Consider the following end-of-life case in Thailand:
A thirty-nine-year-old Thai construction worker, Gaew, falls at work hitting his head on the pavement. Unconscious, he is taken to the hospital in Bangkok where he is intubated and placed in the intensive care unit. His physician, Dr. Nok, feels that Gaew has very little chance of recovery and informs his brother, Lek, of his prognosis.
Seeing his brother suffering, Lek makes the decision to remove his brother from the ventilator. Dr. Nok says that such an action is unethical and it cannot be done because their religion, Buddhism, forbids it. Not only is killing strictly prohibited, but various doctrines in the religion teach that the last part of the body to die is the breath.
Gaew, like many Buddhists, has no advanced directive. In their culture the self changes from moment to moment and a person is not the same as they were ten days ago. It would be impossible for a person to know what they would want years later in a different state of consciousness.
In order to not compromise their own karma, Dr. Nok and Lek prepare a strategy to circumvent their dilemma. Gaew’s physician feels that it is Gaew’s mental attachments that are preventing him from dying and if they can unknot his mind Gaew’s spirit might be released. Lek tells the doctor that Gaew’s wish was for Lek to ordain as a monk before dying. Even though they cannot know for certain what is troubling Gaew’s mind in his new state of consciousness, they feel that this might be a key to release Gaew from his suffering.
Lek and Dr. Nok decide that Lek should leave his brother to go ordain as a monk for several days, then return to Gaew. Though Gaew has very little brain activity, Dr. Nok feels that he may still be able to hear his brother’s voice when he tells him of his ordination. This way, they can relieve Gaew’s suffering while not damaging their own karma.[1]
When it comes to solving ethical issues in medicine in a global context, some experts have argued that there is no such thing as “global bioethics.” In the case above, two bioethicists, Scott Stonington and Pinit Ratanakul, argue that Western bioethics is insufficient to solve the problems that arise in the practice of conventional medicine in non-Western contexts. They point out that typical Western bioethical principles such as the ones proposed and popularized by Beauchamp and Childress (principles of autonomy, beneficence, nonmaleficence, and justice)[2] fail to give any helpful ethical guidance in this situation. To their credit, Stonington and Ratanakul point out some of the weaknesses and inadequacies of some aspects of contemporary Western bioethics. They show that Western bioethics has been whittled down to principles most important to those who live in the West, that is, freedom and autonomy. Nevertheless, they do not give a proper justification of their own position.
Stonington and Ratanakul intend to show that end-of-life issues involving ventilators in Thailand demand that a case be made for local difference when it comes to bioethics. As far as they are concerned, if this case is persuasive, it nullifies any legitimate grounds for a global bioethics. “Thai” bioethics requires a focus on the concepts of interdependence and compassion. Thai bioethics takes into consideration the complexities involved in a shame-based culture. These issues which are important to the Thai population play a minimal role in medical decision-making in the West. Granted, this may well be the case.
Nevertheless, a question must be raised here: Does not “Thai” bioethics reflect an ethics which has also been whittled down to mere principles important to those in the East? In other words, how do these different emphases in medical decision-making expressed in the West and East respectively prove to undermine a case for global bioethics? Are not compassion, interdependence, freedom, and justice universally recognized as goods which everyone would want and get if they could? One would be hard-pressed to find anyone who would disagree on this point.
In order to address these questions, we may find helpful conceptual resources in the work of C.S. Lewis. Before we begin to analyze Lewis’ arguments and their relevance to a case like this, a few more comments are in order. First, few bioethicists would ever argue against the reality of cultural diversity and the need for cultural sensitivity in medical settings. However, culture diversity and cultural sensitivity do not in themselves undermine the idea of a global bioethics. Second, the problem is that the arguments that some experts want to raise against global bioethics go much deeper than issues concerning cultural differences. Their underlying assumption seems to be that the new global medicine requires a new ethic altogether—an ethic that addresses not only cultural diversity and the new complex questions that arise in medicine because of new technologies, but also one that addresses the issue of “ethical diversity.”
