international bioethics

Ethics, Medicine and Public Health (2017) 3, 269—278

Available online at

ScienceDirect www.sciencedirect.com

PHILOSOPHICAL CONSIDERATIONS

A pragmatic approach to multicultural/international bioethics Une approche pragmatique de la bioéthique international ou multiculturelle D.R. Cooley (Director of the Northern Plains Ethics Institute, professor of philosophy and ethics, Fargo-Moorhead Chamber of Commerce Distinguished Professor) Department of history, philosophy, and religious studies-Dept 2340, North Dakota State University, Minard 422J, P.O. Box 6050, Fargo ND 58108, United States Received 24 March 2015; accepted 25 April 2017 Available online 16 June 2017

KEYWORDS Bioethics; Foundation; International; Multicultural; Pragmatism

Summary In Swift’s Gulliver’s Travels, each nation thinks that it is It. ‘‘It’’ being defined here as a sociocentric position in which one’s social group, in this case, a country, is believed to be superior to every other group in regards to the former’s values and principles. Of course, if the society has the best values and principles possible — or possible within the given context — then its members have a moral obligation to not only uphold their code but to try to convince other societies to adopt it as well. Sociocentrism becomes problematic when citizens cannot change their minds even in the face of overwhelming empirical evidence that their cultural beliefs are false. In the case of Lilliput and Gulliver, for example, the approximately six-inch tall Lilliputians continued to believe that they comprised the most powerful nation on Earth in the face of evidence that the ‘‘Man-Mountain’’ could easily destroy their entire civilization merely by eating them out of existence, and that his sheer power could not be controlled by the Lilliputian army and navy combined. Yet, the Lilliputian emperor still referred to himself in power terms that France’s Louis XIV would have found excessively aggrandizing. The same affliction is experienced by many in the developed world when it comes to thinking about morality. Non-First World countries are often perceived as being backward or underdeveloped not only in their industry and markets, but in their social conventions and morality. At times, this claim is accurate. The treatment of women as chattel, slavery as a practice, abuse of those with unpopular sexual orientations, or other morally irrelevant characteristics is to be condemned as

E-mail address: [email protected] http://dx.doi.org/10.1016/j.jemep.2017.04.016 2352-5525/© 2017 Elsevier Masson SAS. All rights reserved.

270

D.R. Cooley wicked. They show a defect in the person’s moral values or principles that requires rectification, and possibly, amends being made. On the other hand, there are many social norms that offend developed world citizens but may only be the result of squeamishness with the socially different, e.g, polyamory and arranged marriages, and health care practices. Each of these could and are morally wrong in certain circumstances, but we can imagine situations in which they are morally permissible. Much, but not all, of what ISIL does is morally reprehensible, but why its leaders act in a certain way is understandable. ISIL society shares a very similar belief with ancient China’s Mandate of Heaven: anyone with the mandate could do anything he wanted because what he was doing had to be favored by Ti¯ an. The fact the person was in power was sufficient evidence that the mandate was upon him, and when he began to lose power, that meant that the mandate had been removed. Given some Sunni belief systems, possessing Western freedoms with social disruption is eschewed. For many, it is better to have 100 years of security without freedom than 1 day of freedom without security. Therefore, authoritarian rule that does not go to excess too many times is to be preferred, which explains why an ISIL force of a mere 10,000—30,000 was able to take and control Mosul, a city of 1.5 million inhabitants. In what follows I will argue for why a pragmatic approach needs to be taken toward bioethics, especially when it comes to interactions between cultures and nations. Along the way, an explanation for why this approach is the most reasonable will be sketched out using the foundation of evolutionary adaptation and advantage, neurophysiology, and how morality actually works. The result will be a moral theory that rejects the notion that there is one right solution or position on a matter, and replaces it with the more nuanced positon that there can be many right actions and good values that depend, in part, on the situation’s context. What I am proposing is not cultural relativism in which each society is its own measure of morality, but rather a pragmatic position that evaluates based on whether something works sufficiently well in the situation to reasonably have the potential to achieve flourishing. © 2017 Elsevier Masson SAS. All rights reserved.

MOTS CLÉS Bioéthique ; Fondation ; International ; Multiculturel ; Pragmatisme

Résumé Dans les Voyages de Gulliver de Swift, chaque nation pense que c’est Lui. « Il » étant défini ici comme une position sociocentrique dans laquelle le groupe social, dans ce cas, un pays, est considéré comme supérieur à tous les autres groupes en ce qui concerne les valeurs et les principes. Bien sûr, si la société a effectivement les meilleures valeurs et principes possibles — ou possibles dans le contexte donné — alors ses membres ont l’obligation morale non seulement de respecter leur code, mais d’essayer de convaincre d’autres sociétés de l’adopter aussi. Le sociocentrisme devient problématique lorsque les citoyens ne peuvent pas changer d’avis, même face à l’évidence empirique écrasante que leurs croyances culturelles sont fausses. Dans le cas de Lilliput et de Gulliver, par exemple, les Lilliputiens d’environ six pouces de haut ont continué à croire qu’ils constituaient la nation la plus puissante de la Terre face aux preuves que la « Montagne des Hommes » pourrait facilement détruire toute leur civilisation simplement en les mangeant et que sa puissance pure ne pourrait pas être contrôlée par l’armée de Lilliputiens et la marine combinées. Pourtant, l’empereur lilliputien se référait à un pouvoir bien supérieur à celui qu’avait connu Louis XIV. La même affliction est vécue par beaucoup dans le monde développé quand il s’agit de penser à la morale. Les pays qui ne sont pas du Premier Monde sont souvent perc ¸us comme étant arriérés ou sous-développés non seulement dans leur industrie et leurs marchés, mais aussi dans leurs conventions sociales et leur moralité. Parfois, cette affirmation est exacte. Le traitement des femmes comme un bien, l’esclavage comme une pratique, l’abus de ceux qui ont des orientations sexuelles impopulaires, ou d’autres caractéristiques moralement privées doivent être condamnées comme mauvaises. Ils montrent un défaut dans les valeurs morales de la personne ou des principes qui nécessitent une rectification, et éventuellement, que des amendements soient apportés. D’un autre côté, il existe de nombreuses normes sociales qui offensent les citoyens du monde développé, mais qui résultent de différences fondamentales notamment avec les mariages arrangés et les pratiques de soins de santé. Chacun d’entre eux pourrait et est moralement inacceptable dans certaines circonstances, mais nous pouvons imaginer des situations dans lesquelles ils sont moralement admissibles. Beaucoup, mais pas tout ce que fait l’ISIL est moralement répréhensible, mais pourquoi ses dirigeants agissent de la sorte est compréhensible. La société ISIL partage une croyance très similaire avec le Mandat du Ciel de la Chine ancienne : toute personne ayant

