Towards an indigenous African bioethics

K G Behrens, BA, Hons BTh, MA, DLitt et Phil

Steve Biko Centre for Bioethics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: K G Behrens (kevin.behrens@wits.ac.za)

In response to a perceived moral crisis in South Africa and Africa, I argue that there is a need to seek ways to restore the dignity of the people of Africa, whose values, beliefs and cultures were denigrated in the past. One way is for African bioethicists to begin to apply indigenous African philosophy, thought and values to ethical issues. This project is important (i) to restore dignity; (ii) because a bioethics grounded in indigenous ideas is more likely to be accepted by Africans; and (iii) because such ideas can enrich bioethical discourse. Highlighting the central importance of relationality, community and harmonious relationships in African thought, I conclude that we should adopt a revised version of principlism that incorporates these salient African moral conceptions.

S Afr J BL 2013;6(1):32-35. DOI:10.7196/SAJBL.255

In 2012 we commemorated the 35th anniversary of the death of Steve Biko. The circumstances surrounding his death have relevance to bioethics. His brutal, humiliating treatment by the police was part of the reprehensible human rights abuses perpetrated by the apartheid state. The involvement of medical doctors in these wrongs – and the initial reluctance of the Medical and Dental Council and the Medical Association of South Africa to take disciplinary action against those practitioners who were complicit in his torture and death – were serious moral failures on the part of the medical profession.

Yet, reflecting on Biko’s legacy, it is impossible for many to remember past wrongs without drawing current comparisons. The 2012 shooting of strikers at Marikana by the police echoed the Sharpeville massacre of 1960. Reports of police brutality and the abuse of powers call to mind past injustices. Service delivery protests and wildcat strikes paralleled apartheid-era grassroots protest. The abuse of tender processes, cronyism and corruption are alarming. South Africa has fallen in Transparency International’s annual corruption index from 34th to 69th position in the 12 years since 2000.1 Failures in education, especially the non-delivery of textbooks and the dismal performance of learners in standardised language and numeracy tests, lead many to ask whether life has improved for most South Africans since democracy, as do failures in healthcare. The inability of hospitals to provide patients with medication, the failure of poorly serviced equipment, and the non-payment of service providers reflect a health system in crisis. Maladministration and incompetence place countless patients at risk. Accounts of practitioners abusing state resources for personal gain at the expense of patients, private health sector fraud and over-servicing, and increasing numbers of professionals falling foul of the ethical standards of the Health Professions Council of South Africa point to an ethical crisis in the health professions. Concerns about the moral health of the nation seem justified.

Instead of reflecting on Biko’s historical legacy, many would rather ask, ‘What would Biko say about South Africa today?’

The need to reclaim dignity

The signs of a profound moral crisis in our country are impossible to ignore. It is also disingenuous not to acknowledge that this moral malaise has its roots in past injustices. Colonial and apartheid regimes systematically subjected the majority of our people to inhuman conditions and robbed them of their dignity. Life became cheap and brutish in a context in which people were denied their basic rights.

Biko famously claimed that the ‘most potent weapon in the hand of the oppressor is the mind of the oppressed’. He pointed out that centuries of ‘oppression, denigration and derision’ had left blacks with an ‘inferiority complex’.2 The oppressed had internalised the negative image of themselves projected by the oppressor. ‘The colonialists … turned to the past of the oppressed people and distorted, disfigured and destroyed it. No longer was reference made to African culture, it became barbarism. Africa was the ‘dark continent’. Religious practices and customs were … superstition …. No wonder the African child learns to hate his heritage.’2 For Biko, the oppressed would never be truly free until they reclaimed their dignity and rejected their enforced inferior image of themselves: ‘The first step … is to make the black man come to himself; to pump back life into his empty shell; to infuse him with pride and dignity.’2

Much has changed since Biko wrote these words. Despite South Africa’s peaceful negotiated transition to a constitutional democracy, Biko’s vision of a people who have reclaimed their dignity still eludes us. Having the vote and constitutionally guaranteed rights does not restore the dignity of those whose identity was denigrated for centuries. Despite improved access to basic services, education and healthcare, and an expanded system of social grants, many remain mired in poverty. Unemployment and inadequate housing leave communities prone to hopelessness and the associated social problems of crime, violence and substance abuse. Some argue that many current moral failures in South Africa are a result of greed, materialism and the lust for power among a new elite and middle class, who cannot blame poverty or deprivation for their failures.

