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Jonsen, A. R., Siegler, M., and Winslade, W. J. (1998). Introduction. In Clinical Ethics, 4th edn, ed. A. R. Jonsen, M. Siegler, and W. J. Winslade. New York: McGraw-Hill, pp. 1–12.

Murphy, T. F. (1995). Sperm harvesting and post-mortem fatherhood. Bioethics 9: 380–98.

Royal College of Physicians and Surgeons of Canada (2001). General Standards of Accreditation. Ottawa: Royal College of Physicians and Surgeons of Canada (http://rcpsc.medical.org/residency/accreditation/gen standards_e.html) accessed 14 June 2006.

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Bioethics Education Project. Ottawa: Royal College of Physicians and Surgeons of Canada (http://rcpsc. medical.org/ethics/index.php) accessed 14 June 2006.

Shalit, R. (1997). When we were philosopher kings. The New Republic 28: 24.

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Singer, P. A., Cohen, R., Robb, A., and Rothman, A. (1993). The ethics objective structured clinical examination.

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Appendix: bioethics teaching resources

The Royal College of Physicians and Surgeons Bioethics Education Project (http://rcpsc. medical.org/ethics/index.php) provides curricular modules for teaching bioethics to residents in medicine, surgery, obstetrics and gynecology, psychiatry, and pediatrics.

The College of Family Physicians of Canada has prepared a bioethics curriculum that is available on its website (www.cfpc.ca/English/cfpc/ communications/health%20policy/Bioethics% 20Curriculum/default.asp?s-1).

The Canadian Bioethics Society website (www. bioethics.ca/) provides links to university bioethics centers and bioethics organizations throughout Canada.

Useful websites for US organizations include the US National Institutes of Health Bioethics Resources on the Web (www.nih.gov/sigs/ bioethics); the Georgetown University Kennedy Institute of Ethics (www.georgetown.edu/ research/kie/) and the Georgetown University National Reference Center for Bioethics Literature (www.georgetown.edu/research/nrcbl), which holds the center’s database of bioethics organizations and provides assistance for using BIOETHICSLINE, an online medical ethics database available through Internet Grateful Med (http://www.frame-uk.demon.co. uk/guide/grateful_med.htm). The American Society for Bioethics and Humanities offers multiple resource links on its website (www. asbh.org); The Center for Law and the Public’s Health at Georgetown and Johns Hopkins website (http://www.who.int/ethics/en/) links to national and international ethics resources.

The International Research Ethics Network for Southern Africa (http://www.irensa.org/cgi/ about.cgi) provides educational resources, regional contacts and news on current research.

UNESCO Bangkok website (http://www. unescobkk.org/index.php?id=41) provides a downloadable textbook and accompanying teacher’s guide. The site also links to multiple regional bioethics resources and organizations.

The Bioethics and Society Research Registry, Oxford University website (http://www. bioethicsandsociety.org/) provides links to bioethics courses offered in the UK.

The Council of Europe Bioethics Division website (http://www.coe.int/T/E/Legal_affairs/

Legal_co-operation/Bioethics/) provides news and links to bioethics events in Europe.

The International Association of Bioethics website (http://www.bioethics-international. org/iab-2.0/index.php?show=index) is a good venue for communicating with colleagues from around the world.

More extensive educational programs that are accessible to clinicians while they continue their professional work include the Alberta Provincial Health Ethics Network Distance Education

Course: Introduction to Bioethics (www.phen. ab.ca/disted/); the MHSc Bioethics Program at the University of Toronto Joint Centre for Bioethics (www.utoronto.ca/jcb/Education/ mhsc.htm); the Medical College of Wisconsin Center for the Study of Bioethics distance learning programs (http://www.mcw.edu/ bioethics/depage.html); and the Alden March Bioethics Institute at Albany Medical College (http://www.bioethics.org/), which provides formal graduate training to clinician–teachers.

In an increasingly interdependent world we are all threatened by widening disparities in wealth and health, and by failure to achieve the goal of more widespread respect for basic human rights. In such a world, further complicated by significantly different cultural perspectives on the good life, it is necessary to consider how relationships between individuals, institutions, and nations should be structured in order to reduce injustice and improve prospects of human well-being, peace, and security.

In Ch. 43, Solly Benatar outlines global disparities, defines global bioethics, argues that global bioethics is important, and examines how crosscultural differences could be considered and reconciled in theory and in medical practice without resorting to moral relativism.

In Ch. 44, Jerome Singh examines the legal and ethical responsibilities of health professionals in relation to care of those who are victims of torture and degrading treatment. After defining dual loyalty and describing how dual loyalty dilemmas arise, he refracts the rights of detainees through the ‘‘lens’’ of the principles of biomedical ethics, and shows how international human rights law, several United Nations Resolutions and international medical ethics guidelines provide a framework for protecting such vulnerable persons. His chapter, inclusive of a description of how it is possible for those in authority to become complicit in abusing detainees, is of special topical interest given the

recent treatment of detainees in Guantanamo Bay and Abu Ghraib prisons.

