Anthropology, Bioethics, and Medicine: A Provocative Trilogy

Anthropology, Bioethics, and Medicine: A Provocative Trilogy
Author(s): Jessica H. Muller

Source: Medical Anthropology Quarterly, New Series, Vol. 8, No. 4, Conceptual Development in
Medical Anthropology: A Tribute to M. Margaret Clark (Dec., 1994), pp. 448-467
Published by: Wiley on behalf of the American Anthropological Association
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JESSICA H. MULLER
Departmentof Family and CommunityMedicine
School of Medicine
Universityof California,San Francisco
Anthropology, Bioethics, and Medicine: A

Provocative Trilogy
This article investigates the contributionsanthropologicalperspectives

can maketo thefield of bioethics.Four dimensionsof an anthropological
approachto bioethics are presented: the contextualnatureof bioethical
dilemmas; the cultural embeddednessof moral systems; the culturally
pluralistic characterof many bioethicalproblems;and the examination
ofthefield ofbioethics as a culturalphenomenon.Thediscussionexplores
how moral dilemmas and the means to resolve them are inextricably
boundto their institutional,economic,and social contexts,how different
culturalsystems have differentmoral codes with differentstandardsfor
behavior, and how bioethical conflicts often arise in culturallyplural
health care settings. In addition, it discusses the challenge offered to
anthropologiststo examine the values, cognitiveframework,and social
organizationofbioethics. Thearticle concludeswitha discussionof ways
that anthropological methods and knowledge can be applied in the
bioethics arena. [bioethics, medical decision making, moral behavior,
cultureof biomedicine,United States]
he purposeof this article is to continue the dialogueon the relationshipof

anthropologyand bioethics. The term "bioethics"-increasingly heard in
hospitalcorridors,publicpolicy debates,majormedicaljournals,textbooks,
and the media-has come to refer to inquiry into the ethical implications of
scientific and technologicaldevelopmentsin medicine. Althoughphysicians and
others have long ponderedquestions relating to ethics of medicine, the field of
bioethics did not emerge until the late 1960s and early 1970s when the study of
ethics-the philosophicalinquiryinto principlesof moralityand right and wrong
conduct-began to be systematically applied to the domain of medical activity
(Clouser 1974). Since then, bioethicshas grownrapidlyas a discipline.It has seen
the emergenceof a largeliteratureon ethical issues in medicine,the establishment
of centers, conferences, and professional organizationsthat address bioethical
developments,the introductionof courses in medical ethics in many medical and
Medical AnthropologyQuarterly8(4): 448-467. Copyright? 1994, AmericanAnthropologicalAsso-

ciation.
448

ANTHROPOLOGY, BIOETHICS, AND MEDICINE 449
nursing schools, and the creation of hospital "ethics committees" to help patients,
families, and staff make morallydifficult decisions about their medicalcare (Fox
1990; Jonsen 1993; Marshall1992).
Although scholarsfromdifferentdisciplineshave been drawnquicklyinto the
bioethics arena,social scientists,with a few notableexceptions, have been slow to
turntheirattentionto the examinationand analysis of bioethicalquestions.Lieban
(1990) and Marshall(1992) suggest that while anthropologiststraditionallyhave
investigated the normativebehaviorand moral codes of the cultures they have
studied(e.g., Hsu 1961;KluckhohnandStrodtbeck1961;Whitinget al. 1966),they
have been less interestedin bioethics for three reasons: the notion of cultural
relativityhas not had a place in the moralthinkingof bioethics untilvery recently;
the developmentsin Westernbiomedicine,which have triggeredextensivebioethi-
cal debates, have not been the focus of anthropologicalresearchbecause of the
discipline's traditionalemphasis on research in non-Westernsocieties; and the
different trainingand interestsof anthropologistsand ethicists have not fostered
cross-fertilizationbetweenthe two disciplines.
In recent years, however, interest in the intersectionof anthropologyand
bioethics has been growing. Publications and conferences on the subject are
appearing,'anda numberof social scientists(e.g., Clark1990, 1991, 1992;Fabrega
1990; Fox 1990; Kunstadter1980; Lieban 1990; Weisz 1990) have called for
culturalanalyses of ethicaldilemmasin healthcare settings. Given these develop-
ments, it becomes pertinentto reexamine the relationshipof anthropologyand
bioethics (for an earlier discussion, see Marshall 1992). In the discussion that
follows, I consider the evolution of the field of bioethics, including its existing
conceptualframework,as well as new theoreticalmovements in bioethics. I then
examine four dimensions of an anthropologicalapproachto bioethics: (1) the
contextualnatureof bioethicaldilemmas;(2) the culturalembeddednessof moral
systems; (3) the multiculturalcharacterof many bioethicalproblems;and (4) the
challenge of examiningthe field of bioethicsas a culturalphenomenon.The article
concludes with a discussionof the methodologicalandtheoreticalcontributionsan
anthropologicalapproachcan make in the evolving bioethics arena.
The Evolution of Bioethics

Technologicalandscientificadvancesin medicineandthe biologicalsciences
helped both to create the field of bioethics and to define its parameters.Its
emergenceas a distinctdisciplinein the United States was associatedwith several
key events that took place in the 1960s and early 1970s. Among them were the
selection of patients for chronic dialysis in Seattle, Washington, in 1962; the
initiationof hearttransplantationin SouthAfrica in 1969; and the disclosureof the
TuskeegeeandWillowbrookexperimentsin 1972, in which AfricanAmericanmen
and mentally retardedchildrenwere used in life-threateningexperimentswithout
their knowledge (Jonsen 1991; Rothman 1991, 1993). These events stimulated
public debate on such topics as how societal resources should be allocated to
maintainlife and what the parametersof informedconsent should be for patients
and participantsin medical research. They also caught the attention of moral
philosophersandmoraltheologianswho beganto apply formalanalysisfromtheir
respectivedisciplines to ethicalproblemsin medicine (Jonsen 1994).

