Understanding African Values & Moral Theory in Healthcare Ethics

1. African Values & Moral Theory Kevin Behrens Kevin.behrens@wits.ac.za

2. Why should we consider African Values & Moral Theory?

3. Why Should We Consider African Values & Moral Theory? HPCSA – Core Curriculum on Human Rights, Ethics & Medical Law Some of the expected outcomes of the curriculum are that trained HCP should: • Show respect for patients and colleagues without prejudice, with an understanding and an appreciation of their diversities of background and opportunity, language and culture. • Use his or her professional capabilities to contribute to the community and to individual patient welfare. • Demonstrate awareness, through action or in writing, of the legal and ethical responsibilities involved in individual patient care and the provision of care to populations. • Demonstrate an ability to engage in ethical reasoning and decision making.

4. Why Should We Consider African Values & Moral Theory? Ability to engage in ethical reasoning and decision making. • To enable you to do this, we need to equip you with knowledge and skills including: • An understanding of moral theories and principles • The practical competence to apply these to actual moral issues you will encounter • This involves ‘…offering students a skill, primarily cognitive in this instance; a set of conceptual tools to clarify and respond to moral difficulties that arise in the practice of medicine… [where] medical ethicists seek to enable medical trainees to deliberate use of the conceptual apparatus of ethics to decide upon morally acceptable courses of action in difficult situations’ (Huddle 2005: 885-6). • No reason why only Western ethical values and notions should be relevant

5. Why Should We Consider African Values & Moral Theory? An understanding and an appreciation of [patients’] diversities of background and opportunity, language and culture. • Almost all bioethics is based on Western ethical theories & principles • But, most of our patients belong to African cultures, and so do many of the HCP we train • African cultures have their own values, moral constructs and principles • Surely, we ought to be open to seeing what some of these can contribute to our moral decision making • One of the responsibilities of a HCP is to help patients make difficult moral choices – if we understand how they might see the issues, we can do this better

6. Why Should We Consider African Values & Moral Theory? • It goes without saying that this applies to other cultures & worldviews, too • Our ethical thought can be enriched by inputs from many other sources • But, African thought has been very neglected in this process • And we are in Africa, attending to patients who have a mainly African cultural heritage • Many Africans, of all socio-economic groups, still routinely consult with traditional healers, use traditional medicines, even when they are also under the care of dentists / doctors schooled in Western medicine • Recognising & understanding this better, may make Western practitioners more effective

7. Why Should We Consider African Values & Moral Theory? We are more likely to get buy-in & moral change from people if we appeal to moral values and notions they are familiar with • Speaking about environmental ethics Callicott writes: ‘A persuasive environmental ethic, however, cannot be constructed de novo. It must be located in a more general cognitive context, and it must retain continuity with the moral ideas and ideals of the past. Accordingly, the handful of Western philosophers working in the field of environmental ethics have begun with various strains of Western moral philosophy and sought to extend them to the new environmental questions’ (Callicott, 1994: xv). • This applies to all ethics. People are more likely to respond to moral challenge based on ethical values with which they are familiar • Africans will more likely buy in to morality based on African ideas and values

8. Why Should We Consider African Values & Moral Theory? • Possibly the single most important reason for us to study African thought is because none of us is as smart as all of us • We stand to LEARN from other perspectives, and enrich our own ability to reason ethically • Godfrey Tangwa, the most well-known and prolific African bioethicist, wrote in Bioethics1996; 10(3): 183-200.: • “It is clearly up to western Bioethics and western systems of thought and practice in general to allow African Bioethics and African culture in general to influence them. If only more westerners could really honestly try to get into the spirit and swing of things African, in the same spirit that many Africans have honestly and enthusiastically got into the spirit and swing of things western, humankind and the entire biological world might stand to reap great benefits.”

9. Why Should We Consider African Values & Moral Theory? • “Africans have tried. From western Christianity through western languages and education, to western systems of thought, philosophies and fashions, Africans have honestly and enthusiastically got into the spirit of things western. In the process, Africans have benefitted from western culture and used it to enrich their indigenous cultures. But, unfortunately, in so doing, Africans have neglected some vital aspects of their own indigenous cultures which could, in turn, have helped to humanise and enrich western culture. As there is no possibility of Africans imposing these putative benefits of African culture on westerners through any putative ‘blackman’s burden’ and ‘decivilising mission’, it is really up to westerners to salvage these cultures for the enrichment of western culture and the benefit of humankind, since western culture is, indisputably, the overwhelmingly dominant culture of our historical epoch.”

