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The 19th University of Malawi

Inaugural Lecture

Blantyre

Presented by

Prof. Joseph-Matthew Mfutso-Bengo, PhD., M.A., Dipl.

Professor of Bioethics and Director of the Center of Bioethics for Eastern and Southern Africa (CEBESA) www.cebesa.mw

Head of Health Systems and Policy Department

School of Public Health, College of Medicine, University of Malawi

On 10th April 2015

Revised January 2016

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Content

Acknowledgements

Abbreviations and Acronyms ...................................................... viiiIntroduction.................................................................................... 2What is bioethics? ......................................................................... 5

Bioethics as a bio-medical ethical discourse .................................... 7Bioethics as environmental and animal rights discourse .................. 8Bioethics as a research ethics discourse ........................................ 10

Why do African countries need bioethics? ................................ 14Bioethics is a decision making tool to manage moral dilemma and conflict of interests .......................................................................... 15Bioethics as a tool for moral reprogramming and value-based education ........................................................................................ 18Bioethics as a means to promote moral capital/dividend, professionalism, integrity and compliance ...................................... 19

The scientific methodology of bioethics ..................................... 20Deontology: A theory about sense of duty, self-control & rule of law as factors for personal and organizational success ........................ 21Consequentialism: A theory about how to maximize benefit at minimum cost/risk/harm .................................................................. 22Casuistry: Most of our problems were already solved by somebody, somewhere ..................................................................................... 23Virtue ethics: A theory about good character as basis for common good & human development ........................................................... 24

Christian virtue ethics ................................................................... 25

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Modern understanding of virtue ethics and umunthuology virtue ethics ............................................................................................ 26

Principles of bioethics made simple ................................................ 27Beneficence: The desire to be good and to do the best as the basis of human and organizational growth ................................... 28Non-maleficence: Safety first. How to avoid harm in the process of doing good .................................................................................... 29Rule of Double Effect (RDE): What to do when doing good means doing harm at the same time ........................................................ 30Autonomy: A theory about self-knowledge, self-respect, self-control ........................................................................................... 32Justice: How treating unequals equally is unequal & unjust ......... 36

Frameworks, international ethical codes and guidelines ................ 37Ethical codes ................................................................................ 37Rights based approach................................................................. 38ADPIE ........................................................................................... 39

The short history of bioethics as an academic discipline ......... 41The history of bioethics as an academic discipline in Malawi/Africa.................................................................................. 42Towards an African Bioethics ...................................................... 47

African bioethical local contextualization of global bioethical principles (beneficence, justice, autonomy) in resource allocation . 47African bioethics of umunthuology: Contribution of African-Malawi bioethics to a global bioethics discourse ......................................... 54

Umunthuology bioethics framework in summarized form ............. 54Umunthulogy between tradition and modernity: How the modernity can benefit from umunthuology as moral capital ............................ 58

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Examples of Ubuntu/umunthu in action .......................................... 63Umunthuology in the context of environmental and animal ethics .. 65Bioethics as moral capital, moral power and moral authority.......... 68Umunthuology/Ubuntuology bioethics as moral capital .................. 71Umunthuology/Ubuntuology/moral capital as comparative advantage for sustainable economic growth in Africa ...................................... 76Simple mathematic modeling of moral capital ................................ 80

Final Recommendation-investment in Malawi/African Moral Transformation Program- MA-MOTRAP ...................................... 82

Moral capital dividend & moral hazards .......................................... 82Moral capital in the context of medical practices and professional training ............................................................................................ 82KAS Professionalism model, a new framework for promotion of sustainable professionalism (in Malawi MA-MOTRAP) .................. 83National shared moral vision ........................................................... 88Creating collective corporate moral identity .................................... 90Moral capital mainstreaming or nationwide moral learning ............. 91Initiation ceremonies as moral empowerment ................................ 92Moral Vision 20:20 (MV20:20) ........................................................ 93

Three moral reasoning quick tests ............................................... 94 .................................................... 96

A template for personal integrity scan/moral audit ....................... 97Emotional intelligence ................................................................... 99

Moral Capital Index and LEGS Framework for the moral capital implementation .............................................................................. 100Moral Capital Index for Research Institutions ............................... 103

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Conclusion ............................................................................... 105My personal dream and vision ............................................... 110Bibliography............................................................................. 111Selected publications of Prof. Joseph Mfutso-Bengo ......... 117

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Acknowledgements

First of all, I wish to praise God. I thank Him for the gift of life, the gift of my parents, my family, the gift of my friends, the gift of my career, and for this opportunity as well as His grace that has enabled me to publish this book which is a revised version of the inaugural lecture which was presented on 10th April 2015 in Blantyre, Malawi. It was titled Bioethics as

Sustainable Development within a Competitive Globalized World.

God has been favorable to me throughout my life. He sent some great teachers, mentors, advisors and companions on my way and I wish to thank them for their selfless, empowering contributions to my success and their wise advice even if I cannot list all their names.

I wish to thank my mother for bringing me to his world, for her love and for her prayers. I thank my father Matthew Mfutso-Bengo for his wisdom, his education and the values he has instilled in me, like hard work, trusting in God, fairness, goodness, self-control and discipline. Father Villa inspired me - even at a young age when I was an altar boy - that life is beyond pursuing material things, to go beyond what one can see and to include spiritual values.

aracter.

My wife Eva Maria and my children Thoko Gabriel and Tadala Magdalena have shown not only big love but also selfless support of my academic career and love for Africa. I wish to thank my wife for the critical review of the manuscript and for her good and wise comments. They stood with me in times of difficulties. I also thank my German parents-in-law for their constant understanding and for sharing my vision. I wish to thank John Banda for his encouraging words.

I thank my brothers and sisters, nephews and nieces. Thanks to God, I have witnessed the miraculous prophetic healing of some members in my family by God when all scientific medical treatment had reached its boundary or failed.

The teachers at the Inter-congregational Seminary in Balaka, especially Father Pino and Father Chamello were preparing us to take up positions of responsibility in the society. I thank the Comboni-Missionaries for opening my doors to success. So, my career is the result of investment not only in education as transmission of knowledge and skills but also in spiritual and character mentorship.

I wish to thank Prof. Konrad Baumgartner my PhD supervisor and mentor in Germany. I am deeply indebted to Marga and Willi Seitz and Dr. Robert and Susanne Seitz, who opened their beautiful home and invited me to stay with them for free when I was a PhD student; they treated me like their own son for more than five years in Germany. They are still treasured in my heart.

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My academic career was promoted by a number of outstanding scholars. They are too numerous to mention. I wish to thank Prof. Broadhead and Mr. Benedicto Wokomaatani Malunga. Without their insistence and vision to see the signs of the times to recruit a bioethicist when many people did not understand the changing trends in higher education, I would not be here today. I thank Dr. Chiwoza Bandawe for warmth and goodness when receiving me in his department.

Furthermore, I would like to highlight Prof. Malcom Molyneux, who mentored me as young researcher and Prof. Terrie Taylor for introducing me to some American bio-ethicists. I wish to thank Prof. Cam Bowie for everything that I have learnt from him, especially about fundraising and program development. I also benefited from the academic discourse with some of the world re-known bioethicists Dr. Nancy Kass, Dr. Ezekiel Emanuel, Prof. Ames Dhai, Prof. Ruth Macklin, and Prof. Jeremy Sugarman.

I am intensely grateful for the fruitful cooperation with my honored colleague Prof. Adamson Muula. I wish to acknowledge the contributions of my bioethics team. I wish to thank my team members and co-authors from the Center of Bioethics for Eastern and Southern Africa, namely Francis Masiye, Dr. Lucinda Manda-Taylor, Dr. Vincent Jumbe, Dr. Paul Ndebele, Khama Mita, Dr. Isabel Kazanga.

I wish to thank the Chancellor, Vice-Chancellor and Pro-vice-chancellor and management of the University of Malawi for all the support rendered to give bioethics the space, time and resources it deserves.

This inaugural lecture was organized by two Committees, one at University level, chaired by Prof. Alfred Mtenje and another one at college level, chaired by Dr. Lucinda Manda-Taylor. Thank you very much.

I also wish to thank all individuals and organizations whose resources went to this occasion and Lambart Publisher. May God reward you for all you have done!

Prof. Joseph Matthew Mfutso-Bengo

Professor of Bioethics

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Abbreviations and Acronyms

AMANET African Malaria Network Trust (NGO) CEBESA Centre of Bioethics for Eastern and Southern Africa CoM COMESA

College of Medicine Common Market for Eastern and Southern Africa

COMREC College of Medicine Research Ethics Committee DFID Department for International Development (UK) EDCTP The European and Developing Countries Clinical Trials

Partnership GPI Global Peace Index ICMJE International Committee of Medical Journal EditorsKAS Knowledge Attitude Skills LEG LEGS MA-MOTRAP

Leadership, Ethics, Governance Leadership, Ethics, Governance, Systems Malawi (Africa) Moral Transformation Pedagogy

MABIRU Malawi Bioethics Research Unit MRW Medical Rights Watch NAC National Aids Commission NIH National Institute of Health (US) PABIN Pan-African Bioethics Initiative SADC Southern African Development Community Umunthu Chichewa: Humane, the Banthu word is Ubuthu UNESCO United Nations Educational, Scientific and Cultural

OrganizationWHO World Health Organization

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Introduction The aim of this book is to contribute in solving the prevailing problem of loss of moral capital nationally and globally, to decrease moral hazards and moral capital loss containment costs. Africa needs to address this issue urgently because the costs of loss of moral capital is harming Africa as a place of doing business and can obstruct the prevailing Africa Rising sentiments. The author argues that the current problems of underdevelopment, system failures, lack of capacity and poverty in Africa are not caused by lack of resources and less by lack of technical competence but mainly by lack of moral capital. That is the poverty of the mind. This is in line with Bingu Wa Mutharika who used to say Africa is not poor but the people of Africa are poor (Bingu Wa Mutharika 2010).

Intentional lack of development in Africa is affecting the youth, the girl child, and the elderly most, and this In long term this will also affect the ruling elite due to dangers of social unrest, extremism, loss of hope, investment, economic growth, conducive environment for doing business and mass exodus (the loss of human capital). Moral capital propels development and gives a sense of purpose to the booming youthful population. Rapid population growth needs to be transformed into a demographic dividend through moral capital. Self-awareness, organisation and self-control are components of moral capital which can be used to gain not only a demographic dividend and but also to control unplanned population growth.

However this is an opportune time for Africa to invest in moral capital so as to improve professionalism and to reap the benefits of moral capital dividend and to become competitive in a globalized world. Moral capital is a comparative social advantage where corruption and fraud have become a global phenomenon. Moral

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capital in a nation leads to efficiency and effectiveness of all organizations in it.

This book shows how bioethics can contribute to creation of personal and collective moral capital identity. Historically bioethics and medical ethics were the first disciplines to address the issue of lack of professionalism. In the process, bioethics and medical ethics incorporated and developed theories, principles, techniques and guidelines which could be used in other disciplines and professions to promote and mainstream moral capital, professionalism and integrity so as to reap moral dividend.

The author has developed this handbook for ethical decision-making, character formation and mind building which has been made simple and practical for public use. After an introduction to basic theories and mind building tools in bioethics the author introduces the concept of African Bioethics principle of umunthuology/ubuntuology as a social game changer in character training and mind building pedagogy for social transformation. Out of umunthuology bioethics principle the author developed KAS model for sustainable professionalism. In the last part the author gives practical suggestions how to increase moral capital dividend further on a personal, organizational, national and global level and how to reduce and prevent moral risks and moral hazards. The author is proposing moral audit, integrity scans, integrated aptitude/aptitude test, moral capital personal coaching, Moral Capital Index, KAS-model for sustainable professionalism, LEGS framework to run resilient, efficient systems and for effective policy implementation, as tools for growing moral capital and improving professionalism which are the basis for competiveness, economic growth and sustainable development. He also suggests mind and character building techniques for building personal, organizational and national collective corporate moral capital identity.

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Moral capital is the basis for sustainable professionalism and development, nationally and globally. Many countries have been investing in knowledge and skills only and less on right attitude (moral capital). Failure to invest in moral capital is costly in terms of containment costs, moral hazards, corruption, inequity and loss of competitiveness. In the modern world where the knowledge gap is narrowing through ICT countries and individuals will gain comparative advantage through moral capital investment. Therefore moral capital education and mind-building are necessary building blocks for a resilient, growing organization and economy. This book is targeting primary school, secondary, tertiary educators, and it also includes all professionals.

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Bioethics is a critical, objective, systematic analysis and reflection of human morality and cultural norms, based on critical moral reasoning standards and not moralisation. Moral reasoning standards and techniques are internationally acceptable proven ethical standards which are in a form of ethical theories, principles, guidelines, frameworks and ethical modelling. In short, ethics is the study of morality. The word morality means the rightness and wrongness, goodness and badness, guilt and innocence of an intention, motivation, omission, commission or action. Morality is acceptable intention, action, character and behaviour in a given cultural-social context. Ethics begins by recognizing what is good and differentiating what is good from

You prevent and avoid harm by doing or promoting what is good through moral reasoning, moral dialogue, judgment or discernment. Morality consists of:

Moral conscience Moral beliefs and systems Moral rules and values Moral principles Moral reasoning Moral problem and consideration Moral capital, status, power and authority Moral dilemma and moral distress

What bioethics is not? Bioethics is not an automated moral answering machine with ready-made moral answers. To the contrary it gives human beings skills to help one resolve or manage the dialectic conflict between good and evil and right and wrong. In simple language, it does offer proven and viable tools to resolve moral problems, dilemmas and conflict of interests using moral reasoning techniques. Ethics is not law, cultural norms, and religious beliefs,

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It helps to manage ethical and practical dilemmas. Some examples of ethical dilemmas are corruption, abortion issues, euthanasia, cloning, genetics, biological moral enhancement, potential benefits and harm of artificial intelligence research, designer babies, prenatal diagnosis, nanotechnology, refusal of treatment, balancing autonomy with justice and beneficence as well as other new health care technologies. (The Baltimore Sun 2003) Bioethics also gives moral skills to make ethical judgment and a sense of objectivity. It gives guidance on how to handle conflict of interests and some of its suggestions have even been translated into legal rules. Bioethics leads also to both inner morality of medicine (internal moral control based on voice of conscience) and external social control based on fear of the law.

Bioethics as environmental and animal rights discourse The history of animal ethics started with moral enquiry as to whether animals have got a moral status or not, whether animals do feel pain or sadness or not. There were times when other humans were considered less human and were given a marginalized moral status such as slaves, women, indigenous people and people of color. Do other living beings have moral status?

Animal ethics does not only deal with animals in research but how we treat, keep, even how we slaughter, use, handle or protect animals.

that emerged from modern moral philosophy especially utilitarianism and the animal rights movements.

Aristotle had denied the moral status of animals so that human beings could not treat them justly. Thomas of Aquinas, a Christian Philosopher and Theologian argued biblically that animals were subjected to the rule of human beings. Whereas Kant argued that cruelty towards animals may result into brutalization of human

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behavior in general. The utilitarian Jeremy Bentham argued that what matters morally is not whether animals can reason, but whether they can suffer. This understanding of animal as sentient beings was the foundation for animal rights and protection movement. The utilitarian Peter Singer, in the book Animal Liberation, argues that the interests of sentient beings in combination with the criterion of the ability to feel pain and suffer should be given equal consideration. (Singer 1985) Regan proposes that sentient beings that are able to see themselves as subjects of life and have an inherent value, which implies prima facie duties from human beings towards animals. Habermas emphasizes the role of human beings as surrogate decision makers for animals in discourse ethics.

differences between humans and animals. This correlates with Midgley, a proponent of virtue ethics, for acknowledging that animals are part of human existence. Others derive the obligation of care and responsibility from the asymmetrical relation (Donovan and Adams). The fundamental idea of granting a living being a moral status is to protect the particular being from various kinds of harm. (Midgley 1983, reprinted 1998, 11-13).

Environmental ethics became a very important issue globally due to advancement of nuclear technology, awareness on effects of pollution, limitation of resources and climate change. The philosophies on Environmental ethics are divided in two groups: anthropocentrism and physio-centrism or non-anthropocentrism.

The anthropo-centrists stress, that values depend on human beings. Values are relational. They require a rational being. Hence, animals or nature are not per se objects of morality. The environment should be

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respected and protected for the sake of human beings or for the sake of nature itself with human as surrogate decision makers.

Physio-centrism does not presuppose rational human beings. Eco-feminism argues from the aspect of dominion and care. Deep ecologists argue that human beings are part and not distinct from

thing is right when it tends to preserve the integrity, stability and

as a mere resource but as a source of energy.

Some argue it is not intrinsic worth of nature by rationality which matters, but an intrinsic worth due to uniqueness or beauty. But even beauty stems from a particular valuer. Environmental ethics precautionary principle heavily influenced environmental protection legislation from 1970s, and institutionalization of Environmental Impact Assessment.

While medical ethics has matured to a point, where we reached a consensus on decision-making methods and accepted principles of justice, beneficence and autonomy, animal and environmental ethics is much more controversial and might tend to search for philosophical foundations for subjectively desired results. It seems animal ethics has reached a consensus that animals should not be subjected to sufferings unnecessarily, which influences animal protection laws.

Bioethics as a research ethics discourse Bio-medical research in the world including Africa, has witnessed a tremendous growth in the past decades until to date. The great demand for clinical research created many ethical challenges such as issues of coercion, therapeutic misconception, undue inducement, standard of care, post-trial benefit sharing, ethical jurisdiction in multinational research, ethics of placebo control and randomization.

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This led to the birth of another branch of bioethics called international research ethics. Research ethics uses the same theories and principles of bioethics as its methodology. For the past 80 years, ethical issues in biomedical research have received increasing attention because of several cases of research misconduct such as stated below.

