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From the Local to the Global: Bioethics and the Concept of Culture
Leigh Turnera
a
McGill University, Montreal, Quebec, Canada

To cite this Article Turner, Leigh(2005) 'From the Local to the Global: Bioethics and the Concept of Culture', Journal of

Medicine and Philosophy, 30: 3, 305 320


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Journal of Medicine and Philosophy, 30:305320, 2005


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ISSN: 0360-5310 print
DOI: 10.1080/03605310590960193

From the Local to the Global: Bioethics


and the Concept of Culture

Journal
0360-5310
0JNJMP
ournal of Medicine and Philosophy,
Philosophy Vol. 30, No. 03, April 2005, pp. 00

Bioethics
L.
Turner and Concept of Culture

LEIGH TURNER

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McGill University, Montreal, Quebec, Canada

Cultural models of health, illness, and moral reasoning are receiving


increasing attention in bioethics scholarship. Drawing upon
research tools from medical and cultural anthropology, numerous
researchers explore cultural variations in attitudes toward truth
telling, informed consent, pain relief, and planning for end-of-life
care. However, culture should not simply be equated with ethnicity. Rather, the concept of culture can serve as an heuristic device
at various levels of analysis. In addition to considering how participation in particular ethnic groups and religious traditions can
shape moral reasoning, bioethicists need to consider processes of
socialization into professional cultures, organizational cultures,
national civic culture, and transnational culture. From the local
world of the community clinic or oncology unit to the transnational workings of human rights agencies, attentiveness to the concept 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 the
social sciences and humanities. According to a classic formulation by
Edward Tylor in 1871, Culturetaken in its wide ethnographic sense is that
complex whole which includes knowledge, belief, art, morals, laws, custom, and any other capabilities and habits acquired by man as a member of

Address correspondence to: Leigh Turner, Ph.D., Biomedical Ethics Unit, Faculty of
Medicine, McGill University, 3647 Peel St., Montreal, Quebec, H3A 1X1, Canada.
E-mail: leigh.turner@mcgill.ca
305

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society (Tylor, 1871). Writing over one hundred years later, anthropologist
James L. Peacock asserts, Cultureis a name anthropologists give to the
taken-for-granted but powerfully influential understandings and codes that
are learned and shared by members of a group (Peacock, 1986).
Contemporary anthropologists continue to struggle with the concept of
culture. The term is widely used to characterize shared ways of world making and forms of local knowledge. Critics of the culture concept suggest
that the term essentializes heterogeneous modes of understanding, as the
inhabitants of a particular community or nation are described as having a
common, uniform culture. In turn, proponents of the term insist that the
concept of culture plays a valuable role in attending to patterns of socialization into the mode of life of a particular geographically and historically situated community. Contemporary anthropologists explore the emergence of
cultural models in specific social settings. Given the manifold uses and
applications of the culture concept, there is no single, concise definition of
the term capable of satisfying all parties or capturing every subtlety of the word.
Some uses of the culture concept emphasize cognition and cultural
models; other approaches focus upon social practices and everyday social
interaction. At present, there are both calls for the continued use of a helpful concept, and adamant claims that the concept of culture obscures tensions and cross-currents within communities, fails to explain significant
historical changes in popular understandings, minimizes intragroup differences, and belittles the significance of personal agency. Acknowledging the
contested, perennially problematic character of the term, the concept of culture is frequently understood to refer to the tacit knowledge or webs of
meaning through which particular humans in specific social settings interpret their existence (Geertz, 1973).
As bioethicists increasingly attend to the role of ethnicity in shaping
modes of moral reasoning, and the role of organizations in structuring ethical 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 to
lead to more fruitful explorations of the relationship between cultural models and modes of moral deliberation.
In the early part of the twentieth century, anthropologists commonly
explored the culture of isolated, small-scale communities at the geographic
peripheries of the major colonial powers, as well as marginalized indigenous societies within industrializing Western nations. Margaret Meads
research in Samoa and New Guinea and Bronislaw Malinowskis research in
the Trobriand Islands popularized notions of the anthropologist as a specialist in the mores of isolated communities located at the peripheries of the
major economic and political powers. Now, however, the concept of culture
is used to explore social practices and patterns of understanding in a variety
of 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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ture, the culture of biomedicine, and the culture of science. The concept of
culture is no longer simply used to explain the ways of life and forms of understanding of distant societies, but now refers to the dominant values, symbols,
social practices, and interpretive categories of any community. Instead of studying small-scale communities in New Guinea or South America, many contemporary cultural anthropologists study the organizational culture of start-up
biotechnology firms, intensive care units, and managed care organizations.
Furthermore, medical anthropologists and bioethicists are increasingly
attuned to the role of ethnic traditions, cultural norms, and religious practices in shaping understandings of illness, death, and dying. Before turning
to an examination of an emerging research agenda on professional culture,
organizational culture, and civic culture, I want to explore an important new
wave 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.

