IAB PRESIDENTIAL ADDRESS: BIOETHICS IN A GLOBALIZED WORLD – CREATING SPACE FOR FLOURISHING HUMAN RELATIONSHIPS
Conflict of interest statement: No conflicts declared
Prof. Nikola Biller-Andorno, University of Zurich, Institute of Biomedical Ethics, Zollikerstr. 115, Zurich 8008, Switzerland. E-mail: email@example.com
Bioethics in a globalized world is meeting a number of challenges – fundamentalism in its different forms, and a focus on economic growth neglecting issues such as equity and sustainability, being prominent among them. How well are we as bioethicists equipped to make meaningful contributions in these times? The paper identifies a number of restraints and proceeds to probe potential resources such as the capability approach, care ethics, cosmopolitanism, and pragmatism. These elements serve to outline a perspective that focuses on the preconditions for flourishing human relationships as a way to address bioethical challenges in a globalized world.
As this paper will focus on relationships, I will start with a few introductory words about my own relationship to the International Association of Bioethics.
As a young medical student with an urge to reflect more profoundly on what was taught in medical school, I found a wonderful home at the Bioethics World Congresses. Not only were the programs packed with issues that were topical and exciting; there were also the stars in the field from all over the world, being surprisingly accessible to a young scholar's questions and thoughts; and there were the wonderful women of the Feminist Approaches to Bioethics, who eloquently and poignantly articulated what I had just vaguely felt to be somehow inappropriate.
The conference venues seemed to hum like a beehives with voices of ethicists from different regions, with diverse opinions and interests; all together under one roof committed to discussing issues they truly cared about. I was deeply impressed by the energy and inspiration emerging from these settings.
Looking back I think what so impressed me then was the existence of a community, of people I could relate to. In the early 1990s, such a vibrant community did not exist in Germany, my native country, where bioethics was still a fledgling field.
When I started to have a dual role as a bioethicist and as a mother I had to miss several World Congresses. For a number of years it has not been easy to juggle the different responsibilities. At the same time, my professional work has certainly been inspired by the – sometimes unexpected – insights that come with raising children. I would therefore like to dedicate this paper to parents, in particular to mothers, who have gone through the same or similar struggles, trying to keep all balls in the air as gracefully as possible.
In what follows, I will, in a first part, provide an analysis of what I perceive as potential or real restraints of our field moving forward. In a second step I want to sketch a positive programmatic vision of how bioethics could develop in the future, tapping into resources that can help us prepare for the bioethical challenges we encounter in a globalized world.
I. THE ‘BUSINESS OF BIOETHICS’: ARE WE ON TRACK?
When I was asked as a student what I wanted to specialize in and I replied ‘bioethics’, I frequently got a frown, followed by a question such as ‘What? Biotechnics?’. This has completely changed. Now, when I tell people what I am doing, they usually reply ‘Bioethics – oh yes, that's interesting!’ I assume this establishment of bioethics as a recognized profession or ‘business’, so to speak, is true for quite a number of countries.
Although the development of the field over the last decade has been truly impressive I do think it is worthwhile to pause for a moment to have a closer look at what may impede further advances. And I do think this is particularly important as our globalized world is faced with some formidable challenges.
Among these challenges is certainly the economic crisis that – although stock exchanges and CEO's salaries may have recovered – has left its scars in many places, among them universities. Not only have resources been cut for important public and social services but there is also a sense of weariness and disappointment in those political and economic leaders who are perceived as being mainly interested in securing campaign contributions, and business opportunities for their own clientele rather than in shaping preconditions for as many people as possible to sustainably live a life in peace, liberty and at least modest wealth. It is indeed hard to see the reasonableness or even the rationality, for that matter, of prioritizing the profitability of shares over effective measures against climate change, or tax breaks over universal health care coverage.
The financial crisis was – or is – not only about a huge loss of money but also about rising inequalities, hitting those hardest that are already underprivileged and vulnerable – the poor, the sick, and, in many cases, women. A deep sense of frustration, increased poverty, and less public investment in areas such as education are a fertile soil for the second challenge, fundamentalism in its different forms. I am worried that an important objective of our Association, ‘to uphold the value of free, open and reasoned discussion of issues in bioethics’ will ring rather hollow to those who believe in the strict and undisputable adherence to sets of specific rules they consider binding. How can we engage individuals who believe it is justified to outlaw, threaten or kill others for a ‘wrong’ word, cartoon, dress or glance? We risk falling behind human rights standards that were globally acknowledged more than half a century ago, including the right to life, non-discrimination, and freedom of thought, conscience and religion as well as freedom of opinion and expression. And again, it is likely to be women who will suffer most.