Yet we know that such a lack of care for others and the community is foreign to a traditional African way of life. There is a seeming willingness among some Africans to embrace selfishness and materialism – is this not another symptom of people who have not freed themselves from an internalised sense of inferiority, grounded in the past? Clestus Andoh of Cameroon writes: ‘This attitude of assimilating Western values and ideologies into Africa can give rise to a situation of self-dehumanisation and outright self-subversion both in terms of dignity and self-esteem … leading to what is perceived as a collapse of traditional culture and of traditional ethics.’3

Confronting the moral crisis

There are many indications of a serious moral crisis in our country which need to be addressed. Tougher anti-corruption laws and interventions ensuring greater accountability will help. But, the key to moral regeneration is a change in values. I believe we must return to Biko’s wisdom. For the previously oppressed to be ‘architects of a normal society’,2 they need to re-affirm their own human dignity. Equally, those who were oppressors must recover their humanity by acknowledging the wrongs of the past and seeking to build a just future. We must realise that for all the achievements of our young democracy, unless the challenges of poverty and social inequity are solidly addressed, many will never recover their basic human dignity and be able to become partners in building a better society for all. Democracy is insufficient and radical social change is required to ensure that far more people have a decent quality of life.

The need for an indigenous African bioethics

What does this have to do with bioethics? Firstly, many of these social problems and moral failures are closely linked to human health. Public health concerns must recognise that our moral obligations extend into the spheres of policy and social justice. Our health system must be radically reformed. To improve our health indicators, wastage of resources, mismanagement and incompetence must be dealt with, and poverty, unemployment, poor education, inadequate housing, nutrition, sanitation and other vital services must be addressed. We also need a new approach to bioethics that is solidly grounded in the values of our own people and continent. To reclaim their dignity and re-affirm their identity, Africans must be able to appeal to their own culture, moral traditions and ethical values when reflecting on their ethical problems and dilemmas. A contextualised and indigenous approach to ethics is necessary to restore the dignity of our people.

Bioethics has rightly been accused of being dominated by Western values and ethical concepts.3 This is particularly true in Africa, where bioethics is generally taught in the same form as in America and Europe. Furthermore, little academic work and few publications on bioethics reflect indigenous African thought, philosophy or values. Exceptions include Godfrey Tangwa, Segun Gbadegesin and Joseph Mfutso-Bengo,4-9 who have contributed significantly in this regard. However, most bioethics publications related to Africa deal with issues in research ethics,10 and focus less on applying African values to ethical issues than on applying Western moral systems to the African context. Notable recent exceptions include articles by Thaddeus Metz and Cletus Andoh.3 , 11 , 12 Nonetheless, the body of bioethical work based on African values is tiny compared with that based on Asian and other non-Western worldviews.

Therefore, there is an urgent need in South Africa and Africa for more work that engages with bioethical issues from the perspective of African philosophy and values. Andoh writes: ‘In order that African traditional ethical values are not seen as irrelevant for contemporary society and researchers, there is a serious need for bioethics in Africa to reclaim and return to the roots of African thinking so as to reconsolidate a true African authenticity. For bioethics to be authentically African, Africans must endeavor to root it, ground and fashion it according to their cultural norms as well as practical realities.’3 He adds, ‘There is a need … for Africans to reclaim their world view if they want to maintain their identity in the face of change.’3

The second, most pressing reason for an authentically African bioethics is to restore dignity. People are also more inclined to accept ethical ideas with which they are familiar. To have an impact on society and positively influence the quality of moral life, bioethics must be capable of moral formation. Practitioners are more likely to respond positively to bioethical notions that resonate with their pre-existing values and moral convictions. Andoh writes that to nourish ‘ethical principles grown from African soil is a necessity for Africa especially as people in life act in ways that are more consistent with the values they hold’.3

A third reason for African bioethicists to reflect on indigenous thought is because doing so can deeply enrich our ethical discourse. Biko wrote, ‘We can extract from our cultures a lot of positive virtues which should teach the Westerner a lesson or two’.2 Meanwhile, Tangwa observes that ‘It is clearly up to Western Bioethics … to allow African Bioethics and African culture … to influence them. If only more Westerners could … try to get into the spirit and swing of things African, in the same spirit that many Africans have honestly and enthusiastically got into the spirit and swing of things western, humankind and the entire biological world might stand to reap great benefits.’4

What can African thought contribute to bioethics?

African moral perspectives can contribute significantly to bioethics. While I do not claim that a single African worldview exists, nonetheless some salient, characteristically African conceptions and ideas are shared by many sub-Saharan Africans. I also do not claim that these notions are unique to Africa. For instance, there are clear parallels between other communitarian perspectives and the feminist ethics of care and African thought, which do not detract from their potential to deeply enrich bioethics.

