AFRICAN CULTURE AND MEDICAL ETHICS

by
Joseph Kenny, O.P.

for

Health-Related Biotechnology in Africa:
Ethical, Legal and Social Implications (ELSI)
of Transfer and Development
An International Workshop/Symposium

sponsored by

WORLD HEALTH ORGANZATION
NICEF/UNDP/WORLD BANK/WHO SPECIAL PROGRAMME FOR RESEARCH AND TRAINING IN TROPICAL DISEASES

In collaboration with
West African Biotechnology Workshops Series (WABWS)
West African Bioethics Program

and the
College of Medicine, University of Ibadan, Nigeria
Ibadan, Nigeria: 4-6 April 2005

African culture is said to revolve around the celebration of life. By life is meant not merely physical life, health of tissues and good functioning of the body, but also sharp senses and intellect in the pursuit of truth and goodness in the context of a community. This in some way approximates the American Constitutional phrase, "life, liberty and the pursuit of happiness". The only difference is that in African tradition this is a communal pursuit, whereas in America it is in the context of rugged individualism.

Medicine meets human life by facilitating conception, monitoring gestation and assisting birth. Thereafter it accompanies a person through life primarily by preventive medical care and, when there is need, by treating disease or damage from accidental or other forms of aggression. Finally, medicine meets a person preparing for death, and maybe afterwards by collecting organs for transplant. At every stage procedures have to be considered which require not only a medical but also an ethical, or may we say moral, assessment.

Foundations of medical ethics

Medical ethics, as any ethics, can have multiple foundations. Some of these are based on Enlightenment philosophy. We should be able to spot, however it is packaged, the utilitarianism of John Stuart Mill or Kant's deontologism. These approaches give rise to an ethics, but one that is flimsy, based on select advantages a policy may deliver, or its anthropological acceptability, or on the legal support it may happen to have, or the backing that certain intelligentia give it.

On the other hand, teleological and personalist approaches have older and more perennial roots. These give rise to what is not mere "ethics" in the popular sense, but can properly be called "medical morals", which considers the intrinsic rightness or wrongness of any procedure. A clash between ethics and morals occurred in February of this year, when "a judge recommended that a Roman Catholic pharmacist in Wisconsin be reprimanded and required to attend ethics classes after the pharmacist blocked a woman's attempt to fill a prescription for birth control pills in 2002."[1] This could be compared to ordering a Muslim to take an ethics course because he would not sell alcohol. Opting out of active cooperation in something morally objectionable can become a clash with legal ethics.

Besides different philosophical approaches, we find the voices of Christian churches, Islam and Traditional Religion. The latter determines the cultural bias inherited by people of all religions, while the Christian churches and Islam add a Scriptural reference into the discussion, creating among their adherents a new composite cultural sensitivity and ethical tradition.

On the international scene, the Catholic Church has produced some of the most detailed and systematic treatises on medical ethics, incorporating Scripture, philosophy, culture and scientific data.[2] Muslims have also entered the arena, and medical ethics has become a major programme in the secular academia.

An African Christian and Islamic consensus

The ethics of traditional society in Nigeria, coupled with Christian or Islamic norms, has constituted a widely accepted moral standard, focusing on respect for life. The following are some of the Christian or Muslim values that have reinforced or coalesced with or sometimes sublimated African traditional values:

In the Old Testament

The first chapters of Genesis set the tone that prevails throughout the Old Testament. Man is made in the image and likeness of God (1:27). The drama of Cain killing Abel (chapter 4; cf. Job 16:18) points not only to God's concern for the innocent, but also for the guilty Cain. And Abel's blood crying to God from the earth announces the sacredness of life focused in its primary symbol, blood (Cf. Gen 9:6). Violating the sacredness of life entails the death penalty (Ex 21:12 ff.; Num 35:16 ff.). Shedding the blood of animals in sacrifice in substitution for human blood was a symbolic expression of the covenant submission and consecration of human life to God (Lev 1; Ex 24), we could say an expression of islâm in the fundamental meaning of the word.

The New Testament

The Old Testament is so emphatic about the sacredness of life that one would think nothing could be added. Yet the New Testament introduces a radically new perspective. The symbolic covenant consecration of human life in the Old Testament gives way to a new covenantal relationship in which human life is really received by God and allowed to share in his own life. This is primarily realized in the incarnation of the Word of God (John 1); it is extended to all humanity who, by faith and sacraments, are made brothers of Christ (Heb 2:11) and members of his body (1 Cor 12:12 ff.).

