SPECIAL ISSUE PAPER
IAB Presidential Address: Contextual, Social, Critical: How We Ought to Think About the Future of Bioethics
Address for correspondence: Prof. Angus Dawson, University of Birmingham, School of Health & Population Sciences, Birmingham B15 2TT, UK. Email: email@example.com
There are many things that could be said about the future of bioethics. I've previously argued in this journal that we ought to see bioethics as having at least two key characteristics.1 First, it should be thought of as a broad area of disciplinary enquiry, covering all ethical issues in medicine and the life science: hence the term, bio-ethics. For this reason, the focus of discussion in this journal and the discipline of bioethics ought to be not just on issues in medical ethics, but should cover a much broader set of ethical issues related to human, animal and environmental ethics, public health etc. Second, bioethics should be seen as, essentially, a critical discipline, one focused on articulating, analysing and questioning assumptions and evidence related to the ethical issues within this broad domain. I refer to this as the Socratic spirit of bioethics, and I argue that this is something that we should seek to preserve and enhance through a sceptical questioning. With this approach, bioethics can never be reduced to a set of particular principles, nor can it simply involve a commitment to a particular theory or method, nor does it make any sense to think of bioethics as involving the pursuit or creation of a single overarching text or declaration. In this article I begin to sketch out a vision of bioethics that is responsive to context, and is reflective, tolerant but robust.
More particularly, I want to explore a set of issues relating to just one aspect of the critical perspective that I wish to defend; namely, the appropriate balance to be struck between the philosophical and the sociological, the descriptive and the normative, the local and the universal. Such issues are not as often discussed in bioethics as I think they ought to be. Perhaps this lack of discussion of deeper, more theoretical issues reflects the nature of contemporary bioethics itself. Bioethics can be seen to be a largely fragmented area of activity, with all kinds of activities, positions and methods. One response might be to just accept this cacophony and to join and even celebrate the throng in the marketplace of ideas. However, such an approach seems to require a commitment to some form of relativism and, whilst this is one option, it needs to be argued for and not just assumed. I don't think it is a viable option, as I will argue below. However, what I'd like to do is stimulate debate and hope that the issues I raise here will be explored in more depth in the future. My key message is that we can treat other cultures with respect, but that this should not blind us to the potential dangers from inappropriate tolerance. Sometimes practices are wrong, and this is true in our own as well as other cultures. We should not be afraid to say so.
1. An Example: Sex Ratios in India
To ground our discussion and make sure that we are not lost in endless abstract thought, let's focus on an example. The data contained in the Provisional Population Totals from the Indian Census 2011 relating to sex ratios (number of females per 1000 males) are startling.2 For example, consider this selection of figures for the number of females relative to males from different states and union territories (UTs) in India:
- Kerala: 1084
- Maharashtra: 925
- Jammu & Kashmir: 883
- Daman & Diu: 618
Kerala's ratio is roughly where the figures would be if left to natural forces, as males are more prone to early death. Many other states and territories in India seem to demonstrate some degree of deviation from what is expected in terms of the biological norm. This requires explanation, with the most likely reason being that females are differentially aborted, neglected or even killed. Of course, this trend is something that has been noted before.3 Is this an issue for bioethics? On my broad definition of bioethics, it is, because it involves actions affecting human lives. Even on a narrower definition of bioethics, one focused on a correspondence between bioethics and medical ethics, it ought to be so too, given the evidence of the role of reproductive technologies and selective abortion in bringing about such differential sex ratios.
Whilst it is true that the overall sex ratio at the national level in India (940) has moved closer to what we might expect by seven points since the Census of 2001, and whilst the ratio has also narrowed in twenty-nine states and union territories, in three major states (Jammu and Kashmir, Bihar, and Gujarat) it has actually widened. There will always be reason to dispute empirical evidence, but let's assume that the data supplied by the census is at least roughly accurate. Indeed, there are no reasonable grounds for not accepting such data as evidence of the general picture in India.4 If we accept the data as accurate, we can then ask: what should we do, if anything, in response to such information?
2. Three Erroneous Approaches
In this section I will outline and discuss three possible responses to such data as that relating to sex ratios in India, and suggest why each of them is erroneous.