10. Why Should We Consider African Values & Moral Theory? • It should seem a little strange that so little attention has been given to African thought & what it can contribute to bioethics Why have African Values & Moral Theory been overlooked? • Pre-literate history: Many ideas have only recently entered the written record • Prejudiced early accounts: Many of these were written by Christian apologists who sought to show African thought was primitive • Scepticism about African Philosophy: Until very recently, many in the West thought it was nonsense to talk of African Philosophy • Western intellectual arrogance • Failure of African theorists themselves to produce work on these matters

11. Why Should We Consider African Values & Moral Theory? • “It is extremely important to understand the fact of a kind of 21st-century racism that is undermining the development of our knowledge of … ethics and other fields of enquiry. Any intellectual, no matter how liberal or enlightened, who either explicitly or implicitly suggests that there is nothing to be learned from Africa is terribly ignorant of Africa, and is, in my opinion, suffering from this phenomenon. Even today, many writers still do not expect the ‘Dark Continent’ – as ‘traditionally’ portrayed by the Enlightenment thinkers and colonial anthropologists – to be the source of … ideas that can help the contemporary world solve… problems. In current discourse ‘Africa’ still appears, even if only in its absence, as some kind of black hole of evil” (Kelbessa, 2005: 21).

12. Why Should We Consider African Values & Moral Theory? • “More often than not the term [African philosophy] tends to revive apparently innate skepticism on the one hand and to stimulate ingrained condescension on the other. The skeptic, unswervingly committed to the will to remain ignorant is simply dismissive of any possibility, let alone the probability of African philosophy. Impelled by the will to dominate, the condescendor is often ready to entertain the probability of African philosophy provided the judgement pertaining to the experience, knowledge and truth about African philosophy is recognised as the sole and exclusive right of the condescendor” (Ramose, 1999: 2). • Basically, it boils down to prejudice or racism: Africans aren’t capable of thinking philosophically • Thankfully, this has changed significantly in the last few decades

13. African Philosophy: A Brief Introduction

14. African Philosophy: A Brief Introduction • We need to distinguish between African Thought & African Philosophy • Philosophy is a particular kind of intellectual endeavour, characterised by the methods it uses • Philosophy is about applying reason to systematically, robustly and analytically reflect on important questions • When we talk about African thought, we usually mean indigenous African ideas, which most likely are not found in written form • But, anthropologists, religious scholars and others have tried to account for and record these ideas • This is essentially descriptive work: it just tells us what certain African people believe • African Philosophy needs to apply analytical thinking to the project

15. African Philosophy: A Brief Introduction H OderaOruka has identified 4 main trends in African Philosophy: • Ethnophilosophy (Tempels, Senghor, Mbiti) • Early accounts of African thought, more descriptive than really analytical • Nationalist-ideological Philosophy (Nyerere, Nkrumah, Kenyatta) • Of the ‘Philosopher Kings’: Leaders after independence. Focussed on justifying African socialism & ‘democracy’ • Philosophic Sagacity (Sage Philosophy) (Oruka) • Identification of ‘sages’ (with unwritten philosophies) & recording & analysis of their ideas 4. Professional Philosophy (Wiredu, Appiah, Gyeke, Masolo) • Trained philosophers, using academic methods to reflect on questions from African perspective

16. African Philosophy: A Brief Introduction • There are five main branches of Philosophy: • Epistemology (study of knowledge) • Aesthetics (study of art & beauty) • Logic (study of reasoning) • Metaphysics (study of reality, especially that beyond scientific realm) • Ethics (study of moral values, right & wrong actions) • Philosophy is also applied to many subjects: • Philosophy of science, language, history. Political philosophy • Environmental ethics, Business ethics, bioethics • African Philosophers address most of these • But, I am only concerned with African ethics: values and moral theory

17. African Philosophy: A Brief Introduction The kinds of questions I am interested in are: • What contribution can African thought/philosophy make to bioethics? • What are some characteristic African notions regarding the moral life and ethics? • How do these differ from Western or other notions? • How can these enrich our moral thinking? • How can we apply these to specific ethical issues? • Will our moral judgments be in any way different if we take these African notions into account? • Can we describe an “African Moral Theory”? How would this differ from Western moral theories? • So, we need to revise Western moral theories, first.

