Med Health Care and Philos (2012) 15:419–429 DOI 10.1007/s11019-012-9443-3

SCIENTIFIC CONTRIBUTION

Is there a Mediterranean bioethics? Pierre Mallia

Published online: 16 October 2012  Springer Science+Business Media Dordrecht 2012

Abstract Is there a special Mediterranean approach to Bioethics and if so what are the roots of this approach? And why not a Bosphorus, or a ‘lake Michigan’ bioethics? The answer to such a question depends on the focus one takes on defining ‘Mediterranean’? On the one hand one can refer to the Mediterranean region which includes the surrounding coasts, having Europe on its northern coast line, northern Africa on its southern coast line (and these will include the north and South West coasts), and in the Eastern region countries which border with Middle-Eastern countries. This approach is the approach currently being taken by European Parliamentarians when they speak about the Mediterranean, namely including countries like France, Italy and Libya. On the other hand there is the look upon the Mediterranean as ‘Southern Europe’; this is a more ‘traditional’ way on how westerners view the Mediterranean. This common approach is often recognized when, for example, we speak of ‘Mediterranean diet’, or, ‘Mediterranean Temperament’. It would include Eastern countries like Greece and Cyprus. This article focuses on these two approaches to Mediterranean ethics after discussing issues pertaining to the region which are important to define in this context. It then analyses the need for having a Mediterranean approach to bioethical issues. Keywords Southern Europe
Northern Africa
Deontology
Euro-med partnership

P. Mallia (&) Bioethics Research Programme, Medical School, University of Malta, Msida, Malta e-mail: [email protected]; [email protected]

Introduction Why a Mediterranean Bioethics and not a Bosporus or a Lake Michigan bioethics? What is so special about the Mediterranean, rather than speaking about a European bioethics? Clearly the answer has to lie within the history, cultures and the North-south and West-East cross-roads that the sea provides. The Mediterranean has been described as the sea where two worlds meet (Bradford 2000: 20). Bradford describes the Island of Levanzo, in Italy, having only about three hundred inhabitants, as showing the marks of a people who have strains of Phoenician, Greek, Roman, Arabic and Norman. It has a Customs harbour called Cala Dogana (the word Cala being Arabic for ‘inlet’. In fact many Mediterranean islands now forming part of Europe have inherited significant portions to their dialects from the period of Arab occupation, perhaps the most significant being the Maltese language which although written in Roman letters and having inherited significant vocabulary from Italian, Franch and English, has a basic semitic grammar. It is a language in its own right; the only one which has sentences made up of one word. Clearly the Mediterranean is the sea where the Arabic and the Roman worlds meet. The term Mediterranean is said to derive from the Latin word mediterraneus, meaning ‘in the middle of earth (medius = middle; terra = land, earth), probably because it was the centre of the known world. The Arabs referred to it as Bahr Rom, meaning the sea of Rome. When one traditionally spoke of ‘the Mediterranean’ world, notwithstanding the acknowledgement that the Southern European and Northern African coast were acknowledged to legitimately be within the realm of the sea, people often though about the former. Hence, we speak of a Mediterranean temperament, and, when we speak of a Mediterranean diet, we refer to ‘‘a modern nutritional

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recommendation inspired by the traditional dietary patterns of poor coastal regions of Spain, southern Italy, Crete, and coastal Greece in the 1960s’’, as described in the Wikipedia, to mention a ‘popular’ source. Older geographies often referred to the climate of these countries as well, in particular with regard to a ‘Mediterranean climate’, when referring to the growth of grape for wine-making. Whilst acknowledging the Northern African coasts as part of the area, the ‘Mediterranean climate’ hardly refers to this coast but brings in mind Spain, France, Italy, Greece and Malta (Shearman and Franklin 1923: 14). Clearly in speaking about a Mediterranean Ethics we must define what regions we are talking about. Are we referring to the broadly Christian southern European and eastern Mediterranean countries, or are we including the Muslim countries of Northern Africa and countries on the Eastern coast including Israel? When speaking in the context of European bioethics, ethicists often refer to the Mediterranean region as southern European countries (Gracia 1993). It is as if there is no need to speak about bioethics in northern African countries, on the one hand because they are not part of Europe, and on the other hand because bioethics in these Muslim countries has not perhaps been taken much into consideration by Western ethicist until recently. Clearly UNESCO has been a pioneer in bringing into the cultural dialogue the ‘two worlds’ (2007). Conversely, when speaking about a European Bioethics, Ten Have (2001) does not refer to southern European countries and concentrate on the central continental countries. When ethicists do speak about the former, they are clearly identified as southern European (Gracia Ibid.) as if to show that there exists a clear difference within the European continent in how bioethics is done—a centralsouthern divide. Nowadays, it would seem to be politically incorrect not to include all countries surrounding the Mediterranean sea when speaking about anything in the Mediterranean. Whilst this paper considers both approaches, the European Union clearly identifies the ‘Mediterranean’ as a region on its borders. The European Commission External Relations Directorate General has Mediterranean on its agenda (Ferrero-Waldner 2007: 3). For example one of the goals of Euromed is to ‘Establish Chairs of Euro-Mediterranean studies… specifically in relation to the media, ethics and society’ and to have a dialogue between cultures such as through the Anna Lindh Foundation (Euro-mediterranean Partnership 2007: 63). Clearly the word ‘Euro’—‘Mediterranean’, implies a relationship between Europe and northern Africa and not between Europe and the southern Mediterranean. Euro-Mediterranean is seen as part of the EU’s ‘external relations’. (This is a misnomer unless it implies that the southern European countries are not part of Europe as they are part of the Mediterranean; clearly

