Bioethics and multiculturalism

The scope of bioethics has considerably broadened during the relatively short history of its institutionalized development. In fact the meaning of the term “bioethics” – when it was coined by the German theologian Fritz Jahr in 1927 – expressed the moral imperative to harmonize biological research and applications with the respect for the different forms of life existing on the planet, and a similar idea was associated also with this same term when it was independently reintroduced by the American biochemist Van Rensselaer Potter in 1970. Nevertheless, during the first decades following 1970 the concrete concerns of the bioethical debates regarded the more restricted domains of medicine and biotechnology, while topics like animal rights or environmental ethics remained marginal (despite the fact that some important works advocating such rights were published precisely in those years). Today the situation is very different, and one can say that all forms of investigation and activity that can affect the sphere of life at large are considered as proper topic of bioethical debates. Yet this broadening is still limited in another sense: the new issues that are put on the bioethical agenda are ‘generated’ by advancements in medicine, life sciences and related new technologies, and have ‘repercussions’ on the social, legal and political sphere (for instance, regarding health policy). Less perceived is the inverse effect, that is, that new phenomena of social nature, that have immediate socio-political consequences, can also have important consequences of specific bioethical nature. We are going to analyze one such phenomenon, that is, migration.

When we speak of migration today we mean something different from the traditional fact that certain persons abandon their native place of residence and go “abroad” with the aim of finding a more suitable place to live for a variety of reasons, that could go from the search of a good job to the condition of being forced to go into exile for political reasons. This phenomenon has always existed in history and regarded single individuals or small groups of individuals, who were qualified as “emigrants” from their country of origin and “immigrants” in the new country of residence. When we speak of migration today we mean the displacement of entire populations that enter the borders of an already settled population and want to find in that territory their final destination. This phenomenon is not totally new, having occurred some times in human history, and has produced deep changes in it. The best known example is perhaps that of the so-called “Barbarian invasions” that eventually produced the end of the Western Roman Empire in the 5th century, an event that is usually indicated as the beginning of the Middle Ages. Such old migrations usually concerned nomadic populations that for centuries had been accustomed to make violent incursions, raids, plunders and then returned to their nomadic way of life, but in that final stage they became stable occupants of a part of the invaded territory and gradually mixed themselves with the original population. Today nomadic populations are almost inexistent and migration concerns people who are inhabitants of a given territory or even citizens of a given state and leave their country in order to settle in a different one.

This substantial novelty requires a pertinent study of the nature, the causes and the forms of contemporary migration which in the last decades has become, so to speak, more ‘spectacular’ due to its magnitude: hundreds and hundreds of people have come daily especially to certain European countries and their presence has produced a great amount of political, social, economic and diplomatic problems, tensions and debates that have impressed the public opinion. The U.S.A. too face a similar situation, due to the conspicuous flow of migrants coming from Central America who constantly try to cross their southern border. The core of these debates can be schematized as follows. (A) It belongs to the international norms accepted by almost all the Western countries that they have the obligation to receive refugees who are fleeing war or political persecution (they have the “asylum right”); (B) a norm of the international law states that ships have the obligation to rescue people at sea whose lives are in danger for whatever reason. The straight forward application of these norms has produced a considerable accumulation of migrants in certain countries and posed serious problems of economic, social and political nature deriving from the legitimate rights of the people of the host countries. It lies out of the limits of the present paper to analyze these issues. We want only to focus on certain specific bioethical issues that are directly connected with the massive presence of migrants in a country.

Two issues are of purely medical nature. The first consists in the fact that in the country receiving the migrants the number of people for which health care must be provided increases notably and can easily overstep the available facilities, also independently of the fact that the migrants can hardly contribute to the sustainment of the health care system. The second is related with the fact that migrants are often divided in large ethnic groups possibly sharing a congenital immunity with respect to a certain disease of which they can be healthy carrier and which could produce an epidemic in the country of arrival (or the other way around if they are not immune with respect to a disease against which are protected the people of the host country).¹ The complexity of these two problems is obvious, and their solution requires agreements and commitments at the international level that are still far from being even imagined.

