Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 29 (6) November 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: Holistic Bioethics- Darryl Macer
185
Ownership issues in autologous stem cell therapies 186- Patrick Foong Chee Kuen
The right to privacy vs. the right to know
191
- Nader Ghotbi
Current challenges in the healthcare system ofPakistan196- Sumaira Khowaja-Punjwani
Love of science needs to be tempered with humanity 200- D. S. Sheriff
Attitudes and eating habits among Pakistan
i undergraduate medical students
201- Zoheb RaUique and Aqsa Fatima
The ethical nihilism of hedonistic posthuman sex
203- Jan Gresil S. Kahambing
Pragmatic Organ Donation: Reinterpreting Vroom’s
Expectancy Theory
208- Osebor Ikechukwu Monday
Eubios Declaration for International Bioethics
213
Ordering Renewal
216
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations (AUSN),

https://www.ausovereignnations.org
Email: darryl@eubios.info
EJAIB adopts and complies with the Committee on Publication
Ethics (COPE) Publication ethics and malpractice policy. All
potential authors should have read these guidelines and bysubmission of an article for publication you acknowledge thatyou have complied with this policy. Violations will be handled inproportion to the intention and seriousness of the violation.
Registered address of EJAIB: P.O. Box 16 329, Hornby,
Christchurch 8441, New Zealand

Editorial: Holistic Bioethics- Darryl Macer
Email: darryl@eubios.info
EJAIB has always published a broad range of papers on
bioethics, with a very inclusive conception of whatbioethics is. We are still faced with the big challenges ofbioethics, when we see the loss of innocent lives every

minute around the world. At the end of this issue, the lastfor the 30th year of EJAIB, I reprint the 2002 Eubios
Declaration of Bioethics. This has been a modus operandiof the Eubios Ethics Institute for three decades, and welook forward to the coming new decade starting in 2020.
The seven contributions included in this issue cover arange of topics. Patrick Foong Chee Kuen explores legal
questions of the ownership related to stem cell therapies.
These range of therapies are becoming more common,and individualized treatment is now an option provided to
many. The last paper in this issue by Osebor Ikechukwu
Monday examines how different theories of ethics may be
useful with regard to organ donation and retrieval. This
week I had the pleasure to visit the OneLegacy Organ
Retrieval Center in Redlands, in the Greater Los Angeles
area, and we can see how the process of both tissue andorgan donation has developed into an altruistic service tomany persons.
We have two papers from Pakistan. Sumaira KhowajaPunjwani examines some of the current challenges in the
Pakistan healthcare system, and Zoheb RaUique and Aqsa
Fatima look at some attitudes to health and diet among
medical students there. As the old axiom says, “We arewhat we eat”. When we extrapolate from the desires ofour food, we can extend them to hedonistic objectives oflife, as Jan Gresil S. Kahambing has done in questions ofpostman sex.
Nader Ghotbi explores an example of the balance of
two human rights that are so often used in bioethicaldialogue, the right to privacy versus the right to know.
Social ethics and customs, and taking responsibility forour actions are concepts which youth and adults use, atleast theoretically. We need to extend these to practicalbioethics, as we agreed two decades ago in the Eubios
Declaration of Bioethics.
This August 2019, we had a successful Joint AUSNTohoku University Sendai Bioethics Roundtable, and in
August 2020 we are preparing for Kitami 2020 (YPA20),
and the second Sendai Bioethics Roundtable. We also
anticipate the forthcoming ABC21 conference in late 2020,
to continue the traditions of annual conferences of the
Asian Bioethics Association. Thank you for your support
for another year. Hope to see you in one of our many
venues. This month in ABC20 in Dhaka followed by theEighth Joint AUSN-Chulalongkorn University Bioethics
Roundtable in Bangkok on Cross-cultural Bioethics.

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

Ownership issues in autologous
stem cell therapies- Dr. Patrick Foong Chee Kuen

Western Sydney University, Australia
Email: P.Foong@westernsydney.edu.au
Abstract
The growing industry of unproven stem celltherapies has focused on using autologous cells inorder to enable patients to beneUit from medical
treatment by their own cells. There have been efforts
to stringently regulate untested stem cell therapies
in many countries, including Australia (the new TGA
regulation). However, some patients, their caregivers
and patient support groups support reducing
regulations to make these therapies more accessible,
especially treatments that use cells harvested fromthe patients. They believe that patients have an
inherent legal right to ownership and unlimited useof their own stem cells. They argue that government
regulatory authorities should not intervene. At
present, there is no precedent on the ownership ofregenerative tissues, in Australia or elsewhere.
Views on property rights in regenerative tissue haveprofound implications for the future of theregulation of autologous cells. This article will
explore the various judicial interpretations of theownership rights of biological materials andsuggests that patients may have property rights overtheir own stem cells based on the courts’ decisions
in recent cases.
Introduction
Around the world, untested stem cell treatments
have now focused on using autologous cells forpatients who may beneUit from their own cells. There
have been efforts to regulate such unethical stem celltherapies in some nations, including Australia.
However, there are patients, their caregivers andpatient support groups who support reducing
regulations to make these therapies more accessible,
especially treatments that use stem cells collectedfrom the patients themselves. There is a public
perception that patients have an inherent legal rightto ownership and thus unlimited use of their own
stem cells, i.e. ‘my cells are my cells’. Accordingly,
they argue that government regulatory authorities

should not intervene in imposing stringent
regulation on the industry.
Views on property rights in autologous cells haveprofound implications for the future of theregulation of autologous cells. Currently, there is nolegal precedent on the ownership of humanregenerative tissues, in Australia or elsewhere. The
case in favor of self-ownership of stem cells stands
on uncertain grounds and thus the time has come toreanalyze the law. This complex topic is likely to be asource of future litigation. This article will explore
various judicial interpretations of the property
rights of human biological material with a focus on
Australian law. While there are conUlicting views on
whether, and to whom, to confer proprietary rights
in such a highly complex area, this article suggeststhat patients may have property rights over theirown stem cells based on the courts’ decisions inrecent cases.
Sipp’s analysis of public submissions to the
FDA regarding ownership of stem cells
In some countries, measures have been adopted tostrictly regulate unproven stem cell-based
treatments. These nations include Australia (the new
TGA regulation; see later) and the US. Patients, theircaregivers and patient advocates claim that
regulatory bodies (e.g. the US Food and Drug
Administration, FDA) should not interfere in
imposing strict laws on the stem cell sector (Sipp,
2017). They contend that the government gets in theway of innovative regenerative medical treatments.
They support reducing formal and stringent
regulations in order to make these therapies moreaccessible, especially since these treatments use
stem cells which are harvested from the patients.
There are stakeholders, including patients andpatient groups, who identify autologous cells as
personal property, adopting the language ofownership and identity. An analysis by Douglas Sippof Riken Centre for Developmental Biology and Keio
University School of Medicine of 400 submissions
from the American public submitted to the US Foodand Drug Administration (FDA) revealed strong
opinions supporting the ownership of autologous
cells by patients they come from (Sipp, 2017).
The written comments were submitted to FDA in
response to draft FDA guidance documents released
to the American public earlier.1 The submissions

1 The draft document are as follows: US FDA, Same surgical procedure exception under 21 CFR 1271.15(b): questions and answers

regarding the scope of the exception (2014)www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Tissue/UCM419926.pdf
US FDA, Minimal manipulation of human cells, tissues, and cellular and tissue-based products; draft guidance for industry and Food andDrug Administration Staff (2014). www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/
Guidances/CellularandGeneTherapy/UCM427746.pdf
US FDA, Human cells, tissues, and cellular and tissue-based products (HCT/Ps) from adipose tissue: regulatory considerations; draft
guidance for industry (2014)www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/tissue/ucm427811.pdf
US FDA, Homologous use of human cells, tissues, and cellular and tissue-based products; draft guidance for industry and FDA Staff (2015)
www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/tissue/ucm469751.pdf.

Eubios Journal of Asian and International Bioethics 29 (November 2019)were in response to the invitation for comments on a
website hosted by the FDA. For instance, the FDA
received comments like the following:2“My cells are MY cells. They are not a drug, they
are a part of my body. No one, including the FDA,
has any right to prevent me and my doctor fromusing my body in any way which I deem
acceptable. Control over one’s own body is
supposed to be an inalienable right. Please don’ttake another one of my rights away.”“My body is not a drug. It shouldn’t be held to thesame standards as those used for the production ofpharmaceuticals. This greatly oversteps bodily
autonomy. It is my right to use my body in amanner that myself and my doctor deems Lit. it is
not the right of the FDA to impinge on this.”“Cells are part of our body; how can someone say
they are drugs [sic]?”“It is criminal to take what is inherently mine,
steal it, and not let me use it for my own beneLit forthe protection of big pharma $$.”
While this is an occurrence in the US context, it isinteresting to know what the legal position is on
proprietary rights over autologous cells in Australia
if there are Australian patients who may raisesimilar concerns. This article explores the existing
body of literature and litigation cases on proprietaryinterests in human bodily material.
Innovative autologous stem cell therapies inAustralia and the new TGA regulation
Stem cells are cells that can differentiate into othertypes of cells and are also capable of self-renewal or
multiplying to produce higher numbers. The aim ofstem cell research is to use or manipulate the stem
cells to help regenerate lost tissue. Stem cell-based
treatment is any treatment that uses or targets stem
cells. Autologous stem cell treatments use stem cells
collected from the patient’s own body, not donatedcells. The doctor then harvests the patients’ stem
cells, processes them in a way intended to elicit atherapeutic effect and reintroduces it back into thepatient’s body.
Currently, the majority of these procedures are
considered experimental. Despite this, there areprivate clinics in Australia and elsewhere in theworld that offer unethical stem cell treatments forvarious diseases and conditions. Australia has stem
cell businesses offering autologous stem cell
treatments and it is growing to more than seventy(Munsie, 2017). This nation has some of the world's
highest concentration of stem cell clinics (Berger,
2016) with websites directly advertising various
medical procedures to consumers including the187

treatment of stroke, osteoarthritis, sports injuries
and even anti-ageing therapies. There is anincreasing number of for-proUit private clinics
advertising and offering untested stem cell medical
treatments to vulnerable patients. Though these areunproven therapies, there are accounts ofunsubstantiated claims of cures and adverse medical
events.3 For example, Mrs Sheila Drysdale passed
away as a result of hypovolemic shock following
blood loss caused by liposuction and a stem cellprocedure used to extract stem cells to treat her
dementia condition. The autologous treatment was
performed by a cosmetic physician at a private clinic.
This tragic incident highlights critical matters
including the vulnerability of very ill patients andtheir caregivers, the ethics of the medical
professionals, the lack of science backing the medical
procedure and whether there was informed consent
provided. There were a number of cases in US as
well.
In 2017, the Therapeutic Goods Authority (TGA)
announced some proposed changes to the
Therapeutic Goods Regulations 1990 to introduce
stringent regulatory requirements aroundautologous cell and tissue therapies including stem
cells in 2018.4 These amendments are designed to
set up gradual regulatory oversight of the products
commensurate with the safety risks to patients. A
more signiUicant proportion of the autologous cell
products, including stem cells, will be subject to TGA
regulation. The proposed amendments do not
become law until they have the Governor General’s
approval. Examples of autologous cell and tissue
products are skin grafts, bone grafts, blood andblood components (plasma, serum, platelets) andstem cells. It is beyond the scope of this article toexplain the TGA regulation in detail.5 Like the US
FDA’s new strict laws, these regulatory changes will
have the effect of restricting access to autologous cell
treatments for Australian patients.
Examining the existing body of case law onhuman biological material
The topic of the ownership of the human body ishighly complex in ethical and legal terms. Thissection of the article examines a collection of
litigation cases in human biological material,
whether the body or body parts or tissues, in various
common law jurisdictions. Currently, there is nolegal precedent on the issue of proprietary rights ofstem cells.
In the case of a corpse or body parts that havebeen removed and processed, the legal principle isthat no one can legally own a dead body. In Haynes’

2 US FDA, Relating to the regulation of human cells, tissues, or cellular or tissue-based products. Docket ID: FDA-2015-D-3719

www.regulations.gov/docketBrowser?rpp=50&po=0&dct=PS&D=FDA-2015-D-3719&refD=FDA-2015-D-3719--0018
3 See Coroners Court New South Wales, Inquest into the death of Sheila Drysdale (2016)
http://www.coroners.justice.nsw.gov.au/Documents/Findings%20Drysdale.pdf.
4https://www.tga.gov.au/autologous-human-cells-and- tissues-products-regulation.
5 For more information, read Patrick Foong, ‘Stemming the Tide of Unproven Autologous Stem Cell Therapies in Australia’ (2018) 3 UNSWLaw Journal Forum.

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

Case (1613) 12 Co Rep 113; 77 ER 1389, the courts
held that there could be no property in a corpse. Thiscase offered the foundation of the concept ofownership of a dead human body. Over time, thisantiquated rule has been eroded. It remained
unchanged until 1908. In Doodeward v Spence(1908) 6 CLR 406, the Australian High Court heldthat a person could obtain a possessory interest in
biological material by the lawful application of workand skill to preserve it. Doodeward bought apreserved corpse of a two-headed fetus (still-born)in an auction in order to display it in a public
exhibition. When the police conUiscated the fetus,
Doodeward sued for its return. According to theprosecution, as there is no right of ownership in
human corpses, Doodeward had no legal right topossess it. The High Court held that the fetus should
be returned to Doodeward as lawful work or skill
has been bestowed on it and accordingly, it has
attained attributes which distinguished it from amere corpse awaiting burial. The fetus had beenpreserved in a bottle with spirits (parafUin oil) by Dr.
Donahoe; it cannot be treated as a non-entity andwas accordingly legally protected. This principle is
known as the Doodeward exception or the work &skill exception.
The line of cases (of US jurisdiction) analyzed
below concern a different type of scenario to thosethat are of interest in this discussion. They concern
the donation of human tissue to be used in a
research context, i.e.; where the human biologicalmaterial/ waste is removed from a living person.
Nevertheless, these cases offer meaningfulinterpretations in the debate. First, in Moore v the
University of California (1990), Moore, a cancer
patient (hairy-cell leukemia), underwent a
splenectomy at the University of California Los
Angeles (UCLA) Medical Center. His attending
physician, Dr. John Golde, requested him to return to
UCLA for several appointments. During these visits,
the doctor withdrew samples of blood, blood serum,
skin, bone marrow aspirate and sperm from Moore.
Dr. Golde established a cell line from Moore’s
biological material which was subsequently
patented. Between 1984 and 1990, the patent
generated more than $3 billion. Moore sued Dr.
Golde and other defendants, alleging that his
physician did not disclose economic interests in his
cells prior to obtaining his consent to theprocedures. Moore also claimed the right to a sharein the proUits made from the biological material
excised from him. The Supreme Court of California
rejected Moore’s claim. The courts deemed that thepatented cells were different from those taken from
Moore and therefore could no longer be regarded as
his property. Moreover, there was a lack of judicial
precedent in California to support Moore’s claims.
Another case, Greenberg v Miami Children’s
Hospital (MCH) Research Institute (2003) concerns alegal suit brought by Daniel Greenberg and other
patients, against Dr. Rueben Matalon, who wasresearching the genes linked with Canavan disease(a rare genetic condition that occurs most frequently
in Ashkenazi Jewish population) to establish aprenatal diagnostic test. Using various biologicalmaterials such as urine, blood and tissue samples
donated by Greenberg and other patients, Dr.
Matalon and his team successfully isolated the gene
responsible for the Canavan disease. Unknown to theplaintiffs, MCH applied and obtained a patent for the
genetic sequence. The plaintiff alleged that they had
generated huge royalties from Canavan disease
testing. Greenberg and other donors sued Dr.
Matalon and MCH, asserting that they had not been
told of the commercial developments. If they had
been informed of Dr. Matalon’s intention of
exploiting their genetic material, they would nothave donated their biological material. While thecourt recognized that a doctor/researcher is under alegal duty to provide information and to seek thepatient’s informed consent, the responsibility does
not extend to cover a researcher’s economic
interests. To impose a duty could ‘chill medical
research’ and it may pressure researchers always toassess whether a disclosable occurrence had arisen.
The court stated that the obligation to obtain
informed consent could have detrimental effects on
medical research; it would give research subjects
total control over how medical research progresses
and who gains from the study. Similar to Moore case,the court stated that a research product developed
from human tissue is distinctive from the original
tissue; it becomes the property of the researcher/research institute and the donor retains no legal
rights to it.
Finally, in Washington University v Catalona(2007), Dr. William Catalona who was a highly
respected urologist/researcher requested hispatients for their consent to use their biologicalmaterials, such as blood and tissue, excised in
prostate surgery in order to conduct medical
research on urologic diseases. The patients had tocomplete an informed consent form in which they
acknowledged they were aware that they were
contributing to research that could beneUit society
and further, they had waived their rights to bodytissues donated and developed in any productthrough research. The biological samples werehoused in the biological bank of Washington
University (WU). Owing to a dispute, Dr. Catalona
resigned from WU. He was offered a position at theNorthwestern School of Medicine (Northwestern).
He then notiUied his patients by letter of his
departure and requested for their authorization totransfer their biological samples to Northwestern.
While many patients agreed, WU refused toauthorize the transfer and brought an action against
Dr. Catalona, seeking to establish ownership of thebiological samples. Some patients supported theremoval of their biological samples to Northwestern
to enable Dr. Catalona to continue his research on
prostate cancer. They claimed to retain their rights ofownership in the biological material. The court heldthat the patients had contributed their biologicalEubios Journal of Asian and International Bioethics 29 (November 2019)
materials to research and therefore no longer
retained either property rights in it or the right toauthorize its transfer. In short, they had donatedtheir biological materials to WU as valid inter vivos
gifts. Thus, a donor loses their legal rights toownership of their biological material the moment it
is donated to the researcher for research purposes.
Taken together, these cases acknowledge that theright to control biological material excised from adonor terminates at the time of donation. Donors
then cannot insist on any legal rights of ownership in
their biological material removed as they had
abandoned any possessory interest in their tissue.
And the researchers who have used the tissue tocreate a fresh product may acquire a proprietaryinterest in it while the progenitor will have nointerest.
Recent cases: ownership of human tissue(sperm, stored or extracted)
There are several relatively recent cases, especiallyin Australia, that raise the question of ownership of
the semen, whether stored or extracted. The courtsin these cases recognized that sperm is capable ofbeing considered as property. First, with reference toa UK court of appeal case, in Yearworth v North
Bristol NHS Trust [2009], six men sued as theirsemen (which contained their sperm) in frozen
storage was damaged in the medical facility. This
group of men were cancer patients and were
undergoing chemotherapy. They had intentions ofstarting a family and there was a risk of infertility forpatients who are undertaking chemotherapy. The
stored semen was destroyed as the amount of liquid
nitrogen in the tanks fell below the required level.
The men did not provide a fee, thus there is nocontract in the absence of consideration. The Courtof Appeal criticized and rejected the Doodeward
principle, due to its lack of logic. The court held thatthe men had ownership of their sperm which they
had ejaculated under both bailment and negligence.
For a claim in the tort of negligence, the men had
ownership of their sperm. And they too had aproperty interest in the sperm that could beprotected through the contract of bailment. Thisdecision was made despite the fact the men had
exercised no skills over the storage of their sperm.
This case was a Uirst in multiple respects: It was the
Uirst time that property rights had been
acknowledged in favor of the originators/
progenitors of human bodily substances, i.e. the men
who ejaculated their semen despite the absence ofan application of work and skill. It was also the Uirsttime that bailment had been applied as the basis forrecognizing such rights. The men’s stored semen isdifferentiated from other bodily material removed to
be abandoned, e.g. amputated limbs and cut hair.
In Australia, there are several recent cases thatraise the question of access to the sperm, whether
stored or extracted, of the deceased by his widow/
co-executors of the deceased’s estate. In contrast to
Yearworth, the plaintiffs were not men who