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‘euro-‘ refers to the EC in Brussels—a political entity). The ‘‘European Neighbourhood Policy (ENP) which was launched in March 2003 with the aim of developing ‘a zone of prosperity and a friendly neighbourhood—a ‘ring of friends’—with whom the EU enjoys, close, peaceful and co-operative relations’ (European Commission 2003)’’, (Nugent 2006: 501). The ENP is ‘based on existing bilateral relations between the EU and the ENP states. As such, ENP action plans (covering mainly trade, aid and political and cultural cooperation) are negotiated with each state rather than there being an overall ENP action programme’, and includes countries from former Soviet and northern African states and the Palestinian Authority (the Balkan states, as well as Russia and Turkey having an agreement of their own) (Ibid. 502). This shows that within the context of ‘euro’ in euro-mediterranean, lie the southern European states, and therefore the ‘mediterranean’ means those countries outside the EU which border the Mediterranean sea as well. It would not include, for example, a relation between Italy and Malta, or Germany and Italy. It is clearly a cross cultural creation for peace and prosperity, which by default would include a cultural exchange. In fact the euro-Med Partnership is described as a collaboration between the EU and southern Mediterranean states and is a ‘pillar’ of the neighbourhood policy of the ‘wider Europe (an arc spanning from Morocca in the far West to western Russia in the far north. (Dinan 2005: 533). Understanding whether there are unpinning common cultural issues which determine a common approach to bioethics is therefore significant. It is true that the euromediterranean partnership arose from worries within southern Mediterranean countries about the economic consequences of the single market programme which would widen the economic divide between member and non-member Mediterranean states (Ibid. 537), despite the launch of the Global Mediterranean Policy two over two decades early. At the other end there were also concerns over Isreali–Palestinain relations and the instability in this area. This brought about a strive for more cultural and ethical understanding.

Background: what Mediterranean are we referring to? So what do we mean by Mediterranean? Clearly, any fruitful discussion on bioethics in the region must take into consideration the different approaches, if any, of southern European states, and, for any historical/cultural basis which can engender common approaches, which arise from the ‘two worlds’ which the Mediterranean brings together. This in turn can serve as a basis for any discussion of ‘global’ bioethics, for if one cannot bring together the ethical approaches of neighbouring states, it is doubtful that

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any approach, including mid-level principlism, can have any weight on a uniform global bioethics. Garrafa et al (1999) describe Diego Gracia as having had an important role in the distribution of bioethics which he considers basically an ‘American movement’ (Ibid. 37). They quote him as saying that, ‘because modern bioethics made its appearance in the Anglo-American culture, Europeans in general, and mediterraneans (italics mine) in particular, have attempted not simply to ‘import’ or ‘translate’ bioethics, but rather to ‘recreate’ or ‘remake’ the discipline according to their own culture and ethical traditions’ (Ibid. 37–38, from Gracia 1993: 98). Gracia speaks of the adoption of the principlist model into the Latin, in particular, the Mediterranean traditions, in his writings. Garrafa et al describe his proposal to transform the four principles into two moral basis—private and public duties (Idem). The private duties, ‘of a theological basis’ would include beneficence and autonomy, whilst the public duties, ‘of a deontological basis’, made up of non-maleficence and justice. Whilst not necessarily agreeing with this classification, what needs to be pointed out is the word ‘theological’. This is further understood in the context of him saying that Mediterraneans view bioethics as something foreign (Idem), not because they are strange but because of their emphasis on autonomy, which, Gracia asserts, does not have the same weight in Mediteranean countries as for anglo-saxon countries. Again the focus here is on the use of the term ‘mediterranean’ countries, which is identified with the Latin countries of Europe. This is not to say that Diego Gracia is not sensitive to the fact that the Mediterranean basin is the focus of crosscultures and that historically different religions have come into contact, and neither that in any way he is interpreted here as implying that by Mediterranean bioethics he only means southern European countries, but to emphasise the point that if there is a Mediterranean bioethics which concerns itself with northern African coast countries as much as it concerns itself with southern European countries, this is only a recent development, ant in the nineties, when European approaches to bioethics was still being defined, the concern over Mediterranean was largely that of Latin countries, who therefore had a Christianity which was largely Catholic. It is unclear, and neither would an issue need made, whether Christian Orthodox, on which we will have more to say later, was included. Suffice to say that in this article, all Christian countries will be grouped under the heading of southern European. The point that is being made is that in order to answer ‘what’ Mediterranean we are speaking about, we cannot really choose between the two. In the minds of Europeans, ‘Mediterranean’ most probably refers to those southern European countries, which have largely a Christian ethic (notwithstanding developments); but that ‘Europe’ now