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II. CULTURAL PRACTICES AND BIOETHICS


An emerging body of literature in the fields of bioethics and medical anthropology explores how cultural norms are linked to understandings of truth
telling, decision-making, and end-of-life care within different ethnic groups
(Berger, 1998a). Studies on cultural variations among and within ethnic
groups suggest that not all inhabitants of Canada, the United States, Great
Britain, and other Western settings share common values and understandings. Qualitative studies of cultural norms within Navajo, Chinese-Canadian,
and Korean-American communities reveal how different interpretive categories, language patterns, family structures, and understandings of reasonableness contribute to distinctive understandings of decision-making, autonomy,
family life, and healing. However, the concept of culture can be fruitfully
addressed beyond the study of the interpretive categories of participants
within particular ethnic groups. For example, the study of cultural models is
helpful when examining processes of socialization into particular professional worlds, organizational cultures, national civic cultures, and global
culture. The concept of culture, then, is useful when considering ethical
issues in medicine and health care from the "micro setting of the clinical
encounter to the "macro level of the regional, national, and international
organization 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 of


explanatory models of health, illness, and moral obligation that are embedded 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, and
policies seem reasonable and moral, whereas other norms, practices,
and guidelines are regarded as irrational or immoral. Whether examining
the predominant mores of a particular ethnic group, or comparing the core
moral norms of civic culture in one nation with dominant social values in
other national settings, the concept of culture serves as a reminder of local
variations in understandings of health, illness, suffering, and death.

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A. Communication in Clinical Settings and Explanatory Models


of Health and Illness
Many patients bring to the clinical encounter explanatory models of health
and illness that are quite distinct from the interpretive categories found in
Western biomedicine. There are numerous anthropological and sociological
studies 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 the
meaning of symptoms and illnesses can make communication between
patients and health care providers very difficult (Breen, 1999). Several scholars argue that medical interpreters working in the capacity of culture brokers can act as mediating agents in such situations by translating cultural
understandings and expectations and promoting shared understandings of
worthwhile 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 where
bioethics and the anthropological and sociological study of medicine need
to be more closely linked. For example, decisions by ill individuals to refuse
particular kinds of treatment or insist upon specific forms of care can raise
questions about reasoning abilities and decision-making capacity. To assess
the rationality of decisions made by patients, physicians and nurses need to
understand how patients interpret their illnesses and comprehend the diagnostic, prognostic, and treatment-related information provided by members
of the health care team. For example, a patient might refuse a particular
kind 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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309

provider to request a consultation from the psychiatry service. The statement could generate questions about the capacity of the patient to make
reasonable decisions. In contrast, within the local religious community of
which the patient is a member, such a statement might seem entirely appropriate and suited to the patients current situation. Assessments of capacity
to make decisions are very much dependent upon background presumptions concerning what constitutes reasonable understandings and sensible assessments of particular circumstances (Powell, 1995).
In settings where patients understandings of reasonable conduct
diverge from the judgment of health care providers, members of the health
care team need to consider whether they have adequately explored their
patients cultural models of health, illness, and moral deliberation. These
background understandings play an important role in contributing to how
patients respond to particular recommendations. For example, in situations
where patients refuse treatment due to a desire to preserve the integrity of
the body rather than undergo major surgery that leads to the amputation of
a limb, physicians need to carefully consider whether cultural understandings of death, afterlife, and embodiment ought to be recognized and
respected rather than viewed as signs of the incapacity to make reasonable decisions. Considerable caution needs to be exercised when assessing
the reasoning capacities of individuals from cultural backgrounds that are
poorly understood by health care providers. In the absence of concerted
efforts to comprehend how particular patients interpret their circumstances,
health care providers are likely to impose their own ethnocentric, highly
judgmental presumptions about reasonable conduct upon their patients.