189

generated and ejaculated their sperm but theirwidows who sought a court order for the extractionof their late husbands’ sperm. In this type of cases,
known as posthumous conception, the widow
wishes to use her late husband’s sperm for
fertilization. In this line of cases, there is ongoingdisinclination of Australian courts to acknowledge
rights in the tissue where there is no work and skill.
In Bazley v Wesley Monash IVF Pty Ltd [2011), theplaintiff (Mrs. Bazley) was the widow. Like theYearworth case, Mr. Bazley was diagnosed withcancer and deposited his semen. He subsequently
passed away. The unit storing the semen theninformed the widow that it could no longer retain
the semen without a court order authorizing thestorage. The issue was whether the stored semen
was property. If it was, rights in relation to it could
vest in the widow as his personal representative
under Queensland succession law. The Doodeward
exception was applied and the court stated that thestored sperm of the husband could be property. The
court adopted a broad view of what amounted towork and skill and that this notion included mere
freezing, so the sperm would be considered as
property.
Collectively, the recent legal cases in the UK andAustralia may suggest a likely move from the ‘noproperty’ rule to a fresh approach to the status ofhuman tissue, e.g. the Yearworth case (Skene, 2013).
But it is noted that these cases involve a unique andunusual set of circumstances and the discussion islimited to semen, whether stored or extracted.
Accordingly, it is a challenge to envisage to what
extent a similar approach might in the future beapplied in the case of regenerative tissue.
The agency argument in Re Edwards
An interesting point is the agency issue raised in Re
Edwards (2011). In that case, following the death ofher husband, the widow (Mrs. Edwards) sought a
court order for the extraction and preservation ofher husband’s sperm. Unlike Bazley, the husband, in
this case, did not deposit his semen before he died.
Hulme J applied the Doodeward principle to thesperm. In conjunction with the other decisions
similar to Bazley, the court stated while the sperm
was capable of being property, the deceased had noright to his semen while he was alive and as a result,it could not pass to his estate upon death. The judge
explained that despite the widow herself had not
applied any work and skill, the task performed (i.e.
the sperm removal) by the technicians was done on
her behalf. He said, “… the property lay in the doctors
and technicians who lawfully exercised the work or
skill, such as was the case with Dr. Donahue in
Doodeward v Spence. However, the better view is thatthe doctors who removed the sperm and the doctor
and technicians who then preserved and stored it
did not do so for their own purposes but performed
these functions on behalf of Ms. Edwards. In effect,
they were acting as her agents and thus did not190

Eubios Journal of Asian and International Bioethics 29 (November 2019)acquire any proprietary rights for their own sake.”6Thus, the technicians obtained no property rights fortheir own purpose since they were acting as Mrs.
Edwards’ agents. The technicians’ work granted thewidow an interest under the Doodeward principle,
which was sufUicient to give her possession of herlate husband’s sperm. In this case, the court
considered only the right of possession to thedeceased’s sperm and not more. It has not extended
to resolve property issues on human tissue.
In a similar case, Re H (no 2) [2012], the Supreme
Court of South Australia afUirmed Re Edwards case. In
this case, the widow applied for a declaration that
she was entitled to possession of her deceased
husband’s sperm soon after his death. The judge
stated: “The Repromed staff who exercised work andskill did so not for their own purposes, but
performed these functions as a consequence of theorders of the Court. They were acting as agents anddid not acquire any entitlement to the sperm in theirown right ... In substance, I agree that the applicant is
the only person in whom entitlement to the sperm
could lie. The sperm was removed on her
application. In my view, the applicant has a prima
facie entitlement to possession of the sperm ...”7 Inother words, the staff performed as an agent to thewidow in principle and she is the genuine holder ofthe property.
These cases involve the discussion of the widow’s
right to possession of her deceased husband’s semen
and it is uncertain whether the judges might apply
this agency argument to the case of regenerative
cells.
Performing autologous stem cell treatments:
lawful application of work and skill and theagency argument
In the case of autologous cells, it is difUicult to foresee
what approach the courts might adopt. As Loane
Skene stated: “It remains to be seen whether the
principles in the stored semen cases will be
extended to other types of bodily material or
conUined to reproductive materials … the cases todate have all involved stored semen and we do notknow if the same principles will be applied to otherstored bodily material such as cord blood andautologous blood banks, or even organs fortransplant and tissue in biobanks and other researchrepositories …” (Skene, 2012). This section of thearticle explores the possible application of the
Doodeward exception as well as the agency
argument raised in Re Edwards to autologous stem
cell treatments.
In autologous cell therapies, the patients become
their own stem cell donor. These cells are collectedin advance from the patient and returned to thepatient at a later stage. The processes involved areoften long and complicated. The doctor collects thepatients’ cellular material, processes it in a way
6 Re Edwards (2011) 81 NSWLR 198, [88].
7 Re H (no 2) [2012] SASC 177, [60].

intended to elicit a therapeutic effect andreintroduces it into the patient’s body.
Stem cells could be recognized as property byjudges on the basis that human tissue (e.g. sperm)
has been accepted as property in recent cases(Yearworth, Bazley, Edwards). Like the men’s stored
semen for future use, stem cells which are processed
and reinjected are differentiated from other bodily
material removed in order to be abandoned, e.g.
tissue/waste donated for research purposes such as
excised tissue and amputated limbs (Moore).
To perform the highly complex autologous cellprocedure involves a great deal of work and highskill, as explained above. The processed cellularmaterial possesses different attributes compared toits original state. The Doodeward work and skill
exception is very likely to apply in the case of stem
cell treatments. This is a highly skillful procedurerequiring great expertise of appropriately qualiUied
medical practitioners. The rights generally vest in
the individual or establishment that take on thework and skill, e.g. Dr. Donahoe who preserved thetwo-headed stillborn fetus in parafUin oil in
Doodeward or the fertility center that froze thesemen in tanks of liquid nitrogen in Yearworth. Thus,
it can be argued that in the case of autologous stem
cell therapies, the doctor who performs thetreatment has property rights over the patient‘scells.
Another possible argument is that in performing
the stem cell procedure, the doctor is considered as
an agent who performs the service on behalf of his/her patient (Re Edwards). The patient visits the
medical professional to be treated via this medical
procedure. The patient’s autologous cells are
harvested, processed and reinjected into their bodies
on their behalf and for their purposes and no otherperson would have any interest in them. The workand skill are executed by the physician in the serviceof the requesting party, the patient. Based on thisagency argument, it can then be contended that thepatient may have property rights over their stem
cells. Accordingly, this would suggest that the patient
has a right to sue in civil cases, e.g. the law of tort ofconversion and negligence if it is negligently lost or
harmed.
Conclusion
Currently, it is uncertain and speculative whether the
Doodeward work and skill exception might beextended to apply in the case of regenerative tissue.
There is a signiUicant scope of reconsideration of thisspeciUic area of law. Based on recent cases, it can beinterpreted that in performing autologous celltherapies, the doctor has applied lawful work andskill, and further, the doctor acts as an agent onbehalf of their patient. Thus, the patient hasproperty rights over their own autologous cells.

Eubios Journal of Asian and International Bioethics 29 (November 2019)
Nevertheless, regardless of who the autologous
cells belong to, it is argued that the TGA, as aregulatory body, has an ethical function in imposing
and enforcing strict laws to curb unprovenautologous stem cell therapies. Even if the court
acknowledges the patient as the legal owner of theirautologous cells, the TGA has a critical role in thestringent regulation of untested autologous stem celltherapies. While patients may insist that government
regulatory authorities should not interfere by
imposing strict laws on the industry that denies orlimits their access to these innovative medical
treatments, it is counter-argued that it is TGA’s
crucial responsibility to protect vulnerable patientsin such unproven stem cell-based therapies. And thisis irrespective of who legally owns the autologous
cells.
To provide clarity in the law, there may be
persuasive arguments to legislate8 but before
determining revisions in the law, it is essential toconduct public deliberations and debates inAustralia to explore the scientiUic, medical, ethicaland societal issues. A legislative review which entails
in-depth and insightful discussions among various
stakeholders and public submissions are long
overdue. Since the release of the Report of the
Independent Review of the Prohibition of Human
Cloning for Reproduction Act 2002 and Research
Involving Human Embryos Act 2002 (Heerey Review)in 2011, there has been no review on the existing
regulatory framework on stem cells. As a thoroughlegislative review is overdue, I strongly propose that
it ought to be conducted to explore the need forpossible law reform on stem cell issues, including
ownership of stem cells. Furthermore, a thoroughlaw review will also enable the discussions of manyo t h e r c r i t i c a l , c o n t rove r s i a l m a t te r s , e . g .
mitochondrial replacement therapy (MRT), humangenome editing, etc. where there have been recent
developments overseas. It is time to conduct anoverdue thorough law review of the Australian law
where this speciUic issue of ownership of autologous
cells could be addressed along with many otherethically controversial issues surrounding research
involving human embryo.
References
Barbro Bjorkman and SO Hanson, ‘Bodily Rights andProperty Rights’ (2006) Journal of Medical Ethics.
Ben White, Fiona McDonald and Lindy Willmott, Health
Law in Australia (2018) Thomson Reuters.
Carlo Petrini, ‘Ethical and Legal Considerations regarding
the Ownership and Commercial Use of Human
Biological Materials and their Derivatives’ (2012)
Journal of Blood Medicine.
Coroners Court New South Wales, Inquest into the death of
Sheila Drysdale (2016)
http://www.coroners.justice.nsw.gov.au/Documents/
Findings%20Drysdale.pdf.

191

Department of Health Therapeutic Goods Authority
https://www.tga.gov.au/autologous-human-cells-andtissues-products-regulation.
Douglas Sipp, ‘Identity and Ownership Issues in theRegulation of Autologous Cells’ (2017) Regenerative
Medicine.
Essentially Yours: The Protection of Human Genetic
Information in Australia (ALRC Report 96).
Patrick Foong ‘Stemming the Tide of Unproven
Autologous Stem Cell Therapies in Australia’ (2018) 3
University of New South Wales Law Journal Forum
Israel Berger et al., ‘Global Distribution of Business
Marketing Stem Cell-based Interventions’ (2016) Cell
Stem Cell.
Loane Skene, ‘Arguments against People Legally Owning
their Own Bodies, Body Parts and Tissue (2002)
Macquarie Law Journal.
Loane Skene, ‘Proprietary Interests in Human Bodily
Material: Yearworth, Recent Australian cases in Stored
Semen and their implications (2012) Medical Law
Review.
Megan Munsie, Cameron Stewart, Ian Kerridge, ‘Finally
Unproven Stem cell Practice Might be
Curtailed’ (2017) The Conversation https://theconversation.com/Uinally-unproven-stem-cellclinic-practices-might-be-curtailed-86388.
Megan Munsie, et al., ‘Open for Business: A Comparative
Study of Websites selling Autologous Stem Cells inAustralia and Japan’ (2017) Regenerative Medicine.
Nicholas Rolf, ‘Making Something into Nothing: Reforming
the “No Property” Rule for Human Tissue (2013) 21
Journal of Law and Medicine.

The right to privacy vs. the right toknow- Nader Ghotbi, Ph.D.
Ritsumeikan Asia PaciUic University (APU), Beppu
city, Japan
Email: nader@apu.ac.jp
Abstract
There are times when two essential human rights
may appear to be in conUlict, or need to be balanced
against one another. This paper examines the right ofa party, such as ofUicials, a group of people or anindividual, to ‘privacy and conUidentiality’ whenothers may have a conUlicting ‘right to know’ about
them. Although this conUlict has already been studied
by other researchers, there is a lot of controversy
about a rightful balance in new technology driven
situations. I conducted a survey on the views ofcollege students over an actual case of a university
associate professor whose immoral conduct had
been reported to a few of the faculty by a PhD
student who had given birth to his child on thepromise of marriage while the teacher was already8 Not all authors agree with statutory reform; see Nicholas Rolf, ‘Making Something Into Nothing: Reforming the “No Property” Rule for

Human Tissue (2013) 21 Journal of Law and Medicine.