In a concrete way this relationship of men to God and to one another is manifested in a law of love which is both more emphatic than the Old Testament (Rom 13:8-10; Jn 13:34-35; 15:9-17) and more demanding in its moral applications, as shown in the Sermon on the Mount (Mt 5-7).

Life became a sacred communion with the divine and at the same time a renunciation of self-centeredness in favour of outreach to the well-being of others.

The Qur'ân and Islamic tradition

Islamic ethics is founded on God's initiative in creating men and guiding them, particularly through prophets. Man's response is meant to be one of submission, or islâm. This is expressed fundamentally by faith in God and his revelation, then by obedience to God's law. Regarding respect for life, we can note particularly the following passages:

The erosion of this tradition

While the African traditional plus Christian or Islamic ethical perspective has been good and has influenced countless individuals and social structures, it always has had to coexist with sin. We can say the same of any good ethical system anywhere or any time. We cannot look back, say to pre-colonial Africa, and romanticize about a golden age that never existed. Sin has always been there. But at present the ethical consensus that prevailed in Nigeria has been shaken by two factors:

What we see now is not a conversation between the heirs of African values and proponents of global modernity, which could lead to an evolution of African values, but we see African values being abolished and replaced by imported secular ones. The needed conversation, if it can be launched, should lead to an African concept of modernity and a modern concept of Africanness.

Problems

The problems medical ethics has to face are many.

Conception can be assisted by the timing of copulation or by fertility drugs. It is quite another thing to manufacture babies in vitro or by cloning, whether for implantation, after selecting and expending the rest, or for the purpose of harvesting stem cells. A critique of this practice involves both fundamental principles of respect for life and a consideration of negative consequences. For instance, a fetal stem cell is a wild card. It can develop into anything whatsoever, like a tumor or something totally unintended. Marrow transplant, such as Mr. Alonge of the U.C.H. Surgery Department did on my leg, is a different proven sort of stem cell treatment.

There are ways of finding out the sex and the physical condition of a baby in the womb. If the baby does not measure up to expectation, in some places it can face abortion. In India now many young men have to forego marriage because there are not enough marriageable girls to go around, as a result of aborting girls.

African traditional society had no place for abortion, and in some places the guilty would be punished by death. In Nigerian cities today, however, the practice is rampant.

When a young girl comes for abortion, there is a need to link her to social services to provide an alternative: a place to have her baby and a way to place it for adoption by a childless couple yearning to have a baby. Unfortunately abortion becomes a profit-orientated industry, as in the U.S., where procedures are provided instantly and without question at any point of the pregnancy in exchange for paying the fee. The providers of such services have no interest in suggesting to the girl an alternative solution.

By way of contrast, I refer you to the work Abdul Sattar Edhi is doing in Pakistan.[4] Over a period of fifty years he has built up a private foundation to provide medical and medical-social service to the poor of Pakistan, currently running on a $10,000,000 budget. It does not operate on a give-away basis, but attempts to get people to stand on their own feet and help themselves and one another. Outside every Edhi center there is a cradleCshaded from the sunCwhere unwanted babies can be left anonymously. The centers care for them and arrange for adoption. In some Muslim countries, as Egypt, the fundamentalists win popular support by providing inexpensive excellent medical care in mosque clinics. Nigerian Muslims, however, in spite of the high number of their medical personnel, have yet to move seriously as a body into community health care, expecting an incompetent government to manage this and Sharî`a as well.

If a baby scales through to birth, it has a better chance of having its life respected, although we hear of babies here and there tossed onto dust bins or abandoned at places where they can be picked up. Often parents find it difficult to provide adequate feeding, and when sickness does come they cannot afford treatment. It is a major challenge for the medical world to accommodate the problem of indigence. In the U.S. there formerly were charity hospitals run by religious people, but these have been forced out of business by expensive high-tech innovations, mal-practice insurance and the formation of profit-orientated hospital chains. No mercy is shown to those who do not have health insurance and cannot afford to pay. I am only grateful that I am over 65 and can make use of MEDICARE, which pays for about 80% of any medical bills I incur in the U.S.

In this context, we should weigh the merits of government versus private medical provision. Government is usually not very good in managing any business, and we hear the call for privatization as the answer. On the other hand, there must be good and well implemented legislation to supervising private practice and helping it to interface with community needs.

In Nigeria mal-practice suits are not common, and that ought to make medical treatment more affordable. In any case, the health of patients demands competency on the part of medical personnel. It is malpractice to take a "let my people go" attitude towards medical students who are doing poorly.

