Medicine and the possibility of a universal ethics

Dr. James Drane

Russell B. Roth Professor of Clinical Bioethics (Emeritus)
at Edinboro University of Pennsylvania

• Introduction:A Society of Moral Strangers
• Cultural Based Morality
• Getting beyond cultural differences via medical ethics
• The content of a universal ethics
• Universal principles and concrete norms
• The case of female circumcision
• Conclusion
• Notes

Introduction: A Society of Moral Strangers

There is something which human beings around the world seem to share: i.e. the tendency to reduce deep and elusive complexities about human existence to short, simple, slogan-like formulae. Abortion complexities, for example, generate oversimplified slogans about life and choice. The same is true of pressing political and religious issues. Slogans in their turn, reinforce artificial group boundaries formed around these synthesized belief statements. Some persons belong to more than one such group: a club, a protest group, an advocacy organization, a fringe political party, a fundamentalist group, a gang, a militia. The group or organization reinforces the simplified belief statements, strengthens unfounded superiority claims, and creates a narrow and separate culture.

Bolstered by fellow believers in the group, along with visual identifiers like badges, metals, particular styles of clothes or hats, etc... the endurance of the artificial social boundaries and separate cultures are guaranteed. Every group becomes something like a sect. Every sect adopts some version of "we are the only true church" idea. Those outside the narrow cultural boundaries are considered lost, enemies, odd, different, or not worthy of respect.

Societies, in both developed and developing nations, have become fragmented into separate cultures of fellow believers on the one hand and moral strangers on the other. People feel the need to belong, and to be part of some group or another. Many have a strong need to belong among "the saved" or the "superior". They split off from "the others" and make few attempts to communicate outside their sectarian "communities." Separate cultures become stronger while the broader culture, which used to be called civil society, weakens. When civil societies disintegrate, prejudice, racism, and sectarianism flourish. Tolerance, brotherhood-sisterhood, and respect for persons who are different have again become major challenges as we approach the third millennium.

How can something so basic to human survival as respect for other human beings become so easily endangered? What happened to that sense of wonder and respect which is grounded on looking into another human face. Who can come into contact with a small child without feeling tenderness and love? Sad to say, the answer even to this last question is that there are many who can, especially if the child is from a different racial or cultural or "religious" group. For more and more of our fellows, the human experience of respect based on seeing the other´s face has been lost. For more and more human beings the foundation of a universal ethics has been lost and only members of their own narrow culture matter.

If all this is true, then, it seems appropriate, once again, to inquire about the possibility of recovering a unviersal ethics. We need to recover universal values and articulate universal standards which bind all humans; ones which would draw us back into respectful, indeed even friendly communication with one another; ones which would help us to appreciate our groups or cultures without losing appreciation for others. Is it possible that the concept of disease, the experience of illness and a medical professional´s commitment to help persons in distress might help us all to find our way back?

Cultural Based Morality

Different cultures are assumed to have different moral values. Stated in its usual way, people are different and so, too, are their morals. "It is impossible to develop trans-cultural or universal ethical standard," is a widely held conviction in the U.S. Cultures are taken to be the sole source of ethical standards and the term culture referes to ethnic, racial, religious, linguistic, nationalistic divisions and even to the beliefs and behavioral patterns of smaller particular groups. The assumption is that no way exists to ground a universal ethics. We humans are assumed to be hopelessly divided. A person might be pushed to admit that babies and children are the same everywhere, but the idea that common beginnings might be the ground of a common human structure from which common ethical standards may be derived is not given serious consideration. Universal human traits, if they exist, are assumed to disappear in the course of human development and consequently only culturally different people remain.

Without universal values and standards, ethical disagreements have to be settled either by force or tolerance. Radical cultural relativity logically assumes pessimism about objective moral standards and leads either to patterns of force or to an ethics of tolerance. Despite the absence of any convincing arguments to support the validity of their beliefs, cultural groups in the U.S. struggle with one another politically, not to advance tolerance but in order to impose what they consider to be right. Morally divided groups prefer force and fight to legislate their ethical convictions.

