The Cambridge textbook of bioethics

different numbers, for whichever of the G7 cared to increase its ODA to 1% first. Since each of the G7 is in the same boat as Italy, the corruption and waste objection at least begins by being irrelevant.

(2001). Life expectancy figures given are for 2003 and have been taken from the 2005 Human Development Report (UN Development Program, 2005), except in the case of Kerala, where they are for 1988–91 (Krishnan, 1997).

The cases

According to the non-ideal theory of justice we have discussed, which of our opening cases represent examples of global distributive injustice? What are rich nations obligated to do about it?

In Yemen, life expectancy (60.6 years) is less than 10 years below the global average (67.1 years). It, therefore, exceeds the cut-off point we added to the 1% obligation, in order to bring Rawls (1999) and his followers into our coalition of the willing. This means that, in non-ideal theory, Yemen is not a case of global distributive injustice. It also means that worse-off jurisdictions (those below the cut-off point) have priority over Yemen for receiving transfers from the G7.

In Zambia, life expectancy (37.5 years) is almost 30 years below the global average (67.1), well below the cut-off point. Zambia is, therefore, a case of global distributive injustice. Any nation in the G7 that has not already expended its 1% elsewhere – that is, every G7 nation (including Japan), since none has reached 1% – can make progress in discharging its obligations by transferring $1.627 billion annually to Zambia (i.e., $144 per capita) to improve the fundamental determinants of its population’s health. Zambia is one of the countries with priority over Yemen.

This chapter condenses and simplifies material from Sreenivasan (2002 and 2007), which interested readers may wish to consult. For more on current debates about international distributive justice, see Caney (2005, Ch. 4). For more on the social determinants of health, see Marmot and Wilkinson (1999). For more on global health and development, see Mehrotra and Jolly (1997) and Leon and Walt

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There is no doubt that modern clinical medicine in the West is practiced in a pluralistic and multicultural context. Yet nowadays, there is frequently a divide between the moral values of clinicians and those of their patients. Whereas many clinicians, whatever their own personal beliefs, ascribe to a basically secular morality that emphasizes such values as individual autonomy and social utility, many of their patients ascribe to cultural and religious traditions that emphasize such values as obedience to God and the responsibility of families and communities to care for their own. In addition, whereas it is usually quite easy to negotiate respect for the strictly ritual requirements of such patients in such areas as prayer and diet, it is more difficult to negotiate great differences in moral perspectives between clinicians and their patients when it comes to practical questions involved in medical treatment in general and the treatment of the patient at hand in particular. Sometimes these differences need to be more generally negotiated in the public policy discussions that take place in hospital ethics committees or even in legislative and judicial settings. Other times, these differences need to be more particularly negotiated on a case-by-case basis between clinicians and their patients and the patients’ immediate families, plus those from their traditional communities authorized by patients and their families, such as priests, rabbis, pastors, or imams, to provide them with moral guidance or even moral governance.

This section aims to acquaint clinicians with such potential differences between their moral values

and the moral values of their patients and their families and communities. It does not suggest, much less propose, ways that these moral differences can be negotiated in a clinical setting. This section is, therefore, descriptive and not prescriptive. Nevertheless, such information will surely be useful in making informed moral judgements when dealing with patients who come from the religious and cultural traditions discussed in this chapter.

Here the distinctive views on basic issues in biomedical ethics from a significant number of the world’s major religions and cultures are represented. The authors of these distinct contributions to this section of the book are all experts in the ethics of their respective religious and cultural traditions, especially in the way their traditions deal with biomedical questions. Despite their intellectual expertise in both the theoretical and applied ethics of their own traditions, the contributions of all the authors in this section will be easily understood by those having little or no familiarity with these traditions. Also, accessible references in English for further reading and inquiry are provided.

In terms of the relation of religion and culture at work in all of these contributions in one way or another, one can see that if ‘‘culture’’ is the way of life of a particular community having historical continuity from a premodern time into the present and intending to persevere into the future, then one can see that ‘‘religion’’ lies at the core of all these cultures. But what is ‘‘religion’’? Clearly, there is no one overriding general definition of a class called

‘‘religion’’ in which all the ‘‘religions’’ discussed here (or anywhere else) are simply its specific manifestations. Instead, one can only see certain overlappings between the various traditions themselves. That is, there are some things that some social phenomena usually called ‘‘religions’’ have in common with some other ‘‘religions,’’ and other things they have in common with some other ‘‘religions.’’ Nevertheless, perhaps one can say that what all of the religions dealt with in this section have in common is that moral decisions in all of them are made by reference to some transcendent reality; that is to something or someone beyond human making and human control. As such, ethics in all of them is in one way or another part of worship. Other than that, though, almost all the other commonalities are between specific cultural traditions rather than among all of them, let alone encompassing them all in some larger structure.