The HIV/AIDS era has focused world attention on lack of access to essential life-extending drugs for millions of people. Moving from concerns about individuals to concerns for whole groups of people, Jillian Clare Cohen and Patricia Illingworth address in Ch. 45 the question of how access to medicines for all could be improved. They attribute the imbalance in access at a global level to government and market failures and then describe how changes to TradeRelated Aspects of Intellectual Property (TRIPS) coupled to enhanced corporate social responsibility could facilitate improved access to necessary drugs globally.

Moving to what ought to be done to narrow injustice at a global level, Gopal Sreenivasan concludes the section by arguing in Ch. 46 that, in the absence of a theory of international distributive justice to which all could agree, it would be possible to reduce disparities in wealth and health significantly through the application of ideas emanating from a theory of non-ideal justice.

A clinician might ask, ‘‘Why should clinicians care about global health ethics? I am already faced with a multitude of local ethical dilemmas and issues, why should I think global bioethics affects my clinical practice?’’ Firstly, because this book is aimed at clinicians in both industrialized and developing nations, it illustrates that, to varying degrees, there are problems in many healthcare

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settings with access to and distribution of medical services and in respecting human rights. Secondly, clinicians practicing in the industrialized world should have some sense of solidarity with their colleagues in the developing world, especially

regarding some of the more pressing issues they face. Thirdly, it highlights to clinicians the importance of recognizing the existence of reasonable ethical pluralism in bioethics and how different cultural and political conditions affect

our conception of bioethics in industrialized nations.

The chapters in this section do not attempt to deal comprehensively with all aspects of global bioethics and global health ethics. However, we hope that they provide readers both with a sensitizing introduction to a broad set of ethical considerations on issues that impact profoundly on the health of whole populations and with references through which to pursue further study.

The AIDS Clinical Trials Group Study 076 (ACTG 076) made an important contribution to prevention of HIV infection when it established that mother-to-child transmission of HIV (MTCT) in the USA and France could be significantly reduced by giving antiretroviral drugs to pregnant women orally for 8 weeks or more prior to childbirth (median 14 weeks) and intravenously during labor, as well as to the newborn child for 6 weeks in the absence of breast feeding (Connor et al., 1994). A major controversy developed when in subsequent studies of MTCT in developing countries shorter courses of treatment were compared with placebo. Although there is no reason to believe that the ACTG 076 regimen would not work in developing countries if it could be applied, placebo studies were undertaken instead. The rationale was that use of the ACTG 076 regimen was precluded in developing countries, not only by its extremely high cost but, more relevantly, because women do not present early enough in pregnancy to receive this prolonged and intensive regimen. In addition they are anemic and malnourished, unable to stop breast feeding, and have difficulty providing treatment to a child for a six-week period (Varmus and Satcher, 1997). Consequently, cheaper and more easily applied preventive methods needed to be studied to enable rapid application of this preventive method to save many lives in developing countries.

What is global health ethics?

Global health ethics is a suggested means through which to promote widely values that include

meaningful respect for human life, human rights, equity, freedom, democracy, environmental sustainability, and solidarity (Benatar et al., 2003). It is contended that failure to pursue adequately such values that play an essential role in improving population health is the underlying basis for new threats to health, life, and security within nations and across the world. Global health ethics could promote this set of values – which combines genuine respect for the dignity of all people and a conception of human development that goes beyond that conceived within the narrow, individualistic ‘‘economic’’ model of human flourishing (Doyal and Gough, 1991; Bensimon and Benatar, 2006). Foremost among the values to promote is solidarity, without which we ignore distant indignities, violations of human rights, inequities, deprivation of freedom, undemocratic regimes, and damage to the environment.

A framework that combines an understanding of global interdependence with enlightened long-term self-interest has the potential to promote a broad spectrum of beneficial outcomes, especially in the area of global health. Health and ethics provide a framework within which such an agenda could be developed and promoted across borders and cultures. An extended public debate through a multidisciplinary approach to global health ethics could promote the new mindset needed to improve health and to deal with threats to health at a global level.

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That mindset requires recognition that health, human rights, economic opportunities, good governance, peace, and development are all intimately linked within a complex, interdependent world. The challenge of the twenty-first century is to explore these links, to understand their implications, and to develop processes that could harness economic growth to human development, narrow global disparities in health, and promote peaceful coexistence. This process requires that interest in health and ethics be extended beyond the micro level of interpersonal relationships and individual health to include ethical considerations in relation to public and population health at the levels of institutions, nations, and international relations (Benatar et al., 2003).

A global agenda must, therefore, extend beyond interpersonal ethics and mere rhetoric on universal human rights to include greater attention to individual and institutional duties, social justice, and interdependence. The relatively new interdisciplinary field of bioethics, when expanded in scope to embrace widely shared foundational values, could make a valuable contribution to the improvement of global health. A vision, discussed in detail elsewhere, offers a way forward for global health reform through five transformational approaches (Benatar et al., 2003):

developing a global state of mind

promoting long-term self-interest and not merely short-term interests

striking a balance between optimism and pessimism about globalization

developing capacity in disadvantaged groups

achieving widespread access to public goods such as education, basic subsistence needs, and work; this requires collective action, including financing (to make sure they are produced), and good governance (to ensure their optimum distribution and use).

