African Perspectives on Some Contemporary Bioethics Problems [1 ed.] 9781527535626, 9781527534667

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African Perspectives on Some Contemporary Bioethics Problems



African Perspectives on Some Contemporary Bioethics Problems By

Godfrey B. Tangwa

African Perspectives on Some Contemporary Bioethics Problems By Godfrey B. Tangwa This book first published 2019 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2019 by Godfrey B. Tangwa All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-5275-3466-9 ISBN (13): 978-1-5275-3466-7

To my children and grandchildren and to all African scholars and researchers

TABLE OF CONTENTS

Introduction..........................................................................1 Chapter One .......................................................................10 Fundamental Principles of Ethics Chapter Two .......................................................................29 The Traditional African Perception of a Person: Some Implications for Bioethics Chapter Three .....................................................................41 Giving Voice to African Thought in Medical Research Ethics Chapter Four ......................................................................56 Traditional Medicine Chapter Five .......................................................................70 How Not to Compare Western Scientific Medicine with African Traditional Medicine Chapter Six .........................................................................78 Assisted Reproduction Technologies (ART) and African Sociocultural Practices, Worldview, Belief and Value Systems: With particular reference to Francophone Africa Chapter Seven ....................................................................91 Moral Status of Embryonic Stem Cells: Perspective of an African Villager Chapter Eight ...................................................................108 Third Party Assisted Conception: An African Perspective Chapter Nine ....................................................................124 The Universal and the Particular in Current Discussions of International Bio-Medical Ethical Guidelines

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Chapter Ten ......................................................................159 Research with Vulnerable Human Beings Chapter Eleven .................................................................171 Ethics, Human Rights and Sexual/Reproductive Health in Africa: Exploratory Socio-Cultural Considerations Chapter Twelve .................................................................190 Leaders in Ethics Education: Godfrey B. Tangwa

INTRODUCTION

This book is sequel to my Elements of African Bioethics in a Western Frame (Langaa Research and Publishing CIG, Mankon, Bamenda, 2010) which was intended to provoke and inspire African scholars interested in the field of bioethics. That book opens with an interview I had had (2006) with the medical students' magazine of the University of Groningen, The Netherlands, in the course of which I gave some biographical snatches about myself. The present book fittingly ends with another interview with the International Journal of Ethics Education (2016) in which there are further biographical snatches about myself. I am basically an African villager and one of the un-forget-able lessons I learnt growing up in my village of Ndzenshwai-Shisong in the Northwestern grasslands of Cameroon is about the inestimable value of the human being simply as a human being and the absolute moral equality of all humans. All my efforts in bioethics have been underpinned and informed by this simple conviction. Critics of my substantive views and ideas in bioethics have usually argued that the idea of 'African bioethics' does not exist and may have possible applicability only in the future. If the idea of an ‘African bioethics’ does not yet have a thoroughly convincing extra-mental referent, the same is not the case with the idea of an ‘African perspective on bioethics’ and I have not wished to claim more than the existence of the latter for the time being. I have not proposed a coherent substantive theory of African bioethics and I accept this fact as one of my limitations to the extent that such a theory is necessary or desirable; but I hope that, under my provocation and inspiration, some other mind will propose such a theory. The Western academic enterprise has put a lot emphasis and value on peer reviewed publishing. While this has led to desirable quality control in publishing, it has also been

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Introduction

linked with commercial and market forces with the consequence that these publications have not been easily accessible or affordable to many academics and knowledge seekers especially in the so-called developing world. Knowledge ought to be considered a human good and ventilated to all and sundry as freely as possible or at minimal cost. In 1992 or thereabouts, I had published a paper in a Western journal on the problematic of African philosophy. I was sent two copies of the journal and a number of off-prints of my article which I had to pay for. The journal was neither available nor accessible nor affordable to academics in Africa, with the result that my thoughts and arguments on a relevant and important issue at the time were lost to those who would have critiqued them and possibly advanced knowledge on the question at issue. The question at issue was the existence of African Philosophy which, like African Bioethics today, was being denied existence, doubted or called into question. Twenty five years later, I wanted to have the said article republished in a book edited by some African colleagues. It needed a lot of efforts and the help of one of my former students abroad to access the article, which had already gone electronic and accessible by paying a respectable fee, and to obtain permission to have it reprinted. So, in real terms, my only reward as author of the article in question were the two free copies of the journal I got at first publication and perhaps the fact that I could present the article as an academic achievement towards promotion to a higher academic grade. I have no idea how much the publishers of my article reaped financially from selling it to knowledge seekers, but can the fact that I had no share at all in the harvest pass the test of ordinary fairness and justice? More recently, a peer review journal invited me to an interview as one of the 'global leaders of ethics education' (See the last chapter of this book). For publication of the interview, I was prompted electronically online to choose between open access and closed access publication. I quickly chose open access in line with my strong belief that knowledge products should, as much as possible, be made as widely accessible as possible to all and sundry. I expected

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to be asked to pay some money for the open access option but, in the worst case scenario, I thought this would not exceed about 300 US Dollars; but it turned out that the fee for having the interview published open access was 2200 Euros! and it was already too late to reverse my open access option. I did not readily have that sort of money and, while I was still running around in an effort to raise it, the publisher started threatening me with legal action for non-payment of the open access fee. The industrialized Western world is the global role model for all other worlds, regions and countries of our planet, especially in domains such as profitable commerce, but it seems to have a fundamental impulse towards opportunistic exploitation, a moral ailment that ought not to be taken lightly. Apart from the problem of accessibility and affordability of intellectual and academic end products, it is not easy for someone of a different socio-cultural and economic background to get published in Western peer-review journals, and not only for reasons of quality control. Sometimes one cannot escape the impression that the peer-review system is used as a sort of intimidation or discouragement and even censorship against ideas that attempt fundamentally to challenge Western paradigms and generally accepted ideas and practices. Below is a telling sample of a peer-review of an article I submitted for publication and my attempted responses to the reviewers' comments. My original paper as submitted, before peer-review, correction and publication, is published here unedited as Chapter 9 of this book. While the published journal article correctly expresses my ideas, they were forced in many instances, through compliance with the demands of peer review, into a mode and mould that was not originally theirs. What I wanted to communicate in the article and how I wanted to communicate it are better expressed in chapter 9 below than in the published article. In a cross-cultural conversation the manner of saying what one says as well as the idioms one employs in saying it are as important as what is said.

Introduction

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Response to Reviews Comments for the author Reviewer 1 Comment 1 There is a huge gap between the over-detailed history of the CIOMS negotiations and some rather absurd generalities concerning universalism and relativism. In the end the author seems to subscribe to a variety of Millian liberalism as being a supposed ethical universal; yet he also declaims at length against Western philosophy. There are a number of other major contradictions, such as his assertion on p. 2 of the abstract that there is a permanent and ineradicable tension between the universal and the particular, and his claim elsewhere that we can easily get from the universal to the particular by modifying the universal to fit the shape of each community's particular requirements. The language is bombastic and emotive, and the entire piece generally not of the level one would expect of a JME article. My response I am unable to agree with the above comment. There certainly is a difference in the level of abstraction and generality in my discussion of the work of the CIOMS writing group and my more general opening discussion of the concepts of universalism and relativism; but they are connected, and the opening general discussion is meant to dress the broad philosophical background and framework for the more practical and particular issues discussed in the rest of the paper. My general discussion may be challengeable in whole or in its details, but it does not contain any ‘absurdities’. Any ‘declamations’ in the paper are not directed against Western philosophy as such, within which I

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not only have had my broad formal philosophical formation but from which I draw heavily in my arguments. My critique of aspects of Western philosophy in no way implies its rejection. The ‘assertion on p. 2 of the abstract’ which the reviewer considers ‘one of a number of other major contradictions’ has been removed from the abstract. However, it may appear contradictory only if the nuance of the word ‘tension’ is overlooked. But nowhere in the paper is it claimed that ‘we can easily get from the universal to the particular by modifying the universal to fit the shape of each community’s particular requirements’. My claim rather is that any universal norm (of thought, talk or conduct), in its practical application, inevitably is ‘shaped’ and ‘coloured’ by context, perspective and other particularistic data that necessarily impinge on it. My language may in parts be emotive because of my involvement with and passion for the issues I am discussing. None of my arguments, however, is emotive in the sense of being directed to the reader’s emotions; all my arguments are directed to the mind and aim to achieve acceptance through rational persuasion. My language is certainly not ‘bombastic’, if I correctly understand that term to mean “pompous”. As to whether the entire article is up to the standard expected of JME articles, is not for me to judge. Comment 2 There is some interest, however, in the narrative surrounding the CIOMS guidelines negotiations, in which the author was personally involved. I’m not sure whether this would make a full article, or something like an update of the sort Anne Sommerville’s BMA team provide. If the sections on the CIOMS negotiations were to make a full article, the narrative would have to be signposted much more

Introduction

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clearly and given some overall coherence. Namecalling would also have to be eliminated, as would the blanket assertion that Western interests have all been on one side in these negotiations and African on the other. Many African commentators (e.g. Fred Mhalu in Tanzania, or Nicolas Meda in Burkina Faso) have argued on the same side as those Western commentators who favour laxer, differential standards for African trials, whereas some Western commentators (e.g. Marcia Angell) are on the side of the ‘angels’ (sorry about the pun). Ruth Macklin does recognize this in the quote reproduced, but the author seems not to have picked up the point. My response I cannot reduce my article to a mere narrative about the CIOMS guidelines negotiations without abandoning its main purpose and aim, which are to use that narrative as an illustration and a rider to a discussion of the problematic of developed world research in the developing world and to suggest a general framework for the formulation and application of such guidelines, from the point of view and perspective of a developing world thinker. There is no ‘name-calling’, in the sense of ad hominem arguments, in my paper. I have, nevertheless, further suppressed all personal allusions or attributions from the discussion of the revision of the CIOMS guidelines in my revision. I have introduced further qualifiers and rephrased certain sections of the article to remove any impression that the article is treating of earthly angelology versus daemonology or in any sense claiming that in this discussion all Africans are on one side pitted against all Westerners on the other side.

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Reviewer 2 Comment 1 The author addresses a fine set of issues and provides an interesting and engaging summary of the major controversies and outcomes of recent attempts to revise and update international ethical standards of research. As a whole I found the article to be honest, clear, and thought provoking. However, I was vaguely dissatisfied at the end and ultimately found the ethical analysis almost disappointing. I found myself hoping that the author would provide a more compelling argument to support his own prescription. For example, the author's conclusion that CIOMS Guideline 11 places "purely scientific and economic consideration ahead of ethical considerations" needs to be supported. At times I felt that I needed to know more about the opposing view, and that the author was simplifying the ethical arguments invoked by those the author disagrees with. My response I have retouched the concluding sections of my article in the light of the above comment. I cannot, however, elaborate more arguments in support of my point of view and prescription without further lengthening what already is a long article I am at pains to shorten. Comment 2 The author states that the answers to some of the questions raised by international research should be arrived at with the input of all the relevant parties and diverse communities and cultures and a balancing of different points of view. This is not controversial, but one wishes the author could give more direction to that view.

Introduction

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The author touches on the issue of ethical imperialism and the need to "complete the process of decolonization", but does not explore it in depth, nor does the author explain its practical implications. My response I have again rephrased parts of the concluding sections of my article in the light of the above comment. One of the possible practical implications of completing the process of decolonization would be the enhancement of the input of developing world partners, stake-holders and communities in any joint process seeking ethical answers to international research problems or dilemmas. An example of such a joint process of deliberation, as against starting off with a set of externally pre-determined rules, is currently being attempted by Ezekiel Emmanuel and his team of the Department of Clinical Bioethics, NIH, with remarkable results. The approach has permitted them to pose the question: “What makes clinical research in developing countries ethical?” and to come up with a set of “Benchmarks”. Thoroughly elaborating on my view here and drawing its full practical implications would require another full article. The first chapter of this book reuses some of the material in my chapter (Chapter 7: Ethics in African Education) of the Handbook of African Educational Theories and Practices: A Generative Teacher Education Curriculum, edited by A. Bame Nsamenang and Therese M.S. Tchombe, Bamenda: Presses Universitaires d’Afrique, 2011, and was previously presented as a Keynote Lecture at the 30th International Congress on Occupational Health (ICOH), Cancun, Mexico, 18-23 March, 2012. The second chapter was previously published in Theoretical Medicine and Bioethics, Volume 38, Number 2, pp. 101-110,2017. The third chapter was previously published in the Encyclopedia of Global Bioethics, DOI 10.1007/978-3319-05544-2_421-1#; Springer Science+Business Media Dordrecht 2015. The fourth chapter was previously published

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in Developing World Bioethics, Volume 7, Number 1, pp. 4144, 2007. The fifth chapter was previously published in Current Practices and Controversies in Assisted Reproduction: Report of a WHO Meeting, edited by Effy Vayena, Patrick J. Rowe and P. David Griffin, Geneva, World Health Organization, pp. 55-59, 2002. The sixth chapter is an unpublished paper previously presented at various conferences. The seventh chapter was previously published in Bioethics 21 (8): 449-457, 2007. The eighth chapter was previously published in Theoretical Medicine and Bioethics. 29(5): 297-306, 2008. The ninth chapter is the original unedited version, before peer review, of the paper previously published as "Between Universalism and Relativism: A Conceptual Exploration of Problems in Formulating and Applying International Biomedical Ethical Guidelines". Journal of Medical Ethics. 30: 63-67, 2004. The tenth chapter was previously published in Acta Tropica, 1125: S16S20, 2009. The eleventh chapter was published as Chapter 7, (pp. 213-232), GLOBAL BIOETHICS AND HUMAN RIGHTS: Contemporary Issues, edited by Wanda Teays, John-Stewart Gordon and Alison Dundes Renteln, Lanham/Boulder/New York/Toronto/Plymouth, UK: Rowman & Littlefield, 2014. The twelfth chapter is an interview previously published in the International Journal of Ethics Education: 91-105; DOI 10.1007/s40889-015-0001-8, (2016). Some of my favourite arguments and narratives reecho across several chapters of this book, the prize or price of the strength of my convictions and my intellectual passion for my subject matters. I hereby thank all previous publishers for their kind permission to republish the materials here.

CHAPTER ONE FUNDAMENTAL PRINCIPLES OF ETHICS

[This chapter reuses some of the material in my chapter (Chapter 7: Ethics in African Education) of the Handbook of African Educational Theories and Practices: A Generative Teacher Education Curriculum, edited by A. Bame Nsamenang and Therese M.S. Tchombe, Bamenda: Presses Universitaires d’Afrique, 2011, and was previously presented as a Keynote Lecture at the 30th International Congress on Occupational Health (ICOH), Cancun, Mexico, 18-23 March, 2012.]

Abstract Four fundamental ethics principles are identified as having been widely discussed in current moral literature. These are, namely, respect for autonomy, beneficence, non-maleficence and justice. It is argued that, while these principles are couched in the language and idioms of the industrialized Western world, they have cross-cultural relevance and validity in their overarching and plastic nature, even if they may not everywhere be thought of or stated in the same terms and idioms. They form a set of values which complete and balance one another and none can be said to be more important than any other, although situational and contextual pressures may result in the tendency to lay emphasis on some over others. These principles are equally relevant and important in all fields of human endeavour and activity within all possible human contexts and perspectives. Given diverse and ever changing existential and situational conditions, ethical reflection/deliberation is necessarily a perennial and

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continuous human imperative; and nowhere is this more evident than within professional occupational ethics with its daily dilemmas and perplexities.

Introduction Four moral principles, describable as ‘fundamental’, have been widely discussed in the contemporary ethics literature. These principles are respect for autonomy, beneficence, nonmaleficence, and justice or fairness. While these principles are couched in the language and idioms of the industrialized Western world, where they have been most discussed and debated, they have cross-cultural relevance and applicability, even if they are not everywhere conceived or expressed in the same terms. The principles are also relevant to, and applicable in, all fields of human endeavour and activity, irrespective of context, situation or perspective. They are particularly important for professionals in any domain because their specialized knowledge and skills greatly increase their capacity for doing both good and bad.

What is ethics? An easy description of ethics is that it is an articulate field of study that deals with the morality of human actions and behaviours. Morality consists in judgments of human acts, actions or behaviours as right or wrong, as good or bad. Ethics can also be defined as the study of the fundamental principles of morality and their applications in actual concrete situations. The terms ‘ethics’ and ‘morality’ are often used interchangeably, but the concept of morality is much broader than that of ethics. Even before we start dealing with or studying ethics, or articulately discussing ethical problems, we already have a sense of morality, and we have made many moral judgments without necessarily consciously and explicitly reflecting on the principles underlying them. Human beings everywhere seem to have a sense of moral intuition from which they immediately can judge some acts or actions or behaviours as right or wrong,

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good or bad. Ethics presupposes that we already have a sense of morality, and consists partly but importantly in articulate reflection on the general principles underlying our moral judgments and intuitions. Ethics is a normative discipline because it seeks to study or to lay down the norms of acceptable human conduct or behaviour. Systematic moral reasoning, or articulate ethical reflection, can be applied to any issue in any domain of human activity. Ethics is therefore inescapable since it is pervasive and important in all domains where human beings operate or act, or simply live their lives. Ethics is, of course, particularly important for professionals and other people with special skills (Pellegrino 2002, pp. 378-384), because their specialized knowledge, expertise and endowments increase their capacity to do good or bad. In traditional societies, the conduct, behaviours and actions of professionals are typically regulated by sundry taboos and ritual restrictions, and in modern societies by written codes and ceremonial oaths.

Natural allies and companions of ethics The natural allies or road companions, to use a common metaphor, of ethics are law, human rights theory and practice, civics, religion, and the customs, taboos and traditions of communities or societies. All the above are necessarily mingled and interwoven with ethics, but ethics is separable from each and all of them. Ethics is, moreover, rationally more compelling than any of its road companions. For example, no law, custom, or cultural or religious practice is justifiable if it is unethical, i.e. if it can rightly be judged as morally wrong or bad, because, in a sense, all these road companions are meant to serve morality, and morality is more important than all of them. As Rebecca Cook and colleagues have rightly pointed out (Cook et al., p. 90): “…law aims to serve the ethical principle of justice. Accordingly, it is not an ethical justification of a policy simply that it is legal. It is not even an ethical justification

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that a democratic government of a country had a popular mandate to introduce or support the particular law, and that it has been upheld by a country’s most significant court according to the country’s constitution. These features alone, while legally and politically significant, do not show that the law is ethical”.

Ethics is, however, limited to acts, actions and behaviours that are free, purposive and intentional, and liable to impact on other creatures. Un-free or externally compelled acts/actions are not voluntary or responsible acts/actions, and cannot therefore be qualified as morally right or wrong. It can also be argued that acts/actions that have no possibility of affecting other creatures are not relevant to ethical appraisal. That is why it is plausible to argue that, if only a single individual existed in the universe, s/he would have no need for ethics or morality, as anything s/he chose to do would be right, or rather neither right nor wrong. If you were the only creature in the world, you could act and behave in any way you liked without bothering about morality, except perhaps to the extent that you believe another superior being such as God exists, and expects you to behave in certain ways rather than in others.

Natural challengers of ethics The natural challengers, adversaries or enemies of ethics are amoralism and egoism. An amoralist is someone who sees no reason why s/he should do what is morally right or avoid what is morally wrong, especially as doing what is morally right does not always pay off personally, whereas immorality is often personally beneficial. The defiant question ‘Why should I be moral?’ is one that is very difficult to answer satisfactorily. It is a challenge objectively to justify morality because morality is something that is both objective and subjective. If someone truly does not have any moral intuitions, and feels no need at all to be moral, there may be no third-party arguments that would be convincing to him/her. It is doubtful whether it is possible for a human being to be completely destitute of a sense of empathy and

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sympathy, i.e. a sense of identification with and kindred feeling towards, at least, other human beings, if not other non-human creatures; if that were truly possible, such a person might be called an amoralist. Egoism or selfishness may be related to, but cannot be justified by, the fact that humans are necessarily egocentric beings. Egocentrism simply means that each human being is self-centered, and cannot perceive and appreciate the world other than from his/her own point of view. This need not, but sometimes does, lead to egoism or selfishness. The disputable theory of psychological egoism is that human beings are, by nature, selfish and self-seeking in everything they do. According to psychological egoism, therefore, human beings are naturally selfish and cannot help being selfish. But to the extent that human beings are capable of genuine altruism (concern for others) and selfless love, the theory of psychological egoism is false. Some human beings do sometimes make sacrifices, even of their lives, for others. How would this be possible if psychological egoism were true? Morality is not possible without altruism, empathy and sympathetic impartiality, and it can be argued that they are also part and parcel of human nature.

What is culture? Culture is basically a way of life of a group of people, underpinned by adaptation to a common environment or ecological niche, a common worldview, similar ways of thinking and acting and doing, similar attitudes and expectations, and similar ideas, beliefs and practices, etc. There is a remarkable diversity and variety in the human cultures of the world and in the ecological niches in which cultures and individuals flourish. This diversity, an observable fact, is similar to the equally remarkable diversity of the biological world, of the different species that populate the earth. Cultures and sub-cultures are like concentric circles (Tangwa 1992, pp. 138-143), and there is no human being who does not fall within at least more than one such circle; the nuclear family or, more ideally, the extended

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family in its African conception, might, in fact, be regarded as delimiting the smallest of such cultural circles. Thus, like biological diversity, cultural diversity is an observable fact, something that is there for us to notice, recognize and appreciate. Unlike culture, morality is grounded on human rationality and common biological nature, and on basic human needs (for food, shelter, clothing, self-expression, etc.), which – being common to all irrespective of culture – may be regarded as defining what it is to be human. For this reason, divergence of moral opinion, both within and across cultures, is a descriptive fact that falls short of the prescriptive ideal. Moral imperatives are necessarily universal. That it is morally wrong to kill, steal or lie, that truthfulness, honesty, kindness and reliability are good in themselves, are universal imperatives not limited to any particular people or culture. But moral thinking and particular practices may differ from culture to culture, and even from person to person within the same culture. This is because of environmental constraints, existential pressures and human limitations, which include the impossibility of perceiving from more than a single point of view, the impossibility of being an experiential participant in all human existential situations, and their couplings with human ego-centrism and fallibility. It is for this reason that some human practices or behaviours, such as homosexuality, polygamy, circumcision, paedophilia, incest, prostitution, abortion, capital punishment, rape, etc., are controversial; they are considered by some, or at times, as morally wrong and by others, or at other times, as permissible. In discussing such issues, personal or cultural prejudices are likely to induce a perception of selfevident rightness or wrongness, where in fact the case may not be so clear. We therefore always need both critical selfawareness and sympathetic understanding when dealing with issues concerned with self and others.

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No human culture is perfect Human ego-centrism, coupled with ethnocentrism (the tendency to be too firmly implanted within one’s ethnic group, thereby allowing it to define all of one’s perceptions and relations with all outside groups), naturally leads individuals to perceive their own culture as the culture, but critical observation and reflection can help to correct any such mistaken perception. Professor Michael Novak in his book, The Experience of Nothingness (Novak 1970, p.16), remarks that every culture differs from others according to the ‘constellation of myths’ that shapes its attention, attitudes and practices. In his view, it is impossible for any single culture to perceive human experience in a universal, direct way. “...each culture selects from the overwhelming experience of being human certain salient particulars. One culture differs from another in the meaning it attaches to various kinds of experience, in its image of the accomplished man, in the stories by which it structures its perceptions.”

"Of course, men are not fully aware that their own values are shaped by myths. Myths are what men in other cultures believe in; in our own culture we deal with reality. In brief, the word ‘myth’ has a different meaning depending upon whether one speaks of other cultures or of one’s own. When we speak of others, a myth is a set of stories, images and symbols by which human perceptions, attitudes, values and actions are given shape and significance. When we speak of our own culture, the ordinary sense of reality performs the same function. In order to identify the myths of one’s own culture, therefore, it suffices to ask: What constitutes my culture’s sense of reality?” Culture is like a congenitally tinted pair of spectacles through which we look at reality. We inevitably impose our particular cultural tint on everything we perceive, but critical awareness can lead us to the realization that ‘objective reality’ is multi-coloured. It is very important always to try to see or imagine things from the point of view and perspective

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of the other. No human culture or community is perfect, although some may be more advanced or better-off in some respects than others. There may be activities/skills at which any one culture is ‘better’ than all the others, but a culture in general cannot be described as being ‘superior’ or ‘inferior’ to another on that basis. In Cameroon, for example, it would be generally agreed that, while both the Oku people and the Nso’ people engage in wood-carving, the former by far excel the latter in this activity; but it cannot on that account be said that the Oku culture is superior to Nso’ culture. To say that one culture qua culture is ‘better’ or ‘superior’ to another is like saying that a donkey is better than or superior to a horse. A donkey qua donkey cannot be superior or inferior to a horse qua horse because a donkey is not a horse, nor vice-versa; they are two different creatures with very different evolutions, aims and purposes. Cultures qua cultures can be said to be equal in the same sense in which human beings are equal, in spite of great differences in their individual and individuating attributes and characteristics. We could qualify such equality as ‘moral’ equality, not to be confused with other senses of equality. From most other points of view, human beings are rather demonstrably unequal but, in spite of their un-equality in those respects, they are all equally human, for which reason they should always be treated with fairness and equity. All human cultures are, however, perfectible, because none is perfect; and none can be perfect, given that human beings, the creators of culture, are imperfect beings. The limitations of cultures are directly related to the limitations of human beings who, both as individuals and as communities, are the creators of culture. Human limitations, especially human fallibility, are impossible of complete eradication, in spite of the very strong impulse, present to varying degrees within all individuals and all cultures, to strive for certainty and infallibility under the invincible impulse and optical illusion that they can be achieved. Such an impulse euphemistically may be described as ‘the desire to be God’. However, human limitations need not be a

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hindrance to striving for perfection or to making clearly recognizable moral or cultural progress.

Ethics in African traditional education Moral strength and uprightness was one of the focal concerns of education in traditional Africa. Such education, unlike the Western education that has since become the norm in Africa, was not uniform throughout Africa, because it was not based on any formal syllabus. Nevertheless, it was derived from the same metaphysical worldview and its aims and purposes were generally the same, namely, to instil discipline, strength of mind, body and character in the young. It was both formal and informal. The formal aspects of traditional education were dispensed through traditional lodges, such as Ngiri and Nwerong among the Nso’ of Cameroon, and through all manner of initiations and apprenticeships in various trades and professions. The informal aspects were inculcated everywhere at all times through a social system and cultural practices where there was great respect for age and the elderly, who in turn spared no opportunities to teach and to correct the young, through communal activities such as collective work, ceremonies, rituals, song, dance, the narration of tales, fables, parables, proverbs, riddles. The formal aspects of traditional education in Africa usually lasted several years and required various degrees of concentration and seclusion from the general public. To take some examples again from my own natal background among the Nso’ of the grassy highlands of Bamenda in the North West region of Cameroon, education in the two principal lodges attached to the royal palace, Nwerong and Ngiri, lasted for about 8 years, during which, for purposes of avoiding distraction among others, the trainee wore a mask when going out of the seclusion and after which one earned the title of ‘Shey’ with the privilege among others of founding a lineage. The procedure for the acquisition of wives for graduates of these lodges was well laid down in the tradition. (Fonka and Banboye Undated, p. 28). Apprenticeship in

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professions and trades such as blacksmithing, wood carving, healing, wine tapping, basket making, mat weaving, drumming and dancing, etc. took variously anything from 3 years upwards. It would be very interesting to know the detailed content of these formal aspects of traditional African education but we are not able to go into such detail here. It is one of the aims of this chapter to inspire such further detailed research. Regarding the centrality of the moral impulse of traditional education, the practice of any profession or trade in the traditional setting always involved ritual restrictions and taboos, calculated to prevent abuse of specialized knowledge. It was, for example, strictly taboo for a herbalist or other medicine practitioner, who generally had a thorough mastery of the particular characteristics and effects of the flora of their particular environment, to give a pregnant woman any substance with the aim of causing an abortion; or for a hunter, who equally had thorough mastery of the fauna, to sell or otherwise give a non-edible species of any animal to others under false pretext. Violation of such restrictions and taboos usually called for ritual expiation, cleansing and purification; otherwise, the violators were liable to encounter serious misfortune. Communal consciousness and the extended family system ensured moral compliance as the moral uprightness of the individual was not an individual/private affair but the concern of a large number of people with kindred feelings who shared in the fate of the individual, good or bad, in more than a vicarious or standoff manner. When it comes to moral matters, to matters concerning God and the ancestors – the main addressees in daily prayers and supplications - , to ceremonial matters connected with birth, initiation, marriage or death, to matters concerning fortune/misfortune, adversity and well-being, Africans are first and foremost relational beings, belonging to a series of ever widening concentric circles of relationship. This is one reason for the obsession with moral uprightness and the centrality of morality within the African traditional educational system. An individual’s immoral acts/actions are perceived as

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directly threatening to a wide circle of relations. This might be contrasted with the situation within Western culture where individualism makes of personal morality a largely individual affair, even though ethics, both private and public, does have an important place in the Western educational system, both traditional and modern.

The basic/fundamental principles of ethics A principle is a general rule or formula that applies to many particular cases/instances. It is a standard of reference, and is necessarily universal rather than particular. It is abstract rather than concrete. Of course, the pre-conditions for and fundamental principles of morality ought to be the same for all societies and all cultures, because these are based on human beings being rational and social beings, imbued with some sense of morality that underlies ethical thinking. Those who study the peculiarities of different societies, such as social scientists, might often end up with an exaggerated highlighting of the differences, resulting in moral relativism, and fail to realize, for example, that the mores of the various societies are derivable from principles or considerations that are common to them all. Acceptance of the moral equality of all human beings is perhaps the first pre-condition for morality. Where this initial moral equality is denied some human beings, acts will be carried out – such as colonizing, enslaving or massacring – which come across as highly immoral, like a slap in the face, thereby indicating that human moral equality is a moral imperative imposed by human reason itself. Other fundamental moral principles have been widely discussed in the moral literature of the Western world, notably, respect for the autonomy of others, beneficence, non-maleficence and justice. In simple terms, these principles have to do with respect for all other humans as moral equals, making sure that our actions are well-intended/motivated and calculated to achieve good ends or results, avoiding the infliction of harm, and treating others with fairness and equity (Beauchamp and Childress, 2001).

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Autonomy The word autonomy comes from two Greek words: nomos (‘rule’) and autos (‘self’), giving it the literal meaning of ‘selfrule’ or ‘self-governance’. Autonomy implies an individual who is master of himself/herself and can act, make free choices and take decisions without the constraint of another. The principle of autonomy therefore implies both the freedom of each individual to act and the obligation of others to respect that freedom. The principle is thus alternatively described as ‘respect for autonomy’ or simply ‘respect for others’. The necessary pre-conditions for autonomy are competence (the capacity to be a moral agent) and liberty or freedom. Individual autonomy may be diminished or completely absent, as in the case of minors, aged people with diminishing mental capacities, the mentally handicapped or incapacitated persons, prisoners, etc. The principle of autonomy can be said to be the first, though not necessarily the most important, of the fundamental principles of ethics. It is based on the moral imperative of respect for other human persons as moral equals. Such respect demands treating them as ‘ends’ in themselves and never merely as ‘means’ to any other end, treating them with consideration, giving due regard to their point of view, and respecting their well-considered choices. Without supposing autonomy in others, societal ethics would be a non-starter. Personal autonomy and freedom are ethically limited by the autonomy and freedom of other persons; that is why, in every society/community, discussion, compromise and legislation are indispensable to harmonious living. The principle of autonomy accords very well with an individualistic perspective of life and may be overemphasized in discourse within individualistic cultures like Western culture, and de-emphasized in communal cultures where the community is usually given precedence over the individual. But it is equally important in all cultures, including communal cultures like African culture, in which individuality, as distinguished from individualism, is also highly respected. It is quite possible for a culture to be communal in the sense of recognizing or affirming the superiority of the community

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over the individual, while at the same time recognizing the uniqueness and importance or individuality of each person. The recognition of such individuality in African culture can be seen during naming, initiation and burial ceremonies. In all such ritual ceremonies, it is the individual strictly before God, the ancestors and his/her destiny.

Justice Justice is fairness or desert or entitlement; it implies giving to each his/her due. Justice requires that ‘equals be treated equally and un-equals unequally’, unless there is a reasonable justification for treating them differently. The general moral idea or intuition underlying the principle of justice is that which states: ‘Do unto others as you would have them do unto you if you were in their place and they in yours’. According to John Rawls (Rawls 1999, p. 3): “Justice is the first virtue of social institutions, as truth is of systems of thought. A theory, however elegant and economical, must be rejected or revised, if it is untrue; likewise, laws and institutions, no matter how efficient and well-arranged, must be reformed or abolished if they are unjust.”

An untrue theory, no matter how attractive, must be rejected; an unjust system or procedure, no matter how convenient or profitable, must be reformed. Society/community is a collaborative venture, and distributive justice is concerned with the fair distribution of the goods, benefits, advantages, etc. that result from collaborative ventures. However, morality/ethics not only includes but also goes beyond strict justice. Philanthropy and supererogatory acts/actions are also part and parcel of morality. Philanthropy is helping others in need without getting or expecting anything in return, and a supererogatory action is a good action that benefits another person but that is in no way obligatory or required, and can be neglected without incurring any blame. That is why Rawls also argues for a procedural principle according to which inequitable distribution of goods in any

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society is justifiable only if it is to the advantage of the least favoured or least privileged members of that society.

Beneficence and non-maleficence The principles of beneficence and non-maleficence are best considered together. They are like two sides of one and the same coin, although each is distinct and important in its own right. Some ethical theorists, following the example of the Belmont Report (1979), tend to omit non-maleficence from the list of fundamental ethical principles, but such omission is highly questionable. In simple terms, beneficence means doing good and non-maleficence means avoiding evil/harm. They are complimentary ethical principles, the one imposing affirmative duties and the other negative ones. However, not all achievable good is ethically mandatory; as stated above, some good is supererogatory (i.e. desirable or commendable, but not obligatory); direct harm, however, ought always to be avoided. If you give the needy beggar money, you have done something good and commendable or praiseworthy; but, if you do not give the beggar money, you have done no harm and nothing wrong. But, of course, it not only is good but also highly recommendable and praiseworthy to help the beggar and others in need. In practice, of course, and especially for the professional, there will be many acts/actions that are situated at the interface or borderline between strict duty and voluntariness or philanthropy. A colleague of mine recently provided me with a good example, where in the theatre one night the director urgently asked the audience if a medical doctor was present who could help render emergency first aid. Another colleague of mine, who is a medical doctor, once ran across a pregnant woman in labour while doing his early morning jogging exercise. In such cases, only professional conscience and/or a stipulated code of conduct helps to determine whether it is a case of duty or supererogation. Some people consider non-maleficence to be the most basic of all the cardinal principles of ethics because it lays down a minimalist condition for ethical correctness, as if to say:

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‘even if you do no good, at least do no harm’. Many medical professionals seem to have realized the moral rock-bottom nature of non-maleficence, and have adopted it as their motto, as in the expression ‘primum non nocere’ – first (above all) do no harm! In African conceptions, doing harm and other types of evil attract calamity and other misfortunes, not only on the agent of the action but on his/her relations and community; by contrast, doing good is not expected necessarily to attract any benefit. However, it is not always enough that we have done no harm; sometimes even without doing any harm, we do wrong; take the man who climbed up a cola-nut tree and hid behind its leafy branches so he could peep at naked ladies when they were bathing in the shade behind the house. He did them no harm, as he argued in his defence when he was caught, but he certainly did them wrong. In the borderline or grey-area cases between strict duty and philanthropy/supererogation, most people would agree that failure to help would be wrong and professionally below expectation, even if no direct harm was done.

Scope and applicability of moral principles The pre-condition for morality and the four fundamental principles of ethics are, in a loose and general sense, equally relevant to and important across all cultures, in all fields of human endeavour and activity, and within all possible human contexts and perspectives. In practice, they function as a team or single value set, completing and balancing each other, in such a manner that one cannot be singled out as being more or less important than any other, and none can claim to be absolute, since any of them can be violated, given a sufficient ethical justification. For these reasons, synthetic minds might tend to view them as all hanging from one single stem, whereas analytic minds may regard them as analyzable into various branches. In any case, one ethical principle, in a particular context and existential situation, can take precedence over another, or one ethical norm or rule can countermand another, as when, for example, one

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were to violate confidentiality or break a promise to save a human life. By contrast, a non-ethical reason can never justify the violation of an ethical principle, norm or rule. From these fundamental principles, many other derivative principles can and have been formulated to help morality along. (Tangwa 2015, pp. 5-6). Some such procedural principles are metaphorical, others mythical, and still others simply practical. Examples of some of such derivative principles and metaphors, in my view, include: human rights, human dignity, human solidarity, sacredness of human life, ‘created in God’s image and likeness’, etc. But, beyond myths and metaphors, which harmlessly and quite usefully (from the moral perspective), can be taken literally, critical reflection should suggest to us that (staying on the metaphoric plane) the chameleon is not without chameleonic dignity, nor the aloe vera plant without aloeveric dignity. Every creature and every existing thing have their own intrinsic value and inner reasons, even if unknown to human beings, for being there. The focus and emphasis on human beings can therefore only be justified from the point of view of moral agency, not from that of morality as such. Some moral ‘patients’, being non-human, non-rational or incompetent, have no conceivable moral obligations at all, whereas moral agents bear the whole weight of responsibility for whatsoever they choose or refrain from choosing to do or act upon. The four principles, in the terms, language and idioms I have stated them are, of course, very much a paradigm of the industrialized Western world, where their relevance and urgent applicability have been made abundantly manifest by various activities that have violated or run the risk of violating them, such as human enslavement, colonization and medical experimentation on humans. They, nevertheless, remain equally important even where they seem to be lying dormant for want of any perception of urgent risk or hazard, the discussion of which would surely have brought them to the fore. The industrialized Western world should be credited for the coinage of the very convenient terms and idioms in which these principles are

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discussed today. But the fundamental principles themselves are not absent in any human culture, even if they are not thought of or understood in the same terms. The salient point about these principles is not that they are four in number – the BIG FOUR – as some people refer to them (I suggest below that within my own natal culture they can be reduced to two adages), but rather that they are clearly overarching as well as necessarily plastic in their applicability, leaving ample room for cultural perspective, situational context and existential pressure to impinge on them. Reflecting on my own natal culture, the Nso’ culture of the grassy highlands of Bamenda in the North Western region of Cameroon, I can say that these principles are captured in and derivable from two guiding adages: the one that states that ‘a human being is a human being simply by being a human being’, and the other that states that ‘the essence of a human being is having a good heart (will)’. The first of these adages implies that a human being, irrespective of his/her descriptive and particularistic attributes, is autonomous and of inestimable worth and must therefore be treated with due consideration and equity by other human beings (respect for intrinsic value, autonomy and justice). The second adage implies that a human being is less than human if s/he does not shun evil, including avoidance of harm, or if s/he is not imbued with good purposes and intentions (beneficence and non-maleficence). These principles are what make living in communities or societies as human beings possible and harmonious. They may not be ‘discovered’ for some time or theoretically nailed onto an analytic frame, but they are there alright, implicitly wrapped up in social norms, traditions and practices. Moral/ethical rules are different from all other rules. They are general, applying to a wide variety of particular cases and instances. They may be expressed in, mixed/mingled with, or reflected in laws, societal customs, cultural practices, taboos, etiquettes, etc. They are perceived as universal and timeless, not as timely or context-bound. They are anchored

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in simple rationality, not specialized knowledge. They are uncompromising in their demands; they transcend laws, politics, economics, customs, social practices and even cultures. For example, any law, custom or social practice that is unethical must be rejected, whereas no particular action or practice can ethically be justified simply by stating that it is the law, custom or social practice. A morally bad law, custom or social practice must be rejected. However, moral/ethical norms are not absolute or exceptionless. The moral rule that we may not kill can, for example, justifiably be violated in self-defence against an assailant bent on killing. Moral rules or norms need plastic firmness and flexibility, not cast-iron rigidity; they do not have application in abstracto. To apply them is to place them in particular, contextual situations, and they are then like water. Water poured into a container immediately assumes the shape and colour of the vessel without ceasing essentially to be water (Tangwa 2004, p. 67). Thus, what is of critical importance is for every person, every culture and every part of the world, every specialized profession, to reflect on the applicability of these principles in their own particular context and situation, and to draw from them appropriate practical rules of procedure. There is no doubt, for example, that the Hippocratic Oath intuitively captures some of the basic elements of the ethics of therapeutic medical practice but, in our age and time, Hippocratic ethics is evidently insufficient and incapable of providing clear guidance for diagnostic and preventive medicine, let alone for emerging contentious issues, such as those arising from stem cell therapies, technologically assisted reproduction, biobanks, gene/genome editing, etc. Ethical reflection/deliberation is necessarily a perennial and continuous human imperative; and nowhere is this more evident than within professional occupational ethics, with its daily ethical dilemmas and perplexities.

