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Bioethics Today: Culture, Democracy and Law

Bioethics Today: Culture, Democracy and Law

welcome to this course on issues in bioethics this is the module one and unit five where we’ll discuss ah bioethics today culture democracy and law so this is in a sense ah lecture which concludes the introduction to this course
which also try to understand how modern bioethics appears in different societies different cultural
backgrounds particularly with reference to india and several other developing countries
where cultures are very strong or rather communities are very strong and in that sense the nature
of moral theories the nature of moral ethical frameworks are different from that of the
european context so we’ll discuss the nature of major problems
facing contemporary bioethics in that sense today particularly as i mentioned with reference
to other civilizations and cultures when you consider other civilizations and cultures
the priorities will be different and there are several difficulties we encounter in this
context so that will be addressed a little bit then cultural and other differences to
reach modern day bioethics has to be sensitive towards the nature of ethical deliberations
factors to be taken into account so in this context we should be adopting a very different
model of ethical deliberations to arrive at solutions to ethical problems so i would call
it a phronetic approach in bioethics so we will conclude this lecture with a note on
what i mean by a phronetic approach in bioethics so now let us ah discuss ah nature of problems
that modern bioethics encounter in different cultures so we have most bioethical issues
we have already seen this when you discuss some of the important problems and issues
that emerge they involve a host of problems like ah economic social cultural legal and
scientific without really considering these different aspects that ah create a situation
we will not be able to understand and evaluate the real problem and also try to find reasonable
solutions to this problem so when you consider the problems we have to take into account
all these factors again ah this also points to the difficulties in arriving at a global
bioethics because ah if you consider the idea of the
notion of global bioethics as a set of norms and standards which would probably guide ah
practice of medicine across cultures and civilizations are rather across different countries then
ah it is very difficult to arrive at one set of such principles or one set of such norms
and protocols because different cultures have different practices and customs and beliefs
and it is very difficult to apply a set of universal norms in the same way in these different
civilizations so it is in this context i would say that we can think of a phronetic approach
i will discuss about it slightly later again differences in the nature of ah problems
ah the ethical problems that arise in different countries like developed countries and developing
and underdeveloped countries are going to be very different the priorities will be very
different in these countries we know that in india the major concern is one of the major
concerns is access to medical care because many people do not have access to medical
care they will have to walk several kilometers to reach the nearest health care centre and
to access ah health care this may not be a situation in a developed country so we have
to adopt a different approach definitely in our ah culture again central ah moral concerns also differ
this is what i mentioned because ah more important concerns in some in cultures like in countries
like ours will be ah issues related to the question of justice where ah the access and
ah many other issues related to that justice is a major concern in bioethics a while in
many developed countries the individual autonomy is ah one of the fundamental concepts this
is not to say that individual autonomy is not a concern in our country or in ah developing
countries individual autonomy is very important in these countries as well because modern
medicine demands that ah the individual needs to be protected in a certain manner the rights
of the individuals need to be protected no doubt about it but at the same time priorities
might change so we’ll just see one ah recent news item
which has appeared in one of the newspapers it says that over 20 percent of dalit children
are not immunized in rural ah Gujarat this is a study conducted by ah us born based organization
east-west management institute it says that over 20 percent of dalit children are not
immunized in ah rural Gujarat this shows that how caste plays an important role here in
our country in our culture and ah we cannot avoid considering this ah factors like this
in our country when we talk about ethics this directly refers to a problem in justice because
injustice has been done accessibility due to several social factors like caste religion
ah financial background gender these are several such issues which are relevant in countries
like ours which may not be the case in a developing country in a developed country so naturally the priorities are different
culture has a role in ah determining the rightness and wrongness of an action so this ah again
points to the fact of relativism which we will be discussing a little bit in detail
in ah some of the coming lectures but of course relativism is not just a theoretical possibility
it is an actuality different cultures and different views about what is right and what
is wrong and this needs to be taken into account when we deliberate upon ethical issues and
find solutions so this also calls for a very different approach in bioethics so these are
all challenges posed towards developing a global bioethics which is ah which which has
certain norms which are universal again issues like ah privacy and confidentiality
