Kathryn Muyskens

The dominance of ableist assumptions in precision medicine has recently been challenged, notably by Mintz, Stramondo, and Tabor (2024). Yet a similarly radical critique exists in Daoist traditions, particularly in the philosophy of Zhuangzi. While Mintz, Stramondo, and Tabor call for greater disability inclusion in genetics and genomics, they do not fully engage with how cultural and philosophical worldviews shape responses to genetic intervention. Drawing on our research on preimplantation genetic testing for monogenic disorders (PGT-M), we argue that concepts like ziran (自然naturalness) and wuwei (無為non-action) can deepen our understanding of disability inclusion, particularly in Asian contexts. The comparatively restrictive approval of PGT-M in Asia reflects cultural discomfort with disrupting what is seen as nature’s course. Zhuangzi’s allegories—especially those illustrating “the usefulness of the useless”—challenge dominant hierarchies of ability and provide clinicians with tools to engage more sensitively with patients who may see genetic testing as ethically troubling. This paper integrates Daoist insights to propose a globally inclusive bioethics, one that affirms non-intervention as a legitimate stance and broadens how we conceive of naturalness, disability, and autonomy. By doing so, we aim to enrich debates around precision medicine and support ethically pluralistic genomic care.

Contemporary Western bioethics, informed by liberalism and utilitarianism, has developed alongside a proactive, interventionist model of medicine marked by the assumption that every illness has a cure and that pain is unnecessary. In contrast, medical practice in much of Asia reflects different philosophical roots. One of these, Daoism, embraces a very different attitude towards medical intervention. Within Daoist philosophy, the unique understanding of naturalness or spontaneity ( ziran, 自然) helps illuminate some anti-interventionist trends within medical practice in parts of Asia historically influenced by this tradition. We illustrate this through the relatively low uptake of epidural use among expectant mothers in Japan. Although Daoism originated in China, Daoist concepts influenced the formation of Zen Buddhism through the historical transmission of Chinese philosophy and medicine, particularly during the Tang and Song periods. Although often subtle, this influence has shaped modern cultural attitudes discussed below. Philosophical Daoism is usually discussed in relation to two main texts, the Laozi and the Zhuangzi. ‘Dao’ (道) is understood as the metaphysical source of all things and the guiding principle of nature. A closely related concept is ‘ziran’ (自然), often translated as spontaneity, naturalness or being ‘self-so’. If Dao is the guiding principle, ziran is the way it is expressed in the natural world. Importantly, ziran exists at multiple levels: an overarching ‘ziran’ of nature and a personal ‘ziran’ of each individual. In Daoist philosophy, there is a strong belief in the inherent goodness of nature and going with the flow of nature is often held up as an ethical ideal. Along with this, the concept of health is often understood less as the elimination of disease and more as …

Interest in the integration of traditional and biomedical health practices is growing globally, as indicated by the WHO’s 2023 global summit on traditional medicines. The place of traditional medicines in a biomedical health system is also gaining attention locally in the Singaporean context, where recent health policy changes have emphasised an integrative approach that prioritises continuity of care to improve health outcomes. Yet, this drive towards increasing integration between different medical paradigms presents ethical and philosophical challenges that are underexplored. In addition to the familiar worries about efficacy, risks of drug-herb interaction and the efficient use of resources, this paper argues that integration efforts must also contend with deeper ontological and normative divides that exist between medical paradigms. For the purposes of our discussion, we focus on traditional Chinese medicine and biomedicine within Singapore. While we do not go so far as to argue that these identified challenges are insurmountable, we claim that they must be made explicit, understood and responded to before the aim of integrating traditional and biomedical practices can be realised effectively. We conclude by proposing new orientations for collaborative practice between divergent medical traditions.

Sergio Canavero made headlines in 2017 for a controversial medical procedure – the world’s first human head transplant (HHT). Though the operation was only carried out on a corpse, and has yet to be successfully tested on any living person (if it ever is) the mere possibility itself raises serious questions for the philosophy of personal identity as well as form medical ethics in general. This paper explores an often neglected perspective on this intersection of personal identity and bioethics: the Confucian tradition. While most existing debates are framed through Western metaphysical and individualistic ethical assumptions, Confucianism offers a fundamentally different account of what persons are and what medicine is for – one that shifts the terms of the discussion in interesting and profound ways. Confucianism’s relational conception of identity and role-based ethical framework provide a unique take on the questions of who the post-transplant person would be, and what counts as legitimate medical intervention. Understanding these differences is important beyond merely increasing cross-cultural understanding, but for expanding the normative tools available to contemporary transplant ethics and revealing assumptions that standard Western approaches often leave unexamined. Ultimately, we argue Confucianism would treat HHT as impermissible – not due to metaphysical or religious objections, but because (given the foreseeable medical consequences) it does not preserve the embodied, relational, and functional conditions necessary for moral cultivation and the good human life.

