Medical ethics in a multicultural society.

Abstract

Contemporary research and teaching in medical ethics is unduly influenced by the imagery of stability, order and uniformity. Many commentators presume the existence of a placid social order and pay little regard to differences in understandings of birth, illness, suffering, death and the nature of healing. Moral philosophers such as John Rawls and Norman Daniels, for example, argue that with the existence of an ‘overlapping consensus,’ morality is in a state of ‘side reflective equilibrium’1. Tom Beauchamp and James Childress, two of the earliest proponents of the ‘principlist’ approach to bioethics, take this view2, as do advocates of case-based moral reasoning (casuistry) such as Albert Jonsen and Stephen Toulmin3. Notwithstanding methodological differences in the manner these philosophers address practical ethical issues in medicine and healthcare, all of them presume the existence of a stable, settled moral order. ‘Society’ is discussed in monolithic terms, and both principlists and casuists pay remarkably little attention to the role of religion and culture or ethnicity in shaping understandings of such topics as abortion, physician-assisted suicide, prenatal genetic testing, stem-cell research or the withdrawal of treatment in end-of-life care. Relying upon philosphical approaches that presume the existence of shared principles and moral paradigms, contemporary ethicists commonly neglect to address important differences in the moral understandings of particular religious communities and ethnic groups4. The notion of ‘common morality’ tends to obfuscate the complex realities of providing medical care in multicultural, multifaith societies5. In pluralistic settings, different interpretive communities can exist, with distinctive understandings of what constitutes moral conduct, forms of evidence and reasoned arguments6. In short, commentators on the ethics of medicine and healthcare greatly over-simplify their task by presuming widespread social support for norms and practices that are in reality subject to vigorous dispute. Let us consider the position of a physician or nurse in London, New York, Sydney or Toronto, where patients come from diverse cultural and religious backgrounds. Some patients wish to receive detailed information about their diagnosis, prognosis, and treatment options. Other patients follow a different cultural script, expecting family members to make important health-related decisions and shield them from ‘bad news’. Some patients, fearful that they will become captive to sophisticated medical technologies, prepare advance directives refusing various possible medical interventions. Others, perhaps because of deep religious belief, want ‘everything done’, and insist on cardiopulmonary resuscitation even in circumstances deemed medically futile by healthcare providers. Some families seek to practise their religious traditions by asking physicians to circumcise their male children—an act that other groups see as child abuse and a violation of human rights. Members of some right-to-die organizations insist that compassionate healthcare providers and legislators would permit physician-assisted suicide, whereas members of many Jewish, Muslim and Christian religious communities declare that legalization of physician-assisted suicide would seriously devalue human life. To contribute usefully to contemporary debates, ethicists need to better address the multiethnic, multifaith character of contemporary social settings7. They need to recognize the existence of a plurality of ‘communities of interpretation’ and ‘local moral worlds’8.