which are very important in developed societies but are not even thought of as priorities
in many developing and underdeveloped countries see for instance if you go to a typical government
hospital in rural india if you go to a maternity ward or gynecology ward you see women lined
up to have a consultation with the physician the doctor the gynecologist will be sitting
there and ah in her room and many patients will be standing there in a queue to have
a consultation with her and along with women there will be their husbands as well so everyone
is listening to everyone else there is no question of confidentiality patient confidentiality
we cannot implement practically implement ah this ethical norms which is of course very
important but unfortunately because of social situations this is not the priority here the
priority is care health care the priorities whether the physician this gynecologist is
able to provide the required care for the women who have lined up there that is more
important and again when you talk about cultural differences
most of the theoretical frameworks we talk about or we consider to understand an ethical
problem in ah the context of ah medical practice these ethical frameworks we find that their
products of enlightenment europe see let us take for example ah the two important approaches
deontologyism and utilitarianism which will be discussing later in detail so both of these
approaches have ah originated somewhere around 17 18 and 19th centuries in europe and they
were typical european ah frameworks again the four principal approach which is
so prevalent today the principlist approach which is advocated by thomas becham and others
this is also i mean this this approach of course has some universal appeal because it
talks about four very important ethical principles to be adopted by all physicians they are not
ethical frameworks but rather they are ah this approach is not an ethical framework
it is it talks about fundamental principles which cannot be violated which cannot be neglected
when you practice medicine principles like autonomy beneficm and non-maleficm and justice but even then we can find that these principles
are fundamentally individual centric though there are ah principles like ah no harm theory
and ah justice they are all also emphasized by the principlist approach but somewhere
ah when you go along you feel that you know a little more importance is given to individual
autonomy and individual centric they have become and ah so naturally the emphasis is
on ah individual autonomy and rights which i have already mentioned and i reassert is
extremely important in today’s context we will discuss that because we cannot neglect
the importance of individual rights in today’s context of ah the practice of modern medicine since we are talking about ah ethical frameworks
one of the important very important ethical ah framework is developed by immanuel kant
which is one of the important deontological theories which we will be discussing later
which talks about ah duty but ah the word deond means duty so it emphasizes on duty
but cantion duty is of a very different kind it says that duty ah implies or duty emphasizes
on a can but ah it says that one ought to do ones duty but at the same time an ought
implies a can so he or she the person who performs the action ought to do the right
thing because he or she can do it there is some sort of an individual freedom
which is a recognition of an agency the individual agent who is free from all other factors social
political economic all other factors that the individual is capable of thinking independent
of all the factors that might influence him he or she is capable of using that reason
that universal reason ah which is their and ah such an individual such a model of an individual
is ah very difficult to find in rural india even today i mean this is not to underestimate
people from rural india because i do not mean that this is an incapability there is a lot
of strength to be part of ah in being part of societies and communities also but at the
same time we have to strike the right balance by being part of a family by being part of
a society and a community we should also be able to take independent decisions as independent
individuals and this is the requirement this is a necessity of our times and modern medicine
demands that because otherwise they will gross injustice done to us now again ah since we are talking about cultural
differences again you know the different frameworks of ethics developed in different cultures
like the buddhist and hindu bioethics they emphasize more on community and on humanity
to some extent because buddhism for example consider the essential oneness of oneself
and nature or the rest of the world and even in hinduism the broad ethical perspective
of hinduism when we talk about vasudeva kudumbakam and all kinds of things they also sort of
ah point to some sort of a unity of entire humanity or entire living creatures so there
is a conception that the entire world is a community a one unit with integral parts not
recognizing the individuality the uniqueness and the independence of individual units again roles of individuals has in the social
whole determine identities in these societies because we have already ah seen this you know
the idea of dharma when we have discussed ah the ancient indian bioethics which emphasizes
this concept of dharma dharma is often associated with a role and individual play in a particular
society so it is role based and ah the social role is very important here because what role
that individual plays in that society is important here that determines is dharma now the attempt
is to arrive at the balance as i already mentioned between the individual and collective welfare
ah by often sacrificing the former so even this was a concern even for the ancient societies
that you have to arrive at some sort of a balance between oneself and the society one’s