In this paper, we set out to examine the implications of a Daoist philosophical perspective within the clinical encounter. Specifically, we will explore how the unique and sometimes radical views of the Ancient Daoist philosopher Zhuangzi (and the concepts of ziran 自然 “nature” or “spontaneity”, the fasting of the “heart-mind” cheng xin 成心, and wuwei 無為 “non-action”) can invite us to reframe and reconceptualize some of the common assumptions that currently govern the doctor-patient relationship, as well as prompt us to reflect anew upon the proper goals and scope of medical practice itself. We take the view that ethics need not be limited to a set of rules. Ethics can be thought of as a set of skills and abilities that include perspective taking, tolerance and openness to experiences. This allows us to explore and critically engage with Zhuangzi’s unique philosophy and appreciate its contribution to the bioethics literature, in particular with its applications in caring for patients with disability and chronic illness. Our analysis leads us to coin the term “reciprocal-emerging” to express the dynamic and transformational of nature of the doctor-patient relationship through a Zhuangzian lens.

Debates in public health ethics have been dominated by the assumptions of Western liberalism: a priority given to liberty and autonomy over other values, an individualistic view of social ontology, a focus on personal responsibility, a minimal set of obligations (only created through consent), and a marginalization of social, cultural, and religious context. Examining issues in public health ethics from the perspective of a different moral tradition reveals that such assumptions are not timeless truths, but rather choices that require justification. In this paper, we briefly outline a view of Confucianism and explore how this approach can be used to articulate a critical approach to much contemporary public health ethics. Confucianism suggests a radically different perspective toward obligations, agency, and responsibility, as well as a more relational conception of social ontology and a shared notion of well‐being. Of course, some discussion in public health ethics, within the constraints of Western traditions, has pushed in this direction before. In offering a Confucian perspective on public health ethics, we are not suggesting that Confucianism is the one true approach to ethics and that everyone should become a Confucian. We are, however, seeing our discussion as a source of epistemic critique of Western liberalism, exposing the need for more active defense of assumptions at its core, as well as providing an opportunity to broaden the set of values that inform justifiable public health policy.

The WHO has recently been advocating for a more inclusive approach within healthcare systems, urging the integration of traditional medicines with biomedicine. Which traditions are perceived as authentic, authoritative or legitimate is as much a political question as it is a conceptual or scientific one. This paper will pose the question: is integration in fact desirable? Proponents may argue that integration will produce a number of benefits: more efficient use of healthcare resources, greater range of patient choice, and respect for the intellectual contributions of traditional medicines. Yet, I will argue that given the deep ontological divides across traditions, traditional medical practices are often incommensurable with biomedical paradigms, meaning integration is ultimately infeasible. Furthermore, to the extent that integration is pursued, it is likely to replicate colonial attitudes toward indigenous practices and repeat rather than remedy the very forms of epistemic injustice it would claim to avoid.

Some countries are legalizing same‐sex marriage and assisted reproductive technologies (ART) for homosexual couples. One unique form of ART, ROPA (Reception of Oocytes from Partner), recently stirred up controversy in China, when a custody dispute between a female same‐sex couple who used ROPA brought this reproductive model into the public eye. Some Western scholars have argued for the legitimacy of ROPA from the perspective of autonomy and reproductive rights. Yet, these arguments do not easily translate into all cultural contexts, as this case will show. There is a need to articulate the ethical considerations of such technologies in light of local philosophical traditions. To that end, this paper will explore the permissibility of ROPA from a Confucian lens, exploring Confucian perspectives on naturalness, filial piety, family and social harmony. Accordingly, we hope to further the discussion of cross‐cultural bioethics.

Epistemic humility has garnered increased attention in recent years, including within the realm of clinical ethics and is increasingly accepted as an important part of patient-centred practice and clinical care. However, while literature on the topic often states what epistemic humility isnot, there have been few positive definitions given for the term. Further, these few positive definitions downplay the relational nature of epistemic humility, in other words, the ways in which epistemic humility is developed within the clinical encounter through the relationship between doctor and patient. In this paper, we will present a positive account of epistemic humility, situated in ethical medical education and practice, and show how it can be identified, modelled and cultivated. We provide a character-based account of epistemic humility that emphasises the relational nature of epistemic humility, that is, that views epistemic humility as formed through relationships rather than solely inhering in an individual’s internal mental processes or external presentation and which is embedded in a social context such as a clinical encounter.