The force of various forms of what might be called traditional moral beliefs and sentiments varies from patient to patient. Some patients are quite articulate and coherent in expressing their moral beliefs and sentiments, or they are quite clear about whom they themselves designate to articulate these beliefs and sentiments for them. Other patients are less articulate, less coherent, and frequently less than wholehearted in affirming any traditional moral view for themselves. Then, there are patients who affirm no traditional moral view or who have rejected the traditions in which they were once participants, whether actively or only passively (as in the case of a tradition into which one was only born, yet recognized by others as being a member of it). Therefore, it is extremely important that the clinician should not only be aware of the tradition from which his or her patient comes but also should evoke from the patient just what his or her relation is to that tradition: wholehearted, halfhearted, rejecting, or non-existent. Frequently, especially in situations of long-term treatment, such information about the patient’s religious position is as important, or almost as important, as information about the patient’s physical condition. Minimally, such information should be sought

when the psychological state of the patient is being examined and assessed.

The recognition that the patient’s moral perceptions require attention in the clinical setting does not, of course, imply that those perceptions are correct or valuable for the whole process of clinical treatment. There are patients who are often very much misinformed about what their own tradition teaches about a particular moral issue. In fact, there are even times when a so-called ‘‘religious’’ position masks psychological pathology. Therefore, this section of the book, with its brief but accurate accounts of the moral positions on basic biomedical issues of the various traditions considered, can be helpful to a clinician when trying to ascertain whether a patient is accurately representing his or her own tradition on the moral question at hand, or whether the patient is expressing his or her private confusion or pathology. (Of course, such knowledge will be of no use to a clinician who considers all religion to be pathological per se, which is also an issue that needs to be examined when treating a religious patient.) Yet, even when a patient is correct about the position of his or her tradition on the moral question at hand in his or her own treatment and no psychological pathology is evident, such religious points of view cannot be allowed to dominate the ethical aspects of clinical decision making. These traditions should have a voice but not a veto. Clinicians and other healthcare professionals are bound by their own moral convictions, professional ethics, often by mission statements of the healthcare institutions where they work, and by the law. For example, the dominant role of the family in many traditionally based moralities can run counter to modern secular notions that only the autonomy of the individual patient is to be taken into consideration. This is especially important to note when a child is the patient and who cannot be expected to make his or her own moral decisions, but also in the case of many adults who would say that they freely accept the authority of their family and their traditional community (often seen as an extension of the family) to make major decisions affecting their lives and their health.

The attention of clinicians to the religious views of their patients can also enrich their own personal process of developing a cogent moral point of view. When this happens, there is genuine dialogue

between clinicians and patients and the communities in which they all live – both with each other and apart from each other. This section seeks to contribute to that ongoing dialogue.

Mr. A, a 70-year-old Aboriginal elder who speaks only Ojibway, is admitted to a tertiary care hospital for diagnostic investigation of possible prostate cancer. Initially, only a female interpreter is available, and she has difficulty translating the physician’s references to the penis while obtaining consent for cystoscopy. When asked to tell Mr. A that the procedure would aid in cancer diagnosis, she refuses to translate the concept of cancer directly and, instead, uses the word for ‘‘growth.’’ The patient responds that he does not fully understand the diagnostic test but trusts the interpreter and the urologist and agrees to sign the consent form. During cystoscopy, both his son and a male interpreter, are present to translate. Following the biopsy and other diagnostic tests, Mr. A, his son, the male interpreter, and the urologist meet. Addressing the son and the interpreter, the urologist explains that Mr. A has advanced cancer spreading to bone. When asked by the son about treatment, the urologist replies that any attempted curative treatment would probably cause more risk and discomfort than would pain relief and other palliative measures. The interpreter begins to translate the urologist’s summary, but his explanation of the diagnosis is interrupted by the son, who says that he will communicate directly with his father. He states that the interpreter should not have used the Ojibway word ‘‘manitoc,’’ which denotes cancer through the cultural metaphor of ‘‘being eaten from within,’’ and that direct reference to cancer and his father’s terminal prognosis will promote fear and pain. He adds that his father has given him responsibility to interpret and to act as his proxy decision maker. The son further opposes the physician’s attempt to communicate the prognosis directly to Mr. A, stating that direct references to death and dying

may ‘‘bring death closer.’’ The urologist argues that Mr. A needs to understand his diagnosis and give informed consent for possible treatment or the more likely palliative measures. The son replies that he will not lie to his father but that he needs time to communicate with his father through a more gradual and indirect process. The physician and son finally agree that the son will involve other family members over the next 48 hours. The physician and family arrange to meet again in two days and, in the meantime, to hold a ‘‘sharing circle’’ (Table 47.1, below) in which patient, family members, and caregivers will discuss palliative care and answer Mr. A.’s questions.

What is Aboriginal bioethics?

The literal translation of Aborigine is ‘‘the people who were here from the beginning,’’ which is not synonymous with ‘‘indigenous,’’ and referred to the Australian Aborigines. There are groups all over the rest of the word who are referred to as Aboriginal peoples and who have distinct cultures. This chapter is based on those in North America. Although philosophies and practices analogous to bioethics do exist in Aboriginal cultures, the concept of bioethics is not generally differentiated from the ethical values and frameworks for decision making that are applied in all dimensions of living. Accordingly, ethical values that may be held by Aboriginal people will be addressed rather than a formal, codified