own welfare and the welfare of the society and the concept of dharma in the indian context
is largely used for this purpose but often it happens that when you try to strike a right
balance it becomes very difficult you may have to sacrifice yourself the individual
for the sake of the collective whole collective welfare and the stress is on duty for collective welfare
obligations and responsibilities are more important than rights so rights of the individual
become important only when you are able to treat and consider the individual as an independent
unit it is got this conception has got its advantages and disadvantages which will discuss
later now given all these facts we will also have
to see the present context of modern medicine as it is practiced in different societies
and different cultures we all know that modern medicine is an highly complex science and
as a science it presupposes certain universal premises certain universal principles and
it is followed in different cultures and different civilizations in the same manner as far as
a scientific aspect of medicine is concerned the diagnostic methods are concerned more
or less the same principles are employed the scientific principles are almost the same only the way in which it is practiced is different
in different cultures now in the beginning of this ah lecture i mentioned that the practicing
of medicine involves certain interest a various interest like economic interest social political
etcetera all these are part of that entire you know a process a social activity we called
we call practicing of medicine there are economic factors social factors political factors cultural
factors religious factors all these factors play very important role though we are practicing
a science which is a universal science which is based on universal premises on at the same
time we all know that though it is a universal science the practice of the science the practice of medicine is ah highly regulated domain there are regulations ah internal as well
as external medical bodies regulate themselves there are several medical bodies which we
have mentioned in the previous lecture that they regulate themselves they have ah prescribed
ah they have come up with certain regulations certain norms and standards which physicians
and other healthcare professionals have to follow when they practice medicine at the same time there are external governmental
regulations they have to follow so in one sense the autonomy which ah medical professional
communities employ are to some extent limited and there are of course the protocols the
norm’s legal guidelines and policy statements of hospitals of ah societies of countries
which are legally binding to some extent so in this context we will see what are the
mo.. major impetus for change in ah our society when we see medicine in our society or society
like ours countries like ours which are not ah countries where modern medicine has actually
emerged modern medicine is the product of european enlightenment so this has come to
civilization likes ah countries like ours through various processes and now we have
a decent medical institution in our country but the practice of this medicine demands
that we have to see it in a very different light we cannot we can no longer remain as
a ancient society which values traditional moral prescriptions we have to change our
value perceptions of course see for instance i sometime back i mentioned about the concept
of autonomy which is so central in the principalistic approach and in the practice of modern medicine
in many developed countries the individual patient is treated as the authority to take
decisions the final decision has to be taken by him
or her because the individual is considered as a person who has the ability to take decision
which is good for him he is an agent he or she is an agent a moral agent who knows better
than others what is good for him or her so this is a presupposition of enlightenment
europe which i sometime back mentioned about immanuel kant’s ethical theory the deontologism
or any such ethical frameworks presuppose such a concept particularly kantian theory
the the categorical imperative which kant talks about assumes that there is an individual
who can take independent decisions and ought implies a can i repeat but to say that these are all western and
ah to argue that since they are all western they are irrelevant in our country in our
culture in our civilization is ah not the right attitude because we have society has
changed a lot we have already undergone several decades of democratization our society has
undergone a lot of changes and democratization is ah very important part in that we have
become a democracy we are no longer those ancient societies what india was sometime
back so we have formulated a constitution with specification of fundamental rights and
now we conduct our country we rule our country on the basis of a very modern constitution
which emphasizes the so-called enlightenment values and most of us have come to agree that
these values are very important as far as india as a modern country is concerned we cannot do away with that so in that context
the constitution ensures that there are certain very important rights the constitution recognizes
the value of the individual value of a liberal free individual though at the same time the
constitution knows that ah recognizes that the individual is part of certain community
and all that but more important is individual rights wherever on occasions where human rights
are violated the courts will step in and try to protect the individual from communities
and societies and other individuals and institutions so this is very important and this is a very
important feature of democratization process which is not the case in other countries say
for example in pakistan this may not be the case because they still remain more or less
