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From the Local to the Global Bioethics and the Concept of Culture

Leigh TurneraaMcGill University, Montreal, Quebec, Canada

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Journal of Medicine and Philosophy, 30:305320, 2005Copyright Taylor & Francis, Inc.ISSN: 0360-5310 printDOI: 10.1080/03605310590960193

NJMP0360-5310Journal of Medicine and Philosophy, Vol. 30, No. 03, April 2005, pp. 000Journal of Medicine and Philosophy

From the Local to the Global: Bioethicsand the Concept of Culture

Bioethics and Concept of CultureL. Turner

LEIGH TURNERMcGill University, Montreal, Quebec, Canada

Cultural models of health, illness, and moral reasoning are receivingincreasing attention in bioethics scholarship. Drawing uponresearch tools from medical and cultural anthropology, numerous

researchers explore cultural variations in attitudes toward truthtelling, informed consent, pain relief, and planning for end-of-lifecare. However, culture should not simply be equated with ethnic-

ity. Rather, the concept of culture can serve as an heuristic deviceat various levels of analysis. In addition to considering how partic-ipation in particular ethnic groups and religious traditions can

shape moral reasoning, bioethicists need to consider processes ofsocialization into professional cultures, organizational cultures,

national civic culture, and transnational culture. From the localworld of the community clinic or oncology unit to the transna-tional workings of human rights agencies, attentiveness to the con-cept of culture can illuminate how patients, family members, and

health care providers interpret illness, healing, and moral obligations.

Keywords: bioethics, concepts of culture, ethnicity, pluralism,

universalism

I. INTRODUCTION: THE CONCEPT OF CULTURE

Culture is one of the most protean, hotly debated concepts found in thesocial sciences and humanities. According to a classic formulation byEdward Tylor in 1871, Culturetaken in its wide ethnographic sense is thatcomplex whole which includes knowledge, belief, art, morals, laws, cus-tom, and any other capabilities and habits acquired by man as a member of

Address correspondence to: Leigh Turner, Ph.D., Biomedical Ethics Unit, Faculty ofMedicine, McGill University, 3647 Peel St., Montreal, Quebec, H3A 1X1, Canada.

E-mail: [email protected]


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306 L. Turner

society (Tylor, 1871). Writing over one hundred years later, anthropologistJames L. Peacock asserts, Cultureis a name anthropologists give to thetaken-for-granted but powerfully influential understandings and codes thatare learned and shared by members of a group (Peacock, 1986).

Contemporary anthropologists continue to struggle with the concept ofculture. The term is widely used to characterize shared ways of world mak-ing and forms of local knowledge. Critics of the culture concept suggestthat the term essentializes heterogeneous modes of understanding, as theinhabitants of a particular community or nation are described as having acommon, uniform culture. In turn, proponents of the term insist that theconcept of culture plays a valuable role in attending to patterns of socializa-tion into the mode of life of a particular geographically and historically situ-ated community. Contemporary anthropologists explore the emergence ofcultural models in specific social settings. Given the manifold uses and

applications of the culture concept, there is no single, concise definition ofthe term capable of satisfying all parties or capturing every subtlety of the word.

Some uses of the culture concept emphasize cognition and culturalmodels; other approaches focus upon social practices and everyday socialinteraction. At present, there are both calls for the continued use of a help-ful concept, and adamant claims that the concept of culture obscures ten-sions and cross-currents within communities, fails to explain significanthistorical changes in popular understandings, minimizes intragroup differ-ences, and belittles the significance of personal agency. Acknowledging thecontested, perennially problematic character of the term, the concept of cul-ture is frequently understood to refer to the tacit knowledge or webs ofmeaning through which particular humans in specific social settings inter-pret their existence (Geertz, 1973).

As bioethicists increasingly attend to the role of ethnicity in shapingmodes of moral reasoning, and the role of organizations in structuring ethi-cal issues, the concept of culture is likely to play a greater role in bioethics.Stronger ties between bioethics and the social sciences are also likely tolead to more fruitful explorations of the relationship between cultural mod-els and modes of moral deliberation.