A pragmatic approach to multicultural/international bioethics

271

le mandat peut faire tout ce qu’il veut parce que ce qu’il a été choisi par Tiân. Le fait que la personne était au pouvoir était une preuve suffisante que le mandat était sur lui, et quand il a commencé à perdre le pouvoir, cela signifiait que le mandat lui avait été retiré. Étant donné certains systèmes de croyances sunnites, on se protège des libertés occidentales et des perturbations sociales. Pour beaucoup, il vaut mieux avoir 100 ans de sécurité sans liberté qu’un jour de liberté sans sécurité. Par conséquent, une règle autoritaire qui ne va pas trop loin trop souvent est à préférer, ce qui explique pourquoi une force ISIL de 10 000 à 30 000 hommes a pu prendre et contrôler Mosul, une ville de 1,5 million d’habitants. Dans ce qui suit, j’expliquerai pourquoi une approche pragmatique doit être adoptée pour la bioéthique, surtout quand il s’agit d’interactions entre cultures et nations. En cours de route, une explication pourquoi cette approche est la plus raisonnable sera esquissée en utilisant les fondements et l’avantage de l’adaptation évolutionniste, la neurophysiologie, et montrera comment la morale fonctionne réellement. Il en résultera une théorie morale qui rejette l’idée d’une solution ou position unique sur un sujet et la remplace par une position plus nuancée dans laquelle il peut y avoir beaucoup d’actions justes et de valeurs en fonction la situation et du contexte. Ce que je propose n’est pas le relativisme culturel dans lequel chaque société est sa propre mesure de moralité, mais plutôt une position pragmatique qui évalue le fonctionnement réel d’une situation et sa possibilité d’amélioration. eserv´ es. © 2017 Elsevier Masson SAS. Tous droits r´

Introduction In Swift’s Gulliver’s Travels, each nation thinks that it is It. ‘‘It’’ being defined here as a sociocentric position in which one’s social group, in this case, a country, is believed superior to every other group in regards to the former’s values and principles. Exceptionalism, in other words. Of course, if the country or society actually has the best values and principles possible — or possible within the unmitigated context — then its citizens have a moral obligation to not only uphold this code but to try to convince other societies to adopt it as well. Sociocentric exceptionalism becomes problematic when citizens cannot change their minds, even in the face of overwhelming empirical evidence that their cultural beliefs are epistemologically suspect or false. In the case of Lilliput and Gulliver, for example, the approximately six-inch tall Lilliputians continued to believe that they composed the most powerful nation in the world. And this despite overwhelming proof that the ‘‘Man-Mountain’’ could easily destroy their entire civilization merely by eating them out of existence, and that his sheer strength could not be controlled by the Lilliputian army and navy combined. Yet the Lilliputians still referred to their emperor in terms that France’s Louis IV would have found excessively aggrandizing. Many developed world bioethicists and others suffer from the same affliction when it comes to thinking about morality. Non-First World countries are often viewed as backward or underdeveloped not only in their industry and markets, but in their social conventions and ethics. At times, this claim is accurate. The treatment of women as chattel, slavery as an institutional practice, and abuse of those with unpopular sexual orientations or other morally irrelevant characteristics are to be condemned as wicked. Such thinking and acting show a defect in moral value or principle that requires rectification, and most likely, amends being made. On the other hand, there are many social norms that offend developed world citizens but may only be the result of squeamishness with the socially different, e.g.,

polyamory, arranged marriages, and child brides1,2 . Each of these could and are morally wrong in certain circumstances, but we can imagine situations in which they are morally permissible. Sunni ISIL society, for example, has a belief very similar to ancient China’s Mandate of Heaven. Anyone with the mandate could do anything he wanted because what he was doing was favored by Ti¯ an. The fact the person was in power was sufficient evidence that the mandate was upon him. It is only when he begins to lose power — as evidenced by his failures — that citizens know that the mandate has been lifted3 . Much of what Sunni ISIL does is morally reprehensible, but not all. For example, given some Sunni belief systems, possessing Western freedoms with their attendant social disruption is eschewed. According to many Sunnis, it is better to have 100 years of security without freedom than one day of freedom without security4 . Therefore, authoritarian rule that does not go to excess too many times is to be preferred to Western chaos, which explains why an ISIL force of a mere 10,000—30,000 fighters was able to take and control Mosul, a city of 1.5 million inhabitants.