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views (politically) the Mediterranean as those countries bordering the Sea and which therefore has to recon with cross-cultural and cross-religious issues in bioethics— which for political correctness should be the correct view. But whilst the latter has to take on more important if there is to be any fruit from a euro-Mediterranean dialogue, be it economical or not, one has to admit that traditional definitions, at least for the traditional European, is largely southern European. This is also reflected in the north/south divides existent in European ethics and cultures. When we speak about a ‘Mediterranean temperament’ we are really referring to Latin countries. In speaking about the sustainability, management and conservation of cultural heritages, Guccio and Mignosa (2010) say that ‘to analyze the Euor-Mediterranean initiatives, first of all, it is necessary to delimit the Mediterranean region defining the boundaries and the criteria used to identify it (geographical, political, historical, cultural).’ Indeed UNESCO defines the area as a privileged vector of exchanges of knowledge, values and goods, and a source of ‘cross-fertilization’ between cultures. Guccio and Mignosa point out that whilst there is no doubt about the link (from historical artifacts) between Europe and the Mediterranean, one must not forget the areas diversity and variety: ‘The Mediterranean s the result of movement and meeting of peoples and individuals, the circulation of goods and the transmission of knowledge, skills, cultures and beliefs. As a result, there is a historical multicultural tradition in the Mediterranean basin. Possibly, the awareness of this past constitutes a common heritage that has left an indelible mark on this area. The Mediterranean, then, is not only a physical space more or less homogenous but also the combination if identity features and their cultural products’. It is no wonder that the Latin mediterraneus probably meant ‘‘in the middle of the earth’’, with ‘Mare Nostrum’ meaning such to the Mediterranean people (Ibid.).

Mediterranean bioethics Mediterranean ethics in Southern Europe Ruth Macklin (2006), also quoting Gracia, notes that there is less preoccupation with autonomy and principlism in general on the European continent than in the United States. This is especially so in southern European states. She notes that Gracia however also admits that recently, the European continent, following the advent of bioethics, has had a change in the doctor-patient relationship, whereby doctors are more aware of the principle of respect for autonomy and that autonomy is now high on doctors’ attitudes. This however, she says, is an evolutionary change of the doctor patient relationship rather than something

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inherent. However this evolutionary change cannot be attributed only to European doctors but is something which has taken on a world-wide view with the evolution of the four principles. Although this started in the Unite States, one cannot say that the attitude of US doctors fared any better than their European counterparts. If anything a ‘respect’ for autonomy came about because of defensive medicine which is a direct result of the high litigation in this region of the world. Since bioethical principles evolved in a time of the communication boom, one can safely say that the concept of autonomy evolved at quite the same time everywhere and promoters of the four principles like Raanan Gillon (Gillon 1996), who were pioneers in bioethics made sure that this happened. It is quite true however that there was resistance to principlism not only in Europe but also in the United States (Dubose et al. 1994). Several articles ranging from the promotion of virtue ethics (Pellegrino 1995) to common ethics (Clouser and Gert 1995) reflected the same feeling on the European continent. Southern European literature which quoted the four principles reflected also a highly deontological attitude (Caretta 2007: 78). In the Anglo-Saxon region it would seem fair to say that principlism inserted itself more comfortably with the mostly utilitarian approach. This can be reflected in the Case of the Maltese Siamese Twins (London and Knowles 2001). Malta, being a southernmost catholic European country used to refer difficult cases to the UK even before joining the EU owing to a bilateral agreement with the countries. Malta would treat British tourist, which are many, free when they needed medical care in hospital and in return the UK offered specialized care. This agreement however omitted a discussion on what to do in the case that the treatment required an ethical resolution (Mallia 2002a: 208). The parents, following advice given by their Curia that it was possible to allow nature to take its course rather than follow heroic treatments, which is a common catholic principle dating from Pope Pius XII (1952), opted not to kill one of the daughters in order to save the other. Arguments of the sort that the twins could be considered one person (Azzopardi 2000) would obviously not hold as phenomenologically everyone would consider them to be two beings still attached. The British social services thought otherwise and a long battle ensued in courts which resulted that the judge allowed for the separation of the twins whilst doing their best to save both. Of course one knew beforehand that the parasitic twin would not survive and interestingly the verdict was not following the principle of double effect which would have probably been acceptable on a southern European ethic. It was a utilitarian choice. Catholic moral analysis made sense on the both a concept of extraordinary means and casuistically consistent.