In the early part of the twentieth century, anthropologists commonlyexplored the culture of isolated, small-scale communities at the geographicperipheries of the major colonial powers, as well as marginalized indige-nous societies within industrializing Western nations. Margaret Meadsresearch in Samoa and New Guinea and Bronislaw Malinowskis research inthe Trobriand Islands popularized notions of the anthropologist as a spe-cialist in the mores of isolated communities located at the peripheries of themajor economic and political powers. Now, however, the concept of cultureis used to explore social practices and patterns of understanding in a varietyof social settings. Indeed, it is quite common in both colloquial and scholarly

parlance to find references to corporate culture, teen culture, popular cul-


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Bioethics and Concept of Culture 307

ture, the culture of biomedicine, and the culture of science. The concept ofculture is no longer simply used to explain the ways of life and forms of under-standing of distant societies, but now refers to the dominant values, symbols,social practices, and interpretive categories of any community. Instead of study-

ing small-scale communities in New Guinea or South America, many contem-porary cultural anthropologists study the organizational culture of start-upbiotechnology firms, intensive care units, and managed care organizations.

Furthermore, medical anthropologists and bioethicists are increasinglyattuned to the role of ethnic traditions, cultural norms, and religious prac-tices in shaping understandings of illness, death, and dying. Before turningto an examination of an emerging research agenda on professional culture,organizational culture, and civic culture, I want to explore an important newwave of research on cultural norms, communication, and decision-making.Since the mid-1990s, anthropologists and bioethicists have made important

contributions to the study of ethnicity and models of reasoning.

II. CULTURAL PRACTICES AND BIOETHICS

An emerging body of literature in the fields of bioethics and medical anthro-pology explores how cultural norms are linked to understandings of truthtelling, decision-making, and end-of-life care within different ethnic groups(Berger, 1998a). Studies on cultural variations among and within ethnicgroups suggest that not all inhabitants of Canada, the United States, GreatBritain, and other Western settings share common values and understand-ings. Qualitative studies of cultural norms within Navajo, Chinese-Canadian,and Korean-American communities reveal how different interpretive catego-ries, language patterns, family structures, and understandings of reasonable-ness contribute to distinctive understandings of decision-making, autonomy,family life, and healing. However, the concept of culture can be fruitfullyaddressed beyond the study of the interpretive categories of participantswithin particular ethnic groups. For example, the study of cultural models ishelpful when examining processes of socialization into particular profes-

sional worlds, organizational cultures, national civic cultures, and globalculture. The concept of culture, then, is useful when considering ethicalissues in medicine and health care from the "micro setting of the clinicalencounter to the "macro level of the regional, national, and internationalorganization of health care systems and social networks.

III. CULTURE AND BIOETHICS

Bioethicists can benefit from better understanding the interpretive horizons

that constrain how moral reflection and deliberation is framed (Ricoeur,


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1976). In particular, bioethicists need to appreciate the importance ofexplanatory models of health, illness, and moral obligation that are embed-ded within the cultural frameworks of patients and their family members(Kleinman, 1980). Attentiveness to various cultural norms can promote a

better awareness of why particular understandings, social practices, andpolicies seem reasonable and moral, whereas other norms, practices,and guidelines are regarded as irrational or immoral. Whether examiningthe predominant mores of a particular ethnic group, or comparing the coremoral norms of civic culture in one nation with dominant social values inother national settings, the concept of culture serves as a reminder of localvariations in understandings of health, illness, suffering, and death.

A. Communication in Clinical Settings and Explanatory Models

of Health and Illness

Many patients bring to the clinical encounter explanatory models of healthand illness that are quite distinct from the interpretive categories found inWestern biomedicine. There are numerous anthropological and sociologicalstudies that explore the diverse range of understandings of health, healing,and illness around the world (Murdock, 1980; Shweder, Much, Mahapatra,& Park, 1997). Language differences and distinctive understandings of themeaning of symptoms and illnesses can make communication betweenpatients and health care providers very difficult (Breen, 1999). Several schol-

ars argue that medical interpreters working in the capacity of culture bro-kers can act as mediating agents in such situations by translating culturalunderstandings and expectations and promoting shared understandings ofworthwhile courses of action (Kaufert & ONeil, 1990; Kaufert & Putsch,1997).