These are no easy days for bioethics, yet I am convinced our input, our good will and our commitment are particularly needed today. Does bioethics have the right tools for contributing anything meaningful to the challenges we are facing? As Dan Wikler described in his Presidential Address in San Francisco almost 15 years ago, bioethics has transitioned from a focus on the clinical encounter to a consideration of healthcare systems, including issues of distributive justice, and has subsequently moved on to a bioethics of population health, employing concepts such as human rights.1
Since Dan's speech there have been important developments: International Organizations, such as WHO and UNESCO have taken up bioethics as an area of work, and have developed activities especially in the developing world; we have witnessed how in the US an important moral concern, improved access to healthcare, was taken up in healthcare reform bills that were eventually signed into law after a fierce political struggle.
With a view to the conceptual and methodological as well as institutional and procedural advances that were achieved over the last decade or so we have reason to be confident that bioethics does indeed have a meaningful contribution to make. But in order to be as well prepared as we can possibly be, I do think we should continue to keep a critical eye on possible impediments that may come with the establishment of bioethics as a discipline, a profession, a business in its own right. If the circumstances at large are outside our control, we may have somewhat more influence on the ‘internal factors’ of our field that may still significantly affect our functioning.
Whose business is it?
Although a bioethics community has emerged – on a regional as well as on a global scale – the field is not without frictions. Those of us who are dedicating all or most of their professional time to the field will be quite familiar with the issues I am about to raise.
We bioethicists are a colourful crowd, bringing together many different disciplines, skills and experiences. At first sight, this interdisciplinarity appears to be an attractive feature. In many instances it is also a necessity: if bioethics is to engage in ‘real world’ questions and problems it needs to address them through a combination of empirical and normative work. Empirical work is needed in order to get a good grasp of the problem and its contextual features. Normative work consists in a careful ethical analysis of the empirical findings. So far, so plausible. For the day-to-day business of bioethics, however, its inherent interdisciplinarity does not necessarily make things easier.
Frequent phenomena are fights about who may legitimately do what work. Have you ever conducted interviews as a non-social scientist? Have you ever ventured to produce a normative statement as a non-philosopher? And in addition there are theologians, lawyers, and clinicians – physicians and nurses, all defending their claims to the key expertise. How much time and energy is wasted in this kind of trench battle will depend on local circumstances. But certainly, cross-disciplinary interactions are not always along the lines of the ‘3 R's’ of good bioethical conduct that Matti Häyry identified in his address at the 9th World Congress in Croatia: recognition, responsibility and respect.2 Rather, mutual disregard or disdain is not uncommon, even if not openly admitted.
Wouldn't then the obvious way out be to announce the birth of a new breed, the ‘bioethicist proper’, who does not belong to any of his or her ‘parent disciplines’ but combines useful skills and knowledge from several of them? The danger is that such a scholar will fall between all stools, and get support from very few people. On a national or regional basis there are frequently not enough bioethicists around to be available as peer reviewers for grants or publications. Grant proposals, for instance, may be judged by someone who has no knowledge of the subject or of the standards in the field.
An auxiliary science?
So on the one hand we have a young and exciting field that allows for unorthodox and innovative work, without being stifled by a specific canon, at least not to the same degree as is the case for other, more traditional disciplines. However, there is yet another danger lurking around the corner. Bioethics may be perceived by some as an auxiliary science, that has to justify its existence or its use of resources by being useful in the sense of facilitating life for other disciplines. This can take many different forms. One of them is the rubber stamp function: If a project includes an ethics work-package, it is – I would hypothesize – more likely to be perceived as morally acceptable. Another job consists in increasing public acceptance and trust by reflecting, for example, on the ethical ramifications of some new technology.
