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What are the Limits of Bioethics in a Culturally Pluralistic Society?

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Kerry Bowman discusses the evolution and central tenents of modern bioethics within its broader context.

Image courtesy of interviewee. March 21, 2024

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This video video discusses the complexities and challenges facing the field of bioethics, particularly in the context of increasingly pluralistic societies where diverse cultural perspectives intersect with Western ideals of autonomy and individualism. The speaker highlights that bioethics has traditionally emerged from Western philosophical thought, emphasizing principles such as autonomy, beneficence, non-maleficence, and justice. However, the focus on individual rights can be limiting, especially in non-Western cultures where collective values might be more significant.

This video video further elaborates on how these cultural differences impact ethical decision-making in healthcare. It addresses the limitations of autonomy, particularly illustrated during the COVID-19 pandemic when societal pressure and vaccination policies conflicted with individual choices. The speaker criticizes the oversimplification of cultural diversity, arguing against the assumption that increasing diversity within medical institutions automatically resolves underlying cultural tensions.

Ultimately, the speaker advocates for a deeper understanding of cultural influences and complexities within bioethics, suggesting that a broader and more nuanced perspective is needed to navigate the ethical dilemmas presented by emerging technologies and healthcare practices. The discussion calls for a more rigorous examination of cultural beliefs and values, recognizing that ethical considerations must account for varying interpretations across different communities.

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There really are many limits in a lot of ways.

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Um, you know, one of the central features of bioethics is,

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is the concept of autonomy, meaning the rights

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and choices of the individual person.

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And you know, the challenge with that

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as western societies become more

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and more pluralistic is,

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is many people are coming from non-Western cultures.

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And within those non-Western cultures, the concept

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of the individual,

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may not be the most dominant, element.

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It may be far more about the collective

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and moral reasoning may come much more from interdependence

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than independence.

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You know, I would say mostly, you know,

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we have adapted to that.

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Uh, it's not always perfect,

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but that's one of the big limitations is, is bioethics,

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is is really emerging from western cultures,

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particularly in North America

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to a somewhat lesser extent in Western Europe.

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Um, it is very much focused on the concept of the individual

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and autonomy, and, and that does present challenges.

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There's no question about that.

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Modern bioethics exists really from, you know,

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western philosophical thought, and,

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and it's very, very influenced by the concept of principal.

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That would be autonomy, that would be beneficence,

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non maleficence and justice.

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Uh, there's other ethical, you know, elements

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and reasons as well,

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but, that is what it is coming from.

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And, you know, why do we have bioethics in western

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societies generally?

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There's many reasons, but,

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but, you know, western societies are increasingly

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and very often secular by constitution.

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And, and so, you know,

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western societies are no longer simply a, a Christian

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or Judeo-Christian heritage.

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Um, there's multi, multi, ways of thinking about things.

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There's diverse political views and bioethics.

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Remember, ethics is an analysis.

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It's not, you know, this is right and wrong.

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Ethics is an active inquiry as to

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what would make something the best choice,

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what would make something the best course of action.

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That's what ethics is. So it morally pluralistic societies.

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Um, it, it is something that's increasingly used.

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But, you know, I do go back to my original statement

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that it's focus on autonomy

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and the individual can be somewhat

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limiting, within that.

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But, but bioethics is really a, a way of looking at

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what are the tough ethical questions.

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And as the 21st century moves along,

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it's getting tougher and tougher.

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And, one of the real challenges

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with emerging biotechnology,

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and I speak now of things like artificial intelligence

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and, genome mapping and genetic engineering

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and these types of things, is, you know, so often

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with bioethics, we would look

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At what are the risks and what are the benefits?

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And in the 20th century, that was challenging enough.

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But, in, in 21st century emerging technologies to say,

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you know, with something like emerging artificial

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intelligence, what are the risks?

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What are the benefits? This is very, very hard to quantify.

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And, and within what timeframe, we don't know,

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with genetic engineering benefits seem to be substantial.

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Risks are not really understood very well.

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So these are some of the great challenges

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of bioethics in western culture.

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I think it remains. So what it is, is exactly that.