1 Most people do not realize that the practice eschews children from having to carry out sexual activities. The bride is supposed to remain in her father’s household until she is physically mature. (This issue is too complicated to deal with adequately here). 2 There is also a growing body of literature showing sociocentric Western students working to provide local health care can do harm based on their sociocentric exceptionalism. For example, Western students might assume that Western treatments are readily available in resource constrained areas, have ‘‘language barriers impeding communication [and] cultural barriers to understanding the meaning of patients’ statements or actions’’ [1]. See also [2,3]. 3 It is sort of a combination of the ancient Greek principle that might makes right and a form of divine command theory. 4 Plato makes a similar claim in The Republic when he argues that democracy is the worst society because it is chaos, whereas an aristocracy entails no freedom but perfect happiness through each element of society working in harmony.

272 In what follows, I will argue for why a pragmatic approach toward bioethics, especially when it comes to interactions between cultures and nations. Pragmatic international/multicultural bioethics is based on the foundations of evolutionary adaptation and advantage, neurophysiology, social science, and how morality actually works in the human world. The result is a moral theory that rejects the notion that there is only one right solution or position in each situation, and replaces it with the more nuanced positon that there can be many right actions and good values that depend, in part, on the situation’s context. What I am proposing is not cultural relativism in which each society is its own measure of morality, but rather a practical position that both is based on science and evaluating whether something works sufficiently well in each situation to reasonably achieve individual or social flourishing within a given situation.

Pragmatism’s foundations Pragmatism focuses on what is practical rather than what is metaphysically possible [4,5]. It seeks to eliminate the dichotomy between science’s a posteriori thinking and religion’s and ethics’ a priori reasoning, both of which create standards that reflect more of the individual’s abstract values and principles, such as The absolute, eternal truth, than they do reality. The pragmatic approach requires us to find sufficient common ground on which to build a universal theory of bioethics that can be sufficiently flexible in contextual situations. Too far in one direction ends in the absurdity of perfectly consistent morality for a world that cannot exist, even in ideal circumstances, whereas the other extreme is occupied by relativism, which undermines morality’s raison d’être. Finding common ground begins in science. Thomas Kuhn argued that there are core values — simplicity, scope, compatibility, consistency, plausibility, accuracy, fruitfulness, and so on — that all scientists share, but how those values are permissibly used can change from person to person or scientific paradigm to scientific paradigm [6]: [Pragmatism] puts us into the position of Kuhn’s revolutionary scientist who must choose how to project the values. . .of established practice into new terrain and, at the very same time, must oversee how things go and adjust accordingly. What falls to the wayside. . .is not truth itself but the substantial image, or idol, that some have made of it [7]. In a pragmatic ethics, just as in science, there are limitations based on what is causally possible. We can desire that pain be intrinsically valuable instead of merely extrinsically worthy at times — especially since that value alteration would remove a great deal of negative worth in the world and reduce our obligations to do something about it — but the human mind cannot comprehend someone desiring pain for its own sake. On the other hand, it is simplicity itself to understand someone acting on the scant grounds that it is a good or right thing to do. Pragmatism’s role, then, is to create a moral system that works in the given circumstances whatever those are.

D.R. Cooley Pragmatic ethics recognizes that at bioethics’s core there are common, possibly universal, values and principles to tell us how to work with those values [8,9]. Morality is possible, in part, because of how our minds/brains are structured because of evolutionary adaptation and social conditioning. In fact, homo sapiens have an innate moral sense that is ‘‘the capacity to make certain types of judgments — to distinguish between good and bad, kindness and cruelty’’ [10]. To make these judgments, there must be specific feelings and motivations, such as compassion, empathy, fairness, status, punishment, and a natural tendency to favor one’s own group and those for whom one cares over others [10]. In addition, there must be some process or principles that take these values, feelings, tendencies, and such, and then produces the judgment outcome based on whether some standard has been met. The inherent moral sense is not limited to a few, nor should it be considered to be unique to each person in the sense that there is no common ground that provides a base for a common language of morality which every moral agent can understand5 . David Hume argues that our values are universal such that: [E]very [language] possess one set of words which are taken in a good sense, and another in the opposite, the least acquaintance with the idiom suffices, without any reasoning, to direct us in collecting and arranging the estimable and blamable qualities of men [11]. Bernard Gert contends that there are ten universal rules of morality, which are based on collective values humanity shares including prohibitions on murdering, causing pain, as well as prescriptions to keep promises and do one’s duty [12,13]. Although Gert’s particular rules might be insufficiently comprehensive and flexible, they do identify common values and how they work in human morality.

Evolution’s role To explain why there is universal (general) morality, let us examine the biological/neurophysical aspect of it. For morality to be universal, it is intimately linked to the human brain and its natural workings that are a result of evolutionary adaptation or are by-products of evolution [8,14—19]. Basically, those entities that were better suited to survive and reproduce in the environment they inhabited did just that, whereas those less suited fared poorly or died off. The result was generations of descendants carrying beneficial characteristics that allowed them to function better in that ecological system than those who lacked those features. However, the evolutionary change came about, those 5 By a common language of morality, I mean that we have an ability, in many cases, to understand the moral values and principles of other people when they express them to us. We often also comprehend why they made the decisions and took the actions they did even when they are not explained to us. That understanding is not limited to a purely rational justification but the emotive components as well. That is, we can feel sufficiently similarly as they do about their values and principles to appreciate both, although we might not agree with how they used them to justify their actions and decisions.