As an experienced bioethicist you can gauge quite well what the effect of your taking certain positions will be. Who will like you, and show it by inviting you to author a paper in their high impact journal? Who will certainly never again invite you to give a plenary speech at their annual conference? This will lead you to a conflict of interest. Are you really going to voice your opinion loudly on a certain issue that you know will upset an important ally? What if you simply turned your attention to another, less contentious, more ‘rewarding’ issue? It is easy to be upset about such considerations. But in a quiet moment, we may wish to think twice about the different factors that shape our individual research agendas.
Finally, another charge that has been raised against bioethics is that it is too exclusive. One concern is that bioethicists form an élite club that ‘ordinary’ people with good common sense and a genuine interest in the issues cannot access. Another, much discussed worry is that bioethics as such is a Western undertaking with an imperialist impetus. Although these charges tend to become less acute it is important to remain aware of them.
Is it a business anyway?
Managing the bioethics biz
Should bioethics be considered a business in the first place? Whether we like it or not, science does have an entrepreneurial component, as does engagement for civil society. Those who invest in us want us to make good use of the resources they spend. So we are trying to be good entrepreneurs: we raise additional funding, we publish, and we make our findings available to the interested public. We tailor our topics to potential funding sources or to attract the attention of society or the benevolence of a professional group; and we present results in a way that pleases reviewers and editors. This is true for other fields as well but I think bioethics is in a particularly vulnerable situation, as we cannot simply address our own community but need to stretch beyond to reach and convince colleagues from other disciplines: molecular biology, nephrology, health policy – you name it.
Who's driving the bus?
Not being self-funded does not necessarily mean we have to ‘sing the tune of those whose bread we eat’, as a German saying goes, although there may be instances in which not doing so leads to sanctioning. But acknowledging we are not freely shaping our agenda according to the issues we consider most important helps us understand how the bioethical ‘10/90 gap’ may have come about that Alex Capron described in his Beijng Address in 2006.3 It is usually easier to obtain a grant on the ethics of some new high-tech medicine with promising business potential than on improving access to health care in some faraway country. In addition, it will be good for your status as a representative of a nice little soft skill if you hang out with the big shots – not surprisingly, genetics and neurosciences have received a lot of bioethical attention, much more than issues such as poverty or sustainable development.
I am not saying this to discourage us – quite to the contrary. But I think acknowledging the continuous risk of our priorities getting distorted, especially from a global point of view, is an important step in holding on to or reclaiming our agenda. Another important element is the realization that we can achieve more together. We need a strong bioethics community that can set standards and provide mutual support, insisting on certain topics not being left out. Continuing to cultivate the open, inclusive and fair discourse that has become the hallmark of the IAB, will be a good warranty for our remaining on track.
II. BIOETHICS AS AN ASSET: ARE WE MAKING FULL USE OF ITS POTENTIAL?
I am now coming to the second part, the positive vision. I am convinced that bioethics is an invaluable asset in confronting the challenges of a globalized world as they relate to health care and the biological sciences. I have already referred to the important advances that have helped bioethics explore the different areas of clinical decision-making, healthcare systems, and population health. Although interests and priorities may have changed over time I do not, by the way, see these areas as consequent stages, as I believe they all remain valid and in need of further work.
What I am suggesting now is neither a stage nor an area of work, but could rather be called a lens, borrowing from terminology introduced by Sue Sherwin.4 This lens may not even be entirely new, but consists of several elements that to me seem apt to address an underdeveloped aspect in a lot of bioethical reasoning.
The deficit I am struggling to address is captured in a dry remark by Solly Benatar: ‘Ethics is about relationships, of course.’5 This may not be as obvious as it sounds. A good deal of bioethical reasoning is concerned with the autonomous, rational individuals that inhabit sterile theoretical worlds. This perspective seems to neglect utterly what many would say counts most in a fulfilled life, that is, flourishing human relationships. I would venture to say that flourishing relationships are a precondition of human flourishing.
Exploring the enabling conditions for flourishing human relationships seems a worthwhile endeavour to me: How can we remove obstacles and create spaces for such flourishing, under the conditions of today's world, with its focus on economic efficiency, competition and success?
What are flourishing human relationships?
You could now reply to me ‘Well, that's a nice idea, but in a pluralist world such as ours we are never going to agree on what the term is supposed to mean.’ I am less sceptical; I believe that flourishing human relationships are a very basic notion that our human species has always depended on for its survival.
