Within the International Observatory on End of Life Care we have chosen a particular framework/template for global ethical analysis. This is the so-called Four Principles approach to health care ethics. The principles are:

Beneficence : the obligation to provide benefits and balance benefits against risks

Non-maleficence : the obligation to avoid the causation of harm

Respect for autonomy: the obligation to respect the decision-making capacities of autonomous persons

Justice: obligations of fairness in the distribution of benefits and risks

This is not to say that other, or even competing, frameworks for ethical analysis are not relevant. Elsewhere, we have discussed in great detail that particular issue, as well as the various strengths and weaknesses of the approach – and, indeed, whether or not the approach is at all worthwhile.⁸¹

We may note, however, that the approach is used world-wide and that it has gained remarkable acceptance since 1979, when it was first introduced.⁸² This may at least be taken as a sign of the global potential of the approach. Furthermore, and highly relevant in our context here, scholars have used it analysing the African ethical “map”. ^{83 , 84} In so doing, they have managed to highlight both similarities with, and differences between, “African” ethical thinking and the ethical thinking represented by the Four Principles approach.

The African world-view, religion, the The Vital Force Principle, and the principles of Beneficence and Non-maleficence. Peter Kasenene⁸³ claims that there is such a thing as a common African-ness that characterises the culture and world-view of Africans – notwithstanding the fact that there are remarkable differences in values among Africans; urban and rural, educated and illiterate, Christian or traditionalist.

As far as religion is concerned, Anne Merriman reports that in Uganda, “it’s about 90 per cent Christian, 10 per cent Muslim, and the Muslim religion is very integrated with the Christian religion – they even marry Christians and don’t insist that they change their religion”. We may note that what has been named The Vital Force Principle within African thinking has a profound religious meaning in that “this vital force is hierarchical, descending from God through ancestors and elders to the individual”, and, that “whatever increases life or vital force is good; whatever decreases it is bad”. ⁸³

That also means there is a direct link between the vital force principle and the principles of beneficence and non-maleficence: “Following the vital force principle, everyone has a duty to do good to his or her neighbour, especially to friends, relatives and clansmen”, and the very same principle “establishes the duty not to cause harm, injure or do anything that reduces the vital force of the individual members of the community or threatens its collective existence”.⁸³ In summary, then, this very important aspect of African thinking does indeed appear to be congruent with the two first principles of the Four Principles approach to health care ethics.

The role of Justice. Due to the communal nature of African societies, observes Kasenene,⁸³ “justice is highly valued”, and “justice is first and foremost a social affair”, meaning that “an offence against an individual is an offence against the community, and for the good of the community everyone’s needs must be attended to without discrimination. Health care is, consequently, made available to everyone according to his or her needs”.⁸³

The Ugandan Government’s policy of making morphine available to all patients who need it, free of charge, across districts, is a very clear example of this. The interview with dispenser Peter Mikajjo is revealing as far as the details of this policy are concerned. Also, Jack Jagwe – who has earlier been in Government services for some 30 years – has much to say on this policy. In the words of the interviewer, “almost uniquely among certain of the countries in Africa, [ Uganda has] managed to have morphine availability and its regulations integrated into Government policy”.

Perhaps intuitively, we tend to think of justice in terms of treating people equally. Yet that idea seems to go only halfway since people often have different needs and thus treating them equally could mean that some people will not get enough of what they need. Hence, according to what has been called Aristotle’s formal theory of justice, philosopher and physician Raanan Gillon notes, “equals should be treated equally and unequals should be treated unequally in proportion to the morally relevant inequalities”.⁸⁵ Surely a morally relevant inequality is the one between those who are not sick and those who suffer from a life-limiting illness like cancer or AIDS, and who therefore will be in need of good pain control, e.g. in the form of morphine.

The issue of patient autonomy. The principle of autonomy may be said to be of less importance in the African setting than in, say, most European societies (although this is arguably not so if one compares with some southern European societies like Spain, for instance.⁸⁶ Claims Kasenene: “In African culture ... beneficence has a higher value [than autonomy], which justifies paternalistic interventions either by the doctor ... or by the family.”⁸³ Now paternalism has been defined thus by the philosopher Gerald Dworkin: “By paternalism, I ... understand roughly the interference with a person’s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests or values of the person being coerced”.⁸⁷ And, more succinctly, another philosopher, Derek Parfit, says of it: “We are paternalists when we make someone act in his own interests”.⁸⁸

That people are sometimes treated paternalistically should also be seen in the light of the so-called Communalism Principle of African traditional ethics, according to which “to be is to belong, and an individual exists corporately in terms of the family, clan and whole ethnic group”.⁸³ There is thus a strong current of collectivism in African societies – something than runs counter to the occasionally quite extreme individualism of Western societies, an individualism that is a presupposition of what we may call “the ideology of autonomy” (seen most starkly, perhaps, in the euthanasia and so-called “right to die” movements). In concrete terms, this collectivism or communalism comes to the surface when relatives “want the doctor or nurse to let them know what the patient is suffering from”.⁸³ Additionally, observes Kasenene, “individual autonomy is not respected when the community believes that the person is acting against himself or herself”. ⁸³

That the principle of Beneficence thus has the upper hand is something that comes across very clearly in the interviews with Anne Merriman, Ekiria Kikule, and Michelle McGannon. They all point to the Ugandan practice of not telling patients about diagnosis and prognosis when they face terminal illness. Anne Merriman mentions the case of a doctor, even, who was not told: “recently [a doctor] died ... he had an operation, was diagnosed as cancer of the stomach, nobody told him the diagnosis, they told it to the family, they didn’t tell him – but he knew, of course he knew”. Michelle McGannon frames the issue of truth-telling in terms of patient confidentiality: “I think sometimes that really ties in with the confidentiality, they’ll go and tell a relative possibly instead of telling the actual patient first of all”.

Apparently, the lack of respect for autonomy as far as disclosure of diagnosis and prognosis is concerned must also be seen in relation to a culture that denies death. To quote Anne Merriman in her reference to Jack Jagwe - a colleague who happens to be one of the other interviewees: “we teach end-of-life ethical issues. One of them is that people can’t accept that people are going to die. Dr Jagwe, you heard me teasing him today about death, he’s a year older than me and I keep saying to everybody, ‘Now look, when you reach my age, you should be able to know that death’s gonna come any time,’ you know, ‘Oh, God forbid,’ says Dr Jagwe [chuckles]. ... the doctors have the feeling about death, they won’t acknowledge that it happens, the senior doctors in particular won’t acknowledge that it happens. So if a patient goes into the hospital and they’re seen to be terminally ill, they will do everything to resuscitate them”.

Finally, another way to look at these issues is through the principle of non-maleficence. Patients are not told the truth because doing so is perceived as harming them psychologically – including taking away hope – as well as culturally (cf. the culture of death denial).