By Richard A. Buabeng
Introduction
Bioethics raises questions primarily due to rapid developments in healthcare, biological science, and biotechnology. Issues such as abortion, in vitro fertilization, organ transplantation, pharmaceuticals and drug development, biomedical research, human rights, distributive justice, environmental/climate justice, palliative or end-of-life healthcare, gene editing, and healthcare technologies, as well as plants and seed alterations, are among the many that involve bioethics. The omnipresence of biological beings provides the space, irrespective of the context, for bioethicists and philosophers to pose questions, draw attention, and caution towards thinking and determining what is just, humane, acceptable, or otherwise. This article sheds light on the critical role bioethics plays within healthcare and how relevant it is for sustainable healthcare in Ghana and Africa.
Historical Antecedent
The field of bioethics originated within the United States of America, largely following the Nuremberg trials that addressed the atrocities committed by the Nazis and allied organizations during the Second World War. In response, the Universal Declaration of Human Rights (UDHR) was adopted in 1948. However, during and after these trials, a troubling and unethical syphilis experiment was conducted on impoverished African American men by the US Public Health Service (UPHS) from 1932 to 1972, aiming to study the life cycle of untreated syphilis disease. The CDC noted that despite having a cure for the disease, the researchers neither administered it nor obtained informed consent from the participants, showcasing a continuous disregard for their human rights even after the UDHR had been established.
Bioethics as a Discipline
Bioethics, as an interdisciplinary field, draws from diverse areas, including medicine, public health, biotechnology, law, and the humanities (such as history, philosophy, religion, politics, modern and ancient languages and literature, media, and cultural studies, among others). Despite its origins in various fields, bioethics has evolved into a distinct discipline, developing its own methods for empirical and non-empirical inquiry and scholarship. This development establishes a framework for meaningful and progressive engagements.
However, concerns have been raised about the push by the global north for the application of Western bioethics as an ethics framework for the world. While the concept of what is right and wrong is universal, it is largely subjective, influenced by socio-cultural, economic, environmental, and even political realities. Therefore, Western philosophical and ethical perspectives cannot be applied universally because of cultural and geographical foundations of bioethics. We can agree that these two foundations influence our perceptions of things. Such things in the areas of politics, nutrition, education, relationships, healthcare, even the structure of our healthcare system among others. Some scholars have raised questions about whether these above named are healthcare on the continent is structured on African philosophical and ethical grounds and, if not, what the bioethics framework of Africa entails.
Concerns of African Bioethics
There is a growing call for the development of a framework for African bioethics, reflecting concerns that discussions within African academia have been predominantly confined to Western thought. Dr. Munyaradzi Felix Murove in 2005 bemoaned the hindering of genuine discourse by Western scientific and philosophical perspectives’ overshowing of African bioethics. Despite efforts across Africa aiming to establish a bioethics framework rooted in African values, evidence reveals the negative impact of past and present missionaries and Western-trained anthropologists on suppressing authentic discussions of African bioethics, particularly in the degradation of indigenous medicine.
Others suggest there is dissatisfaction with the hegemonic presentation of Western bioethics as global bioethics. In 2014, Dr. Felix Chukwuneke a Bioethicist, Professor and Consultant Maxillofacial Surgeon at University of Nigeria Teaching College of Medicine Ituku-Ituku-Ozalla, Nigeria and his colleagues also argued that global bioethics emphasizes freedom, autonomy, and morality inclined to individualism, diverging from African conceptual origins. African bioethics has long been neglected, partly due to the dominance of Western bioethical concepts in biomedicine, reflecting post-colonial struggles in many African countries. While the outcomes of Western ethical approaches in biomedicine are acknowledged, they continue to face limitations and challenges, refusing to fully embrace African ethics. Also, Dr. John Barugahare, a professor from the department of Philosophy at Makerere University, published a paper in 2018 where he revealed that in sub-Saharan Africa, resistance to international recommendations for medical and health research partnerships is perceived as inconsistent with African worldviews and labelled as “bioethical imperialism“. The wholesale adoption of Western bioethical principles in the African health context faces criticisms due to apparent socio-cultural disparities. This observation from Dr. Ceaser Atuire, a philosopher and ethicist at the University of Ghana along with his colleagues argued that, despite the successes in adopting Western healthcare interventions, critical issues relating to social, economic, and environmental determinants of health persist among African communities. These concerns, criticisms and resistance may be partly coming from Africa’s historical experiences with western imperialism, colonialism, and neo-colonialism.
