Who are bioethicists?

Like many academic fields, bioethics faces challenges with respect to equity, diversity and inclusion. While the demographics of bioethics practitioners are understudied, what we do know suggests bioethicists as a group are unrepresentative of the global population they increasingly serve. In an analysis of who produces bioethics knowledge and what theories and concepts they draw on, Pratt and de Vries reported that the field’s leading institutions and scholars are situated in the world’s politically and economically dominant countries.7 Despite gestures towards global equity, diversity and inclusion, ‘much of the work in global health ethics today continues to draw on theories, principles, values, concepts, and worldviews from the global North’7 (p 329). Within countries, bioethicists are a privileged set, more educated and wealthier than the general population. A 2024 survey of US bioethicists showed that they tend to come from more educated families and are generally whiter, more liberal and less religious than the overall American population.8

It follows, unsurprisingly, that bioethics scholarship emanates from a narrow subset of the world’s population. Studies show that relative to their proportion in the global population, authors from high-income countries produce a disproportionate share of the bioethics literature. In a quantitative analysis of top-cited articles in bioethics journals between 1975 and 2014, Jin and Hakkarinen found that 84.5% of highly cited articles were from the USA, and 65.3% were from the UK or Canada.9 Yet, just 7% of the global population lives in high-income countries, 33% in middle-income countries and 60% in low-income countries.10 Borry et al investigated the geographical distribution of bioethics publications by analysing 4029 articles published in nine journals between 1990 and 2003 and reported a similarly lopsided geographical distribution: 59.3% of articles (n=2390) were from the USA, 13.5% (n=544) from the UK, 4% from Canada (n=160) and 3.8% (n=154) from Australia.11 Normalised to population size, smaller affluent countries, such as New Zealand, Finland and Sweden, exceeded the USA in productivity. The authors concluded that bioethics displays ‘geographic bias’11 (p 339).

If we consider international bioethics conferencing, these biases persist. To give one prominent example, Schmidt reported that at the 2022 World Congress of Bioethics, held in Basel, Switzerland, participation rates were 42% from high-income countries, 12% from middle-income countries and 4% from low-income countries.12

Bioethics is WEIRD

Taken together, these findings align with Henrich et al’s general hypothesis that the cultural backdrop that informs many academic fields is WEIRD.13 A robust body of empirical studies documents that the values associated with WEIRD people differ appreciably from the rest of the world, and from most of the people who have ever lived.14 Henrich et al characterise this ‘particularly thin, and rather unusual, slice of humanity’13 (p 61) as

highly individualistic, self-obsessed, control-oriented, nonconformist, and analytical. We [WEIRD people] focus on ourselves—our attributes, accomplishments, and aspirations—over our relationships and social roles. We aim to be ‘ourselves’ across contexts and see inconsistencies in others as hypocrisy rather than flexibility… we are less willing to conform… We see ourselves as unique beings, not as nodes in a social network… When acting, we prefer a sense of control and the feeling of making our own choices…15 (p 21)

Henrich goes on to characterise people in WEIRD societies as tending ‘to look for universal categories and rules with which to organize the world,’ and they ‘tend to stick to impartial rules or principles’ while showing ‘less favoritism toward …friends, families, co-ethnics, and local communities than other populations do’15 (p 22).

In line with these claims, Fox and Swazey argued in an influential 1984 paper that the scope of bioethics is excessively narrow and North American centred, contrasting it with the ‘medical morality’ they observed as medical sociologists embedded in mainland China.16 Chinese medical morality, they claimed, tends to be

rooted in a conception of the individual in relation to statuses and roles, enmeshed in the network of human relationships that this involves. In this conception, the individual steadfastly strives to meet [their] responsibilities and carry out [their] duties ever more totally and perfectly, guided by certain principles, inspired by particular maxims and exemplars, and in conformity with concrete rules.16 (p 340)

While WEIRD approaches underscore the value of individual self-determination, Fox and Swazey characterised Chinese medical morality as highlighting a series of ordered, interconnected relationships that put duties to others first. For example, they reported that nurses in China were instructed to ‘Serve the patient wholeheartedly…. Put the interests of the patient first all the time…think what the patient thinks, be as eager as the patient is, and be as worried as the patient feels…. We should treat our patients as our sisters and brothers…’16 (p 341). This description of Chinese medical morality training does not necessarily show that Chinese nurses practise Chinese medical morality, or even that they would endorse it if asked. Nurses might say they act as they do because ‘that’s the tradition,’ or even, ‘we are Chinese’ (and that’s what Chinese people do).