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So principle is what we must keep in mind is it's,

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it's not one principle.

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It it, it's kind of got four moving parts.

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And those moving parts are exactly the autonomy,

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the rights choices,

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and freedom of the individual, to,

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to make an informed decision.

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Onus is on the healthcare worker to make sure

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that the person is informed.

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Beneficence needs to be of benefit.

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Maleficence means to do no harm.

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And justice is often looking at the larger picture.

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Is it fair to larger numbers of people?

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It really emerged in the United States as, you know,

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in the late 20th century as a model for looking at many

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of the ethical dilemmas within hospitals.

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I'm gonna speak honestly here.

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I I'm a person that's been working in hospitals for decades

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as a bioethicist.

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I'm also a professor of bioethics.

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I don't find principal, I find it useful to

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sort of parse and examine the different aspects

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of a dilemma, but I don't find it unbelievably helpful

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in, in really directing,

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a way forward in many, many cases.

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Um, you know, one

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of the real tensions in bioethics is not just

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what ought we do, but who ought decide.

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Uh, you know, if if there's someone on life support,

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they're not recovering, you know,

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they're not showing any significant signs of recovering,

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the family is saying, do everything.

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The medical team are saying, you know,

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that this is not a good investment.

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This is futile treatment.

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You know, the real tension there is not just

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what ought we do, but whose decision should that be?

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And, you know, that will play out differently depending on

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different countries in, in, you know, Canada, which is

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where I am in the United States, it likely will be

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in the US it would depend on, on, on the funding,

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source funding,

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but it would likely be what the fa when I say family,

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I'm assuming we have a patient

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that can't participate in these decisions.

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It would likely be what the family would want us

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to do in other countries.

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And often, perhaps even in Britain, it would be a model

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of best interest, you know, what's in the best interest

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of the patient, which would often actually be defined

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by doctors, but we wouldn't do that.

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So what you're seeing is actual cultural differences in the

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interpretation of bioethical

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Principles.

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Um, so our greatest weight in North America would really,

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really be in on autonomy

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and in other places, you know, throughout western society

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and non-Western society.

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Um, you know, when it got into things like what's a benefit,

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what's harm, you know, if those things are defined

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by a family, it's gonna be very different than if they're

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defined by physicians.

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So this is, again, is one of the challenges of bioethics.

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And, one of the ways it works,

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there's other competing bioethical theories.

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There's u utilitarianism and deontology

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and vir ethics, ethics, you know, they're all tools.

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They're all tools. I personally, as a practicing bioethicist

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working in hospitals, don't find any of them.

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Um, if there's any single theory that I, I really lean into

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to give me answers, I, I think that what happens

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with complex problems is you need to look at them from

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as many angles as possible.

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And what bioethical theories do is, is, is it provides

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a lens, and you can change that lens depending on the theory

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to hopefully deepen and forward your thinking.

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What you see with cultural pluralism is, is,

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is a term I'm gonna introduce here,

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and maybe some people listening know it already an

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explanatory model of illness, simply meaning

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what do people believe has caused their illness?

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How best should it be treated?

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What's the significance of it?

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Um, and what you see with different cultures is that the,

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you know, this is defined differently by different people as

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to what the cause and the treatment of an illness should be.

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So, so this is very, very tough

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because what, what we,

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we were always going on the assumption and,

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and too often in bioethics that the patients in front

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of us have a completely western view of, of,

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of medicine that they believe

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that medicine is completely a biological process.

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Um, you know, it's, it's, it's not highly symbolic.

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It's, it's not treated in alternative ways.

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And, and that's often not the case.

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And that's one of the areas where,

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where bioethics can be limiting.

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But again, it depends on the bioethicist.

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I mean, you know, bioethics can also be the first ones

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to say that there's deep cultural, you know,

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influences going on here,

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and that the perceptions

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of illness is very much culturally constructed

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and draw the attention of the broader team to these things.

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So, so that is, is, is definitely one of the things that,

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that, that we see.

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But, you know, speaking of alternative, you know, I,

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I'm gonna bring up the pandemic, which is, you know,

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technically not over,

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but hopefully we're through the worst of it.