During World War II obviously unethical atrocities were committed by doctors during the Nazi Regime in Germany, which was responsible for genocide. Doctors carried out mass executions and also made medical experiments with people with disabilities and inmates in concentration camps, e.g. freezing people, bone-grafting, injecting diseases, exposure to phosgene and mustard gas, experimenting on twins, new sterilization methodthe Nuremberg trials the Axis powers judged not only political leaders and decision-makers but also doctors involved. (Resnik 2011) (Encyclopedia of Bioethics)

The Tuskegee experiments where Black American prisoners were subjected to unethical research. The objective of the research was to find out the natural development of syphilis when left untreated. However the research participants were given placebo when there was already a drug that could treat the syphilis. Also five years ago, 2010, while researching on Tuskegee, Susan Reverby discovered another unethical research, carried out by the US in Guatemala, in the 1940s with 1300 subjects who had venereal diseases in order to test the efficacy of penicillin. Only 700 were given the medicine and 83 died. Subjects were not informed that they were participating in an experiment and there were many other similar incidents. (Urdaneta 2011)

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History has shown that humans can disrespect other human beings for the gain of new knowledge. In 1966 Henry Beecher published an article in the New England Journal of Medicine which exposed 22 unethical studies in biomedicine, including the Tuskegee syphilis study and the Willowbrook hepatitis study. (The Baltimore Sun 2003, 2-3)

The new thinking among bio-medical research sponsors is to promote ethical research. Hence a good balanced bioethical platform is attracting good research and research sponsorship. Due to high cost of litigation, unethical research and researchers have proven to be costly.

The prevailing situation on research is that 90% of the global research and funding is done in 10% of the global population, whereby 90% of the global population only received 10 percent of research funding and projects. This is what we call the 10-90 gap. This shows there is a lot of back log of research in developing countries including Malawi. Therefore there was an imbalance in responding to research questions between those affecting developed countries (e.g. heart disease, cancer, beauty surgery etc.) and those affecting developing

10-90 gap in research funding, many research funders such as Bill and Melinda Gates, Wellcome Trust, DIFID, NIH and EDCTP have scaled up research funding to developing countries by providing research capacity grants.

These research capacity grants include also bioethics capacity strengthening grants. This is because good science is good ethics and without research integrity one cannot have good science. However, of late, focus has been on the ethical implications of carrying out biomedical research for neglected diseases in low

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socioeconomic settings such as Malawi. This is especially so because of the increasing number of multinational biomedical research institutions working in developing countries. A key principle that informs and grounds all major ethical guidelines in research is the principle of informed consent. There is a general consensus among researchers and ethicists that acquiring an effective informed consent from research participants is a prerequisite to the conduct of an ethically sound study as stipulated also in the Malawi Constitution. There is a general assumption that getting genuine informed consent in practice tends to be difficult; it is believed that problems of getting quality informed consent are even greater in settings with low social-economic status. However our bioethics studies conducted in Blantyre and Lilongwe have shown it is possible to have a valid informed consent in low socio-economic settings provided it is done in good faith.

In our bioethics research findings, we discovered that the majority of the research participants were able to differentiate between research and treatment but they chose to participate freely in order to access better medical care and not for the desire for generalizable knowledge. The ethical question one could ask is: Is it reasonable to join research in order to get good care? What is the difference between a researcher who joins a research team for the sake of desire to publish and the research participant who joins a study with a desire to get better medical care? Are both decisions rational? Ezekiel Emanuel et al. 2004, while responding to the question, what makes a clinical trial ethical, came up with the following ethical benchmarks.

Collaborative partnership Scientific validity Fair subject selection Favorable risk benefit ratio

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Independent review Informed consent Respect for subjects (potential and enrolled)

Why do African countries need bioethics? Here in Malawi and Africa, the media has been reporting some unethical behavior such as drug theft in hospitals, falsification of results by lab technicians, cashgate stealing of public funds discovered in 2013 (Majanga 2014), conflict of interests, loss of moral values, and lack of professionalism among some professionals. In 2014, the Malawi Medical Council reported 120 complaints of professional misconduct. (Kasakura 2015). The cashgate scandal has exposed corruption and lack of professional integrity on a scale unprecedented for Malawi and is being persecuted. Furthermore countries loose a big part of their GDP through illicit financial flows. ( At the same time cashgate is a social game changer, in the sense that it has created a rare collective desire and opportunity for national reform agenda. In the Western history, bioethics stated as a reaction to rapid progress of biomedical sciences, research misconduct and medical malpractices which did provoke moral philosophers, moral theologians and some biomedical scientists to start thinking of ethics of bio-medical sciences.

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Why does a country need bioethics?

What happens if a country ignores bioethics?

To prevent professional misconduct

To promote professionalism and moral capital

To prevent negligence To manage conflict of interests and ethical dilemma

It is a decision making framework and tool

- Loss of confidence and public trust - It promotes corruption like cash-gate

scandal in Malawi - Loss of professionalism, rule of law,

security, democracy and sustainable development

- It discourages performance, instead it promotes mediocrity

- It increases the cost of doing business and violence containment cost, currently at 28 billion kwacha http://www.unicef.org/malawi/resources_16284.html

Bioethics is a decision making tool to manage moral dilemma and conflict of interests To be human is also to learn to resolve and manage dilemma and conflict of interests.

Medical landscape is changing quickly due to rapid technological advances. In dealing with life and death situations, doctors and health professionals do sometimes confront moral uncertainties and distress in dealing with some cases. (Maluwa, et al. 2012) This moral uncertainty is called an ethical dilemma.

It is an unpleasant situation where one is supposed to do action A+B but humanly, economically and practically speaking one can only do either action A or B. E.g. a surgeon who is performing a caesarian section discovers a complication may need to decide whom to save, mother or child. Suppose a hospital has only one oxygen machine but there are four patients who are in urgent need of the machine. A moral dilemma is when a rational human being ought to do or is obliged to do more than one ethically acceptable and desirable

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actions or options -Actions A+B but humanly speaking one can only choose action A or B. Moral problems occur in different forms:

Moral Dilemma: Two or more moral obligations or option, but one can only afford to do one. One is not clear which one to choose or prioritize.

Moral Distress: One knows what to do, however due to issues of access and lack of capacity one has no means to solve the commonly solvable clinical problem.

Dilemma of Justice: Which is the fairest way to allocate national benefits among equally deserving candidates?

Dilemma of Authority: Who is dutifully responsible and has the authority and power to act or take decision in this situation?

Dilemma of competing interests (conflict of interest): Among the competing interests which one are primary interests and which one is a secondary interests.

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industry. Conflict of interest policies were revised by NIH. Furthermore, NIH made a rule for intramural research, that NIH researchers cannot hold stock in pharmaceutical or biotech companies or consult with these companies for pay (Resnik 2011). Similarly the Medical Council of Malawi has developed its Code of Ethics, 1990 (revised version) adressing the same crucial issue of conflict of interest among physicians.

Conflict of interest can be managed through

Moral knowledge and competence Acknowledgement of the conflict Disclosure depending on context Possibility of recusal in decision making

Bioethics as a tool for moral reprogramming and value-based education Albert Einstein said: Most people say that it is the intellect which makes a great scientist. They are wrong: it is character. Despite him being one of the greatest scientists of our time he saw the need for responsible character and he advocated for the ethical use of human knowledge in nuclear science.

Bioethics forms character and creates awareness and the ability to deal with contradicting values and principles. Neuroscientists (Spitzer 2003) have shown that early adolescent years still play a crucial role in the development of values when our brains have developed the maturity to deal with conflicting rules. Therefore ethics training for our medical students happens at a crucial time and cannot be left to secondary school or family background only.

Character formation, training and mind building in discipline, obedience, necessary disobedience, sense of personal responsibility, honesty, self-interest in any given situation, goal-orientation, self-control and self-

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discipline does not only enhance professionalism in general, it is also the foundation of sustainable careers of our students, healthy patient-physician relationships, healthy staff relationships. It makes up the back-bone of any society. Dr. Kamuzu Banda had been aware of that when he created the once famous, nowadays forgotten, four cornerstones of unity, discipline, obedience, loyalty for nation-building. These were part of primary and secondary curriculum (civics).

Bioethics as a means to promote moral capital/dividend, professionalism, integrity and compliance Unlike in the West where loss of moral capital has been compensated by a strong rule of law, some of African countries have unfortunately lost both internal control (morals) and external control (lack of good governance/rule of law). This will be explained further below in the Chapter on KAS model. Many of African countries find themselves in what one could call uncommitted middle it neither has a coherent traditional value system nor has embraced modernism in its totality with its rights and obligations based on strict social contract, democracy, rule of law, good governance and human rights. The ideal situation is to achieve what the author calls moral capital cultural equilibrium where one integrates the best values of the ones traditional culture with the best values of the modernity e.g., Japan. What good is it to educate a generation of knowledgeable and skilled leaders, who are led by greed, egoism or limitless over-excitement or who can easily be pressurized to succumb to existing low standards and systems of theft and collusion in a workplace? What is the use to invest in youth knowledge and skills only without right attitude? The world needs people who understand that it matters more to add value to this world, than to be successful. What good is it to fabricate falsified data, which cannot be replicated by any other scientist for the sake of personal fame? When we prepare students and researchers how to deal with difficult situations beforehand, it is easier for them to

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reach a good decision. A fire-fighter practices danger, so that in a situation of real danger, he can act out of routine. Oftentimes it is pressure, stress, fear, over-excitement or undue influence that stops one to act rationally and responsibly. Therefore attitude and thinking patterns need to be deeply anchored in the minds of the students, to translate into a person of good character and professional behavior.

The scientific methodology of bioethics Ethical dilemmas are managed using decision making tools based on moral reasoning which uses moral theories such as deontology, utilitarianism, casuistry, virtue ethics, umunthuology, ethical principles, frameworks, guidelines, ethical codes and ethical modeling like the Rule of Double Effect (RDE). Personal, community, political and corporate ethical decision, justification, opinion, advice and judgment can be made using one, more than one or a combination of these theories and principles. The goal of managing personal, institutional, community, and national ethical dilemmas and moral problems is to reach ethical, reasonable balanced, moral capital equilibrium, fair and objective judgment or decision.

One tends to learn morality from the social context and actions one takes. Experience of evaluation of our actions determines morality (Spitzer 2003). By giving false excuses for unprofessionalism one programs oneself and others for it for the future.

People tend to use self-defense or rationalization mechanism when confronted by moral dilemmas or conflict of obligations. This reaction could lead to wrong and unethical decision. The following are some (false) rationalization examples:

Everyone is doing it anyway (universalism). No one is watching me.

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No one cares anyway. No one will know that I have done it. It does not hurt anyone I know.

. I want to eat well, too.

. They do not pay me well.

Bioethical theories go deeper in the analysis. According to Beauchamp and Childress such theories shall be sufficient clear, coherent, complete and comprehensive, explanatory powerful, able to justify, have output power and be practicable. (Beauchamp T. L. 2001, 339,340).

Deontology: A theory about sense of duty, self-control & rule of law as factors for personal and organizational success A theory known as deontology (Beauchamp T. L. 2001, 348-352) concerns itself with ethics of duties (Greek deon: duty) and the relations between the moral person (the do-er) and the object of moral problem (the done-to or done-by). The theory concerns itself with rules of conduct and behavior, not simply the consequences of actions. The means matters more than the end. For example, deontologist thinker will oppose condom use to prevent HIV/AIDS because the condom use is not an acceptable means but abstinence due to religious beliefs. By following the rules of conduct, actions are to be judged right or wrong, not simply by their results but by their correlation with the recognized rules of conduct. So all being equal, right conduct is prescribed and can be anticipated, even if the consequences may not be to the greatest benefit or the greatest number. Thus in medicine, deontology often speaks to the standard of care that must not be breached and to the respects of rules of conduct or standard operation procedures. Its emphasis is not on

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sympathy or on what one feels but the sense of duty that is owed to the ones who have the right to claim.

basis for the call to the duties as demanded by the rules of conduct and standard of care. Immanuel Kant (1724-1804) is the main proponent of this theory; one must act not only in accordance with but for the sake of obligation. He stipulates:

Act in such a way that when people see you acting may declare your action as a universal law of humanity. Never use humanity or yourself as merely means to an end. What is fair for one is fair for all. (see Beauchamp T. L. 2001)

Consequentialism: A theory about how to maximize benefit at minimum cost/risk/harm Teleos means goal. Logos means study. Telescope means to see ahead. Teleology (Beauchamp T. L. 2001, 348-352) is the study of goals or consequence. The main proponent of utilitarianism or consequentialism is John Stuart Mills. One of the offshoots of teleology and consequentialism is utilitarianism. The term

usefulness. means

something useful or has utility value. Utilitarianism is concerned more with results or the consequences of an action, omissions and commissions than the means . Utilitarianism could be used as a criterion of decision making at personal, institutional or community level especially in determining and quantifying benefit and risk by doing benefit and risk assessment or risk/risk assessment where one is confronted by only options of different risks. This is done to attain favorable benefit/risk ratio or favorable risk/risk ratio. For example, according to utilitarianism condom use could be acceptable means to achieve the good results of preventing HIV/AIDS.

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The advantage of the theory is that it judges a policy, an action, omission or resolution as good or wrong depending on its efficacy, efficiency and sufficiency to bear good fruits and good results on the ground. It underlines that the greatest good is useful and brings good results to a greatest number of people at minimum cost or risk, and it also means useful things and actions are good and useful actions. This shows that utilitarianism is practical ethical theory. It values the usefulness of an action to save life, protect, promote happiness and promote life and community welfare and wellness. There is also a link between valuing and timing and prioritization when assessing benefits and risks. The theory is criticized by those who argue that goodness or badness of action does not depend on success or the goodness, failure of its results or consequences alone. For example, there are some actions, like killing, cheating, lying, which are intrinsically either good or bad by themselves. In its practical application, teleology means to make a risk and benefit assessment or a risk-risk assessment. When making a risk analysis, one needs to consider:

The short-term and long-term consequences The likelihood of risk/benefit (probable, minimal, more than minimal)

The degree of risk/benefit involved The duration of risk/benefit Benefits can be direct, indirect or aspirational. Risks can be physical, psychological (e.g. shaming), economic, social (e.g. lack of public trust in a profession) and, environmental harm.

Casuistry: Most of our problems were already solved by somebody, somewhere The 90% of my problems, social-moral problems and dilemmas were already resolved by someone at one point,

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somewhere in the world, who had a similar problem . Therefore one needs not to invent a wheel which was invented. Casuistry is case-based moral reasoning to bring about a common good, common moral understanding and consensus of a particular moral case. Casuistry is similar to case law where previous cases can help to resolve the moral dilemmas caused by new cases. What lawyers would call a leading case in the development of case law, casuists would call a paradigm case.

from cases, history, precedents and circumstances. Appropriate moral judgments occur, they say, through an intimate acquaintance with particular situations and the historical record of similar cases. Casuists dispute, in particular, the goal of a tidy, unified theory

(Beauchamp T. L. 2001, 392-393) The casuist tends to assesses and evaluates similarity or differences in moral cases in order to discern the truth and compare with other previous similar cases. In casuistry the social moral consensus formed around cases is vital. This model extends the way we naturally learn as human beings about morality to a society and recognizes the limitation and deficits in other bioethics theories, which are based on principles. But can human beings be freed from rules and principles? What is the basis for evaluation of new, unheard situations and dilemmas?

Virtue ethics: A theory about good character as basis for common good & human development Virtue ethics has experienced a renaissance in the 20th century and originated from ancient and medieval thinking. Sison explained in 2003, why virtues matters for leaders. Virtue ethics or value-based ethics focuses on character, good behavior, motivation, virtues and practical or moral wisdom. Havard defines virtues as a sound habit of

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the mind, the will and the heart that helps to achieve personal excellence and professional effectiveness. (Harvard, 2007)

Virtue ethics were propagated first by Socrates, then Plato followed by Aristotle. O character influences what one does. One needs to be good and to have good motive in order to do good. Its emphasis is put on a peethics is not necessarily contrary to utilitarianism or deontology but can be used complementary. Intention and motivation of an action count a lot more than the result of an action or omission. According to virtue ethics, virtues can be learnt through character formation, training and mind-building.

Christian virtue ethics Some Christian philosophers like St. Augustine differentiated human behavior into three categories: virtues vice and sin. St Augustine as philosopher propagated that virtues are good habits and vices are bad habits. A good habit forms character and develops what is natural (natural law). Whereas bad habits undermine what is natural. Sin violates eternal law, in other words it undermines what is supernatural (See Long, 2010).

Good habits are willed by nature and they can be acquired through constant, regular and repeated practice and exercise of virtue. However human will is perfected not in what is natural but in supernatural. Augustine argued that human soul and heart is restless until it rests in God. This means that human being will find true happiness, peace, fulfillment and restfulness not in nature (created things) but in the supernatural (creator) (See Long, 2010). The supernatural can also mean things which are metaphysical like peace/reconciled heart, love, goodness, trust, justice, forgiveness, hope.

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The consequences of virtues (good

habits)

The consequences of vices (bad habits)

The consequences of sin (evil

intentions, action and omissions)

Self-improvement of nature Self-actualization

Destruction of nature

Self-destruction and destruction of others

Lies, destruction and death

Forms human character

Undermines and destroys character Bad habits is prone to sin and can lead to sin

Undermines and destroys good habits and promotes bad habits.

Virtues are basis for professionalism, for the sense of purpose and desire for common good

Unprofessionalism can lead to violation of natural law and can be criminalized

Undermines human will and the sense of self control, holiness, natural law Sin ought not to be criminalized if it does not manifest itself in bad habits/behavior.

