V. Implication of an African American Bioethical Perspective
Bioethics addresses the ethical problems posed by modern medicine and *229 biotechnology. Bioethics is not a single, distinct academic discipline, but is comprised of practitioners from medicine, philosophy, theology, law, nursing, medical history, medical anthropology, medical sociology, and related fields. While bioethics lacks a single, accepted methodology, it has traditionally focused on mid-level ethical principles, such as autonomy, beneficence, justice, and nonmaleficence.
These principles are intended to be a regulative guideline, stating conditions of the permissibility, obligatoriness, rightness, or aspirational quality of actions *230 falling within the scope of the principle[s]. However, there have been a number of challenges to the content of the principles.
Eurocentric bioethics focuses on the individual, ignoring the interests of others who are intimately affected, such as the family and the community. This focus on the individual is based on a philosophy that regards the self, and only the self, as the end per se. However, the African American perspective views this reliance on ethical egoism to be misplaced. African Americans believe that it takes a whole village to raise a child, and thus, at a minimum, African Americans view ethical egoism to be contradictory to the raising of healthy children. Furthermore, even as adults, none of us function as islands; we all must rely on others for, at a minimum, reaffirmation of our self-assessment.
Second, Eurocentric bioethics embraces Kantian ethics, which are antithetical to Afrocentric bioethics. Kantian ethics require universal norms and an impartial perspective, which is inattentive to relationships and community. Kantianism privileges abstract reasoning over virtue, character, and moral emotions. Kantian ethics maintain that the only way we can morally constitute ourselves is by free and rational choice. It is the exclusivity of that claim that is troubling. African Americans believe that we morally constitute ourselves not only through free and rational choice but also through our parents and our community.
Third, Eurocentric bioethics tends to view the patient or research subject generically, without attention to race, gender, or insurance status. As a result, the development of laws and bioethical principles, discourse, and *231 practices are informed by the values and beliefs of one group: White, middle-class, males.
Eurocentric bioethical principles such as autonomy, beneficence, and informed consent do not have the same force when viewed through the African American bioethical perspective of distrust. These principles leave considerable room for individual judgment by health care practitioners. The flaw of a principle-based paradigm is that very judgment. The application of the principles will be subject to other values held by the society. In a racist society (such as ours), the judgment is often exercised in a racist manner.
Thus, Eurocentric bioethics has adopted rules and has applied them with little, if any, concern for how race or other characteristics affect the working of the rules. In fact, numerous studies have documented a disparity between traditional bioethical practice and the needs of minority populations. For instance, African Americans notably differ from European Americans, both in their unwillingness to complete advance directives and in the desires expressed regarding life-sustaining treatment. Substantially more African Americans and Hispanics wanted their doctors to keep them alive regardless of how ill they were, while more . . . whites agreed to stop life-prolonging treatment under some circumstances. . . .
Eurocentric bioethics fail African Americans because bioethicists believe, first, that people behave in ways that can so far be predicted a priori that empirical evidence about their behavior is superfluous and, second, that people *232 think and act rationalistically, seeking always to maximize and exercise autonomy. Furthermore, when dealing with bioethical concepts, courts have shown little interest in dealing thoroughly with empirical evidence, or the effects of judicial doctrines. However, the reality is very different. People act in ways that are more consistent with the values they hold, rather than following any particular bioethical principles. And racism is a *233 strongly held value in our society.
African Americans have been experimented on without consent, thus violating the principle of autonomy. We have been treated and experimented on in ways which have caused us harm, thus violating the principles of nonmaleficence and beneficence. We have been given different treatment and provided different access to health care, thus violating the principle of justice. At best, the judgment in applying the articulated principles has been exercised fairly consistently in a manner which disadvantages and harms African Americans.
The implication for the African American community is the failure of bioethical problem-solving to take into consideration those factors important to solving problems in the African American community. Most of the problem-solving has been at odds with the affirmation of the African American individual and the African American community. In fact, for the most part, mainstream bioethicists have consistently neglected to comment on the social ills or injustices such as the [African Americans'] enslavement, the injustices and discrimination they have suffered, the stereotyping of their language and culture, and their disadvantaged economic, political, educational, and health *234 status. As a result of this lack of affirmation, or, this oppression, we are in danger of losing our own perspectives--our own gifts.
The continued destruction of the African American community results from the lack of consideration given to our perspectives. The African American community has a history--and a present context--that is characterized by medical mistreatment and health care exploitation. European Americans have a history that is racist and conspicuously indifferent to community, religion, virtue, and personal experience. African Americans face the health care system with anxiety, fear, and disaffection. Such anxiety, fear, and distrust will not be alleviated until bioethics constructs a practical, ethical approach to the anxiety and fear which would lead to community empowerment. Such a practical approach would require behaviors such as: reinstatement of community hospitals; assuring urban perinatal health care; encouraging traditional lay-midwifery; and reestablishing the extended family. *235 However, such practical approach must be based on not only on the traditional Eurocentric principles but also on:
recognizing the needs of the community and not just the individual self;
formulating bioethical and legal solutions involving both the family and the community; aggressively training health care providers and institutions about the African American perspective, thus making the barrier of distrust easier to overcome;
eliminating the disparities in health status;
aggressively reducing the existing disparities in health care delivery in the African American community.
One problem that some bioethicists may have with acknowledging an African American perspective is the failure of all African Americans to concur in a description of an ethical belief system. However, such a requirement is not necessary or even possible. Not all individuals of any group will believe or act alike. No one expects that all European Americans accept the dominant view in their culture. Nevertheless, a view may be an accurate description of some significant aspect of European American culture. However, my experience shows that attempts to assert, define, and explain the impact of bioethical or legal behavior on African American culture is met with resistance. European Americans often base the resistance on an assertion that such perceptions about African American culture are not representative. I often wonder if this resistance is based on some attempt--unconscious or conscious--to avoid having to truly structure a multi-cultural society and keep the Eurocentric view dominant. Until bioethicists begin to explicitly address these concerns, African Americans are not likely to begin to place their trust in the American health system. Ultimately, bioethicists must recognize the existence of a spirit, a set of social structures and norms in African American life that are worthy of acquisition by Blacks and Whites.
[FNa]. Professor of Law, The University of Dayton School of Law. J.D., 1987, Lewis and Clark College--Northwestern School of Law; M.S.N., 1978, University of Washington; B.S.N., 1972, University of Texas