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Global Medical Ethics

It is of course an impossible task for a lawyer-programmer to independently make a sound design of the developments of a pandemic in four different cultures. But such is not necessary for making a beginning.

For a first estimation I use literature and Wikipedia mixed with personal experience. David A. Cummiskey of Bates University has begun a book on how developments in medical ethics are linked to different cultures worldwide. Chapters II, III and IV (from 2010) deal with the question of how Islam, Confucianism and Buddhism respectively tend to embed the ethical questions raised by the revolutionary medical technologies currently available.

I do not know if I fully follow that division into cultures because, in terms of identity of COVID measures, I have to work by jurisdiction. If I continue to assume that my COVID games mimic jurisdictions, I have to choose a few countries that represent cultural differences. I already chose the Netherlands (as EU representative, my own jurisdiction, Western in a treaty context), the US (as neo-liberally and neo-imperially Western), Saudi Arabia (as Islamic) and China (as Tao-Buddha-Confucius-Mao-ist or, for convenience, TBCM culture).

It is obvious to consider what is called “the West” as one culture. I think that the treaty nature of the EU, Obama’s actions in the Middle East and Trump’s with regard to Europe have shown that there are reservations about this. My position is that Europe and the US, insofar as they once formed a single culture, have now grown sufficiently apart to show their own identities from a cultural point of view.

To see whether these cultural differences are also expressed in observed data, I show a few graphs made available by the Worldbank and the WHO.

The Netherlands

WHO health expenditure profile

The WHO provides overviews per country, not only with what the government spends per capita on health care per year, but also with what is earned per capita in the country and what per capita are paid as out-of-pocket health costs (I assume that these are costs that these as protection against moral hazard cannot be insured). The overview runs from 2000 to 2018. In 2018, 10.0% of GDP ($ 5,306.5 from $ 53,201) in the Netherlands goes to healthcare. Of that, the government pays 64.9% ($ 3,444) and 10.8% is borne by the individual citizen (around $ 573). The remainder (25.1%, $ 1,332) is raised by the citizen through other means, usually through supplementary insurance. Usually the rest represents a gray area, where what is not covered by compulsory insurance turns out to be so necessary that it must be paid for. In the EU, this area is determined on the one hand by the political choice of what should and should not be included in the basic package. Discussions in this area also include covering costs for the (often extravagantly expensive) treatment of rare diseases (EU) to the treatment of age-related ailments and the responsibility of the autonomous individual to take timely measures (the latter especially in the US and China).


In 2018, 16.9% ($ 10,623) of GDP ($ 62,918) per person in the US goes to healthcare. The government then pays 50.4% ($ 5,354) and 10.8% ($ 1,148) is charged to the individual citizen as out-of-pocket. The remainder (37.8%, $ 4,015) is raised by the citizen on other foundations, usually through supplementary insurance. This rest has been colored with Obamacare in the US since 2014 and subsequently fallen into the contrarian hands of the next administration. The new administration may reinvigorate it.

Saudi Arabia

In 2018, 6.3% ($ 1,485) of GDP ($ 23,337) per person in Saudi Arabia goes to health care. The government then pays 62.4% ($ 953) and 14.4% ($ 213.84) is charged to the individual citizen. The remainder (23.2%, $ 345) is raised by the citizen on other foundations, usually through supplementary insurance. There is no social health insurance in Saudi Arabia.

In 2018, 5.3% ($ 500.5) of the GNP ($ 9,364) per person in the PRC goes to health care. The government then pays 57.9% ($ 290) and 35.1% ($ 176) is charged to the individual citizen. The remainder (7%, $ 45) is raised by the citizen in some other way, usually through additional insurance.

By way of Summary

I first put the data from the WHO profiles in a table, for 2018:

per capitaNetherlandsUSASaudi ArabiaChina
HC expenses$5,306-10%$10,623-17%$1,485- 6%$501- 5%
Gov.HC exp.$3,444-65%$5,354-50%$953-62%$290-58%
Out of pocket$573-10%$1,148-11%$214-14%$176-35%
Rest.pc$1,332-25%$4,015-38%$345-23%$45- 7%

The table shows major differences, but also major similarities. Before thinking any further about what these might mean in the light of the cultures in which they are embedded, I think it is necessary to look at the differences in economic development. Sfter all, the healthcare in Saudi Arabia is known as particularly high-quality and the modern healthcare in China is also (in Western eyes) of a high standard. That may be, but the numbers do not necessarily support that interpretation. After all, the Chinese government spends $ 290 per citizen per year on health care, which is more than 18 times multiplied in the US. I conclude with a few additional charts from the World Bank:

It is clear that the economic progress in the various countries shows serious differences.

Interpretations and discussions follow elsewhere.