The question arises should sin be criminalized or should judgment be left to God? When sin manifests itself in bad behavior the society can protect itself through legal means. Not every sin has to be criminalized so long as it does not undermine the state law.

Modern understanding of virtue ethics and umunthuology virtue ethics The author considers African umunthuology principle as a form of virtue ethics and that good virtues matter for pursuing common good. Logically the question arises, what character traits and virtues are

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morally desirable? (Beauchamp T. L. 2001). Sison calls virtues moral capital (Sison 2003). According to Aristotle virtues are learned through awareness, willingness and regular practice. Havard further explained that virtue so as to perceive its intrinsic beauty and desire it strongly (a matter of the heart); b) act virtuously habitually (a matter of the will) and c) practice all the virtues simultaneously with special attention to prudence (a matter of reason.) 1(See Havard 2007).

Therefore the author argues that for umunthology virtues to survive the community and nation ought to consciously and purposefully market, promote, practices and positively reinforce the umuthuology virtues.

Principles of bioethics made simple Since we are not always familiar with a multitude of dilemmas, we need principles that we can recall to make decisions. Principles help to analyze a scenario and unpack its initial complexity. The principles were set out in the Belmont Report.

A medical dilemma can be analyzed under the three main principles of bio-medical ethics according to the Belmont report (The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research 1979):

beneficence non-maleficence respect of person/autonomy justice

Human experience has shown that these principles can also be used to resolve some human dilemmas in other disciplines and

1 https://en.wikipedia.org/wiki/Virtuous_Leadership)

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professions. For example: to support a strike or not, where and to whom allocate scarce national resources, how to resolve gender issues, whether to report a financial crime at your workplace, whether

whether to join a political party for business opportunities, whether to

Beneficence: The desire to be good and to do the best as the basis of human and organizational growth The words beneficence comes from two Latin words bene and facile which mean do well or produce well. It originates from virtue

ethics of having good intention, willing good, wanting what is good and avoiding or preventing what is bad and harmful. Beneficence means:

Do good and resist evil intentions. Maximize benefit. Reduce and prevent harm and evil.

The process of maximizing benefit is actualized through benefit and risk analysis, identification, assessment. However humans are confronted with dilemma of two goods. The goal of beneficence is to achieve favourable benefit-risk ratios or a favourable good-good ratio. A lady might have a marriage proposal from two good men, and in this context it is a dilemma here is between two goods and between good and evil.

There might well be differences of opinion between a doctor and a patient. The doctor may base his opinion on a technical competence

s and needs. However, the patient may confuse his personal interest and wants with his best medical needs. In this context beneficence ought to be seen as the best interest of a patient. The best interest should mean

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best medical interest. In the case of conflict between a patient who is

assent or consent so long as the doctor is acting in the best medical interest of the minor (See also Malawi Child Protection Act). The powers used in this context are called

case they wish to refuse medical treatment, when minors are not involved and when it is not a notifiable disease or in the public interest as stipulated in Malawi Public Health Act.

Non-maleficence: Safety first. How to avoid harm in the process of doing good This is the first ethical principal of medical ethics which states that first do no harm if you want to do good. The precautionary approach is needed in the process of wanting to do good. This shows that safety matters first even before pleasure.

For example a parent who organizes a pool-party for his child ought birthday to think about safety and supervision before inviting people. Another example could be the precautionary approach that is practiced in environmental assessment of presumed good technologies with unknown risks. Even if a person sees a personal benefit in accepting a bribe, there will be harm done at the same time, namely to the society by increasing costs for others and also to oneself because one can become a victim of the very same culture of corruption and fraud that one has created in another transaction. The same applies to the use of violence.

Good will and eagerness to save life should respect safety measures. This is the reasons why doctors are required to respect safety and treatment procedures. This principle seeks to prevent and avoid

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intentional and unintentional harm and negligence. This can be done through what one could call benefit and risk assessment. Most medical interventions can in some circumstances be harmful and much clinical decision-making is concerned with assessing risks and benefits. The principle demands knowledge of possible harms and when these are likely to occur, and how they are going to be managed when they occur. It underlines the need to assess the possibility and probability of harm and risk before intending to do good. In practice the physician ought to assess the risk of any intervention by doing benefit and risk analysis or risk and risk analysis in case one is faced by two risky options. The moral imperative/command that above all, do not harm, should always be kept in mind by all physicians. There will be no defense to plead that harm was not intended, if there was a proven evidence by expert advice, that it would have been clearly foreseen and discovered through risk and benefit assessment. The knowledge of possible risk alone is the first step to actually implementing proper measures of risk management and harm reduction.

This risk assessment can be applied by anybody in making personal choices and decisions, for example a girl who decides to get married or pursue education.

Rule of Double Effect (RDE): What to do when doing good means doing harm at the same time In human life and experience one discovers that one does not always have an option to choose between a benefit and a risk. Sometimes one is confronted only with two risks. One has got a dilemma make a decision based on which one is lesser risky. RDE is a theory which can help one to deal with those dilemmas.

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For example, a pregnant woman in labor will die unless the physician performs a craniotomy meaning crushing the head of the unborn fetus. In case he does nothing both will die.

In this case out of two risky options, one might choose the probably lesser risky or harmful (see above). This concept is in line with the principle of double effect.

Beauchamp, Childress describe the principle of rule of double effect

effects, one good and one harmful (such as death) is not always (Beauchamp T. L. 2001, 128) E.g. in a situation

when pain-killers shorten the life of a dying patient with crucial pain.

The following four conditions should be present at the same time:

1. The act must be good. 2. The agent intends only the good effect, but the bad one is not

willingly intended. 3. The bad effects must not be a means to the good effect.

(Distinction between means and effect) 4. The good effect must outweigh the bad effect. The bad effects

are only ethically tolerable, if there is a proportionate reason that makes good for the foreseen bad effect. (Beauchamp T. L. 2001, 131)

These criteria help to make a decision when doing good means doing harm at the same time. Criteria one and two are based on virtue ethics and deontology respectively, while criteria three and four root in utilitarianism.

These criteria can also be used when taking a national loan for which interest has to be paid (harm) by the next generation in order to buy

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food in times of hunger (benefit) due to a drought when no other means are available.

Autonomy: A theory about self-knowledge, self-respect, self-controlThe word autonomy is a combination of two Greek words that is

nomosautonomy can be defined as self-knowledge, self-governance, self-rule, self-driven, self-respect and self-control. Autonomy might mean self-control against irrational and illegal personal orientations, motive, intentions and interest. The principle of autonomy does also imply having intellectual & emotional capacity to differentiate good from evil, right from wrong, irrational motive from rational motive. It also means that one has the competence to pursue what is good and right; and to avoid what is bad and wrong. word autonomy, according to umunthuology, autonomy is understood as the principle of respect of person. It is communalistic, and not individualistic. According to African umunthuology ethical principle, respect of others (diversity) begins with self-respect of dignity. Autonomy is a form of self-respect, and the one who respects oneself will also respect the community, others, the environment, standard operations procedures, and rule of law. Forced marriages, sexual harassment at work place, sex relationship of adults with minors are failures to respect the other. The same applies to religious intolerance and intolerance against the success and self-actualization of talents of others (jealousy & envy). Human autonomy does not imply an absolute freedom but a responsible freedom based on self-respect, mutual respect and inter- freedom stops where autonomy begins. For example, a thief disrespects the freedom of property and privacy of the proprietor. Lack of accountability is a form of disrespect, too. Human autonomy and freedom is not absolute but can be limited by the law in

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accordance to Syracuse principles such as in national public health and community interest for example. Historically, the principle of autonomy was propagated by Emmanuel Kant (1724 1804) who underlined in one of his principles called categorical imperative that humanity ought to be used not merely as a means but an end and what is fair for one is fair for all. The human being is a rational being capable of making autonomous decision based on good will and

because every other virtue can be used to achieve immoral ends(the virtue of loyalty is not good if one is loyal to an evil person, for example). The good will is unique in that it is always good and maintains its moral value even when it fails to achieve its moral intentions. Kant recognized that moral law precedes autonomy.

The principle of autonomy has been actualised in bioethics through the concept of informed consent (Mfutso-Bengo and Taylor, Response to Rennie: Is there a place for benevolent deception? 2004) (Taylor-Manda L, Masiye, Mfutso-Bengo J 2015) Informed consent to be ethical needs competence as precondition and as a necessity. This competence could be legal - age of consent - but also does require mental capacity that means ability to comprehend, understand, and process information and procedures. This should be done in a context, in an environment and atmosphere that is voluntary, free from coercion, oppression, exploitation and manipulation (See Mfutso-Bengo E, Mfutso-Bengo J. 2016 for law and ethics on consent in Malawi).

Other bioethical concepts which have evolved from the principle of autonomy are respect of confidentiality and privacy. The principle of autonomy was underlined in the Nuremberg Ethical Code which was

2 En.wikipedia.org/wiki/Kantian_ethics_note_4#cite

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issued after the Second World War where Jews were forced to participate in research without respecting their autonomy. The Belmont report was issued as a result of the Tuskegee research scandal, where African Americans were subjected to an unethical clinical trial in which the research investigators wanted to find out the natural development of syphilis when left untreated. This occurred when treatment against syphilis was available.

One of the ethical dilemmas in bioethics is how to balance and manage conflict of obligation between the principles of beneficence and autonomy. Can one talk of benevolent deception or therapeutic privilege? Can a doctor override the patient autonomy in the best medical interest of the patient? In bioethics there is a dispute about the primacy between principles of beneficence and respect of autonomy. Is benevolent paternalism ethical? (Beauchamp T. L. 2001, 165)

However, the World Value Survey, which compared prevailing values The desire for free choice

and autonomy is a universal human aspiration, but it is not top priority when people grow up feeling that survival is uncertain. As long as physical survival remains uncertain, the desire for physical and

(World Value Survey)

In umunthuology the aspect of individualism is Whereas

the inidvidual or personhood comes from the community, survives in the community and finds self-actualization in the community. Team spirit and cooperation in a community acknowledges individual diversity, diversified talents. Hence community does not always require uniformity but conformity (acceptance of responsibility and rules of engagement). The

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Justice: How treating unequals equally is unequal & unjust The word justice is derived from Latin iustitia meaning righteousness or equity. Justice is defined as fairness, fair play, equality and equal opportunity. It is the most controversial principle of the three principles of the Belmont report. It is especially important in the area of sharing health resources. Especially in developing countries health resources are scarce. This makes it more important that such resources are distributed in a fair and open manner so that the public can see and be aware of the reasons for particular decisions. E.g. here in Malawi there is a budget to send critical patients outside the country for treatment, particularly for diseases which cannot be treated in Malawi. The question is, is it possible to have any open system of decision-making and ethical criteria to determine and prioritize the patients to be sent?

The essential health package is meant to be free for all both poor and rich. However in a research conducted done by Isabel Kazanga (J. M. Mfutso-Bengo, et al. Handbook of Global Bioethics, Malawi, 2014, 1271-1287) it was revealed, that it is not the poor but the rich who benefit most. Very often the poor patients are sent back to buy medicines themselves at their own cost, while people of higher social status are given high standard free care, without paying anything. Can we say the system needs to be revisited? Could we reverse the roles, so that it is the rich who are to pay a user fee? Is it ethical in a country where health services are over-stretched and inadequate not to compensate the inadequacy through the user fee for those who can?

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Can Malawi as a country with little resources live without an ID system3, without knowing exactly how many people are eligible for health care?

There are different forms of justice namely: natural justice, social justice, criminal justice, mob (in) justice and procedural justice.

The principle of justice will be illustrated in depth later in this discourse.

Frameworks, international ethical codes and guidelines

Ethical codes Ethical codes in the bio-medical context are the Nuremberg Code, the Helsinki Guidelines, CIOMS, the Belmont report, the US National Research Act, the Code of Federal Regulations (CFR), Guidelines for Good Clinical Practice (ICH-GCP), NEBAC, UNAIDS guidelines and others.

In Malawi, the Code of Ethics for medical doctors was developed by the Malawi Medical Council. We have also ethical guidelines developed by the National Commission of Science and Technology and ethical guidelines of the National Health Sciences Research Committee of Malawi. Meanwhile other industries have followed with ethical codes in their respective fields, e.g. for construction, media and code of ethics for directors for good corporate governance by the Institute of Directors.

Ethical codes give clear rules for behavior and serve as concretization of general theories and can be the basis for indirect legal enforcement through disciplinary measures. However ethical theories and

3 The new national registration system is currently being implemented to issue birthcertificates and IDs.

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principles are still needed to solve medical dilemmas in an unforeseen situation.

Rights based approach Some scholars use legal or moral rights as basis of morality (Beauchamp T. L. 2001, 355-358). Ethical dilemmas are understood as a clash of rights and obligations. While deontology uses the duty and obligation as a starting point, liberal rights-based ethics considers the right, the entitlement, e.g. personal freedom, right to freedom of conscience, right to health, etc. Meguid has analysed how the legal right to health can be translated into even a legally enforceable position at law in the Malawian context, when hospitals are under-staffed when its employees are attending training workshops. (Meguid 2010) Rights typically correlate with obligations or duties. Human rights and human duties go together. This meaning got lost when

. study of 2012 discovered that human rights are perceived by some as entitlements against the state. However they are also a moral or legal obligation of everybody.

One talks of violation of a right, if its limitation is not justified. A justified limitation is a mere infringement of a right. There is a dispute, whether absolute rights exist. The Syracuse principles can morally justify the limitation of rights in the public interest, i.e. public health interest. This justification must be based on principles of necessity, proportionality, least infringement, justified by the law and must be reasonable.

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SYRACUSE principles

All human rights can be limited. Certain rights are inviolable e.g. human dignity

Limitation must be for a legitimate objective: to secure due recognition and respect for the rights and freedoms of others

Determined by law Strictly necessary in a democratic society, to achieve the purposeand Imposed in the least intrusive manner possible

Limitations of rights must be reasonable. Not arbitrary

Sec. 44 Malawi Constitution, 1994 entails similar principles for lawful limitation of human rights: They need to be in the public interest, be reasonable and be necessary in an open and democratic society and must be comparable to international human right standards and must be prescribed by a law of general application.

Like the Syracuse principles, UNAIDS guidelines provide, that human rights can be limited under the following circumstances:

Provided for by law Based on a legitimate interest Proportional to the interest Decisions to restrict human rights must be reasonable. Need to find links and balance between public interest and human rights.

ADPIE ADPIE (see www.wardclass.com) is an example of a classic decision making model developed in the context of nursing.

Assess Diagnose

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Plan Which alternatives and options are available? What are the consequences of actions/non-actions? What are the values and professional issues at stake? Decide which course of action to take or not! Give justification.

Implement Evaluate

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The short history of bioethics as an academic discipline The origin of bioethics/medical ethics: Hippocrates (c. 460-377 BC) is considered the father of Western medicine and he was the first to link ethics to medicine through his Hippocratic Oath. However, it was Thomas Percival (1803) who actually coined the word medical ethics. The first person to use the word Bio-ethik which means in English bioethics was a German scholar called Fritz Jahr, and this was in the year 1926. He c bio

ethos

where he discussed the use of plants and animal in biological research, (Resnik, 2011).

American biochemist, Van Rensselaer Potter, who on his article The Bioethics, The science of Survival discussed the term bioethics in the social context of human solidarity with biosphere creating an interdisciplinary discipline connecting biology, medicine, ecology and ethics. In 1973, Callahan did clarify the new subject of bioethics as an academic discipline which uses methodological procedures and strategies for decision making process. It was through the initiative of Shriver and Hellegers who first proposed the need for institutionalizing bioethics through creation of a bioethics institute in which researchers should examine and analyze medical dilemmas. In response to this call, the institute was created in 1971 as the Joseph and Rose Kennedy Center for the Study of Human Reproduction and Bioethics, and it was later renamed as the Kennedy Institute of Ethics (the Institute of Society, Ethics, and the Life Sciences, 1969) (Department of Medical History and Ethics University of Washington School of Medicine Albert R Jonsen 1998, 26-27)

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In the beginning the word bioethics was used interchangeably to medical ethics. It was Potter in 1970 who defined medical ethics, animal ethics and environmental ethics as part of bioethics. Bioethics was first institutionalized as part of theological, philosophical and medical disciplines, and later in the modern times it has become a standalone interdisciplinary discipline found mainly in medical schools, health research centers, biotechnological and basic health sciences. (Online Encyclopedia of Bioethics)

The history of bioethics as an academic discipline in Malawi/Africa4

When one studies the Chewa creation myths, one sees already aspects of linkage between ethics and science. It was caused by disobeying ethical procedures in research by playing with two sticks, one hard, and one soft despite a strict warning from elders. This ended up causing a fire which could not be controlled. All this happened at Kamphirintiwa near Lilongwe in Malawi. (Schoffeleers 1979, republished 1989, 147-187) This mythology shows that the bioethical questions have been thought through even by our forefathers and foremothers.

In modern Malawi, the issue of bioethics has been taken up as an object of learning and research. The College of Medicine was one of the first institutions in Africa to introduce mandatory training of all college students in bioethics starting in 2001. This was made possible due to a change of US research policy on research funding for overseas research involving human research volunteers. Any US

4 See also Mfutso-Bengo, et al., Towards an African Ubuntuology/uMunthuology Bioethics in Malawi in the Context of Globalization in Bioethics around the Globe, ed. C Myser, Oxford, 2011

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government funded research must follow the research regulations of the US.

In 1997, ICMJE, which represents over 400 biomedical journals, decided to revise its authorship guidelines about ethics of research publication. This directive meant that no one could publish on research involving human beings in these international peer-reviewed journals without ethical clearance certificate or approval (Resnik 2011). This also necessitated the need to strengthen the College of Medicine Research Ethics Committee in Blantyre, Malawi.

