• Ethics- Medical

Over the last two decades or so, the need to decolonise bioethics and make it inclusive, equitable and accommodative of voices from the traditionally marginalised global South has received increasing attention in academic scholarship. The recent publication by Pratt and de Vries offers a very comprehensive critical analysis and thoughtful overview of the issue, using global health ethics as its starting point.1 I fundamentally agree with their characterisation of the issue as an ‘epistemic justice’ problem. I further find their recommended conceptual and practical ideas for measuring epistemic injustice and ethical responsibilities to promote epistemic justice very thoughtful and insightful. However, I find their responses to possible objections to their arguments a bit hasty and unclear, especially the idea that ‘greater epistemic justice calls for global health ethics to advance a transcultural framework of ethical values and principles’ (p. 7). They look ambiguous on their position on the fundamental global bioethical question regarding the possibility of an intercultural ethical framework. I think the question of whether there are global ethical values and principles that are commonly shared among human beings in the global world is a fair and legitimate issue that deserves deep attention and a persuasive answer by those who call for more inclusive and equitable global bioethics. I attempt to flesh out this issue in a bit more detail to further enrich the discussion.

Pratt and de Vries endorse interculturalism in epistemology. They argue that ‘cognitive justice’ in bioethics requires the acknowledgement of plurality of knowledge and ‘intercultural translation and mutual learning’ (p. 8). However, they seem reluctant and uncomfortable endorsing interculturalism in ethics. What should be the ethical framework of global bioethics and global health ethics? Do their theory of epistemic justice support or reject intercultural ethical framework? They seem vague and ambiguous on the ethical framework that is reasonably appropriate for global bioethics and global health ethics. For example, they write that ‘it is not clear that greater epistemic justice and any transcultural framework of ethical values and principles that emerges would necessarily give rise to universal values and principles’ (p. 7). I think a defence of epistemic justice to make global bioethics (including its subfields of global health ethics, global research ethics and so on) equitable and accommodative to inclusive voices concomitantly requires an endorsement of an intercultural ethical framework (with shared values and principles). Else, global bioethics would be left without an ethical root/foundation, given the attempt to liberate and decolonise it from cultural hegemony and imperialism.

It seems that their ambiguity is generated by the difficult question regarding what the idea of intercultural ethics actually entails. The authors seem to accurately capture the view that the idea of intercultural ethics implies the notion of ethical universalism. They look hesitant to endorse such an idea, given the negative connotations that the idea carries, at least from the standpoint of efforts to decolonise bioethics from the hegemony of Western imperialism. Critics2–4 tend to agree that the current form of bioethics universalises and imposes on the global world Western ethical principles and values. So, the idea of ethical universalism has a bad taste in the mouth of many critics of the current form of global bioethics. This uneasiness seems to underlie Pratt and de Vries’ view that, even if intercultural framework identifies universal values and principles, there is still a question of ‘whether their application is universal or whether there would be permissible variability in terms of how they are applied across contexts’. They further wonder that ‘perhaps there are no absolute, universal values and ethics is to a large extent a matter of context and interpretation’. It is not clear from these ambiguous statements whether the authors are endorsing or expressing scepticism about the possibility of (or a need for) a universal (global) intercultural ethical framework for global bioethics that at the same time allows its principles to be interpreted and applied to suit particular cultural contexts. An endorsement of such sceptical position that denies the possibility of a validly sound global (universal) ethical framework would commit them (perhaps inadvertently) to bioethical relativism (in contrast with bioethical interculturalism).

In criticising the dominance and universalisation of Western thought in bioethics, we should be careful that this does not lead us into a retreat to an endorsement of bioethical relativism which involves scepticism about the possibility of a shared or common intercultural ethical framework for global bioethics. I rather think that interculturalism helps to obtain a non-imperialistic morally valid global (universal) ethical framework for developing global bioethical principles and guidelines (especially for global health research). Transcultural bioethics rejects the arrogance of cultural imperialism which absolutises the dominant values of Western cultures. The challenge of transcultural bioethics, as Gbadegesin (1998) reminds us, ‘is to underscore the universality of bioethics without undermining the significance of distinct cultural identities’.5

Transcultural bioethics serves as a forum for dialogue and discussion in which people from diverse cultures can all participate on an equal footing (Gbadegesin, p. 26). It explores shared or common values (and the principles, rules and practices undergirding them) which could be fundamentally used to formulate global bioethical principles and global health ethical guidelines. The fact is that some bioethical issues are global and transcultural (have no respect for cultural boundaries), as illustrated by the spread of COVID-19 and the Ebola pandemics across cultures in the global world. Intercultural bioethics offers a participatory forum for understanding, debating, exploring and addressing global bioethical issues. A challenging issue is the question regarding the conditions for the possibility of transcultural bioethics, and how it would be different from the current Western-dominated bioethics that we have today. How do we deal with the various conflicting beliefs and values of distinctive cultures to facilitate intercultural dialogue? How does bioethics handle the reality of cultural differences? For example, consider the Western emphasis on individual autonomy vs non-Western (eg, Japanese and African) emphasis on communal, relational and family autonomy.

The reality of cultural variation and pluralism in the global world should not justify a retreat to bioethical relativism. Bioethical relativism is an invalid inference from the reality of cultural variations in the global world. It argues from the truism about the plurality of different culturally embedded values and then infers that such pluralism warrants respect for a range of equally valid cultural approaches to bioethics. This belief in equally valid cultural bioethics implies a sceptical view that there is no such thing as common morality that serves as a framework for global or intercultural bioethics. In contrast, bioethical interculturalism acknowleges the reality of cultural relativism but it denies the validity of ethical relativism.