Originally, the word "globe" referred to a ball created by winding thread together.1 In this era of globalization, we are increasingly aware that we are intertwined. We need to reconsider, in a profound way, a foundational ethical question: How should we live together? Nurses are strategically placed—by our history, our education, and our experience in working across diversity and caring for all—to contribute to the discourse exploring this question. We might begin by asking ourselves: What does a shift to a global frame of reference mean to the ethical practice of the 11 million nurses providing health care around the world? Although nursing has had an international perspective for over a century (in 1870 nurses were serving with the International Red Cross), an international outlook (one that exists "among nations") is different than a global one. What are the ethical concerns for nurses living and working in a global community? In this article, the argument is made that we are living in a global age, followed by the identification of three key health ethics issues on which we, as nurses, need to reflect and act. These issues are the advances in biotechnology and the business associated with it, the pressing demands of equity and justice in global resource allocation, and the challenge of devising a universal ethic that is respectful of diverse values to guide action in the area of health.
LIVING IN A GLOBAL VILLAGE
It is said that you need to leave home to truly recognize who you are. Space travel has allowed us to see the Earth and to behold ourselves as we really are—beings living together on one small planet. The science and technology that made this vision possible also are connecting us to one another in a new kind of way. McLuhan's2 "global village" has come to fruition. Technological advancement has changed the way we travel and communicate to such a degree that geographical space no longer defines "neighbor." We may not know the person living next door, but we may have a daily "over-the-fence" chat with someone thousands of miles away via e-mail. Contemporary images and icons are recognized worldwide. Satellite dishes bring Star Trek and Bay Watch into the lives of villagers in the far Arctic and along the shores of the upper Amazon River. Mickey Mouse speaks nearly every language; children in Beijing are asking their parents for "Kentucky Fried Chicken." Whether or not things go better with Coca-Cola, everyone knows what you are talking about.
The conception of a nation as a place that has a language, culture, and literature distinct from the rest of the world is fading. The spread of the English language and American cultural products, as well as worldwide movements such as that for women's rights, has diminished that meaning and decreased the power of the nation state as our chief frame of reference.3 Like the butterfly's wing of chaos theory, environmental, economic, or political events in one part of the world have effects thousands of miles away. Courtesy of Internet technology, anonymous stock, bond, currency, and transnational investors drive the marketplace, having become a force strong enough to affect national economies and bring down governments.4 It seems, in fact, that a line between international and domestic issues can no longer be drawn.
We have instead what Jowitt5 terms "intermestic situations," with political borders increasingly irrelevant. We watch war, famine, epidemics, and the sufferings of the poor a continent away "live" from our homes. With this immediacy, television takes us beyond family, local community, and nation in such a way that the scope of our moral concern is altered.6 We see (or must actively refuse to see) distant human distress and anguish as they are happening. Our pressing problems are global ones: the effects of human activities on the environment, nuclear weaponry, chemical and biologic terrorism, and emergent and resurgent infectious diseases3,6-8 Science, always a force moving beyond national boundaries, is increasingly a global influence. A striking example of this is the recent worldwide cooperation of scientists in deconstructing human biology in the Human Genome Project. The ultimate consequences of this discovery will be so immense that they are difficult for us to imagine. In fact, the magnitude of the changes currently affecting our world is almost too great for us to grasp.9 What is becoming absolutely apparent, however, is our fundamental interdependence.
The shift to a global frame of reference signifies epochal change in the bases of our societal actions and organizations.3 It is noteworthy that the term "globalization" is most often used in the economic sense, referring to the rise of a worldwide economy driven by transnational corporations and the spread of a free-market ideology. In The Lexus and the Olive Tree, Freidman4 describes how economic globalization has come to replace the Cold War as the force that shapes all domestic policies and international relations. Rather than the world being divided into "friends" and "enemies" according to one's alignment in the politics of the Cold War, everyone now has become a "competitor." The imperatives of the marketplace are depicted as the sum and substance of daily life. At this point, it seems that the global village is foremost a consumer society, a society whose members' value is based on their capacity for and commitment to the consumer role.10 The reality of the free market as the dominating paradigm can be illustrated with one chilling example: Russia's once top-secret missiles are up for sale via a 511-page catalogue, with weapon details listed on the Internet at www.tommax.military.com.11
In Globalization: The Human Consequences, Bauman10 declares that this form of economic globalization is radically different from globalization as a hope of a universal order. The ideal of a universalism in which the life conditions of all people are made similar—so that life chances are more equable—is not shaping current forces. Bauman finds that the process of globalization is dividing even as it unites. A localizing phenomenon is occurring so that while those with resources are becoming "global" and literally or virtually mobile, those without resources are fixed in their localities. Being fixed locally in a globalized world means being separated and excluded. Separation, according to Bauman, is one of the major survival strategies in the new global order—there is no more loving or hating your neighbors; one just keeps them at a distance. In a free-market ideology, no one is responsible for anyone else. Collective action on social issues is not part of the discourse.