C. Truth Telling and Informed Consent


Cultural explanations of health and illness, along with understandings of the
appropriate social roles of family members and health care providers, are
interwoven with interpretations of what constitutes thoughtful moral conduct. Numerous studies note that within many communities, there are
widely shared understandings that health care providers should not provide
information concerning terminal diagnoses to seriously ill patients (Blackhall, Murphy, Frank, Michel, & Azen, 1995; Orona, Koenig, & Davis, 1994).
In particular, diagnoses associated with various forms of cancer are closely
linked to the common cultural norm that patients should not be fully
informed of their illnesses. To disclose such information in a frank, forthright manner is, in some cultural contexts, understood by family members
and seriously ill patients to undermine the health of the patient by encouraging negative thoughts and condemning the patient to a form of social
death (Gordon, 1990). While physicians might think of diagnostic and
prognostic information as largely descriptive, family members sometimes
understand the provision of bad news to play a causal role in hastening

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the dying process. Thus, within some communities, cultural norms exist
where the health care provider who wants to proceed in a compassionate
manner is assumed to be a caregiver who will protect the ill patient and
support the family in shielding the sick person from upsetting information.
Reports concerning disclosure practices in Japan, Ethiopia, China, and Italy
all note styles of communication in which physicians convey negative
information to family members, who then conceal this information from
their seriously ill relatives (Akabayashi, Fetters, & Elwyn, 1999; Beyene,
1992; Gordon & Paci, 1997; Pang, 1999). While disclosure patterns are
changing in numerous regions around the world, there are still many families and larger social networks in North America and other regions where
the communication of terminal diagnoses to patients is regarded as a callous, uncaring act.
Cultural models of health and illness that tacitly assume that family
members rather than individual patients should receive diagnostic and prognostic information differ from autonomy-based laws and policies intended
to promote dialogue between patients and physicians. Unsurprisingly, North
American physicians guided by the principle of respect for patient autonomy experience considerable frustration when they encounter families who
insist that physicians should conceal diagnostic and prognostic information
from the patient. These requests, arising after transformations in the culture
of American medicine in the 1970s and 1980s that served to promote patient
autonomy and reduce the sphere of parentalistic behavior in medical
practice, raise complex questions about the boundaries of tolerable and
intolerable forms of medical care in multiethnic, pluralistic settings.

D. Advance Care Planning


Cultural models of death and dying play a significant role in how processes
of advance care planning are interpreted in particular communities.
Advance care planning is usually intended to enable patients to select surrogate decision makers and articulate the kinds of health care they would
choose or refuse in particular circumstances. However, articles by Berger
(1998b) and Frank et al. (1998) suggest that within some ethnic communities there is limited interest in engaging in conversations intended to
promote advance care planning. Murphy et al. (1996) report that in the
Korean-American and Mexican American populations they studied, there
was limited support for the use of advance directives. They suggest that
within some communities open disclosure and detailed planning for end-oflife care is understood to cause ill individuals to lose hope. While the failure
to use advance directives is a complex phenomenon, cultural norms within
many ethnic groups deter seriously ill individuals from planning the dying
process 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 on


treatment can seem highly presumptuous and inappropriate. Health care
organizations that strongly endorse advance care planning need to attend to
such concerns lest they risk unintentionally alienating the communities they
serve. Bureaucratic forms and institutional policies that are of great benefit
to some individuals are sometimes profoundly unsettling to patients with
different understandings of illness and death.

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IV. BEYOND THE EQUATION OF CULTURE WITH ETHNICITY


Much of the existing qualitative research in bioethics examines cultural
models of health, illness, and moral reflection within the context of particular ethnic groups. Participant observation, ethnographic research, in-depth
interviews, and grounded theory research are becoming increasingly common research methods within bioethics. These methods are often used to
study the local norms of a particular community.
Some of the shortcomings of this focus upon ethnicity and cultural
norms are becoming apparent. For example, Blacksher (1998) notes that the
study of ethnic differences can promote cultural stereotypes, essentialize
the values of particular communities, and mask variations in norms within
specific groups. Focusing upon the shared moral norms of a particular ethnic group can lead to the neglect of conflicting understandings and cultural
differences within particular ethnic groupings.
A focus upon ethnic differences can serve to obfuscate underlying
commonalities across communities. Furthermore, emphasizing shared cultural norms within particular communities can obscure the importance of
socioeconomic status, gender, level of education, and personal experience.
The concept of culture can carelessly be used to wash away the personal
features that distinguish the members of a group from one another. A focus
upon cultural norms can also suggest that particular cultural models are
timeless and traditional rather than quite recent responses to emerging
issues and situations. Finally, the study of cultural differences amongst ethnic groups provides only limited insight into how widely variant practices
ought 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, efforts
amongst bioethicists to adjudicate normative conflicts in multiethnic, pluralistic settings are in the early stages of development. The widespread emphasis in bioethics scholarship upon notions of a common morality,
reflective equilibrium, and shared paradigms of moral reasoning leaves
bioethicists ill-equipped to recognize the markedly distinct ways in which
moral matters can be framed.

