Dissecting Bioethics

‘‘Dissecting Bioethics,’’ edited by Tuija Takala and Matti Häyry,

welcomes contributions on the conceptual and theoretical dimensions
of bioethics.
The section is dedicated to the idea that words defined by
bioethicists and others should not be allowed to imprison people’s
actual concerns, emotions, and thoughts. Papers that expose the
many meanings of a concept, describe the different readings of
a moral doctrine, or provide an alternative angle to seemingly self-
evident issues are therefore particularly appreciated.
The themes covered in the section so far include dignity, natural-
ness, public interest, community, disability, autonomy, parity of
reasoning, symbolic appeals, and toleration.
All submitted papers are peer reviewed. To submit a paper or to
discuss a suitable topic, contact Tuija Takala at [email protected].

Relational Autonomy and Multiculturalism

FABRIZIO TUROLDO

The Rise of Autonomy came to the fore, resulting in moral

conflicts relating to autonomy. Further-
The principle of autonomy, through
more, in this period, some countries had
various court rulings, gradually became
proceeded with the compulsory sterili-
part of medical practice and tradition in
zation of the mentally retarded, raising
the second half of the 1800s, notably further conflict and discussions on the
when the emergence of surgical anaes- issue of autonomy. What irreversibly
thesia began to raise serious questions decided the indispensability of the right
regarding informed consent. In fact, to autonomy, however, was the scourge
surgical anaesthesia was initially used of Nazism, which inflicted Europe with
not only to avoid pain but also to combat all its violence and horrors in the 1930s
patients’ resistance to operations. Physi- and 1940s.
cians in the 1800s, as is well known, The Nuremberg trials in 1946 drew
believed that opposition to an effective the international community’s atten-
cure was a clear sign of incompetence tion to experiments carried out on
and were, for the good of that patient, human beings in Nazi concentration
permitted to proceed against his or her camps. Twenty doctors were among
will. In the late 1800s, American courts the accused. It was during this trial
were besieged by complaints of patients that the importance of the participant’s
who considered themselves unwitting informed consent was defined as a safe-
victims of surgery. In the early 1900s, the guard in the defense of autonomy.
issue of mandatory vaccinations also During the trials, certain fundamental

Cambridge Quarterly of Healthcare Ethics (2010), 19, 542–549.

Ó Cambridge University Press, 2010. 0963-1801/10 $20.00
542 doi:10.1017/S0963180110000496
Dissecting Bioethics

principles, comprising the ‘‘Nurem- one of the first ways of implementing

berg Code,’’ were established, the first autonomy, especially in cases of pre-
of which mandated that ‘‘the voluntary viously agreed upon DNR.
consent of human subjects is absolutely In the 1950s, the first automatic res-
necessary.’’ pirators were introduced in Denmark,
In the United States, meanwhile, pumping air into the lungs through
shocking cases of harmful experiments a tube in the trachea. These respirators
conducted without the subjects’ in- prolonged the lives of patients suffer-
formed consent had led to wider recog- ing from bulbar poliomyelitis and
nition of the principles of autonomy amyotrophic lateral sclerosis. This con-
and informed consent.1 The first case dition of prolonged life in a progres-
occurred in 1964, at the Jewish Chronic sively worsening condition recalls
Disease Hospital in New York, where the mythological figure of Tithonos,2
elderly patients were unwittingly inoc- whose beloved, the goddess Eos, asked
ulated with carcinogenic cells so doc- Zeus to give him eternal life but who
tors could study the development of realized later that she should also have
the disease. Similar experiments at asked for eternal youth. Therefore Titho-
New York’s Willowbrook State School, nos gradually became older and sicker,
a residential unit for orphans, between unable to die. The prospect of being
1959 and 1970 came to light in which reduced to this led to a widespread
children were inoculated with the hepa- movement in favor of the patient’s
titis virus for the same purpose. As right to decide when to stop a specific
recently as 1972, members of the treatment.3
African-American community in Tuske-
gee, Alabama, were selected and, without
What Kind of Autonomy? The
their knowledge, infected with syphilis,
Concept of Relational Autonomy
once again so its development could be
studied in the absence of treatment. Autonomy, as we have seen, is ex-
In the 1940s, the issue of autonomy’s tremely relevant. But once its impor-
importance was also highlighted by the tance has been recognized, numerous
introduction of new cardiopulmonary questions arise: for example, what kind
techniques, cardiotonic drugs (procaine of autonomy? Is autonomy an inherent
and adrenaline), and electric defibrilla- given or is it something we constantly
tion followed by external cardiac mas- strive to achieve? Can autonomy be
sage in the 1960s. Hospitals began absolute or does it need to be in re-
organizing teams of physicians, nurses, lation to others?
and technicians, specifically trained in It is obvious that we are not born
administering these new options. In autonomous and that through educa-
1974, the American Cardiologic Associ- tion our parents and society aim to
ation laid down resuscitation criteria, promote autonomy. As Immanuel Kant
discouraging its use in cases of irrevers- observed, the main difference between
ible terminal illness. Nevertheless, the a child and an adult is that the child is
adoption of the criteria resulted in much heteronomous whereas the adult is au-
controversy because, being imple- tonomous. In other words, a child finds
mented in emergencies, the criteria ig- the rule (nomos) of his moral conduct in
nored the patient’s real condition. another (eteron) person whereas adults
Therefore a new guideline emerged in are able to find this same rule (nomos) in
many hospitals: the ‘‘Do not resusci- themselves (auton). Psychology studies
tate’’ (DNR) order, which constituted also confirm this idea of a progressive