Let us start out with some negative examples: Primo Levi's account of the Nazi concentration camps is certainly a classic one. Levi describes the glance the chemist Dr Pannwitz threw at him, denying the recognition of him as a fellow human being – the annihilation of a human relationship: ‘This thing in front of me’– Levi interprets this glance as saying, ‘This thing in front of me belongs to a species which it is obviously appropriate to suppress. In this particular case it is necessary first of all to ascertain that it does not contain some usable elements.’6
In ‘The Land of Green Plums’, Herta Müller, the winner of the 2009 Nobel Prize in Literature tells the story of five young Romanians living under Ceausescu's dictatorship. She describes the despair of not being able to maintain meaningful interpersonal relationships under the conditions of persecution by the secret service. The tragedy is captured in the final phrase of the novel: ‘ “When we are silent, we become unpleasant”, said Edgar, “when we talk, we become ridiculous.” ’7
Another impressive account of the complete ruin of human relationships is offered by Roberto Saviano, the author of ‘Gomorrah’, whose topic is the Camorra, the Neapolitan crime syndicate. In his report, which is full of incredible violence, he writes: ‘The logic of criminal business, of the bosses, coincides with the most aggressive neoliberalism. It dictates, even forces the rules of business, of profit, of triumph over all competitors. The rules, dictated or imposed, are those of business, profit, and victory over all the competition. Anything else is worthless.’8
All these accounts of wrecked human relationships are characterized by violence, be it physical or psychological, of extreme manipulation, instrumentalization and exploitation. The other is looked at as an entity to be used, destroyed, suppressed, rather than someone to be respected, cared for, and supported. Dictatorship, the right of the strongest, a struggle for and abuse of power, the lack of any law with democratic legitimation form the context in which such destructive interactions appear like a functional strategy.
I assume that we do share another vision: a vision of a world in which the sheer joy about the existence and thriving of another – think of your partner or friends, your children or grandchildren – can be felt and can enrich our selves; a world in which attending to an other is experienced as meaningful and worthwhile; a world in which caring for others can be balanced with caring for oneself, and in which the work of care is fairly distributed; a world in which everyone can expect to be cared for when needed.
It is possible that we would disagree when it came to judging the quality of individual relationships. In fact, I would expect this to happen, as questions such as ‘Who owes what to whom?’ are likely to yield different responses, depending on a number of contextual factors. One way to go about this would be to try and define rules or criteria for determining the appropriateness of relationships. Another way is to explore consensus about favourable conditions and obstacles for the flourishing of human relationships. Extreme competitiveness, for instance, would quite clearly need to be considered a detrimental factor, prompting a focus on individual achievement and providing an incentive to profit from the weaknesses of others. Using others for my own interest, maximizing my own benefit, being superior to everybody else, if cultivated in excess, are certainly not dispositions that will motivate me or enable me to appreciate fully the importance of a non-instrumental view of the other.
Creating space for flourishing human relationships
In the following, I want to probe some conceptual resources that may be useful in spelling out what an approach focused on flourishing human relationships might look like. Before I delve into this let me stress that I am not claiming nor even intending to combine those different elements in some kind of super-theory, nor do I think these are necessarily the only elements that could be invoked.
Flourishing human relationships may be associated with an Aristotelian notion of human flourishing. Indeed I consider flourishing relationships as a precondition for human flourishing, although the concept is not necessarily bound to an Aristotelian ethics.
Flourishing human relationships are addressed in one of Martha Nussbaum's capabilities, that of ‘affiliation’, which includes ‘being able to live with and toward others, to recognize and show concern for other humans, to engage in various forms of social interaction; to be able to imagine the situation of another; having the social bases of self-respect and non-humiliation; and being able to be treated as a dignified being whose worth is equal to that of others.’9
The capability approach, however, targets individual flourishing as a criterion of social justice, whereas I am more interested in exploring the potential of relationships as a lens through which to analyse some of the bioethical challenge we encounter today.
A promising and obvious candidate for an approach that values the primary importance of relationships is care ethics, which has largely been developed by feminist scholars. ‘Care’, says Virginia Held,’ is probably the most deeply fundamental value.’10 We would not exist, had we not been cared for from the first moments of our lives. And it is hard to imagine a flourishing relationship without a care dimension.