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Future scholarship on cultural norms within particular ethnic groups will


have to address the challenges posed by critics of this line of research. Of
perhaps even greater significance, there needs to be a reconsideration of the
common assumption that to study cultural models is to study the local norms
of particular ethnic groups. In addition to addressing the cultural models of
various ethnic groups, bioethicists need to attend to forms of professional culture, organizational culture, civic culture, and global culture. As scholarship in
these areas of enquiry develops, bioethicists will need to become increasingly
attuned to the work of colleagues in cultural psychology, medical anthropology, medical sociology, cultural psychiatry, and globalization studies. While
there are many challenges associated with the promotion of new directions in
multidisciplinary research, the field of bioethics is likely to benefit from closer
collaboration with colleagues from various branches of the human sciences.

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V. PROFESSIONAL CULTURES OF MEDICINE


While ill and injured individuals bring cultural models of health, illness, and
morality to the clinical setting, much greater attention needs to be given to
the distinctive organizational and professional cultures of health care providers. Numerous studies of medical education, for example, examine the
way in which physicians undergo processes of socialization that promote
particular moral norms and modes of behavior (Becker, Geer, Hughes, &
Strauss, 1961; Good, 1994). Studies of student culture in medical school typically examine socialization practices in the anatomy laboratory and clinical
setting, 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 in
the enculturation process. Immersion into specialized technical vocabularies
as well as the donning of distinctive modes of dress such as the white coat,
the stethoscope, and other markers of symbolic capital signal the gradual
metamorphosis of the medical student into the medical professional.
In addition to enculturation into the broad norms and interpretive categories of Western biomedicine, health care providers are socialized into the
cultural worlds of particular specialties and disciplines (Anspach, 1993;
Bosk, 1979). For example, Good, Good, Schaffer, and Lind (1990) studied
the discourse and ethos of American oncology, and found a moral world
permeated by the rhetoric of hope and optimism. Similarly, Joan Cassell
(1991), in Expected Miracles: Surgeons at Work, provides a detailed ethnographic sketch of the culture of surgeons. During her anthropological
research, Cassell found a masculine culture where being ballsy is
encouraged, and the competent surgeonmuch like an astronaut or top
gun 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 to


enter a culture with a distinctive rhetoric, set of norms, and body of presumptions concerning the moral care of patients. While medical communities, much like other social groups, are not altogether homogeneous, there
are standards of practice that are acceptable in some professional cultures
while these same practices and norms are viewed with suspicion or condescension in other settings. Many of the conflicts between physicians and
nurses, for example, can likely be traced to socialization into different professional norms and standards of responsible practice.

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VI. ORGANIZATIONAL CULTURES


Anthropological and sociological studies of intensive care units, neonatal
intensive care units, psychiatric wards, and oncology wards all trace the distinctive forms medical care takes in particular local worlds. Western biomedicine takes many different shapes, and the local organizational culture
of the geriatrics wing or prenatal genetic counseling service can be quite
distinct from the transplantation unit or the psychiatric unit. Indeed, proceeding from specific medical specialties and units, it is possible to contrast
the culture of the pediatric hospital with the culture of the geriatric facility,
or the religious, non-profit health care facility with the secular, for-profit
health maintenance organization.
There can be meaningful variations in the organizational culture of
entire health care facilities. Sometimes these distinctions are the product of
explicit organizational philosophies, in which organizational principles or
mission statements are used to promote a culture of respect for patient
choice or support the values of a particular religious tradition. In other
instances, unspoken, tacit norms inform the culture of organizations. For
example, some for-profit health maintenance organizations and long-term
care facilities in the United States are accused of providing inadequate care
to patients, because corporate norms of profit making are privileged over
other organizational and professional values (Diamond, 1992).
Variations in organizational cultures mean that clashes over organizational philosophies, core institutional values, and mission statements frequently arise during the course of organizational mergers. The conflicts can
be particularly acute when religious health care facilities merge with secular
institutions, or when organizations where employees pride themselves on
promoting womens health, pediatric care, or geriatric care merge with organizations lacking such a specific orientation. In regions where restructuring
measures are leading to the consolidation of previously distinct health care
facilities, attentiveness to variations in organizational culture is particularly
significant. When conducting cost-benefit analyses of such mergers, executives 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 care


facilities with distinct organizational cultures.