Right-wing American politicians especially, along with militia members, for example speak very negatively of the U.N. Any suggestion that the U.S. might be bound to respect ethical standards which are at odds with what they believe to be national interests is considered absurd. What is right and good for one group may indeed be disastrous for other people, but it is taken for granted that each must push and fight to impose its own cultural values and interests. The idea, for example, that anyone should sacrifice national or economic advantage to what is good for people in other cultures or good for human kind is considered to be political heresy and anti-American. The assumption is that universal ethical obligations are nonexistent. Cultural goods are all there are. When these come into conflict, there are only two options: either fight to impose one culture´s values on others, or promote a culture of tolerance in which every culture (or individual) is on its own, in a free, competitive market environment. The options are either economic struggle or all-out war.

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Getting Beyond Cultural Difference Via Medical Ethics

The proposition that human beings, so divided culturally, and "religiously," can come to agreement about a universal anthropology or "theology" from which universal ethical standards could be derived, is admittedly a difficult one to argue.(1) But the idea that universal medical ethical values and standards might be derived from a common-sense understanding of the ends and purposes of medicine seems more feasible. If babies are the same everywhere, and solicit from emotionally normal people a disposition to protect and help, the same is true of people with illness and disease. Disease and illness are objective realities which we can all recognize no matter what our cultural, philogophical or theological differences. We may not be able to agree about the nature of man or what constitutes the universal structure of a human person. Admittedly, the nature of reality will always be problematic but not so, or less so, the nature of human disease. Cholera, T.B., Malaria, Leprosy, and AIDS create the same painful and needful human conditions everywhere. These commonalities can serve as a basis for developing standards for how people who suffer from disease should be treated. Said differently, the reality of disease and pathology, as well as the needs of sick people, are so robust and obvious that they can structure or serve as the foundation of an objective medical ethics, characterized by universal or trans-cultural ethical standards.

It is one thing to agree about the structure of reality, and a much easier thing to agree about the pathological deterioration of a physical system (e.g. the circulatory, respiratory, immune system). Pathologies can be agreed upon even if we might disagree about whether the source be a lesion, an imbalance, a microbe, or the influence of an evil spirit.

The possibility of developing objective medical ethical standards based on universal disease conditions and associated patient needs is enhanced by the fact that in mainline western medicine, disease is understood by using widely agreed upon scientific categories. Mainline medicine´s response to disease is based on laboratory science´s universal research methodologies. All important medical research ultimately requires the involvement of human subjects. Fifty years ago, in 1947, experience with the way Nazi doctors used human subjects for scientific medical research lead to the first modern secular expression of a universal medical ethics. The Nuremberg Code´s ethical standards have been expanded and refined but remain in place everywhere. They provide us with an example of an objectively based universal ethics.(2) No matter where research involving human subjects is carried out it creates the same ethical dangers both for human subjects and the same ethical standards for their protection.

Clinical ethical standards are also created by medical treatment. Medical technology shapes both scientific resarch and clinical treatment of disease. How can technology be used humanely on people who have a disease or are ill? How can inhumane use of medical technology be avoided? How can vulnerable patient´s needs best be addressed when the available technological interventions are dangerous? These are questions asked wherever medicine is practiced. It is easier to argue against inhumane uses of medical technology than it is to recognize inhumanities of other sorts. Could anyone justify the way Nazi doctors used technology on sick, uninformed and vulnerable patients? A culture-based ethical relativism seems less obvious once one enters the smaller worlds of scientific research and medical practice.(3)

Modern western medicine in effect seems able to generate a medical ethics which transcends particular cultures, just as illness, disease, and scientific research do. After Nuremberg, other universal standards were promulgated.(4) Revulsion caused by disrespect of human subjects generated the same ethical standards for proper treatment of research subjects everywhere.(5) Later, the standards governing the use of research subjects were applied to the treatment of patients.(6) Cultural standards certainly exist in modern medicine, but so too do universal ones. Within the smaller world of medicine it is easier to recognize ethical standards which are peculiar to cultures and those which transcend cultures.