Just last month a student came to me asking to defer his exam because he was suffering from a very painful boil in his buttocks. He had been to a clinic and the doctor prescribed anti-biotics, but he found no improvement. Then a Benedictine monk who deals with herbal medicine took a look at it. He brought a teaspoon of palm oil and smeared it on the aperture. As he predicted, the white spot inside protruded and began to lick the palm oil. It was a worm. A firm squeeze brought out a healthy white maggot-looking worm which began wiggling on the ground. If this were Europe or America, one might have called in a lawyer.

As death approaches, other ethical choices have to be made. Traditional norms do not permit people to suggest that the person is going to die or to start burial arrangements. Yet the dying person on his or her own may raise the question of death. The person has a right to know his condition. He should be free to accept or reject pain-killers that reduce his mental alertness. It is a problem to counsel a person to accept death and perhaps make a will or any other necessary arrangements, including the donation of organs.

Conclusion

We observed the need for a conversation between the heirs of African values and proponents of global modernity, which could lead to an evolution of African values. Otherwise, we would find the majority giving way to imported secular values, while traditionalists who refuse modernity incarcerate themselves in an undifferentiated past.

African culture and ethics should not be considered an antiquity to be consigned to the museum, but as something living and capable of adapting to changing circumstances. It did this when it came into contact with Christianity and Islam. It can do it again when confronted with the realities of a high-tech society. It is a question of critically examining the ethics of secular western society, filtering out what is wrong or inapplicable, absorbing or adapting what is good, and grafting it onto one's own philosophy or world-view.

Such a conversation should result in an African concept of modernity and an modern concept of Africanness.

Questions

  1. Discuss the nature of traditional Nigerian ethical norms and their distinctiveness in the face of norms brought in by "globalization".
    • Identify African/Nigerian traditional norms affecting medical practice.
    • Discuss how these were modified by Christianity or Islam.
    • Discuss how these survived and were incorporated in Christian/Muslim society.
    • Evaluate their present strength in a changing society.
    • Show how traditional norms concur or conflict with norms accepted and exported by Western nations.
  2. Propose ways of making medical care responsive to social needs.
    • The question of indigence
    • Other options for abortion applicants
    • Preventative medicine education
    • Education on how to care for simple things without a doctor
    • Careful use of herbal or locally manufactured medicine

REFERENCES

Ashley, Benedict M. & O'Rourke, Kevin, Health care ethics, a theological analysis. St. Louis: The Catholic Health Association of the United States, 3rd ed. 1989.

Varga, Andrew C., The main issues in bioethics. New York: Paulist Press, 1984.

National Conference of Catholic Bishops (U.S.), Documentation on the right to life and abortion. Washington D.C.: United States Catholic Conference Publications Office, I, 1974; II, 1976.

General:
http://www.foresight.org/Nanomedicine/Ethics.html - a vast number of links to texts and sites of all persuasions.
http://library.colstate.edu/resources/m_eth.shtml - another large collection of links.

Catholic:
http://www.catholiceducation.org/directory /Current_Issues/Medical_Ethics/ - lively discussions of many issues
http://www.catholicculture.org/docs/doc_view.cfm?recnum'2774 - paper by Dianne N. Irving
http://www.ecatholicism.org/category.cfm?Category'15 - important links

Islamic:
http://islam.about.com/library/weekly/aa072700a.htm - brief statements with links
http://www.islamicmedicine.org/ethics.htm - a book of articles on every aspect of medical ethics
http://www.islam usa.com/im1.html - another Islamic textbook, comprising articles by different authors.

NOTES

1. http://www.cnn.com/2005/US/04/01/birth.control.governor.ap/index.html.

2. Some of the more important Papal and other Roman documents on bioethics are: Congregation for the Doctrine of the Faith, Declaration on Procured Abortion (1974), Declaration on Euthanasia (1980), Instruction on Respect for Human Life in its origin and on the Dignity of Procreation: Replies to Certain Questions of the Day (Donum Vitae), 1987; Pope Paul VI, Encyclical Letter, On the Regulation of Birth (Humanae Vitae), 1968. Pope John Paul II has made countless statements, among them: Apostolic Letter, On the Christian Meaning of Human Suffering (Salvifici Doloris), 1984; To All the World's Bishops on Combatting Abortion and Euthanasia May 19, 1991; Evangelium vitae, 1995; Fetus as a Patient, Discourse to International Congress, April 3, 2000.

3. Abundant information on U.S. programs in Nigeria dating from 1987 (though in abeyance during the Abacha administration) can be found on the website: http://www.africa2000.com.

4. See Richard Covington, "Humanitarian to a nation," Saudi Aramco World, Nov/Dec 2004, 33-43; available also on:
http://www.saudiaramcoworld.com/issue/200406/humanitarian.to.a.nation.htm.