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And when I say the pandemic, I of course, I

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of course mean the COVID-19 pandemic.

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And here's a real limitation of bioethics,

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because bioethics will say the rights

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and freedom of the individual.

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People can decide for themselves, you know,

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let them be informed and let them make their decisions

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All over the world.

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What was happening is when the vaccines were introduced,

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the vaccines I I speak of now, you know, in for,

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for COVID-19, there was a subset of people that said,

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you know what, I'm not interested.

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I, I think the research is too fast.

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I, I don't believe what I've been told and I don't want it.

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And really what they got was an awful lot

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of very aggressive push.

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I, I'm pro-vaccine, let me be very clear here,

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but I'm just trying to analyze this situation.

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What they got was a lot of pushback from society in terms

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of, you know, vaccine passports

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and people that were denied access to their,

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to their place of employment.

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And, you know, some people lost their jobs and,

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and those types of things.

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So autonomy really didn't work well for us at all.

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Um, and,

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and so what we really learned

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during the pandemic is autonomy really

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has some serious limits.

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Uh, my observation is we all love autonomy.

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As long as patients are doing what we think they should do,

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we don't love it so much when they come up with something

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that we don't think is a good idea.

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Um, and so that's always the great limitation with it.

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Now, you know, resistance to vaccines, how much of

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that was culturally influenced?

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A little, not much. I mean, most of the people

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that were really against vaccination,

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there wasn't complex cultural factors.

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They simply did not trust a government.

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And in, you know, in, in my country, Canada,

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we had some real pushback.

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We had some very strong political movements

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against vaccination.

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And I would argue it, it's led to a level of,

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of political polarization

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that we're still still dealing with today.

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So, you know, I'm, I'm being kind of harshly critical

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of bioethics because the mandate of bioethics is

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so incredibly difficult, that it's very, very hard

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to find models that are always gonna work in

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complex problems.

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The conclusions and the implications from the work is for

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bioethics to work well.

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Bioethics needs a much, much deeper,

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perspective on culture.

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And what has really happened in recent years

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with cultural awareness is that cultural awareness.

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You know, we, what, we tend to think that

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because our medical, I, I'm speaking

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of western culture in general,

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because our medical schools are now more,

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more culturally diverse than they used to be,

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because our physicians are male, female is is far better.

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Uh, there's greater cultural and,

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and racial diversity that we've kind of dealt

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with a cultural problem.

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I would say we have not.

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Um, because we all have culture

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and no matter what cultural background someone is from,

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we all have cross-cultural blind spots.

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And that is one of the problems.

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So one of the problems I see is,

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and I'm not against diversity, inclusion, equity, I, I,

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I think those are, are, are important principles

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To live by, but we have had this belief

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that following diversity and inclusion

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and equity is going to solve cross-cultural problems.

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It doesn't, it, it,

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it's very important in a democratic society to be inclusive.

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And I respect that. But, you know,

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culture is not in the conscious mind,

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and that's where we really fall down.

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And so, you know, people will say, I don't have a problem

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with other people's cultures.

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I don't have a problem with my own culture.

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I don't, but you know, we're not fully conscious of

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what culture is.

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And I would argue in the last 10 to 15 years, there's less

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and less focus on a deeper analysis, almost anthropological

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of what's going on with cross-cultural differences

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because we're far more focused on, on political inclusion.

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And I think the inclusion is a good thing,

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but we have to think about what is, what is it that we need

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to include and, and how does it work?