Relationships are constituent of our selves. They define who we are, although this identity is not static. Rather, it is continuously and actively shaped by a self-reflective moral agent who starts, shapes, maintains and terminates relationships according to his or her own self-understanding and priorities. Being able to balance care for oneself and for others is a criterion for moral maturity. This constant allocation process requires self-reflection: Who am I, to whose needs do I respond, and what priority does addressing these needs have?
This means, however, that care is also about rights and justice: I have the right, at least a prima facie right, to take up, to continue or to end a relationship, I have the right – and possibly the duty – to question or to criticize relationships that I consider unfair. ‘Relationships involve considerations of power’, the Benatar quote wisely continues. Care ethics is thus not about romanticizing closeness and self-sacrifice but about understanding and critically examining relationships.
Just a side remark on the much discussed relationship between care and gender: the theorist in me would like to believe that gender is irrelevant to moral reasoning, the mother that I also am continues to observe that there is something to a gender association. I had an occasion recently when I saw my two daughter bury a dead mouse they had found in our garden – giving it a name, inventing stories about why she (it was a she) had been such a nice mouse, and putting flowers on the grave, while my son raced down our little hill with a bobby car, trying to outperform himself as he lacked a competitor. He did not disapprove of the burial scene that happened close by, he just was not intrigued by it. I am telling this story as I think it has something to do with the reception of care themes in mainstream philosophy. Maybe some of us are just dispositioned to find this exciting stuff, whereas others think it is quite unremarkable. The interesting question is then whose judgement should count.
Care ethics helps us to understand some basic moral principles in relational terms: Autonomy can be seen as the capacity to weigh perceived responsibilities towards oneself and various others. The precondition for doing so – to perceive the needs giving rise to the responsibilities in the first place – is empathy. Equal opportunity for all to have the relative freedom to decide for or against accepting certain responsibilities and to have their decisions respected would be a matter of fairness. Empowerment, finally, could be understood as the opposite of instrumentalization, which exploits the vulnerability of the other for one's own purposes through coercion or manipulation. Relationships can then be judged according to criteria such as: Are they maintained autonomously, i.e. do they reflect a decision on the part of the carer or the cared-for that corresponds with his or her self-understanding? Has this relationship been taken up under fair conditions? Is it exploitative? This is just a very rough sketch to show what an important resource care ethics is for the exploration of flourishing human relationships.
I can only very briefly touch on the two remaining elements, cosmopolitanism and pragmatism. Care ethics raises tough allocation questions: Whose needs entail responsibility on my part, on the part of my institution, my community, my country? The key feature of cosmopolitanism is that it regards, as Thomas Pogge formulated, individual beings as ultimate units of moral concern’, irrespective of their nationality.11 Or, as Seyla Benhabib put it: ‘every moral agent, who has interests and whom my actions [. . .] can impact and affect in some manner or another is potentially a moral conversation partner with me.’12 And Iris Young states, explaining her ‘social connection model’ of responsibility: ‘all agents who contribute by their actions to the structural processes that produce injustice have responsibilities to work to remedy these injustices.’13
Cosmopolitanism clearly tells us that we cannot limit the scope of our moral concern to those around us. Human flourishing will depend – and increasingly so in a globalized world – on flourishing human relationships, not only of those who are physically or emotionally close to each other, but on a global scale. Cosmopolitanism can help us to better grasp this challenge.
Finally, how is pragmatism an interesting resource in this context? Care ethics emphasizes the continuous moral work of moral agents, scrutinizing, weighing and balancing their different responsibilities. This moral work is not always reflected in moral theories, which sometimes produce highly abstract statements that are far removed from the everyday experience of concrete moral agents.
Pragmatism, on the other hand, can be understood as a method for improving our value judgments. Rather than searching for eternal truths, the pragmatist maxim consists in clarifying hypotheses – the truth of a statement, the rightness of an action, the value of an appraisal – by identifying their practical consequences. Pragmatists are focused on understanding what would be the best option for a concrete moral agent – with a view to his or her moral commitments and other contextual factors. We as moral agents continuously have to negotiate the specific rules for what constitutes decent – as a minimal version of flourishing – relationships. These rules need to be tested for their aptitude in real life, with a view to peaceful coexistence in functional societies.