A significant and important ethical tension in resource allocation and public health ethics is between utility and equity. We explore this tension between utility and equity in the context of health AI through an examination of a diagnostic AI screening tool for diabetic retinopathy developed by a team of researchers at Duke-NUS in Singapore. While this tool was found to be effective, it was not equally effective across every ethnic group in Singapore, being less effective for the minority Malay population than for the Chinese majority. We discuss the problematic normative nature of bias in health AI and explore the ways in which bias can interact with various forms of social inequalities. From there, we examine the specifics of the diabetic retinopathy case and weigh up specific trade-offs between utility and equity. Ultimately, we conclude that it is ethically permissible to prioritise utility over equity where certain criteria hold. Given that any medical AI is more likely than not to have lingering bias due to bias in the training data that may reflect other social inequalities, we argue that it is permissible to implement an AI tool with residual bias where: (1) its introduction reduces the influence of biases (even if overall inequality is worsened), and/or (2) where the utility gained is significant enough and shared across groups (even if unevenly).

Artificial intelligence (AI) has attracted an increasing amount of attention, both positive and negative. Its potential applications in healthcare are indeed manifold and revolutionary, and within the realm of medical imaging and radiology (which will be the focus of this paper), significant increases in accuracy and speed, as well as significant savings in cost, stand to be gained through the adoption of this technology. Because of its novelty, a norm of keeping humans “in the loop” wherever AI mechanisms are deployed has become synonymous with good ethical practice in some circles. It has been argued that keeping humans “in the loop” is important for reasons of safety, accountability, and the maintenance of institutional trust. However, as the application of machine learning for the detection of lumbar spinal stenosis (LSS) in this paper’s case study reveals, there are some scenarios where an insistence on keeping humans in the loop (or in other words, the resistance to automation) seems unwarranted and could possibly lead us to miss out on very real and important opportunities in healthcare—particularly in low-resource settings. It is important to acknowledge these opportunity costs of resisting automation in such contexts, where better options may be unavailable. Using an AI model based on convolutional neural networks developed by a team of researchers at NUH/NUS medical school in Singapore for automated detection and classification of the lumbar spinal canal, lateral recess, and neural foraminal narrowing in an MRI scan of the spine to diagnose LSS, we will aim to demonstrate that where certain criteria hold (e.g., the AI is as accurate or better than human experts, risks are low in the event of an error, the gain in wellbeing is significant, and the task being automated is not essentially or importantly human), it is both morally permissible and even desirable to kick the humans out of the loop.

This article discusses the application of artificially intelligent robots within eldercare and explores a series of ethical considerations, including the challenges that AI (Artificial Intelligence) technology poses to traditional Chinese Confucian filial piety. From the perspective of Confucian ethics, the paper argues that robots cannot adequately fulfill duties of care. Due to their detachment from personal relationships and interactions, the “emotions” of AI robots are merely performative reactions in different situations, rather than actual emotional abilities. No matter how “humanized” robots become, it is difficult to establish genuine empathy and a meaningful relationship with them for this reason. Even so, we acknowledge that AI robots are a significant tool in managing the demands of elder care and the growth of care poverty, and as such, we attempt to outline some parameters within which care robotics could be acceptable within a Confucian ethical system. Finally, the paper discusses the social impact and ethical considerations brought on by the interaction between humans and machines. It is observed that the relationship between humans and technology has always had both utopian and dystopian aspects, and robotic elder care is no exception. AI caregiver robots will likely become a part of elder care, and the transformation of these robots from “service providers” to “companions” seems inevitable. In light of this, the application of AI-augmented robotic elder care will also eventually change our understanding of interpersonal relationships and traditional requirements of filial piety.

Culture, health, and medicine intersect in various ways—and not always without friction. This paper examines how liberal multicultural states ought to interact with diverse communities which hold different health-related or medical beliefs and practices. The debate is fierce within the fields of medicine and bioethics as to how traditional medicines ought to be regarded. What this debate often misses is the relationship that medical traditions have with cultural identity and the value that these traditions can have beyond the confines of the clinical setting. This paper will attempt to bring some clarity to the discussion. In so doing, it will delve into some controversial areas: (1) the debate around whether liberal states ought to embrace multiculturalism, (2) the existence and nature of group-differentiated rights, (3) the question of whether healthcare systems ought to embrace medical pluralism, and (4) what this would entail for policymakers, clinicians, and patients. Ultimately, I argue that liberal democratic states with multicultural populations ought to recognize medical pluralism as a matter of respecting group-differentiated and individual human rights.