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References Beauchamp T. M. and Childress J. F. (2001), Principles of Biomedical Ethics (Fifth Edition), New York: Oxford University Press. Cook et al. (2003), Reproductive Health and Human Rights: Integrating Medicine, Ethics and Law, Oxford, The Clarendon Press. Fonka L.S. and Banboye W. (Undated, circa 1950), Nso’ Marriage Customs By L.S. Fonka with Methods of Wife Acquisition By W. Banboye (A Nso’ History Society Production), Lagos, Nigeria: Nooremac Press 6. Novak, M. (1970), The Experience of Nothingness. New York: Harper and Row. Omoregbe J. I. (1979), Ethics: A Systematic and Historical Study, London: Global Educational Services. Pellegrino, E. (2002), “Professionalism, profession and the virtue of the good physician”, The Mount Sinai Journal of Medicine, 69, pp. 378-384. Rawls J. (1971/1999), A Theory of Justice (Revised Edition), Cambridge, Massachusetts: The Belknap Press of Harvard University Press. Tangwa G.B. (1992), “African Philosophy: Appraisal of a Recurrent Problematic. Part2: What is African Philosophy and who is an African Philosopher? COGITO, Winter, pp. 138-143. Tangwa G.B. (2004), “Between Universalism and Relativism: A Conceptual Exploration of Problems in Formulating and Applying International Biomedical Ethical Guidelines”, Journal of Medical Ethics, 30, pp. 63-67. Tangwa G.B. (2015), "Traditional Medicine" Encyclopedia of Global Bioethics, edited by Henk ten Have, Article ID: 399514 · Chapter ID: 421; DOI 10.1007/978-3-31905544-2_421-1; # Springer Science+Business Media Dordrecht 2015.

CHAPTER TWO THE TRADITIONAL AFRICAN PERCEPTION OF A PERSON: SOME IMPLICATIONS FOR BIOETHICS

[Previously published in Hastings Center Report, 30(5): 3943, 2000]

Introduction Western moral philosophy is driven by the attempt to sharply distinguish persons from the rest of the cosmos, and then to identify the ways in which persons must be treated. The traditional African approach is different on both counts. Wir dzë wir! (A human being is a human being simply by being a human being.) In Lamnso’, my natal language, there is the saying, wan dzë wan a dzë lim Nyuy: a baby/child is a baby/child, a handiwork of God. The saying signifies the unconditional acceptance of a neonate, irrespective of how it comes about, no matter how it is, no matter what its particularizing and individuating physical and mental attributes. Wan dzë wan leads directly to wir dzë wir at the level of the adult human being. Wir dzë wir can best be rendered into English as “a human being is a human being is a human being, purely and simply by being a human being.” The implication of these sayings is that while the Nso’, the indigenous speakers of Lamnso’, surely recognize various stages in the progressive maturation of a human being —

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babies, infants, children, young persons, adults, or elders — and although Nso’ society is a very hierarchical one with great respect accorded to titled individuals, to age and experience, and while they can further regroup those who fall within any of these categories according to still other criteria, such categorizations do not carry any moral significance. Moral consideration and desert, in the Nso’ conception, are indiscriminately due to all human beings, regardless of their individuating characteristics, status, or social rank. Nso’ morality is thus human-centered in the sense that only human beings are deemed to be moral agents, with moral obligations and responsibilities, but not in the sense that moral consideration and concern are limited to human beings. Human beings have various moral obligations, duties, and responsibilities toward God, nonhuman animals, plants, and inanimate nature, but these are not considered in any sense as reciprocal. (Tangwa 1999a, p.5). From the point of view of logic, wan dzë wan and wir dzë wir may sound like contentless tautologies, but within their linguistic and cultural universe they connote the reverential respect with which anything human is approached. Wan dzë wan and Wir dzë wir are also plastically loose and flexible rather than cast-iron rigid with regard to exactly what they encompass. The term wir stands indiscriminately for both human being and human person, as typically distinguished in Western discourse, while wan performs the same function indiscriminately for child, baby, or infant (irrespective of age). But this imprecision and plastic flexibility may be exactly what is required. The meaning of the terms is evident without being spelled out in precise detail. It is like a big Bamenda gown that is never made to be tight and can fit many different people of greatly differing shapes, sizes, and other particulars — or a single individual through many changes in shape, size, and weight. Any attempt to nail either of the terms onto a hard analytic frame, by specifying necessary and sufficient criteria, conditions, or capacities for being human or for being a child, would make it evaporate into thin air. The moral worth of the entity for which the Bamenda gown is made remains constant and unchanging through whatever

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physical, mental, and socio-politico-economic changes she or he undergoes.

Personhood in the West Western philosophy has a perennial obsession with the concept of a person, and more importantly with criteria for personhood that would clearly segregate those entities worthy of moral consideration from those without or with less moral worth. There have been great debates, for instance, about the moral status of foetal material, foetuses, human infants, children, mentally defective people, braindead patients, animals, and plants, with assumptions and implications about how they can or should be used or treated, and how their treatment differs from that of paradigmatic humans. This attempt at discrimination has greatly confused moral discussion on a wide range of issues in bioethics. Abortion “on demand,” for example, may thus be justified on the grounds that the foetus, unlike the pregnant woman, is not a person. The centrality of this kind of discussion in Western ethics is exemplified nicely by Tristram Engelhardt’s influential book The Foundations of Bioethics—which is properly, of course, on the foundations of American bioethics: Persons, not humans, are special… Morally competent humans have a central moral standing not possessed by human foetuses or even young children. . . . Only persons write or read books on philosophy. It is persons who are the constituents of the secular moral community. Only persons are concerned about moral arguments and can be convinced by them. Only persons can make agreements and convey authority to common projects through their concurrence. To choose, to make an agreement, is to be conscious of what one is doing. It requires the self-reflexivity of self-consciousness. Otherwise, there is a happening, not a doing. (Englehardt 1996, pp. 135-136)

Englehardt goes on to define persons as “entities who are self-conscious, rational, free to choose, and in possession of a sense of moral concern” (p.136) and concludes that human

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“foetuses, infants, the profoundly mentally retarded, and the hopelessly comatose” are nonpersons, having no “standing in the secular moral community” and falling “outside of the inner sanctum of secular morality” (p.139) But what this line of reasoning really establishes is only that human persons are moral agents, carrying the whole weight of moral obligations, responsibilities, and duties on their shoulders, not that human persons possess greater moral worth and deserve greater moral consideration than other beings. Intuitively, from the point of view of the common sensibilities and practices of human beings in most societies the world over, it would appear that a human infant or a mentally or physically handicapped human being deserves if anything even greater moral consideration than a paradigmatic person as described above. The morality of an action or procedure is to be determined from the standpoint of the agent rather than that of the patient (the recipient of action). In other words, a moral agent can do moral good or evil, irrespective of whether the patient of his or her action (or lack thereof) is a person, a nonhuman animal, a plant, or even an inanimate thing. What the attributes of selfconsciousness, rationality, and freedom of choice do, as well as those of power and wealth, is load the heavy burden of moral liability, culpability, and responsibility on the shoulders of their possessor. Human persons are not morally special, they are morally liable. Some Western thinkers, especially ecologists, vegetarians, animal rights activists, and biocentrists, are now attempting to move away from the anthropocentric focus of Western moral thinking and discourse.(Regan 1983; Taylor 1986; Warren 1997; Wetlesen 1999) But by and large, Western ethical theory has concentrated on the object of morality, the patient, to the neglect of the subject, the agent. This orientation is probably another example of the ascendancy in Western culture of the principle “might is right,” also exhibited in Western imperialism, colonialism, domination, exploitation, and monopoly commerce. Indeed, the orientation has helped give the Western world a clear head start and a current lead in the long-distance race of human survival,

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wellbeing, and prosperity. By concentrating on the patient rather than the agent, Westerners have been able to shift critical attention from themselves and their actions onto their victims. In that way, they have been able to carry out colonization, enslavement, and exploitation with quiet consciences, by stipulating “objective” criteria for being human that their victims did not fulfil. It is an astounding fact that Western colonialists could describe some of the sophisticated cultures and civilizations they came across in Africa and other parts of the so-called third world as savage and barbaric. They may of course have honestly perceived them as such; but if so their perception was itself likely affected by the motivating agenda of colonization, domination, and exploitation.

Latent philosophies One of the challenges in discussing the African perception of persons is that of locating it, of identifying the oeuvre of African philosophy in which it is found. For the most part, of course, African philosophy is not set out in monographs and journals; rather, it is manifested in, held by, African peoples themselves. In other words, it is the perception of a group of people. A group, even of thinking beings, is not a thinking thing; it does not have a mind to perceive or think with. The idea of a “collective mind” is only a metaphor, and in Western philosophical literature, the critical examination of perception has often led to either epistemological scepticism or solipsism. Nevertheless, any identifiable group of people, sharing a common culture and world view, necessarily shares certain ideas, convictions, attitudes, and practices that can be attributed to it as a group, without any implication of exceptionlessness at the level of the individual. In every society or human community, there are two types of philosophy, whether oral or written: forensic and latent. The forensic philosophies of a society or community are those which are openly admitted, recognized, presented, or even propagated as such, and are thus usually more palpable, so to speak. They could easily be mistaken for the whole of that society’s or community’s philosophy. Latent philosophies, on

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the other hand, may be accepted unconsciously, not openly recognized or presented as such, although they are nevertheless manifested in attitudes and behaviour. They provide the general framework for the society’s or community’s world view, belief systems, customs, and other social practices. Controversy and disagreement are the marks of forensic philosophies, while consensus is the chief attribute of latent philosophies. The latent philosophies of any society or community are arguably more important than its forensic philosophies. They are the philosophies people live by rather than merely talk about; they are the grounds on which people act or react the way they do, do the things they do, refrain from doing the things they refrain from doing, and have the attitudes they have. The perceptions manifested in a group are connected more with latent than with forensic philosophies, although erroneous perceptions are typically corrected by means of the latter. In fact, one of the proper missions of a forensic philosophy in any society should be a constant re-examination and calling into question of its latent philosophies. Further, the process by which communal consensus is reached on any controversial issue in any society clearly shows that latent philosophies must once have been forensic philosophies, and that it is generally successful (convincing) forensic philosophies that transform into latent philosophies. Indeed, it is the legitimate ambition and aim of every really earnest forensic philosophy to become, as far as possible, a latent philosophy. In the domain of morality, correct practice, even if it is without any theory, is far better than correct theory without practice. It is clear that the Western conception of a person is part of a forensic philosophy, elaborated against the background of several competing latent as well as other forensic philosophies. An especially clear and persuasive expression of it is found in Englehardt’s work, as well as in the works of Peter Singer and Michael Tooley. Qualifying this conception as “Western” by no means implies that all Westerners accept or are even aware of it, but the conception has nevertheless had a significant influence on legislation in Western countries, and it may even be gradually transforming itself

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into a latent philosophy, if widespread acceptance and practice of, say, nontherapeutic abortion or human vital organ acquisition is indicative. By contrast, the efficacy of the Nso’ latent philosophy of a human being can equally be deduced from the resistance to all forms of nontherapeutic abortion or human organ transplantation in Nso’ society, even now that modern Western medicine has rendered these fairly safe, easy, and affordable.

The African Perception of a Person In talking about the traditional African perception of a person, I am of course abstracting, and for a specific prescriptive purpose. The descriptive data from which I am drawing my abstractions are mainly from my own cultural background among the Nso’ of the grassy highlands of Bamenda in Cameroon, but also from other African peoples, as far as I know them. In their essentials, African cultures, metaphysics, attitudes, and customs are at least very similar, if not entirely the same. This close family resemblance, analogous to the family resemblance of Western peoples and cultures in spite of their differences, is enough for my purposes here; my generalizations and prescriptions do not need to be exceptionlessly true to be valid. In addition, it could in one respect be said that the African concept of a person is not and in fact cannot be any different from the Western concept, unless there is some linguistic problem of translation or interpretation. Both understand a person to be a fully self-conscious, rational, free, and selfdetermining being. If the African perception of a person differs from the Western perception, this is not because it does not recognize the various developmental stages of a human being or qualitative differences based on the degree of attainment of positive human attributes or capacities, but rather because it does not draw from these facts the same conclusions as are drawn in Western ethical theory. In particular, the differences between, say, a mentally retarded individual or an infant and a fully self-conscious, mature,

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rational, and free individual do not entail, in the African perception, that such a being falls outside the “inner sanctum of secular morality” and can or should thus be treated with less moral consideration. But since the Western preoccupation with personhood would seem to be dictated precisely by the need to draw such a consequence, it ought also to be said that the African concept of personhood is totally different from what is found in the West. The African concept applies to the human being in all its developmental stages and to all its possible conditions. This way of applying the concept is not determined solely by its descriptive content, but also by associated elements of African philosophy. Myths about, say, the superhuman psychic powers of physically or mentally handicapped persons or their liability to be used as disguises by God and other spirits no doubt arose in order to help people put prescription into practice. (Tangwa 1999b, p.277). But the actual justification for how the African perception of the person is applied has to do with the African world view. I have described this world view elsewhere as eco-bio-communitarian, implying that there are plastic walls between as well as interdependence among human beings, superhuman spirits, nonhuman animals, plants, and inanimate objects and forces. (Tangwa 1996, p. 276). Within this world view, transmigration, reincarnation, transformation, and transmutation, within and across species, are believed to be possible. Such possibilities have consequences for how human beings regard what we may call the other items of the furniture of the universe, especially other living species. In effect, the line separating human beings from the other ontological entities that populate the world, in the African world view, is neither hard and fast nor straight and clear. Since a human being can conceivably transform or be transformed (with or without knowledge or consent) into any of the other ontological entities, in this life or in the life after death, no human being can confidently claim to know that he or she is not the “brother/sister” of any other thing in existence.

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All this engenders an approach toward nature and all living things that is cautious, reverentially respectful, and almost ritualistic. It brings about a deep-seated attitude of live and let live, be and let be, which finds practical expression in such practices as the system of consensus for resolving interpersonal and intercommunity disagreements and differences. Thus the image popularized by Julius Nyerere, the father of a communalistic socio-political ideology known as Ujamaa, based on the African concept of familyhood, of African elders sitting under a tree and discussing until they agree. The Western concept of a person no less than its African counterpart seems to reflect a further judgment about how it is to be applied that does not follow from its descriptive content. This value judgment, moreover, seems to be dictated by economic considerations and the need for scientific progress and technological refinement. Science, technology, and commerce constitute the unholy trinity of engines behind the constant rethinking of moral categories in the Western world. It is instructive to note, for instance, that until organ transplantation became a reality, Western thinkers and moralists were not preoccupied with “defining death,” a task for which a presidential commission was set up in the United States in 1964. It is unthinkable that Americans did not know the meaning of death or were not sure when a person had died until the presidential commission pronounced on the issue. Similar purposes are served by the Western classification of peoples, cultures, and countries into first, second, and third; advanced, advancing, and backward; or developed, developing, and underdeveloped. These distinctions are also mainly value judgments rather than descriptive abstractions to which real content can be assigned.

Science and sensitivity The central thought I want to advance is that the Western conception of a human person, as a category or subset of human being, is appropriate only for the ascription of moral

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responsibility, liability, and culpability rather than for the ascription of moral worth, desert, eligibility, or acceptability into the moral community made up, as it necessarily is, of both moral agents and patients. By contrast, the African or Nso’ perception of a human being, which applies to the elusive entity underlying all categories, stages, and modalities of a human being, although conceptually less neat and analytically less firm, seems to accord better with our ordinary moral intuitions and sensibilities and is thus more appropriate for non-discriminatory morality in general. Non-western cultures are indebted to Western culture for its scientific and technological contributions to humankind. However, one of the chief motive forces of Western culture in general, and of its science and technology in particular, has been the spirit of commerce, omnivorous discovery, and experimentation, fired by the profit motive, within the context of the latent philosophies of materialism and possessive individualism. Thus Western science and technology have helped to create in the modern world both great affluence and prosperity and great inequalities and poverty. Traditional African societies were marked in contrast by an egalitarian impulse and levelling tendency, today greatly eroded by contact with the West. In traditional Nso’ society, for instance, wealth by itself did not confer any social status. To gain social status, a wealthy person normally had to swap virtually all his wealth for redistribution in exchange for titles and honours. Witchcraft also provided safeguards against the consolidation of wealth or power. Yet, while conditioned by the awe and respect for “the other items of the furniture of the universe,” human wellbeing was certainly given the highest priority, and within human wellbeing a very high value was accorded to human health. Health was seen as the value of all values—the value that made other values possible and achievable. As long as one was healthy little else mattered and all other achievements were within the bounds of the possible. Health care within traditional Africa was within the reach of all and sundry, irrespective of social status or economic situation, because the only condition for access to health care was that one be ill.

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There is no doubt that modern Western medicine, based as it is on the scientific method, is superior to traditional African medicine, which was rather weak in diagnosis, pharmacology, and the systematization of knowledge. But Western medicine and medical technologies, like Western culture and technology in general, have the fatal weakness of being driven and controlled by apparently morally blind economic forces and interests. Economic determinism rules the Western world and culture to such an extent that even ethical issues are couched and discussed in economic terms and language. The most imperative of moral categorical imperatives seems to leave the Western world unimpressed and unruffled unless it is somehow stated in terms of or connected with economic and marketing considerations and cost-benefit analyses. Even the moral philosopher is constantly prompted in the Western world to demonstrate a position’s “cash value.” It would be ideal to combine the efficiency of Western science and technology with the moral sensibilities of traditional Africa. Western culture could empower African culture while African culture humanized Western culture. How can this be done? I have no answer right away, but the first step would be to try separating, conceptually to begin with, the kernel of Western science and technology from its Western packaging— the entire value system, assumptions, expectations, propaganda, and evangelical spirit surrounding it. Western science and technology could be put to different and more humane uses if they were received in other cultures without the socio-politico-economic and metaphysico-religious conceptual structures that accompany them in the West, within which they were first created. When you are offered a meal, you do not take the dishes with you after eating the food. African culture should gratefully avail itself of the generous offerings of Western culture, especially Western science and technology, but it should not appropriate the dishes of the benefactor.

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Acknowledgments I would like to thank The Hastings Center, and particularly its director of international programs, Daniel Callahan, for support, and Virginia Ashby Sharpe for her useful comments on an earlier version of this paper. I thank the editors and their reviewers for their comments and suggestions that resulted in this final version of the paper.

References Engelhardt, T.H., The Foundations of Bioethics (New York: Oxford University Press, 1996). Regan, T., The Case for Animal Rights (Berkeley: University of California Press, 1983); P.F. Taylor, Respect for Nature: A Theory of Environmental Ethics (Princeton, N.J.: Princeton University Press, 1986). Tangwa, G.B., “Is Bioethics Love of Life? An African View Point,” IAB NEWS 9 (1999a): 46. Tangwa, G.B., “Genetic Information: Questions and Worries from an African Background,” in Genetic Information: Aquisition, Access and Control, ed. A.K. Thompson and R.F. Chadwick (New York: Academic/Plenum Publishers, 1999b). Tangwa, G.B., “Bioethics: An African Perspective,” Bioethics 10, no. 3 (1996). Warren, M.A., Moral Status: Obligations to Persons and Other Living Beings (Oxford: Clarendon Press, 1997). Wetlesen, J., “The Moral Status of Beings Who Are Not Persons: A Casuistic Argument,” Environmental Ethics 8, no. 3 (1999).

CHAPTER THREE GIVING VOICE TO AFRICAN THOUGHT IN MEDICAL RESEARCH ETHICS

[Previously published in Theoretical Medicine and Bioethics, Volume 38, Number 2, pp. 101-110, 2017]

Abstract In this paper I consider the virtual absence of an African voice and perspective in global discourses of medical research ethics against the backdrop of a high burden of diseases and epidemics on the continent and the fact that the continent is actually the scene of numerous and sundry medical researches. I consider some reasons for this state of affairs as well as how the situation might be redressed. Using examples from HIV/AIDS and EBOLA diseases, I attempt to show that the marginalization of Africa in medical research and medical research ethics is deliberate rather than accidental. It is causally related, in general terms, to a Eurocentric hegemony derived from colonialism and colonial indoctrination cum proselytization. I end by proposing seven theses for the critical reflection and appraisal of the reader.

Introduction The idea of ‘giving voice to African thought in medical research ethics’ recalls the ‘African Philosophy’ debate that raged for decades, particularly in the 1970s and 1980s [1, 3, 12, 17, 18]. The debate was sparked by the following provocative question: “Given the absence of written texts and

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of identifiable individual philosophers in the traditional past, how could there be traditional African philosophy?” The debate arose among African scholars and academics formally trained in Western pedagogic institutions where they had been exposed to the various branches of Western academic philosophy. In the face of this question some African scholars, exemplified by Paulin Houtondji [3] argued that the claim that there is philosophy in the absence of written texts and identifiable philosophers is at best a claim about the existence of a collective philosophy, a folk philosophy, an ethno-philosophy, a consensual philosophy common to all members of a group. Such a claim they, however, considered a fallacy and a myth. Some people conceded that there is ‘African thought’ and even ‘African philosophical thought’ but denied that there is anything like ‘African philosophy’. Many others felt that denying the existence of African philosophy was denying the humanity of Africans and the existence of a distinctive African culture. The entire problematic seems to revolve around two senses of philosophy [17, 18] (1) as a system or set of fundamental beliefs and convictions, usually reflected in actions (“philosophy at the second moment of vision” [15]) or (2) as a consciously articulate critical discourse (verbal or written) that is necessarily individual in origin or a corpus or system of such discourses with the supporting structures in which they are symbolically encoded. The purpose of philosophy in the second sense is arguably to convert it into philosophy in the first sense. Philosophizing is not an end in itself, a purposeless exercise, a prize in a vacuum, a purely aimless intellectual pastime. Its aim is or should be discovery/demonstration of the good, the true and the beautiful with a view to making use of them in human living. Human thought and action are dialectical – earnest thought necessarily manifests in action and actions provide the agenda for reflection. African philosophy is therefore any work or discourse, any reflective critical thought that arises mainly from, is rooted in, or is in some other sense about the

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African historical, cultural, social or political experience or in some sense is specially or particularly relevant to Africa. A further important question is the following: Is the work of such an African/non-African philosopher classifiable as African philosophy? Yes, if and only if it is about Africa or is relevant to the African contemporary, historical, sociocultural, politico-economic experience/context. A single work can, of course, be relevant to several contexts, to varying degrees, all at once. It is quite possible for the work of a nonAfrican to be justifiably classed as African philosophy and for the work of an African to fail meeting the conditions of such classification. But, in general, a good reason is called-for in either classifying the work of a non-African as African philosophy or the work of an African as non-African philosophy. It can therefore be concluded that, if there is African philosophy and/or an African philosopher in the above sense, then, a fortiori, there is African thought! And if there is African thought, we can legitimately talk about giving voice to African thought in medical research ethics! This thought, though marginalized in the current global state of affairs, is important because reality and human experience are too vast and too diverse to be captured by one culture or conceptual paradigm, be it globally dominant or not. Medical research ethics is coextensive with and has directly evolved from medical ethics in general through healthcare ethics and there is no human culture which has not been preoccupied with healthcare and therefore healthcare ethics. Western proselytization and colonial mentality might lead one to dismiss this claim lightly in the manner some African and non-African Christians or Islamists dismiss African Traditional Religion as being nothing but Paganism/Heathenism and of no consequence or religious value.

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Why give voice to African thought in medical research ethics? The idea of giving voice to African thought in medical research ethics is compelling not only on the idea that reality and human experience are vast and diverse and cannot be adequately captured by one paradigm or from one perspective but also on the consideration that the continent of Africa has, historically, been: colonized, exploited, indoctrinated, proselytized, mentored, marginalized and excluded. Cumulatively, these historical experiences had turned many Africans into more or less mute and mimetic beings, or disciples and catechists of received foreign systems on the world stage. And yet, the continent, because of its high burden of diseases and epidemics, is the scene of numerous medical researches by all and sundry researchers from all over the globe for all and sundry motives and motivating factors. There is a crying need for conceptual decolonization for both Africans and non-Africans having to do with Africa [11]. The exploitative agendas and greediness of erstwhile colonizers of Africa and of the so-called developed world and its determination to maintain global hegemonic dominance is complimented by inducement and proselytization of elite Africans, especially experts, to subvert the emergence of Africa as an equal partner on the global stage. An African scientist or other expert who decides to stay and work in Africa on local problems faces a huge dilemma. African governments or non-governmental agencies do not yet seem aware of the importance of funding research for development. The scientist or expert is left with only the option of applying for funding to Western governmental or non-governmental agencies. But these are not philanthropists. Funding comes usually with strong strings attached, including the compulsion to work within a rigid procedural framework, including even the ethics rules to be followed. African scientists and experts working with Western funding are very comfortable and can rapidly achieve high professional standards and status but they are at the service of Western global dominance and hegemony. That is why there has been

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little change in Africa and the lives of Africans in spite of the high level African scientists and experts working for Western institutions and agencies both in and out of Africa.

Culture, context and healthcare Culture is the way of life of a group of people, underpinned by adaptation to a particular environment, worldview, similar ways of thinking and acting and doing, similar attitudes, expectations and practices [15]. There is great variety and diversity between the different African ethnicities, but they are all united by commonalities which give them a remarkable family resemblance analogous to the family resemblance of groupings in some ways remarkably different from one another but all justifiably bracketed under the term ‘Western’ [13, p. 3]. In Western culture, in which literacy, science, technology and individualism predominate, health is understood mainly as the absence of disease, particularly of bacteria and viruses; hence, evidence-based medicine and evidence-based Allopathic medical research. In African culture, in which orality/aurality, communalism and relatedness predominate [4, 20], health is a much more complex concept and healing from affliction or misfortune is more than a technique for eliminating a scourge or contagion [16]. Different cultural contexts offer opportunities for discovering and appreciating different perspectives, paradigms and frameworks. As the most successful human culture (materially) Western culture, understandably though not acceptably, has a big mouth but small ears; thanks to colonization, proselytization and domination. But it must not be forgotten that other cultures also have a holistic perspective on life and the universe that needs listening to and appreciating, even if it speaks only in whispers. In the World Federation of Cultures [5], one hand cannot tie a bundle; one culture cannot fix the world. Cultures are like dancing masquerades, to recall a metaphor popularized by the African novelist, Chinua Achebe. None of the masquerades

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can be ignored and none can adequately be viewed from a single or static position. If we attempt comparing and contrasting industrialized Western culture with African traditional culture, it can be said that Western culture is predominantly an anthropocentric literate culture, technologically advanced, epistemologically and morally driven by an obsession with certainty and a Manichean syndrome that strictly distinguishes good from evil, respectively; with an attitude that leaves the impression of knowing all that is knowable; open to and shaped in many ways by free market forces and profit motives, outwardlooking, dominant and domineering of other cultures which it tries to assimilate or at least proselytize into its ever expanding universal vision and operations. By contrastive comparison, traditional African culture is a ‘live and let live’ culture, predominantly oral rather than literate, marked by great variety and diversity; in essence eco-bio-communitarian [13], tolerant, cautious, non-aggressive, non-proselytizing and inward-looking.

Culture, disease and medical research Every individual human being lives within a particular cultural framework, which may involve overlapping and intersecting cultural perspectives, whether or not s/he be aware of this. Cultures form intersecting concentric circles [19]. A particular disease (physical or mental) may have the same or similar ‘causes’. Understanding of a disease, its perceived causes and possible remedies, are cultureanchored. Within African culture it may not be enough to identify the physical cause of an ailment or illness, as there is a tendency to search for the cause of the cause in a regressive chain that can terminate only in God or else become interminable. The ontology of the African cultural universe recognizes non-material beings and presences, including dead-living ancestors, sundry spirits, divinities, gods and God. Cultural context is therefore all important in healthcare and treatment of illness needs to be culturecongruent to be effective and satisfactory.

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Industrialized world medical research because, apart from being based on physicalism and materialism, it is also generally market-oriented and profit-driven, tends to be susceptible to morally blind economic forces, as a consequence of which it engages to a high degree in ad hoc rationalizations and justifications. For these reasons, the ethical challenges of industrialized world research, especially in non-Western contexts, are many and varied. Is it possible to combine commercial motives with philanthropic altruism or ethical imperatives in general? Can high-tech medical research avoid harming the vulnerable or exploiting the desperately weak, poor and ill? Can it avoid undueinducement or the application of double standards?[14]. Can it apply convincingly the imperative of respect for the autonomy of others, their culture and way of life? These questions indicate high ethical hurdles which cannot easily be surmounted. Nevertheless, the attraction to do medical research in the socalled developing world, particularly in Africa, is nothing if not overwhelming for myriad reasons: altruistic philanthropy, abundant availability of suitable research subjects, thanks to a high burden of diseases and epidemics of all descriptions, poverty, ignorance and weak regulatory frameworks, etc. In the wake of the HIV/AIDS and EBOLA pandemics, for instance, most vaccine candidate and other hopeful unproven therapy trials are concentrated in Africa. The question as to whether such trials can, even in principle, ethically be carried out is an important and unanswered one.

The WHO and the Ebola epidemic Take, for example, the recent EBOLA epidemic which broke out in West Africa during the first quarter of 2014[22]. By 12 August 2014, the WHO released a short statement captioned “Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD): Summary of a panel discussion” [21] which generally was well received and appreciated around the world. The statement in effect endorsed a procedure that is justifiable from the point of

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view of ordinary commonsense intuition, namely that, in the face of certain death and absence of any proven remedy, it is ethically acceptable to try a hopeful unproven remedy in attempt to save life. On 29-30 September, 2014, the WHO organized a “consultation to assess the state of the art work to test and eventually license candidate Ebola vaccines” in which “more than 70 experts, including many from affected countries in West Africa are supposed to have taken part. This panel considered and apparently approved urgently carrying out clinical tests on humans of some candidate Ebola vaccines in the development pipeline, including Chimpanzee adenovirus serotype 3 (Chad 3) by Glaxo Smith Kline + others and Recombinant vesicular stomatitis virus (rVSV) vaccine by a consortium involving Canadian Public Health plus others. On July 31 2015, a ground-breaking publication “Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial” [2] was published in the very influential, THE LANCET, copyrighted by the WHO, with some of its high officials as co-principal investigators/co-authors. The announcement of this publication in newspapers, radio and television was accompanied by hyperbole quite uncharacteristic of the scientific domain: the results of the clinical test were variously described as “spectacular”, “first time ever”, “100% effective”, “game changer”, etc. The successful molecule, hurriedly tested on Africans in Guinea, had originally not been developed or prepared against the Ebola virus but rather as an anti-bioterrorism product for North Americans, and had been subjected to non-human animal tests but not yet human tests. The following preliminary questions thus naturally arise: •

Was the WHO statement on clinical trials for Ebola of September 2014 tailor-made to ensure tests in humans of this particular candidate vaccine?

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• •

Was this not an opportunistic trial reminiscent of the TROVAN trials for meningitis during an epidemic in northern Nigeria in 1996? As an agency of the United Nations with oversight for global health, is it right for the WHO itself to engage directly in commercial drug discovery, development and clinical tests, while at the same time issuing guidelines and directives for all and sundry research competitors on how these should properly and ethically be done? Can the WHO avoid conflict of interest and/or favouritism and discrimination in such situation?

The HIV/AIDS epidemic and VANHIVAX When the HIV/AIDS epidemic broke out in early 1980s, one of the African scientists who tackled it in a serious and determined manner by researching towards a possible vaccine was Professor Victor Anomah Ngu of the Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Cameroon. Anomah Ngu, oncologist and professor of surgery, had won the Laskar Prize for Cancer Research in 1972 and was therefore no neophyte in this domain. But his work on HIV/AIDS did not receive any recognition, let alone support, from either the local authorities or the powerful developed world and he eventually passed on to eternity (2011) without having had the opportunity of confirming or disconfirming his candidate vaccine, Vanhivax[6-8]. His idea of an immunotherapeutic vaccine which seems to have gained scientific currency today was dismissed by some as an impossible and contradictory concept. In 2000, Ngu and I had made a joint presentation “Effective Vaccine against and Immunotherapy of HIV: Scientific Report and Ethical Considerations from Cameroon”[9, 10] at the 5th World Congress of Bioethics, 21-24 September, in London, UK. The gist of our presentation is carried in the following abstract:

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Chapter Three In this oral presentation, we intend to propose to the global community, the scientific results, as well as to evoke some ethical implications and considerations, of biomedical research carried out by V. Anomah Ngu during the past ten years in Cameroon. The initial results of the research were first presented to the Cameroon Academy of Sciences on 2 December 1999 in a paper titled: ‘Vaccines for the HIV: Past Efforts and Future Prospects’. The problematic that set off the research was the puzzle as to why the natural HIV infection provokes immune responses that fail to kill and eliminate the virus from the body. The intuitive hypothesis of the research was the conviction that the key to an effective vaccine against the infection lay in identifying, understanding and eliminating the reason for this failure. Given the gravity of the HIV/AIDS, especially in sub-Saharan Africa and other poor regions of the world, some of the ethical imperatives motivating the research include finding a simple and effective vaccine that can be cheaply and affordably produced, using traditional rather than high technology methods. In this presentation, we intend to highlight and discuss these ethical concerns within the context of the north/south dichotomy. We will also discuss the role and ethics of funding scientific research, the relationship between wealth and poverty, health and disease in the modern world and, lastly, attempt justifying testing directly on humans what we have tentatively named VANHIVAX, the simple vaccine discovered through V. Anomah Ngu’s research. The vaccine has so far been tested on a very limited scale (on HIV-positive persons) in Cameroon with what we consider very hopeful and promising results.

Our conclusion was that the promise of this preliminary report would be fully realised only after its confirmation in a study, involving a better and bigger sample size selection of patients, in a collaborative effort, with adequate logistic support. We were confident that, after such confirmation, effective and cheap vaccines could confidently be proposed for trial to the public with a high probability of acceptance, because the vaccine would have shown its effectiveness in patients in the therapeutic context. We hoped that the WHO and other interested partners could then lead the production of vaccines on a regional or sub-regional basis, using the type or sub-type of the virus prevalent in each region.

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Nothing of what we expected came to pass although a number of research teams from Europe and the USA did come to see Ngu in Yaounde, pretending they wanted to collaborate with him in his candidate vaccine project but, as it clearly came out in the end, only wanting to have the scientific details of his protocol because, having had it and departed, he never heard from them again. In 2005, 17-19 October, the African Aids Vaccine Programme (AAVP) was organizing a conference in Yaounde, Cameroon, to which I was invited as an ethicist. I noticed from the programme and list of participants that Victor Anomah Ngu was not invited to this meeting which was by invitation only. I immediately sent the following email to the organizers of the conference: “I suggest that you find space in the programme to invite Professor Victor Anomah Ngu to make a presentation of his claims to have a candidate AIDS Vaccine, VANHIVAX. Although his claims may not be scientifically uncontroversial, this is no good reason for not hearing him out but rather a very good reason for letting him present his idea so that other scientists might assess it in all scientific rigor and objectivity. If the adjective “African” in The African AIDS Vaccine Programme, has any real significance, it would surely be a little surprising to hold such a conference in Cameroon while completely ignoring Anomah Ngu and his claims.”

He got eventually invited to the meeting as an observer! During the recent Ebola epidemic in West Africa (2014-2015) some African medical scientists and allied experts decided to do something unprecedented. They came together and urgently created the Global Emerging Pathogens Treatment Consortium (GET) [http://www.get-africa.org/], aimed at coordinating an effective response not only to the Ebola epidemic but to any future similar emerging deadly pathogens. They created several work groups and launched many capacity-building initiatives to harness indigenous knowledge and experience, with the view to using culturally appropriate methods and procedures. Scientifically, they initiated research on the use of blood plasma (plasmapheresies) of Ebola survivors for the treatment of

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Ebola patients. The GET got some collaborators from the developed world but otherwise very little particular encouragement, let alone support. Of the African physicians and other medical personnel who were victims of the deadly Ebola infection – Sheik Umar Khan, Obi Justina Ejelonu, Ameyo Adadevoh, John Combey, John Taban Dada, Patrick Shamndzee, Eric Thomas Duncan, Martin Salia – none got offered any of the unproven experimental substances, such as ZMapp, which at least saved the lives of some of their Western philanthropic counterparts such as Kent Brantly and Nancy Writebol. In this situation, it is hard to know what attitude to recommend to an observant African. But, given the moral equality of all human beings and their epistemological and moral limitations, a strong case can be made for an attitude at once of self-reliance and cautious optimism, an attitude that avoids pessimism and extremism of all types but that maintains a healthy skepticism at all times.

Some theses for reflection and critical consideration Before concluding, let me propose 7 theses for your reflection and critical consideration. 1. Some populations (not to say races) seem particularly suitable as subjects of medical experimentation, thanks to their disease burden, genetic configuration, poverty, ignorance and perceived dispensability 2. Exploitation has a natural tendency and the necessity to simulate philanthropy 3. It seems very difficult for the privileged anywhere: rich, knowledgeable, powerful – to refrain from exploiting the exploitable 4. In all cases of human exploitation of humans, the exploited are, at least partly, accomplices of their own exploitation 5. Among all exploited populations are individuals who reap enormous benefits/advantages as apostles,

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disciples, interpreters, catechists and propagandists of the exploiter’s dogmas and agendas 6. Those who committed the medical research scandals we learn about in bioethics are the same people who have elaborated the most articulate rules of procedure for ethical medical research 7. The impulse of the industrialized Western world for power and control is nicely complimented by the strong belief among Africans that African problems require external solutions

Conclusion In spite of the numerous biomedical researches that have been carried out and continue to be carried out all over the African continent, the thinking, views and perspectives of Africans are not evident in the global bioethics discourse where their voice can be said to be almost completely absent. In this paper I have attempted to highlight this situation, to hazard an explanation and to hint at a general framework needed for redressing the situation. The main objective of this paper has been to provoke further critical thinking on the marginalization of Africa, especially in the biomedical domain, in spite of its potentialities and available human and material resources.

References 1. Bodunrin, P.O. 1985. Philosophy in Africa: trends and perspectives. University of Ife Press. 2. Henao-Restrepo, Ana Maria, Ira M. Longini, Matthias Egger, Natalie E. Dean, W. John Edmunds, Anton Camacho, Miles W. Carroll et al. . 2015. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. The Lancet 386 (9996):857-866. doi:10.1016/S01406736(15)61117-5.

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3. Hountondji, P.J. 1996. African Philosophy: Myth and Reality. 2 Aufl. Bloomington: Indiana University Press. 4. London, L., G. Tangwa, R. Matchaba-Hove, N. Mkhize, R. Nwabueze, A. Nyika, and P. Westerholm. 2014. Ethics in occupational health: deliberations of an international workgroup addressing challenges in an African context. BMC Med Ethics 15:48. doi:10.1186/1472-6939-15-48. 5. Mazrui, A.A.A. 1976. A World Federation of Cultures: an African perspective. New York, USA: The Free Press,. 6. Ngu, V. A, and F. A Ambe. 2001. Effective Vaccines against and Immunotherapy of the HIV: A preliminary Report. Journal of the Cameroon Academy of Science 1 (1):2-8. 7. Ngu, V. A, F. A Ambe, and G. A Boma. 2002. Significant reduction of HIV loads in the sera of patients treated with VANHIVAX. Journal of the Cameroon Academy of Science 2 (1):7-12. 8. Ngu, V. A, B. H Besong-Egbe, F. A Ambe, J. A Ngu, and C. G Caspa. 2007. The conversion of HIV sero-positive to sero-negative following VANHIVAX. Journal of the Cameroon Academy of Science 7 (1):17-20. 9. Ngu, V. A, and G. B. Tangwa. 2000. Effective vaccines against the immunotherapy of the HIV: Scientific report and ethical considerations from Cameroon. In Fifth World congress of Bioethics. Imperial College, London, UK. 10. Ngu, V.A, and G.B Tangwa. 2015. Effective Vaccine against and Immunotherapy of the HIV: Scientific Report and Ethical Considerations from Cameroon. Journal of the Cameroon Academy of Sciences 12 (2):76-83. 11. Nyamnjoh, Francis B. 2012. ‘Potted Plants in Greenhouses’: A Critical Reflection on the Resilience of Colonial Education in Africa. Journal of Asian and African Studies. doi:10.1177/0021909611417240. 12. Oruka, H.O. 1990. Sage Philosophy: Indigenous Thinkers and Modern Debate on African Philosophy. Acts Press, African Center for Technology Studies. 13. Tangwa, G. B. 1996. Bioethics: an African perspective. Bioethics 10 (3):183-200. 14. Tangwa, G. B. 2002. International regulations and medical research in developing countries: double standards or differing standards? Not Polit 18 (67):46-50.

