Autonomy, Beneficence, and Gezelligheid: Lessons in Moral Theory from the Dutch

A s i a n B i o e t h i c s R e v i e w S e p t e m b e r 2 0 0 9 Vo l u m e 1 , I s s u e 3 218 Autonomy, Beneficence, and Gezelligheid: Lessons in Moral Theory from the Dutch H I L D E L I N D E M A N N When bioethics was in its infancy, it was viewed as a distinctly American discourse, though faint snatches of conversation wafted in from England when the wind was blowing easterly. Of the 104 articles and case studies published in the Hastings Center Report in the first four years of its existence, only four looked beyond the borders of the United States. Now that the field has come of age, however, it has increasingly gone global. The International Association of Bioethics recently held its ninth World Congress, the journal Developing World Bioethics is eight years old, the World Health Organization’s Global Summit of National Bioethics Advisory Bodies has met regularly for the past seven years, and bioethics centers are found in every country from Albania to Zimbabwe.1 The globalization of bioethics poses a problem for American bioethicists. For one thing, as a culture, we Americans have never felt much need to understand how things operate in other parts of the world. In 2007, the U.S. State Department estimated that only about 27 percent of Americans carried passports, which suggests that as many as three-quarters of the people in the United States may never have visited another country.2 And because English is spoken widely around the world, many of us have never felt we needed to acquire other languages, either. More importantly, though, American bioethicists have not got the theoretical resources to work in cross-cultural settings. All we have are two approaches to ethics that are mostly at odds with each other, and neither of which is up to the job. In their enormously influential Principles of Biomedical Ethics, Tom Beauchamp and James F. Childress promoted the use of four middle-level principles that can be derived from almost any conception of the good and the right and are said to be applicable anywhere. Principlism, as it is now called, remains by far the most popular way to do ethics in the United States. According to the medical F R O M T H E H A S T I N G S C E N T E R R E P O R T 218–230 Asian Bioethics Review September 2009 Volume 1, Issue 3 219 A u t o n o m y, B e n e f i c e n c e , a n d G e z e l l i g h e i d H i l d e L i n d e m a n n sociologist Raymond de Vries, “Nearly all bioethical deliberations that occur in hospital ethics committees, in committees that advise professional bodies, and in research ethics committees invoke the four principles of autonomy, beneficence, nonmaleficence, and justice.”3 Less widely used but stubbornly enduring are narrative approaches to bioethics. These take many different forms, but they all accord stories a central role in moral matters: stories, it is variously claimed, are required to teach us our duties; to make actions, persons, or situations morally intelligible; to guide morally good action; and to justify our actions on moral grounds.4 Because stories capture the imagination and stir the emotions while principles can seem cold and cerebral, narrative approaches are prized for their celebration of our humanity — not a bad thing in health care settings where dehumanization can seem to be an institutional mandate.5 Each camp has its criticisms of the other. The narrativists (as I shall call them) are dissatisfied with the principlist’s one-size-fits-all approach: because the four principles are designed to be plugged in anywhere, they are too streamlined to engage the rich particulars of any actual situation. For the principles to do their work, concrete features of people’s embodiment, social position, and relations with others must...