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

married and had a child. I asked the students if they
believed protecting the privacy of the teacher was
more important than the school’s right to know. I
also asked if they believed a child born to the single
mother in such a relationship has the right to know
about his father, or the single mother has the right tokeep that information conUidential. Finally I asked
the students if they believed in general that the ‘rightto privacy and conUidentiality’ was more important
than the ‘right to know’. This paper reports on the
results of this survey on 222 students at aninternational university in Japan.
Introduction
In USA, the public ‘right to know’ was Uirst suggested
as a speciUic legal concept by Cooper (1956) who was
the director of a news agency at the time. The rightto know in his view meant ensuring that citizens
would have access to information essential for
protecting democracy. Emerson (1976) emphasizedon the right to know as the basis for acquiring theneeded information, and the communication of theinformation to others so that the freedom of
expression would be realized. John De Mott (1978)
discussed the necessity of citizens’ access togovernmental and public information for scrutiny
while protecting the privacy of citizens fromunwanted exposure. He also emphasized that there
could be situations of conUlict between the two in
which Uinding a balance could be a difUicult task.
However, according to him, the US constitution did
not provide assurance for neither of these rights andcourts could have their own interpretation, except
for one general rule: citizens’ privacy must be
protected unless disclosure of information is in the
public interest. Situations may change; therefore,setting laws may not satisfy the dynamic need tobalance the right to privacy against the right to know
in every instance. An example is provided by Baker(1987) who referred to the need of the schools toaccess students’ data to deal with increasing acts ofviolence in school while a recent law had limited
such access to ensure educational data of students
would not be misused by third parties.
Viano (1992) pointed at factors that inUluenced
the activity of media regarding criminal information
related to individuals who needed to protect
themselves against unwarranted exposure. Vianoemphasized on the role of social, cultural, andpolitical forces in moving the balance to one way or
the other which underscores the need of the society
to develop policy based on a code of ethics. It can besaid that the media play a signiUicant role in gauging
the public view as well as the legal system’s rulingover an acceptable line between the right to know
versus the right to privacy.
As Harris (1997) has noted, Hippocrates
stressed on the physicians’ responsibility over theconUidentiality of their patients’ medical issues in the
4-5th century B.C. That is why the Hippocratic Oath
includes a statement on the privacy of patients’
medical information. Without this sort of medical

privacy, it is hard to create the needed trust in
patients to provide the physician with all private
information needed to make a diagnosis. However,
the modern systems for management of medical
information are far too complex to be maintained bya physician’s oath; meanwhile, these systems help
provide the beneUit of integrated access to theinformation by various healthcare departments.
Wyld et al. (1992) discussed the challenges in thedelicate balance of the privacy and conUidentiality
rights of HIV positive people versus the right toknow of other patients and anyone else who might
be affected by the risk of exposure to HIV.
Pape (1997) examined the situation where thepublic may beneUit from access to more information
about their doctors’ record of practice, while thatmight cause a change in the practice of physicians
towards defensive medicine and Uinally leave thepatients worse off, with a general decline inhealthcare quality. Borna and Avila (1999) discussed
the issue of the need for conUidentiality of citizens’
genetic information and its delicate balance,
including the right of insurance companies to know
about them to manage their risk. However, access tosuch information might lead to signiUicantly higher
cost of health insurance or its denial from high-risk
individuals because of their genetic makeup.
Gross (2004) discussed the fragility of
democracies and the need for continuous vigilance
to protect them through the right to know and accessto information, though that may conUlict with thecitizens’ right to privacy in some instances. The
important issue would be Uinding the right balance
to the periled situation of safety and security incountries where terrorism became a real threat after
the September 11 terrorist attacks on the US. On theother hand, many countries around the world haveused the terrorism threat as an excuse to downplay
the citizens’ right to privacy and conUidentiality overtheir personal information and in some cases evenlegal entities have infringed on the rights of citizens.
Such examples demonstrate the challenges facing
ethical philosophers in balancing the right to privacy
versus the right to know in a dynamic, modern andtechnologically driven world where information
plays an important role in every aspect of the life of
citizens.
Deloney (2007) pointed to the result of studies
that showed most adopted children as well as theirbirth parents wanted to have access to birth records
while many US states limited such access to protect
the privacy rights envisioned by law. Banisar (2011)
has suggested that the right to privacy and the rightto know may together help hold governments
accountable to citizens, but the potential conUlictbetween them may lead to controversial situations
where mechanisms are needed to reduce conUlictand balance the rights. Symons (2017) discussed the2016 change in Australian law whereby donorconceived children were given the right to accessinformation of anonymous donors, including theirname, date of birth, ethnicity, physical characteristics

Eubios Journal of Asian and International Bioethics 29 (November 2019)and genetic conditions, even if the donor had
requested anonymity. Apparently, the right to know
won over the right to privacy in this case. But there
are other cases arising in both the healthcare sector
as well as social policy, information security andgovernance.
Some laws may already exist to help clarify therightful balance in situations where a conUlict arises
between the right to privacy versus the right toknow, such as leaning on the right of the community‘to know’ about a sex offender having a criminal
history who takes residence in a neighborhood.
However, the law may not specify what should bedone in countless other examples. For instance,
researchers in Pakistan examined whether a nurse
should notify others to sexual abuse of a housewife
by her husband when the hospital and local tradition
insisted on keeping silent about it to presumably
protect the privacy of the married couple (Hirani and
RaUiq, 2019). This example demonstrates the role ofculture and cultural differences in determining theright balance, and other complex issues which need
to be considered before arriving at an ethicaldecision.
Research method
A survey was electronically distributed among 229
college students enrolled in the course of Bioethics
in 2018. They were asked to examine an actual caseand answer three essay questions that followed thedescription of the case study. The survey was
designed to require responders to reUlect on the caseand use arguments in order to support their answer,
rather than immediately choosing from among 4 or 5
possible choices. The essay format was an attempt toreceive well thought responses rather than reUlex
answers. The description of the case was as follows:“Assume you are a university professor. A female
student from a different school has contacted you
to report that your colleague, a married man witha child, has deceived her into an affair and thenleft her with nothing after getting her pregnant.
She is now a single mother with little income tosupport her child and, at the same time, to keep
studying at the university until graduation while
she cannot ask her family to support her because
in her culture (as a Kazakh) it is shameful to havea child without a father. She is heart-broken andresource-less.”
Question 1: With enough proof that she is telling
the truth, is the right of the teacher to privacy andconUidentiality more important, or the right of theschool to know? Explain your choice.
With a little investigation, you realize the same
story happened to a Japanese lecturer by the sameman. She is also a single mother now working inanother school in Tokyo but is upset that she wasdeceived into an affair with a married man
teaching at your university. Both women havechosen not to reveal the identity of the father to

193

their child because they don’t want their children
to have any relation with an evil man, as they say,in the future.
Question 2: Do you think the children have a rightto know who their father is, or the mothers havethe right to keep this matter as a private issue andkeep it conUidential? Explain your choice.
Question 3: With this case as an example amongtens of other examples, how would you discuss
the right to know versus the right to privacy andconUidentiality? Which one is more important andwhy?
The use of an actual case study helped motivate
the students to discuss it seriously and work onarguments that would support their view on thematter. By providing two different perspectives, theprivacy right of the teacher (toward the school) andthe privacy right of the mothers (toward theirchildren) against the right of the school and thechildren to know, respectively, the survey enabled
the students to consider the conUlict from many
angles. Finally, they would suggest which rightseemed more fundamental to them in general.
Findings and Discussion
Out of 229 students, 222 (%97) responded to thesurvey questions. The results of the survey havebeen summarized in Table 1. As seen in Table 1, themajority of students believed that the school’s rightto know dominated the right of the teacher to his
privacy; 148 students (%66) considered the right ofthe school to know more important. Theirarguments included the potential of harm to otherstudents including a similar risk to female students,
the responsibility of the school to provide a safe
environment and to protect students from possible
abuse, the social responsibility of teachers todemonstrate higher standards of moral behavior
considering the special merits of a professor’s
position in a university, and the use of deceptive
behavior that could have legal ramiUications.
However, 64 students (29%) considered the right of
the teacher to his privacy more important. Theirarguments included the fact that the student was anadult and thus responsible for her own actions, thematter had not happened on the campus and wasthus a personal matter, and that law had notenvisioned similar cases of deception as illegal, eventhough they may not be ethical behavior. There were10 (%4) students who wanted both the school toknow and the privacy of the female student to beprotected. Five students (%2) believed that the rightto privacy and the right to know as in case of the Uirstquestion were equally important, and thus suggested
using a third approach where mediation could be
used to reach a satisfactory compromise solution forboth the teacher and the single mother, including
teacher’s Uinancial support for the child. The
responses of 5 students were not clear and werethus disregarded.

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

Table 1: Results of a survey on 222 college students
over the right to privacy and conUidentiality vs. theright to know
Q1: Teacher’s right to privacy and con7identiality
vs. School’s right to know about teacher’s actions
64 (%29)
students
supportteacher’s rightto privacy

138 (%62) students support
school’s right to know
10 (%4) students also want extra
care for victim’s privacy
in total 148 (%66) students want
the school to know

5 (%2) students consider both rights equallyimportant and suggest mediation instead(5 students provide no clear answer)
Q2: Mothers’ right to privacy and con7identiality vs.
Children’s right to know their father
59 (%26)
students
supportmothers’ rightto privacy

116 (%52) students support
children’s right to know their father
28 (%13) students recommend
waiting for child maturity
in total 144 (%65) students want
the children to ultimately know
their father

16 (%7) students consider both rights equallyimportant and suggest counseling instead(3 students provide no clear answer)
Q3: Right to privacy and con7identiality in general
vs. Right to know in general
34 (%15)
students see
right to privacy
as moreimportant

50 (%22) students see the right toknow as more important

125 (%56) students consider both rights equallyimportant and suggest case by case decisions(13 students provide no clear answer)

As for the second question regarding the right ofthe mothers to keep the identity of the father hidden
versus the right of the children to know the identityof the father, 144 students (%65) in total believedthat children had the right to know their father.
Their arguments included the inalienable right ofevery individual to know both their parents, theemotional strain on a fatherless child, and thepotential of keeping good relations between a father
and his children in the future. Among this group of
students, 28 (%13) students believed that children
should know their father but only later when theyreached a level of maturity that enables them tounderstand the complicated situation. However, 59
students (%26) believed the mothers’ right toprivacy dominated the children’s right to know their

biological father. Their arguments included
protecting the mother from more emotional burden
and stress, the futility of a father who would not
Uinancially support his biological children, andpossible further risks to both the mothers andchildren. Sixteen (%7) students considered bothr i gh t s to b e e q u a l ly i m p o r t a n t a n d t h u s
recommended the use of counselling for the mothers(and also children) to help them make a decision.
Three students did not provide a clear response tothis question.
As for the third question over the choice of theright to privacy and conUidentiality versus the rightto know, in general, an overwhelming number ofstudents (125 students, %56) responded that bothrights were important and the decision in each caseneeds to be reached after careful consideration of
circumstances especially the possible consequences,the parties involved, and the nature of conUlict. For
example, many students referred to the right ofprivacy over the use of the Internet by people versus
the right of the governments to search for terrorism
suspects, and the right of people to know about
corrupt ofUicials and businesses free of governmental
interference. Having stated their concerns, 34
students (%15) believed that in general the right ofindividuals to privacy would be a more important
issue, and 50 students (%22) believed that the rightto know would provide more beneUits and would
thus be more important than the right to privacy.
Thirteen students (%6) provided no clear responseto the third question, which might be related to the
difUiculty they had in choosing a side; however, theiranswers were too vague and were thus disregarded.
A question in this research was whether students
would be able to discuss and argue over thecomplexity of balancing the right to privacy against
the right to know. I hypothesized that the extremelycommon use of social media platforms such as
Facebook among college students would enable
them to be familiar with the privacy versus publicity
issues over the Internet. The rich arguments anddebates submitted by the wide majority of students
conUirms this point. In the case of Facebook, as an
example, when a user determines the level of privacyof his/her own page, and every time he/she decides
to conUirm or reject a friend request for access to
his/her page, and so on and so forth, there is a needto balance privacy against the will to publicize one’s
personal information, sociopolitical views, interestsand friendships. The majority of college students inthis survey demonstrated their familiarity andrecognition of the signiUicance of a balance between
the right to privacy and the right to know. However,no student referred to another approach forachieving such balance which is in fact a basic
discussion when the general topic of rights versus
responsibilities is debated. Let me elaborate.
One may try to balance the right to privacy against
the responsibility one has regarding transparency. It
is not only the government which should betransparent about its policies and Uinancial

Eubios Journal of Asian and International Bioethics 29 (November 2019)transactions. For example, any individual who
engages in starting intimate relations with anotherindividual should be transparent about his/hermarital status, and gradually other aspects of his/herlife that is needed in an intimate relationship. Also,
one may try to balance the right to know (bypublicizing information) against the responsibility torespect other individuals and their autonomy to live
as they choose. Following on this approach may help
us avoid the conUlict between the two rights, while
maintain a healthy balance in the execution of theserights regarding the responsibility that comes withthem.
Conclusion
This survey demonstrates the ability of college
students to engage in serious discussions overcomplex and controversial situations where the rightto privacy and the right to know are in conUlict. The
majority of students (%65) stated that both the rightto privacy and the right to know are important, and abalanced decision would depend on the speciUicsituation in each case and the possible consequencesthat may be envisioned. Interestingly, the students
had come up with various lines of argument
including a reference to the existing laws, social
norms, and a consideration of possible consequences
to any decision. For example, some students referredto the futility of informing the school system as it
would probably just try to cover it up to protect its
image which turned out to be true. It can be claimed
that college students are well aware of the many
instances that the right to privacy may be challenged
by the right to know, as they are facing suchdecisions on an everyday basis using social media
platforms such as Facebook, Instagram and etc.
It is important to consider that while themajority of students had picked a side answering to
the Uirst and second question, they had realized that
it was not possible to make a general ruling on thethird question without having the speciUics of thecase and the situation in hand. As the majority ofstudents have stated, both of these rights areimportant in a democratic society and when conUlicts
appear, the speciUic circumstances and particularly
the consequence of a decision need to be carefully
examined. The responses also show that law does
not provide an answer in many instances andtherefore, ethical debate and decision-making areneeded to resolve conUlicts.
References
Baker, M. (1987). The teacher’s need to know versus thestudent's right to privacy. Journal of Law Education,
16(1), 71-92.
Banisar, David. (2011). The Right to Information andPrivacy: Balancing Rights and Managing ConUlicts. The
World Bank. Governance Working Paper Series.
Borna, S. & Avila, S. (1999). Genetic Information:
Consumers' Right to Privacy versus Insurance
Companies' Right to Know a Public Opinion Survey.
Journal of Business Ethics 19(4): 355-362.

195

Cooper, Kent. (1956). The Right to Know: An Exposition of
the Evils of News Suppression and Propaganda. New
York: Farrar, Strauss and Cudahy.
Crane, A. E. (1986). The right to know versus the right toprivacy. Annual Survey of American Law, 1986(3),645-666.
Deloney, W. (2007). Unsealing adoption records: The rightto privacy versus the right of adult adoptees to Uind
their birthparents. Whittier Journal of Child and Family
Advocacy 7(1): 117-144.
De Mott, John. (1978). The People's Right to Know Versus
Right of Privacy. Speech: talk presented to the Fineman
Discussion Group. (Philadelphia, PA, March 11, 1978).)
Emerson, Thomas I. (1976). Legal Foundations of theRight to Know, Wash. U. L. Q. 1.
Gross, E. (2004). The struggle of democracy against
terrorism protection of human rights: The right toprivacy versus the national interest the proper balance.
Cornell International Law Journal 37(1): 27-94.
Harris, R. E. (1997). The need to know versus the right toknow: Privacy of patient medical data in an
information-based society. Suffolk University Law
Review 30(4): 1183-1218.
Hirani, Afshin A. A. and RaUiq, Nasreen. (2019). Silence inviolence: a curse or a goodwill? Eubios Journal of Asianand International Bioethics 29 (3): 109-112.
Pandiani, John A, Banks, Steven M.and Schacht, Lucille M.
(1998). Personal privacy versus public accountability: A
technological solution to an ethical dilemma. The
Journal of Behavioral Health Services Research 25(4):456-463.
Pape, J. (1997). Physician data banks: The public's right toknow versus the physician's right to privacy. Fordham
Law Review, 66(3), 975-1028.
Symons Xavier. (2017). The right to know versus the rightto privacy: donor anonymity and the Assisted
Reproductive Treatment Amendment Act 2016 (Vic).
The Medical Journal of Australia 207 (9): 377-378.
Viano, E. C. (1992). The news media and crime victims:
The right to know versus the right to privacy. In E. C.
Viano (Ed.), Critical issues in victimology: International
perspectives (pp. 24-34). New York, NY, US: Springer
Publishing Company.
Wyld D. C., Cappel S. D., Hallock D. E. (1992). The right toknow and the right to privacy: HIV testing and healthcare management. The Health Care Supervisor
10(3):56-66.

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

Current challenges in thehealthcare system of Pakistan- Sumaira Khowaja-Punjwani, Ph.D.

