Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 29 (2) March 2019www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2019 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page

Editorial: Youth and Disaster45- Darryl Macer
Buddhism and post-liberal peacebuilding: Building aholistic peace model by interconnecting liberal peaceand Buddhist peace46- Juichiro Tanabe
Analysis of Euthanasia from the Cluster of Concepts to
Precise Definition
53- Mohammad Manzoor MalikThe Surrogacy Industry in Georgia and Japanese Patients
56- Masayuki Kodama
Bioethics Issues in Arab Society
59- Abdul Jaleel Kadhim Alwali
Hope for the best and prepare for the worst: Ethicalconcerns related to the introduction of healthcare
artificial intelligence64- Atsushi Asai, Taketoshi Okita, Aya Enzo, Motoki
Ohnishi, Seiji Bito
Measuring Individual Quality of Life in Japanese Women
with High-Risk Pregnancies: Clues for Improving Care
Plans and the Hospital Environment71- Mayumi Nishikata, Mio Tanaka, Michio Miyasaka
A race inside the body: decision of the fate of newborn78- Shyrose Sultan, Samreen Siraj, Zainish Zafarullah,
Afsheen Hirani, Nasreen Rafiq

Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign
Nations (AUSN), https://ausovereignnations.org
Email: darryl@eubios.info
EJAIB adopts and complies with the Committee on
Publication Ethics (COPE) Publication ethics andmalpractice policy. All potential authors shouldhave read these guidelines and by submission of anarticle for publication you acknowledge that you
have complied with this policy. Violations will behandled in proportion to the intention andseriousness of the violation.
Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: Looking Beyond
Disaster at the Boundaries- Darryl Macer
Email: darryl@eubios.info
One of the programmes of Eubios Ethics Institute is
Youth Looking Beyond Disaster (LBD) Training
programmes, and from 12-15 April we will hold thetenth forum, this time in Istanbul, the boundary between
Europe and Asia. The LBD program enhances oureffectiveness for disaster reslience. Disasters have noboundary. We invite all readers to the forum. We will
also have a further forum in July or August in USA.
I also have the pleasure to announce the publicationof the recent book from Eubios Ethics Institute,
Philosophy and Practice of Bioethics across andbetween Cultures, Editors: Takao Takahashi, Nader
Ghotbi & Darryl R. J. Macer, which includes over twenty
papers from the Kumamoto Bioethics Roundtables.
Later in 2019 we will start a series of Tohoku/Sendai
Bioethics roundtables, so please keep an eye out for theannouncements on the websites.
In this issue of the journal we have 8 papers, to fllow
on the ten papers in the January 2019 issue, both withextended number of pages because of the increasing
number of submissions. We welcome more papers, andthere may be some more discussion of the gene editing
ethics featured in the Bangkok Statement in the January
2019 issue and accompanying papers.
In this issue there are a range of bioethics issues
included, from reproductive services and health care to
end of life care. We offer perspectives from different
countries and different groups of persons.
Juichiro Tanabe presents a holistic model for peace,
Buddhism and post-liberal peacebuilding: Building aholistic peace model by interconnecting liberal peaceand Buddhist peace, at the start of the issue. The scopeof bioethics as the love of life must include ways that we
can make peace not only with our own decisions, and theclient-professional relationship, but also within andbetween societies.
- Darryl Macer

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Eubios Journal of Asian and International Bioethics 29 (March 2019)

Buddhismandpost-liberalpeacebuilding: building a holistic
peace model by interconnecting
liberal peace and Buddhist peace- Juichiro Tanabe, PhD.
Kumamoto University, Kumamoto, Japan
Email: juichirotanabe@hotmail.com
Abstract
This paper examines a post-liberal hybrid holistic peacemodel that interconnects liberal peace and Buddhist
peace. Following the critique of liberal peace in the postliberal peacebuilding, there has been a rising urgency tobuild a complementary relationship between the liberalpeace thesis and non-Western vision(s) of peace. This
research seeks to be an exemplar of that by constructing
a hybrid peace model that combines Buddhist peace andliberal peace. While liberal peace represented bydemocracy, human rights, and market-oriented economy
is structurally and institutionally oriented, Buddhism hasdeveloped internal dimensions of peace. This paper
explores how Western structurally and institutionallyoriented liberal peace and Buddhist inner peacecharacterized as the practice of multiple functions ofmind, reflective self-awareness, non-dualistic thinking
and compassion to empower humankind internally, cancomplement each other to offer a post-liberal hybrid
holistic peace model.
1. Introduction
The critique of liberal peacebuilding as the imposition ofWestern values upon post-conflict zones has raised theurgency to build a complementary relationship between
the liberal peace thesis and non-Western vision(s) ofpeace in post-liberal peacebuilding. Peacebuilding
requires both the wisdom of Western liberal peace andthat of non-Western zones. This research seeks to offer a
hybrid peace model that integrates Buddhist peace andliberal peace. The paper begins with the hallmarks ofliberal peace, its critique and the background of theemergence of the concept of post-liberal peace.
The second section analyzes the Buddhist view ofconflict dynamics and its inner peace. Here, theempowerment of individuals with the multiple functionsof mind such as reflective self-awareness, non-dualistic
thinking and compassion is offered as Buddhist inner
peace. The third section of this paper examines a holistic
peace model that interconnects the spirits of liberalpeace and Buddhist inner peace, with a critical analysisof the core themes of liberal peace – human rights,
democracy, and market-oriented economy – from a
Buddhist perspective. First, the analysis will
demonstrate that Buddhism stands by human rights
principles; that is, the inherent dignity and equality of all
humankind from the perspective of the doctrine of the
Buddha-nature. Second, the analysis proposes acomplementary relation between democracy and inner
peace. It will be claimed that democracy as free andconstructive public dialogue and deliberative interactionof political thought and empowerment of citizens withreflective self-awareness, non-dualistic thinking andcompassionate mind complement each other tostrengthen democracy itself. Third, the examination will
demonstrate that despite a cautionary stance towards
market-oriented economy, Buddhism acknowledges
economic well-being as crucial to internal enrichment.
An economic system that ignores human dignity anddeprives citizens of their spiritual and philosophicaldevelopment cannot be recognized an an authentic
system. An authentic economic system in post-liberal
hybrid holistic peace would be the one that contributes
to spiritual as well as material wealth based on theprinciples of social justice and equality.
The paper will conclude with the proposition of postliberal hybrid holistic peace formed by four elements:
the promotion of human rights; the promotion of
dialogical and transformative democracy based on selfcritique and mutual learning; sustainance and furtheringof the economic system, philosophical and spiritualfulfillment of citizens based on social justice and equity;and inner peace characterized as reflective selfawareness, non-dualistic thinking, multi-perspectival
approach, and compassion.
2. On liberal peacebuilding
2.1. Hallmark of liberal peace
Liberal peacebuilding founded upon the liberal peacethesis has assumed a central role in contemporary
peacebuilding enterprise in the post-Cold War era(Newman et al, 2009). The liberal peace thesis posits
that states which employ democracy and develop
economic interdependence based on free trade, securestable domestic politics and peaceful international
relations (Richmond, 2014). The advocates of liberalpeace claim that democracy and free-trade economic
interdependence guarantee national, regional andinternational order and stability.
International community managed mainly by liberalstates has come to connect peace and security withmarket-oriented development, democracy, rule of law,human rights and a vigorous civil society (Richmond,2005). Underpinned by this liberal hypothesis, liberalpeacebuilding that seeks to promote democracy, humanrights principles, and market-oriented economic reform
for a lasting peace (Newman et al, 2009) as the transfer
of liberal systems would empower people to resolve
their differences of interests, goals and values nonviolently and make governments accountable andresponsive to peoples’ needs.
2.2 Critique of liberal peace and rise of post-liberal
peace
However, liberal peacebuilding has been critiqued for its
standardizing, and universalistic pretentions and its
concomitant failure to engage with local cultural
practices of peacemaking and conflict resolution andwith the manifold insecurities of everyday life in local
societies (Selby, 2013). Following the critique, culturally
and locally oriented peacebuilding have been proposedfor post-liberal peacebuilding as local culture has
valuable knowledge and methods to achieve durable andstable peace.
However, another hallmark of post-liberal peace isthat while cultural and local wisdom should play themain role in peacebuilding enterprise, it needs to beacknowledged that neither liberal peace nor locally orEubios Journal of Asian and International Bioethics 29 (March 2019)culturally oriented peace framework can achieve asustainable peace alone. Rather, what is required in postliberal peacebuilding is to deconstruct binary or
dichotomous thinking of either liberal peace or locally or
culturally framed peace as the absolute foundation for alasting peace. The core of post-liberal peace is a hybrid
peace recognizing that both liberal peace ideals andculturally-oriented peace visions are indispensable(Richmond, 2011). It is a reframing of peacebuilding
enterprise as a dialogical and pedagogical process inwhich liberal peace ideals are creatively modified in
distinct cultural contexts to contribute to positivetransformation to pave the way for a durable peace.
Stated otherwise, post-liberal hybrid peacebuilding is todeepen inter-cultural or inter-civilizational dialogue thataims to learn from each other and co-construct asustainable peace through an equal and complementary
relationship.
And this research stands by the ethos of post-liberal
hybrid peace vision that builds a complementary
relation between liberal peace and Buddhist peace.
Though Buddhism has developed its own peace theory, it
engages a dialogical and mutually learning process withliberal peace thesis to build a hybrid holistic peace ideal
for future sustainable peace.
3. On Buddhist inner peace
3.1. Buddhist view of conflict dynamics
Though many scholars including Oliver P. Richmond,
David Chandler, Roger Mac Ginty, Michael Pugh, to namebut a few, have developed the critiques of liberal peaceand explored post-liberal peace visions, on a Buddhist
view, the problem of liberal peace thesis is that it ishighly structurally and institutionally oriented and thehuman inner dynamics of peace has been
underdeveloped.
The main focus of Buddhism is human mind, which isstated in the Dhamapada: “All experience is preceded bymind, led by mind, made by mind” (Fronsdal 2005: 1).
The Surangama Sutra states: “The Tathagata has always
said that all phenomena are manifestations of mind andthat all causes and effects (all things from) the world toits dust, take shape because of the mind” (Luk, 2001: 16).
These statements do not deny the existence of objects
outside our minds. What they imply is that the qualities
and conditions of the world are dependent on theconditions of our minds (Lai, 1977). They also show thatthe root cause of problems facing humanity including
conflict and violence is attributable to mind and that at
the same time inner serenity and well-being can beachieved by human beings themselves. In other words,
the main focus of Buddhism is epistemological; that is,
how our way of knowing and understanding reality
affects peace and conflict dynamics. It does not denysocial structural dimensions of peace. Rather, what thisresearch seeks to demonstrate is that while social andstructural causes and conditions for peace must not beignored, critical analysis of human epistemology and thedevelopment of inner peace and empowerment of
individual citizen through the development of internal
dimension of peace could broaden the purview of ourunderstanding of peace.
In a Buddhist view, one of the main causes of conflictand violence is the belief and enactment of our values,

47

worldviews or perspective as absolute or complete.
From time immemorial, human beings have developed
conceptual thought or linguistic knowledge as a tool tomake sense of the reality of the world and communicate
with fellow human beings (Ichimura, 1997). We inhabitsocially constructed and historically evolved andsucceeded life-worlds that form cultural patterns –identities, beliefs, values and norms – as scaffolding formeaningful experience (Reysen and Katzarska-Miller,2013). We build certain frame of references – patterns ofworldviews, cultural values, political orientations andideologies, religious doctrines, moral-ethical norms andparadigms in intellectual enterprise, to construct aconceptually framed reality and lead a meaningful life.
However, while constructing the frame of referencesocial or cultural conditioning is essential to make senseof reality, Buddhism argues that the fundamental
problem with the construction (of frame of reference)lies in our propensity to privilege our frame of reference
as absolute or complete and in the reification ofunderstanding of reality and the objectification of theother (Zajonc, 2006). The belief in the universality andcompleteness for the frame of reference causes us to bedogmatic and exclusive of other views and thoughts(Ramanan, 1978). The extreme attachment to certain
views and values elapses into polarity or negation ofother views, values, and ultimately of people who are
different from us.
The belief in absoluteness and completeness of ourframe of reference also causes us to be predominated by
the dualistic thought as the only way of thought.
Dualistic thought is informed by the principle of the
excluded middle (Nicolescu, 2006) or “either-or” stance(Nagatomo, 2000). As the dichotomous relationshipbetween in-group and out-group founded upon the
dualistic thought becomes sharpened, an imbalanced
attitude invested by extreme in-group self-interest,
desire, and needs is favored and promoted at theexpense of others.
When we become disconnected from others as aresult of dualistic or dichotomous thought, it becomeseasier to propagate violence of any form upon thoseoutside the boundary. In a dualistic logical andepistemological structure, we tend to project negative
qualities upon the outside and see those objectively
belonging to them, which promotes self-righteousness
and leads to a discriminatory attitude and behavior. The
mind in dualistic stance swings from extreme to extreme,and sticks to dead-ends, whereby values, ideas, or normsof our own are not viewed as one of many alternatives,
but the only right one: Other possibilities are dimlyconceived or denied as wrong or inferior (Wade, 1996).
Though building a provisionally coherent thoughtsystem is an inevitable part of human life, it causes us toexaggerate differences between people and create
supposedly firm and fixed boundaries between the ingroup and out-group because a dualistic thought mode
exerts control on our frame of reference. Forming
sedimented ways of seeing the dynamic and complex
reality with fixed perspectives restricts the patterns ofawareness and limits our intentional range and capacity
for meaningful commitments (Hershock, 2006), whichthen impedes a constructive communication between
those having different frames of reference to address

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Eubios Journal of Asian and International Bioethics 29 (March 2019)

complex global and local problems including conflict that
requires those having different values, perspectives andgoals to cooperate (Nicolescu, 2006). Whereas social orcultural frames of reference and dualistic logic
foundation form a natural process in developing ourunderstanding of reality, it becomes the crux of the
problem for its very nature.
3.2. Buddhist inner peace model
As the mixture of an absolute belief in a frame ofreference and dualistic thinking constitutes conflict andviolence, the path to inner peace is to control our own
mind dynamics and overcome extreme attachment to acertain thought or frame of reference.
The first aspect of Buddhist inner peace is thepractice of reflective self-awareness. Reflective selfawareness is the practice of stepping back from ourcurrent frame of reference to critically examine ourpattern of thought, values and logics that shape ourexperience (Park, 2008). When completeness oruniversality is claimed for a certain frame of reference, itcauses us to be dogmatic and exclude other views orthoughts. Dissemination of a certain philosophicalframework as absolute or complete in the life-world
becomes the constitutional power of institutional
violence in human social and global arena (Park, 2008).
Reflective self-awareness helps us to recognize that
all ways of thinking and knowing are socially or
culturally constructed, contextual and contingent.
Through awareness, we learn to know that alternative
ways of thinking and knowing are available and learn tobe open to others’ views, values and norms to explore
more inclusive ones. The development of self-knowledge
through reflective self-critique of our frame of reference
generates pliability and flexibility with thoughts (Schliz
et al, 2010). We can sharpen the capacity tosimultaneously hold multiple perspectives and patternsof thought with an awareness that embraces all
perspectives without adhering to a position in any form
as complete to approach the reality (Hart et al, 2000).
The practice of meta-cognitive awareness like reflective
self-awareness stimulates worldview transformation
since it can bring us back to square one, from whichrevision of our model of the world becomes possible(Schliz et al, 2010). Learning to hold a belief as the best
working hypothesis we have at the moment, and being
consciously willing to change the belief system or
thought mode according to different circumstances,enhances the ability to appreciate and explore multiple
viewpoints and find comfort in unfamiliarity. By
integrating reflective self-awareness into our intellectualand practical enterprise of peace and raising theconscious awareness present in them to engage inconstant critique of our assumptions, the possibility oftranscending a particular belief system and approaching
the world from multiple perspectives will be a viable
reality.
The second aspect of Buddhist inner peace is thepractice of non-dualistic thinking. Non-dualistic thinking
means to understand the interdependent andinterpenetrating nature of conceptual thoughts framing
different views and understandings of our reality. Whilethe logic of the excluded middle staticizes and fixates
differences or oppositions, non-dualistic thinking sees

them as dynamic relationality and temporal phenomena(Hershock, 2012) whereby opposing prima facie views
and perspectives are not seen as a hardly fixed pair of
opposites but as inter-relational and interpenetrating
constructs. This refers to neither total erasure ofdifference nor demise of all distinctions into all-frozen
sameness. Rather, it transforms how we view differences
and oppositions beyond dualistic understanding.
With the recognition of a dependent origin in thenature of a conceptual or linguistic frame of reference,
we learn to understand that any form of symbolic
knowledge shaping dichotomous relationship cannot beseen as existing outside the purview of interdependency(Muller, 1998). Non-dualistic thinking is theconsciousness of the total and interminable conflict inconceptual thought or frame of reference claiming its
absolute and complete status and the consequent
recognition that the harmony of the world is a harmonyof opposites and contradiction. The transcendence ofdualistic thought empowers us to appreciate that the
opposite of a deep truth is another deep truth and to
hold multiplex and complementary both/and thinking(Braud and Anderson, 1998). Consequently, capacity forsynthetic, integrative thinking and appreciation for thediversity of values and perspectives can be honed.
However, the proposition of non-dualistic thinking
does not deny the logic of the excluded middle. Rather,
the relationship between non-dualistic thinking anddualistic one is complementary and not mutually
exclusive. By enacting both dualistic and non-dualistic
thinking according to distinct circumstances, we cansharpen flexibility in our thinking and creativity inmanaging differences.
The third aspect is the practice of compassion.
Originating from the Latin co-suffering, compassion is an
acknowledgement of shared humanity and thecommonalities in both suffering and aspiration among
those having different identities (Pruitt and McCollum,2010). It is to feel others’ pain, sorrow, despair orsuffering as our own as well as to have clear awarenessof interdependent origination of any phenomenon (Hoyt,
2014). A compassionate mind inspires the developmentof a quality of loving kindness, a universal and unselfish
love that extends to ourselves, to friends and family, andultimately to all people (Pruitt and McCollum, 2010).
The practice of compassion means to practice unitybased worldview. The unity-based worldview is theconsciousness of the oneness of humanity (Daneth,2006). It is an awareness that our and others’ well-being
are interdependent and interpenetrating: Our own peaceof any kind would be impossible to achieve without
considering and acting to promote others’. It is atransition from self-centered and dichotomous tensionsof in-group and out-group processes to an all-inclusive
state of awareness of our fundamental interconnection.
The awareness of our fundamental interdependence
does not deny the uniqueness or individuality of each ofus. It is a qualitative transformation in the view of thenature of identity. Instead of seeing our identity as anindependent and fixed entity with firm boundaries, there
comes a perspectival shift to understand it as aninterconnected web of life with no fixed nature. Realizing
identity as an open and dynamic living system within alarger interdependent and interconnected system

