Ssebunnya Beyond the Sterility of Distinct African Bioethis

Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) Volume 17 Number 2017 pp 22–31 doi:10.1111/dewb.12106 BEYOND THE STERILITY OF A DISTINCT AFRICAN BIOETHICS: ADDRESSING THE CONCEPTUAL BIOETHICS LAG IN AFRICA GERALD M SSEBUNNYA Keywords African bioethics, Principlism, common morality, conceptual bioethics, empirical research bioethics, communitarianism, ethno-philosophy ABSTRACT In the current debate on the future of bioethics in Africa, several authors have argued for a distinct communitarian African bioethics that can counter the dominancy of Western atomistic principlism in contemporary bioethics In this article I examine this rather contentious argument and evaluate its validity and viability Firstly, I trace the contextual origins of contemporary bioethics and highlight the rise and dominance of principlism I particularly note that principlism was premised on a content-thin notion of the common morality that is in need of enrichment I also contend that bioethics is essentially two-dimensional, being both conceptual and empirical, and indicate the lag in Africa with regard to conceptual bioethics I then appeal for authentic engagement by 1) African health care professionals, 2) African health care training institutions, 3) Africa’s bioethics development partners, and 4) African bioethicists and philosophers, towards addressing this critical lag I underline the need to maintain the essential universality of bioethics as a discipline I particularly argue against the pursuit of a distinct African bioethics, as it appears to be rooted in sterile African ethno-philosophy Rather, African bioethicists and philosophers would well to elucidate the universalisability of insights from traditional African thought, for the benefit of bioethics as a whole Thus we must engage beyond the sterility of a distinct African bioethics authentically reflecting on the essentially universal contemporary bioethical concerns - to effectively articulate a viable trajectory for bioethics in Africa INTRODUCTION The current debate on the future of bioethics in Africa is arguably most remarkable for its ethno-philosophical overtones Several authors1 have argued for a distinct African bioethics that can counter the dominancy of Western ethical thought in contemporary bioethics, which is rooted in A.K Fayemi & F A Akintunde On the Myth Called ‘African Bioethics’: Further Reflections on Segun Gbadesin’s Account Bangladesh Journal of Bioethics 2012; 3(3): 4–11 autonomy-dominant principlism.2 They particularly argue that Western-conceptualised bioethics is essentially atomistic and lacks the harmonious communitarian matrix that characterises traditional African thought - and thus this may The term principlism was first coined in the 1980s by Bernard Gert and H Danner Clouser ‘to refer to all accounts of ethics comprised of a plurality of potentially conflicting prima facie principles’ (T.L Beauchamp & J.F Childress 2009 Principles of Biomedical Ethics 6th ed New York: Oxford University Press: 371; G.M Ssebunnya A Trifocal Perspective on Medicine as a Moral Enterprise: Towards an Authentic Philosophy of Medicine J Med Philos 2015; 40: 8–25 doi:10.1093/jmp/jhu044: 23) Address for correspondence: Gerald M Ssebunnya, MB ChB, DPhil, Padre Pio Medical Centre, Plot 16739 Depenqa Road, Gaborone-West, P.O Box 601977, Gaborone, Botswana Email: gmssebu@gmail.com Conflict of interest statement: No conflicts declared © 2016 John Wiley & Sons Ltd Addressing the Conceptual Bioethics Lag in Africa render contemporary bioethics contextually irrelevant to Africa.3 Some advocate, therefore, for a distinctive African approach to bioethics that is rooted in traditional African ethical thought.4 In this article I evaluate the validity and viability of the argument for a distinct African bioethics Whereas there is ambiguity as to what constitutes “African bioethics”, by “a distinct African bioethics” I refer to any Afrocentric version of bioethics that is conceptually unique and separate from the mainstream version of contemporary bioethics that first emerged in the United States about five decades ago.5 Hence, after examining the major strands of the rather contentious argument for a distinct African bioethics, I will briefly outline the contextual background that led to the emergence of mainstream bioethics as a discipline, so as to situate the need for a comprehensive development of bioethics in Africa I will particularly highlight the notion of the common morality, and the emergency and dominancy of principlism in contemporary bioethics I will argue that bioethics is necessarily two dimensional, consisting of a conceptual dimension in which is rooted the co-essential action-guiding empirical dimension I will then demonstrate that whereas empirical research bioethics is relatively well-recognised in Africa, there is an evident lag with regard to conceptual bioethics I will argue that there is an urgent need to effectively address this conspicuous lag through a comprehensive and authentic African engagement I will contend that the argument for a distinct African bioethics is unfruitful for the viability of contemporary bioethics in Africa, not only because bioethics is essentially universal, but also because such an argument appears to be rooted in sterile African ethno-philosophy Let us first briefly examine the major strands of the argument for a distinct African bioethics THE ARGUMENT FOR A DISTINCT AFRICAN BIOETHICS The intensely passionate argument for a distinct African bioethics may be traced to ‘the intensely polemical character of what goes by the name African philosophy.’6 Shutte,7 like many other authors on African philosophy, K.G Behrens Towards an indigenous African Bioethics S Afr J Bioeth Law 2013; 6(1): 32-35 DOI:10.7196/SAJBL.255 Ibid A.R Jonsen 1998 The Birth of Bioethics New York: Oxford University Press; D.J Rothman 2009 Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making New Brunswick: Aldine Transaction A Agada African Philosophy and the Challenge of Innovative Thinking Thought and Practice: A Journal of the Philosophical Association of Kenya 2013; (1): 41–67: 46 A Shutte 1995 Philosophy for Africa Milwaukee: Marquette University Press © 2016 John Wiley & Sons Ltd 23 has attempted to