18. Recap of Western Moral Theories

19. Recap of Western Moral Theories Moral Theories • One of the most important theoretical questions that ethics asks is: • How do we decide what is the morally right thing to do in any situation? • Here we are concerned to come up with a theory of right action • We don’t just want to claim that action A or action B is right or wrong, we want a theory that can give us the basis for knowing whether ANY action is right or wrong • There area number of main types of moral theories of right action that have been proposed • The 2 most influential: consequentialism (utilitarianism), & duty based (deontology) • + Virtue Ethics

20. Recap of Western Moral Theories The Cash in a Suitcase Thought Experiment Consequentialism: • An action is morally right if the CONSEQUENCES of that action are on balance more positive than negative for the greatest number • Positive i.t.o. pleasure / happiness / well-being Duty theories (deontology): • There are certain actions that we have a duty to perform or to refrain from performing • Keeping promises is such a duty (not lying, killing, stealing) • Universalizability: if everybody decided to break their promises to suit themselves, no-one would ever believe promises that are made. Contracts would be meaningless. So, for instance, nobody would give credit to anyone else.

21. Recap of Western Moral Theories The Trolley Car Thought Experiment Consequentialism: • It is morally obligatory for us to flick the switch Duty theories (deontology): • Flicking the switch make us responsible for choosing some lives over others and complicit in the wrong • It would entail using the sacrificed person as a means, and not respecting the person This also raises issue of the difference between doing & allowing • Intention is irrelevant to the consequentialist

22. Recap of Western Moral Theories The Organ Donor Thought Experiment Consequentialism: • Cannot account for why this act would be wrong • Lives are exchangeable • End justifies means Duty theories (deontology): • We cannot treat persons just as means to our own ends, we need to respect their inherent value • Boils down to ‘respect for persons’ • No life can replace another • No just ends without just means

23. Recap of Western Moral Theories • Act Consequentialism seems to lead to very intuitively wrong conclusions, especially since lives are exchangeable • These problems can be (partially) resolved by another form Rule Consequentialism • Instead of subjecting each action to a calculation, more general moral rules are tested against the requirement of achieving the greatest good for the greatest number • E.g. moral rules like not lying, stealing, murdering • Always choose an action that is required by a rule whose acceptance would have the best overall consequences for the greatest number of people • A rule such as ‘We cannot regard human lives as exchangeable’ could resolve the problem

24. Recap of Western Moral Theories 1. Consequentialism (Utilitarianism) • Theory of right action: An action is morally right if the CONSEQUENCES of that action are on balance more positive than negative for the greatest number • Requires a calculation of all of the good consequences minus all of the bad consequences of an action • Only consequences count, so intentions are irrelevant • Some of the problems can be overcome by rule consequentialism • Instead of subjecting each action to a calculation, more general moral rules are tested against the requirement of achieving the greatest good for the greatest number

25. Recap of Western Moral Theories 2. Deontology: • Duty-based theories • Theory of right action: Actions that are morally right are those who we have a duty to perform or to refrain from performing • How do we know what these rules or duties are? • Common morality: there are a number of moral duties agreed to by most people in the world, and that have proven themselves as helpful in creating a good society • Universalizability: these duties or rules should apply to everyone in the same way (I can’t expect special rules that apply just to myself) • Respect for Persons: Treat people with respect due just because they are persons. Most common deontological approach.

26. Recap of Western Moral Theories 3. Virtue Ethics • Possibly the oldest moral theory going back to Plato & Aristotle • Instead of a focus on actions/duties, it is concerned with character • Instead of rules, it promotes developing good habits of character • It is more based on being than doing & seeks to produce excellent persons. • ‘Always act as a virtuous person (person of good character) would’ • Virtues: fairness, friendliness, generosity, loyalty, patience, self-discipline, courage, dependability, compassion, benevolence, etc • It has appeal, has become very popular recently • But apply it to any of the thought experiments…. It does not easily provide answers to moral dilemmas. What would a good person do?

