Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 28 (3) May 2018www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2018 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page
Editorial: Health and Technology
81- Darryl Macer
Ethics and Risk Factors for Esophageal Cancer &Awareness of Cancer Related Health Services Among
Adults in Rural Kilimanjaro, Tanzania: A Prerequisite forCancer Down Staging
82- Josephine Joseph Mwakisambwe, Fred Kasasi, Elia J
Mbaga and Darryl Macer
Jahr’s Bioethical Imperative & Euthanasia
95- Michael Cheng-tek Tai and Phyllis Hsu
HIV/AIDS Health Promotion: Coverage of disabled
people within academic literature and Canadiannewspapers
98- Syeda Farwa Naqvi and Gregor Wolbring
Is Organ Farming a Panacea to Organ Crisis? EthicalImplications
103- Osebor Ikechukwu Monday
Sharp Safety Curriculum for Health Workers
109- Guntur Heri Putranto and Winny Setyo Nugroho
ABA Renewal and EJAIB Subscription
111
Eubios Ethics Institute Books
112

Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President,
American University of Sovereign Nations (AUSN)
Email: darryl@eubios.info
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Publication Ethics (COPE) Publication ethics andmalpractice policy. All potential authors shouldhave read these guidelines and by submission of anarticle for publication you acknowledge that you
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Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: Health and Technology
This issue of EJAIB considers themes in healthand technology with papers from Tanzania, Canada,
Indonesia and two others addressing generalphilosophical issues of bioethics.
Technology can bring about many benefits forusers if they have access to services. The first
paper by Dr. Josephine Mwakisambwe and colleagues

presents an analysis of knowledge and access to cancer
services, and in particular, Esophageal Cancer, in rural
Tanzania. Similar circumstances may exist in many
countries, and effective public health programs can also
reduce the incidence of cancer. Although there are also
public education programs in many countries, theeffectiveness of these programs is unclear.
Michael Tai and Phyllis Hsu take us back to theorigins of bioethics, and how the bioethics of Fritz Jahr,
the first person to actually use the term Bioethics, in
1927, can be useful for persons in Asia, and around theworld, as they contemplate the question of euthanasia.
Syeda Farwa Naqvi and Gregor Wolbring review theliterature on HIV/AIDS Health Promotion, which is justas critical as it was two eacdes ago, even though soe
complanaceny is seen because of the greater access toantiretoriiral drugs nowadays that may allo persons
living with HIV to maintin a reasonable quality of life
(QOL). Guntur Heri Putranto and Winny Setyo Nugroho
review the literature on Sharp Safety, and found sevenkey elements for the curriculum.
Osebor Ikechukwu Monday asks whether organ
farming is a panacea to the Organ Crisis, or whether it isunacceptable. There are many views on where we canobtain organs to save human life, and whether
xenotransplanatation is an ethical solution to overcome
the organ shortage. Osebor writes from a Nigerian
perspective on some of these questions, with broad
applicability.
. - Darryl Macer

82

Eubios Journal of Asian and International Bioethics 28 (May 2018)

Ethics and Risk Factors for
Esophageal Cancer & Awarenessof Cancer Related Health Services
Among Adults in Rural Kilimanjaro,
Tanzania: A Prerequisite forCancer Down Staging- Josephine Joseph Mwakisambwe, M.D., MBGPH
Kairuki Hospital, 322 chwaku street, Mikocheni,
P O Box 63500 Dar es Salaam, Tanzania;
Dalian Medical University, China; Research Felllow, American
University of Sovereign Nations, Arizona, USA; Email:jjmwakisambwe@yahoo.com- Fred Kasasi, M.D, M.P.H
Mayogu Muhimbili University of Health and Allied Sciences. P
O Box 65001, United Nations Rd, Dar es Salaam, Tanzania
Email: kasasimayogu@gmail.com- Elia J Mbaga, M.D., Ph.D.
Muhimbili University of Health and Allied Sciences. P O Box
65001, United Nations Rd, Dar es Salaam, Tanzania Email:eliajelia@yahoo.co.uk- Darryl Macer, Ph.D., Hon.D., MPH
President, American University of Sovereign Nations, Arizona,
USA Email: provost@ausn.info

Abstract
The mortality and morbidity resulting from noncommunicable diseases including cancer in sub- SaharanAfrica are predicted to overtake that of infectious
diseases by the year 2030. Esophageal cancer is on theincrease in Tanzania. This study estimates risk factors
for esophageal cancer, ethical issues and the level ofawareness of cancer related services among adults inrural Kilimanjaro. A cross sectional descriptive study
was conducted of adults aged 18 years and above inthree wards, namely, Kahe, mabogini and Arusha Chini,
Moshi Rural District, Kilimanjaro region. Face-to-faceinterviews were conducted with a total of 419
individuals. The mean age was 36.47 (standard deviation(SD) =13.49) years. Of those who participated, 211(50%) were male and 60% reported to have completed
primary education. A majority (71%) of participants
were knowledgeable about esophageal cancer risk
factors. Overall, 15% and 23% of the participants
reported to have been smoking and drinking alcohol,
respectively. Male respondents were almost three times
more likely to be smokers as compared to female
respondents (OR=2.696; 95%CI: 1.372, 5.299; p=0.004).
Moreover, people who were self-employed were about
five times more likely to be smokers as compared tothose who were unemployed. (OR= 4.847; 95%CI: 1.019,
23.05; p=0.047). Male respondents were almost two
times more likely to be drinkers as compared to female
respondents (OR=1.918; 95%CI: 1.097, 3.351; p=0.022).
Overall, the level of awareness of cancer related healthservices was about 70%.
The study findings confirm that despite a good level ofknowledge about risk factors for esophageal cancer, thepractice of exposure to risk factors is alarmingly high.
Awareness of where to seek cancer related healthservices was high with hospitals been mentioned by the
majority though there was low understanding on