450 MEDICAL ANTHROPOLOGY QUARTERLY
From its beginning,the centralpreoccupationsof the field of bioethics have

been moral dilemmas in the practice of medicine and in scientific and clinical
research.Some of the first efforts of the bioethics movementwere directedtoward
protectingthe rights and welfare of the subjectsof research.The Belmont Report,
producedby the National Commission for the Protectionof Human Subjects of
Biomedical and BehavioralResearch in 1978, described how ethical principles
could be appliedto the ethics of research(Levine 1986; NationalCommissionfor
the Protectionof HumanSubjectsof Biomedical and BehavioralResearch 1978).
In additionto humanexperimentation,bioethicists also became interestedin the
ethical issues surroundingorgandonorshipand transplantation, the conditionsfor
or
prolonging ending life, new reproductivetechnologies, genetic screening,and
definitionsof personhood.They beganto addresssuchquestionsas who is a person,
when is a persondead, whatis minimalacceptablequalityof life, and when should
medical treatmentbe withheld or withdrawn.Recently, bioethics has become
progressivelyconcernedwith the economics of healthcare,in particular,questions
relatingto the allocationof scarce resourcesand cost containment(Fox 1990; see
also Jonsen 1993; Rothman1991). Debates on all of these issues have addressed
the relationshipbetweenpatientsand health care practitioners,particularlyphysi-
cians, in climatesof changinghealthcare technologies.
The ConceptualFoundationsof Bioethics

Bioethics is a field whose origins lie in the branchesof Western(primarily
Anglo-American)philosophy and law that give primacy to the individual and
emphasizeindividualrights, self-determination,and privacy.Its theoreticalorien-
tation and methods for approachingproblems have been shaped by the moral
philosophers,theologians, attorneys,physicians, and biologists who have domi-
nated bioethics. The subjects they have studied and the ways in which they are
discussed reflect U.S. preoccupationswith the rights of individuals,fairness and
equity in access to benefits,such topics as abortionand aging, andregulationsand
guidelines devised to resolve many of these problems(Jonsen 1993).
Fox suggeststhatthreeconvergingfactorshave shapedapproachesandvalues
in the field of bioethics:
Americanphilosophyandphilosophers havehadthegreatestmoldinginfluence
Americananalyticphilosophy-withitsemphasison
onthefield.Itis principally
theory,methodology, andtechnique,andits utilitarian,
neo-Kantian,and"con-
tractarian"outlooks-in which the majorityof philosophersmost active in
bioethicsweretrained.Theirphilosophicalpositivismis reinforced
by theprinci-
ples and rulesof "beingscientific"thatphysiciansand biologistshave been
educatedandsocializedto applyto theirown professionalwork,andthatthey
havebroughtto bioethics.In turn,therationalismof American law,its emphasis
rights,andthewaysinwhichithasbeenshapedbyWestem-Ameri-
on individual
can traditionsof naturallaw, positivism,and utilitarianismoverlapwith and
enhancekey attributes andscientificthoughtin bioethics.
of the philosophical
[1990:208-209]
Groundedin these traditions,bioethics emphasizeslogic, codified rules and
techniques,and rigorous,precise, objective thinking.It seeks to develop rational
guidelines for humanconduct-rules or proceduresof reasoningthatcan be used

ANTHROPOLOGY, AND MEDICINE
BIOETHICS, 451
to assess the moralityof a given courseof action(Clouser 1978). This aim is based
on the premisethatindividualsare rationalhumanbeings who shouldengage in a
process of moral reasoning, based on normativerules or principles,to arrive at
decisions in situationsof conflict or ambiguity.The emphasishereis on prescriptive
behavior-how decisions ought to be made ratherthanhow they are made.
The frameworkthathas dominatedmuch of bioethicshas been the four-prin-
ciples approachdevelopedby BeauchampandChildress(1979). At the heartof this
moral code is the principleof respect for autonomy.Reflectingthe deeply rooted
Americanbelief in individualism,as well as bioethics' groundingin Westernlaw
and philosophy, autonomyhas become a centerpiece of contemporarytheories
about how patients and physicians in health care settings should relate to one
another. This principle holds that people who are able to make decisions for
themselves have the rightto determinetheirown course of action,even when they
refuse medical treatment,and that others have the obligation to respect their
decisions (Beauchampand Childress 1979; President'sCommission 1983). Com-
mitmentto this principleover the last two decadesreflectschangesin notionsabout
what constitutesthe physician's moralresponsibility;the emphasisnow is less on
traditionalideals of medicalbenefit andmoreon the rightsof patients(Beauchamp
1994).
Threeotherprinciplesin additionto autonomyhave commonlybeen invoked
to guide moraldeliberations.The principleof beneficence refersto the obligation
to providebenefitsandto balancethemagainstrisks;in medicine,it involves acting
in the patient's best interest. The principle of nonmaleficence pertains to the
obligation to avoid causingharm.The principleof justice expresses an obligation
of fairness in the distributionof benefits and risks, and it refersparticularlyto the
criteria by which scarce and expensive resources are distributed.For example,
concernsaboutdistributivejustice raisequestionsabouthow muchtreatmentought
to be providedfor young children with severe central nervous system anomalies
who are expected to die or how expensive, scarce medical treatmentshould be
distributed.
In general,thefour-principlesapproachassumesthatethicaldecisions canbest
be made by applyingthe principlesand more specific rules to particularsituations.
Moral dilemmasarise when moral considerationscan justify takingeither of two
opposing courses of action (Beauchamp and Childress 1979). Disputes often
involve complex disagreementsabout factual interpretations,as well as conflicts
betweenmoralprinciples.Bioethicists attemptto identifythe values implicatedby
the variouschoices, discussthe implicationsof these choices, andassess conflicting
ethicalprinciples.They aim to assist clinicians,patients,family members,or policy
makersby clarifyingrelevantissues, exposing fallacious reasoning,and assisting
in the resolutionof moraldilemmas.
Bioethics Evolving
In spite of its influence over bioethical thought,the principlesapproachhas
been criticized in recentyears for being acontextual,ethnocentric,reductionistic,
and sterile (cf. Hoffmaster 1992a). The approachhas been called a "mantraof
principles"where "the principleshave functioned ... like a ritualincantationof
normsrepeatedwithlittle reflectionor analysis"(Beauchamp1994:8).Clouserand