A pragmatic approach to multicultural/international bioethics feelings, emotions, and principles make morality possible in homo sapiens. The evolutionary grounding story gains greater credibility by recognizing that other species have the same emotions and emotional reactions underlying human moral values and principles. De Waal shows that empathy is ‘‘the original, pre-linguistic form of the inter-individual linkage that only secondarily has come under the influence of language and culture’’ [15]. Empathy causes various species to respond to distress and need for help from other individuals by exhibiting the very same behavior, including facial expressions that humans exhibit to other humans in the same situation [15]. Sympathy, which Hume claims is fundamental to morality, is impossible without empathy, because sans that fellow feeling, there is no desire to want to share or participate in the other’s problem. Without sympathy, morality involving required mental states and actions toward others could not exist. There are several other shared emotions and principles appearing in homo sapiens and other species cognition which make human morality not only possible, but a shared trait: • bio-altruism and a simple ethical system based on punishment [20]. Bio-altruism occurs when an individual appears to be sacrificing her interests to benefit another individual to gain a future benefit; • reciprocal altruism which requires the ability ‘‘to remember and evaluate who conferred the benefit, what degree of benefit it was, and what would constitute a similar benefit’’ [14]; • cognitive features that require higher-order reasoning including sympathy-related traits, norm-related characteristics, and getting along [21]: ◦ cognitive empathy, internalization of rules and anticipation of punishment, moralistic aggression against violators of reciprocity rules, community concern and maintenance of good relationships, and accommodation of conflicting interests through negotiation require a higher order of thinking than those found in species that merely react to external stimuli; • understanding simple physical principles, such as ‘‘how space and time constrain object motion’’ and have an appreciation of goals and intentions [22]. Besides these shared features, there are unique cognitive traits which make a normally functioning adult homo sapiens essentially different from other primate adults, such as our power to simulate what is going on in other people’s minds [23,24]. Reading another person’s intentions involves taking the evidence about them that we observe, and by mirroring it in our own minds, generating the same intentional mental state, although we lack commitment to bringing the intended state about. What might make this uniquely human is our ability to take this information, and then process it into a moral system with right and wrong actions and duties. Granted that morality does not lend itself to deductive logic’s certainty, there can still be sufficient justification provided for the claim that certain emotions and some rudimentary moral principles are the result of evolutionary adaptation in homo sapiens. All cultures and the citizens of them have had ethical codes. In those codes, there is sufficient similarity to be able to construct a language of morality that every moral agent can, at least, grasp and agree to the

273 fundamentals. Heisenberg’s principle of common cause then can be used to reasonably establish that the agreement is best explained as the result of a common cause rather than having different sources, as relativism would allow. Now this common cause could be socialization or evolutionary adaptation. Given the commonality between homo sapiens, primates, and other species, the most likely cause given our best scientific reasoning is evolutionary adaption.

Socialization’s role Our brain structures help create and limit the morality we have, but that is not the end of why we have the morality we do individually or in groups. It is reasonable to believe, based on available evidence, that ‘‘cortical microcircuitry is not innately specified by evolution but is progressively constructed by the postnatal experience of processing different kinds of input’’ [25]. For example, studies of the capacity for face processing in infants show that specialization and localization grow very gradually rather than being in place and fully operational at birth [25]. How information is processed, hence, is not fully hard wired in human brains, which indicates that morality is partly nurture. Learning also explains why different cultures have different conceptions of individuals and others [26]. This could very well explain Hume’s contention that different societies have the same set of moral values but arrange them in different ways [11]. Other areas show that a genetic trait, such as aggression, is universal, but how that trait is expressed can be a result of convention or some other form of relativistic learning [27]. Hence, biology provides the platform for morality, but socialization and learning further refine and build upon it [28]. To obtain a more accurate understanding of human ethics, we need a more inclusive, complicated picture of its origins, components, and working.

The biological and learned causes of sociocentric exceptionalism Human beings and human persons are the product of evolution, learning and adaptation. Many of our mental processes and the beliefs formed by them should be understood in this way. In fact, the mental platform that makes ethics possible also gives rise to psychological biases, including sociocentric exceptionalism. There is an evolutionary advantage in believing that one’s group is morally superior to all others, or being ‘‘groupish’’ at the very least [29,30]. The beings who were members of the first collaborative group would be more likely to survive and reproduce than unaffiliated singletons. Shared workload was helpful firstly because it caused group members to be able to complete complex, multi-agent tasks that benefitted each of them. Food gathering for a hunter-gather society takes a great deal of energy; if there is a diversity of individuals creating food from different sources, then it becomes far more likely that everyone gets the calories they need to survive and reproduce. Collaborative work also contributed greatly to our ancestor’s survival in other ways. No one person can stay awake always, therefore there had to be cooperation that produced security from natural and artificial dangers. Cooperation

274 also allowed for social interaction required for mating, caring for offspring, and doing the other tasks that all socialized animals perform. Finally, belonging to a group and working efficiently with it provides senses of self and worth. We need to belong so that we can feel valued in some way. No person is born with a sense of self-esteem — an internal valuation — that is created solely by the person’s appreciation of herself. Self-esteem must be built through being successful in facing challenges in everyday life, as well as functioning in a socially approved way. Being successful within the social conventions are rewarded by other community members showing that recognition in some positive manner, such as support or increased offers for positive interactions. Moreover, when unsuccessful in one’s pursuits, external comforting from one’s clan helps to augment one’s self-worth. To receive care even in failure means one must be valued by those offering it. Finally, those with stronger positive social networks receive more affirmative feedback and reinforcement from their community than those the community shuns. If self-esteem is necessary for flourishing and evolutionary fitness, then those entities more strongly belonging and successfully functioning in the group is likely to be better off than those less apt. The impact of this evolutionary force on how people process information and make decisions can be seen. Although this dichotomy is often too simplistic, humans basically think as Foxes or Hedgehogs. The Hedgehog is not a nuanced beast. It knows one big thing — generally something most other people in society believe — and then makes all his decisions fit that idea, value, or principle, regardless of whether they can be adequately accommodated by it. A Hedgehog’s brain ‘‘operates automatically and quickly with little or no effort and no sense of voluntary control’’ [31]. Hedgehog thinking’s advantage is quick, intuitive decision making with certainty in any situation, especially challenging ones. Hedgehogs believe with total confidence in what and why they are doing something, and then do it. Although appealing because Hedgehog thinkers exhibit so much confidence in their judgments, they can be rather dangerous if we are truly interested in doing and being what we should [32]. Other legitimate values and ways of doing things are rejected by Hedgehogs as defective, which often leads to an unacceptable intolerance of reality and better decisions in the circumstances. Foxes, on the other hand, are far more nuanced because they use pluralistic values and principles in a slow, deliberative process. Instead of making the situation fit the one big idea, the principles and values employed in a certain set of circumstances are selected on the basis of how well they fit those circumstances and the agent’s goals. Moreover, absolute certainty is generally not a feature of Fox thinking. In fact, Foxes are open to re-examining and altering their views as new information becomes available. Foxes also know that many situations are complex with many different interconnected factors and relationships involved. From many moral factors, the Fox weaves a complex solution that works for many, if not most, of the stakeholders. Unlike Hedgehogs, whose personal identity and selfworth is bound to being right all the time because they have only one big idea defining who they are, Foxes are not threatened by challenges to their views and decisions. They are