Eubios Journal of Asian and International Bioethics 29 (March 2019)inspires us to see that we cannot discriminate ourselvesfrom the inter-relational web of life without damaging
both others and ourselves (Loy, 1993). The recognitionof fundamentally interconnected and interpenetrating
nature of any human relation arouses a sense of
responsibility to act in interdependent andinterconnected relations and drives us to try to gratify
basic needs of all beyond group boundaries and promotejustice for others as well as for ourselves (Daneth, 2006).
This does not mean that all of us achieve the same wellbeing, basic needs and justice. It rather emphasizes that
we become conscious of the interdependent andinterpenetrating nature of different ideas and goals ofpeace, basic needs and justice and make a mutual
contribution to help achieve each other’s ideas of peace.
As represented by reflective self-awareness, nondualistic thinking, and compassion, the essence of
Buddhist inner peace is the development and practice ofmultiple functions of mind beyond but including thesocial and cultural purview of thinking and knowing
with a holistic view of reality. Undergirded by theenactment of multiple functions of mind, peace means acontinuous, relationally-expanding and interdependence
enriching process in which we experience differences oreven opposition as an opportunity to mutual insight andinspiration to explore something new. In this view, at thecore of conflict resolution and transformation and peacelies the necessity for the practice of mutual self-critiqueand transformation by those in conflict. In Buddhist view,conflict needs to be understood and enacted withinterdependent and interpenetrating epistemology andconsequently, a departure from dualistic or dichotomous
approach and the practice of non-dualistic thinking mustbe at the core of conflict resolution or transformationand sustainable peace.
Founded upon interdependent and holistic
epistemology, peace is an ongoing exploratory andeverlasting process that explicates new values andmeanings to achieve and sustain interdependent andmutually liberating and transformative relational
dynamics. Peace is not the suppression or elimination ofdifferences or disagreements, but rather the readiness toaccord with differing situational dynamics, responding
without exclusive reliance on any fixed views andprinciples, in order to amplify and accelerate relationally
manifest mutual appreciation (Hershock, 2012).
Encountering diversity ultimately means valuing
creativity; that is, significant innovation and relationaltransformation in the direction of unprecedented
appreciated coordination (Herschock, 2012).
Accepting interdependent and interpenetrating
epistemology, valuing diversity and participating inmutually transformative activities beyond the social andcultural framework would not be easy. However, sincenothing is absolutely destined to be, there is no warrant
to claim any situation in which we find ourselves to be
intractable (Park, 2008). Rather, it needs to beacknowledged that human beings and socio-cultural
frames of reference are complex systems that keepincorporating the histories of their constitutive
dynamics into the continuously ongoing processes of
their own environment and contextually responsive selftransformation and evolution (Hershock, 2012). As there
is no closure of meaning-making, changing our values,49

visions and actions is a possible reality to embody
interdependent and transformative relational dynamics.
4. Exploring a complementary relation between
Buddhist inner peace and liberal peace forhybrid holistic peace
As examined, Buddhist peace theory focuses on humaninternal dimensions. Empowerment of individuals withmultiple functions of mind and a holistic epistemology
seeks to promote peace as interdependence andtransformation. Qualitative enrichment of human mind
is at the core of Buddhist inner peace as increasing thenumber of citizens empowered with skills and abilities ofmultiple ways of thinking and compassionate andemphatic mind would contribute to filling society itself
with self-conscious citizens capable of bringing about
necessary positive changes.
However, the critical problem with Buddhist inner
peace theory is that it tends to ignore the macro
economic and political aspects that stifle people’s ability
and opportunity to satisfy their basic needs and pursue
their envisioned life (Brantmeier, 2007). Inner peace
presented could neither be appreciated nor applied tothose without appropriate food, clothing, and shelter, as
well as those without proper access to social services
such as education and healthcare (Hershock, 2006).
Though internal dimension of peace founded uponempowerment of citizens with multiple functions ofmind beyond but including socially and culturally
conditioned frame of reference is crucial, learning andemploying the spirits of liberal peace would make peace
more sustainable. How Buddhism understands humanrights principles, democracy and market-economy will
be examined.
5. Buddhism and human rights
The conventional view is that human rights is a Westernvalue that has been disguised as a universal value andimposed on non-Western zones. However, this research
disagrees with the view and claims that Buddhist inner
peace needs the promotion of human rights andBuddhist teachings contain the spirit of human rights
principles. Human rights are the rights that everyone
equally has because she/he is a human being (Donnelly,2013). At the core of human rights lies the ideal ofinherent human equality and dignity. The promotion ofhuman rights means the promotion of human equality,
dignity, and worth inherent in all human beings, which
enhances positive conditions for human development(Jeong, 2000).
Though Buddhist sutras or holy texts do not havedirect links to contemporary ideas of human rights,
certain ideals in Buddhist teaching show the spirits ofmodern human rights. One of the most conspicuous
ideals would be the doctrine of inherent Buddha-nature.
The teaching of the Buddha-nature means that all people
regardless of social status have Buddhahood or divinity
or precious nature and the potential to embody what the
Buddha, the Gautama, was awakened to by liberating
himself from suffering and spreading the wisdom andcompassion to the society. It is widely acknowledgedthat the historical Buddha criticized the social
discrimination and caste system of his age (Shiotsu,

50

Eubios Journal of Asian and International Bioethics 29 (March 2019)2001), which is stated in Suttanipata: “People are notborn base; nor are they born Brahmins. By their actions
they become base, and by their actions they become
Brahmins.” The doctrine of Buddha-nature implies thenatural rights concept of people being born free andequal. Being born free and equal, the Buddha-nature
doctrine claims that all human beings have equal
potential for self-realization even though the way toachieve self-actualization will not necessarily be
identical (Shiotsu, 2001). The ethos of human rights
underpinned by the principle of inherent equality anddignity of all human being beyond but including
diversity of human characters is to be found in
Buddhism.
What should be emphatically noted is that theenhancement of human rights helps to develop Buddhist
inner peace. As explained, the core of Buddhist inner
peace is the development and enacting of multiple
functions of mind founded upon a holistic view ofinterdependent and interconnected nature of our world
including different or even opposing conceptual or
linguistic knowledge shaping our reality. It isqualitatively enriched human development not only
physiologically, and psychologically, but philosophicallyand spiritually. However, without a proper external
environment, it would be impossible for us to internallyenrich ourselves.
The role of human rights is to secure the conditions
that undergird the possibility of human flourishing andfulfillment (McCarthy, 2001). The promotion of humanrights can create social conditions that help us sharpen
the skills and abilities for multiple ways of thinking andknowing and a compassionate mind that appreciates theunity in diversity. Human rights and Buddhist inner
peace form a virtuous cycle of building a harmonious
and sustainable society. To guarantee human rights
principles and social environment in which citizens canenrich their minds holistically would contribute toincreasing self-reflective and transformative agents who
further human rights more widely, which becomes afoundation for a sustainable society.
6. Buddhism and democracy
In line with human rights, the foundations of democracy
are equal dignity and liberty of the citizens, equality
before the law, and pluralism (Crick, 2002). Buddhism
also contains the spirits of democracy. The early
Buddhist community was open to all people beyond
caste, class, ethnicity, culture and gender and its
emancipatory and compassionate philosophy excluded
none (Hershock, 2012). The Buddhist doctrine ofdependent origination, that is, the teaching ofinterdependent and interpenetrating relationship also
underpins the horizontal and symbiotic relationships
between people having different backgrounds, values
and views. This shows the basic compatibility between
Buddhism and the principles of democracy.
While Buddhism acknowledges democracy as an
ideal system, Buddhist inner peace and democracy cancomplement each other to strengthen democracy inrealizing what it aspires to achieve. As Sen claims,
democracy cannot be identified with majority rule andvoting (1999). It entails multi-faceted requirements,
which include voting and respect for election results but

also the protection of liberties and freedoms, respect for
legal entitlements, and securing free discussion (Sen,1999). Public reasoning is the core of democracy. In the
broader perspective of public reasoning, democracyneeds to guarantee free public discussion anddeliberative interaction of political thought and practice(Sen, 2003). Democracy means to give citizens anopportunity to learn from each other and contribute to
the construction of social values and priorities.
Engagement in dialogue and accepting the change of
one’s viewpoint or adding new perspectives to one’s
original values and goals constitute the core of
democracy.
Buddhist inner peace as empowerment of individual
citizens with multiple functions of mind and complex
view of reality can be of help in enacting democracy as
public discussion based on value diversity andappreciation of change. What needs to be avoided is theattachment to any form of extreme position and belief indualistic thinking as absolute. And free and constructive
public dialogue requires its participants to possess thecapability to transcend their positional confinement; forpublic dialogue to freely and creatively occur, there is aneed for citizens to be capable of going beyond thelimitations or the purview of one’s positional perspective(Snauwaert, 2010). Empowered citizens with reflective
self-awareness,
non-dualistic
thinking
andcompassionate mind can become an autonomous andcritical agent in a collaborative and dialogical context byovercoming the tendency to think and act uncritically on
established ideas and views of others as fixed.
Political efficacy in democracy, that is, the capacity toengage in critical and transformative political action, isdependent upon cognitive, ethical and self-reflective
capacities of citizens (Reardon and Snauwaert, 2011).
Empowerment of citizens with multiple functions ofmind facilitates the perception of a wider scope ofsystemic and dynamic inter-relationships with diverse
values and interests, which creates space for therecognition of human dignity of all participants andmoral inclusion beyond differences and more complex
and integrative forms of reasoning. Beyond simple
majoritarianism and balloting, democracy is not the
suppression of differences or disagreements, but rather
our readiness to accord with differing situational
dynamics, responding without exclusive reliance on
fixed views and principles to amplify and boost
relationally mutual appreciation (Hershock, 2012).
Democracy means valuing creativity; that is, significant
innovation and relational transformation in the directionof unprecedented and yet meaningfully enacted
capacities for appreciative coordination (Hershock,2012).
Valuing diversity and participating in publicreasoning for mutual transformation is not an easy task
as we are not totally free of the influence of the socialand political environment. However, a critical aspect ofauthentic democracy is the enhancement of the ability of
individual citizens to engage in critical evaluation ofexisting knowledge and values and creation of new ones
(Feucht, 2010). The achievement of such ability emerges
out of the practice of reflective self-critique and analysis
of views and values from multiple perspectives based on
non-dualistic logic. The maturity of internal

Eubios Journal of Asian and International Bioethics 29 (March 2019)
competencies of individual citizens reflects the maturityof democracy. The sharpened ability to exploit multiple
functions of mind – reflective, compassionate and multiperspectival functions – will contribute to strengthening
dialogical and transformative dimensions of democracy.
7. Buddhist view of market-oriented economy
What needs to be noted emphatically is that Buddhism
does not deny economic activity itself. In Buddhist
dependent
origination
doctrine,
physiological,
psychological, and spiritual dimensions of human being
are interdependent for maturity. Accordingly,
individuals need proper economic circumstances tofollow and achieve spiritual development (Mosler, 2011).
Deprivation of basic human needs will prevent any
individual from being able to sustain bodily functions(Mosler, 2011) for psychological health andphilosophical and spiritual practice. A minimum
economic well-being must be established for inner peace
and the development of multiple functions of mind to
become a critical and transformative agent.
However, Buddhism takes a cautionary stancetowards market-oriented economy that liberal peace
advocates. While western model of market-oriented
economy creates profit and could boost macro economy,
it opens up the system to a multiplicity of interests andencourages social competition and can exacerbate theclash of different stakes without accommodating thosedifferences for far-sighted mutual benefit and worsen
the gap between the rich and the poor. Excessive
reliance on market-economy could lead to inequality andsocial injustice. In his religious journey, the Buddha
started his mission of reforming the unjust social order
based on loving-kindness, equality and solidarity (Badge,2014). Anything that ignores or impairs human welfare
cannot be accepted as the message of the Buddha (Badge,2014). An economic activity or system that degrades
human dignity and deprives citizens of their opportunity
for self-actualization cannot be acknowledged as alegitimate system.
What Buddhism seeks to achieve through economic
system is spiritual wealth as well as material one(Mosler, 2011). While showing a critical stance toward
western market-economy, it would be a mistake toassume that Buddhism denies market economy
categorically. What Buddhism critiques is the lack ofspiritual aspect and holistic view for social justice. In
principle, in the western discourse, individuals are
assumed to be rational, self-interested beings who areprepared to act justly but who are more prone to seek
their interests regarding wealth (Mosler, 2011). In
Buddhism, human beings are perceived as potentiallycompassionate individuals with an insight into reality,and human relationships are considered mutuallyinterdependent and restraint is needed regarding
excessive self-centered views and behavior as they leadto problems including violence. Buddhism is founded
upon the understanding of human relationships of any
kind as interdependent and interpenetrating and acompassionate mind-set that inspires us to respond toothers with empathy, respect and care, and it iscommitted to promote and enact dignity of all andspiritual fulfillment, envisioning an economic systemthat sustains and promotes social justice and equity.

51

A Buddhist envisioned economic system does notdeny individuals working for their own self-interest
since spiritual fulfillment needs proper physiological andsocio-economic conditions. However, Buddhism also
warns that if individuals work exclusively for their own
self-interest and benefit at the expense of others, thatwould end up with moral corruption of society and cause
conflict. In the Buddhist view, market-oriented economy,
while creating certain benefit and improving macro
economy, needs to integrate moral and philosophicalfoundations that help individuals engage in economic
activity with a holistic view of mutual interdependence
and interpenetration of all participants and promote
both material and spiritual achievement. The economic
system that is required in post-liberal peace is the onethat undergirds human physiological, psychological, andspiritual maturity.
8. Post-liberal hybrid holistic peace model
As shown in Figure 1, Buddhist inner peace and thepillars of liberal peace thesis – human rights, democracy,
and market-oriented economy – can build acomplementary relationship to strengthen internal andexternal aspects of peace. As the figure illustrates, four
elements: enhancement of human rights principles,
promotion of dialogical and transformative democracy
based on self-critique and readiness for mutual learning,an economic system that sustains and furthers
philosophical and spiritual fulfillment as well as material
one based on social justice, and equity, and developmentof inner peace founded upon multiple functions of mind
represented by reflective self-awareness, non-dualistic
thinking, compassion, and multi-perspectival approach –constitute post-liberal hybrid holistic peace.
All four aspects are interconnected andcomplementary to each other to pave the way for asustainable society and human relationships. When wedevelop peace on physiological, socio-political, economic,
philosophical and spiritual levels in an integrative way,
we can optimaly improve our potential to become acritical and transformative agent for a peaceful world.
Figure 1 Post-liberal hybrid holistic peace model(Original model by the author)
Inner peace: Multiple
functions of mind:
Reflective self-awareness,
non-dualistic thinking,multi-perspectival
approach, and compassion

Promotion of Human
RightsPost-liberal
hybrid holistic
peace
Economic system
sustaining and furthering
material, philosophicaland spiritual fulfillment of
citizens based on social
justice and equity

Promotion of dialogicaland transformative
democracy based on selfcritique and mutual
learning

52

Eubios Journal of Asian and International Bioethics 29 (March 2019)

9. Conclusion and research implications
Seeking to show itself as an exemplar of post-liberal
hybrid peace model, this research has explored a holistic
peace model based on a complementary relationshipbetween liberal peace thesis and Buddhist inner peace.
Building a complementary relationship between
different visions of peace is not easy. However, it needs
to be recognized that every peace view is partial andtranscending one’s purview of peace and learning fromother culturally and philosophically constructed views
will be of great benefit in the long-run.
The
present
globalinterdependentandinterconnected situation shows us a moral obligation toactively pursue politics of inter-civilizational dialogue toengage in a concrete practice of cross-cultural learning
to address global challenges including violent conflicts.
Based on an awareness of the presence of different
cultures and civilizations in global affairs, dialogue is an
open-ended process in which we view critically andsympathetically one tradition from the points of view ofanother and vice versa.
Given that peace research has become a global
agenda, which requires those with distinct philosophicaland intellectual backgrounds to appreciate andcooperate each other and that peacebuilding enterpriseis a complex and multi-faceted phenomenon thatdemands creativity and flexibility of those engaged in it,
it is certainly not the time to make a clear and fixeddemarcation between Western and non-Western blocks
but, more importantly, it’s time for each of us to rid
ourselves of narrow self-imposed perspectives orboundaries and initiate a dialogue within the larger
context that includes both West and non-West. The
intellectual enterprise of knowledge creation andlegitimation is never a static substance but an everlasting process that keeps renewing itself and theresearch explored in this paper should not be an
exception.

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Analysis of euthanasia from thecluster of concepts to precise
definition- Mohammad Manzoor Malik
Department of Philosophy and Religion, Graduate Schoolof Human Sciences, Assumption University of Thailand
Email: philomalik@gmail.com
Abstract
There are common concepts between euthanasia andsuicide because euthanasia is historically connected withthe discourse on suicide. In widespread literature on
euthanasia there is confusion over the concepts anddefinitions. These definitions are analyzed in this paper
and along with other conclusions and distinctions theresearcher has substantially defended his definition of
euthanasia. There are two different usages of the term
euthanasia: a narrow construal of euthanasia and broad
construal of euthanasia. Contrary to other researches,
the researcher agrees only with the narrow construal ofeuthanasia, i.e. active euthanasia. The researcher’s
definition of euthanasia is: intentionally causing aterminally ill person’s death through an action
performed by a physician. As a result, passive euthanasia
is expunged from the definition of euthanasia. In
addition to that, the definition excludes suicide, assisted
suicide, and physician-assisted suicide.
1. Introduction
Concepts are at the core of philosophical investigation.
Describing concepts and definitions is one of the maintasks of philosophical practice and activity. Likewise,
attempting to understand the meaning of the output ofvarious disciplines and questioning their underlying
principles besides clarity are also key tasks of philosophy.
Regarding bioethics, especially euthanasia, philosophy
plays a role in all the above-mentioned areas ofconceptualizing, defining, clarifying, understanding
beside discussing its ethical dimensions and evaluating
the scores of arguments that are part of the narrative anddiscourse on the subject.
The complexity of defining euthanasia emerges fromits historical background and current usage. In other53

terms, the issue of euthanasia is both old and new. It’s
traditional and the underpinnings of its discourse are old,connected with suicide on which thinkers andphilosophers since the ancient period have held positions.
The late twentieth century represents two aspects of theissue of suicide. The debate becomes divided into two
separate discourses: suicide and euthanasia. Both thesesubjects became separate along with their subject matterand arguments, though there is an unavoidable overlap
between them. The nature of euthanasia became special
because it touches on medical profession and debate
over rights and duties. Thus, euthanasia became aninterdisciplinary subject of legal analysis in various
countries.
The origin of euthanasia, most of its conceptual
framework, and some of its main arguments is in suicide.
Therefore, a lucidity of the issue, clarity of the concepts,
and precision of the main definitions employed in the
discourse are sought in the following sections of thepaper.
2. Conceptual History of Euthanasia
Euthanasia is old in the sense that it is connectedconceptually and historically with the historical debate ofsuicide. Suicide included concepts such as that Athenianlaw treated suicide as a crime (Mair, 2007, pp. 26-30), so
the concept of crime developed. Hippocrates (460-370
BCE) worked on its approval through calling it antiprofessional for a physician (Hippocrates, 2005); Plato
worked against disapproval of suicide through concepts
like judicial decree, excruciating misfortune, and moral
disgrace (Plato, 1980, p. 268); Aristotle developed theconcept of citizenry against suicide (Aristotle, 1999, p.
84); Annaeus Seneca (4 B.C.E.-C.E. 65) presented
concepts like individual autonomy and quality of life infavor of suicide (Seneca. (1917/ 1998, pp. 35-39).
Against suicide, Aquinas presented three concepts: selfperpetuation
responsibilities,
individual
andcommunitarian responsibility, and divine authority overlife (Aquinas, 1947, 11, 11, Q.64, Art.5.). Michel deMontaigne presented the concept of personal choice infavor of suicide (Ferngren, 1989, pp. 159-61).
During the Renaissance, Thomas More (1478-1535)
defended suicide for issues like torturous and incurable
illness by rationalizing concepts such as starvation andopium (More, 1999, p. 22.). David Hume (1711-1776)
worked on the moral permeability of suicide when life ismost plagued by suffering through concepts such asindividual autonomy and social benefit (Hume, 2004,
p.2-8). Other philosophers of the Age of Reason, such as
John Locke and Immanuel Kant, opposed suicide. Lockeargued that life, like liberty, represents an inalienable
right, which cannot be taken from or given away by anindividual (Ferngren, 1989, pp. 173-75). For Kant (17241804), suicide was a paradigmatic example of an actionthat violates moral responsibility. Kant believed that theproper end of rational beings requires self-preservation,and that suicide would therefore be inconsistent withthe fundamental value of human life (Kant, 1785). This
brief historical survey provides a score of concepts thatare present in the discourse of euthanasia.
Euthanasia is new in the sense that most of the debate
on the issue treats the matter as a consequence ofadvanced modern medical technology. The continuous