A potentially perilous element of globalization is the "free for all" fostered in world affairs.3,4,10 We are not in control of the powerful forces, particularly the economic ones, that are shaping our lives and our futures. There is no sign "of a centre, of a controlling desk, of a board of directors, of a managerial office."10(p59) Freidman exhorts, "No one is in charge."4(p93) Not even in America is it different. Albrow3 coined the term "globality" to replace "globalization" in an effort to eliminate the connotation of necessary outcomes that "-ization" suggests. In his book on the global age, he argues that the world is significantly transforming, but the change is nondirectional and with an open future (including the possibility of "deglobalization"). We can no longer have faith in the teleology of progress. In these postmodern times, there is no endpoint to which we are evolving.
As our technological power radically alters the human and the nonhuman world and ungoverned transnational economic forces shape our relations with one another, moral issues are being raised for which we have no real precedents. The global condition of human life and our new power to affect the very nature of existence (perhaps even to extinguish it) are demanding a reshaping of our moral horizons.6,10,12 Hans Jonas,12 the late American ethicist, warned us more than 20 years ago that the altered nature of human action calls for a radical change in ethics. The solidarity of our interest with one another, and with nature, must move us to a new kind of humility and an ethics with responsibility as the imperative. Jonas' words have even more significance today. In this era of globalization, new conceptions of rights, duties, and responsibilities are required. We need an ethics that acknowledges the excess of our power over our wisdom and understanding. We need an ethics that addresses our essential interdependence.
What form would such an ethics take? Is a macro-ethic appropriate to global times? Is it even a possibility, given the diversity of values and beliefs in the world? What would it mean in the realm of health ethics? Before such questions can be answered, there must be dialogue around core issues. Nurses can contribute to such a dialogue and must, if we take our commitment to the health and well-being of our societies seriously. Following is a description of three particular issues that nurses will need to address as they consider what this era of globalization means to the substance of nursing ethics.
THE BUSINESS OF BIOTECHNOLOGY
On June 26, 2000 the Human Genome Project and a biotech company, Celera, jointly announced that the working draft of the DNA sequence was complete. This accomplishment is so profound that human evolution may be fundamentally and forever changed. With it, incredible possibilities for human health are opened, including opportunities for identifying individuals' predisposition to inheritable diseases (eg, diabetes and Alzheimer's disease), for revealing genetically oriented disease prevention and treatment strategies (eg, the breast cancer suppressor gene), for stimulating the development of new biologic therapeutics and vaccines, and for extending human longevity.
This new knowledge, however, has significant potential for abuse. Fearful images of what could occur have been portrayed for the public in movies. Gattaca, for example, is the story of a cold, segregated, controlled society based on genetic discrimination. Discrimination based on genetic makeup, however, is not science fiction. In 1998 Israeli scientists were said to be developing an "ethno-bomb," made from lethal viruses and bacteria designed to attack persons with particular DNA.13 In the United States, federal agencies already are banned from using genetic testing in employee selection, or at least are banned from denying a promotion or job to persons based on their genes. Privacy protection of medical information is increasingly a concern. In fact, the nefarious use to which information could be put, especially by insurance companies, is substantial.