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and gradual growth toward autonomy. essary expenses? Who will care for any
The Swiss psychologist Jean Piaget, the children? Are there members who are
author of The Moral Judgment of the willing to assume more responsibility?
Child4 was a pioneer of these studies. These are relational issues, not medical
Piaget showed that children gradually ones, and during these discussions,
improve their capacity to be autono- patients become increasingly aware of
mous, shifting from moral behavior the limitations and boundaries of au-
based essentially on the authority of the tonomy. Step by step, autonomy moves
adult to more mature moral behavior from being an abstract concept to one
based on responsibility toward others that is real and concrete and finally to
and on objective moral rules. In this one that is ready to be implemented.
growth process, horizontal relationships
with other children have an extremely
important role, further to the vertical The Concept of Relational Autonomy
relationships with parents. Piaget’s stud-
in Contemporary Philosophy
ies were expanded by the American
psychologist Lawrence Kohlberg be- The concept that autonomy is relational
tween the 1950s and 1980s.5 rather than individual and could, there-
The process of becoming autono- fore, secure broader consent is a central
mous is never ending. We are not born issue in current philosophical debates,
autonomous, and we never defini- especially in the fields of moral and
tively conquer autonomy. This is why political philosophy.7 From a feminist
Kant, after describing the difference perspective that does not wholly reject
between children and adults, states the concept of autonomy, the accusa-
that even adults of his era felt an tion that the ideal of autonomy is in-
urgency to improve their capacity to herently masculinist8 or fundamentally
be autonomous. Therefore, as Kant individualistic and rationalistic9 has
pointed out, the main task of enlight- been comprehensively explored. Jenni-
enment was to help humanity in this fer Nedelsky was the first to review the
never ending process of conquering concept of autonomy, going beyond
autonomy.6 its individualistic and rationalistic un-
This process of developing autonomy derstanding, and thus challenges other
can also be found in healthcare. When feminist perspectives that regarded
patients go to a physician with a certain this concept with suspicion. Nedelsky
health problem, they are not prepared reconceptualized individual autonomy
to make a decision. They first need to as relational autonomy, recognizing the
know the exact nature of their problem extent to which people are socially
and what their options are in terms of embedded and the fact that their iden-
medical treatment and so forth. In the tities are shaped within the context of
process of understanding their situa- social relationships and social deter-
tion, and by means of discussions with minants, such as ethnicity, class, reli-
their physician, patients gradually be- gion, race, and gender.10 Other feminist
come more and more autonomous. thinkers, like Nancy Chodorow,11
However, often this relationship is not Virginia Held,12 and Evelyn Fox
enough for patients to be sufficiently Keller,13 found that this concept held
autonomous. To undergo important much promise if reconceptualized to
medical treatment, patients might need avoid being defined in opposition to
to discuss practical issues with their both femininity and relations of depen-
families: Can the family afford the nec- dence and connection.