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This is not to say that there were people, including catholic ethicists who disagreed back in Malta (Caruana Galizia 2000). Interestingly, British ethicist Raanan Gillon supported the view of parental rights (Gillon 2000). Several other cases will reflect on the differences between southern European ethics and more libertarian approaches. But what is of interest is that these cases often involve a public debate and one can notice a strong undercurrent of religious values conflicting with people who would nowadays take a more ‘rights’ approach. This can be seen in various confrontations on abortion and euthanasia. When the ship Women On Waves went on the outskirts of Malta, a media debate ensued about abortion. No matter how much one tried to keep religious dogma out of the discussion and have a purely secular debate, invariably clergy were involved in the discussion and although one can argue against abortion on purely biological grounds that life begins at conception, many arguments on life beginning at implantation and life beginning when there is a primitive streak did not appeal to the general public and much of the discussion centered around when the soul enters the human entity (Arena 2005). Even if twinning had to occur before 14 days one cannot exclude that ontologically this was bound to happen. In 2008 the case of Eluana Englaro, a lady in her thirties who had entered into a persistent vegetative state in her late teens, hit the media when a Catholic Bishop asked the Premier of Italy, Silvio Berlusconi, not to allow the stopping of feeding to the girl who had been in that state for over 12 years since she was 17 years old. The father did not wish for her to be kept alive in that way and argued that she had also expressed this wish before her accident. This was equated with euthanasia and a public outcry ensued. Actually the Pope only commented on the case by saying that life had to be respected from conception to the natural death. But what in fact is a natural death. The Church’s teachings on end-of-life decisions are clear—that no extraordinary measures need be taken obligatorily and that if the patient cannot give consent then the position of the family has to be taken into consideration (Catholic catechism). This was explained in 1952 by Pope Pius XII (Popes address to doctors). However the distinction between ordinary and extraordinary is not always easy and many argued that food and water should always be ordinary. In reality this is a problem also a question in the UK. But the Catholic position is clear that the distinction should not be made on the state of the art of the treatment. That artificial feeding is a form of treatment was content able—although a recent article attempts to clarify that since it involves medical expertise to insert a nasogastric tube and since complications can arise and moreover this is given only to sick people would argue in favour that it is a specialized form of treatment (Clary 2010). Whether this should be acceptable or not is determined by whether the person had to perceive this as extraordinary treatment. Yet

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what is important is that the public outcry was made mostly on religious grounds. In was indeed a pity as by the same religious grounds, the teachings of the Church may be interpreted otherwise. What was popularly important was whether prima facie this was interpreted as euthanasia or not. The Italian media showed street protests from both sides with one side calling the other ‘assasini’ (murderers). It would be fair to argue that euthanasia is a more heavily contested issue in southern Europe than in central Europe. In the UK, decisions by courts and the royal colleges of physicians seem to be more acceptable by the public although there is media coverage.1 It would also be fair to assume that this southern European attitude is due to the greater influence of the Catholic church in the central regions of southern Europe. If one moves to other European countries one sees that in Malta the government has to date still not legislated a bill on reproductive technology because of the highly controversial issues that it raises. The Church has concerns on simply IVF, even if it did not involve the killing of embryos was reflected in a reaction by the former archbishop when the Ministry of health issued the first draft of the Reproductive Technology document which in itself was very conservative—allowing for the fertilization of the minimum number of eggs so as not to allow freezing of embryos, and allowing IVF only to legitimately married couples. Still the contention was there (Mallia 2002b). Admittedly there are many people now who would agree that infertile couples be allowed IVF and this is reciprocated also by clergy working at pastoral level (Mallia 2010). But allowing IVF for homosexual couples and for single individuals is still highly contented (Mallia 2010 Ibid.), whereas this is more acceptable at popular level in central and northern Europe. If one were to move east to Greece, one can recall the controversy when the government in collaboration with the Greek Orthodox church, imposed obligatory directive counseling with recommendation for testing before marriage in order to reduce the penetrance of thalassaemia major. This was condoned by the World health Organisation but not by UNESCO (Mallia and Ten Have 2003). It is paradoxical that the general trend on genetics is against selection and selective abortion, or at least that the controversy exists all over Europe. But when it came to a question of allocation of resources, the Greek government was persuaded to do otherwise. Nevertheless the struggle to justify the position was clear. There are clear differences in European approaches to bioethics from that of Northern American (Ten Have 2001). There are also clear differences, as elaborated by Gracia, from mainstream European approaches to southern 1

This perhaps reflects the ‘Mediterranean’ temperament alluded to earlier.

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European approaches. Where Gracia does not elaborate is perhaps the difference between various southern European states. There is an arc ranging from Spain through France, Italy, Malta, Slovenia, Croatia, Monte Negro, Greece and perhaps Turkey. Postponing Turkey to the next section which deals also with Muslim ethics, there is a clear trend in religious traditions which reflect a proportional deontological attitude in the countries. Whereas there is no doubt that deontological attitudes do prevail in all, the central countries from which catholic doctrine emanates tend to be more conservative towards catholic values. There is a greater emphasis on virtue ethics (Gracia 1993). However the southwestern countries have all legislated for issues like abortion more easily and are in general more traditionally liberal. Greek orthodox tend to be less stringent in their attitude towards bioethics as they are, for example, to the question of interpreting divorce from the same New Testament. The orthodox church collaborated with the Greek government in marrying couples on the condition of the pre-marital genetic counseling and no questions seemed to be raised on genetics itself or on directive counseling. This could have been due to the fact that the thalassaemia question was pressing much before the ethics of genetics was a central debate in bioethics (before, for example, the FP4 Euroscreen project funded by the EU). Nevertheless the practice continues. Conversely when, following the Italian law on reproductive technology (2004), a referendum was held to extend research on the embryo and have a more liberal approach to reproductive technology to include embryo experimentation, the Catholic church intervened and took advantage of the law stating that a referendum is not valid in Italy if\50 % of the population entitled to vote turn out, and officially requested people not to go and vote. Pope Benedict XIV appeared in a press release with Cardinals and Bishops on his sides. The resonance of the public was generous to say the least and the referendum did not reach the required amount of votes. This shows not only that the Catholic Church is actively involved in bioethics debate but that the southern European countries like Italy respond well to the values it promulgates when called to do so. The central southern countries of Malta and Italy seem to respond more to tradition Catholic ethics when it comes to bioethical issues especially relating to beginning and end of life choices, although one cannot exclude Spain entirely but it does not seem that much public controversy has arisen on these issues in this country over the past 10 years. It is true therefore that southern European countries have tried to ‘recreate’ or ‘remake’ bioethics ‘‘according to their own cultural ethical traditions’’ (Gracia 1993), and that defining a Mediterranean bioethics for southern europes involved important elements of historical and cultural