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15. Tangwa, G.B. 2010. Elements of African Bioethics in a Western Frame. Mankon, Bamenda: Langaa RPCIG. 16. Tangwa, G.B. 2015. Traditional Medicine. In Encyclopedia of Global Bioethics, ed. Henk ten Have, 1-8. Springer International Publishing. 17. Tangwa, Godfrey. 1992. African Philosophy: Appraisal of a Recurrent Problematic: Part 1: The Sources of Traditional African Philosophy. Cogito 6 (2):78-84. 18. Tangwa, Godfrey. 1992. African Philosophy: Appraisal of a Recurrent Problematic: Part 2: What Is African Philosophy and Who Is an African Philosopher? Cogito 6 (3):138-143. 19. Tangwa, Godfrey B. 2004. Bioethics, Biotechnology and Culture: A Voice From the Margins. Developing World Bioethics 4 (2):125-138. doi:10.1111/j.1471-8731.2004.00088.x. 20. Tutu, Desmond. 1999. No future without forgiveness. New York: Doubleday. 21. WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD). Summary of the panel discussion. 22. WHO. 2015. Ebola virus disease. Fact sheet N°103.

CHAPTER FOUR TRADITIONAL MEDICINE

[Previously published in Encyclopaedia of Global Bioethics: DOI 10.1007/978-3-319-05544-2_421-1#; Springer Science+Business Media Dordrecht 2015]

Abstract In this article, traditional medicine is understood and treated as systems of medicine or healthcare distinct from the global paradigm of scientific medicine, as they have evolved and exist in the various human cultures of the world. Such systems are closely connected with the adaptation of various human groups to their physical environment or ecological niche and the social organization that makes their day to day living possible and meaningful. These healthcare or medical systems might be given various appellations from various points of view or perspectives but they are basically aimed at and result from the basic need of human beings to maintain health, guess and diagnose the causes of illness, treat illness and prevent its occurrence. Scientific medicine, because of its alliance with technology and commerce, its global push and globalizing effects, stands as a gigantic rival to all such traditional systems with which, willy-nilly, they have to deal.

Keywords Traditional medicine, Western scientific medicine, homeopathic medicine, allopathic medicine, holistic medicine, globalization, body, mind

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Introduction The term ‘traditional medicine’ (TM) is ambiguous in the sense that it has more than one meaning. There is a sense in which every society, country or culture has its traditional medicine which may be compared and contrasted with its modern medicine as it has evolved under new discoveries or improved techniques and external influences. Sometimes the term ‘traditional medicine’ is used to refer to any medicine based exclusively on plants and other natural products in the environment. Sometimes ‘traditional medicine’ is used as a contrastive term to denote health practice other than ‘Western scientific medicine’ (WSM) which variously is also designated in available discourse and writings as ‘allopathic’ ‘conventional’, ‘mainstream’ ‘dominant’ or ‘orthodox’ medicine. Traditional medicine may thus be understood as medical systems and practices as they had evolved over generations within various cultures or societies before the modern era, characterized by closer contact between the various peoples that populate the earth and the Western-driven phenomenon of globalization. A discussion of traditional medicine in general is therefore inevitably an exercise of comparing alternative systems of medicine or healthcare and practices to the globally dominant system of Western scientific medicine. Apart from such approach, there is the possibility of studying in their own right the anthropology, history and development of each medical system or healthcare practice different from the dominant paradigm. Such a vast study cannot be undertaken here and must be left for various experts better qualified and interested in carrying out such studies. Sometimes the following terms are used to designate traditional medicine: indigenous medicine, folk medicine, alternative medicine, parallel medicine, complementary medicine, soft medicine. The World Health Organization (WHO) defines traditional medicine as “…the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses” (WHO 2008). This is a good general working definition that needs only unpacking and elaboration for each valid case of TM.

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Healthcare systems like Homeopathy, Naturopathy, Osteopathy, Chiropractic, Shamanism, Faith Healing, [Weil 1995] are mainly counter-positional to allopathic or WSM and are best understood and appreciated within the Western world, particularly the United States of America, where they have flourished as rivals of the dominant healthcare system.

History and development The earliest history and development of TM is hidden behind the veil that separates written records from unwritten history. But if we extrapolate from the present to the past, we can surmise that, in adapting and surviving in their environment, the various peoples and corresponding cultures of world learned by induction and experience the uses of available mineral, botanical and animal materials in sustaining health, preventing infections and curing diseases. The history of WSM is usually traced back to Hippocrates of Cos (460-37 7 BC), popularly called the “Father of Medicine”, because he introduced the scientific approach to healing by seeking physical rather than magical/religious/supernatural causes for disease. His followers, such as Claudius Galen of Pergamum (c. 129-199 AD) “who holds the same place in the history of medicine as Ptolemy does in the history of astronomy and geography” [Farrington 1944, p. 294] and Maimonides (1135-1204 AD), further developed his system to make it the foundation of WSM as it is. The ethical quintessence of this system is the idea that the health and wellbeing of the patient is the overriding consideration of medicine. Maimonides perhaps gave it the clearest expression when in his so-called Physician’s Prayer he stated “May I never see in the patient anything but a fellow creature in pain…”. The roots of Western traditional medicine might be traced further back than Hippocrates to the Babylonian Code of Hammurabi (c. 1754 BC) in ancient Mesopotamia which regulated amongst other things the practice of medicine and surgery. These early foundations of Western medicine were further developed with influences from ancient Egyptian, Arabic and

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Roman elements. In the European so-called Middle Ages, Avicenna alias Ibn Sina (980-1037 AD) wrote a medical treatise, The Canon of Medicine, in which, for the first time, the idea of clinical trials was clearly introduced, earning him the title of “Father of Early Modern Medicine”. The development of Western medicine reached its apogee with the European Industrial Revolution of the 18th and 19th centuries which drew its impetus from the slogan that ‘Knowledge is Power’ (Francis Bacon, 1561-1626) convertible into commercial value, from the idea that all knowledge is unqualifiedly good, from the belief that nature is, in principle, completely knowable and controllable, and from perception of the universe as something which should be explored, subdued, dominated and exploited [Tangwa, 2002, p. 3]. Distinct countries, cultures or regions whose traditional medicine had greatly flourished and deserve focal study and appreciation in their own right include but are not limited to China including Taiwan, Korea, Japan, [Park Hye-Lim et al. 2012] India, Mexico, Africa, etc. The history and evolution of any of these systems of medicine and healthcare would be unique and most interesting, but all are likely to be different and distinguishable from WSM in two important respects: relationship to technology and the market, without necessarily ruling out the possibility of a traditional medicine system evolving in imitation of WSM. WSM is so interwoven with technology that it is properly called ‘techno-medicine’. The use of technologies in medicine and healthcare (‘telemedicine’) is progressively overcoming hurdles and challenges previously posed by time and space and ‘nanotechnologies’ are facilitating medical research and applications at the atomic and molecular levels. On the other hand, the resources needed for these developments are made available by the open capitalist market, thereby further cementing the marriage, so to speak, between medicine and the market within the industrialized Western world. There is no doubt that market forces have driven up healthcare costs enormously, especially of medical technologies. The relationship between medicine and the market has been widely and critically discussed but seems iron-cast and

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unstoppable. The question continues to be raised as to whether the institutions and traditions of Western medicine and healthcare are morally compatible with market theory, thinking and practice and it has been suggested that there is such an intrusive conflict of values between the two that they should not be conjoined no matter how attractive the apparent consequences may appear; but the marriage waxes on ever stronger.

Conceptual clarifications/Definition Wherever human beings have lived, there has been the need to adapt themselves to the peculiarities of their physical environment or ecological niche. In doing this they develop common ways of facing the same problems, similar ways of doing the same things, similar attitudes and expectations, and eventually similar ideas, beliefs, ways of thinking and practices – this is their culture. A culture, therefore, is what results from the adaptation of a group of people to a particular environment and is necessarily underpinned or anchored on a shared worldview [Tangwa 2014, pp. 20132014]. The need to maintain health, to prevent disease, to guess the cause of disease and to treat it, develops naturally along with other aspects of the culture. This is their traditional medicine, with strong links to their environment and their culture. It is important and inevitable that this medicine be ‘indigenous’. Medical ideas coming from abroad remain foreign until they have been accepted, domesticated and indigenized. Traditional medical knowledge is not limited to knowledge of the medicinal properties of herbs, animal products or minerals, although these latter types of knowledge are an indispensable part and parcel of it. Traditional medical knowledge covers all that is necessary to maintain health, prevent disease and treat ailments, be they physical, psychic or mental. That is why the WHO definition quoted in the introduction above is a good working definition. Traditional medicine is necessarily holistic and to the society/community in question, it is their ‘conventional’ ‘mainstream’, ‘orthodox’ medicine, while incoming new ideas and practices can be described as ‘unconventional’,

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‘unorthodox’, etc.; unless and until they have been domesticated and indigenized. From this point of view, it is regrettable that Western scientific medicine, globally dominant and expansive though it be, is referred to in the dominant literature and discourse variously as orthodox, mainstream, conventional, medicine as if it were so in all possible domains and contexts. Many people today use the term ‘traditional medicine’ simply as a contrastive term to Western scientific medicine, otherwise known as allopathic medicine, by comparison and contrast with homeopathic medicine. However, it must be recognized that Allopathic medicine is the most influential medical system in the world today. The global influence and various appellations and designations of allopathic medicine create a conceptual problem that needs clarifying in any discussion of traditional medicine. In little more than a century, Western traditional medicine had rapidly evolved, thanks to science, technology and the Industrial Revolution, resulting in ‘Western scientific or allopathic medicine’. WSM or allopathic medicine is essentially Dualistic, having accepted the sharp distinction between body/mind introduced by Rene Descartes (the ‘father’ of modern Western philosophy) and opted to concentrate on the former, under the conviction that all diseases have traceable physical causes. For this reason, medical systems that do not accept the body/mind dichotomy, let alone prioritize the physical over the nonphysical, can be termed “holistic” in contrast to WSM. The close alliance between WSM, commerce and the open market, has also had the effect of enormously empowering its health research and development. Concomitantly, the Western world had overrun the rest of the globe, using conquest, enslavement, colonization, proselytization, commerce and education. Consequently, WSM is also present to varying degrees in nearly all other parts of the world. Western culture, Western systems and practices, Western science and technology, have spread and become dominant in most parts of the modern world. However, Western scientific medicine should accurately be described as such and not as ‘conventional’, ‘orthodox’ or ‘mainstream’ in non-Western cultures/contexts where it is not yet the first

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or only port of call for health-seeking behaviour. Countries/cultures whose TM has evolved satisfactorily and is still strong and dominant within their context today are mainly those which had escaped Western colonization, proselytization, education or domination – China, Korea, Japan, Vietnam might be plausible examples.

Ethical dimensions The fundamental ethical values, principles, precepts and injunctions that guide, have guided, and should guide TM are no different from those that have been identified in WSM and given such very catchy titles as autonomy, beneficence, non-maleficence, justice. [Beauchamp and Childress 2001]. These four principles are evidently basic and many procedural rules, precepts and injunctions can be derived from each of them. They have been widely discussed in biomedical ethics literature and given the descriptive name ‘principlism’. In TM these basic moral principles may not be stated or discussed in these terms but they are recognized and captured in various idioms, metaphors and other figures of speech. To easily realize this it is important to understand that autonomy, to begin with, connotes and implies respect for the otherness, individuality, distinctiveness and dignity of other human beings and, by extension, even that of nonhuman beings (plants, animals and inanimates). Justice or fairness is equity in dealing with and treating others, as conceived under autonomy above. Beneficence or doing good, at least in the intentional/motivational orders, is ensuring that acts/actions are motivated by the intention of achieving noble ends/aims/objectives. Non-maleficence, which sets the rock-bottom, minimalist condition for ethical correctness, is the avoidance of doing harm knowingly, deliberately or willingly. Overarching these four principles is the very idea of morality as a human value and of moral equality and equity as the cord that binds together and renders operational the four fundamental principles. Where this is not recognized or seriously taken into consideration, neither the four principles nor moral sensibility in general can get off the ground, let alone have applicability.

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The pre-condition for morality and the four fundamental principles of ethics are, in a loose and general sense, equally relevant to and important across all cultures, in all fields of human endeavour and activity, and within all possible human contexts and perspectives. In practice, they function as a team or single value set, completing and balancing each other, in such a manner that one cannot be singled out as being more or less important than any other, and none can claim to be absolute, since any of them can be violated, given a sufficient ethical justification. For these reasons, synthetic minds might tend to view them as all hanging from one single stem, whereas analytic minds may regard them as analyzable into various branches. In any case, one ethical principle, in a particular context and existential situation, can take precedence over another, or one ethical norm or rule can countermand another, as when, for example, one were to violate confidentiality or break a promise to save a human life. By contrast, a non-ethical reason can never justify the violation of an ethical principle, norm or rule. From these fundamental principles, many other derivative principles can and have been formulated to help morality along. Some such procedural principles are metaphorical, others mythical, and still others simply practical. Examples of some of such derivative principles and metaphors may include: human rights, human dignity, human solidarity, sacredness of human life, ‘created in God’s image and likeness’, etc. But, beyond myths and metaphors, which harmlessly and quite usefully (from the moral perspective), can be taken literally, critical reflection may suggest that (staying on the metaphoric plane) the chameleon is not without chameleonic dignity, nor the aloe vera plant without aloeveric dignity. Every creature and every existing thing have their own intrinsic value and inner reasons, even if unknown to human beings, for being there. The focus and emphasis on human beings can therefore only be justified from the point of view of moral agency, not from that of morality as such. Human beings are the only moral agents on earth. Some moral ‘patients’, being non-human, nonrational or human but incompetent, have no conceivable moral obligations at all, whereas moral agents bear the

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whole weight of responsibility for whatsoever they choose or refrain from choosing to do or act upon. The four principles, in the terms, language and idioms I have stated them are, of course, very much a paradigm of the industrialized Western world, where their relevance and urgent applicability have been made abundantly manifest by various activities that have violated or run the risk of violating them, such as human enslavement, colonization and medical experimentation on humans without their knowledge and well-informed, voluntary consent. They, nevertheless, remain equally important even where they seem to be lying dormant for want of any perception of urgent risk or hazard, the discussion of which would surely have brought them to the fore. The industrialized Western world deserves credit for the coinage of the very convenient terms and idioms in which these principles are discussed today. But the fundamental principles themselves are not absent in any human culture, even if they are not thought of or understood in the same terms. The salient point about these principles is not that they are four in number – the BIG FOUR – as some people refer to them, but rather that they are clearly overarching as well as necessarily plastic in their applicability, leaving ample room for cultural perspective, situational context and existential pressure to impinge on them. In some cultures, such as Nso’ culture of the grassy highlands of Bamenda in Cameroon, within which the author of this article was born and with which he has first hand familiarity, these principles are captured in and derivable from two guiding adages: one that states that ‘a human being is a human being simply by being a human being’, and the other that states that ‘the essence of a human being is having a good heart (will)’. The first of these adages implies that a human being, irrespective of his/her descriptive and particularistic attributes, is autonomous and of inestimable worth and must therefore be treated with due consideration and equity by other human beings (respect for intrinsic value, autonomy and justice). The second adage implies that a human being is less than human if s/he does

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not shun evil, including avoidance of harm, or if s/he is not imbued with good purposes and intentions (beneficence and non-maleficence). These principles are what make living in communities or societies as human beings possible and harmonious. They may not be ‘discovered’ for some time or theoretically nailed onto an analytic frame, but they are there alright, implicitly wrapped up in social norms, traditions and practices. In most of the so-called developing world, particularly in sub-Saharan Africa, it is estimated that about 80% of the populations depend on TM as opposed to WSM as a means of healthcare [WHO 2002].But owing to rapid and intensive urbanization, slow-down or breakdown in traditional systems, TM in most countries has been invaded by quacks, charlatans, con-wo(men), and all manner of livelihood seekers. In most of these countries, TM exists side by side with WSM. In some of these countries practitioners of WSM have contempt for, a superiority complex against and an exploitative/colonizing attitude towards TM, often referring to its practitioners as ‘witchdoctors’, ‘necromancers’, sorcerers, etc. This attitude, derived from the impressions and reports of the early colonial adventurers and scholars [Kingsley 1964; Conrad 1950] and from Western education in general is highly resistant to correction; but, while witchdoctors, necromancers and sorcerers there certainly are in these settings, they are not equivalent to healers even though they could have a tangential connection with the healthcare system. TM is basically an art rather than a science. It is usually coextensive with personal/family primary healthcare. It is necessarily holistic, aimed at the well-being of the whole composite human person – body, mind and soul. Heretofore it has had no particular or direct connection with commerce or even the idea of earning a living; its benefits for the practitioner were mostly indirect and voluntary on the part of treated patients. TM is easily accessible and affordable to the populations that it serves and, like any other cultural practice, is modernisable. Some practitioners of TM undergo

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several years of apprenticeship under a master. Others simply exhibit mastery of the art (divine endowment?) without any prior training (like in the case of some poets, painters, carvers, drummers, dancers, sculptors, etc.). In TM there has been no formal ‘research’ in the sense of welldesigned controlled experiments but, in its modernization, scientific experiments could be introduced. It is, nevertheless, evidence based in the sense that a bone-setter, for example, who sets no bones will not have any patients seeking him/her for bone-setting. TM depends on, respects and preserves biodiversity, a not inconsiderable attribute in our climate changing modern world.

The moral impulse in traditional medicine The moral impulse is central in traditional education and in the practice of any profession or trade, including medicine, in the traditional setting that always involved ritual restrictions and taboos, calculated to prevent abuse of specialized knowledge [Tangwa 2011, p. 97]. As a professional group, practitioners of TM, especially in the countries of subSaharan Africa, for example, were controlled and restricted by many ritual taboos – such as never administering or making available a poison to anybody, never ever helping to end a human life, be it that of a foetus or a terminally ill patient, etc. Violation of such taboos was sanctioned by mystical loss of professional knowledge and special endowments or by personal misfortune or by a bad death. But in an age where belief in God and other living spirits, let alone fear of divine anger and retribution, are on the decline; where belief in physical causes for physical effects is on the rise, however, taboos become an increasingly ineffective method of behaviour control. Hence the abuses and scandals that today, unlike yesterday, can be observed and catalogued in TM. There are three main arms or dimensions of healthcare delivery systems in most developing countries, especially in sub-Saharan Africa: authentic and uncorrupted traditional

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medicine which functions mainly in the rural areas; modern Western-style medicine which operates through hospitals and pharmacies mainly in urban areas; and medicinal hawkers who combine both traditional and modern medicines and operate in both urban and rural areas. While ethics has a firm foothold in the first two categories, it is almost completely absent in the third which, incidentally is the most rapidly expanding, on account of generalized poverty and ignorance. The sale of fake or expired drugs and the promotion of dangerous self-medication are some of the consequences of this situation. On the other hand, Westernstyle medicine is notorious for such ethics problems as corruption, iatrogenic harm, bribe-taking and inefficiency.

Conclusion As an important and inevitable aspect of every identifiable culture, traditional medicine exists in all parts of the world. The history, development and current situation of traditional medicine within each country or culture is varied depending on its relationship with allopathic or scientific Western medicine and the internal factors that have influenced its growth. Allopathic Western medicine, based on science and technology, is the most powerful healthcare system in the world today and its spread and influence has been greatly assisted by phenomena such as colonization, proselytization and globalization. In the face of this fact, other healthcare systems, be they traditional or otherwise, have mainly two existential options: merging and integrating with allopathic medicine or cohabiting peacefully side by side with it. Whatever the case, Western or rather global allopathic or scientific medicine is likely to be profoundly affected and modified by traditional and other systems of healthcare in the various countries of non-Western culture where it has taken root.

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References Conrad, Joseph (1950). Heart of Darkness and The Secret Sharer. New York: New American Library Edition. Farrington, Benjamin (1944). Greek Science: Its Meaning For Us. Harmondsworth, Middlesex: Penguin Books Ltd. Kingsley, Mary (1964). West African Studies. London and Edinburgh: Frank Cass & Co. Ltd. Tangwa G.B. (2002). Genetic Technology and Moral Values: An African Opinion. Polylog (online): http://them.polylog.org/6/ftg-en.htm, accessed 04/01/2015 Tangwa G.B. (2014). “Ethics, Human Rights and Sexual/Reproductive Health in Africa: Exploratory Sociocultural Considerations” (Chapter 7, pp. 213-232), GLOBAL BIOETHICS AND HUMAN RIGHTS: Contemporary Issues, edited by Wanda Teays, John-Stewart Gordon and Alison Dundes Renteln, Lanham/Boulder/New York/ Toronto/Plymouth, UK: Rowman & Littlefield. Tangwa G.B. (2011). “Ethics in African Education” (Chapter 7), Handbook of African Educational Theories and Practices: A Generative Teacher Education Curriculum, edited by A. Bame Nsamenang and Therese M.S. Tchombe, Bamenda: Presses Universitaires d’Afrique, 2011, pp. 92-106. Weil, Andrew (1998). Health and Healing. Boston and New York: Houghton Mifflin Company. IARC MONOGRAPHS VOLUME 82. http://monographs.iarc.fr/ENG/Monographs/vol82/mon o82-6A.pdf, accessed 27/12/2024. WHO (2008). Fact sheet No. 134, December 2008.

Further readings Aceme Nyika. “ETHICAL AND REGULATORY ISSUES SURROUNDING AFRICAN TRADITIONAL MEDICINE IN THE CONTEXT OF HIV/AIDS”. Developing World Bioethics, ISSN 1471-8731 (print); 1471-8847 (online), Volume 7 Number 1 2007, pp 25–34. Godfrey B. Tangwa, “HOW NOT TO COMPARE WESTERN SCIENTIFIC MEDICINE WITH AFRICAN TRADITIONAL

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MEDICINE.” Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) Volume 7 Number 1 2007, pp 41–44. Daniel Callahan and Angela A. Wasunna. Medicine and the Market: Equity v. Choice. The Johns Hopkins University Press, 2006.

CHAPTER FIVE HOW NOT TO COMPARE WESTERN SCIENTIFIC MEDICINE WITH AFRICAN TRADITIONAL MEDICINE

[Previously published in Developing World Bioethics; ISSN 1471-8731 (print); 1471-8847 (online); Volume 7 Number 1 2007, pp 41–44].

Abstract In his commentary on Aceme Nyika’s paper ‘Ethical and Regulatory Issues Surrounding African Traditional Medicine in the Context of HIV/AIDS’,1 Godfrey B. Tangwa charges the author with inappropriately using expressions, terminology and criteria of evaluation appropriate in Western scientific medicine to judge African traditional medicine (TM). He seriously frowns on Nyika’s suggestion that African TM needs to be incorporated into, and subjected to the canons of Western scientific medicine. Such a suggestion, he believes, is a prescription for invasion, colonization and exploitation so characteristic of the relationship between Africa and the Western world. However, he thinks that African TM is quite compatible with Western scientific medicine. In his paper, ‘Ethical and Regulatory Issues Surrounding African Traditional Medicine in the Context of HIV/AIDS’,2 Aceme Nyika addresses African traditional medicine in the context of the HIV/AIDS epidemic. In his estimation, more than 80% of Africans use traditional medicine (TM), including, notably, in the treatment of HIV/AIDS, mainly because TM is more affordable and available in comparison

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to what he terms variously as ‘orthodox medicine’, ‘conventional medicine’ or ‘scientific medicine’. However, whereas orthodox medicine, in his opinion, is practiced under stringent regulations and ethical guidelines emanating from The Nuremberg Code, African TM seems to be exempted from such control, and, although there have been calls for TM to be incorporated into the ‘health care system’, less emphasis has been placed on ethical and regulatory issues. Therefore, he thinks that it is important to carry out ‘research’ on TM, ‘in order to improve and demystify its therapeutic qualities’,3 to extend intellectual property laws to cover traditional knowledge and biodiversity, and to create a framework of partnerships involving traditional healers’ associations, scientists, policy makers, patients, community leaders, members of the communities and funding organizations as the best means of achieving such ends. Although some of the author’s recommendations are laudable, such as extending intellectual properties laws to cover traditional knowledge and biodiversity, some of his basic assumptions are questionable and his understanding of traditional medicine faulty or, at any rate, biased, and evidently lacking in sympathetic distant or close participant observation. There are, moreover, a number of glaring inconsistencies, if not contradictions, in some of his claims and declamations. Firstly, and most generally, in this paper the author uses criteria of evaluation and terminology appropriate in one domain, namely, modern (Western) scientific medicine, to apply in another domain, namely, traditional (African) medicine, without first considering whether this is possible, let alone necessary. African TM cannot, for instance, be reproached in the manner of the author for not conforming its practice, like ‘orthodox’ medicine, to ‘stringent regulations and ethical guidelines emanating from The Nuremberg Code’.4 What connection or relationship is there between African TM and the regulations and guidelines emanating from The Nuremberg Code?5 African TM was not an accomplice in, let alone the one responsible for, the medical

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atrocities that resulted in the ‘Nuremberg Trials’ and The Nuremberg Code. The entire baggage of terminology, discourse and associated activities emanating from, and historically connected with, The Nuremberg Code – experimentation on humans, informed consent, autonomy, beneficence, non-maleficence, justice, vulnerability, clinical study, ethics review committee (ERC)/ institutional review board (IRB), guidelines, regulations, etc. – have no prima facie application or meaning in TM. That is not to say that malpractices and abuses, even atrocities requiring vigorous ethical intervention, may not be occurring in African TM, particularly nowadays. Traditional medical practice is not without its own ethos and system of regulations, and the author himself does inform us of the condemnation by both national and international traditional medical practitioners and associations of some of the malpractices and abuses he relates as if they were typical of, and limited to, TM. African TM, especially as practiced today within the socio-cultural syncretism of the urban cities, has been invaded by all manner of charlatans, quacks and conmen whose primary motivation and objective is sheer economic survival. TM should not be confused with witchcraft or connected with bogus beliefs that lead some people to commit atrocities such as child rape and ritual murder. Medical abuses and malpractices may, and do, of course, occur in medical practice everywhere and are in no way restricted to African TM; they equally occur in scientific medicine, The Nuremberg Code and ‘stringent regulations and guidelines’ notwithstanding. Secondly, the author’s bias against African traditional medicine come out rather strongly in the terms and expressions he uses in characterizing it: ‘necromancy’, ‘superstition’, ‘witchcraft’, ‘magical’, ‘bogus’, ‘cruel mixtures’, ‘paternalistic’, etc. He perceives traditional medicine as perpetual ‘trial and error’, amounting to ‘poorly designed experimentation’ with human patients without ethical approval and without informed consent from patients. In his

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view, it requires regularization, ‘monitoring’, ‘standardization’, demystification and incorporation into ‘mainstream primary healthcare systems’.6 The author does not make any distinction between medical therapy and medical research. The distinction is quite important because the ethics of medical research are quite different from the ethics of medical practice, even within Western scientific medicine. Medical practice is governed by a medical ethos, according to which the health of the patient takes first consideration, whereas in medical research the primary objective is to gain knowledge or to validate a commercialize-able pharmaceutical product. The ethical requirements of medical research are therefore quite different from those of medical practice. Paternalism, for example, might be acceptable, tolerable or defensible in medical practice, but certainly not in medical research. The use of a promising but unproven product or method might be justifiable in desperate situations in the therapeutic context, but certainly not in the research context. In this article the author seems to be using criteria of ethical appropriateness for medical research to judge African traditional medical practice. Thirdly, and by the author’s own estimation, over 80% of Africans depend on TM that, moreover, has been practiced for centuries before the advent of scientific medicine. What then, in this situation, justifies considering TM as unorthodox and unconventional and requiring regularization and incorporation into ‘mainstream primary healthcare systems’? In what sense can a system on which only 20% of a population depends for their healthcare needs be considered as ‘mainstream’ while that on which more than 80% depends, and have depended for centuries, be considered as unconventional/unorthodox? Is it not, rather, scientific medicine that should be considered unorthodox/unconventional and requiring incorporation into the mainstream in this situation? Or, are we to understand orthodoxy, conventionalism and mainstream-ness in a stipulative and prescriptive manner, simply as relating exclusively to scientific medicine? Systems of minority rule

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are, of course, not unknown, but they at least need some attempted justification. Scientific medicine is, of course, very powerful, and in many respects clearly superior to African traditional medicine, but might is not always right and that, in any case, is beside the point. Fourthly, the author’s description of traditional medicine under the sections entitled ‘Supernatural TM’ and ‘Herbalism’ is simplistic and lacking in inside experience or sympathetic outside observation. According to the author, ‘orthodox medicine is arguably based on the axiom of Aristotle’s dualism, which separates the spirit from the body and focuses on the latter [while] TM is based on both spiritual and physical components of personhood.’7 It is not clear what we are to understand by ‘Aristotle’s dualism’, but if this refers to Aristotle’s metaphysical theory in de Anima in which he postulates that soul and body are aspects of a single substance, standing in the relation of form to matter, from which the so-called body-mind philosophical problem arises, then this is the very crux of the matter. Aristotle himself never recommended a focus on the body to the neglect of spirit/soul/mind, but rather considered them as aspects of one and the same reality/entity. If body/soul, matter/mind, physical/spiritual dualism is admissible, then scientific medicine, by limiting itself to treatment of the body, clearly leaves out an important element of the human being, while TM appropriately addresses both components of the human being. Only if we assume that dualism is false, and monistic materialism or epiphenomenalism right, can we affirm that the focus of scientific medicine, as affirmed by the author, is more appropriate than the focus of TM. But given the plausibility of dualism or pluralism, African TM generally aims not only at bodily health but also at psychical, mental and spiritual harmony and rhythm, not only for the individual but also for the community, including the living-dead ancestors and even the as yet unborn. The latter may be consulted and addressed through prayer, incantations and divination in a process that can appropriately be described neither as ‘supernatural’ nor ‘necromancy’. A ‘scientific’ health provider

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may also pray to ‘the Lord’, ‘the Spirit’, ‘the Blessed Virgin’ or the ‘saints’ on behalf of his/her patient without being charged with necromancy. Moreover, only a relatively small part of African TM involves the need to look beyond the purely physical causes or treatment of ailments. Mainstream African TM uses herbs and other natural substances in treating diseases, and few indeed are the patients who need divination and other spiritual procedures, or healers who combine divination and other spiritual procedures with the art of healing. It is clear that the author is ready to concede some marginal value to TM only because ‘complimentary’ or ‘alternative’ medicine (CAM) is becoming popular in the West and because some products of herbalism have been demonstrated in scientific laboratories in the absence of ‘magical and spiritual powers’. In any case, it is quite clear that the author is standing firmly on the side of ‘research scientists’, ‘regulatory authorities’, ‘phamaceutical companies’ and ‘bioethicists’ against the ‘bogus’ ‘paternalistic’ traditional healers and their supposedly misguided clientele: for which reason he wants TM incorporated into scientific medicine for better regulation and control. In essence this is a plea for the conversion of TM to scientific medicine, analogous to the conversion of ‘paganism’ to Christianity, under the invincible conviction that the latter is self-evidently true and the one and only path to salvation, while the former is patently false or evil. This is a prescription of that invasion, colonization and exploitation, which Africa has been familiar with since its first contact with the Western world. Fifthly, and lastly, the evident problem underlying the paper is the following: Can and should African traditional medicine be incorporated into, merged with and subjected to the canons of ‘orthodox’, Western ‘scientific’ medicine? Within that context, it would be desirable, among other things, to say something about how some of what the author concedes as desirable elements of traditional medicine, such as availability and affordability, could be preserved when the merger takes place, or how ‘biopiracy’, for that matter, will be

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avoided. In its home base amongst rural communities, African TM is a practice within a closely-knit community whose members perceive their welfare, wellbeing and destiny as common and closely linked. Even before the professional healer is sought, the traditional African patient him/herself, or other members of the family/community, would have already tried the common remedies for the ailment, remedies that are generally known to all. And, the healer, when s/he arrives in the community, can hold consultations in the open courtyard, because the members of the community keep no secrets from each other and the ailments of each are the genuine concern of all. The elaborate greetings of African cultures are partly calculated to pass on information especially about the health status and welfare of members of the community. In such a situation, the idea of ‘confidentiality’, so much emphasized in Western medicine, has no direct application and is simply inoperative. Undue secrecy in such a context could provoke suspicions of witchcraft. African traditional medicine is quite compatible with Western scientific medicine, but this compatibility need not involve takeover and control of TM by scientific medicine. My own village of Shisong, in the north-western highlands of Bamenda in Cameroon, affords a paradigmatic example. For about three quarters of a century now, Shisong has had a Catholic hospital (today with a specialized cardiac surgery centre) where Western scientific medicine is practiced. From its inception the hospital has always striven to ensure some of the clear advantages of traditional medicine, such as accessibility, availability and affordability, though these have been under constant threat of elimination, especially in this era of HIV/AIDS. The communities that make use of the Shisong hospital know very well what particular ailments to take to the hospital and what to take to the traditional healers. Sometimes the doctors at the Shisong hospital will advise a patient to seek traditional healing, and quite often traditional healers refer patients with conditions they know they cannot handle to the hospital. At Shisong hospital, consultation and in-patient admissions have adapted to the African communal system.

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Shisong hospital (and there are many similar Western style hospitals in the same region) is, of course, only one possible face of Western scientific medicine in the African context. Other possible faces look quite unattractive, conjuring up the spectre of a complete take-over of peoples’ lives and healthcare by a powerful self-righteous system the building pillars/underpinnings of which include colonization, exploitation and monopoly, and putting healthcare beyond the reach of the vast majority of the people.

Notes 1

2 3 4 5

6

A. Nyika. Ethical and Regulatory Issues Surrounding African Traditional Medicine in the Context of HIV/AIDS. Developing World Bioethics 2007; 1: 25-34. Ibid. Ibid. Ibid: 25. The Nuremberg Code. 1949. Trials of War Criminals Before the Nuremberg Military Tribunals Under Control Council Law. Nuremberg, October 1946-April 1949. Washington, DC: US Government Printing Office: No. 1; Vol.2: 181-182. Nyika, op. cit. note 1, pp. 25-34.

CHAPTER SIX ASSISTED REPRODUCTION TECHNOLOGIES (ART) AND AFRICAN SOCIO-CULTURAL PRACTICES, WORLDVIEW, BELIEF AND VALUE SYSTEMS: WITH PARTICULAR REFERENCE TO FRANCOPHONE AFRICA

[Previously published in Current Practices and Controversies in Assisted Reproduction: Report of a WHO Meeting, edited by Effy Vayena, Patrick J. Rowe and P. David Griffin, Geneva, World Health Organization, pp. 55-59, 2002.]

Introduction Although it is often controversial or misleading to make generalizations about Africa, one of the safest and less controversial of such generalizations is that human procreation is highly valued in African cultures. This should not, of course, be interpreted to mean that there are parts of the world or cultures where procreation is not valued. Procreation is a value for human beings in general and within all human cultures. But the ways and manner in which this value is manifested and expressed differs from place to place, from culture to culture, and these differences can be used as a rough gauge of the extent or magnitude to which the value is affirmed or upheld against competing values. There is no part of Africa where children are not greatly valued and where, as a consequence, large families do not exist or polygamy is not practiced.

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Children are so highly valued in Africa that procreation is everywhere considered the main purpose of marriage, is the main cause if not justification for polygamy and other forms of marriage which may be considered more or less strange from the perspective of other cultures, while childlessness remains the main cause of divorce, as a childless marriage is considered to be equivalent to no marriage at all. The idea of ‘illegitimate child’ or ‘bastard’ is one that could make no sense and had no application in traditional Africa because of the very high value placed on children. In Cameroon, it is very common for the parents of a girl who is approaching her thirties as a childless spinster to urge her to try and get a child by all means ‘before it becomes too late’. If afterwards she finds a husband, her parents are usually only too happy to keep her pre-marital child, who often, in any case, bears her father’s name.

Some consequences of the great love for offspring All population control policies, family planning strategies, birth control plans and all recommendable procedures that obstruct the direct link between sexual intercourse and possible conception have had to reckon with very resilient attitudes in Africa arising ultimately from a world-view and value system in which children and, consequently, conception are greatly valued. The failure of the condom, for example, to serve as a method of prevention against the deadly HIV/AIDS infection in some parts of Africa to the same extent as elsewhere in the world is directly linkable to this fact, that the high value placed on children and procreation has been transferred to the sexual act as basically an act of fecundation. It is very significant to note that, in cases of certain cancers, many Africans prefer death to having any of their bodily parts directly connected with reproduction surgically removed. In traditional as well as modern Africa, there is, perhaps, no category of patients that the healer consults more frequently than the infertile woman and the impotent man. These are

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medical conditions that very few Africans are willing to accept with resignation as long as the last possible healer has not been consulted and the last possible method or product tried. Everywhere in Africa also, there is some form or other of the maternal cult, which considers motherhood the plenitude and crown of womanhood, while a childless man may often be bracketed with the children, a very degrading thing in a culture in which great respect is accorded to age and status. Again, on the approach of death, a childless person is particularly terrified because, while death is considered a transition into the realm of the ancestors, the living-dead, life, well-being and prosperity in that realm is believed to depend on the reciprocal interaction between the progeny and the ancestors, between the living kin and the living-dead (Tangwa1996, p. 191). It therefore goes without saying that assisted human reproduction of almost any putative type would, prima facie, be of great interest in Africa; and that assisted reproduction technologies (ART) could not fail to generate great interest and even excitement in Africa. Nevertheless, ART in Africa is fraught with a number of problems and contradictions. But, before considering these, let me briefly present the situation in Cameroon and Francophone Africa.

ART in Cameroon, the central African sub-region and francophone Africa In the Francophone countries of central Africa as well as the rest of Francophone Africa, as indeed in sub-Saharan Africa in general, the socio-cultural system, attitudes and practices make infertility and childlessness in general a highly undesirable condition and, more or less, a metaphysical curse. The social importance attached to fertility cults (ibid. p. 190), to birth, naming and initiation rituals, to marriage, death and burial ceremonies, flow from a logic of and accord well only with generalized fecundity and procreativity. Any assistance towards fertility is therefore highly valued and sought.