modalities of treatment among adults in Rural
Kilimanjaro. Intervention measures should aim at
further increasing knowledge of cancer risk factors andreduce the practice of such risks. Ethical matters
including truth telling, ageism and autonomy need to beaddressed to improve the perception of cancer related
health issues and health seeking behaviour.
1. Introduction and Objectives
Cancer is one of the Non-communicable Diseases(NCDs) that are becoming a public health problem
globally. It is an increasing problem in Africa because of
aging and growth of the population as well as increased
prevalence of risk factors associated with smoking,alcohol, obesity, physical inactivity, and reproductive
behaviors, and of certain infectious agents of importancein cancer etiology. Cancer affects the majority of the
body parts including the esophagus. Symptoms often
include difficulty in swallowing and weight loss. Other
symptoms may include pain on swallowing, a hoarse
voice, enlarged lymph nodes (glands) around thecollarbone, a dry cough, and possibly coughing up or
vomiting blood. Cancer is among the causes of morbidity
and mortality worldwide, with approximately 14 million
new cases and 8.2 million cancer related deaths in 2012
expected to rise to 22 within 20years (WHO, 2014).
Esophageal cancer (EC) is one of the least studied anddeadliest cancers worldwide and it is the sixth among all
cancers in mortality (Res., 2011; Practice, 2008).
Esophageal cancer types include squamous cell
carcinoma and adenocarcinoma. Studies show that,smoking, drinking hot tea, red meat consumption, poor
oral health, low intake of fresh fruit and vegetables, andlow socioeconomic status are some of the risk factors ofesophageal cancer. Furthermore, Barrett’s esophagus isclearly recognized as a risk factor for the cancer, anddysplasia remains the only factor useful for identifying
patients at increased risk, for the development ofesophageal adenocarcinoma in clinical practice (Yuwei,2013).
Esophageal carcinoma affects more than 450,000
people worldwide with rapid increase and about 75% of
the cases diagnosed in Asia (Siegel, 2015). The overall 5year survival of patients with esophageal carcinoma
ranges from 15% to 25%. Diagnoses made at earlier
stages are associated with better outcomes than thosemade at later stages (Pennathur, 2013).
In Africa, there are 715,000 new cases and 542,000
cancer deaths annually (Jemal, 2008). Malawi has
highest number of cases of EC of 24 per 100,000. In SubSaharan Africa, it was the 5th commonest cancer with
15,150 male cases and 7,200 female cases estimated tooccur in 2002. Esophageal cancer is increasing in the
Sub-Saharan African Region and varies geographically.
This is due to various reasons such as lack of awarenessand knowledge on the disease in the public globally(FitzGerald, 2008; Hemantha, 2010; Duron, 2013).
According to the report done at Ocean Road Cancer
Institute (ORCI) for the period between 2006 and 2009,
the number of new cases of EC per year increased from181 per year in 2006 to 307 cases per year in 2009
(Mamsau, 2013). Oncologists at ORCI have noted ahigher number of EC patients referred from the
Kilimanjaro region than other regions of Tanzania,