The transcendent standards are familiar to most readers of this paper. Patients and research subjects for example, must be treated with respect and respect involves some version of what we call informed and free consent. This ethical requirement remains valid even in cultures where women have little power to control most aspects of their lives or where the health care system has no money for medications being tested! This first positive ethical standard enunciated at Nuremberg was followed by many negative ones. All forms of physical torture with physician involvement have been condemned. The same is true of the use of psychiatric interventions on political dissidents. The proscription against the use of psychiatric intervention on political dissidents was issued over against opposition coming from countries and cultures which habitually violated it.(7)

Modern medical ethics in effect can serve as an encouraging example of international ethical dialogue directed toward creating universal ethical policies and concrete ethical standards for implementing abstract values like respect and justice. A universal or trans-cultural medical ethics actually exists and is expanding.(8) In international medical ethics, one culture does not impose its values or policies on others. Rather a dialogue occurs about how the universal and trans-cultural principles will be implemented. Cultural or national ethical review committees might be required to apply the universal standards, but these latter are not set aside or subjugated to contrary particulr customs.(9)

The statement that different cultures generate different ethical standards is a platitude. It ignores another truth, i.e., that trans-cultural commonalities also exist. Admittedly, these are more difficult to recognize and to formulate. Different geographies, histories, languages, religions, racial and ethnic strains, obviously are out there and so is the facile conclusion that these contribute to different moral practices. But, different cultures also have common elements, and more ethicsl communalities exist based on shared human conditions than some people are disposed to recognize.

Cultural contents, including religious and ethical standards, also change and develop. Evolution is as clear in religious and cultural based ethics as it is in other areas of life. Ethical values and standards, even though at present divergent, can move toward convergence under the influence of shared experience, especially important experience like sickness and medical treatment, experimentation and human involvement in research. Modern medicine, in both its research and treatment modalities, pushes different cultures toward ethical convergence and trans-cultural ethical standards.

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The Content Of a Universal Ethics

Arguing against culture-based ethical relativism is made difficult by the fact that all important ethical commonalities are embedded (and hidden) in language instead of being out there on the surface of reality to be perceived and measured. Even common ethical values generated by the same background medical conditions often are expressed differently. North Americans, for example, prefer rationalistc, secular, principle-based talk about ethics. Another culture may express the same ethical values in religious language or in virtue categories; in a more narrative and less rationalistc style. But these differences do not destroy an underlying objective ethics, one which obliges researchers and subjects, doctors and patients, no matter what their cultural identities and religious beliefs.

An ethnocentric ethics may be more obvious, but difficulties in articulating universal medical ethical standards are not insurmountable. We have already seen universal standards articulated by the U.N. and other international organizations. Supporting these is an international ethics which is already in place. We agree for instance that in order to be ethical, medical treamtent has to be beneficial to the person or at least it must strive to be so. Even involvements in medical research must provide a sick subject with benefit. Treatments like experiments always involve some risk which has to be measured against anticipated benefit. Patients in different cultures can certainly respond differently to benefits and risks but balancing these is part of a trans-cultural ethics. Harming a patient, or merely feigning help, or refusing to help is wrong in research in treatment and is so everywhere.

We see confirmation of the fact that medicine creates common ethical standards and values by looking not just at recent international delcarations but also at different historical medical codes: Hippocratic, Chinese, Persian, Indian, Hebrew, and Japanese Codes. These were produced in different historical times and in different cultures and yet provide powerful examples of common ethical standards. The ancient codes all called for physicians to suppress self interest in favor of the interests of the sick person. Altruism toward sick and needy patients was always a medical ethical obligation. This special form of love broke down into universal proscriptions against killing and harming and taking sexual advantage of patients. It also meant guarding patient´s secrets and confidences.

Today we speak of truthful communication which patients require in the sense of honest information about their condition, as a condition for free choice from among real medical options. If one or more ways exist to eliminate the disease or re-establishment function or relieve pain, then the patient must be involved in the selection of an option. The way respect is shown elsewhere may not be as individualistic as the U.S. style of informed consent but its absence cannot be tolerated no matter what cultural custom might dictate. Patient respect in the form of a requirement of informed consent is a modern addition to the older values of beneficence and non-maleficence. It is however equally universal and an example of how medical ethics, like all forms of ethics, evolves,

It may seem strange but truth or truthfulness, historically, was not a medical or physician value. Doctors in fact were considered exempt from the requirement to speak the truth. Today things are changing in this regard. Doctors too have to tell the truth to patients. There are exceptions to the rule and subtleties exist in determining just what truthful communication involves in medicine, but a requirement not to lie, has become another trans-cultural ethical standard.