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Endoscopic surgery centre in Yaounde In Francophone Africa, Cameroon could pass for a leader in the domain of medically assisted reproduction and two centres for in vitro fertilization and embryo transfer (IVF-ET) exist in Yaounde and in Douala, although they each present very different attitudes, results and outlook. Other Francophone African countries, notably Gabon, Central African Republic, Congo, Chad, Benin, Mali, Algeria, Equatorial Guinee, Burkina-Faso, etc. have all had some of their patients coming to Cameroon or are currently trying to learn from Cameroon and are in the process of setting up their own facilities for medically assisted reproduction involving extracorporeal fertilization. On the initiative and under the patronage of Cameroon’s First Lady, Chantal Biya, the Centre de Chirurgie Endoscopique et Reproduction Humaine Chantal Biya (CCERH) was inaugurated in Yaounde on March 6, 1998, while Professor Gottlieb Lobe Monekosso was minister of Public Health in Cameroon. Conceived as a part of the Fondation Chantal Biya, the CCERH is presently hosted by the Department of Obstetrics, Gynaecology and Human Reproduction of the Yaounde General Hospital. The Centre is headed by Professor Jean-Marie Kasia and is well known in Cameroon and the central African sub-region through its wellpublicized claims, on Cameroon Radio and Television, to be performing successful endoscopic surgery conceptions and births and to be running a diploma course for the African region in endoscopic surgery. A visit to the Centre, however, may not confirm these claims but may rather raise doubts about them. The personnel of the Centre, while comporting themselves proudly, on account of being employees of the First Lady, are not forthcoming with any information concerning their work and professional activities, which they seem to regard as some sort of state secrets. I visited the CCERH on April 18 and 19, 2001, after a long and sustained effort to have an appointment fixed with its director, Professor Kasia. In the course of my initial enquiries about the Centre, I had come across the opinion that the

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director of the CCERH was an arrogant, ignorant person, basking in the sunshine of political patronage, and the information that he once caused a journalist to be arrested, locked up and tortured for trying to poke-nose into what was going on at the CCERH. As I met Professor Kasia, I tried to clear my mind of all prejudice and announced to him up front that my immediate interest in the Centre and its work and achievements was motivated by a paper I was requested to write on the state of the art of ART in Francophone Africa for the WHO Special Programme of Research Development & Research Training in Human Reproduction. On hearing this, Professor Kasia immediately pulled out a sheet from his drawer and brandished it to me, saying that it was a letter from the WHO appointing him something or other that I do not now recall and that, if the WHO needed any information on his Centre, they would surely have asked him. According to him, the information I wanted was the type of information any journalist would want and he considered it sensitive information, having a political dimension that only he could properly handle. I agreed that a journalist might seek the same information I was seeking but pointed out that I was seeking it for nonjournalistic purposes and that, the WHO apart, I was an academic, professionally interested in ethical problems arising within human reproduction. Whereupon, he gave me a lecture on what ethics should be: an a posteriori science and not an a priori enterprise in which priests and pastors, who know nothing about what you are doing, pontificate on what you should or should not be doing. I went away from the CCERH with the impression of a beautiful and wellequipped centre where nothing of significance seemed to be happening. On both of the two days I visited the Centre, I saw no patients waiting for consultation and, upon enquiry, I learned that even the widely publicized diploma course in endoscopic surgery for which a Cameroon government decree was signed and widely publicized over the mass media is still to go operational.

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Congress on endoscopic surgery In 1999 (1-3 December), about 750 delegates from all parts of the world gathered in Yaounde for a “Pan-African Congress on Endoscopic Surgery in Gynaecology” under the theme ‘What Gynaecological Surgery in Africa in the Year 2000?’ Going by the press reports (See CAMEROON TRIBUNE, Monday, December 06, 1999, centre spread, pp. 89), all the congress participants were unanimous that gynaecology in Africa in the year 2000 would be marked by great technological progress, particularly in endoscopic surgery. During this conference, which held at the Yaounde Conference Centre (Palais des Congres), an exhibition endoscopic surgery operation was performed at the CCERH and transmitted live by the Cameroon Radio and Television (CRTV) to Congress participants. The scientific patron or godfather of the CCERH, Professor Maurice Antoine Bruhat, of the Faculty of Medicine of Clermant-Ferrand in France, also took time to explain the advantages of endoscopic surgery as against other cut-open surgical techniques. According to him, ES is done without a major incision on the stomach, is less painful, more economical as the patient spends fewer days in hospital, poses fewer risks of infections as large wounds are not involved, and is aesthetically better as it leaves behind no major scars.

Assisted reproduction centre in Douala The Centre de Techniques de Pointe en Gynecologi-Obstetrique (CTPGO), Douala, went operational in the middle of 1996. The Centre, which works in collaboration with Dr. Guy Cassuto’s Laboratoire DROUOT (Paris), is run by a team of 4 gynaecologists and 2 biologists and is headed by Dr. Guy Sandjon. The other members of the team are: Drs. Berthe Bollo, Monique Onomo, Ernestine Gwet-Bell, Christian Pany and N. Akoung. I visited the CTPGO for a day on 23 May 2001. During the over three hours that I spent at the Centre, I noticed about 20 patients, some as couples, presenting for consultation or

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treatment. I had earlier had an appointment arranged by Professor Robert Leke (President of the Cameroon Gynaecological Association) for me to talk with the leader of the Centre, Dr. Guy Sandjon. I sat in his consultation waiting room for over two hours among his clients, with some of whom I engaged in spontaneous ‘small talk’ about the Centre, while, from time to time, he himself came out to encourage me to sustain my patience, so that he could finish seeing all his patients before receiving me. Of course, it did happen that my ‘small talk’ with some of the patients in the waiting room traversed our respective purposes for being there, otherwise, they were not informed and had no idea of why I was there and probably presumed that I was a fellow patient. When he finished consulting, Dr. Sandjon called me into his consulting room and I had a chat with him, and looked through an album of pictures of some of the procedures carried out on patients and of ‘Tommy’, the code name of their very first successful live birth of three years before. Since 1997, the CTPGO has attempted IVF-ET on a total of about 200 women, of which 45 have been successful, giving a percentage success rate of about 22.5% as against 25% reportedly in the industrialized world. The average age of the couples seeking to undergo the procedure in Douala is about 45 years, a factor on which the Centre partly blames the high rate of failure. The main indication for the treatment has been problems connected with the fallopian tubes of the woman (91%). A number of potential patients have presented seeking IVF-ET with sperm other than that of a husband but have, so far, been turned away on the grounds that the Centre is still too young, has no facilities for gamete storage and that the ethical problems involved here are more complex and require more careful consideration. Since 1997, the per patient cost of the treatment in Douala has progressively been reduced from 1.5 million (about US$ 2500) through 1.2 million (about US$ 2000) to 1 million (about US$ 1700) francs CFA today. The Centre claims that all its babies are doing fine and that it is following up on several of them systematically.

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Evaluation Although medically assisted reproduction, generally, and IVF-ET, particularly, generates a lot of interest in this part of the world, for reasons some of which have already been evoked, it also raises many questions and problems. It can be said that, for good or ill, ART has a place and a future in Africa. But one of the problems connected with it has to do with its cost. At a cost of 1 million francs CFA (about US$ 1700) in Cameroon, for instance, (said to be only about 25% of the cost elsewhere), this healthcare procedure is affordable to only a very small minority of the small though by no means negligible number of couples who stand in need of it anywhere in Africa. Infertility is commonly understood to be indicated if, after 12 months of regular normal sexual practice without contraception, a couple has not succeeded in achieving pregnancy (Pepperell et al. 1987, p. 1). Between 75%-80% of all couples are said to achieve pregnancy within these circumstances and, if the waiting period is extended to 24 months, around 90% of all couples succeed in achieving pregnancy. In the absence of any reliable statistics, there is no reason to suppose that the incidence of infertility in Africa is much more or much less than the global average which has been estimated at 10% (Harrison and de Boer 1977, p. v - Preface) It is not, therefore, a healthcare service that public health authorities could justifiably try to promote in the face of other urgent health and reproductive health problems facing a greater proportion of the population. It is thus most suitable for only the private sector, where pure economic considerations, the profit motive and promotional advertisement will be the main determinants of developments. ART, whose medium and long-term impact is still to be assessed, is liable to subvert and destroy traditional African socio-cultural ideas, attitudes, customs and practices that hitherto have adequately handled and cushioned the problem of infertility. In most parts of Africa, biological parenthood is de-emphasized to the advantage of social parenthood. Because of this, infertile persons, frequently under a veil of ignorance, can solve their problem of the need for children by the help not of a technology but of other

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human persons. The possibilities are many and varied: a brother or other relation discretely fathering a child for another, a sister more or less openly begetting a child for another with the latter’s husband, a wife marrying another wife1 to beget children for her with her husband, begging, giving and receiving of a child as a special gift, adoption of children, assimilation of children into families without prior intention or further calculations, etc. Although some sort of counselling would usually be given to couples seeking ART, the psychological effects of undergoing the procedures, especially on the non-successful cases, need to be very carefully assessed. And, although ART children are said to be not any different from any other children and to be generally doing fine, only careful and long-term study and follow-up can determine their psychological if not physiological status vis-à-vis children conceived and born more normally. For now, the fact that these children are ‘test tube babies’ is concealed from themselves and their neighbours, but, sooner or later, it will become known.   1 The practice is quite common among several African communities whereby a married woman who is unable to beget children of her own arranges to marry another woman, on whom she may personally pay the dowry, so that the latter could beget children with the former’s husband, and such children are considered as her (the ‘woman-husband’)’s children. For a description of this practice among the Igbo of Nigeria, see Uchendu 1965, pp. 50-51. Marriage in Africa is a very complex institution with a diverse variety of interesting variations from community to community. Among my own people, the Nso’ of the Bamenda highlands of Cameroon, while the variation described above was not practiced, some ‘Queen Mothers’ such as the famous Yaa wo Faa (Tangwa 1998, p. 7) could marry many other women who begot children (with any men of their own choice) and such children were considered as the Yaa’s children. That is how some Nso’ people today proudly pass for second-degree princes and princesses (won-wonntoh) when, in fact, they have no drop of royal blood in them. The bottom line is that, in many parts of Africa, biological parenthood is downplayed in favour of social parenthood and that marriage is considered as being more of a family, lineage and community affair than a contract between individuals (Lantum 1982, pp.295-296).

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Furthermore, infertility might have a genetic origin and the resort to ART to solve this problem means that the genetic defect involved is sustained and perpetuated in the population in such a way that resort to the technology will be the only option for an ever-increasing number of persons within that population. So, the more ART is used to solve infertility, the more will infertility increase. This prospect needs to be carefully weighed against the present benefits of providing satisfaction to sterile couples or other persons seeking non-conventional parenthood. The providers of ART in Africa presently operate within a legal and ethical vacuum, as the legal systems of most African countries have not yet caught up with the rapid developments in the field of reproductive health, as indeed in many other domains, while precise ethical guidance is not yet available. There are therefore real dangers of abuse and the possibility of unregulated experimentation without any fear of consequences or repercussions. Providers are thus left with only their own personal moral sensibilities and sensitivity or their consciences as the guiding lights for their actions and acts within the field. But ART is certainly an area where personal morality and good intentions alone, while necessary, are far from being sufficient. The domain belongs to public morality and needs both clear ethical guidelines and appropriate legislation. Above all, the wider implications of ART – its mechanization of reproductive processes, its severance of the link between ‘love making’ and ‘baby making’, its dispelling of the mystery of procreation through human mastery, its de-mystification of motherhood, so central to the status of the women in African cultures, its reduction of reproduction to production and the human control and obsession with quality implied, etc. – would be quite hard to harmonize with the most general of African metaphysical and religious conceptions and beliefs, values systems, ideational and ideological thrust, customs and consolidated practices.

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Conclusion There seems to be some contradiction about the worldwide concern with, interest in and promotion of ART that needs recognizing. How can this concern and interest be reconciled with the global emphasis on and campaigns for population reduction, whose success can be seen in the downward trend of population growth, especially in the industrialized world? In describing the advantages of endoscopic surgery (Vide supra) Professor Maurice Antoine Bruhat quite ironically remarked that the greatest challenge of medicine in the third millennium would be the control of reproduction because it is no longer desirable to continue breeding at random and filling the earth with great numbers of people. Concern with population reduction would seem more consistent with encouraging the infertile courageously to accept their condition rather than trying to do everything to help them overcome it. Before asking (any of) the fertile to voluntarily refrain from procreating in the interest of population control, would it not be logical first to ask the infertile to voluntarily spare themselves the trouble, cost and pains of medically assisted reproduction? As a fertile person, to become aware of the trouble and pains infertile persons take just to get a child, is to realize just how lucky one is to be fertile. Such a realization is not likely to be a help towards the prospect of voluntarily refraining from procreating, which alone can eventually help to reduce the population growth rate of poor or impoverished African countries or communities to manageable proportions. Although at the individual personal level African people’s attitudes towards ART may be determined by their technophobia or technophilia, it is clear that, at the level of society or culture in general, technology as such is not what counts but rather the uses to which it is put, its general implications and the surrounding packaging with which it comes. In my natal language, Lamnso’, there is the saying: ‘wan dze wan a dze lim nyuy’ (a child is a child, the handiwork of God), which connotes the unconditional acceptance and love of a neonate, irrespective of its individuating and particularizing characteristics. (Tangwa

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2000, p. 39). This, incidentally, has the implication, among others, that the ART child would be as equally welcome and as equally loved as any other child conceived and born in any other manner. The moral implications of this saying are very important in view of the innumerable differences and enormous variety with which individual babies/human beings come from the hand of God or Nature. In view of this, one of the deeper and more important implications of ART is that it is inevitably concerned with quality control (Fletcher 1988, pp. 16-17, 77, 152, 159-160) and that this concern has the direct implication that we can no longer say that a child is a child, the handiwork of God, but rather, in this case, a deliberate work of human hands or, more precisely, of human technologists. Fletcher’s work just cited, which attempts to discuss the ethics of increasing human control of the reproductive domain, is a paradigm of optimism and big thinking about reproduction technology. The work is full of such expressions as: ‘quality control’, ‘controlled human baby making’, ‘increasing the quality of the babies we make’, ‘human reconstruction of humans’, ‘biological manufacture of human beings to exact specifications’, ‘discarding the surplus’ etc. In the African perspective, within the context that I have tried to describe, suggesting that one putative baby is of ‘better quality’ than another would be considered quite outrageous, if not completely meaningless. Part of the ‘packaging’ of ART, as it comes to other peoples and cultures from the industrialized Western world, that would not sit well with African ideas and attitudes is its almost overt connection with business and commercialisation, patenting and marketing, talk about quality control, shopping and advertising, and all the media publicity that goes with these. This packaging can and needs to be modified or changed if ART is to be firmly implanted on the background soil of traditional African culture, customs and practices. Within that background, the category of mystery, the God-metaphor and the constant affirmation of human limitations and fallibility are very important and cannot be easily discarded or ignored.

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References Fletcher, Joseph (1988), The Ethics of Genetic Control: Ending Reproductive Roulette, Buffalo, New York: Prometheus Books. Harrison, R. G. and de Boer C. H. (1977), Sex and Infertility, London, New York, San Francisco, Academic Press. Lantum, Dan N. (1982), Nuptiality in the Jakiri District of Cameroon’, ABBIA, 38-39-40, 273-298. Pepperell, R. J., Hudson, Bryan and Wood, Carl (1987), The Infertile Couple, Eddingburgh, London, Melbourne and New York, Churchill Livingstone. Tangwa, Godfrey B. (1998), Road Companion to Democracy and Meritocracy: Further Essays from an African Perspective, Bellingham, USA, Kola Tree Press. Tangwa, Godfrey B. (1996), ‚Bioethics: An African Perspective’, BIOETHICS, ISSN 0269-9702, vol. 10, No. 3, 183-200. Tangwa, Godfrey B. (2000), ‚The Traditional African Perception of a Person: Some Implications for Bioethics’, Hastings Center Report 30, No. 5, 39-43 Uchendu, Victor C. (1965), The Igbo of Southeast Nigeria, New York, Chicago, San Francisco, Toronto, London, Holt, Rinehart and Winston.

CHAPTER SEVEN MORAL STATUS OF EMBRYONIC STEM CELLS: PERSPECTIVE OF AN AFRICAN VILLAGER

The hand that reaches beneath the incubating hen is not guiltless - African adage-

[Previously published in Bioethics. 21(8): 449-457, 2007]

Introduction I am not a ‘researcher’ on African villagers. I have neither competence nor inclination to do ‘empirical research’ let alone on African villagers. I am an African villager and the villager to whose perspective or opinion allusion is made in the title of this paper is none other than me. Were I to attempt doing research on African villagers, I would be up against an insurmountable egocentric predicament. I have used the adage above and the story of the hen and the egg below simply to recall the worldview and metaphysical milieu within which my argument on human embryonic stem cells has become viable. They are heuristic devices and mere riders to my argument. The argument itself, I believe, can stand independently of its surrounding context, packaging and metaphor of presentation; and, because it is expressed in the English language and attempts to conform, more or less, to the Western paradigm for academic communication, may evoke skepticism regarding its African label. However, no village in the world and no culture is an island unto itself. Cultures form partly overlapping and intersecting concentric circles, giving cultural purists an impossible task. I am, of

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course, both situated and embedded, but I am less concerned about this fact and much more concerned about making a philosophical argument that aims at rising above contingent particulars to the level of the philosophical/universal. My intuitive starting point is that, in spite of the increasing harmony in the chorus of support around the globe for the creation of ‘human embryonic stem cells for therapeutic purposes’, the very simple and straightforward question of what they really are still needs to be clearly and unequivocally answered, as the first step towards determining their moral status and passing any ethical judgment on such creation and the uses to which any type of human embryonic stem cells might be put. My simple and straightforward purpose in this paper is clearly and unequivocally to attempt answering this question and addressing the issue of the moral status of human embryos, against the background of traditional African moral attitudes, sensibilities and sensitivity. The question of whether it is morally right or wrong to create human embryonic stem cells and what would be morally right or wrong to do to or with such entities obviously depends on the prior question of what they are, and what they are also determines their moral status. We treat, say, a piece of wood in certain ways because it is a piece of wood; we treat a dog in certain ways because it is a dog and we treat a human being in certain ways because it is a human being. It would be inappropriate and possibly morally wrong to treat a dog the way we would treat a block of wood or a human being the way we would treat a dog. On the other hand, we need to separate carefully the question of how something comes about from the question of its moral status and/or worth. I would not here directly be addressing the issue of the moral rightness or wrongness of cloning or of embryonic stem cell research, let alone the question of whether or not they should be legally proscribed, which have been much discussed in recent times. The question of the nature and status of embryonic stem cells is, however, one on which

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policy-makers, politicians and lawmakers need to inform themselves thoroughly and to reflect adequately before attempting to legislate about it; for there can be no better reason for scraping, abrogating, amending, disregarding or defying a law than that it is morally repugnant and/or unjustifiable. Of such a putatively bad law it is better it were never made. But one good thing about the law is that it is always amenable to modification, abrogation or amendment, if and when it can convincingly be demonstrated to have been mistaken.

What are embryonic stem cells? ƒ Embryonic stem cells (ESC) are derived from embryos – that is, ova fertilized inside a woman’s body or outside the body in vitro. The embryos from which human embryonic stem cells are derived are usually four or five days old, called blastocysts; ƒ ESCs derived from in vitro fertilization and cultured in the laboratory are usually for research purposes; ƒ Such cell culture results in embryonic stem cells which can be frozen and preserved, exported to other labs for further culture and experimentation; ƒ Many diseases might be treatable by transplanting cells generated from human embryonic stem cells: Parkinson’s disease, diabetes, traumatic spinal cord injury, Purkinje cell degeneration, heart disease, etc. ƒ All stem cells are capable of dividing and renewing themselves; ƒ They are unspecialized, but can give rise to specialized cell types; ƒ They lack tissue-specific structures to permit specialized functions, but can give rise to specialized cells, e.g. heart muscle cells, blood cells, nerve cells, etc. ƒ Stem cells, in themselves, cannot be the subject of moral concern as they cannot pretend to have human ontological status; ƒ Only the embryos from which the cells are derived can pretend such status and are the reason why ESC research may be morally questionable;

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ƒ ESCs are said to be pluripotent; they can become all cell types of the body; ƒ Adult stem cells (ASCs) are limited to differentiating into cell types of their tissue of origin; ƒ ASCs are, however, said to suggest plasticity or ability to increase the number of cell types they can become; ƒ ESCs can easily be grown in large numbers but ASCs are rare in mature tissues and cannot easily be multiplied in cell culture; ƒ For therapeutic purposes, ESCs have the advantage over ASCs, in that they can be grown in large numbers; ƒ ASCs, however, may have the potential advantage that in therapeutic use, where the same patient’s cells are cultured and reintroduced into the patient, there would be no immune system rejection, a problem with transplant surgery and potential problem with donor embryonic stem cells.

Having moral status/worth To have moral status or worth is to count/matter, to have value, from the moral point of view or perspective. The moral point of view or perspective is that from which anything is viewed and considered in its own right as an end itself and not as a means or an adjunct to the ends, purposes of another. Moral value and worth are different from instrumental, utilitarian, pragmatic, economic values/worth, although these also have their own moral ramifications and implications. Moral value/worth is the rock-bottom intrinsic value on which other values may be built or superimposed. Now the question of how or how not to treat/use something partly at least depends on what the thing is. And what a thing is, is a metaphysical question, specifically an ontological question, which conceptually is logically prior to all other considerations about the thing in question.

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Ontological status of human embryos Biologically, when does a human being come into being? A human being can be said to come into being when a human egg (ovum) and a human seed (sperm) happen to meet and successfully to fuse in such a way that fertilization or conception can be said to have occurred. This event usually happens in the womb of a human female but may also and today increasingly be made to happen outside of the womb in a laboratory dish (in vitro). A human embryo emerges somewhere along the time line after this momentous event of fertilization or conception. Now is the method/manner by which an embryo comes about relevant to its ontological status, that is, to what it is, in this case, to its being an embryo? Obviously, not! An embryo is an embryo! If we call the immediate result of fertilization or conception simply a conceptus, there is a series of scientific terms that have been applied to this entity in its developmental progress. Such developmental nomenclature, in ascending order, includes: blastocyst, zygote, embryo, foetus, neonate, baby, infant, child, minor, adolescent, adult, etc. This development is, moreover, accompanied by the emergence or acquisition of different attributes or capacities or characteristics: sentience, conscious awareness, cognition (moods, emotions, thoughts), competence, responsibility, and culpability. The critical question is this: Can a morally significant line be drawn anywhere along this developmental continuum? Or, to put it another way, can a difference of kind as opposed to degree be established between any two of these designated categories? We should answer in the negative on the weighty ground that an embryo, for instance, considered from the moral point of view and perspective, could not pretend to have greater moral value/worth than, say, a zygote or blastocyst. It could, of course, lay claim to greater capacities or attributes, but such capacities or attributes might be significant and important only from the point of view of moral responsibility, not from that of moral worth/value.

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Until a human being acquires the attribute of competence, that is the capacity to make autonomous free choices, for example, s/he lacks moral liability, responsibility and culpability. But both before acquiring and after losing that attribute, s/he remains a human being, exactly equal in moral worth/value to any other.

Utilitarian consequentialism In the ongoing discussion about cloning and stem cell research, many people seem to imply in their arguments that we should determine the status of a cloned embryo from the uses to which it will be put. In this way, the alleged prolongation of human life expectancy that would be made possible (1200 years, according to some recent speculations!) or the ‘innumerable illnesses’ that could be cured or the ‘millions and millions of patients’ who stand to benefit from such scientific developments could easily acquire the ring, in the popular mind, of being part and parcel of the definition of a cloned embryonic stem cell. In spite of the popular appeal of consequentialist utilitarianism, if a procedure or course of action is unambiguously morally wrong, then no amount of putative beneficial consequences can morally justify it. This incidentally signals the problem with attempting to determine what actions/procedures are morally right or wrong solely from a consideration of their consequences. Consequentialist utilitarianism1 has a prima facie appeal not only because it accords with ordinary common sense in many situations but also because we do indeed make use of consequentialist reasoning in the many choices that we make daily. Its central idea of weighing and calculating consequences is also very attractive in that it accords very well with modern scientific and mathematical measurability, calculability, precision and the certainty they imply, thereby holding the promise (a false promise) of transforming ethics   1 See Tom L. Beauchamp and James F. Childress (2001): Principles of Biomedical Ethics. 5th Edition. Oxford, New York: Oxford University Press. Pp. 340-348.

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and morals from a field rank with controversy and disputes into one of verifiable objectivity where subjective prejudices have no place at all. The prospect of ‘evidence based ethics’ is no less appealing than that of ‘evidence based medicine’, but neither of them, as a holistic approach, it seems to me, can be satisfactory. As a general moral theory of human action, consequentialism is quite unconvincing and rationally indefensible; for the simple reason that no amount of supposedly good consequences can ever justify the intentional, free and voluntary performance of an action known or even only believed to be morally wrong. On the other hand, an honestly well-intentioned good act that produces unforeseen bad consequences cannot be said to have been a morally evil action. If I rescue a man from drowning and he heads home and immediately murders his pregnant wife and child, it cannot, by any stretch of the rational or moral imagination, be the case that my rescue action was morally wrong because its bad consequences by far outweigh the good consequences. Furthermore, any human action, considered in relation to its future consequences, has massive causal ramifications, which stretch infinitely into the future, such that our lack of certain knowledge about the future is by no means the only problem facing consequentialist assumptions. Given a glimpse of the massive chain of causal ramifications that is set in motion by any one of our actions, it would be bewildering to even start computing its consequences. The type of future knowledge required for consequentialism to be credible and viable is simply an epistemological daydream of omniscience. However, consequentialism is credible, viable, workable and important as a partial or subsidiary moral theory. In situations where we are dealing with alternative possibilities or courses of action whose moral rightness is not in doubt or with inescapable/unavoidable alternatives of evil actions, consequentialist reasoning and calculations are simply inevitable, in spite of our imperfect knowledge of the future and of the full causal ramifications of our actions. Such a partial or subsidiary moral theory might be derivable from

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what has been termed ‘rule utilitarianism’2 which is an attempt to salvage consequentialist utilitarianism from its most fatal weaknesses; at which point, however, its deontologist adversaries might triumphantly claim that it has effectively collapsed into Kantian deontologism. At any rate, as a generalized and ultimate ethical theory, utilitarianism in its consequentialist original version cannot work because the question it is designed to be able to answer, namely, ‘Which human acts/actions are morally right and which wrong?’ can only be answered retrospectively, long after it has ceased to be of any use as a guide for the morality of the acts/actions in question.

Categorizing human beings We could discriminate between human beings and categorize them according to innumerable putative criteria. But such discrimination and categorization has no bearing on the question of the moral status and worth of the beings thus discriminated and categorized. If any moral status or worth can be assigned to any human being, it is by virtue of the simple fact of being a human being and not by virtue of possessing any particular individual attributes or characteristics, attributes and characteristics that we gain or attain and lose at different points of our lives as humans. One of the best attempts in Western discourse to define human moral status and worth in terms of specifiable attributes and characteristics is that of the concept of ‘personhood’. As it turns out from this effort, a person is a human being who is competent, capable of acting responsibly and making free choices. But personhood thus defined effectively marks out human moral agents who are morally responsible and culpable for their actions rather than human beings who alone possess moral worth3. From the point of view of moral status and worth, a human being   2 Ibid, P. 343. 3 See Godfrey B. Tangwa (2000): The African Perception of a Person: It’s Implications for Bioethics. Hastings Center Report. 30(5): 39-43.

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is a human being, purely and simply by being a human being. Human beings who are not persons are capable only of being human moral patients, liable to be acted upon by persons but incapable of acting competently and responsibly. This lack in no way diminishes their moral status and worth as human beings and the moral consideration with which they should be treated. If anything, such lack of competence and the capacity to act responsibly argues for the greater moral sensitivity and consideration required by moral agents in dealing with such beings. They are vulnerable beings. Immature children, mentally handicapped people, ought and usually are treated by us with greater moral sensitivity and consideration, because of their incapacity to talk/fight back, their inability to help themselves. How morally monstrous would it be to assign them a lower moral status and worth on account of their incapacity, vulnerability and helplessness! Is it because of their inability to stage a demonstration down-town that they lack fundamental human rights? We can, of course, draw lines to mark the various developmental stages of a human being from the ‘moment of conception’ or from the ‘moment of cloning’ (?) but such putative lines, like all other criteria of discrimination or categorization, however useful they may be in other respects and for other purposes, have no bearing on the question of the moral status and worth of the developing entity. Moral worth should not be confused with economic or utilitarian worth or with any other type of worth considered from any other point of view and perspective than that of morality. To have moral status and thus worth is to matter and to count from the moral point of view, that is, that point of view from which anything is perceived and considered as an end in itself rather than a means or an adjunct to the ends and purposes of another. The status and worth of a human being is a metaphysical, ontological, datum that not even God/Nature, which supposedly created it, can do anything again to change or diminish. It is perfectly meaningful and sensible to

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distinguish between a foetus, an embryo, a zygote and a blastocyst, just as it is perfectly meaningful and sensible to distinguish between an adult, an adolescent, an infant and a baby. Meaningful lines can also be drawn among human beings on the basis of their various degrees of mental competence. But all such distinctions and categorizations have no bearing at all on the moral status or worth of the categories distinguished. Furthermore, it is not easy to draw sharp lines between these categories, but then, what would be the purpose of wanting to draw sharp lines? There is evidently no morally relevant purpose, beyond marking out responsible moral agents, in attempting to draw such lines, although they could be drawn for other, non-moral purposes. All human beings possess the same moral status and worth as human beings and as possible moral patients, although they possess different levels of responsibility and culpability as moral agents.

Sentience as a mark of moral status and worth? Bonnie Steinbock4 has developed one of the most interesting moral status/worth theories based on Joel Feinberg’s ‘interest principle’, elaborated in the latter’s Harm to Others (1983). The gist of her theory, which evidently is in many respects an improvement on personhood theories, is as follows: Morally significant entities are the type of entities to which rights are ascribable. A necessary condition for the ascription of rights is having interests, concerns, cares or a stake in things. This, however, is not possible without conscious awareness. Without conscious awareness, an entity cannot have desires, preferences, hopes, aims, goals, or care about anything. In other words, nothing matters to   4 Bonie Steinbock (1992): Life Before Birth: The Moral and Legal Status of Embryos and Fetuses. New York: Oxford University Press. See also Bonie Steinbock (2002): Moral Status, Moral Value, and Human Embryos. Unpublished Conference Manuscript, Santa Clara University 2002 Conference: “On the Who, What, and Why of Moral Status”). 

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non-sentient, non-conscious beings. (Steinbock admits that this line of argument would not convince someone with an animistic conception of the universe and, even though she does not know how to disprove such a conception, she is sure that it is inconsistent with a scientific outlook, although she does not say why a scientific outlook should be presumed preferable to an animistic one). Now, the most basic and primitive kind of awareness is sentience, the capacity to experience pain and/or pleasure, which evidently precedes higher cognitive states and capacities such as having thoughts, emotions or moods. For Steinbock, therefore, sentience marks the cut-off point for morally significant entities and, even though it is a matter of debate and dispute among the experts as to when exactly a human foetus becomes sentient, there is no doubt, in her view, that the very early embryo, such as pre-implantation embryos, cannot be sentient since it has not yet developed even the rudimentary structures of a nervous system. The obvious conclusion then is that the very early embryo is not a morally significant entity. A possible counter-argument to the above that Steinbock recognizes is the argument from potentiality which holds that even early embryos are potential human beings, on account of which they should have the same rights, especially the right to life, as actual human beings. But Steinbock thinks that this counter-argument commits a logical error in equating potentiality and actuality, the rights of a merely potential human being with those of an actual human being, whereas a potential human being has any rights at all contingent on its becoming an actual human being. If early embryos, potential human beings, are accorded the same status and rights as actual human beings, then we might as well, so her arguments goes, make the same concession to individual sperm and ova, which can equally be considered as potential human beings.

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In my view, the above argument, an attempted reductio ad absurdum, which is very well elaborated in Harris5, as Steinbock recognizes, commits a more grievous logical error of its own, which logical error, moreover, is shared by the counter-argument against which it is addressed. But, before pointing out this logical error, it is worth remarking that the resort to ‘rights talk’ is of no help in this rational discussion, inasmuch as the metaphoric and heuristic language of rights, while it certainly has a great emotive value in the modern world, itself needs a basis and grounding in morality. Also, it needs pointing out that non-conscious, non-sensient living things and even inanimate things should not so easily be brushed aside as having no interests, once it is admitted that interests need not consciously be formulated, let alone expressed. It may be quite wrong to think or assume that pre-conscious, pre-sentient entities such as fertilized eggs have no interests. It is evidently in their interest, and why not then conceivably their interest (?) to be properly enwombed or incubated for their normal and logical development. This could even be said (metaphorically speaking) to be their uniquely overwhelming interest until they develop the capacity of having other interests. Of course, it cannot be claimed that ‘if Y is in the interest of X then X necessarily has an interest in Y’. But it can be claimed that ‘if Y is in the interest of X, then X should and would have an interest in Y, provided only that X realizes that Y is in his/her/its interest’. Furthermore, and in the same metaphoric mode of reasoning, it can be argued that every living thing has an interest, a kind of metaphysical interest, in continuing to live and even that every existent (being), living or non-living, has an interest in continuing to be (subsisting). Is this not, perhaps, the reason that, matter, while it can change from form to form, cannot completely be destroyed or annihilated, or why is it really so difficult to destroy matter?

  5 John Harris (1985): The Value of Life: An Introduction to Medical Ethics. London: Routledge and Kegan Paul. Pp. 11-12.

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Now to the logical error committed in thinking of human embryos as potential human beings. First the counter argument: The counter argument was that even though a human embryo may not pass the sentience test to qualify as having interests of its own, it should be accorded the same rights as actual human beings, including the right to life, on account of being a potential human being. Steinbock’s and Harris’s retort to this is that, if we grant pre-implantation embryos the same status and rights as actual human beings, then we might as well grant gametes (ova and sperm) the same status and rights, since they can also be considered as potential human beings. Harris’s elaboration referenced above is worth quoting: To say that a fertilized egg is potentially a human being is just to say that if certain things happen to it (like implantation), and certain other things do not (like spontaneous abortion), it will eventually become a human being. But the same is also true of the unfertilized egg and the sperm. If certain things happen to the egg (like meeting a sperm) and certain things happen to the sperm (like meeting an egg) and thereafter certain other things do not (like meeting a contraceptive), then they will eventually become a new human being.

The grievous logical (category) error committed on both sides of the argument here is the constant reference to an embryo, a fertilized egg, as a potential human being, whose rights including the right to life (!) should or should not be protected. An unfertilized egg and sperm are certainly potential human beings and remain in that state of mere potentiality no matter how close they may come, short of joining and fusing. Every time a mature and fertile man and a mature and fertile woman come into close proximity such potentiality is in danger, but only in danger, of transforming into actuality. Until something happens that brings the ovum and sperm together, the danger remains forever only a danger, an actualizable but unactualized dispositional property. But, from the moment that the egg and sperm, through whatever process, join and fuse, potentiality has transformed into actuality, fertilization has occurred. From

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that moment, an existent, a living thing, a human being, has been created. Let biologists give us any name they like for this entity and it will remain a potential zygote until it satisfies their criteria for zygotehood, a potential embryo until it develops to an embryo, a foetus, a baby, an infant, etc. A human being cannot be a potential human being because nothing can be both potentiality and actuality at the same time. Once a human egg is fertilized, its one and only chance as potentiality to become a human being has been irreversibly actualized and it now becomes potential other things (foetus, baby, stubborn child, adolescent, adult, embryologist, philosopher, etc.) but never a potential human being again.

Conclusion: African villagers and their hens In spite of the rather rapid breakdown in traditional ways and practices in recent times, in my natal village of Ndzenshwai-Shisong, it still is the case that practically everyone knows the household to which nearly every hen and every cock, scratching around, belongs. Now, when a hen starts laying eggs, in our village, it is a note-worthy event. From time to time, people would approach the owner of the hen begging for or asking to buy an egg, while the owner would occasionally also pick an egg from the nko’ ngwΩv (the specially prepared basket where the hen lays her eggs) to prepare for a meal. But, from the moment the hen starts permanently sitting on the eggs, it is taboo to remove any more eggs, and any attempt to do so is always greeted with a loud cry from the incubating hen, clearly calculated as a symbolic protest against such unbecoming behaviour. Sometimes, of course, in desperation, the taboo is broken, but not without considerable feelings of guilt. These feelings of guilt may increase or decrease, depending on whether, on cracking the egg, the yoke is discovered to be still bright yellow or to have changed or started changing colour - a clear indication that a chicken, a living being, was already in the early stages of formation. In our village, the hand that reaches for an egg from under the warm underneath of an

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incubating hen is a guilty hand! This does not, of course, mean that a fertilized incubating egg is already a full and complete chicken, ready to cackle and scratch around the yard, caught and sold on the market day, have its neck wrung, plucked clean and prepared for a meal, or that it should be treated in the same way a chicken is treated. What it does mean, however, is that it has crossed the wide metaphysical gap separating the beings from the non-beings of the chicken family. Some people think that cloned human stem cells have a different moral status from other human concepti because they are brought to being without any intention of having them develop into full human beings. Human life may necessarily begin with conception but, it is argued, not all conception necessarily begins a human life6. But, if we cannot draw a morally significant line on the basis of the developmental stage of a human being, as argued above, neither can we draw one on the basis of the purpose and intention of its creator. Be that as it may, it is a fact that, even before the discovery of in vitro fertilization (IVF) and cloning in particular, human beings were already aware of the moral status and worth of human beings, without first being privy to the aims and purposes for which God/Nature created them. The ability to fertilize human gametes extracorporeally or the ability to clone human reproductive cells may be a wonderful or a terrible development, but this has nothing to do with the metaphysical and moral status of the entities so created. Our legitimate interest in curative medicine and in biomedical research should not lead us to seek a stipulative definition that unjustifiably discriminates against and excludes some human entities from the category ‘human’. I have tried to keep my argument clear and simple and dare hope that I have succeeded in doing so. It has not been my concern here to argue to the question whether or not   6 In June 2002, at a public lecture at Johns Hopkins University in Baltimore, USA, I listened to the well-known American ethicist, Arthur Caplan, arguing along these lines.

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therapeutic stem cell research, or stem cell research of any other description, per se, is morally right or wrong. My more limited preoccupation here has been with the moral status of human embryos, no matter their origin and purpose. Whether or not embryonic stem cell research is justifiable, it evidently cannot be justified on the grounds that humanly created human embryos have a different moral status from any other type of human embryos, just as it cannot be argued that human embryos have a different moral status from other human beings simply on the ground of their being lower down the developmental ladder towards personhood or adulthood. A newly born human baby is not and cannot be treated as a fully developed human adult; but this in no way implies that it has a different and lower moral status/worth from that of a fully mature human adult. Embryonic stem cells are human beings at the very earliest stage of their individuated existence and development and, from the point of view of ontological or moral status, a human embryo is not different from any other human being at any other stage of its being or development and a reproductive clone in no way differs in its moral status from a therapeutic clone. Any attempted justification of cloning and/or human embryonic stem cell research should face squarely the human moral status and worth of every human embryo, irrespective of how it happens to come about, irrespective of the aims and purposes of its creator. Human embryos, just like other human entities, ought not to be treated with levity or dealt with in a wanton/impunious manner. The reason for this is not because a human embryo is already a full and complete human being which should be treated in exactly the same ways as a fully mature human being. A human embryo is not a fully mature human being and cannot be treated as such. However, a human embryo is a being that has crossed the great metaphysical chasm separating humans from merely potential humans and actual non-humans. All human beings are not exactly the same; each possesses quite different descriptive and individuating characteristics; but all human beings are equally human, which is the basis of the metaphor of moral

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equality and the idea of moral status as distinguished from other kinds of equalities and statuses. Introspection does not reveal any degrees in the individual’s perception of his/her own moral worth or human-ness, through all spatiotemporal vicissitudes, from the first moment of selfconsciousness until its cessation. The individual’s own personal sense of moral worth would seem to be intrinsic and permanent. A morally significant line cannot be drawn between human embryos and other human beings. To attempt drawing such a line is to start on a slippery slope without any wedge. There is no implication in all I have said above that stem cell research in and of itself is morally wrong, since stem cells as such have no moral status/value. Moreover, we do often carry out morally acceptable research on other categories of humans besides embryos, including fully competent human adults. My point is simply that stem cell research ought to admit and recognize the fully human moral status of the embryos from which stem cells are derived. From my point of view, use of adult stem cells and of embryonic stem cells derived from, say, spontaneous abortees would be morally less questionable and less problematic. Is there any ethical reason why stem cell research should not limit itself to deriving stem cells from such ethically less questionable and less controversial sources?

CHAPTER EIGHT THIRD PARTY ASSISTED CONCEPTION: AN AFRICAN PERSPECTIVE1

[Previously published in Theoretical Medicine and Bioethics. 29(5): 297-306, 2008]

Abstract The central importance of reproduction in all human cultures has given rise to many methods and techniques of assisting reproduction or overcoming infertility. Such methods and techniques have achieved spectacular successes in the Western world where processes like in vitro fertilization (IVF) constitute a remarkable breakthrough. In this paper the author attempts reflecting critically on assisted reproduction technologies (ART) from the background and perspective of African culture, a culture within which human reproduction is given the highest priority but which also exhibits a highly ambivalent attitude to modern technology-assisted methods of reproduction. The author considers the ethical crux of reproductive technologies to be linked to the issue of the moral status of the human embryo and argues that a morally significant line of demarcation cannot be drawn between embryos and other categories of humans.   1 I thank the staff of the National Reference Center for Bioethics Literature (NRC), Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA, for their kind help in making some literature available to me while I was researching on this paper. I thankfully acknowledge the support of the Alexander von Humboldt Foundation in the writing of the paper. 