452 MEDICALANTHROPOLOGY
QUARTERLY
Gert(1990) have cautionedthat"principlism"cannotoffer a unifiedguide to action

becauseit lacks moraltheoryto tie its principlestogether "thefourprinciplesoften
have great rhetoricalvalue but they play no useful role in determininghow one
morallyought to behave"(Clouserand Gert 1994:260).
Some critics have rejectedthe principleof autonomy,in particular,claiming
thatbioethicshas been overwhelminglypreoccupiedwith the notionsof autonomy
andindividualism(Callahan1984;PellegrinoandThomasma1989; Veatch 1984).
Attentionis being drawnnot only to the theoreticalandpracticalproblemscreated
by the notion of autonomy (e.g., Clouser and Gert 1990, 1994), but also to the
priority autonomy has assumed in moral reasoning in health care ethics. The
"absolutizationof patient autonomy"(Pellegrino 1992:17) in bioethical analyses
raises serious concerns for some critics because its thrusttoward individualism
ignores the duties we owe others as membersof the humancommunity,thereby
diminishinga sense of communitarianethics or the common good. The focus on
autonomyhas also been criticizedfor reflectingthe interestsof white, middle-class
North Americans (Fox 1990; Fox and Swazey 1984; Hoffmaster 1990; Weisz
1990). Othersclaim thatthe rhetoricof individualismdoes not capturethe realities
of the doctor-patientrelationship or clinical practice, where a web of social
relationshipsmay have more weight than the individual patient in addressing
bioethicaldilemmas (e.g., Hoffmaster1992a;Pellegrino 1994; Zaner 1988).
The dominanceof a U.S. perspectivein bioethicshas also been challengedby
those advocatinga more internationalapproach(Criggeret al. 1988; Gillon 1994;
Pellegrinoet al. 1992; Veatch 1989). While in industrializedcountriesbioethical
dilemmas have arisen in large partout of the use and abuse of high-technology
medicine,less is knownaboutconcernsin developingcountries,includingdeficient
provisionof healthcare,extremelyinequitabledistributionof medicalservices,and
national differences in response to bioethical dilemmas. As Donnelley (1988:2)
points out, the ethical answers to questionsabout abortion,genetic screening,or
reproductionseem significantlydeterminedby where the questions are asked.
Many of these concerns aboutthe conceptualframeworkand applicationof
orthodox bioethics have been voiced by advocates of new trends in bioethical
thought (e.g., casuistry, virtue theory, feminist ethics, and ethics as narrative,
experiential,or interpretivephenomena).Althoughvarying in theoreticalorienta-
tions, foci, and methods, these alternativeapproachesshare the perceptionthat
principle-basedethics is overly abstract,removed from moral and psychological
realities,and anglo, male, and middle-classin its orientation.Moreover,it ignores
the gender, life stories, and cultural identities of moral agents (Pellegrino
1994:362). The emergingtheoreticalmovementsoffer otherapproachesto ethical
decision making.The contemporaryversionof casuistryholds thatmoralthinking
rarely begins with the invocation of a principle;rather,moral knowledge must
develop incrementallythroughthe analysisof concretecases (Arras 1991; Jonsen
1991, 1994; Jonsen and Toulmin 1988; Wildes 1993). This case-drivenapproach
contrastswith the theory-drivenmethod where a moral theory is developed first
and then appliedto particularcases.
Feminists arguethatmedical ethics does not reflect the lives and experience
of women; therefore,its principles,the questionsit asks, and its conductof moral
debates should be altered to focus more on issues of inequality, diversity, and

ordinaryexperience(Cook 1994; Liaschenko 1993; Warren1989). Proponentsof

virtue ethics (Drane 1988; Pellegrino 1994) stress the doctor-patientrelationship
andthe virtuesthatcharacterizethe "goodphysician,"such as benevolence,caring,
andrespect.Advocatesof ethics as interpretive,experiential,or narrativephenom-
ena arguethatmoralityis createdandenactedthroughexperienceas interpretedby
the participants(Carson1990; Zaner 1988).2Moralcategoriesare seen as embed-
ded in ongoing formsof social practiceandexperience;therefore,ethicalreasoning
should focus on practicesratherthan on the applicationof abstractmoral theory
(Hoffmaster 1990, 1992a;Jennings 1990). Those suggesting the use of narrative
ethicaltheoryclaim thatpayingattentionto the narrativesof patientsandproviders
will reveal ethical reasoningas well as ethical comportmentby examiningmoral
dilemmas within a biographicalframework (Benner 1991; Brody 1988, 1994;
Maciunasand Moss 1992; Uden et al. 1992).
An Anthropological Approach to Bioethics