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VII. CIVIC CULTURE AND THE ORGANIZATION OF


HEALTH CARE SYSTEMS
The concept of culture can be utilized in the study of particular ethnic
groups, the socialization of health care professionals, and the organizational
values of institutions. In addition, cultural models of risk, insurance, and
social solidarity can be related to civic culture and the social organization of
health care systems (Graves, Beauchamp, & Herle, 1998). Specifically, the
organization of health care at the macro level of the state, province, or
nation can be justified according to different normative frameworks. Here,
civic culture is particularly significant. Libertarian or neo-conservative interpretations of how health care should be provided, as with more communitarian or social democratic accounts of the most justifiable normative
ordering of the political economy of health care, draw upon particular cultural models of individualism and the merits of commercial markets (Reinhardt, 1997). Within many nations, more communitarian, social democratic
models of the provision of health care presently vie against neo-conservative or libertarian normative claims that question the extant public-private
mix, and promote more market-oriented approaches to health care. Debates
about the provision of funds for publicly supported health care are typically
linked to larger visions of the just social order, the appropriate role of governmental agencies and the free market, and notions of shared social
goods.
The manner in which cultural norms and civic values are embedded in
everyday forms of language use can be quite subtle, as when patients are
relabeled as customers or clients, health care professionals are viewed as
human capital, and clinical judgment is reconstrued as intellectual capital (Alper, 1984). The culture and rhetoric of free-market models has in
many settings replaced other normative orderings of health care systems.
While this examination of the concept of culture is not the place to
debate the merits of various systems of health care delivery, the substantive
point here is that particular understandings of the normative ordering of
health care systems are closely connected to interpretations of community,
autonomy, solidarity, and the appropriate spheres of governmental organizations and market mechanisms. Civic cultures can vary from region to
region, and it is unsurprising that the normative cultures of health care systems in the United States, for example, are quite different from the normative cultures of health care systems found in other societies (Kingdon,
1999). While considerable care is needed when comparing the civic culture 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 of


individual liberty can be discerned in a number of domains. These differences are recognizable in regulations concerning the ownership and use of
firearms, social welfare programs, taxation schemes, and core stories about
the origins of nations. There are many ways in which civic cultures within
settings where social democratic movements have some political power
would seem to be more concerned with social solidarity than settings
informed by more individualistic, autonomy-based forms of civic culture.
Whether these national differences in the normative ordering of social institutions persist will depend upon the kind of normative civic culture communities within various nations seek to promote. Of course, the role of the
popular media and powerful corporate conglomerates in influencing the
substantive content of public moral discourse deserves careful consideration. In the contemporary marketplace of ideas, the capacity to publicize
specific versions of civic culture is closely related to access to the mass
media outlets and revenue sources needed to promote particular accounts
of 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 the
role of civic culture in a variety of settings. In particular, there is a large
body of literature on the civic culture, or civil religion, of the United States
(Bellah, 1975). Scholarship in the area of civic culture typically examines
widely shared, diffuse cultural norms at the level of the province, state, or
nation. The concept of civic culture usually refers to the core norms, shared
stories, myths of origin, and dominant symbols of large-scale societies such
as Canada and the United States. However, with the formation of the United
Nations at the end of the Second World War, the creation of the World
Health Organization, World Trade Organization, and the International
Monetary Fund/World Bank, and the establishment of transnational humanitarian organizations such as Doctors Without Borders and Amnesty International, 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 that
promote the cultivation of distinctive cultural identities, countervailing
tendencies that dissolve rigid ethnic, religious, and national boundaries
clearly exist (Toulmin, 1994). Some social theorists discern signs of an
emerging global human rights culture. Other commentators detect the rapid
globalization of commercial markets, where global capitalism obliterates the
significance 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 of