B. Competency to Make Decisions and Capacity Assessment

Cultural understandings of morality, health, and illness have implications for

most of the familiar topics in bioethics. Indeed, there are many areas wherebioethics and the anthropological and sociological study of medicine needto be more closely linked. For example, decisions by ill individuals to refuseparticular kinds of treatment or insist upon specific forms of care can raisequestions about reasoning abilities and decision-making capacity. To assessthe rationality of decisions made by patients, physicians and nurses need tounderstand how patients interpret their illnesses and comprehend the diag-nostic, prognostic, and treatment-related information provided by membersof the health care team. For example, a patient might refuse a particularkind of therapy, insisting that the future course of illness is dependent on

Gods will. In the clinical setting, such a comment might lead a health care


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provider to request a consultation from the psychiatry service. The state-ment could generate questions about the capacity of the patient to makereasonable decisions. In contrast, within the local religious community ofwhich the patient is a member, such a statement might seem entirely appro-

priate and suited to the patients current situation. Assessments of capacityto make decisions are very much dependent upon background presump-tions concerning what constitutes reasonable understandings and sensi-ble assessments of particular circumstances (Powell, 1995).

In settings where patients understandings of reasonable conductdiverge from the judgment of health care providers, members of the healthcare team need to consider whether they have adequately explored theirpatients cultural models of health, illness, and moral deliberation. Thesebackground understandings play an important role in contributing to howpatients respond to particular recommendations. For example, in situations

where patients refuse treatment due to a desire to preserve the integrity ofthe body rather than undergo major surgery that leads to the amputation ofa limb, physicians need to carefully consider whether cultural understand-ings of death, afterlife, and embodiment ought to be recognized andrespected rather than viewed as signs of the incapacity to make reason-able decisions. Considerable caution needs to be exercised when assessingthe reasoning capacities of individuals from cultural backgrounds that arepoorly understood by health care providers. In the absence of concertedefforts to comprehend how particular patients interpret their circumstances,health care providers are likely to impose their own ethnocentric, highlyjudgmental presumptions about reasonable conduct upon their patients.

C. Truth Telling and Informed Consent

Cultural explanations of health and illness, along with understandings of theappropriate social roles of family members and health care providers, areinterwoven with interpretations of what constitutes thoughtful moral con-duct. Numerous studies note that within many communities, there arewidely shared understandings that health care providers should not provide

information concerning terminal diagnoses to seriously ill patients (Black-hall, Murphy, Frank, Michel, & Azen, 1995; Orona, Koenig, & Davis, 1994).In particular, diagnoses associated with various forms of cancer are closelylinked to the common cultural norm that patients should not be fullyinformed of their illnesses. To disclose such information in a frank, forth-right manner is, in some cultural contexts, understood by family membersand seriously ill patients to undermine the health of the patient by encour-aging negative thoughts and condemning the patient to a form of socialdeath (Gordon, 1990). While physicians might think of diagnostic andprognostic information as largely descriptive, family members sometimes

understand the provision of bad news to play a causal role in hastening


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310 L. Turner

the dying process. Thus, within some communities, cultural norms existwhere the health care provider who wants to proceed in a compassionatemanner is assumed to be a caregiver who will protect the ill patient andsupport the family in shielding the sick person from upsetting information.

Reports concerning disclosure practices in Japan, Ethiopia, China, and Italyall note styles of communication in which physicians convey negativeinformation to family members, who then conceal this information fromtheir seriously ill relatives (Akabayashi, Fetters, & Elwyn, 1999; Beyene,1992; Gordon & Paci, 1997; Pang, 1999). While disclosure patterns arechanging in numerous regions around the world, there are still many fami-lies and larger social networks in North America and other regions wherethe communication of terminal diagnoses to patients is regarded as a cal-lous, uncaring act.

Cultural models of health and illness that tacitly assume that family

members rather than individual patients should receive diagnostic and prog-nostic information differ from autonomy-based laws and policies intendedto promote dialogue between patients and physicians. Unsurprisingly, NorthAmerican physicians guided by the principle of respect for patient auton-omy experience considerable frustration when they encounter families whoinsist that physicians should conceal diagnostic and prognostic informationfrom the patient. These requests, arising after transformations in the cultureof American medicine in the 1970s and 1980s that served to promote patientautonomy and reduce the sphere of parentalistic behavior in medicalpractice, raise complex questions about the boundaries of tolerable andintolerable forms of medical care in multiethnic, pluralistic settings.