Eubios Journal of Asian and International Bioethics 28 (May 2018)
despite similarities of population between regions,distance between the consultant hospital in the region
and ORCI, and quality of roads between the consultant
hospital and ORCI. It is shown that Male patients 55
years and older had higher incidence of esophageal
cancer than female and younger patients (Ngoma, 2016).
The majority of esophageal cancer patients in
Tanzania are diagnosed at advanced disease stages(stage III and IV) at palliative stage when little can bedone (70-80% of the cancers) despite the efforts done by
the Government through MNH and ORCI and othercancer screening programs that play part in treating
cancer patients (Ngoma, 2006). These increased numberof esophageal cancer cases have led to the increased
early/ premature deaths, increased morbidity, increased
disability and social discrimination.
Studies have shown there is poor knowledge of cancer
in Kenya and other developing countries. Due to a lack ofstructured health education programs, it is assumed thatknowledge of cancer and its associated symptoms, andrisk factors is also poor in this region of Kenya (Duron,2013). However, there is limited information on theprevalence of risk factors and knowledge of EC andawareness of cancer related health services in Tanzania.
It is also not known the extent to which people
understand the risk factors for EC to inform
development of educational materials. Therefore thisstudy will show the prevalence of risk factors andknowledge of esophageal cancer and illuminate on the
ethics and awareness of cancer related health services
among adults living in Rural Kilimanjaro, Tanzania.
Socio-economic-demographic characteristic e.g. sex,
gender, occupation, income, level of education andhistory of having a relative who had Esophageal cancer
can influence the knowledge on EC and practice of risk
behavioral factors of esophageal cancer e.g. smoking,alcohol intake directly. But also knowledge of EC may
have an influence the practice of risk behavioral factorsof EC directly. These may also determine accessibility ofhealth facilities. Accessibility of health facilities may also
determine the knowledge and behavioral factors throughthe education and treatment offered at the hospital.
This study will assist knowing the extent of risk ofwhich will help the policy makers to identify geographic
areas needing special consideration. Also the study will
help in knowing the risk factors and its determinants
that will help in designing intervention measures toaddress EC. Ethical matters surrounding will also be
illuminated in hope that policy makers will tackle suchsaid issues. Lastly, the findings will help to downstage
cancer. This is the first study in Tanzania to provide suchinformation for Kilimanjaro region.
The main objective is to determine the level ofknowledge and extent of practice of esophageal cancer
risk factors among adults in rural Kilimanjaro region,
and what is the level of awareness of and ethical issues
facing cancer related health services among adults in
Rural Kilimanjaro. Specific objectives include:
1. To determine the level of knowledge of esophageal
cancer risk factors among adults in Kilimanjaro. 2. To
determine the practices associated with esophageal
cancer risk factors among adults in Kilimanjaro.
3. To identify the determinants of practice of selected83(smoking and alcohol consumption) esophageal risk
factors among adults in Rural Kilimanjaro, Tanzania.
4. To assess the level of awareness of and ethical issues
facing cancer related health services among adults inrural Kilimanjaro, Tanzania.
2. Risk Factors for Esophageal Cancer
2.1. Red meat (Diet)
Red meat might be directly one of the risk factors ofcolorectal and esophageal cancers or indirectly because
diets high in meat may be deficient of other dietarycomponents such as fibre and polyphenols from fruit andvegetables. Cooking meat at high temperatures may leadto the formation of mutagenic and carcinogenic
heterocyclic amines through the interaction of muscle
creatinine with amino acids as well as the formation of
N-nitroso compounds. Frying, grilling, broiling or
cooking on coal can potentially induce these changes.
Haem in meat can act as a nitro sating agent promoting
the formation of N-nitroso compounds. Darker meats are
more abundant in haem than white meats and therefore,high consumption of red meat (beef, pork, or lamb) could
increase the risk of colorectal and esophageal cancers.
Haem iron has been positively associated in theliterature with the development of colonic polyps,
adenomas and esophageal and colorectal cancers(Pericleous, 2013) (Amanda, 2011) (Salehi, 2013).
But a diet rich in fruits and vegetables which containzinc and selenium reduces the risk of esophageal cancer.
Hence the habit of eating fruits and vegetables is a
protective habit from getting esophageal cancer (Wu,2010). These foods contain many anti-carcinogenic
substances, such as vitamins, carotenoids and flavonoids.
Possible mechanisms of action include modulation of
Deoxyribonucleic Acid (DNA) methylation, protection
from and repair of DNA damage, induction of detoxifying
phase II enzymes and promotion of apoptosis. A recent
expert report concluded that consumption of vegetables
and fruits probably protects against development ofesophageal and gastric cancer (Steevens, 2011;
Stephanie, 2010; Torin, 2015).
2.2. Obesity
Obesity is an increased risk of several types of cancer
such as; cancers of the breast (in women who have been
through menopause), colon, rectum, endometrium(lining of the uterus), esophagus, kidney, pancreas, andgallbladder. Therefore, eating a healthy diet, being
physically active and keeping a healthy weight may help
reduce risk of some cancers (NCIS, 2015). Being
overweight and obesity have been directly related toesophageal adenocarcinoma, but not to squamous cell
carcinoma. The influence of obesity on esophageal
adenocarcinoma and gastric cardia adenocarcinoma isrelated to higher incidence of gastro-esophageal reflux inobese persons since the risk of gastro-esophageal reflux
is related to the risk for Barrett’s esophagus (L.R., 2010).
2.3. AgeAge is the most important risk factor for many cancer
types. According to the National Cancer Institute’s
Surveillance, Epidemiology, and End Results program,the median age of cancer diagnosis is 66 years. Although
the common age of most cases of esophageal cancer is 50

84

Eubios Journal of Asian and International Bioethics 28 (May 2018)