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Keywords Assisted human reproduction; infertility; in vitro fertilization (IVF); African culture; human embryo; moral status; industrialized Western world

Introduction Human reproduction is important within all human cultures. This, in fact, is an understatement. It is more accurate to say that reproduction is central to all human cultures; so central that it shapes, affects and influences most other aspects of culture. It is therefore not surprising that infertility is perceived with varying degrees of seriousness as a problem within all cultures. Within the group of sub-cultures which can be bracketed under the descriptive term ‘African’ and which form the general background of my reflection here, infertility is certainly perceived as a very serious problem for which various cultural ‘solutions’ have been found. Attempts to overcome infertility have given rise to various practices all over the world. Among such practices, one of the most recent is in vitro fertilization and embryo transfer (IVF & ET) which stands out as a global breakthrough in conception assistance and the fight against infertility that can hardly be ignored by any culture in any part of a modern world, a world that is increasingly becoming a veritable ‘global village’. For that reason, IVF has become almost synonymous with assisted reproduction or conception, whereas other methods of ‘assisting’ do exist and IVF does come with its own very serious problems – social, legal and ethical. Assisted Reproduction Technologies (ART) have developed with such speed that legislation, socio-cultural norms and practices everywhere are breathless trying to catch up with the speed of the evolution of things in the domain. The world’s first ever ‘test tube’ baby, Louise Brown, was delivered by caesarean section in England a little over two decades ago (July 1978) as a global novelty that instantly

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transformed Drs. Patrick Steptoe and Robert Edwards, the scientists responsible for the feat, into world celebrities. Today things have advanced so fast and so far that debates and controversies over abortion and the moral status of the human foetus have been abandoned unsettled and attention focused on novel and more exciting issues, such as plural parenthood, planned orphan-hood (Landau 1999), designer babies, gametes trade, reproductive and therapeutic stem cells research and cloning. One is reminded of a monkey that enters a farm and, instead of eating one pumpkin to the finish, chooses instead to bite all the pumpkins, without eating any completely, to the finish. Human technological culture seems profoundly incapable of pausing to take stock of its own successes, let alone failures, or even of just taking some time to savour its achievements before moving on; so powerful is the momentum for progress and continuous innovation that one is again reminded of a heavy vehicle without any brakes rolling down a steep slope. The combined efforts of religious opponents, militant feminists and other critics of the human reproduction revolution have so far failed to slow down, let alone stop, the continuously accelerating evolution of things in the domain. It is in the domain of reproduction more than any other that one finds tantalizing evidence of the possibility that technology has outrun and taken control of culture, just as culture can be said to have slowly seized the initiative from nature (Ferre 1994, pp.237-238). No culture, no peoples, and no part of the globe can remain indifferent to these developments in human reproduction options, in spite of their being entirely the fruit of the flourishing of the material aspects of Western culture, because they concern what is of great importance and interest to all human beings and because Western culture has a highly globalizing (let alone colonizing) impulse, thrust and effect. It is time to pause, to take a critical look at, to reflect on and to assess the aims, ends, purposes and appropriateness of the various methods and practices of assisted conception. Here I attempt such a critically reflective exercise, as a participant observer, from

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the background and perspective of African (particularly Cameroonian) culture, on a few aspects of ART which I consider crucial from an ethical point of view, and from the vantage position of an African who has relative familiarity with Western industrialized culture, ways of life and practices.

State of the art Assisted reproductive technologies (ART), an achievement of what is generally termed ‘the Western world’, started as a way of helping infertile/childless couples, highly motivated to become biological parents, to achieve their desire. But within a couple of decades, they have developed to the extent of completely shattering even Western traditional understandings and definitions of parenthood. A good glimpse of the state of the art in the domain might indirectly be got from the types of legal and social problems and perplexities arising in Western contexts from recent practices and activities. In recent litigations, particularly in the USA and Australia, where these technologies are most highly developed and used, as many as five or more people have been known to dispute and fight over rightful parenthood of a single child (Christian Science Monitor, January 07, 2002; Steinbock 2002), because it is indeed now possible for a baby to result from a donated or purchased egg, a donated or purchased sperm, a donated or purchased embryo, a hired womb, and a well-to-do couple standing by to receive and raise the child. Furthermore, the technique of cyro-preservation (by which gametes as well as embryos can be frozen for future use) has made it possible for the biological parent of a child to be someone who is no longer living, a fact which only a few decades ago would have been inconceivable. The traditional connection, within all human cultures, between parenthood and responsibility for the upbringing and welfare of the child has thus become uncertain and confused. In the emerging controversies, the courts and legal systems seem ill-equipped to adjudicate, for lack of familiarity with the issues at stake and of firmly established precedents.

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Heretofore, a motherhood dispute anywhere could definitively be settled by convincing proof of the act of “giving birth” – the person who gives birth being indisputably the parent, mother, of the born child - ; but today, a couple could seek to have their names entered as the parents in the birth certificate of a child, related or not related to them in any way, that has just been delivered by another woman. Even more intriguingly, a woman could today become pregnant with her daughter’s child and give birth to her own grandchild (Battersby 1987a&b). Traditional adoption laws and practices are also fast becoming obsolete with the phenomenon of embryo adoption or donation (for those who equate the embryo with other freely disposable personal property). Furthermore, the increasing phenomenon of postmortem conception is raising social and legal perplexities as to whether the name of a dead person can rightly be entered in the birth certificate as the father of a newly born child and/or whether such a child can claim any right of inheritance, irrespective of the dead person’s will or absence of a will. What these perplexities and the controversies they engender indicate is that ethics, which can be considered the parent of both social practices and legal systems, should lead the way in this difficult terrain.

Assisted conception and African culture How do developments in assisted reproduction impact on African culture and what are the prospects of modern methods of assisted conception in Africa? One of the least controversial generalizations that can be made about Africa and African culture is that procreation is greatly valued in Africa and within all African sub-cultures (Tangwa 2002, p.1). Of course, the same is true to varying degrees in all human cultures all over the world. But in Africa and within African cultures, the great value attached to procreation manifests itself more glaringly in the existence of large monogamous families, the practice of polygyny/polyandry, and elaborate social rituals and ceremonies connected with birth, puberty, circumcision, marriage, motherhood and death. For African women in particular, motherhood is

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considered the plenitude of womanhood and, in spite of increasing Western influences, very few African women indeed would willingly and voluntarily accept to remain childless under any putative set of circumstances. In Africa the ideas of a childless marriage or of marriage for mere companionship and sexual gratification, accepted without question in other places and cultures, are ones that, if not totally absent, are considered as veritable oddities. In Africa, infertility and childlessness are the main causes of breakup of marriages as well as the justification for the widespread practice of polygamy and sundry other forms of marriage. Infertility and other causes of childlessness are perceived as serious problems requiring serious attempts at solutions and there is scarcely any other category of patients who consult the traditional healer or the Western-trained modern doctor more than men and women desirous but unable to procreate for whatever reason. Traditional solutions for such conditions have usually included not only attempts to treat infertility and other causes of childlessness, such as erectile dysfunction and impotence, but also socio-cultural practices aimed at overcoming the problem of childlessness for those whose infertility or other causes of childlessness have defied treatment. Such practices are many and varied (Tangwa 2002, p.8) including, inter alia, discrete assistance from fertile or more potent relatives or friends, heterosexual woman-to-woman marriages (Uchendu 1965, pp.50-51), child gift, adoption, etc. For these reasons, biological parenthood is greatly de-emphasized to the advantage of social parenthood. In many African communities there is the saying or belief that only the biological mother of a child knows the true biological father of that child. Such knowledge is considered a privileged secret which she is never obliged to reveal except in some specific ritual contexts. The ideas underlying the saying include the belief that biological motherhood as opposed to fatherhood is a publicly easily verifiable fact, the justification or preference for social as opposed to biological parenthood and the adage that a child is a child irrespective

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of how it comes about. Of course, the biological mother of a child may not necessarily know its biological father and, with recent developments, the woman who gives birth to a child may not necessarily be its mother. But the perceived centrality and privileged position of women in procreation have fixed and defined the status of women in all traditional African cultures. The high value placed on offspring and parenthood and, by implication, on fecundity in Africa, means that, prima facie, all types of assisted conception generate a lot of interest. That is why IVF, which is of fairly recent introduction and whose prospects for really taking root cannot yet be confidently predicted, has spread rapidly in Africa, in spite of its prohibitive cost and very high rate of failure. Outside of the Republic of South Africa, where both the technology and practice of assisted reproduction are quite comparable to that of the Western industrialized world (Spiro 1972, Strauss 1983, Battersby 1987a&b, South Africa 1986a&b, Michelow 1988), the first tentative attempts at ART in the rest of Africa were not made until the mid-eighties. Today, however, there already are ART clinics in the following African countries: Nigeria, Ghana, Zimbabwe, Cameroon, Kenya, Sierra Leone, Senegal, Guinea, Togo, Benin and Uganda, although their individual success rates remain, in most cases, a matter of mere speculation, as they tend, outside of their publicity pronouncements, to be rather secretive about their activities and achievements.

Art in Cameroon In my own country, Cameroon, artificial donor insemination (A.I.D.) has been practiced intermittently at the University Centre for Health Sciences and the Central Maternity, both in Yaounde, since 1984 (Njikam-Savage 1992, p.907). Artificial husband insemination (A.I.H.) must have been practiced for much longer, although no facts and figures are available, because it is much less problematic, being generally in line with the traditional practice whereby a parent or other older relative sometimes assisted a young

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couple in teaching them the act of proper coitus for achieving pregnancy. In the work just referenced, Njikam-Savage carried out an investigation of the possible determinants of the acceptability of A.I.D. among both fertile and infertile couples, presenting for consultation at the University of Yaounde Centre for Health Sciences. Her sample size comprised 102 infertile and 98 fertile persons, of whom 113 were females and 87 males. Her study revealed many contradictions and ambivalence in attitudes towards A.I.D.: on the one hand a great need and interest in achieving pregnancies, and, on the other, a reluctance to accept A.I.D. This is not surprising, inasmuch as infertility, especially for the woman is a highly undesirable condition. The childless woman suffers …considerable social discrimination especially in the rural areas. She is often the centre of hostility in addition to being considered a person to be feared and hated because childlessness is often seen as a retribution for some wicked deeds performed in the past or previous promiscuous life (Ibid, p. 908).

It would thus seem logical for the infertile woman to avail herself of any means to achieve pregnancy, thereby escaping social scourge and attendant psychological trauma. However, marriage within the culture is essentially patri-local as well as a family/lineage rather than an individual affair, and a woman is considered as giving birth to a child for her husband and his family. The method that a married woman uses to achieve a pregnancy must therefore be one which is also acceptable to the husband and to the extended families on both sides. Presently two ART clinics, which I have personally visited, do exist in Yaounde and Douala. In Yaounde, the Centre de Chirurgie Endoscopique et Reproduction Humaine Chantal Biya (CCERH), a subsidiary of the Fondation Chantal Biya, is well known in the whole of the Central African sub-region for its well-publicized claims on radio and television to be performing successful endoscopic surgery conceptions and even to be running a diploma course in the specialization.

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But, in April 2001, when I went to the clinic to enquire about its activities and its success and failure rates, no information, unfortunately, was forthcoming. A Nigerian friend and collaborator of mine, Osato Giwa-Osagie, himself an African pioneer in the domain (having established the first IVF clinic in Lagos in 1984 and achieved his first successful birth in 1989) had the same experience in Ghana when he tried to get information on two IVF clinics in Tema (GiwaOsagie 2001). In spite of the interest, even excitement, generated by in vitro methods of conception in Africa, this technology would seem to raise more problems and worries than the solutions it presently provides. Firstly, by comparison with the other urgent health needs of the continent, IVF addresses the reproductive needs of only about 10% (Pepperel et al. 1987, p.1) of the populations, of which only a tiny fraction, moreover, can afford the cost. Secondly, for some decades now, it has been quite evident that, to achieve sustainable development, Africa needs to curb rather than increase its birth rate. Such a need is generally not consistent with the resort to or promotion of extraordinary methods and means of conception. Thirdly, given the problems and uncertainties connected with this method of conception, it is debatable whether it is wise to allow it to subvert hitherto quite satisfactory socio-cultural methods of dealing with problems of infertility. Fourthly, the lack of an appropriate ethical and legal framework for IVF practices in Africa creates the danger of the possibility of unrestrained experimentation on enthusiastic but inadequately- informed innocent subjects. Lastly, in spite of its prima facie and superficial appeal, IVF is fundamentally antithetical to the deepest of African cultural values in its de-mystification and mechanization of procreation, its substitution of production, depending on human technologists for reproduction, depending on God/Nature, and its debasement of motherhood, the basis of the fertility and maternal cults and the status of women, so central in the metaphysico-religious conceptions of African cultures. For these among other reasons, there is understandable ambivalence in the attitude of many Africans towards artificial methods of assisting conception (Njikam-

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Savage, O.M. 1992; Oshuntokun 1992). Such ambivalence would seem to be further justified if we consider the contradictions and controversies surrounding technologyassisted reproduction within its own domain of origin.

Medically assisted reproduction in the Western industrialized world Medically assisted human reproduction, involving extracorporeal fertilization, is a fruit of developments in Western science and technology. As such, it is in harmony with the main foundational pillars of Western culture – its possessive individualism, scientific spirit, technophilia and commercial impulse. A paradigmatic gamut of some of the reasoning and arguments in favour of the technological revolution in human reproduction can be found in The Ethics of Genetic Control: Ending Reproductive Roulette (Fletcher 1988). Fletcher who considers the artificial glass ‘womb’ (petri dish) a much safer environment for gestating human babies than the human womb which he terms a very dangerous and hazardous environment, is an ardent supporter of the technological control of reproduction. Such control has reached the stage where open commercial advertisements are placed in college campus newspapers and magazines seeking egg ‘donors’ or vendors with a certain level of intelligence quotient (I.Q.) and certain physical attributes and characteristics and where test tube babies are said to be poised to “hit the stock market” (Spallone & Steinberg 1987, p.6). There have, however, also been Western technophobes and opponents and critics of artificial insemination and particularly of in vitro as opposed to in vivo conception. From inception, medically assisted reproduction involving artificial insemination or IVF has had its implacable critics and opponents in the Western world, such as the Roman Catholic Church (Congregation… 1987); but, by and large, it is considered in the normal order of developments and has a strong appeal for its potential users or those who stand to benefit from it. A non-negligible factor in the over-all appeal

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of IVF in the Western world is the fact that, with the feminist revolution, resulting in the legalization of abortion, delayed marriages and working wives, childbearing, which for women anywhere is ideal at the prime of youth, is often delayed until natural conception is no longer easy or even possible. Apart from the Catholic Church, the other vehement Western critics of ART have been some of the feminists, who link it to the pervasive institution of patriarchy and male domination, suppression and oppression of women (Corea 1985, Spallone & Steinberg 1987). Gena Corea represents, perhaps, the polar opposite attitude within the Western world towards technologically assisted reproduction from that represented by Joseph Fletcher. Corea sees ART as part and parcel of the patriarchal, maledominated, medical establishment’s desire to control women and their bodies. In her view, while the women who undergo the procedures seem to do so willingly, they cannot really be said to have given their fully informed consent. Probing beyond the surface reality (“foreground”) of ART to its “background”, the social and political context in which it flourishes, she posits that reproductive technologies are not just a matter of scientific medicine but also, and above all, a serious socio-political affair by which “pharmacrats” (her coinage for reproductive medical technologists) seek to gain access and control of the female body. She explores the relationship between ART and both racism and eugenics and links that relationship with concerns about “genetic deterioration” and the obsession with “upgrading human genetic quality”. In her view, the inferior who must not be perpetuated and who need upgrading translate into men of black race and women of all races. Corea who considers motherhood a “cruel institution” believes, however, that men, who are more or less outsiders to the reproductive experience, are envious of women because of the latter’s continuous reproductive experience, genetic continuity and close connection to the human species, and, for that reason, seek a variety of ways, including ART, of making the reproductive experience their own.

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The ethical crux of art If we leave aside the socio-political, legal and cultural arguments and concerns, ethical debate and concerns over ART would boil down to determining the status of the human embryo. This is the philosophical quintessence and ethical crux of the matter. Artificially assisted conception as practiced today indispensably involves the processes of embryo creation, experimentation, manipulation, discarding of unfit or surplus embryos, preservation and transfer. Human embryos are thus central to the whole business and what is or is not ethically appropriate to do in artificially assisting conception cannot be determined without considering the moral status of the embryo. The issue is highly contentious and controversial and has been further complicated by the fact that it has consequences or ramifications with abortion, which, in most parts of the industrialized Western world, is generally accepted as a ‘right’ or, in any case, has the legal status of a right. Here again, African conceptions and attitudes, which are not disposed to admitting any significant difference between the moral status of the embryo and that of any other human being at any other stage of its maturation, would be markedly different from those of the dominant conceptions and attitudes of the industrialized Western world. Both abortion and ART involving creation, manipulation and experimentation with embryos have been ‘justified’ on the grounds that the embryo, at the very best, is only a potential as distinguished from an actual human being and, as such, lacks the moral status and rights accordable to human beings. It is a biological fact that a distinct human life begins at conception. From that moment of conception, the conceptus develops through innumerable stages and, if disease or accident does not intervene earlier, dies in and of old age. It is my well-considered view that, while we can legitimately draw demarcation lines and categorize human beings on the basis of the different positions they occupy on the human biological developmental ladder, for various purposes, such categorization cannot serve the purpose of determining moral status and worth. Furthermore, a human

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embryo is no more and no less a potential human being than any other human being at any other stage of its development, because nothing can be both actual and potential at the same time in the same respect. In other words, calling a human embryo a potential human being is a serious conceptual (category) mistake. An infant, for instance, is a potential adult but not a potential human being, for both adult and infant are human beings. For me, moral status and worth are accordable to a human being as a human being and not on the basis of any further attributes or characteristics; or else, there is no rational justification for drawing the line of demarcation at one point rather than another on the developmental/time ladder (Tangwa 2007). Of course, attempts have been made to justify such a moral line of demarcation on the basis of the idea of personhood. But what personhood really marks out are responsible and culpable human beings, not human beings who alone possess moral status and worth (Tangwa 2000).

Conclusion Assisted conception is important because of the value placed on human reproduction across all human cultures. In Africa, many traditional methods exist for dealing with the problem of infertility without actually solving it. Modern technologyassisted methods of solving infertility problems generate a lot of interest all over Africa but also a lot of skeptical ambivalence, on account of their novelty and unclear moral acceptability. The human being is also accepted in all human cultures as having supreme moral value/worth, but it is not very clear that ART respects this moral value in its handling of and dealing with human embryos. It would be extremely contradictory if, in attempting to satisfy the great human need for reproducing other human beings, the value and worth of the human being were to be devalued. Reckless experimentation and manipulation of human embryos for any purpose cannot be morally justified. Such reckless experimentation and manipulation, under myriad pretensions,

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such as researching for new magic treatments or advancing science, are what seem to characterize current practices and achievements in the domain of reproductive technologies. For this and other reasons, there is considerable ambivalence towards technology-assisted conception in Africa, even if the great need for procreation ensures that there will be continuing and sustained interest in options made available by modern technology. ART that proceeds cautiously, with due and uncompromising moral respect for the human being from its first moment, seems quite possible and would be morally unobjectionable and greatly valued in all cultures of the modern world. There is nothing wrong with ART as such, just as there is nothing wrong with technology as such; but the problem resides with the manner and purposes of its uses. And moral considerations apart, economic and political motives, and such other motives as ‘maintaining strategic leadership’, overt or covert, are what may easily subvert putting ART, like other good ideas and discoveries, into good, morally acceptable uses with which all cultures could feel completely at ease.

References Baruch, E., d’Adamo, A. Jr., and J. Seager, (Eds.) (1988): Embryos, Ethics, and Women’s Rights: Exploring the New Reproductive Technologies. New York, London: The Harworth Press. Battersby, J.D. (1987a): Woman Pregnant with Daughter’s Triplets. [News]. In The New York Times; Apr. 9: A1, A9. Battersby, J. (1987b): South Africa Woman gives birth to 3 Grandchildren and History. [News]. In New York Times; Oct. 2: A9. Congregation for the Doctrine of the Faith (1987): Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation: Replies to Certain Questions of the Day. Vatican City: February 22, 1987.

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Corea, G. (1985): The Mother Machine: Reproductive Technologies from Artificial Insemination to Artificial Wombs. New York: Harper and Row. Ferre, F. (1994): Technology, Ethics and the End of Nature. In Oruka, O. (ed): Philosophy, Humanity and Ecology: Philosophy of Nature and Environmental Ethics. Nairobi, Kenya: ACTS Press. Fletcher, J. (1988): The Ethics of Genetic Control: Ending Reproductive Roulette. Buffalo, New York: Prometheus Books. Giwa-Osagie, O. (2001): Personal Correspondence. Kass, L. and Wilson, J. (1998): The Ethics of Human Cloning. Washington DC: The AEI Press. Landau, R. (1999): Planned Orphanhood’. Social Science and Medicine; 49: 185-196. Michelow, M. (1988): Mother-Daughter In Vitro Fertilization Triplet Surrogate Pregnancy. Journal of In Vitro Fertilization and Embryo Transfer. 5(1): 31-34. Njikam-Savage, O. (1992): Artificial Donor Insemination in Yaounde: Some Socio-Cultural Considerations. Social Science and Medicine. 35(7): 907-913. Oshuntokun, B. (1992): Biomedical Ethics in the Developing World: Conflicts and Resolutions. In Pellegrino, E., Mazzarella, P., and Corsi, P., (eds.): Transcultural Dimensions in Medical Ethics. Frederick, MD: University Publishing Group; [105-143]. Spallone, P. and Steinberg D. (1987): Made to Order: The Myth of Reproductive and Genetic Progress. Oxford, New York etc.: Pergamon Press. Silver, M. (1997): Remaking Eden: Cloning and Beyond in a Brave New World. New York: Avon Books. South Africa (1986a): Regulations Regarding the Artificial Insemination of Persons and Related Matters: Government Notice No. R. 1182 of June 1986’. (Government Gazette, 20 June 1986, Vol. 252, No. 10283, pp. 28-35). South Africa (1986b): ‘Suggested Code of Practice for In Vitro Fertilization’ (Department of National Health and Population Development. Ad Hoc Committee of the National Health Laboratory Service Subcommittee). In South African Medical Journal; Oct. 25; 70(9): 561-562.

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Steinbock, B. (1992): Life Before Birth: The Moral and Legal Status of Embryos and Fetuses. New York: Oxford University Press. Steinbock, B. (2002): Moral Status, Moral Value, and Human Embryos’. [Unpublished conference manuscript]. Strauss, S.A. (1983): Artificial ‘Donor’ Insemination: A South African Court Declares the Child Illegitimate. Medicine and Law. 2(1): 77-79. Tangwa, G.B. (2000): The Traditional African Perception of a Person: Some Implications for Bioethics. Hastings Center Report. 30(5): 39-43. Tangwa, G.B. (2002a): Assisted Reproduction Technologies (ART) and African Socio-Cultural Practices, Worldview, Belief and Value Systems: With Particular Reference to Francophone Africa’. In Current Practices and Controversies on Assisted Reproduction; Report of a WHO Meeting. WHO Publication (forthcoming). Tangwa, G.B. (2007): Moral Status of Embryonic Stem Cells: Perspective of an African Villager. Bioethics. 21(8): 449457. Uchendu, V. (1965): The Igbo of Southeast Nigeria. New York, Chicago, San Francisco, Toronto, London: Holt, Rinehart and Winston.

CHAPTER NINE THE UNIVERSAL AND THE PARTICULAR IN CURRENT DISCUSSIONS OF INTERNATIONAL BIO-MEDICAL ETHICAL GUIDELINES

[Previously published in another version as "Between Universalism and Relativism: A Conceptual Exploration of Problems in Formulating and Applying International Biomedical Ethical Guidelines". Journal of Medical Ethics. 30: 63-67, 2004.]

Abstract Biomedical research in the ‘developing world’, of which there is increasing incidence, has often encountered problems of compliance with the requirements of international ethical guidelines for such research. In some parts of Africa, for instance, researchers have encountered problems with the application of the ethical requirement of, say, informed consent, confidentiality, non-undue-inducement etc., in particular concrete situations. In some instances, some of such requirements have proved to be simply inapplicable in the manner they apply in the ‘developed world’, suggesting that the ethical requirements as laid down in the international texts might stand in need of significant adaptation to local context and perspective. On the other hand, recent attempts at revising and updating international medical ethical guidelines, such as the Declaration of Helsinki and the CIOMS International Ethical

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Guidelines for Biomedical Research Involving Human Subjects, have been bedevilled by intractable controversies and wrangling regarding both the content and formulation of some of the guidelines. These problems and difficulties arise from a permanent and ineradicable tension between the universal and the particular, the absolute and the relative, the theoretical and the practical. They also are not unrelated to differing conceptions about the relationship between culture and morality, instrumental rules and moral norms, and about the nature, purpose, and role of ethical guidelines. Some of them also arise from a tendency to confuse and to assimilate or conflate ethics with culture, custom, tradition or consolidated practice, on the one hand, and, on the other, from an implicit equation of what is ethical with what is in the interest or to the advantage of the strong, powerful and influential. (The ancient philosopher Thrasymachus, (c.400 BC) reputed to have defined justice, shockingly wrongly, as whatever is in the interest and to the advantage of the strong and powerful, nevertheless, laid his finger on what, in fact, is an existential tendency of all times). Within all cultures and societies, power and injustice are next door neighbours who often end up as bed mates. In this paper, I will attempt to explore these and related issues, to uncover the underlying problematic and to prescribe an approach at both the theoretical and practical levels liable to considerably reduce, if not completely eliminate, some of these problems and difficulties.

Key words/concepts Universalism, relativism, ethical imperative, research, perspective, context, culture.

guideline,

Introduction Problems that arise at the level of formulation of biomedical ethical guidelines are mainly conceptual and theoretical,

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while those that arise at the level of application of such guidelines are mainly practical and procedural. At the first level, there is the need to capture clearly in concepts and language an ethical imperative and, at the second level, there is the need to translate an ethical rule or recommendation into concrete action within a specific place and time. Moral rules are different from instrumental and other rules in that, while they are indeed meant to regulate particular concrete actions in time and space, their outlook and formulation must not depend on nor be constrained by particularities but must have something of the universal and timeless about them. To say that it is morally right or wrong to do or not to do something is to imply that it is so under all other similar circumstances, irrespective of place, time, and socio-cultural context. Moral norms/rules may, of course, be expressed in, mingled/mixed with or reflected in laws, societal customs, cultural practices, taboos, etiquette, etc. But all these differ from moral norms/rules proper in that they are, by their very nature and raison d’être, context-bound. A law, for instance, has no jurisdiction and no applicability outside of its area of sovereignty and there is no reason to recommend the purely cultural practices of one society to another. One way of expressing this is to say that moral norms/rules are ‘universalizable’ or generalizable, in a similar though not exactly identical sense in which one of the main goals of biomedical research is to gain “generalizable knowledge”, in the sense of knowledge which is objectively rather than subjectively anchored, is in principle repeatable and applicable in all relevantly similar circumstances. Universalizability is, moreover, a defining and distinguishing mark of moral as distinguished from non-moral judgments. Moral rules are necessarily universal as well as abstract and, if their dynamic and dialectical relationship with concrete particulars is not properly appreciated, they may appear rather empty (Little 2001). A moral judgment commits the person making it to upholding the same judgment in all appropriately similar circumstances, irrespective of place, time and who may happen to be involved. This is very

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different from expedient and other judgments such as judgments related to ‘winning strategies’ in any game or other activity. Ethical demands are, moreover, uncompromising in a way that other demands, such as the economic, the political, the social and even the legal, are not. In these latter demands, a certain measure of expediency or inconsistency may be permissible or tolerable, whereas expediency or unjustifiable inconsistency is completely antithetical to morality. Morality has a special status which is evident from consideration of the fact that, while there is no better reason for condemning or recommending abolition or change of a law, custom, social or cultural practice than that it is morally obnoxious, no violation of a moral injunction could ever be justified on such grounds as that it is required by the law, is the social custom or usual practice. But the uncompromising and universal nature of an ethical rule or judgment does not imply that it could never justifiably be violated if the particular situation and circumstances so warrant. To a deranged potential murderer in hot pursuit of his potential victim, for example, it would be justifiable and warrantable for any third party, such as a bystander, to lie, without any implication that lying is thereby not universally morally wrong. Ruth Macklin (Macklin 1999) expresses this differently and quite appropriately by making a distinction between universalism and absolutism. Moral rules are universal but not absolute, because absolutism implies exceptionlessness, whereas human epistemological limitations make it impossible to absolutely rule out the possibility of justifiable exceptions to any such rules. Such putative exceptions, however, can in no way be the grounds for the postmodernist relativistic position that moral judgments are or ought to be entirely culture-bound or culture-dependent. In other words, accepting the possibility of justifiable exceptions to the applicability of a moral rule, in all spatio-temporal contexts and circumstances, in no way implies moral relativity, let alone the absurd idea of ‘geographical morality’ or ethics which change at territorial borders (Fidler 2001).

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Obeying or applying an ethical rule, however, is necessarily done within the constraints of particular place, time, circumstances and perspective. Nevertheless, sometimes an ethical injunction or moral rule suggests itself, is made manifest or becomes necessary from an encounter with particular concrete problems in a particular place or time. The relationship between theoretical ethical guidelines and their practical application is therefore a very close and dialectical one. What rules and guidelines attempt to express are principles of action whose significance and importance is related to that of the actions themselves that they attempt to regulate. An ethical rule or guideline cannot itself attempt to exhaustively enumerate all the possible particular actions permissible or prohibit-able under its application, nor all the possible exceptions to its applicability that would be justifiable. The statement that there are ethical universals, that is, norms and values that have cross-cultural validity, which Ruth Macklin attempts to demonstrate against the claims of ethical relativism, is a true statement, but it is an understatement. It would be more accurate to say that all ethical norms or rules are cultural universals (Wiredu 1996), because a rule or norm cannot properly be described as “ethical” unless it is understood as having cross-cultural validity, in the sense of being perceived as applying in all similar circumstances, irrespective of place and time. However, no such rule or norm has application in abstracto. To apply any such rule or norm, is to operationalize it or to fit it within a particular socio-cultural milieu, within a particular context and circumstances. These particularities will, inevitably, have some feedback effect on the nonessential aspects of the rule or norm, affecting its form and manner, perhaps, but not its essential content – the ethical imperative it seeks to express. Water poured into differently shaped vessels immediately assumes the shape of each vessel but remains essentially water. Of course, its chemical composition could be affected if the vessel contains a soluble substance, but the shape of the vessel itself is of no great consequence.

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It is in the nature of a rule, ethical or otherwise, to be general, applying to a wide variety of appropriately similar cases or situations. Different situations and different cases may be similar to varying degrees but hardly identical. If a rule is too rigid, it may stifle action, whereas the purpose of rules is not to stifle action but to ensure correct action. On the other hand, a rule which is too liberal or too vague could open itself to justifiable violations in every particular case, in which case it is as good as no rule at all. An ethical rule needs to combine judicious rigidity with judicious flexibility; in other words, it needs to be plastically rigid as well as plastically flexible. Plastic rigidity ensures that subjective elements, egocentric data and particularistic considerations will not subvert the principle while plastic flexibility ensures that the principle will not countermand nor render itself sterile in the realm of practical application.

International ethical guidelines In recent years, there has been an explosion in biomedical research activities, especially in the so-called developing world, which has witnessed the highest incidence of epidemics, deadly diseases and other medical conditions, mainly by industrialized world researchers, thanks to great improvements in medical technologies, research techniques and research funding in the Western world. These activities have been accompanied in some instances by abuses and malpractices reminiscent of, even if not equate-able in their moral outrageousness with those which first shocked the conscience of the world and led to the first modern set of regulatory ethical guidelines for medical practice and research, the Nuremberg Code (1947). The situation has been further complicated by the emergence of the deadly pandemic, HIV/AIDS, against which an urgent treatment and/or vaccine is an unquestioned necessity. These activities, abuses, and danger of abuse have brought to the foreground the need for complying with existing ethical regulations, the need for revising and updating some of such regulations, and the need for formulating new regulations to

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cover new and emerging situations not envisaged by existing regulations. Beginning with the Nuremberg Code, all international ethical guidelines, notable among which are: Declaration of Helsinki (WMA 1964, 1975, 1983, 1989, 1996, 2000), International Ethical Guidelines for Biomedical Research Involving Human Subjects (CIOMS 1993, 2002), Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (Council of Europe 1997), Note for Guidance on Good Clinical Practice (ICH 1996), have as their main concern the protection of the health, dignity and human rights of the human subject of medical practice or research. But biomedical research in the developing world, especially in Africa, faces many challenges, dilemmas and difficulties in trying to conform and comply with some of the regulations and stipulations as laid down in the international regulatory texts. In a community in which people do not keep any important secrets from their kith and kin, under pain of being suspected of having been initiated into witchcraft, for example, the idea of confidentiality, so much emphasized in Western biomedical ethics and in the international regulatory texts, is practically inoperative in its Western form and boils down essentially to trust and confidence ensuring reliability. In such a community, it is no use assuring research subjects that you will be protecting their confidentiality by locking up what they are telling you in a cupboard to which you alone have the key when they don’t know whether you are a good person who can yourself be trusted with their story and do ‘know’ that any witch can get into any locked cupboard, if necessary. In such a community or similar other, the Western biomedical ethical dogma of, say, autonomy, again well reflected in the regulatory texts, may boil down essentially to respect for other human beings as being morally radically equal to yourself. Furthermore, in a situation of generalized poverty combined with a high burden of disease, as we have in some parts of the world today, especially in some parts of sub-Saharan Africa, there

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is no way to prevent victims and potential victims of a deadly epidemic such as HIV/AIDS from being unduly induced by any type of research participation proposal that holds out the slightest possibility of any type of treatment. This situation is responsible for what, on the one hand, has been termed the ‘therapeutic fallacy’ by which research and other investigative procedures may deceptively be presented as if they were therapeutic interventions and what, on the other, I would call the ‘therapeutic illusion’ whereby research subjects persist in believing, even against dissuasive explanations, that they are undergoing treatment as opposed to experimentation. In such a situation, the prohibition of inducement, due or undue, has no practical applicability and, if strictly observed, would amount to a prohibition of all medical research, which may not be ethical or even sensible, all things properly taken into consideration. This, however, does not mean that autonomy, confidentiality and the need to avoid undue inducement are wrong ideas but only that they are the form and linguistic idioms in which some important ethical imperatives would be expressed in Western countries, within a Western framework, within Western culture, characterized, as they are, by both material affluence and extreme possessive individualism. Within other countries, cultures and frameworks, they could assume slightly different forms and/or expressions, for the ‘containers’ are different, and so the same ‘water’ of ethical imperatives could take a different shape and form but serve essentially and adequately the same function. I have been privileged in recent years to participate in the discussions of researchers, scientists and ethicists on these problems, particularly as they impact on the African continent. I have been involved in the creation of the PanAfrican Bioethics Initiative (PABIN), whose main aim/objective is to foster the development of bioethics in Africa, with a particular focus on the ethics of biomedical research. I have keenly followed the discussions over some of the controversial articles of the revised latest version of the Declaration of Helsinki (2000), and I have been privileged to

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participate as a member of an informal “writing group” in the work of revising and updating the CIOMS International Ethical Guidelines for Biomedical Research Involving Human Subjects (issued in 2002). It is from such vantage position that I am here attempting to reflect on the formulation of guidelines as well as their application. At the level of formulation of such guidelines, the main problem has appeared to me to be that of striking a balance at a high level of abstraction between universalism and relativism, between rigidity and flexibility, between competing perspectives, while at the level of application the main problem to me has seemed to be that of appropriate sensitivity to context and particularity, to culture, manner, procedure and idiosyncrasy. I dare hope that such attempt may contribute towards suggesting a simple and clear conceptual model for both formulating or revising and applying international ethical guidelines, in a less controversial manner, conscious of both the universal nature of ethical imperatives and the enormous diversity and variety of global cultures, systems of thought, ways of conceptualizing and thinking, languages, religions, customs, traditions and practices, as well as the great variation in the global distribution of wealth, power and economic status and their impact on other factors. It is also my hope that such effort might provide a clear framework for the formulation, under the auspices of, say, the Pan-African Bioethics Initiative (PABIN) or the African Union (AU), of panAfrican Guidelines and/or Standard Operating Procedures for Bio-medical research, an urgent and critical necessity in the light of the present disease burden of the African continent, its health needs and recent experiences. For given the unquestioned importance and necessity of ethics in medical research, it is further necessary to have regulatory frameworks at several different levels. A visual model for such a system of regulations would look like concentric circles, with the widest circle representing well-formulated international guidelines and the smallest circle delimiting the standard operating procedures of local or institutional ethics review committees/boards. In any case, it simply will not do

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for the peoples of the ‘developing world’, especially in Africa, to approach medical research ethics in the same spirit and manner or with the same attitude with which, in the colonial era, they approached European catechetical doctrines and dogmas, which simply had to be learnt by root in question and answer form, then repeated accurately as a means of certification, for baptism or confirmation and admittance to holy communion.

The Helsinki declaration and CIOMS guidelines Among international ethical guidelines, pre-eminence is generally accorded to the Declaration of Helsinki (DoH) and the CIOMS International Ethical Guidelines for Biomedical Research Involving Human Subjects. These two documents have had the widest global reach, are the most frequently quoted, and have been most influential, especially in the formulation of other guidelines and regulations. Medical ethical guidelines and other such documents differ according to various aspects: some apply to specific geographical or regional areas or jurisdictions, some have a more outwardlooking posture in the sense of envisaging externally conducted research, some target specific domains such as pharmaceutical, HIV vaccine, or epidemiological research, some include legal underpinnings while others do not. But among all such guidelines and documents, it is the DoH and the CIOMS Guidelines that have the widest global reach and applicability. They have both also been recently revised and updated, the DoH in 2000 and the CIOMS Guidelines in 2002. Furthermore, there is a symbiotic relationship between the DoH and the CIOMS Guidelines, the latter having been partly conceived as a more detailed unpacking of the provisions of the former, with an emphasis on research in the so-called developing world. In the Introduction to the Guidelines (CIOMS 1993, p.9), it is clearly stated, among other things, that the Guidelines are “…a logical development of the Declaration of Helsinki…intended to indicate how the ethical principles embodied in the

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Declaration could be effectively applied in developing countries.” Moreover, there has been regular communication and consultation between the two bodies responsible for each of these documents, with the World Health Organization (WHO) playing a key middle role, and some individuals have been involved with the debates and crafting of both documents. The general rationale for revising and updating of ethical guidelines is the fact that, with rapid developments in science and technology, new situations constantly arise which were not foreseen by existing guidelines as well as the fact that some problems encountered with the practical application of some guidelines necessitate and warrant their reformulation. When the new, revised and updated Declaration of Helsinki was first presented to the public during an international conference organized for the purpose in Pretoria, South Africa, 27-28 March 2001, Dr. Delon Human, Secretary-General of the World Medical Association (WMA) which is responsible for the document, explained the main motivations for the revision in the following terms: The DoH is a statement of ethical principles to provide ethical guidance to physicians involved in research, and not only to thinkers and scholars in this field. When we therefore realized that there was genuine confusion caused by some of the articles in the previous version, we embarked on a comprehensive, consultative revision process to try to improve the DoH. Here I refer to issues such as the distinction between therapeutic and non-therapeutic research, the meaning of the “best proven diagnostic and therapeutic method”, the standard of care ethically required for participants in biomedical research and the use of placebos in research. …When the DoH was first established in 1964, there was no human genome to contend with, no international databases facilitating research on millions of individuals’ identifiable data or tissue and probably no serious economic conflict of interest to researchers. We all know that this has changed and we are confident that the additions to the DoH have strengthened the document. (Human 2002, pp. 3&4).

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Other motivating reasons for the revision were international debates sparked off by charges, as much unrefuted as unproved, that Western world medical researchers and their sponsors and funders were escaping the strict regulatory frameworks and financial burdens of research in the Western world in preference for poorer ‘developing world’ environments where they were taking advantage of poverty, ignorance, abundance of diseases and lack of regulations, to test new experimental drugs and treatments, as well as a desire to take into account the role of non-Western cultures in the document. As for the CIOMS Guidelines, their main purpose, as stated in the “Background Note” of the 1993 edition, is: …to indicate how the ethical principles that should guide the conduct of biomedical research involving human subjects, as set forth in the Declaration of Helsinki, could be effectively applied, particularly in developing countries, given their socio-economic circumstances, laws and regulations, and executive and administrative arrangements.