Limits of Autonomy in Bioethics

00:00:00 - There really are many limits in a lot of ways. you know, one of the central features of bioethics is, is the concept of autonomy, meaning the rights and choices of the individual person. And you know, the challenge with that as western societies become more and more pluralistic is, is many people are coming from non-Western cultures. And within those non-Western cultures, the concept of the individual, may not be the most dominant, element.
00:00:33 - and moral reasoning may come much more from interdependence than independence. You know, I would say mostly, you know, we have adapted to that. it's not always perfect, but that's one of the big limitations is, is bioethics, is is really emerging from western cultures, particularly in North America to a somewhat lesser extent in Western Europe. it is very much focused on the concept of the individual
00:01:05 - There's no question about that. Modern bioethics exists really from, you know, western philosophical thought, and, and it's very, very influenced by the concept of principal. That would be autonomy, that would be beneficence, non maleficence and justice. there's other ethical, you know, elements and reasons as well, but, that is what it is coming from. And, you know, why do we have bioethics in western
00:01:36 - There's many reasons, but, but, you know, western societies are increasingly and very often secular by constitution. And, and so, you know, western societies are no longer simply a, a Christian or Judeo-Christian heritage. there's multi, multi, ways of thinking about things. There's diverse political views and bioethics. Remember, ethics is an analysis. It's not, you know, this is right and wrong. Ethics is an active inquiry as to
00:02:09 - what would make something the best course of action. That's what ethics is. So it morally pluralistic societies. it, it is something that's increasingly used. But, you know, I do go back to my original statement that it's focus on autonomy and the individual can be somewhat limiting, within that. But, but bioethics is really a, a way of looking at what are the tough ethical questions. And as the 21st century moves along,
00:02:41 - And, one of the real challenges with emerging biotechnology, and I speak now of things like artificial intelligence and, genome mapping and genetic engineering and these types of things, is, you know, so often with bioethics, we would look At what are the risks and what are the benefits? And in the 20th century, that was challenging enough. But, in, in 21st century emerging technologies to say,

Challenges in Modern Bioethics and Autonomy

00:03:14 - intelligence, what are the risks? What are the benefits? This is very, very hard to quantify. And, and within what timeframe, we don't know, with genetic engineering benefits seem to be substantial. Risks are not really understood very well. So these are some of the great challenges of bioethics in western culture. I think it remains. So what it is, is exactly that. So principle is what we must keep in mind is it's, it's not one principle.
00:03:44 - And those moving parts are exactly the autonomy, the rights choices, and freedom of the individual, to, to make an informed decision. Onus is on the healthcare worker to make sure that the person is informed. Beneficence needs to be of benefit. Maleficence means to do no harm. And justice is often looking at the larger picture. Is it fair to larger numbers of people? It really emerged in the United States as, you know, in the late 20th century as a model for looking at many
00:04:19 - I'm gonna speak honestly here. I I'm a person that's been working in hospitals for decades as a bioethicist. I'm also a professor of bioethics. I don't find principal, I find it useful to sort of parse and examine the different aspects of a dilemma, but I don't find it unbelievably helpful in, in really directing, a way forward in many, many cases. you know, one
00:04:50 - what ought we do, but who ought decide. you know, if if there's someone on life support, they're not recovering, you know, they're not showing any significant signs of recovering, the family is saying, do everything. The medical team are saying, you know, that this is not a good investment. This is futile treatment. You know, the real tension there is not just what ought we do, but whose decision should that be? And, you know, that will play out differently depending on
00:05:20 - where I am in the United States, it likely will be in the US it would depend on, on, on the funding, source funding, but it would likely be what the fa when I say family, I'm assuming we have a patient that can't participate in these decisions. It would likely be what the family would want us to do in other countries. And often, perhaps even in Britain, it would be a model of best interest, you know, what's in the best interest of the patient, which would often actually be defined
00:05:51 - So what you're seeing is actual cultural differences in the interpretation of bioethical Principles. so our greatest weight in North America would really, really be in on autonomy and in other places, you know, throughout western society and non-Western society. you know, when it got into things like what's a benefit, what's harm, you know, if those things are defined by a family, it's gonna be very different than if they're