years (NCIS, 2015). A study in Tanzania was carried outthat showed that Male patients 55 years and older had
higher incidence of esophageal cancer than female andyounger patients (Ngoma, 2016).
2.4 Alcohol
Alcohol can increase your risk of cancer of the mouth,
throat, esophagus, colorectal, larynx (voice box), liver,and breast. The more you drink, the higher your risk. The
risk of cancer is much higher for those who drink alcohol.
(Pelucchi, 2011). According to data from 2009, an
estimated 3.5 per cent of all cancer deaths in the UnitedStates (about 19,500 deaths) were alcohol related (NCIS,
2015). A study in China was done and about 15.2% ofesophageal cancer deaths in men and 1.3% in women
were caused by alcohol drinking.
2.5 Exposure to smoke (smoking, cooking, charcoal
burning and others)
Tobacco use is a leading cause of cancer and of deathfrom cancer. People who use tobacco products or
second-hand smoke have an increased risk of cancer
because tobacco has many chemicals that damage
human DNA. Tobacco use causes 20% of global cancer
deaths. Tobacco use causes many types of cancer,
including cancer of esophagus (WHO, 2014; Jon, 2013).
The risk of esophageal adenocarcinoma is approximately
twice as high among current smokers as it is amongpeople who have never smoked, but smoking causes
more of esophageal squamous-cell carcinoma thanesophageal adenocarcinoma (Rustgi, 2014). Excessive
use of fuels such as kerosene, wood, charcoal, coal or
anthracite in enclosed places with limited air supply may
lead to esophageal cancer due to emission ofcarcinogenic polycyclic aromatic hydrocarbons (PAHs),
such as benzo[a]pyrene (BaP) (Pacella-Norman, 2002).
2.6. Exposure to pesticide use in agriculture
Also unsafe use of pesticides has been shown to be oneof the risk factors of esophageal cancer (Bonner, 2012).
2.7. Radiation
Radiation of certain wavelengths, called ionizing
radiation, has enough energy to damage DNA and cause
or treat cancer. Ionizing radiation includes radon, x-rays,
gamma rays, and other forms of high- energy radiation(NCIS, 2015). Esophageal cancer is a radiation doserelated complication of radiotherapy for breast cancer,
but absolute risk is low (Morton, 2012).
2.8. Beverages
Studies show that both green tea and coffee
consumption, but not black tea consumption, haveprotective effects on esophageal cancer (Ju-Sheng, 2013).
Also hot drinks contribute to the chances of getting
esophageal cancer since they cause destruction of DNA
of cells.
2.9. Gastro-esophageal reflux disease
Gastro-esophageal reflux disease (GERD is a chronic
condition that affects 10-26% of the general population.
It presents with acid regurgitation which in long term
may cause esophageal ulceration, fissures, bleeding,strictures and the pre-malignant Barrett’s esophagus.

Other symptoms include heartburn, water brash which
are precipitated by local food such as banana meals,beans and food spices (Mwita, 2014).
2.10 Genetic risk factors
Familial clustering in Barrett’s esophagus andadenocarcinoma has been observed. In one genome wide,
combined linkage-association analysis, germ line
mutations were identified in one of three candidate
genes Mutant macrophage scavenger receptor 1 (MSR1),
Activating signal cointegrator 1 complex subunit(ASCC1),
and Collagen triple helix repeat containing 1 (CTHRC1)
in 11% of patients with Barrett’s esophagus or
adenocarcinoma. MSR1 is associated with cyclin D1 overexpression, which results in more rapid cell-cycle
progression. In another genome wide association study,
susceptibility loci for Barrett’s esophagus andadenocarcinoma were identified in CREB-regulatedtranscription co-activator (CRTC1), BARX Homeobox 1(BARX1) which encodes a protein involved in esophageal
specification, and Forkhead box protein P1(FOXP1)
which encodes a protein involved in esophageal
development (Rustgi, 2014).
2.11 Prevention
Several observational, clinic-based cohort studies haveshown a significant association between treatment with
proton-pump inhibitors and a decreased risk of highgrade dysplasia and adenocarcinoma in patients withBarrett’s esophagus, although limitations of thesestudies included possible selection bias (Rustgi, 2014).
Other studies show a 40 to 50% reduction in the riskof esophageal adenocarcinoma and squamous- cell
carcinoma with aspirin or non-steroidal antiinflammatory drug (NSAID) treatment. Given the
additional cancer reducing benefits of aspirin and
NSAIDs, these medications have been recommended forgeneral cancer chemoprevention in high-risk group(Rustgi, 2014)
A meta-analysis of 13 studies involving humans
showed a 28% reduction in the risk of esophageal
adenocarcinoma among overall statin users, ascompared with nonusers, and a 41% reduction in therisk of esophageal adenocarcinoma among patients withBarrett’s esophagus. However, there was considerable
inconsistency in these studies and no clear associations
with dose, duration, or statin type (Rustgi, 2014).
Esophageal cancer could be prevented through theapplication of existing cancer control knowledge, and byimplementing programs for tobacco control, and early
detection and treatment, as well as public healthcampaigns promoting physical activity and healthierdietary patterns (Jemal, 2011).
2.12 Treatment
The disease is diagnosed by biopsy done by an
endoscope (a fiberoptic camera) (Stahl, 2013).
Endoscopic eradication therapy with radiofrequency
ablation significantly reduces the frequency of
progression to cancer for patients with high-grade
dysplasia. The treatment of the cancer maybe surgical(esophagectomy) or non-surgical depending on the stageof the disease. There are two types of non-surgicaltherapies which are chemotherapy and radiotherapy.