The emphatic focus on the ‘developing world’ is also to be found in other ethical or regulatory documents, with a little less global reach and prestige than the CIOMS Guidelines. Such, for instance, are the United States National Bioethics Advisory Commission’s (NBAC’s) Ethical and Policy Issues in International Research: Clinical Trials in Developing Countries (2001) and the Nufflied Council on Bioethics’ The Ethics of Research Related to Healthcare in Developing Countries (2002).

The controversial guidelines or articles In the very lively global atmosphere of debate, facilitated by easier and faster means of communication, we are liable to overlook the fact that, while it is not easy to formulate any of the ethical guidelines in thoroughly satisfactory concepts and language for everybody, there are very few of the guidelines that have been particularly controversial. What

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this signifies is that there may be more global ethical consensus (to the extent that non-Western views/perspectives have been represented or taken into account) than we care to admit and there may be more to the controversial guidelines than purely ethical issues and considerations. Of the 30 paragraphs of the newly revised version of the Declaration of Helsinki, real controversy has centred on only two, paragraphs 29 and 30. #29. The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists. #30. At the conclusion of the study, every patient entered into the study should be assured of access to the best proven prophylactic, diagnostic and therapeutic methods identified by the study.

So, really controversial debate has centred on the closely interrelated issues of the ‘standard of care’ to be used for participants during a study, from which the whole issue of placebos arises, and the question of the level, type and duration of post-study care. Looking at previous versions of the DoH, it is very interesting to notice the following: (1). The seminal ideas of paragraphs 29 and 30, which are now separate guidelines in the 2000 version, were captured in a single guideline in the 1996 version, which read: In any medical study, every patient – including those of a control group, if any – should be assured of the best proven diagnostic and therapeutic method. This does not exclude the use of inert placebo in studies where no proven diagnostic or therapeutic method exists.

(2). In the 1975 version, the second part of the guideline, referring to placebo, added in the 1996 revision, did not exist and the guideline simply read:

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In any medical study, every patient – including those of a control group, if any – should be assured of the best proven diagnostic and therapeutic method.

(3). In the original 1964 Declaration, there was no mention at all of either placebo or standard of care. The seminal idea of paragraph 30 (DoH 2000), first introduced in the 1975 version in Tokyo, Japan, insisting on ‘best treatment’ for research study participants, presumably in light of previous practical experience, can be seen as being very much in line with the fundamental mission of the Declaration to protect the life, health and interest of human subjects of biomedical research. For over 25 years, it remained uncontested and unchanged. But in the period leading up to the 2000 revision, it was put under question by some very influential voices and a strong lobby seeking a relaxation in its stipulation or a reinterpretation of its demands so as to accommodate clinical trials and medical research in which less than the best treatment could be assured for participants. In fact, this lobby and the powerful influences and interests behind it seem to have been largely responsible for the decision to carry out the revision which culminated in the 2000 version of Helsinki. Crudely but succinctly put, the line of argument of those who favoured a relaxation in or reinterpretation of the stipulation of the guideline was that comparing a new intervention or product with what was less than the best treatment might be more efficient in demonstrating effectiveness, using fewer trials and less time and money, and also that it did not make sense to offer the best available treatment to people in ‘resource poor’ environments, whose health system could not sustain it, or who would subsequently not be able to afford it after the trials. The opposing point of view and perspective is well expressed by a researcher of the University of Pretoria, South Africa (IJsselmuiden 2001): For many health researchers working with and in poor communities and countries, the attempts at reducing the

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minimum requirements for treatment in control arms of studies came as an ‘unbelievable’ development. Those who are not distanced from these communities by oceans or socio-economic gaps are seriously concerned about the efforts to reduce the potential benefits of research involving these specific individuals and communities rather than, as current ethics would have dictated …to strengthen the protective and distributive nature of health research in vulnerable populations.

In any case, the WMA, when it met in Edinburgh, Scotland, to adopt the 2000 version of the DoH, decided to reaffirm the protection of research study subjects and raised the idea of best treatment again to the status of an independent guideline. However, the protagonists of a lower standard of protection partly carried the day by introducing clever subtle qualifiers into the guideline – “at the conclusion of the study” and “identified by the study” – whose net achievement is to push any worry over the standard of care obligation to the post factum period of the study. And, as IJsselmuiden had correctly remarked and predicted in the presentation referenced above, the pressure to lower the ethical demand seems ‘massive and well resourced’ (ibid, p.8) and there is ‘a great likelihood that the current phrasing of paragraphs 29 and 30 will be very temporary indeed’ (ibid, p.6). This became very clear when, in the course of the same conference, some of the other presenters launched a severe attack on Helsinki 2000. The gist and thrust of their arguments were that the distinction made in the Declaration between therapeutic and non-therapeutic research is illogical; that the Declaration is out of touch with contemporary ethical thinking especially in its position on placebo controls and that, for these reasons, the Declaration had been widely disregarded and had lost its authority and prestige. The canvassed and expected modifications to Helsinki 2000 might have occurred as early as October 2001, when the 53rd WMA, the only body with the authority to make formal changes to the Declaration of Helsinki, was scheduled to meet in India (3-7 October), but the meeting failed to take

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place. The WMA Council, which apparently has the right to interpret but not to change the DoH, however, did the best that could be done under the circumstances and issued a highly ambivalent statement of clarification on the interpretation of paragraph 29 of the DoH. The note reads: The WMA is concerned that paragraph 29 of the revised Declaration of Helsinki (October 2000) has led to diverse interpretation and possible confusion. It herby affirms its position that extreme care must be taken in making use of a placebo-controlled trial and that in general this methodology should only be used in the absence of existing proven therapy. However, a placebo-controlled trial may be ethically acceptable, even if proven therapy is available, under the following circumstances: 

Where for compelling and scientifically sound methodological reasons its use is necessary to determine the efficacy or safety of a prophylactic, diagnostic or therapeutic method, or where a prophylactic, diagnostic or therapeutic method is being investigated for a minor condition and the patients who receive placebo will not be subject to any additional risk of serious or irreversible harm. All other provisions of the Declaration of Helsinki must be adhered to, especially the need for appropriate ethical and scientific review.



Whatever can be made of this ‘clarification’ the substantive revision of Helsinki 2000 is still awaited, as the 53rd/54th WMA General Assembly in Washington D.C., USA, from 2-6 October 2002, failed to grapple with the substantive issue, although it did approve inclusion of the above note of clarification as a footnote to paragraph 29 of the Declaration. Such revision, whenever it may come, will have to contend with relevant revisions now already made to the CIOMS Guidelines (2002), in spite of the hierarchical position of subordination of these to the DoH. Another draft note of clarification as well as a complete reformulation of article 30 is currently under consideration. The revision of the CIOMS Guidelines, in which I have been privileged to be involved, went almost concurrently with those of the DoH. After the adoption of Helsinki 2000 and

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the controversies that ensued over paragraphs 29 and 30, this work of revision continued, inevitably perhaps, in the shadow of these controversies. A draft version of the revised Guidelines placed on the internet in June 2001, for public appreciation and comment, attracted hundreds of comments and suggestions from both individuals and corporate bodies from all over the globe. Many of the comments and suggestions were very constructive and very detailed and presumably did help the ‘writing group’ of the Guidelines to do a better job of formulating and commenting on the guidelines. The new document now has 21 guidelines as against 15 in the old, and it is quite evident that many of the guidelines are carefully and sensitively formulated. My recollection and general observation are that the more specific and detailed any guideline attempted to be, the more disagreement and controversy it elicited. CIOMS 2002 Guideline 11 is a good case in point. In the evolution of its various formulations and reformulations (see below), it is hardly controversial if, in each case, the Guideline had been limited to only the first paragraph, where the ethical imperative underlying the guideline is stated in broad, general terms. There were difficult guidelines and guidelines on which only an uneasy compromise could be reached or issues over which strong minority voices simply had to give in but, again like in the case of the DoH, real intractable controversy concerned only the guideline on the use of placebos in clinical studies, and this evidently partly because it tries to give too much specific detail. It is possible to write a whole book on the history of this guideline which started as Guideline 7 and ended as Guideline 11, but my remarks on it here will be both brief and sketchy. Looking back, and remembering the controversy over paragraphs 29 and 30 of Helsinki 2000, it appears that CIOMS 2002, Guideline 11, was the main purpose of the revision of the CIOMS Guidelines and that the immediate motivation was to make placebo controlled trials in ‘resource poor’ settings possible a priori without violating any international ethical guidelines. The guideline is the only one

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that begins with stipulative definition of terms and explanatory notes, a precedent now also followed in the currently being discussed proposed revision of article 30 of the DoH. An earlier draft of the Guideline, while it was still Guideline 7, read as follows, with possibly acceptable deviations discussed only in the commentary to the guideline.

Guideline 7: Placebo-controlled studies In biomedical research, “the benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists.” (Declaration of Helsinki 2000, Articles 28 and 29). Any departure from this principle requires a sound scientific and ethical reason to use a control other than the best current method. But the strong opponents of Helsinki 29 and 30 within the ‘writing group’ argued that no reference should be made to Helsinki in this guideline because Helsinki was mistaken and misleading on the issue.1 In the draft placed on the internet in July 2001 for public appreciation and comment, Guideline 7 (eventually 11) read as follows:

Guideline 11: Choice of control in clinical trials As a general rule, research subjects in the control group of a trial of a diagnostic, therapeutic, or preventive intervention should receive an established effective intervention. In some circumstances it may be ethically acceptable to use an alternative comparator, such as placebo or "no treatment."

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Placebo may be used:   

when no proven intervention exists; when withholding an established effective intervention would expose subjects to, at most, temporary discomfort or delay in relief of symptoms; when use of an established effective intervention as comparator would not yield scientifically reliable results and use of placebo would not add any risk of serious or irreversible harm to the subjects.

Within the CIOMS ‘writing group’, the above guideline was the subject of the sharpest disagreement and polarization. The reactions from the public were equally polarized, with some highly praising and others condemning the guideline. It is therefore not surprising that when a CIOMS meeting was convened in Geneva (February 27-March 1, 2002) to review the revised guidelines, the same sharp disagreement and polarized controversy continued. In that situation, a small carefully selected editorial committee was appointed to redraft the guideline and it was also agreed to have an explanatory note to the guideline highlighting its controversial nature as well as another note on the issue of standard of treatment, proposing new concepts/terms and stipulative definitions. It was now also clarified that the CIOMS Executive Committee was the only body that could formally approve the new revised version of the Guidelines. The explanatory notes proposed were as follows:

Note 1 on Guideline 11 The text and commentary of draft Guideline 11 were revised at the CIOMS Guidelines Conference held in February/March 2002 and the revised text was intensively discussed. Nevertheless, although the revision was well received, disagreements persisted. Some participants expressed reservations about, or opposed, the ethical acceptability of the exception to the general rule limiting the use of placebo to the three conditions set out in the Guideline. They held that the exceptional use of a comparator other than an

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established effective intervention could be interpreted to permit exploitation of poor and disadvantaged populations. They advanced three arguments: ƒ Placebo control could expose research subjects to risk of serious or irreversible harm when the use of an established effective intervention as comparator could avoid the risk. ƒ Not all scientific experts agree about conditions under which an established effective intervention used as a comparator would not yield scientifically reliable results. ƒ An economic reason for the unavailability of an established effective intervention cannot justify a placebo-controlled study in a country of limited resources when it would be unethical to conduct a study with the same design in a population with general access to the effective intervention outside the study. Proponents of the exception argued that the populations of the poorer countries were in desperate need of low-cost, technologically appropriate, public-health solutions to their burden of disease, and were therefore liable to exploitation. It was for the Guidelines, however, to encourage research to find local solutions, while providing clear guidance on how to protect against exploitation. In the drive to find global solutions for the global marketplace there was a risk of ignoring the importance of the local context. The spirit of the Guidelines was to promote essential, scientifically sound and ethical research that is responsive to the needs of diverse countries and communities.

Note 2 on Guideline 11 ‘Best current intervention’ is the term most commonly used to describe the active comparator that is ethically preferred in controlled clinical trials. For many indications, however, there is more than one established ‘current’ intervention and expert clinicians do not agree on which is superior. In other

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circumstances in which there are several established ‘current’ interventions, some expert clinicians recognize one as superior to the rest; some commonly prescribe another because the superior intervention may be locally unavailable, for example, or prohibitively expensive or unsuited to the capability of particular patients to adhere to a complex and rigorous regimen. ‘Established effective intervention’ is the term used in this Guideline to refer to all such interventions, including the best and the various alternatives to the best. In some cases an ethical review committee may determine that it is ethically acceptable to use an established effective intervention as a comparator, even in cases where such an intervention is not considered the best current intervention. The Guideline itself then follows:

Guideline 11: Choice of control in clinical trials As a general rule, research subjects in the control group of a trial of a diagnostic, therapeutic, or preventive intervention should receive an established effective intervention. In some circumstances it may be ethically acceptable to use an alternative comparator, such as placebo or "no treatment". Placebo may be used:   

when no proven intervention exists; when withholding an established effective intervention would expose subjects to, at most, temporary discomfort or delay in relief of symptoms; when use of an established effective intervention as comparator would not yield scientifically reliable results and use of placebo would not add any risk of serious or irreversible harm to the subjects.

An exception to the general rule is applicable in some studies designed to develop a therapeutic, preventive or diagnostic intervention for use in a country or community in which an established effective intervention is not available and unlikely in the foreseeable future to become available, usually for economic or logistic reasons. The purpose of such

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a study is to make available to the population of the country or community an effective alternative to an established effective intervention that is locally unavailable. Accordingly, the proposed investigational intervention must be responsive to the health needs of the population from which the research subjects are recruited and there must be assurance that, if it proves to be safe and effective, it will be made reasonably available to that population. Also, the scientific and ethical review committees must be satisfied that the established effective intervention cannot be used as comparator because its use would not yield scientifically reliable results that would be relevant to the health needs of the study population. In these circumstances an ethical review committee can approve a clinical trial in which the comparator is other than an established effective intervention, such as placebo or no treatment or a local remedy. At a February-March 2002 CIOMS meeting, the above guideline, in spite of its inclusion of too much particularistic and controversial detail, might unanimously have been approved if the last paragraph, outlining an exception, had simply been deleted, but its proponents were too tenacious and well placed to prevent its deletion. It is thanks to the combative spirit of Ruth Macklin, fortuitously a member of the CIOMS Executive Committee, that the guideline does not appear as above in the final approved version of the revised Guidelines. In a last minute message to members of the CIOMS Executive Committee, before final approval and adoption of the new revised CIOMS Guidelines, Ruth made, inter alia, the following, rationally compelling, proposal (Macklin, Email message) which got accepted: Message to the CIOMS executive committee regarding guideline 11 In light of the considerations described below, I propose an alternative to Guideline 11 as distributed to the Executive Committee for their approval, and also a change in the plan to include Note 1 in the preface or introduction to the revised CIOMS Guidelines.

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There is sharp disagreement regarding the acceptability of the “exception” to the general rule for the ethical use of placebo controls in clinical trials. The exception is described in the long paragraph following the three basic conditions stating when placebos may be used. This disagreement was evident at the CIOMS meeting held in February-March 2002; the disagreement arose amongst members of an editorial committee appointed by CIOMS to provide an initial draft of the guidelines; the disagreement appears in published articles in scholarly and professional journals; and both sides of the controversy were represented in comments submitted to CIOMS following the posting of the draft guidelines on the CIOMS website. Researchers as well as ethicists take positions on opposing sides; people from developing as well as from industrialized countries are also on both sides. Given the strength of opposition to the “exception” to when placebo may be used, and the fact that reasonable people disagree, it is inappropriate to include the paragraph allowing for this “exception” as part of the guideline itself. Instead, it would be appropriate to include this paragraph as part of the commentary under the guideline, along with the objections that are stated in the Note originally proposed for the preface or introduction to the guidelines. The controversy should be acknowledged, and the views of both sides represented in the commentary.

My own prescription The above proposal is substantially what we now have as Guideline 11. The controversial ‘exception’ has been pushed to the commentary on the Guideline. In my opinion, it does not belong there. It does not belong anywhere in the Guidelines. That it has found its way into the Guideline at all shows the ultimate practical superiority of power and influence over both reason and moral sensitivity. When a powerful and rich big man intones a song, everyone tries to sing along, even if the pitch is evidently wrong. The consequence, invariably, is that everyone else ends up with disabled vocal chords and the powerful big man then continues alone with his unmelodic tune, in his harsh strong voice, to his desired end. I do not, however, mean to imply that the said exception might not possibly be justifiable (like

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lying) under some peculiar particular circumstances, but only that such putative particular circumstances cannot be specified in advance, a priori, in ethical guidelines of this type, without turning them into de facto self-fulfilling prophecies. A good deal of moral progress has been made in the world in our epoch. The abolition of slavery and the slave trade, the end of overt colonialism, the increasing emancipation and empowerment of women everywhere, the reduction in racism and discrimination, increasing sensitivity in the treatment of non-human animals, the widening popularity of the concept of human rights, etc., are all clear indices of the moral progress that has been made. If such progress continues to be made at the global level, there is no doubt that CIOMS Guideline 11 will again be revised, and the first thing that will have to be thrown out will be the outrageous idea of ‘ethically exceptional use of placebo control’ which evidently places purely scientific and economic considerations ahead of ethical considerations, contrary to Helsinki, paragraph 5, which unequivocally, in line with both reason and ordinary common sense, requires that the interests of the human subject of biomedical research be placed above the interests of both science and society. Furthermore, the reasoning supporting the exception appears to me to be in the nature of rationalizations for violations of an ethical imperative that have either already been committed, are underway or are envisaged. These rationalizations are reminiscent of a priest-confessor pronouncing absolution in advance to a potential penitent who has not yet committed sin but intends or stands in danger of doing so. But, even if a sin, once committed, is absolvable, it is morally outrageous to pronounce absolution in advance of the commission of the sin. Ethical guidelines should not specify acceptable violations of themselves. And CIOMS, as the self-ordained High Priest, as it were, of the ethics of international biomedical research, ought not to provide ‘advance absolution’ for rationalizations of violations of ethical imperatives of such research.

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The rationalizations take on an altruistic/philanthropic garb in justifying the exception on grounds of making “available to the population of the country or community an effective alternative to an established effective intervention that is locally unavailable”. While the critical issue here obviously is the question of why an established effective intervention should be unavailable, or why some countries/populations/communities should be so poor in a world of abundance, another is that we are still to see, anywhere in the world, a preventive, diagnostic or therapeutic drug with the label “specially manufactured” for such and such a population, community or country. We are not likely ever to see such. Besides, even in the richest of countries, effective and cheaper alternatives to more expensive interventions and drugs are a crying need. Another thing that should be thrown out of these Guidelines are all the numerous references to ‘developing’ / ‘resourcepoor’ countries or ‘populations and communities with limited resources’, and the like. These terms may sound like the epitome of accurate, definite descriptions, but they have no permanent and immutable referents. There is no country or community permanently fixed as ‘developing’, ‘resource poor’, or as ‘having limited resources’, irrespective of what resources are in question. Nor is there any which can be deemed as permanently endowed with unlimited resources, irrespective of what resources are referred to. The obvious convenience of these terms and categories notwithstanding, they are post-colonial terms and categories that might be an indication that the colonial attitude and mentality, with its group and unite to rule and exploit policy, did not go away with colonialism. These terms, together with their opposite counterparts, including such others as ‘Western rationality’, ‘the industrialized world’, ‘the civilized/democratic world’ etc. ought now to be abandoned in favour of calling a spade a spade, Asia Asia, Africa Africa, Ethiopia Ethiopia, Cameroon Cameroon, South Africa South Africa, Iraq Iraq, etc. It is time to abandon the last lingering vestiges of the colonial attitude and mentality, on both sides of the colonial divide, in favour of calling every region, country, community, people, by their proper name.

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Ethical principles and norms, like scientific laws, are by their very nature general rather than particular, abstract rather than concrete. They determine and regulate particular actions and instances but cannot themselves be determined or regulated by particular actions or cases. International ethical guidelines should be guidelines, a framework for guiding particular actions, and not detailed ready rules of thumb that can be safely applied without any danger of doing moral wrong. As Benatar and Singer (2000) have rightly remarked, guidelines are like constitutions that require interpretation. No constitution can possibly incorporate its own comprehensive interpretation. No ethical guideline can possibly list all the putative exceptions to itself and, that apart, it is odd for any rule to seek to include the conditions of its own violation. When God said “Thou shall not commit adultery” he certainly knew under what conditions adultery may be permissible or forgive-able, but it would have been extremely odd if he had added “Unless you are in love; s/he is separated from and no longer loves the spouse; and would commit both murder and suicide if you continue to refrain from adultery”, which could be considered a very good argument on consequentialist utilitarian grounds for committing adultery. Biomedical research rules of thumb are best elaborated at the local rather than international level, be that a region, country or part of a region or country. All this in no way implies that the sort of relative detailing of the DoH attempted by the CIOMS Guidelines, for easy comprehension and applicability under the very different conditions and situations of the various global communities, is unnecessary. To the extent that any of the Guidelines expresses a genuine ethical imperative, to that same extent would it be universally relevant and applicable. But to apply it in a particular concrete situation, it must necessarily be shaped and coloured, like water in a container, by all the data furnished by particular context and perspective. More detailed discussion of necessarily highly general ethical guidelines with illustrative examples, as attempted in parts of the CIOMS document, can be a great help in indicating the

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possible shape and colour a guideline might assume in different socio-cultural milieus. But no such illustrative a priori details can provide advance justification for violation of ethical imperatives without prior in situ contextual appreciation of all the particularizing constraining or compelling concrete circumstances. This is the more important as both the DoH and CIOMS Guidelines, in spite of their international intention and outlook, have a wholly Western orientation, are set within Western metaphysical, epistemological and axiological paradigms, and couched in the language, idioms, and conceptual categories of the Western world. But for those who seek ready rules of thumb that can be applied thoughtlessly with a guarantee of exoneration from blame, no set of truly international ethical guidelines could ever be formulated. To attempt formulating such rules of thumb for the international community, given its immense cultural diversity and situational differentiation, is to distrust and to undermine the rational ability and/or moral sensitivity of some human beings in appreciating and acting in accordance with moral imperatives, norms or rules. For the CIOMS Guidelines to be more serviceable globally and universally, the input of the various different global communities and cultures in their formulation and expression would be necessary. For no culture, community or other group of people generally homogenous in their attitudes and ways of thinking and acting are capable of experiencing reality holistically and of appreciating all that is ethically relevant and appropriate, for and on behalf of all others. In their present form and shape, and notwithstanding the great improvements in their recently revised version, the CIOMS Guidelines are, more or less, a copyright of some Euro-Americans, who have used their enormous economic, political, intellectual, technological, resources to push their perspectives, interests and ideas, under the guise of universal consensus and even philanthropy. The controversy over some of the articles of both the DoH and CIOMS Guidelines would seem to illustrate this. This is not to say that putative ethical

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guidelines which might have benefited from the input of the various global cultures and peoples would be completely accepted everywhere without any controversy. That is a luxury not given to ethical judgments or discourse, even within such an ideal homogenous unit as the nuclear family. The point, however, is that disagreement and controversy at that point would be fair, just and equal as between equal stakeholders, and not smack of the will, actual or perceived, to domination and exploitation.

Conclusion International ethical guidelines need to be formulated not only in general as opposed to particularistic terms, but in such general terms as would make sense and meaning to variously and differently situated and circumstanced human communities, groups and assemblages. This is not a task that is likely to be adequately accomplished by one conceptually or ideologically homogenous group of human beings, for and on behalf of all, no matter how well intentioned and well equipped it may be. No human being or group thereof can perceive from the point of view and perspective of another, altruistic goodwill notwithstanding. What a good international ethical guideline requires in its formulation and expression is a balancing of different but not necessarily conflicting points of view and perspectives, the underlying ethical imperative alone remaining constant. So formulated, its practical application would already be easier, to the extent that the ethical imperative underlying the formulation and expression is easily comprehended, now requiring only interpretation and translation into the idioms, expressions, practices and manner of doing within any given community or locality. Much of the difficulty in doing this arises from confusing or presenting cultural particulars as universals or from too much emphasis and concentration on the mood, manner or vehicle for expressing an ethical imperative, to the detriment of the imperative itself. To avoid this, it is necessary, in the formulation of each guideline, to be quite clear what ethical

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imperative is at stake. It is quite conceivable that one and the same guideline could be expressed in completely different words, concepts and images for different communities, even using the same language, such as English, which has developed as many varieties as there are identifiable groups using it. At the level of application, the important thing is again to grasp the ethical imperative underlying the guideline, and cultural and circumstantial particulars will then do the work of ‘shaping’ and ‘colouring’ the guideline, without any need for further deliberate effort. If an ethical imperative cannot be identified in a guideline, then it may be a guideline but it is not an ethical guideline and complying with it can only be for non-ethical reasons, such as political or economic expediency or the necessity to obey a master. Such, in outline and very general terms, is, hopefully, the simple and clear conceptual model and framework that I would recommend for the formulation and application of international ethical guidelines. Any further attempt to be clearer and more specific would surely trap me within the contradictions arising from the tension between the universal and the particular, the absolute and the relative, the theoretical and the practical. Ethics and morality are first and foremost about what I/we ought or ought not to do and only secondarily about what others ought or ought not to do. In this regard, there is something that a country like the USA seems to have got quite right and that is attempting to provide detailed ethical guidelines for its biomedical researchers, both at home and abroad, although the usual limitation of such guidelines to “those who receive federal funding” greatly attenuates their purely moral impact. If such guidelines are well formulated, they should be binding and strictly observed by US researchers and not be violated on the grounds that they do not make sense to or are considered unnecessary by other people with whom they happen to be dealing. One does not change one’s moral conviction and do what one considers morally wrong on the grounds that other people think and do differently. If I consider adultery morally wrong, I would not

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become an adulterer by visiting a community where free exchange of spouses happens to be considered right. Respect for others as moral equals forbids imposing one’s own ideas and convictions on them, but there is no moral principle that permits doing what one considers morally wrong. How then could one’s ethics possibly be deemed to change at any border? The frustration usually expressed over alleged moral diversity is a pretended/pretentious frustration. Moral diversity cannot stop anyone from doing what is morally right or avoiding what is morally wrong, because this is completely determinable from the point of view and perspective of the agent of the action, subject only to not imposing it on others. Since the Nuremberg Code, what have, so far, taken place in the formulation of international ethical guidelines have been attempts to universalize and globalize a particularly powerful paradigm, the Western paradigm; even if it has much to recommend it and has also admittedly attempted to borrow and to incorporate into its framework a few foreign ideas. The push to globalize Western ideas, paradigms, practices and ways of life in this domain should not be described as ‘ethical colonialism/imperialism’ because that is a contradiction in terms, but rather as colonialism/imperialism simply, and what is required, in that respect, is properly to complete the process of decolonization, which is in and of itself a very important ethical issue. Ex-colonized peoples are liable to have suspicions and misgivings of projects, even apparently philanthropic ones, initiated and pushed by erstwhile colonizing powers, because of post-colonial experiences tending to support the view that the process of decolonization has not been completed beyond mere symbolism. Giving an increasing voice to other communities, peoples and cultures, and incorporating their views and perspectives in international regulatory documents as attempted, albeit in as yet a rather timid manner, in CIOMS 2002, is one way of helping to complete the process of decolonization in a world increasingly threatening to become a global village.

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References International Guidelines Nuremberg Code (1947) Declaration of Geneva (Physician’s Oath) (WMA 1948, 1994) Declaration of Helsinki (WMA 1964, 1975, 1983, 1989, 2000) International Guidelines for Ethical Review of Epidemiological Studies (CIOMS 1991) International Ethical Guidelines for Biomedical Research Involving Human Subjects (CIOMS 1993, 2002) Note for Guidance on Good Clinical Practice (ICH 1996) Universal Declaration on the Human Genome and Human Rights (UNESCO 1997) Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (Council of Europe 1997) The Ethics of Clinical Research in Developing Countries (Nuffield Council on Bioethics, Discussion Paper 1999) Operational Guidelines for Ethics Committees that Review Biomedical Research (WHO 2000) Ethical Considerations in HIV Preventive Vaccine Research (UNAIDS 2000) Ethical and Policy Issues in International Research: Clinical Trials in Developing Countries (National Bioethics Advisory Commission – NBAC – 2001) The Ethics of Research Related to Healthcare in Developing Countries (Nufflied Council on Bioethics, Launch of New Report 2002) Books Beauchamp, T. and Childress, J. (2001): Principles of Biomedical Ethics. 5th edition. New York: Oxford University Press. Beck, R. and Orr, J. (1970): Ethical Choice: A Case Study Approach. New York: The Free Press. Braun, D. (1997): The Rich Get Richer: The Rise of Income Inequality in the United States and the World, Chicago: Nelson-Hall.

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Brody, B. (1998): The Ethics of Biomedical Research: An International Perspective. New York: Oxford University Press. Bryant, J. (1969): Health and the Developing World, Ithaca and London: Cornell University Press. Bryant, J. and Harrison, P. (1996): Global Health in Transition: A Synthesis: Perspectives from International Organizations. Washington DC: National Academy Press. Chetley, A (1990): A Healthy Business? World Health and the Pharmaceutical Industry. London: Zed Books. Daniels, N. (1985): Just Health Care. New York: Cambridge University Press. Daniels, N., Light, D. and Caplan, R. (1996): Benchmarks of Fairness for Health Care Reform, New York, Oxford: Oxford University Press. Daniels, N., Kennedy, B. and Kawachi, I. (2000): Is Inequality Bad for Our Health? Boston: Beacon Press. Daniels, N. and Sabin, J. (2002): Setting Limits Fairly, Can We Learn to Share Medical Resources? New York: Oxford University Press. DeMarco, J. and Fox, R. (eds.) (?). New Directions in Ethics: The Challenges of Applied Ethics. New York/London: Routledge & Kegan Paul. Engelhart, T. (1986): The Foundations of Biomedical Ethics. New York: Oxford University Press. Falk, R. (1999): Predatory Globalization: A Critique. New York: Polity Press. Fisher, F. (1998): Medical Ethics Today. BMJ Publishing Group. Fisher, F. (2001): The Medical Profession and Human Rights: Handbook for a Changing Agenda. London: Zed Books. Harrison, L. and Huntington, S. (2001): Culture Matters: How Values Shape Human Progress. New York: Basic books. Levine, R. (1988): Ethics and Regulation of Clinical Research. 2nd edition. New Haven: Yale University Press. Levine, R., Gorovitz, S. and Gallagher, J. (2000): Biomedical Research Ethics: Updating International Guidelines – A Consultation. Geneva: CIOMS. Macklin, R. (1999): Against Relativism, Cultural Diversity and the Search for Ethical Universals in Medicine. New York/Oxford: Oxford University Press.

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Marmot, M. and Wilkinson, R. (1999): Social Determinants of Health. New York: Oxford University Press. Mazrui, A. (1976): A World Federation of Cultures. New York: The Free Press. Rawls, J. (1999): A Theory of Justice. Revised edition. Cambridge, Mass.: Harvard University Press. Novak, M. (1970): The Experience of Nothingness. New York: Harper and Row. Ruigrock, W. and Van Tulder, R. (1995): The Logic of International Restructuring, London: Routledge. Scruton, R. (1994): Modern Philosophy: An Introduction and Survey. New York: Penguin Books. United Nations Development Program (1999): Human Development Report 1999. New York: Oxford University Press. Wilkinson, R. (1996): Unhealthy Societies: The Afflictions of Inequality. London: Routledge. Winkler, E. and Coombs, J. (eds.) (1993): Applied Ethics: A Reader. Oxford UK & Cambridge USA: Blackwell. Wiredu, K. (1996): Cultural Universals and Particulars: An African Perspective. Indiana: University Press. .

Articles Baker, R. (1998): A Theory of International Bioethics: Multiculturalism, Postmodernism, And the Bankruptcy of Fundamentalism. Kennedy Institute of Ethics Journal .8(3): 201-231. Baker, R. (1998): A Theory of International Bioethics: The Negotiable and the Non-Negotiable. Kennedy Institute of Ethics Journal. 8(3): 233-274. Baker, R. (1999): Negotiating International Bioethics: A Response to Tom Beauchamp and Ruth Macklin. Kennedy Institute of Ethics Journal. 8(4): 423-453. Beauchamp, T. (1999): The Mettle of Moral Fundamentalism: A Reply to Robert Baker. Kennedy Institute of Ethics Journal. 8(4): 389-401. Benatar, S.R. and Singer, P.A. (2000): A New Look at International Research Ethics. BMJ. 321: 824-565. Benatar, S. (2001): Distributive Justice and Clinical Trials in the Third World. Theoretical Medicine. 22: 169-176.

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—. (2001): South Africa’s Transition in a Globalizing World: HIV/AIDS as a Window and a Mirror. International Affairs. 77, 2: 347-375. Bezruchka, S. (2000): Is Globalization Dangerous to Our Health? (Culture and Medicine). West J Med; 172: 332334. —. (2000): Medical Tourism as Medical Harm to the Third World: Why? For Whom? (Editorial) Wilderness and Environment Medicine. 11: 77-78. —. (2001): Societal Hierarchy and the Health Olympics. CMAJ. 164(12): 1701-1703. Blum, L. (1991): Moral Perception and Particularity. Ethics. 101 (July): 701-725. Christakis, N. (1992): Ethics are Local: Engaging CrossCultural Variation in the Ethics for Clinical Research. Social Science Medicine. 35(9): 1079-1091. Fidler, D. (2001): “Geographical Morality” Revisited: International Relations, International Law, and the Controversy over Placebo-Controlled HIV Clinical Trials in Developing Countries. Harvard International Law Journal. 42(2): 300-354. Human, D. (2001): Why the World Medical Association Decided to Revise the Declaration of Helsinki. [Unpublished conference address]. IJsselmuiden, C. (2001): Research Design as a Focal Point for Science and Ethics. [Unpublished conference presentation]. Lenman, J. (2000): Consequentialism and Cluelessness. Philosophy & Public Affairs. 29(4): 342-370. Little, M. (2001): On Knowing the ‘Why’: Particularism and Moral Theory. Hastings Center Report. 31(4): 32-40. Macklin, R. (1998). Ethical Relativism in a Multicultural Society. Kennedy Institute of Ethics Journal. 8(1): 1-22. Macklin, R. (1999): A Defence of Fundamental Principles and Human Rights: A Reply to Robert Baker. Kennedy Institute of Ethics Journal. 8(4): 403-422. Schuklenk, U. and Ashcroft, R. (2000): International Research Ethics. Bioethics. 14: 158-172. Tangwa, G. (1996): Bioethics: An African Perspective. Bioethics. 10(3): 183-200.

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—. (2000). Traditional African Perception of a Person: Some Implications for Bioethics. Hastings Center Report. 30(5): 39-43. Toulmin, S. (1981): The Tyranny of Principles. The Hastings Center Report; December 1981: 31-39.

Acknowledgements This paper was written as the ‘practicum’ part of the Johns Hopkins-Fogarty African Bioethics Fellowship Training Program. The whole work was supported by part of a grant (No. R25TW01604) from the Fogarty International Center, National Institutes of Health, DHHS, Bioethics Training for Developing Country Professionals/Researchers. I am immensely grateful to the Fogarty International Center (a subsidiary of the National Institutes of Health, NIH) and to the Johns Hopkins University for awarding me the fellowship and for the enormous resources placed at my disposal during the fellowship. I am particularly indebted to my fellowship advisors – Adnan Hyder, Nancy Kass and Jack Byrant – who read through each of the several drafts of this paper and provided me with very stimulating comments and suggestions, as well as important source materials. I must also thank Professors Ruth Macklin and Emmanuel Chukwudi Eze, who each gave a thorough critical reading to the penultimate and second drafts, respectively, of this paper and saved me from many possible blunders. I am also thankful to the various conference and seminar audiences to whom I have been privileged to expose the ideas and arguments of this paper, for their stimulating responses. Lastly, I thank the Ministry of Higher Education and the University of Yaounde 1 in Cameroon, and especially my department, the Department of Philosophy, for providing me an address/academic base and particularly for permitting me in 2002 to benefit from the Hopkins-Fogarty Fellowship.

CHAPTER TEN RESEARCH WITH VULNERABLE HUMAN BEINGS

[Previously published in Acta Tropica, 1125: S16-S20, 2009].

Abstract Some categories of human beings are particularly vulnerable vis-à-vis medical research. Vulnerability could be considered as the liability to be harmed, exploited, deceived, cheated, wronged, or otherwise unfairly treated, in roughly that descending order of importance. Vulnerable human beings obviously include the incompetent (minors and mentally handicapped adults), the desperately poor, ill or ignorant, prisoners, refugees, pregnant women, subordinates in highly authoritarian systems, etc. Vulnerability in itself does not imply that no research whatsoever should be carried out with such categories of humans but only that it should be carried out only under very special conditions. In this chapter we treat of vulnerability in research of particularly developing world populations, of the types of research which exploit such vulnerability, and of why and how research subjects should be protected. Our emphasis in this chapter is to stimulate practical reflection on the possible vulnerabilities of potential research subjects that researchers or investigators need to avoid exploiting rather than an adequate theoretical treatment of the issue.

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Keywords Vulnerability, Developing World, Research Protection, Coercion, Deception, Inducement.

Subject,

What some regulations state regarding vulnerability In the first paragraph of the commentary on Guideline 13 of the CIOMS International Guidelines for Biomedical Research Involving Human Beings (2002), vulnerability is defined as follows: “Vulnerable persons are those who are relatively (or absolutely) incapable of protecting their own interests…they may have insufficient power, intelligence, education, resources, strength or other needed attributes to protect their own interests.” Although this definition could be criticized for being too objective, as making reference to “those others”, it does pick out the main attributes which render human beings vulnerable. The Declaration of Helsinki (2008), the leading international regulatory document on research with human beings, addresses vulnerability in six of its articles: 9, 17, 26, 27, 28 and 29. Helsinki #9 Medical research is subject to ethical standards that promote respect for all human subjects and protect their health and rights. Some research populations are particularly vulnerable and need special protection. These include those who cannot give or refuse consent for themselves and those who may be vulnerable to coercion or undue influence. Helsinki #17 Medical research involving a disadvantaged or vulnerable population or community is only justified if the research is responsive to the health needs and priorities of this population or community and if there is a reasonable

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likelihood that this population or community stands to benefit from the results of the research. Helsinki #26 When seeking informed consent for participation in a research study the physician should be particularly cautious if the potential subject is in a dependent relationship with the physician or may consent under duress. In such situations the informed consent should be sought by an appropriately qualified individual who is completely independent of this relationship. Helsinki #27 For a potential research subject who is incompetent, the physician must seek informed consent from the legally authorized representative. These individuals must not be included in a research study that has no likelihood of benefit for them unless it is intended to promote the health of the population represented by the potential subject, the research cannot instead be performed with competent persons, and the research entails only minimal risk and minimal burden. Helsinki #28 When a potential research subject who is deemed incompetent is able to give assent to decisions about participation in research, the physician must seek that assent in addition to the consent of the legally authorized representative. The potential subject’s dissent should be respected. Helsinki #29 Research involving subjects who are physically or mentally incapable of giving consent, for example, unconscious patients, may be done only if the physical or mental condition that prevents giving informed consent is a necessary characteristic of the research population. In such circumstances the physician should seek informed consent from the legally authorized representative. If no such

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representative is available and if the research cannot be delayed, the study may proceed without informed consent provided that the specific reasons for involving subjects with a condition that renders them unable to give informed consent have been stated in the research protocol and the study has been approved by a research ethics committee. Consent to remain in the research should be obtained as soon as possible from the subject or a legally authorized representative. The CIOMS International Guidelines (2002) treat of vulnerability in Guideline 13 and of two categories of particularly vulnerable humans in Guidelines 14 and 15. Guideline 13: Research Involving Vulnerable Persons Special justification is required for inviting vulnerable individuals to serve as research subjects and, if they are selected, the means of protecting their rights and welfare must be strictly applied. Guideline 14: Research involving children Before undertaking research investigator must ensure that:

involving

children,

the

x the research might not equally well be carried out with adults; x the purpose of the research is to obtain knowledge relevant to the health needs of children; x a parent or legal representative of each child has given permission; x the agreement (assent) of each child has been obtained to the extent of the child’s capabilities; and, x a child’s refusal to participate or continue in the research will be respected. Guideline 15: Research involving individuals who by reason of mental or behavioral disorders are not capable of giving adequately informed consent

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Before undertaking research involving individuals who by reason of mental or behavioral disorders are not capable of giving adequately informed consent, the investigator must ensure that: x such persons will not be subjects of research that might equally well be carried out on persons whose capacity to give adequately informed consent is not impaired; x the purpose of the research is to obtain knowledge relevant to the particular health needs of persons with mental or behavioural disorders; x the consent of each subject has been obtained to the extent of that person's capabilities, and a prospective subject's refusal to participate in research is always respected, unless, in exceptional circumstances, there is no reasonable medical alternative and local law permits overriding the objection; and, x in cases where prospective subjects lack capacity to consent, permission is obtained from a responsible family member or a legally authorized representative in accordance with applicable law.