as a theocratic society where one particular religion and its ah principles are considered
as very important and most many of these principles are not really modern they have originated
several decades or several centuries back but most of the principles which we consider
in our constitution as valuable are modern they are rational they are based on rational
and they are open to rational deliberations and critical evaluations this process of democratization
is a very important feature very important phenomenon ah we have to take into account
when we deliberate upon modern-day bioethics in our country again the formulation of government
policies with public health initiatives many of ah the government policies in the examine
the whole history of health policy in india we could see that there is a definite aim
many of these policies are aimed at some sort of doing justice to society doing justice
to certain certain communities and sections of people in the society so to provide them better access to provide
them better quality and many other things are ah part of our policy deliberations and
they also value the modern values the modern theoretical frameworks then another very important
feature of our society is the active involvement of judiciary which is very striking which
is very important as far as ah our country like india is concerned and which is also
which also contributes heavily to the democratization process that still happens in our society
judiciary plays a very important and judiciary’s role is ah largely confined to the interpretation
of law and the law is actually provided by the constitution and the constitution i already
mentioned is based on certain values which are modern which are rational which are not
theocratic so in that way the active involvement of judiciary is very important and then another
one is media media plays a very influential role in the public perception and understanding
and deliberation of ethical issues many issues in ah recent in the recent past if you examine
many ethical issues have been discussed by the media by experts in the media and ah this
has helped a lot to significantly shape the perception of the public about ethical ah
issues say let us take one example classic example is the aruna shanbaug case
which has happened sometime back and ah in this case what is happen was the contribution
of judiciary to an ethical discourses phenomenon so that is the reason why i am taking up this
case here because this is one case which has gone to the court and the apex court has taken
a decision and come up with a verdict which is hailed as a balance verdict so what is
happen was ah it is interpreting and clarifying the legal aspects the court has come up with
ah a very clear interpretation of certain legal provisions that are available in cases
like this and it but at the same what is more important about this case is that it is quite
unprecedented in that way what is very important is that it initiated the aruna shanbaug case
initiated a larger discourse in the public domain which involved the scientific community
because the doctors and also pharmacist and many other scientific science people of science
were involved in this the supreme court actually took all their
inputs and help ah then the physicians ah nurses they also were very much part you know
nurses are the caregivers and they were looking after aruna for decades so their contribution
their inputs were also very important and treated as so by the supreme court then the
hospital administration where ah the the hospital in which aruna was admitted and she was she
spent her ah last days or rather the last few decades in her life social activist public
intellectuals ethicist media and finally and most importantly the judiciary so you could see that this aruna case is so
landmark case in the whole history of indian bioethics and indian judiciary because it
involved inputs are contributions from ah several walks of life several stakeholders
everyone likes communic.. scientist activist everyone was involved in this process and
contributed to the ethical deliberations and discourse that was happening and this is aruna one is her old photograph
and the other one is ah towards almost towards ah the time of death and the story has ah which everyone knows
after being sodomised while being strangled with a dog chain in 1973 she was largely brain-dead
so these are certain scientific facts which we have to underline she was largely brain-dead
cortically blind unable to speak or walk or have control over body movements so the question
is that whether we can to what extent we can consider aruna as a person as a person so
that you know you have to respect the the rights of a person and who takes decisions
because aruna is incapable of taking any decision and she is brain-dead if you if a person is
brain dead that is almost equivalent as considering as dead then again according to medical report
she is in a permanent vegetative state thats another very interesting and very important
input in this case so all these are considered by the court when a social activist named pinki virani
approached the supreme court with the plea to euthanise aruna which is again very unprecedented
in india because india indian law does not allow euthanasia active euthanasia where the
patient is ah being assisted by the physicians to end his or her life but here the ah social
activist ah pinki virani has approached the court with precisely that request and the
nurses at ah the hospital king edward memorial hospital in mumbai who were caring for aruna
oppose this plea and there was this whole argument the court reviewing the stellar care
given at kem by the nurses stated that the nurses were the next friend of aruna this
is a very interesting observation so the next friend since aruna has no agency since aruna is not in a position to take decisions for herself it is her next friend who can take