A Current Ghanaian healthcare situation
Following its independence from colonial rule, Ghana inherited a Western-centric healthcare system from Britain, side-lining indigenous approaches for cultural and political reasons. Over the years, this system has not undergone comprehensive reform, contributing to persistent healthcare inaccessibility and inequity for rural and impoverished populations, as noted by de-Graft Aikins and Koram in “The Economy of Ghana Sixty Years After Independence.” Indigenous healthcare lacked formalized status within the Ghanaian health context until recently, despite the acknowledgment that Ghanaians, particularly in rural areas, often rely on or combine indigenous and orthodox medical practices. To develop effective and efficient healthcare interventions, would it not be appropriate to consider the philosophical and ethical values of the Ghanaian people? These values are drawn from traditions, culture, religions, education, and the worldview existing within our communitarian structured society. This guides how people perceive their natural environment, determine ethical and moral standards, and define what is considered good or bad health.
Therefore, Service users or patients (clients), base their expectations of healthcare services on these values. Unfortunately, due to unscrupulous health practitioners/providers’ unprofessionalism and poor cultural sensitivities, patients’ rights and dignity are violated. These raises a question in my mind whether this contributes to the numerous medico-legal issues and ethical concerns being brought against health providers in the last five years. The media is awash with numerous reports of medical negligence, medico-legal issues and ethical misconducts. The cases of “Kwaku Agyiri-Tetteh and Kwaku Sodokeh vs University of Ghana Hospital and Two others (2018)” and “Dr. ELA Chimbuah and captain J.K. Nyamekye vs Attorney General (2021)” are two of many court cases that took the headlines. As far as I know, healthcare providers in Ghana undergo comprehensive trainings, encompassing theoretical and practical aspects, to attain the expected competence necessary for their professions. Regulatory bodies, typically one or two, oversee licenses and permits, ensuring adherence to accepted standards of care for both biomedical and indigenous health practitioners. So, why are we experiencing these problems? Has there been a root cause analysis to identify the gaps and failure within this pluralistic health system or we continue to push them under the carpet hoping that the next person will come and fix it for us.
Recently, the Vice President and the Minister of Health have expressed concern about the increasing number of Ghanaians suing health providers for alleged breaches of their duty of care, highlighting the importance of maintaining high standards. While some issues are resolved through arbitration or negotiated settlements within healthcare facilities, practitioners found in breach may lose their licenses, serving as deterrents to others.
Patients, however, voice bitter complaints about perceived violations of their rights, feeling shut down and unable to express their opinions. Some professionals, possibly due to educational differences, may look down on patients, mocking contrary views not considered medical. Patients often seek healthcare elsewhere, with some turning to indigenous practitioners, herbal medicines, or faith healing immediately after leaving the hospital. Jonathan Dapaah who lectures at the Department of Sociology at the KNUST Ghana revealed in his paper that Health Practitioners in Nigeria were found to discriminate and acted unethically towards clients with HIV/AIDS. Similarly, research in 2020 by Bienvenu Salim Camara and his colleagues at the Centre National de Formation et de Recherche en Santé Rurale in Guinea concluded that in Sub-saharan the practitioner–patient relationship showed evidence of poor communication, disapproval of service, domineering language, dictatorial words, and unprofessional examination on the part of health practitioners. Such unethical behaviour violates the patients Human Rights. It is possibly a factor contributing to patients seeking alternative and better treatments services. Also, Bosire and his colleagues in 2022 observed a shift in the once-held position of health practitioners in people’s lives, with faith and traditional healers, gaining prominence. These practitioners effectively communicate in the patient’s “language,” operating within socio-cultural and religious contexts to address holistic needs, fostering trust through proximity, understanding socio-cultural circumstances, closeness, and friendship.