What do anthropological perspectives add to the burgeoning field of
bioethics?To begin to explore this question,I outline in this section four overlap-
ping dimensionsof an anthropologicalapproachto bioethics. They pertainto the
contextual nature of bioethical dilemmas, the cultural embeddednessof moral
systems,the multiculturalcharacterof manybioethicaldilemmas,andthechallenge
of examining the field of bioethics as a culturalphenomenon.For this discussion,
I draw on the work of social scientists and others who take anthropological
perspectivesin theirwork. Although these studies reflect differencesalong disci-
plinaryand theoreticallines, they all representefforts to broaden,deepen,or refine
bioethicalanalyses.
Let me prefacethis discussion with two disclaimers.First, it is by no means
only anthropologistswho offer these perspectives.The bioethics literaturehas a
growing numberof examplesof writingsby nonanthropologistswho are sensitive
to these issues (e.g., Fox 1990; Hoffmaster 1990, 1992a, 1992b; Jennings 1990;
Weisz 1990, to namebuta few). Second,just as it may be dangerousto assumethat
all moral conduct in healthcare settings can be explained by recourseto a set of
four principles, so it is equally dangerous to assume that there is only one
anthropologicalapproachto bioethics;anthropologyencompassesnumeroustheo-
retical approaches,methods,and foci of study. In spite of this diversity,however,
anthropologyhas embodiedparticularpoints of view and assumptionsthatshape
an anthropologicalapproachto bioethics.
Moral Decision MakingIs Contextual

It is a basic anthropologicaltenetthatall cultureshave some degreeof internal
consistency and thatmany items of behaviorand many customs formpatternsand
interrelationshipsthat,in turn,compose the culturaltapestryof a group (Rosman
and Rubel 1992). When translatedinto the realm of moral behavior,it is assumed
thatmoral dilemmasand the means to resolve them cannotbe separatedfrom the
institutional,political, economic, social, and culturalcontexts in which they are
embedded.The anthropologicalposition sees the definitionof a medicaldilemma
and the ways in which it is handled as inextricably bound to broad cultural

454 MEDICAL
ANTHROPOLOGY
QUARTERLY
conditions that influence health and illness behavior generally.This notion, now
appearingwith increasingfrequencyin thebioethicsliterature,is a radicaldeparture
from orthodoxbioethicalanalyses,which typicallybuilttheirargumentson decon-
textualizednormativeprinciplesand rules and often lacked an empiricalbase'or
considerationof the many factorsthat shape particularcircumstances.The "con-
textualist"approach,on the otherhand, takes as its point of departuretwo basic
assumptions.First,to understandthe "rumpledreality"of moraldecision making,
it is criticalto examine how people actuallybehave in problematicsituationsand
the reasonsorjustificationsthey give for theirbehavior.The applicationof abstract
rules or principlesoften is not sufficientto grasp the complexities or subtletiesof
real-lifesituationsof moralconflict.Second, in orderto understandhow something
becomes defined and actedon as moralor immoral,carefulscrutinymust be given
to the political, institutional,andsocioculturalfactorsthatlead to the conditionsin
which ethical dilemmas appear.Organizationalstructure,power and statusdiffer-
entials, explanatorymodels of differentactors,or varyingexpectationsregarding
the patient-practitioner relationshipall shapethe definitionandresolutionof moral
problems.
These assumptionsbecome apparentin the few studies that have been done
by social science investigatorsin NorthAmericanhealthcare settingsin whichthe
focus has been the same issues thathave triggeredbioethicaldebates.While not all
of these studies explicitly frame their results in terms of ethical discourse, their
focus is on understandingactualdecisions or the complex contextualfeaturesthat
shape specific clinical encounters. For example, the work by Koenig (1988)
provides one of the few culturalanalyses that touches on the ethical implications
of changingmedical technologies.She looks at how a moralimperativeto provide
treatmentis created among physicians throughthe routinizationand consequent
acceptanceof a new medical technology and argues that the moral meaningof a
technology is embeddedin and expressedthroughchanges in social organization.
The evaluationof a new techniqueas a standardtherapymust derive, therefore,
from an understandingof the social setting in which treatmenttakes place.
An area that has attractedextensive bioethical analyses in the United States
but few anthropologicalinquiriesso far is that of truth-tellingand disclosureof
medical information.This issue has been examinedin relationto the "discourseof
hope" surroundingthe treatmentof cancer(Good et al. 1990), telling a patientfor
the first time that she has breastcancer (Taylor 1988), and revealing HIV status
(Marshallet al. 1991). Similarly,the ethical issues concerninginformedconsent,
although discussed widely in bioethical debates, have received relatively little
anthropologicalconsideration.Discussions of informed consent that have been
influencedby anthropologicalperspectives(e.g., Hahn 1982; Kaufertand O'Neil
1990; Levine 1991) have examinedhow culturalfactors affect obtainingconsent
and have questionedthe universalvalidityof the informedconsent model. Kaufert
and O'Neil's study (1990) of healthprofessionals'attemptsto get signed consent
agreementsfrom Native Canadiansis a particularlygood example of what can
happenwhen healthpractitionersandpatientsspeakdifferentlanguagesandattach
differentmeaningsto symptomsand treatments.
The ethics of decision makingatthe beginningandend of life has also received
sustained attentionin the bioethics literature.What level of treatmentshould be