First, some writers might argue that sex selection can be justified through an appeal to the idea of reproductive liberty. Such an approach suggests that our choices about what children we have, and when, is just a straight application of a more general commitment to individual liberty or autonomous choice. On this view, there is nothing wrong in selecting the sex of a child (at least in relation to pre-birth choices).5 This is a nice theoretical argument, but we have to be aware of the possible dangers that may arise from taking such a philosophical approach. In essence, it seems to miss something; what we can refer to as the consequences that arise from the particular social context or the social reality of accepting such general arguments in different places. The argument is general and abstract, and this means that its application in different cultural contexts is ignored. For example, in a country where sex selection choices might be related to ‘family balancing’ consideration, where the consequences of choices may be an explicit commitment to a equality between the sexes, the implications could be very different from a choice made in a society where there are deep and widespread cultural preferences for children of one sex over another. Philosophical debate about sex selection is often conducted as if such cultural differences do not exist or do not matter. However, I suggest that the way that such arguments are understood or applied in different contexts is something that ought to be considered relevant to such debates, as the social context makes a difference to real human lives. In essence, such philosophical argument may result in the attempted justification of discrimination and inequality.
A second approach to such data might be to adopt and apply a pre-formed framework, such as a universal declaration or a human rights framework or some other general moral theory or perspective. However, this approach runs the risk of over-generalizing moral discussion by appealing to abstract and absolutist moral formulations. Why should we think that such a declaration would be against sex selection rather than in favour of reproductive liberty? The answer is, of course, that such documents tend to be the product of a limited group of representatives, often with a commitment to a generally conservative approach to bioethics, and, ironically, a reluctance to tackle some of the stark injustices in their own societies relating to social and gender inequalities. Indeed, such views are often reflected in such documents themselves, and so it is little surprise that they articulate a particular set of assumptions about ethics; namely a rather legalistic, rule-based approach, that will find it difficult to capture or respond to the particularities of culture. Such a view, despite being a frequent target of philosophical critique, actually shares much with the first approach.
Third, there is an equal but opposite danger, if we choose to move away from a general appeal to reproductive liberty or a universal declaration and focus instead on the description of a sociological practice, according it a normative significance just because it happens to be followed in a particular place or culture. Sociological approaches are not normatively neutral in the way that their advocates often seem to believe. Deciding to ‘merely’ describe and not ‘judge’ a cultural practice is a decision that encapsulates a normative commitment, and a pretty significant one, at that. On this approach, it will be argued that we ought to be neutral towards any such data and consider them to be due to cultural differences. In other words we can choose to note such findings as interesting facts, but they ought not be subject to critique as this is held to be inappropriate. Such a stance seems to involve a commitment to relativism of some kind. On this view, such practices are to be understood, but are not legitimately open to debate, not to be labelled as wrong, and presumably not to be the focus for change.
The starting point for thinking about moral relativism is often the observation of apparent moral disagreement or conflict (across space or time), where society A says ‘we should do x’ and society B says ‘we should do y’, where ‘x’ and ‘y’ are conflicting responses to the same (or similar) situations. However, relativism involves two more substantial claims, which are allegedly inferred from the factual claim that disagreement exists. They are that such a conflict cannot be resolved and that either view is equally morally valid. This makes clear that when moral relativism is invoked, it involves both descriptive and normative elements. The key claim is not that labelling moral claims as true and false is invalid, but that such determinations needs to be judged relative to the views of a group, culture or society etc. There are a number of potential objections to relativism, such as the fact that any disagreement might only be relatively superficial, as many apparent conflicts are not real and may in principle be resolvable. If there really is irresolvable conflict, why should it follow that either view is equally valid? Even if we choose to accept that what is true for society X is what is believed by the members of that society, why does it follow that we are forced to endorse the behaviour resulting from such a view as being true (even if it is only for them)?
I have suggested three ways not to think about the case of sex ratios in India; so, how should we do so? In the next section I will outline a general theoretical approach that attempts to offer a satisfactory approach to how we ought to think about these issues.
3. Context, the Socially Relevant and the Real
Despite the fact that we might have strong prior normative commitments, I want to argue that our starting point in bioethics ought to be to aim to understand all of the relevant features of the area of study, including the particular social context. For this reason, a focus on careful and close observation, and attempts at gaining understanding, is essential. This means that the use of empirical social scientific methods is fundamental to good ethics. We must acknowledge, when we contemplate such examples as the differences in sex ratios in India, that the situation is complex, that there are multiple areas of sensitivity, and that cross-cultural judgments in particular must be conducted carefully. As a result we ought to be what I will call epistemically modest: accepting that we can be in error, proposing interpretations and proposals cautiously, open to discussion and the need for revisions in our view. This is a call for a form of non-ideological pragmatism.