54

Eubios Journal of Asian and International Bioethics 29 (March 2019)

development of advanced medical technology has
brought various moral issues under new scrutiny andethical evaluation. For example, by using artificial lifesustaining technology delay of death is possible against
the wishes of patients who may be in pain and or otherforms of suffering. Moreover, it is also possible to keeppeople alive who are in a coma or a persistent vegetative
state. In cases like these, sustaining life versus taking life
or allowing someone to die become moral dilemmas inface of employing various life sustaining medical
technologies and use of lethal injunctions and morphine.
3. Suicide and euthanasia: conceptual parallelism
The above concepts are present in the discourse andnarrative given by proponents and opponents ofeuthanasia. These concepts directly or indirectly touch
the issue of euthanasia from many perspectives and link
the issue with philosophical tradition. Such mixture ofconcepts shows that the problem of euthanasia has along history of philosophical discussion. However, mostof the discussion revolves around the issue of suicide.
The discussion of suicide in a broader sense could be
related to the problem of euthanasia since their aim is
termination of life. Suicide is a general concept whereas
euthanasia is special. Euthanasia is about terminally ill
persons whereas suicide is a comprehensive concept
including all forms of self annihilation. However, lines of
distinction could be drawn between suicide andeuthanasia. “Euthanasia is an alleged solution for the illsof dying, whereas suicide is an alleged cure for the ills of
living” (Donnelly, John, 1998, p.10). On the other hand,wishing death and planning steps towards ending one’s
life is shared by both euthanasia and suicide. Both ofthese issues share many common threads which bringsuicide and euthanasia on parallels, if not completely,
nevertheless, partially. Therefore, in the historical sketch
the distinction between suicide and euthanasia is
irrelevant because suicide is general and in principle it
includes euthanasia. And “Indeed, to justify either one,
suicide or mercy killing, is to justify the other” (Fletcher
1987 / 1989, p. 91).
4. The need to define euthanasia
It is important to have a clear definition of euthanasia. As
a matter of fact, defining euthanasia and the relevantterms deserve a thorough tactful analysis because muchof the confusion which besets the contemporary
euthanasia debate can be traced to imprecision in
definition: “Lack of clarity has hitherto helped to ensurethat much of the debate has been frustrating and sterile”(Otlowski, 1997, pp. 16-17).
The discussions on euthanasia have made it amultidisciplinary subject; however, the issue in its
essence is connected with medicine. On December 4,
1973, the House of Delegates of the American Medical
Association (AMA) asserted its position on the issue of
euthanasia as follows:“The intentional termination of the life of one humanbeing by another--mercy killing--is contrary to thatfor which the medical profession stands and iscontrary to the policy of the American Medical
Association. The cessation of the employment of
extraordinary means to prolong the life of the bodywhen there is irrefutable evidence that biologicaldeath is imminent is the decision of the patient and/or
his immediate family. The advice and judgment of thephysician should be freely available to the patient and/or his immediate family.” (as cited in Rachels, 1975 /1994a, pp. 112-113)
The AMA’s position on the issue came to be named asconventional doctrine on euthanasia (CDE) or traditionalview. It is important to mention that AMA’s position,although adopted in the United States; its message wasadopted by the World Medical Association's Declaration
on Euthanasia, adopted by the 38th World Medical
Assembly, Madrid, Spain, in October 1987, states:“Euthanasia, that is the act of deliberately ending thelife of a patient, even at the patient's own request or at
the request of close relatives, is unethical. This does
not prevent the physician from respecting the desire ofa patient to allow the natural process of death tofollow its course in the terminal phase of sickness.”(World Medical Association, 2002, Section, 1)
The declarations by American Medical Association(AMA) and the World Medical Association can be helpful
in developing concise and precise concepts anddefinitions that are important for any meaningful
discourse on euthanasia.
5. Defining euthanasia
Euthanasia etymologically comes from two Greek words,
eu, well, and thanatos, death; it means good or easy death(Baird & Rosenbaum, 1989, p. 9). Gradually the meaningof the word changed from easy death to the actual
medical deed to make death easy. Finally, it gained themeaning of mercy killing. The common synonym foreuthanasia in both lay and professional vocabularies has
been mercy killing (Koop, 1989a, p. 69). MerriamWebster's dictionary defines euthanasia as "an easy andpainless death, or, an act or method of causing death
painlessly so as to end suffering: advocated by some as away to deal with victims of incurable disease" (2008).
Similarly, the Euthanasia Society of America, founded in
1938, defines euthanasia as the "termination of humanlife by painless means for the purpose of ending severe
physical suffering" (Hardon, 2004, Euthanasia, para.14).
The American Medical Association’s Council on Ethicaland Judicial Affairs (1992) defines the term as follows:“Euthanasia is commonly defined as the act of bringing
about the death of a hopelessly ill and suffering person ina relatively quick and painless way for reasons of mercy”(p. 2230).
Though euthanasia is mercy killing in the sense of
painlessly putting a terminally ill patient to death, theabove-mentioned definitions lack clarity and could leadto misunderstanding. There are other definitions whichsuggest that euthanasia also means refusing unwanted
care or withdrawal of ongoing care (Adams, 1992, p.
2021). Therefore, there are two different uses of the term“euthanasia.” The first is sometimes called the narrow
construal of euthanasia. In this view euthanasia isequivalent to mercy killing. Thus, if a physician injects apatient with a drug with the intent to kill the patient, thatwould be an act of euthanasia; but if the physician
withholds some extraordinary and excessively
burdensome treatment from a patient and allows thepatient to die in a natural way, that does not count as an
example of euthanasia. The second view, is sometimes

Eubios Journal of Asian and International Bioethics 29 (March 2019)
called the broad construal of euthanasia, it includes bothmercy killing and cessation of extraordinary medical
treatment: active euthanasia and passive euthanasia. The
broad construal is more widely used; although this paper
supports the narrow construal of euthanasia.
Active euthanasia or euthanasia by action, also called
mercy killing or positive euthanasia, is intentionallycausing a person’s death by performing an action such as
giving a lethal injection. Passive euthanasia or euthanasia
by omission, also called negative euthanasia, is thewithholding or withdrawing the unnecessary andextraordinary medical treatment. Rachels (1983) widens
the definition of active euthanasia; according to him it
refers to the intentional and /or direct killing of an
innocent human life either by that person, suicide, or byanother, assisted suicide (p.19). Gifford (1993) describes
the difference between the two types of euthanasia:“Passive euthanasia involves allowing a patient to die byremoving her from artificial life support systems such as
respirators and feeding tubes or simply discontinuing
medical treatments necessary to sustain life. Active
euthanasia, by contrast, involves positive steps to end thelife of a patient, typically by lethal injection” (p. 1546).
Active and passive euthanasia are the maincategories; however, they are further classified
depending on the relevant factors or circumstances such
as Voluntary, Involuntary, and Non-voluntary euthanasia.
The American Medical Association’s Council on Ethicaland Judicial Affairs (1992) makes three distinctions
concerning consent and euthanasia as follows:“Voluntary euthanasia is euthanasia that is provided
to a competent person on his or her informed request.
Non-voluntary euthanasia is the provision of
euthanasia to an incompetent person according to asurrogate’s decision. Involuntary euthanasia iseuthanasia performed without a competent person’s
consent.” (p. 2230)
These distinctions while combined with the active/
passive distinction form six different types of euthanasia:
voluntary active, voluntary passive, non-voluntary active,
non-voluntary passive, involuntary active andinvoluntary passive. Closely related to euthanasia areterms such as assisted suicide and physician assisted
suicide. Assisted suicide is when someone provides anindividual with the information, guidance, and means totake his or her own life with the intention that they will
be used for this purpose. Likewise, when it is a doctor
who helps another person to kill himself or herself it iscalled physician assisted suicide. However, there is a
sharp difference between euthanasia and physician
assisted suicide. The AMA’s Council on Ethical and
Judicial Affairs (1992) states as follows:“Euthanasia and assisted suicide differ in the degree ofphysician participation. Euthanasia entails aphysician performing the immediate life ending action(e.g., administering a lethal injection). Assisted suicide
occurs when a physician facilitates a patient’s deathby providing the necessary means and /or information
to enable the patient to perform the life-ending act(e.g., the physician provides sleeping pills andinformation about the lethal dose, while aware thatthe patient may commit suicide).” (p. 2231)

55

6. Euthanasia: what it is and what it is Not
The researcher holds that euthanasia is only the narrow
construal of euthanasia; that is active euthanasia alone.
The researcher’s contention is that since euthanasia
enfolds the meaning of intentional, mercy killing in what
has come to be known as passive euthanasia, intentional
killing is not part of the withholding or withdrawing theunnecessary and extraordinary medical treatment. The
confusion between suicide, assisted suicide, andphysician assisted suicide, and euthanasia also deserve
analysis. This confusion of terms is very widespread in
the well circulated literature on euthanasia; mostimportantly, Rachels, as noted earlier, confuses theseterms too; his definition of active euthanasia includes
mercy killing, suicide, assisted suicide and physician
assisted suicide (Rachels, 1983, p.19).
The researcher holds that passive euthanasia, suicide,assisted suicide, and physician assisted suicide are noteuthanasia; only active euthanasia “mercy killing” iseuthanasia. The researcher’s understanding is consistent
with AMA’s definitions; intentionally causing aterminally ill person’s death for the reasons of mercy bya physician. The definition includes: voluntary, nonvoluntary, and involuntary active euthanasia. The
definition excludes: suicide, assisted suicide, physicianassisted suicide and passive euthanasia.
The definition is based on the facts that: (1) the deathis caused by an agent (human) instead of the subject (thepatient), (2) the causing of death is intentional (3) the
death is caused either by the request of the subject or thestate of the subject to make it different from a purehomicide (4) the death is caused by commission or
action and (5) the subject is terminally ill and (6) theagent to cause the death is a physician. Therefore,
euthanasia as defined above will include only active
euthanasia.
The reasons for not considering passive euthanasia
as euthanasia include: (1) the death is natural, and not
artificial (2) the death is not caused by action of any
agent. Suicide, assisted suicide, and physician assisted
suicide are excluded because the death is not caused byan agent other than the subject. The very integral factorof the notion of euthanasia is being killed by some agent(person) instead of the subject.
7. Conclusion
The study showed that there are two different usages of
the term, euthanasia: narrow construal of euthanasia,
which refers to mercy killing or active euthanasia; andbroad construal of euthanasia, which refers to bothactive and passive euthanasia. The researcher agrees
only with the narrow construal of euthanasia, i.e. active
euthanasia. The researcher’s definition of euthanasia is:intentionally causing a terminally ill person’s death byperforming an action by a physician. As a result, passive
euthanasia is expunged from the definition because
euthanasia means intentional mercy killing; and inpassive euthanasia intentional killing is not part of thewithholding or withdrawing the unnecessary andextraordinary medical treatment. Therefore, theresearcher’s definition includes only active euthanasia“mercy killing” as euthanasia. The definition excludes:
suicide, assisted suicide, physician-assisted suicide andpassive euthanasia. The very integral factor of the notion

56

Eubios Journal of Asian and International Bioethics 29 (March 2019)of euthanasia is being killed by some agent (person)
instead of the subject.
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Aquinas, St. T. (1947). Summa theologica. (Benziger Bros. ed.).
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Hume, D. (2004). Essays on suicide and the immortality of thesoul. Kessinger Publishing.
Hardon, J. A., S.J. (2004). Moral theology. Retrieved March 5,2007, from http://www.therealpresence.org/archives/
Moral_Theology/Moral_Theology_004.htm
Kant, I. (1785). Fundamental principles of the metaphysic ofmorals. (Thomas Kingsmill Abbott, trans.). Retrieved July 2,
2006, From http://www.grtbooks.com/
Koop, C. E. (1989a). The right to die: The moral dilemmas. In R.
M. Baird, & S.
E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp. 69 -85).
Buffalo, New York: Prometheus Books. (Original work
published 1976)
More, T. (1999). Utopia (David Wootton, Trans.). Indianapolis:
Hackett Publishing.
Mair, A.W. (2007). Suicide: Greek and Roman. (J. Hastings ed.,)Encyclopedia of religion and ethics (V.12, pp. 26-30). Varda
Books.
Otlowski, M. (1997). Voluntary euthanasia and the common law.
Oxford: Clarendon Press.
Plato. (1980). The laws of Plato (T. L. Pangle, Trans.). New York:
Basic Books.
Rachels, J. (1983). Barney Clark's key. [Electronic version]. The
Hastings Center Report, 13 (2), 17-19.
Rachels, J. (1994a). Active and passive euthanasia. In A.
Norcross, & B. Steinbock (Eds.), Killing and letting die (2nded., pp.112 -120). New York, USA: Fordham
University
Press. (Original work published 1975)
Seneca. (1998). On the proper time to slip the cable. In J.
Donnelly (Ed.), Suicide: Right or wrong? (pp. 35-39). New
York, USA: Prometheus Books. (Original work published
1917)
The World Medical Association. (2005). Resolution oneuthanasia.
Retrieved February 20, 2007, fromwww.wma.net/e/policy/e13b.htm

The surrogacy industry in Georgia
and Japanese patients- Masayuki Kodama, MD
National Institute of Fitness and Sports in Kanoya, Japan
E-mail: kodama@nifs-k.ac.jp
Abstract
On 19 February 2015, a law regulating reproductive
medicine (surrogacy) passed the legislative process inThailand and was next enacted with the approval of thecabinet and King Bhumibol Adulyadej in July 2015. Since
then, some intermediary surrogacy agencies based in
Thailand, including Japanese surrogacy agencies, havedeveloped a multinational surrogacy industry with
branches in Georgia. This paper is an attempt to clarify
the present state of the Georgian surrogacy industry, andalso the risks inherent in the Georgian surrogacy
industry. The paper aims to provide information which isrelevant to the Japanese patients seeking surrogacy
treatment as well as researchers in reproductive
medicine. Japanese couples need to carefully examine
the various options offered by foreign surrogacy
agencies and hospitals, because some of them operate
without being well versed in the support they provide
over procedures to have surrogate children recorded inJapanese family registries so that they may acquire
Japanese nationality. Those who are planning toparticipate in Georgian surrogacy tourism should keep
up with the latest legal developments in Georgia, andponder deliberately whether they still want to go ahead
and take part in the reproductive medicine programs
there, if at all.
1. Introduction
Thailand’s status as a surrogacy hub in the early 21st
century has rivaled India’s, greatly galvanizing its
economic development. However, the industry has seen
dramatic upheaval in the country since 2014. Patientsfrom developed nations seeking surrogacy treatment
fled Thailand en masse with the enactment of theProtection for Children Born Through Assisted
Reproductive Technologies Act, 2015, on July 30th, 2015.
While these refugees initially found greener pastures in
Nepal and the Mexican state of Tabasco, public outcry
over the flood of gay couples seeking surrogacy
arrangements led the authorities in Nepal and Tabasco
to issue complete bans on commercial surrogacy by theend of 2015.
In response to these developments, manyorganizations turned their attention to Cambodia as analternative site for surrogacy operations, where the lackof legislation concerning reproductive medicine de facto
permitted surrogacy treatment. Among them was the
New Life Global Network (NLGN), which opened a local
branch in the country in March 2015. However, theCambodian government soon followed suit with its
neighbor by announcing a complete ban on commercial
surrogacy in all medical facilities in Phnom Penh on
November 3rd, 2016. (Readers can find an early accountEubios Journal of Asian and International Bioethics 29 (March 2019)of these developments in a 2016 paper by the author.1)
As of this writing (March 2018), NLGN is expanding its
surrogacy business from its local foothold in Thailand toother locations in Southeast Asia, including Vientiane in
Laos and Naypyidaw in Myanmar.
The two primary intentions of the Protection forChildren
Born
Through
Assisted
Reproductive
Technologies Act, 2015 were to ban commercial
surrogacy and regulate altruistic surrogacy. With its
passage and enactment, where will so-called ‘surrogacy
refugees’ from developed countries, including Japan,
turn in their search of a new host country offering
reliable, safe, and secure access to the reproductive
medical services they need?
The author’s continuing research into surrogacy in
Asia (Kodama, 2012, 2014abc, 2016, 2017) suggests
their exodus from Thailand will likely shift demandprimarily to the USA (California, Nevada, etc.), Georgia(Gruziya)2 , Ukraine, and Russia.3
One Ukraine-based surrogacy brokerage firm, BABY 4
YOU, has targeted Japanese surrogacy refugees since2016, offering detailed information about the process
along with video infomercials in Japanese on its website4.
Boasting comprehensive support by both Japanese andJapanese-speaking Ukrainian staff, the agency ispartnered with two hospitals in the Ukrainian capital ofKiev: Family Source Clinic5 and the Kiev City Maternity
Hospital6.
The Law of Georgia “On Health Protection” Article
143 provides that the surrogate retains no parential
rights in respect of the child.
1) Extracorporeal fertilization (IVF) is allowed in thefollowing cases:a) For the purpose of treatment of infertility, as well as incase of risk of transmission of genetic disease on a wife’s ora husband’s part, by using sex cells or an embryo of thecouple or a donor, if the couple’s written consent has beenobtained.
b) If a woman has no uterus, for the purpose of transfer
and growth of the embryo obtained as a result of
fertilization to the uterus of another woman (“surrogate
mother”). The couple’s written consent is obligatory.

1 Kodama, M.: The Present State of Regulations Concerning
Surrogacy in Thailand, Japanese Association for Philosophicaland Ethical Researches in Medicine, Journal of Philosophy andEthics in Health Care and Medicine, 10, 64-68, 2016.
2 The Japanese government decided to change the country’s
official name from the exonym Gurujia (Russian: “Gruziya”) to
Joojia (English: “Georgia”) on April 22nd, 2015.
3 Public awareness of Russia as a surrogacy option washeightened with media coverage of the birth of a baby boy to
Izumi Maruoka, a freelance television announcer, on January
3rd, 2018 via a Russian surrogate mother.
4 https://www.dairibo.com/about_UA.html
5 Opened in 2013, and headed by Dr. Strelko Galina (M.D.,
Ph.D.), a leading specialist in IVF.
https://www.youtube.com/watch?v=kW9vh7SWaP4
http://www.medicare-4u.com/doctors/galina-strelko/,
Ukraine, 04053 Kiev, 31/33 Kudryavska str., infertility-kiev
hospital(Clinic Family Source) https://dairibo.com/clinic.html
6 Opened in 1918 and headed by Chief Doctor Natalia P.
Goncharuk (M.D., Ph.D.).
https://www.youtube.com/watch?v=fRH357mYJMY, Ukraine,
01011 Kiev, 5 Arsenalna str., Maternity Hospital

572) The couple is considered to be parents in case of thechildbirth with the responsibility and authority ensuingfrom it. A donor or a “surrogate mother” has no right to berecognized as a parent of the born child.
Extracorporeal fertilization (IVF) Article 144:
For the purpose of artificial fertilization it is possible touse female and male sex cells or an embryo conserved by
the method of freezing. The time of conservation isdetermined according to the couple’s will by establishedprocedure.
Article 143 permits in vitro fertilization,
gamete/embryo provision, and surrogacy. The parents ofthe surrogate child must be those commissioning thesurrogacy, and not gamete/embryo donors or surrogate
mothers. Article 144, “Extracorporeal Fertilization (IVF),”permits the cryopreservation of gametes and embryos.
The text of the Law of Georgia on Health Protection
restricts surrogacy to heterosexual married couples inwhich the wife lacks a uterus, but both commercial
surrogacy and altruistic surrogacy are permitted inpractice. In January 2014, the Minister of Justice ofGeorgia stated plans to enact surrogacy-regulating
legislation to ban commercial surrogacy and restrict
surrogacy to altruistic surrogacy, but deliberation on thebill was suspended in 2016, due to pushback from
opposition voices.
Another agency, the Thailand IVF Support Center,
provided surrogacy services in Thailand catering toJapanese clients until 2014. With the passage andenactment of the Protection for Children Born ThroughAssisted Reproductive Technologies Act, 2015, theagency’s reproductive director Takehiko Yokosuka
relocated his surrogacy business operations to the
Georgian capital of Tbilisi, attracted by the opportunity
presented by the legalization of commercial surrogacy inGeorgia in 1997 with the enactment of the law On HealthProtection. 7 He established a local brokerage firm,
Georgia Surrogacy Japan, in partnership with Dr. Tamar
Khachaouridze, chief of the Surrogate Motherhood
Center of Georgia and director of the association Hopefor the Future8, which mediates surrogacy arrangements
between the Surrogate Motherhood Center of Georgia
and Japanese customers.
This paper explores and reviews the practices andconditions of the surrogacy industry in Georgia, thebirthplace of NLGN and the base of operations for theJapanese-run brokerage firm Georgia Surrogacy Japan.
In the following sections on Risks facing the
Georgian surrogacy industry and Conclusion, theauthor describes factors and trends in Georgia and Japanthat could disrupt the industry, which should be
carefully considered by potential surrogacy patients andreproductive health researchers in Japan.
2. Risks facing the Georgian surrogacy industry
Georgia is chiefly an agricultural nation: its primaryindustries are farming, food processing, and mining.
Wine has always been a powerful domestic industry that
7 https://www.surrogacy.ge/it/the-best-surrogacy-legislation
8 Hopefor the Future was established in 2000, and began
accepting applications for Georgian surrogate mothers and egg
donors at the same time.