decisions for her and it is not activist like pinky virani who are arunas next friend but
the nurses who were caring aruna for the several decades and now we can see that there are several
questions raised and clarified by supreme court verdict like for example when can one
say that a person is brain dead and in a permanent vegetative state this is the clear scientific
question again what are the rights of such a person which is an ethical and legal issue
what are the responsibilities of the care providers and the state when a person is declared
to be in a permanent vegetative state again raises several social issues as well as ethical
issues the apex court provided clear guidelines on each question so that is what makes this
case landmark again it suggested that the need for collective deliberations this case actually points to the need for
a collective deliberations involving different stakeholders to arrive at clear and correct
see here ah we can see that the apex court has not unilaterally decided ah or come up
with a final verdict it has taken into account the inputs provided by all the stakeholders
so this fact makes the aruna case quite interesting and relevant now it also suggest that we need
to come up with new models of trust relationships protocols and contracts in our society because
as i already mentioned we are now trying to apply certain norms which have originated
certain ethical norms and standards and principles which do not have their conceptual roots in
our history they have originated somewhere else but for
certain historical reasons they have become now important in our context as well and this
demand certain considerations or rather reconsidered we need to reconsider certain existing models
the validity of certain existing models in our society like the models of trust between
physician and patient or rather in our traditionally in our society ah we believe that the physicians
are trusted by the patients there is an unquestionable trust but we now realize that this is no longer
valid again relationship between patient physician
family members others they have all undergone change and we have to come up with very clear
protocols to guide to ah regulate ah procedures and also decisions and actions taken by physicians
and other healthcare professionals so we need to arrive at a better clarity on roles obligations
and rights and this situation definitely raises a host
of issues so now ah let us see ah let us try to conclude with ah a larger picture so when
we try to situate modern bioethics in our country in society like ours in non-western
non-european societies we are now encountering a host of problems because there are problems
related to pollution poverty war terrorism and many other issues which are socio political
and economical in nature so we have to consider all these factors when we try to deliberate
upon bioethical issues and bioethical solutions industrialization of course is another very
important problem globalization of healthcare practices and procedures calls for certain
common guidelines and norms this i have already mentioned on the one hand we have differences
we are culturally different we are ah politically different we are socially different we are
economically different at the same time there needs to be some commonalities some common
frameworks we have to agree upon see for instance nobody can deny the importance
of confidentiality whether we are able to you know allow or rather afford to have confidentiality
is a different question privacy autonomy decision-making rights nobody can deny the value of these
ah concepts in today’s world because ah medicine is no longer those days ancient practices
healing practices it has become a complex scientific technological activity so we need
to assert we need to be sensitive to the rights of the individual and protect and try to protect
them so we have arrive at some common guidelines and again on the other hand we have to deal
with ah issues related to the question of social justice and ah tackle the newly emerging
technologies and the host of the kind of problems ethical issues they raise and threats to the
individual and personhood and many other issues right of patients ah decision-making process
the roles patients have in the decision-making process the possibility of exploitation and
harm all these aspects have to be taken into account when we try to situate or when we
try to understand what role modern bio med.. medical ethics has in our societies and patient
autonomy of course it will be interesting to see how the individual
is situated in ah these context even in our society even in countries like ours how the
individually situated the model of social self becomes often inadequate because i refer
to this concept of social self with many of our societies many of the societies which
are rooted in communities which still value community morality the social self is more
or less important than the individual self but the model of social self is becoming increasingly
inadequate in today’s world with the breaking down of traditional family system joint family
system that itself is a major change initiated a major change now we have nuclear families
and nuclear families will have very limited space very confined space iso.. insulated
space in which individuals have a possibility and ability to grow as individuals not as
collective groups or social selfs so technological and scientific situations
offer more opportunities now on the one hand there are certain positive opportunities these
technologies offered to these ah in our societies like lead a better life to be more independent
the technology helps us to be more and more independent to take independent decisions
ah and all that and also new forms of exploitation so on the other hand the darker side of this
technology is that it also leaves a lot of room for exploitation physicians and healthcare