27. Recap of Western Moral Theories 4. The Ethics of Care • Another challenge to the dominance of consequentialism & deontology has come mainly from feminist philosophers • Feminism in the 1960s & 70s was dominated by the idea that the supposed psychological differences between men & women had been exaggerated – basically we are all just human • But, from the early 1980s this began to change • In 1982 Carol Gilligan claimed that it is true that men & women think differently about morality. But, this does not mean that men’s moral thinking is better than women’s – they are just different • She claimed that men tend to think in terms of the application of abstract moral principles & base their decisions on rational calculation, impersonal duty, respecting contracts etc

28. Recap of Western Moral Theories • Women’s morality is centred on caring for others, being concerned about their interests and attending to their needs • ‘Caring, empathy, feeling with others, being sensitive to each other’s feeling all may be better guides to what morality requires in actual contexts than may abstract rules of reason, or rational calculation, or at least they may be necessary components of an adequate morality’. (Virginia Held, 1990). • The supposed differences between men and women may not be as clear or significant as these authors suggest, but their challenge to male-dominated ethics is plausible • Do we not need an approach to ethics that considers caring, empathy, sympathy, emotion, etc as relevant? • Whilst this approach is still not dominant, it has been taken up well by some bioethicists. Perhaps because of the nature of medical practice.

29. Recap of Western Moral Theories • Ethics of care not only focusses on the need to promote good relationships and include emotional considerations in our thinking • It also emphasises the place of special relationships, such as family relationships • Neither consequentialism nor deontology in standard form are able to account for our moral intuition that it is morally right to give some priority to our own family & friends – the poor person in a far away country has an equal claim on my extra income to my own child • Somehow this seems to be wrong, and the ethics of care can give us grounds for justifying why

30. Recap of Western Moral Theories 5. The four principles: (mid-level – not a ‘moral theory’) • 1 Respect for Autonomy • Individual autonomous choice & decision making. Basis for informed consent & respecting confidentiality • 2 Nonmaleficence • Avoid harming others • 3 Beneficence • Doing good for others, promoting their interests & well-being • 4 Justice • Distributive justice. Fair allocation of health resources. Distribute benefits & harms fairly

31. Towards an African Moral Theory

32. Towards an African Moral Theory • Clearly, there is not a fully developed African moral theory such as Utilitarianism or Deontology • But, there are some distinctive ethical conceptions to be found • Africa is also a vast continent, with many different peoples. There is no single African worldview or philosophy • But, there are some notions that seem to be shared by quite a number of different indigenous groups • So, we need to construct a moral theory based on salient African ideas and values • Thad Metz (UJ) has made it a major part of his work to do this: He is trying to articulate a moral theory (Ubuntu) that he thinks should be taken as seriously as the classical Western theories

33. Towards an African Moral Theory Some widely-shared African moral notions/values: • The essence of African morality is often expressed in these two (or similar) expressions: • “I am because we are” • “A person is a person through other persons” • The main idea is that we can only become a real or authentic (virtuous) PERSONS through our relationships with others • We are mutually dependent. What I do affects others, and vice versa. • Because of this, we need to consider others • Family analogy is often used to explain this. Just as the members of a family realise that they depend on each other, and therefore look after each other and seek the good of the family, so we should do so in other relationships

34. Towards an African Moral Theory ‘[Ubuntu] speaks to the very essence of being human…. It … means my humanity is caught up, is inextricably bound up, in theirs. We belong in a bundle of life…. Harmony, friendliness, community are great goods. Social harmony is for us… the greatest good. Anything that subverts or undermines this sought after good is to be avoided like the plague’ (Tutu, 1999: 34-35). • Harmonious, communal relationships are valued • Metz argues that Ubuntu requires 2 things: identity and solidarity • Identity: individuals conceive of themselves as part of a ‘we’ not just an ‘I’. We understand ourselves to be in this business of life together with others. As it goes with others, so it goes with me. • Solidarity: we express this by working together for the common good, helping one another and caring for one another