This means that the moral work of individual moral agents can be an important source of inspiration and should be heard in ethics discourses. It also means that real life consequences of philosophical statements would matter for their evaluation, strengthening the policy dimension of bioethical questions and their academic analysis. Pursuing this further might result in a model of a ‘consultative bioethics’, in which options for action would be jointly examined in non-dogmatic way by those who might be affected by the consequences of the action.
Flourishing human relationships and bioethical challenges in a globalized world
What does all of this mean with regard to concrete bioethical issues? I think using flourishing human relationships as a lens is going to change the way we ask questions, to change our analysis and our priorities.
If we consider human beings as free and dependent, as autonomous and interrelated, it is evident that human flourishing depends on flourishing human relationships. This is not to be mistaken for the close relationship with a loved one. As world citizens, we need to consider a larger circle of others that matter to us morally. This means, for instance, that an ethical assessment of international organ trading cannot be reduced to a simple risk-benefit calculation but needs to include the implications for human relationships: Could it be that the potential recipient is entering into a scheme characterized by social injustice and exploitation?
Although I have limited this paper to human relationships I do think it would be worthwhile eventually to include our relationship with other species and the environment in a more comprehensive analysis.
If flourishing human relationships are a precondition for human flourishing, understanding and fostering the enabling conditions, creating spaces for such relationships is a moral imperative. This holds particularly true for institutions where caring is supposed to play a central role, such as hospitals. An important task, then, is to study whether caring relationships are possible in the respective institutional context, and to identify protective and harmful factors. For example, if we look at attempts to increase cost-efficiency and competition in health care, frequently by the means of financial incentives, it would be crucial to look at the implications for the possibility of caring relationships to unfold in such a setting. What is the intense pressure to save time and money going to do to a field that was once described by the dedicated physician Howard Spiro as having caring at its heart?14
For the analysis of ethical conflicts, a focus on flourishing human relationships would mean going beyond the identification of conflicting principles, such as autonomy vs. beneficence, and analysing what certain requests or decisions do to relationships. Think of Amenábar's wonderful movie ‘Mar Adentro’ (‘The Sea Inside’), which features Ramón Sampedro, a Spanish sailor who has been quadriplegic for 28 years and is requesting assisted suicide: ‘To love me means to help me die’, he says. Does Ramón instrumentalize the women he intends to convince to help him?
Finally, if we choose to embrace the pragmatic test of fitness for real world problems as a criterion for the validity and relevance of a contribution, what would happen to a lot of discussions on biotechnological developments, that usually receive a lot of attention? For example, it may appear intellectually very appealing to debate if we shouldn't all be popping the pink pill that would turn us into environmental angels, once it became available. However, wouldn't it be at least as exciting – and arguably of greater practical relevance – to try and understand the societal causes for the rising interest in ‘enhancers’ and to think of ways to empower individuals to make wise choices, regarding their own health and development as well as the relevance of environmental protection?
Using flourishing human relationships as a lens through which we consider bioethical challenges will yield different questions and emphases from a view focused on individual moral agents. The examples I have cited regarding organ trading, financial incentives in health care, assisted suicide, and enhancement, call for refining and complementing our analytical tools. Some promising work has already been done: I am thinking of concepts such as relational autonomy, vulnerability, social justice and solidarity, which have been elaborated and illustrated in various contributions over the past three days. I am looking forward to the ongoing cross-cultural discourse on these issues, including suggestions for sustainable policy options.
The fascinating and inspiring discussions I have been able to witness during this 10th World Congress of Bioethics have given proof once more that the International Association of Bioethics is a wonderful agora for all of those who strive to understand and address the bioethical challenges we encounter in our globalized world.
I would like to thank Dr Margaret Caudill, who allowed me to witness, in my early years as an aspiring bioethicist, what it means to practice medicine as a genuinely caring physician.
Nikola Biller-Andorno directs the Institute of Biomedical Ethics, University of Zurich, a WHO Collaborating Centre, as well as the PhD program ‘Biomedical Ethics and Law’ (medical track). She serves as President of the International Association of Bioethics (2009–2011), as deputy editor of the Journal of Medical Ethics, and as a member of the Central Ethics Commission of the Swiss Academy of Medical Sciences.
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