capture the uniqueness of traditional African ethical thought in his elaboration of the concept of ubuntu He argues that an articulated conceptualisation of ubuntu would elucidate a comprehensive framework that reflects the rich African ethical and socio-political understanding of humanity as being necessarily interpersonal Similarly, Metz8 attempts to articulate a characteristically African normative principle of harmony in what he terms African ethics or the ‘values associated with the largely black and Bantu-speaking peoples residing in the subSaharan part of the continent’ He surmises that ‘the most justified normative theory of right action that has an African pedigree is the requirement to produce harmony and to reduce discord, where harmony is a matter of identity and solidarity.’9 He concedes, however that such a distinctively African ethics remains in need of further refining to answer such questions as to the universal applicability and globalisation of harmony as a normative ethical principle.10 Several other authors have brought to the debate on the future of bioethics in Africa similarly strong views about an indigenous African bioethics Andoh,11 for instance, discusses‘two different conceptions’ of bioethics in Africa, namely, ‘ethno-ethics’ and ‘professional or academic bioethics’ Akin to ethno-philosophy, ethno-ethics refers to ‘sets of moral principles rooted in culture [and] revolves around harmonious coexistence with the cosmos and the promotion, defence and protection of [human] life’ Andoh’s overall objective, however, is ‘to incorporate African views and approaches to the current bioethics debates’12 - rather than to develop a distinct African bioethics In fact, he states that ‘the aim of [his] work is to reform and inform the moral minimalism of Western bioethics about African values and principles.’13 On the other hand, Behrens’ call for Africa’s own version of principlism14 seems to suggest a call towards a distinct African bioethics He argues that ‘[t]o 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.’15 He rightly points out that authentic African communitarianism, characterised by the intricate inter-relationships and interdependence of members in a given African community, has significant value in enriching contemporary bioethics The tenet of Behrens’ proposal, however, is ‘that we African bioethicists [should] develop T Metz Towards an African Moral Theory J Polit Philos 2007; 15: 321 Ibid: 340 10 Ibid 11 T.A Andoh Bioethics and the Challenges of Its Growth in Africa Open J Philos 2011; 1(2): 67-75 DOI:10.4236/ojpp.2011.12012: 69 12 Ibid: 67 13 Ibid 14 Behrens, op cit note 15 Ibid: 33 24 Gerald M Ssebunnya our own version of principlism that incorporates the salient features of African ethics’.16 He specifically proposes that the African version of principlism should away with the principle of respect for autonomy, as derived by Beauchamp and Childress, and revert to the original and arguably more inclusive Belmont Report principle of respect for persons He further echoes Metz’s view on African harmonious identity and proffers the African principle of harmony to replace the current principle of justice in Western principlism He argues that the principle of justice is encompassed in that of harmony in an even broader African-enriched perspective He contends that ‘[t]here is more to healthy, harmonious, co-operative relationships than justice alone entails’.17 In the face of these and other contentious views about a distinct African bioethics, Serequeberhan18 aptly reminds us that ‘it is out of the concerns and needs of a specific horizon that a particular philosophic discourse is articulated.’ Contemporary bioethics discourse certainly emerged out of particular concerns and needs Let us, therefore, first briefly examine the context in which bioethics emerged and developed as a discipline in the West and then consider its appropriate African trajectory THE EMERGENCY OF BIOETHICS AS A DISCIPLINE In his concise account, A Short History of Medical Ethics, Jonsen19 chronicles fourteen major ethical events and concerns in the West that pre-occupied the medical profession from the 1940s to the 1980s, and weighed heavily towards the birth of bioethics as a discipline.20 These include, firstly, the 1947 Nuremberg trial of the Nazi doctors for crimes against humanity, which culminated in the establishment of the Nuremberg Code for experimentation on human subjects The second monumental event was the 1953 discovery of deoxyribonucleic acid (DNA) as the basic genetic molecule, which certainly opened the door to the unprecedented possibilities in genetic engineering The third event, which prompted a whole new debate on the ethics of organ transplantation, was the first kidney transplantation on 23 December 1954 The fourth event, in May 1960, was the approval of the oral contraceptive pill by the United States Food and Drug Admin16 Ibid: 34 Ibid: 34 18 T Serequeberhan 2005 Philosophy and Post-Colonial Africa In African Philosophy: An Anthology E.C Eze, ed Malden, MA: Blackwell Publishing Limited, 9–22: 12 19 A.R Jonsen 2000 A Short History of Medical Ethics New York: Oxford University Press 20 G.M Ssebunnya 2013 The Eclipse of the Good Physician: A Trifocal Perspective on Medicine as a Moral Enterprise, (dissertation) Johannesburg: St Augustine College of South Africa 17 istration, which precipitated an intense debate on the ethics of human reproductive health The fifth event was the debut of chronic haemodialysis on March 1960, which accentuated the ethical dilemma in allocating scarce resources in health care The sixth event, which incidentally happened in Africa, was the first successful heart transplantation on December 1967 This monumental feat certainly jolted our understanding of the notions of human life and death Consequently, the seventh major ethical event was the Harvard definition of brain death on August 1968 The eighth major ethical event is probably the most cited post-World War II scandal in empirical research bioethics, namely, the infamous Tuskegee syphilis research project, which was publicly exposed on 26 July 1972 The next major emotive event was the unprecedented Roe v Wade United States Supreme Court decision on 22 January 1973, which has radically polarised the debate on abortion