Triple vulnerability and rationalizations for research Developing world populations, particularly those of SubSaharan Africa, are vulnerable in many dimensions as far as medical research is concerned. They are vulnerable as members of economically disadvantaged groups; a fact recognized in Helsinki #8 and CIOMS Guidelines 10 and 13. They are also vulnerable as members of medically disadvantaged groups, bearing a heavy burden of neglected or so-called orphan diseases. Then again, many of them are vulnerable as incompetent minors increasingly used as research subjects. In Sub-Saharan Africa, vulnerability is not limited to research subjects but extends to scientists, researchers, institutions, and even governments because of their relative lack of capacity and empowerment vis-à-vis their developed world counterparts.

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In spite of these multiple vulnerabilities there has been not a decrease but an enormous increase in developed world medical research on human beings in the developing world, particularly in Sub-Saharan Africa. This increase in research activity has been accompanied by appropriate rationalizations. Some of these are the following: It is argued that since the majority of diseases and epidemics, requiring research for solution, are occurring in the developing world, it makes sense to conduct the researches where the solutions are needed. It is further argued that the current researches are likely to result in medicines which are more available and affordable to developing world populations than currently existing ones. Furthermore it is pointed out that the process of researching will contribute to capacity-building and infrastructure development in the developing world. It is even argued that the availability of epidemics and abundant sundry diseases and lack of constraining regulatory frameworks can be considered as incentives for marketdriven research which otherwise would not be attracted to invest resources into such research. All this indicates that developing world populations stand in serious need of protection from the possible abuses of research. Even in the industrialized developed world, like anywhere else, in human affairs, it is not easy to avoid taking advantage of and exploiting the weak, needy, poor, sick and ignorant. And if we look at the history of scandals, abuses and atrocities in medical research, in conjunction with contemporary malpractices, then there is every reason to emphasize and insist on protection for research subjects in the developing world. Moreover, biomedical research in the contemporary world has become big business and, where big business, driven by economic power and the profit motive are at play, ethics, justice and fair play are always likely to be swept under the carpet.

Ensuring the protection of research subjects To ensure the protection of biomedical research subjects in the developing world, a certain framework, which is quite

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evident in the case of research in the developed world, is necessary. First and foremost in such a framework is rigorous scientific and ethical review of research protocols before they are approved for carrying out on the field. Secondly, there is the need for appropriate supporting legal, human rights and advocacy structures. Thirdly, there is the need for an enabling liberal and democratic environment as well as continuous and systematic creation of awareness of what medical research is all about. Direct responsibility for the ethical conduct of medical research on humans falls on four categories of persons: scientists who design and carry out the research, ethics committees or review boards which study and approve research protocols, sponsors and funders who provide the means and resources for carrying out research, and host and sponsor county authorities who permit and enable research to be carried out. Of these, more direct and immediate responsibility falls on the researcherscientists or investigators who are in day to day contact with the research subjects on whom they perform the investigative procedures and manoeuvres. The principal investigator (PI) in any research project carries the heaviest responsibility for its ethical conduct.

Exploiting vulnerabilities The exploitation of human vulnerabilities has been abundantly manifested in coercive research, deceptive research and inducive research. Coercion achieves an aim or objective through blatant or subtle threat of a harm perceived by the victim as greater than compliance. Coercive research is perhaps the most unethical type of research imaginable; it is arguably equivalent in moral obnoxiousness to research on completely innocent subjects who have not the faintest idea of what is going on. Most of the historical abuses and atrocities involving experimentation on human beings (Emanuel 2003, pp.1-20; see also the chapter on “Health Research Ethics Comes to Africa” in this book) involved coercive research. That coercive research is still not only possible today but easily exemplified can only be attributed to the claim that human beings do not easily learn from

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history. Next in moral gravity to coercive research is deceptive research. In deception the victim is made to misread or to misunderstand a situation, to have an illusion, delusion, mirage, etc. Deceptive research not only is quite possible but abundantly exemplified today, particularly in sub-Saharan Africa. All research involving the so-called “therapeutic misconception” (where investigative procedures may be presented to appear to the subjects as therapeutic), “therapeutic illusion” (where in spite of explanations to the contrary research subjects themselves stubbornly believe investigative procedures and products to be necessarily therapeutic), research without or with inadequate informed consent, are varieties of deceptive research. The remedy for deceptive research lies in thoroughly and adequately wellinformed research subjects combined with procedures that respect the four cardinal principles. (See the chapter in this book on “Fundamental Principles and their Application in Health Research and Review Process). Closely following behind coercion and deception for the bronze medal in moral obnoxiousness is inducive research. An inducement is something offered with the intention and purpose of making someone act against their own better judgment or doing what they would otherwise not have done. Inducement is a serious problem in present day research especially in the developing world. It cannot properly be fully appraised without taking into consideration the distinction between the agent/patient of moral action. A high burden of disease, combined with desperate poverty and ignorance makes people highly vulnerable to inducive research. Too much enthusiasm to participate in research may be a sign that inducement rather than informed consent is at work, for even if it be granted that research subjects often access healthcare and treatments which they would otherwise not be able to access, it cannot be assumed that they would still be willing to subject themselves to research if they could access such benefits in normal healthcare. Inducing rather than rationally persuading subjects to participate in research is always ethically wrong. Deciding whether something, an offer, a benefit, or even a due, is an inducement can be appraised only in situ within a particular

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context. This is similar to the issue of whether a double standard is being applied or only a different standard (Tangwa 2001, pp. 156-162). As moral agents we can guess what would induce the patients of our actions to behave in various ways, but we will never know for certain why people act/behave the way they do. But we always know for certain when we pose an act with the intention and purpose of achieving a specific end. From the point of view and perspective of the agent, inducement is completely knowable and completely avoidable, and this is all that matters from that point of view. You know very well when you are throwing corn to feed the chicken and when you are throwing it as a bait to catch it and cut its throat; the chicken may not know the difference. From the point of view of the patient, of course, the patient also has the moral duty not to allow him/herself to be induced rather than rationally convinced. No moral agent can perform another’s moral duties. A distinction has usually been made between “due” and “undue” inducement (Emanuel 2004, pp. 100-105; CIOMS 2002, Guideline 7, p.45). The explanation underlying the distinction is that sometimes reimbursements to study participants for lost earnings, travel costs and other expenses incurred in the course of taking part in a study or other non-monetary benefits connected with the study may be so attractive to them as to cause them to join the study against their own better judgment. The distinction may be ill-advised; for once it is admitted, it would be legitimate to ask when an inducement is rightly due to a research subject and how this is different from compensation or recompense. If it be admitted that a “small” inducement may be permissible while only a “big” inducement is unacceptable, the question naturally arises as to how small an inducement should be to be appropriate. Should the answer to this question be “Small enough to induce”? But, in that case, why is a big inducement objectionable, since it would equally induce and, in addition, benefit the subject more? Compensations, reimbursements and deserved benefits may, of course, under certain circumstances, induce potential research subjects. This is a serious matter which ought seriously to be addressed in contexts and situations where it

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obtains. A distinction can thus be made between “dues” and “inducements”. But the distinction between “due” and “undue” inducements ought to be abandoned. An inducement is an inducement and cannot be “due” to a research subject. Research subjects may be reimbursed or compensated for whatever, with due care taken to ensure that this is not inducive; they should never knowingly be induced into the research.

Another type of deception in research In social science research, there is a type of deception that is considered legitimate. This is in cases where the research question is such that giving adequate information about it to potential participants would countermand the results through conscious or unconscious behaviour change. A researcher investigating, for example, who is investigating, say, wife bashing or child abuse in a community is likely to obtain false results through behaviour modification if s/he explains fully and completely the object and purpose of the research to the potential participants. In such cases, it is argued that it is permissible to withhold some information from the participants until the end of the research. At the end of the research the whole strategy is then disclosed to the participants in a process termed “debriefing”. It is hard to imagine any situation in biomedical research where it would be ethically justifiable purposely to deceive or withhold information about the study from study participants.

Conclusion: Kisumu declaration Developing world populations particularly those of subSaharan Africa are highly vulnerable in medical research which has witnessed an exponential increase in recent years for various reasons. While much of this research is easily justifiable as aiming to serve the urgent health needs of the populations subjected to it, care must be taken to avoid harming, exploiting or otherwise treating research subjects in ethically unacceptable ways. The research scandals that

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have been witnessed in recent times in countries such as Nigeria, Kenya, Tanzania, Cameroon, etc. show that the protection of research subjects, particularly in sub-Saharan Africa, is an important ethical imperative whose observance cannot be taken for granted. So let me conclude this paper with the Kisumu Declaration; so called because it was proposed by me during the very first AMANET Health Research Ethics Workshop in Kisumu, Kenya, and enthusiastically adopted by all the participants. The Declaration could serve as the solemn undertaking of all stake-holders in any research project. Kisumu declaration of moral integrity and noble intent We, the investigators, sponsors and funders of this study/research, hereby solemnly declare, on our honour, that our intentions in carrying out this research are noble and primarily motivated by the desire to acquire knowledge that could help in alleviating suffering and improving the lot of human beings, without any distinction or discrimination; that we have no overt or covert intention or any hidden agenda to harm, deceive, exploit or unfairly to treat, now or in the future, any human being or group of human beings. We solemnly pledge that, in carrying out this research, we will maintain the utmost respect for all participants and experimental subjects and objects, including any plants and animals. We will do everything within our powers to prevent knowledge gained through this research from being abused or used in ways contrary to the above solemnly declared aims and intentions.

References CIOMS 1993, 2002, International Ethical Guidelines for Biomedical Research Involving Human Subjects. Emanuel, E.J. (2004), “Ending Concerns About Undue Inducement”, Journal of Law, Medicine and Ethics, Spring Vol. 32:1, pp. 100-105. Tangwa, G.B. (2001), “Moral Agency, Moral Worth and the Question of Double Standards in Medical Research in Developing Countries”, Developing World Bioethics, Vol. 1, No. 2, November, pp. 156-161.

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WMA 1964, 1975, 1983, 1989, 2000, 2008, Declaration of Helsinki.

CHAPTER ELEVEN ETHICS, HUMAN RIGHTS AND SEXUAL/REPRODUCTIVE HEALTH IN AFRICA: EXPLORATORY SOCIO-CULTURAL CONSIDERATIONS

[Previously published as Chapter 7, (pp. 213-232), GLOBAL BIOETHICS AND HUMAN RIGHTS: Contemporary Issues, edited by Wanda Teays, John-Stewart Gordon and Alison Dundes Renteln, Lanham/Boulder/New York/Toronto/ Plymouth, UK: Rowman & Littlefield, 2014].

Keywords Ethics, human rights, law, reproductive health, sexual health, culture, relative, universal, Africa

Introduction Since “human reproduction is the means by which each society perpetuates itself and its traditions”1 the importance of reproduction for all human societies is self-evident, as no society could possibly want to go out of existence. All human societies also cherish their culture, customs and traditions as things of value and of the very last importance. Human cultures, with their different customs, traditions and practices are also remarkably diverse, differing from one another in many practical details. If we define culture as “a

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way of life of a group of people, underpinned by adaptation to a common environment, similar ways of thinking and acting and doing, similar attitudes and expectations, similar ideas, beliefs and practices, etc”1i then it needs no saying that culture is intrinsically relative, relative to the society or people for which it has application. But human cultures, divers as they may be, do have some things in common. They are all human cultures, each and all held together or underpinned by reason or rationality and morality (ethics). Rationality and morality can be called the universals of cultures. They are of the very essence or definition of being human or having a culture and no human culture seems possible without them. Human rights for their part are a subset or derivative of ethics/morality, a powerful heuristic device or tool for canvassing ethical conduct and facilitating behaviour change in the modern world. Similarly, law is also a derivative or subset of ethics/morality with the notable advantage of being more robust and efficacious in its coercive and behaviour changing effects, but with the limitation of being restricted to particular or specific politicogeographical areas of jurisdiction. The idea of “international law” or of “international human rights law” is today still basically a prescriptive ideal whose limitations are set by the idea of “national sovereignty”. In modern societies, particularly in the so-called Western world, good conduct and responsible behaviour are assured by the interplay between ethics, human rights and law. In traditional societies, particularly in Africa, good conduct and responsible behaviour were assured by the interplay between ethics, customs and taboos. Many of the mores, customs and taboos of such societies were aimed at regulating sexual behaviour and reproductive conduct. The concepts of human rights and positive laws were not evident in an explicit manner in traditional societies although their essence was incorporated in ethics, customs and taboos. The idea of “customary law” is a modern concept which basically looks back at traditional society and deduces its laws from its mores, customs, traditions and taboos.

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In considering the intersections and interplay between ethics, human rights and sexual/reproductive health in Africa, therefore, it is important to consider the traditional state of affairs in its stable or evolving forms and how the modern concept of human rights and the prescriptive ideals of international law might impact on the situation to effect a smooth and acceptable mutation. In what follows, I attempt sketching a loose framework, from the point of view and perspective of African culture, within which this interplay can function. I start by discussing the place of human reproduction within African cultures; next, I discuss the ideas of reproductive health and sexual health; then I discuss a paradigm case of a system of traditional African marriage as the background context in which to conceptualize the reproductive and sexual problems of the traditional setting; then I discuss the interplay between human rights and reproductive and sexual health and I end with a case study on disclosure and confidentiality of HIV/AIDS status whose purpose is not current topicality but simply to highlight and demonstrate the complex nature of the actual interplay between private and public ethics, human rights and health in the contemporary African context.

Human reproduction and African cultures As a matter of fact, all human societies and cultures in all historical epochs have been deeply concerned, if not obsessed, with reproduction and allied processes; a concern/obsession reflected in laws, religious dogmas/injunctions, customs, traditions, taboos and practices. Until quite recently, to talk of human reproduction was to talk of sexual reproduction. Asexual reproduction was the curious method of some nonhuman lower species that we learned about in high school biology. But today, asexual methods of human reproduction have become possible with technological advances, although some of them are still highly controversial and ethically debatable. In any case, it is not likely that asexual methods of reproduction such as artificial insemination, in vitro fertilization and embryo transfer (IVF & ET), or cloning will

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become the norm in any speculatively foreseeable future. For the time being and foreseeable future, human reproduction and human sexuality are still yoked like two mules marching in tandem, which alone can carry forward the cart of human survival and of human cultures. But whether yoked or separated, both sexual activity and reproductive processes (pregnancy, gestation/incubation and child birth) involve significant risks of ill-health. And while human reproduction and by consequence human sexuality have been a concern and a value in all human cultures, this is even more so the case in African cultures, noted for their great love of procreation, large families, and the practice of polygamous forms of marriage. Children are so highly valued in African cultures that procreation is the express and main purpose of marriage and its absence the main cause of divorce or conversion of monogamy into polygamy, while childlessness for whatever reason, is a highly undesirable state of being for both men and womenii1. This state of affairs has resulted in a situation of great ambivalence in the attitude of many Africans to modern biotechnological methods of assisted reproduction. On the one hand, the great need for offspring attracts to these methods and, on the other, there is the technophobia of nonindustrialized cultures and that mistrust of the artificial and the demystified arising from the background of traditional religion and worldview. The idea of ‘reproductive health’ and of ‘sexual health’ as a minor consequential corollary was present in African traditional cultures and was assured by means of customs and taboos. Such for instance were practices whereby a pregnant woman left the husband’s lineage and returned to her own lineage until she had safely delivered and weaned her baby; the prescription or proscription of the intake of certain foods during pregnancy; the consumption of various substances by men to enhance potency and erectile staying power; the prohibition of sex with a menstruating woman; the tabooing of incest or of sex with minors etc. Rightly or wrongly, these prescriptions and proscriptions were believed

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to be either enhancing or subversive of sexual and/or reproductive health. In this situation, sexual health was considered important for the married or, in any case, procreating adult, but not for the unmarried young for whom sexual activity was not only proscribed but often severely repressed. This was more so for young girls for whom virginity at marriage was a highly cherished value. While it is true that no other category of patient consults the modern physician or the traditional healer more than the barren woman or impotent man1v, the reasons for this have less to do with a desire to enjoy sex as an independent value, and more to do with a desire to maintain potency for parenthood. The same underlying reason is partly responsible for the frequent refusal of many African patients to accept surgical removal of any organs closely connected with procreation, (even if on account of advanced age or other such reason they now serve merely a symbolic function), such as breasts or testes, even under threat of death; the other part being the value attached to intactness of limbs and other bodily members in life or in death. The idea of ‘sexual health’ as a separate and independent value, therefore, is not very evident in traditional African cultures. And yet, only a little reflection is required to realize at least the plausibility of the claim that sex was meant by nature for its own sake and not merely as a tool for reproduction and that, in the cause of evolution, it had probably taken time for humans to realize that there was a direct causal link between the sexual act and the event of pregnancy resulting in birth. It is easy to understand that under a strong religious or magical worldview humans could attribute pregnancy and childbirth to supernatural forces, until observation of mating amongst domestic animals and its evident consequences pricked their sceptical consciences regarding mating amongst humans. In any case, the actual situation of things is that many different and complex factors - increasing acceptance of single-hood as a respectable mood of existence, delayed

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marriage, pressures on family size, earlier emancipation of young people of both genders from strict parental control, etc., - have contributed to make sex without its procreative component the only option for an increasing number of people. This and the fact that the customs and traditional practices of Africa have been severely subverted, for good or for ill, by the contact with Western cultures, religions and education, and are slowly receding into the past, makes modern legislation and other supporting structures for reproductive and sexual health an urgent necessity. Such legislation needs to be fully aware of and sensitive to traditional attitudes and practices so as to facilitate a smooth transition to a modern setting and to salvage what is of enduring value in them, so as not to throw away the baby with the bath water. It is also necessary to avoid imposing the ideologies or idiosyncratic practices of one culture on another, as it were. Cultural borrowing is inevitable and is justifiable only where what is borrowed is demonstrably both rational and ethical. There is no need, for instance, to legislate, say, polygamy out of African cultural practices, when it cannot convincingly be demonstrated that, as a form of marriage, it is any less rational or ethical than other forms of marriage in Africa and elsewhere. Such practices are best allowed to die a natural death under the impact of other modernizing or globalizing influences rather than being legislated out of practice.

Reproductive health The World Health Organization (WHO) has popularized the understanding of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”v. Along the same conceptual path, reproductive and sexual health can be understood as a state of complete physical, mental, and social well-being in the domain of reproduction and sexual activity. Such a definition is evidently an ideal standard, necessary as the target of aspirations and practical projects; in practice it is hardly achievable for all members of any society or human community. The actual over-all state of health of any

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individual at any given point in time will always be less than complete or perfect. In fact, at the individual level, even if such a state of complete or perfect mental, physical, and social well-being were achieved, one could hardly know for certain that it had been achieved; human ambitions and aspirations will, understandably, always stay ahead of the status quo or what is actually achievable, because human beings are by nature aspiring but limited beings. Be that as it may, while reproductive health has been a perennial concern from time immemorial in all societies and cultures, it is only in recent times that it has received the focal attention of medical researchers and research funders. Programmes and projects and associations now abound [for example, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Family Health International (FHI), Planned Parenthood Association (PPA), etc.] which are making a great impact globally on reproductive health. Furthermore, assisted reproduction technologies (ARTs) and assisted conception are making reproduction not only possible for those for whom it would otherwise have been impossible but safer and healthier than was possible in the past. Except for the very sophisticated methods, like ICSI (cytoplasmic sperm injection) and EF (embryo freezing), nearly all the other ARTs are already available in Africav1, although in terms of demand there is a clear preference for artificial insemination using a husband’s sperm (AIH) as against other possible options. But economic factors will likely ensure increasing resort to the other methods of ART. Economic determinism is already leading to both a delay in the assumption of the burdens of parenthood and a reduction in family size for many Africans. Delayed parenthood will come with difficulties in achieving conception normally or naturally, making resort to ARTs inevitable.

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Sexual health As already mentioned above, the idea of sexual health as a separate and independent value was almost completely absent in traditional African societies. But even in Western societies where for a long time sexual health has been accepted as an integral part of reproductive health, it is only recently that sexual health has emerged as a clearly separate and independent value. Many factors, as already mentioned above, are responsible for the increasing importance of sexuality as a separate and independent concern, irrespective of reproduction. These include, besides those already enumerated, such phenomena as voluntarily childless marriage, much earlier introduction to sexuality, increasing rates of sexually transmitted infections particularly of HIV/AIDS, increasing recognition or acceptance of homosexuality, the impact of biotechnologies on reproduction, etc. The WHO has already announcedvi1 the imminent publication of a number of very important studies focusing exclusively on sexual health, such as: Defining sexual health: Report of a Technical Consultation on Sexual Health; Wood K. and Aggleton P., A conceptual framework for sexual health programming; and Integrating sexual health interventions into reproductive health programmes: experiences from developing countries. Cook, Dickens and Fathala have characterized sexual health as including “the ability to enjoy mutually fulfilling sexual relationships, freedom from sexual abuse, coercion, or harassment, safety from sexually transmitted diseases, and success in achieving or in preventing pregnancy”vii1. In the context of Africa, where traditional ways of thinking, attitudes, habits, and practices still hold sway, this understanding of sexual health in its comprehensiveness involves a call to a different way of looking at things and developing new attitudes, habits and practices, inasmuch as the idea of sexual pleasure within the traditional world-view was simply a welcome by-product of a process aimed at fecundation in which the idea of preventing pregnancy would have been self-contradictory. Even the idea of fertility regulation in that context boiled down to child spacing, and

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the person seeking permanent sterilization would have been looked upon as indeed “odd” if not downright evil. It is against such background also that the various forms of marriage in Africa, especially family-arranged marriages can properly be understood. In some cases the bride and groom could be meeting for the first time on their wedding night. In arranging a marriage, the family was always less concerned about the physical beauty or sexual attractiveness of the marriage partner and more concerned about such other qualities as good family background, general physical and mental health, reliability, honesty, hard work and, above all, likelihood of being fertile. In that setting it was extremely difficult to find convincing reasons for, say, refusal of a potential spouse on grounds connected with mere personal preference/choice or for divorce of any marriage which had been blessed with at least an offspring. A woman who had borne offspring with the husband knew very well that her place in the patri-lineage was more secure than that of her husband who could always be reminded that the woman was not his wife alone but the wife of the entire lineage. This situation, as sketched above, is in a state of rapid mutation and change, under the powerful influences of contact with Western culture and Western religions, the emergence of sundry epidemics connected with sexuality, the phenomenon of globalization, increased migration, the information revolution etc. Under the impact of these phenomena, it is evident that the traditional African family and traditional African marriage, ideas, attitudes and practices related to sexuality and procreation can no longer be wholly sustained. Infection rates for HIV in adolescents, for instance, reveal that sexual debut which previously could only be extrapolated from the rate of teenage pregnancies outside of marriage is nowadays generally occurring before the age of 15. At the same time the highly disastrous consequences of a single HIV infected person in a large polygamous harem are better imagined than described. Change is inevitable and almost complete on many issues at the ideational level, but is still to impact completely on attitudes and practices. For example, many Africans today

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readily accept the idea of individual choice as a consequence of individual autonomy of, say, a marriage partner, but this still has to be reconciled and harmonized with attitudes and practices that emphasized community and group values over individual ones. Nor is it a matter of “either/or” in the exclusive sense; for the two sets of values (which summarily can be described as ‘communal’ and ‘individual’) are reconcilable and harmonize-able, although the result to be expected will surely be heavily shaped and coloured by context and perspective. Nearly all traditional African communities affirm by varying degrees and conceptual appellations the philosophy of Ubuntu1x which in actual fact is a balance between individual autonomy and communal values; establishing a dialectic relationship between them by means of which alone each finds meaning. John Mbiti has popularized this philosophy with the epigram: “I am because we are; and since we are, therefore I am”.

Traditional marriage among the Nso’ as a paradigmatic example Marriage is a particularly important area where traditional African customs, laws, and ethics seemed to coalesce perfectly. Marriage, of course, is a cultural universal, in the sense that even though marriage-less societies have been advocated (in Plato’s Republic, for example), no actual culture has ever succeeded in doing without it. But the form and shape that marriage takes is culture-bound, a cultural particular. In Western cultures, marriage is generally understood as a legal union between two individuals to the exclusion of all others, till death or legal divorce do them part. In traditional African cultures marriage is understood mainly in (extended) familial terms as the inclusion rather than exclusion of many others, as marriage typically turns two hitherto indifferent lineages into significant others of each other. In my natal culture, that of the Nso’ of the Western grasslands of Cameroon, as elsewhere in traditional Africa, both monogamy and polygamy were practiced within a

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plastically flexible framework that tried to balance both freedom and rigidityx. This plastic flexibility when transported to the modern setting without the supporting traditional structures is liable to result in the type of promiscuity and sexual license characteristic of many present day urban towns and cities of Africa. Traditional marriage in Nso’ was fairly indissoluble but it was not required that one signed a contract or took a vow to maintain the chosen marital status for life, because it could change without such change having been wished or foreseen. But to be married at all was to assume sexual responsibility. A married person was not expected to engage in casual or opportunistic sex, which was tantamount to wasting a precious procreative treasure. If a married man proved sexually insatiable and medication failed to help, the wife would be the first person to initiate the search for a co-wife or co-wives for him. If a married woman proved sexually insatiable the situation was much more complex but two frequent results were either separation or she could seek sexual satisfaction outside, with the covert approval of the husband but, in any case, any children she bore traditionally belonged to the husband, as long as there had been no divorce. Among the Nso’ both polygamous and monogamous marriages exist, although polygamy is preponderantly for kings (afon), great councilors of the kingdom (vibai) and lineage/compound heads (atarla’). Amongst these categories, polygamy is not a matter of choice. As soon as you are selected and installed into any of these positions, you automatically inherit all the wives of your predecessor in position before adding to that harem your own wife or wives and any new ones you might acquire in the course of time. For ordinary citizens, there were, before the recent introduction of “civil status marriage”, three main roads to a recognized valid marriage (monogamous or polygamous) in traditional Nso’: vidjin (orthodox marriage), kincem or nceemi (unorthodox marriage) and villem (wife inheritance)x1. In orthodox marriage, the first or only daughter of a woman who had also married in orthodox fashion is always given out

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in marriage by her maternal grandfather (taryiy) and all the other daughters by their paternal lineage head (tarla’ or fai). A father arranged the marriage of the first wife of each of his sons as well as the marriage of each of all the first or only daughters of all his daughters. A peculiarity of Nso’ marriage, vis-a vis marriage amongst other African peoples, is that there is no bride price/wealth or dowry. Ceremonial gifts are, however, exchanged at prescribed times with the proviso that the total value of marriage gifts received on behalf of a girl should not exceed the total value of the gifts that were given on behalf of her mother. A lot of time and attention are, however, devoted to checking the familial background of the prospective spouses to make sure that there is no blood relationship between them and that there exists no old and unsettled grudge, quarrel or feud between the two family lineages. In Nso’ marriage between blood relations up to the fifth degree is taboo. The prospect of marriage is also an occasion and an incentive for the ritual settlement of persisting differences, grudges and problems between families, lineages and communities. But once the marriage ceremonies and rituals have been performed, the two families/lineages now become “in-laws” (a sëjuu) committed to coming to each other’s assistance in times of need, such as tilling, harvesting, building, birth, marriage, death, etc. In unorthodox marriage, a man takes unto himself a wife and a woman a husband without the above formalities of orthodox marriage; they simply ‘move-in together’. Though recognized and tolerated, this form of marriage was not at all encouraged. Children begotten of such marriages belong, by Nso’ custom and tradition, to the parents of the woman, the man being considered in this situation as a mere “he-goat” (kibev), having no claim whatsoever over his own biological offspring. Furthermore, female children begotten through this form of marriage cannot marry in orthodox fashion but must also marry, if at all, in unorthodox fashion. They miss all the colourful rituals and ceremonies of orthodox marriage. This was a great disincentive and constraining factor for this form of marriage. However, many of such marriages, if they proved stable, happy and successful,

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could, retrospectively, be orthodoxified, by performing all the requirements of orthodox marriage, some, obviously, merely symbolically. In villem (wife inheritance) a man inherits the widow of his father, son or brother as his wife. When the occasion arises, it is usually the lineage head, in consultation with the women and elders of the compound, who checks for possible impediments and who decides who is to inherit whom. This form of marriage served as a sort of insurance and security for married women and had the consequence of reinforcing polygamy amongst ordinary citizens by converting initial monogamists into polygamists, whether or not they were enthusiastic about such conversion. This form of marriage did not necessarily or always have a sexual dimension. Sometimes the wife or wives inherited might have already attained menopause, in which case sexual relations were not expected. Other factors that tended to promote polygamy (or polygyny to be more exact) in this setting were: power, wealth and popularity. If a man was wealthy, powerful or socially popular, families and lineages tried to associate with him by offering him one of their daughters in marriage. What would it take to modernize a marriage system such as that sketched above? No matter how modernization may be conceived, ethics, human rights, and law, in that order of priority, need to be implicated. Clearly unethical practices can never be justified anywhere or at any time. Ethically controversial or ethically neutral practices are highly recommendable or dis-recommendable to the extent that they cohere or fail to cohere with human rights principles. The law should ideally come in only when the ethics and human rights issues have been clearly and unequivocally settled. An additional reason for this is the thought that in all societies, as the ancient Greek philosopher, Thrasymachus (c. 400 BC), is reputed to have remarked, the law tends always to protect the interest of the strong and the powerful of the society. An antidote to this tendency is provided by human rights principles and discourse, which, nevertheless, need to strive to avoid the above Thrasymachian pitfall of laws.

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This is the time to ensure that what is of enduring value in the traditional system should not be thrown away with what must change. Empirical research on a myriad of issues in this domain to determine the current state of affairs is strongly indicated. What, for instance, is the rate of singlehood among mature adults in the various African communities? What is the actual rate of polygamous marriages? What is the current family size average? What is the rate of homosexuality, if it exists? What is the rate of celibacy amongst unmarried mature men and women? What is the frequency of sexual encounters among different categories of men and women in given communities, etc.? One way of helping along justifiable change, however, would be the linkage of desirable changes with the concept and principles of human rights, a highly heuristic device liable to assist rapid change in behaviours and practices but also liable to be used covertly by powerful and influential cultures in proselytizing and propagating their own values.

Human rights and reproductive/sexual health The idea of human rights may be a purely heuristic device, but, in practice, it is a quite powerful means of effecting positive changes in systems otherwise highly recalcitrant to change. Human rights have such a strong appeal around the globe that their profession constitutes the highest form of political correctness in the contemporary world, while their violation draws the automatic condemnation of all and sundry. Human rights are, of course, not provable and cannot be philosophically justified without either logical circularity or reference to the most general assumptions of ethical principles. As Mann et al have rightly stated: Modern human rights is a civilizational achievement, a historic effort to identify and agree upon what governments should not do to people and what they should assure to all. Human rights are nonprovable statements that derive their legitimacy from having been developed, voted upon and adopted by the nations of the world and having been

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incorporated into the domain of international law; they do not achieve their status from divine inspiration or religionxi1.

But even though human rights are not directly derivable from religious doctrines, they are quite compatible with religious worldviews. The Universal Declaration of Human Rightsxii1, the touchstone document for human rights discourses is, of course, a purely secular document aimed at providing protections in the public domain particularly. Its focus is on societal-level conditions and determinants of well-being, including health and related issues and concerns. There is no religion or culture for which human well-being and the pre-conditions of its attainment are not a central concern. In public health the central concern is that of ensuring the conditions in which citizens can live healthy lives, avoiding preventable disease, disability, and premature death. In present day Africa there are arguably more infectious and epidemic diseases than have ever been seen in the past. Public health is the particular responsibility of civil authorities and governments and, for that reason, human rights concerns in public health focus primarily on governmental actions/inactions and how they impact on human health, human well-being and other rights enshrined in international human rights law. Public health targets populations rather than individuals and uses epidemiologic methods and procedures with the aim of preventing illhealth, disability and premature death. The disciplines and sciences that sustain public health include epidemiology, sociology, economics, biostatistics, bioinformatics, bioethics, etc. These give modern public health comprehensiveness in its appreciation of the health situation of society that was not possible in traditional settings. The concept of human rights provides an important imperative for monitoring governmental responsibility and accountability relative to fundamental rights affecting human health. Violations of human rights, such as unjustified discrimination, torture, and other forms of physical and psychological abuse impact directly on health

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and well-being. These considerations, relevant and applicable to all countries, are critical for African countries in their present situation, where traditional ways of life and governance have been displaced, with as yet nothing definite and firm enough to replace them, and where civil war, poverty, disease, dictatorship and make-believe democracy are the order of the day. Public health and human rights are natural allies. Public health goals and human rights norms when combined complement each other and lead to more effective and sustained health policies and programmes. As already mentioned, human rights are non-provable, but they do not derive their legitimacy solely from the fact of “having been developed, voted upon and adopted by the nations of the world and having been incorporated into the domain of international law”x1v. Certainly human rights have been greatly empowered by such procedures and acts which ensure that they will be respected and not violated with impunity. But such empowerment notwithstanding, whatever can be canvassed as a human right can also independently be established and justified, using only common sense and the most general of moral principles, although the justification of morality itself remains irremediably problematic and the cause of interminable controversies, as there is no antidote to extreme moral skepticism or amoralism. Legislation also tends to put issues in a straitjacket whereas the very rapid evolution of our thinking and attitudes in an age of information revolution and globalization calls for constant reappraisal and revision of our accepted ideas, attitudes and practices. The delivery of healthcare, particularly in reproductive and sexual health, is fraught with quandaries and dilemmas for both the provider and the receiver in which the generally accepted fundamental bioethical principles of autonomy, beneficence, non-maleficence and justice are either in conflict or need delicate balancing. Dealing with adolescents, HIV positive people, polygamists, homosexuals, prostitutes, wives of physically abusive men, husbands of verbally abusive women, etc., for examples, pose peculiar ethical

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problems in each case. Take, for instance, the principle of autonomy, which imposes on health workers or care providers the duty of respect for persons and their privacy or confidentiality. But there will be circumstances in which breaching confidentiality may seem ethically correct to protect the health of the public at large or even to protect the well-being and future interest of the very person whose confidentiality is being breached. An adolescent, for instance, seeking, say, an abortion or permanent sterilization creates a situation in which many ethical dilemmas must be faced by both herself and her healthcare provider. In such a case, can her health-seeking behaviour be helped without very careful counselling or without the knowledge and consent of the parents? Such and many other similar ethical dilemmas in the African context concern simple basic issues that need to be carefully thought through in the prospect or process of using legislation grounded on ethics and human rights to effect changes in the traditional systems of Africa.

Conclusion In a world fast becoming a veritable global village, thanks to the technological and informational revolutions, no culture will be able to remain an island unto itself. The local and the global are fast fusing into one. Disciplines are equally collapsing into an inter-disciplinary general pool. In this situation, human health and particularly reproductive and sexual health, ethics and human rights are fruitfully contending with each other. African culture and social life have no choice but to join in the dance. Africa needs to listen carefully to the global drum beats of reproductive and sexual health, ethics and human rights, but it needs to dance its own dance with its feet firmly planted on the solid ground of its own culture, social life, historical experience and worldview.

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References Rebecca J. Cook, Bernard M. Dickens, and Mahmoud F. Fathalla, Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law, Oxford: Clarendon Press, 2003, p. 3. i1 Godfrey B. Tangwa, “Morality and Culture: Are Ethics Culture-Dependent?” in Bioethics in a Small World, edited by F. Thiele and R. E. Ashcroft, Berlin/Heidelberg: Springer Verlag, 2005 ii1 http://www.ohchr.org/en/udhr/pages/introduction.aspx. [Accessed 02 October 2013] 1v http://www.ohchr.org/en/professionalinterest/pages/ ccpr.aspx. [Accessed 02 October 2013] v http://www.ohchr.org/EN/ProfessionalInterest/Pages/ CESCR.aspx. [Accessed 02 October] 2013 v1 http://www.justice.gov.za/trc/. [Accessed 02 October 2013] v1i London L, Rubenstein L, Baldwin-Ragaven L. The problem of Dual Loyalty and role conflict in Public Health. In: Beracochea E, Weinstein C, Evans D (Eds), Rights-Based Approaches to Public Health. Springer. Chapter 7, pp 119141, New York, 2010 v1ii London L, Kagee A, Moodley K, Swartz L. Ethics, human rights and HIV vaccine trials in low income contexts. J Med Ethics 2012; 38: 286-293 1x Baldwin-Ragaven L, de Gruchy J, London L. An Ambulance of the Wrong Colour: Health Professionals, Human Rights and Ethics in South Africa, University of Cape Town Press, 1999. x London L. Human rights, environmental justice, and the health of farm workers in South Africa. Int J Occup Environ Health, 2003; 9: 59-68. xi London L. Dual Loyalties and the Ethical and Human Rights Obligations of Occupational Health Professionals. Am J Ind Med, 2005; 47: 322-32 xii London L and G. McCarthy. Teaching medical students on the ethical dimensions of human rights: meeting the challenge in South Africa, J Med Ethics, 1998 August; 24(4): 257–262. 1

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Godfrey B. Tangwa, “ART and African sociocultural practices: worldview, belief and value systems with particular reference to Francophone Africa” in Current Practices and Controversies in Assisted Reproduction, edited by Effy Vayena, Patrick J. Rowe and P. David Griffin, Geneva: World Health Organization, 2002. Ibid, p. 56.

CHAPTER TWELVE LEADERS IN ETHICS EDUCATION: GODFREY B. TANGWA GODFREY TANGWA UNIVERSITY OF YAOUNDE 1 / CAMEROON BIOETHICS INITIATIVE (CAMBIN), CAMEROON

[Previously published in the International Journal of Ethics Education (2016) 1:91–105; DOI 10.1007/s40889-015-00018]

Short bio Please provide a short bibliography (biography?) with an emphasis on educational activities (maximum of 500 words). Godfrey B. Tangwa, PhD, is Professor and former Head of the Department of Philosophy at the University of Yaounde 1, Cameroon. He has recently retired from full-time teaching at the University but continues to do research and to supervise a number of graduate students. Born in Shisong in the Northwest Region of Cameroon, he attended Sasse College in Buea and the Universities of: Nigeria in Nsukka, Ife in Ile-Ife, and Ibadan in Ibadan. His doctoral specialization is in the area of epistemology and metaphysics and his teaching and research interests span the areas of African philosophy, inter-cultural philosophy and Bioethics. He lectured at the University of Ife from 1978-1986 and joined the University of

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Yaounde in 1987. He is one of the leading contemporary Bioethicists of sub-Saharan Africa who has gained international recognition. He has been a member of the International Association of Bioethics (IAB) since 1992, was on its Board of Directors from 1997 to 2003 and served as Vice-President of the association between 1999 and 2001. His recent research grants and projects include the following: 1. (As Co-Principal Investigator), Exploring Perspectives on Genomics and Sickle Cell Public Health Interventions. Funded by the National Institutes of Health (NIH). September 2013 – July 2016. 2. (As Coordinator), Documenting facilities and needs of ethics committees and implementing a training intervention to strengthen ethical review capacity in Central Africa. Funded by the European and Developing Counties Clinical Trial Trials Partnership. February 2012 - December 2013. 3. (As Coordinator), Mapping of Francophone African Research Ethics Committees. Funded by the Council on Health Research for Development, COHRED. March 2011 - December 2011. 4. (As Coordinator), Strengthening Ethical Review Capacity in Africa. Funded by the African Malaria Network Trust (AMANET). February 2007- September 2011. His academic and professional interests and preoccupations swing like a pendulum between theoretical issues and practical matters in medical ethics and philosophy of medicine, global bioethics, research ethics, clinical ethics, research regulation and governance, international ethics guidelines, ethics committee work and capacity-building in bioethics. His work is informed by the conviction that useful theorizing should arise from empirical data while good practice and policy should be based on justifiable coherent theory. His work is firmly anchored in Africa although he frequently takes short-term research fellowships, honours invitations to give lectures, make presentations or examine students, in other parts of the world.