D.R. Cooley willing to be wrong and to alter one or more of the many things they know. They have diversity in their values and principles, which means that the loss of a few leaves the rest in place [32]. Hence, a Fox’s identity and self-esteem is not jeopardized. Even though Fox thinking is vital in multicultural and international bioethics since the issues are so complicated and the stakes so high, there has been insufficient environmental pressure to abandon the Hedgehog’s way thinking when it comes to sociocentric exceptionalism. Being a Hedgehog in society continues to work rather well in many cases. In fact, Hedgehog thinking generally outperforms Fox cognition if being successful is measured by influence in one’s sphere and certainty in one’s position. Since conformity to existing simplistic social values is how Hedgehogs operate, there is no threat to their or other’s self-esteem, identity, or anything else one values, unlike challenging the status quo. Hence, other society’s nonconforming values and principles are safely, automatically, and unconsciously rejected by Hedgehogs even though those values and principles might do a better job in a particular moral dilemma. If we add other psychological biases affecting most people [33], such as the zero-risk bias, which shows we favor certainty even if that is counter-productive, confirmation bias, and conservatism bias, then it becomes clear why being a Hedgehog is so successful in the sense that many prefer it to Fox reasoning [34,35]. Our constant indoctrination into our surrounding societies, and reinforcement of socially acceptable or unacceptable beliefs and behavior throughout our lives, also strongly inclines us to be sociocentric exceptionalists: Stories emerge from active social interchange, modify because of social interchange, but in their turn, constrain social interchange as well. They embody ideas concerning what forms for action and interaction are possible, feasible, desirable, and efficacious, hence at least by implication what forms action and interaction would be impossible, impractical, undesirable, or ineffectual. Even if the individuals involved harbor other ideas, the embedding of stories in social networks seriously constrains interactions, hence collective actions, of which people in those networks are incapable [36]. If we do well, then we do well relative to the social groups in which we live. We must make their values ours, and then work diligently to preserve them so that we remain part of the group, and a valued part. Our herd mentality, for instance, heavily influences how people behave, even making them reject what their reason tells them [37—41]. Once group membership is established, even if it is based on flimsy, arbitrary grounds, group members begin discriminating in resource allocation in favor of their group [34]. Our self-esteem is bound to the indoctrination and reinforcement. If Thomas Hobbes was correct, then each of us has an inherent desire-for-power in our human interaction and personality, which makes us competitive with each other. Those who are more successful in society are the ones who are awarded more of what is valuable in that society. These individuals, in turn, dominate because they are valued for being successful. If Hedgehog thinking’s aggressiveness worked for those now in power, then doing the same thing

A pragmatic approach to multicultural/international bioethics by those desiring power should also work for them. Therefore, when others want to build their self-esteem, they also exhibit power behavior that the powerful have. In the end, the bandwagon effect is fed, in part, by the desire for enhancing self-esteem through acquiring power for oneself. In addition, living one’s life is often easier if one uses simple, swift, intuitive thinking to solve all problems, no matter how complex the latter are. The more nuanced Fox thinking requires greater use of resources, whereas Hedgehog thinking allows fast decisions with tremendous force to be made. Hedgehog thinkers profited, and continue to do so. Their confidence in their simplistic solutions impresses their audience, who can easily understand those solutions and find the dominance enticing. Fox thinkers are generally at an evolutionary disadvantage. Not only do they use more energy and resources to perform their deliberative thinking, but in times in which decisive, quick action was required — flee, fight, or attack — their responses were too slow. Fox thinkers appear weaker than Hedgehogs because the former are far more hesitant to make grand pronouncements. They fail to persuade because they present solutions that might not be understandable to the audience, and must do it in a complex way with lots of hedging. Hedging, of course, makes it appear as if the Fox is unsure, or even worse, trying to dissemble. Hence, it is unsurprising that Hedgehog thinking holds sway over the Fox’s when it comes to winning in the natural and social environments. This result, of course, has an enormous impact on international and multicultural moral plurality. The issue, therefore, is to find a way to manage the Hedgehog thinking tendency to allow Fox thinking to prevail, although Hedgehog thinking will never be eradicated. And that management issue is where pragmatism is useful.