Eubios Journal of Asian and International Bioethics 28 (May 2018)
Chemotherapy depends on the tumor type, but tends
to be cisplatin-based (or carboplatin or every three
weeks with fluorouracil (5-FU) either continuously or
every three weeks. Chemotherapy may be given after
surgery, before surgery or if surgery is not possible.
Radiotherapy is given before, during, or after
chemotherapy or surgery, and sometimes on its own tocontrol symptoms. Treatment with a curative intention
is restricted to localized disease, without distantmetastasis: in such cases a combined approach that
includes surgery may be considered. Disease that is
widespread, metastatic or recurrent is managed
palliative. Early detection of symptoms of esophageal
cancer is associated with an increased likelihood of early
diagnosis of cancer. Hence making curative treatment
feasible (Jones, 2007).
3. Methodology
3.1. Sample Selection
The Kilimanjaro Region is one of Tanzania's thirty one
administrative regions. The regional capital is themunicipality of Moshi. According to the 2012 national
census, the region had a population of 1,640,087, which
was lower than the pre-census projection of 1,702,207.
For 2002-2012, the region's 1.8 percent average annual
population growth rate was the 24th highest in the
country. It was also the eighth most densely populated
region with 124 people per square kilometer. The
population is mainly comprised of the Chaggas. The
region comprises of seven districts namely; Hai, Moshi
Rural, Mwanga, Moshi Municipal, Rombo, Same and Siha.

Region (31)district (169)ward(urban)> street
ward(rural) > village

Figure 1: Tanzania administrative regions
The study was conducted in the wards of Moshi rural
District, Kilimanjaro region (Kahe, Mabogini and Arusha
Chini). The Kilimanjaro region has relatively well-off
communities
withincreased
practice
NonCommunicable Disease related life styles behaviors suchas drinking local brew especially among Chaggas.
Furthermore, use of pesticides for coffee and rice
plantation is common predisposing these communities
to high risk of cancer. Hence there are higher cases of
esophageal cancer. The area was also selected due to agood network of health facilities necessary for theplanned referral system of the cases.
The study population was adults (18 years and above).
With a reported prevalence of 47% who were not awareand knowledgeable about EC (Duron, 2013), theestimated sample size of the study was 383 adults. Dueto estimated non- respondence of ten percent, theminimum numbers of adults recruited for the study was85

426 adults.
Purposive sampling technique was used to select theregion and the wards; Kahe, Mabogini and Arusha Chiniwards of Moshi rural District were selected conveniently.
In each ward, the list of people aged above 18 years wereobtained from the ward council office and the number ofpeople from each ward were chosen from the list using
systematic sampling technique. In the event that the
selected person was ineligible, the next person in the list
was chosen until the sample size estimated was
attained.
Inclusion criteria: The adults living in households inthe community in Rural Kilimanjaro and willing toparticipate in the study
Exclusion criteria:
1. Adults who were severely ill and could not participate
in the study.
2. Patients who had already been diagnosed with EC or
any other cancer in the community
3. Adults who were health professionals in thecommunity
3.2. Research instrument
A structured questionnaire consisting of closed andopen ended questions with a consent document wasused. These tools were translated into Kiswahili toobtain data from the study participants and to ensure
they understood the contents properly. It containedquestions to explore socioeconomic demographic
characteristics of respondents, respondents’ knowledge
and practice of risk factors of esophageal cancer andawareness of cancer health related services (It isavailable from the first author).
The Swahili version interview schedule was pre tested
in the field to know if it would be clearly understood by
the respondents and if corrections arouse they would bemade for better understanding of the respondents
without changing the meaning. This was conducted in
Kibaha focusing on the duration of interview, types ofquestions.
3.3. Ethical clearance and permission processing
The protocol for this study was approved by American
University of Sovereign Nations (AUSN), School of
Medicine Institutional Review Board (IRB). The approval
was on the agreement that participation in the study
must be voluntarily. Also the participants were explained
about the study. Permission to conduct the study wassought from the District Executive secretary and selected
Ward Executive Officers. Through village leaders, theparticipants (adults) were informed about the study atleast two days before the actual day for data collection.
Confidentiality of all study participants was assured.
Everybody was informed that no names or direct
identification made to the questionnaire except
numerical identification.
3.4. Data collection procedures
Face-to-face interviews were conducted using a semistructured questionnaire. Data was collected on daily
basis from morning to evening except the weekends
until the number required in each facility was obtained.
The questionnaire had both closed and open endedEubios Journal of Asian and International Bioethics 28 (May 2018)

Table
1:
Distributionofsocio-demographic
characteristics of study participants, among the Wards
and the Total (N=419)
Variables

Kahe

Mabogini

Arusha
Chini

Total

Sex

N (%)

N (%)

N (%)

N (%)

Male

77(46)

93 (56)41 (48)211(50)Female91 (54)73 (44)44 (52)208(50)Age Group
18-45yrs

123(73)126 (76)

68 (80)317(76)46-59yrs

32 (19)26 (15)15 (18)73 (17)

12 (8)

15 (9)2 (2)29 (7)

Not attend

13 (8)

3 (2)

4 (5)

20 (5)

Primary97 (58)100 (60)

49 (58)246(59)Secondary47 (28)45 (27)24 (28)116(28)Tertiary

11 (7)

18 (11)8 (9)37 (9)

Employed

14 (8)

38 (23)20 (24)72 (17)

Peasant

79 (47)65 (39)19 (22)163(39)Self employed57 (34)

4 (2)

2 (2)

63 (15)

