Global bioethics and moral pluralism: towards a criteriology at the hospital

To the editor

As we published in the Journal of Translational Medicine in 2023 [1], we have begun to apply in our recent studies in empirical bioethics a particular ethical theory: ‘global bioethics’. However, we have also begun to rework this teleological theory to provide, more formally, greater operationality for the resolution of ‘bio-ethical issues’(i.e. tensions between medical and/or biological practices and moral values and/or standards), pre-identified by various methodological approaches (e.g. qualitative approach, etc.), at a global scale (i.e. ‘macro-bio-ethical issues’; e.g. country, etc.), and/or local scale (i.e. ‘micro-bio-ethical issues’; e.g. institution, etc.), and then resolved by this theory, as a function of the real and/or potential consequences for ‘survival’ and/or ‘happiness’, at individual and/or collective levels. Practical limitations have nevertheless emerged in the face of ‘moral pluralism’ (i.e. the presence of several moral frameworks) , in our case, at the hospital.

Worldwide, this pluralism results from the existence of ‘cultural areas’ that differ to various extents. These spaces are delimited to various degrees, and at a given point in time present cultures displaying various degrees of difference, or homogeneity. At the regional scale, phenomena relating to multiculturalism may also apply, themselves emanating from other complex phenomena (e.g. human migration, etc.). In hospitals, and elsewhere, as we have ourselves observed, this pluralism influences the likelihood of medical and/or biological practices being accepted, or refused, by individuals, or groups of people [2]. This pluralism must be better taken into account in global bioethics, as a leading ethical theory, to increase the operationality of this theory and, thus, its practical pertinence, especially at the hospital.

In this theory, our first postulate is that survival and happiness are the only two legitimate ‘bio-ethical objectives’ common to the whole of humanity, consciously or otherwise. Our second postulate is that these objectives are wholly or partially, and explicitly or implicitly, conditioned by different cardinal criteria correlated with these different moral frames of reference of individuals and/or society [3]. We then began to characterize these frameworks, as a means of outlining these criteria, by analyzing the content of a collective work by colleagues, which remains a reference in this domain within the French-speaking world [4]. Here, we present a summary of this analysis and its perspectives, a draft of which we have formulated in French in the chapter of another collective work [5].

We first manually identified and listed in alphabetical order 12 principal moral frameworks, which we developed into the corresponding number of chapters: the ‘Animist framework’, the ‘Buddhist framework’, the ‘Catholic framework’, the ‘Confucianist framework’, the ‘Hindu framework’, the ‘Islamic framework’, the ‘Jewish framework’, the ‘Kantian framework’, the ‘lay framework’, the ‘Orthodox framework’, the ‘Protestant framework’ and the ‘Utilitarian framework’. We then characterized, manually again, the basis, aims and rules of each framework, through excerpts that appeared significant, which we sometimes rearranged, from which we induced these criteria. These frameworks and criteria are non-exhaustive, and they are collated in a detailed table for greater clarity (N.B. see the table).

Table 1 Graphical summary of the analysis of content

We can distinguish several tendencies from this table. The Catholic, Islamic, Jewish, Kantian, lay, Orthodox, Protestant and Utilitarian frameworks can be grouped together, contrasting with a second group of frameworks consisting of the Buddhist, Confucianist and Hindu frameworks. In the first group of frameworks, humans appear to be dissociated from nature, for various spiritual, religious and/or philosophical reasons, whereas this does not appear to be the case for the second group of frameworks. In addition, for similar reasons, the individual is generally more important than the collective in the first group of frameworks, although this is debatable for the Islamic, Jewish and Utilitarian frameworks, whereas the opposite is true for the second group of frameworks. The Animist framework, which is certainly more unique, converges more with the Buddhist, Confucianist and Hindu frameworks.

These frameworks and the criteria obtained through their analysis clearly have their limitations. Firstly, they are based on the contents of a single book. Secondly, a synthetic exercise of this type necessarily leads to simplifications, particularly for the Animist and Protestant frameworks, which are very heterogeneous. These frameworks and criteria are, thus, neither exhaustive nor definitive. As such, they need to be expanded by more empirical studies. They nevertheless provide indications, and constitute a preliminary basis for a criteriology that will eventually make it possible to render global bioethics more operational, particularly in hospitals. Furthermore, this ‘new’ global bioethics could better incorporate emerging paradigms such as ‘global health’ and ‘one health’.

Implicitly, these paradigms are included in global bioethics right from the start, because they fully condition our survival — and our happiness. However, they were included in an initial approach that we consider to be insufficiently pluralist and pragmatist in that, retrospectively, this approach appears to be too secular and materialist. In other words, there is an excessive expression of political and philosophical systems, essentially linked to the lay framework that is proving difficult to apply beyond the confines of the West. The survival and happiness of one set of people are not always those of another, which is why a criteriology such as that proposed here is useful. However, this criteriology should not favor a certain moral relativism, particularly as concerns racism, sexism or homophobia.