Saifee Burhani School of Nursing, Saifee Hospital
Trust, Karachi, Pakistan
Email: skpunjwani@sbson.edu.pk
Abstract
The healthcare sector plays a signiUicant role inshaping human happiness and well-being. It also hasa signiUicant impact on the economic progress of thecountry as healthy populations live longer, are moreproductive, and health is tied to human welfare. This
paper evolved out of my PhD Dissertation titled“Past, present and future trends of nursing
workforce migration: analysis and policy
implications”. This article provides an overview
about the healthcare delivery system of Pakistanwith demographics and health indicators
comparative to regional countries. Moreover, it
provides a 5-year analysis of healthcare facilities inPakistan with respect to population. An attempt has
been made in this article to highlight challenges that
healthcare system of Pakistan is currently facing,with recommendations and conclusion.
Overview of healthcare system of Pakistan
The healthcare system of Pakistan can be
categorized in to two sectors i.e. private and public.
The public sector caters for 27% of the population,
mostly government employees and members ofarmed forces, who are either governed by theFederal Government or a Provincial Government.
Federal Government encompasses Ministry of
Defense under which military healthcare system andcantonment boards function, and Ministry of Healthunder which research institutes, hospitals andvertical programs function. In the Constitution of
Pakistan, the responsibility to provide healthcare isof provincial governments except in federally
administered areas.
The healthcare delivery system of Pakistan isthree-tiered, consisting of primary, secondary andtertiary healthcare. Primary healthcare includes
basic health units (BHUs) and rural health centers(RHCs) and provides the Uirst level of healthcare. It
provides curative and preventive health services.
Secondary healthcare includes Tehsil headquarters(THQs) and district headquarters (DHQs). It is anintermediate level of healthcare mainly concernedwith provision of technical, therapeutic anddiagnostic services. Also, specialist consultation andinpatient admissions are part of secondary
healthcare. Referrals from primary and secondary
healthcare services are sent to tertiary healthcare formore specialized inpatient care, which includes
teaching hospitals. In Pakistan, the public healthsector expenditure is 2.689% of GDP (World Bank,2015). Private sector serves the remaining 73% of
the population on out of pocket payments andincludes major hospitals, individually practicing
general practitioners (GPs), dental clinics, Hakeem,
homeopathies, healthcare facilities from nongovernmental organizations (NGOs) or philanthropic
organizations (Hassan, Mahmood, & Bukhsh, 2017)(See Figure 1).
Demographics and health indicators ofPakistan
Pakistan is categorized as a low-to-middle income
developing country with annual per capita income of
USD 1,580 (World Bank, 2017). Population census
illustrates Pakistan as the 6th largest populous
country with a population estimate at 197 million(World Bank, 2018). 41.61% of the total population
belongs to age group of 0 to 14 years, 55.10% are 15
to 59 years, and 3.30% are over 60 years of age(Demographics of Pakistan: Wikipedia, 2019). As far
as the health indicators of Pakistan are concerned,
the regional countries Human Development
Indictors are much better than Pakistan (See Table
1). As per World Bank, Pakistan had the highest
population growth rate of 2.0% followed byPhilippines 1.5% in 2017. Pakistan is at the top of
the ranking in the regional life expectancy 67 years,
Infant Mortality Rate (IMR) per 1,000 births of 61
and Under 5 Mortality Rate per 1,000 live births of
75. In Maternal Mortality Ratio per 100,000, only
Nepal is below to Pakistan with the difference of 80
in 2015.
As per World Bank reports for regional countries,
Pakistan has the 2nd lowest health expenditures (%of GDP) which was 2.75 in 2016 after Bangladesh of
2.37 in the same year. Highest among the region is
Nepal which is 6.29 (% of GDP) in 2016 (See Table
2).
Table 2: Regional Countries Health Expenditure %of GDPCountry

Year 2016

Pakistan

2.75

India

3.66

Bangladesh

2.37

Sri Lanka

3.89

Nepal

6.29

Bhutan

3.45

China

4.98

Malaysia

3.80

Indonesia

3.12

Philippines

4.39

Thailand

3.71

Source: World Bank

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

197

Table 1: Health Indicators Regional Countries Comparison
CountryLife
Expectancy(2017)

IMR per 1,000(2017)

Under 5 Mortality
rate per 1,000 live
births (2017)

MMR per
100,000(2015)

Population growthrate (2017)

Pakistan

67

61

75

178

2.0

India

69

32

39

174

1.1

Bangladesh

73

27

32

176

1.0

Sri Lanka

75

08

09

30

1.1

Nepal

71

28

34

258

1.1

Bhutan

71

26

31

148

1.2

China

76

08

09

27

0.6

Malaysia

75

07

08

40

1.4

Indonesia

69

21

25

126

1.1

Philippines

69

22

28

114

1.5

Thailand

75

08

10

20

0.3

Source: World Bank

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

Healthcare Facilities in Pakistan 2013-2017
Data on the resources available to the healthsystem is essential for government to formulate
policies and actions to meet the health related
needs of the population. Hospital beds are used as aparameter to identify the availability of inpatient
services to population.
There is no global norm for the density of
hospital beds in relation to total population. In theEuropean region, there are 63 hospital beds per
10,000 population whereas in the African region
the ratio is 10 beds per 10,000 population (WHO,2009). As per Pakistan Bureau of Statistics 2018
data (See Table 3), the total number of healthcare
institutions is around 14,224 with 128,167 beds
which means there is 1 bed for 1,537 persons
residing in Pakistan.

registered nurse for 1,898 population, 1 registeredmidwife for 5,176 population and 1 registered lady
health visitor for 10,707 population (See Table 4).
However, the international standard is 4 nurses per
1 doctor which means there should be 1,576,000
nurses and currently, Pakistan has 93% shortfall ofnurses (See Table 5). Considering the above
statistics, it can be said that the healthcare system
of Pakistan is facing severe challenges in terms ofscarcity of resources. The problem needs to berecognized as a superseding impediment for which
immediate action is required as health workers
especially nurses are an important part of themission to achieve MDGs on time.

Table 4: Human Resources for Health inPakistan

Table 3: Healthcare Facilities in Pakistan

Human Resource

Facilities for Health2013 2014 2015 2016 2017

for Health

Number of Institutions

13680

13802

14101

14219

14224

Total Number of Beds

118378118170119548122769128167

Source: Pakistan Bureau of Statistics 2018
Current scenario of the healthcare workforce inPakistan

The resources for healthcare in Pakistan are in a
critical stage because of workforce deUiciency. In the
WHO Health report 2006 Pakistan was one of the
57 countries with a critical health workforce
deUiciency. Currently, there are no well-deUined
policies or plans for human resource developmentin the healthcare sector. The National Health policy
for Human resources for health (HRH) in Pakistan
was developed in 2000. The health policy ofPakistan (2009) states that they will develop a“comprehensive health workforce policy by 2010”,
but so far, no such policy has been published.
Globally, there are 13 physicians per 10,000
population, ranging from a low of 2 physicians per
10,000 in the African region to a high of 32 per
10,000 in European region (WHO, 2009). As per
Pakistan Bureau of Statistics 2018 data, there are atotal 208,007 registered doctors which means interms of ratio Pakistan has 1 doctor for every 947
population. However, international standards are 2
doctors per 1,000 population which means Pakistan
has a shortfall of 47%. Global data suggests that
there are 28 nurses and midwives per 10,000
population with huge variations amongst thecountries and regions. In the African region, there
are 11 nurses per 10,000 compared with 79 per
10,000 in the European region (WHO, 2009).
Considering 2018 data provided by Pakistan
Bureau of Statistics 2018, there are a total of103,777 registered nurses, 38,060 registeredmidwives and 18,400 registered lady health visitors
in Pakistan. Talking in ration terms, there is 1

2013

2014

2015

2016

2017

Registered Doctors

167759175223184711

195896208007

Registered Dentists

13716

15106

16652

18333

20463

Registered Nurses

86183

90276

94766

99228

103777

Registered Midwives

32677

33687

34668

36326

38060

Registered Lady

14388

15325

16448

17384

18400

Health Visitors

Source: Pakistan Bureau of Statistics 2018

Current challenges
Currently, there are many weaknesses andchallenges facing the healthcare system of Pakistan.
As evidenced in the literature, major challenges
include the double burden of disease, verticalservice delivery structure, lack of monitoring in
health policy and health planning, growing
population outburst, poverty, illiteracy, lack ofhealth education in community, poor housing, poor
sanitation and sewerage. Moreover, poor
governance, scarcity of resources, inequity,
insufUicient and untrained human resources, andabsence of well-deUined policy on human resource
development, compromised training and lack offormal in-service training, migration of skilledworkers, structural mismanagement , andmaldistribution of workforce and gender
insensitivity present major challenges in the way toprovide quality healthcare services in Pakistan. The
severe shortage of healthcare professionals andinadequate allocation of funds to primary
healthcare sector, lack of access and affordability ofhealthcare services especially for the rural
population of the country is a great concern.
The unavailability of an efUicient national healthinformation management system at primary andsecondary level, lack of medical research andtechnology at national level is also a reason for
substandard service delivery. Health policies areEubios Journal of Asian and International Bioethics 29 (November 2019)
insalubrious with feeble implementation. The
major factors of these inefUiciencies are that thehealthcare system of Pakistan has been designed bypoliticians whereas implemented by the healthprofessionals on the ground, insufUicient healthcare
Uinancing in public sector, ineffective utilization of

199

allotted Uinances due to corruption and political
intrusions, and lack of accountability resulting inpoor or no performance (Hassan, Mahmood, &Bukhsh, 2017; Punjani, Shams, & Bhanji, 2014;
Kurji, Zohra, Premani, & Mithani, 2016).

Table 5: Human Resource for Health in Pakistan – Standards and Shortfall
Human
Resource for
HealthTotal
Registered

Per
International
Population
Standard(2017)

Required for a
population of
197 million

Shortfall

Shortfall(%)

Doctors

208,007947

2 per 1,000
population

394,000

185,99347.20

Dentists

20,4639627

1 per 1,000
population

197,000

176,537

89.61

Nurses103,7771898

4 per 1 doctor

1,576,000

1,472,223 93.41

Midwives

38,0605176

1 per 5,000
population

39,400

1,340

3.40

Lady Health
Visitor

18,40010707

1 per 10,000
population

19,700

1,300

6.59

Source: WHO Global Code of Practice on International Recruitment of Health Personnel Implementation
Strategy Report 2011 – Pakistan; Pakistan Bureau of Statistics 2018

Conclusion
Health statistics in Pakistan show serious gaps inpublic service delivery. There is a dreadful need to
explore the array of opportunities, which canbeneUit the sector many folds, once adequate
attention and resources are allocated. Similarly,
multiple layers of health sector, stemming fromassisting staff to skilled staff to highly skilled
professionals require solid reforms. Policy makers
should prioritize their focus towards adequate andquality provisioning of public education and healthservices in order to build a solid foundation for
long-term economic growth. However, higher
allocation of budget to a speciUic sector will notnecessarily bring improvement in health indicators,
unless speciUic measures are implemented tocorrect the underlying inefUiciency in spending. In
order to have a meaningful outcome in terms ofcomparable parameters, priority should be tofollow international best practices. There is noquick Uix that can be obtained by spending money,
bringing foreign aid, investing in infrastructure etc.,
if standards in human capital are not enhanced andmaintained at that level.
References
Demographics of Pakistan: Wikipedia. (2019, April 21).
Retrieved May 08, 2019, from Wikipedia: https://en.wikipedia.org/wiki/Demographics_of_Pakistan

Hassan, A., Mahmood, K., & Bukhsh, H. A. (2017).
Healthcare System Of Pakistan. International Journalof Advanced Research and Publications, 1(4),170-173.
Kurji, Zohra, Premani, Z., & Mithani, Y. (2016). Analysis of
the Health Care System of Pakistan: Lessons Learnt
and Way Forward. J Ayub Med Coll Abbottabad, 28(3),601-604.
Punjani, N., Shams, S., & Bhanji, S. (2014). Analysis ofHealth care Delievery Systems: Pakistan Verus UnitedStates. International Journal of Endorsing Health
Science Research, 2(1), 38-41.
WHO. (2009). Health workforce, infrastructure, essential
medicines. World Health Organization. Retrieved May
09, 2019, from https://www.who.int/whosis /whostat/EN_WHS09_Table6.pdf
World Bank. (2017). Retrieved April 03, 2019, fromhttps://data.worldbank.org/indicator/
NY.GNP.PCAP.CD?locations=PK
World Bank. (2018). Retrieved May 08, 2019, from World
Bank: https://data.worldbank.org/indicator/
SP.POP.TOTL?locations=PK
World Bank. (2015). Retrieved April 03, 2019, fromhttps://data.worldbank.org/indicator/
SH.XPD.CHEX.GD.ZS?locations=PK

200

Eubios Journal of Asian and International Bioethics 29 (November 2019)Love of science needs to betempered with humanity- D. S. Sheriff, Ph.D.
Member of National Academy of Medical Sciences
Professor and independent Research Worker
drdsheriff@gmail.com
Introduction'Is man an ape or an angel?' asked Charles Darwin.
One could say that Man is an angel in technology
and an ape in social Life. Sitting in an unknown
corner of a computer room with a humble
experience of teaching Biochemistry to many sets ofmedical students, a moral fear seemed to grip at thedawn of my life. ScientiUic achievements, medical
marvels, space travel and a great journey of humanlife have resulted in a better standard of living. It
has also created weapon wielding, trigger happy
rebellious individuals with a confused frame ofmind.
As we try more to saturate the curiosity ofhuman mind with more knowhow and greed toconquer all avenues of knowledge, time and again.
Nature teaches humanity lessons through natural
disasters and calamity in the form of a virus to afury of Uive elements air, water, atmosphere, Uire andearth. The glorious capsules of science housing
artiUicial intelligence to robotic science have madethe basic human values of family, friendship, loveand social responsibility to take a backseat. Our
children in posterity may have the company ofchildren born out of science. They may havefamilies one with biological parents and other withengineered parents. Science with its great scientiUic
minds, intellectuals, philosophers and thinkers
sharing their experiences in the journal need to bereminded of human nature which is at stake withmany challenges apart from climate change andnuclear threat. It is just an apprehension of ateacher of science who with his limited vocabulary
and scientiUic ability shares his moral fear. The
question that haunts our mind is:“Are we on the edge of Moral degradation anddisintegration with the human mind dancing to thetunes of science and technology pushing humans tosideline? In spite of nature’s lessons humans areliving in the soap bubbles of pomp, pleasure andplunder.”
We are witnessing chaos and confusion
everywhere with violence in many forms crippling
the human spirit. The world is under the inUluenceof leaders with tunnel vision and narrow thinking.
Gandhiji, Nelson Mandela, Martin Luther King havebecome monuments erected on the pedestal ofarrogance of human power and intolerance. Peace
and tranquility have become hide-outs of ordinary
people with military might and political power
hovering around like drones with scant respect forhuman life and dignity. Humanity is trying toembrace technology over nature like the Pharaohs

and followers choosing their God, wine and women:
the vast Expanse of the sea, limitless reach of space,but the limited vision of human mind and thegreatness of nature, and the magic of God’s will thatcan control the Uive elements on Earth.

Figure 1. ConUlicts around the world threaten the peacein the world: Syria, Afghanistan, Palestine, Mexico,
Korean Peninsula, Yemen, Iraq, Kurds, South China Sea,
East China sea Pakistan, Lebanon, Republic of Congo,
Somalia, India, South Sudan. Egypt, Central African
Republic, Ukraine, Nigeria, Libya, Mali.

Religious doctrines seem to dictate andhypnotize the thought process of many young
minds. Doctored dogmas, and lists of do and don’ts,
have made the human mind a closed chamber. It issaid that “Chance favors the prepared mind”. How do
we describe the prepared mind? A mind that has
been inUluenced by didactic studies, religious
indoctrination and social structure that harm theinherent intellectual curiosity of the youngsters.
Few have realized the futility of such doctrine based
life style and resorted to a corporate culture of fast
food and high-tech life.
They say keep your mind open. An open mind isnecessary to receive information nascent, new andinnovative. Therefore, we need to create an
unpolluted sterile environment to Uine tune themindset of youngsters so that they could evolve
their thought processes, develop independent
thinking and nurture a life that respects the Uive
elements of nature and protects the Earth from
pollution of air, water and atmosphere.
Alvin TofUler said: “Our moral responsibility is not
to stop the future, but to shape it ... to channel our
destiny in humane directions and to ease the traumaof transition.”
It is our duty to shape our science, give direction
and temper it with humanity so that posterity could
still reap the beneUits of science, keeping our Earthsafe with love of our family, and respect humanity.