Challenges in Bioethics and Cultural Perspectives

00:06:21 - So this is, again, is one of the challenges of bioethics. And, one of the ways it works, there's other competing bioethical theories. There's u utilitarianism and deontology and vir ethics, ethics, you know, they're all tools. They're all tools. I personally, as a practicing bioethicist working in hospitals, don't find any of them. if there's any single theory that I, I really lean into to give me answers, I, I think that what happens
00:06:53 - as many angles as possible. And what bioethical theories do is, is, is it provides a lens, and you can change that lens depending on the theory to hopefully deepen and forward your thinking. What you see with cultural pluralism is, is, is a term I'm gonna introduce here, and maybe some people listening know it already an explanatory model of illness, simply meaning what do people believe has caused their illness? How best should it be treated? What's the significance of it?
00:07:25 - you know, this is defined differently by different people as to what the cause and the treatment of an illness should be. So, so this is very, very tough because what, what we, we were always going on the assumption and, and too often in bioethics that the patients in front of us have a completely western view of, of, of medicine that they believe that medicine is completely a biological process. you know, it's, it's, it's not highly symbolic.
00:07:56 - And, and that's often not the case. And that's one of the areas where, where bioethics can be limiting. But again, it depends on the bioethicist. I mean, you know, bioethics can also be the first ones to say that there's deep cultural, you know, influences going on here, and that the perceptions of illness is very much culturally constructed and draw the attention of the broader team to these things. So, so that is, is, is definitely one of the things that,
00:08:26 - But, you know, speaking of alternative, you know, I, I'm gonna bring up the pandemic, which is, you know, technically not over, but hopefully we're through the worst of it. And when I say the pandemic, I of course, I of course mean the COVID-19 pandemic. And here's a real limitation of bioethics, because bioethics will say the rights and freedom of the individual. People can decide for themselves, you know, let them be informed and let them make their decisions
00:08:55 - What was happening is when the vaccines were introduced, the vaccines I I speak of now, you know, in for, for COVID-19, there was a subset of people that said, you know what, I'm not interested. I, I think the research is too fast. I, I don't believe what I've been told and I don't want it. And really what they got was an awful lot of very aggressive push. I, I'm pro-vaccine, let me be very clear here, but I'm just trying to analyze this situation.

Limits of Autonomy in Pandemic Responses

00:09:29 - of, you know, vaccine passports and people that were denied access to their, to their place of employment. And, you know, some people lost their jobs and, and those types of things. So autonomy really didn't work well for us at all. and, and so what we really learned during the pandemic is autonomy really has some serious limits. my observation is we all love autonomy. As long as patients are doing what we think they should do,
00:10:01 - that we don't think is a good idea. and so that's always the great limitation with it. Now, you know, resistance to vaccines, how much of that was culturally influenced? A little, not much. I mean, most of the people that were really against vaccination, there wasn't complex cultural factors. They simply did not trust a government. And in, you know, in, in my country, Canada, we had some real pushback. We had some very strong political movements
00:10:31 - And I would argue it, it's led to a level of, of political polarization that we're still still dealing with today. So, you know, I'm, I'm being kind of harshly critical of bioethics because the mandate of bioethics is so incredibly difficult, that it's very, very hard to find models that are always gonna work in complex problems. The conclusions and the implications from the work is for bioethics to work well. Bioethics needs a much, much deeper,
00:11:03 - And what has really happened in recent years with cultural awareness is that cultural awareness. You know, we, what, we tend to think that because our medical, I, I'm speaking of western culture in general, because our medical schools are now more, more culturally diverse than they used to be, because our physicians are male, female is is far better. there's greater cultural and, and racial diversity that we've kind of dealt with a cultural problem.
00:11:34 - because we all have culture and no matter what cultural background someone is from, we all have cross-cultural blind spots. And that is one of the problems. So one of the problems I see is, and I'm not against diversity, inclusion, equity, I, I, I think those are, are, are important principles To live by, but we have had this belief that following diversity and inclusion and equity is going to solve cross-cultural problems. It doesn't, it, it,
00:12:07 - And I respect that. But, you know, culture is not in the conscious mind, and that's where we really fall down. And so, you know, people will say, I don't have a problem with other people's cultures. I don't have a problem with my own culture. I don't, but you know, we're not fully conscious of what culture is. And I would argue in the last 10 to 15 years, there's less and less focus on a deeper analysis, almost anthropological of what's going on with cross-cultural differences

Rethinking Inclusion: What and How?

00:12:45 - And I think the inclusion is a good thing, but we have to think about what is, what is it that we need to include and, and how does it work?

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