D. Advance Care Planning

Cultural models of death and dying play a significant role in how processesof advance care planning are interpreted in particular communities.Advance care planning is usually intended to enable patients to select surro-gate decision makers and articulate the kinds of health care they wouldchoose or refuse in particular circumstances. However, articles by Berger

(1998b) and Frank et al. (1998) suggest that within some ethnic communi-ties there is limited interest in engaging in conversations intended topromote advance care planning. Murphy et al. (1996) report that in theKorean-American and Mexican American populations they studied, therewas limited support for the use of advance directives. They suggest thatwithin some communities open disclosure and detailed planning for end-of-life care is understood to cause ill individuals to lose hope. While the failureto use advance directives is a complex phenomenon, cultural norms withinmany ethnic groups deter seriously ill individuals from planning the dyingprocess in an anticipatory manner. Indeed, for individuals within some

communities, planning a future course for illness and physical decline, and


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signing documents that refer to particular illness states and limitations ontreatment can seem highly presumptuous and inappropriate. Health careorganizations that strongly endorse advance care planning need to attend tosuch concerns lest they risk unintentionally alienating the communities they

serve. Bureaucratic forms and institutional policies that are of great benefitto some individuals are sometimes profoundly unsettling to patients withdifferent understandings of illness and death.

IV. BEYOND THE EQUATION OF CULTURE WITH ETHNICITY

Much of the existing qualitative research in bioethics examines culturalmodels of health, illness, and moral reflection within the context of particu-lar ethnic groups. Participant observation, ethnographic research, in-depth

interviews, and grounded theory research are becoming increasingly com-mon research methods within bioethics. These methods are often used tostudy the local norms of a particular community.

Some of the shortcomings of this focus upon ethnicity and culturalnorms are becoming apparent. For example, Blacksher (1998) notes that thestudy of ethnic differences can promote cultural stereotypes, essentializethe values of particular communities, and mask variations in norms withinspecific groups. Focusing upon the shared moral norms of a particular eth-nic group can lead to the neglect of conflicting understandings and culturaldifferences within particular ethnic groupings.

A focus upon ethnic differences can serve to obfuscate underlyingcommonalities across communities. Furthermore, emphasizing shared cul-tural norms within particular communities can obscure the importance ofsocioeconomic status, gender, level of education, and personal experience.The concept of culture can carelessly be used to wash away the personalfeatures that distinguish the members of a group from one another. A focusupon cultural norms can also suggest that particular cultural models aretimeless and traditional rather than quite recent responses to emergingissues and situations. Finally, the study of cultural differences amongst eth-

nic groups provides only limited insight into how widely variant practicesought to be accommodated or tolerated in multiethnic settings.Whereas there is a rich debate on the limits of tolerance and the nature

of multicultural citizenship within the field of political philosophy, effortsamongst bioethicists to adjudicate normative conflicts in multiethnic, plural-istic settings are in the early stages of development. The widespread empha-sis in bioethics scholarship upon notions of a common morality,reflective equilibrium, and shared paradigms of moral reasoning leavesbioethicists ill-equipped to recognize the markedly distinct ways in whichmoral matters can be framed.


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Future scholarship on cultural norms within particular ethnic groups willhave to address the challenges posed by critics of this line of research. Ofperhaps even greater significance, there needs to be a reconsideration of thecommon assumption that to study cultural models is to study the local norms

of particular ethnic groups. In addition to addressing the cultural models ofvarious ethnic groups, bioethicists need to attend to forms of professional cul-ture, organizational culture, civic culture, and global culture. As scholarship inthese areas of enquiry develops, bioethicists will need to become increasinglyattuned to the work of colleagues in cultural psychology, medical anthropol-ogy, medical sociology, cultural psychiatry, and globalization studies. Whilethere are many challenges associated with the promotion of new directions inmultidisciplinary research, the field of bioethics is likely to benefit from closercollaboration with colleagues from various branches of the human sciences.

V. PROFESSIONAL CULTURES OF MEDICINE

While ill and injured individuals bring cultural models of health, illness, andmorality to the clinical setting, much greater attention needs to be given tothe distinctive organizational and professional cultures of health care pro-viders. Numerous studies of medical education, for example, examine theway in which physicians undergo processes of socialization that promoteparticular moral norms and modes of behavior (Becker, Geer, Hughes, &Strauss, 1961; Good, 1994). Studies of student culture in medical school typ-ically examine socialization practices in the anatomy laboratory and clinicalsetting, whereby students are transformed into experienced professionals(Hafferty, 1991; Sinclair, 1997). Various rites of passage including formal,official examinations and unofficial hazing rituals mark different stages inthe enculturation process. Immersion into specialized technical vocabulariesas well as the donning of distinctive modes of dress such as the white coat,the stethoscope, and other markers of symbolic capital signal the gradualmetamorphosis of the medical student into the medical professional.