Writing in 2023, Pratt and de Vries suggest that many differences between Chinese medical morality and American bioethics persist: there is an ‘epistemic hegemony of Eurocentrism, which originated during the era of colonialization and continues today’7 (p 326). It is manifest, they continue, in ‘[t]he presentation of the works of a few European philosophers as ‘universal truths,’’ which leads to ‘denying the possibility that these philosophical accounts were themselves located in particular historical moments and lived experiences’7 (p 326).

Exemplifying this concern, Childress and Beauchamp champion their four principles of biomedical ethics—autonomy, beneficence, non-maleficence and justice—(hereafter ‘principlism’) as ‘universal norms shared by all persons committed to morality’ and describe them as ‘broad, abstract, and content-thin’1 (p 164). In response to the charge that principlism leans Western, Childress and Beauchamp defend their approach as friendly to difference, requiring only that culturally diverse alternatives not violate the common morality principlism sets forth. For example, in response to Hong Kong scholars who stressed that Confucian ethics differs from liberal, individualistic frameworks of Western societies because it assumes obligations and virtues of filial piety, recognises obligations of children to care for their parents and holds that governments should promote the fulfilment of those filial obligations, Childress and Beauchamp maintain, ‘[t]his kind of moral diversity in identifying moral agents and their responsibilities is certainly within the bounds of principles derived from the common morality and in no way contradicts them’1 (p 172). Their response might suggest that principlism functions as a test for Confucian ethics, or more generally that ethical systems that are not WEIRD must at least meet WEIRD standards. While Childress and Beauchamp state that the four principles ‘are only prima facie binding…and each one of them can thus be overridden by one or more prima facie norms,’ the norms principlism weighs are not Confucian virtues, but autonomy, beneficence, non-maleficence and justice principles1 (p 171).

Another illustration of bioethics’ WEIRDness is UNESCO’s Universal Declaration on Human Rights and Bioethics. The Declaration states as its aim: ‘to provide a universal framework of principles and procedures’17 (Article 2). The framework affirms, ‘The interests and welfare of the individual should have priority over the sole interest of science or society’17 (Article 3). While the Declaration recognises solidarity as well as autonomy, it baldly states, ‘In no case should a collective community agreement or the consent of a community leader or other authority substitute for an individual’s informed consent’17 (Article 3). Thus, despite calling for ‘due regard’ for cultural diversity, the Declaration’s core values are fundamentally individualistic17 (Article 12). As Rosemont notes, a bedrock presupposition of the Declaration is that human beings have rights, an idea that originated in Western thought about ‘human beings as freely-choosing autonomous individuals’ that traces to ‘epistemological reflections of Descartes, and… found moral and political expression in such writings as those of John Locke, the Virginia Declaration of Rights, the Declaration of Independence, and the French Declaration of the Rights of Man…’18 (p 73). Rosemont concludes, ‘Clearly the framers of this Declaration, overwhelmingly drawn from the culture of the Western industrial democracies… propose a particular moral and political perspective…as the standard toward which all nations, and all peoples should strive’18 (p 73). While the Declaration’s framers regarded human rights to be free-standing, Rosemont’s analysis brings to light that Western social, cultural and historical contexts, which are not universally shared, underpin the Declaration’s moral claims and explain, in part, why they may seem more obvious and compelling to some than to others.

A problem with WEIRD approaches to global bioethics is that they omit large swaths of humanity. This undercuts the field’s ability to articulate values that can gain global traction and inspire global collective action. By claiming to be culturally neutral, WEIRD bioethicists ignore their own positionality and pay insufficient attention to diverse contexts where bioethics’ values are formulated and applied.