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

Attitudes and eating habits among
Pakistani undergraduate medical
students- Zoheb RaLique
Department of Community Medicine, Liaquat
University of Medical and Health Sciences (LUMHS),
Jamshoro Sindh, Pakistan
Email: scorpionzoheb@hotmail.com- Aqsa Fatima
Liaquat University Hospital (LUH) Hyderabad,
Sindh, Pakistan
Abstract
Poor eating habits among students are acontemporary problem faced by a huge chunk ofpopulation like students at schools, colleges, anduniversities. Students have unhealthy habits ofeating junk food and skipping meals at regularintervals which in turn put negative effects on theirhealth. Several studies are being conducted toassess the eating pattern among students at various
stages. This study was conducted at a medical
university to determine the attitude of medical
students towards their eating habits. A total of 246
students responded to the questionnaire to Uind out
their attitudes. This study was conducted in
September 2018 and it was shown that the majorityof students were having healthy eating habits andwere taking meals regularly and also using fruits
and vegetables, though some of the students were
eating junk food also.
Introduction
Poor eating habits are often linked with poor healthamong young adults. The majority of population of
any country especially the third world indeveloping countries is comprised of young adults
specially students from school to university life.
University students are well known to become
involved in risky lifestyle behaviors which include
risky eating habits.
Students are often stressed due to study and also
the hormonal changes at this age due to puberty
that increase their caloric need and requirement.
The students use junk food and skip meals andsuffer from health issues 2. This is also a major
concern for public health. Students use less fruits
and vegetables and more snacks and junk food andunhealthy soft drinks. Some research shows thatthe most pivotal factors predicting selection of foodamong adults comprise: taste, nutrition, cost,convenience, weight control and pleasure. It isbecause of this reason that students and young
adults often go outside to eat and have independent
decisions of eating as they have transition fromadolescents and go through the university period
which is a signiUicant event 3. Unhealthy dietary
habits together with lack of physical activity areoften associated with an increased ratio ofo b e s i t y a n d o t h e r h e a l t h p ro b l e m s l i ke

201

osteoporosis4. This study was also conducted toassess the attitude of undergraduate medical
students towards their eating pattern and behavior.
Research methods
To assess the attitude of undergraduate medical
students at LUMHS Jamshoro regarding their eating
habits, a self-report structured questionnaire wasdesigned. The study population included the 4thyear MBBS students. A total of 246 students
participated in this study; 42 students didn’t returnthe questionnaire and 65 students were absent.
There were 353 students enrolled in the batch. The
questionnaires were distributed among students at
the end of their community medicine
demonstration classes. It took 4 working days tocomplete the study which was conducted in
September 2018. The students took 15 to 20
minutes to Uill the questionnaire. All the students
willingly consented and took part in this study. The
questionnaire which was used in this study
consisted of 21 questions in
Total.
Results
A total number of 246 Undergraduate MBBS
Students participated in this study. There were 98
males and 148 females. Table 1 shows the
responses of students to the questionnaire.
Discussion
This study was done to assess the attitude ofundergraduate students regarding their eating
habits. One pivotal part of everyday nutritional
intake is breakfast5. Regular consumption of
breakfast is necessary for students to combat thefatigue due to a tough teaching schedule. In thisstudy 67% of students had breakfast taken daily. In
other questions about daily consumption of lunch
and dinner, 85% and 88% of students responded
that they have taken daily lunch and dinner,respectively. But 49% of students were taking lessthan 3 meals per day, and 29% of students
responded that they took more than 3 meals daily.
Vegetable and fresh fruits are considered richsources of vitamins, minerals and dietary Uibers.
Daily consumption of vegetables was reported by
39% of students, while 33% of students responded
that they rarely used vegetables and 66% of
students responded that they often ate vegetables.
In this study 41% of students consume fruits daily
and 66% eat fruits one or two times per week.
Other data in this study show that 46% of students
consume fruits rarely in a week. In this study 56%
of students had taken fast food once or twice per
week.
Responses to some other questions show that69% of the students rarely use fast foods and 8%
eat fast foods daily. The consumption of snacks is awell-known aspect of young adults and teenager’s
food habits and behavior.

202

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

Table 1: Attitude of undergraduate students
towards eating habits
Statement and Response (1) Yes(2) No1. Do you take breakfast daily (1) 164 (2) 82
2. Do you take lunch daily(1) 210 (2) 36

3. Do you take dinner daily(1) 216 (2) 30

4. Frequency of meals less than 3 times daily(1) 120 (2 ) 126

This study shows that 49 % of students use
snacks daily and 53% of students have taken snacks
once in a week. In response to other questions, 30%
of students responded that they have consumed
snacks two times or more per day. This study also
shows that meat was consumed by 84% of students
in a week. In this study 75% of students had
consumed up to 2 liters of water per day and 35%
consumed more than 2 liters per day.

9. Daily consumption of Fruits(1) 100 (2) 146

Conclusion
The results of this study conclude that the majority
of undergraduate medical students have good andhealthy eating habits and they take meals regularly.
The results also show that students have a tendency
towards eating fruits and vegetables but not daily
and in fact they eat them few times in a week. In
other results students took fast food and snacks
sometimes in a week, some students took snacks
daily. The majority of students consumed somemeat or protein in a week time and they drank up
to 2 liters of water per day. This study concludes
that students and especially medical students needbetter awareness of healthy eating habits and more
use of fruits and vegetables instead of junk food,snacks and fast food.

10. Consumption of Fruits rarely in a week
(1) 112 (2) 134

References

5. Frequency of meals more than 3 times daily(1) 72(2) 174
6. Daily consumption of Vegetables(1) 96(2) 150
7. Consumption of Vegetable rarely in a week(1) 82(2) 164
8. Consumption of Vegetable frequently(1) 162 (2) 84

11. Consumption of Fruits once or twice in a
week(1) 164 (2) 82
12. Consumption of Fast food daily(1) 20 (2) 226
13. Consumption of Fast food rarely in a week
(1) 170 (2) 76
14. Consumption of Fast food once or twice in a
week(1) 138 (2) 108
15. Meat (protein) consumed in a week
(1) 206 (2) 40
16. Vegetables consumed in a week
(1) 204 (2) 42
17. Frequency of having snacks daily(1) 120 (2) 126
18. Frequency of having snacks once in a week
(1) 130 (2) 116
19. Frequency of having snacks twice or more
per day(1) 74 (2) 172
20. Intake of Water up to 2 liter per day(1) 184 (2) 62
21. Intake of Water more than 2 liter per day(1) 86(2) 160

Elijah Dacy. (2012). Breakfast Consumption Habits ofYouth Living in Low Income Neighborhoods in a
Large Three County Metropolitan Area. Nutrition &Health Sciences Dissertations & Theses. Paper 29.
JinaTanton Et al. (2015). Eating Behaviours of British
University Students: A Cluster Analysis on a
Neglected Issue. Advances in Preventive Medicine.
https://doi.org/10.1155/2015/639239.
Nasrin Sultana Chowdhur. (2014). Eating habits andNutritional status among the Bangladeshi Medical
Students Depending upon BMI. Updat Dent. Coll
Journal 4(1):10-14
Sameer Deshpande, Michael D. Basil & Debra Z. Basil(2009). Factors InUluencing Healthy Eating Habits
Among College Students: An Application of the HealthBelief Model, Health Marketing Quarterly, 26:2,
145-164. DOI: 10.1080/07359680802619834
Silvia Lupi Et al. (2015). Assessment of lifestyle andeating habits among undergraduate students innorthern Italy. Ann Ist Super Sanità 51(2):154-161. DOI: 10.4415/ANN_15_02_14.

Eubios Journal of Asian and International Bioethics 29 (November 2019)203

The ethical nihilism of hedonistic
posthuman sex

stars. But we won’t. And we’re slowly learningthat fact . And we’re ver y, ver y pissed
off.” (Palahniuk, 1996)- Jan Gresil S. Kahambing
Leyte Normal University, Tacloban City, Philippines
Email: vince_jb7@hotmail.com

Realizing this depressing condition, humanity
projects of a post-humanity that shall transcend theinherent limitations of the human. The posthumanproject allows for the movement of by-passing thegaps and hindrances of human experiences in orderto achieve a more accurate, intensiUied, and willedresult. The current project in all its ambiguous
engagements and processes, capped in thetranshumanist persuasions, understands thehuman as something that can be improved. Posthumanity hence imagines the contemporary era as
an ongoing forecast of a far better locus of one’s lessrestricted freedom. However, in Žižek’s lens, theconsciousness of nihilism becomes fully conscious
in this current era. In Like a Thief in Broad Daylight:
Power in the Era of Post-humanity (2018), Žižek
describes the full form of contemporary nihilism. To
quote at length:

Abstract
This paper presents the ethical nihilism that looms
in the condition of sex in the posthuman. It takes
over from the backdrop of Hauskeller’s descriptionof the singularity as having a “glorious sex life.”
While such a condition is heavily leaning towards
hedonistic ethics, the paper critiques that it merely
masks nihilistic ethics. The pleasurable picture of‘happy rapists’ and ‘masturbatory sex’ in posthumanity with sexual afUluence faces a disturbing
nothingness that caters to the extreme possibility of
being sexless. Following from Žižek’s exposition ofHouellebecq’s novel The Elementary Particles(2000), which runs counter to Houellebecq’s later
novel The Possibility of an Island (2005), theposthuman poses paradoxes that point to anihilistic ethical domain. Later, the paper presents
two paradoxes: Uirst, the paradox of hedonism or
happiness, and second, the paradox of wealth ornothingness.
The end of the human as ethical nihilism
In 1932, Aldous Huxley published his dystopiannovel Brave New World, insinuating the darker than
KaUkaesque Huxleyian possibility that ‘maybe’ thisworld is another planet’s hell. Although the otherdark perspective is associated to George Orwell in
his novel 1984, the way theorists view the futureseems too shadowy, as if the mode of negation (orAuLhebung in a Hegelian sense) becomes a spectral
object fascinating the interests of any thinker who
wishes to view ‘the future’. And is it not the socalled contemporary era ‘today’, pointed already as‘the future’ from the past, also bombarded by darkinsinuations, so that an apt phrasing can only beformulated through the nuances of a deadlock suchas death – ‘the death of God’ à la Nietzsche (1974),‘the death of the author’ à la Barthes (1967) or ‘thedeath of philosophy’ à la Hawking (2010) – and, theother term, end – ‘the end of history’ (Fukuyama,1992), ‘the end of literature’ (Coover, 2018), or ‘theend of man’ (Foucault, 1994)? Such an ‘end’ of man
opens the consciousness of the nihilistic backdropof his fate. In Chuck Palaniuk’s Fight Club, one canalready read in literature the looming nihilism andmeaninglessness (and consequently, anxiety) of theend of the 20th century in transition to the 21st
century:“We’re the middle children of history, man. No
purpose or place. We have no Great War. No
Great Depression. Our Great War’s a spiritual
war… our Great Depression is our lives. We’ve all
been raised on television to believe that one day
we’d all be millionaires, and movie gods, and rock“Today’s nihilism – the reign of cynicalopportunism accompanied by permanent anxiety– legitimizes itself as the liberation from the old
constraints: we are free to constantly re-invent
our sexual identities, to change not only our job
or our professional trajectory but even our
innermost subjective features like our sexual
orientation. However, the scope of these freedoms
is strictly prescribed by the coordinates of theexisting system, and also by the way consumerist
freedom effectively functions: the possibility tochoose and consume imperceptibly turns into asuperego obligation to choose. The nihilist
dimension of this space of freedoms can only
function in a permanently accelerated way – themoment it slows down, we become aware of themeaninglessness of the entire movement” (Žižek,2018, p. 8).
If anything can be inferred from today’s nihilism,
it is that the human in this regard faces adevastating realization at the end of his rapid
progressive freedoms. The swift movements ofman’s choices are left with a paradoxical mark in
the end. The paradox of freedom here does notpoint to the inability to achieve the horizon of vastchoices ahead but the inability to confront thenothingness that happens after. What if, because ina Huxleyian new world, the serious problems are‘diseases of plenty: Drugs and food and porn areomnipresent, and so are opioid overdose, type II
diabetes, and loneliness (Smith, 2018)’, does one
have to reevaluate again the paradoxical choices of
one’s freedom?
Ethical nihilism therefore points to the abysmal
character of freedom. The emptiness that underlies
within one’s ethical choices cannot in any way
dispel the fact that once the realization of themeaninglessness of the whole path sets in, the gameis over and the optimism that radically exposes therecognition of anything human or even posthuman

204

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

becomes a vain attempt at transcendence. That is tosay, we enter into ethical nihilism precisely when
the human is set against a paradoxical relation of
his freedom to the nothingness of his desires.
What is telling of the mention of desire in his
nihilistic backdrop is the notion of sex. Žižek points
that desire in the posthuman era can alter even“innermost subjective features like our sexual
orientation” and reinvent sexual identiUications.
What this means in Hauskeller’s understanding isthat the posthuman condition will have to deal
more about sex with the prospect of hedonistic ormore intensiUied pleasure.
Glorious hedonism: Hauskeller’s happy rapist
and masturbatory posthuman sex
Hauskeller (2014) situates that the posthumancondition is associated to having more andintensiUied sex in his Sex and the PosthumanCondition while discussing such relationship inarguments as ‘the Glorious Sex Life of the
Posthuman’, ‘Sexbots on the Rise’, ‘the Engineeringof Love’, ‘Synthetik Love’, and ‘Kissengers andSurrogates.’ Machines, robots, and AI are playing
major roles in the redeUinition of sex and its
function. For instance, a Kissinger as a device canenable a person to kiss his romantic partner evenon the other side of the world. The resurgence ofsex dolls with Uleshy synthetic skin and AI
controlled reUlexes in sexual movements also
govern this landscape. Another would be theinsertion of sex in virtual reality platforms. The
common thread that unites these topics is that
arguably, in the future that is today, sex will still
reside in the condition of the posthuman. Even if
technology will evolve in a fast-paced manner, sex
will still be there and humans will still Uind ways toinsert sexuality into technological advances.
Hauskeller here exposes that in the literaladvent of post-humanity where anything canhappen, the event is referred to as the “singularity,”that is, when humanity is conjoined altogether,following Kurzweil (2005). Kurzweil, “when being
asked whether we will still have sex after the
singularity… stresses the importance of sex as ane s t a b l i s h e d way o f c o m m u n i c a t i n g w i t hothers” (Hauskeller, p. 85). This allows, he says, foran “expansion of human relationships” able to“switch from one form” to “a very different form.”
Hauskeller emphasizes the comment of a Youtube
watcher on Kurzweil’s presentation that the best
scenario of future sex:
“Will be through mind uploading when we canmake thousands of copies of our creative brains
assisted by an advanced AI cloud, then they would
each think up a sexual fantasy and send themback to you. Then you’d pick the best out of thosefantasies, go into VR, and get on with it. And they
can be with any person, face, body, voice,behavior, an empath, whatever. Can’t get better
than that.” (Cf. Hauskeller, p. 86).

When this happens, “sex and porn become infact indistinguishable because all things (including
other persons) are reduced to being just anothersexual titillation device” (Hauskeller, p. 86). Becauseof this, the body is no longer organic but artiUicial,replaceable, so that the “transhumanist fantasies ofa sexual future” – herein understood as “sublimatedrape fantasies” – can be concluded on a happinessthat makes us all “happy rapists” (p. 87). With theprospect of mind-uploading, virtualization ofvenereal pleasures becomes a norm and theconsideration for an ‘other’ – a being not the sameas oneself – dissipates into the background. If there
is, therefore, an acknowledgment that follows froma rapist style posthuman sexualization, it is that“the glorious sex life of the posthuman is essentiallymasturbatory” (p. 7).
Moreover, what makes this masturbatory
glorious is the possible detachment of sex from themachinations of the body – herein acquiring thefunction of the ‘other’ that loses its signiUicance inthe virtualization scheme of events. The basic
assumption is that “a single body is a deadly
fate” (Hauskeller, p. 6). In order to acquire an
immortalization that allows for a full exploration ofsexual possibilities, one has to consider thedisregard for one’s body as the sole andconventional perfect matter of an intended form.
Here, Hauskeller says:“the body as a meat puppet has its expiry datewritten all over it. The metaphor is designed toexpress and invite disgust, to persuade us that the
body is a despicable thing that we cannot get rid
of soon enough” (pp. 7-8).
This is a result of a juxtaposition that happens
when we are confronted with the ability toreplenish and acquire material constitutions formore pleasure found in machines. Putting Ulesh to
our desires and making them real becomes theprioritized criterion of this glorious hedonism:“whatever we can imagine, we will be able to do.
Or rather, whatever we can imagine, we will beable to imagine in a way that makes it feelreal” (p.8). This is the case so that “what wereally need is sexual pleasure (as often as muchas possible), but without sex, that is without theneed to engage our own body (or certain parts ofthe body) and to engage with one another” (p.8).
In contrast to the human body that isdeteriorating, machines are immortal and arecapable of replacing their own parts for new
experiences (e.g. sex dolls replaced with moreadvanced human-like features). Moreover, “minduploading, for instance, to a computer or to a new
body, is the achievement of immortality by making
the body replaceable” (p. 45). This feature of
replaceability in terms of bodily constitutions is
simply not the case with humans wanting to
rejuvenate old and weak parts. But the machines