58

Eubios Journal of Asian and International Bioethics 29 (March 2019)brings in foreign capital, a fact that still holds true today.
However, ever since commercial surrogacy and otherinfertility treatments were legalized in 1997, assisted
reproductive medicine has become the country’s single
greatest source of foreign revenue. Propelled by thesurge in surrogacy tourism, the Georgian economy
enjoyed impressive GDP growth for a time: 9.3% in 2005,
12.4% in 2007, and 6.4% in 2010. Today, however, thereal GDP growth rate is stagnant (2.7% in 2016), and thecitizen unemployment rate remains high (12.4% in 2014,
11.9% in 2015).9
National income is low—per capita GDP was a mere
3,892 USD in 201610—which has effectively resulted in
no shortage of applicants for surrogate motherhood.
Divorced single mothers and impoverished married
women with children are the lifeblood of the surrogacy
industry. Georgian law stipulates that couple
commissioning surrogacy be recorded on the surrogate
child’s birth certificate as the legal parents. This meansthat typically, the requesting couple and the surrogate
mother have no need to meet except for when they sign
the surrogacy contract and hand over the child.
Surrogacy brokers make it abundantly clear to surrogate
mothers that they will simply be the womb mother, notthe legal mother, of the child they will bear. Many poor
surrogates initially wrestle with internal conflict about
their role, viewing it through the lens of traditional
morality. Eventually, compelled by economic necessity,
most warm to the idea of being, in effect, an ‘incubator’.
Risk Factor #1
The Georgian Apostolic Autocephalous Orthodox
Church’s condemnation of commercial surrogacy stands
in stark relief to this social trend, with officials
proclaiming that “women should not be used as
incubators”. Ilia II, the spiritual leader of the Church,
castigated commercial surrogacy in January 2014 on
moral grounds. His inappropriate remarks, including
statements that surrogate children are “pitiful” and“should not be baptized”, could inflame prejudice against
this blameless group. All the while, the Church has
remained conspicuously silent on alternative means toenrich the impoverished citizens seeking to participate
in the surrogacy industry. Georgia’s bid to become amember state of the EU, which prohibits commercial
surrogacy, is another crucial factor that plays into thedebate. Proposed legislation by the Ministry of Justice toban commercial surrogacy was leaked in 2014, arousing
fierce debate over its merits.11 With mounting domestic
controversy about its pros and cons, tighter restrictions
and even surrogacy bans may be on the horizon: no one
should take the future of the industry in the country for
granted.
Risk Factor #2
9 Basic Data on Georgia, Japan Ministry of Foreign Affairs. (inJapanese)
http://www.mofa.go.jp/mofaj/area/georgia/data.html
10 Ibid.
11 Theproposed legislation would have restrictedcommissioning parties and surrogate mothers to Georgiannationals, and permitted only altruistic surrogacy. The bill met
resistance from groups supportive of commercial surrogacy,and has not yet been deliberated as of the time of this writing.

Georgia has failed to provide legal resources to support
the repatriation of surrogate children ever since On
Health Protection was enacted in 1997. With no solution
in sight, surrogacy brokers have deliberately avoided theissue. Confronted with the problem, the Georgian
government amended the law in 2014 to open up
Georgian citizenship as a legal possibility to surrogate
children unable to acquire citizenship in the homecountry of the requesting party. However, requesting
couples and their children can get stopped short inGeorgia if the surrogacy arrangements fail to meet thelegal requirements as revised by the Georgian
administration in 2012. (These might include omissions
or errors in the surrogacy consent form signed by the
couple, the certificate of uterine embryo transfer, thebirth certificate, or improper authentication of thesigned surrogacy contract.) Mistakes made byinsufficiently knowledgeable (or simply sloppy) brokers
can result in the surrogate child being placed in a childprotection center. Moreover, the surrogate mother andegg donor could be called on to testify in court, violating
their privacy.
There have even been cases where a shoddy broker
incorrectly recorded the surrogate mother as the child’slegal mother on the birth certificate issued by the local
hospital. Such illegal actions have drawn uproar andstern rebukes from others in the industry. In effect, thisallows the surrogate mother to legally refuse to transfer
the surrogate child, and raise him or her herself. In theworst-case scenario, the mother could be a conduit forhuman trafficking to a third party.
3. Conclusion
In its current form, On Health Protection protects therights of the couples who commission surrogacy
arrangements, but not necessarily those of theimpoverished Georgians desperate to become surrogate
mothers. For example, there are no regulations about the
number of times a woman can provide surrogacy
services. Robust legal provisions to assiduously protect
the health of surrogate mothers would be desirable inthis regard.
Georgia is a poor Eastern European country where
18% of the population lives below the international
poverty line (1.25 USD per day: 2009-201212). The
government’s advocacy of surrogacy tourism as national
policy pulls in huge numbers of surrogacy refugees fromdeveloped countries, which has brought it face to facewith a variety of problems even as it drives the national
economy. Recent years have seen officials attempt toaddress these issues with legal reforms, on a trial-anderror basis.
Japanese couples who want to pursue surrogacy inGeorgia should be mindful of the myriad legal
procedures and bureaucracy that await them. In Georgia,
they need an exit permit for their child, as well as thebirth certificate issued by a local hospital. In Japan, theyneed to enter him or her in their family registry, alongwith the necessary processes to grant citizenship and apassport. There are two ways to record a foreign-born
12 JapanCommittee for UNICEF, “The State of the World’sChildren 2015”. (in Japanese) https://www.unicef.or.jp/
library/sowc/2015/pdf/15_04.pdf

Eubios Journal of Asian and International Bioethics 29 (March 2019)
surrogate child in the family registry in Japan: as alegitimate birth to a Japanese mother and father, and as
an illegitimate birth to a surrogate mother. As noted
above, On Health Protection requires the couple
requesting surrogacy to be listed as the legal parents on
the surrogate child’s birth certificate. Accordingly,
Japanese couples should report the child as a legitimate
birth to a Japanese mother and father in theirmunicipality of residence, in order to officially record
him or her in the family registry. Couples will encounter
no issues at all with the Japanese legal system if themother of the foreign-born child is Japanese and under
50 years old.
However, when the mother is 50 years or older, thebirth must be reviewed by the Civil Affairs Bureau due toa 1961 directive by the head of the Civil Affairs Bureau of
the Ministry of Justice. The Supreme Court has
interpreted Article 779 of the Japanese Civil Code to
define a child’s legal mother as his or her birth mother.13
Therefore, if a Japanese mother 50 years or older
reported the child as a legitimate birth to a Japanesemother and father, the reviewers would never allow theregistration because they think that there’s no way themother over 50 years old can be the birth mother,according to the aforementioned Article 779, eventhough the Georgian birth certificate specificallydesignates the Japanese mother as the mother of the aGeorgia-born child. This technicality could not only
prevent a foreign-born child from being recorded in thefamily registry, but also leave them stateless unless anduntil the Georgian courts grant them citizenship.
Japanese couples must research their options withcaution, as some foreign surrogacy agencies andhospitals operate without a full understanding of theprocedures for recording children in Japanese family
registries and acquiring Japanese nationality.
Those who utilize Georgian surrogacy tourism would
be well advised to keep abreast of the latest legal
developments in the country, and carefully weigh theadvantages and disadvantages of pursuing reproductive
medicine services there.

References

Kodama, M. (2014) Preliminary Research on Legal Restrictions
and the Current State of Surrogacy in Multiethnic Singapore,
Biocosmology－Neo-Aristotelism, 4(4), Autumn 2014, 461-468.
Kodama, M. (2013) Preliminary Research into the Spiritual
Backbone of Vietnam for an Investigation of Vietnamese
Reproductive Medical (Surrogacy) Ethics, Biocosmology−NeoAristotelism, 3(4), Autumn 2013, 642-651.
Kodama, M. (2012) The Present State of Commercial
Surrogacy in India and Ethical Assessment of Physician in
Charge Dr. Nayna Patel―Ethical Research Concerning Indian
Reproductive Medicine, Especially Commercial Surrogacy,
EJAIB 22(2), 85-90.
Kodama, M. (2014) The Current State of Surrogate
Conception in Japan and the Ethical Assessment of Dr. Yahiro
Netsu, EJAIB 24(1) , 12- 17.
Kodama, M. (2016) The Present State of Regulations
Concerning Reproductive Medicine, Particularly Surrogacy, inboth India and Thailand, EJAIB 26(1), 4-8.
13 Supreme Court Grand Bench, 27 April 1962, Minshu, Vol. 16,
No. 7, p.1247.(in Japanese)

59

Kodama, M. (2017) Risks Present in the Cambodian Surrogacy
Business, EJAIB 27(2), 40-44.
Law of Georgia “On Health Protection” Article 143 (Georgia)
Extracorporeal fertilization (IVF) Article 144 (Georgia)
Announcement No. 1/2540 on the Standards of Services
Involving Reproduction Technology, 1997 (Thailand)
Announcement No. 21/2545 on the Standards of Services
Involving Reproduction Technology, 2002 (Thailand)Protecting Children Born Through Assisted Reproductive
Technology Medical Act, 2010 (Thailand)Protection for Children Born Through Assisted Reproductive
Technologies Act, 2015 (Thailand)
https://www.anzen.mofa.go.jp/info/pcspotinfo_2017C060.htm
l (Cambodia)
https://blog.goo.ne.jp/adragonisflying12345/e/683a2d7d482
84efe5868d3f3824e2f6f (Japan)
http://news.e-smc.jp/topics/201006181600.php (Japan)
https://azuki0405.exblog.jp/19561054/ (Japan)
https://gm747.jimdo.com/ (Japan)
Whittaker, A.：Patriarchal Bargains and Assisted Reproductive
Treatment in Thailand, Gender, Technology and Development,
18(1), 9-31, 2014
Miwa, M.: Regulations on Assisted Reproductive Technologies
in Asian Countries: Especially on the Indian and Thai
Regulations, Reference, National Diet Library Research andLegislative Examination Stations, 63(4), 65-94, 2013.
Study Group for Thinking about ART and Health Care (2011,
October 11). Surrogacy Law in Georgia. Retrieved fromhttps://azuki0405.exblog.jp/14734289/
Study Group for Thinking about ART and Health Care (2014,
August 27). Surrogacy Law in Georgia 2. Retrieved fromhttps://azuki0405.exblog.jp/21053212/
Study Group for Thinking about ART and Health Care (2015,
July 15). Georgia Research Findings. Retrieved fromhttps://azuki0405.exblog.jp/21955135/
Study Group for Thinking about ART and Health Care (2016,
February 6). A Country Where Surrogacy Cannot be Banned(Georgia
Research
Findings).
Retrievedfromhttps://azuki0405.exblog.jp/22842856/
Study Group for Thinking about ART and Health Care (2016,
June 8). Opinion of the Georgian Apostolic Autocephalous
Orthodox Church: Women Cannot be Treated as Incubators.
Retrieved from https://azuki0405.exblog.jp/23183551/

Bioethical issues in Arab society- Abdul Jaleel Kadhim Alwali
Department of Philosophy, College of Humanities andSocial Sciences, United Arab Emirates University, Abu
Dhabi, UAE
Email: Abdeljelil.kazem@uaeu.ac.ae
Abstract
Recent bioethical issues that have emerged in the field of
medicine include, but are not limited to, eugenics(artificial insemination), palliative care (end of life care),euthanasia (medical resuscitation), abortion, and thedevelopment of enhanced human body parts. Thesebioethical issues have raised ethical questions related tothe use of modern technology and how it may affect the
future of society. These questions consider issues suchas: what is the identity of future children? Have humanbeings become a commodity exchanged by those whohave the ability to own them? What is the meaning ofjustice in medical treatment? How can physicians andnurses perform humanitarian work? Discussions of thesequestions should begin by determining their

60

Eubios Journal of Asian and International Bioethics 29 (March 2019)

relationships with typical social and cultural values insociety, such as life and death, marriage, family,
fatherhood, motherhood, relatives, and next-of-kin. This
paper presents a review of the important Arabic
literature that has been written on these bioethicalissues to show the contributions of Arab scholars in thisfield. Arabic studies in bioethics can be classified into
three types: original Arabic writings, translated studies,and congresses held in the Arab region.
1. Introduction
The term ‘bioethics’ can be defined as “the ethics of
medical and biological research”.14 Bioethics as a field is“concerned with the ethics and philosophicalimplications of certain biological and medical
procedures, technologies, and treatments, as organtransplants, genetic engineering, and care of theterminally ill”.15 With bioethics as a part of philosophy,
the philosophers discussed bioethical issues that havebecome a global concern in recent years.
Bioethics is a new field of philosophy that was
introduced by Henry K. Beecher in his 1966 article
entitled Ethics and Clinical Research16, which criticized
the unethical approach of studies such as the Tuskegee
Syphilis Study, which is well-known for being unethicalregarding both its dependent variable and human rights.
The dependent variable used in the Tuskegee
experiment was “whether persons with syphilis were, infact, better off without the treatment”. 17 The subjects(participants) were mostly illiterate African-Americans
from Tuskegee, Alabama (USA). The scientists who
conducted the experiment knew that penicillin had
become the standard treatment for curing syphilis by
1947, so they could have closed the study andadministered penicillin to all the subjects; however, they
withheld treatment from the participants and continued
the experiment.
With regard to human rights, there are six aspects ofthe study which can be considered highly unethical: no
informed consent was obtained; the participants were
not informed of all dangers; participants were autopsied
after their death to cover their funeral costs; scientists
denied some patients treatment in order to observe theindividual dangers and fatal progression of the disease,rather than giving them the cure even though it was
known and available; and the designers used amisleading advertisement, which promoted ‘Last Chance
for Special Free Treatment’ although no treatments were
given to the patients.18
14 Oxford Dictionaries | English. (2018). bioethics | Definition ofbioethics in English by Oxford Dictionaries. [online] Available at:https://en.oxforddictionaries.com/definition/bioethics[Accessed 30 Dec. 2018].
15 www.dictionary.com. (2018). the definition of bioethics.
[online]Availableat:https://www.dictionary.com/
browse/bioethics [Accessed 30 Dec. 2018].
16 Beecher,
H.K., 1966. Ethics and clinical research.
In Biomedical ethics and the law. Boston, MA: Springer. pp.215227.
17 Explorable.com. (2008). Tuskegee Syphilis Study - Researchwithout
Empathy.
[online]Availableat:https://explorable.com/tuskegee-syphilis-study [Accessed 30
Dec. 2018].
18 ibid

In response to the Tuskegee Syphilis Study, theNational Commission for the Protection of Human
Subjects of Biomedical and Behavioral Research wasestablished in 1974 to identify the basic ethicalprinciples for conducting human research and to develop
just and ethical guidelines. This can be considered thebirth of bioethics. From this point, ethical conduct
became a crucial issue in medicine for three reasons: (1)inhumane treatment of research participants had
become public knowledge; (2) 1960s was a uniqueperiod of social and political change; (3) advances intechnology led to new medical dilemmas. The four
principles of bioethics are: autonomy, beneficence, nonmaleficence, and justice. Thus, the social, political, andhistorical events described created the new field of“applied ethics in medicine”19 — Bioethics.
This leads to an investigation of medical ethics, whichis considered the elementary stage of this new ethicalfield, because philosophical and ethical heritage focuseson the concepts of human lives, duty, responsibility,
human dignity, and the special covenants of medical
ethics. In addition, medical ethics implementsinternational standards for the protection of patientsand the ethical framework for medical careers, which isconsidered the basic reference for the international
declaration of human dignity.
Bioethics as a concept has been used in Arab culturein the following contexts: ethics of life, ethics of biology,
ethics of scientific research on organisms, ethics of
medicine and biology, ethics of health and life sciences.
This paper presents a review of the important Arabic
literature that has been written in Arabic on thesebioethical issues to show the contributions of Arabscholars in this field. To illustrate that, I will classify the
Arabic bioethics literature into three types: originalArabic writings, translated studies, and congresses heldin the Arab region.
2. Bioethics literature in Arab society
The impact of bioethical issues in Arab society is very
weak and marginal; publications on the subject are very
rare. It has not received much attention in Arab society
compared to other societies around the world. This isbecause Arab society has tended to focus on otherinternational political issues such as globalization, theclash of ideas, the clash of cultures, and the Arab spring.
This indicates that these issues are more important toArab society than bioethical issues, not only because
they are considered significant political issues, but
because some governments have encouraged Arabscholars to discuss them.
Researchers have classified Arabic studies inbioethics into three types. The first type is the writings ofArab scholars in this field (original Arabic bioethics
writings). The second type is texts on this subject whichhave been translated into Arabic (translated materials).
The third is the conferences and symposiums held in the
Arab region to discuss this topic (congresses andconferences).

19 Kunis,

C.L., 2018. Morality and Medicine: An Historical
Perspective, lecture delivered at Global Bioethics Initiative, July
26 2018, New York, USA.

Eubios Journal of Asian and International Bioethics 29 (March 2019)
Figure 1. Number of bioethics issues papers written in
Arabic literature (original Arabic bioethics writings,
translated texts, and congresses), using the keyword“bioethics”
SourceUAEU
Library

SultanQaboos
Universit
y Library

Subjects

Original Arabic
writings

Congresses
Original Arabic
writings

Congresses

Numberofbioethics
papersBooks

9

Journalarticles
Newspaper
articles0

Books
Journalarticles
Newspaper
articles

62
6
0
17
155
33

3. Original Arabic bioethics writings
These researches have been written by Arab scholars;
however, these publications are very few and limited.
They have addressed general topics in the field ofbioethics, such as scientific thinking, biology, genetics,
science and moral values, and genetic engineering.
Examples of these studies include:
Saleh, Fawaz’s, Legal Studies of Medical andBioethics.20 This book consists of six chapters. The firstchapter provides information about bioethics and its
relationship with law, the second chapter discusses theprinciples on which bioethics is based, the third chapter
states the importance of human rights and dignity, thefourth chapter provides evidence and proof regarding
bioethics, and chapters five and six focus on thedevelopment of medicine, the effect of biomedicine on
patients, and the responsibilities of the doctors. The
book not only focuses on the aspects of law, but also on
the ethical considerations of medicine.
Padela, Furber, Kholwadia, and Moosa’s Dire
Necessity and Transformation: Entry-points for Modern
Science in Islamic Bioethical Assessment.21 In this book,the authors discuss how modernity, globalization, andtechnological advancements challenge religious systems
to revisit their traditional doctrines and ethical codes inorder to provide guidance for contemporary society. The
dialogue between tradition and modernity is apparent inbiomedicine where scientiﬁc advancements present
novel ethical challenges to patients, healthcare workers,
and society at large.

20 Saleh, F. (2015). Legal studies in medical and bioethics.
[online] Acatap.org. Available at: http://www.acatap.org/index.php/40-acatap-books/scientific-books/123-31-8-2015147 [Accessed 30 Dec. 2018].
21 Padela, A.I., Furber, S.W., Kholwadia, M.A. and Moosa, E.,
2014. Dire Necessity and Transformation: Entry-points forModern Science in Islamic Bioethical Assessment of Porcine
Products in Vaccines. Bioethics, 28(2), pp.59-66.

61

Chamsi-Pasha and Albar’s Western and Islamic
Bioethics: How Close is the Gap?22 This article presents
the history of the four principles of biomedical ethics inIslamic teachings and elaborates on the differences
between Islamic and contemporary Western bioethics.
Padela, Arozullah, and Moosa’s Brain Death in Islamic
Ethico-Legal Deliberation: Challenges for Applied Islamic
Bioethics. 23 In this paper, the authors analyze theverdicts of the Organization of Islamic Conferences’
Islamic Fiqh Academy (OIC-IFA) and the Islamic
Organization of Medical Sciences (IOMS) from theperspective of applied Islamic bioethics and raise several
questions that, if answered by future juridical councils,
will better meet the needs of clinicians and bioethicists.
Rady, Verheijde, and Ali’s Islam and End-of-life
Practices in Organ Donation for Transplantation: New
Questions and Serious Sociocultural Consequences.24 This
study concludes that: 1) many practical aspects of endof-life organ donation conflict with the Islamic faith’score principles of care for the dying and their families; 2)
defining the societal role of transplantation medicine is
not uniquely a matter of accounting for technicalcapabilities and expertise; 3) Muslim scholars should
critically evaluate new evidence about end-of-life
practices in organ donation, their effects on the care ofterminally ill patients and their families, and theconsequences on the cultures of Muslim communities
worldwide.25
Padela’s Islamic Medical Ethics: A Primer.26 This paper
seeks to achieve two things: to introduce the scope ofIslamic Medical Ethics literature and to develop an
Islamic perspective on bioethical issues such as abortion,
gender relations within the patient-doctor relationship,
end-of-life care, and euthanasia.
Ateega Beljl’s Euthanasia Between Permissibility andCriminalization.27 This article provides explanations of
the meaning of euthanasia and the history of its
development, its different types and justifications, aswell as medical, legal, and Islamic perspectives of
euthanasia.
Zakaria Fouad’s Scientific Thinking.28 The important
chapters in this book are: The problem of inheritance

22 Chamsi-Pasha, H. and Albar, M.A., 2013. Western and Islamic

bioethics: How close is the gap? Avicenna journal of
medicine, 3(1), p.8.
23 Padela, A.I., Arozullah, A. and Moosa, E., 2013. Brain Death inIslamic Ethico-Legal Deliberation: Challenges for Applied
Islamic Bioethics. Bioethics, 27(3), pp.132-139.
24 Rady, M.Y., Verheijde, J.L. and Ali, M.S., 2009, June. Islam andend-of-life practices in organ donation for transplantation: newquestions and serious sociocultural consequences. HEC
forum 21(2), p.175.
25 Rady, M.Y., Verheijde, J.L. and Ali, M.S., 2009, June. Islam andend-of-life practices in organ donation for transplantation: newquestions and serious sociocultural consequences. HEC forum,21(2), p.175.
26
Padela, A.I., 2007. Islamic medical ethics: aprimer. Bioethics, 21(3), pp.169-178.
27 Ateega, B. (2006). Euthanasia. [online] Fdsp.univ-biskra.dz.
Availableat:
http://fdsp.univbiskra.dz/images/revues/mf/r6/m6-13.pdf [Accessed 30 Nov.
2018].
28 Zakaria, F., 1978. Scientific Thinking. The World of Knowledge,
No.3, Kuwait.