There was a call for the establishment of the Office of Research Integrity in the US after noticing alarming numbers of cases with fabricated data. In 1989 NIH required that all graduate students on training grant receive education in research ethics. Since 1999 this training requirement was extended by the Office of Human Research Protection (OHRP) and NIH to all people who conduct research or oversee human subject research. This training requirement was extended by NIH and OHRP for all people conducting research abroad with human research participants (Resnik 2011). This new US research ethics training requirement also did affect the Malawi College of Medicine research and academic institutions funding. It was in a way, a blessing in disguise. It did indirectly force College of Medicine (University of Malawi, UNIMA) to introduce bioethics training for researchers and students in response. Through the initiative of Prof. Robin Broadhead a bioethicist was recruited in 2001 despite some strong opposition and resistance from some members of faculty. The newly recruited bioethicist was mandated to come up with a white paper for the development of a College of Medicine Bioethics Unit. Indeed in 2001 Malawi Bioethics Research Unit (MABIRU) was created by Joseph Mfutso-Bengo.

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Therefore, the modern understanding of bioethics spread to Africa towards the end of the last millennium and beginning of this century

institutions like Johns Hopkins Bioethics Institute, and Prima Arena, AMANET, EDCTP just to mention a few to spread the message of bioethics in Africa.

Therefore in 2001, Malawi hosted an NIH funded international conference, which was attended by over 200 African and international delegates to discuss emerging bioethical issues in Africa. This conference marked one of the milestones in the beginning of mass awareness of bioethics as an academic discipline on the African continent. Out of this Blantyre Bioethics Conference one additional concept, the concept of collaborative partnership was added as number eight to the seven research ethics benchmarks, developed by Ezekiel Emmanuel et al. (see framework above). It is a research ethics framework for review and verification on what makes a clinical trial ethical or not. (Emanuel, et al. 2004, What makes Clinical Research in Developing Countries Ethical?) This ethical benchmark has become a gold standard in ethical review internationally; in addition the conference formulated another globally accepted fair benefit bioethical framework. (Emanuel Ezekiel, Mfutso-Bengo J.M.,et al., 2004, Moral Standards for Research in Developing Countries

)

In 2003 MABIRU applied successfully for a big competitive bioethics research grant from Wellcome trust for bioethics research. With the help of this Wellcome trust bioethics research funding, five social scientists (one PhD level, two Master level and two Bachelor level scientists) were recruited to join the bioethics unit. In 2004 the center of bioethics won the prestigious Fogarty bioethics training grant to transform the bioethics unit to become a regional center of excellence

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of postgraduate bioethics training for the Southern and Eastern Africa. In the same year, the Malawi Bioethics Unit rebranded to the Center of Bioethics for Eastern and Southern Africa, in short CEBESA.

With this funding, CEBESA was able to award over 200 postgraduate certificates in bioethics and train more than 6 Master students from Malawi, Eastern Africa and Southern Africa in Masters of Public Health specializing in Bioethics. Due to this funding the bioethics center was able to recruit another bioethicist from Zimbabwe, Dr. Paul Ndebele, to become the deputy director of the center. With the Fogarty training bioethics grant Malawi had become the second country in Africa, after South Africa, to qualify for establishment of a center of excellence for bioethics postgraduate training. Dr Paul Ndebele left the center in 2009. In 2010 he was replaced by Dr Lucinda Manda-Taylor as the deputy Director of CEBESA who also became first IRB administrator of College of Medicine Research Ethics Committee and one of the first IRB administrators in Africa. This followed the restructuring of COMREC, so as to make it more efficient. Then the post of Research and Ethics Compliance Officer was created and added to the new COMREC structure. Mr. Francis Masiye was recruited as the first Compliance Officer. These two posts were made possible with the funding by EDCTP research ethics capacity building grant. After the end of grant in 2011, College of Medicine made a decision to continue to fund the positions of Compliance officer and College of Medicine Research Ethics Administrator from its own resources.

Another milestone of Malawian contribution to the bioethics discourse was the 2004 international conference in partnership with NIH and PRIMA ARENA, which attracted over 250 guests from Africa and beyond. Out of this conference, the African Bioethics Organization was formed, called Partnership for Enhancement for Human

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Protection in Africa in partnership of PRIMA ARENA, with Prof. Mfutso-Bengo as its first president. In 2005, Malawi won a competitive bidding to host the prestigious Global Forum for Bioethics which takes place every three years in a different continent. The conference was attended by over 300 delegates including United Nations, European Union, US government representatives and many African and Asian delegates.

Apart from hosting critical international bioethics conferences, Malawi contributes not only through training, but also through published research on bioethical issues from an African perspective. The research work in African bioethics includes the areas of informed consent, therapeutic misconception, the ethics of good participatory practice, community engagement, understanding of refusal of participation, ethical jurisdiction in international research, ethics of exportation of samples beyond the boundaries, research on knowledge, attitude and practice of circumcision and many others. Malawi has been a major contributor to the African bioethics literature.

Although applied ethics had been taught in the traditional disciplines of theology and philosophy, bioethics had not existed as a standalone discipline. This happened only with the introduction of the bioethics training grant supported by the Fogarty grant, in 2001 and 2004, which was given to Malawi and South Africa (SARETI-University of Kwazulu Natal and ARENSA -University of Cape Town). Later it was given to University of Ibadan-Western Africa Bioethics, Moi University and University of Cairo to establish training centers in bioethics.

Even though bioethics is taking roots in Africa, and more countries are starting bioethics training, there are still very few African universities that offer bioethics programs at Masters Level (currently Moi University, University of Cairo, University of Ibadan, Witwatersrand

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University, Kwazulu Natal University, University of Cape Town). There is still much to be done to develop the field of bioethics in Africa.

Towards an African Bioethics The development of Western bioethics provoked the reaction of African scholars of coming up with an African bioethics. The three main proponents of the African bioethics are Godfrey Tangwa, Segun Gbadegesin and Joseph Mfutso-Bengo, according to Behrens, 2013. He argues that in comparison to other regions African bioethics is still in its infancy (Behrens 2013). There is a growing debate among bioethics scholars in Africa on what constitutes an African bioethics. This has resulted in grouping bioethics in Africa into three main categories namely:

Wholesale adoption of Western bioethics in Africa, African bioethics, which seek to understand the Western bioethics principles and theories according to an African perspective

The more radical approach of African indigenous bioethics that wishes to come up with the African bioethics principles and theories independent of any of the Western bioethics thought

African bioethical local contextualization of global bioethical principles (beneficence, justice, autonomy) in resource allocation The following discourse of justice will consider a practical example of African contextualization of bioethical principle of justice in the area of resource allocation for health and education of health professionals. We will see how, equality of merit and equality of needs, which are both defined as justice according to the Belmont report, need to be contextualized to a particular society.

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What is justice according to ethical perspective? Justice is wrongly perceived as equal treatment for all at all times. Aristotle defined justice as treating equals equally and unequals unequally. This definition of Aristotle could be considered as one of the best definitions of justice. However, this definition needs to be complemented with John Rawls moral theory of principle of difference. (Rawls 1975, 75). Therefore the first step to establish real justice is to establish whether there is difference no difference Where there is no difference in equality equals ought to be treated equally based on merit and this is what is called comparative justice/procedural justice which is actualized in first come first serve principle. If there is a difference -comparative

ethical justification of the difference should be in accordance to normal human reason standard. In principle when all things considered and when there is no difference in equality, equals ought to be treated equally. In this context, treating equals unequally is unjust and unfair.

established, then to treat the unequal differently and unequally, could be the most equitable, fair and just decision to do.

In this context, when one applies the same moral logic in the way public university student scholarships and support were managed in Malawi before the reform of 2015, one discovers that unequal, for example, a student from poor community day secondary school was treated equally in the same manner with a student coming from an expensive private high school, regardless of his/her social conditions and conditioning. This understanding of justice could lead to more inequities. A student from the expensive school, for example, ended

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up getting upkeep allowance of every month which in practice one did not necessarily need and the poor community day secondary school student had to fend for him/herself when in reality s/he actually needed the upkeep allowance because s/he cannot afford the basic necessities of life and the fees and upkeep cost. This ethical dilemma is also underlined by Jane Hammill, in her article

methodology used in Maryland in US to identify the talented and gifted children in primary and secondary schools for funding using community funding program called (TAG).

In the same vein Rania Combs in her newsletter titled When Equal Is Not Equitable: How tdilemmas and distress which parents meet when deciding how to

... in some situations, an equal distribution may not seem fair. For example, suppose one of your children is a doctor with a very successful practice, while your other child is an elementary school teacher, who earns significantly less. Perhaps one of your children is disabled and will never be able to provide financially for himself. Or you have a close relationship with one child, while the other child is estranged. In situations such as these, an unequal distribution may appear to be more equitable. But how can you divide your estate unequally without inviting resentment, hurt feelings and perhaps a legal challenge?

The Malawi government is like a parent to both students. One is at a poor community day secondary school and another at an expensive private high school. In this context equal treatment between the poor day secondary school student and the rich student was unfair, unjust and insensitive because they are not equal.

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Firstly they are unequal because the rich school is an indicator for good income of the parents, who obviously were able to afford a costly secondary school. In case there was an extreme change in social conditions of the students coming from rich private schools or families (e.g. due to bankruptcy or death of a guardian or parents who left nothing), the burden of proof falls on the student to prove his sense of incapacity to warrant government financial support.

Secondly, the students from the rich private school had a better preparation to succeed in the final exams. Results in final exams do not only reflect academic potential and intelligence but reflect also the quality of preparation, availability of books, student entrance exam coaching etc.

A needs assessment checklist or test, if well designed, can capture in the system the genuine needy students.

Therefore all stakeholders needed to make sure to promote real equity and not to defend or perpetuate unfair privileges in the name of defending the poor, when actually the rich were the ones who were benefitting more than the poor. It seems that in Malawian context the privileged students and deprived students were being treated equally when considering their selection on academic results (seemingly merit) only. However in upkeep allowance there was

r not. Actually the unequal were treated equally but to the advantage of the rich and privileged students who get upkeep allowance and qualify for scholarship at the expense of disadvantaged students. Can we imagine, how much difference it would have made if we would have diverted the funds being paid to subsidize the upkeep costs of the students of rich parents to subsidize tuition and upkeep costs of those who are in need?

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The former practice principle of difference in his theory of justice. The principle of difference underlines that where there are social and economic inequalities, social benefits are to be arranged to the benefit of the least disadvantaged of the society. This is the ethical, moral philosophical basis for the legal concept of affirmative action, which is also found in the Malawi Constitution. It is based on the need to redress inequality, to empower the disadvantaged. In other countries like U.S. and South Africa affirmative actions are used for black

Affirmative action is based on moral difference which is in turn categorized and determined by age, gender, disability and deprivation depending on social imbalances.

Treating those who are unequal unequally can be justified when inequality could benefit the most disadvantaged of the society or country- that is, the equal treatment should not be achieved by worsening the social and economic situation of the already most disadvantaged of the society (Rawls 1975) (Stanford Encyclopedia of Philosophy)

The government should be applauded by being courageous in tackling this issue of inequity. This is what the new Student Loan and Grant Bill for Higher Education and their implementers can address. The issue of inequality in accessing government financial support has to be dealt with urgently. The wrong allocation of scarce resources for up-keep for those who have already demonstrated, that they can afford education and upkeep, will come to an end. The reality shows that university selection takes more people from the rich schools than from poor schools. However, this does not necessarily mean that the poor schools do not have intelligent, hard-working students with high

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academic potential. Ignoring and not including this academic potential of the poor students was under-utilization of human capital.

This is called social justice in a form of equity based on need (non-comparative justice) and not merits (comparative justice). Point of moral reasoning is, should a student from a rich school with one from a poor school be treated as equals or unequal? Ethically according to these moral systems, they are not equals but unequal therefore they need to be treated unequally. According to Belmont report the principle of justice has to be considered together with the principles of autonomy and beneficence. The principles of beneficence and non-maleficence, says firstly do not harm. By allocating scarce resources to people who can actually more than afford their up-keep, one takes away scarce resources from those who are genuinely in need and deserving due to their academic potential. This constitutes social- harm. Spending a lot of national financial resources on upkeep of few students who could afford and sending the majority who could not afford had repercussion on number of trained health personnel in a country with dire shortage of health personal, resulting in a low doctor or nurse: inhabitant ratios.

These scarce resources could be allocated and invested to increase access of those who genuinely cannot afford the basic human needs to access higher education. Thereby, according to the principle of beneficence, Malawi will maximize the potential of human resource utilization and human capital. This translates to a greater number of students and health professionals in a country that has shortage of health personnel.

The principle of autonomy underlines that a human being is a free, rational being to make his own decisions and also free to decide about his destiny, free from coercion and exploitation. In social

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context autonomy means what? Is freedom of autonomy not freedom from unfair competition, unfair trade and unfair agreement? Was the competition between a student from a rich and a basic school fair? In a country where the quality gap between these two schools is so huge, could we talk of competition on justifiable merit? Freedom is associated with hope. When people are deprived of their hope of social mobility, then you are creating a cocktail of instability and violence. Therefore autonomy, beneficence and justice are all interrelated.

Among the three principles one discovers that justice is the most neglected not only in Malawi but around the globe. The way we apply justice can make or break a country. If you want peace, work for justice. (Pope John XXIII 1963) John Rawls in his book theory of justice also described the linkages between social order and stability and equity and fairness. Without effective justice systems and fair play and fair trade we risk mob (in) justice.

The mob (in)justice is the most primitive and unjust form of justice because it violates the basis on which justice is built: that is natural justice: that is the right to be heard and to be presumed innocent until proven and found guilty; mob (in)justice is often not proportional and reactionary and charged by emotions. It can lead to a death of an innocent person, unwarranted destruction of property and already limited infrastructure.

Recently we have witnessed the emergence of sporadic forms of mob (in) justice in the country. This is a very sad development which if left unchecked could explode to become an uncontrollable orgy of violence such as the xenophobic killing of immigrants in South Africa, tribal killings in South Sudan or Kenyan tribal post-election violence. Mob justice does satisfy the inner human desire of revenge for

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unfairness. However giving a blind eye to mob justice can lead to loss of social innocence and can create the basis and provide criminal elements fertile social climate for violence and social volatility. It is well known that violence begets more violence. Social violence begins in a small way. Any tolerance to violence whether religious or secular, ought to be discouraged as soon as possible.

With the coming of democracy in Malawi the natural justice principle is taking root in many institutions and in the country. However in social justice where one looks at fairness of social systems and structures, there is still room for improvement. Social justice in a form of distributive justice, there is still wrong understanding of justice as equality for all at all time.

African bioethics of umunthuology: Contribution of African-Malawi bioethics to a global bioethics discourse

Umunthuology bioethics framework in summarized form The word umunthuology comes from two words umunthu which derives from Chichewa language meaning humane and logos which comes from Greek meaning word or study. Umunthuology is the study of humanism. What is being humane? How can one become humane? It presumes that not every human being is humane (uyu simunthu). For human being will become humane through good relationship. I am because we are which is opposed to Descartes'

Umunthuology-respect of human life and human person, valuing discipline, self-control, hard work, solidarity, interdependence and protection of common good, common sense and value of harmony of creation. Therefore umunthuology is an acceptable character for any form of human interaction: economic, social, psychological, spiritual. Morality is not individualistic but communal. Umunthuology targets the whole human race and is not tribalistic.

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Without willing common good one cannot achieve personal goodness and common sense. Common good is the cause of solidarity. This is based on self-sacrifice and self-discipline and not the sacrificing of the other. Self-discipline is meant for self-control. Self-discipline is there to limit self-interest in order to balance self-interest with community interest. Common good is the source and goal of common sense and common interest. Common sense is not common because not all humans or nations seek common good or interest but self-interest. One cannot achieve personal goodness (umunthu) without seeking common good and self-control. Therefore good decisions should try to balance common interest with personal interest. The idea of goodness has biological, social, spiritual, cosmological and ethical dimensions. African umunthuology (being humane) is theistic not atheistic. It is the other who can pass judgement whether one is good or not.No one can declare himself to be good. Morality is not seen in an individualistic manner but it is communal. Therefore, the need of independent ethical review. Umunthuology is not contradictory to the normal reasonable person standard. The African morality presupposes that every person who does not seek common good and self-control cannot achieve personal goodness, progress and common sense. The solidarity is based on self-sacrifice, self-control or mutual sacrifice and not the sacrificing of the other.

In the Malawian context, bioethics is seen as a relationship of human being with oneself, with nature, and with other human beings. This relationship is based on cooperation, mutual respect, reciprocity, solidarity, common sense, common good, hospitality, fairness, and it is rooted in the Malawian (African) moral thinking of umunthu, or

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ubuntu, as it is commonly known in many Bantu speaking African countries. Ubuntuology/umunthuology means being humane. It is a critical, objective and systematic reflection or study of African humanism, morality and moral systems. The author considers ubuntuology/umunthuology as the main theory of African Bantu bioethics. The umunthuology theory starts with defining what African humanism is, and how one can become humane. The theory pre-supposes that the biological requirement and appearance of a human being is necessary but it is not the cause of being human. It also argues that not every human being is humane (uyu simunthu). One becomes humane through relationship and initiation which is based on acquisition of right knowledge, right attitude and right skills appropriate for a particular community, organization and context. To be good is to behave rightly, and to behave rightly is to relate well. Those who relate well are considered good and humane. Good people are thought to have done good, right, and useful actions. The word seful deed is not materialistic but it has to be understood to mean that knowledgeable and skillful persons with goodness and good attitude are useful. Knowledge and skills without goodness and right attitude are useless or good for nothing and often dangerous. According to umunthuology all human knowledge and skills are meant to promote wellbeing, goodness, personal and common good. One becomes good not for oneself but to make others better. Therefore one cannot separate personal goodness from common good. The concept of goodness and rightness has biological, social, natural, supernatural, cosmological, and ethical dimensions. It is the others who can pass judgment on whether one is right or good. According to umunthuology, common sense is gained through constant search forcommon good. Therefore, in umunthuology ethical principle, moral goodness and rightness are not the same, but are interdependent. For instance, an action can be right but not good; e.g., killing in self-

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defense. Killing is bad but killing in self-defense in a face of a dangerous criminal (called Nachipanti)5, is a right and wise thing to do.

