‘Is there an Asian Bioethics? Alternative Understandings of Ethics in Medicine’ – Bob SimpsonInterview Peripheral Visions: Anthropological Perspectives on Bioethics, Biomedicine and Biotechnologies in Sri Lanka, (Social Scientists’ Association, Colombo 2022), reflects on the intersection between medicine and society, calling attention to the varied ways in which medical knowledge is received in different cultural contexts. Bob Simpson, author of the book and emeritus professor of anthropology at Durham University in England joined an online discussion on the book organised by SSA on 20 October 2022. The session was moderated by Darshi Thoradeniya of the Department of History, University of Colombo. Polity is pleased to publish an edited version of the transcript of the talk. DT: Thank you Bob for joining us today to discuss your book. Peripheral Visions is about how modern bioethics and biomedicine work in an island nation in the Global South. It shows very succinctly why we cannot and should not attempt to understand the body as an anatomical object, but rather as a social, political and cultural being. It is a profound piece of interdisciplinary work between anthropology, medical practice, ethics, and the human body. I now invite Bob to talk about his research and field experience in Sri Lanka, using the title of the book, Peripheral Visions, as an entry point. BS: Thank you very much. I’m absolutely delighted to be here. It’s good to revisit some of the themes that cropped up in the book. The book was an attempt to pull together a whole lot of work. When I put it all together, there were lots of different themes and connections and I began to think about this in terms of what the book might be called; and this idea of peripheral visions came up. Now, this is not a particularly new idea and I think it goes to the core of anthropological methodology. In the introductory chapter I have talked about blessings and curses. The blessing is that one could be interested in a wide range of things because anthropologists start a methodology based on holism and not constraining things within frameworks which determine what it is that you want to look at, rather than what it is people on the ground are telling you is of interest. The curse of course is that this can be construed as a very loose uncoordinated methodology, and that is often the criticism that is levelled at an anthropologist. But notwithstanding that, the idea of peripheral visions is that when you start to look at one thing, people often will try to explain it by making connections to other things. Even though you’re looking at one thing, your vision might be pulled to look at something else. One example was asking people about artificial insemination and sperm donation which in the early 2000s was very new on the scene. In response, people would make links with blood donation, eye donation. What is of interest in anthropology is what knowledge people are calling on to help them make sense of things. So that took me in the direction of an interest in blood donation, and finding out what was going on in blood donation. Eye donation also proved to be absolutely fascinating and I think is in many ways unique to Sri Lanka in the way it was articulated. So, this idea of peripheral vision I hope captures something about the anthropological approach. An anthropological methodology which tries very hard not to be constrained by frameworks but attempts to give over to the informant, to the interlocutor, the ability to explain their world in their terms. And that is one of the – as I see – objectives of anthropology and ethnography; to understand people’s world in their own terms; which is what I was trying to do in relation to the new reproductive and genetic technologies in the book.DT: Can I now invite you to talk about some of the terms that you look at and explore as an anthropologist? For instance, what do you mean by ‘Asian ethics’ and how does it differ from bioethics in the rest of the world? BS: The way that I use the term ‘Asian bioethics’ is not as a thing. It’s more as a position that people take in trying to make sense of what is going on in relation to these new technologies. My view is that when new technological developments arrive from the West, they come not with ethics as something separate, but with ethics built-in. What I’m talking about here are basic things like ideas of personhood, autonomy, obligation, and relationships that are all built in to the ethics that come with new technologies. When they arrive, there is a sense that they don’t quite fit. So, at the local level, people begin to think about the things that don’t fit. There’s a whole debate about the relationship between global ethics – a universal standard, a singular, one-size-fits-all ethics – which in truth is driven by Western ideas of ethics; a Judeo-Christian, Western tradition which kind of blocks out a lot of other voices. But, of course, those local voices begin to creep in and say; “Well hang on. How are our ethics different from these other ones? How can we not just have the Western models roll over us? How are we going to engage with this?” So, this then begins to generate local thinking. And one of the things that was happening in those early 2000s in relation to this debate is, it gave rise to the question ‘is there an Asian bioethics?’