ever since The tenth major ethical event was also a court decision that mandated the discontinuation of the life support of Karen Ann Quinlan on 20 May 1976 to allow her to die, as she was presumed to be in a persistent vegetative state As she surprisingly went on to live spontaneously for the next ten years, the ethical drama about end of life decision-making was particularly intense The eleventh event was the sensational birth of baby Louise Brown on 25 July 1978, the first such birth from an artificially fertilised embryo, and this sparked a resurgent ethical debate on human reproductive rights The twelfth ethical event was the death of Baby Doe, born with Down’s syndrome in the spring of 1982, whose parents adamantly refused life-saving corrective surgery for the baby’s congenital abnormalities The next event highlighted serious ethical concerns about the cost-benefit analysis of emerging biotechnologies It was the first implantation of an artificial heart, on December 1982, in a patient who survived, albeit precariously, an unprecedented 112 days The fourteenth and last major ethical event on Jonsen’s chronological list was the elucidation of arguably the most gruesome pandemic of modern times, the Acquired Immunodeficiency Syndrome (AIDS) It was finally revealed, on 11 April 1983, that AIDS was caused by a predominantly sexually transmitted virus, the Human Immunodeficiency Virus (HIV) Evidently, the ravages of the HIV/AIDS pandemic - ranging from stigma to research ethics and resource allocation - continue to pre-occupy contemporary bioethics discourse It is critical to note that although most of the events chronicled above largely occurred in the West, they certainly reverberated and impacted globally, culminating in the irreversible transformation of Western medicine and health care in general Evidently, the intense debates on the emergent spectrum of unprecedented ethical concerns that were largely initiated in the West were certainly universally relevant, not least due to the global impact of the © 2016 John Wiley & Sons Ltd Addressing the Conceptual Bioethics Lag in Africa biotechnology revolution Indeed, as Fukuyama21 points out, the pace of contemporary biotechnology poses a real possibility of transforming human nature into a posthuman state of existence In other words, the unprecedented bioethical concerns of the 20th Century, which culminated in the birth of bioethics as a discipline, were also, in principle, Africa’s own existential concerns Subsequently, in light of the rapid biotechnology revolution and the emerging complex bioethical concerns, the United States’ National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (NCPHSBBR) produced the famed Belmont Report,22 which was issued on 30 September 1978 This landmark report highlighted three fundamental ethical principles, namely, 1) respect for persons, 2) beneficence and 3) justice, which were ‘to provide an analytical framework that will guide the resolution of ethical problems arising from research involving human subjects.’23 Subsequent debates and revisions of these principles culminated in the emergence of principlism as the dominant ethical framework in contemporary bioethics However, it is vital to note that principlism was premised on the contentious notion of common morality The Common Morality and the Rise and Dominance of Principlism in Contemporary Bioethics The most compelling account of principlism is arguably the one articulated by Beauchamp and Childress24 in their best-selling book, Principles of Biomedical Ethics Here the three fundamental ethical principles in the Belmont report were revised and expanded to four basic prima facie moral principles essential to biomedical ethics, namely, beneficence, non-maleficence, respect for autonomy, and justice Notably, the original Belmont principle of beneficence was reformulated and subdivided into two: beneficence and non-maleficence Meanwhile, the principle of respect for persons was reformulated into the principle of respect for autonomy Contrary to the authors’ stated intention for non-superiority among the four prima facie principles, it is remarkable that the principle of respect for autonomy has tended to be pre-eminent in principlism Another salient development in principlism was that, in order to render it universalisable, it was grounded in a the21 F Fukuyama 2003 Our Posthuman Future: Consequences of the Biotechnology Revolution London: Profile Books 22 National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research (NCPHSBBR) 1979 The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research Available at:https://science.education.nih.gov/supplements/nih9/ bioethics/guide/teacher/Mod5_Belmont.pdf [Accessed Dec 2015] 23 Ibid: 24 Beauchamp & Childress, op cit note © 2016 John Wiley & Sons Ltd 25 ory of common morality.25 This is supposedly a universal morality consisting of universally acceptable moral norms, rules of moral obligation and standards of action Characteristically, the common morality is ‘a product of human experience and history and is a universally shared product.’26 Moreover, common morality precepts not ‘rely on ordinary shared moral beliefs for their starting content; and they make no appeal to pure reason, rationality, natural law, a special moral sense, or the like.’27 In other words, the common morality is essentially content-thin and does not have a foundational philosophical theory It is rather ‘a heap of obligations and values unconnected by a first principle’.28 In fact, Beauchamp and Childress specifically acknowledge ‘that the common morality does not now, and has never in fact, included a provision of equal moral consideration for all individuals or conferred moral status on all individuals.’29 Thus by grounding principlism in a conceptually content-thin common morality, it is apparent that the two authors pragmatically opted for Western libertarian socio-political correctness and evaded a contentious but foundational concept, the dignity of the human person, which is arguably what confers inalienable moral status on all human beings Indeed, it is vital to note that the ensuing advocacy and activism for principlism - as the preferred ethical approach in contemporary bioethics - was not only characteristically emotive but was also clearly aimed at