The common goodness is expressed through solidarity. Solidarity is understood as self-sacrifice or mutual sacrifice, instead of sacrificing the other. According to African umunthuology/ubuntology to be humane is to be in relation, and to become humane is through being constantly in relation. Being in relation is an essential aspect of being human. The African umunthuology understands that all created beings are together interconnected, interdependent, and interrelated. They are also connected and dependent on the creator and the created cosmos. A human person exists as a person in a family and in an extended family. This concept of extended family6 is extended to strangers, foreigners, and the living dead and friendly spirits, in the other words it embraces the whole humanity. Speaking on the same theme, Kenneth Kaunda, an African humanist and former President of

Let the West have its technology and Asia its

human relations (Hilmer 2011, 103). See also (Mfutso-Bengo J. M., In the name of the rainbow, 2001) and (Mfutso-Bengo and Masiye, Towards an African Umunthology Bioethics in Malawi in the context of globalization 2011, 152-163). African humanity is defined in the context of the community. To be is to belong to each other; no man is an island. The real esteem of the human being must be based on assumption that no race, no class, or group has a monopoly of all human gifts and knowledge. -Bengo, 2001) There is a 5 Nachipanti is a name of a dangerous criminal who was caught and arrested in Malawi. He used to steal at night only wearing underpants and this is the reason he was called nachipanti. 6 The true concept of extended family can be promoted to promote the respect of human dignity regardless of tribe, gender, religion and nationality. Today some have reduced the concept of extended family only to their tribe or blood relations.

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no person can embrace it It is through human interaction, and not rejection and

projection, that humans will achieve their potential. Marginalization and segregation, whether divine or human, deny the richness and variety of hum the fundamental human right is the right to love and to be loved (Shorter 1994, 117 . Thus we are persons in a community and not against the community. Humanization and reconciliation processes find clear expression in the context of being in relation, in being in communion through communication and commitment to truth, justice, and mercy. see Mfutso-Bengo 2001)

Umunthulogy between tradition and modernity: How the modernity can benefit from umunthuology as moral capital Practically Africa is in transition between tradition and modernity. The

the dialectic between socio-economic and cultural North South conflict. In Chichewa the word have . Therefore one has in order to live and one does not live in order to have. It has become an inner conflict on African soil among Africans themselves. The modern Africa, influenced by the Western capitalism, has a tendency to desire to be in order to have more material wealth and status symbols than to be in order have more life, more solidarity, more sharing and more relations. To the negative extreme some people would rather have a bad relationship, with oppression, jealousy and envy than not to have a relationship at all. The need to relate can also lead women or men to endure oppressive relationship. This shows that relationship matters more. However oppression, envy and jealousy are considered

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as simunthu/not humane in umunthuology (See Mfutso-Bengo, 2001, p.45).

The focus is shifting in the modern African society from community to individualism. However, how can we protect the moral capital of umunthu/human goodness and the concept of extended family the concept of inclusiveness? Why is the traditional African value of umunthu disappearing? Can one protect umunthuology in the context of modernism? How can the modernity benefit from the umunthuology concept of extended family in formulating inclusive policy?

Efficiency and efficacy were part of the traditional value system, and even today are values which are part of a modern business culture. However these traditional values have to be translated from the traditional village setup to the modern office setup. They were taught in the traditional African society through proverbs (Van Breugel, 2001 p.266).

Below the author by using proverbs wishes to demonstrate relevance of Umunthuology.

Use of opportunities The sniffing tobacco in your nose is yours but the one on your hand can be taken away by the wind.

Efficient use of time as a resource When the sun shines, bask in it

Efficacy Mr. Frog finished the journey with hopping.* Killing the snake is to cut off the head.* One mango tree does not feed the whole village.*

Hard work Just staying does not find a shirt.*

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To have something; but effort.* The fire-fly gives itself light.*

Common humanity/extended family

Mwana wazako ndiwako yemwe meaning your neighbors child is yours you can benefit a lot.

Risk assessment To jump when there is no fire. (yet seen.) *

cannot pass twice. (Certain mistakes cannot be corrected)*The fearful crow died of old age. (Caution)*

Teamwork One man cannot carry a roof. Alone, alone cannot produce history.*

Intellectual property/organizational knowledge

Knowledge is like a baobab tree one man cannot embrace it

alone. Leadership When you climb the back of an

elephant you think there is no dew. (Warning to leaders not to forget the grassroots)

Obedience/Taking advice The one who did not listen, listened when the axe fell on his head.*

Research/Knowledge/Information: The white thing killed the goat.* (Looking at outer appearance without considering true nature.)

Training To straighten a tree, but at the beginning.*

Sustainability A greedy monkey will eat his own stomach.

(The proverbs marked with * are taken from the collection of Dicks, 2006, the others are from Matthew Mfutso-Bengo, oral tradition).

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The author thinks that umunthuology (human goodness) can survive globalization and modernity because the sustainable basis for the modern community will depend not only on law, external control but also internal controls, moral capital, conscience, team work, common good, reciprocity, good intentions, good will and good faith. All these are internal human values which are propagated by umunthuology which are the basis for modern human progression. Umunthuology also gives people a sense of belonging, identity and purpose which is an important factor for mental health (See Mfutso-Bengo, 2001, p.45). The author thinks that increasing individualism leads to increasing mental health problems (increased health bill) and destructive fanatical behavior. The traditional African umunthuology sense of community, belonging, identity and purpose can prevent radicalism and fanatical and self-destructive behavior which is found in subcultures with distorted purpose found in countries where the sense of belonging and identity has been displaced by individualism and materialism. Umunthuology values of honesty, trustworthiness, reciprocity, hard work and acting in good faith are necessary for any social contract in a modern world. Umunthuology promotes respect of life, persons, common good, common sense, solidarity, hospitality, respect of rules/obedience, peaceful co-existence and conflict-resolution. Hence it even exceeds the requirements of modern human rights and requirements of successful business.

One needs to ask which forces tend to dominate, manipulate and exploit the spirit of umunthu/human goodness. This makes umunthu seem to be less attractive to some modern Africans even though they are in the same need of it, not knowing that they need it in order to prosper economically and be competitive in the modern world.

The author argues that without economic development the traditional values of umunthuology in Africa will also be put at risk and

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disappear. A society which is not developing can neither protect its traditional ethical values nor its natural resources/environment/cultural heritage in a fast changing globalized world. Underdevelopment is anti-human, anti-social and anti-culture hindering the protection of values and the environment.

True sustainable development ought to strive to incorporate, protect and sustain traditional moral values of community, common good, common sense of belonging, of identity and purpose of good for human race in its economic progress instead of nurturing a culture of personal greed. In summary:

Four stages in umunthuology for human self-actualization

Community building Teamwork Solidarity Reciprocity Sacrifice Trustworthiness Honesty

We are therefore I am. I am therefore 7

Sense of belonging/extended family

Being part of humanity Accepting others Being accepted by others

Sense of identity Self-awareness Without self-respect one cannot respect others Being recognized by other human being I am therefore we are. We are therefore

8

Sense of purpose Sense of meaning of life and human interconnectedness Sense of direction Self-fulfillment Personal and common good

7 Mbiti 1975 8 Mbiti 1975

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Examples of Ubuntu/umunthu in action In the following the author gives some examples of umunthu as it is practiced in the traditional Malawian society.

A human person is called to be human when s/he is able to understand to have knowledge of the cultural values, has life and technical skills to sustain his life and his family, e.g. ability to build a house, to cook, to cultivate a field, to make hoes etc. and when he has got a right attitude. The three competences are pre-requisite for being a human in a community. Therefore skills and knowledge alone without right attitude one is called . Thi means, you are not human. (similar to German: ). The human person who has got right attitude but is not skillful and lacks knowledge is called

his full human potential. In order to be fully human in Umunthuology one has to have three united but distinct competences, namely required knowledge, right attitude and required skills appropriate for a particular community. Right attitude in this context includes goodness, virtues, consideration and respect of those who are unable to realize their full potential.

An example for umunthu/Ubuntu is the solidarity by showing presence during funerals of anybody including people of low profile. It is a usual scene to see mass gatherings of people accompanying a coffin. It is part of showing respect; There is a true story where a group of tourists stopped to the funeral process to cross the road and they were amazed with the mass gathering, and asked the villagers what a kind of high profile person has died? To their surprised the villagers answered that it was one of the villagers who was insane. Even though he/she was poor, he/she is accorded respect. This respect is based on the principle of reciprocity and solidarity, that every person can die and that every

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person needs people to bury him/her. The remaining family needs solidarity and consolation, and that all humanity belong one extended family9.

Another typical feature is a culture of hospitality and welcoming. This is also one of the aspects of umunthuology ethics where not only family members but the family is extended to even strangers. This is why Malawi is called the warm heart of Africa, because it is very welcoming country to the strangers. This aspect of umunthuology is a moral capital that can be promoted and be transferred into the service sector to improve customer care.

Ubuntuology/umunthuology is a practical moral principle. It forms the essence of Malawian (African) identity. Obviously, Africa does not measure up in terms of the technological advancement and material prosperity of the West, but Ubuntuology/umunthuology KAS model

Because of this outlook, in the ubuntu/umunthu way of life, elements like loneliness, unhappiness, and internal violence that are characteristic of individualism do not seem to be highly prevalent. Thus, an ubuntu/umunthu theory of bioethics is perhaps one of the most precious gifts that Africans can share with the rest of the world. The author believes it offers a unique paradigm for solving the cultural and social/economic problems confronting the world today, as it adopts a holistic approach in advancing human development and welfare.

Therefore the author thinks that Umunthuology is a moral capital. Umunthuology creates resilience and mental stability for a human being and social harmony, in a time when other parts of the world face increased psychological burden due to loneliness and isolation or

9 This concept of extended has been reduced to ones relatives only. This is lost opportunity to translate the concept of extended family into modern inclusive economy and policy making.

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extreme behavior of fanatics due to lack of sense of belonging, purpose and community solidarity. Umunthuology can be used to create collective moral identity. Umunthuology emphasizes the importance of the principles of reciprocity, solidarity, common sense and teamwork to achieve best results for the common good conducive to fair business trade-offs. However, Umunthuology has been abused by some few elite who misunderstood and distorted umunthu sense of solidarity to promote tribalism, nepotism, envy and jealousy.

Umunthuology in the context of environmental and animal ethics According to African world view survival of the planet is linked to the survival of the human being him/herself. Protection of the environment is based on anthropocentrism. In this sense, it is the responsibility of the human person to live in harmony and in reconciliation with nature and environment and God, the creator of the creation. If there is no harmony between nature and humanity it is not the environment which is guilty but the human person is responsible for the environmental catastrophe. (See J. M. Mfutso-Bengo 2001, 206 and 207).

Anthropocentricity means that the African person considers his/herself as being at the centre of the universe. In this way, visible and invisible parts of the universe are at his/her disposal through physical, mystical and religious means. Humanity is not the master of the universe. He/she is only the centre, the friend, the beneficiary. For that reason, he/she has to live in harmony with the universe, obeying the laws of natural moral and mystical order. However, the human beings disorderly way of relating to nature and to his/her fellow human beings shows that humanity is not fully the centre of the universe. S/He is called to grow in his/her awareness of being

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The problem the world is facing is to achieve a reconciled biodiversity of life species. To reconcile bio-diversity is to safeguard the survival of all creation including the weakest and smallest life form. The African anthropocentric view is a clear critique to those Western authors, e.g. Drewermann (Drewermann 1981, 143) or Carl Amery, who think that one of the causes of ecological disaster in the world is anthropocentric view of the universe.

According to Malawian creation mythology among the Chewa, the first cause of ecological degradation ever recorded among the Chewas, was not anthropocentric but anthropo-egoistic. According to the

misuse of technology and science. Human arrogance, disobedience and pride are mentioned as sources of ecological disaster.

The myth as recorded by Prof. Schoffeleers:

y and below him was the earth - waterless and without life. One day, dark clouds began to cover the sky. Lightening flared and peals of thunder were heard. Then the sky opened and from it God, the first human pair and all animals

t the soft surface hardened and turned into rock. On this rock God, men and animals lived together in happiness and peace. One day, man accidentally invented fire by playing with two twirling sticks, one soft the other hard. Everybody warned him to stop, but he did not listen. In the end the grassland was set alight in fire and there was great confusion. Among the animals, the dog and goat fled to man for safety, but the elephant, the lion and their companions ran away, full of rage against main. The chameleon escaped by climbing a tree. He called out to God to follow him, but God replied that he was too old to climb. In the end the spider spun a thread lifting Him up on high. Thus God was

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driven from the earth by wickedness of man. As He ascended he pronounced that henceforth man mus(Chakanza 1987, 5) (Schoffeleers 1979, republished 1989, 147-187)

The African Malawian environmental perspective is not cosmological but anthropocentric. However this anthropocentric view is not atheistic but theistic. This Chewa creation mythology demonstrates that environmental protection is linked to human being responsible behavior. World environmental order is linked to God s order, and disobeying God s standard operation procedures would lead to destruction and degradation of environment. Here the human being seems to be fascinated by created things (new technology of fire) ignoring the creator. By disobeying God the created human being is losing control of what he thought was controllable (the new discovery-fire becomes unmanageable). This myth does not obviously stand in contradiction to environmental ethics and it can be reconciled with utilitarian thinking, animals as sentient being (ability to feel pain) who fear to be harmed by fire. The innovative skills of humans go hand in hand with responsibility of human beings, which creates obligations and duties towards animals and nature as an ethical imperative (Kant).

In Africa the practical experience has shown that wildlife protection needs to involve and benefit local communities in order to be successfully practiced, thereby creating new companionship and partnership. This myth considers animals not in hierarchical structure, less as objects to be exploited, but as autonomous companions of human beings. Here also, the myth demonstrates, that animals have got their own interest and are capable of making decision whether to follow the human beings or not. The old Western, biblical based anthropocentric approaches subjected them to a human master without any choice. According to biblical and Western creation

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perception the human and animal relationship is hierarchical and not presented horizontally as a partnership despite a diverse nature.

The efforts on international environmental protection show also that the gap between environmental protection and social protection still needs to be bridged. Climate justice is meant to balance environmental protection with social protection. Human and environmental concerns have to be reconciled and should not be in contradiction.

Whether we like it or not, the fact is that the human being holds the keys to self-destruction or reconstruction, to corruption or correction, to repression or reconciliation. To be the centre means to have a caring and creative responsibility towards humanity and nature. So being at the centre means responsibility. The fact that a human being can, does not always mean that he ought to. Any discovery ought to be assessed in line to precautionary principle (J. M. Mfutso-Bengo 2001, 211).

Bioethics as moral capital, moral power and moral authority As a reaction to one of the biggest business scandals and fraud at ENRON, Alejo Sison, Virtue Matters? bserved, that amount of human, intellectual or social capital could make up for the lack of moral capital among workers for the long- He understands moral capitalpossession and practice of a host of virtues appropriate for a human being within a particular socio- (Sison 2003)The advantage of moral capital is that it perfects the human being as a whole person. It goes beyond a superficial commitment to values, but a cultivation of habits and virtues. We are not only what we say, we are what we regularly and habitually do. Alejo Sison introduced the concept of moral capital, because he observed an accumulation of

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interest in return. The individual does not only gain a particular skill but benefit with his whole person. We also see that the individual and its organization or society gain a competitive advantage over others. Virtuous worker do not only reduce the costs caused by unprofessionalism, moral hazards, litigation and fraud, but they also tend to work better and contribute more to an organization and even a nation, thereby creating an attractive environment for investments, competitive labor force and labor market. A virtuous leader has both power and authority, the word virtue comes from Latin word called virtus which means power and strength (Havard 2008). This power

is based on authority which derives from the strength of character. Many leaders have power without authority because they lack virtues which are the building blocks with which a resilient and good character is built. Lack of authority often leads to abuse of power which in turn undermines authority itself even more. Without authority further illegal, undemocratic and violence are required and employed to preserve power without authority. No leader can sustain power without authority. This is a leadership vicious circle, which at the end leads to a loss of both authority and power due to lack of effectiveness and performance. A post or an office whether elected or appointed gives a leader power but not authority, but power without authority undermines power (see Havard 2008). The main hindrance to become a transformative leader is lack of character and moral capital.

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Moral capital for sustainable professionalism

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Redefining Moral capital in the context of umunthuology-bioethics

Umunthuology/Ubuntuology bioethics as moral capital Therefore umunthuology becomes a moral capital when the appropriate knowledge and appropriate skills are complemented by right attitude or moral character traits of umunthu namely: unity, harmony, peacefulness, goodness, openness, resilience, hardworking spirit, responsible behavior, responsiveness, solidarity, loyalty, honesty, self-control and discipline. These virtues of umunthuology can facilitate efficiency, teamwork, initiative, productivity, integrity and ability to learn new things thereby making an institution (A) to have comparative advantage over similar institution (B) with similar technical competence but without moral capital. This is because technical competence differs with moral competence. Umunthu is

to be called warm heart of Africa. The loss of umunthu means the loss of comparative advantage

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in the age of globalization. Umunthu has become moral brand - warm heart of Africa and moral capital dividend because warm heart of Africa brand brings tourists who spend their forex in Malawi. Moral capital is moral power because it can influence investors to invest; it can be used for negotiating in labor disputes. It can also be used to persuade other colleagues to seek what is good and right and avoid what is bad and wrong. Umunthu as moral capital has power that is moral power.