Without the universal value of honesty, personal relationships cannot develop and this is especially true of therapeutic relationships. Lying is an enemy of curing, no matter what the culture. Manipulations of patients through lies pollutes the doctor-patient relationship and the whole context of modern medicine. Universal medical ethics requires of doctors that they struggle against self promotion because this easily leads to a compromising of truthfulness. Lying and other forms of willful patient deception are violations of a trans-cultural medical ethics.

Paradoxically, respecting different cultures is another important universal ethical value because it is tied to respecting human persons who are what they are, to some extent, as a result of their culture´s language, art, literature, customs, religion, and law. Respecting a culture involves respecting the identiy of persons formed in that culture. Violating some cultural forms and practices amounts to violating persons. When conflicts develop in intercultural doctor-patient relationships, conceptual clarity and careful procedures for working toward morally defensible resolutions is one more trans-cultural ethical requirement. Mediating procedures are especially important in situations of apparent conflict between universal standards and particular cultural norms.

Respect for culture is a universal but not an absolute ethical value. Limits exist to the respect due to cultural norms. Cultures cannot treat sick people anyway they like, cannot use medical technology anyway they like, cannot use human beings in research anyway they like, cannot intervene into the human genome anyway they like, cannot make whatever laws they like to reduce population. The issues raised everywhere by modern medical practice may generate different cultural responses, but no response is ethically admissible just because it is a longstanding cultural practice. We will see examples of this delicate problem in the next sections.

What one culture approves may create unacceptable impositions on people in another culture. A rich nation, for example, which approves the purchase of organs would create a terrible imposition on a poorer neighbor pushed to self mutilation and child slavery in order to survive. If money alone is allowed to determine access to treatments, only the most wealthy will live, and they will do so at the expense of the most deprived. That would be wrong even if it receives cultural approval from radical free market capitalist believers. Reproductive health practices may differ from culture to culture. The same is true of confidentiality standards, and what is considered to be just or equitable health care delivery. But this does not mean that anything goes, or that no limits exists to what a culture may approve or disapprove.

If certain medical ethical standards are trans-cultural so too are certain medical ethical dilemmas. How much autonomy does the patient have and how is this balanced with a physician´s professional standards? How much power does the public health officer have and how is this balanced with individual patient autonomy? Medical practice is an economic reality, but how can economics be kept from turning medicine into a purely monetary enterprise? Technology inevitably plays a role in human reproduction but what are the limits of technologically engineered reproduction? Research using human subjects is necessary but at what point does it cross over into being manipulation and misuse of human beings?

Cultural differences do not require ethical relativism but, rather, fuel a drive to articulate standards which transcend cultures and oblige us all. A trans-cultural medical ethics is based on common dimensions of human persons, common scientific assumptions, common conditions created by disease, and the commonalities inherent in the relationship between a sick person and the doctor from whom help is sought. Given the shared background assumptions of modern medical science and the shared technologies of modern medicine´s interventions, humane medical help can and should conform to common ethical standards no matter what the cultural context. Medical ethics can be trans-cultural because the science of medicine and the experience of sickness both are. Trans-cultural or universal ethical standards may not be obvious, but intercultural dialogue to identify them and to articulate them is a worthwhile enterprise.

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Universal Principles And Concrete Norms

To argue convincingly for the existence of a universal medical ethics is just the first step in a complex and difficult project. The next step is to attempt to move from abstract universal values, to concrete norms or rules covering specific situations. The general values or principles are helpful in determining what to do in a clinical situation but something more is needed. It is one thing successfully to ground a universal medical ethics in the form of basic values (respect, beneficence, truth, love, life, justice) and another thing to apply these principles coherently to cultural practices or to develop concrete policies for a set of particular circumstances. A workable universal medical ethics must be closely linked with the every day circumstances of medical practice.

The first thing to note about moral choices made in actual medical practice is that they tend to be made with some sense of urgency. They are not the kind of choices one can afford to mull over or talk about forever. And yet they are full of subtitles and complexities. The choices are important both for the patient and the doctor. The pressing urgency of many clinical decisions, however, cannot justify instinct-driven decisions or shoddy decision making procedures.