In addition to enculturation into the broad norms and interpretive cate-

gories of Western biomedicine, health care providers are socialized into thecultural worlds of particular specialties and disciplines (Anspach, 1993;Bosk, 1979). For example, Good, Good, Schaffer, and Lind (1990) studiedthe discourse and ethos of American oncology, and found a moral worldpermeated by the rhetoric of hope and optimism. Similarly, Joan Cassell(1991), in Expected Miracles: Surgeons at Work, provides a detailed ethno-graphic sketch of the culture of surgeons. During her anthropologicalresearch, Cassell found a masculine culture where being ballsy isencouraged, and the competent surgeonmuch like an astronaut or topgun fighter pilotdisplays the right stuff of aggressiveness, assertiveness,

and technical precision.


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To enter a profession, or professional sub-group in medicine, is toenter a culture with a distinctive rhetoric, set of norms, and body of pre-sumptions concerning the moral care of patients. While medical communi-ties, much like other social groups, are not altogether homogeneous, there

are standards of practice that are acceptable in some professional cultureswhile these same practices and norms are viewed with suspicion or conde-scension in other settings. Many of the conflicts between physicians andnurses, for example, can likely be traced to socialization into different pro-fessional norms and standards of responsible practice.

VI. ORGANIZATIONAL CULTURES

Anthropological and sociological studies of intensive care units, neonatal

intensive care units, psychiatric wards, and oncology wards all trace the dis-tinctive forms medical care takes in particular local worlds. Western bio-medicine takes many different shapes, and the local organizational cultureof the geriatrics wing or prenatal genetic counseling service can be quitedistinct from the transplantation unit or the psychiatric unit. Indeed, pro-ceeding from specific medical specialties and units, it is possible to contrastthe culture of the pediatric hospital with the culture of the geriatric facility,or the religious, non-profit health care facility with the secular, for-profithealth maintenance organization.

There can be meaningful variations in the organizational culture ofentire health care facilities. Sometimes these distinctions are the product ofexplicit organizational philosophies, in which organizational principles ormission statements are used to promote a culture of respect for patientchoice or support the values of a particular religious tradition. In otherinstances, unspoken, tacit norms inform the culture of organizations. Forexample, some for-profit health maintenance organizations and long-termcare facilities in the United States are accused of providing inadequate careto patients, because corporate norms of profit making are privileged overother organizational and professional values (Diamond, 1992).

Variations in organizational cultures mean that clashes over organiza-tional philosophies, core institutional values, and mission statements fre-quently arise during the course of organizational mergers. The conflicts canbe particularly acute when religious health care facilities merge with secularinstitutions, or when organizations where employees pride themselves onpromoting womens health, pediatric care, or geriatric care merge with orga-nizations lacking such a specific orientation. In regions where restructuringmeasures are leading to the consolidation of previously distinct health carefacilities, attentiveness to variations in organizational culture is particularlysignificant. When conducting cost-benefit analyses of such mergers, execu-

tives need to include in such assessments an awareness of the various facets


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of care that can be marginalized or eliminated by consolidating health carefacilities with distinct organizational cultures.

VII. CIVIC CULTURE AND THE ORGANIZATION OFHEALTH CARE SYSTEMS

The concept of culture can be utilized in the study of particular ethnicgroups, the socialization of health care professionals, and the organizationalvalues of institutions. In addition, cultural models of risk, insurance, andsocial solidarity can be related to civic culture and the social organization ofhealth care systems (Graves, Beauchamp, & Herle, 1998). Specifically, theorganization of health care at the macro level of the state, province, ornation can be justified according to different normative frameworks. Here,

civic culture is particularly significant. Libertarian or neo-conservative inter-pretations of how health care should be provided, as with more communi-tarian or social democratic accounts of the most justifiable normativeordering of the political economy of health care, draw upon particular cul-tural models of individualism and the merits of commercial markets (Rein-hardt, 1997). Within many nations, more communitarian, social democraticmodels of the provision of health care presently vie against neo-conserva-tive or libertarian normative claims that question the extant public-privatemix, and promote more market-oriented approaches to health care. Debatesabout the provision of funds for publicly supported health care are typicallylinked to larger visions of the just social order, the appropriate role of gov-ernmental agencies and the free market, and notions of shared socialgoods.