As Jal Mehta and Christopher Winship argue, often taken to be opposites, with morality grounded in altruism and a commitment to the common good, power is located in self-(Jal and Winship, Moral Power) Power is often associated with political, economic, military or religious fanatical power. However, moral powperceived moral stature, is able to persuade others to adopt a particular belief or take a particular course of action. We argue that moral power is a function of whether one is perceived as morally well-intentioned, morally capable, and whether one has moral standing to

(Jal and Winship, Moral Power). Therefore moral power has to do with perceived moral status and standing by the uncommitted middle. The uncommitted middle according to Winship et al., is undecided group who occupied the middle ground. Therefore morality has power to persuade, influence and redirect a public opinion and beliefs using moral persuasion, moral status and standing.

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Graphic: Jal Mehta and Christopher Winship - moral power figure

Source: http//scholar.harvard.edu/files/cwinship/files/moral_power--final_1

When one considers Nelson Mandela it becomes obvious, that political power alone would have made a peaceful transition impossible since most black Africans were calling for revenge and the white minority did not trust any unknown leader due to fear of having

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a similar negative experience like white settlers who lost their land in Zimbabwe and were chased from Mozambique. Using his moral power, authority and status he managed to persuade both groups who trusted him. He even became a global moral brand. This moral icon attracted more investment and capital than any other brand in South Africa. A brand worth billions US-Dollars based on moral character, a valuable dividend gained on his moral capital. (Power-point slides on Mandela and moral capital below were taken from Joseph Mfutso-Bengo public inaugural lecture 2015)

Nelson Mandela as an example for moral capital, brand and power

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investment. A lot of institutional, human failures are caused by inability to value and invest in moral capital.

The concept of umunthuology requires putting moral capital as the necessary first step to all capital. The financial capital is based on the invention of money, a creation by human beings. Obviously an investment in knowledge generation and appropriate skills creates human capital but moral capital is the combination of knowledge generation and appropriate skills plus right attitude (moral character).

Umunthuology/Ubuntuology/moral capital as comparative advantage for sustainable economic growth in Africa The 1960s and 70s were marked by social rebellion against excessive moral and social control. Morals were abandoned and the focus became human rights and freedom and science. Governments invested in human capital that is in knowledge generation and skills development but not in moral values, moral character formation and right attitude. However, over the past decades, humans, corporate world, governments and even more so the citizens have paid dearly by ignoring investment in moral capital. Moral capital is when technical knowledge and skills are complemented by moral competence (right attitude). The new trend even in the West and in Asia is to move from materialistic society to post-materialistic or post neo-liberal society by starting a discourse on value based planning to create a value based society and organization. Therefore, there is a movement to move from human capital to moral capital. One can witness in Malawi a renewed sense of critical self-assessment and increased discourse on issues of corruption, integrity, mental roadblocks for private and public sector in the media and public discourse. This goes beyond an analysis of legal cases but is a questioning of the collective conscience. The Malawi

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government propagates national public service reform based on ethical pillars of patriotism, integrity and hard work since 2015. The World Value Survey (Ingelhart-Welzel Cultural Map see above)

ed a key role in economic development, the emergence and flourishing of democratic institutions, the rise of gender equality, and the extent to which societies have an effective government. (World Value Survey). For example Americans, Canadians and the Irish show relatively higher levels for traditional values than North European Countries and yet they have had rapid economic development. Here one can ask whether values determine economic development or the other way around. The author believes that umunthu values do not contradict economic development. Since it fosters aspects of professionalism it can even be source of rapid sustainable human and economic development.

The world is living with an illusion that capitalism can prosper without investing in Moral capital. Capitalism, as an economic system, needs moral society and moral persons for it to function properly. There is a prevailing assumption that capitalism flourishes on egoism and individualism. The reason of global economic downturn is also a lack of justice and lack of inclusion. An inclusive distribution of economic and natural and health resources will grow markets. The bigger the market the bigger is the potential for economic growth. Ethical misconduct and increased inequities can lead to economic crisis, which in turn could lead to health system breakdown.

Moral capital also propagates the concept of just economics. Contrary to prevailing assumption propagated by Rand, that self-interest, greed and egoism are the engines of capitalism; one sees that capitalism as

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free trade cannot survive without ethical values like honesty, transparency, reliability and mutual trust. These values have been promoted as part of medical professionalism. However, this can be mainstreamed to other professions. The author argues that justice is not a limitation to economic growth, but does facilitate honest transaction and rapid and sustainable economic growth.

Hence, justice can be a source of economic growth according to the following example. The moral capital social equation of justice is clear and simple.

Equal opportunity + entrepreneurship = sustainable market growth.

Entrepreneurship - equal opportunity = market saturation => less demand => more supply.

Therefore distributive justice grows markets.

Sustainable market growth = sustainable demand and supply => sustainable development

When one talks of market people may quickly think of sellers and buyers. However, in the context of medicine and health, markets refer to patients, clients, and others who seek medical assistance. One assumes the potential buyer is the one who is rich. However globally, the gap between the rich and the poor is increasing, even within countries.

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According to the GINI World 2014 INDEX the number of very rich people is growing very slowly, although the volume of their wealth is growing rapidly, whereas the number of the poor is increasing rapidly. The global economic crisis is not caused by lack of money but lack of markets; because there are very few rich buyers chasing too many goods which have been supplied by very few business owners. Hence by excluding the majority of the global population from the market, one is in return actually destroying the market. Maximizing economic benefit to maximum number of people will grow the market. By growing the market one is growing the economy. Economic growth without inclusiveness and justice cannot be sustainable. Hence if a society wants a sustainable economic growth and peace, let them work for justice and inclusion.

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A simple mathematical modeling will demonstrate how justice (inclusiveness, equal opportunities) do grow markets and how growing markets do grow the economy. However there is need to have other means to ensure fair competition between infant and established industries and to create an enabling and re-enforceable, conducive business environment.

Simple mathematic modeling of moral capital

Simplified overview on the link between market and distributive justicebased on assumption that one person can eat one bread per day

Stronger middle class => stronger markets => stronger economy

Suppose you have a bakery located in a posh suburb with a population of 100 persons and another one located in a middle income suburb with a population of 10000. The selling price for one bread is 1 Dollar. 100 rich people in a posh area cannot eat more bread than the middle class person living in a middle class suburb of 10000 persons. Hence the bakery in a posh suburb has a high cost of

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supply but less demand. The cost of rent and labor would be higher in a posh suburb than in the middle class area.

In the posh suburb you can sell maximum bread for 100 Dollars, whereas in the middle class the seller can sell bread for maximum 10 000 Dollars. However, he will not be able to get these 10 000 Dollars, if it was not a middle class suburb but a slum, where people cannot even afford to buy their daily bread.

This simple model can be extended, that the rich could spend more than 100 Dollars by buying luxury pastries for 200 Dollars, however at some point a level of saturation of consumption is achieved. Remaining spending power of the rich would end up in investment and financial services or it can be used for creating opportunities for career progression and social transformation, it could either circulate in the same small group of the rich or among a wider population.

If country A has a GDP of 20,000 US-Dollars but only 10% of the population possesses and contributes to the GDP, then it means the country internal consumption expenditure is underperforming by 90%. Therefore it means 90% less demand for consumption.

This is the reason, why countries are striving, including Malawi, to widen their market by forming regional markets and trading blocks, e.g. SADC, COMESA etc. If one wants peace on earth, harmony in this society and sustainable development, let all work for justice. Therefore justice is not an option, but a social and economic necessity. So long as one has allowed slums to grow one is also growing trouble and violence.

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Final Recommendation-investment in Malawi/African Moral Transformation Program- MA-MOTRAP

Moral capital dividend & moral hazards Therefore one needs to make investment in Moral capital to increase or to prevent the decline of Moral Capital. Moral Capital needs investment in three human KAS -pillars: knowledge, attitude, skill.This can be supported by social systems to be sustainable which comprise of ethical cultural norms, character formation and training, role modeling, justice, social systems, effective rule of law, self-character programming and community collective character programming based on MOTRAP (means Moral Transformation Pedagogy). Where an organization is failing to reap benefits of moral capital dividend, it reaps moral hazards (Dembe, Boden 2003) instead.

Moral capital in the context of medical practices and professional training A lot of professional training is based on philosophy of professionalism which is based on the Kant moral theory of deontology. This states that professionals should act out of duty and obedience to the standard operation procedure (external social control), and is based less on the strength of the internal moral control, in other words moral character (virtue ethics, good habits). This kind of understanding of professional behavior works well to a certain extent - in the context of good government (effective rule of law and an efficient bureaucracy or strict social or religious controls as it is found in small communities or strong traditional communities). This is in accordance with Hans Jonas who said, that human beings change or follow rules because of pressure and not pleasure. That means this concept of professionalism does to a certain extent function in the west, Middle East like Dubai and developed countries

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like Singapore. It works because of strong good governance (rule of law and fear of litigation for medical malpractice). It becomes problematic in the countries with weak governance systems (weak rule of law or weak social and religious grid). Therefore one could propose that medical training and practice should integrate the principles of moral capital and apprenticeship, thereby transmitting expected medical knowledge, expected ethical behavior and expected and required skills. In this context Moral Capital means technical medical competence should be complemented by moral competence especially since it is a context where there is no fear of the law and no social pressure. In other words medical knowledge and skills must be complemented by the right attitude. That also means that medical leaders need to be with their students and juniors on the wards and in clinics demonstrating this attitude.

The ideal situation for sustaining professionalism is to integrate internal moral control with external social control. However between the two forms of controls, the former can survive any pressure.

KAS Professionalism model, a new framework for promotion of sustainable professionalism (in Malawi MA-MOTRAP) Minimalistic understanding of professionalism without right attitude or strong rule of law or strong and religious cultural systems undermines the professionalism. Even though the West has weak moral value systems, this deficit in moral competence has been or can be compensated by strong governance systems (rule of law) which provide checks and balances. In that context lack of moral character can be compensated by strong rule of law, strong religious and

to appear like acting properly ;

thereby maintaining a social appearance of professionalism. In a country or organization where there is lack of moral character, the

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strong governance system can compensate for the moral deficit. These organization or countries can still remain competitive and efficient as long as the pressure remains, but lack of moral capital will sooner or later also lead to erosion of the controlling system, e.g. fraudulent auditors. Right attitude (moral character) leads to an interior competence, while knowledge and attitude are exterior competence. (See also J M Mfutso-Bengo, E Mfutso-Bengo, 2016)

Reasonableness, justice, equality, logic, predictability, accountability, transparency, efficiency, feasibility, sufficiency and objectivity are principles of ethical bureaucracy. One aspect of ethical bureaucracy for example is procedural justice. It is often practiced in administrative context e.g. in the orderly management of patients in the hospitals. Equal patients are treated equally but those who are unequal, with an extra need or an emergency, the last can be the first. That shows that procedural justice is complemented with other forms of justice whereas to achieve fairness and justice, justice can be implemented in one case based on need (emergency) or in another case based on merit.

This form of justice is sometimes violated when one stands on the line to wait to be served but it seems normal to find some people without any form of moral guilt jumping over the line to be served first even at hospitals. Lack of discipline does cost time and undermines efficiency. The most disciplined and organized societies tend to be also efficient, sufficient and competitive for example Germany, Japan, Singapore and Switzerland just to mention a few.

Ethical bureaucracy can help to minimize corruption or to check corrupt practices. Efficiency requires bureaucracy; good bureaucracy impedes unfair advantage and unnecessary flexibility. With moral capital a highly bureaucratic organization can achieve high efficiency

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and competitiveness. Without moral capital, one can use the same bureaucracy to block good things in order to be bribed or even to achieve wrong objectives and things (e.g. Nazi efficient but immoral bureaucratic machinery).

However, behavior change and acting correctly based on fear of the law alone is not sustainable. In addition, complete social control is not possible in a democracy that respects human rights. Therefore democracy must be complemented with an investment in moral capital for it to function.

Western world: knowledge + skills + rule of law = professionalism, exterior morality

Traditional world: knowledge + skills + strong governance through strict social grid (religion/tradition) = professionalism

KAS professional model: knowledge + skills + attitude = professionalism=>integration of both interior and external morality

One cannot have sustainable professionalism without all three components of appropriate Knowledge, right Attitude (moral character) and right Skill. Therefore good skills and knowledge alone without investment in right attitude (moral character) are not enough for sustainable professional behavior.

Technical competence = knowledge + skills Moral character = moral competence

Moral competence + technical competence = moral capital => professionalism

(See also J M Mfutso-Bengo, E Mfutso-Bengo, 2016)

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The author is convinced that Malawi and Africa is making a big mistake by investing only in skills and knowledge without the right attitude (moral capital education). The African continent may lose its comparative advantage of having a strong human capital. It will not be competitive when it does not invest in moral capital like what the moral regeneration movement programs in South Africa (www.mrm.org.za) are doing. Some of the Western countries like Germany are moving from human capital to moral capital, e.g. Berlin introduced in 2006 ethics as mandatory and not just optional subject in its secondary schools. To the contrary Malawi is moving from cheap, unskilled labor force (manpower) to human capital instead of jumping straight to moral capital - which means integrating technical competence with moral competence. Integrity comes from good character and not from good knowledge or technical skills. Malawi could leap frog from manpower to moral capital without losing traditional umunthu (ubunthu) values that other countries have lost and struggle to regain. Hence, the author suggests the implementation of MA-MOTRAP, Malawi/African Moral Transformation Pedagogy for the complete integration of all three components of KAS professional model namely; appropriate knowledge, right attitude (moral character) and good appropriate skills development. This is crucial to have professionalism among our health workers, so that they have the inner strengths to adhere to existing Codes of Ethics despite peer pressure, stress or economic survival pressure.

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The following chart10 gives an idea of the vast variety of virtuous character traits and attitudes. It depends on the context which ones are of higher importance, though all of them are desirable for any human being for the common good.

Teacher Citizen Politician Self-control Self-control Self-control Umunthu Umunthu Umunthu Integrity Integrity Integrity Justice Courage Self-sacrifice Initiative Peacefulness Foresight Honesty/ Trustworthiness

Solidarity Prudence

Benevolence/ Non-maleficience

Gratitude and appreciation (absence of jealousy and envy)

Wisdom

Discretion and decency

Consideration/Common sense

Honesty/ Trustworthiness

Alertness Respect Attentiveness Confidentiality Sense of belonging Dependability Diligence Hard work Decisiveness Patience Patriotism Openness Punctuality Maganimity Visionary

Policeman Entrepreneur Girl child Courage Honesty/Trustworthiness Boldness Discipline Innovativeness Honesty Self-control Initiative Discipline Justice Courage Self-control Determination Responsibility Foresight

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Resilience Responsiveness Discretion Respect Alertness Prudence Loyalty Politeness Maganimity Team work Hospitality Resilience Punctuality

National shared moral vision Since personal morality is the fruit of community collective identity and formation according to umunthuology, making the society aware of the professional KAS model can help our health workers in their clinical work and create a competitive labor force. The work setting is influenced and conditioned by prevailing values in the society.

The first ethical practical recommendation is administrative in nature and could be implemented within the next six months. This is creation of moral values visibilities in all our institutions. At national level, there is a need of national moral vision, similar to the four cornerstones of Dr. Hastings Kamuzu Banda. Dr Hastings Kamuzu Banda having helped Malawi to political independence, he quickly discovered that people were divided according to tribal lines, the people were more loyal to their tribes than to country, there were divisions among Malawian politicians to decide what kind of political and economic policies to follow, either socialism or capitalism, people were not used to organized work. Dr. Hastings Kamuzu Banda began his rule by advocating a new Malawi built on a shared national moral vision which he called the four cornerstones on which Malawi was founded. Ignoring and an intentional abandonment of ethical cornerstones namely: loyalty, unity, obedience and discipline11 have

11 As one commends Dr Hastings Kamuzu Banda, the first President of Malawi for proposing and promoting the four ethical cornerstones to build the new independent Malawi which resulted in making Malawi a peaceful and disciplined country. He is also accredited for laying a solid foundation of envy and jealousy, when he did not want to see anybody building a taller

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lead this country to lose its moral capital which in return has led Malawi labor force to start losing its global competiveness and attractiveness especially in South African labor market. During Kamuzu time Malawians dominated the South African labour market due to that time prevailing perception that Malawians were honest, polite, disciplined, hardworking, peaceful, resilient and eager to learn. Chirwa, 1998 describes Malawi workers as important for South African mines due to their skills, work discipline and lack of militancy. Nowadays some have reduced cornerstonesinto t -for-all , these have been propagated new rich-the middle class (some of the middle class) have exploited the umunthuology virtue of relationship to mean: no relation/no political connection => no career progress and business. For them professionalism is misunderstood as strategic networking and relationship through reciprocal favoritism instead of performance, technical competence, integrity and hard work. As result corruption is rampant. In this context, the Malawi New Public Sector Reform Program has come at the right time. However it should be complemented by a national moral vision and a collective moral capital identity strategy as proposed in the new three ethical pillars of nation development namely: Patriotism, integrity and hard work which are being propagated and promoted by Prof Arthur Peter Mutharika since 2015.