What has been argued for thus far in this paper is a medical ethics which one finds in international medical declarations, codes, and conventions. It is an ethics of very general standards. Medical ethics codes speak about ethics at an abstract level of discourse. The most recent Convention on Human Rights and Bio-medicine of the Council of Europe(10) speaks of dignity of all human beings, integrity, equitable access, therapeutic benefit, the primacy of human beings, free and informed consent. This last general requirement is broken down into standards for adequate information and free consent, even for mentally disabled patients or in emergencies. One specific negative policy was formulated against the disposal of human body parts for financial gain.

Work on this Convention began in 1989 and concluded with final approval in Nov. 1996. Its policies are intended to sreve as international standards which build upon the 1948 U.N. Universal Declaration of Human Rights and subsequent international conventions and covenants. The Convention points toward creating an intercultural unity in ethical standards for biology and biomedicine.(11)

This latest statement of international ethics attempts to set general standards and assumes that in different cultures these will be somewhat differently applied. In fact, in every instance, a gap will exist between the universal ethical standards and the cultural circumstance or medical context in which these will be applied. The universal standards alone are not anough. Before they generate ethical policies for particular cultures, a detailed examination of cultural circumstance and clinical context is required. A flat-footed, direct, and unsubtle application of general principles will oftentimes create more harm than good. Said differently, universal ethical principles are fundamental and yet will usually require some adjustment in order to be properly applied. Culture will never invalidate universal ethical principles or require that they be violated. Culture, however, will always require consideration for the way principles are applied via rules and norms.

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The Case Of Female Circumcision

The issue of female circumcision provides us with an example of the relationship between universal principles and concrete cultural applications. Those who deny the validity or even the possibility of a universal medical ethics opt simplistically for cultural relativism. They will accept the way certain cultures manipulate the sexual organs of young women. Whatever is right or acceptable in a particular culture will be considered right and acceptable. General principles like beneficence, non-maleficence, truth, and respect are simply set aside. On the other side are universalists who proceed deductively from the abstract principles to immediate proscription of any and every practice related to female sexuality. Cultural context are left completely out of consideration. A middle ground perspective gives close and careful attention to cultural context in order to understand just what universal values and principles require and how they should be applied to change the situation of young girls whose loving parents believe that female circumcision is a necessary good.

Female circumcision is a term which describes different types of genital surgeries performed usually on very young girls in many African, Indian, Malaysian and Middle Eastern Cultures. It involves partial or total clitoridectomy, sometimes with an added surgical closure of the vaginal opening. An estimated 100 million women are subjected to circumcision which is usually performed without anesthesia in non-sterile conditions. Besides the immediate pain associated with the procedures, infections are common. So too are long term ill effects like infertility, painful intercourse and diminished sexual response.

In most cultures where it is practiced, female circumcision is a "woman´s thing", i.e. controlled by female rather than male family members. It is such a common practice that it is understood by many to be "normal" and "natural." In addition, it is considered a requirement for marriage, an ethnic marker, a way of proving virginity and protecting family honor, even a way of enhancing a husband´s pleasure. Religious support for the practice in Islam is usually linked to beliefs about ritual purity and the need to control female sexuality rather than to the authority of Islamic scripture. (Male circumcision on the other hand is required both in Islamic and Jewish scripture).

Because female circumcision is strongly rooted in certain culture it is even practiced on non-Muslim girls. It is a marriageability requirement for them too, as well as a way of keeping their husbands sexually satisfied. The daughters of more affluent, secular parents may be sent to physicians in order to reduce the pain and infection. But even for them it is believed to be a protection from sexual involvement when they have to wait until after their university educations in order to marry.

Objections to female circummcision based on universal ethical principles are strong and spreading. They can be traced centuries into the past. Catholic missionaries at first considered the practice to be wrong and forbade it, only to relent, when catholic girls found themselves unmarriageable. More recently, feminists have embraced the anti-circumcision cause and have involved the World Health Organization in their crusade which is carried out under the banner of Women and Children´s Health. The circumcision practices have been publicized in the popular press and are often labeled as mutilation, torture, barbarism and ritualized abuse. Because circumcision is practiced even in Europe and America by immigrants from Africa and the Middle East, legislation has been introduced both in Europe and North America to ban the practice. In Canada, The College of Physicians and Surgeons developed a policy statement which barred the procedure. By contrast, the vast majority of women in the cultures where it is practiced still consider it a normal preparation for womanhood.