An objection to this analysis is that it overstates East-West differences. Hasn’t globalisation had a homogenising effect, reducing the authority of traditional values? In reply, despite the diminished roles of Confucianism in formal education and the growing influence of Western culture, Confucian values continue to be transmitted within families. Although globalisation may lessen the influence of some traditional values, they remain a powerful force. Confucianism has existed for over 2500 years in China and continues to exert an influence across East Asia, not only in China but also Hong Kong, Japan, Singapore, Taiwan, Vietnam, Korea and other locations. Chan writes that although East Asian societies ‘have undergone modernization and been exposed to the powerful forces of global capitalism… Confucian values such as the importance of the family, the respect for learning and education, and the emphasis on order and harmony remain significant in these societies’19 (pp 88–89). Likewise, human rights, individual autonomy, equality and liberty remain at the heart of bioethics in the West, despite greater exposure to non-Western values.

Another objection holds that East-West dichotomising conveys ‘a distinctly Eurocentric perspective’20 (p 14). According to Sen, ‘East Asia itself has much diversity, and there are many variations between Japan and China and Korea and other parts of East Asia’20 (p 14). Nie underscores that focusing on differences can have the unfortunate effect of reinforcing cultural stereotypes.21 In response, we reiterate that our approach offers an analysis of the bioethics landscape at a high level of abstraction, glossing over many nuances. The aim is to propose a general approach to cross-border bioethics that we think would improve over the current one.

Personhood views

‘Personhood’ refers to having a superlative moral worth meriting respect, non-interference and a right not to be killed or destroyed. Leading Western views characterise the specific requirements for personhood vis-à-vis a set of sophisticated cognitive capacities. According to Jaworska and Tannenbaum, the sophisticated cognitive capacities view says that personhood is ‘Neither a relation the individual stands in…nor a capacity whose exercise requires active participation of another (eg, the capacity to relate to others in certain mutually responsive ways)’22; instead, the qualities that underpin personhood are intrinsic to individuals. Exemplifying a sophisticated cognitive capacities view, Kantian ethics holds that what confers dignity and moral worth to individuals is their ability to reason about morality and impose moral reasoning upon themselves. Also emphasising sophisticated cognitive capacities, utilitarian ethics emphasises that persons possess capacities for suffering and enjoyment. Bentham, for example, holds that the relevant question for deciding moral considerability is ‘not, Can they reason? nor Can they talk? but, Can they suffer?’23 (Kindle locations 5973–5990). Singer likewise claims that ‘[t]he capacity for suffering is…not only necessary, but also sufficient for us to say that a being has interests’ and deserves to have their interests considered equally with the interests of all other beings24 (p 23).

East Asian approaches regard personhood differently. While diverse, many renderings of Confucian ethics consider the source of a person’s moral worth to be performing well in social roles and relationships. Bockover, for example, asserts that Confucian personhood arises through the enactment of primary virtues that find expression by engaging in social roles and relationships; for example, ren (仁) (the virtue of loving kindness, compassion or humanness) is expressed as an activity that, when practised authentically, ‘establishes one as a person and supports human flourishing’25 (p 178). A related feature of Confucian approaches is that they tend to regard personhood as an achievement resulting from ongoing effort. Yu and Fan express it, thus: ‘people must develop and actualize their potential…to…mark themselves [off] from other animals. Indeed, if people do not cultivate moral virtue, they are little different [from] animals….’26 (p 174). Since efforts to realise moral excellence can be weak or strong, and immature or well developed, Confucian personhood tends to display two further features: an individual can be more or less of a person, and an individual’s status as a person is apt to change over time, as the person matures and develops, rather than being stable or fixed. Lastly, Confucian ethics generally understands personhood as in some important sense derivative from social relationships. Ramsey distinguishes ‘strong’ views that hold ‘persons are no more, or nothing above, the nexus of their roles’ from ‘moderate’ views that consider social roles and relationships necessary, not sufficient, for personhood27 (p 238). Hui exemplifies the strong view, stating that ‘a person is never seen as an isolated individual but is always conceived of as a part of a network of relations…a person is always a ‘person-in-relations’’28 (p 23). Fingarette indicates a moderate account, construing personhood as both enacted by individuals and transcendent. People enact personhood by consistent efforts to acquire li, with ‘all sincerity and good faith, with all right-heartedness and reverence’29 (pp 194–195). Personhood’s transcendent aspect arises when li is fully mastered, becoming effortless, elevating individuals ‘from the beasts and from the inanimate’30 (p 82). Fingarette calls the full expression of li ‘beautiful’, ‘noble’ and ‘sacred’30 (p 83), while Loy states, ‘the agent possessing ritual propriety is like someone who is able to dance, as opposed to someone… following a recipe of steps’31 (p 293). Table 1 summarises differences between East Asian and Western personhood.