Pragmatic bioethics Pragmatic morality is unbound by absolute, eternal rules that care nothing for the situation’s context or what we are trying to achieve. At times, absolute principles might tell us to do something that is not only useless but leads to dangerous situations that make it impossible to achieve the goals of individual and social flourishing. For instance, we should speak out against racism, but what if the situation is a medical consultation filled with violent, unrestrained racists? Although noble, confronting racism is a supererogatory action in this situation rather than a required one. Hence, we ought always to do what is right and be good people, but the rules for how to achieve that end must be flexible, and likely, might not be consistent overall. For pragmatism, there are always multiple permissible solutions to moral problems. Pragmatic morality as a universal is most plausibly ‘‘a creative, cooperative enterprise whose end is to better the world by trying to realize in ourselves and others nurturing goods such as caring, considerateness, compassion, sympathy, and love [42]. For example, a pragmatic person accepts and evaluates situations using the: • external world society’s rules, practices, and customs; • rules and responsibilities associated with specific roles the agent is playing at the time;

275 • claims that others have on the agent and the agent has on others; • maxims growing out of previous judgments that the agent has made, to maintain ethical consistency; • in conflict situations, what is right on balance; • which consequences are important and their value, as well as the value of other relevant things; • which if any mediated consequences count and which do not [42]. Moreover, a person using pragmatic morality finds what works in the situation with the ultimate goal of our or others’ flourishing6 . Pragmatism does not require finding the right action. Such a thing probably exists only in mechanistic, fictional worlds in which pure reason makes sense. In addition, there are always many alternative actions can be good enough. For example, a rock can work for pounding a nail into the wall, although a hammer would function more efficiently. If a tool is needed for a fine cut, such as in surgery, then the mere fact something can slice through skin and flesh does not entail that it is good enough. Our end goal here is to preserve or improve health, and a fine steel blade which has been properly sanitized is far better means to that end than a rusty kitchen knife. Pragmatism’s goal is to make the world a better place, not to make it perfect. Pragmatism promotes moral growth based on our experiences. Over time, with sufficient stimulation, memory, and thoughtfulness, we can see what tends to work in which circumstances and what does not. Pragmatic naturalism is not a relativistic theory in that anything can be morally right or wrong depending on the whim of an individual or the conventions of a society. Instead, morality must be based on ‘‘central human desires and needs, arising from our special type of social existence’’ [28]. Although we might weigh universal moral values differently, we refine principles we have or develop new ones that will satisfy those values. Not every person will come to the same answer in each circumstance, but there is an objective range of what is acceptable and what is not that applies to all moral agents in the situation. To determine what works well enough in a situation, pragmatism requires us to first set a goal we are trying to reach, so that we can evaluate actions based upon their ability to reach that stated end. Philip Kitcher and I select different ends for morality. The one I propose is the flourishing of our individual selves and those of our group’s, societies, cultures, or anything else that can flourish, whereas Kitcher’s adopts ethical progress to fix altruism’s failures. In fact, Kitcher argues that morality can change over time, and it is not a mere change, but rather progression. To support his claim, he carefully examines what appear to be improvements in our ethical systems, including but not limited to the rejection of an eye-for-an-eye

6 Although there are those who would disagree with such a definition and purpose, and possibly vehemently, it is a reasonable position to take. To criticize it would raise the question as to what would be more accurate or better, when this goal and definition build the very foundations of what makes morality possible for us in the first place. On those grounds, it’s very reasonableness shows that it should be respected, even if a person disagrees with it.

276 retributive justice system, the equalization of women’s civil status to that of men, and the repudiation of slavery [28]. Nevertheless, the question is whether there is social ethical progress, which means that ethics, through its values and normative principles, change, or it is just the case that our understanding of morality gets better over time? The latter is obvious from the improvement in how women and others in many parts of the world are treated. Unlike the early 19th century, we now understand that Mary Wollstonecraft was correct when she argued that men and women are equal as persons, and therefore have the same morality with the same rights and responsibilities from it. So, the change is merely extending the application of universal values and principles to where they should have been in the first place, but not a relativistic alteration to what values and principles are. There is a need for social progress in international and multicultural bioethics. Societies should ensure appropriate treatment, that everyone is respected as they ought to be, that social utility is served, and whatever else is necessary for individual and social thriving. Part of that progress requires a recognition that there are two types of change relevant to the moral system. That being said, there has to be flexibility to allow for permissible differences in ethical codes between cultures and societies. Some of morality’s malleable values and principles change over time — Relativism — whereas we also get better at applying ethics’ unmalleable values and principles — Realism.

Managing sociocentric exceptionalism and other biases Both relativism and realism play legitimate parts in pragmatic international and multicultural bioethics and morality. First, we need to identify what can change in moral codes’ values and principles, and which things, if any cannot. Of the unmalleable or immutable are the structures or groundwork in our brains/minds that makes morality possible in the first place. Given evidence across species and societies, it is clear that we share the basics of morality in common because our brains are structured similarly as a result of evolutionary adaptation. In addition, all societies have essential basic values and rules, such as truth telling, promise-keeping, and respect for social mores, to be able to form and survive. These are acquired through learning, as well as being genetic. They cannot be altered because they are ‘‘hardwired’’ either through genetics or learning, and at best, can be managed rather than modified. Unmalleable morality has both good and bad implications. First, it is good in the sense that it provides us with general, universal principles and values, as far as they are developed at this foundational level. This level is an objective standard to our ethics by which we can explain why we have the morality each of us must have, evaluate any additional moral components to be built atop it, learn as we try to build our overall morality, and evaluate others’ values and principles. Having these invariables in place also is a bad thing in that it limits our morality. At times, we could think of better systems of ethics, such as pure cost-benefit analysis or