With the race to identify the human genome finished, scientists are now competing to be the first to clone a human being. Professor Severino Antinori, an in vitro fertilization (IVF) specialist of the International Association for Human Reproduction Infertility Unit in Rome, and Professor Panayiotis Zavos of the Kentucky Center for Reproductive Medicine announced their human cloning project in March 2001.14 They are going ahead despite strong warnings from researchers such as Ian Wilmut of the Roslin Institute in Edinburgh, the designer of that famous sheep, Dolly. Although Wilmut's scruples did not extend to the replication of an animal, he is against human cloning for social and ethical reasons, as well as for the practical reason that cloning technology is still limited. He believes that the inevitable failures in any human cloning attempt (such as birth defects) will arouse public concern and set back other research, such as the therapeutic cloning of embryonic stem cells for use in treating diseases such as Parkinson's.15
Genetically modified (GM) foods are already a reality in the global marketplace. Whereas consumers in some countries, such as those in the European Union, are resistive and hostile to the introduction of genetically engineered biologic products, other consumers, such as those in Canada, are largely unaware that they are using them. Canada does not require the labeling of engineered food unless it alters the nutrition of that food or poses a risk of allergy. More than 50% of the Canadian canola crop and 30% of its soybean crop are genetically modified to resist herbicides and pesticides, respectively.16,17 Use of plants modified to resist drought or to contain higher amounts of essential nutrients could be vital in feeding the world, and fruits and vegetables could be modified to act as vaccines for diseases such as hepatitis B.18 It may be too soon to know, however, whether GM foods can be harmful to human health, wildlife, or the environment, and some argue that they should not be grown outside research facilities until such knowledge is available.19 One problem is that it is difficult to control GM plants' interaction with the rest of the environment. Another is that mistakes can be made. Canada, for instance, inadvertently provided Scottish farmers with GM rapeseeds that were sown over 11,000 acres of land.17 Ultimately, getting people to accept GM foods may be a matter of marketing. If feeding the hungry and providing vaccines do not excite consumers and secure their support, the opportunity for products such as a GM potato that can make low-fat chips likely will.17
Vaccines and potent pharmaceuticals are other major contributions of the business of biotechnology. Powerful new weapons in the fight against disease are increasingly available, particularly for those living in the developed world. Access to new products in less developed areas, however, is a current problem surrounded by much controversy. Although the pharmaceutical industry is interested in expanding into emerging markets in developing countries, it is encountering political and regulatory constraints: failure to respect and enforce intellectual property rights, drug piracy, pricing restrictions, and lack of consistency in standards of regulation and enforcement.8 As well, companies expect the manufacture of particular drugs to be profitable if the drugs are to be made widely available. For instance, Eflornithine, the cure for trypanosomiasis, the fatal sleeping sickness that infects an estimated 300,000 people a year in Africa, became available because it was discovered that it removes female facial hair, making it a more marketable product.20
The acquired immune deficiency syndrome (AIDS) pandemic is bringing the accessibility issue to a head. While life-extending drugs have made the human immunodeficiency virus (HIV) infection more a chronic illness than a death sentence in affluent regions, millions are dying in Sub-Saharan Africa from AIDS without access to the drugs. Pharmaceutical companies are under considerable international pressure to provide AIDS drugs at lower prices to these areas. South Africa is being taken to court by the pharmaceutical industry over its plans to promote the import or local manufacture of AIDS drugs. The industry argues that this infringes on their intellectual property rights.21 Proponents argue that it is imperative to protect these rights so that generated revenue can be used to support research. (This argument is usually countered by the fact that 30% to 60% of the research and development costs for antiretroviral drugs was funded by public money in the United States and Europe.20) Some countries nevertheless are producing generic AIDS drugs in the time lag before international patent laws apply to them or through a loophole in global trade rules that permits the breaching of patents during national emergencies. At a cost to Brazil of $3,000 a year (compared with the $10,000 to $15,000 cost in the United States), it offers the generic drugs free to its citizens with AIDS.21 The bargaining between the drug conglomerates and desperate countries continues, but in the meantime, United Nations Secretary General Kofi Annan has reached an agreement with major corporations to accelerate substantially their reductions in the prices for AIDS treatment for the least developed countries (LDCs).22
The extraordinary advances made in biotechnology have enormous and unpredictable implications for the quality of life and the rights of humans and other living beings. Coupled with the open-ended pressures of the global free market, these "advances" may bring with them potentially devastating consequences for how we live together. How do we respond when embryos are put up for sale on the Internet ($500 each),23 or when we learn that kidneys from prisoners executed in China can be bought for transplant in Taiwan,24 or when a new life form is patented? Do we respond? In The Enigma of Health Gadamer cautions that our social-political consciousness has not evolved at a pace with our scientific and technological progress, that "the progress of technology encounters an unprepared humanity."25
In 1997, the United Nations Educational, Scientific and Cultural Organization adopted a Universal Declaration on the Human Genome and Human Rights. In it, human rights principles are applied to interventions affecting human genes, emphasizing particular concepts: the human genome as the heritage of humanity, the dignity of the human person, and the rejection of genetic reductionism. The protection of the individual and solidarity for vulnerable families and populations are stressed. Freedom for research development, however, also is an acknowledged priority.26,27 There are now calls for an international advisory organization to oversee the genetic engineering of plants and animals.19
Will international declarations and advisory groups be sufficient mechanisms to address the significant and escalating changes brought about by our quest for biotechnological know-how? How do we answer questions never before raised, such as who owns particular genes and sequences of DNA or newly created life forms? Is it too late to ask whether limits should be placed on the extent of biotechnological research and development? Should we be tinkering with genes when, for many parts of the world, the most acute biotechnological problem is a safe water supply?