given to seriously ill newborns?When should therapeuticmeasures be used to

prolong physiological function beyond the point at which a person's capacityfor
social interactionis gone? How should decisions about the use of life-sustaining
technology be made, and who should make them?Although these questionshave
been debatedextensively, less is known aboutdecision makingin clinical settings
and the factors that influence it. These issues, however, are beginning to be
addressedin recent ethnographicstudies of clinical settings. Studies of neonatal
intensive care units (e.g., Anspach 1982, 1987; Frohock 1986; Guillemin and
Holmstrom 1986; Hahn 1987; Levin 1986) have shown the dominance of the
technologicalimperativein shapingthe definitionof moralissues in these settings
and the limited role of parents in neonatal decision making. These studies also
demonstratethat the meaning of such notions as "treatment,""prognosis,"or
"personhood"cannot be taken for granted but emerges out of the particular
situations.When a "baby"becomes a "person,"for example, depends not only on
the medical natureof the newborn's condition, but also on his or her response to
treatmentandthe perceivedpersonalitycharacteristicsthatcaregiversreadinto the
behavioralresponsesof the newborn.Jennings,referringto Frohock'swork(1986),
remindsus that"the moral statusof the newbornis not something that is simply
given. It grows out of rational interactionin a cultural setting that gives that
interactionmeaning"(1990:270).
Anspach's (1982, 1987) discussionof the treatmentof seriously ill newborns
in the neonatal intensive care unit relates life-and-deathdecisions to the social
context in which they take place. She found that nurses and physicians made
differentprognosticjudgments aboutinfants because of the way work is divided
in a neonatalintensive care unit.Physicians,who had brief, sporadiccontactswith
patients, assessed prognosis largely on the basis of diagnostic technology, while
nurses,who sustainedmore continuouscontactwith infantsand parents,assessed
prognosison the basis of cues gleanedfrominteractionwith infants.These differing
prognosticationsoften led to conflicts in decisions about whether to initiate,
maintain,or withdrawlife-sustainingtreatment,leading Anspachto conclude that
the organizationalfeatures of technology-intensivemedical settings shape the
life-and-deathdecisions thathave to be made.
Similarobservationsare emergingfrom ethnographicstudies at the otherend
of the life cycle, regarding dying and death in contemporaryU.S. hospitals.
Slomka's research(1992) found that when family and physicians had differing
views about the use of life-sustaining treatmentin an intensive care unit, the
patient's demise was a "negotiateddeath"involving progressivebargainingover
the meaning and use of various medical technologies. She concluded that "deci-
sion-makingoften is less a questionof the applicationof traditionalethical values
than one of a 'cascade' of decisions, which occurs in the context of differential
power relationsamong professionalsandpatientsand families"(1992:252).
In my analysis (Muller 1992) of the use of "slow" or "limited"codes, less
thanfull resuscitationattempts,situationsin which cardiopulmonaryarrestis met
with, I consideredthe negotiatedandculturallyconstitutednatureof a practicethat
is consideredethically questionable.Ratherthan analyzing this practicein terms
of conflicting abstractmoral principles, I analyzed it in the context of resident
physicians' work in hospitals, where it emerges as an unofficial, negotiatedre-

456 MEDICAL
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sponse to the complex and often ambiguoussituationsthatarisewithincontempo-

rarymedical practice.
This researchalso revealed that how and when physicians-in-trainingdeter-
minedthatpatientswere dying was not simply a biological"given"but was shaped
by the ways they constructeda vision of therapeuticpossibilityandinterpretedclues
aboutpatients' capacitiesfor interaction(Muller 1987; Mullerand Koenig 1988).
In otherwords, pathophysiologicalstates and transitionswere given meaningand
significancein this biomedicalrealmthrougha process of interpretationof certain
cues and informationemerging in the context of treatment.Bioethical considera-
tions arose when participantsinvolved in the care of a patient had differing
definitionsof the patient'ssituationand,therefore,failed to reachconsensus about
the statusof that individualor the appropriategoals for patientcare.
The CulturalEmbeddednessof Moral Systems