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values. Whether this is so for the whole of the Mediterranean region is now discussed. Ethics in the context of a Euro-Mediterranean dialogue Matulic (2007) asserts that it ‘‘must be noted that defining bioethics as Mediterranean is not some mere geographical demarcation, but rather implies and involves the vital elements of the historical realisation of a cultural circle that has demonstrated its superlative theoretical and practical efficiencies at the level of creating a distinctive, namely the Western, civilisation. Just as the complex of Western civilisation transcends and exceeds the limits of geographical boundaries with its reflective penetration and practical efficiency, the same can reasonably be expected from regional Mediterranean bioethics, in which the regional determines the conception, the cradle and source of the idea that determines, characterises and conditions the human research of meaning and happiness from a metahistorical perspective. The external, i.e. civilisational, research of the meaning and significance of the roots of Mediterranean bioethics is to be followed by the internal, i.e. philosophical, research of the meaning and significance of its roots’’. When speaking in the context of a euro-mediterranean ethics as described above to achieve the goals of the UE, this strongly applies as well. For if there is to be a cultural exchange one has to understand the needs and contexts of why a Mediterranean bioethics which includes northern African and middle eastern countries is needed. This can be found within the goals and scopes of the Euro med partnership in general. Why have a Mediterranean bioethics which includes these countries? Or is this merely a futile academic exercise? In the case of distinguishing southern Europe from Europe, the scope is valid in its own right in order to understand that a broad ‘European bioethics’ cannot take for granted any ethical uniformity over the map of Europe. Since the formation of the European union and the facilitation of movement of people from one State to another, be it for economic reasons or otherwise, the same people are going to need health care and within health care will arise problems of a bioethical nature. One also envisages movement of people to obtain services from one country because they are controversial in another. Will the case be the same for the coastline of the Mediterranean? As pointed out earlier, the Euro-Med partnership is a pillar of the EU’s neighbour ‘wider Europe’ policy. Dinnon, D. (2005) concedes that the countries of the wider Europe are extremely diverse culturally, historically, ecumenically, and politically. ‘‘Many have little in common with each other apart from geographical propinquity to the EU. Some are a cause of acute concern to the EU, being vulnerable to economic collapse,

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political extremism, and religious fundamentalism and being sources (or potential sources) of illegal immigration and smuggling of people and drugs. Above all, the EU wants to try to stabilize the region around itself. Inevitably, the European Neighborhood Policy speaks of promoting good governance, economic liberalism, respect for human rights, sustainable development, and social cohesion—sincere and admirable goals that are hardly realistic in all cases. The EU would become active in the financial process to promote these goals, yet there are no guarantees that the member states will fund such objectives, ‘‘or that the new policy will improve the quality or effectiveness of existing EU initiatives in the vast ‘‘pan European and Mediterranean regions’’’’. Be this as it may any consideration of bioethics in the Euro-Med partnership has to work within these objectives in mind lest it be a mere academic exercise, which given the differences that exist, is doubtful what meaning and interpretation a definition of Mediterranean Bioethics has in this context. On the other hand, at the other end of the Mediterranean lies the Israeli-Palestinian conflict. All developments, which culminated in the Barcelona Process, were made against these backdrops. Whilst economic and financial affairs were at the heart of the new Euro-Med partnership (Ibid. 538), the success of the Barcelona process depended on the EU’s ability to promote such regional development, whose chief steps were to enhance regional security and strengthen cultural and educational ties. The exercise is certainly not to attain the creation of free trade zone, and, given the volatility of surrounding countries, potential financial benefits come secondary to the political and security goals. A mutual collaboration of this sort must definitely include a cultural dialogue of values, and even if one had to consider the potential movement of people in the Mediterranean zone, bioethical issues are nowadays at the heart of values. It is worth pointing out some similarities in the region: 1.

2.

Both southern Europe and northern Africa are influenced, through their respective religions, by ethics derived from ancient Greece and Rome, which are largely Aristotelian. It may have taken time and for them both to accept what was considered a pagan ethics, but it would be difficult to dispute that the roots of ethics in these regions is not deontological. It is also true that most countries are becoming more liberal and this may be more so for the European states, but there seems therefore to be more issues on which euro-med countries be in agreement than at first meets the eye. That they are deontological in their normative ethics is obvious. Both southern European and northern African countries are highly influenced in their values by their

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3.