Perhaps the most significant salient African moral perspective is the importance of community. Biko writes: ‘The oneness of community … is at the heart of our culture.’2 It is trite to describe traditional African ethics as communitarian and oppose it to Western individualism. However, there is much more to this communitarian ethic than just an emphasis on the importance of community. Africans often refer to the sayings that ‘A person is a person through other persons’ or ‘I am because we are’ as expressing the essence of an African philosophy. 11 This implies that authentic personhood or true humanity require being in relationship with others.3 It has become popular to refer to this philosophy as ubuntu, but whatever it is called, the idea that authentic personhood can only be attained through being in relationship or in community with others is pervasive in Africa.

Grounding this notion is the belief that we are all interdependent. The individual’s well-being is tied up with that of others. Desmond Tutu writes: ‘[Ubuntu] speaks to the very essence of being human …. It … means my humanity is caught up, is inextricably bound up, in theirs. We belong in a bundle of life …. Harmony, friendliness, community are great goods. Social harmony is for us … the greatest good.’13

Thaddeus Metz, who has written prolifically on ubuntu, aims to develop it as a moral theory comparable with dominant Western moral theories such as deontology and utilitarianism. He characterises ubuntu as entailing that ‘An action is right just insofar as it is a way of living harmoniously or prizing communal relationships, ones in which people identify with each other and exhibit solidarity with one another; otherwise an action is wrong.’11 For Metz, the key to this African ethic is harmonious relationships characterised by identifying with others (or conceiving of oneself as part of a group or community) and by solidarity (caring for one another and seeking the good of others).12

The emphasis on community, identifying with others and solidarity and caring makes ubuntu a relational ethic that prizes harmonious relationships. This challenges Western bioethics, which focuses on individual autonomy and the rational application of abstract theories and moral principles to ethical issues. It also resonates with the ethics of care, highlighting the central importance of caring, emotion and relationships in moral decision making. This philosophy echoes the call from other communitarian perspectives for bioethics to take the fact that we are embedded in communities and families more seriously.

This challenge is timely. In her address as president of the International Association of Bioethics (IAB), Nikola Biller-Andorno calls for bioethics to take a serious look at its role through a different lens, one which focuses on enabling ‘flourishing human relationships’. She writes ‘A good deal of bioethical reasoning is concerned with the autonomous, rational individuals that inhabit sterile theoretical worlds. This perspective seems to neglect utterly what many would say counts most in a fulfilled life, that is flourishing human relationships.’14 Perhaps African bioethicists could help lead the way to such a bioethics?

An African-inspired principlism

How can this important challenge from the president of the IAB get the attention it deserves? More African bioethicists must start applying their own values and moral positions to bioethical issues. Mainstream bioethical discourse must also recognise these important moral concepts. The dominant influence in bioethics, particularly at the level of practitioners on the ground, is Beauchamp and Childress’s principlism,15 despite the limitations of this approach. Principlism proposes that the four principles of respect for autonomy, beneficence, non-maleficence and justice reflect a ‘common morality’ and can form the basis for all moral decision making. I conclude by proposing that we African bioethicists develop our own version of principlism that incorporates the salient features of African ethics as identified above.16

How can Beauchamp and Childress’s principles be adapted to incorporate these important African ethical considerations? The principles of beneficence and non-maleficence reflect moral convictions shared by Africans. However, the principle of respect for autonomy is of greater concern, and has been the most questioned by theorists for several reasons. If Beauchamp and Childress are to continue to claim that their principles reflect the so-called ‘common morality’, the principle of respect for autonomy needs to be revised. Many consider that it is too individualistic, with too much emphasis on autonomous decision making, and that it is too Western or even American.

Therefore, I propose that the principle be revised, with a return to the original principle established in the Belmont report: the principle of ‘respect for persons’. This seems richer and deeper and includes respect for autonomous decisions, without implying that autonomy should always trump other principles when they conflict. Secondly, I propose that the principle of ‘justice’ be renamed ‘harmony’. This could reflect a truly African perspective on ethics that acknowledges the importance of relationality and taking cognisance of the individual’s being embedded in community and family. Since justice is an important aspect of harmonious relationships in society, everything entailed by the principle of justice would be included in the new principle of harmony. However, this new principle would be richer, broader and more inclusive of the concerns of communitarians, care ethicists, virtue ethicists and ubuntu-ists. Justice has always been a principle with a relational focus, but has been too narrow in its focus. There is more to healthy, harmonious, co-operative relationships than justice alone entails.

Conclusion

Perhaps Africa can lead the way in enriching principlism (and bioethics more generally) by replacing the familiar Georgetown mantra with a new African-inspired mantra of:

• respect for persons

• beneficence

• non-maleficence

• harmony.

This might go some way towards fulfilling Biko’s vision: ‘We believe that in the long run the special contribution to the world by Africa will be in the field of human relationship … the great gift still has to come from Africa – giving the world a more human face.’2

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