JUSTICE, SOLIDARITY, AND RESOURCE ALLOCATION
The negotiations over lower pricing of AIDS cocktails seem moot when many of those with AIDS in LDCs are too poor to buy adequate amounts of food for themselves and their children. Poverty is the cause of much of the disease, disability, and death that are in our power to prevent.28,29 Ninety percent of the global burden of disease is situated within the Third World, the area of the globe that has access to only 10% of the resources for health.30 The World Health Organization (WHO) emphasizes that, if we are ever to achieve health for all, ways must be found to permit people to overcome poverty and to recover from disadvantage, rather than being permanently immobilized by them.31 The globalization of the marketplace, however, is resulting in greater, not lesser, marginalization of the poor.
Although the rhetoric supporting a worldwide free-market economy creates a picture of more wealth for everyone, this is not happening. The shocking fact is that, according to the 1996 United Nations Human Development Report,32 358 people have more wealth than the combined incomes of 45% of the world population (ie, 358 rich people own more than 2.3 billion poor people). As marketplace values replace other ones, in particular that of solidarity, there is a race to see which localities can give the highest productivity for the lowest wages. In their efforts to lure transnational investors, governments are privatizing former public services to meet corporate demands for lower taxes. The poorest countries, many with economies weakened by the structural reforms demanded by the World Bank in the 1980s, end up as the losers in global trade.33 Furthermore, national governments, in this era of globalization, cannot control the fiscal fluctuations that affect the lives, and livelihoods, of their ordinary citizens.
There are some strategies being recommended that could reduce the enlarging disparities between the rich and the poor. Kapstein34 believes that it is possible to reconcile globalization with a moral sense of social justice. Societies that accept a responsibility for the welfare of all citizens and that support health care and education will be able to increase productivity, wealth, and domestic peace if there is international cooperation to create just economic policy. He argues that the International Monetary Fund and the World Bank need to demand that official lending programs strengthen rather than slash social nets (as their structural adjustment programs have required in the past). A poor reputation in social policy should be a barrier, not a condition, for investment in a nation. It also has been suggested that a global tax, collected by transnational authorities (eg, a tax on particular natural products such as oil and gas), could be levied and the monies redistributed to the global poor. Such taxes would be something similar to the Islamic "zakat," a mandatory obligation on those of wealth and not considered "charity."35
How might economic policies and reforms affecting the quality of life (including the health) of a people be evaluated? Nobel Prize winner Amartya Sen proposed an alternative to the focus on measures of opulence (such as Gross National Product per capita) and on utility (opportunities for the satisfaction of subjective preferences, an approach in which deprivation can be accepted as normal), both of which ignore the distribution of resources. He recommended that a "capabilities" approach be taken. The prime question to be asked becomes: "What are the people of the country in question actually able to do and to be?"36 With this approach, inquiries are made into the variable need for resources that would allow people to become capable of an equal level of functioning.
Examining the functioning of females in a region, for instance, can reveal "cooperative conflicts," situations in which interests of a cooperative body (such as a family) are divided. The well-being of some members may be at the expense of others, such as when there is an underlying assumption that women's work is an unlimited resource.37
In the past, in many regions of the world, women were absent when economic reforms were discussed and initiated, and they had little influence in the development of economic policy. This is beginning to change. For instance, the Gender and Economic Reforms in Africa (GERA) program has been formed in response to the lack of women's input during the structural adjustment and economic reforms imposed by the World Bank in many African countries, reforms that led to privatization of health care and education. Research sponsored by this program indicates that, although the international economic community holds up micro-credit initiatives as a cure for poverty, many women prefer improving health services over better access to credit.38 Attention needs to be paid to the life situations of women in a community. We know that the education of women, particularly those of maternal age, is one of the strongest factors positively correlated with the health of a nation.39
In the last two decades there has been increasing recognition that more than good genetic endowment, personal health, coping practices, and health services are necessary for health. In 1997, building on previous work such as the Ottawa Charter for Health Promotion,40 the Jakarta Declaration was drafted.29 It calls for a global alliance on health promotion and inspired the WHO Resolution on Health Promotion, adopted at World Health Assembly in May 1998. The Jakarta Declaration delineates peace, shelter, education, social security, social relations, food, income, the empowerment of women, a stable ecosystem, sustainable resource use, social justice, respect for human rights, and equity as prerequisites for health. Any community, including a global one, must attend to these factors and their complex interactions if health for its members is to be achieved and sustained.41 Underlying the declaration is the assumption that health is a basic human right, as well as an essential for social and economic development.