relegating the foundational concept of the dignity of the human person In fact, Macklin,30 one of the most ardent advocates of principlism, vehemently argued that the concept of human dignity is useless and should be totally dismissed from contemporary bioethics discourse, in favour of autonomydominant principlism Meanwhile, Gillon,31 a self-confessed principlism activist, hailed the common morality and principlism as the key to moral ecumenism that would liberate us from what he viewed as the moral imperialism of the traditional moral theories Remarkably, it was Macklin’s hyperbolic stance that prompted the resurgence of the human dignity debate in bioethics today.32 It is evident that the resurgent debate on human dignity highlights the inadequacy of the concept of the common morality in grounding principlism as an ethical framework As we have already noted, the common morality simply 25 Ibid Ibid: 27 Ibid: 387 28 Ibid: 396 29 Ibid: 391 30 R MacKlin Dignity Is a Useless concept BMJ 2003; 327:1419-1420 31 R Gillon Ethics Needs Principles – Four Can Encompass the Rest – and Respect for Autonomy Should Be “First Among Equals” J Med Ethics 2003; 29: 307–312 32 G.M Ssebunnya On the Secularisation of the Image of God: The Resurgence of the Human Dignity Debate in Contemporary Bioethics Discourse Missionalia 2012; 40(1/2): 105–118 26 26 Gerald M Ssebunnya presupposes universally agreeable moral norms It lacks a foundational theory or comprehensively integrated moral content that can effectively guide the application of principlism, especially when conflict arises among the four principles.33 Thus although it embraces the universally upheld moral character traits (such as benevolence, non-malevolence, truthfulness, and trustworthiness, among others), the common morality is characteristically abstract with regard to the conceptual dimension of the essentially two-dimensional discipline of bioethics The Two-Dimensional Essence in Contemporary Bioethics It is critical to note that contemporary bioethics as a discipline is essentially two-dimensional, being both conceptual and empirical My premise is that, as a discipline of applied ethics, bioethics is necessarily grounded in foundational ethical theory and this constitutes its conceptual dimension Thus conceptual bioethics is informed by traditional normative ethical theories, which may be broadly divided into: 1) deontological theories (the ethics of simply obligation or duty), such as Kantianism; and 2) teleological theories (the ethics of the good as the end), such as virtuebased ethics and utilitarianism It is also informed by, among others, socio-political philosophy (which includes communitarianism and liberalism) and phenomenology It is worth noting that no single traditional normative ethical theory suffices as the foundational theory in bioethics.34 Arguably, however, the central concepts in conceptual bioethics, which underpin the moral imperative in bioethics, are the dignity of the human person and the human good At the same time, bioethics has the practical function of resolving ethical dilemmas in biomedical research and practice This necessitates, therefore, an integrated objective action-guiding ethical framework (such as principlism),35 which thereby constitutes the empirical research ethics dimension of bioethics In other words, empirical research bioethics concretises conceptual bioethics, and conceptual bioethics anchors empirical research bioethics Evidently, empirical biomedical research ethics has tended to dominate contemporary bioethics discourse Indeed, current efforts with regard to bioethics in Africa are predominantly focused on training African researchers on the principles and methodology of ethical biomedical research Indisputably, these current African bioethics programs have been invaluable in sensitizing researchers in Africa – and Africa as a whole – about the primacy of ethics in biomedical research In this respect, supportive partnerships such as the Johns Hopkins-Fogarty African 33 34 35 Ssebunnya, op cit note 20 Ssebunnya, op cit note Ibid Bioethics Training Program, and the Europe and Developing Countries Clinical Trial Partnership (EDCTP) are indeed commendable Meanwhile, because of the morally pluralistic nature of contemporary bioethics, the conceptual dimension of bioethics today remains understandably non-consensual Nonetheless, moral pluralism does not diminish the essence of conceptual bioethics and may actually be harnessed towards enriching our understanding of the moral imperative in bioethics Moreover, given the abstract notion of the common morality, the foundational role of conceptual bioethics is particularly critical in Africa and other areas where bioethics as a discipline is relatively in its infancy Indeed, lack of conceptual internalisation of bioethics in Africa may render the authentically derived ethical principles in principlism unappealing and apparently irrelevant to Africa, as Behrens36 has pointed out Thus an articulated African conceptualisation and subsequent internalisation of bioethics is critical to avoid a sense of Western conceptual imperialism It emerges, therefore, that Africa’s greatest contribution to bioethics might be in engaging, elaborating and enriching the foundational moral content of bioethics (as implied in the common morality) rather than in the categorical rejection of Western conceptualised principlism (with a view to formulating a distinct African bioethics) Indeed, given the rapid biotechnology revolution and current globalisation, it is imperative that Africa addresses its glaring conceptual bioethics lag, so as to effectively contend with the unprecedented global existential bioethical concerns, which include trans-generational genetic engineering and human cloning Moreover, conceptual reflection in bioethics is necessarily a continual process with ever new horizons, even in the West where the discipline is evidently more advanced In fact, the resurgence of the intense debate on the concept of human dignity in contemporary bioethics, which in the United States culminated in a specially commissioned presidential task force report in 2008,37 highlights the need for sustained conceptual reflection in bioethics Accordingly, contemporary bioethics needs to be grounded and internalised in Africa