respect for international human rights around the world, or a corporate,
commodified McWorld where the only universal norms are the commercial values of the marketplace (Barber, 1996).
Whatever narrative is used to frame contemporary processes of globalization, bioethicists have contributed very little to the critical analysis of an
emerging transnational culture. A great deal of macro analysis in bioethics
does not proceed beyond the boundaries of the nation-state. For example,
most discussions of social justice and access to health care resources focus
upon particular nations such as Canada, the United States, and Great Britain.
Whereas medicine is understood by many medical educators to include the
field of international health, there is remarkably little scholarship in bioethics that takes global social order, global health, and transnational institutions 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 greater
interest in the emergence of a transnational set of moral norms and legal
standards (Mann, Gruskin, Grodin, & Annas, 1999). Bioethicists are gradually beginning to acknowledge the globalization processes that are widely
recognized in the fields of economics, sociology, cultural psychiatry, and
international relations.
As bioethicists develop new research agendas that look beyond the
borders of the nation-state, there is likely to be increased attentiveness to
the tension between universalist and pluralist accounts of moral reasoning. At present, conflicts related to the tension between local cultural
models of moral reasoning and universal moral claims are found in discussions concerning appropriate ethical frameworks for multinational clinical
trials, the need for transnational regulatory agencies, and the goals of transnational humanitarian agencies. If bioethicists are going to make meaningful contributions to public debates in this period of globalization, there will
need to be a shift in thinking. The macro-level of scholarly analysis will no
longer be the organizational ethics of a particular institution or priority setting 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 an
emerging transnational, global culture.

IX. MORAL REASONING, CULTURAL UNDERSTANDINGS,


AND SOCIAL CONFLICT
To attend to the significance of culture is not to suggest that bioethics or
morality 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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317

to acknowledge a plurality of moral norms, social practices, and kinship


patterns while maintaining that particular practices are more humane and
justifiable than alternative forms of life. However, the concept of culture
complicates the task of normative deliberation by acknowledging the varieties of local knowledge (Geertz, 1983). By attending to the existence of
multiple webs of meaning, the concept of culture serves to challenge
mainstream scholarship in bioethics that emphasizes the existence of an
ahistorical, universal common morality, and presumes a moral order that
exists in a state of widespread reflective equilibrium.
While there do exist core moral norms embedded in laws, institutional
policies, and social practices in the United States, Great Britain, Canada, and
other nations around the globe, there are numerous communities with
mores that challenge various facets of these different civic cultures. In many
settings, 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 in
highly spiritualistic terms. Patients from communities that promote familial
solidarity rather than individual autonomy sometimes question dominant
understandings of the importance of truth telling and patient autonomy.
Representatives of various religious communities frequently express skepticism toward secular public policies. Since the early 1980s, neo-conservative
political parties in many Western nations have challenged existing publicprivate mixes of health care.
These various ways of thinking about illness, health care, patient-physician relations, professional culture, organizational culture, and civic culture
suggest that models of deliberating about morality can vary amongst social
groups. Consequently, to embed particular moral norms in professional
codes, institutions, laws, and educational programs is to engage in the normative work of promoting particular moral norms, while pushing other ways of
worldmaking to the margins of reasonable public debate. This normative
boundary work is evident in the field of bioethics, but it is also found in less
self-consciously normative decisions concerning the licensing of health care
providers, 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 in
bioethics will likely become more attentive to the cultural models of members of particular ethnic groups, the role of enculturation into particular
medical specialties, the moral culture of organizations, civic culture and
social 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 bioethics
will need to move beyond the equation of culture with the mores of particular ethnic groups. Perhaps bioethics research in the future will be less
exclusively oriented toward the contributions of physicians, lawyers, and
philosophers, and more attentive to the interpretivist approaches of scholars
in the anthropology and sociology of medicine and other branches of the
human sciences (Fox & Swazey, 1984; Muller, 1994). The concept of culture
can be fruitfully explored at various levels of analysis, and should not be
used only with reference to the exploration of the norms, understandings,
and practices of distinctive ethnic groups. While there are many obstacles to
the emergence of a global, transnational social order, we are likely on the
cusp of a new wave of bioethics scholarship that will increasingly attend to
such institutions as the World Health Organization, World Bank, and Doctors Without Borders. The concept of culture will likely continue to prove
useful not just in the study of ethnic differences and local organizational settings, but also in the study of newly emergent social institutions and transnational agencies.

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