Consequently, health facilities become settings of mistrust, as they are perceived to be outside people’s everyday lives, leading individuals to put their trust in religious practices and faith healing when faced with physiological and psychological distress. Most African cultures including Ghana’s, emphasise a holistic approach to restoring balance to the individual—addressing the well-being of the soul, spirit, and body. This stands in contrast to the focal point of biomedicine.
There appear to be a disconnect between biomedical practitioners and the local population. Why does it appear that people feel more connected to indigenous healthcare practitioners? James Marcum a researcher at Baylor University, USA in 2005 concluded that western biomedical viewpoint regards the human body as a tangible device, akin to a machine composed of distinct replaceable parts, repairable in case of faults. This reductionist approach portrays the body as an assemblage of parts, potentially diminishing the patient’s sense of personhood. On the other hand, Kwasi Konadu a Pan-African Historian and Anthropologist argued that the foundational principles of indigenous African medical science provide a holistic outlook on health and well-being, encompassing variables such as family, the perception of the universe, craftsmanship, nature, and cultural surroundings, all while deeply respecting the human being. Building on this perspective, Bosire et al. assert that researchers have, over time, criticized biomedicine for its focus on problems rather than on patients, highlighting a trust deficit. The presence of relationism is a significant philosophical concept in the Ghanaian socio-cultural context. Its absence within the patient–practitioner interactions undermine sustainable healthcare.
A Utopian Ghanaian Health System
How might a Ghanaian health care system structured based on a Ghanaian philosophical culture and ethics in tandem with existing contemporary health system look like?
- Akan Symbol of Solidarity & Unity in Healthcare Harmony
Envision a healthcare system influenced by the Akan philosophy, with the Adinkra symbol “Boa Me Na Me Mmoa Wo” (Help Me and Let Me Help You) as its guiding principle. In this scenario, healthcare practitioners blend modern medical practices with traditional Akan holistic healing methods. Patients actively participate in treatment decisions, emphasizing holistic well-being. With the communitarian structure of our societies, does the integration of “Boa Me Na Me Mmoa Wo” principle foster solidarity, resilience, adaptability, and unity within the patient, practitioners and community? How might this holistic approach lead to more sustainable health outcomes and strengthened community bonds?
- “Ananse” Leadership in Healthcare Governance:
Imagine a healthcare governance structure inspired by the wisdom of Ananse, the spider in Akan folklore known for cleverness. In this scenario, leaders in healthcare, both traditional and biomedical, emulate the problem-solving skills of Ananse as a leadership concept. Governance decisions prioritize flexibility, creativity, and inclusivity. How does adopting the spirit of Ananse in healthcare leadership contribute to innovative solutions, adaptability to changing health needs, and a sense of collective responsibility within the community?
- Picture a Ghanaian healthcare scenario where a patient, deeply rooted in Ghanaian cultural beliefs or specific family value (s), seeks treatment. A Western-trained healthcare professional, unfamiliar with these cultural intricacies, approaches the patient purely from a biomedical standpoint.
In one scenario, the clash of perspectives jeopardizes effective communication, mutual understanding, and trust, leading to dissatisfaction and potential non-compliance.
Now, envision health practitioners educated in Ghanaian bioethics. They seamlessly integrate traditional beliefs, fostering harmonious interactions that respect patients’ cultural backgrounds. Treatment decisions align with both biomedical aspects and the patients’ cultural and philosophical beliefs, resulting in a positive health outcome.
These thought experiments also emphasise the need for Ghanaian bioethics in health professions education, ensuring cultural sensitivity and understanding to navigate diverse beliefs for a patient–centered health system.
Importantly, Barugahare suggested care is necessary: focusing solely on identity should not be the exclusive, and arguably not the primary, objective of the discussion. Recognizing that context plays a vital role in selecting, interpreting, and applying ethical principles in specific local environments. Our emphasis should be on an unbiased exploration for bioethical principles capable of addressing moral challenges in African and global health, regardless of their origin. Simultaneously, we should prioritise strategies to ensure adherence to the identified principles.