Now, it is one thing to acknowledge the reality of cultural diversity; it is quite another to claim that if there is cultural diversity, it follows that there is also ethical diversity. The argument that is being made, in other words, is that ethics is subjective and particular. Those, like Stonington and Ratanakul, who take ethical diversity to be prima facie true assert that is it necessary then to jettison “traditional” ethics altogether because of its irrelevance and inapplicability in modern situations. In order to develop a new ethic, so the argument goes, which takes into consideration cultural and ethical diversity and questions arising from technological complexities, we must start from scratch.
Is that possible? Can we start from scratch, from a moral vacuum as it were, and create a whole new “diverse” ethical system to meet the needs of modern medical ethical issues? C.S. Lewis says it is simply not possible. He argues that we never start with a blank state; if we did, however, we would end with a blank slate. Those who claim that we need a new ethic can give no moral motive for entering into a new ethic unless that motive was borrowed from traditional morality, which, according to Lewis, is neither Christian nor non-Christian, neither Eastern nor Western, neither ancient nor modern, but general. The moral law, in other words, is objective, not subjective. Lewis does not give a religious argument in order to support his claims concerning the objective nature of morality; but one that is based on reason—that grand, classic, and robust understanding of reason.
Lewis associates the current problem with ethics and morality with the fragmentation of thought brought about by modernism. He makes the point that after studying the natural world, human beings began to study themselves. When they did this, it was “as if we took out our eyes in order to look at them.” Reason then appeared to be nothing more than chemical or electrical events in the brain which itself is the by-product of a blind evolutionary process. In light of this, there is no good reason to think that human beings can know anything about ethics or morality or truth.
In the world of science the consequences of the contemporary disposition to undermine reason is minimized in that the scientist must assume the validity of his or her own reason, if for no other reason than to prove its subjectivity. This subtle dance with subjectivity can be dangerous for the scientist. There seems to be a move away from the use of words like truth and reality as defining terms of the scientist’s overall objectives; instead, there is much talk about the objective being “practical results.”
It is quite a different story when it comes to practical reason, where the full forces of the consequences of subjectivism are felt. Until modern times no influential thinker ever doubted that our judgments of good and evil were rational judgments or that what they discovered was something objective. It was taken for granted that in temptation, desire and passion were diametrically opposed not to a feeling, but to reason. Lewis shows that the contemporary view is quite different. Value judgments are not judgments at all. They are feelings forged in a community by forces in its environment and its traditions, and varying from one community to another. To say that something is “good,” in other words, is to say that one has a preference for it, a preference that has been shaped by one’s social environment.
It is important to hear Lewis in his own words as he expands on the consequences of this view:
But if this is so, then we might have been conditioned to feel otherwise. “Perhaps,” thinks the reformer or the educational expert, “it would be better if we were. Let us improve our morality.” Out of this apparently innocent idea comes the disease that will certainly end our species . . . if it is not crushed; the fatal superstition that men can create values, that a community can choose its “ideology” as men choose their clothes. Everyone was indignant when they heard the Germans define justice as that which is to the interest of the Third Reich. But it is not always remembered that this indignation is perfectly groundless if we ourselves regard morality as a subjective sentiment to be altered at will. Unless there is some objective standard of good, overarching Germans, Japanese and ourselves alike whether any of us obey it or no, then of course the Germans are as competent to create their ideology as we are to create ours. If good and better are terms deriving their sole meaning from the ideology of each people, then of course ideologies themselves cannot be better or worse than one another. Unless the measuring rod is independent of the things measured, we can do no measuring. For the same reason it is useless to compare the moral ideas of one age with those of another: progress and decadence are like meaningless words.[3]
In his essay, “The Poison of Subjectivism,” Lewis drives the point home that the whole attempt to get rid of traditional morality as something merely subjective and to substitute it with a new morality is wrong. This can be stated in two propositions:
The second proposition deserves a bit more attention. Lewis points out that traditional morality bids us to honor our parents and cherish our children. By isolating the second injunction alone, we set up a “futuristic” ethic, making concern for our children the sole criterion for ethical decision-making. Traditional morality tells us to love and care for our families more than we do strangers. Separating the first command from the second, we construct either a racist ethic or an aristocratic ethic where the claims of our relatives or our class are the sole criterion.