Unemployed18 (11)59 (36)44 (52)121(29)60 + yrs
Education level

Occupation

ended questions were post-coded and entered on theinterview schedule. Data entry and analysis were doneusing statistical package for social sciences (SPSS)
version 18.
Data analysis was carried out by running descriptive
statistics and Cross tabulations. Comparison between
propositions were done using chi square test while t-test
was used to compare differences between means.
Multivariate logistic regression analysis examined forindependence association between our outcome variable(EC risk factors which were alcohol, cigarette smoking,drinking of hot beverages, exposure to pesticides, redmeat consumption) and various predictors (Socioeconomic-demographic characteristics, Health system
factors e.g. accessibility of health facilities, screening,referral system, Past medical history of esophageal
cancer in the family). A p- value of less than 0.05 wasconsidered statistically significant for the association
between independent variables and dependent variables
4. Results
4.1. Socio-demographic characteristics
Refer to Table 1.
4.2. Level of knowledge on risk factors
4.2.1. Level of knowledge on smoking as risk factor foresophageal cancer
Of all participants interviewed, 84% wereknowledgeable about smoking as a risk factor foresophageal cancer. The proportion knowledgeable washigher among male (53%) than female (47%) (P=0.04).
This level of knowledge did not differ by
A total of 419 individuals participated in the study andthe mean age was 36.47 (standard deviation (SD)
=13.49) years. Of those who participated, 211 (50%)
were males, and 60% reported to have completed
primary education. Most of them were Peasants (39%)
and unemployed (29%) mostly with a monthly income ofless than TZS.50000. The general characteristics arepresented in Table 1.
64.3%

84.3%

Monthly income e(TZS)

74.7%

questions. The closed ended questions provided morestructured responses and open ended questions
provided additional information. The interview started
with introduction after receiving permission from thevillage authority. Then with the acquisition of consent
from the participants. Introduction and consent from theparticipants. Assurance of confidentiality was made to
the participants.

76.5%

86

53 (62)247(59)50-100,000

41 (24)26 (16)8 (9)75 (18)> 10000029 (17)44 (27)24 (28)97 (23)Single56 (33)39 (24)28 (33)123(29)Married82 (49)118 (71)

52 (61)

252(60)

Separated

11 (7)

8 (5)

4 (5)

23 (6)

Divorced

4 (2)

0

0

4 (1)

Widowed15 (9)

1 (1)

1 (1)

17 (4)

Figure 2. Reported family history of esophageal cancer inlower Moshi, Kilimanjaro region

Collection of data from the participants was performedin the household in a private room for 20 minutes. This
activity was conducted for three to four weeks. After
collection of data, filled-in interview schedules werechecked for completeness and consistency of the
responses. Only the interview schedules that were
properly and completely filled were analyzed. Open

4.2. Level of knowledge on risk factors
4.2.1. Level of knowledge on smoking as risk factor foresophageal cancer
Of all participants interviewed, 84% wereknowledgeable about smoking as a risk factor foresophageal cancer. The proportion knowledgeable washigher among male (53%) than female (47%) (P=0.04).

2.1%

22.4%
1.2%

KAHE

2.4%

2.4%

Marital Status

23.2%

96 (58)

13.3%

98 (58)33.3%< 50000

MABOGINI

ARUSHACHINIOVERALL

Yes

Dont knowNoEubios Journal of Asian and International Bioethics 28 (May 2018)
This level of knowledge did not differ by87

Eubios Journal of Asian and International Bioethics 28 (May 2018)88

Table 2: Knowledge of smoking as a risk factor foresophageal cancer among adults in lower Moshi,
Kilimanjaro (N=419)
Variables
Total
pYes % No % N (%)
value
Name of the ward:
Kahe

41.7

31.9

168(40)

Mabogini

39.1

42.0

166(40)Arusha Chini

19.1

26.1

85(20)

Male

52.6

39.1

211(50)Female47.4

60.9

208(50)Not attended

5.4

1.5

20(5)

Primary

56.6

69.6

246(59)Secondary

28.0

26.1

116(28)Tertiary

10.0

2.9

37(9)

0.24

Sex
0.04

Education level
0.07

Family history of esophageal cancer
Yes

24.6

15.9

97(23)

No

73.4

81.2

313(75)

I don’t know

2.0

2.9

9(2)

Single28.9

31.9

123(29)Married

60.0

60.9

252(60)

Separated

6.3

1.5

23(5)

Divorced

0.9

1.5

4(1)

Widowed

4.0

4.4

17(4)

0.28

62.3

247(59)50-100,000

18.0

17.4

75(18)> 100000

23.7

20.3

97(23)Name of the ward
Kahe

48.2

27.4

168(40)

Mabogini

40.8

37.8

166(40)Arusha Chini

11.0

34.8

85(20)

Male

53.7

45.1

211(50)Female46.3

54.9

208(50)Not attended

5.9

3.1

20(4.8)

Primary

53.7

66.5

246(59)Secondary

29.0

25.6

116(28)Tertiary

11.4

4.9

37(9)

<0.001

Sex
0.086

0.22

Family history of esophageal cancer
0.579

yes

27.1

17.1

97(23)

No

71.8

79.3

313(75)

I don’t know

1.18

3.66

9(2.15)Single28.2

31.1

123(29)Married

60.4

59.8

252(60)

Separated

5.9

4.9

23(5)

Divorced

1.18

0.6

4(1)

Widowed

4.3

3.7

17(4)

0.019

Marital status

Monthly income (TZS)
58.3

Table 3: Knowledge of alcohol as a risk factor foresophageal cancer among adults in lower Moshi,
Kilimanjaro (N=419)
Yes
Total NpVariables
No % (%)%
value

Education level

Marital status<50000(p<0.001) and family history of esophageal cancer(p=0.019) but it did not differ by marital status(p=0.923) and monthly income (p=0.099). The results
are shown in Table 3. 54% of those with primaryeducation considered alcohol as a risk factor foresophageal cancer compared to 6% of those had neverattended school (p=0.22).