D.R. Cooley Kantianism, but those systems would only be operable by creatures with a different mental foundation from human persons, and the ability to see into the future or to be purely rational. Relativism’s force can be found in social conventions — Conventionalism — and in the individual choices we make — Existentialism. Learned morality can fall anywhere on a scale of being unable to be changed, such as what happens when a person is indoctrinated as a bigot, to being easily altered given some stimulus. Core values and principles are the foundations of the person’s identity, which means that essential portions of the superstructure built upon that foundation are dependent upon it. Committed racists can have, for example, what Kwame Anthony Appiah calls false consciousness or cognitive incapacity. In the former, our ideologies cause epistemic closure so that we cannot even acknowledge new facts that threaten our positon [43]. The latter is a different form of epistemic closure; the new facts can be acknowledged, and they should be sufficient to cause an alteration to a rational person’s position, but the actual person is unable to change his or her mind [43]. In either epistemic closure type, the values and principles are unmalleable. Hence, certain racists cannot stop being racist merely by being shown that their bias is irrational. Perhaps the easiest way to tell the difference between malleable and unmalleable principles and values is how close the value or principle is to being part of the individual’s essential or core nature. If it is a fundamental value or principle, then it is difficult to change because it alters and perhaps threatens the individual’s identity or self-esteem. Those values and principles that are loosely held or are entangled with less significant or fewer values and principles are very malleable to relevant overriding stimulus. They are not an existential threat to the person’s core being or identity. It is at this point that a method for dealing with Hedgehog thinking that causes sociocentric exceptionalism and other biases can be sketched out. The most practical approach is to use what already exists as morality’s base rather than trying to create something new out of whole cloth. Firstly, bad values and principles must be dealt with in ways suitable to their natures. Those that can be altered through the moral agent’s effort or social change should take that path as long as doing so is practical and performed in a pragmatic way. If morality is making the world a better place, then it becomes a prima facie obligation on each person’s part to be reasonable when it comes to malleable beliefs and positions, and then act accordingly. If there is this universal base for morality, then it can be appealed to or used when trying to get Hedgehog thinkers to change their minds7 . Arguments would incorporate this moral language in an effective way so that sympathy, reciprocal altruism, and so on in the Hedgehog thinker are generated, which then gives motivation to change a recognized bias. For example, if belonging is a central desire of human beings, especially Hedgehogs, then an appeal to this desire can function to change people for the better — or

7 If there is no commonality in homo sapiens ethics, then it would most likely be pointless to try to improve any society that is not one’s own because of the lack of common reference.

A pragmatic approach to multicultural/international bioethics worse — but we want the better here [30]. There is also a desire to be respected, which entails that the person is valued, which can be used to make people want to avoid defective reasoning because it might cause them to question that value. On the other hand, unmalleable bad values and principles can only be managed. Appiah argues that even those with the strongest epistemic disclosure have a moral duty to avoid making decisions in areas in which she has adequate evidence to rationally believe she is unethically biased [43]. For example, if a Hedgehog thinker is shown that his position is based on illicit morality, such as racism or religious bigotry, then reason dictates not to use an irrational process that will only produce unreasonable results. As a reasonable person who knows that she is unable to function as a reasonable person in a particular situation, then she tries to avoid or has some mechanism in place that makes her decisions and interactions with other individuals sufficiently justified in those situations. The incentive for a Hedgehog thinker to take due care could be those shared moral principles and values that, if violated, makes the person feel negative emotions and have bad emotional reactions, as well as facing possible social condemnation, such as shame. Secondly, we can use the good similarities in values and principles to build consensus on international and multicultural bioethical issues. That is, we take advantage of how people already think about ethics because they must think about it in that way, and then tie it into the natural desire to belong to the herd or group. If we use the ‘‘groupish’’ or bandwagon inclinations discussed above, we can convince the Hedgehog adopt what he perceives to be the group’s views so that he can preserve his identity and self-esteem. If we design decision procedures with the shared values and such, then there is far less chance of social shaming. In addition, acting in accord with how these features function in the personal psyche is far easier than to go against them. As a result, guilt and other negative internal emotions can be avoided, and it is possible that the person receives positive feedback by doing things that are in accord with her foundational morality. Even if these approaches fail to convince others of a right and good pathway, they can still function to create an adequate understanding between people. To make better decisions and take more effective action when it comes to dealing with other nations and cultures, for instance, it is necessary to sufficiently comprehend them. In other words, we should learn that culture’s ‘‘language’’ enough to be able to speak it. Roby Barrett has argued that many mistakes the Western powers have made in their dealings in the Middle East are a result of imposing the Western powers’ values and principles in areas in which neither side can speak the cultural language of the other [44]. Barrett advocates for cultural competency in international and multicultural relations. Before people form beliefs or draw conclusions, they should learn the history and language of the culture, but possibly more importantly, live in the culture as a respectful observer-member of it to understand the involved complexities. In other words, a cultural immersion, which would allow the observer-member to be able to pragmatically use Holmes’ seven rules to achieve individual and social flourishing, thereby making the world a better place.

277 Given cultural competency’s demands, not everyone can immerse herself in one or more cultures to learn the subtleties of their values and principles. There will also always be a gap between being a life-long member of a group and being someone who is trying to fully understand why the group is as it is, but this should not put an end to morality across cultures. The fact of the matter is that we do not always agree with each other, and that does not necessarily pit one person against another. Rather, as all Foxes know, reasonable people can reasonably disagree, yet understand why the other acted as she did. The way this is possible is with a common set of values and principles that creates, so to speak, a language of morality that each person can understand in international or multicultural decision making in bioethics. If, at the end of the day, this is all that we can do, then it is enough to avoid some of the current religious, political, international, or multicultural intolerance. It is, as a pragmatic Fox would say, good enough.

Disclosure of interest The author declares that he has no competing interest.