To recognize the complexities involved in applying universal ethical standards to cultural practices is not to give up on the project. An effective international ethics must be able to take the subtle steps toward concrete application of broad principles to particular heatlh related practices. Sensitive and nuanced application begins with a thorough understanding of how the health related practices are experienced by persons within a culture. Outsiders don´t always get a clear picture of this simply by looking at a practice through a Western cultural lens.

Patience is required. Cultural practices in developing nations may not change as rapidly as they do in modern societies but they do change. To extract a cultural practice from its settings and to consider it unalterable is to stereotype a complex and essentially developing phenomenon. One recognizable instance of cultural ethical evolution is a widespread acceptance today and appreciation of western medical interventions when faced with life-threatening situations. Trusted local medical practitioners can help to avoid oversimplified misunderstandings of the culture and insensitive applications of the universal principles. They can be important for starting up dialogue and mediation between the universal and the cultural.

The aim of applying universal principles to problematic cultural practices is to prevent a health related harm or to advance a medical good. In order to accomplish one or the other objective, the consequences of cultural practices and mandated changes must be carefully assessed. Sometimes added harm may occur as a result of moral interventions. These latter, made by outsiders, can easily come over as self righteous and condemnatory.

Finding the right voice for speaking about ethics and morality is critical. Questions like how much can be said and to whom, have to be addressed. Simple condemnations may be clear and honest but seldom accomplish the intended goods. Statements that express understanding of how questionable cultural practices originally developed can modify and moderate dialogue intended to make moral changes. Success depends upon finding the right language for expressing the moral judgement and the right sources of moral authority.

If moral judgements are being made by persons from another culture, some language which recognizes the moral inadequacies of both cultures may help. This reduces the possibility of a bioethical judgement coming over as moral imperialism. Some statements of respect for the culture whose practices are being judged also help. An admission and recognition of the perspective from which the judgement is being made is honest and helpful: e.g. "from the perspective of modern western medicine, this or that practice causes serious and long term damage. It aggravates the existing symptons and provides no compensating medical benefit."

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Conclusion

There is no way of avoiding the ethical dimensions of human behavior. Even the research scientist not involved with human beings has to ask himself or herself whether it is right or good to be involved in a particular project (e.g. gene mapping or nuclear physics). If this is true of work in physics and genetics, it is certainly true of work in an applied science like medicine. Every doctor, in every culture, with every patient, has to ask whether what he or she proposes to do, or is being asked to do, is ethically right. It is more than understandable that healers in every culture developed an ethical code. Sensitivity toward the needy ill was always required, as well as respect for their human dignity, a guarding of their secrets, and a commitment not to take advantage of their vulnerability or to do them harm.

Consideration of culture in the application of a universal medical ethics can never equate to a betrayal of universal standards. To keep this from happening, doctors and nurses, who are already culturally formed, need to be formed by the universal ethics. It is all too easy for health care professionals to be influenced by cultural/political powers to violate historical and universal standards. The universal norms and policies (for example, against torture, abuse, mutilation) have to be given real force in order to counter cultural pressure on medical persons who earn their living working from others (e.g. a government or the military). International professsional associations need real political power to counter political power from other institutions within a culture.

Doctors and nurses in every culture have to receive ethical education and must experience the solidarity of the universal medical community in order to stand up against economic and political pressures which often demand ethical violations. Unless a global or universal medical ethics is taught effectively to future doctors and nurses, it will never be translated into practice. And unless universal medical associations monitor medical practice and respond to reports of ethical violations, the universal ethics will amount to a list of platitudes. If ethical violations occur, global medical associations have to intervene.

The medical ethical failures which took place in Nazi Germany provide lessons which cannot be ignored. German medicine was the most highly regarded scientific medicine in the world. Doctors who worked for the state (most doctors in a socialist system) and/or for the military were first ready to label political dissent a disease and then to report on their patients. These initial ethical failures preceded an even closer cooperation with political powers regarding "inferior persons" (mentally ill, Gypsies, Jews) which first called for less treatment and ended up calling for mass murder. The apparent ease with which many doctors and nurses carried out state sanctioned immoralities shows how important it is to provide explicit and thorough ethical training, followed by a strong awareness of the medical behaviors being monitored by international medical associations. Immediate resistance has to be instilled to any use of medical personnel or medical interventions for accomplishing non medical objectives (for example, military readiness, preference for male babies, insurance eligibility).

