Bioethics and democracy in developing countries
In BMC Medical Ethics (free online access here), Ghaiath Hussein takes a shot at an answer. And his answer is: politics. The flourishing of bioethics, according to Hussein, depends on a number of political factors that are not present, or only faintly present, in developing countries. The first is an 'atmosphere of freedom' where people can engage in moral reasoning without fear of censorship of or punishment for their beliefs. That atmosphere of freedom in turn depends on a socio-legal framework in which the rights, duties and responsibilities of individual citizens -- both in regard to health and other important values -- are spelled out, understood by the populace, and protected by legislative and judiciary systems. Of course, the development of bioethics is aided to some extent by economic factors, in particular the progress in health systems development and creation of medical technologies. But these would not give rise to bioethics debates they did not engage with public expectations of receiving decent medical care, and citizens having some say in health policy decisions.
It is easier to see what Hussein is saying by reflecting on the place of bioethics within totalitarian or politically oppressive regimes. Where there is little press freedom, there will be less (and less diverse) public debate about controversial issues in medical research and practice. Where those working in bioethics are regarded as 'human rights activists' and subject to special state scrutiny, it will be difficult to motivate people to pursue these interests. Where people think of health care as a 'gift', and death as a common (and mostly unavoidable) event, the provision of sub-standard medical services will not be regarded as a failure of government and a moral outrage. Where Ministries of Health have historically acted (or currently act) as an arm of an oppressive state, and are as corrupt as any other branch of government, there will be little public trust in ethical codes, regulations, licencing boards, or ethics committees that are attached to these ministries or have received their seal of approval. All of these factors, according to Hussein, have diminished the impact of bioethics in many developing countries, and have reduced it to a mere academic pursuit, tolerated by the powers that be because it is poses no threat to them.
Hussein suggests that bioethics, in some places, is a deeply subversive activity. If real bioethical activity took place in some developing countries (he includes his own Sudan), there would be an ugly and dangerous clash with the established political order. So he suggests a softer approach: depict bioethics as a mere aid to decision-making (rather than embodying important rights and values); couch bioethics in religious or religious-friendly terms; adapt bioethics to local contexts rather than depict it as a fancy 'Western' import. Once it is conceptualized this way, it becomes clearer how long and difficult the road will be before bioethics becomes a social force in developing countries.