other healthcare professionals even have hospital administration industries all possibilities
of exploitation are also available just to clarify this point which i’ve discussed
i will ah take a case of a living kidney donation case which is from the book which i have ah
given the details here the case happens in a particular ethnic background mister ab 57 years and arab citizen and father of three children two sons one is 22 years old a student and another one is 27 years a married man and a daughter who is 32 years old but unmarried he has acute chronic renal failure and all the three children were found to serve as
potential kidney donars now the youngest son was diagnosed as a most
resilient ah for this family’s choice that is very interesting is the 32 year old daughter
who is unmarried so this is a very typical situation the younger son with 22 years old
is being diagnosed as the most resilient for this but the family’s choice is a 32 year
old woman according to their ethnic background the unmarried female has an inferior family
status so obviously that is the reason for the family choice now psychological counselling
found that the right to refuse had not been considered by the family this woman had the
right to refuse but that has not been considered now what is what can we do such situation how does the modern bioethical deliberation
approach this case and what would be the solution it is a complex issue i am not here to provide
a solution to the problem i have just presented an issue just to show that how complex situations
are in different cultures whether to respect the family’s decision which is very important
in civilizations and cultures like this it is very important or we should respect the
woman the right of the woman to refuse which is again very important because such a problem
has occurred because of the technology which modern medicine has introduced so it is a
modern context that makes things much and much complicated like this so naturally we
need to respect or we need to also consider the ethical values which a modern society
advocate which emphasizes on individual rights autonomy and all that so it is a very complex
situation i am not trying to arrive at a clear-cut solution
to concrete issues like this which we come upon or which we encounter in our societies
my only suggestion is that as i mentioned when i discussed arunas case that it calls
for deliberations it calls for very detailed deliberation from different wakes walks of
life different stakeholders involved the inputs of scientific community the inputs of other
professional societies the input of inputs of legal experts of ah various other people
have to be sought and of course media has to take it up and discuss it so that we can
arrive at some sort of an understanding a common understanding which will help us to
or rather which will guide us to the right decision what we have arrive at is a realization that
there is only a very limited scope for universal bioethics because cultural differences cannot
be neglected but at the same time modern medicine is not philanthropic and not a charity affair
this also we have to keep in mind modern medicine is highly backed by industrial interest profit
maximization interest and various other ah you know power structures are sponsoring it
so we have to be very careful and in this context the individual is the more vulnerable
the most vulnerable entity is the individual so there is a need to come up and protect
the individual so that also cannot be avoided corporatization and technologization are also
rampant in the so-called non-european societies so we cannot say that these issues will not
figure in our societies are in non-european societies because they are also undergoing
what we broadly call as the modernization process and this technologisation or corporatization
offers possibilities to patients and also more situations where they may be
exploited so there are two sides of the coin which i have already emphasized that is on
the one hand the positive the possibilities and on the other hand the the negative possibilities
of exploitation and coersion so the principles of autonomy beneficence and non-maleficence
and justice which we have mentioned today modern bioethics considered as very important
principles they are not totally irrelevant in in other societies considering modern medicine’s
ability to cause because so is a very important ah the only thing is that these principles
have to be adapted culturally and this cultural adaptation process is not a very simple process
for that we need high-level deliberations we need a lot of deliberations a lot of discussions
and this ethical discourse has to develop in society like ours and we need to aim at
or aim towards a phronetic approach a phronetic means you know the emphasis the term phronesis
is used by aristotle and greek tradition to highlight the the difference of ethical ah
knowledge which is which is not which is practical wisdom the ethical knowledge is practical
wisdom which is different from technical knowledge or ah other kinds of theoretical knowledge
it is not a purely theoretical knowledge ethical knowledge is not theoretical purely it is
practical wisdom so one needs to know that there are certain
universal norms and the validity of the universal norms have to be accepted but one needs to
know how these universal norms can be applied to concrete context which are culturally and
ah politically economically determined and decided so this should be the kind of an ideal
which we are looking towards so this with this lecture i am winding up the introductory
part of my lecture series from the next lecture onwards we will try to see the theoretical
frameworks that have shaped the very nature of ethical deliberations in bioethics for
the time being we will wind up now thank you

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