Travelling bioethics

When there are no strikes or natural disasters, travelling usually is a pleasure. Some of us have returned from the annual conference of the American Society for Bioethics and Humanities in San Diego, while others have good memories of the 10th World Congress of Bioethics in Singapore last summer. But not only bioethicists are travelling, bioethics itself is as well, following the globalization of health care and medical research. Anthropologist Petryna (2009), in her interesting book When experiments travel, has shown how the clinical trials industry has moved into the developing countries, using the poor as research subjects and ignoring all the norms that have been established in the developed world. Bioethics has become a global concern and has now really moved into a new stage involving all countries and cultures. This issue of the journal testifies of this expansion of the scope of bioethics. However, there are different perspectives on the globalization of bioethics. In this issue, Gielen et al. (2011) report about the attitudes of palliative care professionals in New Delhi towards withholding life-sustaining treatment. The need for palliative care exists everywhere. It is therefore interesting to study how non-treatment decisions are made in other countries. The authors refer to the specific context in India, such as the legal provisions that facilitate that refusal of life-sustaining treatment can be regarded as suicide, making physicians reluctant to withdraw or withhold such treatment. The authors also, though succinctly, refer to the socio-economic context, pointing out that financial considerations play an important role in treatment decisions. Regardless of these different contexts, however, the respondents use more or less the same normative framework for decisions to withhold life-sustaining treatment as in the West. It is difficult to know how representative the opinions of less than 30 physicians and nurses in various palliative care settings in New Delhi are for palliative care professionals in India. After all, the respondents are highly educated people, imbued with the attitudes of palliative care and not much influenced by Hindu beliefs. But the study demonstrates that there are two different research approaches to global bioethical issues. One approach is to study other countries to examine how ethical problems are perceived, presented, addressed, for example to examine how treatment decisions in palliative care are made in India or other countries. We can apply the usual research methods with the standard questionnaire and hypothetical cases to gauge the opinions of colleagues in India. The results often trigger a response similar to the exclamation of surprise of Western tourists in Bangkok or Nairobi: ‘it is just like home’—‘they have everything we have’. Modern health care is universal, medicine is almost the same everywhere, and people have similar diseases. Why should bioethics be different? Everybody who leaves the main roads and looks beyond the glamorous buildings finds a different reality. Nairobi has one of the vastest slumps in Africa, while Bangkok has huge areas of cardboard huts ‘sheltering’ illegal laborers from the Northern provinces. Palliative care in India is fine, but can we ignore the context? India is a vast country, with 25% of the population below the poverty line. The majority of the population has no access to health care; only 10% of the population has health insurance. There is a shortage of doctors and nurses, and a significant lack of hospital beds. Even if there are adequate health facilities, basic sanitation is lacking. There is no city at the moment with full-day water supply. Within this context, H. ten Have (&) B. Gordijn Dublin City University, Dublin, Ireland e-mail: [email protected]