However, such an approach is not a mere endorsement of descriptive sociology, as I want to suggest that we need to affirm the importance, indeed the centrality, of the normative within bioethics. We should not be afraid to be critical of some practices once we have come to understand them. When something is wrong, we should say so, and we then ought to see such commitments reflecting in our actions and arguments about relevant policy. Of course, epistemic modesty also entails a kind of ethical modesty. Our moral judgments must also be open to reflection, discussion and the capacity for change. However, if it is the case that the best explanation for a difference in sex ratios is that girls (and women) are systematically undervalued, seen as being of lesser value than males, and that this is reflected in widespread cultural practice, resulting in action aimed at ending a girl's life whether through explicit choice or neglect, we ought to be unafraid to say that this is wrong, and seek to do something about it.
My own meta-ethical preference is for a form of moral realism, that entails that moral issues and questions have determinate answers and something about the world makes our judgments true (or false). However, just because there is an answer, theoretically, does not mean that we know it. There is no reason to think that realism need be dogmatic; as it can allow for the kind of epistemic and moral modesty just outlined, as well as being able to respond to the particularities of individual situations through a focus on the relevant issues and values, whilst retaining normative bite. The investigation and our developing understanding of a situation provides us with a range of relevant reasons to act or propose policies, and we will have to determine which of these reasons are most important. In the light of competing claims, it seems to me, that we are required to make a judgment about what is best, and the most sensible approach is surely one that is able to provide the best reasons for the proposed action and/or policy. Moral realism need not commit you to any suspicious metaphysical entities or faculties, and arguments are available to rebut the standard arguments against.6 Moral realism remains the most economical and plausible basis for anyone wanting to justify having a firm set of ethical and political commitments and wishes to seek to act to change the world.
When people contemplate moral realism they may be tempted to assume that appeal must be to general claims such as ‘always tell the truth’. It might be thought that such a proposition is something that we must always hold to be true. However, this is to mistake absolutism for moral realism. Some forms of moral realism might advocate moral absolutism, but it is not a necessary feature of this approach. My own preference is not to characterize moral claims in such general terms, but to focus on reasons. This still allows us to preserve realism about moral judgments, but avoid over-general claims. For example, there may be good reason in some circumstances not to tell the truth, even if we think it is generally something that we ought to do.
This approach takes us back to the critical aspect of bioethics I mentioned before. It is important that we look out for commitments to conventional thinking, such as priorities that we might tend to assign to particular facts, values or reasons. For example, in bioethics it is common to assume that individual choices should always prevail over other considerations, through an appeal to the value of respect for autonomy. Such an assumption may involve a hidden commitment to autonomy as being absolute in nature or as a presumptive value. It may also involve assumptions about the nature of individual agency and how individuals come together in social groups. Non-individual or social values, such as trust, solidarity, and community etc. may be less visible.7 Other common assumptions are that what happens to be the law in any particular jurisdiction, is what we ought to do. The law is obviously an important means of shaping behaviour, but the fact that something is legal, does not make it morally right. The other problem with the law is that it can be, and often is, ignored. India is a good example of this phenomenon as, arguably, there is no shortage of legislative provision protecting women, but there is a lack of compliance and enforcement.8
Clearly, arguing for moral realism is a controversial thesis, but I will seek to respond to various possible objections to such a view during the rest of this article.
4. Objections: Pluralism, Multiculturalism, and Tolerance
A possible objection to the kind of view I'm proposing here is to suggest that it does not allow for pluralism; where, presumably, pluralism is held to be a good thing.9 However, it is important to see that we might be pluralists in different ways. One common view, associated with the kind of relativism that descriptive sociologists often seem committed to, is judgment pluralism. This is the view that there can be a number of different legitimate judgments about what we ought to do in relation to the same situation. Such a view might be justified by appealing to the idea that different groups might have radically different approaches to morality, and that it is appropriate to judge situations, morally, from the perspective of such a group: such judgments are true ‘for that group’.
However, judgment pluralism can be contrasted with what we can value pluralism, which has nothing to do with relativism. A value pluralist holds that there is more that one value that is important when it comes to making our moral judgments. For example, someone might think that both justice and beneficence are important to morality. Value pluralism is a sensible position because the alternative, value monism, involves the difficult-to-defend claim that there is only one relevant value when it comes to making our moral judgments. It is hard to imagine such a view having any plausibility. For example, even libertarians who act as if liberty is the only relevant moral consideration don't really seem to mean it, as they often want to invoke other considerations at times (such as safety or respect for property rights etc.). The interesting debate ought to be not whether value pluralism is true, but what the relevant values that we ought to take into account should be. So, value pluralism does not imply judgment pluralism, but judgment pluralism requires relativism to be true.