References [1] Crump JA, Sugarman J. Ethical considerations for shortterm experiences by trainees in global health. JAMA 2008;300:1456—8. [2] Crump JA, Sugarman J. Global health training: ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 2010;83:1178—82. [3] Lukolyo H, Rees CA, Keating EM, et al. Perceptions and expectations of host country preceptors of short-term learners at four clinical sites in Sub-Saharan Africa. Acad Pediatr 2016;16:387—93 http://www.sciencedirect.com/science/ article/pii/S1876285915003411. [4] James W. Pragmatism and other essays. New York: Pocket Books; 1963. [5] Peirce CS. In: Buchler J, editor. Philosophical writings of Peirce. New York: Dover Publications, Inc; 1955. [6] Kuhn TS. The structure of scientific revolutions. 2nd ed. Chicago: The University of Chicago Press; 1970. [7] Fine A. Relativism, pragmatism, and the practice of science. In: Misak C, editor. New pragmatists. Oxford: Clarendon Press; 2007. p. 50—67. [8] Krebs DL. The origins of morality: an evolutionary account. Oxford: Oxford University Press, Inc; 2011. [9] Boehm C. Explaining the prosocial side of moral communities. In: Clayton P, Schloss J, editors. Evolution and ethics. Grand Rapids: William B. Eerdmans Publishing Company; 2004. p. 78—100. [10] Bloom P. Just babies: the origins of good and evil. New York: Crown Publishers; 2013. [11] Hume D. In: Hendel CW, editor. An inquiry concerning the principles of morals. New York: Macmillan Publishing Company; 1957. [12] Gert B. Morality: its nature and justification. New York: Oxford University Press; 1998. [13] Gert B. Common morality. Oxford: Oxford University Press; 2004. [14] Broom MD. The evolution of morality and religion. Cambridge: Cambridge University Press; 2003.

278 [15] De Waal F. Primates and philosophers: how morality evolved. Princeton: Princeton University Press; 2006. [16] Haidt J. The emotional dot and its rational tail: a social intuitionist approach to moral judgment. Psychol Rev 2001;108:814—34. [17] Hauser M. Moral minds. New York: HarperCollins Publishers; 2006. [18] Pinker S. The language of instinct. New York: William Morrow; 1994. [19] Zamulinski B. Evolutionary intuitionism: a theory of the origin and nature of moral facts. Quebec: McGill Queen’s University Press; 2007. [20] Campbell B. How much in the human conditions is without counterpart in other animals? In: Wesson R, Williams EPA, editors. Evolution and human values. Atlanta: Rodopi; 1995. p. 117—37. [21] De Waal F. Good natured:the origins of right and wrong in humans and other animals. Cambridge: Harvard University Press; 1996. [22] Santos LR, Lakshminarayanan V. Innate constraints on judgment and decision-making? Insights from children and nonhuman primates. In: Carruthers SL, Stich S, editors. The innate mind, 3. Oxford: Oxford University Press; 2007. p. 293—310. [23] Brown WS. Nonreductive human uniqueness. In: Murphy N, Knight CC, editors. Human identity at the intersection of science, technology and religion. Farnham: Ashgate Publishing Limited; 2010. p. 97—115. [24] Heim MS. A cross-section of sin: the mimetic character of human nature in biological theological perspective. In: Clayton P, Schloss J, editors. Evolution and ethics. Grand Rapids: William B. Eerdmans Publishing Company; 2004. p. 255—72. [25] Karmiloff-Smith A. Why babies’ brains are not Swiss army knives. In: Rose H, Rose S, editors. Alas poor Darwin: arguments against evolutionary psychology. London: Jonathan Cape; 2000. p. 144—56. [26] Markus HR, Kitayama S. Culture and the self: implications for cognition emotion and motivation. Psychol Rev 1991;98:224—53.

D.R. Cooley [27] De Melo-Martin I. Taking biology seriously. Lanham: Rowman & Littlefield Publishers Inc; 2005. [28] Kitcher P. The ethical project. Cambridge Harvard University Press; 2011. [29] Haidt J. The righteous mind: why good people are divided by politics and religion. New York: Pantheon Books; 2012. [30] Greene JD. Moral tribes: emotion reason and the gap between us and them. New York: Penguin Books; 2013. [31] Kahneman D. Thinking fast and slow. New York: Farrar Straus and Giroux; 2011. [32] Tetlock PE. Expert political judgment: how good is it? How can we know? Princeton: Princeton University Press; 2006. [33] Raymond J. Most of us are biased. Nature 2013;495:33—4. [34] Banaji MR, Greenwald AG. Blind spot: hidden biases of good people. New York: Delacorte Press; 2013. [35] Ross HJ. Everyday bias. London: Rowman & Littlefield; 2014. [36] Tilly C. Stories, identities, and political change. Lanham: Rowman & Littlefield; 2002. [37] Colman A. Oxford dictionary of psychology. New York: Oxford University Press; 2003. [38] Bikhchandani S, Hirshleifer D, Welch I. Learning from the behavior of others. J Eco Perspect 1998;12:151—70. [39] Asch SE. Effects of group pressure on the modification and distortion of judgments. In: Guetzkow H, editor. Groups, leadership, and men. Pittsburgh: Carnegie Press; 1951. p. 177—90. [40] Asch SE. Opinions and social pressure. Sci Am 1955;193: 31—5. [41] Asch SE. Studies of independence and conformity: a minority of one against a unanimous majority. Psychol Monogr 1956;70:1—70. [42] Holmes RL. Basic moral philosophy. Belmont: Thomson Wadsworth; 2003. [43] Appiah KT. Racisms. In: May L, Sharratt SC, editors. Applied ethics. Englewood Hills: Prentice Hall; 1994. p. 333—44. [44] Barrett R. U.S. policy and Iraq: pragmatism and progressive ideals. Northern Plains Ethics J 2014;2:5—29 http:// northernplainsethicsjournal.com/NPEJv2n1/robybarrett.pdf.