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respective religious traditions. Whilst it is true that these traditions have come into conflict in the past, culminating in the great siege which took place in 1565 between the Muslims of the Ottoman empire and the Order of the Knights of Saint John, which following its expulsion by the same ottoman Empire, were given the Island of Malta by King Charles V of Spain, who was at the time also king of the ‘two Sicilies’ (Sicily and Naples), (The defense of the Island was described by Queen Elizabeth 1, ‘‘no great lover of either Catholics or Spaniards’’, remarked during the course of the siege: ‘‘If the Turks should prevail against the Isle of Malta, it is uncertain what further peril might follow the rest of Christendom’’ (Bradford 2000: 418), it is also true that more recently there have been various ecumenical levels of dialogue between the religions. Although Pope Benedict XIV is a staunch believer that Europe should remain Christian and true to its roots (Ratzinger 2005), it is also true that there can be a common understanding of deontological values which derive from the same source. Catholic, Orthodox Christian and Muslim faiths are all deontological (Serour 1996: 78). This is a strong basis for a common understanding of bioethical issues. Whilst it is true that there are differences on the interpretation of when the soul enters the embryo (Muslims are allowed to terminate a pregnancy in its beginning if there is a medico-legal cause), the Catholic faith also held for the first millennium that the soul enters the body of the embryo with the formation of the brain. One can quote Canto XXV of Dante Alighieri’s Purgatory (Bianchi 1924) as a sign of the thoughts of the time. But if we accept that there is a southern European Mediterranean bioethics, which is based on more deontological principles, it should be noted that neither within these countries is there agreement on specific issues like abortion and euthanasia. It would therefore seem not to be logical to hold specific differences between the Muslim and Christian cultures either. If one were to contrast Christianity with Judaism, on the other hand, the Judeo-Christian tradition is itself an indication of common ground which one need not enter into here. The Israeli-Palestinian conflict goes beyond simple disputes on religion, although in the remote past it may have been one of the contentions. It is more of a political question of land. The problems faced with accepting the Principle of respect for autonomy are similar. In preparation for a pan-Arab meeting for Cardiac and vascular physicians and surgeons,2 collection of ethical cases for a session on ethics shows that Arab countries have problems, as

Pan Arab Conference on Cardiology, Dubai, May 2011.

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with southern European countries with the concept of autonomy. One cardiac surgeon, who trained in Ottawa and worked there for several years, admits to adhere to principlism which was promoted in Canada, but when in his country finds it difficult to apply the same principles. The case he relates pertains to a Bedouin elderly gentleman who refuses potentially life-saving cardiac surgery, involving valve replacement. In his culture the family members, including the sons and daughters, may over-ride their father’s decision. As a surgeon who wants to save this gentleman’s life, his question, whether he should not respect the wishes of the patient, would be anathema in the Western world of America and Canada, and perhaps most of Europe. Without going into the obvious issue that not all the Arab world is the same, and people speaking Arabic in Dubai will not understand the Arabic spoken in Libya, what one can ‘take home’ from this case is the similarity of situations faced in southern European countries, where many doctors would find themselves in the same situation and where truth-telling is culturally sensitive as well (Dalla-Vorgia 1992). Culturally sensitive issues may not be as different in the modern world. Just as European women from southern Europe whose country does not offer abortions may travel to other EU states for the procedure, young northern African ladies who have had sexual intercourse before marriage are known to travel to to other northern African countries to have plastic surgery on their hymen. It is custom for the father of the future spouse in Libya, for example, to request an examination of the maid by a gynaecologist, and if he is not satisfied he can request a second opinion. In both cases it is he who chooses the gynaecologist of his trust. Whilst this would clearly be one of those human rights issues (for example, the choice of one’s own doctor) which the Barcellona Declaration has as its objectives, the point here is that cultural issues are not that important for younger generations, and secondly that both southern European countries and northern African countries have problems with reproductive technologies, albeit of a different nature. Nevertheless the normative values of the younger generations of both cultures seem to be changing, whilst overall still being influenced by deontological preferences. It is true also that mainstream western bioethics nowadays concerns itself also with transgender issues, with sexual orientation, and a myriad of other topics which are still anathema to many southern European people. Whilst their countries make considerable efforts to give equal rights, it is also probable that it is less likely that same-sex marriages will be accepted as easily in southern Europe than in central and

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northern European countries. It is also probably true that homosexuality may still be more frowned upon by many people and only time will phase these objections out. Therefore, whilst many Muslim countries are accused of not respecting human rights of homosexuals, the issue pertains more on a political level than on a bioethical level. If the euro-med countries had to discuss whether to offer IVF to unmarried or homosexual couples, their normative values will more than probably be in agreement, although, given EU membership it is probably also true that legislation would be facilitated in the European countries, but not without a fight as seen with the 2004 Italian biotechnology law discussed above. It is also worth considering that Muslims seems not to be threatened by the foundations of Christian morality but by ‘the cynicism of a secularized culture that denies its foundations’ (Ratzinger 2006: 33). In this regard southern European countries are more akin to Muslim culture.