Conclusion
My intention is not to create a dichotomy between different perspectives but to bring attention to fundamental issues we have overlooked in our ongoing struggle to address the enduring effects of the colonial legacy, which has significantly eroded the identity of Ghanaians and Africans. The question arises: can we establish a healthcare system in Ghana that is purely inspired by Ghanaian philosophy, free from Western influences? Moreover, without considering the social, cultural, and philosophical perspectives of Ghanaians and Africans, there is a continued risk of unsatisfactory practitioner–patient interactions, leading patients to seek alternative healthcare options, including indigenous and faith-based healing, even when the latter lacks empirical foundations, allowing charlatans to defraud our people and taking advantage of our failed health systems not just in Ghana but across sub-Saharan Africa promising them of healing that fails materialise and enriching themselves in the process.
Numerous instances highlight the substantial influence of our ethical and philosophical culture on our worldview. It is my hope that we embark on a quest for self-discovery, seeking the truth about ourselves rather than relying on external narratives. This journey necessitates self-belief and the creation of a sustainable health system by investing in our pluralistic healthcare approaches to ensure Universal Health Coverage.
In conclusion, the burgeoning field of bioethics in Africa presents significant opportunities. The Ghanaian Health System stands to gain considerably from trained Bioethicists/Clinical Ethicists. We use knowledge and skills from diverse fields including philosophy, medicine, nursing, law and religion to advocate for the best interests of patients and healthcare practitioners. This involves resolving conflicts, enhancing ethical policies and compliance, and ultimately elevating the standards of care in healthcare facilities. Similar to Nigeria and South Africa, it is imperative for the Ministry of Health in Ghana to establish, if not already in place, a dedicated Bioethics Department or Division responsible for addressing compelling bioethical issues within the healthcare system. This strategic move is a step towards building a sustainable healthcare system that prioritizes the well-being of the people of Ghana.
Reference:
- Aikins, A.D and Koram, K. (2023). Available at: https://academic.oup.com/book/7355/chapter-abstract/152164980?redirectedFrom=fulltext.
- Atuire, C.A., Kong, C. and Dunn, M. (2020). Articulating the sources for an African normative framework of healthcare: Ghana as a case study. Developing World Bioethics. doi:https://doi.org/10.1111/dewb.12265.
- Barugahare, J. (2018). African bioethics: methodological doubts and insights. BMC Medical Ethics, 19(1). doi:https://doi.org/10.1186/s12910-018-0338-6.
- Camara, B.S. et al (2020). What do we know about patient-provider interactions in Sub-Saharan Africa? a scoping review. Pan African Medical Journal, 37. doi:https://doi.org/10.11604/pamj.2020.37.88.24009.
- Chukwuneke, F., Umeora, O., Maduabuchi, J. and Egbunike, N. (2014). Global bioethics and culture in a pluralistic world: How does culture influence bioethics in Africa? Annals of Medical and Health Sciences Research, 4(5), p.672. doi:https://doi.org/10.4103/2141-9248.141495.
- Dapaah, J.M. (2016). Attitudes and Behaviours of Health Workers and the Use of HIV/AIDS Health Care Services. Nursing Research and Practice, pp.1–9. doi:https://doi.org/10.1155/2016/5172497.
- Konadu, K. (2008). Medicine and Anthropology in Twentieth Century Africa: Akan Medicine and Encounters with (Medical) Anthropology, African Studies Quarterly, Volume 10, Issues 2 & 3.
- Marcum, J. A., (2005), “Biomechanical and Phenomenological Models of the Body, the Meaning of Illness and Quality of Care”, Medicine, Health Care and Philosophy , 7(3): 311–320. doi:10.1007/s11019-004-9033-0
- Murove, M.F. (2005). African Bioethics: An Explanatory Discourse. Journal for the Study of Religion, 18(1), pp.16–36. Available at: https://www.jstor.org/stable/24764253 [Accessed 13 Jan. 2024].
Written by
Richard A. Buabeng,
Bioethicist and RN