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Nevertheless, Catriona Mackenzie autonomy and is emblematic in that it

and Natalie Stoljar, although appreci- represents many other similar cultures,
ating the efforts of feminist thinkers to whether African, Asiatic, or even Med-
reconceptualize autonomy, criticized iterranean. Although holding different
the outcome of this circumscribed re- values from North American and
conceptualization of autonomy that fo- European culture, at the same time, as
cused primarily on intimate dyadic a result of contemporary medical tech-
relations, particularly between mother nology, it is faced with the same ethical
and child. In Mackenzie and Stoljar’s challenges. One could even go as far as
view, these limited perspectives failed to say that, by looking at Japanese
to address the complex effects of oppres- culture, we are able to foresee what
sion on agents and the social dimensions the future holds for other cultures with
of agency and selfhood.14 Together, fem- values similar to those of the Japanese,
inist critiques of traditional notions of but which have not yet had to confront
autonomy, along with the feminist need the same ethical questions posed by
to recognize the importance of autonomy new technology.
in protecting the agent against oppres- In their article describing cancer
sive socialization, provided the main treatment in Japan,17 Susan and Bruce
impetus for a relational approach to Long report that the diagnosis is usu-
autonomy.15 ally only revealed to the family, espe-
cially when the patient is terminally ill.
In Japan, the paradigm for dealing
The Multicultural Context: Different
with a confirmed cancer diagnosis
Ways of Conceiving Autonomy and
seems to be encapsulated in the state-
Relations
ment: ‘‘If it’s curable it’s cancer, if it’s
Unlike in North America and Europe, terminal it’s something else.’’ The fact
in other societies, individual autonomy that in Japan the patient’s autonomy is
does not play as central a role. In not considered the supreme value is
differing cultural contexts, relational also confirmed in an article written
autonomy is morally more acceptable by Japanese authors, who asked 654
than individual autonomy. Further- physicians and medical students in
more, in these cultures, when we talk the Yamaguchi Prefecture what they
about relational autonomy, the stress is would do if indispensable life-saving
more often on relation than on auton- medical treatment was rejected by the
omy. In the Far East, in Africa, and patient. The result was that 40% said
even in some minority groups within that they would override the patient’s
Western societies, other values are con- wishes and proceed with treatment
sidered more important. The work of with the family’s consent.18
Blackhall and Carrese as well as many Another study19 compares attitudes
others is a reminder of the fact that the toward ethical decisionmaking and au-
typical Western emphasis on the tonomy issues among academic and
patient’s autonomy and individualism community physicians and patients in
is, from a global point of view, the Japan with those in the United States.
exception and not the rule.16 The study shows that the majority of
both U.S. physicians and patients, as
opposed to a minority in Japan, agree
The Japanese Case
that in the event of a patient being
Japanese culture offers a particularly diagnosed with incurable cancer, the
interesting perspective with regard to patient should be informed before the

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family. On the other hand, a majority of anthropologist Emiko Ohnuki-Tierney

Japanese respondents agree that the states.21
family of an HIV-positive patient should Michael D. Fetters, Director of the
be informed despite the patient’s oppo- University of Michigan’s Japanese
sition to such disclosure, in contrast to a Health Program and a physician who
minority of U.S. respondents. This study routinely treats Japanese expatriates
demonstrates that Japanese physicians in his clinical practice in the United
and patients rely more on family and States, defines the concept of auton-
physician’s authority while placing less omy in Japanese culture as ‘‘family
emphasis on patient autonomy than autonomy,’’ a notion that is remarkably
U.S. physicians and patients. similar to our ‘‘relational autonomy.’’
In an article on critical care ethics in ‘‘Given the traditional importance of
Japan, three Japanese authors describe the family,’’ Fetters says, ‘‘it is unlikely
exactly what Japanese people mean by that (in Japan), at least for the imme-
‘‘respectful treatment’’: diate future, respect for patient auton-
omy as conceptualized in Western
Respectful treatment is different in
Japan from what it is in Western
bioethics will be the only model.’’22
culture. It is expressed in the word Ruiping Fan confirms this idea in a spe-
motenashi. If a person is highly re- cial issue of The Journal of Medicine and
spected, he or she is not supposed Philosophy focusing on ‘‘Critical Care in
to be bothered by anything. The Asia’’:
respected person does not have to
Asian people do not practice self-
make any decisions because deci-
determination in the explicit fashion
sion-making is always accompanied
required in the West. Rather, they
with risks and responsibilities. Every-
engage in the family-determination of
thing should be as the person likes
medical decision-making.. . .. The East-
without the individual ordering any-
ern cultural assumption is that a family
body to do anything. For example, in
member’s disease is an issue for the
the Meiji era, the emperor controlled
whole family. Special fiduciary obliga-
Japan with the prime ministers; and
tions are recognized: the family must
the duty of the prime ministers was to
take care of the sick. This is appreciated
help the emperor as he wished without
as removing burdens from the patient,
asking him what he wanted. If every-
including the burden of listening to
thing went well, it was the achievement
medical information from a physician
of the emperor. If anything went wrong,
or signing treatment procedures. In-
it was the fault of the prime ministers.
stead, a family representative must talk
Another example is welcoming guests.
with the physician and make every-
In Japan guests should be served what
thing work smoothly in the best interest
they want without telling the hosts
of the sick.23
what they like. Asking guests what they
like is regarded as rude. Guests should
not have to say a word to obtain exactly
what they like. This is the ideal way of The Chinese Case
treating a respected person. Treating
a patient in the ICU is similar.20 Chinese culture is similar to Japanese
culture, and China shares some reli-
This particular attitude could be ex- gious background with Japan. Confu-
plained by the fact that, in Japanese cianism, for example, is deeply rooted
culture, a person is structurally defined in both societies and, from a Confucian
in relation to others instead of being an point of view, man is unable to conceive
independent, individual person, as the of his existence as being possible and