The scope for a Mediterranean bioethics There are clearly cultural differences between southern European, the rest of Europe, northern Africa and the east Mediterranean. Cultural dialogue cannot depend on any attempt to make culturally sensitive issues adhere to more western ideas. In point of fact some of the western ideas are now known to have existed even in the Mediterranean. Christopoulos et al. (2008) point out that aspects of informed consent as practiced in the west today were already a legal aspect in seventeenth and eighteenth century eastern Mediterranean regions; ‘‘Although it is often vigorously argued that consent, informed or otherwise, is a recent phenomenon and that no sources testify to its existence before the twentieth century, it is difficult to accept that a process for regulating the common and fundamental parameters in the relationship between doctor and patient and the planning of treatment had not concerned previous eras. A review of the Registers of the Islamic Court of Candia (Heraklion) in Crete, a series of records that touches on, among other things, matters of medical interest, reveals that the concept of informed consent was not only known during a period that stretched from the mid-seventeenth to the early nineteenth century, but it was concerned with the same principles that prevail or have been a point of contention today’’. Conversely attitudes of the Greek population nowadays show that there is no clear answer whether they would always want to know the truth. Often an ‘it depends’ attitude has been shown to exist in a study carried out ne Dalla-Vorgia et al. (1992). It has also been argued that

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the defence of rights of the person in Mediterranean ethics does not depend solely on the autonomy of person independently from society, but rather on the interdependency of persons and nations (Lopez-Ibor and Crespo 2003). It is argued that rights are based ‘‘on a synthesis of civic humanism and liberalism’’ deriving from the spirit of Greek democracy, the Enlightment, and the achievement of the nineteenth and twentieth centuries. In this context, and in view of attempts to develop a ‘global’ bioethics, one must learn from lesson of the past. Should countries come into loggerheads with each other on ethical issues? The concept of female circumcision has taught us that things are not always what they seem to be at face value. Whilst there are many women within societies that have this practice that argue against it, much of the initial literature was rather judgemental, when eventually it transpired that this practice was culturally sensitive. We must learn also from European case law. The case of the Siamese twins showed how the anglo-saxon ethics, which resolved itself in the UK courts, came to loggerhead with the Catholic tradtion (Jacob 2000). Whilst it is true that this bilateral agreement did not take ethical issues into consideration as they were not foreseen (Mallia 2002a op. cit), such experiences can show us that countries within Europe can differ. Since the second approach of having a Mediterranean bioethics involves the European ‘wider Europe’ of euro-med, one should contemplate whether we would want the courts to be the final arbiters of ethical issues, and hence cultural values. Whilst it is envisaged that people should have rights and freedoms to travel to countries for services which are not available in their countries, and whilst it is also acceptable for foreigners of a country not to seek the same type of ethically-laden care which they would find in their own country (in Malta this issue was discussed by the Bioethics Consultative Committee with regard to the prescribing of emergency contraception to foreigners (Mallia 2005), one should be sensitive to values of people which may not involve killing at the beginning and at the end of life. Therefore any fruitful Mediterranean bioethics must take into consideration the cultural acceptance of practices. Circumcision may be practiced by jaws for religious reasons, although reasons of cleanliness are given. Certainly, even in southern European countries circumcision is not practiced at birth rituals. It would be frivolous to speak of a Mediterranean bioethics which respects culture if Jewish people are not allowed to carry out the procedure in other countries on the grounds that it may not be medically indicated. In this context interstate conferences such those of the European association for Jewish studies, the most recent ‘Judaism in the Mediterranean context’ held in Italy (2010) are not only fruitful but to be encouraged. UNESCO and the Regional Office for the Eastern Mediterranean of

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the World Health Organization (WHO/EMRO) have started a bioethical initiative in the Arab and Eastern Mediterranean Region in order to ‘‘join their efforts to plan and implement various bioethical projects together’’. The outcome of such exercises can show whether it would be fruitful to hold similar efforts on a larger scale within the Euromed context, either by UNESCO or by the EU itself, or collaboratively. Certainly there can be no doubt that if we want a safer euromed region, the place to start is culture and such efforts would be useful to say the least. Gracia (2010) argues that the inability to apply American principles to different cultures shows the importance of such trans-cultural studies. The histories of the people need to be appreciated. Speaking within the context of Latin American bioethics Gracia asserts that this culture stems form a Latin and Mediterranean tradition. The same principle therefore would apply to countries of the Mediterranean. Finally we should emphasis that interest in a Mediterranean Bioethics should not reflect a nostalgia for values which were otherwise lost to a western-word counterpart. This would not be fair judgment on Western and in particular American Bioethics. It has been argued that whilst Europe conceived the Enlightment, the United States, in the times of Jefferson, implemented it (Steele Commager 2000) and therefore Europe, and in particular the Mediterranean owe their development of positive Western values, such as the greater respect for rights and autonomy, and, for those who want it, individualism. Conversely historians tell us that the Renaissance was a nostalgia of past ethical values and virtues of the Greek and Roman period which were lost to the Middle ages, when authors such as Petrarch started to show a nostalgia (Rabb 2006: 84–85). Thinking about a Mediterranean ethics as simply a nostalgia by some European people who see a degradation of some sorts of society would not be fruitful. We have to think of a Mediterranean bioethics in order to respects cultures, values and the histories and idiosyncracies of people in general. On a higher level such values will encourage mutual respect between people; that pluralism need not be relativism. In many southern European countries the Catholic Church remains a strong quasi-political force especially when it comes to reproductive technology and the history of obstetrics (Savona-Ventura 1995); it also influences the decisions politically in both bioethical and socio-religious issues (Grima 1989). There is undeniable cultural overlap of the interaction of religion and society in a euro-Mediterranean level. On the other hand one cannot negate that bioethics lies also within a realm of mutual understanding of cultures. There are similarities, for example, between Islam and Christianity when today’s media and terrorism tend to magnify differences. Lagarde (2001: 301–308) makes a compelling argument of the similarities, starting from the

