000? [7]

What then does Potter think about anthropocentrism, a concept borne from environmental ethics? I raise this because traditional anthropocentrism results in human overpopulation and progressive extinction of other species. On this matter, Potter states [8]:

Neither were biocentrists, as Leopold might appear, nor anthropocentrists, as Otto might appear. Both are the ancestors and forerunners of real bioethics, although neither extrapolates to a consideration of organizational obligations in terms of what may now be called real bioethics: not biocentrism, not anthropocentrism, but a combination of both (p.181).

In other words, a confrontation between global bioethics and anthropocentrism is also needed. The warning about anthropocentrism is a necessary perspective for global survival, but if that call is issued, then can developed nations criticize the drilling of oil and deforestation needed for the economic development of LMICs? Can we criticize individuals in LMICs for having embraced anthropocentrism? As we continue in our failure to resolve issues such as global warming, should developed nations in the Western world actually be thinking about global survival?

In global bioethics discussions thus far, discussion on environmental ethics has been far from sufficient. Simply including some countries in Africa, Asia, and South America as authors in the Handbook of Global Bioethics does not guarantee that we will achieve a global perspective. After all, human rights, human dignity, justice, and biocentrism/anthropocentrism are all concepts derived from Western philosophy. If we never move even slightly away from this philosophical framework, then our thinking will never reach the neglected persons in LMICs. I am not advocating for the abandonment of the Western way of thinking, but I would welcome any new schemes yielding resolution of this issue, regardless of whether the developers are Western philosophers or not.

A new perspective in global bioethics is needed. Does global bioethics truly embody the conviction to do away with anthropocentrism? Can humankind actually construct a combination of both humanistic biocentrism and an enlightened nature-conscious anthropocentrism?

11.4 Universalism Versus Relativism

Universalism versus relativism is a long-standing debate in Western philosophy. However, in the 50 years in which global bioethics has evolved, the discussion has not moved forward in a meaningful way. In general, it appears that Western philosophers have agreed that the radical extremes (extreme universalism and extreme relativism) should be discarded, but that is all.

Moreover, several researchers have attempted to test the theory that revised universalism is akin to arguing for the lowest moral common denominator, adopting only that on which those from all cultures/religions/societies can agree [9,10,11]. Let us once again examine the contents of the Handbook of Global Bioethics [1].

In the debate on globalization of ethics, Kymlicka (2007) has suggested that global ethics is a two-level phenomenon: at one level there is a self-standing international human rights discourse defining a minimum set of standards agreeable to all. At a second level, there is a multiplicity of different ethical traditions. These “local” traditions define what is ethically required beyond and above human rights. The same discussion can be used for global bioethics. On the one hand, there is a set of minimum standard on which traditions and culture agree; this is expressed in international human rights language and elaborated into specific bioethics principles. On the other hand, there are many efforts to articulate more specific bioethics standards in the context of specific religious and cultural traditions. (p.13)

If I were a Western philosopher, I likely would have followed this path. However, we must ask, to what extent have any of these academic challenges contributed or could contribute at all to the development of global bioethics in a practical manner?

Widdow and colleagues state the following [12]:

However, to leave the paper here would leave unanswered, and more importantly unacknowledged, the questions of relativism and universalism that beset all areas of global ethics and indeed all areas of global study and practice. (p.110-111)

As a partial conclusion, they reject the through-going cultural relativist position and the exportation of Western individualistic values as if they were universal.

Nonetheless, this partial conclusion is nothing but a broken record, and their use of “beset” may even give the impression that Western authors are bound by an obsessive/compulsive curse. Thus I propose to Western philosophers that, “only when thinking about the philosophical foundation of global bioethics, they must set aside terms involving the opposition between universalism and relativism,” and work to construct a new framework of thinking. With regard to my question in the previous section (“Does global bioethics reject anthropocentrism?”), I believe that no matter how much we revise universalism and relativism, we cannot expect concepts worthy of serving as a philosophical foundation for global bioethics to emerge. While it is fine to propose a revised universalism that discards anthropocentrism, we must ask: will such scholarly effort/work lead to any concrete behavioral guidelines? The “combination of both, a humanistic biocentrism and an enlightened nature-conscious anthropocentrism” mentioned in a previous section offers the exact same composition. Of course, I am not proposing that we set aside the framework of universalism versus relativism for all academic arguments in Western philosophy. However, they may come to realize that they have been using this as a premise; this may allow them to rethink this notion. I would like to think that this would lead to the envisioning of the next development.

In recent years, anthropology has come to be known as an academic field that assumes the stance of relativism, for which a major premise is the respect of different cultural values and plurality. In the past the field has assumed such a stance while failing to promote any norms, but that trend started to change in recent years, so that anthropology which strongly promotes norms is more common. In sociology as well, some researchers advocate strongly for norms. Meanwhile, the fields of ethics and moral philosophy—supposedly the classic fields of normative ethics—have come to acknowledge the importance of descriptive ethics and empirical ethics in the last 20 years, while in the field of bioethics, empirical ethics has gained wide acceptance. From a descriptive narrative approach, methodologies capable of arriving at normative conclusions are being developed. What does this all mean?