Priorities change if we seriously embrace the perspective that every human being, regardless of economic and geographic situation, has a right to the opportunity for a healthy life. Health must then be considered within a broad social and political context with justice as a key ethical concern.30,42 The criteria for the allotment of resources for health are then based on need rather than ability to pay. Although worldwide free-market forces are increasingly structuring health as a commodity rather than as an entitlement, this is a change from the international efforts of the past. Following the horrors of World War II and the Holocaust, efforts were made to create a more secure, peaceful world in which the dignity and rights of every individual were recognized and protected. WHO's constitution, adopted in 1946, outlined a fundamental right for all persons to "the enjoyment of the highest attainable standard of health." In 1948 health as a right was included in the Universal Declaration of Human Rights (UDHR).43 Article 25 of the UDHR acknowledges that everyone has a "right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control."43 Aspects of the right to health have been included in many of the international rights documents that followed the UDHR, such as the International Covenant on Economic, Social and Cultural Rights, and UN Resolution 46/119 (Protection of Persons with Mental Illness and Improvement of Mental Health Care).
If health is conceived as a right of members of the global community, ways must be found to distribute health-related resources in a just way. Difficult questions need to be asked, questions such as: Should we be spending resources on lung transplants in one region while those in another lack the resources to fight tuberculosis? Health policies and practices, whether deliberately or through neglect, can affect human rights adversely.44,45 How can we assess and monitor the impact of public health policies on human rights?46 How can we respond to national policies that have global effects on the right to health?
This year, for instance, the United States withdrew from the 1997 Kyoto Treaty, an initiative to fight global warming, as "It is not in the United States' economic best interest."47 Under the treaty, the United States, by 2001, would have had to reduce carbon dioxide, methane, and other pollutant emissions to 7% less than 1990 levels. This American decision has ramifications for the health of the entire planet. Is this the type of issue to which health professionals need to respond? If so, how? We need to clarify our role and responsibilities as health professionals in protecting rights and exposing rights violations. If we value equity and justice we need to consider how, as nurses, we will uphold them within the larger global community.
Reutter48 believes that if nurses adopt a critical social perspective, they can act to reduce inequities. This would involve understanding the experience of the impoverished (eg, by asking critical questions), as well as facilitating collective strategies and community involvement in meeting community needs. Nurses need to understand the context of poverty in terms of the systemic forces that influence access to the prerequisites for health. If nurses decide to become politically active regarding health and public policy, they will need to develop the skills necessary to advocate for structural changes to alleviate poverty and its effects. Many already have the know-how and experience to help community groups with their own advocacy. Nurses and other health professionals who work in the trenches, so to speak, can provide first-hand evidence of the ramifications of economic, social, and political reforms on the health of individuals, families, and communities. Nurses working with disadvantaged groups are often less removed from them, socially and economically, than other professionals and may be able to understand and help them articulate their views. Nurses can, themselves, take positions on policy issues such as housing and its affordability, social welfare reform, employment policies, and environmental standards.49
Nursing academics and researchers could consider the activist role as well. Academics can help those challenging oppressive or detrimental practices by making theory accessible rather than obscure and by showing ways to question relevant political assumptions.50 For instance, nurse researchers can raise issues of distributive justice in clinical research situations such as when research participants, exposed to the risks of experimental trials, are unlikely to be able to afford the resulting benefits. This is a major concern regarding research undertaken in developing countries by researchers based in developed nations. Nurses must be made aware of the international guidelines for research, such as the Council for International Organizations of Medical Sciences (CIOMS) guidelines and the Declaration of Helsinki. They need to secure a place on the committees conducting ethical reviews of research proposals and to help ensure that when persons consent to participate in research that such consent is freely given, not brought about by being too poor to reject proffered inducements.51
Reutter48 urges nurses to "think upstream" to the broader societal contexts of health, to attend to the interrelationships between health and socioeconomic status and to the inequities that exist in access to the determinants of health. Health professionals need to work with those outside the health sector as well if significant improvements in the health of populations are to be secured.52 Naeema Al-Gasser, Chief Nurse Scientist, WHO, in opening the year 2000 conference of the Global Network of WHO Collaborating Centers in Nursing, urged nurses to act to advance "health security." WHO identifies health security as universality in health care, access to education and information, right to food in sufficient quantity and good quality, and the right to decent housing and to live and work in an environment where known health risks are controlled.
Can we imagine how the need for health security translates into the everyday life of the less fortunate of the world's population? In the article "Death Stalks a Continent,"53 journalists reviewed the current situation of HIV/AIDS in Africa. They attempted to capture our moral imagination by beginning with a request for readers to picture living in the southern quadrant of Africa. Imagine a life, they ask, with a dying infant (one of your three children) and a husband rarely home because he must work away, whose promiscuity makes the marriage bed a deathtrap.