A second dimension of an anthropologicalapproachto bioethics is its com-
parative, cross-culturalemphasis. It is an anthropologicalgiven that different
culturalsystems have differentmoralcodes with differentstandardsfor behavior
anddifferentexpectationsfor relationshipsthatareplayedout in healthcarearenas.
Views aboutwhat is ethical vary by culturalgroup,and the mechanismsthatexist
in differentculturalgroups for handlingethically problematicsituationsare also
culturallyspecific.
Fabrega(1990) and Lieban (1990) suggest thatto explore the ways in which
morality and medical practice are embeddedin culture, we need to broadenour
gaze beyond the issues defined as moralwithin the bioethics frameworkand deal
broadly with comparativemedical ethics. The anthropologicalimperative is to
investigate what Lieban (1990:223) calls the "ethnoethics"of medicine in non-
Westernsocieties, which would tell us not only aboutcross-culturalvariationsin
ethicalprinciplesof medicine,butalso aboutvariationsin theissues thatin different
societies become defined as morallyrelevantor problematic.
Investigatorsare now beginning to look directly at the moral dimensions of
medicalpracticeandsystemsof healingin culturesotherthanourown. Forinstance,
Brown(1992) examinesthe influenceof culturalvalueson approachesto deathand
the allocationof scarceresourcesin cross-culturalhealthcare.Hunt's (1992) study
of cancertreatmentin southernMexico exemplifies the ethical problemsthat can
arisewhenbiomedicalknowledgeandtechnologyaretransferredfrom one cultural
settingto another.Using her experienceas a programofficer for the FordFounda-
tion in Egypt, Lane(1994) describeseffortsto develop a code of researchbioethics
for Egypt. She describeshow the social and culturalcontext of the productionof
biomedical researchin Egypt influences the interpretationand applicationof the
four bioethicalprinciplesupon which internationalcodes arebasedand arguesthat
for bioethicalcodes to be effective, theirapplicationmust be sensitive to Egyptian
cultural,social, and political values.
Otherstudieshave focused on theculturallyconstitutednatureof ethicalissues
andmoralsystems. Fox andSwazey (1984) pointout in theircomparativestudy of
medical ethics in the United States and China that medical morality in China is
rootedin a conceptionof the individualin relationto statusandrole andenmeshed
in the networkof humanrelationships.Unschuld (1979) presentsa compendium

of the ethical writings of physicians in Imperial China, which elucidates the

expected ethical obligations of these medical practitioners.Locke and Honde's
paper(1990) on organ transplantsand definitionsof deathin Japanillustratesthe
different ways medical ethical questions are handled in differentcountries. The
workof Gordon(1990, 1991, 1994) andGordonandAllamani(1989) demonstrates
how culturalbeliefs and values shapethe practiceof nondisclosureof "badnews"
in Italy. Feldman (1992a, 1992b), in her comparisonof the treatmentof patients
with AIDS in Franceand the United States,suggests thatthe processes of decision
making and truthtelling are fashionedout of distinctiveculturalvalues-those of
autonomyand informationin the United States and trustand social ties in France.
These studies suggest thateven in countriesthatrely on a biomedicalconcep-
tual framework,biomedicine is not uniform,and ethical issues differ. Moreover,
they illustratethe vital role of culturein medical ethics as it shapes the definition
of ethicaldilemmas,the designationof the importantplayers,and the resolutionof
the dilemmas.
CulturalPluralism and Bioethics

Anotherdimension of an anthropologicalapproachto bioethics is a primary
emphasis on dilemmas resulting from culturalpluralism.Within bioethics, there
traditionallyhas been little interestin exploringthe ethical implicationsof cultural
pluralismand culturalcontact (Kunstadter1980). Experiencesin North American
healthcare, however,demonstratethatculturalgroupsdo not necessarilysharethe
culturaltraditionsandpremisesin bioethicalanalysis,nordo they acceptbioethical
principlesas guides for moral behavior.The practiceof disclosure, for example,
while fundamentalto patient care in the United States, is not takenfor grantedby
all cultures. Similarly, the principle of autonomy, which has flowered in the
particularculturalclimate of the United States, is not universallyacclaimed as a
guiding moralprinciple.Otherculturalgroups,as the Japanese,for example, may
stress conformity and the suppression of individualism for the sake of group
harmonyand social responsibility(cf. Kimura1992; Locke and Honde 1990).
Reflecting anthropology'straditionalinterestin culturalpluralismand cross-
culturalcomparison,as well as an increasinglyheterogeneouspopulation,investi-
gatorsarenow beginningto explorebioethicalissues in NorthAmerica,wherethere
may be fundamentaldifferences in the culturaltraditionsand values of providers,
patients,and families. Studies that have examinedthese issues include investiga-
tions of ethicaldecision makingaboutcancertreatmentin cross-culturalsituations
(Koeniget al. 1992), differingculturalexpectationsof the treatmentof ethnicelders
(Kim 1983), differing constructionsof prenataldiagnosis among geneticists, ge-
neticscounselors,andpatients(Rapp1993),discrepanciesbetweenthe explanatory
models of health care workersand patientsthat affect informedconsent (Kaufert
andO'Neil 1990), the differentlanguagesof risk used by healthcareprovidersand
Inuit women (Kaufertand O'Neil 1993), differingresponses to life-supportdeci-
sions (Klessig 1992), and culturaldifferencesrelatingto disclosureof information
about diagnosis and prognosis or terminationof treatment(Barnes et al. 1993;
Beyene 1992; Meleis and Jonsen 1983).
Analysis of cross-culturalethical issues in an outpatientclinic of a large,
multiculturalurban hospital focused on the ways in which cultural values and