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worthy outside society, its institutions, autonomy is only acceptable within

and rules. A Chinese scholar, reflecting a small and narrowly defined group
upon Confucian values and medical of cultural environments? Such a con-
technologies, states that ‘‘keeping fa- clusion does not take into account that,
milial integrity and orderly familial as much as individuals might be sup-
relations may be even more important ported by their collective identity, it
than keeping bodily integrity for Con- might also be oppressive in that they
fucianism.’’24 This statement is echoed might feel obliged to accept their
by another Chinese author, who re- group’s choices, contrary to their will
marks that, ‘‘in traditional Chinese or beliefs. This is why Moller-Okin
ethics, a person is relation-based’’25 criticizes multiculturalism, saying that
and, therefore, ‘‘this means that it is it defends culture’s rights while ignor-
the ethical relations that make a person ing the vulnerability of more fragile
what he is.’’26 In traditional Chinese individuals, such as women.29 This is
thought, ‘‘the essence of a person lies true, particularly in a patriarchal society,
in how that person can group with where the aforementioned concept of
other persons.’’27 ‘‘family autonomy’’ may imply that the
In spite of the fact that it has been husband decides for his wife and not
influenced by the West for a long time, vice versa. Therefore Moller-Okin pro-
in Hong Kong, Chinese traditional val- poses that extolling cultural differences
ues are still deeply rooted in its pop- does not necessarily mean ignoring
ulation, as shown in an article on the realities within these different
critical care ethics in Hong Kong: cultures.30
In Moller-Okin’s opinion, in order to
Individual rights, autonomy and self-
determination, while important ele-
avoid intolerant multiculturalism it is
ments of Western culture, are not not only necessary to recognize the
emphasized in traditional Chinese rights of different cultures but also
culture. Instead, the Chinese usually those of the individual. In fact, if we
treasure the individuals’ responsi- only recognize the rights of cultures,
bility towards their families, as well we then legitimize cultures that op-
as respect for parents and older gen- press their single members, because
erations. In contrast to the western they do not recognize the individuals’
belief in self-determination, the tradi- rights to distance themselves from
tional Chinese family prefers to keep their culture and their right to re-
‘‘bad’’ news, like incurable terminal
nounce it, if they so choose. Michael
diseases, from the patient. . . . Doctors
Fetters, in his article on Japanese fam-
in our community always need to
consult and discuss with the patient’s ily decisionmaking, relates the story of
family whether telling the truth to ‘‘a young Japanese woman afflicted
a particular patient is desirable.28 with cancer, who chose to stay in the
United States, as she felt uncomfort-
able with the approach to cancer man-
agement in Japan,’’31 a clear example of
The Limits of Multiculturalism and
willingness to distance oneself from
the Need for Autonomy
a cultural pattern. Reflecting upon this
What conclusions can be drawn from case, Fetters says that ‘‘the clinician
analyzing the aforementioned studies must resist the assumption that a patient
on the diversity of Japanese and will anticipate a model of family auton-
Chinese cultures? Would it be fair to omy or paternalism simply because the
say that the principle of individual patient’s associated culture is generally