Peoples and cultures are different but they are also somewhat the same. We human beings share illness and the need for medical assistance. We share beliefs in the basic asumptions of scientific medicine and the relationship between a scientific healer and a needy patient. Some different health related practices must be allowed to stand, while others must not be allowed because they violate basic principles. Sometimes, changes in cultural practices required political power and dicisive action. Universal medical ethics, however, has to be more than promises and principles. It has to get down to details and make changes in medical practices which benefit patients in whatever culture they happen to be immersed.

Perhaps medicine can set an example for respectful humane treatment of human beings across cultural divides. "Doctors Without Borders" and "Physicians for Human Rights" are already setting a powerful example of how persons in all cultures should be treated. They provide proof of the acceptability of western scientific medical interventions in non-western cultures. Their doctors remind us of the medical implications of human rights. Medical professionals are the "priests" of today´s world. If they effectively "preach" a Univrsal Ethics by the way patients in every culture are treated, maybe a truly civil society can be rescued. Maybe people locked in narrow cultures which distorts their view of others can be freed. Maybe the human family and humane society can survive.

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NOTES:

1. This difficult proposition however is being advanced by Hans Kung, a German Catholic Theologian. He organized a Parliament of The World´s Religions in Chicago in 1993 and has published a number of books on this topic: GLOBAL RESPONSIBILITY: IN SEARCH OF A NEW WORLD ETHIC (SCM Press, Long/Continuum, New York 1991), A GLOBAL ETHIC: THE DECLARATION OF THE PARLIAMENT OF THE WORLD´S RELIGIONS (SCM Press, London/Continuum, New York 1993), and YES TO A GLOBAL ETHIC (Continuum Publishing Co, New York 1996). His is an ethic of four basic principles derived from world religions.
2. THE NUREMBERG CODE, Washington D.C.: U.S. Government Printing Office, 1949.
3. Later on, the same ethical standards used to judge Nazi doctors were applied to condemn similar technological abuses by U.S. physicians. News of grossly unethical behavior by some Nazi physicians during World War II as followed in the U.S. by a series of revelations of similar ethical failures involving experimentation on vulnerable patients in American medicine (Willow Brook School, Jewish Hospital in New York, and the Tuskagee Syphilis Study). In 1966 Henry K. Beecher, a Harvard physician, published an article in the New England Journal of Medicine in which he exposed patterns of unethical conduct in medical research.
4. The U.N. Universal Declaration of Human Rights (1948) joined to the international Covenant on Civil and Political Rights (1966); The Declaration of Helsinki (1964) promulgated by the world Medical Association and revised in 1875 (Tokyo), 1983, (Venice), 1989 (Hong Kong); The International Ethical Guidelines for Biomedical Research Involving Human Subjects (1982)(1993).
5. International standards mentioned in NY Times.
6. The Nuremberg Code (1947) set the standard of free and informed consent by competent subject/patients. Over the years the elements of information, free consent, and competency, essential for ethical research, were applied as well to patient involvement in treatments procedures. Informed Consent constitutes the foundation of modern medical ethics, both research and clinical, world-wide.
7. At the time of its final passage the most frequent violators and main source of opposition was the Soviet Union. Today the violators are in totalitarian and fundamentalist states.
8. The following are examples of ethical codes and declarations which claim international status. They come from different sources: Amnesty International, The Declaration of Stockholm on the Prevention of Torture; from the U.N., Principles of Medical Ethics; from WHO, Declaration of Geneva, International Code of Medical Ethics; from the World Psychiatric Association, Declaration of Hawaii; from the International Council of Nurses, Statement on Nurses and Torture.
9. Virtually every developed nation today has some type of National Ethics Committee which sets policies and proposes statuatory regulations to legislatures.
10. CONVENTION FOR THE PROTECTION OF HUMAN RIGHTS AND DIGNITY OF THE HUMAN BEING WITH REGARD TO APPLICATION OF BIOLOGY AND MEDICINE: CONVENTION ON HUMAN RIGHTS AND BIOMEDICINE. The Council of Europe. Strasbourg, Nov. 1996.
11. The term bioethics was not used because in the minds of some, it was identified with the opinions of Peter Singer, an Australian who endorses active euthanasia for declining elderly and defective infants.