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Eubios Journal of Asian and International Bioethics 29 (March 2019)and control of human qualities, Science and humanvalues, and Science and ethics in the present age.
Saeed Al Hafar’s Biology and Human Destiny.29 In thistext, the author predicts the possibility of human cloning,
and recommends applying genetic scientists’ discoveries
according to ethical values.
Mohameed Al-Rubaie’s Genetics and Humanity.30 This
research is an introduction to human genetics andgenetic engineering technology. The author raises
several questions; for example, do only wealthy
countries benefit from these scientific advancements?
Will the gap between North and South be reduced? Could
the results be used for military purposes?
Abdullah Al-Omar’s Science and Moral Values.31 This
book explores the neutrality of science and the
responsibility of scientists and researchers towards
society and life, as well as the sanctity of human life. The
author rejects the practice of human cloning on the
grounds of loss of identity.
Nahedh Al-Basqmi’s Genetic Engineering and Ethics.32
The issues presented in this book are related to humanexperimentation, artificial reproduction, abortion,
human organ transplantation, disease and death, andhuman enhancement.
Ahmed Mahmoud Subhi’s Philosophy of Medicine.33
This book presents an investigation of the relationshipbetween philosophy and medicine throughout history,
the responsibility of doctors towards patients, and themoral issues regarding this relationship.
Mohammed Abed Al-Jabri’s Ethics and Bioethics.34 In
this text, the researcher asks the question: To what
extent is it permissible to use science to control the areasof reproduction and offspring, the field of genetics,
change of living organisms, the field of mind, legitimacy,and death?
Hassan Mousa’s, Reproduction Controversy Science,
Religion and Morals.35 This book provides a discussion of
the subject of cloning from the perspectives of science,
religion, philosophy and ethics.
Joseph Malouf’s Ethics and Medicine. 36 This study
considers contraception, abortion, artificial insemination,and euthanasia. The author presents the Islamic andCatholic views of these new ethical issues.

29 Al Hafar, S., 1984. Biology and Human Destiny. The World ofKnowledge, No.83, Kuwait.
30 Al-Rubaie, M., 1968. Genetics and Humanity. The World ofKnowledge, No.100, Kuwait.
31 Al-Omar, A., 1990. Science and Moral Values. Kuwait: Dar
Nashar.
32 Al-Basqmi, N.,1993. Genetic Engineering and Ethics. The
World of Knowledge, No.174, Kuwait.
33 Subhi, A.M. et al., 1993. Philosophy of Medicine. Beirut: Dar
Alnahtha Alarabi.
34 Al-Jabri, M.A., 1997. Ethics and Bioethics. Beirut: Centre for
Arab Unity Studies.
35 Mousa, H. (1997). Reproduction Controversy: Science, Religion
and Morals. Damascus: Dar Al-Fker. Avaliable at[http://www.neelwafurat.com/itempage.aspx?id=lbb7711337590&search=books].
36 Maluof, J. (1997). Ethics and Medicine. Beirut: Almaktaba
Albuleseya.
Availableat[https://libserver.bethlehem.edu/webopac/records/1/64952.
aspx].

4. Translated studies
The translated studies have tended to focus on thenature of life, genetics, and biology, and unlike theoriginal Arabic bioethics texts, have not addressed thedetails or any specific issue of modern medical ethics.
Some examples of these studies are as follows:
Atighethci Dariusch’s Islamic Bioethics; Problems andPerspective, is translated from Italian to Arabic by Lubna
Alraidi.37 This book provides a critical analysis of thedifferent perspectives and debates in Muslim countries
in terms of religious and legal points of view. It also
discusses new technologies in biology, organ donation,and genetics cloning.
Pierre-André Taguieff’s Bioethics: Towards a Projectof Intellectual Cause, is translated by Abdulhadi Al edresi.
This book was written by a French philosopher anddirector at the French National Center for Scientific
Research in the Paris Institute of Political Studies. The
subject of the book is bioethics as an ideological issue
and its meaning from different perspectives.38
Frances Kreek’s Nature of Life, is translated by
Ahmed Mostajer.39 This book provides a description andanalysis of the phenomena of nature, the creativity of lifein the past and present, and the expectation of life
development in the future. It does not consider new
bioethics issues.
Harsenay and Hton’s Genetic Prediction, is translatedby Mastafa Ibrahem. 40 This text investigates the
problems of science research and its goals and evaluates
the developing field of genetic engineering and its effecton ethics, especially regarding gene modification andhuman enhancement.
Roz Steven’s Biology, Ideology and Human Nature, istranslated by Mustafa Ibrahim Fahmy. 41 This bookencourages supporters of human enhancement todispose of criminals and people with disabilities. The
author uses biological determinism as a model for the
research, based on the theory proposed by Darwin and
Hobbes.
Genetic Code of Man, by a group of authors, istranslated by Ahmed Mostajer.42 This book addresses theimpacts of biology and medicine in the twenty-first
century on ethics, law, and society.
Gregory E. Benis’ Who Fears the Cloning of Man, istranslated by Ahmed Mostajer & Fatima Naser.43 In thisbook, the author examines the problems caused byadvanced genetic engineering in humans, particularly
Dariusch, A., 2006. Islamic Bioethics: problems andperspectives.
Availableat:[http://gate.ahram.org.eg/News/2051698.aspx]
38 Pierre-Andre, T., 1986. Bioethics: Towards a Project ofIntellectual Cause. Available at http://www.geocities.ws/
cuadernosdelnorte/dosseticidrissi.html.
39 Kreek, F., 1988. Nature of life. Translated by Ahmed Mostajer.
The World of Knowledge, No.125, Kuwait.
40 Harsenay and Hton, 1988. Genetic Prediction. Translated by
Mastafa Ibrahem. The World of Knowledge, No.130, Kuwait.
41 Steven, R., 1990. Biology, Ideology and Human Nature.
Translated by Mustafa Ibrahim Fahmy. The World of Knowledge,
No.148, Kuwait.
42 Group of authors, 1997. Genetic Code of Man. Translated by
Ahmed Mostajer. The World of Knowledge, No.217, Kuwait.
43 Benis, G.E., 1999. Who’s afraid of human cloning. Translatedby Ahmed Mostajer & Fatima Naser, Dar Sotor, Cairo.
37

Eubios Journal of Asian and International Bioethics 29 (March 2019)
their impact on families and human dignity. The writer
identifies two positions in the field of cloning, the first is
the theory of non-sexual reproduction through cloning(supporting this theory). The second position is natural
reproduction through sex. He has rejected this cloning
because it affects the integration of the family andhuman dignity.
5. Congresses and conferences
This aspect of Arabic bioethics studies is comprised ofconferences held in the Arab region, including
Casablanca, Morocco, Algeria, Lebanon, and Dubai. The
topics addressed at these conferences relate to medical
ethics, biology, human rights, gene modification, andother ethical issues regarding birth control technology.
However, the number of these publications is very
limited and considered insignificant compared to theimportance of bioethics issues and the number ofWestern publications which have addressed these issues.
Nevertheless, some examples of these conferences are as
follows:
Tenth Annual Congress on Drug Formulation andAnalytical Techniques, held December 10-11 2018 in
Dubai, UAE, organized by the University of Chicago.
Theme: ‘Inventing a formula for Drug Development andAnalytical Techniques’. This conference sought todetermine how innovators are closing the gap between
product development and adoption, to better identify
cyber threats and reduce information security risks, andto debate the potential of greater cross-industry andcross-sector collaboration in the race for faster, cheaper,and better cures.44
First International Bioethics Conference held at
Sultan Qaboos University, Muscat sultanate ofOmann,2015. Around sixty researchers attended theopening ceremony of the conference, which aimed toinvestigate important ethical issues in the field of
medicine and biology, and how these can lead todifferent perspectives depending on society, beliefs, andresearch. The conference presented six main topics fordiscussion over three days: bioethics from an Islamic
perspective, the contemporary challenges of bioethics,
the issues of ending life and its consequences, global
bioethics and benefit sharing, Ebola and its bioethicalproblems, and genetics and biotechnologies.45
Bioethics Issues for Women: Ethics of reproductive
health- social and political conditions in Arab countries,
held at the University of Beirut, Lebanon, in 2014. Thisconference focused on public health workers, primarily
physicians, nurses, and healthcare teams. It explored the
difficult ethical, social, and legal issues of genetic
technology and assisted reproductive technologies, aswell as future threats to Arab regions regarding issues
44 Alumni Association: Alumni, Parents, Families & Friends.
(2018). 10th Annual Congress on Drug Formulation & Analytical
Techniques.
[online]Availableat:https://alumniandfriends.uchicago.edu/events/2018/10thannual-congress-drug-formulation-analytical-techniques-1[Accessed 20 Nov. 2018].
45 Squsys.squ.edu.om.
(2015). SQU Conference. [online]
Availableat:https://squsys.squ.edu.om/ConfSys/Default.aspx?msg=msgrc&lang=en [Accessed 17 Oct. 2018].

63

related to medicine, ethics, political implications, andpoints of view that could affect every process of researchin reproductive healthcare.46
Symposium on Human Right and Genetics, held in
Rabat, Morocco, in 1997. The topics of this symposium
were the ethical dilemmas posed by the progress ofgenetic engineering, the definition of the ethics ofknowledge, and the threat to the future of the humanbeing and his dignity. The symposium emphasized theimportance of scientific knowledge as a value ofcivilization, of not evaluating scientific progress withemotional attitudes, and of respecting human dignity
and the mysteries of creation.
6. Bioethical dilemmas in Arab society
1. Telling the truth to the patient
Some Arab people sell their property (home,furniture, valuable goods) or take loans to pay for
medical treatment. However, if a patient has a chronic or
incurable disease, should they be told that their case isincurable and hopeless, and therefore there is no need tosell anything or obtain loans for treatment? Even if thepatient is told about their situation, then social customs
imposed by family members create a pressure to treat
the patient regardless of consequences or the results.
Should treatment follow tradition or science?
2. Family members’ priority
As humans, all family members have an equal right toreceive medical care; there should be no discrimination
among family members. However, in some countries, afather has less priority than a mother, or a baby is not
given the same importance as a father or mother. In thiscase, what would religion or culture dictate? Who has
the priority in a family to receive medical care?
3. Right to live
In the majority of Arab countries, some poor people
sell their body parts to cover living costs. In these cases,
the hospitals list them as “donors”. However, this is
fraudulent because they are not donors. The
beneficiaries of this business are rich patients who
obtain the body parts. Ethically speaking, do rich people
have the right to receive donations from the bodies ofpoor people because of their money?
4. Medical services
In most, if not all, Arab countries, the medical services
provided are lower quality compared with services
offered in developed countries. Therefore, many patientsseek expensive medical care outside their countries.
People who receive this type of medical care can beclassified into two types:
Rich people who can afford the travel and treatment
costs and travel to a country of their choice in order toreceive sufficient medical care. Some Arab governments
also offer financial support for selected patients toreceive medical care in other countries.
People who cannot afford medical care expenses or
do not receive support from their government will die
from their illness or their family will sell whatever theyWebsite.aub.edu.lb. (2014). Bioethics Issues for Women.
[online]Availableat:
http://website.aub.edu.lb/
fm/shbpp/Documents/BiNWIAR-conference-flyer-FINAL-201-2014.pdf [Accessed 22 Oct. 2018].
46

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Eubios Journal of Asian and International Bioethics 29 (March 2019)

can to raise money for travel and medical care. Is thisethically acceptable?
5. Human body trafficking
In other cases, some people are promised job
opportunities outside of their countries but they become
victims of human body trafficking. These individuals
usually die. Ethically, who is responsible for these cases?
7. Conclusion
It is not possible to find religious answers to mostbioethical issues in medical science; therefore, someinterpretation is required. However, should thisinterpretation be led by religious clerks or philosophers?
In the context of Arab culture, it is important to notethat interpretations proposed in Islamic philosophy led
to the execution of several philosophers who wereaccused of being heretic. Indeed, neither religious clerks
nor philosophers have provided a significant focus tological explanations for these issues. Likewise, a searchof Islamic philosophy regarding Islamic, Arabic, andcultural heritage does not provide solutions for most ofthese modern issues.
Thus, although future values will not be the same ascurrent values, it is vital to formulate the meanings of
freedom, duty, responsibility, human dignity, and thedevelopment of dialogue between science, philosophy,
and ethics.

Hope for the best and prepare fortheworst:
Ethicalconcerns
related to the introduction ofhealthcare artificial intelligence- Atsushi Asai
Department of Medical Ethics, Tohoku University
Graduate School of Medicine, Sendai, Miyagi, Japan
Email: aasai@med.tohoku.ac.jp- Taketoshi Okita
Department of Medical Ethics, Tohoku University
Graduate School of Medicine, Sendai, Miyagi, Japan- Aya Enzo
Department of Medical Ethics, Tohoku University
Graduate School of Medicine, Sendai, Miyagi, Japan- Motoki Ohnishi
Department of Health and Welfare Public Policy,
Laboratory of Public Health, Aomori University of Healthand Welfare, Graduate School of Health Science, Aomori,Japan- Seiji Bito
Division of Clinical Epidemiology, National Tokyo
Medical Center, National Hospital Organization, Tokyo,
Japan
Abstract
Background: The introduction of healthcare AI tosociety as well as the clinical setting will improve
individual health statuses and increase the possible
medical choices. AI can be, however, regarded as a
double-edged sword that might cause medically andsocially undesirable situations. In this paper, we attempt

to predict several negative situations that may be facedby healthcare professionals, patients and citizens in thehealthcare setting, and our society as a whole.
Discussion: We would argue that physicians abuse
healthcare AI through their excessive and dependent useof it, and they will focus only on the AI services in theiroffice and patient medical data and information, andforget to observe the patient in their clinical encounters.
In the era of AI introduction, data from the wearable
terminal or AI advice will become the primary target ofthe physician’s interest, and could be regarded as apatient surrogate. Paternalism would be paradoxicallyresurrected by the introduction of state-of-the-art AI. A
physician’s conflict of interest related to AI as acommercial product could strongly influence his or her
actions in clinical settings. We also worry that thegeneral public will become uneasy and hypersensitive
slaves to information, compulsively and uninterruptedly
requesting healthcare information concerning their own
health and advice from AI. An AI system capable ofexpressing proper and timely empathy to suffering
patients could deprive healthcare professionals of theirroles in terms of hospitality and emotional exchange.
Finally, entire societies would soon share andconsolidate healthcare sensitive information from all in
the general public as part of a totalitarian healthcontrolled society where individual privacy and personalsecrets could be neglected. The advent of the healthcontrolled society could lead to the metamorphosis of
the concept of privacy itself into something completely
different.
Conclusion: Although AI which surpasses humanhealthcare professionals may never appear, hoping forthe best and preparing for the worst is the best approachto take. To this end, we present some potential
countermeasures including conducting clinical researchand social investigations concerning problems
surrounding the introduction of AI and developing
guidelines for its appropriate use.
1. Background: the current situation concerning
healthcare artificial intelligence (AI) and our aims
Artificial intelligence (AI) is a general term that implies
the use of a computer to model intelligent behavior withminimal human intervention or the automation of
intelligent behavior (1, 2). AI is either an entity or systemwith artificially created intelligence that aims to makeadvanced and precise inferences for a large amount ofknowledge data that processes information at an
overwhelmingly high speed (3). Employment ofhealthcare AI (hereafter, AI) is anticipated to support
healthcare professionals in clinical settings and in othervarious activities. Examples include an automatic
medical interview system, automatic creation ofdischarge summary, presentation of diagnostic
hypotheses and treatment recommendations, imaging
interpretations for computed tomography magnetic
resonance imaging (MRI), pathology, and fundus findings(4, 5, 6). In the United States, AI has already been used in
medical student education to teach diagnostic skills (6).
It can be argued that medical facilities with nospecialists such as in cardiovascular disease, neurology,
or radiology benefit greatly from AI-based medical
support. Misdiagnoses of myocardial infarction, cerebral

Eubios Journal of Asian and International Bioethics 29 (March 2019)
infarction, and intracranial hemorrhage could be
reduced and overlooking of minute cancer findings may
be avoided. Telemedicine using the Internet is also a
possibility. Even within the field of general medicine, AI
could reduce the uncertainty of physician diagnoses,
widen the range of differential diagnoses, and would
likely increase the options for medical treatment. Any or
all of these outcomes would be highly desirable.
Suskind and Suskind claim that patients will notgenerally be seen by physicians, but instead by nurses
equipped with AI of diagnostic and treatment functions.
These AI systems might be used when a patient is seen
by a ‘physician’s assistant,’ a new class of healthpractitioner (5). Wearable terminals with AI and
implantable sensors have enabled laypersons to monitor
their own health status. AI is expected to analyze
relevant data with accuracy comparable to that of
medical doctors (5, 6). AI could also personalize medical
treatment and simultaneously anticipate future diseasesof patients by analyzing their DNA. It may even be
possible to obtain a second opinion and medical
consultation from experts or AI. The use of a medicalcare robot may also be anticipated (5, 6). Elderly people
living alone could be soothed by conversation with therobot, which may prevent decline in cognitive function(7). Suicide counseling using a social networking service(SNS) has also begun (8).
The wearable terminals that remind patients to taketheir medicine, to weigh themselves, or warn against
engaging in unhealthy behavior or eating could also be
realized, with further improvements in health conditionas yet another possibility. Face-to-face communication
may not be required anymore with the introduction ofhealthcare AI (5). Those in the general public could
choose between going to a flesh-and-blood doctor or an
AI doctor. In the future, clinics with only AI and no
human medical professionals may emerge. In particular,
it is not too much to assume that fully automated medical
diagnoses by AI would become a reality in radiology or
pathology (6). If healthcare AI use is inexpensive,
medical expenses paid by ordinary citizens will be
reduced, and those who would otherwise refrain fromusing medical services due to financial reasons would be
able to receive the necessary medical care (5).
The introduction of healthcare AI to society as awhole, as well as in the clinical setting, will thereby
improve individual health statuses and increase thepossible medical choices; these would certainly benefit
healthcare providers as well as patients and the generalpublic. Expanding the use of AI in medical facilities andin daily life will continue to accelerate in the future. We
would argue that without assuming an extremely antiscience and anti-technology position, no one could claim
strong opposition against the use of AI in the world, withthe exception of those fearful of losing his or her job due
to AI replacing human workers. We do not oppose theintroduction of AI because of aforementioned benefits tothe clinical setting and society as a whole. However,every bioethical issue has at least two sides (9). AI can be
regarded as a double-edged sword that might cause
medically and socially undesirable situations, eventhough it certainly has the potential to make our society
better and healthier than ever, just as current smart
technologies such as direct-to-consumer (DTC) self-65

monitoring devises and smartphone apps may create adouble-edged sword for therapeutic relationships andpatient safety (10).
In the present paper, we attempt to predict several
negative situations that may be faced by healthcare
professionals (mainly physicians), patients and citizens,
human relationships in the healthcare setting, and oursociety as a whole. We present potentially problematic
situations that arise as a consequence of using AI’s
ability to process an overwhelmingly large amount ofhealth-related data and information at a very high speed,
not only in the medical field but also in the everyday
living situations of individuals. Our discussion of issues
surrounding healthcare professionals will focus
primarily on physicians. However, future changes in therole of the physician and the patient-physician
relationship would obviously affect other healthpractitioners. We conclude by proposing several ways todeal with the unfavorable situations that we predict inthis paper.
We begin by clarifying that our arguments are
speculative, as our predictions could be simply
delusional and nothing problematic actually occurs. We
would welcome that scenario, in fact, but we do believethat we should predict the worst possible scenarios inorder to prepare the necessary countermeasures. We do
not discuss issues related to the situations that AI could
completely overtake whole human capacity or any otherproblems concerning AI with personality or selfconsciousness.
2. Undesirable impacts of healthcare AI on physician
clinical practice and attitudes
Abuse of healthcare AI by physicians and resulting
loss of professional skills: We would argue thatphysicians may abuse healthcare AI through theirexcessive and dependent use of it. As a result, they may
neglect to master, maintain, and continue the necessary
honing of their professional skills. Some authors suggestthat clinicians may turn to machine learning for
diagnosis and advice about treatments, and not simply asa support tool (11). Others have pointed out thatphysicians are liberated from the burden of upkeep andthe stress of making the appropriate medical decisions(12). We suspect that some physicians may try to use AI
to diagnose and treat patients who do not actuallyrequire any AI support; these may include patients withsimple upper respiratory inflammation, urinary tract
infections, or asthma, who can be diagnosed easily by
medical interviews or physical examination. We would
argue that AI might be used routinely in addition to otherexisting methods of work-up, without muchconsideration. As such, they may not appreciate thepossibility for AI misdiagnosis, biased advice, orinappropriate recommendations. Information enteredimproperly to the AI system is not reflected in the
diagnosis, and erroneously entered numerical values cancause serious errors.
Reasons for physician abuse of healthcare AI include
patient demand for its use, a physician’s lack ofconfidence, anxiety about either a misdiagnosis or
inappropriate treatment, and insufficient clinicalexperience. If a physician becomes blindly dependent on
AI for any reason, their clinical and interpersonal skills