Social robots, fetuses and nature

Different East-West understandings of personhood lend support to different practical views about which entities count as persons. Consider first, social robots. Would Confucian ethics regard a social robot as a person? Fingarette’s view suggests not, since social robots (for now) lack the ability to act as intentional agents with sincerity and good faith in their efforts to become virtuous. However, Hui’s position that being a person is derivative of social relationships is compatible with social robots achieving personhood within robot–human relationships. Similarly, Jecker and Fan’s view invites the possibility of personhood for social robots provided we can form relationships with social robots where we enact Confucian virtues.32

Western approaches tell a different story. Kantian and utilitarian ethics reject robot personhood as long as robots lack sophisticated cognitive capacities like rationality or phenomenal consciousness. Thus, Curtis and Savulescu say, ‘There is nothing in principle that prevents a machine from having a moral status (from being considered morally important in its own right). But it would need to have an inner life that gave rise to a genuine interest in not being harmed.’33

Consider next the moral standing of prenatal human life (hereafter ‘fetuses’). Kwon interprets Confucian ethics as suggesting that ‘human life is not valuable in itself, but rather acquires a value in the context of relationships’34 (p 224). Since four of five primary relationships in Confucian ethics (ruler-subject, father-son, elder-younger brother, husband-wife and friends) are family relationships, it could be argued that the fetus’s status as a (future) family member carries moral weight. According to Wong, filiality is ‘one of the most distinctive characteristics of Confucian ethics’.35 Yet, Fan stresses that the relationally derived value of the fetus is a matter of degree:

In order to become a full person, it is not enough to be conceived, to be born, to eat, breathe, drink, excrete, enjoy sensual pleasure, or avoid physical pain. Rather, it is to become a participant in the rites, first passively, and gradually actively. It is the transformation of the act of mere biological human existence into sacred human rites that entitles a human being to become a full person.36 (pp 226–227)

Within the West, different versions of Kantian ethics yield different accounts of fetus’s moral standing. Wood understands Kant as holding that rational nature is respected only by respecting rational nature in a person and rules out personhood for beings who have rational nature ‘only potentially, or virtually, or [have] had it in the past, or [have] parts of it…’37 (p 189). Korsgaard gives another interpretation: fetuses are persons from the moment of conception because they belong to a type, homo sapiens, that has the capacity for rationality and for willing the moral law on themselves.38 Utilitarian ethics focuses on the fetus’s capacity for suffering and enjoyment. For example, Singer holds that fetuses who have not developed the capacity for suffering and enjoyment have no moral standing of their own.39 Later fetuses that can experience pleasure and pain yet lack self-awareness or preferences would have relatively low moral status: ‘the calf, the pig and the much-derided chicken come out well ahead of the fetus at any stage of pregnancy—whereas if we make the comparison with an embryo, or a fetus of less than three months, a fish shows much more awareness’39 (pp 135–136).