You go to work past a house where a teenager lives alone tending young siblings without any source of income. . . . Over there lies a man desperately sick without access to a doctor or clinic or medicine or food or blankets or even a kind word. At work you eat with colleagues and every third one is already fatally ill.53(p28)
Powerful images are evoked by this description of a life. Are we able, however, to imagine that it could be our own lives? Are we willing to see ourselves in such a situation of vulnerability and suffering? Is it too overwhelming to contemplate? Can we picture doing something to change the situation, to make a difference? These journalists conclude that the wealthy world must use both its zeal and its cash to help southern Africa if this "plague" is to be stopped.
Benner54 argued that the starting point in health care ethics needs to be in recognition and relationship to such human reality. The principle of justice can provide us with "ethical moorings" but it is not sufficient: "The moral and emotional work of meeting the other and caring for the other in situations of need and vulnerability are hidden in the language of rights, autonomy and justice."54(p160) She suggests that we need to embrace more than justice—we need to strive for mercy, generosity, hope, and even love.
The American ethicist Arthur Caplan55 decries the emphasis on autonomy and individual rights in Western societies. He believes an "obsession" with individualism has led to a denial of our mutual dependency and diminished our sense of brotherhood. He recalls an old Boys Town advertisement depicting a teenage boy carrying a younger boy on his back with the slogan, "He ain't heavy; he's my brother." He notes that today, to be realistic, the slogan would have to read: "He's pretty heavy but I got paid twenty bucks to carry him so I will for awhile."55 Helping one another with the inevitable burdens of illness, death, and disability is not supererogatory, Caplan argues. It is the decent thing to do.
We do know that a factor common to ordinary men and women who have reached out to help others—to the extent that they risked their own lives—is "inclusiveness." These individuals have a tendency to regard all people as equals, without regard to social status or ethnicity.56 At the 1996 UNESCO forum on moral universalism and economic triage, philosopher Richard Rorty maintained that the real question of our times is: "Who are we?" That is, who are the members of our moral community? To whom do we have responsibilities? Is it possible to form a meaningful moral community to which every human belongs?
THE POSSIBILITY OF A UNIVERSAL ETHIC
Can we conceive of a macro-ethic that could guide our moral actions in a global community? How might we create and support dialogue about what constitutes a "good life," about our relationships with one another, about our rights, our responsibilities? Is it even possible to articulate a universal ethical framework, given the diversity of cultures, values, and beliefs in the world? Can we hope to achieve cross-cultural understanding, let alone consensus about basic life assumptions?
There are those—"universalists"—who embrace a belief that all humans share an intrinsic human nature that connects us. It is on this assumption that human rights are based. There are others—"relativists"—who find this idea untenable. The American Anthropological Association, for instance, argued against the drafting of the UDHR on the basis that no common humanity existed.57 Cultural relativists maintain that cultural differences are such that values in one culture, and therefore the persons living in that culture, cannot be comprehended by those living in another. The possibility of significant intercultural dialogue is denied, given that no single religious, moral, cultural, or philosophic perspective can be used to frame the discourse. The relativist viewpoint usually is grounded in tolerance and a respect for diversity, but it has serious implications for the viability of a global society. An inability to understand and communicate with one another seems like an insurmountable barrier to the development of a true community.
How do we manage our interdependence if our differences are so complete? In a discussion of peace and violence in Africa, Kaphagawani says that those who deny "that a Yoruba can understand a Luo or a Julu" are wrong.58 All languages, he argues, share a small subset of universal concepts. He finds, for instance, that although what is considered normal or deviant varies between cultures, the ideas of normalcy and deviance are universal. Martha Nussbaum, a philosopher who takes an admittedly universalist and essentialist position, rejects the extreme relativist stance, quoting Aristotle's comment in Nicomachean Ethics: "One may also observe in one's travels to distant countries the feelings of recognition and affiliation that link every human being to every other human being."59 She constructs an argument for a common humanity using a set of functional capacities basic to all humans, one that complements well Sen's idea of functional capabilities. This account of the shared capacities that distinguish human life from other forms includes our awareness of our mortality; our embodiment; our need for food, drink, and shelter; the fact that we experience sexual desire; are mobile; and have cognitive capacities (perceiving, imagining, thinking). Humans, she points out, are extremely dependent in early infancy, have a capacity for practical reason, and feel some sense of affiliation to other humans and a relatedness to other species and to nature. We can experience humor and play, and we have a separateness that gives each human life a unique context. Nussbaum59 also delineates a second level of human functional capacities, those that she believes are fundamental to a good life. Among them are the capacities to have good health; to be adequately nourished; to use the senses; to imagine, think, and reason; and to have attachments. These, she argues, should be the goals of societies for their citizens. If Nussbaum and other universalists are right, humans do have enough in common to open a dialogue about collective human needs and problems, about hopes and expectations for the earthly community in which they have to live.