0.793

A total of 419 individuals participated in the study andthe mean age was 36.47 (standard deviation (SD)
=13.49) years. Of those who participated, 211 (50%)
were males, and 60% reported to have completed
primary education. Most of them were Peasants (39%)
and study ward (p=0.24), marital status (0.579), monthly
income (p=0.793) and education level (p=0.07) 25% of
those who considered smoking as a risk factor for EC had
a family history of EC compared to 75% of those whoreported to have no family history of esophageal cancer(p=0.28).
4.2.2. Level of knowledge on alcohol as risk factor foresophageal cancer
Of all participants interviewed, 61% wereknowledgeable about alcohol as a risk factor foresophageal cancer. The proportion knowledgeable washigher among male (54%) than female (46%) (P=0.086).
This level of knowledge differed by study ward

0.92

Monthly income (TZS)< 50000

58.0

60.4

247(59)50-100,000

15.7

21.36

75(18)>100000

26.3

18.3

97(23)

0.099

4.2.3. Level of knowledge on hot beverages as risk factor
for esophageal cancer
Of all participants interviewed, 48% wereknowledgeable about hot beverages as a risk factor foresophageal cancer. The proportion knowledgeable washigher among male (54%) than female (46%) (p=0.184).
This level of knowledge differed by study ward
(p<0.001) and education level (p=0.044) but did not
differ by marital status (p=0.705) and monthly income(p=0.462). The results are in Table 4. 23% of those who
considered hot beverages as a risk factor for esophageal

Eubios Journal of Asian and International Bioethics 28 (May 2018)cancer had a family history of esophageal cancer
compared to 76% of those who reported to have nofamily history of esophageal cancer (p=0.085).
Table 4: Knowledge of Hot beverages as a risk factor foresophageal cancer among adults in lower Moshi,
Kilimanjaro (N=419)
Variables
Yes % No %Total Np(%)
value
Name of the ward
Kahe

44.8

35.9

168(40)

Mabogini

47.8

32.3

166(40)Arusha Chini

7.5

31.8

85(20)

Male

53.8

47.3

211(50)Female46.2

52.7

208(50)<0.00189cancer compared to 23% of those who reported to haveno family history of esophageal cancer (p=0.176).
Table 5: Knowledge of Red meat consumption as a risk
factor for esophageal cancer among adults in lower
Moshi, Kilimanjaro (N=419)
Variables
Yes % No % Total N
p(%)
value
Name of the ward
Kahe

52.1

27.7

168(40)

Mabogini

42.7

36.4

166(40)Arusha
Chini

5.2

35.9

85(20)

Male

47.9

52.9

211(50)Female52.1

47.1

208(50)Never
attended

4.2

5.3

Primary

56.8

60.7

246(59)

Sex

Sex
0.184

20(5)

Not attended

3.5

5.9

20(5)

Primary

55.3

61.8

246(59)Secondary

28.6

26.8

116(28)

Secondary

27.2

28.2

116(28)Tertiary

12.6

5.5

37(9)

Tertiary

11.7

5.8

37(9)

0.044

Family history of esophageal cancer

0.194

Family history of esophageal cancer

yes

23.12

23.18

97(23)

No

76.38

73.18

313(7)

0.50

3.64

9(2)

0.085

Marital status

Yes

22.1

24.3

97(23)

No

77.0

72.3

313(75)

I don’t know

0.9

3.40

9(2)

Single32.4

26.2

123(29)Married

56.8

63.6

252(60)

Separated

4.2

6.8

23(5)

0.176

Marital status

Single31.2

27.7

123(29)Married

59.3

60.9

252(60)

Separated

4.0

6.8

23(5)

Divorced

1.0

0.9

4(1)

Divorced

1.4

0.5

4(1)

Widowed

4.5

3.6

17(4)

Widowed

5.2

2.9

17(4)

0.92

Monthly income(TZS)< 50000

0.304

Education level

Education level

I don’t know

<0.001

0.23

Monthly income(TZS)

59.8

58.2

247(59)50000100000

15.6

20

75(18)>100000

24.6

21.8

97(23)

0.099

4.2.4. Level of knowledge on red meat consumption asrisk factor for esophageal cancer
Of all participants interviewed, 51% wereknowledgeable about red meat consumption as a risk
factor for esophageal cancer. The proportion
knowledgeable was higher among Kahe residents (52%)
compared to residents of Mabogini (43%) and Arusha
Chini (5%) (p<0.001). This level of knowledge did not
differ by sex (p=0.304), marital status (p=0.225),
monthly income (p=0.714) and education level(p=0.194). The results are in Table 5. 77% of those who
considered red meat consumption as a risk factor foresophageal cancer had a family history of esophageal< 50000

59.6

58.3

247(59)50-100,000

16.4

19.4

75(18)>100000

23.9

22.3

97(23)

0.714

4.2.5. Level of knowledge on pesticides exposure as risk
factor of esophageal cancer
Of all participants interviewed, 68% wereknowledgeable about pesticide exposure as a risk factor
for esophageal cancer. The proportion knowledgeable
was higher among male (52%) than female (48%)(p=0.184). This level of knowledge differed by study
ward (p<0.001) and education level (p=0.002) but it did
not differ by marital status (p=0.612) and monthly
income (p=0.083). The results are in Table 6. 25% of
those who considered pesticides exposure as a risk
factor for esophageal cancer had a family history ofesophageal cancer compared to 75% of those whoreported to have no family history of esophageal cancer

Eubios Journal of Asian and International Bioethics 28 (May 2018)90(p=0.319).