Consider the scientists who say that they must get rid of “taboo” traditional morality so that they can conduct their inquiries without interference because the potential health, comfort, prosperity, and security of posterity is their sole end. The scientists then demand involuntary euthanasia of all the aged and “unfit.” But the duty to care for posterity on which the scientists base their whole ethical system was derived from the same source which commands that we honor the aged and commit no murder.
These monolithic ethical systems are then used as grounds to attack the traditional morality which gives them validity in the first place! Starting from scratch, from the supposed ethical moral vacuum, we could not attain any of them. If reverence for parents or care for strangers is merely subjective, open to human opinion, and a by-product of the forces of nature, then so is cherishing our children and love for our families.
New moralities which bid us to consider the local nature of ethical concerns reflect a confusion of thought concerning what is really being said. Lewis suggests that we have two alternatives. Either the injunctions of traditional morality must be accepted as universally recognized principles of practical reason, or else there are no values at all. Values are merely the product of irrational emotions. It is completely meaningless, Lewis says, to dismiss traditional morality as subjective, irrelevant and outdated to attempt to reintroduce a value at some later stage in our philosophy. Any value we reintroduce can be countered in the same way. “Every argument used to support it will be an attempt to derive from premises in the indicative mood a conclusion in the imperative. And this is impossible.”[5]
Modern culture does resist this line of reasoning by presenting two objections:[6]
Lewis responds to these two primary objections with the following two points:[7]
Does a permanent moral standard impede progress? On the contrary, except on the assumption of a changeless standard, progress is impossible. If the good is a fixed point, it is at least possible that we should get nearer and nearer to it; but if the terminal is as mobile as the train, how can the train progress towards it? Our ideas of the good may change, but they cannot become either better or worse unless there is an immutable standard by which we can measure them.
This last point may seem to contradict the argument that traditional morality is an objective standard which does not change. Lewis offers an answer that can only be understood by comparing a real moral advance with mere innovation. Moral philosophers from the Stoics to Confucius who say, “Do not do to others what you would not like them to do to you,” succeeded by the Christian who says, “Do to others as you want done to you” reflect a real moral advance.
The morality of Friedrich Nietzsche, which finds no rational grounds for value judgments at all, is a mere innovation. The refinement of the Golden Rule is an advance because those who recognize the validity of the Stoic’s and Confucius’ moral principle will be able to accept the Christian principle as a positive extension of the same principle. The Nietzschean ethic demands that we all start from scratch and become “value-creators,” the very thing which is impossible to do. “It is the difference between a man who says to us: ‘You like your vegetables moderately fresh; why not grow your own and have them perfectly fresh?’ and a man who says, ‘Throw away that loaf and try eating bricks and centipedes instead.’”[8]
Do these arguments for the objective and universal nature of morality and ethics mean that we will never face moral quandaries like the ones encountered in the case in Thailand? Not at all, says Lewis. It is the moral law that creates these questions in the first place, just as the rules of a particular game creates problems related to that game. The person who is not literate is free from grammatical problems. The person who does not know algebra is free from algebraic problems. A person who is sleeping is free from all problems (for the moment!). Lewis acknowledges that ethical conflicts will indeed arise and that some of these conflicts will be solved wrongly. What shall we make of this inevitability in light of the claims made here concerning the timeless applicability of traditional morality? Lewis sums it up best when he says the following:
This possibility of error is simply the symptom that we are awake, not asleep, that we are men, not beasts or gods. If I were …recommending traditional ethics as a means to some end, I might be tempted to promise you the infallibility which I actually deny. But that, you see, is not my position. I send you back to your nurse and your father, to all the poets and sages and law givers, because, in a sense, I hold that you are already there whether you recognize it or not: that there is really no ethical alternative: that those who urge us to adopt new moralities are only offering us the mutilated . . . text of a book which we already possess in the original manuscript. They all wish us to depend on them instead of on that original, and then to deprive us of our full humanity. Their activity is in the long run directed against our freedom.[9]
Now that Lewis’ view on the moral law has been discussed, it remains to examine exactly how his view can help us with regard to global bioethics in general and with regard to the end-of-life case concerning the 39-year-old Gaew, a Thai construction worker, in particular. First, Lewis demonstrates that principles such as compassion, duty, interdependence, freedom, and justice—all crucial to bioethics in general—do not require a new morality. All of them can be traced back to the objective moral law which has always been here. These principles cannot be reached by scratch or by way of a blank slate as it were; nor can they be attained in a “moral vacuum” because no such vacuum exists. As soon as the word “ought” is invoked, we are already operating within a moral landscape.