Eubios Journal of Asian and International Bioethics 29 (November 2019)and merchandises for these can easily replacebroken connections:“Our products partake in a new version ofimmortality: “industrial re-incarnation.” They
have a serial existence. This light bulb or washingmachine may give up its ghost after a few years,
but then we can easily get a new one that isexactly like the old one…Their very
reproducibility and replaceability guarantees
their immortality” (p.45).
If placed side-by-side with machines, what wefeel, says Hauskeller, is Promethean shame. It is:“what we feel when we compare ourselves to thewonderful machines that we have created andrealize how inferior we really are. This shame isone of the reasons why we are so keen on
transforming ourselves into machines” (p. 40).
Machines acquire material realization of desire
and the posthuman as a product and not only aconsumer of such machines as they can achieve
better pleasure experiences. To situate this,Hauskker says that “we can imagine our posthumansuccessors to be able to erect their penises andmoisten their vaginas at will, always assuming they
will still have genitals” (p. 46). Here, the glorious
sex within the posthuman condition is inherently
linked for the acquisition of more pleasure. In thisglorious condition for the posthuman:“pleasure is both intrinsically valuable, and thus
an end in itself, and an important tool aiding ourascent to ever-higher levels of existence” (p. 9).
Houellebecq contra Houellebecq: nihilistic
ethics in the posthuman
What is problematic, however, in the hedonism of
sex in posthuman affairs is that subjectivity here
becomes a matter of material construct. Says
Hauskeller:“It is not really the fact that we are essentiallyalone when we are having sex with a robot, that
we are in fact just using a particularly
sophisticated masturbation device. What disturbs
me about it is rather that at the same time we are
persuading ourselves that we are not alone, that
we really are with someone.” (p. 13).
The Uirst critique that can be hurled then against
the posthuman glorious sex is that even if there
would be a “happiness machine” that can produce
the glory of sex in the singularity, such machinethat Hauskeller recalls from Bradbury is:“all a lie. Nothing of it is real. The happinessmachine is in fact a sadness machine. The
problem is that we have to go back to reality, andreality is not like that” (Hauskeller, p. 89).
This thought dispels the notion that “we humans
were free and the machines we constructed
determined and unfree” because “this is no longer

205

so.” “Today, in a curious contortion, we are the ones
who appear unfree, and the machines enjoy the
freedom that we lack” (Hauskeller, p. 44).
Hauskeller relies one of his core arguments on
Michel Houellebecq’s 2005 novel, The Possibility ofan Island where, in a post-apocalyptic future,cloning has pervaded reproduction and Daniel themain character with his clones, despite being
successful, are questioning the integrity of thewhole setting. For Hauskeller:“the series of Daniels from today to the distantfuture represents the endless cycle of rebirths orrather, to be more precise, our various
phenomenal existences that do not allow a realescape from this life of suffering” (p. 59).
However, this is not to be seen for him as adeeply negative thing. In fact, the body as a sole
locus of transformation provides a surer way ofentering into a more satisUied state, so that “thevery tragedy of our bodily existence is also its one
redeeming quality” (Hauskeller, 2014, p. 59). And
yet this redeeming quality is directed towards theviability of sexual pleasure. To quote from
Houellebecq (2005), sexual pleasure is:“in truth the sole pleasure, the sole objective ofhuman existence, and all other pleasures—
whether associated with rich food, tobacco,
alcohol, or drugs—were only derisory anddesperate compensations, mini-suicides that did
not have the courage to speak their name,attempts to speed up the destruction of a bodythat no longer had access to the one realpleasure.” (p. 341).
That is to say, sex is the only thing that mattersand it must not be in any way detached from life.
Acknowledging that the novel has an immersion
into Schopenhaurean philosophy, Hauskeller notesthat “we truly live only through our sexualbodies” (p. 63).
But a second critique can still be made even withusing Houellebecq again as frame of reference. In
Houellebecq’s ‘nihilistic classic’ novel The
Elementary Particles (2000), Žižek contrasts a
different picture. There, Houellebecq compares thetwo dispositions of the half-brothers Bruno andMichel Djerzinski, against a domain in which any
particular man can be represented from humanity
in general. In such a dark picture, the modernity
that signals the air of contemporariness in theirtime is one that is fraught with a humorless,meaningless, tragedy. As Houellebecq describes:“Humor won’t save you; it doesn’t really doanything at all. You can look at life ironically for
years, maybe decades; there are people who seemto go through most of their lives seeing the funnyside, but in the end, life always breaks your heart.
Doesn’t matter how brave you are, how reserved,
or how much you’ve developed a sense of humor,
you still end up with your heart broken. That’s
when you stop laughing. In the end there’s just

206

Eubios Journal of Asian and International Bioethics 29 (November 2019)the cold, the silence and the loneliness. In the end,
there’s only death.” (Houellebecq, 1998).
Bruno is an “undersexed hedonist high school
teacher who ended up in a psychiatric asylum after
he tried to grasp the utter meaninglessness ofsexual permissiveness looming in their time, thelicense of almost any emancipatory act that caters
to collective orgies” (cf. Kahambing, 2018, Žižek,n.d.). He and his half-brother continue to grapple
with an existential exile that cannot be redeemed
even by the study of philosophy, or marriage, or anamassing consumption of pornography. Modern
society has made such that the nihilistic regime
cannot in any way be penetrated even by thepainful truths of philosophy’s musings, the intimacy
tied to the traditional but often tediousrecuperations of marriage, and the excess point ofan extreme visionary of one’s sexual desire to caterto one’s venereal pleasures.
Michel, a brilliant biochemist, “invented aconsiderable panacea to the grotesque practices ofsexual rampage at hand. He invents a gene that selfreplicates, capable of sustaining a new humanity
but with a twist in its genetic codiUication”: this selfreplicating gene allows for the birth of a‘desexualized entity,’ or ‘genetically modiUied
asexual humanoids’ but, similar to the realization of
the clone Daniels in The Possibility of an Island, they
are also devoid of passion (cf. Kahambing, 2018).
Žižek caps the rationale of the present predicament:“the novel ends with a prophetic vision: in 2040,
humanity collectively decides to replace itself
with genetically modiLied asexual humanoids inorder to avoid the deadlock of sexuality - thesehumanoids experience no passions proper, nointense self-assertion that can lead to destructive
rage (ZNS).”
What Žižek thereby offers here is that
Houellebecq’s novels The Possibility of Island and
The Elementary Particles can present two different
scenarios. On the one hand, a hedonistic ethics ofsex via Hauskeller’s argument can possibly
supplant the enduring problem of the body’s
limitation. The posthuman experience of sex canrely on such limitation as a jumping board for amore pleasurable option. On the other hand, Žižek
opens the thought of a possible asexual experiencein dealing with desire in the posthuman. Meaning
to say, the critique that counters Houellebecq
through Houellebecq himself Uinds an argument
against the hedonistic ethics of the posthumanwhen such relies on another ontological injunction
as an escape while not fully acknowledging theposthuman future of glorious sex as a real event.
Hence, no matter how one inserts technology into
sex, this argument still belongs to the argument of
the abyss or can be rerouted again on the nihilistic
ethics of the times. To be able to critique the sexual
rampage of post-humanity, one must argue against
the position of the afUluence of sex as an abyss. The
nihilism that underlies it is not a future recognition,

but is already an underlying element in the ongoing
wealth of posthuman sex. Two paradoxes can beroused here.
Paradox of hedonism or happinessFirst, the nihilistic ethics of the posthuman moves
forward from the paradox of hedonism. Accordingly,
it is self-defeating to make pleasure “the only thingthat we desire for its own sake.” The twoconventional reasons are the following:“one claims that we are systematically
incompetent at predicting what will make us
happy, while the other claims that the greatest
pleasures for human beings can be found incertain special goods which hedonists cannot
enjoy” (Diez, 2019).
Here, the basic utilitarian injunction is that:“a real human lover can be replaced by a robot
without loss if and only if other people canalready never be more than means for us, if they
already are, for all intents and purposes, merely
sexbots in disguise” (Hauskeller, p. 14).
But it can also be argued, as a Uirst claim, how
the intensity of pleasures cannot guarantee
happiness in itself, or that happiness is an“unethical category” since “we don’t really want
what we think we desire” (Žižek, 2012). The second
claim is equally important, namely, that having
more important and rewarding things is notnecessarily credited to pleasure in a sense of thematerial, bodily, or instinctive tangible attainmentof desire. The posthuman project might even go
beyond not just our understanding of theconventional hedonist pleasure practices, i.e. withharem and orgies – but also intellectual quests ornoble pursuits like the achievement of happiness as
higher pleasures. The crucial point that constantly
gets reiterated for Žižek is that:“Happiness was never important. The problem isthat we don’t know what we really want. Whatmakes us happy is not to get what we want. But
to dream about it. Happiness is for opportunists.
So I think that the only life of deep satisfaction isa life of eternal struggle, especially struggle withoneself. We all remember Gordon Gekko, the role
played by Michael Douglas in Wall Street. What
he says, breakfast is for wimps, or if you need afriend buy yourself a dog, I think we should say
something similar about happiness. If you want
to remain happy, just remain stupid. Authentic
masters are never happy; happiness is a categoryof slaves.” (Žižek, 2014)
Paradox of wealth or nothingness
Second, the counter-argument for the extreme ofsexness is nihilistic since afUluence or abundance
also does not guarantee completeness but
nothingness. The broad wealth of posthuman sex,
seen in the intensiUied new forms of pleasure, mustEubios Journal of Asian and International Bioethics 29 (November 2019)
then confront with the other extreme ofsexlessness. How can this be radically possible? In
Incontinence of the Void, Žižek goes through theparadox of abundance:“The paradox of wealth resides in the fact thatthe more you have, the more you feel the lack—it
is again the superego paradox (the more you
follow the injunction, the more guilty you are),discernible also in the paradox of anti-Semitism(the more Jews are destroyed, the more powerful
are those who remain)” (Žižek, 2017, p. 205).
If there is then a post-humanism that will reside
into the future, it will only be radically possible
within the coordinates of paradoxes: it does not
only need an abyss but also the paradox of anotherextreme, the extreme of sexlessness. That is to say,that this goes back again to the predicament of
Houellebecq’s The Elementary Particles regarding
the abundance and hedonistic widespread practicesof sex: people are having threesomes, orgies, and soon. But even if such argument will be put in the
posthuman era where we have sex robots, sex dolls– this extreme of sexness is still a symptom of anabyss. And there is an obvious paradox in suchhedonistic practice which cannot simply be solved
by a mediocre, slow, change. Society is growing
more and more in its divisions of the sexes, whichcurrently expands sexual differences into 33 (hence,
the “+” in LGBT+) – albeit for Žižek this means
subjectivity itself – so that it needs the event of an
end of sexuality that can fracture this abyss ofplenty. Proceeding to the possibility of an asexual
post-humanism, all the retroactive musings of thepast will be dealt with as radical breaks setting thestage of the event.
Conclusion
The hedonistic ethics of posthuman sex is hereinparadoxical. It essentially points to the lack that subsists
in a happy or afUluent condition. The ethical junction
remains nihilistic since the scope of freedom accorded
for the transition towards the posthuman opens
contradictory interpretations. Authors that may provide
openings for posthuman sources like Houellebecq in thiscase can be interpreted differently so that the diversity ofreferences imply a variety of arguments as well.
In Žižek’s Sex and the Failed Absolute (2019), herecapitulates Uive steps in the evolution of sexuality. The
last one is a posthuman consideration that prospects onan asexual state: “with the prospect of posthumanity…
the scientiUically engineered asexual reproduction
cancels sexuality, which is also threatened by theprospect of asexual symbolic identiUications” (p. 159).
This perhaps conjectures on a higher probability that
posthuman sex is leaning not towards more sex but in its
extreme, asexuality.
Such a forecast is inherently
philosophical, or more particularly, ethical since it
reUlects as an attitude of the current ethos (Huxley,
1957). What it faces, however, is a consistent set ofparadoxes offering no linear path ahead.

207

References
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Dietz, A. (2019). Explaining the Paradox of Hedonism.
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Fukuyama, F. (1992). The End of History and the Last
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Hauskeller, M. (2014). Sex and the Posthuman Condition.
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Hawking, S., and Mlodinow, L. (2010). The Grand Design.
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Houellebecq, M. (2000). The Elementary Particles. New
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Houellebecq, M. (2005). The Possibility of an Island.
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New Bottles for New Wine: Essays (pp. 13-17).
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Kahambing, J. G. (2018). Without Sex: An Appraisal ofŽižek’s Posthumanism. International Journal of Žižek
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Kurzweil, R. (2005). The Singularity Is Near: When
Humans Transcend Biology. New York: Duckworth
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Nietzsche, F. (1974). The Gay Science (W. Kaufmann,
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Smith, K. (2018). We Live in Huxley’s Dystopia, Not
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Žižek, S. (2017). Incontinence of the Void: EconomicoPhilosophical Spandrels. Cambridge: The MIT Press.
Žižek, S. (2018). Like a Thief in Broad Daylight: Power inthe Era of Post-Humanity. Penguin.
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Eubios Journal of Asian and International Bioethics 29 (November 2019)

Pragmatic Organ Donation:
Reinterpreting Vroom’s
Expectancy Theory- Osebor Ikechukwu Monday
Department of General Studies (Arts and Humanities)
Delta State Polytechnic Ogwashi-Uku PMB 1030 Nigeria.
osebordarry@yahoo.com osebormonday1@gmail.com
Abstract
Organ transplantation is one area in which scientists
have achieved amazing results in the 21st century. The
shortage of organs remains a serious problem facing
medical science, yet, thousands of human organs buried
every day, especially from the victims of brain-dead.
Organ grafts are important in order to the treatment oforgan failure such as liver disease, kidney failure and soon, occasioned by acute medical conditions. This paper
contends that the root cause of organ shortages is thereliance solely on altruistic organ donations. The
altruistic organ donation is good, as far as they go, butthey do not leave far enough. We further argue that
Victor Vroom’s Expectancy Theory if successful should
expand the organ pool for transplantation.
Keywords; Motivation, Organ commerce, deceased
donor, posthumous organ sale altruism, organ pool
1. Preface
Altruism is a philosophy of the happiness of others. In
addition, altruism is a traditional philosophy in many
cultures, religion, and it is a secular understanding of
morality. In the extreme sense, altruism is a selUlessness
attitude and its opposite is selUishness. Suzanne (2012)
maintains that Auguste Comte used his 1851 coinage"altruism" (from the Italian adjective altruism, meaningothers' or other people's) to mean reUlective emotions
whose impulses worked to beneUit others, with ethicalconsequences. It is fundamental to have unselUishness in
our lives with the goal that our locale can Ulourish andprevail overall. Without benevolence, a network does not
Ulourish together. This absence of unselUish endeavors
towards a superior network will result in a narrowminded society spiraling into catastrophe. This is thereason while altruism is important for organ donation.
Furthermore, Helping other people and participating in
the network of organ donation will permit a promising
future for all, because we are parts of a whole. Getting
the message out of benevolence can guarantee this, givesome assistance to other people and others will tail us in
the walk towards a more brilliant, charitable futureespecially, to save life among candidates on the waiting
list for organ transplantation and recovery.
"To live for others," Comte (1852) writes in his
Catechism writes "Afford[s] the only means of freely
developing the whole existence of man. . . . None but thesympathetic instincts can have an unimpeded scope, for inthem each individual Linds himself aided by all others, who,on the contrary, repress his self-regarding tendencies”.
Titmuss (1970) argued that altruism is a system of
reliance on voluntary donation; the donation of bloodshould be largely in the hands of non-market system,
which is more effective than one that treats human bloodas another commodity. Critics would say that Titmuss’s
postulation is a protected principle of non-market supplyof human organs.
Moorlock et al. (2014) cite the NufUield Council of
Bioethics Report, that altruism as entailing a selUless gift
to others without expectation of remuneration. Steve,(2014) asserts that altruism is a matter, which setshumans apart from almost all other species. Although
there are examples of altruism in certain animal
behavior, they do not appear to exist at the same level ofcognition and consideration as in Man. Greg Moorlock, etal. further viewed altruism as a long taken guiding
principle, for the management and expansion of theorgan pool. It is an ethical principle of selUlessness, which
does not qualify the doer but another individual, who
may not be genetically related. Altruism holds that theindividual has an ethical commitment to help, serve
others; if important at the penance of personal
circumstance. Charitableness is the unbiased andsacriUicial worry for the prosperity of others. It is ademonstration to advance another person's welfare,even at a hazard or cost to oneself. Although altruistic
acts remain unclear whether and how rates would organ
donation increased. A mind boggling scenario arises;
would altruism go far enough to supply the neededorgans for human transplantation? (Steve, 2013)
Considering the relevance of altruism and the current
organ crises around the world, the interest for organtransplantation has quickly expanded everywhere
throughout the world amid the previous decade becauseof the expanded rate of indispensable organ
disappointment, the rising achievement and more
noteworthy improvement in post transplant results.
However, the unavailability of adequate organs fortransplantation to meet the existing demand has resulted
in major organ crises. In this sense, one would make acase for the insertion of incentive into the organ pool, inorder to expand the pool of organ donations. Altruism isgood, but it does not leave far enough to match the highdemand for viable organs among candidate on thewaiting list for organ transplant and recovery. Gneezy
and Rustichini (2000) argued that if incentive is inserted
into the organ pool, further performance will improveorgan donations into the organ pool (Sharp andRandhawa, 2014).
Moorlock et al (2014) also cite the NufUield Council
on Bioethics and reiterated the importance of altruism toexpand the organ pool. Altruism, long promulgated as
the only principled basis for the donation of bodily
material, and will continue to play a central role in moral
philosophy. While some of the claims made for altruism
may be overblown, the notion of altruism as
underpinning important communal values expresses
something very signiUicant about the kind of society inwhich we want to live.
Sharp et al (2014) argues that organ donation fromthe altruistic standpoint seems problematic, because, itcannot motivate the intending organ donors to registerwith the organ pool, without the individual opting out. In
this sense, altruism is a philosophy of goodwill andEubios Journal of Asian and International Bioethics 29 (November 2019)
volition. Humankind continues reliance on altruism forthe expansion of organ pool will fail because altruism
had failed to provide the needed surplus organs to matchthe high demand of organ grafts, for the treatment oforgan failure, among candidates on the waiting list fororgan allocation and recovery. We contend that thecontinued reliance on altruism for organ supply is one
among the cause of organ crisis, in this sense, incentives
would increased organ donation.
In America and Israel 1999-2010, the efforts of thesegovernments to increase organ donation in their states
have persisted, because they rely much on altruistic
donors, without applying the business philosophy ofmotivations/incentives. Osebor cites Heather that in1999, some 40,000 Americans were on the waiting list
for kidney transplantation. By 2009, the list had grown
to nearly 83,000 people, whereas only 16,500 people
received a transplant. In Israel, the number on thewaiting list for kidney donors has increased from 490 in2006 to 690 in 2010, while the number of kidneytransplants from deceased donors decreased from 87 to
65. At the same time, there was stepped up live kidney
donations from 54 to 78. Thus, taking into accounttransplants from both deceased and living donors, there
is only about one donor for every Uive potential
recipients, both in Israel and in the USA, 2010 (Osobor,2018). Gohh et al. (2011) would support the above
assertion that "currently, approximately 35000 patients
wait for kidneys in the United States, which represents a
2.5-fold increase from 1988 to 1997"
This review focus on the expansion of the organ poolthrough motivation not altruism, we argue that Victor
Vroom's Expectancy Theory of motivation if successful
could help to expand the organ pool for transplantation
and recovery.
2. Survey Of Victor Vroom's Expectancy Theory Of
Motivation
Motivation has been deUined and explained by various
philosophers, theologians, and managers. Pranav andShilpi (2013) cites the Cambridge Dictionary of
Psychology, deUine motivation as the willingness to makean effort in the pursuit of a goal. Motivation is thepossible utilization of resources, co-operation in work
environment, employees and employer goal-directed,
and achieving co-ordination in the work environment.
Pranav and Shilpi (2013) further assert that there arevarious theories of motivation. These theories can bedivided into two broad groups which are Content
theories that focus on individual needs and Process
theories that focus on cognitive processes (that occur inthe minds of employees) which motivate them. Examplesof Content Theories are -Maslow's Hierarchy of Needs
Theory, Herzberg's two Factor Theory, and McClelland's
Theory of Needs. Instances of Process Theories are Cognitive Evaluation Theory, Reinforcement Theory Goal
Setting Theory, Equity Theory and many others14.
Victor Harold Vroom is a Canadian businessphilosopher; he is currently at Yale school ofmanagement. Vroom was born August 9, 1932, and his
research interest concentrates on the expectancy theoryof motivation, work motivation, leadership, and decision-