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He was elected Fellow of the Cameroon Academy of Sciences (CAS) in 2007 and has recently been proposed for election as a Fellow of the African Academy of Sciences (AAS). He is the Chairperson of the Cameroon Bioethics Initiative (CAMBIN) which he founded in 2005; an executive committee member of the Pan-African Bioethics Initiative (PABIN), founded in 2001, and the Chairperson of the recently created Cultural, Anthropological, Social and Economic (CASE) working group of the Global Emerging Pathogens Treatment Consortium (GET). He has over seventy academic publications to his credit, including nine books, over twenty book-chapters and several peer-reviewed articles in international academic journals. You are one of the leaders in global bioethics. Why did you become interested in this area of ethics? I don’t know about being one of the leaders in global bioethics. What I do know is that, with a background in philosophy (mainly Western analytic philosophy in an African context), I have been greatly interested, indeed fascinated, by moral problems in general. As an undergraduate student (University of Nigeria, Nsukka, 1974-1977) my philosophical main courses were the history of Western philosophy (Ancient/Greek philosophy, Medieval/Scholastic philosophy, Modern Philosophy, notably British Empiricism and Continental Rationalism and Contemporary Philosophy), the Problems of philosophy, notably appearance and reality, phenomenalism, induction, body/mind, determinism/indeterminism, universals, etc., Moral philosophy, Logic and African philosophy – taught from the point de départ of the provocative question as to whether any such thing as African philosophy exists. I had been admitted into the University to do English and Drama but succeeded in shifting to Philosophy, after convincing my academic advisor, Chinua Achebe, to support my case for changing departments. It is thanks to substantive problems in Ethics and to Logic that I did not regret the change in discipline when I was introduced to the so-called Linguistic Movement in philosophy and it began appearing to me as if philosophy might be a discipline of interminable quibbling

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over trivialities. The suggestion that moral philosophy was a second-order, meta-ethical enterprise in which we study the language or discourse used by moralists in expressing their approval or disapproval of various things people do rather than about what people ought or ought not to do [See W. D. Hudson, Modern Moral Philosophy, London and Basingstoke: Macmillan and Co. Ltd., 1970] troubled me profoundly. For my final year long essay, I wrote a 42-page dissertation on The Problem of Akrasia or Weakness of Will and Prescriptivism, under the supervision of the late Hilary Staniland, 1941-1976, author of (Universals, New York: Doubleday & Company Inc., 1972). Susan Hilary Staniland is one of my teachers and mentors that I never caught making a slip of the tongue /mind and that had never ever stammered in the course of responding to a question for clarification following any of her lectures. It is thanks to her that I developed an abiding interest in Logic and clear thinking. Chinua Achebe, who voluntarily read every chapter of my final year long essay as I was writing it, greatly encouraged me by telling me that weakness of will was one of his fundamental personal problems and that he would be very grateful to me if I discovered the philosophical solution to it. I did not. Our final year work and examinations in 1977 were evaluated and assessed by Odera Oruka, an external examiner from the University of Nairobi, who seemed sufficiently impressed with my work as to ask to talk with me after his external examining duties were over. He told me he had to bring me to his department in Nairobi for graduate work and promised to look for the means to do so during the course of the year. For my Masters in Philosophy (1978-1979) I went to the University of Ife (today Obafemi Awolowo University), Ile-Ife, where the head of the Philosophy Department, Professor Olubi Sodipo, who had heard about me from Odera Oruka, had sought me and offered me a teaching assistantship. I eventually wrote an M.A. dissertation under Sodipo’s supervision on the subject: Nkrumah and Nyerere on

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Socialism; A Comparative Study (1979), examined by Kwasi Wiredu from the University of Ghana, Legon. Kwasi Wiredu happens to be, in my opinion, the African philosopher whose thought and work are clearest and most rigorous. Other external examiners I had for the M.A. programme were Robin Attfield and Barry Wilkins, both from the University of Wales, Cardiff, in the UK. Perhaps without knowing it, they saved me and my M.A. programme from one of my teachers with whom I was not getting on too well and who had vowed to me that as long as he was there I would never get an M.A. from Ife. A number of things at Ife contributed in directing my conceptual interest and footsteps towards the highway of bioethics. The department had a regular staff seminar series in problems of ethics to which scholars from many other disciplines came. It was at one of those seminars I met Professor of surgery, Akin Bankole, an oncologist, who eventually invited me to see some of his terminally ill patients and to facilitate some of his seminars in medical ethics with his graduate students. My second ever published academic article [“A Case for Positive Euthanasia” The Nigerian Journal of Philosophy, Volumes 4 and 5, Nos. 1 & 2, 1984/1985, pp. 75-80] was written at this time. It was also at Ife that I was introduced (by Chris Nwodo) to the works of Karl Raimund Popper, whose philosophy struck me as being profoundly earnest and about real substantive philosophical issues, in contrast to the ‘quibbling over trivialities’ that had nearly put me off philosophy earlier. I eventually wrote my PhD thesis under the joint supervision of Peter Bodunrin and Lansana Keita on Karl Popper’s Theory of Indeterminism for the University of Ibadan (defended in 1984 with Vernon Pratt from the University of Lancaster in the UK as external examiner). My doctoral specialization was thus in the areas of epistemology and metaphysics. But, no matter what domain of philosophy I have stumbled in, my propensities have clearly been first and foremost towards practical and applied philosophy or philosophizing which at least aims at making a difference in the real world, even if it may also serve incidentally as an intellectual pastime.

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Ethics, in my view, is a branch of philosophy completely and immediately concerned with making a difference in human acts, actions, decisions, choices and behaviour. Who were the teachers who have inspired you to choose a professional career in bioethics? What have they learned you? Although I do often describe myself as a bioethicist, I do not consider myself as having a ‘professional career in bioethics’. I do bioethics but, at the same time, I do many other things. The situation in Cameroon as it still is does not yet permit a career in bioethics. In fact I do more bioethics when I travel outside of Cameroon than in Cameroon. That said, most of my teachers in bioethics have been informal mentors rather than formal classroom teachers. The notable exception here is the post-doctoral fellowship I did at the Johns Hopkins University (Baltimore) in the USA (2002), under the Fogarty African Bioethics Programme, run by Nancy Kass, Adnan Hyder and Ruth Faden, who were all my teachers among many others. The programme included a weekly seminar at the Department of Clinical Bioethics of the National Institutes of Health (NIH) as well as the yearly week long world famous bioethics seminar of Georgetown University. For my practicum on this learning programme, I did a ‘theoreticum’ which resulted in my article: “Between Universalism and Relativism: A Conceptual Exploration of Problems in Formulating and Applying International Biomedical Ethical Guidelines”. [Journal of Medical Ethics. 30: 63-67, 2004]. Apart from the mentors I have already mentioned in the course of my formal philosophical development, the International Association of Bioethics (IAB) which I joined in 1992 and its members, especially those of its successive boards of directors, has been most effective in my bioethics formation. At the IAB I met some of the most brilliant bioethicists in the world and listened with fascination to their views and discourses, some of which were coherently brilliant demonstrations defending positions which seemed to me fundamentally counter-intuitive; and I would sometimes try to contribute to the discussions of this

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intellectual cream of the cream of the western world, culture and civilization, from the point of view and perspective of the African villager that I am. The IAB organizes World Congresses of Bioethics every two years and a smaller conference or meeting, involving mainly members of the board and some bioethics group or association, every intervening year. It is the task of the IAB Board of Directors to organize these meetings as well as to oversee the running of the official journal of the association, Bioethics. The very first World Congress of Bioethics had taken place in Amsterdam, the Netherlands, in 1992, the second in Argentina in 1994. I was not able to attend either of these first two congresses, but I attended the next (1996) in San Francisco, the USA, thanks to an invitation and sponsorship from Alex Capron, the Congress President. At that Congress I made an oral presentation on “Birth and Death in African and Western Cultures”. Shortly afterwards I was elected into the Board of Directors of the association and acted as VicePresident of the Board with Ruth Macklin as President from 1999-2001. In 1998 the World Congress of Bioethics took place in Tokyo, Japan. I attended the congress and made an oral presentation on “Globalization or Westernization? Ethical Concerns in the whole Bio-Business” [published in Bioethics. 13(3-4): 218-226, 1999]. The Japan Congress was preceded by two satellite Roundtable Conferences at Tsukuba University, Tsukuba Science City, notably, the Fourth International Tsukuba Bioethics Roundtable (TRT4) and the Second Conference of the International Association on Feminist Approaches to Bioethics (FAB2). I attended both satellite meetings. At TRT4, I was asked to react to the views of the convenor of the Roundtable, Professor Darryl Macer, who has written a book proposing that ‘Bioethics is love of life’. My reaction was entitled ‘Is Bioethics love of life? An African View-Point’ [published as Chapter Thirteen, pp. 186-188, of my book, Elements Of African Bioethics In A Western Frame, Mankon, Bamenda: Langaa Research & Publishing CIG, 2010]. At the FAB2, I was mainly a keen listener. I heard many interesting views and arguments expressed. But, in spite of considering

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myself a male feminist, in the sense that I firmly believe in the necessity to empower women all over the globe through the dismantling of all structures of unjust discrimination and oppression, through the instauration of fairness and equity and due consideration of their gendered roles, I was shocked to listen to a loudly applauded suggestion that, because impregnation is often an act of violence committed by the ‘impregnating sex’ on the woman, every couple should have special mutual consent forms which should be signed before every act of intercourse so that, in the event where pregnancy results in the contrary case, the woman could sue for damages and compensation! I earnestly hoped that African feminists, with some of whom I had debated recently, could find less mechanical and less absurd ways of empowering women in marriage. By far the most remarkable and memorable presentation I listened to in Tsukuba was that of Wendy Orr, a young, articulate and militant female medical doctor from South Africa who was a member of the recently concluded Truth and Reconciliation Commission (TRC) under the chairmanship of Archbishop Desmond Tutu. Wendy’s revelations about some of the findings of the TRC were profoundly shocking. She talked about South Africa’s Chemical and Biological Warfare (CBW) programme. According to her: The work of the scientists involved in the CBW programme was covert and secretive in every imaginable way. It was conducted under the guise of private ‘front companies’ supposedly conducting commercial research and development work; it was funded from undeclared, unaudited secret government coffers; research and experimentation were conducted on a strict ‘need to know’ basis with little or no communication or interaction between scientists working on different projects or between scientists inside and outside the programme. The aim of the programme was to develop agents harmful to individuals, groups and communities.

Wendy pointed out that, apart from about two or three medical doctors, those involved in the CBW programme were ‘chemists, engineers, physicists and veterinarians, who did not see themselves as bound by any particular ethical codes

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of conduct’. For this reason, she observes that ‘present conventional approaches to Bioethics/Medical Ethics may exclude certain groups of scientists or leave gaps which allow them to exclude themselves from ethical obligations’. She further lists a few of the projects which were pursued under the described milieu of secretive and non-interactive scientific research in disregard of all concern for ethics and human rights as follows: x The production of thousands of kilograms of street drugs (like Ecstasy and Mandrax), supposedly for use as crowd control agents. x Research into the use of various carrying agents for organophosphate poisoning, for example, beer, whiskey, chocolate, shampoo. x The development of ‘applicators’ which were, in effect, murder weapons, for example, screwdrivers which could inject poison into a chosen victim and leave an almost undetectable external puncture wound. x Research into toxic agents which are easily administered, lethal, tasteless, odourless and undetectable in the body. x Research into and the stockpiling of millions of drug resistant cholera, anthrax, plague and botulinum organisms. Most shockingly of all, Wendy revealed that: x In spite of the fact that South Africa was supposedly subject to international sanctions, the SADF received support for this programme from a number of foreign countries, including the USA, the UK, France, Israel, China and Germany. She concluded her presentation by drawing attention to the saying that ‘all it takes for evil to succeed is for good men (and women) to stand by and do nothing’. She finally wondered what role organisations like the International Association of Bioethics could play in addressing, drawing attention to and halting ‘evil’ science.

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The next World Congress of Bioethics (2000) took place in London, UK. I not only attended it but made a joint presentation with Cameroon’s foremost medical scientist and oncologist, Victor Anomah Ngu, on “Effective Vaccine against and Immunotherapy of the HIV: Scientific Report and Ethical Considerations from Cameroon”. Our abstract read as follows: In this presentation, we wish to draw the attention of the global community to the scientific results, as well as to evoke some ethical implications and considerations, of biomedical research carried out by V. Anomah Ngu during the past ten years in Cameroon. The initial results of the research were first presented to the Cameroon Academy of Sciences on 2 December 1999 in a paper titled: ‘Vaccines for the HIV: Past Efforts and Future Prospects’. The problematic that set off the research was the puzzle as to why the natural HIV infection provokes immune responses that fail to kill and eliminate the virus from the body. The intuitive hypothesis of the research was the conviction that the key to an effective vaccine against the infection lay in identifying, understanding and eliminating the reason for this failure. Given the gravity of the HIV/AIDS, especially in sub-Saharan Africa and other poor regions of the world, some of the ethical imperatives motivating the research include finding a simple and effective vaccine that can be cheaply and affordably produced, using traditional rather than high technology methods. In this presentation, we intend to highlight and discuss these ethical concerns within the context of the north/south dichotomy. We will also discuss the role and ethics of funding scientific research, the relationship between wealth and poverty, health and disease, in the modern world and, lastly, attempt justifying testing directly on humans what we have tentatively named VANHIVAX, the simple vaccine discovered through V. Anomah Ngu’s research. The vaccine has so far been tested on a very limited scale (on HIVpositive persons) in Cameroon with what we consider very hopeful and promising results.

After this presentation which had drawn a huge audience and during which Anomah Ngu handled questions and comments related to the science and I those related to the ethics, the BBC Science journalist invited both of us for an interview which lasted about an hour. Responding to the

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many pointed questions, we felt the case for VANHIVAX had been even better expressed than during the presentation. Back to Cameroon after the Congress, we emailed the BBC journalist in question requesting a transcript of what might have been broadcast of our interview; whereupon he responded that he was very sorry the interview had not registered on the recording machine. I really needed to increase my usual level of credulity to believe that. Subsequently, several research teams from some prestigious institutions from the USA and Europe came proposing to Anomah Ngu collaboration in his vaccine project; but when they got the protocol to go and study closely, he never heard from them again. Meanwhile, in Cameroon itself, both the government and the scientific community were bitterly internally divided in their opinions about the candidate vaccine. Eventually, Victor Anomah Ngu passed on to eternity on 14 of June 2011, without having validated VANHIVAX. I felt sad listening to all the post-humus flattery heaped over him and his candidate HIV vaccine on the occasion of his funeral ceremonies by government functionaries and some of his scientific colleagues who, at best had completely ignored and at worst purposely subverted his efforts towards finding a cheap and affordable solution to the HIV/AIDS pandemic. The 2002 World Congress of Bioethics took place in Brasilia, Brazil, under the general theme: “Bioethics, Power and Injustice”. My oral presentation at this congress had for topic: “The HIV/AIDS Pandemic and the Ethics and Politics of Vaccine Research in Africa”. Herewith the abstract of the presentation: If the HIV/AIDS epidemic is the scourge of the millennium, Africa is its global headquarters. Over twothirds of all cases of HIV/AIDS are in Africa, where the epidemic has claimed over 17 million lives since its outbreak and continues to spread at the fastest rate. The African situation is particularly critical because of high levels of generalized poverty, illiteracy, poor communications infrastructure, a heavy burden of other diseases coupled with poor health facilities, and lack of the political will to vigorously address these urgent problems. In this presentation, I argue that the African situation calls for

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urgent innovative measures, among which the search for an effective vaccine remains the highest of priorities. These urgent needs cannot be addressed without considerable international cooperation and collaboration. However, developed world medical research in the developing world, particularly in Africa, runs the danger, more than anywhere else, of falling afoul of all the cardinal principles of ethical research: non-maleficence, non-exploitation, respect of autonomy and justice, because developed world research, being market-oriented and profit-driven, is highly susceptible to morally blind economic and political forces. On the other hand, skepticism in Africa, arising from past abuses, and constantly circulating rumours and conspiracy theories are not helping matters. The presentation concludes that a predatory attitude and an atmosphere of suspicion need immediate redressing through genuine cooperation/collaboration, deliberate confidence building and research projects that are transparently well-intentioned and unquestionably ethical. The next World Congress of Bioethics was in Sydney, Australia (2004), under the general theme: “Deep Listening: bridging divides in local and global ethics”. I was not able to attend this meeting but I attended the next in Beijing, China (2006), under the general theme: “A Healthy and Just Society”. My oral presentation at this meeting had for title “On the moral status of embryonic stem cells” and for an abstract the following: One of the most important and awesome achievements of modern biotechnology is the possibility of cloning embryonic stem cells. The possible revolutionary role of such stem cells in curative, preventive and enhancement medicine has been well discussed around the globe. However, the question of the moral status of cloned embryonic stem cells which is critical in determining the moral rightness or wrongness of using them has not been clearly and unequivocally answered. In this presentation, taking inspiration from the African adage that “the hand that reaches beneath the incubating hen is not guiltless” I shall attempt answering this question. I shall propose and defend the conclusion that a morally significant line cannot be drawn between human embryos and other

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human beings and then draw the consequences for stem cell research. My article “Moral Status of Embryonic Stem Cells: Perspective of an African Villager”, [Bioethics. 21(8): 449-457, 2007] was developed from the above presentation. I nearly attended the 9th World Congress of Bioethics in Croatia. I had duly prepared for it, putting for the first time rather respectable personal financial resources into procuring a return ticket from Cameroon and researching on the topic of “Advance Directives” in view of a round-table discussion in which I was invited to give an African view and perspective on the subject. But, owing to a misunderstanding between me and the local organizers of the congress as to whether a Schengen visa would permit my entry into the country and, in the alternative, if they could arrange a visa on arrival for me, I arrived at Zagreb airport on the eve of the congress, full of optimism and expectations, only to be promptly bundled into a detention cell and deported back to Cameroon the next day as an illegal immigrant. Still under shock from the experience in Croatia, I missed the 10th World Congress of Bioethics in Singapore (2010). But I was present at the next two: Rotterdam, The Netherlands (2012) and Mexico City, Mexico (2014). The Rotterdam Congress had for a general theme: “Thinking Ahead: Bioethics for the Future, the Future of Bioethics, Challenges, Changes, Concepts”. At this congress we (Beyene Petros from Ethiopia, Wen Kilama from Tanzania and myself from Cameroon) organized a symposium, under the auspices of the Pan African Bioethics Initiative (PABIN), on capacitybuilding in research ethics in Africa. For the Mexico congress, I proposed to make two oral presentations: “Globalization and world peace: is sustainable world peace an achievable goal?” and “Are ethics local or universal? The case of homosexuality in Africa and elsewhere”. The abstracts of both presentations were accepted but I was restricted to one oral presentation and the organizers choose the second. Here are the abstracts of both presentations.

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Ethics are partly local and partly universal or, to put it another way, ethical values necessarily have universal outreach but the application of such values in concrete contextual situations is necessarily constrained, shaped and coloured by local realities and conditions. How does this square out with a practice like homosexuality, severely condemned by some in some contexts, tolerated by some in others and approved by some to the extent of legalizing homosexual marriage in others? In this paper, focusing mainly on Africa, where all three attitudes to homosexuality are manifest, I discuss the ethics of homosexuality in relation to the question as to whether ethics are local or universal. In recent years some African countries have come under considerable diplomatic pressure from countries and agencies of the Western world to legalize or decriminalize homosexuality as a human rights issue. The main thrust of my argument is that, while homosexuality between fully competent consenting individuals is ethically unobjectionable as an act that causes no harm and does no wrong to any putative third party, the legal approbation or proscription of homosexuality is ethically highly prejudicial and inadvisable. What may ethically be wrong in homosexuality is no different from what may ethically be wrong in heterosexuality, such as rape, sex with minors or incompetent adults, exploitative sex, non-consensual sex, etc. The law should be directed at what ethically may be wrong or harmful in sexuality, not at what may rightly be claimed to be a sexual orientation, a state of being beyond freedom and choice. The third millennium has so far been marked by unprecedented violence and loss of human life on a massive scale. Beginning with the terrorist attack in New York, USA, on 11th September 2001, both terrorism and counterterrorism have continued to send many innocent human beings to their untimely deaths on a more or less massive scale, with a more or less regular rhythm. When we further consider intractable wars and civil wars, here and there, around the globe, it becomes evident that we are living in a world of unprecedented human-made violence. When we add to this the natural causes of untimely human deaths – epidemics, tsunamis, typhoons, hurricanes, earthquakes,

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sundry accidents, etc., - it appears clear that we are living in a world more dangerous than has ever been the case before. And yet human beings remain those creatures beyond all others on earth endowed with the capacity to reflect on the problems of the world, to anticipate them and to solve them before they become overwhelming. The prospect of a globalizing world in one of its positive aspects has held the promise of a world evolving towards democracy, good governance, health, peace, prosperity, abundance and human flourishing all over the globe. What has happened to optimistic human dreams and how may they even partially be realized? In this presentation I make bold to attempt answering this question. Sustainable world peace seems to me the indispensable condition for the realization of optimistic human dreams. The condition further seems to me realizable and I will attempt suggesting how it may be realized. The thrust of my argument involves transcending the traumas and mind-set of the great world wars, enhancing and strengthening the United Nations Organization and waging a relentless struggle against the madness of power all over the world. To get back to my mentors at the IAB, the list is very long but I must mention in an indicative manner a few by name: Peter Singer (the Australian), Alex Capron, Dan Wikler, Alasdair McIntyre, Ruth Macklin, Ruth Chadwick, Hans van Delden, Soren Holm, Solly Benatar, John Harris. The intellectual personality of Peter Singer was looming large over the IAB at the time I joined the association. It was always a great pleasure listening to him make any presentation in his loud clear voice and following the compelling logic of his reasoning. He also happens to be one contemporary bioethicist who openly lives by his moral convictions. He, for instance, does not eat animal-based foods and has a standing arrangement whereby he gives up a sizable percentage of his monthly income to charity on the grounds that most Westerners including himself are far too well-off and too comfortable and should consider giving up part of their incomes to alleviate abject poverty in other parts of the world. It is one of the ironies of contemporary

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advanced societies that Peter Singer has frequently been heckled and hounded out of some of his lecture venues. Peter Singer has been chiefly responsible for the shift in attitude towards treating non-human animals more humanely in the Western world and in considering speciesism as a moral aberration. But, his utilitarian coherence and consistency notwithstanding, it appears to me counterintuitive to compare or to equate some categories of human beings with non-human animals, as he does. Such comparison and/or equation is not necessary in arguing as he does for a change in human attitudes and treatment of non-human animals. The most capacity-endowed nonhuman animal, while its right to life and flourishing on its own, without consideration of human beings, must be affirmed, cannot be equated with a human being, no matter how destitute of such capacities, simply because it is not a human being. Speciesism, understood simply as the recognition of a being as human, seems to me inevitable, if we are to take moral agency, responsibility and culpability seriously. For, in spite of any human-like capacities, no nonhuman animal can be considered a moral agent. Moral agency, in my view, is what gives human beings, above all other earthly creatures, their moral worth and value. The moral worth and value attributable to human beings that are not moral agents is symbolic and analogical and lies on the same continuum with the moral consideration given by humans to non-humans. Even if non-human animals displayed no capacities similar, let alone equal, to those of humans, human moral sensibility and sensitivity would still apprehend the need for treating them with due consideration. It is such moral sensibility and sensitivity that is wanting in cases such as racism and chauvinism where moral equality is, moreover, evidently quite demonstrable. The failing of the racist or the chauvinist is not at the level of logic or reasoning but at the level of moral sensibility and sensitivity. The moral responsibilities of human beings towards non-human animals, other living creatures and inanimate things cannot be linked, let alone justified, by the

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idea of sharing the same or similar capacities and attributes. It is simply a consequence of the human sense of the moral. Another member of the IAB whose work I found fascinating and provocative but counterintuitive to my native instincts, is John Harris. In his book The Value of Life: An Introduction to Medical Ethics [London: Routledge and Kegan Paul, 1985, pp. 11-12], Harris argues as follows: To say that a fertilized egg is potentially a human being is just to say that if certain things happen to it (like implantation), and certain other things do not (like spontaneous abortion), it will eventually become a human being. But the same is also true of the unfertilized egg and the sperm. If certain things happen to the egg (like meeting a sperm) and certain things happen to the sperm (like meeting an egg) and thereafter certain other things do not (like meeting a contraceptive), then they will eventually become a new human being.

The intended consequence of this argument is that a human embryo is only a potential human being whose moral worth or value is the same as that of a sperm or an unfertilized egg. I have critiqued this argument in my article “Moral Status of Embryonic Stem Cells: Perspective of an African Villager”, [Bioethics, 21(8): 449-457, 2007]. The gist of my argument is that there is a logical error in thinking of a fertilized ovum, the human embryo, as a potential human being. An unfertilized egg and sperm are together certainly a potential human being and remain in that state of mere potentiality no matter how close they may come towards each other, short of joining and fusing. Every time a mature and fertile man and a mature and fertile woman during a certain period of her menstrual cycle come into close proximity such potentiality is in danger, but only in danger, of transforming into actuality. Until something happens that brings the ovum and sperm together, the danger remains forever only a danger, an actualisable but un-actualized dispositional property. But, from the moment that the egg and sperm, through whatever process, join and fuse, potentiality has transformed into actuality and fertilization has occurred. From that moment, an existent, a living thing, a human being, has been created. Let biologists give us any name they like for this entity and it

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will remain a potential zygote until it satisfies their criteria for zygote-hood, a potential zygote until it develops to an embryo, a foetus, a baby, an infant, etc. A human being cannot be a potential human being because nothing can be both potentiality and actuality at the same time. Once a human egg is fertilized, its one and only status as potentiality to become a human being has been irreversibly actualized and it now becomes potential other things (foetus, baby, child, adolescent, adult, embryologist, philosopher etc.) but never a potential human being again. I must link this to my article “Traditional African perception of a person: Some Implications for Bioethics” [Hastings Center Report. 30(5): 39-43, 2000], whose main point, I think, was not sufficiently well articulated or else was well articulated but has been generally ignored. The main point of that article was that the Western conception of personhood as widely discussed seemed to me to delimit a category of beings that are morally responsible and culpable for their actions and not beings which alone posses moral value and worth. What is your view of the current status of bioethics teaching? Bioethics teaching seems to me to be waxing very strong in the Western world, to the point of even exaggeration; witness the explosion in the number and varied methods of courses offered, online and offline, the countless congresses, conferences, colloquia, symposia, seminars, webinars, workshops, and the ubiquitous establishment and functioning of ethics review committees or institutional review boards (IRBs) as they are called in the United States of America. Asian and Latin American countries seem to me to follow very satisfactorily the Western countries in their awareness and teaching of bioethics. But the situation is different for the African continent. While many of the bioethical problems and dilemmas occur in Africa and while there is indeed evidence of the beginnings of awareness and bioethics education here and there, it is, arguably, only in the Republic of South Africa that bioethics teaching and education seem to match the glaring need for it.

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How do you assess the development of ethics education over the past decades in your area of work and in your region? In sub-Saharan Africa, bioethics awareness and consequent efforts at bioethics education came slowly and painfully, following certain awakening events: the HIV/AIDS epidemic (mid 1980s), the Rio Earth Summit (1992), the Beijing Conference on Women (1995), a peep behind the veil of Apartheid in South Africa following its collapse (1994), the realization that Africa was slowly and surely becoming the developed world’s ‘septic tank’ epitomized in the dumping of toxic waste in Côte d’Ivoire (2006), etc. One of the immediately actionable catalysts of efforts at education and capacity-building in bioethics was biomedical research led by northern scientists, aimed at finding a cure or a vaccine against HIV/AIDS. International and northern-country regulatory guidance for such research required ethics review and approval in both the northern country carrying out the research and at the local site where the research was being carried out. Such ethics review of research projects and protocols was readily available in the northern countries, even if under a general prima facie conflict of interest induced by a historical predatory instinct but, in many African countries, few people even in the ministries of health had ever as much as heard of ethics review of research proposals. Capacity-building in biomedical research ethics and education in bioethics generally thus became a glaring urgent need for Africa. To start in Africa south of the Sahara and north of the Limpopo, one of the earliest seminars on Health Research Ethics in Africa was organized by the African Malaria Vaccine Testing Network (AMVTN) in Arusha, Tanzania, from November 1-4, 1999. This was an internationally very well attended conference during which the suggestion to create the pan-African Bioethics Initiative (PABIN) was made. PABIN was later formalized at a conference in Lusaka, Zambia, in 2001. PABIN set for itself the following strategic action plan items: 1. Developing an overview of existing ethical review committees within the African Region and maintaining a registry; 2. Developing competent in-country ethical review

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systems; 3. Contributing a concerted African voice to international discussions on ethics and science in health research; 4. Assisting national health authorities in Africa with the development of national guidelines for ethical review; 5. Developing educational programs in ethics and GCP that are integrated into university curricula; 6. Establishing national systems for accrediting health research ethics review committees in Africa; 7. Acting as an information exchange and meeting ground between African researchers and ethicists as well as an interface between Africans engaged in health research and the international community. With encouragement and funding from WHO TDR, PABIN functioned quite well during the first five years of its existence and by 2007 had about 324 members in 26 African countries; but it soon ran into organizational and managerial bad weather and lack of funding. Concomitantly with the PABIN, the AMVTN which had now evolved into the African Malaria Network Trust (AMANET), with funding from the Gates Foundation, the EDCTP and other European agencies, was carrying out both basic and advanced training in research ethics and GCP in many African countries through workshops, seminars and free online courses. The AMANET ran out of steam in 2014. Some of the documented evidence of AMANET’s efforts in this regard includes the following publications: •

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•

Chilengi, R., A. Nyika, G. B. Tangwa, R. A. Noor, S.W. Ramadhani, Bosomprah, S. and W. L. Kilama. Role of e-learning in Teaching Health Research Ethics and Good Clinical Practice in Africa and Beyond. Cambridge Quarterly of Healthcare Ethics, (forthcoming). Nyika, A, W. Kilama, R. Chilengi, G. Tangwa, P. Tindana, P. Ndebele, and J. Ikingura (2009). Composition, training needs and independence of ethics review committees across Africa: are the gate-keepers rising to the emerging challenges? Journal of Medical Ethics, 35: 189-193. Nyika A, Kilama W, Tangwa G.B, Chilengi R and Tindana P. (2009). Capacity Building of Ethics Review Committees across Africa Based on the Results of a

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Comprehensive Needs Assessment Survey. Developing World Bioethics. 9(3): 149-156 ACTA TROPICA: (Supplement) Proceedings Seminar on Health Research Ethics in Africa,2001, Vol. 78, Suppl. 1

About the same time, for French-speaking Africa, the Networking for Ethics on Biomedical Research in Africa (NEBRA), funded by a European Union grant, was created as a collaboration between the four countries of Gabon, Benin, Gambia and Mali with European partners. NEBRA was created to understand ethical issues arising in individual African countries, to identify people already involved in reviewing ethics of research and to meet their needs. Before NEBRA ran out of steam, the Training and Resources in Research Ethics Evaluation (TRREE) for Africa was created with funding from the EDCTP and a host of other European funders. TRREE has trilingual free online courses in research ethics in French, English and German. All these training efforts in bioethics and biomedical research ethics have usually flourished for a time and then waned for lack of sustainable funding, but they have collectively left behind considerable pockets of informed opinion and awareness which ensure that continuing efforts will be made to anchor capacity-building in the domain on firmer and more sustainable local support. The Republic of South Africa was one of the African countries most severely hit by the HIV/AIDS epidemic and, coupled with the dismantling of the Apartheid system and the Mandela phenomenon, it developed the best general awareness for the importance and necessity of bioethics and health research ethics. From about 1999 I got repeatedly invited to South Africa to give lectures or to participate in conferences, seminars or workshops by Solly Benatar at the Centre for Bioethics, Groote Schuur Hospital, University of Cape Town; Carel IJsselmuiden and Graham Howarth at the University of Pretoria; Doug Wassenaar at the University of Natal, Pietermaritzburg; Ames Dhai and Abdul Kareem at the University of KwaZulu. Around 2001, the Fogarty International Center of the National Institutes of Health

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(NIH), USA, launched a call for training projects in international research ethics in Africa. The two winners were the South African Research Ethics Training Initiative (SARETI) which proposed courses in Advanced Learning in International Health Research Ethics as well as short term Fellowships, and a full Masters and PhD degree programmes and the International Research Ethics Network for Southern Africa (IRENSA) which proposed a Post-Graduate Diploma in International Research Ethics for very senior mid-career personnel of relevant institutions. I was on the international teaching faculty of the IRENSA programme throughout the period of its existence between 2003 and 2010 and I am still on the international advisory board of SARETI. You have published a very interesting book: Elements of African bioethics in a Western frame (2010). How has the book been received? What are the specific components of African bioethics? This book was published by Langaa Research & Publishing CIG (Bamenda) and is being distributed by Amazon but I am not in a good position to say how it has been received. Some two years ago Langaa paid me a modest sum of money as royalties from the sale of the book but that is all I could go by in guessing how the publication is doing in the book market. I do, however, receive occasional emails from people asking how they could get the book or if I could be kind enough to send them a copy. One of the motivations for publishing the book was in response to many graduate students in diverse institutions around the globe who would write to me saying they were working on such or such a bioethics issue or problem from an African perspective and had been advised to approach me for advice on how to go about it. Not knowing how one could respond to such a request, I have usually simply advised that if they read some of the articles I have written in bioethics myself they might possibly be inspired. The follow up is usually to ask how they could lay hands on my articles in bioethics. There is no particular content that is unique to African bioethics. Any putative issue or problem in bioethics can be

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studied or addressed from an African point of view or perspective; that is to say, from the standpoint of African culture, worldview, ideas, historical experience and practices. Such a study would not be possible for anyone who is completely ignorant about African culture or who has nothing but contempt for it or for anyone who takes the Western hegemony and paradigms as universal imperatives for humanity. African bioethics in the same sense in which we talk of American bioethics, for instance, will only emerge with complete mental decolonization and an increase in the volume of works produced from an African viewpoint and perspective. I had planned a second volume to the above book, promised in the Introduction, entitled African perspectives on some contemporary bioethical problems which is still an unpublished manuscript. Are they (there?) specific dimensions to ethics education in Africa? Can you elaborate? For sure there are specific dimensions to ethics education in Africa; the first and most important dimension being that it has to be relevant to the multi-faceted realities of the continent. When this is unpacked, it includes basing general ethics education on the historical experiences and existential problems that Africans face and taking seriously their sociocultural values, ideas and practices into consideration in proposing answers, solutions and prescriptions. Some of the main focal issues and areas of concern in ethics education in Africa would therefore include though not limited to the following: tradition and modernity, colonial legacies, biodiversity, disease and treatment, poverty and disease, medical practice, biomedical research, procreation, population, gender and marriage, power and accountability, racism, terrorism, human rights, equality. Can you describe your teaching activities? Who are your students? As a University teacher (first at the University of Ife, today Obafemi Awolowo University, and then at the University of Yaounde, today University of Yaounde 1), my students have

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been mainly graduate and undergraduate University students and the subjects I have taught have been mainly philosophy courses: introductory logic, introduction to philosophy and philosophizing, epistemology, metaphysics, philosophy of science, political philosophy, philosophy of religion, moral philosophy, etc. Regarding supervision of graduate students’ work, I have over the years supervised about thirty dissertations at the Masters level and about six at the PhD level, with two still to be completed. The other category of students I have had to deal with are the seminar and workshop participants of the various capacity-building in research ethics and bioethics in Africa projects in which I have participated. I have learned as much from these students as I ever taught them on account of their high level of professional competence and interdisciplinary diversity. With the explosion in numbers at the University, combined with the absence of resources and teaching aids and facilities, teaching at the University has left little time for any other activities and I am much relaxed now that I have withdrawn from full time teaching. However, within those limitations, I have struggled to do what research I could and to keep pace with academic developments at the global level. Of immense help in this regard have been fellowship awards like that of the Alexander von Humboldt, the Hastings Center or short-term appointments as adviser or consultant to bodies such as the WHO and various funded invitations to academic conferences and professional meetings. In your view, what are the core objectives of bioethics education? The core objectives of bioethics education in general, in my view, are to help bring rationality, moral sensibility and sensitivity to human relationship and interaction with fellow living beings, including plants, animals and other humans, at all levels and in all dimensions. Among the core objectives some specific ones would be more urgent on account of their connection with problems likely to affect life, health, wellbeing or security on a large scale. Such, for instance, would

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be objectives related to biotechnology and biomedicine, war and terrorism, climate change, large scale migrations, deadly infectious epidemics, research on genes and the genome, etc. What are the specific challenges you meet in teaching bioethics in your region? My particular region, the Central African region, is dominated by French-speaking countries, all former colonies of France excepting only Equatorial Guinea and a small but significant part of Cameroon which is English-speaking. The Politico-Administrative system that predominates in the region is highly centralized dictatorships resembling monarchies, which pretend to varying degrees of success to be democracies. The first and most important preoccupation of the ruling regimes of the region is staying on in power, which they easily achieve if the former colonial power whose virtual presence is moreover felt everywhere at all times has no serious objections. It is in this region of Africa more than any other that sons have succeeded, attempted succeeding, or are likely to succeed their fathers as head of state. Consequently, in spite of adequate economic resources, the region is economically very backward and this impacts directly on teaching in general and teaching bioethics in particular. A couple of years ago, I was one of the co-authors of a publication in Bioethica Forum on the situation of health research ethics in the region: [Odile Ouwe-Missi-OukemBoyer, Nchangwi Syntia Munung, Francine Ntoumi, Aceme Nyika and Godfrey B. Tangwa. “Capacity building in health research ethics in Central Africa: key players, current situation and recommendations”. Bioethica Forum / 2013 / Volume 6 / No. 1, pp.4-11.] in which many of the specific efforts and challenges of capacity-building in research and research ethics are discussed. Personally I have been much distressed by the lack of institutional interest, let alone support, for my efforts in introducing and teaching bioethics and health research ethics in particular at the University of Yaounde 1, notably at the Faculties of Medicine and Biomedical Sciences and Arts, Letters and Social Sciences.

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What is your vision for ethics education? Will it expand and become more important? Will it be sidelined because of financial or political pressures? Will it be associated with global concerns and growing awareness of bioethical problems? Given the urgent problems confronting the world today (global warming and climate change, war and terrorism, mass migrations and deadly infectious epidemics), the need for ethics education is all too evident. Lack of political will is a great stumbling block to the global ethics education necessary to face and tackle these problems in an earnest and meaningful manner. But the human conscience cannot be at rest until it is done. What kinds of activities are needed to expand bioethical education at the global level? And how can these activities be promoted? Every region around the globe and every country of the world needs to fashion its bioethics education to address those bioethical problems that impinge heavily on its day to day living. A global dimension to such bioethics education is inevitable as most of the big bioethics issues have a global scope. But care must be taken to not foist the bioethics education agenda of some regions on others. In the industrialized Western world, for instance, there is an increasing emphasis on empirical bioethics which seems very attractive to people with a science background. Bioethics in the Western world seems in danger of ending up simply as empirical bioethics, especially as it accords rather well with consequentialist utilitarianism, a highly popular theory in the Western system. This emphasis on empirical bioethics may easily unthinkingly be copied by or imposed on other regions or cultures. Empirical bioethics, of course, is important and should have a place within bioethics education. But ethics education, in my view, is incomplete and defective if it does not dwell on some of the fundamental philosophical issues of morality: the is/ought, fact/value, dichotomy, moral intuitions, moral dilemmas, moral reasoning, moral theories and theorizing, moral principles,

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etc. In short, a little moral philosophy and philosophizing seem, to me, indispensable for bioethics education of any kind. Bioethics education should be promoted, first and foremost, by the authorities of each locality, country or region and, secondarily, by international or global agencies and institutions interested in global bioethics and/or collaboration or philanthropy. Otherwise, such education is unlikely to take firm roots.