An important element is still missing in the characterization of contemporary migrations outlined above, namely the fact that big groups of migrants belonging to a single ethnic population have a certain cultural identity constituted by a variety of customs, moral rules, family structure, social conventions, religious believes, general conceptions concerning the natural environment, the nature of humans, the status of men and women, the nature and structure of society, the sense of life, the authority of tradition and so on. These groups are not only culturally different from the culture of the country where they arrive, but also from that of other migrant groups and this fact easily produces a ‘clash of cultures’ whose depth and effects are unpredictable and vary from country to country depending on several factors. There are countries that, for historical reasons, have already a certain experience of ‘multiethnic’ composition and have tried to cope with it according to different ‘models’, whereas for other countries this situation is new and, therefore, more difficult to manage, because it has direct impact on concrete actions and conducts that inevitably emerge also on the public stage. This situation is a direct challenge for applied ethics because it amounts to the difficult task of finding a path for safeguarding the space for an ethical judgment and guidance for concrete ways of action in societies where exists a plurality of ethical conceptions, instead of giving up such a search in the name of an accepted relativism. Therefore, by underscoring the cultural dimension of migration we make explicit the special approach needed today also in bioethics. This special approach consists in appreciating the merits and limits of that methodological procedure that relies upon a comparison of allegedly neutral “rational arguments”. The simplest example is given by the acquisition of the informed consent of a patient to accept or refuse a certain treatment. The acquisition of this consent is considered a moral obligation deriving from the respect for the patient's autonomy, understood as the duty of respecting his/her freedom of decision. This obligation is considered obvious “in itself” today, but actually corresponds to a rather recent cultural evolution of Western societies and is advocated as the contrary of the “paternalist” view of the tradition, according to which the doctor had the right (and the duty) of taking the best decision in the name of the objective interest of the patient. The adjective “paternalist” has an ironic and derogatory flavor, whereas its etymological meaning refers to that “normal care of the good father of family” that is often mentioned in the Civil Code of several modern states, and reflects the notion of an authority based on competence, benevolence and mutual confidence. It is certainly not desirable that such values disappear from the medical practice and without them the informed consent would reduce to an instrument through which the doctor or the hospital protect themselves against possible future legal claims by the patient. It is good that the paternalist attitude be tempered by the respect for the patient's autonomy, but no less important is that the human dimensions of the doctor-patient relation be kept alive in the modern high-tech medicine. The way of conceiving medicine in other cultural contexts could be of help in this effort.

Coming closer to the notion of informed consent, we can consider it as the refinement of the vague notion of free choice. We qualify it as vague because it puts the accent on the absence of external constraints, pressures or impositions, but these minimal conditions apply also to behaviors that are simply spontaneous or even at random, whereas the notion of choice implies the presence of deliberation, the exercise of what we call “rationality” which can be seen as the capability of understanding and proposing sound arguments. Yet rationality is only a part of a more general condition that we can call competence and consists, first, in the capability of correctly understanding the issues implied in the free choice. This understanding is preliminary to the rational comparison of different courses of action and constitutes the framework within which they are considered. In the notion of informed consent, the adjective “informed” underlines the condition of adequate understanding that must be attained by the patient in order he/she to become competent for taking the decision, the subsequent step being his/her having a “normal” capability of reasoning. Precisely this understanding is sensitive to cultural differences, because what a doctor can offer as “information” regarding a certain treatment is the description, in physical and psychological terms, of the patient's conditions during the treatment and as a probable consequence of the treatment, but this information will always receive an interpretation by the patient consisting in a display of value judgments leading to different preferences, among which the work of rational comparison will end up with the final choice. The reasoning in which this comparison consists has little to do with a logical deduction of the kind used in scientific explanations and predictions, and essentially consists in the application of a certain hierarchy of values which is again very sensitive to cultural differences. As a consequence, a certain choice can be considered irrational from the point of view of a given culture while being rational from the point of view of another culture.

The awareness of this circumstance shows how naïve is the proposal to “overcome” cultural differences in bioethical discussion by excluding from it any religious or cultural consideration, in order to keep faithful to the objective ascertainment of facts and applying rigorous logical arguments. For example, the cutting of the hand of a thief can be “seen as” a right punishment required by justice by an orthodox Muslim strictly adhering to the “Sharia while being seen as” an act of unacceptable cruelty by a normal citizen of a Western country. Or blood transfusions are rejected as religiously forbidden by Jehovah's Witnesses and considered as a precious medical practice by people not belonging to this religious confession. It would be easy to continue with examples, but it is not necessary, because the same situation of profound discrepancy exists also within a single culture: for example, in the West there are scholars who maintain that a fetus of a couple of weeks is not yet a human person and others who affirm that it is, and these different interpretations of the ontological status of the fetus have consequences on the ethical issue of the legitimacy of abortion.

The spirit with which we ought to consider the multicultural situation toward which our present and future societies are historically projected is not relativism, that ultimately amounts to the denial of ethical duties, but rather the effort of understanding and dialogue. Indeed, reflecting on the fact that all cultures have moral codes and imperatives – though sometimes very different, – far from weakening the sense of morality should reinforce it, showing that this is a fundamental dimension of the human being and should encourage us to be open and try to understand what we could appreciate and share in other moral traditions. This could lead in the long run to the emerging of some convergence, but this is not absolutely necessary. Really important is the attitude of tolerance that simply means the respect for other persons and their ideas and choices. Therefore, the fundamental moral obligation in this perspective is that no one should be obliged to act against his/her own conscience.