547
Dissecting Bioethics

known not to exercise respect for the 21st Century. Baltimore, MD: Frederick
patient autonomy.’’32 Press; 1996.
2. In the Homeric Hymn to Aphrodite, Aphrodite
We can therefore conclude that cul- tells Anchises the story of Eos and Tithonos.
tures alone do not possess rights; only See Homer. Hymn to Aphrodite, verses 218–
individuals have rights, and among 240, translated by G. Nagy; available at
these rights, there is also the right to http://www.uh.edu/~cldue/texts/
renounce individual autonomy in fa- aphrodite.html (last accessed 30 June 2009).
3. ‘‘Eos syndrome’’ has been defined as the
vor of other important values such as, capability of high-technology medicine to
for example, trusting in a good physi- alter the dying process and prolong low-
cian, family relations, the authority quality life. See Zamperetti N, Bellomo R,
of medical science, and so forth. This Dan M, Ronco C. Ethical, political, and social
perspective is generally called ‘‘liberal aspects of high-technology medicine: Eos and
care. Intensive Care Medicine 2006;32:830–5.
multiculturalism’’33 and, in the view 4. Piaget J. The Moral Judgment of the Child.
presented here, is the only perspective New York: Routledge; 1999.
on multiculturalism that does not op- 5. See Kohlberg L. Stage and sequence: The
press the individual’s rights and is cognitive-developmental approach to social-
therefore the best interpretation of the ization. In: Goslin D, ed. Handbook of Socializa-
tion. Theory and Research. Chicago: Guilford
notion of ‘‘relational autonomy.’’ Press; 2006 [1969]:347–480; Kohlberg L. Essays
on Moral Development (2 vol.). San Francisco:
Harper & Row; 1981–4.
Conclusions
6. Kant I. Beantwortung der Frage: Was ist
What contributions do the above Aufklärung? [Answering the question: What
is enlightenment?]. Berlinische Monatsschrift
reflections on liberal multiculturalism
[Berlin Monthly]; December 1789.
make to current relational autonomy 7. See, for example, Sandel M. Liberalism and the
issues? One could conclude that, al- Limits of Justice. Cambridge: Cambridge Uni-
though the possibility of exercising versity Press; 1982; Kymlicka W. Contem-
autonomy should be universally of- porary Political Philosophy. Oxford: Oxford
University Press; 1990; Benhabib S. Situating
fered, it should never be universally
the Self: Gender, Community and Postmodernism
compulsory, thereby recognizing one’s in Contemporary Ethics. New York: Routledge;
right to entrust one’s life to other 1992.
people and to renounce autonomy in 8. For a radical critique of autonomy as a sex-
the name of other important values, based concept, see Christman J. Feminism
and autonomy. In: Bushnell D, ed. Nagging
such as interdependence, solidarity,
Questions: Feminist Ethics in Everyday Life.
and trust. Herein, the true meaning of Lanham, MD: Rowman & Littlefield; 1995;
relational autonomy lies in an auton- Hoagland SL. Lesbian Ethics: Toward New
omy that is not a slave to itself and in Value. California: Institute of Lesbian Studies;
which relations are not perceived as 1998.
9. See Code L. Second persons. In: Code L. What
limitations but as a means of self-re-
Can She Know? Feminist Theory and the
alization. In other words, autonomy Construction of Knowledge. Ithaca, NY:
can flourish through relations, but only Cornell University Press; 1991; Baier A.
if relations are autonomously chosen. Cartesian persons. In: Postures of the Mind:
Essays on Mind and Morals. Minneapolis:
University of Minnesota Press; 1985; Jaggar
Notes A. Feminist Politics and Human Nature.
Totowa, NY: Rowman & Allanheld; 1983.
1. See Ackerman TH. Choosing between 10. See Nedelsky J. Re-conceiving autonomy:
Nuremberg and the National Commission: Sources, thoughts and possibilities. Yale
Balancing of moral principles in clinical Journal of Law and Feminism 1989;1:7–36;
research. In: Vanderpool HY, ed. The Ethics Nedelsky J. Law, boundaries and the
of Research Involving Human Subjects: Facing bounded self. Representations 1990;30:162–89;

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Nedelsky J. Re-conceiving rights as relation- Contemporary Japan—An Anthropological View.