Such a dialogue seems crucial. The world has become too small; we are too intertwined for silence to be a sensible option. On the other hand, constructing a meaningful discourse on how we should be with one another will not be easy. All communities experience disagreement and plurality of viewpoints; argument and controversy will be nothing new. The real difficulty will be in opening up the space for other than the most powerful voices to be heard. We will need to determine what those who have been silent out of fear or ignorance need in order to speak, and what the rest need in order to listen.
Lane and Rubinstein60 have some practical ideas about getting beyond the impasse between cultural relativism and universalism. They use as an illustration what is becoming the classic example of cultural differences: the practice of female circumcision. Their advice on how to structure a conversation about this issue is informative. They suggest that we first need to recognize one another's priorities—maybe we have not chosen the most pressing topic of concern. (For instance, in their interviews with Egyptian women about female circumcision, one woman asked, "Why do you think that is such a problem? That happened a long time ago and hurt for a short while. My husband's beatings are a much greater problem.") Lane and Rubenstein note further that we need to care about the other's feelings and pay attention to our choice of words. An approach needs to be constructed that is respectful of diversity, based on an awareness that our knowledge of different others is always contingent, tentative, and incomplete.
Drane,61 a medical ethicist, believes that we need to find the right voice to speak about ethics, that when we are judging practices of another culture, like female circumcision, we need to use language that acknowledges the moral inadequacies of our own culture as well. He believes that the existing international dialogue in medical ethics provides a good opening for the consideration of a universal ethic. The experience of illness is a human commonality, and there are commonalities across cultures inherent in the relationship between the sick and those who help them. The professional commitment to help persons in distress is shaped by transcultural ethical standards, remarkably similar across history and cultures.
Some health professionals, of course, would disagree with him. Fan,62 for instance, argues that ethical frameworks, at least in critical care medicine, must be local not global because one cannot share a content-rich bioethics with those committed to different moral premises and value rankings. Fan contrasts the Asian emphasis on the community with the Western value of individualism. Despite such arguments, however, steps have been taken to move from an international perspective in bioethics to a global one.
It was in 1984 that the first Health Policy, Ethics and Human Values Conference of WHO and CIOMS considered the possibility of an international perspective on bioethics. The need for dialogue regarding health policy making, ethics, and human values in different cultures was identified. A decade later, at a conference convened to review the progress on these issues, it was evident that a paradigm shift had occurred. An international perspective was no longer the goal; a "global agenda for bioethics" was developed, involving a search for a universal consensus on essential principles of bioethics, the application of bioethics concepts in human rights discourse, and a call for the World Bank and Regional Development banks to incorporate bioethical principles into project design and assessments. The need for intergovernmental organizations (eg, the World Medical Association, United Nations agencies) to play a substantial role in achieving this agenda was stressed.63
The conversation to derive a global health ethic should be a fruitful one, if it is grounded in a respect for all peoples as potential sources of wisdom. Tangwa,64 for instance, points to the moral sensibilities of traditional Africa as something that Africans can offer a global ethical community. He notes that our contemporary world, while enjoying the benefits of Western science and technology, is allowing "the spirit of commerce and omnivorous discovery and experimentation" to create greater inequalities between the prosperous and the poor.64 He proffers as a better approach the traditional African egalitarian perspective, where moral consideration is indiscriminately due to all human beings, regardless of their personal characteristics, status, or social rank. Tangwa offers as a guiding image for resolving intercommunity disagreements and for reaching mutual understanding that of African elders sitting under a tree and discussing until they agree.
Tangwa would push Caplan's55 concern for a renewed sense of brotherhood further. He notes that because the African worldview includes concepts of transformation (eg, reincarnation and transmutation), there is an awareness of the possibilities of brother/sisterhood with other beings. No hard and fast line separates human beings from other ontologic entities on the Earth. This raises an issue pertinent to any discussion of moral community: Should it extend beyond human life? Do we have an ethical obligation to live in a way that is mindful of other forms of life?
Living in harmony with nature and other life forms would seem to be an imperative in a global habitat. To date, however, we have failed to achieve a sustainable relationship with our environment. We are depleting earth resources, destroying other species, and leaving such large amounts of biologic and industrial waste products that they cannot be recycled expediently by natural processes.65 The claims of nature need to be given voice in our ethical deliberations. JG Engel66 maintained that we must make connections between our personal space and the needs of the community to recognize how our local space connects within the larger natural and cultural spaces. An understanding of our connectedness with the Earth and all its occupants might move us to a greater inclusiveness.