In the context of global bioethics, the framework defined by the classic opposition between universalism and relativism, and that between biocentrism and anthropocentrism, has reached a point where no further progress can be made, while the boundaries between universalism and relativism, and between biocentrism and anthropocentrism, are becoming unclear. Thus I advocate for the search for a new approach that fits the context of global bioethics. I will likely spend the rest of my life elucidating the specifics of such an approach, but I also know that its establishment is unlikely in my lifetime. Let us set aside the opposition between universalism and relativism in order to create a new framework, for if arguments pertaining to global bioethics continue in the same direction, then we will be forever stuck in a dead-end conversation.

11.5 Bioethics Across the Globe (BAG)

In a lecture as transcribed below, Campbell (2008) emphasized the following [13]:

Perhaps, then, what we need to do is abandon the notion of “Asian Bioethics” as though this were some distinct and easily described entity. Instead we should discuss what might be important features of “Bioethics in Asia.” This would suggest that we are dealing with the same discipline, but that the Asian context can add new dimensions, raise new questions or help to shift perspectives.

In the previous section, I suggested that we set aside the terms involving the opposition between universalism and relativism, so that we can construct a new framework of thinking. I alluded to this in the Introduction, but I also have a radical proposal. Namely, that we discard the term “global bioethics.” This is not a proposal to set aside this term temporarily, with the potential for reuse later on, but rather to permanently reject it. As well, when using terms like “Asian Bioethics” and “African Bioethics,” the adjectives “Asian” and “African” also signal relativism. Following Campbell in his lecture, I also believe we should no longer use the term “Asian Bioethics,” as evidenced in my publication “Biomedical Ethics in Asia: A Casebook for Multicultural Learners,” where I have avoided using the term [3].

Therefore, I propose we use “Bioethics Across the Globe (BAG)” in place of “global bioethics.” While I feel that this term embodies a more universal tone, I also wonder if some would interpret the adjective “global” (which already has a universal nuance) to mean that BAG is no longer trying to achieve universalism.

At the very least, BAG is preferable to the current term, “global bioethics.” The time has come to discard the term “global bioethics,” which will forever imply the opposition between universalism and relativism.

11.6 What Can Japan Contribute to BAG?

When Japan ended its period of national isolation in the early Meiji era, it temporarily played down all Japanese culture in order to usher in values and perspectives from the West. The German philosopher, Karl Löwith, who taught philosophy and German literature at Tohoku University in Japan from 1936 to 1941, accurately portrayed the situation in Japanese philosophy as follows:

[Japanese people] are like those living in a two-story house, in which, on the first floor, they think and feel like Japanese, while in the second story all the various European scholarly texts, from Plato to Heidegger, are lined up, cover to cover. The European instructors question where the students are who go from one floor to the next. In actuality, they love themselves as they are. They have not yet eaten from the (proverbial Christian) tree of knowledge and have thus not yet lost their purity. They have yet to take the human out of themselves and have yet to taste the loss of human beings being critical of oneself. [14] (Der europaische Nihilismus, 1940).Footnote 1

This text demonstrates that the Japanese attempted to study and understand modern perspectives of the West but had not accepted them in their entirety. The behavior exhibited here was a survival strategy for participating with Western powers. It was a strategy that Japan was forced to take in order to survive and thrive.

After Japan surrendered in World War II, it recovered economically under the protection of the USA. As Japan is a country with a predominantly single ethnicity, it did not have the added complication of racial conflict and was able to throw itself fully into economic growth. Nonetheless, there were also many values that were lost because of such growth, resulting, for example, in workaholism, working environments that are harsh enough to cause death from overworking, and the loss of identity involved in being a Japanese citizen.

As Japan entered the 1980s, bioethics was imported from the West in the name of “Global Standards,” and Japanese scholars and practitioners themselves accepted these ways of thinking (e.g., self-determination) and societal systems (e.g., ethics review committees). This mirrored the experience from the Meiji era, just after national isolation had ended.

Having examined the ways in which Japan handled bioethics issues thus far, the reader may understand this strategy. Regardless of whether the issue involves brain-death and organ transplantation law, Japan’s perspectives on the moral status of the human embryo, or something else altogether, the survival strategy of the Japanese people has not changed throughout history.

What then might Japan contribute to the development of BAG? It is one thing to be honest and vulnerable, without shame, so that others can truly understand. This honesty alone will promote the beginning of true dialogue. This book was not intended to be a critical assessment of Japan. I have portrayed Japan exactly as I perceive it. Japanese people reading this book should not reject this aspect of their identity (of course, each is free to declare an opposing opinion). We all live on the same planet, in different cultures and with different perspectives and values. These differences may not always be affirmed positively, but there is no need to justify one’s own national stance; rather, we must begin by understanding these differences. This is how Japan “survives.” This stance is the prerequisite for beginning a dialogue about BAG. I could have written solely about the beautiful, harmonious, parts of Japan, but there are already numerous publications that describe these. Every country has positive and negative aspects. My hope is that this book serves as a tool to promote that understanding. If Japan can first and foremost fulfill this role of promoting understanding by not denying the content of this book, it would be a very small first step, but will definitely contribute to BAG.