The manner in which cultural norms and civic values are embedded ineveryday forms of language use can be quite subtle, as when patients arerelabeled as customers or clients, health care professionals are viewed ashuman capital, and clinical judgment is reconstrued as intellectual capi-tal (Alper, 1984). The culture and rhetoric of free-market models has inmany settings replaced other normative orderings of health care systems.

While this examination of the concept of culture is not the place todebate the merits of various systems of health care delivery, the substantivepoint here is that particular understandings of the normative ordering ofhealth care systems are closely connected to interpretations of community,autonomy, solidarity, and the appropriate spheres of governmental organi-zations and market mechanisms. Civic cultures can vary from region toregion, and it is unsurprising that the normative cultures of health care sys-tems in the United States, for example, are quite different from the norma-tive cultures of health care systems found in other societies (Kingdon,1999). While considerable care is needed when comparing the civic cul-

ture of entire countries, the emphasis in some nations upon attending to


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the public good rather than giving precedence to the preservation ofindividual liberty can be discerned in a number of domains. These differ-ences are recognizable in regulations concerning the ownership and use offirearms, social welfare programs, taxation schemes, and core stories about

the origins of nations. There are many ways in which civic cultures withinsettings where social democratic movements have some political powerwould seem to be more concerned with social solidarity than settingsinformed by more individualistic, autonomy-based forms of civic culture.Whether these national differences in the normative ordering of social insti-tutions persist will depend upon the kind of normative civic culture commu-nities within various nations seek to promote. Of course, the role of thepopular media and powerful corporate conglomerates in influencing thesubstantive content of public moral discourse deserves careful consider-ation. In the contemporary marketplace of ideas, the capacity to publicize

specific versions of civic culture is closely related to access to the massmedia outlets and revenue sources needed to promote particular accountsof common sense morality (Hilgartner & Bosk, 1988).

VIII. GLOBAL, TRANSNATIONAL CULTURE

Robert Bellah (1986), Seymour Martin Lipset (1990), and Alan Wolfe (1998)are among those sociologists and political scientists who have explored therole of civic culture in a variety of settings. In particular, there is a largebody of literature on the civic culture, or civil religion, of the United States(Bellah, 1975). Scholarship in the area of civic culture typically examineswidely shared, diffuse cultural norms at the level of the province, state, ornation. The concept of civic culture usually refers to the core norms, sharedstories, myths of origin, and dominant symbols of large-scale societies suchas Canada and the United States. However, with the formation of the UnitedNations at the end of the Second World War, the creation of the WorldHealth Organization, World Trade Organization, and the InternationalMonetary Fund/World Bank, and the establishment of transnational human-

itarian organizations such as Doctors Without Borders and Amnesty Interna-tional, a number of commentators detect the rapid emergence of a global,transnational culture (Lee, 1998; Yach & Bettcher, 1998).

While there are evident signs of ethnic and religious factionalism thatpromote the cultivation of distinctive cultural identities, countervailingtendencies that dissolve rigid ethnic, religious, and national boundariesclearly exist (Toulmin, 1994). Some social theorists discern signs of anemerging global human rights culture. Other commentators detect the rapidglobalization of commercial markets, where global capitalism obliterates thesignificance of national borders and distinctive local identities (Greider,

1997). Obviously, it matters a great deal whether the emergence of a global,


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transnational culture is regarded as a progressive expansion of a regime ofrespect for international human rights around the world, or a corporate,commodified McWorld where the only universal norms are the commer-cial values of the marketplace (Barber, 1996).

Whatever narrative is used to frame contemporary processes of global-ization, bioethicists have contributed very little to the critical analysis of anemerging transnational culture. A great deal of macro analysis in bioethicsdoes not proceed beyond the boundaries of the nation-state. For example,most discussions of social justice and access to health care resources focusupon particular nations such as Canada, the United States, and Great Britain.Whereas medicine is understood by many medical educators to include thefield of international health, there is remarkably little scholarship in bioet-hics that takes global social order, global health, and transnational institu-tions as the focus of analysis. Of course, with the gradual emergence of a

body of literature on health and human rights, there are signs of greaterinterest in the emergence of a transnational set of moral norms and legalstandards (Mann, Gruskin, Grodin, & Annas, 1999). Bioethicists are gradu-ally beginning to acknowledge the globalization processes that are widelyrecognized in the fields of economics, sociology, cultural psychiatry, andinternational relations.

