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and gain a better understanding of the factual as well as normative dimension of a
decision. The four principle approach can thus not only be interpreted as a set of
rules but also as a tool to analyze ethical decision making processes. The principles
are shown to have great heuristic value in such situations. They can help to structure
a problem and to start a multifold reflection of the problem guided by the principles.
Ethical committees in their discussions of ethical problems in clinical situations for
example use the four principles in this way [9].
The twofold aim of ethics between pluralistic theories and applicability implies
a difficult balance between individual ethics, normative ethics and universal ap-
proaches. While legal regulation can be based on ethical as well as political delib-
eration and found through consensus, the expectation towards (universal) normative
ethics is often to tell right from wrong. As already shown this is not easily possible
for reasons shown above. The critique towards universal normative approaches can
best be seen in the critique from the perspective of intercultural and cross-cultural
bioethics. These perspectives strongly emphasize the cultural relativity of norms,
values and ethical considerations. Momentarily the development of bioethics in in-
ternational contexts such as the WHO or World Medical Association is strongly
linked to Western approaches. These approaches mainly focus on normative ques-
tions of national and international regulations like regulation of clinical trials, rules
for doctor-patient interactions or international organ trade. As the same time they
take an individualized view point and strongly protect the autonomy of the patient.
Bowman points at several limitations of western bioethics within intercultural set-
tings [4]. He criticizes the concept of culture and religion in western bioethics where
culture and religion are regarded as two factors among other factors that influence
decisions. These factors are often reduced to stereotypical differences between cul-
tures. He argues for a concept of decisions cannot be seen as embedded within
a cultural framework that shapes these. In order to get a closer understanding of
decision making processes culture needs to be conceptualized not only as one of
many dimensions of a decision but as the specific framework that leads to a very
specific understanding of a situation as a decision. The example Bowman provides
is the culturally different understanding of health, disease and illness. In western
understanding there is a dichotomy between health and illness that is one of the
foundations of western understanding of medicine. In a western understanding a
person is either healthy or sick. In other cultural discourses health and illness are
seen as equilibrium and a person can be healthy and sick at the same time. These
two fundamentally different perspectives lead to different perceptions of decisions
with regard to health care.
This critique shows that not only questions of norms and values but also so-
cial, religious and cultural factors need to be taken into account when talking about
ethical decision making. Ethics as an academic discipline can provide a better un-
derstanding of the intercultural differences between concepts such as health, disease
and illness but also by conducting cross-cultural empirical research in order to bet-
ter understand the framework of decisions and the embedment of norms. Taking
the critique one step further this does not only apply to decisions in different cul-
tures but - maybe to a lesser degree - also to the differences of decisions between