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Eubios Journal of Asian and International Bioethics 29 (March 2019)as a physician are damaged, and this lazy physician runs
the risk of harming his or her patients. Some veteranpathologists have already pointed out that pathologists
run the risk of becoming lazy with the introduction of AI,
saying “if you think that someone will check your work
later, you become lazy in your efforts” (13). Automation
damages human skills. A pilot’s steering skills arethought potentially to decline due to the use of autopilot(6). In a similar manner, physicians wishing to obtain thebest bang for their buck, so to speak, may become more
willing to abandon clinical skills that are currently
perceived as essential by the medical professionalsociety, and instead spend a higher proportion of theirtime acquiring AI operational skills.
Decreased communication time with patients(paradoxical claim): One common claim is that the
introduction of AI will make the diagnosis and treatment
decisions more efficient, allowing the physician toshorten the time spent examining each patient, and thus
could see more patients without compromising quality ofcare. Some have also noted that physicians might also
spend longer with each individual patient (14). In cases
for which diagnostic imaging can be completed quickly
by AI, physicians can concentrate on other aspects of thepatient’s medical care (15). One author commented thatthe ability of AI to automate and help with clerical workthat currently demands so much of a clinician’s time
would also be welcome. Although not currently accurateenough, automated charting using speech recognition
during a patient visit would be valuable and could free
up clinicians’ hands, allowing them to face the patient
rather than spending almost twice as much time on the“i-Patient”—the patient file in the electronic medical
records (16). AI provides physicians with theopportunity to comprehend more fully the patient as awhole. Emotional and holistic exchanges with patients
may be enhanced by creating a different mental
composure for doctors.
That said, we are highly concerned that physicians
will focus only on the AI services in their office andpatient medical data and information, and forget toobserve the patient sitting immediately in front of themin their everyday clinical encounters. Even now, we
believe that some physicians only look at electronic
medical records, and not the patients. This is why we areconcerned that the future will present with physicians
who only look at the digital AI display, the data frompatient records and his/her wearable terminal (orpreviously transmitted data), without listening to thepatient’s voice, see their facial expressions, observe theirgait, or examining the patient’s body. They might evenforget to check the patient’s pulse.
Face time with the patient would be shortened andinterviews would be neglected. In the era of AI
introduction, data from the wearable terminal or AI
advice will become the primary target of the physician’s
interest, and could be regarded as a patient surrogate.
Use of AI would help to shorten examination time perpatient, and some physicians may try to increase thenumber of patients they can see over a given time period,
and the infamous “three-minute clinical session” in Japan
would remain unchanged. Of course, there is also thepossibility that physicians require extra time to operate

AI, which would take up time that should be spent
focusing on patients. Some patients may become
dissatisfied with their “three-minute clinical session,” “noface-to-face communication,” or their “medical
examination lacking any physical contact.” Still others
might be satisfied with or find no issues with this type of
medical care in which their physicians use the latest AI to
direct their treatment.
Resurgence of paternalism: Another concern of ours isthat the introduction of AI will revive paternalistic
attitudes among physicians, as AI may give physicians
more “objectively correct” diagnoses, recommendations,and judgments concerning patient care. Paternalism,
once perceived as obsolete, would be paradoxicallyresurrected by the introduction of state-of-the-art AI.
Diagnostic predictions or recommendations based on AI
are usually presented as digital percentages. For
instance, a patient with a cough and fever would receivea list of AI-based diagnostic possibilities as follows:
upper respiratory tract inflammation (30%), bacterial
pneumonia (20%), bronchial asthma (10%), pulmonary
tuberculosis (1%).
It is highly possible that a physician whose primarysuspicion is that his patient has pneumonia would be
affirmed of his convictions. In this instance, what would
happen if the patient feels relatively healthy and pressed
for time, and prefers to opt out of the physician
recommendations that were backed up by AI? If the AI
judgments concerning the patient medical care plan are
consistent with those of the physician, the latter is likely
to believe that their diagnosis and recommended plans
are objective, robust, and infallible, rather thansubjective, biased, or arbitrary. As an extension, thephysician would more likely regard his or her own
judgments and decisions as more accurate, credible, andvaluable, worthy of blanket acceptance by any patient.
In the above situation, the final recommendation
backed by AI healthcare is perceived as ‘undoubtedly
beneficial’ to the patient, and thus for a patient to refuse
this plan would be more readily perceived as naturally
stupid or foolish, and unworthy of the physician’s
respect. In this manner, AI healthcare could resurrect
paternalism among physicians, who may in turn be moredetermined to manipulate, coerce, or excessively
persuade patients to accept the ‘best plan,’ regardless of
their intentions or hopes.
The most probable role of AI in healthcare will be to
make suggestions to optimize treatment effectivenessand survival time. However, a patient’s wishes regarding
their healthcare can differ with individual values andchange according to the particular circumstances. In
cases for which individual preferences and personal life
philosophies must be taken into account, AI would notwork well (14).
The same is true for situations in which a physician
might rule out pneumonia, AI presents a low probabilityof pneumonia, and yet the patient demand for work-up
and antibiotics is strong. In this case, the patient might
be categorized as “demanding” or “difficult.”
Conflict of interest (COI): A physician’s conflict ofinterest related to AI as a commercial product could
strongly influence his or her actions in clinical settings.

Eubios Journal of Asian and International Bioethics 29 (March 2019)
Some have claimed that clinical decision-support
systems could be programmed in order to generatehigher profits for their designers or purchasers by, forexample, recommending drugs, tests, or devices of which
they are stakeholders, or by altering referral patterns
without patient awareness. There is certainly sometension between the goals of improving health andgenerating profit (11), and healthcare AI could be
programmed to suggest a diagnosis or recommendationthat would financially benefit the medical institution
such as a more serious diagnosis requiring more tests,
more prescriptions, and increased anxiety among thepatients. In addition, advertisements that oversell theeffectiveness of AI may also appear.
If financial resources are invested in the introductionof AI to a particular hospital, physicians could act tocollect a return on this investment. We are concernedthat the similar adverse conducts and harms which had
happened in the field of non-restricted, non-controlled,
and free interventions involving stem cell “treatment”
could occur again. These included false advertising,inadequate or distorted explanations of the effectivenessand harm, serious adverse events including death due tointerventions and poor management, and misdiagnosis(17).
3. Undesirable impacts on patients and the generalpublic: The advent of slaves to information
As far as the general public and patients are concerned,
we worry that the general public will become uneasy andhypersensitive slaves to information, compulsively anduninterruptedly requesting healthcare information
concerning their own health and advice from AI. Adverse
effects due to layperson self-diagnoses would also occur.
Imagine the scenario in which AI provides a differential
diagnosis for a middle-aged man with chest discomfort.
This list may look something like this: Musculoskeletal
pain (40%), gastroesophageal reflux disease (20%),
myocardial infarction (5%), angina pectoris (3%),
thoracic aortic aneurysm dissection (1%) andpulmonary thromboembolism (1%).
The patient’s regular doctor may have alreadydiagnosed the patient with musculoskeletal pain basedon medical interview and physical examination.
However, the patient reading the list provided by the AI
healthcare is now aware of the possibility of “myocardial
infarction,” “thoracic aortic dissection,” and “pulmonary
thromboembolism.” What would his reaction be to thissituation? Arguably, the patient who had been relieved
and satisfied with his doctor’s diagnoses in the past may
suddenly be fearful that he has some other serious
diseases. Naturally, the patient response depends largelyon the patient’s character and their particular case. Thatsaid, a longer list for the differential diagnosis may
increase anxiety in the patient, who may increase theirdemand for further work-up. In these instances, thetypical physician may be unable to assuage the patient’s
fear by simply telling them that their muscle pain isnormal after yesterday’s golfing or weeding.
When an ordinary citizen receives health information,
predictions, or advice presented by AI-based wearable
terminals in the context of their daily life that is detachedfrom a hospital, health-related anxiety can be higher
than that generated in a clinical setting. It has already67

been claimed that the integrity and clinical utility of
information from some DTC smart devices are currently
questionable (10). We predict that some patients would
rush to nearby hospitals with intense anxiety if they
were notified by their AI terminal of an increased heartrate, supraventricular premature contraction, or that
their ECG is showing a complete right bundle branch
block. Other reports from the wearable AI terminals that
could send one running in panic to the nearest clinic
might include being told that one’s arteries are aged as
an 80-year-old, that your fatigue could be due to diabetes
mellitus, or that you have a 5% chance of having cancer.
Laypersons receiving health-related information fromAI literally every day are highly more likely to make selfdiagnoses. As a result, some would rush unnecessarily tothe hospital, while others would begin self-treatmentthat might sometimes cause serious health issues. The
blind belief that AI is infallible, combined with poor
understanding and misinterpretation of AI suggestions,
could make individuals hypersensitive to health-related
information and data about themselves, leading them toact out of confusion. Anxiety would compel them to seek
more and more information, some of which could be
misleading. If parents use a wearable AI to monitor theirchild, their anxiety concerning their child’s health would
be so much greater than their concern for their own
health.
It is pointed out that handling healthcare informationin appropriate ways is difficult for the general public(18). This is because we tend to believe only what wewant to believe and because it is easy to be deceived by
medical hoaxes. Some might think that the Internet is adictionary of information, when sometimes this isactually graffiti or advertisements (18). If a TV program
tells the audience that a sleeping pill is effective intreating diabetes, outpatient clinics are flooded withpatients demanding the sleeping pill the very next day; if
a show reports that natto (fermented soybean product)is good for weight control, then this, too, is sold out
quickly the next day (18). Given these responses and thelikelihood for individuals to regard AI advice as morescientific, precise, and trustworthy than TV program
recommendations; they are even more liable to buy infully to the suggestions of AI. This so-called‘hypersensitivity to health information’ tendency can
become problematic in some individuals who become
obsessive over their health; obviously, individual
reactions to AI information vary widely.
Shinya Tanaka, a Japanese writer, argues that the vast
majority of human beings are currently fully reliant on
the Internet to the point of dependence; they ask theInternet not only about how they can achieve their goals
in life, but also how to choose their own individual
purposes and actions. Tanaka claims that modern-day
people have become slaves to information, dominatedand adversely influenced by something strange called
information, and cannot stop taking it (19). A direct-toconsumer self-monitoring AI device would worsen thissituation even further due to a lack of corrective input
from healthcare professionals. As a result, many slaves tohealthcare information would be created.
Funaki, Japanese philosopher, points out that we are
now beginning to believe that it is safer for us to delegate
the various important judgments to AI than to humans.

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Eubios Journal of Asian and International Bioethics 29 (March 2019)

This is because, by referencing a huge amount of dataand constantly correcting judgments, AI seems to
produce correct answers and is less prone tomisunderstanding. Consequently, AI judgments seem tobe highly more reliable than those from humans (20).
4. Demolition of the traditional physician practiceand the emergence of empathy machines
We are concerned that physicians will be forced into
unemployment because other healthcare professionals
such as nurses will take over the physician’s job by using
healthcare AI. Suskind and Suskind describe how theroles of healthcare professionals (physicians inparticular) can be transformed with the introduction of
AI in clinical settings and in society. Although specialized
medical knowledge forms the core of healthcare
professional practices, AI would offer laypersons directaccess to this knowledge (5). In addition, current
tendency to introduce checklists, standard operational
procedures, various systems into professional works
make traditional individual professional practices
routines. As a result, physicians may be destined to lose
their role as gatekeepers of this specialized knowledge,
as conventional work of a physician could be performedby nurses and quasi-professionals, who can care forpatients with chronic conditions such as obesity anddiabetes (5).
We agree with these above predictions made by
Suskind and Suskind. Physicians may lose their current
jobs and present social status. In an era of extended AI
use, they would no longer be considered experts,
specialists, or consultants; instead, they would fulfill therole of counselor or coordinator working alongside AI.
Some physicians would lose their jobs entirely if the costof AI use becomes cheaper than that required to pay aphysician’s salary. Occupations involving creativity,
management, and hospitality are thought to be more
likely to survive even with the extensive use of AI insociety; the same could be said for nurses, nursing carestaff, childcare staff, and various instructors involved in
hospitality-related jobs requiring emotional sensitivity
and communication (21). In terms of hospitality, these
specialists are far more skilled than physicians, and thus,
even if a physician tried to provide their patients withholistic medical care, they could be replaced by nurses
and others skilled in emotional communication andsensitivity, who also happen to be armed with smart AI
skills.
An AI system capable of expressing proper and timely
empathy to suffering patients (Empathy Machine) could
also deprive the physicians of their roles in terms of
hospitality and emotional exchange. As noted by Suskind
and Suskind, no one can maintain that all professionals
are great listeners and truly empathetic. They also statethat we should not assume that machines and systems
will never be capable of single-handedly (without
humans) exhibiting empathy for human patients. In thefield of ‘affective computing,’ scientists and engineers aredeveloping systems that can simulate empathetic
bedside manner (5). Machines will be equipped torespond to their user in a manner that would appear to
be more empathetic than a human being. People may
even come to prefer confiding in machines over humanbeings, especially in situations involving sensitive or

embarrassing issues (5).
Consider the absolute necessity of a human for
empathetic communication with patients. One study
found that when people thought they were talking to acomputer, they were less fearful of self-disclosure anddisplayed more intense expressions of sadness,compared to those who thought the conversational agent
was controlled by a human, which illustrated that a
conversational agent’s lack of humanness can be astrength (22). On the other hand, intuition and empathy
are thought to be very difficult for AI to offer, and many
individuals may be concerned about AI performing
specific tasks that require human feelings such as
empathy and compassion. Human beings require
personal contact in clinical settings (23).
Even for those who require empathy, we would argue
that it is not essential that the entity offering empathetic
responses to the person in desperate need of emotional
understanding is a flesh-and-blood human being. If
empathy can be demonstrated properly and the patient’s
mindset improves as a result, the empathic existence
could be a machine. Even in today’s society, there aresome individuals who are less comfortable with face-toface interactions with other human beings, and who
would prefer interacting with machines equipped with
communication devices. Do individuals who require
empathy from others necessarily require the true
feelings of living human beings? We are not certain of theanswer to this question.
We have all encountered the arrogant doctor, thenurse in a bad mood, a cold laboratory technician, and aclock-watching pharmacist, all of whom could easily hurt
someone feeling vulnerable. We would also argue that
suffering individuals may often fare better if they had an
empathy machine programmed to express human-like
empathy, rather than hopefully expecting it from humanbeings. The empathy machine lacks emotion, selfconsciousness, and therefore, any resulting self-intereststhat could otherwise cause professionally inappropriate
attitudes among human beings. On the other hand, fleshand-blood professionals could be occupied with theirown issues or emotionally unstable, or even too tired forcompassion, and exhibit indifference to human weakness
and suffering. In a sense, flesh-and-blood human beings
are unstable and predicting their emotional responses isdifficult and troublesome. Humanity is capable ofcompassion and kindness, but fully human traits include
weakness and prejudice. We would also estimate that
only a minority of healthcare professionals can exhibit
authentic empathy toward their patients, and that most
simply do what they are taught and expected to do as
professionals. Therefore, an existence for provision of
empathy needs not be a human being, not to mention,
physicians.
Some people misunderstand AI, believing that AI
exhibits empathetic reactions, and that they have trueemotion and personality, due to our tendency toanthropomorphize inanimate things and seek out humannature even in non-human objects (24, 25). One author
claims that modern-day Japanese people love and haverelatively favorable impressions of robots, compared totheir counterparts in Western Europe. In Europe and theUS, however, the robot is regarded as a threat that could
dominate over human beings (7). Perhaps this tendency

Eubios Journal of Asian and International Bioethics 29 (March 2019)
found among many Japanese people was caused byanimism (perceiving personality and divinity in virtually
every existence) in Shinto, an indigenous Japanesereligion. Consequently, there is the possibility thatJapanese people tend also to anthropomorphize AI
without knowing it.
One study has pointed out that a close relationshipbetween care robots and humans has the potential toisolate people socially, and adversely affect conventional
human relationships (11). It is true that AI can be
regarded as a “fake” human (Simulacra), and thus any
suggestions or advertisements that try to get people tobelieve that AI has emotions, personality, or selfconsciousness are unacceptable. However, as far as theusers understand and appreciate the inherent entity thatis AI, situations in which they feel emotionally
comfortable in communicating with AI are entirely
acceptable, even if these are one-way. An appropriate
analogy might be the joy that some obtain from playing
with or being near to their beloved toys or dolls. Of
course, caution should be taken so as to avoid theaforementioned mistake in the cases of children or
individuals with cognitive impairment or mental
instability using AI exhibiting emotional responses.
5. Arrival of a health-controlled society sharing
extensive personal information and the resulting
metamorphosis of privacy
We predict that entire societies will soon share andconsolidate
sensitive
andrelevant
healthcare
information from all in the general public, through AI
and information networks, as part of a totalitarian
health-controlled society where individual privacy andpersonal secrets could be neglected. The advent of thehealth-controlled society could lead to themetamorphosis of the concept of privacy itself into
something completely different.
Some have proposed to utilize accumulated
information on personal mobile terminals for publichealth. For example, when a patient with influenza isnoted, health authorities would use data from thepatient’s mobile terminal to determine other individuals
around the patient. This could help to contain theinfluenza and other more highly pathogenic viruses andpathogens. It would also allow the identified people to be
informed of the necessity for quarantine or isolation(26). Another proposal is to establish a system in which a
local authority uses data from smartphones or wearable
terminals to preserve individual records of daily steps,
blood pressure, weight, body fat, meal contents, family
history, personal health records, and drug use
information, by sending all data to a central AI. The
system would in turn send back recommendations fromAI pertaining to each individual’s examination (27).
The Japanese novelist Keikaku Ito wrote a novel
entitled Harmony in 2010, describing a world in which
health is considered the most important issue in human
life. Characters in the story insert a device called
WatchMe into their bodies at a certain age; the WatchMe
precisely analyzes biological molecules inside, monitorsthem in real time, and sends the results of the analysis tothe authorities that monitor the homeostasis for all
citizens. All people are socially required to regulate theirhealth strictly, and they must continue to prove their69

health (28). Dave Egars, an American writer, published abestseller in 2013 entitled The Circle, which described a
giant company dealing with hyper-advanced information
communication technology and SNS. Some of the main
characters in this book say, “Secrets are lies,” “Sharing iscaring,” “Privacy is theft,” and “All that happens must be
known (29).”
We would imagine that by employing AI, SNS,wearable terminals, and information collection systems,
our future societies would approve of society-wide
information sharing and health control of all individuals,
and that public health will be prioritized over individual
privacy. It is clear that medical monitoring aimed athealth promotion will become much easier than it istoday due to technological advancements. In the near
future, use of monitoring equipment will also become areality through the use of implantable sensors. Suchsocieties may be dominated by a health supremacy
doctrine, or what could be entitled ‘healthism.’
No one would object to the benefits of living long andhealthy lives. However, if society not only monitors thehealth-related information of literally all individuals in
the community, but then aggregates and analyzes it
constantly as well in order to promote health within thesociety, the individual’s right to not submit one’s own
data, their right to choose which data are available toauthorities or not, and the freedom to engage inunhealthy activities may easily be disregarded. Granting
any society the right to access sensitive personal
information would defeat the individual’s personal rightto privacy and liberty. In the world portrayed in The
Circle, individuals are obligated to let others know thatone’s privacy (29). Such a world comprises societies forwhom their health is controlled by the state; it can also
be a society of mutual surveillance by all citizens.
We worry that a time will come when attachment of
the wearable terminal and inserting it into the body will
become obligatory. The disappearance of one’s secrecy
for self and freedom to engage in anti-healthy behavior isonly growing as a possibility. Of course, societies
comprising healthier people would be preferable, but weare concerned about the potential sacrificing of manyother important values in life in the process. Here again,
paternalism in society would paradoxically beresurrected by the introduction of a state-of-the-art AI.
6. Conclusion
Hope for the best and prepare for the worst; Somepotential
countermeasuresagainstpossibleundesirable situations
In this paper, we have predicted and described several
worrisome situations concerning the introduction ofhealthcare AI in clinical settings. The future isunpredictable, but AI can be regarded and treated as thearchangel described by R.M. Hare: a being withsuperhuman powers of thought, superhumanknowledge, and no human weaknesses including
partiality to self (30). Although the AI in question lacks
any personality or consciousness while the archangel has
both, people are likely to ignore the difference as trivial.
The archangel will be able to immediately scan for allproperties of novel situations, including the consequenceof alternative actions. On the other hand, some flesh andblood doctors could be perceived by R.M. Hare as prole,