The human right to health, insofar as it is widely recognized, is typically thought to include the right to fair access to adequate healthcare, but the operating conception of healthcare in this context has been under-defined. This lack of conceptual clarity has often led in practice to largely Western cultural assumptions about what validly constitutes “healthcare” and “medicine.” Ethnocentric and parochial assumptions ought to be avoided, lest they give justification to the accusation that universal human rights are mere tools for Western imperial agendas. At the same time, a right to healthcare that is not also explicitly the right to effective healthcare rapidly loses meaning. This paper strives to provide an account of medicine with the flexibility to accommodate cultural difference in forms of practice, while also aiding in the articulation of a minimum for medical systems to meet the standards set out in a human right.

Until now, it has mostly been assumed that the kind of health the human right to health is concerned with is clearly understood and universal. Here, I question this assumption and offer an explicitly political and pluralistic account of health that is designed to help guide international and cross-cultural interventions on behalf of health. In order to be a useful mechanism of accountability, the human right to health needs an enforceable minimum standard of health by which to judge situations and to determine if a violation of rights has occurred, but due to its international nature, it also needs to admit a large degree of cultural flexibility. With the account of health that I provide, I hope to clarify what makes up that minimum standard in a way that avoids unjustified parochial bias, while not being so permissive as to undermine the political force of a universal human right.

As political instruments, human rights can be challenged in two important ways: first, by undermining the claim to universality by appealing to a kind of cultural relativism, and second, by accusing human rights of unjustifiably imposing values that are not genuinely universal (which I dub the problem of parochialism). The human right to health is no exception. If a human right to health is to be a useful instrument in mobilizing action for global health justice, then we need to take seriously the ways that health intersects with culture. Universal applicability is essential to both the legitimacy and efficacy of human rights. But without cultural sensitivity, additional injustices and imperialistic harms may be perpetuated. There are two goals within this paper—(1) to show that cultural imperialism is a moral and practical hazard, both in general and for the human right to health in particular and (2) to articulate a way of thinking about the human right to health that can minimize these hazards and arm it with moral credibility and political weight.

A common understanding of the political function of human rights is as a trigger for international intervention, with states typically understood to be duty bound by these rights claims. The unique character of the human right to health raises some complications for these conventional views. In this paper, I will argue that because of the unique character of the human right to health, intervention on its behalf can be justified not only in response to outright violation, but also due to unmet needs of populations. As a secondary goal of this paper, I will attempt to respond to some of the worries about cultural imperialism in human rights and cross-cultural humanitarian interventions, specifically in the context of global health justice.

The unique mix of modern Western and traditional Confucian values in Singapore presents young people with contradictory views on duties to aging parents. It remains to be seen whether the changing demands of modern life will result in new generations giving up Confucian family ethics or whether the Confucian dynamic will find a way to adapt to the new pressures. It is the opinion of this author that the Confucian family structure has mixed potential for the growing crisis of elder care. Alone, both Confucian traditions and typical Western institutional approaches toward elder care fall short of what is necessary for intergenerational social justice, yet a hybrid of the two has great potential for the growing aging crisis. To demonstrate this, I first give a brief account of the history of filial piety in Confucianism as well as the social environment from which it originated. Then I turn my attention to the present issues of an aging population and elder care that face much of the developed world in the twenty-first century. Finally, I show how adherence to Confucian filial traditions can both help to address many of these issues and how it can potentially leave unjust gaps in elder care. Ultimately, I conclude that the crisis of elder care may be best dealt with through a hybrid of Confucian values and Western approaches.

What I seek to do in this paper is to reemphasize what I see as the forgotten or neglected other half of the effective altruist equation. Effective altruists need to take seriously the ways in which their actions contribute to systemic inequality and structural violence. Charitable donation is not enough to create a paradigm shift or stop systemic injustice. In tackling systemic injustice, the ascetic response may allow effective altruists to attack the roots of the problem more directly. Further, the cost-benefit analysis and randomized controlled trials favored by the movement can produce distinctly biased perceptions that leave effective altruists blind to the political dimensions of many types of harm. Balancing ascetic approaches to combating suffering may temper the overzealous focus on cost-effective charities and make room for the support of the causes this narrow focus excludes. Ultimately, this paper defends the basic tenets of effective altruism: that we have a duty to reduce suffering in the world and that we should apply our powers of reason in order to make our labors maximally effective.