458 MEDICALANTHROPOLOGY
QUARTERLY
practicesshapedthe interactionsbetweena teamof U.S. physiciansanda terminally

ill Chinese woman and her family (Muller and Desmond 1992). This study
illustratesthe fundamentaldifferencesin the way biomedicine and certainimmi-
grantgroups conceptualizethe role of the sick person, the family, and the health
careproviderin medicalinteractions.Indiscussingdifferingexpectationsregarding
the role of family membersin medical decision making, the telling of bad news
aboutprognosis, and the withdrawingor withholdingof life-sustainingtreatment,
this studydemonstratesthe conflicts thatcan occur when biomedicalpractitioners
encountermembers of an immigrantgroup with culturalvalues vastly different
from those underpinningbiomedicine.
Bioethics as a CulturalPhenomenon
The final dimension is the premise that bioethics is a social, cultural,and
intellectualphenomenon(Fox 1990) thatshould be examined in its own right.Its
ideology, structure,activities, culture patterns, and social traits are worthy of
investigation,especially regardingtheirsupportfor the beliefs, values, and norms
of U.S. society and U.S. medicine.Few social scientistshave engaged in social or
culturalanalyses of bioethicsas a system of inquiryand action, with the important
exception of the work of Fox and Swazey (1984) and Fox (1990). They have
stressed the importanceof examiningvalues and beliefs emphasizedand de-em-
phasized by bioethics, its cognitive frameworkand style, and its social organiza-
tion.
Researchers are beginning to report on specific aspects of the bioethics
enterprise.Flynn's (1992) study of the underlyingassumptions,discourses, per-
spectives, and practicesof hospitalbioethics committeesexamines how bioethics
is constructedin a particularfashionthroughbioethicscommittees.Marshall(1989)
has analyzed the cultural assumptionsunderlying clinical ethics consultations.
ArmstrongandHumphrey(1994), in claimingthatethics is another"beliefsystem"
that deserves social analysis, suggest that ethical debate can be analyzed as a
situationof high social dramathatdisplaysand reinforcessome of the core social
values of our society.
Contributions of an Anthropological Approach to Bioethics
Generalizingfrom this discussion of empirical work at the intersectionof

bioethics and anthropology,I propose several ways to apply anthropological
methodsand knowledge in the bioethicsarenaas we move into the second half of
the 1990s. If we accept the notion thatbioethics will be enrichedby developing a
more empiricallygroundedtheoryof morality,as suggestedby Hoffmaster(1990,
1992a) and Jennings (1990), then anthropology'suse of qualitativemethodsand
particularinterestin ethnographymake it quite suited to the examinationof how
moralproblemsareactuallyperceivedandhandledby those whom they affect.The
researchercan explore for a particulargroup which issues are defined as moral
issues, how moral questions are framed, and which moral values are invoked.
Ethical issues are situatedin the moral discourse employed by the people them-
selves ratherthan in the languageof the bioethicist.By letting participantsspeak
abouttheirconcers in theirown words,the anthropologicalapproachoffers what

Warrenbelieves bioethics needs: "In medical ethics, we need to do a lot more

listening"(1989:83).
This concern with the meaning thatjust individualsthemselves attributeto
events stimulatesanthropologicalinquirynot into the crises typicallydiscussed in
bioethics (e.g., abortionor withdrawalof life-support),but into everydayethics-
whatWarren(1989:78) calls "housekeeping"issues, the personalissues thataffect
people in their everyday lives. For example, what factors influence people's
decisions aboutwhetheror notto use a DurablePowerof AttorneyforHealthCare?3
Whatdo physiciansperceiveas ethicalissues in theirclinicalpractice,in whatterms
do they discuss them, and how do they attemptto resolve them (e.g., Kaufman
1993)?The moraldecisionmakingof people at riskfor specific diseasescould also
be examined. For instance,researchcould be carriedout with those who are now
faced, many years before the onset of fatal disease, with the choice of whetherto
be tested for the gene determiningHuntington'sDisease.
In contrast to bioethical analysis, the anthropologicalapproach"has not
measuredethical problems against a definitive standardof moral rectitude but
insteadhas viewed themas culturallyconstitutedand continuallyevolving" (Mar-
shall 1992:54). Researchon the culturallyconstitutednatureof moral behavior
revealsnotonly how ethicaldilemmasareculturallyconstructed,butalso how these
constructionsinfluencedecisions aboutethics in medical settings. Along the lines
of Gordon's(1994) workin Italy,anthropologistscould examine culturalassump-
tions of a particulargroup in dealing with disclosure, including what it means to
be a person and expectationsaboutdaily life, social relationships,andthe ordering
of the world.Analysis couldexaminehow these assumptionsaffect ethicaldecision
making in medical settings.
As we have seen, anthropologicalinquiryalso offers the contextualperspec-
tive. It recognizes thatdecisions about mattersof health and illness are not made
in isolation but are made in the context of a web of everyday activities and social
relationships.The focus is not on the individualalone but takes into accountthe
setting and culturalgroup. Consequently,ethical issues should be examined in
context; the ethical ramificationsof a situation cannot be addressed without
consideringthe associatedeconomic, legal, social, or policy issues.
In addition, the cross-culturalperspective of anthropologycan expand the
scope of comparativeethics. Cross-culturalstudies can show, for example, how
culturesvary regardingprotectionof life, the momentof death, and definitionsof
normaland abnormal.Throughexaminingthe moraldimensions of medicalprac-
tice in various cultures,anthropologicalinvestigationscan add to the empirical
knowledge of ethical dilemmasas they are defined, respondedto, and acted upon
in systems of healing otherthanour own. Having an understandingof the cultural
meanings associated with such practices as the telling of bad news, withholding
life-sustainingtreatment,or involving family membersin healthcaredecisions can
also clarify ethical dilemmas appearing in multiculturalsituations. Bioethical
considerationswould be informedby more comparativeanalyses of the meanings
and practicesrelatedto issues such as these.
Moreover,examinationof how ethical issues or dilemmas are interpretedin
particularcultural contexts could also elucidate the "transculturalshapings"
(Mainetti 1992:44) thatoccur when Westernbioethical concepts are transplanted