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Eubios Journal of Asian and International Bioethics 29 (March 2019)or those with human weaknesses to an extreme degree.
Not only does he, like most of us, have to rely on intuitionand sound prima facie principles and good dispositions
most of the time, but he is also totally incapable ofcritical thinking, even when there is the time for it (30. A
prole is generally described as a junior, unskilled worker
or someone who engages in routine or mundane labor.
That said, AI which surpasses human physicians may
never appear. Even more likely is the possibility that any
machine employing AI fails suddenly. There would
certainly be situations in which AI is unexpectedly out oforder. Machines cannot be perfect. Even if the AI is
excellent and empathetic, some people would still
maintain that human physicians are better for them.
Some may even like physicians full of human traits, andwe could argue that not all problems can be addressedusing technology. In addition, due to legal and social
problems, it is unlikely that fully automated andunmanned medical care given by AI alone will be
realized any time in the near future. In any case, hoping
for the best and preparing for the worst is the best
approach to take. To this end, we present some potential
countermeasures and limited proposals. While these areadmittedly
mediocreandperhaps
simplycommonsensical, we feel that no other innovative
alternatives have presented themselves at the moment.
First, we must conduct clinical research and social
investigations concerning problems surrounding the
introduction of AI in our society. These issues may
include matters such as healthcare outcomes, change inhuman relationships in clinical settings, the occurrenceof health-related adverse events by self-diagnosis, andtotal medical expenses. We must also be carefully
observant to note whether excessive use of AI causes
personal social isolation, whether the emotional lives ofindividuals experience adverse effects, and whether theuse of AI is influenced by economic conditions, patient
backgrounds, or cognitive function. We must develop the
AI technology through discussion and consultation
among multidisciplinary experts, alongside those in thegeneral public. At the same time, it is also important toclarify the patient and family expectations of medical
professionals and of AI, and what type of collaboration
they desire.
Second, developing guidelines for the appropriate useof healthcare AI to prevent abuse from happening isessential. It is also mandatory to continue with educationin conventional medical ethics and professionalism; thisshould include that on COI management to prevent
inappropriate or unethical behaviors by healthcare
professionals, as it is predicted that advanced
technologies concerning robotics and AI represent a big
business idea, and that the market for AI healthcare will
increase (23). We believe that the primary goal of
medicine would remain the same even in an era of AI, as
would the ethics therein. Investigating the psychologicalunderpinnings of both patients and the general public asthey are influenced by AI use is also important.
Third, the general public must be better informed of
the appropriate use of AI. Literacy concerning AI mustalso be increased such that the general public canunderstand the limitations of AI, as well as theuncertainties of medical diagnoses and clinicalinterventions. This responsibility falls on the shouldersof those who intend to introduce AI into the generalsociety; namely, healthcare professionals and IT
companies. Furthermore, promotion of safe andappropriate use of such a state-of –art technology
requires a more collaborative approach among different
stakeholders including professional organizations,patient sides, and the general public/consumers (10).
We also have to keep in mind that machines can break at
any time, and thus our confidence in the functionality of
AI must not be exponentially high. In general, our faith inscience and technology should be tempered, andphysicians should continue to hone their professional
skills so that they would be able to help their patients inthe event that a machine fails.
Fourth, we should not be hasty in giving up on
important aspects of life, including privacy, freedom,justice, truth, trust, and moderation, to name a few. We
must work to prevent our societies from becoming
health-controlled societies that are based on an excessive
health supremacy doctrine. Health is very important, but
it is not the only absolute value. In order to ensure that
our society possesses diverse values, scholars ofbiomedical ethics must continue to argue that scienceand technology cannot solve all the problems andtroubles we face in the world.
Fifth, physicians must identify and cultivate thebenefits of being a flesh-and-blood physician, asking“What is the strongest attribute that I have to offer as ahuman doctor?” While AI technology can be morereliable than humans due to its higher consistency inmanaging problems, healthcare professionals bring withthem a personal touch and can deliver a wider range ofassistance (23). That said, we must abandon the ideathat human beings are automatically and unequivocally
better than and preferable to AI, solely by virtue of thefact that we are human beings.
Finally, there seems a strong anxiety about one’s own
health and the anxiety could lead to AI abuse, birth ofslaves of information, and totalitarian health-controlled
society. We wonder how we can manage our stubborn
anxiety about our health and life as a mortal existence
Thus far, no good medicine that can treat our instinctive
anxiety for health has yet become available. While wewill not address this issue here, we do wish to emphasizethat addressing the anxiety we all have about health andlife is essential for the proper use of AI. Otherwise, many
people would become slaves to information and sufferfrom AI poisoning.
List of abbreviations
AI: Artificial intelligence
COI: Conflict of interests
Funding
Our paper has been writing under the support of Human
Information Technology Ecosystem (HITE). HITE is a
research and development (R&D) focus area deliveredby the Research Institute of Science and Technology forSociety (RISTEX), Japan Science and Technology Agency(JST).
Authors' contributions: All of AA, TO, AE, MO, and SB
have equally made substantial contributions toconception, design, acquisition and interpretation ofEubios Journal of Asian and International Bioethics 29 (March 2019)references; have been involved in drafting themanuscript and revising it critically for important
intellectual content and developing ethical arguments
and making conclusions; and have given final approval ofthe version to be published.
7. References

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Measuring individual quality of life
in Japanese women with high-risk
pregnancies: clues for improving
care plans and the hospitalenvironment- Mayumi Nishikata- Mio Tanaka- Michio Miyasaka

Department of Nursing, School of Health Sciences,
Niigata University, Asahimachi-dori, Chuo-ku 2-746, Niigata
951-8518, Japan

Email: nishikata@clg.niigata-u.ac.jp

Abstract
We designed this study to assess the use of the Schedule
for the Evaluation of Individual Quality of Life Direct
Weighting (SEIQoL-DW) survey to elucidate individual
QoL characteristics of pregnant women hospitalized at amaternal–fetal intensive care unit (MFICU) and tosuggest personalized care planning initiatives thatbalance medical treatment and QoL for these women. We
interviewed 20 pregnant women in the MFICU of ageneral perinatal medical center using SEIQoL-DW toassess their perceived QoL. We qualitatively analyzed
and categorized the factors affecting individual QoL of 20
participants selected from the SEIQoL-DW replies andquantitatively evaluated the levels of importance andsatisfaction of each studied variable. The women
identified that their extended families were a constituentof their QoL and had a greater impact than anticipated bycare providers. QoL was negatively impacted by evensmall periods of lack of care. The recognition that
hospitalization ensured the well-being of the fetuses
majorly impacted QoL of expectant women. QoL washigher in women who were able to maintain certain
levels of hygiene and in those entertained duringhospitalization.

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Eubios Journal of Asian and International Bioethics 29 (March 2019)

1. Introduction
From 2000 to 2015, the rates of premature and low birthweight births in Japan have increased and currently
range from 5.3% to 5.8% and 7.8% to 8.5%, respectively(Statistics of Japan 2015). The Ministry of Health, Labourand Welfare began to make improvements to theperinatal healthcare system in 1996 and established ageneral perinatal medical center in each prefecture(Nakamura 2000). The number of beds in the maternal–
fetal intensive care unit (MFICU, the facility for inhospital care of women with high-risk pregnancies indanger of premature labor or those presenting severe
hypertensive disorders of pregnancy, placenta previa, or
multiple pregnancies) has increased from 66 beds in1996 to 715 beds in 2014 (mean, 8.5 beds/10,000
births) (Ministry of Health 2014)
In Europe and the United States, short-term tocolytics
are used for treating threatened premature labor;
however, in Japan, rest and long-term tocolytics are themost widely used management/treatment methods thathas evoked some ethical concerns (Tanaka et al 2004).
The circumstances under which pregnant women are
admitted to the MFICU vary widely and include caseswith latent risk to those in hyper acute phases. The
MFICUs comprise private rooms, large common rooms,
and mixed rooms having individual and large common
rooms. However, because ensuring medical management
and safety of the mother and fetus are the main priorities,
those hospitalized at MFICUs are restricted in theirability to move around and receive visitors; this has led
some to experience lack of freedom and a sense of being
confined (Togashi& Kaneko 2010, Nakazawa et al 2008)
Pregnancy is the preparatory stage for maternal roleattainment; in this stage, women psychologically andsocially prepare themselves by accepting motherhood aspart of their identity and acquiring knowledge related tomotherhood (Mercer 1981, Rubin 1967). However, highrisk pregnant women who are hospitalized in an MFICU
during this stage tend to experience anxiety regarding
their own and their fetus’ health and are less likely tohave a healthy awareness level of themselves as mothers(Matsuura& Shimizu 2016, Nishikata 2009, Tadenuma&
Imazeki 2005). Conversely, positive experiences in
hospitalized pregnant women with threatenedpremature labor in MFICUs and obstetrics wards havealso been reported (Imamura& Nakamura 2013,
Lederman et al 2013), including the preparation formotherhood and deepening of bonds with their partners
as they prepare for the rest of the pregnancy period andthe upcoming delivery.
Only a few studies have assessed the quality of life
(QoL) of women hospitalized in MFICUs. A survey using
the comprehensive index “the Medical Outcomes Study
General Health Survey-short Form 36 [SF-36]”(Nakamura 2012) reported that the scores of pregnant
women with threatened premature labor weresignificantly lower than those of pregnant women
receiving outpatient care or those of Japanese women in
their 30s and that their “social functioning” and“emotional” scores were particularly low. However,standardized QOL measurements, such as the SF-36,
have general definitions for the studied QoL
constituents; therefore, they are useful for evaluating the
QoLs of patient groups, but they do not take individual

patient situations and sense of values into consideration.
The QoLs of high-risk pregnant women hospitalized in
MFICUs are affected not only by their diseases andsymptoms but also by their individual perceptions about
their upcoming maternal role, their family relationships,
and the hospital environment. One idiographic approachcommonly used for evaluating an individual’s personal
perspective on their QoL is the Schedule for the
Evaluation of Individual QoL Direct Weighting (SEIQoLDW) survey (O’Boyle 1994), which is composed of “cues”
given by the respondent herself that indicate the QoL
impact areas and how the area is affected in eachparticular case. Monitoring individual QoLs has been
proposed as a tool for care planning and follow-up ofindividuals in clinical practice (McHorney& Tarlov 1995,
Wettergren et al 2009). Therefore, we hypothesized that
the SEIQoL-DW survey can be used to generate ideas toimprove the support and environment in MFICUs. We
aimed to use the SEIQoL-DW survey to elucidate
individual QoL characteristics of pregnant women
hospitalized in an MFICU and to suggest initiatives for
personalized care plans that balance medical
management and the QoL of women with high-risk
pregnancies.
2. Methods
Participants: The survey was conducted between June2013 and March 2015 at a general perinatal medical
center in Niigata, Japan. Total 20 pregnant women
hospitalized in the MFICU selected by a midwife at thatfacility were included because they were deemed likely
to maintain their physical condition or remain stable
after hospitalization. All the participants signed
informed consent forms for participation.
Data collection: We used the SEIQoL-DW manual toconduct the QoL survey and obtain the perspectives ofthe pregnant women (Hickey et al 1996). Administrationof the SEIQoL-DW includes five successive stages,
comprising
bothqualitativeandquantitative
assessments:
1. Background circumstances leading to hospitalizationin the MFICU.
2. Cue elicitation: The participants were asked toindicate five areas of life (cues) that were the mostimportant for determining their QoL duringhospitalization in the MFICU. They were then asked
to provide reasons for the choice of each cue.
3. Determining the current status for each cue: The
participants were asked to assess their current
satisfaction level for each cue using a vertical visual
analogue scale (0, lowest; 100, highest). They werealso asked to provide reasons for the assessment of
their satisfaction level.
4. Quantification of relative weight for each cue: The
participants were asked to subjectively weigh the fivecues to indicate the importance as a percentage. We
used the relative weighing to determine the relative
importance of each cue (weight) among the others
and used a specialized pie chart to represent the
proportions (the complete circumference wasconsidered as 100%). The participants were asked toprovide reasons for their weighing assessments.

Eubios Journal of Asian and International Bioethics 29 (March 2019)
5. We calculated the sum of the satisfaction level ×
weight scores of each cue to obtain individual SEIQoL
indices.
Data analysis: The audio-recorded interviews weretranscribed verbatim, and the participants’ statements
were carefully read to describe the cues to identify thecategories. Participants with SEIQoL index scores in the
75% quartile (high group) and in the 25% quartile (lowgroup) were identified and compared in terms of thegestational week, gestational age of the fetus at the timeof the interview, and the SEIQoL index. Statistical data
(obtained using the Welch’s test and Mann–Whitney Utest) was analyzed using the SPSS Statistics 23.0
software (SPSS, Chicago, IL, USA). P < 0.001 wasconsidered statistically significant.
Trustworthiness: The main author (M.N.) collected thedata and performed the initial analysis. The second(M.T.) and third (M.M.) authors repeated the analyses.
The results were checked, and two independent
researchers who are familiar with the Japanese versionof the SEIQoL-DW survey and two other experts in thefield of perinatal care made the necessary revisions.
Ethical considerations: The research ethics committee of
the Niigata University School of Medicine approved thestudy (No. 1545). All participants were provided withverbal and written explanations of the study, and theirwritten informed consent was obtained prior to study
initiation.

Fig. 1. Frequency distribution of the SEIQoL index scores
3. Results
Participant characteristics: The age of the 20 participants
ranged from the early 20s to the early 40s. Main
diagnoses made upon admission were threatenedpremature labor (16 patients), intrauterine growth
restriction (3 patients), and deep vein thrombosis (1patients). The gestational age ranged from 25 to 37(mean, 28.9) weeks on admission to the MFICU and from26 to 39 (mean, 32.4) weeks at the time of the interview.
Overview of cues: We found 95 cues in total, withsatisfaction levels ranging from 3 to 100 and weightscores ranging from 5% to 67%. Maximum, minimum,and mean SEIQoL index scores were 86.8, 17.5, and 62.0
± 21.4, respectively. Because the data were widelydispersed, we did not observe a normalized distributionof the SEIQoL index scores (Fig. 1). We generated 13
categories from the cues and interview data. Table 1

73

presents the number of cues classified into each category,
the number of participants providing cues in eachcategory, and the mean values for level, weight, and level× weight. Figure 2 shows comparisons of mean values forlevels and weights of the cues in each category.

Relationship with family
DietManaging physical andmental condition
Growth and health of thefetus
Ability to move without
restriction
Hobbies and free time
Preparing for childbirthand childrearing
Hygiene and beauty
Conversation andcommunication
80

60

40

20

0

20

40

60 (%)

Fig. 2. Comparison of the mean values for categories’
levels and weight
Comparison of the high and low groups: We found no
significant differences in the diagnoses made upon
hospitalization between the patients in the high and lowgroups or in terms of the number of participants
undergoing intravenous therapy or the degree of bed
rest required (Table 2). The results of the intergroupcomparisons of the mean SEIQoL index scores indicateda significant difference at a standard of significance of
0.1% (Welch’s test, t(8) = −9.302, P < 0.001). The median
number of gestational weeks at the time of admission to
the hospital (Mann–Whitney U-test = 10, not significant)and that at the time of the interview were notsignificantly different between the SEIQoL index scoregroups (U = 7.5, not significant).
Table 3 presents the cues indicated by theparticipants in the high and low groups along with thecorresponding levels and weights. The most striking
differences between the two groups were observed in
the attitude toward one’s “relationship with family” and“conversation and communication” involving friends andfamily as well as toward the “growth and health of the
fetus” related to patients’ fetuses. Two of the three cues
related to “relationship with family” in the high group
received levels of ≥80%, and six and three of the ninecues in the low group were evaluated as <50% and<10%, respectively. As expressed by the statement “(Mynephew) is like my own child. We lived together andfrequently saw each other, but now I can’t see him” (#3),
respondents in the low group felt lonely due to living
away from their family members for whom they used tocare. Such emotion was found even toward older
children (#7) and pets (#4, #5).
In the high group, no cues were classified as“conversation and communication”; however, in the lowgroup, three individuals gave such cues. However, as
expressed by the statement “This is the first time in my74

Eubios Journal of Asian and International Bioethics 29 (March 2019)

Table 2: Overview of participants in the High and Low groups
Low group(n = 5)High group(n = 5)

Childbirth history
Primipara
Multipara

3
2

4
1

Employment
Yes
No

4
1

3
2

Diagnosis upon admission (multiple responses)
Threatened premature labour
Intrauterine growth restriction
Twins
Placenta previa

4
1
0
0

4
1
1
1

No. of participants undergoing intravenous therapy

44

Level of bed rest
Walking only to toilet and sink
Walking within MFICUFree movement within hospital

2
2
1

1
3
1

Mean SEIQoL index

29.5 ± 12.4

82.3 ± 2.7

0.001aMedian no. of gestational weeks upon admission

29 (25–31 weeks)

28 (27–32 weeks)

0.599bMedian no. of gestational weeks at interview

31 (26–35 weeks)

33 (31–35 weeks)

0.289ba

Welch's testb

Mann-whitney 's test U

p

82.7

#6

Low group

20.8

17.5

#3

31.3

#4

#7

49.3

#1

28.7

80.0

#5

#16

80.5

#9

81.7

86.8

#8

High group #11

SEIQoLindex scores

ID

3

24

WeightRelationship with family

Level

Category

Nephew

36

WeightCue

6

Relationship with family

Category

Level

Caring for my older child39

WeightCue

5

Conversation and communication

Level

Category

Conversation

44

WeightCue

12

Growth and health of the fetus

Level

Category

Health of the baby

34

WeightCue

81

Relationship with family

Level

Category

Husband50

WeightCue

85

Relationship with family

Level

Category

Visit with husband and daughter

64

WeightCue

95

Growth and health of the fetus

Level

Category

Growth of the baby

56

WeightCue

100

Hobbies and free time

Level

Category

Knitting

57

WeightCue

90

Growth and health of the fetus

Level

Category

Hospitalization for the baby's sake50

WeightCue

100

Growth and health of the fetus

Fetal movements

Cue 1

Level

Category

Cue

23

4

Relationship with family

Grandparents

22

7

Conversation and communication

Emailing friends

25

11

Diet

Meals

28

47

Relationship with family

Husband31

17

Relationship with family

Cat

17

71

Growth and health of the fetus

Hospitalization for the baby’s sake

14

82

Someone to consult

Pregnant women in the same room

21

74

Plans

Filing tax forms

13

74

Growth and health of the fetus

Eating for the growth of the baby

1582

Preparing for childbirth and childrearing

Ankle exercises

Cue 2

19

30

Ability to move without restriction

Looking at the scenery outside

10

55

Diet

Meals

16

53

Ability to move without restriction

Can’t do anything

20

32

Relationship with family

Dog

13

41

Diet

Meals

17

85

Hygiene and beauty

Bathing98

Hobbies and free time

Watch soccer games

10

48

Relationship with family

Eating with my husband

1064Managing physical and mental condition

Rhythms of daily life

15

65

Growth and health of the fetus

Eating for the growth of the baby

Cue 3

Table 3: Cues indicated by participants in the High and Low groups and the corresponding evaluations

