FROM THE THIRD GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE: CONCEPTUAL PERSPECTIVES
African approaches to an enriched ethics of person-centred health practice
Werdie (CW) Van Staden MBChB MMed (Psych) MD FC Psych (SA) FTCL UPLM
Nelson Mandela Pofessor of Philosophy and Psychiatry, Editor-in-Chief South African Journal of Psychiatry and Managing Editor, Philosophy, Ethics and Humanities in Medicine, Division of Philosophy & Ethics of Mental Health, Department of Psychiatry, University of Pretoria, South Africa
‘Person-centred ethics’, containing ‘person’ in the singular, may suggest a commitment to individualism. This paper, however, argues that a person-centred ethic need not be trapped in an a priori commitment to liberal individualism or communitarianism, should one draw on two related core African insights on 1) putting people first and 2) respect for diversity.
“Batho pele” is a Sesotho expression that means “people first”. It is closely connected to the rich concept of “ubuntu”, translated incompletely as “in existence with and through others”. It champions both the person and groups of persons by virtue of an interconnectedness expressed, for example, in the isiZulu maxim “Unmuntu Ngumuntu Ngabantu”, translated as “I am because you are, and you are because we are”.
Putting people first in the ethics of health care has to account for diversity, for diversity is an inevitable characteristic both among individual persons and groups of people. To account for diversity in not merely a general way, the diversity specific to both particular persons and between groups of people in a particular situation and context needs to be taken seriously. Accounting for diversity in this way guided by the ethics “people first” and “ubuntu”, requires a process of shared decision making in which all relevant values, including potential individualist and communitarian values, are taken up in a substantive communicative process that creates in partnership person and people-specific decisions for that very situation, context, and time – a process captured in the African concept of an “indaba”.
Individualism, communitarianism, personal autonomy, diversity, values, communication
Professor C W Van Staden, Department of Psychiatry, University of Pretoria, PO Box 667, Pretoria, 0001, South Africa. E-mail: firstname.lastname@example.org
Accepted for publication: 21 January 2011
‘The ethics of person-centred practice may seem to be invoking an a priori commitment to individualism, making communal considerations at best secondary to that of the individual. I argue in this paper, however, that two core values underscored in African ways of doing provide for an enriched ethics of person-centred health practice that is not so committed. These two values are: putting persons (in plural and singular) first and respect for diversity.
The connection between person-centred practice and health ethics may be thought to be about the principle of having respect for personal autonomy – that is, one of the four principles of bioethics championed by Beauchamp & Childress . Similarly, one may take person-centred practice to be about the rights, interests and values of the individual and if the commitment is to liberal individualism, one may consider societal or other collective interests and values as being of secondary concern. A liberal individualist commitment may even mean that person-centred practice may operate potentially at the expense of societal and other collective values. Similarly, in deontological terms, one may take person-centred practice in health ethics to be about the duties accruing in serving particularly the individual. Or in utilitarian terms, one may take it to be about the good and bad consequences for particularly the individual.
Person-centred practice enriched by African thoughts does not presuppose that ethical priority resides with the individual. An African thought akin to person-centred practice is that of “batho pele”, which is a Sesotho expression meaning “people first” [2-4]. At first glance, being in the plural (that is, “people” rather than “person”), “batho pele” may appear as if to suggest that ethical priority resides with societial or other collective interests. “Batho pele” may accordingly be thought of as being closer to communitarianism in which communal values take priority above individual values. “Batho pele”, however, is not committed to an ethical priority that resides either in the individual or in the society. Rather, it should be understood as being part of a particular way of living, thinking and feeling about yourself and others in ordinary discourse. That is, a way expressed by “ubuntu” . “Ubuntu” may be incompletely translated as “in existence with and through others”. The isi-Zulu maxim “unmuntu ngumuntu ngabantu” elucidates this further, translated as “I am because you are, and you are because we are”. Accordingly, “ubuntu” and “unmuntu ngumuntu ngabantu” champion both the person and society by virtue of an interconnectedness [5-7].
“People first” in its “ubuntu” sense is compatible neither with communitarianism in which the values of individual disappear, nor with liberal individualism. It upholds the idea of respect for the personal (and by implication, personal autonomy). This value is taken neither in isolation from other values, nor as being necessarily more important than other values. “People first” in its “ubuntu” sense requires deontologically that duties serve both the individual and society. It differs, moreover, from Kantian deontology in that duties of importance extend beyond those determined by common standards . Duties also include those determined by case-specific values, even if such values are unique or in opposition to common standards. “People first” in its “ubuntu” sense requires, furthermore, that consequences for both the individual and society are considered as potentially important in deliberations. Where utilitarianism would usually determine whether consequences are good or bad by commonly acceptable standards , the notion of people first in ubuntu requires that case-specific values, even if unique and unacceptable to others, whether consequences would be good or bad, be considered too.
The question not yet addressed at this point is how does “batho pele” and “ubuntu” circumvent giving a priori precedence to either the individual or society? An answer to this question is underpinned by the second value underscored in African thought: respect for diversity. That we consider diversity is apt and paramount here, for diversity is an inevitable characteristic both between people individually and between groups of people.