Recognizing the moral power as one part of moral capital Singapore emphasized discipline and hard work as pillars of sustainable development. It saw this aspect of moral capital as comparative advantage for rapid sustainable economic growth. building than his Chayamba building and persecuted any threat to his political power. Today envy and jealousy are retarding the development of Malawi. The composer of Malawi Anthem Michael Sauka included envy as one of the battles of new Malawi.

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Most professional training in Malawi and Africa is focusing more on skills and knowledge and not on right attitude (moral character). Many bodies and associations are busy protecting the interests of their members rather than to be a guardian of the integrity of the profession. There is global tendency to value monetary personal interest at the expense of moral value. However, the opposite is possible as well. For example the World Medical Association Declaration of Helsinki gives ethical guidelines for medical research involving human participants. The focus shifted from protection of the interest of the researchers to the protection of human participants in research.

Creating collective corporate moral identity (Mbiti 1975).

According to umunthuology the collective professional moral identity is derived from the community. (Bandawe 2010) Without collective moral identity one cannot sustain a personal moral identity. Therefore if the society wants to maintain the person moral identity then it needs to maintain collective moral identity that includes a national shared moral vision. Moral identity is fruit of socialization and not

have therefore I Therefore technical human competence is complemented with

moral competence to achieve moral capital and moral public standing, which creates public trust.

There is need for moral re-programming of all members of staff in the target areas of moral deficiencies. It can be loyalty, responsibility, discipline, punctuality, team-work or self-control etc. The ultimate goals of moral re-programming are: To achieve personal and collective moral identity, in which identification with moral values and integrity is a reality (correct community moral identity).

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Personal moral identity without creating a collective moral identity in an institution or society is not sustainable. It can result in bullying, isolation or lowering personal conviction and standards of an individual, unless that person already has moral power, authority and status.

To achieve correct collective moral identity it is necessary to make an assessment of KAS-pillars in the organization or society. If you have moral deficiencies, character formation can target those moral values which are in deficit and will strengthen what is strong and weaken what is weak.

Moral capital mainstreaming or nationwide moral learning The second recommendation targets institutions of learning. The author proposes reintroduction of civics education and character formation and training in Malawian/African syllabi. Governments, families, institutions and the corporate world have tended to invest their money and energy in promoting a generation of good knowledge and skills (human competence) but they have ignored right attitude (moral competence). Some countries in the world, especially in the West, have made a U-turn in this and now have discovered the importance of moral capital. Without moral character, appropriate technical skills and good knowledge can be dangerous or useless. Good attitude without knowledge and skills constitutes manpower only, and does not allow the society to reach its full potential neither. Appropriate skills and good knowledge alone contribute to human capital. However, the human capital without moral character can only be useful so long as there are checks and balances, monitoring and strong rule of law. The individual depends on exterior control not on interior control. Human capital without moral capital can become disoriented and work against the objectives of the society or an organization.

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Initiation ceremonies as moral empowerment Initiation ceremonies are part of moral socialization of the youth in Malawi. The author recommends incorporating in them aspects of formation of the intended and required character. Sanon 1985, 74 has observed that some of these tend to be ritualistic performance rather than institutions of transmitting moral values and moral competence. Some of them have lost original aspects of making humans more humane or giving the youth a moral character as a man or woman with dignity and prepare them for a role in the society.

Cultural heritage associations could make an audit of information and knowledge packages which is currently being imparted on the youth. Even though traditions and rituals may differ from one tribe to another, one needs a common, unifying package of moral learning objectives to be incorporated into the system of initiation ceremonies. If not, since such initiation covers much of our youth socialization, some youth might come out of the initiation ceremonies with a wounded character.

Cultural ethical audit by cultural heritage associations could also audit and certify initiation ceremonies like other educational institutions for the safety and moral efficacy, so as to avoid or prevent possible social, psychological or physical harm and to ensure value for psychological, spiritual, moral and cultural human development.

Initiation ceremonies should help to empower boys and girls to face challenges of the present Malawi. Initiation of young people into adult world should emphasis more on learning human values than at going through secret rituals. Culture has been identified to possess two possible forces and potential: constructive and unifying force or destructive and divisive force. The initiation ceremonies as a cultural factor ought to be encouraged but there is a need to have them be

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purified, modernized and humanized. Whereas ritualistic aspects of initiation ceremonies can be morally justified and ought to remain part and parcel of the culture, the emphasis should move from ritual performance to value based learning and acquisition of moral values.

Values ought to be evaluated because all values are not the same and do not possess the same value. There must be therefore an evaluation of values so as to identify which values are appropriate for a particular social cultural context. For example when a community lacks the spirit of initiative, of self-reliance, when a community has problems with crime, then the basic moral values like discipline, law and order, loyalty, honesty, co-operation ought to be propagated, promoted and encouraged. For example, in a situation where there is a strong sense of community and sense of dependency, values which enhance individuality, personal initiative, self-reliance, personal choice ought to be encouraged to complement to moral strength or competence of communalism. (Mfutso-Bengo, 2001, 57)

Culture is supposed to protect children and not to harm children in the name of culture. Any exploitation whether religious, political, cultural or economical is contrary to universal human rights and prohibited under the Child Protection, Justice and Welfare Act. The contradiction between negative cultural practices and legislative requirements for child protection should be ironed out. In terms of bioethics principle of non-maleficence any cultural practice which leads to harm of the youth such as HIV/Aids should be stopped or banned in implementation of the existing laws.

Moral Vision 20:20 (MV20:20) Implementation of MV 20:20 can be another practical aspect of a moral transformation pedagogy. It is an instrument of reflection and character building for all professionals including medical professions

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in order to manage conflict of interest, moral dilemmas and stress in health care delivery and in other sectors through moral reasoning. It

telling towards a private health insurance provider.

It means every day:

-building for physical brain-building

-building for metaphysical brain-building

One needs to pause and consider where one goes and what one does. One needs to have vision, see ahead, determine not only ones goals but also examine ones actions and re-actions. Mental exercise means: Pause, see, discern and then act. Moral Vision 20:20 shall use the following test below for the mental building and character formation. One forms a moral character by mental exercise. (See also J M Mfutso-Bengo, E Mfutso-Bengo, 2016)

Three moral reasoning quick tests Ethicist, Frank J. Navran has developed the three quick self-tests: these tests help to raise a red flag for decisions that require further ethical deliberations. They are a social screening tool. It will not give you the answer, but they help you to know where you are standing.

1. The self-test What does my conscience say? Do I feel butterflies?

2. The public scrutiny test What would neighbors think? What if it was on the news tonight?

3. The authority testhusband/wife, parents, role model or person of moral authority say?

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It can be complemented with

4. The legal compliance test What do the laws and regulations of my country and my organization say? Am I within the law or beyond? However, this does not mean that any legality or legal entitlement leads to ethical behavior or wisdom. For example, by breaking South African laws of apartheid, Nelson did something formally illegal, but his motive and actions were ethical. A clinician or a judge may be entitled to strike but it may not be the best ethical, right and wise thing to do. One may have the right to receive medical treatment for free, but to pay user fees would be ethical for those who are rich and can afford. One can have the right to receive a student loan, but if you come from a rich family, giving it up would be the ethical thing to do. In other words, to have a right, is not the same as to be right. (Albert Einstein)

5. Depending on personal belief: The religious test What would God say?

A person, who has experienced the limitation of human effort

Often, if not always, one could experience the failure and limitation and the boundary of human will, human motive and human effort. African humanism is not atheistic but theistic. Bioethics, even though it is using secular principles, does recognize that human beings are spiritual beings. Religious

accordance to the medico-ethical principle of autonomy, which can be overridden for public health interest, emergency or when the patient is a minor or lacks mental capacity. It is a common understanding, that human moral choices are sometimes influenced by their religious beliefs.

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Self-interest is part of our inborn nature. Therefore it can make one blind without external intervention. External intervention can be external opinion of my wife, my church, my God, my friend, laws of the country. An intended action could be against own conscious or the public opinion or the law. Then it does require further scrutiny for management of possible ethical problems and dilemmas. In this

is very valuable.

moral reasoning test Joseph Fletcher, in his book- Moral Responsibility (Fletcher 1967) uses an integrated approach which mainly combines Kant moral theory of deontology with John Stuart Mill s theory of consequentialism. In his simple framework morality in a pocket -, he underlines the four classic factors or ethical cornerstones weighed and ethically evaluated in every moral decisi :

the END sought the MEANS used the MOTIVE involved the foreseeable CONSEQUENCES

Under this analysis, for a decision to be ethical, ALL four moral cornerstones or be memorized

So in the provision of medical and public health services, medical personnel should ask: WHAT is the aim? HOW is it achieved? WHY do I want to do it? And WHERE may this lead to?

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A template for personal integrity scan/moral audit

Virtue Description Personal baseline

Score 1-5

Monthly improve

ment scores

1-5 Belonging/Unity in Diversity

I recognize and fulfill my role as part of humanity.

Boldness I have the confidence to say yes or no to that what is right or wrong and act upon it.

Consideration/ Common sense

I consider the effects of my acts/omission for others. I act with good intention for all.

Innovativeness/Creativity

I am willing to approach things from a new perspective. I look for solutions.

Decisiveness I do not fear to make decisions after weighing different options objectively.

Dependability I keep to promises made and the responsibilities I assumed even when it is not convenient for me. I have a sense of duty.

Enthusiasm I do tasks with joy and without complaining. Resilience/ Endurance

I do not give up even when things get tough.

Peacefulness I am willing to forgive when I was hurt. I am willing to settle conflicts through dialogue.

Gratefulness I recognize and appreciate others for the good they have done to me and to others.

Hard work I do not chose tasks based on personal convenience or reward. I aim to work effectively and efficient.

Initiative I recognize and do what needs to be done without waiting that I am told to do it.

Inspiration I am in good contact with spiritual forces. Loyalty I am committed to those who I am supposed

to serve, including my institution and nation, even if it becomes difficult.

Maganimity I strive for greater ideals and to achieve the best for myself and my institution/nation.

Obedience I carry out valid instructions quickly and correctly with a positive attitude. I do not divert from SOPs or the law.

Patience I cope with difficulties without setting an (inner) deadline.

p.t.o.

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Virtue Description Personal baseline

Score 1-5

Monthly improve

ment scores

1-5 Punctuality I plan my time according to my responsibilities

and duties and make sure I am available when I am needed. I am the right time at the right place I respect the time of others.

Wisdom/ Prudence

I aim to use wisdom derived from truth in day to day action and decision-making.

Sense of reciprocity

I give back when I have received without being asked.

Self-sacrifice I am able to give up pleasurable things today for the investment for tomorrow or for a greater good. I do not want to have success on the costs of others.

Self-efficacy I believe in my potential and I am convinced to reach my goals.

Team spirit I recognize the strengths and weaknesses of others and myself to make a concerted effort for best results.

Transparency/Honesty/Trustworthiness

I am honest about my motives and actions in order to facilitate a fair balance of interests. I disclose relevant facts and do not manipulate or distort information.

? I spend only what is necessary. I do not waste and am resourceful.

Umunthu/Warm-heartedness

I have an attitude of sympathy for others and of acceptance of others. The person I meet is part of me. I have a reconciled heart that can reconcile others. Mtima woleza caring Okoma mtima passionate Mtima wofatsa- patient Mtima wa mtendere - peaceful

Please indicate the virtue ? ...

I eagerly do what is right with transparent motives.

Love Please define.

? ...

I am able to do what is right and reject wrong desires. I am able to delay gratification.

? I take the consequences of my actions. I do damage good.

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Virtue Description Personal baseline

Score 1-5

Monthly improve

ment scores

1-5 ? I recognize that personal achievement is

dependent on investment of others in my life. Hope Please define

Focus Please define

Flexibility Please define

The following other virtues matter in my profession:

1 2 3

Emotional intelligence

The Fletcher Framework needs to be used together with emotional intelligence framework. Self-motives or motives of others can be conscious or subconscious, rational or irrational. Motives can be good or bad, justifiable or non-justifiable. Emotional intelligence according to Rebecca Gulliford, 2003 has got four pillars

1. Self-Awareness

2. Self-Management

3. Social Awareness

4. Social Skills

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Moral Capital Index and LEGS Framework for the moral capital implementation The moral capital index shall use 4 variables called LEGS to measure and rank organization and nations. LEGS stands for Leadership, Ethical engagement, Governance, Systems. LEGS are four building blocks for effective, efficient and equitable policy implementation or programming and mainstreaming. LEGS is very simple to use and quick to remember. For instance four building blocks of LEGS can complement the WHO health systems building blocks which lack the simplicity which LEGS has. In health policy and programming LEGS FRAMEWORK is meant to be four building blocks for a resilient and equitable global health implementation. One needs LEGS to translate evidence based medicine into evidence based medical practice. LEGS is a viable framework to translate research results into policy and practice. However any system needs a LEG to run properly. Therefore LEG (leadership, ethical engagement, governance) is a solid foundation to build a resilient system. LEGS is a framework for ethical, effective and efficient policy implementation. Ethical engagement is having right attitude, ethical perspective and moral reasoning in all aspects of professional engagement, e.g. procurement, recruitment, financing, decision-making, appraisals, service delivery... .

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LEGS = Leadership+Ethical engagement+Governance+Systems

LEGS to run an organization, institution or a nation Leadership

Ethical Effective Efficient Sufficient knowledge and skills Opportunistic in seizing opportunity, Visionary & Ability to motivate

Ethical engagement Right attitude Integrity Honesty Trustworthiness Commitment Benevolence Equity Self-control

Governance

Monitoring and Control Rule of law Transparency Responsibility Accountability Reinforce-ability Information management

Systems that are:

Responsive Dynamic Inclusive Predictable Feasible Self-maintaining Efficient & Effective

Disposing factors12

Ethical engagement Moral capital Leadership

Enabling factors Systems Skills Knowledge Human capital Leadership

Reinforcing factors Leadership Governance Reward Sanctions

The Moral Capital Index and LEGS are humble suggestions in their baby-shoes. The author makes this idea public for those who can polish it into a tool that helps countries to be competitive and 12 Based on Precede-Proceed-Model of behavior change Crosby, Richard, and Seth M. Noar, 2011.

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accountable to themselves and others. Can moral capital gains or losses be measured? The Author is proposing a Moral Capital Index. It will measure the opportunity gain or loss through moral capital gains or losses. The better the moral capital ranking, the higher is the competitiveness. The lower it is, the higher the cost of social control, containment cost and the higher the cost of doing business.

It will measure efficiency and productivity gain or loss through the gain or loss of moral capital.

It will look at perceived competitiveness gain or loss through a perceived gain or loss of a collective moral capital.

It will measure moral capital loss containment costs and moral capital gain opportunity value.

The four variables of moral capital index for nations can use existing measures as illustrated below. The mathematical measurement of moral capital could mean the aggregate or average of World Justice Index, Corruption Index/Transparency International Index, World Bank competitiveness Ease of Doing Business Index, Global Peace Index, World Bank GINI-Index and Human Development Index of UNDP, Ibrahim Index of Good Governance (for African region) and Leadership Performance Index.

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The Moral Capital Index can use the existing global indices:

Leadership Ethics Governance Systems 1. Leadership

Performance Index

2. Global Peace Index

3. Corruption Index/

4. GINI Index

1. World Justice Index

2. Ibrahim Index of quality governance

1. Human Development Index

2. World Bank Competitiveness Ease of Doing Business Index

The author argues that these measures can help to be a pointer, without being exact due to other research confounders. Albert Einstein said, Not everything that counts can be counted and not everything that can be counted counts . There is a need to design the best methodology to measure moral capital gain or loss.

Moral Capital Index for Research Institutions Moral capital assessment, integrity scan and audit for a research institution can use moral capital index as a benchmark using LEGS variables. The Moral Capital Index in Research (MCI-R) can be used to assess moral capital compliance of research organizations, researchers, funders, sponsors, ethics committees or research committees using the following indicators (see J Mfutso-Bengo, E Mfutso-Bengo, 2016).

Leadership Ethics Governance Systems

Moral capital strategic plan

Meaningful

Social value, corporate social responsibility,

Respect for persons, human rights, rule of law and availability of

Ethical bureaucracy based on moral capital (fairness, predictable systems

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collaborative partnerships

Moral capital mainstreaming

visibility of mission statement

moral capital framework

moral capital awareness, sensitivity, responsiveness, moral capital perspective as integral part of design, implementation, monitoring and evaluation of research activities

shared corporate moral identity

Availability and accessibility of quality independent ethics and research review committee

Fairness and justice

post-trial accessgender equality

ethical code of conduct/guidelines /SOPs

Consistent practice of corporate moral capital audit, assessment and integrity scan e.g., in recruitment, promotion and incentives.

and practice, that is objective, predictable, transparent, accountable, responsive, efficient and effective)

Capacity building (includes knowledge, attitude and skills transfer)

Availability of corporate moral character training intervention and ethics training based on KAS model

Ethical performance and output reward systems based on three pillars KAS model (knowledge, attitude and skills) (includes intentional promotion of ethical role models in an organization)

The content of the four LEGS variables can be contextualized depending on the type of organization as shown above for a research organization. One is free to amend it to meet particular needs of an organization. Unlike other Business Ethics Indices it is not only based on consumer perception. These indicators help an institution/person to monitor the trends in moral capital transformation investment in order to benefit from moral capital dividend and increased competitiveness that is associated with it.

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Conclusion The world has become

less peaceful every year since 2008 Therefore there is a need to understand, that Malawian peacefulness based on umunthuology-bioethics is a moral capital and a national-social heritage. As such it needs to be valued, treasured, protected and propagated. (Bandawe 2010) There is a need to continue not only to invest in knowledge and skills but even more in right attitude (moral capital).