Why is global health ethics important?

Global health: disparities and implications

Since the birth of modern bioethics in the 1960s, the world has changed profoundly. Major expansion

of the world economy has been associated with spectacular progress in science, technology, knowledge, healthcare, and in speed of travel and communication, which have been beneficial for many. The dark side of progress includes widening disparities in wealth and health, rapid population growth, the emergence of new infectious diseases, escalating ecological degradation, numerous local and regional wars, a stockpile of nuclear weapons, and dislocation of millions of people (Benatar, 1998). The gap between the income of the richest and poorest 20% of people in the world increased from a nine-fold difference at the beginning of the twentieth century to 30-fold by 1960 – and since then to almost 80-fold by 2000. The gap in health status across the world has also widened (Benatar, 2001). This is illustrated by the fact that although life expectancy improved dramatically worldwide during the second half of the twentieth century this trend has been reversed in the poorest countries in recent years (Kaiser Network, 2006). The emergence and spread of new infectious diseases pose de´ja` vu dilemmas and, together with new terrorist threats, demonstrate how interconnected we all are (Singer, 2002). The recent epidemic of severe acute respiratory distress syndrome (SARS) (Booth et al., 2003; Lee et al., 2003) is a small-scale example of the new, acute, rapidly fatal infectious diseases that may, like the 1918–19 influenza epidemic, sweep through the world with high mortality rates in all countries and accompanying profound social and economic implications. This recrudescence of a public health threat also provided ethical insights into the implications of the interconnectedness of individuals and society and the need to reconsider the ethics of overriding individual rights (Singer, et al., 2003). Consequently, in the first decade of the new millennium we face the grim reality of human life, health, and security being under severe threat.

Growing global instability and threats to human security and well-being from the widening gulf between the world’s ‘‘haves’’ and the ‘‘have-nots’’ call for new ways of thinking and acting. Distinctions between domestic and foreign policy have become blurred, and the need for coherence between local

and international policies is increasingly being acknowledged. Public health, even in the most privileged nations, is arguably now more closely linked than ever to health and disease in impoverished countries. Under such circumstances, linkage of local action to an expanded global health agenda based on shared values and the application of new concepts in public health ethics (Nixon et al., 2005) could facilitate significant improvements in global health.

Cross-cultural considerations in bioethics

In a world characterized by many different value systems and cultures, wide disparities in wealth and health, and common threats (for example new pandemics and environmental degradation), it is of special importance to give consideration to whether there are universal ethical principles that potentially bind us all more closely than we appreciate. If there are, how could these be applied rationally in specific social contexts? This is important both in relation to clinical care of patients (Berger, 1998; Bowman, 2004) and in international collaborative research (Benatar, 2004a).

Rather that attempting to review the extensive debate on ethical universalism and moral relativism (Horton, 1995; Macklin, 1999; Beauchamp, 2003; DeGrazia, 2003; Turner, 2003; Hinman, 2006), I explore here whether areas of disagreement in making ethical decisions may be explicable by failure to understand others and by differing perceptions of social relations. I shall suggest that universal ethical principles applied through moral reasoning, with appropriate consideration of morally relevant local factors, could allow us to find a rational middle ground between the seemingly polarized perspectives of ethical universalism and ethical relativism.

There are two requirements for finding such middle ground. Firstly, it is necessary for scholars to acquire deeper insights into their own value systems and the value systems of others. Secondly, and of equal importance, is the need to avoid either

uncritically accepting the moral perspectives of all cultures as equally valid or rejecting them all as invalid. Instead, and despite the shortcomings perceived by some of such an approach, moral reasoning should be used to evaluate when and how local considerations can be morally relevant in the application of universal principles in local contexts.

Understanding others

Understanding others is essential in a globalizing world. Understanding ourselves and others requires what Ninian Smart (1995) has called ‘‘structured empathy’’ and ‘‘cross-disciplinary study of world views/belief systems.’’ Belief systems provide ways of ‘‘seeing’’ the world that, ‘‘through symbols, actions, and mobilization of feelings and wills to act . . . serve as engines of social and moral continuity and change’’ (Smart, 1995). As world views represent powerful and different starting points from which people think and argue (and generate conflict), it is necessary to understand how they are constructed, used, and abused. While Smart describes several dimensions of world views with special emphasis on these dimensions within religions, his analysis is also relevant for secular world views (Smart, 1995).

Understanding others also requires mutually respectful dialogue. Martha Nussbaum (1997) eloquently argued that three capacities are essential for intelligent dialogue and cooperation between people from different backgrounds in today’s interdependent world: (i) the capacity for critical examination of oneself and one’s traditions, (ii) the capacity to see oneself as bound to all other human beings, and (iii) the capacity to imagine what it might be like to be in the shoes of a person very different from oneself. Jonathan Glover (2001), in his descriptions of numerous genocides across the world during the twentieth century and his quest for understanding why these are perpetrated, concluded that it is only our moral imagination that could enable us to significantly alter our outlook and actions.