Cultivating and Harmonising Virtues and Principles

Introduction

Pain, suffering, disease and sickness are the same among different people and in different cultures, but individuals and cultures deal differently with health and disease. Do we really want to have an option to choose between alternatives: between Eastern or Western traditions, between principles or virtues, between laws, regulations or ethics? Can or should there be different standards culturally and geographically in bioethics and in healthcare ethics in Africa, Asia, Europe and the Americas? Locally restricted traditional cultures seem to lose more and more exclusivity and dominance in a world of global travel, global business, global networks of information and communication, and multicultural urban centres and megacities. Will differences between traditional cultures become obsolete in an ever more rapidly developing universal global culture? Will healthcare and the treatment of patients become more and more standardised? Will quality norms for medical interventions and stanadardised reimbursements schemes replace traditional forms of individualised healthcare? On the other hand, as a result of migration and globalisation, we see Taoist and Hindi patients in Berlin hospitals, Christians and non-believers in Tokyo and Seoul, patients of different cultural backgrounds in megacities — such as Shanghai, Sao Paulo, New York — all being treated along the same local reimbursement schemes and quality standards of intervention. We also see rapid cultural changes in community-based tribal or rural areas towards modern technology and information-based individualistic cultures.

Modern challenges to healthcare and patient treatment seem to be global as well, similar in the East and West. For example:

1. 1. Standardised norms of treatment are devised and based on science and economy and not on compassionate and competent human-human interaction;

2. 2. The primary focus in healthcare ethics is on the ethics of experts and not on health education and ethics of lay people;

3. 3. There is an unfortunate disregard of the institutional and organisational settings, in which modern healthcare is delivered and financed;

4. 4. There is an absence of partnership ethics among stakeholders in keeping people healthy and in building healthy communities and healthy environments;

5. 5. The concentration on principles and rules, rather than on living, teaching and supporting healthcare virtues, does not promote trust-based communication and cooperation virtues; and

6. 6. Professional publications in bioethics and medical care show a disconnect with the history of medical ethics as the majority of references in articles is less than a decade or even shorter.

Principles and Virtues — Conflicting or Harmonising

The dominant set of biomedical principles, "autonomy, nonmaleficence, beneficence, justice", was originally developed in the USA to review and conduct clinical trials, after horrendous, immoral and inhuman abuse of prisoners by German, Japanese and US authorities occurred. Free, well-informed and autonomous consent by research subjects was the most reasonable common denominator in a pluralistic society rich in diverse values, visions and morals, but united by a legal constitution, guaranteeing basic human rights as civil rights. From here, the four principles have made their success into patient care, public health, and medical education, supported by the six editions of Beauchamp's and Childress' Principles of Biomedical Ethics¹ all over the globe, also sponsored by the World Health Organization (WHO), Council for the International Organizations of Medical Sciences (CIOMS) and other international bodies.

Autonomy in the classical European philosophical tradition of the Enlightenment had been criticised as to be inadequate to the disease/sickness setting of a compromised individual's capacity in free decision-making under pain, stress, dependence, ignorance, dementia or other compromised situations. This argument has been voiced in the East and West, where problems arose in applying the autonomy principle in hospitals, nursing homes, and in family and ambulatory care. Quite often, it is not an issue of autonomy, but a matter of communication and trust to evaluate the "interest" or "best interest" of the patient. Therefore, "autonomy" has been rephrased to "respect for autonomy" or "respect for persons", i.e., to the respect of individual values, wishes and fears. In the West as well as in the East, individual values and wishes have and will again and again clash with familial or communal values.

Medical ethics in all countries...