Without investing in peace, which is one aspect of moral capital, the opposite can be very costly. This has been confirmed by Steve Killelea, the founder and executive chairman of the Institute for Economics that developed the Global Peace Index. He said that the global economic cost and impact of containment of violence are equivalent to 19% of global economic growth from 2012 to 2013. Or in other words double the total GDP of all African countries, which is totaling to 2.5 trillion US Dollars. This is resulting in very real costs to the world economy.13

13 Global Peace Index: http://www.peacealliance.org/2014-global-peace-index-released/ (Global Peace Index 2014)

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Source: www.visionofhumanity.org

Malawi has got a very good score on the Global Peace Index, even better than some of the developed countries. Malawi on the Global peace index, GPI, which measures absence of violence, ranks 74globally (in 2013). rank 74 (2013). Despite having a good peace index position, our moral capital of peacefulness position could worsen and is worsening.

Cost of containing violence make up 7% of GDP. Despite a relatively low containment cost per person our global peace index position is good. Malawi ranks at 95 at Positive Peace Index, PPI ahead of Mozambique, Zambia, Kenya, Uganda. Among Africancountries it is on rank 12 out of 44 countries.

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As we have demonstrated in the above bioethical discourse, there is a need to understand that moral capital of peace, unity, tolerance, resilience and security are some of the critical factors for attracting all other forms of capital, including investment and tourism. These can bring forex to fund health care system. Peace as one of the components of moral capital gives Malawi a comparative advantage within a competitive globalized world. Increase in moral capital equals decrease in violence containment costs on the other hand. The savings from reduced violence containment costs could be allocated to the health and education sectors.

Even in our amended Malawi Constitution of 2010 the issue of moral obligations (moral capital) has been articulated in Sec. 12 (2) as a cexercised with due regard for the rights of others, collective security, morality and the common interest

Again, the Malawi Public Service Reform Agenda can be the national stepping stone and national rallying point to make Malawi capital city comparative advantage of peace, unity, discipline, honesty, hospitality, friendliness, hard-work, resilience and professionalism, provided the ethical aspects of it are made visible and propagated national-wide. There is a need to make the Malawi Moral Transformation Program (MAMOTRAP) a national multi-sector program which will target culture, education, spirituality, business, public and private sectors, judiciary and parliament just to mention a few. MAMOTRAP to work shall depend on policy and program implementation model called LEGS, which means leadership, ethical engagement, governance and appropriate systems. MAMOTRAP ought to begin by mind building. This will be done by reviewing the curriculum of primary, secondary and tertiary education in order to

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integrate the three ethical pillars of national development. By introducing KAS syllabus that integrates appropriate knowledge, right attitude and required skills as three united and yet distinct expected outcome of national education plan. South Africa has a similar project called South African Moral Regeneration Movement Program. Cash-gate has demonstrated, that it was not lack of technical knowledge and skills (technical) but lack of moral capital (moral competence) on part of some members of the knowledge-generation of this society, and it has been costly. This has provoked a nation n wide rethinking and reflection.

University of Malawi (UNIMA) strategic plan includes ethical principles. However, these have to be made more visible to staff and students. The introduction of bioethics training at UNIMA ahead of other countries was just one small step.

In our bioethical discourse on moral capital, we defined moral capital-umunthuology as integration of appropriate knowledge, appropriate skills with right attitude (moral character). All these should be present and correct in the checklist of the three pillars of KAS-Sustainable professionalism model. When all these three pillars are present and correct, it constitutes professionalism = moral capital = umunthu

Can Malawi and Africa really develop within this competitive globalized world without moral capital? Can one have real professionalism in the army, in the hospitals, in the school, in the public and private sector without investing in moral capital? The first person to write on moral capital, John Kane, was in political history (abolitionist, anti-slave movement), where he realized that exploitation would bring more violence and war (Kane 2001). Moral capital is the basis for peace and economic growth. Can a country survive as a

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democratic nation without investing in moral capital? The author thinks not.

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My personal dream and vision In my 2001 book in Sou ended with the following dream:

seek and to find consolation, prosperity, peace and security, not through manipulation, suppression, aggression, oppression but through compassion, meditation, mediation, negotiation, demonstration of moral strength (moral capital), respect and care of human rights and responsibilities.

God has heard the cry and groaning of African people and through all of us, he is slowly and silently bringing up a young, ethical, skilled, entrepreneurial and knowledgeable generation, which will make African renaissance, reconciliation and prosperity a reality in this

one day, and African bad news will become good news. The African people and those who live in Africa who for generations have walked in the valley of darkness, of poverty, disease, oppression, slavery, colonialism, dictatorship, corruption and civil wars, will finally in this present millennium see the light of hope, freedom, democracy,

That dream continues.

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Mfutso-Bengo, Joseph Matthew, and Terrie Taylor. "Response to Rennie: Is there a place for benevolent deception?" Trends Parasitol. 20, no. 4 (2004): 164.

Mfutso-Bengo, Joseph Matthew, P Ndebele, V Jumbe, F Masiye, and and others. "Individuals in limited resource settings join clinical trials so as to access better quality care: Findings from a qualitative study of health research participation in Blantyre, Malawi" Malawi Medical Journal 20, no. 2 (2008): 37-41.

Mfutso-Bengo Joseph M., Lucinda Manda-Taylor, Vincent Chipiliro, Vincent C Jumbe, Isabel Kazanga, and Francis Masiye. "Handbook of Global Bioethics,." In Malawi: Bioethics Development, by Ten Have and B ed. Gordijn, 1271-1287. New York: Springer, 2014.

Mfutso-Bengo Joseph M., E Mfutso-Bengo. "From checklist ethics to moral capital: Revisiting post-trial access (PTA) to essential medicines after clinical trials in a developing country in Africa like Malawi", Journal of Health Care Law and Policy, Spring, 2016 (in print)

Mfutso-Bengo, E, Mfutso-Bengo J. "A review of the current Malawian law on consent of adults, children and mentally sick to medical treatment and clinical trials and its ethical implications." Journal of Health Care Law and Policy, Spring, 2016 (in print)

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Selected Publications of Prof. Joseph Mfutso-Bengo

Mfutso-Bengo Joseph M., E Mfutso-Bengo. "From checklist ethics to moral capital: Revisiting post-trial access (PTA) to essential medicines after clinical trials in a developing country in Africa like Malawi", Journal of Health Care Law and Policy, Spring, 2016 (in print)

Mfutso-Bengo, E, Mfutso-Bengo J. "A review of the current Malawian law on consent of adults, children and mentally sick to medical treatment and clinical trials and its ethical implications." Journal of Health Care Law and Policy, Spring, 2016 (in print)

Lucinda Manda-Taylor, Francis Masiye, & Joseph Mfutso-Bengo, Autonomy. in Encyclopedia of Global Bioethics, Springer 2015

Mungwira, Randy, Mfutso-Bengo, Joseph, et al., Is it ethical to prevent secondary use of stored biological samples and data derived from consenting research participants? The case of Malawi in BMC Medical Ethics Journal, December 2015, 1683

Mfutso-Bengo, J.M., Manda-Taylor L., Masiye F., Motivational Factors for Participation in Biomedical Research: Evidence From a Qualitative Study of

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Biomedical Research Participation in Blantyre District, Malawi, Journal of Empirical Research on Human Research Ethics, 10(1) February 2015: 59-64.

Uduma, O., Mfutso-Bengo, J.M.,

& Practice: A Development Education Review, Vol. 15, Autumn, pp. 101-112

Mfutso-Bengo, J.M., et al., Final Report for the Situation Analysis of Male Circumcision in Malawi, 2010

Adnan A Hyder, Adrijana Corluka, Peter J Winch, Joseph Mfutso-Bengo, Elsa Segura and Abdul Ghaffar, National Policy makers speak out: Are researchers giving out what they need? Oxford University Press kjkin association with The London School of Hygiene and Tropical Medicine 2010.

Mfutso-Bengo, J. M., Masiye, F., Muula, A., Ethical Challenges in Conducting Research in Humanitarian Crisis Situations, Malawi Medical Journal; 20 (2) June 2008: 46-49.

Mfutso-Bengo, J. M., Masiye, F., Ndebele, P., et al., Why People Refuse to Take Part in Biomedical Research Studies: Evidence From Resource Poor Areas, Malawi Medical Journal; 20(2) June 2008:58-64.

Masiye, F., Mfutso-Bengo, J. M., et al., Why Mothers Choose to Enroll Their Children in Malaria Clinical Studies and the Involvement of Relatives in Decision Making: Evidence from Malawi, Malawi Medical Journal; 20(2):50 56, June 2008.

Mfutso-Bengo, J. M., Mfutso-Bengo, E., & Masiye, F., Ethical Aspects of HIV-AIDS prevention strategies and control in Malawi, Springer Journal of Theoretical Medicine and Bioethics, volume 29, Number 5, September 2008, pp. 349 356. Published online on January 8, 2009.

Mfutso-Bengo, J.M., Masiye, F., et al., Individuals in limited resource settings join clinical trials so as to access better quality care: Findings from a qualitative study of health research participation in Blantyre, Malawi, Malawi Medical Journal; 20(2): 37 41, June 2008.

Ndebele, P., Mfutso-Bengo, J.M., Masiye, F., HIV/AIDS reduces the relevance of the principle of individual medical confidentiality among the Bantu people of

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Southern Africa, Springer Journal of Theoretical Medicine and Bioethics, 29(5) September 2008: 331 340.

Ndebele, P., Mfutso-Bengo, J., Mduluza, T., Compensating clinical trial participants from limited resource settings in internationally sponsored clinical trials, a proposal, Malawi Medical Journal; 20(2);pp. 42 45, June 2008.

Ghaffar Abdul, Mfutso-Bengo, JM., et al., Use of Evidence in policy making, Policy Brief no 03-11-08 in: Word Health Organization 2008

Mfutso-Bengo, J.M., Ndebele, P., Jumbe, V., Masiye, F., et al., Individuals in limited resource settings join clinical trials so as to access better quality care: Findings from a qualitative study of health research participation in Blantyre, Malawi, Malawi Medical Journal; 20(2): 37 41, June 2008.

Mfutso-Bengo J.M., Muula A.S. Responsibilities and obligation of use of human research specimens Transported across national boundaries, British Medical Council Journal of Medical Ethics, 33 2007:35-38.

Mfutso-Bengo J.M., Muula A.S., Potential benefits and harm of biotechnology in developing countries: ethics and social dimensions, African Journal of Medical Sciences 36, 2007 suppl: 63-7.

Mfutso-Bengo J.M., Muula A.S., Clinical Drug Testing in Developing World: Ethical and Policy Implication. Harvard Health Policy Review, 6 (1) Spring 2005: 106-113.

Mfutso-Bengo J.M., Muula A.S., When is Public Disclosure of HIV Seropositivity acceptable, Nursing Ethics: International Journal for Health Care Professionals; 2005, 12 (3).

Mfutso-Bengo J.M., Terrie Taylor, and Response to Rennie: Is there a place forbenevolent deception? Trends in Parasitology; 20(4) April 2005:164.

Mfutso-Bengo J.M., Muula A.S., Important but Neglected Ethical and Cultural Considerations in the Fight against HIV/AIDS in Malawi. Nursing Ethics; 11 (5) September 2004: 479-488.

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Emaunel Ezekiel, Mfutso-Bengo J.M., et al., Moral Standards for Research in

Hastings Center Report 05/2004; 34(3):17. DOI:10.2307/3528416

Mfutso-Bengo J.M., Muula A.S., Ethical issues in voluntary HIV testing in high prevalence area: the case of Malawi. South African Medical Journal 2003 March (3): 194-6.

Mfutso-Bengo J.M., Muula A.S., Risks and benefit of genetically modified maize donations to Southern Africa: Views from Malawi. Croatian Medical Journal 44(1) February 2003: 102-6.

Faden R.R. Taylor, Mfutso-Bengo J.M., et al., Ethical Considerations in the Formation of Smallpox Vaccine Policy. Bio-security and Bioterrorism. Bio-defense Strategy, Practice and Science 1 (1), 2003: 47-54 :https://www.researchgate.net/profile/Joseph_Mfutso-Bengo/publications?sorting=newest&page=2 [accessed Mar 20, 2015].

Mfutso-Bengo J.M., Muula A.S., Is it ethical for health workers to strike? Issues from the QECH general hospital strike in 2001, Malawi Medical Journal 14(2) 2002:29-31.

Mfutso-Bengo J.M., Terrie Taylor, Ethical jurisdictions in international biomedical research, Trends in Parasitology 18 (5), May 2002.

Mfutso-Bengo J.M., Terrie Taylor, Local Context versus Remote Perspective-Approaching globalisation research ethics through dialogue, American Society of Tropical Medicine and Hygiene, Vol. 65, September 2001, p. 79.

Mfutso-Bengo J.M., Terrie Taylor, Ethical Aspects of clinical research in developing countries, in Malawi Medical Journal Vol.13, No. 2, June 2001, pp. 24-25

Mfutso-Bengo J.M., Ethics and Law in Medicine: A Human Being as Means and End. The Concept of Normative Ethics and Meta-Ethics, Regensburg University 1997.

Mfutso-Bengo J.M., World Trade, Sex-tourism and Sustainable Development: Dialectic between Economics and Ethics, Regensburg 1997.

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BOOKS

Mfutso-Bengo J.M., In the Name of the Rainbow-Politics of Reconciliation in South Africa and Malawi. European Peter Lang Publishers, Frankfurt am Main, Bern. Brussels, New York. Oxford, Vienna 2001

BOOK CHAPTERS

Mfutso-Bengo, J.M. et al., African Bioethics in: Handbook of Global Bioethics, Springer Publishers Netherlands and New York 2013 pp 1271-1287 Print ISBN 978-94-007-2511-9 Online ISBN 978-94-007-2512-6

Mfutso-Bengo, J.M., Masiye, F., Towards an African Umunthuology Bioethics in Malawi in the context of globalization in: Bioethics around the Globe, Oxford Publishers 2011 ISBN 978-0-19-538609-7

Mfutso-Bengo, J.M., & Ndebele P., Conducting research in Malawi: what researchers need to know in: A Gateway to Biomedical Research in Africa, Nova Science Pub Inc., 2008 Chapter IX pp 91-100 ISBN 1-60021-444-4

Mfutso-Bengo J.M., Informed Consent of HIV Testing and in Surgery in: Informed consent - The UNESCO chair in Bio-ethics- HAIFA (2003): pp 45-46, pp 55-56

Mfutso-Bengo J.M. , Malawi in: Handbuch Afrika bd. 3 /2003 http://www.univie.ac.at/handbuch-afrika/laender/Malawibib.htm

BOOK REVIEWS AND ETHICAL GUIDELINES

Mfutso-Bengo J.M. external reviewer of FHI Research Ethics Training Curriculum for community Representativewww.fhi.org/en/RH/Training/trainmat/ethicscurr/RETCCREn/ss/Acknowledgements/

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Mfutso-Bengo J.M., book reviewer on Preparing for the future of HIV and Aids in Africa: A Shared Responsibility, by US Institute of Medicine, The National Academics Press, 2011 www.nap.edu

Mfutso-Bengo J.M., book reviews of HIV Prevention Trials Network Ethics Guidance for Research 2009. www.hptn.org

Mfutso-Bengo J.M., external book reviewer Kathleen M. MacQueen & Mike May. Good Participatory Practice Guidelines for Partnering for Care in the HIV Prevention Trials Network(HPTN). Family Health International Publication 2008. ISBN: 1-933702-30-3. Web site: www.fhi.org

Mfutso Bengo J.M., book reviewer On Scaling up Treatment for the Global AIDS Epidemic, April 2004 of US Institute of Medicine of the National Academies http://books.nap.edu/books/0309092647/html/R1.html

International ethical guidelines: Ethical Issues in Influenza Pandemic Planning and Response, Bellagio International Ethical Declaration 24-28 July 2006

A member of the revision team for International ethical guidelines of Declaration of Helsinki - revised version 2013

Co-authors of College Medicine of Malawi research ethics guidelines, SOPs and research policy

Mfutso-Bengo J.M. external reviewer of FHI Research Ethics Training Curriculum for community Representative www.fhi.org/en/RH/Training/trainmat/ethicscurr/RETCCREn/ss/Acknowledgements/

Mfutso-Bengo J.M., book reviewer on Preparing for the future of HIV and Aids in Africa: A Shared Responsibility, by US Institute of Medicine, The National Academics Press, 2011 www.nap.edu

Mfutso-Bengo J.M., reviewer of HIV Prevention Trials Network Ethics Guidance for Research 2009. www.hptn.org

123

Mfutso-Bengo J.M., external book reviewer Kathleen M. MacQueen & Mike May. Good Participatory Practice Guidelines for Partnering for Care in the HIV Prevention Trials Network(HPTN). Family Health International Publication 2008. ISBN: 1-933702-30-3. Web site: www.fhi.org

Mfutso Bengo J.M., book reviewer On Scaling up Treatment for the Global AIDS Epidemic, April 2004 of US Institute of Medicine of the National Academies http://books.nap.edu/books/0309092647/html/R1.html

International ethical guidelines: Ethical Issues in Influenza Pandemic Planning and Response, Bellagio International Ethical Declaration 24-28 July 2006

A member of the revision team for International ethical guidelines of Declaration of Helsinki - revised version 2013

Co-authors of College Medicine of Malawi research ethics guidelines, SOPs and research policy

INTERNET PUBLICATIONS

Mfutso-Bengo J.M., http://www.abc.net.au/science/slab/tobacco/default.htm

Mfutso-Bengo J.M., Ethics Of Emergency CTC Feeding Programme,http://www.unsystem.org/scn/Publications/AnnualMeeting/SCN30/30th_emergencies.htm

Mfutso-Bengo J.M., Ethical aspects of Ethical aspects of CTChttp://www.fantaproject.org/ctc/ethicsPPT2.pdf