Carol Collier and Rachel Haliburton discuss the desirability of, and potential need for, developing an explicitly Canadian form of bioethics
One question that is often asked within bioethical circles is the degree to which contemporary bioethics is universal, and to what extent it is shaped by different cultural, social, political, and economic considerations in different parts of the world.
This question is driven, in part, by the American context in which the discipline has developed, and the way in which it is answered has implications for the future development of bioethics.
There is no doubt that bioethics, in its beginnings, was an American enterprise. The theologians, philosophers, lawyers, physicans, sociologists and biologists who began raising concerns about the ethical dilemmas that would eventually become the subject matter of bioethics were, for the most part, American. Moreover, the ground-breaking cases that shaped the ethical discussions (e.g. Karen Ann Quinlan and Nancy Cruzan on end of life treatment; Helga Wanglie on futile treatment; Roe v. Wade on abortion rights) were American cases. Important centres for bioethical discussion, such as the Kennedy Institute of Ethics and the Hastings Center, were founded by American thinkers who reflected and wrote on these and other such cases. The accounts they provided, and the ethical conclusions they drew from them, shaped the developing discipline of bioethics in fundamental ways, and were often widely accepted by bioethicists working in other parts of the world. For example, the Harvard Committee on Brain Death, whose recommendations were adopted almost universally in the Western world, permitted the phenomenal growth and development of organ transplantation practices worldwide.
Until the 1990s, the dominance of an essentially American form of bioethics was further solidified by the fact that the textbook industry that emerged as the discipline gained public support and academic credibility took American law, American cases, and American understandings of the place of health care within larger political, social, and economic arrangements as the template according to which bioethical issues should be examined. It is an American form of bioethics which, Fox and Swazey argue, has been exported to other parts of the world. As they observe, “it is noteworthy that bioethics now exists in a wide and diverse array of societies; that the same cluster of modern Western biomedical and technological advances around which American bioethical concerns center are among the core foci of bioethics in these different contexts; and that the major conceptual framework within which bioethical issues are addressed and deliberated in the United States has been internationally diffused” (p. 215).
Despite the fact that Canada has a number of internationally-recognized bioethicists, in our view Canadian bioethics has still been largely shaped by the American model, a model that does not always fit well with Canadian cases, culture, or its health care system. (For example, American bioethics textbooks, almost without exception, discuss exclusively American cases, while Canadian textbooks invariably include American authors and American cases). In our view, Canadian bioethicists—both academic and clinical—need to develop a more distinctively Canadian approach that can better allow us to explore the issues that arise in a Canadian context.
Teaching bioethics in a Canadian context brought out (for us) the limitations of the American model; many issues raised in relation to justice and the health care system are very different in the U.S. due to its private medical system and the availability of private insurance for some Americans and not others. In addition, Canada has a number of landmark cases that have framed the debates differently here than in the U.S. For example, the reasoning behind the U.S. Supreme Court’s decision in Roe v. Wade is quite different from the reasoning behind the Canadian Supreme Court’s decision in R v. Morgentaler, and the American emphasis on states’ rights (along with the current pattern of states bringing in legislation designed to chip away at Roe v. Wade) make the form that debate has taken irrelevant in the Canadian context. At the same time, provincial regulations in the area of abortion in Canada have restricted abortion here in different ways. Likewise, the Chaoulli case, which challenged the legal prohibition on setting up private health care services, demonstrates a striking and important difference between American and Canadian health care contexts: In the American context, it is the public provision of health care resources that needs to be defended; in the Canadian context, it is the private provision of such services that challenges cultural, legal, and political norms.
In the past decade, American bioethics often appears more preoccupied with procedural issues specific to their private health care delivery system than with some of the philosophical debates that shaped its beginnings. At the same time, autonomy has become both the default ethical principle, and the primary lens through which bioethical issues are examined, something that is evident in the American willingness to accept market principles in areas such as reproductive technologies and the delivery of health care, for example. Further, the great cultural divide in the U.S., which brought in its wake the Baby Doe Rules, the Terry Shaivo drama, and the endless obsession with Roe v. Wade, is an American phenomenon that we should resist importing into our bioethical framework.
Our widely shared cultural beliefs, political system, and laws are different enough from those of the U.S. that it would be helpful and desirable to develop a more explicitly Canadian form of bioethics than the one we have been importing from our American colleagues. It is not yet clear what features a distinctively Canadian form of bioethics would have, but the publicly-funded nature of our health care system and the way in which this generates questions of distributive justice that require us to balance individual choices with shared public goods suggests that it would probably be more communitarian and less individualistic than its American cousin.
(Updated on April 16th, 2013)
Carol Collier, Associate Professor of Philosophy, University of Sudbury
Rachel Haliburton, Associate Professor of Philosophy, University of Sudbury
They are the editors of Bioethics in Canada: A Philosophical Introduction