35. Towards an African Moral Theory • Together, identity and solidarity work to promote harmonious relationships • Metz claims we can express these ideas as a theory of right action • ‘An action is right just insofar as it is a way of living harmoniously or prizing communal relationships, ones in which people identify with each other and exhibit solidarity with one another; otherwise, an action is wrong’ (Metz) • So you become a true person (virtue) to the extent that you act to promote harmonious relationships (including adhering to social norms & practices (deontology) and helping others and seeking their well-being (utilitarianism) • Seems to embrace other moral theories • But, focus is on relationships, caring & sharing, maintaining harmony & balance (ethics of care)

36. Towards an African Moral Theory • This notion embraces many ethical norms shared by the West and others prohibiting stealing, lying, murder, etc. • Metz also identifies some specific ethical obligations entailed by this theory of right action and characteristic of much African thought: • Special obligations to family include much wider family members • Strong duty for rich to aid the poor • Greeting others (including strangers) is important • Marrying and having children is a moral requirement • Reconciliation is preferred over retribution when people offend • Decision making by consensus preferred over majoritism • (I add): strong valuing of hospitality, especially to the stranger

37. Towards an African Moral Theory What are some of the implications of all of this for bioethics? The focus on relationships, caring & sharing, maintaining harmony & balance • Different emphasis from: maximising the good for the greatest number or respecting persons • Also different from autonomy, beneficence, non-maleficence & justice • How? • There is some ‘heart’ in this approach. Caring and sharing, compassion and empathy • Western bioethics has been thin on these concepts • Calls to mind the feminist ethicist notion of the ethics of care

38. Towards an African Moral Theory • Some theorists believe that the recent focus on Professionalism in health care is a return to the view that HCPs are expected to be caring, compassionate, understanding and sympathetic – not just expert technicians of the body • What do you think? Do patients have the right to expect such things? • We don’t expect these from other professionals such as engineers, lawyers and accountants. Why of physicians? • Often understood in terms of an implicit social contract between society and the HC profession: • Profession gets relative status, wealth, respect & the right to self-regulation • Society expects specialist knowledge, competence, ethical behaviour & compassion, empathy & understanding

39. Towards an African Moral Theory • “The morality of medicine derives, in part, from the fact that the physician swears an oath acknowledging the primacy of the patient in his or her work as a physician. He argues that the sincere, intentional profession of this primacy is necessary because of the existential predicament of the patient – vulnerable, frightened, largely ignorant, largely powerless, with significantly diminished autonomy. These are the facts of illness. The patient, with no recourse but trust, has a moral claim on a special degree of trust in the care to be rendered” Sulmassy quoting Paligrino • It is the special existential predicament of patients that justifies the need for compassion and focus on patient needs • Some might say that the HCP is losing this dimension, and African thought can re-affirm its central place in medical ethics

40. Towards an African Moral Theory The focus on becoming a virtuous person through community with other persons • There has been a strong resurgence of interest in virtue ethics – African thought encourages this • Why is this important? • Friend visits you in hospital • Insists he is only there because he is doing his duty • How does it make you feel? • Do patients not feel the same about HCPs? If it is only a job and not something you do because of your character, they might not trust you as much. • Social contract: society expects people of moral integrity & character

41. Towards an African Moral Theory The focus on family and community relationships • The Western bioethical notion of autonomy may need to be questioned or re-visited • E.g. the standard Jehovah’s witness case vs. the modified Jehovah’s Witness Case • Is informed consent only of the individual enough – what of family and community? • In cases of futile treatment in SA, it is regarded as acceptable practice to override the decision of family members – is consensus decision making not better? • In SA law the choice to terminate a pregnancy is the right of the pregnant woman alone. Is this morally right?

42. Towards an African Moral Theory • Standard approach to experimentation with human participants is that the individual must give consent. But, in societies where community is stressed this might not be sufficient. • There may be grounds for thinking that Western bioethics gives too much emphasis to autonomy • What may be needed is not to throw out the principle of autonomy, but to acknowledge that there are other factors that ought to be taken into account

43. Towards an African Moral Theory Focus on duty of rich to assist the poor and need to provide hospitality to strangers • The issue of whether healthcare should be universally provided by the State is a huge debate around the world • Some argue that health being such a basic need ought to be provided through taxation like education, emergency service safety & security • Western ethical systems are divided on the subject • Would African thought not suggest that it is a no-brainer: people should get access to health care irrespective of what they can pay for? • Is this not the spirit of Ubuntu?

