Beyond a Western Bioethics: Voices from the Developing World (review)

This is an important addition to the bioethics literature. Throughout this groundbreaking, provocative set of reflections on healthcare and biomedical ethics in the developing world, Angeles Tan Alora and Josephine M. Lumitao, together with eight collaborators from the Philippines, illustrate the stark impoverishment of Western bioethics. As a field of inquiry, Western bioethics espouses a universal vision of autonomy as freedom from constraint on the pursuit of one's own understanding of the good life, unhampered by the vicissitudes of nature and social choice. Embodying thick understandings of the values of liberty and fair equality of opportunity, such a vision is incompatible with the taken-for-granted assumptions of traditional religions and cultures. Western bioethicists often simply assume that the focal point of the moral life is autonomous self-determination, where liberty, as the celebration of free individualistic choice, is integral to the good life for persons. Such a viewpoint dominates discussions of public policy—for example, national and international requirements of social justice—and accounts of moral rationality—including permissible standards of moral evidence and inference. In Beyond a Western Bioethics, the authors step outside of these customary assumptions and start anew. They thereby succeed where so many have failed: taking the Philippines as heuristic, Alora, Lumitao, et al. critically explore the challenges of framing a bioethics that speaks authentically to the developing world, to traditional cultures and religions. Such a bioethics, the reader discovers, possesses a radically different character.

In the Philippines ethics, and thus bioethics, is not primarily an academic discipline, an exercise in consensus formation, or the result of discursive rational argument. Nor is it the search for the guidelines of permissible human conduct in the general tendencies of nature, simple consequence comparison, or the assertion of basic human rights and cardinal moral principles, where the enterprise of morality can be undertaken largely outside of any particular cultural or religious assumptions. Filipino bioethics is richly embedded in the country's distinctive east-Asian culture, influenced by a predominantly Christian and Islamic religious background and the economic circumstances of the developing world. Here society, community, and religion assume a central moral role that has been lost to the West. Whereas Western bioethics focuses on the individual and is almost always expressed in discursive terms, Filipino bioethics is part of a living phenomenological world: "For the West, bioethics is a framework for thought, a conceptual system. For the Philippines it is a way of life, an embodiment of virtue" (4). Family relationships typically take precedence over individualism, with community needs and personal friendships deeply influencing behavior.

Traditional Filipino culture does not share Western obsessions for individuality, equality, and personal autonomy. Instead, the family is the basic social unit: it is the primary means of financial and emotional support, education, career, and healthcare. As Kuan and Lumitao note: "Family interests take precedence over those of the individual members" (23). Families as a whole participate in successes, honors, and shames. As a result, Filipino healthcare does not support patient-based confidentiality or individual-oriented informed consent. Consent is fully family oriented:

When a family member falls ill, he or she is considered to be in need of protection from the harmful effects of knowing the diagnosis, as well as the stress of decision making. Family members automatically take the role of patient advocate, even requesting that the patient not be told the diagnosis. The dominant authority figure (the mother or father) together with older extended relatives take it upon themselves to talk with the physician and decide among treatment options. (24)

Honesty is judged in terms of its function in maintaining important personal relationships (61). Physicians and family members may, out of compassion, lie to patients if it is perceived as maintaining personal or familial harmony and improving care. Such multifaceted concern is similarly apparent in decisions...