It will therefore be apparent that I want to reject the use of the metaphor of using a different ‘lens’ to see the world. It falsely suggests that we can choose, for whatever reason (i.e. ideology, whim etc.), what kind of perspective we want to take upon reality. The metaphor invites us into the emporium of spectacles and suggests we choose those we happen to like the look of, rather than having spectacles fitted with the aim of correcting our defective vision, so that we are then able to see the world as it truly is. In reference to the case of sex ratios, this means seeing the world as one where historical and cultural factors, including entrenched discrimination against women, are part of the world we live in. A realist wants to claim that such sexism is part of our world, but a moral realist can also claim that this is something that we ought to change. A commitment to moral realism is a means to justifying a commitment to social justice, and hence a justification for seeking to change the world, not merely describing it.
Secondly, where does this debate about moral realism leave us in relation to multiculturalism? If we are committed to multiculturalism, does this mean that we cannot be moral realists? Well, again, it really depends what is meant by multiculturalism. If this is a claim that there are many ways of looking at the moral aspects of a situation (and this is somehow linked to cultures), and we are supposed to accept that each such view has equal value, then such a strong multiculturalism would seem to involve judgment pluralism in the form of a commitment to relativism. This will fall foul of the objections outlined above. If multiculturalism is, rather, used as a term to describe the fact that different cultures might have different values to contribute to our universal search for the best approach to thinking about ethical issues, or that in decisions about how to implement the same kinds of values we might allocate weightings to such values differently to take into account existing injustice or past wrongs etc., then this is not mutually exclusive with a commitment to moral realism (at least in relation to the reasons-based approach I have proposed above). This is because such a form of moral realism allows us to take such differences into account. The particularities of the cultural contexts are different, and therefore our judgments may well be different. This is not because we ought to be committed to relativism, but because the morally relevant considerations differ because the cultures differ.10 For example, a commitment to equity might involve unequal distributions between cultures in an attempt to equalize outcomes. So, depending upon how we understand it, either multiculturalism collapses into some form of relativism, in which case it is false, or it is compatible with moral realism, or indeed supportive of it.
A third objection to moral realism, and a possible argument in favour of judgment pluralism, relativism and strong multiculturalism might be the thought that one or more of them are necessary to ensure a justification for being tolerant of the views of others. However, a potential problem with this view is that it appears that each of these positions cannot justify the importance of tolerance beyond their own group. For example, if society A is intolerant and society B is not, can society B legitimately complain about society A? If someone is a consistent relativist, it looks as though such a complaint is illegitimate. This can lead us on to ask: is moral relativism actually a coherent position? Is the advocate of relativism not in fact forced into accepting at least one objective moral truth? If it is argued that any view expressed by a society is as valid as any other, this seems to imply or assume tolerance. However, why should all cultures be bound by the acceptance of tolerance, unless it is an objective moral truth? Here the realist has the advantage, in that she can claim that ‘tolerance ought to be respected’ is a moral truth.
5. Back to the Case
What happens if we do not agree on how we ought to think about a case? Such an outcome could be for a number of reasons. Perhaps you are not convinced by my description of the case, you don't ‘see’ it, perhaps because you understand the case differently. If so, our disagreement is epistemic, in which case we must argue about the evidence. Perhaps you see the case the same way, but you are not convinced that we ought to act on this basis? For example, perhaps you are convinced that men are superior to women. Then our disagreement is normative, and I have to convince you to change your (mistaken) moral beliefs. Perhaps, even if we agree about the case, you might still think of the implications of the case in a different way. For example, such data about sex ratios might motivate you to campaign against such practices or you might be indifferent. Such divergence is not evidence that can support relativism, as I argued before. At most it tells us something about your commitments as a person.
I chose my example of sex ratios in India not because I want to label everything that goes on in India as being morally wrong or because I want to suggest that it is the only place with problems: far from it. I chose it because it is a country in many ways different from the one where I was brought up, but it is also one I know something about. This example cannot just be dismissed as a case of a Western mindset attacking something that is Eastern. This can be seen in the fact that there are many people in India that have written pointing this problem out and are actively campaigning against such practices. For example, there have been a number of papers in the Indian Journal of Medical Ethics on this theme. It is also highly significant that there are regional differences across India, reflecting different beliefs and social practices within one country.
