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Bioethics and Anthropology PDF
Bioethics and Anthropology PDF
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448
nursing schools, and the creation of hospital "ethics committees" to help patients,
families, and staff make morallydifficult decisions about their medicalcare (Fox
1990; Jonsen 1993; Marshall1992).
Although scholarsfromdifferentdisciplineshave been drawnquicklyinto the
bioethics arena,social scientists,with a few notableexceptions, have been slow to
turntheirattentionto the examinationand analysis of bioethicalquestions.Lieban
(1990) and Marshall(1992) suggest that while anthropologiststraditionallyhave
investigated the normativebehaviorand moral codes of the cultures they have
studied(e.g., Hsu 1961;KluckhohnandStrodtbeck1961;Whitinget al. 1966),they
have been less interestedin bioethics for three reasons: the notion of cultural
relativityhas not had a place in the moralthinkingof bioethics untilvery recently;
the developmentsin Westernbiomedicine,which have triggeredextensivebioethi-
cal debates, have not been the focus of anthropologicalresearchbecause of the
discipline's traditionalemphasis on research in non-Westernsocieties; and the
different trainingand interestsof anthropologistsand ethicists have not fostered
cross-fertilizationbetweenthe two disciplines.
In recent years, however, interest in the intersectionof anthropologyand
bioethics has been growing. Publications and conferences on the subject are
appearing,'anda numberof social scientists(e.g., Clark1990, 1991, 1992;Fabrega
1990; Fox 1990; Kunstadter1980; Lieban 1990; Weisz 1990) have called for
culturalanalyses of ethicaldilemmasin healthcare settings. Given these develop-
ments, it becomes pertinentto reexamine the relationshipof anthropologyand
bioethics (for an earlier discussion, see Marshall 1992). In the discussion that
follows, I consider the evolution of the field of bioethics, including its existing
conceptualframework,as well as new theoreticalmovements in bioethics. I then
examine four dimensions of an anthropologicalapproachto bioethics: (1) the
contextualnatureof bioethicaldilemmas;(2) the culturalembeddednessof moral
systems; (3) the multiculturalcharacterof many bioethicalproblems;and (4) the
challenge of examiningthe field of bioethicsas a culturalphenomenon.The article
concludes with a discussionof the methodologicalandtheoreticalcontributionsan
anthropologicalapproachcan make in the evolving bioethics arena.
to assess the moralityof a given courseof action(Clouser 1978). This aim is based
on the premisethatindividualsare rationalhumanbeings who shouldengage in a
process of moral reasoning, based on normativerules or principles,to arrive at
decisions in situationsof conflict or ambiguity.The emphasishereis on prescriptive
behavior-how decisions ought to be made ratherthanhow they are made.
The frameworkthathas dominatedmuch of bioethicshas been the four-prin-
ciples approachdevelopedby BeauchampandChildress(1979). At the heartof this
moral code is the principleof respect for autonomy.Reflectingthe deeply rooted
Americanbelief in individualism,as well as bioethics' groundingin Westernlaw
and philosophy, autonomyhas become a centerpiece of contemporarytheories
about how patients and physicians in health care settings should relate to one
another. This principle holds that people who are able to make decisions for
themselves have the rightto determinetheirown course of action,even when they
refuse medical treatment,and that others have the obligation to respect their
decisions (Beauchampand Childress 1979; President'sCommission 1983). Com-
mitmentto this principleover the last two decadesreflectschangesin notionsabout
what constitutesthe physician's moralresponsibility;the emphasisnow is less on
traditionalideals of medicalbenefit andmoreon the rightsof patients(Beauchamp
1994).
