“We are the children of our landscape”

Lawrence Durrell, Justine (Alexandria Quartet)

Bioethics education reduced to teaching students how to balance a small number of philosophical principles without attention to indigenous values and existing political and socioeconomic realities can convert an important undertaking into a meaningless activity with little impact on the ground. At the heart of this lies the popular analytic, rational framework, Principlism, offered by American philosophers Tom Beauchamp and Jim Childress and which has come to dominate our region of the world (1). Principlism, relying on four easily memorised, mid-level philosophical principles – respect for autonomy, beneficence, nonmaleficence and justice, is being perceived by many as the essence of biomedical ethics and the all-purpose tool with which to approach complex ethical situations.

According to Beauchamp and Childress, these four principles provide the basis for a “common morality” which transcends local values and cultural and social contexts and is universally applicable (2). This ignores the reality that most societies are products of histories and circumstances that differ markedly from those of the USA, the cradle of Principlism and contemporary bioethics. My sessions with students in Karachi serve to highlight that the complexities of human lives and experiences are not easily encompassed within a limited number of ethical principles drawn from Anglo-European philosophical traditions. Moreover, indigenous values including religious beliefs of a society, kinship structures and social interdependencies, life experiences, and indeed political realities, inevitably shape personal and professional moral spheres and influence the language and content of ethical discussions (3).

The variety of ethical lenses through which human beings can “see” the same issue is exemplified in student discussions in Karachi that followed the reading of two very different commentaries by Arthur Caplan, an influential and oft quoted American bioethicist. In one Caplan criticised the barring of polio vaccinations by Muslim militant Gul Bahadur in the northern regions of Pakistan (4), while in the other he focused on the ethics of posthumously conceived children in the USA in the absence of regulatory mechanisms (5).

In his first essay, Caplan expressed moral outrage at Bahadur, chief of a militant group in the Waziristan district of Pakistan, who was blocking administration of polio vaccinations as a retaliation against American drone attacks in that region. He expressed disappointment at the lack of voices in “loud condemnation from all quarters of the world” against Bahadur and his “immoral” and “crass act targeting helpless children of Pakistan and Afghanistan.” He urged that Bahadur be sent an unequivocal global message that “the campaign to eradicate polio [with] the certain result of killing and disabling children” will not stop. In his opinion, as far as American drone attacks were concerned these were a matter for “legal, diplomatic and political forums” to debate. Caplan had published this commentary at a time of heightened drone attacks in Waziristan with mounting deaths.

While our students agreed that Bahadur’s obstruction to polio vaccination was morally indefensible, they argued that Caplan’s ethical analysis was both incomplete and reductive as it failed to address the social and political contexts within which this was taking place. Delinking Bahadur’s actions from American drone attacks in Pakistan, and characterising the first as an immoral act and the second as a political and legal matter, made his analysis “naïve,” “non-contextual,” and “out of touch with ground realities.” CIA recruitment of a Pakistani physician to run a fictitious hepatitis vaccination programme in an attempt to obtain genetic material from bin Laden, something ignored by Caplan, had helped Bahadur to portray the “polio vaccination program as a CIA plot” and vaccination teams as “CIA agents.” Students deemed American manipulation of health services for political expediency not only profoundly unethical but also deeply relevant to the issue under discussion.

Students from provinces adjacent to Waziristan pointed to studies revealing that more Pakistani children had been killed or maimed from the drone attacks than from polio yet this was “not an issue highlighted by bioethicists.” In reality, “those who order drone attacks are also responsible for the lives of innocent children in the same way as those who allow them to be vulnerable to polio,” and children “were being used as fodder” by both parties. One suggested that Caplan’s concluding comment would be equally meaningful if his words “vaccination ban” were replaced with “drone attacks” as in – “The silence over [drone attacks] in Waziristan sends a very loud message that killing and disabling kids is an acceptable strategy in war. It isn’t.”

Caplan’s second commentary dealt with the ethical implications of the “number of [American] men, some married, some not” freezing their sperm before leaving for wars in Iraq and Afghanistan and with children being conceived after their deaths. This was happening in the absence of “laws or rules governing the use of sperm after a man has died.” He quoted cases in which sperm from men who had died unexpectedly was provided to wives, girlfriends and parents “without any explicit written permission from the deceased.” Caplan expressed concern about the “best interest of children” and suggested a “mandatory waiting period” of 90 days following donor death prior to use of donated sperm (to prevent emotional decisions). An important consideration in his ethical analysis was the abuse of the rights of donors which must be protected by “explicit written consent” for posthumous donation similar to advance directives and organ donor cards.

Unlike Caplan, our students chose to discuss posthumous insemination by contextualising it, and focusing on existing social realities and cultural/religious norms of the family rather than on a philosophical debate about reproductive rights and autonomy of the donor to make decisions about his body. Most believed that posthumous creation of children should be impermissible, as it was best for a child to be born within an intact marriage “a legal contract between a man and a woman” (Muslim family laws); and with both parents caring for her. Teachings of Islam were perceived as providing “a [moral] code of conduct for life” and the “family system.” Others opposed posthumous insemination due to social realities in which single parenthood was stigmatised and many women still depended on husbands as breadwinners. “Women have to live in this society” and moreover, would face devastating emotional, psychological and “financial burdens in single-handedly raising a child,” something also considered “detrimental to the child.”

The few who supported posthumous insemination argued that many Muslim laws were made “when women were weak,” but now their roles are changing and “jurists must rethink Islam if it is for all times.” One student commented wryly that science was moving at breakneck speed but Muslim jurists “were still paydal (pedestrian, on foot).” Some also criticised Muslim jurists’ contractual interpretation of marriage stating that spousal emotional attachments could outlast death. Reduction of marriage to a mere contract meant that jurists “lacked understanding of human emotions” as death does not end “emotions and experiences” associated with a spouse.

I have presented these discussions as examples of the diverse ways in which human beings can approach moral issues and how shared histories and values, lived experiences, kinship systems and local socio-political realities shape the narratives and content of ethical discourse. This is equally true for Caplan in America as it is for our students in Karachi. Moral thinking does not take place in a vacuum, and ethical analyses are impoverished if grounded in a philosophical template which is culturally myopic (6). Bioethics education compartmentalised into secular versus religious, modern versus traditional, universal versus relative ignores the multiple identities within which human beings exist. We require an inclusive, more reflective, and socially relevant approach that resonates with those we hope to educate. Bioethics should be taught as a “contact” sport unfolding on rough fields and not reduced to an abstract academic exercise undertaken in classrooms (7).