As bioethicists develop new research agendas that look beyond theborders of the nation-state, there is likely to be increased attentiveness tothe tension between universalist and pluralist accounts of moral reason-ing. At present, conflicts related to the tension between local culturalmodels of moral reasoning and universal moral claims are found in discus-sions concerning appropriate ethical frameworks for multinational clinicaltrials, the need for transnational regulatory agencies, and the goals of tran-snational humanitarian agencies. If bioethicists are going to make meaning-ful contributions to public debates in this period of globalization, there willneed to be a shift in thinking. The macro-level of scholarly analysis will nolonger be the organizational ethics of a particular institution or priority set-ting and resource allocation within the confines of a single nation-state.Instead, if bioethicists hope to contribute to major contemporary social and

ethical debates, they will need to contribute to the critical exploration of anemerging transnational, global culture.

IX. MORAL REASONING, CULTURAL UNDERSTANDINGS,AND SOCIAL CONFLICT

To attend to the significance of culture is not to suggest that bioethics ormorality is relative, in the nihilistic sense that everything is permitted.The very notion of a human rights culture suggests that some social goods

(or global public goods) are basic to human flourishing. It is entirely possible


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to acknowledge a plurality of moral norms, social practices, and kinshippatterns while maintaining that particular practices are more humane andjustifiable than alternative forms of life. However, the concept of culturecomplicates the task of normative deliberation by acknowledging the variet-

ies of local knowledge (Geertz, 1983). By attending to the existence ofmultiple webs of meaning, the concept of culture serves to challengemainstream scholarship in bioethics that emphasizes the existence of anahistorical, universal common morality, and presumes a moral order thatexists in a state of widespread reflective equilibrium.

While there do exist core moral norms embedded in laws, institutionalpolicies, and social practices in the United States, Great Britain, Canada, andother nations around the globe, there are numerous communities withmores that challenge various facets of these different civic cultures. In manysettings, individuals who are Jehovahs Witnesses challenge dominant

understandings of the meaning of blood products and blood transfusions.Christian Scientists draw upon cultural models that categorize illness inhighly spiritualistic terms. Patients from communities that promote familialsolidarity rather than individual autonomy sometimes question dominantunderstandings of the importance of truth telling and patient autonomy.Representatives of various religious communities frequently express skepti-cism toward secular public policies. Since the early 1980s, neo-conservativepolitical parties in many Western nations have challenged existing public-private mixes of health care.

These various ways of thinking about illness, health care, patient-physi-cian relations, professional culture, organizational culture, and civic culturesuggest that models of deliberating about morality can vary amongst socialgroups. Consequently, to embed particular moral norms in professionalcodes, institutions, laws, and educational programs is to engage in the norma-tive work of promoting particular moral norms, while pushing other ways ofworldmaking to the margins of reasonable public debate. This normativeboundary work is evident in the field of bioethics, but it is also found in lessself-consciously normative decisions concerning the licensing of health careproviders, the flow of funding to support particular research initiatives, and

the allocation of resources to promote particular kinds of health care.

X. CONCLUSION

If current scholarship provides any indication of future trends, research inbioethics will likely become more attentive to the cultural models of mem-bers of particular ethnic groups, the role of enculturation into particularmedical specialties, the moral culture of organizations, civic culture andsocial ethics, and global culture. Whereas a great deal of anthropological

and sociological research already addresses the cultural models of various


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ethnic groups, future research that relates the concept of culture to bioethicswill need to move beyond the equation of culture with the mores of partic-ular ethnic groups. Perhaps bioethics research in the future will be lessexclusively oriented toward the contributions of physicians, lawyers, and

philosophers, and more attentive to the interpretivist approaches of scholarsin the anthropology and sociology of medicine and other branches of thehuman sciences (Fox & Swazey, 1984; Muller, 1994). The concept of culturecan be fruitfully explored at various levels of analysis, and should not beused only with reference to the exploration of the norms, understandings,and practices of distinctive ethnic groups. While there are many obstacles tothe emergence of a global, transnational social order, we are likely on thecusp of a new wave of bioethics scholarship that will increasingly attend tosuch institutions as the World Health Organization, World Bank, and Doc-tors Without Borders. The concept of culture will likely continue to prove

useful not just in the study of ethnic differences and local organizational set-tings, but also in the study of newly emergent social institutions and tran-snational agencies.

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from the local to the global: bioethics and the concept of culture

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