as a two-dimensional discipline, with sustained African conceptualisation and reflection on the underlying moral imperative, so as to render bioethics truly relevant to Africa Hence, whereas the empirical research dimension of bioethics has been fairly well-introduced in Africa, there is an urgent need to address the current African conceptual lag in bioethics 36 Behrens, op cit note President’s Council on Bioethics (PCBE) 2008 Human Dignity and Bioethics: Essays Commissioned by the President’s Council on Bioethics Washington, DC: PCBE Available at: http://bioethics.georgetown.edu/ pcbe/reports/human_dignity/human_dignity_and_bioethics.pdf [Accessed Dec 2015] 37 © 2016 John Wiley & Sons Ltd Addressing the Conceptual Bioethics Lag in Africa ADDRESSING THE CONCEPTUAL BIOETHICS LAG IN AFRICA As Andoh38 rightly observes, the bioethics lag in Africa borders on the catastrophic He points out that ‘Africa still lack[s] professionals, experts, professors of bioethics, the institutions, infrastructures and the critical mass of African experts to address the current issues of bioethics from typically an African background to bring out African specificities, approaches and aspects.’39 What is vital to note is that principlism conceptually and necessarily requires specifying,40 and African specificities need not constitute a distinct African bioethics Given the rapid biotechnology revolution, Africa cannot afford to ignore the current bioethics discourse.41 As we have already noted, Africa certainly identifies with the universalisable unprecedented bioethical concerns that led to the emergence of bioethics as a discipline In fact, at least one of the salient bioethical events chronicled above, the world’s first heart transplantation, has a particular African claim Above all, the 20th Century was characterised by a fundamental metamorphosis of the medical profession in general, from a simple physician-patient relationship into a complex multifaceted enterprise with a multiplicity of stakeholders - including other professionals, paraprofessionals, the biomedical industry, and the public at large.42 Thus coupled with a drastically increasing disease burden, and in light of the unprecedented biotechnology revolution, medicine as a profession truly became ‘an open-ended biotechnology experiment [and] biomedical and behavioural research involving human subjects became a major pre-occupation of the medical profession in the 20th Century.’43 The first clarion call towards addressing the current African conceptual lag in bioethics, therefore, is to the African health care professionals themselves A Call to African Health Care Professionals There is certainly an urgent need for African health care professionals to critically reflect on the evolving valueladen profession of medicine from a standpoint of their ‘uniquely distilled lived professional experiences’ in Africa.44 In today’s medical era, when the Hippocratic 27 ethic is largely in disarray,45 health care practitioners must reflectively articulate their role as moral agents with a moral obligation to re-affirm and safeguard the human dignity of their patients Without a doubt, African health care practitioners are the ones best suited to realistically interrogate the conceptual basis of their profession in the African setting, drawing from their lived experience of the phenomenology of the physician-patient relationship It is vital to underline that African health care practitioners need not first become lettered philosophers in order to articulate the conceptual basis of their profession Rather, being moral agents, they only need to draw from the realities of their daily endeavour to discern the multiplicity of values in each clinical encounter, and reflect on the essence of their profession as a moral enterprise.46 In any case, philosophy is about sustained reflective thinking and critical examination of reality.47 Moreover, health care practitioners arguably have a heightened professional sensitivity towards the ethical notion of normativity, albeit generically, as their work largely consists in determining physiological normality and correcting pathological abnormalities Remarkably, more and more African health care practitioners are embracing the empirical research ethics dimension of bioethics, which is especially pronounced in the field of HIV/AIDS care and research Hence, by reflecting on their lived professional experience - in light of the ethical principles of beneficence, non-maleficence, justice and respect for patients’ autonomy - African health care practitioners should derive and contribute invaluable insights towards conceptualising a realistic trajectory for bioethics in Africa Perhaps more fundamental in this regard is the urgent need to articulate both conceptual ethics and research ethics education during the training of African health care professionals It is imperative, therefore, to also call upon all African health care training institutions to prioritise comprehensive bioethics education A Call to African Health Care Training Schools (AHCTS) Contemporary African health care curricula are generally based on the Western Flexnerian model.48 This medical education model is essentially science-centred, usually consisting of a block period of training in basic biomedical sciences followed by a final period of clinical training 38 Andoh, op cit note 11 Ibid: 73 40 Beauchamp & Childress, op cit note 41 Andoh, op cit note 11 42 A.R Jonsen & A.E Hellegers 1977 Conceptual Foundations for an Ethics of Medical Care In Ethics in Medicine: Historical Perspectives and Contemporary Concerns S.J Reiser, A.J Dyck & W.J Curran, eds Cambridge, Massechusetts, and London, England: The MIT Press: 129–136 43 Ssebunnya, op cit note 20, p 83 44 Ibid: 23 39 © 2016 John Wiley & Sons Ltd 45 H.T Engelhardt & F Jotterand 2008 Edmond D Pellegrino’s Project In The Philosophy of Medicine Reborn: A Pellegrino Reader H.T Engelhardt & F Jotterand F, eds Notre Dame: University of Notre Dame Press: 1–19 46 Ssebunnya, op cit note 47 M.M Makumba 2009 Introduction to Philosophy Nairobi: Paulines Publications Africa 48 T.P Duffy The Flexner Report – 100 Years Later Yale J Biol Med 2011; 84: 269–276 28 Gerald M Ssebunnya and certification Indeed, health care training in Africa has diligently espoused this ‘postivistic natural-science paradigm’49 whereby, by high school level, prospective students are exclusively streamlined towards biology and the physical sciences - with minimal exposure to the humanities However, while biomedical sciences may explicate human pathologies and remedies, it is the humane values - garnered mainly from the humanities that can save the patient from being treated merely as a scientific substrate It is notable, therefore, that health care education in the West has acknowledged the deficiency of Flexnerian medical education and undergone numerous reviews and improvements, which have increasingly incorporated the humanities.50 African health care education, on the other hand, is generally still stuck to the basic Flexnerian model There is an urgent need, therefore, for AHCTS to re-orientate their curricula towards a value-laden health care education that can reaffirm and safeguard the dignity of the patient as a human person It is worth underlining that foundational exploration of the concept of the dignity of the human person must be central to any value-laden and patient-centred curriculum that intends to produce compassionate health care professionals Illness inevitably imposes serious vulnerability to patients whose dignity as human persons must be safeguarded at all times, especially because of the unavoidable and often intimate intrusions by health care professionals.51 Thus it is only proper that a physician, into whose fiducious care patients are to entrust themselves, be well-grounded in the concept of the dignity of the human person It is imperative, therefore, that AHCTS undertake comprehensive reviews of their curricula to not only incorporate insights from the humanities but to particularly conceptualise the dignity of the patient as a human person Accordingly, an introductory course on the dignity of the human person should become mandatory in all AHCTS It is understandable, however, that such a comprehensive curriculum review would involve considerable strain on the already limited resources of most AHCTS There is a need, therefore, to call upon Africa’s development partners for worthwhile support in this regard 49 J Kriel 2000 Matter, Mind, and Medicine: Transforming the Clinical Method Amsterdam: Rodopi B.V Editions: 50 J Goldie 2000 Review of Ethics Curricula in Undergraduate Medical Education Med Educ 2000; 34: 108-119; S.L Kanter, P.F Wimmers & A.S Levine In-Depth Learning: One School’s Initiative to Foster Integration of Ethics, Values, and the Human Dimension of Medicine Acad Med 2007; 82: 405–409 51 E.D Pellegrino 2008 The Internal Morality of Clinical Medicine: A Paradigm for the Ethics of the Helping and Healing Professions In The Philosophy of Medicine Reborn: A Pellegrino Reader H.T Engelhardt & F Jotterand, eds Notre Dame: University of Notre Dame Press: 62-84 A Call to Africa’s Bioethics Development Partners It is worth noting that the 1990s saw a series of Africa’s own share of documented acute bioethical concerns These include: Dr McGown’s unethical anaesthesia experimentation in Zimbabwe; Pfizer’s Trovan scandal in Nigeria; and Dr Bezwoda’s unethical breast-cancer chemotherapy trial in South Africa.52 As Ndebele53 observes, however, Africa’s engagement in these and other African bioethical debates has been conspicuously minimal, with the dominant views being those of Western bioethicists and philosophers This is clearly attributable to poor African scholarship in bioethics, particularly as regards its conceptual dimension Notably, intensifying African conceptual scholarship demands appropriate resources and political commitment, especially in terms of budgetary allocation As we have already noted, however, comprehensive development of bioethics in Africa is severely hampered by limited resources Africa hence needs to build authentic developmental partnerships Evidently, the development of bioethics in Africa has already greatly benefited from the generosity of various Western partnerships These include the Fogarty International Center (FIC), the Europe and Developing Countries Clinical Trial Partnership (EDCTP), and the Welcome Trust.54 It is notable, however, that the sponsorship of bioethics training in Africa has so far focused (almost exclusively) on capacity-building in the empirical research ethics dimension of bioethics This has been mainly by way of developing and strengthening African Research Ethics Committees (RECs).55 In fact, as Kruger and Horn56 rightly observe, the current African RECs are meant to simply implement the three ethical principles of the Belmont report, namely, beneficence, justice and respect for persons In other words, they only minimally engage in the vital reflection on the conceptual dimension of bioethics that would ensure the comprehensive development and internalisation of bioethics in Africa It is vital, therefore, that Africa’s development partners assist AHCTS to develop more comprehensive bioethics capacity-building and training programmes that incorporate the essential two-dimensional scope of bioethics At the same time, AHCTS themselves must optimise such partnerships (like the FIC’s Medical Education Partnership Initiative (MEPI)) to prioritise the need for conceptually 52 P Ndebele et al 2014 History of Research Ethics in Africa In Research Ethics in Africa: A Resource for Research Ethics Committees M Kruger, P Ndebele & L Horn, eds Stellenbosch: SUN PRESS: 3–10 53 Ibid 54 Ibid 55 M Kruger & L Horn 2014 Introduction In Research Ethics in Africa: A Resource for Research Ethics Committees M Kruger, P Ndebele & L Horn, eds Stellenbosch: SUN PRESS: 1–2 56 Ibid © 2016 John Wiley & Sons Ltd Addressing the Conceptual Bioethics Lag in Africa enriched bioethics education curricula In fact, AHCTS must not only highlight the two-dimensional nature of bioethics but must also broaden its conceptual dimension by engaging with African philosophers, bioethicists, sociologists and others - so as to capacitate authentic African participation in contemporary bioethics discourse In this regard, an equally imperative call goes to African philosophers, bioethicists and other researchers Kant’s racial ideology and ‘declared the African subhuman: the African lacked reason and therefore moral and ethical content’.62 To Hegel, the African was clearly an