- A Clinical View of Western or Eastern Principles in a Global Bioethics
There is increased knowledge in the lay public about issues in healthcare, particularly in the availability of choices and the exercise of these choices. Accompanying population migrations particularly in an East-West direction and interracial and interreligious marriages have resulted in the need for peoples of varied cultures to live in close proximity to each other and to be involved in each other's lives. The extreme mobility possessed by healthcare professionals and the increasing tendency for the sick to travel out to seek treatment has resulted in the healthcare sector becoming a domain where cultures have come close to each other. The attendant tensions are familiar to the medical practitioner. One result of this tension is the suggestion that there exists an Eastern and a Western set of ethical principles.1,2 A debate on what should prevail has ensued.3,4 Eastern culture is greatly influenced by Confucian, Islamic and Hindu beliefs. Its values like compassion, filial piety, duty, benevolence and a family and community orientation are important not just to Easterners but also to Westerners. These values are the manifestations of a culturally sensitive application of a deeper understanding of the primary ethical principles.
I shall in this paper, through illustrative cases and data from empirical studies, build on the thesis that the primary ethical principles of autonomy, beneficence, nonmaleficence and justice are universal to all peoples, and that it is only their culturally-coloured interpretations and applications that present an apparent difference in values. The illustrations will also show that culturally sensitive application of ethical principles is necessary to end the debate and to strengthen ethical medical practice. The illustrations are primarily drawn from [End Page 3] medical practice in Singapore, a multicultural nation having an extremely high population density. Our main cultures have their sources from Confucian, Islamic, Hindu and Christian beliefs and traditions.
The Different Faces of Autonomy
A deeper understanding of the many faces of autonomy leads to a broader perspective on how people may differently exercise their autonomy. Recently, a South Asian lady presented at our public tertiary hospital delivery room in labour and with features suggestive of impending rupture of the uterus. An urgent caesarean section was proposed to which the lady agreed. However, she and her husband insisted that their religious faith required that the procedure be conducted by an all-female team; even the person who was to push her trolley had to be a female. There were no other accompanying relatives. We were unable to meet this couple's unique requirements and advised that because of the urgency, they reconsider their demand. A colleague from the same religious faith counselled them but in vain; the husband stood firm on this decision, prevented anyone from even speaking to his wife and declared that he would take responsibility for any consequence. He demanded discharge against medical advice. The wife was fully conscious and appeared to be rational; she did not appear fearful of her husband and appeared to be very comfortable and in agreement with the husband's position. Nevertheless, she never verbally expressed her decision and her real thoughts were not known.
An emergency consultation was made to the Hospital's Ethics Committee. Their advice was first to establish from the senior management of the hospital if they were prepared to use their authority to mobilise the resources that will enable the request to be met. Management found no administrative or ethical justification to do so and advised that the couple be immediately provided assistance in transferring to a facility that could accommodate their respect. The two other public hospitals that provide emergency obstetric services were approached; they declined to accept as they did not at that time have an all-female team. They also could not operationally afford to create the existence of such a personalised service. A private hospital agreed and the couple readily agreed to the transfer. Upon reaching that hospital, the couple revealed that they did not have the means to pay for private services. In fact, they did not even have the money to pay for the private...