209

making. Victor Vroom's expectancy theory of motivation
is a cognitive philosophy, which explains individual
distinction in work motivation (Lunenburg, 2011;
Vroom, 1964). The Expectancy Theory explains the
behavioral patterns of people, to choose a particularaction among different alternatives. For Vroom,
expectancy is the effort to choose a particular action, andperformance is the instrumentality for rewards(valence). Here, the individual believes that his/her
efforts are in relationships between performance andoutcomes. The expectancy theory says that individuals
have distinct sets of goals and can be motivated if they
have certain expectations. This theory is about choice. It
explains the processes that an individual undergoes tomake choices. Motivation, according to Vroom, boils
down to the decision of how much effort to be applied ina speciUic task situation. This choice is based on a twostage sequence of expectations (effort leads toperformance and performance lead to a speciUicoutcome/reward). The motivation in work environmentis important because it will lead to a good public image
in the market which will attract competent and qualiUied
people into a concern..
Pranav and Shilpi (2014) argue that Vroom's
Expectancy theory provides an arrange approach, for the
motivation of individual (employee), through amotivated type of calculations (rewards), that would be
beneUicial/ attractive to the employee. This will no doubt
motivate the employee to work toward achieving his/her
personal goals.
In our view, it's an assumption but true, that
Individual joining an organization is because of vitalneed, attracted by motivation, and the previous
experience or skill. The vital need will always inUluence
the behavior patterns/choice of the individual, especiallywhen chosen from different alternatives. In addition, thebehavioral patterns or choice of the individual will go along way to affect how they relate with the organization
they had joined. In spite of the fact that, there arecharges imposed against the idea of vital needs. Crucial
necessities approach needs logical meticulousness since
it excessively individualistic. It is hostile to development
and utilization situated; it is a formula for propagating
Uinancial backwardness, which makes class andindividual objective to be satisUied. We argue that vitalneeds are our most basic needs of survival; food to eat,water to drink, clothing for security, shelter for security,
acquiring all these we argue that they are not ahedonistic attitude, but a necessary need for humanity
The personal goals of the staff can be fulUilled,
through the organizational valence, master plan or work
outcomes. Therefore, the relationship between
organizational valence, master plan, and work outcomes,
should be tailored to the imperative need of theemployee. Thus; "what extent organizational reward
fulUils an employee's personal goals, and how attractive
are those rewards to the worker. This relationship canalso be expressed as the value, the worker gives to thework outcomes". Additionally, it is also important to notethat the organizational rewards/ valance or work
outcomes are dependent on the performance of the staff.
The level of the valence of the individual worker has to210

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

do with his/her performance. The higher the
performance/efforts, results could lead to a higher
reward, vice-versa. Lastly, the perception of theindividual staff that personal effort will lead to rewards
for performance is again important.
3. Philosophical constructs of Vroom's expectancy
theoryThere are three key constructs of the expectancy
theory of motivation;
Valence:
The valence is the effort, and it is a reward for
performance. When the recognized effort is low, thenmotivation will reduce, in this sense, human expectancy
and the instrumentality may be constant, one could saythat the value of effort is depended on the vital need of
the individual. The individual can be motivated to work
better if he knows that ‘better performance will lead to asatisfactory rating (rewards) in the form of recognition
for performance. Valence, Vroom will say that it is thevalue or strength, which individual/organization places
on a noteworthy effort20.
Expectancy:
Expectancy means effort which is related to performancefor a reward. "The expectancy is the subjective
evaluation of the degree of effort really related to theperformance and is the estimate of the probability toreach such performance” (De Simone, 2015). The factorsthat affects human perceptions of expectancy in theorganization include the self-esteem, the self-efUicacy, thesupport of colleagues, the availability of information for
the work activities, the availability of tools to performthe work
Instrumentality:
The instrumentality is the "personal assessment of how
the reward is related to the quality of the performance"
Instrumentality is the objectives, which an individual
ought to achieve (rewards). Thus, Vroom's motivation
theory can also be analyzed using mathematicalequations thus, Motivation = Valence x Expectancy x
Instrumentality22
4. Reinterpretation of Vroom's Expectancy Theory
for Organ Donation
A concise survey of Victor Vroom expectancy theory, one
could say that it is a philosophy of reciprocity in the
management of the organ pool. Pranav and Shilp (2014)
assert that "many experts in the Lield of organizationaland behavioral psychology holds that the Expectancy
theory is one of the most accepted theories of motivation,and that there are substantial evidence to support theclaim". The theory sees motivation as a philosophy thatinspires the intending organ donors, to apply for the
expansion of the organ pool, instead of sole reliance on
altruistic organ donation, which has contributed to organ
crisis. Although Richard Titmuss (1970) argued thatmonetary compensation for donating blood might
reduce the supply of blood donors. In our view, the“crowding out,” philosophy of Titmuss is not withouts ke p t i c i s m a m o n g e c o n o m i s t s a n d b u s i n e s sphilosophers, because the role of motivation issigniUicant to the business of organ donation, sincealtruism has failed to close the gap between the demandand supply of organs for candidates on the waiting list
for organ transplant and recovery. In this sense, we argue
that motivation of organ donors is necessary.
Victor H. Vroom (1964) deUines motivation as aprocess governing choice among alternative forms ofvoluntary activities. However, motivation is a processregulated by the choice of the individual. The individual
makes choices based on the estimates of how wellorganized the expected outcome, consequences, and the
behavioral patterns of the individual to match theeventually of the desired results. Additionally, Motivation
is a product of the individual's expectancy that a certain
effort will lead to the intended performance, theinstrumentality of this performance is to achieve acertain result, and the desirability of this result, is as
known as valence25. Motivation could be Internal orouter variables that animate want and vitality inindividuals to be consistently intrigued and focused onan occupation, job or subject, or to try to achieve an
objective. Motivation results from the communication ofboth cognizant and oblivious factors, for example, the (1)power of want or need, (2) motivator or reward
estimation of the objective, and (3) desires for theindividual and of his or her companions
A critical question arises "Would people get their
desired rewards, even when they agree to donate organs inorder to save candidates on the waiting list for an organtransplants and recovery?” The insertion of motivation
into the organ pool is the expectancy that represents thepotential organ donors' conUidence, trust for registration,
the instrumentality for reward, agreement withconsistencies, and without default.
In my view, motivation is the conUidence and theingredient for the expansion of the organ pool. Ioan
Moise et al. (2013) argue that "Motivation is the art ofgetting people to do whatever you want them to do
because they want to do it”. Stefania De Simone (2015)
maintains that Expectancy theory is more concernedwith the cognitive antecedents that go into motivationand the way they link to each other. It deals with acognitive process based on the idea that people appear
to be in relationships because the effort they put at work,
the performance they achieve from that effort and therewards they receive from their effort and performance.
In other words, people will be motivated if they believethat a strong effort will lead to good performance andgood performance will lead to desired rewards.
The expectancy theory will be a dream in thepipeline, without the active and a sincere participation of
the managers of the organ pool. Vroom over assumed in
his postulation that all the potential organ donors are
already been known. The theory also seems lacking
because it fails to come up with grips- fact about donors
needs. Some donors may be more interested in intrinsic
rewards and not extrinsic rewards vice visa28. Vroom
could not expand the scope of rewards to accommodate
the unique needs of the potential organ donors. This is
our view makes the theory more idealistic andprobabilistic, instead of a utilitarian moral philosophy. In
this sense, individuals will pick among options in orderto streamline results for them identity. Vroom's

Eubios Journal of Asian and International Bioethics 29 (November 2019)
hypothesis accept that conduct results from cognizant
decisions among choices whose reason it is to expand
delight and limit torment.
I argue that, it would be misleading to assume that all
potential organ donors desire the same type of rewards
in order to register with the organ pool without optingout.. Pranav and Shilpi (2014) would support the above
assertion that Vroom did not provide the exact solutions
to the motivation problems, the model also assumes thatpeople are rational and logically calculations therefore,
there is no need to expands the scope of incentive to
make a choice, such assumption in our view, makes thetheory to be too idealistic instead of a practical businessphilosophy. In this sense, the expectancy model attempts
only to mirror the motivational complex prices. It does
not attempt how motivational decisions are actually
made.
However, if one could reinterpret Vroom correctly,
valence means reward for performance, and it is an
instrument of performance. Here organ donors may
value promotion in the workplace or a pay raise, whereas
others may prefer additional vacation days, improved
insurance beneUits, daycare, or eldercare facilities etc., soit depends on what are the vital needs of the individual30
To expand the scope of organ pool, rewards should
accommodate different vital needs; these we argue that
it would lead to more registration of potential donors,
without opting out from the organ pool (Lunenburg,,2011). The above view would encourage moretransplantable organs from donors and would improvehealth outcomes for those with end stage renal disease
and reduce the annual cost per patient. Donating organs
is no walk in the park, but the medical risks are very low
because it is a posthumous organ donation.
The
managers of organ pool should think outside the box,
and making visible studies, about the needs of thepotential organ donors, to ascertain their value as
rewards (valence). They must also accurately assess thepotential donors' capabilities (expectancy) and makeavailable all of the appropriate resources to help them
live a happy life in the society. "The managers can be
beneLitted from the expectancy theory as it assists them tounderstand the psychological processes that cause
motivation. The thinking, perceptions, beliefs, estimates ofchances and probabilities and other such factors ofworkers strongly inLluence their motivation, performanceand behaviour”. The Expectancy Theory to candid is
psychologically appealing, which is built on common
sense theory. The theory explained the scope ofmotivation, through the linkages of efforts, performance,
rewards and personal goals
Therefore, managers of the organ donor pool should
create a conducive environment/climate and culture thatwill increase the motivation levels of the potential
donors, by understanding the factors that motivate andde-motivate organ donors.. Managers of organ donation
pool should expand the scope of incentives for organ
donors to make choice. Amitai (n.d.) asserts that the
Uinancial incentive approach to increasing rates of organ
donation has gained support from several groups andindividuals, including some segments of the medical
community. The American Medical Association (AMA)211

has expressed support for partial Uinancial incentives,
and the United Network for Organ Sharing and Organ
Procurement and Transplantation Network (UNOS/
OPTN) have also recently released a statement endorsing
the study of potential Uinancial incentives for organ
donation. (Some proponents of commodiUication holdthat donors should be paid but that organs should not besold. (Osobor, 2018).
Critics of organ procurement of incentive would saythat the applying incentive in organ harvesting, would
lead to organ marketing. Carl would say that theeconomic incentives may sometimes backUire. To somemoral philosophers incentives for organ donation would
actually decrease because of backlash from current
donors who may feel that Uinancial compensation
undermines their altruistic organ donations. We may notrefute the above assertion but we argue that organ
procurement for incentive would be regulated by law to
avoid malpractices, otherwise, the sole reliance on
altruism for organ donations, would lead to more humanorgans been buried without registration into the organ
pool. The purpose of incentive is to mitigate Uinancial
loss which living donors and an encouragement toregister with the organ pool for posthumous donation.
The shortage of cadaver organs imposes a severe
limit on the number of patients who could potentiallybeneUit from transplantation. Osebor opines that
unfortunately numerous organs are buried rather thandonated; the reason for this loss is because, inter alia,
potential donors and their families fear that the
distribution of donated organs is unfair, and also that
potential donors may receive less aggressive medicalcare. This fear, of course, has contributed to worsening
the organ crisis.
Montana and Charnov (2008) contend that theory
emphasizes the need for organizations to relate rewards
directly to performance and to ensure that the rewards
provided are those rewards deserved and wanted by therecipients Pranav and Shilpi (2014). cite Koontz andWeihrich that "the expectancy theory recognizes theimportance of various individual needs and motivation. It
thus avoids some of the simplistic features of othermotivational theories such as Maslow and Herzberg
approaches. It appears to be more realistic. It serves toharmonize individual goal with organizational objectives.
And it is compatible with the system of managing by
objectives"35
Vroom's Theory of Expectancy theory is not aphilosophy of Organ commerce, presumed consent,
posthumous organ sale but posthumous organ donations
by expressed consent. It is a philosophy of explicit
consent of the individual. Osebor cites Segen that
“explicit consent is a clear and intentional indication ofpreference or choice, usually oral or written, and freely
given in circumstances where the available options andtheir consequences have been made clear (informed
consent). As set out in the UK, express consent
constitutes formal permission to undergo a diagnostic ortherapeutic procedure or to allow the use of personallyidentiUiable information for research, epidemiology,
Uinancial auditor administration, publication and/or torelease into the public domain, without express consent,