Respect for diversity is epitomized in the motto expressed in South Africa’s National Coat of Arms as ‘!ke e: /xarra //ke’ . Written in the Khoisan language, this literally means ‘Diverse people unite’. The motto describes the diversities of various kinds among the citizens and at the same time calls for the nation to unite in a common sense of belonging and national pride – unity in diversity . It defies, however, the confusion between unity and uniformity, valuing the strength and potential of diversity brought about by Nelson Mandela’s idea of a “rainbow nation”. He, together with Mr F W de Klerk, won the Nobel prize for Peace following their work in achieving a political revolution without the extensive violence and destruction that are known to go with such – at the heart of which was the replacement of racism with a core value of respect for diversity. This is no small achievement, for South Africa has 11 official languages and even more ethnic groups. Mr Mandela’s idea of a rainbow nation is apt considering the proportions of the respective mother tongue speakers in the South African population being as follows: isiZulu 23.8%; IsiXhosa 17.6%; Afrikaans 13.3%; Sepedi 9.4%; Setswana 8.2%; English 8.2%; Sesotho 7.9%; Xitsonga 4.4%; siSwati 2.7%; Thsivenda 2.3%; isiNdebele 1.6% .
In the domain of ethics, respect for diversity has necessarily to do with values. Values of diverse kinds include cultural, ethnic, spiritual, religious, societal, personal, institutional, organisational, prescriptive, normative, legal, scientific, and aesthetic values, also values of right and wrong, good (better, best) and bad (worse, worst), etc . On opposite sides of a continuum, some values are convergent in almost all respects, whereas other values are anything but shared, even being in direct conflict with one another. We share some values and for those there is little if any dispute – for example, the value that murder is wrong. About other values, we will never agree and neither should we – for example, the aesthetic values that one attaches to a particular musical composition or a painting. Divergent values are complex and varies from person to person, time to time, place to place, culture to culture, society to society, etc.
Respect for diversity does not deny that shared values have their appropriate place, but takes seriously the divergence of values. It resists, accordingly, attempts to force legitimately different values to the “right” values (for example, by virtue of “my”/ “our” authority, which would be similar to a totalitarian coup), or by proclaiming inappropriate rules and regulations. Respecting diversity call upon, furthermore, recognising that the general or average view and even consensus may undermine diversity, notwithstanding that the general or average view or consensus may serve the convergent values well . Similarly, forcing all values to be “equal” undercuts respect for diversity at least insofar as it would boil down to the anarchy in the “anything goes” of ethical relativism . Respect for diversity, furthermore, is a more modest point of departure than aspiring to respecting (all) the values of people or respecting all people which may be too tall an order even though laudable and desirable . Accounting for diversity also enriches health ethics beyond a health ethics merely constituted by agreed principles and standards of right or wrong (conduct). Moreover, respect for diversity creates a space where persons may be put first – person in both an individual (singular) and societal (plural) sense.
There is a practical way well-established in Africa to put people first and respect diversity. That is, by means of an “indaba”. This isiZulu concept means “meeting” or “matter”. An indaba is a meeting that is called to discuss a matter where everyone has a voice and to create a common story to tell about the matter. Without giving a priori precedence to either the individual or society, all of the values of the role players in the matter are taken seriously - some may be personal, some divergent, some societal, some cultural, or some shared in other ways .
The key activity here is skilful communication, but communication of a substantive rather than merely executive kind. If substantive, communication is a central purpose by itself rather than merely ‘the means to an end’. It values the process of communication even more than the resulting decisions. The communication is about the respective values having bearing in a particular matter. In respecting diversity, the full spectrum of values is accommodated and therefore necessarily those of all the role players including personal values, societal and other collective values. Communication skills are used multi-directionally in creating space for both shared and divergent values. Listening and explaining, for example, are done by all role players, aiming for all to understand.
Substantive communication guided by respect for diversity and ubuntu, generates an attitude of establishing partnerships in making and executing plans and decisions. Thus, even in the face of conflicting values, the stance is that we may approach the differences between the values in partnership. The opposition between the values need not translate into an opposition between the bearers of those values. Rather, the benefits of an apposition (i.e. being on the same side) between the role players instead would speak of ubuntu even in the midst of their conflicting values. Thereby, ‘we’ versus ‘them’ is turned into ‘us’ – battles are turned into alliances in which the variety of contributions is valued.
Respecting diversity and putting people first are not unique values to Africa, however. Much of the approach of Values-Based Practice in health ethics, championed by Bill (KWM) Fulford et al., is for example similar . Another example is the World Psychiatric Association’s insti-tutional program on Psychiatry for the Person makes the person an active participant in protecting him- or herself from illness, promoting and maintaining health, receiving holistic health services and recovering from illness .
Putting people first and respecting diversity in the spirit of ubuntu may be contrasted with other approaches in health. An appealing and justifiable approach for health workers would be to give priority to the health of a person, taking what is good for a person’s health to be good for the person. Even when this is the case, the mistake would be to assume that the converse is necessarily true, for what may be good for the person is not necessarily good for his or her health. Putting people first may require at times that a health worker participates in a decision that is good for the person, even if not good for the person’s health. Thereby, the health worker recognises in the collaborative decision making what is good for the person is more important than what is good for his/her health. This kind of person-centredness goes beyond a person-centredness suggested by respect for personal autonomy, for in case of the latter the health worker may want to distance him- or herself from a decision that is not putting someone’s health first.
Putting people first and respecting diversity in the spirit of ubuntu entails that decisions are to be made in partnerships between health care worker and health care user, which contrasts with an ethics model by which the health care worker(s) provides the information and “ultimately” the health care user has to decide (as for example a predominantly rights-based ethical approach may suggest). Making decisions by putting people first and respecting diversity in the spirit of ubuntu, furthermore, means that the ethical soundness of such decision should be judged by the process of decision making rather than, as a strict utilitarian approach would require, merely the outcome of the decision.
The ethics of person-centred health practice need not be trapped in the a priori commitments of liberal individualism or communitarianism. Rather, the African concepts of ubuntu and batho pele together with respect for diversity, provide for an enriched ethics of person-centred health practice – in which health ethics is of much more substance than merely constituted by agreed principles (like respect for personal autonomy) and standards of right or wrong (conduct).
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