In fact, I believe that we can discover a lot from contact with other cultures and learning to understand them. It is not that I believe that everything is perfect in my own country, and worse elsewhere. We have much to teach each other. We cannot just say that everything is good in one place, and bad elsewhere. There are many things wrong with ethical issues in the UK, for example, in relation to health inequalities. Indeed, given recent changes to the healthcare system, they might actually be getting worse not better. There is plenty that the West can learn from other places in the world if we are willing to do so. To give just one example, recent debates about health promotion policies in the West are often bogged down in debates about the rights and wrong of paternalism. Should we intervene in enforcing the use of crash helmets for motorcyclists, or should we just inform people about the risks and then let them decide whether to wear one or not? However, there are other options. I was recently informed about a motorcycle helmet campaign by the city police in Bhubaneswar, the capital of Orissa, a state on the Eastern coast of India. This campaign involved no forceful advertising, detailed leaflets explaining risks, or hidden cameras or police officers enforcing the law. Rather, it involved the handing of single flowers to those on motorcycles without helmets.11 Such an intervention cannot easily be accused of paternalism, but the act of giving such a flower is redolent with meaning, and provides motorcyclists with the opportunity to pause, think about and reflect upon, their individual behaviour and a common social practice.
We should attempt to understand our own and other cultures, and working with social scientists to better understand out social world is the first step towards doing so. However, we should not just accept descriptive sociology as the method for bioethics. We should not be afraid to engage in critical dialogue and provide reasons for our moral judgments within our own or other cultures. Both abstract philosophy and descriptive sociology are inadequate as approaches to bioethics. Bioethics has to be normative, but discussion has to be grounded in the appropriate social reality. The International Association of Bioethics (IAB), as the leading global bioethics organization, is well placed to lead future discussion on how we ought to approach cultural differences in ethics. I have argued that even when it comes to cross-cultural dialogue we can and should have a contextual, social and critical bioethics.
This article is based upon my Presidential Address delivered on 29th June 2012 at the 10th World Congress of Bioethics, held in Rotterdam, Netherlands. I would like to thank the organizers of the Congress, particularly Inez de Beaufort, for all the work that went into producing such a lively, stimulating and productive Congress. Thanks also to Clancy Pegg, Angela Ballantyne and all the reviewers of the papers in this special issue of Bioethics for their help.
The Future of Bioethics: Three Dogmas and a Cup of Hemlock. Bioethics 2010; 24(5): 218–225 . .
Government of India. 2011. Census of India 2011: Provisional Population Totals, Paper 1. Delhi, India: Office of the Registrar General & Census Commissioner. Ch 5.
More than a 100 Million Women are Missing. New York Rev Books 1990; 37(20). .
There is a significant amount of other evidence of gender-based violence aimed at women in India, including harassment and rape. Discrimination is widespread in relation to access to education, health care and choices about relationships and reproduction. See, for example, Centre Statistics Office. 2012. Women and Men in India. Fourteenth Issue: 2012. Delhi, India: Government of India . I choose to focus on sex ratios, as this is indisputably a bioethics issue, but this should not be taken as a sign that I want to minimize the importance of these other issues.
I will ignore later choices, even though some will argue that the ‘just born’ have no relevant moral status either, and presumably can be killed/let die on grounds of being the ‘wrong’ sex.
I cannot of course discuss all the different arguments relating to moral realism here. For a detailed exploration and defence see: Moral Realism. In The Stanford Encyclopedia of Philosophy (summer 2011 edn). Edward N. Zalta , ed. URL = http://plato.stanford.edu/archives/sum2011/entries/moral-realism/ [Accessed 30 Apr 2013]. .
See op. cit. note 1, for more on this. ,
See Centre Statistics Office, op cit. note 4, for a summary of the extensive legislation covering this issue that already exists in India.
Although the advocates for pluralism need to take care here, if they are opposed to moral realism: how can they defend the idea that pluralism is a ‘good thing’ without invoking a realist claim?
For more on this, see In Defence of Moral Imperialism: Four Equal and Universal Prima Facie Duties. J Med Ethics 2006; 32(4): 200–204 . and .
Chandi Prasad Nanda (personal communication).
Angus Dawson is Professor of Public Health Ethics and Head of Medicine, Ethics, Society and History (MESH) at the University of Birmingham, UK. His main research interests are in public health ethics (particularly issues relating to vaccinations and so-called ‘lifestyle choices’ such as smoking, drinking and eating), professional obligations and the appropriate link between empirical evidence and normative issues. He is the current President of the International Association of Bioethics and joint-Editor-in-Chief of the journal Public Health Ethics.