212

Eubios Journal of Asian and International Bioethics 29 (November 2019)the use of such materials is limited to teaching andtraining”.
However, intending donors are motivated to register,
either as a living donor or as a posthumous organ
donation.
Regrettably, we do not see living organ
donations' as totally altruistic, because it amounts toputting one's life at risk for the survival of another. Fortin
et al. (2010) argues that wanting to donate one's heart
while still alive, or donating a portion of one's lung or
liver would not qualify as altruistic intentions or acts
because it would involve sacriUicing or risking one's life
in order to contribute to another person (Osebor, 2018, p.
18).
For some moral philosophers, there are threesituations which will not be considered as altruistic acts;
helping someone while harming another person, dying
for a cause, and neglecting loved ones in order to bail out
strangers. In this sense, the value of individual life isworthy and should be safeguarded from any kind of
harm. Donating organs, while still alive, in our opinion isan act of inviting harm to oneself. The NufUield Council
on Bioethics Report on Critical Care Decisions on for the"sanctity of life.” (Sarah and John, 2014). Here, all human
lives are of equal (and possibly absolute). Living organ
donation is a calculated exchange of life with another. We
submit that donating bodily material while still alive isunethical and must not be called altruism but organ
commerce, in this, we subscribed to posthumous organ
donations by expressed consent.
Critics like Porter and Lawler (1968) argued that the
expectancy theory is a cognitive hedonism, which
proposes the distinct cognition to choose a course ofaction for the greatest degree of pleasure and withsmallest degree of pain. Yes of course! The principle ofpleasure is to gratify ones "immediate needs and wants"and "avoid pain."We, humans, are seeking the pleasure! It
is our very nature as human beings. We seek pleasure
because it can make us happy and can give us enjoyment.
Through pleasure sensations, we assume that our needs
will be met (Kristoffer, 2011). Pleasure could be viewed
as an incentive for organ donation, but not hedonism, inthe actual sense, pleasure means motivation of thepotential organ donors, to register with the organ pooland save humankind that are on the waiting list for organtransplants and recovery.
Further interpretations of vroom expectancy theory,
one would argue that he is a neoclassical businessphilosopher, who tends to explore the materialistic
aspect of human cognition through the assertion thatpeople's preferences from different alternative is basedon taste, attracted by incentives. Incentive is interpreted
in form of money to buy the vital need. The vital need isthe primary concern of all beings (including animals) for"survival. Mellström and Magnus (2011) cite Frey andOberholzer argued that the introduction of monetary
payments may reduce the intrinsic motivation to behave
altruistically or perform one’s civic duty.
Furthermore, the high and progressively neglected
requirement for transplantable organs prompts
numerous eyewitnesses – including us – to trust that
now is the ideal opportunity to reexamine motivation oforgan donors. I subscribe to the fact that unregulatedorgans would be morally wrong. A superior option isneeded and would be an open organization with solespecialist to give incentives and related motivations toorgan donors, after would-be benefactors are screened
for good physical wellbeing as well as to guarantee thatthey are settling on an educated choice after cautious
reUlection. Indeed, even with shields, some state that
putting a cost on body parts will undoubtedly be
dehumanizing (Cook and Krawiec, 2014). However thebuy or closeout of human organs isn't permitted by law,as indicated by the National Organ Transplant Act(NOTA) and the Uniform Anatomical Gift Act. At present,
the main type of incentive that is lawfully admissible
incorporates repayment for living organ donors' andcosts related with ''travel, lodging, and lost wages(Shaikh and Bruce). We argue that compensation andreimbursement of living organ donors’ is the philosophyof vroom’s expectancy theory.
In conclusion, Vroom expectancy theory is an
incentives philosophy, which attracts potential organ
registration. With the application of expectancy
philosophy into the organ pool, organ donors areboosted by rewards and incentives. This is a committed
effort, for the management of the organ pool. In thissense, I argue that more potential organ donors, who arewillingly and happily participating in the project of organ
registration, will expand the organ pool, in order to savemore candidates on the waiting list for organ transplants
and recovery.
References
Amitai E (n-d). Organ Donation: A Communitarian Approach.
Https://www2.gwu.edu/~ccps/Organ_Donation.pdf
Comte, A. (1852). Catechism positivist or Catechism of
Positivism, trans. R. Congreve, London: Kegan
Philip J. Cook and Kimberly D. Krawiec, “A Primer on Kidney
Transplantation: Anatomy of the Shortage.” Law andContemporary Problems 77, no. 3 (2014).
Marie-Chantal Fortin, Marianne Dion-Labrie, Marie-Jose Hbert,
Hubert Doucet. (2010). The Enigmatic Nature Of Altruism
In Organ Transplantation: A Cross-Cultural Study Of
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Gneezy, Uri, and Aldo Rustichini (2000). “A Fine is a Price.”
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Ioan Moise Achim, Larisa Dragolea, George Balan (2013). The
Importance Of Employee Motivation To Increase
Organizational Performance.
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Kristoffer, l. (2011). Man as "Pleasure-Seekers": The Nature ofbeing civil". http://besoy013.weebly.com/academicrequirements-papers/man-as-pleasure-seekers-the-natureof-being-human
Lunenburg, F. C. (2011). Expectancy Theory of Motivation:
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Montana, P. Charnov, B. (2008). Management. Barron's
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Ethical Implications.
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Monaco. (2011) Controversies in Organ Donation: The
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Steve W. (2013) Altruistic organ donation. Word press,
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Open for signature from 1 March 2002

Eubios Declaration forInternational Bioethics[The Eubios Ethics Institute and the Tsukuba Bioethics
Roundtable Declaration on International Bioethics;
Reprinted from EJAIB 12: 46-48 (March 2002)]
Preamble
The life and medical sciences present many importanteducational, ethical, legal and social issues, which need tobe considered at local, national and international levels.
Following the closure of the Seventh International Tsukuba
Bioethics Roundtable (TRT7), and the discussion at thepreceding six TRT meetings, and consistent with the statedgoals of the Eubios Journal of Asian and International
Bioethics (EJAIB) and the decade of debate that has
appeared in EJAIB, the members of Eubios Ethics Institute,and the further undersigned persons, wish to highlight thefollowing principles for international bioethics:
Descriptions of Bioethics
Bioethics is an interdisciplinary field that needs to be
nourished by debate among all disciplines and people, notlimited to any academic specialty or professionals.
There are a variety of definitions of bioethics, and this variety
is part of the intrinsic value of the field of bioethics. We
consider bioethics to be the process of reflection over ethicalissues raised in our relationships with other living organisms;
the consideration of the ethical issues in spheres including
environmental ethics, health care ethics, social ethics, and in
the use of technologies that affect life; and the love of life.
Bioethics has grown rapidly throughout the world, and shouldplay a central role in professional and public discussions anddebates, and bioethical issues feature prominently in legal,
medical, scientific, and policy agendas worldwide.
Bioethical principles proposed by bioethicists may vary intheir number, names, and organization, yet sufficientconvergence exists to allow us to endorse the ethical valuesof respect for persons, doing good (beneficence), doing noharm (non-maleficence), and justice. Moreover, the virtues ofthe moral agent and his/her relationship to others and theenvironment are emphasized. The examination of theseprinciples is part of bioethics.
5. There are different ways to view bioethics and in
discussions of bioethics we should be clear which approach
we are addressing. These include:
Descriptive bioethics – understanding the way people view
life, their ethical interactions and responsibilities with livingorganisms in their life.
Prescriptive bioethics or normative bioethics examines
what is ethically good or bad, or what principles are mostimportant in making such decisions. It may also be to inquire
into when to say something or someone has rights, andothers have duties to them.
When one person tells another what is ethically good or badthey are prescribing bioethics. If prescriptive bioethics leads
to paternalistic elitism, then we reject it.
6. There are at least two essential approaches to bioethics:
Interactive bioethics is discussion and debate between
people, groups within society, and communities about
descriptive and prescriptive bioethics.
Practical bioethics is action to make the world morebioethical, for example, health projects for medicallydeprived populations, and environmental activism.

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

Personal and Global Bioethics
7. Every person has a lifelong responsibility to develop his or
her own bioethical maturity and values. We could definebioethical maturity as the ability to balance the benefits andrisks of ethical choices, considering the parties involved andthe consequences. At the societal level, public policy and law
need to be developed, which requires a social mechanism
for balancing conflicting ethical principles.
8. International cross-cultural bioethics should be developed,
including studies and discussions, which respect individual
cultures as long as they do not conflict with fundamental
human rights, as outlined in the United Nations Declarationof Human Rights. Nations and members of every society(communities) should honestly reflect on the bioethicallessons of the past. Honest reflection on the bioethicallessons of the past should be encouraged together withefforts to promote reconciliation on all levels.
9. Research on the thinking and reasoning of all people
should be more emphasized in order to understand thediversity of people's thinking. This is necessary for
determining the degree of universality that is possible, andshould be used to complement other research approaches inbioethics. There is no inherent reason to believe a priori thatthe views of one person are intrinsically more valuable thananother, based on gender, age, educational background,physical, mental, or psychological condition or life
experience.
10. Such ethical understanding is necessary to developinternational cross-cultural bioethics, and no one culture
should claim to be the dominant source of the concept ofbioethics.
Freedom of dialogue
11. Freedom of discussion is necessary for bioethicalreflection and an essential feature of democratic life. We
uphold the value of free, open and reasoned discussion, sothat any position is worthy of consideration. In public
discourse, no individual or group can claim to have exclusive
knowledge of the right ethical solution. Only open discussion
can lead to justifiable conclusions.
12. All nations and communities are encouraged to vigilantly
defend the basic freedom of open discussion anddisagreement. Often, this freedom is imperiled and there is
widespread reluctance to discuss problems openly, thereasoned solution of which may run counter to received
opinions and traditions.
Life as a Whole
13. We recognize the dependence of all life (biota) on intact,functioning ecosystems, and the essential services that
ecosystems provide. We urge action to halt environmental
damage by humans that reduces biodiversity or degrades
ecosystem processes.
14. Whereas wildlife provide numerous free services thatmake our life possible and pleasant, cleaning the air, water,
and the soil of pollutants, providing food, medicines and abeautiful place to live, wildlife are in grave danger from theloss of habitat, the spread of exotic species, pollution, anddirect consumption by humans. Wildlife often cannot protect
themselves from humans, so without our help they cannot
survive. The presence of humans greatly reduces theusefulness of a habitat to wildlife. Wildlife reserves act assources for replenishing our supplies of animals and plants.
Therefore, we urge all nations and peoples to make theprotection of wildlife and wildlife habitat a top priority. In
particular we urge them to set aside a large portion of theirterritory, interconnected by the wildlife travel corridors, for the
exclusive use of wildlife, off limits to humans.

Intellectual Property
15. We believe that life is the common heritage of life, and noone group of persons can claim to own a living organism so
as to stop others growing similar organisms.
16. No part of the human body (DNA, gametes, genes, cells,
tissues or organs) should be exploited as a source of profit.
We oppose exploiting people from some countries or groups
to do things that are unacceptable in other countries, forexample trade in human organs, unethical or dangerous
drug trials, or dumping of hazardous wastes, including
nuclear wastes.
Technology assessment
17. We applaud the development of science and technology
if for the betterment of all, and urge the better sharing of thebenefits of technology with all.
Practical methods forappropriate technology (both new and traditional) transfer
should be effected, together with mechanisms to assess thecultural, environmental, ethical, social and health impacts ofsuch technology. Encouraging simpler technologies canoften be preferable to transfer of advanced scientifictechnology.
18. In particular, we call upon all those in the researchcommunity to use any appropriate technology to reduce theburden of diseases and afflictions, both mental and physical,
that afflict persons in all societies, and in particular indeveloping and least developed countries.
19. We do not think that any one technology with the samegeneral goals, like feeding hungry people or curing a given
individual patient, should be singled out for more criticalexamination, rather that bioethical principles should beapplied to protect the interests of living organisms today, andthe future generations.
Ethics Committees and Consent
20. In order to effect this, ethics committees with fullcommunity and ethnic representation, for the purpose ofreviewing research proposals, and monitoring the impact ofscience and technology, should be established immediately.
21. In principle, all research on humans that has the rational
potential to harm should be validated by the documented,
informed consent from competent participants, which isvoluntary and noncoerced. There are important issues todiscuss regarding consent from communities, and we urge
further study on these issues.
We must devote more
research to the topic of research on human subjects wholack the capacity for fully informed consent, such as inpediatric and psychiatric medicine.
Human reproduction and genetic heritage
22. Somatic cell gene therapy for treatment of disease is a
useful medical therapy and may be used when needed andchosen by patients.
However, germ-line gene therapy
should not be attempted until it is technically safe, and a truly
international public consensus has been sought andachieved for what specific cases would be considered
ethical.
23. Therapeutic cloning, for example of tissues or organs,may be a useful medical therapy and may be used whenneeded and chosen by patients.
However, humanreproductive cloning should not be attempted until it istechnically safe, and a truly international public consensus
has been sought and achieved for what specific cases would
be considered ethical.

Eubios Journal of Asian and International Bioethics 29 (November 2019)
Duties to all persons
24. We respect the life of all living organisms, Whenconsidering organisms we have to think of not only those on
the planet Earth now, those that will be brought back to alivefrom the state of being extinct, those made in the future
through natural or deliberate creation, and those that exist inother places. We should consider all persons, no matter theirbody or mental composition, for their intrinsic value and nottheir makeup. Society should consider the use of technology
to reintroduce extinct species or introduce new species tothe ecosystem.
25. We urge reflection on the way that we will treat nonorganic (e.g. robots) or hybrid (e.g. cyborgs) persons, before
they are made. All persons who work towards the love ofothers should be valued as a member of the moral
community. Many persons in this world are not valued
because of speciesism and we uphold the rights of all Great
Apes and other beings capable of loving others andconscious thought.
Bioethics Education
26. To work towards a social consensus requires
participation of informed citizens, which requires education
about issues of bioethical importance. We applaud the public
discussion on bioethics that has started to emerge in a
number of countries, but these efforts need further support.
27. In order to achieve the above goals, greater effort isrequired to educate all members of society about thescientific and clinical background, and the ethical principles
and social and legal problems involved, in the life andmedical sciences. This will enable the active collaboration of
all individual members of society, many academic disciplines,
and the international community.
28. Education of bioethics is to empower people to faceethical dilemmas. Ethical challenges come to everyone. The
process of debate and discussion is important for developing
good minds to face bioethical dilemmas. It also develops
tolerance and respect of others. In these troubled
international times, it is very important to develop toleranceof others, and to learn that everyone as a human being is thesame regardless of race, sex or religion. Same in this sensemeans equally diverse, it does not mean identical.
29. The process of debate and discussion in classrooms isparticularly valuable and we urge all persons, organizations,institutions and countries to take appropriate measures topromote the principles set out in the Declaration, throughpromotion of education in bioethics.
A call to practical ethics now
30. States and institutions should take appropriate measures
to encourage all forms of research, training and information
dissemination conducive to raising the awareness of society
and all of its members of their responsibilities regarding thefundamental issues relating to bioethics, in an open
international discussion, ensuring the free expression ofvarious socio-cultural, religious and philosophical opinions.
31. These goals require the cooperation of all, particularly inthose with more resources, such as multinational
corporations, and rich countries.
We urge all to work
together for all.
Open to improvement and signature
32. We note that progress towards reflection of bioethics canbe made by every person, in both official and unofficial ways,
and the undersigned endeavour to help all who want toprogress the development of bioethics through the social
network of members of the ever diverse, growing and nonexclusive Eubios family.

215

33. This Declaration will be open to signature and text
agreement until a period two months after the publication of
the draft Declaration in EJAIB (March issue), when the
Declaration will be published.
Further persons andorganizations are welcome to endorse, second, or otherwise
use the principles in this Declaration to promote bioethics inthe spirit of this Declaration. This Declaration will also be
known by its simple form, the Eubios Declaration forInternational Bioethics. As knowledge and experience
progress, this Declaration will always be open to revision.
We invite the world to participate.
Declared on the 1 March 2002, and open to signature. Online: http://www.biol.tsukuba.ac.jp/~macer/eeidec.htm
Please return your comments and support by Email to:
Dr. Darryl Macer, Director, Eubios Ethics Institute, Japan
and New Zealand (darryl@eubios.info)

For forthcoming conferences see:www.eubios.info
https://www.eubios.info/
youth_peace_ambassadors_international/
ypa20_kitami_hokkaido
20th Youth Peace Ambassadors Training
Workshop (YPA20) and Indigenous Leaders Global
Summit, Kitami, Hokkaido, Japan, 17-22 August 2020.
Followed by the Second AUSN-Tohoku University
Bioethics Roundtable: Cross Cultural Bioethics
Addressing Advanced Technology: The eirst 20 years
into the 21st Century, 24-27 August 2020. Details andthe draft agenda of these two conferences are on thelinked website. Contact: darryl@eubios.info

Email to Darryl@eubios.info.
EJAIB Editor:
Darryl Macer (Chair, Accredited Universi7es of Sovereign
Na7ons)
Associate Editor:
Nader Ghotbi (Ritsumeikan Asia Paciﬁc University, APU))
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany),
Rhyddhi Chakraborty (India/UK), Shamima Lasker(Bangladesh), Minakshi Bhardwaj (UK), Chris7an Byk(IALES; France), Ken Daniels (New Zealand), Ole Doering(Germany), Amarbayasgalan Dorjderem (Mongolia),
Hasan Erbay (Turkey), Soraj Hongladarom (Thailand),Dena Hsin (Taiwan), Rihito Kimura (Japan), Abby Lippman(Canada), Umar Jenie (Indonesia), Nobuko Yasuhara
Macer (Japan), Masahiro Morioka (Japan), Anwar Nasim(Pakistan), Jing-Bao Nie (China, New Zealand), Pinit
Ratanakul (Thailand), Qiu Ren Zong (China), Hyakudai
Sakamoto (Japan), Sang-yong Song (Republic of Korea),
Takao Takahashi (Japan), Noritoshi Tanida (Japan),
Ananya Tri7pthumrongchok (Thailand), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republic ofKorea).

216

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

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