Lastly, consider non-living nature (hereafter, ‘nature’). Confucian personhood highlights nature–human relationships and asks whether they can be morally good. Fan, for example, holds that ‘neither individual humans nor other natural objects have a standing that can be appropriately appreciated in isolation,’ and advances a ‘weak anthropocentric’ account: humans should serve as ‘nature’s gardeners’, so that both humans and nature can flourish36 (pp 150, 153, 155). Wang explains Confucian views of nature this way:

We love both birds and animals on the one hand and grasses and trees on the other, but it is bearable for us to feed birds and animals with grasses and trees. We love both human beings and birds and animals, but it is bearable for us to kill birds and animals to feed parents, to sacrifice for rituals, and to entertain guests. (Quoted in ref 40, p 55)

Leading Western views standardly reject the possibility that nature has value in itself. Kantian ethics ascribes no intrinsic worth to inanimate objects in nature because they lack the capacity for rationality. Utilitarian ethics also rejects any suggestion that nature is intrinsically valuable, since nature lacks the capacity for suffering or enjoyment. For example, considering the ethics of damming a river to generate hydroelectricity, Singer claims the river is not morally considerable for its own sake, yet might be instrumentally valuable to the interests of conscious beings.39

Epistemic justice

Diverse personhood views present formidable challenges in global contexts when international ethics guidance is sought. To illustrate, consider how Confucian and Western views about fetuses, social robots and nature are manifest in international ethics guidelines for abortion care, AI governance and climate change. The most recent (2022) WHO Abortion Care Guidelines call for safe and effective abortion care41 (p 8). Relevant for our purposes is that the WHO discusses the ethics of abortion services solely in terms of individual rights, emphasising, for example, that unsafe abortion practices around the globe jeopardise the pregnant person’s rights to health, non-discrimination and life. Focusing exclusively on individuals’ rights is WEIRD, because it ignores the relational features of prenatal human life so salient in Confucian ethics; for example, that a fetus is situated within a pregnant person’s body, and within the context of (future) family relationships.

Consider next, international guidance on AI governance. The WHO’s 2021 Ethics and Governance of Artificial Intelligence for Health report identifies protecting human autonomy as the first of six key ethical principles for the use of AI in health.42 The report expresses concern that the Universal Declaration of Human Rights, which protects individual dignity, privacy, confidentiality and informed consent, might be ‘dramatically redefined or undermined’ by AI advances42 (p 2). Again, the emphasis is fundamentally incomplete, since it neglects the relational context in which AI is deployed and the value of AI–human relationships, which figure prominently in East Asian approaches to AI.

Lastly, consider international ethics recommendations on climate change. A 2023 report from The Intergovernmental Panel on Climate Change called for ‘transformative changes’ to stay within the planetary health boundaries required to ensure a safe operating space for humanity.43 Subsequent discussions of values supporting staying within planetary boundaries assume an instrumental view of nature’s value. For example, the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services appeals to ‘nature’s contributions to people’, such as food, medicine and materials required for human well-being to justify planetary boundaries44 (p XIV). Others take a broader view, referring to international, intragenerational and interspecies justice45 (p 632), yet omit consideration of nature–human relationships considered crucial within a Confucian worldview.

Universalising WEIRD values, as these international guidelines do, is ethically objectionable. It contravenes core requirements of epistemic justice that require being fair and inclusive when producing knowledge and assigning credibility to beliefs.46 Universalising WEIRD views about personhood assigns excess credibility to WEIRD views while deflating the credibility of non-WEIRD views. An epistemically fairer approach must recognise both East Asian and Western conceptions of personhood, regarding each as prima facie equal. A fairer approach would take steps to correct entrenched Western biases by balancing them with insights from traditions outside the West.

Lessons from li

An alternative to universalising WEIRD values is upholding value pluralism. Pluriversal frameworks do this by asserting both ontological and normative claims. The ontological claim is that people who hold different values not only subscribe to different beliefs but inhabit different worlds and live different existences. Escobar puts the point this way: ‘the world is made up of multiple worlds, multiple ontologies or reals that are far from being exhausted by the Eurocentric experience or reducible to its terms’47 (p 69). Although we share a material existence, and share many concepts, practices and forms of collective life, we also enact ways of life that exceed the one shared world, generating multiple ‘reals’. Pluriversalism also asserts a normative claim about how people ought to act towards others in a world of many worlds, calling for respecting and caring for multiple worlds and avoiding harming people or destroying other worlds. A pluriversal approach regards others as epistemic equals, that is, equally capable of understanding evidence, evaluating arguments and arriving at justified beliefs. It does not require accepting other people’s values, but rather, accepting that our epistemic peers accept them, and their world is as real to them as ours is to us.