unredeemable primitive savage, and a barbarian far removed from Eurocentric human civilisation.63 Understandably, therefore, the roots of a distinctive African philosophy are emancipatory As Eze64 elucidates: The idea of “African philosophy” as a field of inquiry has its contemporary roots in the effort of African thinkers to combat political and economic exploitations, and to examine, question, and contest identities imposed upon them by Europeans The claims and counterclaims, justifications and alienations that characterize such historical and conceptual protests and contestations indelibly mark the discipline of African philosophy A Call to African Bioethicists and Philosophers Undoubtedly, there is an urgent need for African bioethicists, philosophers and other researchers to articulate a contemporary African philosophical thought that can sustain a viable trajectory for bioethics in Africa It is indisputable that Africa does not constitute a homogeneous philosophical standpoint, and caveats against generalising the traditional African philosophical viewpoints are quite in order.57 Nonetheless, there is a real need for an authentic contemporary African philosophical thought that can resolutely overcome the ghostly legacy of African colonial history Overcoming the Colonial Legacy: The Roots of a Sterile Distinct African Philosophy Overcoming the deeply entrenched colonial legacy is perhaps the most fundamental task for African philosophy, and indeed for conceptual bioethics in Africa African colonialism was characterised by a chronology of 1) the ferocious transatlantic slave trade, 2) the equally brutal European conquest and occupation of Africa, and 3) the imposition of an alien and exploitive colonial administrative system.58 It is particularly critical to note that African colonialism entrenched in the European psyche a philosophical characterisation of the Africans as a subhuman race to whom human civilisation was not intelligible.59 Foremost in dehumanising the African was the Enlightenment philosopher Hume whose ‘“natural” philosophical casting of racial differences framed the African outside of “proper” (read: European) humanity.’60 Kant amplified Hume’s philosophical racial prejudice in his infamous characterisation of the blackness of the African’s skin as ‘“a clear proof that what he [the African] said was stupid”’.61 Following on Kant, Hegel’s characterisation of the African is perhaps the most deplorable as, despite the Enlightenment’s ideals of the dignity of the human person and democracy, he perpetuated Hume and 57 Serequeberhan, op cit note 18 E.C Eze 2005 Modern Western Philosophy and African Colonialism In African Philosophy: An Anthology E.C Eze, ed Malden, MA: Blackwell Publishing Limited: 213–221 59 Ibid 60 Ibid: 214 61 Ibid: 215 58 © 2016 John Wiley & Sons Ltd 29 It is against this complex background, therefore, that various emancipatory trends in African philosophy emerged These included philosophic sagacity, nationalistphilosophical ideology, formal or “professional” philosophy and, most prominently, ethno-philosophy.65 African ethno-philosophy refers to the attempt to derive distinctive philosophical tenets from the indigenous cultural and traditional beliefs and practices of the African people It set out to re-affirm the non-inferiority of the identity and values of the African people, with the general aim of liberating Africa from the repressive colonial psyche Indeed postcolonially, African philosophy simply became equated to the distinctive ethno-philosophy, which was, however, to the great detriment of philosophy in Africa.66 Ethno-philosophy has been criticised for simply being ‘an attempt to construct a philosophical discourse from material with an ethnological interest, thus becoming a hybrid ideological discipline without a status in the world of theory’.67 Yet, as Makumba68 rightly points out, the role of African philosophy in the mental decolonisation and recovery of African values and self-esteem is crucial, as philosophy aims at searching for the highest truth - which is the only way to truly liberate Africa It is not surprising, therefore, that Africa’s emancipation and independence has not yielded the true socio-political freedom and sustainable socio-economic development that was anticipated.69 Africa’s realities today include: the nostalgia of a “glorious” pre-colonial past; the wounds of 62 Ibid: 216 Ibid 64 Ibid: 217 65 H.O Oruka 1991 Sagacity in African Philosophy In African philosophy: The Essential Readings T Serequeberhan, ed New York: Paragon: 47–62 66 Agada, op cit note 67 M.M Makumba 2007 Introduction to African Philosophy Nairobi: Paulines Publications Africa: 122 68 Makumba, op cit note 47 69 Eze, op cit note 58 63 30 Gerald M Ssebunnya colonial subjugation; the unrealised promises of post-colonial independence; the onslaught of astute neo-colonialism; the un-integrated post-colonial education system; and Africa’s relative passivity in current globalisation Moreover, it is vital to note that ‘[t]he insidious nature of neocolonialism is that it internally replicates – in an indigenous guise – what previously was imposed from the outside by the exclusive and explicit use of violence.’70 Clearly, the emancipatory efforts through a distinct African philosophy have been unable to yield fruitful guidance in addressing Africa’s complex realities The problem, as Wiredu rightly observes, is that contemporary African philosophers tend to be polemically preoccupied with the question of an African philosophy instead of actually doing African philosophy.71 In fact, as Agada72 points out, ‘the continued emphasis on ethno-philosophy and the relative absence of intellectual passion and curiosity are the greatest challenges facing African philosophy.’ According to Agada,73 African philosophy is characteristically dominated by polemics because of lack of original conceptual African philosophers: ‘In the absence of originality, analysis is compelled to serve polemic rather than substantive thinking.’ There is an urgent need, therefore, for contemporary African philosophers to go beyond the polemical and sterile argument for a distinct African philosophy, and philosophically reflect on the fundamental questions of human experience in Africa today Beyond the Sterility of a Distinct African Bioethics As Eze74 rightly emphasises, there is a critical need today ‘to abandon the sterile and tendentious question of whether or not there exists an “African” philosophy, and instead to focus on actually cultivating and shaping (and re-shaping), for the future, the nature of philosophy as it is practiced both within and outside Africa among black as well as non-black philosophers.’ Indeed, as Shutte75 surmises, philosophy – African or otherwise – ‘is the search for truths and values that are true and valuable for every place and time.’ In other words, although it is indisputable that every philosophical tradition arises from a particular socio-cultural setting, ‘a successful philosophy is one that is able to grasp what is universally true in the particular circumstances of its setting.’76 70 Serequeberhan, op cit note 18:13 J.I Omoregbe 2005 African Philosophy: Yesterday and Today In African Philosophy: An Anthology E.C Eze, ed Malden, MA: Blackwell Publishing Limited: 3–8 72 Agada, op cit note 6:42 73 Ibid: 46 74 E.C Eze 2005 Preface in Eze E C (ed) African Philosophy: An Anthology Malden, MA: Blackwell Publishing Limited: ix-x: ix 75 Shutte, op cit note 7: 76 Ibid: 71 Authentic philosophy, therefore, transcends culture and is concerned with sustained habitual reflection on the fundamental questions about the wonders of the universe and about the existence, the limitations, the destiny and the ultimate meaning of the human person.77 Indeed, bioethics - like any ethical standard - is essentially not culturally constructed but rather derives from our nature and inalienable inherent value as human persons.78 Hence, authentic African bioethics cannot essentially be exclusivist or categorically isolated ‘from Western philosophy, because philosophy is a universal intellectual engagement, and it will humanity much good if diverse philosophical traditions meet in dialogue that involves reciprocal respect’.79 Moreover, as Omoregbe80 points out, ‘the essence of philosophy is not argument but reflection, and this does not have to take the form of the Western-type argument.’ It is crucial to note, however, that documented philosophical reflections, in the form of books, have been vitally instrumental in the preservation, transmission and dominance of various philosophical traditions.81 It is imperative, therefore, that African bioethicists and philosophers actively engage in documenting their sustained philosophical reflections to enrich the conceptual dimension of contemporary bioethics - drawing from their own uniquely distilled contemporary African vantage point Accordingly, rather than pursuing a distinct African bioethics, African bioethicists and philosophers would well to elucidate the universalisability of communitarian traditional African thought - and thus enrich the contentthin concept of the common morality - for the benefit of bioethics as a whole CONCLUSION It is indisputable that bioethics as a discipline is essentially a universal pursuit that emerged out of concerns about the unprecedented biotechnological threats to the dignity of the human person Thus, primarily, bioethics has a moral imperative and must be conceptualised and grounded in a matrix of moral values Secondly, bioethics is actualisable through an action-guiding analytical framework that underlies empirical research ethics This is the essential twodimensional nature of bioethics that demands sustained reflection and articulation in light of lived human experience The evident lag in Africa with regard to articulating and internalising the conceptual dimension of bioethics is, therefore, an indictment on current African scholarship in bioethics Africa needs to comprehensively embrace 77 78 79 80 81 Omoregbe, op cit note 71 Shutte, op cit note Agada, op cit note 6:47 Omoregbe, op cit note 71: Ibid © 2016 John Wiley & Sons Ltd Addressing the Conceptual Bioethics Lag in Africa bioethics as the universal two-dimensional discipline that it essentially is, given the current unprecedented biotechnology revolution and globalisation Pursuing a distinct African bioethics is evidently unsustainable - and does not advance the universal cause of bioethics as a discipline as it is premised on a sterile emancipatory African ethnophilosophy A viable trajectory for bioethics in Africa demands of African health care professionals and institutions; African governments and development partners; and African bioethicists and philosophers, among others, to resolutely prioritise both the conceptual and empirical research ethics dimensions of bioethics, and authentically participate in contemporary bioethics discourse Africa needs to address its conceptual bioethics lag, and can certainly enrich the content-thin concept of the common morality with © 2016 John Wiley & Sons Ltd 31 profound insights from the communitarian matrix of traditional African thought African bioethicists and philosophers must therefore purposefully engage in comprehensive sustained reflection on the conceptual basis of bioethics Thus we must engage beyond the sterility of a distinct African bioethics - authentically reflecting on the essentially universal contemporary bioethical concerns - to effectively articulate a viable trajectory for bioethics in Africa Biography Dr Gerald Michael Ssebunnya is a medical practitioner at Padre Pio Medical Centre in Gaborone, Botswana, and a post-doctoral researcher in bioethics and philosophy of medicine His current research interests include: articulating a viable trajectory for bioethics in Africa; and examining moral agency and the moral imperative in medicine today Copyright of Developing World Bioethics is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use  ... the conceptual basis of their profession in the African setting, drawing from their lived experience of the phenomenology of the physician-patient relationship It is vital to underline that African. .. pre-occupation of the medical profession in the 20th Century.’43 The first clarion call towards addressing the current African conceptual lag in bioethics, therefore, is to the African health care professionals... to articulate the conceptual basis of their profession Rather, being moral agents, they only need to draw from the realities of their daily endeavour to discern the multiplicity of values in each