. One of the fundamental things was that attention was focused around the Western idea of autonomy and individual decision-making. They are central to Western medical bioethics; versus the idea that in Asian cultures – and these are very large, loose, and probably very unhelpful formulations – bioethics was more about collectivity. It was more about responsibility towards others. It was more about certain kinds of moral rule-based activity. But as an anthropologist I find that very unsatisfactory. The units are far too big: what is Asian? East Asia, South Asia, where does Asia begin and end? Does it include Israel? As an anthropologist, one of my big concerns was with being very specific about the scales at which we’re talking about things. In Sri Lanka it was not so much in terms of these grand Asian bioethics versus Western bioethics, but more in terms of what was happening locally. What was happening locally was that you could almost see it as a series of fractals breaking down, because it is not a question of the Global South versus the Global North; you have the Global North and the Global South in Colombo itself. The transfer of technology is there. The kind of conceptual sophistication around the new technologies is all there. So, we need to bring the scale down to look at what is happening internally within Sri Lanka itself. And what you find is that these binaries, these oppositions between West and East, they need to be dismantled because what is happening locally, in a sense is much more interesting. It is much more complex. This is why I said at the outset, Asian bioethics is about a position rather than an actual thing that you can go and point to. It’s the formulation of arguments which end up being about national cultural integrity. It’s about what you as Sri Lankans feel is appropriate for managing these things. It lies somewhere between simple acceptance of everything that the West throws out on the one hand, and radical nationalism which rejects everything Western on the other.DT: Thank you Bob. Could you also comment on teaching medical ethics in Sri Lanka, perhaps bringing in your experience in the UK also? BS: I think in my teaching career, I started off being very worried about where I was and if I knew enough, and as time went on, I realised that I don’t know enough. But the important question is not how much I know. It’s how much they know. In a sense, the peripheral visions methodology of listening to people, understanding where they are coming from, and where they are at, is all part and parcel of the same thing. It’s about starting where the people in front of you are. And if you could do that then they engage more positively. It’s a different kind of learning experience. It’s embodied; it’s emotional; it’s internalised. They get it. They understand. Because it’s starting where they are. In relation to medical ethics – I would need to be very careful here because I’m not a medical doctor, and I would not wish to dictate to medical professionals how they should teach medical ethics – but having had some involvement with medical ethics in the UK and Sri Lanka, one of the things that I felt was very interesting was that this idea of medical ethics is deeply interwoven in the technologies and practices of Western allopathic medicine. It’s often invisible. But medical ethics is not about dispensing formula. It’s about understanding yourself. It’s about understanding what your feelings are about, because you’re going to be dealing with things where you have to make decisions about other people’s wellbeing, about what is in somebody’s best interest. And these aren’t just abstract decisions. They are decisions that are based in a relationship. So I would think with medical ethics teaching it needs to go beyond giving instructions. We’re not just talking about technicians here. We’re talking about people who should be able to empathise with the sentiments and feelings of their patients.DT: Could you also speak a little about the concept of eye donation, blood donation, tissue donation? Reading that particular chapter, I realised that the way you look at the body is quite different from how I look at it. You go into detail about organs and organ donation. It is a very Buddhist kind of approach. One aspect of the book that I found most intriguing and exciting was how it started by asking people to think about technologies which hadn’t yet arrived but were kind of on the horizon: things like egg donation, sperm donation, and so on. BS: It was all moving forward in quite a piecemeal way. And to understand things people were using analogies. If you have something that is unknown, then as human beings we use metaphor or analogy to link it to things that we know about. And that helps us understand things that we don’t know about. So, when I’d ask a question say about sperm donation, people would be telling me about blood donation. Or they’d be telling me about eye