How does a pluriversal view translate to bioethics? The Confucian virtue, li, suggests an answer that emphasises ritual propriety. While originally applied to formal settings, such as religious ceremonies and court proceedings, contemporary Confucianists extend li to everyday conduct and interactions with parents, teachers, friends, neighbours, etc, where norms for proper behaviour apply.

In all the domains where it operates, li stresses that ‘moral people must also and necessarily be polite people’48 (p 423). Seen through Western eyes, centring politeness might seem odd, yet Kupperman suggests it is Western ethics that is peculiarly ‘preoccupied’ with ‘big moment ethics’, treating ‘almost all of life apart from the big moments as an ethical free-play zone’49 (p 40). Underlying li’s focus is the thought that ‘exchanges and experiences of quotidian life’ are ‘where most people spend most of their days’; they ‘profoundly shape moral attitudes, moral self-understanding, and our prospects for robust moral community’48 (p 422). These unremarkable moments matter, because they affect ‘Whether we feel ourselves respected, our dignity recognized, and so forth….’48 (p 427). In ordinary interactions, subtle cues matter far more than they do in ‘big moments’: ‘The style with which someone commits a murder or grand larceny rarely is of much importance…. But the style in which a friendship or collegial relation is conducted, or (as Confucius pointed out) in one’s help to aged parents, can be extremely important’50 (p 21).

Sarkissian distinguishes descriptive dimensions of social roles, which apply to anyone falling under the role, from normative dimensions, evident when we call someone ‘a great teacher’ or ‘a good friend’.50 Applied to bioethics, we might say ‘bioethicists’ can be described as members of a bioethics community, and normatively, they ought to treat one another well, expressing moral attitudes through ritual practices (table 2).

In bioethics, ritual practices ‘convey … fellow feeling in easily discernible ways, forestalling conflict and protecting individuals from offending, shaming, or insulting one another…’50 (pp 488–489). Li can be critical during periods of upheaval and moral dissensus: in such situations, ‘what is crucially important … is … shared rituals…. What is most destructive … is…de-ritualization….’36 (p 205). When bioethicists master li, tolerance and mutual respect become effortless: ‘With correct comportment, no commands are necessary, yet affairs proceed’ (Confucius, quoted in ref 30, p 24).

This analysis of li suggests an argument for international ethics guidance to reflect plural values, rather than universalising one set of values over others (box 1).

Does value pluralism lead down a slippery slope to ethical relativism? In reply, value pluralism makes a claim about the normative domain. It asserts that the normative domain contains multiple values, rather than a single ‘supervalue’ that all values are reducible to. 51 This leaves open metaethical questions about the truth value and justification of ethical statements.

How do pluriversal methods handle irreconcilable values? In reply, pluriversality seeks compromises that reflect values from multiple moral traditions, mirroring moral standards people from diverse societies recognise and embrace. We agree with Rosemont: ‘there are not… any culturally independent human beings’ who require culturally independent standards; there are only people who live at specific times and places and belong to specific communities18 (p 72). Rather than pursuing a form or moral truth that is wholly detached from people’s lives, we favour an immersive approach to moral truth, one that embeds itself in the distinct and varied ways people understand and enact moral values in their lives.

Is promoting a tolerant, respectful, just, humble and civil bioethics an imposition of East Asian values on the West? In reply, these values are hardly ‘foreign’ to Westerners, although Westerners have distinct ways of specifying and expressing them. For example, in a 2024 review of how humility is conceptualised in American medical practice, Matchett et al reported that physicians render it as a way of relating to self, others and the profession: ‘an honest and balanced stance toward self, an orientation towards others’ needs and well-being, and a deep-seated appreciation for the privilege of caring for others’52 (p 1252). Historically, in the West, medical morality was a code for gentleman emphasising virtue, more closely resembling Chinese medical morality.53 Recent calls to revive virtues in American medicine54 suggest an opening for reincorporating virtue approaches in both medical practice and bioethics.

While this paper has focused on expanding Western bioethics to include East Asian approaches, a fuller analysis would consider multiple traditions outside the West and strive to include them.