19

30

Conversation and communication

Conversation

10

55

Managing physical and mental condition

Constipation

13

82

Relationship with family

My deceased mother8

81

Relationship with family

Family11

95

Hygiene and beauty

Skin care

985

Ability to move without restriction

Go to the store

852

Hobbies and free time

Cooking show

8

51

Diet

Meals

10

60

Ability to move without restriction

Moving

1075Managing physical and mental condition

Not straining myself

Cue 4

15

30

Work

Work

11

55

Hygiene and beauty

Eczema on the face

7

69

Managing physical and mental condition

Mental control

116Preparing for childbirth and childrearing

Buying things for the baby

7

48

Other

Desire to be discharged early

567

Hobbies and free time

Knitting

525

Preparing for childbirth and childrearing

Making preparations at home for the baby

10

94

Relationship with family

Dog

10

72

Managing physical and mental condition

Rest

Cue 5

Eubios Journal of Asian and International Bioethics 29 (March 2019)75

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Eubios Journal of Asian and International Bioethics 29 (March 2019)

life that I have spent so much time not talking to anyone.
Other than my family… I mean, I really have no chance totalk to anyone else” (#16), the level was evaluated as≤30%.
With regards to “growth and health of the fetus,” sixcues were given in the high group, and five of those cues
were given a level of ≥60%. Statements included “I amhospitalized to give birth to a healthy baby” (#5). In the
low group, there was only one cue belonging to thiscategory, and anxiety was expressed by the statement “I
am worried about whether my baby will be born healthy
and normally or with some illness.” (#4), which was given
a level of 12%.
Two participants in the high group and none in the
low group indicated cues related to “hobbies and free
time.” These women found a way to spend their sparetime arising from hospitalization, such as watchingcooking shows and knitting. Moreover, two women eachin the high and low groups gave cues about “managing
physical and mental condition,” with levels of ≥50%;
however, the contents of the cues differed. In the highgroup, a woman understood that her pregnancy could
continue by avoiding exertion and staying in the hospital,
as indicated by her statement “when I move too much, myabdomen contracts, and so I spend my time lying down
and not moving” (#8). In the low group, as indicated by
the statement “my constipation is not getting any better. I
have changed medications since becoming pregnant andso I cannot control (my bowel movements)” (#7), thewoman was stressed by the hospitalization andtreatment, and she was unable to manage her own
discomfort out of consideration of the impact on thefetus.
4. Discussion
Our results indicated that the SEIQoL-DW survey
identified potential areas that care providers may haveoverlooked, where support is required by women in thehigh-risk group. Pregnant women who were separated
from their families because of hospitalization and those
who were under bed rest treatment experience
increased stress and frustration (Cunningham 2001). In
the present study, the participants who were unsatisfied
with their family relationships felt the need to take careof their family members. However, this need was
extended much further than what the medical careproviders thought (i.e., husband, children, and parents),
and included grandparents, nephews, and pets, as well as
deceased children and parents. Hospitalized women withhigh-risk pregnancies are often seen as being cared forby family members; however, they see themselves as
caregivers responsible for their family, and being unable
to fulfill this role even temporarily negatively impacts
their QoL. In the MFICU, the survey was conducted faceto-face because telecommunication was restricted (as inmost MFICUs throughout Japan). Children are notallowed to enter the MFICUs, and family members’ visits
are practically restricted to an open space outside the
MFICU. In addition, the use of mobile phones is
prohibited in the MFICU. This results in the patientsgetting very few opportunities to engage incommunication, which is normally how individuals
maintain their societal ties. Midwives and nurses whoare interested in managing the threatened prematurelabor symptoms of pregnant women limit theirconversations with the pregnant women to topics
related to their symptoms and management; this leaves
the pregnant women feeling that their psychologicalneeds are being neglected (Ejima 2009).
According to our results, the women who recognizedthat their fetal well-being was maintained by their
hospitalization in the MFICU felt that by resting they
were contributing to the health of their unborn child,and their QoL assessment reflected this aspect. In
contrast, for the women who did not understand this
aspect, the growth and health of the fetus was not a
constituent of their QoL. Providing information
pertaining to fetus health and pregnancy continuation to
women with high-risk pregnancies is important toimprove the quality of women’s care, provide guidance
about the management of stressors, and planinterventions to reduce stress and involve their families(Richter et al 2007). It is difficult for the women to selfassess whether the health status of their fetus isprogressing well. Therefore, it is indispensable for the
medical staff to provide them with periodical anddetailed information.
The SEIQoL-DW survey allows evaluators to assign
cues to the domains they consider important. This
becomes a form of direct evaluation and allows theevaluators to ignore the irrelevant domains. The women
who were anxious about the health status of their fetus
did not feel that they themselves were directly
contributing to the sustained health and growth of theirfetus, and they may have not considered fetal health andgrowth as a constituent of their QoL.
Among the constituents of QoL related to personal
well-being, the women identified the cues they weresatisfied and unsatisfied with. The women wereconcerned that they were unable to “soak in a bathtub
daily,” which is common in the Japanese lifestyle, andwere unhappy with certain hospital restrictions, such asthat indicated by the statement “I have to use the shower
at the same time as another inpatient once a day.” Many
pregnant women hospitalized in MFICUs spend most of
their time resting in bed and engaging in entertaining
activities; these women gave high evaluations toactivities, such as watching DVDs and knitting, whichwere considered treats not available to them during
their normal daily lives owing to time constraints.
However, the desire to enjoy meals and move freely
led to dissatisfaction in the MFICU. It is possible that the
restrictions imposed due to hospitalization led to stressin the women. The limited variation and choice in themenu of the Japanese hospital food service have been up
for improvement since few years (Nishiwaki 2014).
However, in the institution wherein our study was
conducted, >50% of the participants considered meals apart of their QoL, the evaluation of which was not high.
These results indicate that the food service of the study
hospital should be improved to increase the level ofsatisfaction. Midwives and nurses of the MFICU areaware of the sense of being “confined” and “controlled”
felt by the women in the high-risk group (Togashi&
Kaneko 2010, Mu PF 2004). However, assistants forstrolls and wheel chair movements, like those in elderly
care facilities, are rarely available even for pregnant

Eubios Journal of Asian and International Bioethics 29 (March 2019)
women with stable symptoms due to care providers’perceptions of prioritizing bed rest.
Improving the care environment of MFICUs: The results ofour study indicate the need for several initiatives for
improving the QoL of hospitalized pregnant women in
MFICUs. These include investigating whether spaces forprivate visits can be implemented to give families thetime required to allow the patients to maintain ties with
their partners and to adjust to transient circumstances,to allow longer visitation times, and to allow family
members to spend the night at the MFICUs. Maternity
wards in Japan often have notable restrictions, includingprohibiting small children from visiting to prevent
infection transmission (Tamura et al 2013).
Implementation of basic infection prevention measures(standard precautions, checking children’s vaccination
records and history of infections, checking for fever, etc.)
may allow relaxation of these restrictions.
The second initiative concerns the need to keep
hospitalized pregnant women in MFICUs, make them feelanxious about their fetus’ health status and growth, andkeep them visually and orally informed about the resultsof cardiotocograms and diagnostic ultrasoundexaminations so that they can gain a sense of the“growth and health of the fetus.” Pregnant women
hospitalized in MFICUs usually do not have much time
for consideration before being admitted to the hospital.
Therefore, medical professionals should provide themwith detailed information regarding daily changes intheir own and their fetus’ health status and other typesof positive feedback that allow them to understand thesignificance of their hospitalization.
The third initiative is concerned with the hospitals
providing certain women’s needs to support their own
lives. Pregnant women need to understand that some
aspects of their lives will change because of
hospitalization; however, the hospital could also ensurethat some aspects do not change. Hospital staff andpregnant women should work together to modify
important aspects. We propose the use of plants forrelaxation (Hasegawa & Shimomura 2014) and creatingareas within the hospital wards for DVD viewing andreading as methods to facilitate psychologicaladjustment to the temporary stay and mandatory bed
rest so as to reduce physical problems and psychologicaltension and anxiety. Meals and the ability to move freely
were QoL cues identified by the patients; however, thewomen were not fully satisfied, and therefore, improving
these services may improve the women’s QoLs.
5. Conclusion
Our study results indicate that the SEIQoL-DW surveys
can be used to elucidate the characteristics of individual
QoLs of women with high-risk pregnancies and that they
provide clues for improving care plans and the hospitalenvironment. The women identified their extended
families a constituent of their QoL to an extent greaterthan that anticipated by the care providers; furthermore,
although temporary, the fact that the women could notcare for their family members negatively impacted theirevaluation of the QoL.
The possibility of relaxing visit restrictions andensuring a space for visits to spend some private timewith one’s family should be explored. Hospitalization77

was considered to contribute to the growth and health ofa fetus; this perception turned out to be a major
constituent of their QoL; therefore, the medical staff
should provide women with detailed information on thehealth status of their fetus. The women were notsatisfied with their meals or with the restrictions
imposed on their movement; therefore, improving these
services may improve the QoL of hospitalized pregnant
women.
Acknowledgments
The authors would like to thank the patients who
participated in the interview surveys as well as theentire staff at the general perinatal medical care center.
We are deeply grateful to Professor Mieko Sadakata andAssociate Professor Kayoko Sekijima for their support
and warm encouragement. This work was supported by
JSPS KAKENHI Grant Numbers 24792489, 15K11697,
18K10418.
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A race inside the body: decision of
the fate of newborn- Shyrose Sultan
Aga Khan University Hospital, Karachi, Pakistan
Email: shyrose_sultan@hotmail.com- Samreen Siraj ; - Zainish Zafarullah; - Afsheen Hirani; Nasreen Rafiq
Aga Khan University Hospital, Karachi, Pakistan
Abstract
Sex-selective abortion is the killing of a girl fetus merely
due to its gender. It has become an emerging problem indeveloping countries mainly due to lack of resources andcultural stereotypes. Illegal abortions have increased andare jeopardizing not only the gender ratio but also thehealth of the mother by exposing them to complicationsand violating their rights. The aim of this paper is toevaluate a case scenario based on many ethical dilemmas
and questions that arise form it. The paper presents the
problem in light of major ethical principles and theories
by counteracting each argument with a counter

argument. Pakistan is a country with increasing
population and gender misbalance. Hence, it is crucial toview the positive and negative side of the conflicting
situation considering the larger benefit and bigger
impact. Government and institutions can implement
many strategies to protect the rights of women and put
an end to the race between X and Y chromosome.
1. The scenario
Pregnancy news brings happiness, excitement and hopeto the family. But, some wicked thoughts andunawareness, changes a joyous birth into a tragedy and aheart-wrenching story. A case of 35 years old married
woman was evaluated. She was a mother of 3 daughters,
belonging to a middle-class family, who came to atertiary care hospital with intestinal perforation. Upon
investigation, it was identified that the lady underwent
unsafe abortion at the 7th month of pregnancy in a local
hospital and thus ended up with the complication. As amatter of fact, this lady underwent abortion because an
ultrasound showed the fetus of a baby girl. According to
the patient, her family and husband wanted a baby boy
and thus aborted the baby girl. Since it was the criticalstage of pregnancy only a local hospital agreed to do theabortion.
2. Discussion
This case is of extreme ethical and moral importance as
it poses direct threats towards the future and safety of
our society that needs immediate action.
1. Is it ethical not to provide justice to the fetus that isaborted on no logical grounds?
2. Is it ethical to expose the mother to complications
and further deteriorate her health?
3. Can beneficence for baby justify maleficence tomother?
4. Is it ethical to disclose the gender of the baby before
birth?
5. Should healthcare providers adopt paternalism?
6. Should communitarianism outweigh liberalism?
These are the questions that should strike on themind of every individual who witnesses such scenarios.
This paper will discuss these questions and the possible
solutions towards this problem on the grounds of ethicalprinciples.
Pakistan is a revolutionary society and transition isthe core of it. The sex ratio of Pakistan according to thecensus of 2017 is 105.07[1]. This indicates that only 100
women are there for 105 men in Pakistan. Percentage
wise 51% are men and 48% women. This imbalance ingender ratio is a potential threat to social peace in ourcountry. Roughly, 890,000 induced abortions happen
that means 1 out of 6 pregnancies are terminateddangerously annually [2]. Gender preference is one of
the highlighted reasons of induced abortions in Pakistan
and is increasing in numbers [3].
3. Consequentialism vs egalitarianism
Consequentialist argues to make decisions based on theconsequences that decision would impose on theindividual or the society [4]. Similarly, the situation
becomes worse for that newborn baby girl when she
comes to world as an unwanted child. Thinking aboutthat newborn baby girl, she might be killed, she might beEubios Journal of Asian and International Bioethics 29 (March 2019)
sold or may be misused. If that does not happen she
would become a target of gender biasness, she would be
deprived of her right of education. She would be asufferer of domestic violence, as she grows up, making
her life even more miserable. Considering such adverse
consequences, abortion on the basis of gender should bepermitted to save the majority from further social harms.
Therefore, decision should be based on consequences
and not equality for everyone as opposed by egalitarians.
Every life becomes a story and that story starts fromthe womb and every unborn deserves justice because it
has life and is made by God. Egalitarian theory suggests
equality and justice for everyone. This means that every
life should have equal rights and must be treated withjustice based on all grounds. Pro-life concept argues in asimilar way that gender of a baby poses no threat to thelife of mother or does any harm to the society and family[5]. No baby should be aborted on the basis of gender. It
is an inhumane behavior, which is unacceptable. Justiceis the basic principle and all individuals should beconsidered equal irrespective of their gender [4].
Therefore,
egalitarian
approachoverrides
consequentialism and no abortion should be done on thebasis of gender, as every life is precious and equallyimportant.
4. Autonomy vs beneficence
Mother is an autonomous human being, with every rightto choose for herself. She has full reproductive autonomy.
It is her choice whether she wants to be a mother orwhether she wants a baby girl or not. On the grounds ofpro-choice theory, only mother can choose between
aborting a baby or not and it should be considered right[6]. Baby has not yet come into being, but mother isalready alive and has multiple responsibilities. She mightchoose this to not let her baby girl suffer in this cruelworld; therefore, mother holds complete autonomy in
her life and decisions. Another instance where abortion
should be permitted is the mother or father’s hatred fora particular gender. If the parents are suffering from any
psychological illness and seeing a girl or a boy neonate
can aggravate their illness, then in that case abortion due
to the gender of the baby might be morally right andsafeguards their autonomy.
On the other hand, paternalism is an action to limit
the persons’ autonomy for their beneficence. Health careproviders could do paternalism by not disclosing thegender of the baby, which could have caused beneficence
for the baby. Moreover, paternalism would be done tosave mother by not aborting the baby at 7 months ofpregnancy that posed debilitating effects on mother’s
health. Therefore, mother’s or family’s autonomy could
be overridden for their own benefit and suchcomplications could be prevented.
5. Liberalism vs communitarianism
Liberalist suggests that it is one person’s choice and wish
that whether they want to have that baby or not and it isthoroughly their autonomy [7]. Liberalist argues that any
parent would want to have sex selective abortion on the
grounds that they want equal gender in their family andit might not be the preference for one gender but
equality for the both the genders. Therefore, it is a single
person’s wish or idea.

79

In contrast, communitarianism theory argues that if
abortion is made legal based on these terms then it canpose devastating effects on our society. If parents areallowed to choose the gender of their newborn then it
changes the relationship between parent and child fromone of ‘gift’ to one of ‘contract’. Selecting the gender, eyecolor, skin color of their baby totally changes the baby
from a blessing to a commodity. Moreover, hatred for aparticular gender affects the views of everyone. The
children of such families will have biased opinions andless respect for girls and would disrupt the education
system by creating havoc of bias [8]. They arethreatening to society, as social and cultural norms are
based on the upbringing of future generations [9].
Therefore,
following
utilitarianism
andcommunitarianism approach, sex- selective abortion
should not be allowed for the good of majority.
6. Our position
Our position is clearly against sex selective abortion.
Gender biasness is deep rooted into social and ethicalproblems. If sex selective abortion were legalized thangender discrimination would prevail in society. People
would solely prefer boys to girls because of the genderstereotypes already developed in our society. In oursociety, a female baby is always associated with thesystem of dowry, considering her as a burden on family.
However, the family of male child holds advantage ofreceiving dowry. Males are considered as the breadearner of the family. Males are allowed more freedom
and security in the society. Consequently, society would
be exposed to more discrimination. Moreover, Islam also
does not permit sex selective abortion. Islam at all
instances talks about gender equality and justice toeveryone and states that no one has superiority overother. The Quran discourages Muslims from favoring one
sex over another when having children as mentioned in
Surah An-Nahl (16:58-59). Therefore gender-based
selection of the baby should not be allowed. Moreover,according to the feminist theory every gender is equalwith equal rights and status. On these bases sex selective
abortion should not be legalized.
7. Consequences
The consequences of our position would be in thebeneficence of the society but would do maleficence tothe mother and baby born. At the level of society, the banon this sex selective abortion would promote genderbalance in society. If the balance in sex ratio weremaintained then the society would be in harmony andthe number of social crimes will be reduced. Additionally,
sex selected babies would consider themselves aspriority over other babies leading to disharmony insociety and more bias. However, this would force people
to keep producing babies until they are satisfied with ababy of their choice and make the babies suffer inpoverty and hunger. Consequently, mothers would
become victims of domestic violence in crime of giving
birth to a baby girl. They would be forced to undergo
unsafe abortion at late trimesters and would end up incomplications and suffering. Moreover, the born baby
might face partiality and violence. Nonetheless, thesenegative consequences can be countered by several
interventions of bridging up this gender gap.

80

Eubios Journal of Asian and International Bioethics 29 (March 2019)

8. Conclusion
In a nutshell, discrimination based on gender is
profoundly embedded in our society and culture. It
would take years and years to uplift woman’ssignificance in our society, guard their rights, andconsider them as equal members and ultimately sustain
their dignity and self-determination. Child’s gendershould not be perceived as determinant of their futureand status. In the hospitals, ethical committees should
deal such cases and counseling of the family or themother should be done. Nurses should be educated todirectly report such incidences without any fear. Pros
and cons of the situation and their harmful effects on thefamily’s future should be explained. Most of these actions
are done due to misconception, unawareness andsocietal pressures, which could be dealt effectively.
At community level, nurses need to work througheliminating gender labels, promoting female education;
their rights in domestic life and providing them withequal opportunities. Importantly, awareness of role andstatus of women in societies in the light Islam should beenlightened by removing the misconceptions ofpatriarchal society. Moreover, social stigmas associatedwith any gender should be eliminated to counter suchpreferences. Additionally, ultrasounds should not be
used to disclose the gender of the baby. This would cause
problems for the mother, as she would have to undergo
unsafe abortion due to familial pressure and jeopardize
her health.
Furthermore, illegal abortions should be of highpriority for the government to take actions on.
Immediate banning of such actions should be done.
Multiple audits should be done to ensure no
performance of unsafe abortions in the state andpunitive measures should be taken against those whopractice unsafe abortion. Moreover, awarenesscampaigns through social media and public sessions
should be conducted about hazards of unsafe abortionand revolutionary gender rules and equalities. A hotline
service should be started for women to reach out in caseof forced abortions or domestic violence.
In the end, ban on sex selective abortion is not theway to achieve these goals, as they do not cure the core
problem. This reduction in discrimination is possible byshifting our concern towards addressing thecircumstances that initiate this partiality. Female
education should be available at easy access and within
the community, so that it influences and welfares at thegrass root levels. Moreover, their fundamental rights,
and security should be reinforced. Non-governmentalorganizations should be self-reliant to develop an in
depth understanding of hurdles and taboos against
women and formulate operational and pertinent
campaigns to eradicate the root causes.
Likewise, system of dowry should be banned in oursocieties so that no one considers the baby girl as aburden on them. As the part of making policies regardingthese recommendations, representatives of women fromurban and rural areas should be involved in
implementation strategies. In a nutshell, only if thethinking and perceptions change, only then this world
would be a better place for newborn female children.
The apprehension is that sex selective abortion would

reinforce gender discrimination and disseminate gendernorms negatively.
9. References

1. Pakistan Bureau of Statistics | 6th Population and Housing
Census. 2017. Available from http://www.pbscensus.gov.pk/
2. Ahsan A, & Jafarey SN. Unsafe abortion: global picture andsituation in Pakistan. 2008.
3. Qayyum K, Rehan N. Sex-selective Abortion in Rural Pakistan.
Journal of Advances in Medicine and Medical Research. 2017;22(12).
4. Beauchamp TL, & Childress JF. Principles of biomedical
ethics, (7th ed.). New York, NY: Oxford University Press;2013.
5. Lee E. Constructing abortion as a social problem: “Sexselection” and the British abortion debate. Feminism &psychology. 2017 Feb; 27(1):15-33.
6. Chervenak FA, McCullough LB. Sex determination by
ultrasound: ethical challenges of sex ratio imbalances andinvidious discrimination. Ultrasound in Obstetrics andGynecology. 2009 Sep 1;34(3):245-246.
7. Burkhardt MA, Nathaniel A. Ethics and issues incontemporary nursing, (4th ed.). Delmar, Australia: Nelson
Education; 2013.
8. Raza A, Sohaib Murad H. Gender gap in Pakistan: a sociodemographic analysis. International Journal of social
economics. 2010 Jun 8;37(7):541-557.
9. Zaidi B, Morgan SP. In the Pursuit of Sons: Additional Births
or Sex-Selective Abortion in Pakistan? Population anddevelopment review. 2016 Dec;42(4):693-710.

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