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Christian prayer of the ‘Our Father’, to the Muslim prayer which is derivative3. Muslims fo not acknowledge the paternity of God, and this prayer does not start with ‘Our Father’, but the equivalent to ‘Our Lord’. The Koran acknowledges Jesus as the Messiah and a prophet and one who is sent by God. Although God does not generate (Koran 112, 1–4), as otherwise there would be an admission of a relationship to a woman or another deity. Lagarde shows how Judeo-Christian traces remain within the Muslim tradition. When questioned how it could be that Jesus was God’s sent one, God’s answer4 is that prophets are brothers because they are from the same father but different mothers and that their religion is the same; but between Jesus and God there is no other prophet. Lagarde shows how ‘the same father’ in the text refers to God and not Abraham, as otherwise He would not have said ‘from different mothers’. Notwithstanding these traces it is also true that we cannot simplify or fall into a naı¨ve relativism. Ibn ‘Arabi, master of Abd al-Qadir, said that he whose malady is Jesus will never heal5. Conversely an understanding of Trinitarian ontology and its challenge to contemporary philosophy may help identify the historical concepts of the Christian, and in particular the Catholic, world, and the deontological derivations which have resulted in placing less accent on efficiency but more on relationship (Caretta 2007).

Conclusion Whether we understand the word Mediterranean Bioethics as meaning those countries which not geographically but traditionally are held to be Southern Europe, or whether we consider the true geographical significance, and thus bring different religions and cultures even further into the equation, any significance must lie within the context of respecting values of people and to warn against any attempts to westernize peoples, be they southern European of otherwise. Within the context of the ‘wider Europe’, the Euro-Med partnership has specific scopes within which questions of bioethics will arise which may be more difficult to resolve. Further studies and collaborative efforts as those by UNESCO and the EU are needed to bring bioethicists and health care professionals in general into dialogue. This has generated some philosophical academic efforts in cross cultural East/West perspectives, for example in end-of-life 3

Quoting Abu Dawud, Sunan, 2, Kitab al-tibb, 19. Quoting from Muslim, Sahib, Kitab fada’ il al-anbiya, 40, 144, 145. 5 Qouting from Abd al-Qadir al-Djaza iri, Kitab al-mawaqif, 1386/1966, pp. 20–22; Poemes metaphysiques, Ed. De l’Oeuvre, Paris 1983, trans. C.A. gilis, pp. 43–44, 53. 4

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decisions (Chattopadhyay and Simon 2007). This is also needed within the European context, to be sure. Unfortunately there is a greater emphasis to Westernize most of the European states when it come to bioethics. We must learn from experiences such as that of the Maltese (Mediterranean) conjoined twins. A euro-Mediterranean bioethics is more of an exercise in working together in a pluralist world. The four principles, including what we mean by respecting autonomy, Justice, and non-maleficence may have to be understood and accepted within the culture in order of have a ‘peaceful zone’. Answering ‘why a Mediterranean bioethics’ becomes a question of its necessity to learn mutually. Whilst there certainly is a southern European bioethics which stands out with respect to the rest of Europe, it is difficult to identify a more broad Mediterranean bioethics given the cultural and religious differences. Yet its conception should be an objection and will serve broadly on mutually recognition of values, which would not only include a westernization of concepts such as rights (something which is legitimate on the part of Europe as a goal), but also to accept pluralistic rites and practices and not judge them with any western philosophy. The Challenge all coastal Mediterranean cultures pose to the rest of the western world is that if they are based on deontology, which seemingly they are, then there is scope for a global bioethics within this tradition. Perhaps one should also consider Ratzinger’s Pascalian proposal: the enlightenment gave us an ethical understanding when thinking of an ethics ‘as if God did not exist’. The limits of enlightenment ethics may be fulfilled if we were to conceive now of an ethics ‘as if God did exist’ (Ratzinger 2006: 51–52). The historical, cultural, and religious influence on Mediterranean countries, including those bordering the east have a close relationship to their respective backgrounds which may make for what can be referred to a Mediterranean bioethics, which would in this opinion be served and based by deontological rather than by liberal or utilitarian foundations.

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