460 ANTHROPOLOGY
MEDICAL QUARTERLY
to otherculturalsettings.Along thelines of Lane's study(1994) of ethicalprinciples

relatingto informedconsent in medical experimentationin Egypt, cross-cultural
researchcould addressdecisions to terminatetreatment,abortion,reproduction,
definitionof death,genetic screening,and otherissues.
There are also theoreticaldiscussions in bioethics to which anthropologists
could contributetheir cross-cultural,comparativeapproach.Those particularly
relevantto anthropologistsconcerncontextandrelativism.What,forexample,does
"context"actually mean? What are its elements? Whose context is it? To what
extent can contextualfactorsbe criticallyappraisedandchanged(e.g., Hoffmaster
1992b)?With respectto relativism,what can anthropologistsoffer to the ongoing
debate aboutthe need for, and possibility of, some form of metaculturalethics or
universal principles (e.g., Armstrong and Humphrey 1994; Pellegrino 1992;
Shweder 1990)?These questionsdeserve anthropologicalreflection.
Finally, it is incumbentupon the anthropologistto answer the challenge of
Fox (1990), Fox andSwazey (1984) andArmstrongandHumphrey(1994) to direct
moreattentionto the field of bioethicsitself. One could examine,for example,how
the term"ethics"is seeping into everydaymedical discourse,as in "ethicsrounds"
or "ethicsconsultations,"or how bioethics's concepts andmethodsof analysis are
being transformedby clinicians,policy makers,journalists,andhospital adminis-
trators.Since bioethicists have paid relatively little attentionto the social and
culturalsourcesand implicationsof their field, Weisz (1990) suggests that social
scientistsconsiderthe practitionersof bioethics as well as its issues and dilemmas.
This pursuitcanprovidebothan analysisof bioethicaldiscourseandan opportunity
for bioethiciststo engage in critical reflection by offering the perspectiveof the
outsider.
Conclusions
By examiningthe culturallyconstitutednatureof moralthoughtand action,

as well as bioethics itself, anthropologistscan enrich bioethical analyses and
contributeto the overall developmentand refinementof this segment of medical
thoughtand practice.At the same time, anthropologists,by examiningmattersof
medicine and ethics, will expand the cultural study of medicine in their own
societies. The study of moralthoughtand behaviorprovidesan importantdomain
for anthropologicalinquiry. It offers theoretical challenges, opportunitiesfor
interestingempiricalresearch,and the chance to apply researchfindings to situ-
ations that,in one way or another,affect all of us. At this pointin the development
of the fields of anthropologyand bioethics, it is the work of bioethicists that has
provokedmuchof anthropologicalreflectionandresearchin the areaof bioethics.
By pursuingthe areasof study outlined above and assemblinga largercorpus of
empiricaldata, the anthropologistmay take a turn at provokingthe bioethicist's
inquiry.This effort may furtherconceptual development,debate, and empirical
researchat the intersectionsof anthropology,bioethics,and medicine.
NOTES
Acknowledgments.I am indebtedto Gay Becker and Genevieve Ames for organizing

the session at the Annual Meeting of the AmericanAnthropologicalAssociation in which

these ideas were first presentedand for their commentson draftsof this article. I am also
gratefulfor the commentsandsuggestionsof BarbaraKoenig andthe anonymousreviewers.
Above all, I wish to thankMargaretClarkfor her many probingand stimulatingconversa-
tions. A firm believer that anthropologistshad something to say about the practices and
ideology of medicine, MargaretClarkrecognizedthatethical issues in the medical arenas
were indeedrich subjectsfor anthropologicalinvestigation.Withouther, I would have taken
a differentpath.
Correspondencemay be addressed to the authorat the Departmentof Family and
CommunityMedicine, School of Medicine, 500 Parnassus,MU-3E, Universityof Califor-
nia, San Francisco,CA 94143-0900.
1. A conference entitled "HumanizingBioethics," sponsored by the Westminster
Institutefor HealthandHumanValues, was held in London,Ontario,Canada,in April 1994.
In 1992, therewas an invitedsession at the AnnualMeetingof the AmericanAnthropological
Associationentitled"Rockingthe Boat: Autonomy,Reality,and AnthropologicalCritiques
of Bioethics."In the same year, anotherinvited session was called "The Anthropological
Enterprisein Clinical Ethics:Issues of Ethicsfor MedicalAnthropology."Another invited
session at the 1993 Annual Meetings of the AmericanAnthropologicalAssociation was
entitled"StudyingPhysicians:Methods,Ethicsand Interpretation."
2. For a discussionof the antecedentsof the interpretiveapproachandsome its current
manifestations,see Marshall1992:53-54.
3. This is a legal document used in Califoria and some other states; it specifies the
medical treatmenta person wants and does not want, should one become incompetent,and
invests a designated person with the legal authorityto make medical decisions on that
person's behalf.
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Anthropology, Bioethics, and Medicine: A Provocative Trilogy

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Anthropology, Bioethics, and Medicine: A Provocative Trilogy

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Anthropology, Bioethics, and Medicine: A Provocative Trilogy

Author(s): Jessica H. Muller

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