ship. Review of Constitutional Studies 1993;1: Madison, WI: Cambridge University Press;
1–26; Nedelsky J. Meditations on embodied 1984:51–74.
autonomy. Graven Images 1995;2:159–70. 22. Fetters MD. The family in medical decision
11. See Chodorow N. The Reproduction of making: Japanese perspectives. The Journal of
Mothering. Berkeley: University of California Clinical Ethics 1998,9:143.
Press; 1978. 23. Fan R. Critical care ethics in Asia: Global or
12. Held V. Feminist Morality. Chicago: Univer- local? Journal of Medicine and Philosophy 1998,
sity of Chicago Press; 1993. 6:556–7; see also Fan R. Self-determination vs
13. Keller EF. Reflections on Gender and Science. family-determination: Two incommensurable
New Haven, CT: Yale University Press; 1985. principles of autonomy. Bioethics 1997;11:
14. See Mackenzie C, Stoljar N. Autonomy 309–22.
refigured. In: Mackenzie C, Stoljar N, eds. 24. Qiu RZ. The tension between biomedical
Relational Autonomy. Feminist Perspectives on technology and Confucian values. In: Tao
Autonomy, Agency, and the Social Self. Oxford: JLP-W, ed. Cross-Cultural Perspectives on the
Oxford University Press; 1999:3–31. (Im)possibility of Global Bioethics. Dordrecht:
15. For an interesting exposition of different con- Kluwer Academic Publishers; 2002:77.
ceptions of relational autonomy, see Friedman 25. Xinhe H. On relational paradigm in bioethics.
M. Autonomy and social relationships: Re- In: Tao JLP-W, ed. Cross-Cultural Perspectives
thinking the feminist critique. In: Tietjens on the (Im)possibility of Global Bioethics.
Meyers D, ed. Feminists Rethink the Self. Dordrecht: Kluwer Academic Publishers;
Boulder, CO: Westview; 1997:55–8. 2002:97.
16. Blackhall L, Murphy ST, Frank G, Michel V, 26. See note 25, Xinhe 2002:97.
Azen S. Ethnicity and attitudes towards 27. See note 25, Xinhe 2002:97.
patient autonomy. JAMA 1995;274:820–5; 28. Cheng F, Ip M, Wong KK, Yan WW. Critical
Carrese J, Rhodes L. Western bioethics on care ethics in Hong Kong: Cross-cultural
the Navajo reservation: Benefit or harm. conflicts as East meets West. The Journal of
JAMA 1995;274:826–9. Medicine and Philosophy 1998;23: 616–27.
17. Long SO, Long BD. Curable cancers and fatal 29. Moller-Okin S. Is multiculturalism bad for
ulcers: Attitudes toward cancer in Japan. women? In: Cohen J, Howard M, Nussbaum
Social Science and Medicine 1982;24:2101–18. MC, eds. Is Multiculturalism Bad for Women?
18. Hattori H, Salzberg SM, Kiang WP, Fujimiya Princeton, NJ: Princeton University Press;
T, Tejima Y, Furuno J. The patient’s rights to 1999.
information in Japan: Legal rules and doc- 30. Moller-Okin S. ‘‘Political liberalism,’’ justice
tor’s opinions. Social Science and Medicine and gender. Ethics 1994;105:23–43.
1991;32:1007–16. 31. See note 25, Fetters 2002:142.
19. Ruhnke GW, Wilson SR, Akamatsu T, Kinoue 32. See note 25, Fetters 2002:142.
T, Takashima Y, Goldstein MK, et al. Ethical 33. Will Kymlicka and Jürgen Habermas are
decision making and patient autonomy. A among the upholders of liberal multicultur-
comparison of physicians and patients in alism (see Kymlicka W. Liberalism, Commu-
Japan and the United States. Chest 2000; nity and Culture. Oxford: Oxford University
118:1172–82. Press; 1989; Habermas J. Struggles for recog-
20. Nakata Y, Goto T, Morita S. Serving the nition in the democratic constitutional state.
emperor without asking: Critical care ethics In: Gutmann A, ed. Multiculturalism: Exam-
in Japan. The Journal of Medicine and ining the Politics of Recognition. Princeton, NJ:
Philosophy 1998;23:610. Princeton University Press; 1994). Jurgen
21. Ohnuki-Tierney E. My very own illness: Habermas’s proposal of multiculturalism
Illness in a dualistic world view. In: pursuing a ‘‘universalism sensible to differ-
Ohnuki-Tierney E, ed. Illness and Culture in ences’’ is also extremely interesting.

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