Threeotherprinciplesin additionto autonomyhave commonlybeen invoked
to guide moraldeliberations.The principleof beneficence refersto the obligation
to providebenefitsandto balancethemagainstrisks;in medicine,it involves acting
in the patient's best interest. The principle of nonmaleficence pertains to the
obligation to avoid causingharm.The principleof justice expresses an obligation
of fairness in the distributionof benefits and risks, and it refersparticularlyto the
criteria by which scarce and expensive resources are distributed.For example,
concernsaboutdistributivejustice raisequestionsabouthow muchtreatmentought
to be providedfor young children with severe central nervous system anomalies
who are expected to die or how expensive, scarce medical treatmentshould be
distributed.
In general,thefour-principlesapproachassumesthatethicaldecisions canbest
be made by applyingthe principlesand more specific rules to particularsituations.
Moral dilemmasarise when moral considerationscan justify takingeither of two
opposing courses of action (Beauchamp and Childress 1979). Disputes often
involve complex disagreementsabout factual interpretations,as well as conflicts
betweenmoralprinciples.Bioethicists attemptto identifythe values implicatedby
the variouschoices, discussthe implicationsof these choices, andassess conflicting
ethicalprinciples.They aim to assist clinicians,patients,family members,or policy
makersby clarifyingrelevantissues, exposing fallacious reasoning,and assisting
in the resolutionof moraldilemmas.
Bioethics Evolving
In spite of its influence over bioethical thought,the principlesapproachhas
been criticized in recentyears for being acontextual,ethnocentric,reductionistic,
and sterile (cf. Hoffmaster 1992a). The approachhas been called a "mantraof
principles"where "the principleshave functioned ... like a ritualincantationof
normsrepeatedwithlittle reflectionor analysis"(Beauchamp1994:8).Clouserand
conditions that influence health and illness behavior generally.This notion, now
appearingwith increasingfrequencyin thebioethicsliterature,is a radicaldeparture
from orthodoxbioethicalanalyses,which typicallybuilttheirargumentson decon-
textualizednormativeprinciplesand rules and often lacked an empiricalbase'or
considerationof the many factorsthat shape particularcircumstances.The "con-
textualist"approach,on the otherhand, takes as its point of departuretwo basic
assumptions.First,to understandthe "rumpledreality"of moraldecision making,
it is criticalto examine how people actuallybehave in problematicsituationsand
the reasonsorjustificationsthey give for theirbehavior.The applicationof abstract
rules or principlesoften is not sufficientto grasp the complexities or subtletiesof
real-lifesituationsof moralconflict.Second, in orderto understandhow something
becomes defined and actedon as moralor immoral,carefulscrutinymust be given
to the political, institutional,andsocioculturalfactorsthatlead to the conditionsin
which ethical dilemmas appear.Organizationalstructure,power and statusdiffer-
entials, explanatorymodels of differentactors,or varyingexpectationsregarding
the patient-practitioner relationshipall shapethe definitionandresolutionof moral
problems.
These assumptionsbecome apparentin the few studies that have been done
by social science investigatorsin NorthAmericanhealthcare settingsin whichthe
focus has been the same issues thathave triggeredbioethicaldebates.While not all
of these studies explicitly frame their results in terms of ethical discourse, their
focus is on understandingactualdecisions or the complex contextualfeaturesthat
shape specific clinical encounters. For example, the work by Koenig (1988)
provides one of the few culturalanalyses that touches on the ethical implications
of changingmedical technologies.She looks at how a moralimperativeto provide
treatmentis created among physicians throughthe routinizationand consequent
acceptanceof a new medical technology and argues that the moral meaningof a
technology is embeddedin and expressedthroughchanges in social organization.
The evaluationof a new techniqueas a standardtherapymust derive, therefore,
from an understandingof the social setting in which treatmenttakes place.