donation. And I’d think “eye donation? What’s that all about?” So, I began to cultivate a relationship with the eye donation headquarters in Colombo and maintained that relationship over quite a number of years. And I was absolutely fascinated because of the rhetorical persuasiveness for people to adopt a particular position in relation to their body after death and what could be done with it. Something very different was going on in relation to the West. In the UK, for example, lots of campaigns will ask about which parts of your body you would be happy to donate. And the one that always gets a cross is eyes: “I don’t want my eyes to be taken, because the eyes are the windows to the soul”; “Taking the eyes away will disfigure the face.” These are the sorts of ideas that prevent people from wanting to donate corneas after death in Britain. People would have anything taken away but their eyes. So, I was amazed to find this in Sri Lanka. You’ve got over a million people having pledged to donate their corneas after death. Why is this? And I got into thinking about it. Then people explained to me that it was about daane; akshi daana. It was about a kind of donation of the eyes. So, when you start to look into the idea of daane a bit more closely, you stumble across the idea of just giving away one’s goods, so to speak. And then you get to daana upa paramitta which is commonly explained in terms of aes, his, mas, le (eyes, head, flesh, blood): I will give away parts of my body. Now, that’s something I’ve never come across in another tradition. I don’t know where it came from. I mean, it’s a very ancient thing in India – this idea of the body being divided up at death. But what you have here is an alignment between some very fundamental and powerful ideas within Buddhism, about daane and giving and how that relates to your karmic bank account, if I may use that expression, on the one hand; and this very modern thing about donation, using body parts to either save a life, improve the quality of a life, on the other. This is a very powerful conjunction. I hate to use the word ‘unique’, but there is something very special here. It struck me how it is all played out in Sri Lanka, which I think comes down again to the question of bioethics; very different ideas about the person, different ideas about death, different ideas about what happens afterwards. There’s something quite unique about eye donations. Something quite unique about post mortem body donation for medical teaching. It doesn’t happen in other places in quite the way that it does in Sri Lanka. And daane of course is a key element within that. Obviously, not all Buddhists would do that. But it is enough of an idea for it to be part of a kind of a cultural movement, a certain kind of shared value system around ideas of the body.DT: And how about India? Have you ever come across these kinds of activities in India? Especially eye donation. This is just out of curiosity I’m asking. Because I remember coming across this idea of a particular attitude towards the body and how it could be fragmented at death. BS: There’s the Sivi Jataka, which is an amazing story of how king Sivi wants to do a good deed. He wants to do the ultimate good thing which is to give his eye to a beggar, a blind beggar, and he takes his eye out and gives it to the beggar. But the blind beggar is of course God Sakra, the king of Gods, who then says “you’ve demonstrated your goodness and you will have the eye of omniscience forever and you will attain enlightenment” and so on. I think that this story was used as one of the primary influencing rhetorical tools for the initial eye donation campaign. Indeed Mrs. Bandaranaike donated her eyes. Eye donation has this incredible history of people at all levels doing it, and it’s very clever the way they do it. People sign the consent form and they put it up on the wall. If the person dies, they get on the phone and there’s a whole network of people involved afterwards; a guy will show up on his Honda 50 with an icebox on the back, and it’s actually becoming part of funeral practice. If somebody dies, you put the flags outside and you have the mala gedara (funeral house), and part of the routine is that you phone the eye donation people, and they come and take the eyes. The family may be watching, the children may be watching, while the eyes are removed. In the UK people would go “you can’t remove somebody’s eyes while the family are watching.” This would be outrageous! But it seems to happen here. And then there’s a sort of poster that is put up above the person’s coffin, with something to the effect that this person has made this remarkable sacrifice. It’s quite an extraordinary transaction that goes on. I think daane is underpinned by a certain logic here: that this is actually going to relieve the suffering of another and will bring back some karmic benefits for the donor.DT: Thank you Bob for that insightful discussion about your book and your work in Sri Lanka over two decades. I must also say we are grateful that you put your articles in one book as a gift for us. It shows what kind of ethical human being you are!