JR Engel describes how a Chicago regional planning project, Nature, Polis, and Ethics, is engaging citizens in the "most radical and elementary of social ethical questions: how ought we to govern ourselves within the conditions of life given to us on this planet and in this place?"67 Such "ecological citizenship" moves us beyond the citizen as consumer, making choices on the basis of preferences and competitive advantage, to a concern for the common good, to a view of the good life as "humans mutually flourishing in a mutually flourishing world."67 It seems necessary, as well, that we must recognize the effects of our actions on those who will come after us. Our descendants have no voice in what is happening at present, but the ramifications of the choices we are making will strongly affect them and the world in which they will live.
Hyakudai Sakamoto,68 the founder of the Japanese Association of Bioethics, believes that for a global bioethics we need a revised humanism, one that is not so excessively human-centric. Coming from an Asian ethos influenced by Taoism, Buddhism, and Confucianism, he conceives of a "holistic harmony" as the foundation for worldwide ethics. This holistic harmony would mean that rather than the autonomous individual being the basic element of bioethics, a greater emphasis would be placed on nature, society, neighborhood, and mutual aid. He presumes the existence of feeling that is common to all people (eg, the feeling of pity) and proposes that such common feeling can be our ethical basis. Sakamoto admits that our initial goal in developing an ethic to serve in these global times realistically may need to be compromise more than harmonize.
Nevertheless, Sakamoto's metaphor of "harmony" seems a rich and useful one. It fits well with the idea of "improvisation," used by philosophers like Nussbaum69 when stressing the need to be attentive to context in ethical situations. When persons such as jazz musicians or actors improvise, they must be more, not less, attentive to their group. They have to be committed to the other performers, to be acutely aware of and responsive to them. It is not that just anything goes; those who excel at improvisation have a deep understanding of the traditions that shape artistic form. Cultivating an attentiveness that supports harmony could be important to a universal ethic.
In describing the preconditions of moral performance, Vetlesen,70 a Norwegian philosopher, says that there must be a receptivity, an attentiveness to action. Without it, we can fail to see ourselves addressed by situations that require a moral response. Until recently our efforts to promote ethical action in health care were primarily centered on the present and immediate issues affecting persons in our own particular communities. In this era of globalization, however, a significant shift is occurring. Our moral space is altering, and the constituents of our moral community are being redefined. We need to broaden our perspectives, to take the globe as our frame of reference as we answer the questions: How should we act? What is the right thing to do?
THE GLOBE AS OUR FRAME OF REFERENCE FOR ETHICAL ACTION
In nursing ethics, suggests Wurzbach,71 moral metaphors have emerged over time that have strongly affected nursing practice. The military metaphor of the 1800s and the advocacy and academic metaphors of the 1960s are examples. She believes two new metaphors are arising today: the "individualist" and "community as caring" metaphors. She urges nurses to examine and reflect on the metaphors used to shape and guide practice. She warns that we must understand how they relate to the times in which we live.
Davis72 points out that certain assumptions about values have been taken for granted in nursing. For example, she points to the strong influence of the United States and the United Kingdom evident in the stance that the self-reliant individual is the ideal. Now that influences are coming from other sources, she wonders what it will mean for the profession. "The question before us is: are there ethical notions of caring, ethical principles and virtues that could be endorsed as true for all nurses everywhere?"72
This article argues that the world has become a global village. If this is true, it seems necessary that nurses consider their changing roles and responsibilities within that village. Nurses must determine, for instance, whether they can actively imagine a world in which there is true opportunity for health for all.73 One of the dangers of our times, however, is that we can become overwhelmed by the immense and rapid changes taking place, by the tremendous amounts of information available to us, and by the media-driven awareness of great human suffering. The temptation to moral minimalism can be strong.6 We are at risk of developing an inhibiting "What can I do about it?" attitude. Nurses, however, are known for asking "What can I do about it?" in an active, rather than in a resigned, way. The mechanisms are in place for responding. The International Council of Nurses and Midwives and the WHO Collaborating Centers in Nursing and Midwifery are there to provide leadership as nurses come to address the new global health issues.
In The Ethical Demand, the philosopher Løgstrup74 wrote that we all, inescapably, depend on one another. He said that we are mutually and, in an immediate sense, in one another's power. He was describing close-up ethical relationships, but we are recognizing how true this is not only close up, but also on a global scale. Now we have to act on that recognition.
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