An area that has attractedextensive bioethical analyses in the United States
but few anthropologicalinquiriesso far is that of truth-tellingand disclosureof
medical information.This issue has been examinedin relationto the "discourseof
hope" surroundingthe treatmentof cancer(Good et al. 1990), telling a patientfor
the first time that she has breastcancer (Taylor 1988), and revealing HIV status
(Marshallet al. 1991). Similarly,the ethical issues concerninginformedconsent,
although discussed widely in bioethical debates, have received relatively little
anthropologicalconsideration.Discussions of informed consent that have been
influencedby anthropologicalperspectives(e.g., Hahn 1982; Kaufertand O'Neil
1990; Levine 1991) have examinedhow culturalfactors affect obtainingconsent
and have questionedthe universalvalidityof the informedconsent model. Kaufert
and O'Neil's study (1990) of healthprofessionals'attemptsto get signed consent
agreementsfrom Native Canadiansis a particularlygood example of what can
happenwhen healthpractitionersandpatientsspeakdifferentlanguagesandattach
differentmeaningsto symptomsand treatments.
The ethics of decision makingatthe beginningandend of life has also received
sustained attentionin the bioethics literature.What level of treatmentshould be
Bioethics as a CulturalPhenomenon
The final dimension is the premise that bioethics is a social, cultural,and
intellectualphenomenon(Fox 1990) thatshould be examined in its own right.Its
ideology, structure,activities, culture patterns, and social traits are worthy of
investigation,especially regardingtheirsupportfor the beliefs, values, and norms
of U.S. society and U.S. medicine.Few social scientistshave engaged in social or
culturalanalyses of bioethicsas a system of inquiryand action, with the important
exception of the work of Fox and Swazey (1984) and Fox (1990). They have
stressed the importanceof examiningvalues and beliefs emphasizedand de-em-
phasized by bioethics, its cognitive frameworkand style, and its social organiza-
tion.
Researchers are beginning to report on specific aspects of the bioethics
enterprise.Flynn's (1992) study of the underlyingassumptions,discourses, per-
spectives, and practicesof hospitalbioethics committeesexamines how bioethics
is constructedin a particularfashionthroughbioethicscommittees.Marshall(1989)
has analyzed the cultural assumptionsunderlying clinical ethics consultations.
ArmstrongandHumphrey(1994), in claimingthatethics is another"beliefsystem"
that deserves social analysis, suggest that ethical debate can be analyzed as a
situationof high social dramathatdisplaysand reinforcessome of the core social
values of our society.
Conclusions
NOTES
these ideas were first presentedand for their commentson draftsof this article. I am also
gratefulfor the commentsandsuggestionsof BarbaraKoenig andthe anonymousreviewers.
Above all, I wish to thankMargaretClarkfor her many probingand stimulatingconversa-
tions. A firm believer that anthropologistshad something to say about the practices and
ideology of medicine, MargaretClarkrecognizedthatethical issues in the medical arenas
were indeedrich subjectsfor anthropologicalinvestigation.Withouther, I would have taken
a differentpath.
Correspondencemay be addressed to the authorat the Departmentof Family and
CommunityMedicine, School of Medicine, 500 Parnassus,MU-3E, Universityof Califor-
nia, San Francisco,CA 94143-0900.
1. A conference entitled "HumanizingBioethics," sponsored by the Westminster
Institutefor HealthandHumanValues, was held in London,Ontario,Canada,in April 1994.
In 1992, therewas an invitedsession at the AnnualMeetingof the AmericanAnthropological
Associationentitled"Rockingthe Boat: Autonomy,Reality,and AnthropologicalCritiques
of Bioethics."In the same year, anotherinvited session was called "The Anthropological
Enterprisein Clinical Ethics:Issues of Ethicsfor MedicalAnthropology."Another invited
session at the 1993 Annual Meetings of the AmericanAnthropologicalAssociation was
entitled"StudyingPhysicians:Methods,Ethicsand Interpretation."
2. For a discussionof the antecedentsof the interpretiveapproachandsome its current
manifestations,see Marshall1992:53-54.
3. This is a legal document used in Califoria and some other states; it specifies the
medical treatmenta person wants and does not want, should one become incompetent,and
invests a designated person with the legal authorityto make medical decisions on that
person's behalf.
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