44. Towards an African Moral Theory • Consider the SA situation: • According to the Green Paper on a National Health Insurance for South Africa, “The 8.3% of GDP spent on health is split as 4.1% in the private sector and 4.2 % in the public sector. The 4.1% spend covers 16.2 % of the population, (8.2 million people) who are largely on medical schemes. The remaining 4.2% is spent on 84% of the population.” • In other words, 50% of what we spend on healthcare provides for 16% of the population, and 50% for the other 84% of the population • Health care provision is skewed: those with the greatest need often have the least access • Is this fair? Is this the kind of society we want to live in? Is this Ubuntu?

45. Towards an African Moral Theory • Environmental Ethics as part of Bioethics • Why is the issue of the integrity and health of the environment a bioethical issue? 1. By definition, bioethics includes environmental ethics Bioethics: ‘The exploration of moral and ethical questions surrounding life, health, science, medicine and the environment’ (North Carolina Association for Biomedical Research) • Bio-ethics: bio, related to biology, about the ethics of living things • A fundamental concern of environmental ethics is based on claim that the ecological crisis is philosophical in nature: • It is because western capitalism & industrial progress only sees human interests as important – nature is there only for our use: Anthropocentrism

46. Towards an African Moral Theory • There are aspects of medicine that impact directly on the environment • Medical waste products & disposal • Energy use by hospitals, equipment, laundry & cleaning • Biologically hazardous materials • Management of infectious diseases & their causes • There is a close association between the social determinants of health and the environment • Social determinants of health: nutrition (food security), sanitation, potable water, clean air • Sound environmental management has a profound effect on human health

47. Towards an African Moral Theory • Global Climate Change will increase the risk to human health significantly • Effects of GCC: changes in climate patterns; changes in distribution of agricultural land; rising sea levels • Concern about tipping points: changes in ocean currents; thawing of permafrost; melting of glaciers and ice caps • Concerns for human health: migration of people; food shortages; spread of infectious diseases; water shortages; poor sanitation & resulting disease burden; increasing poverty • Is the science right? How right does it have to be for us to apply the precautionary principle: if there is a strong risk of harm we should take precautions to prevent the harm as we are able • Environmental ethics is an integral part of bioethics

48. Towards an African Moral Theory The contribution of African thought to environmental bioethics • There are themes in African thought that suggest that not only are we inter-dependent with other persons, we are also inter-dependent with other aspects of nature • Sometimes expressed in terms of our being just a part of nature, rather than being separate from or superior to nature (Historical Western anthropocentrism blamed for ecological crisis) • ‘Within [the African] world-view the distinction between plants, animals, and inanimate things, between the sacred and the profane, matter and spirit, the communal and the individual, is a slim and flexible one ‘ (Tangwa, 2004: 389). • ‘The African is convinced that all things in the cosmos are interconnected. All natural forces depend on each other, so that human beings can live in harmony only in and with the whole of nature’ (Bujo, 1998: 22-23).

49. Towards an African Moral Theory • Murove describes ‘…an ethical outlook that suggests that human well-being is indispensable from our dependence on and interdependence with all that exists, and particularly with the immediate environment on which all humanity depends’ (Murove, 2004: 195 - 196). • Harvey Sindima describes an African cosmology that ‘…stresses the bondedness, the interconnectedness, of all living beings’ (Sindima, 1990: 137). • ‘The pre-colonial traditional African metaphysical outlook… impl[ies] recognition and acceptance of interdependence and peaceful coexistence between earth, plants, animals and humans’ (Tangwa, 2004: 389) .

50. Towards an African Moral Theory • This sense of inter-dependence or inter-relatedness entails the same kind of ethical obligation as the inter-connectedness between humans: because our well-being is so tied up with that of others, we need to be concerned the well-being of others • We should promote harmonious relationships in nature. There should be solidarity and identity with nature (as with other persons) • We should treat other parts of nature with respect • ‘There is community with nature since man is part of nature and is expected to cooperate with it; and this sense of community with nature is often expressed in terms of identity and kinship, friendliness and respect’ (Opoku, 1993: 77). • In ‘…the African understanding of nature… the human person …has the task of showing respect for creation (Bujo, 1998: 214).