Second, with regard to Gaew’s case in particular, it is first important to point out that it is not clear that he is suffering because he arrived at the hospital unconscious. There is no indication that he was in any pain. It is also not clear what is meant by “lack of brain activity.” Does this mean that he is in a persistent vegetative state? Does it mean that he is presenting with signs of whole brain death? These issues need more clarity in order to determine whether or not it is morally permissible to withdraw the ventilator. Dr. Nok holds to the sanctity of life and her conscience forbids her to kill. This is not a uniquely Buddhist position, but can be traced back, as Lewis says, to traditional morality, and the universal disapprobation of unjustified killing. The ethical concern here is about whether or not withholding or withdrawing life-sustaining treatment can be considered “killing” a patient. There is much debate about this issue, and this debate reflects Lewis’ stance that the moral law actually creates questions of casuistry. If we want light shed on these very heart-wrenching and complex end-of-life issues, we need to study, reflect, and gain wisdom. In other words, we must consult the tradition. We must realize that the wisdom we need for ethical dilemmas is discovered, not created, which also implies that we must search for it.
Finally, with respect to the notion that karma is a moral law which describes the consequences of certain behaviors in the afterlife, there is nothing in this assertion which necessarily undermines Lewis’ argument for the objective moral law. The objective moral law, as far as Lewis is concerned, points to a Moral Lawgiver, who is transcendent overall. Lewis is a theist who argues that the moral law reveals something of God’s nature, his holiness. The choices we make in this life, in other words, matter for all eternity. Though Buddhism is a non-theistic faith, it recognizes this law, if you will. Physicians who are also practicing Buddhists do have crises of conscience with regard to certain treatments. This fact, Lewis would say, demonstrates that a moral law is written on their hearts. This is one of his fundamental points.
Lewis goes further to say that this universal moral law points inescapably to the existence of God. The problem now is not so much an ethical one, but a religious one. And this is a problem that Lewis is happy to engage and has done so in many of his writings. The Buddhist and the theist do not see eye to eye on the question of God’s existence. And they cannot both be right. This issue, too, calls for wisdom, study, and reflection in order to get at the truth. The theological question goes beyond the scope of this essay; but suffice it to say that Lewis has made a case for global bioethics through the application of the moral law. But the question of God is one that Lewis believes to be critical to every human being. A thorough search for an answer to this question is neither a trifling nor a needless occupation for us, but rather a necessary and important one.
[1] This is a summary from a case study that appeared in Scott Stonington and Pinit Ratanakul, “Is There a Global Bioethics? End-of-Life in Thailand and the Case for Local Difference,” Public Library of Science Medicine 3, no. 10 (October 2006): 1679-1682, http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030439.
[2] Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 6th ed. Oxford: Oxford University Press, 2008.
[3] C .S. Lewis, “The Poison of Subjectivism” in Christian Reflections, ed. Walter Hooper (Grand Rapids: Eerdmans, 1967), 73.
[4] Ibid., 75.
[5] Ibid., 75-76.
[6] Ibid., 76.
[7] Ibid., 76-77.
[8] Ibid., 77.
[9] C .S. Lewis, “On Ethics,” in Christian Reflections, ed. Walter Hooper (Grand Rapids: Eerdmans, 1967), 56.
Kathy McReynolds, "The Discovery of Global Bioethics through an Application of C.S. Lewis' Thought on the Moral Law,” Dignitas 17, no. 3&4 (2010): 1, 4–5.