Table 6: Knowledge of Pesticides exposure as a risk
factor for esophageal cancer among adults in lower
Moshi, Kilimanjaro (N=419)
Total N
Variables
Yes % No %p-value(%)
Name of the ward
Kahe

44.5

30.9

168(40)

Mabogini

42.1

34.6

166(40)Arusha Chini

13.4

34.6

85(20)

Male

51.9

47.1

211(50)Female48.1

52.9

208(50)Not attended

5.0

4.4

20(5)

Primary

54.4

67.7

246(59)Secondary

28.3

26.5

116(28)Tertiary

12.4

1.5

37(9)

<0.001Sex
0.349

Education level
0.002

Family history of esophageal cancer
Yes

25.1

19.1

97(23)

No

73.1

77.9

313(75)Don’t know

1.8

2.9

9(2)

Single26.9

34.6

123(29)Married

62.2

55.9

252(60)

Separated

5.7

5.1

23(5)

Divorced

1.1

0.7

4(1)

Widowed

4.2

3.7

17(4)

0.319

Marital status

0.61

Monthly income (TZS)< 50000

57.6

61.8

247(59)50-100,000

16.3

21.3

75(18)>100000

26.1

16.9

97(23)

0.083

4.2.6. Level of knowledge on obesity as risk factor foresophageal cancer
Of all participants interviewed, 41% wereknowledgeable about smoking as a risk factor foresophageal cancer. The proportion knowledgeable washigher among male (51%) than female (49%) (p=0. 707).
This level of knowledge differed by study ward
(p<0.001) but did not differ with education level(p=0.537), marital status (p=0.308) and monthly income(p=0.302). The results are in Table 7. 26% of those who
considered obesity as a risk factor for esophageal cancer
had a family history of esophageal cancer compared to74% of those who reported to have no family history ofesophageal cancer (p=0.024).

4.2.7. Level of knowledge on genetics as risk factor foresophageal cancer
Of all participants interviewed, 51% wereknowledgeable about genetics as a risk factor foresophageal cancer. The proportion knowledgeable washigher among Kahe residents (49%) compared toresidents of Mabogini (33%) and Arusha Chini (18%)(p=0.001). This level of knowledge did not differ by sex(p=0.661), marital status (0.149), monthly income(p=0.592) and education level (p=0.059). The results are
in Table 8. 63% of those who considered genetics as arisk factor for esophageal cancer had a family history ofesophageal cancer compared to 56% of those whoreported to have no family history of esophageal cancer(p=0.019).
Table 7: Knowledge of Obesity as a risk factor foresophageal cancer among adults in lower Moshi,
Kilimanjaro (N=419)
Total Np(%)
value
Variables
Yes % No %Name of the ward
Kahe
168(40)57.89
27.82
Mabogini
166 (40)<0.001
37.43
41.13
Arusha Chini85(20)
4.68
31.05
Sex
Male
211(50)
0.707
51.46
49.60
Female208 (50)
48.54
50.40
Education levelNot attended
20 (5)
5.26
4.44
Primary
246 (59)
0.537
56.14
60.48
Secondary
116 (28)
27.49
27.82
Tertiary37 (9)
11.11
7.26
Family history of esophageal cancer
Yes
97 (23)
26.32
20.97
No
313 (75)
0.024
73.68
75.40
Don’t know
9 (2)
0.00
3.63
Marital status
Single123 (29)
29.82
29.03
Married252 (60)
56.73
62.50
Separated
23 (6)
0.31
5.85
5.24
Divorced
4 (1)
1.17
0.81
Widowed17 (4)
6.43
2.42
Monthly income (TZS)< 50000
247 (59)
62.57
56.45
50-100,000
75 (18)
0.302
14.62
20.16
>100000
97 (23)22.81
23.39
4.3. Bivariate association between smoking and sociodemographic characteristics among adults in lower Moshi,
Kilimanjaro
Out of 419 participants who were interviewed in thisstudy, 61 (15%) reported to be current smokers. The
prevalence was higher in male (72%) compared tofemale (28%) participants. The prevalence of smoking issignificantly associated with sex (p<0.001). The smoking
prevalence significantly increased with age where 49%
for those who were 46-59 years compared to 44% (1845 years) and 7% (60 and above years).
The smoking prevalence also significantly increased
with marital status where 56% were married compared
to 21% (Single), 3% (divorced), 13% (separated) and
7% (widowed) (p=0.006). There was significant
difference between level of Education and prevalence ofEubios Journal of Asian and International Bioethics 28 (May 2018)

40%
40%
20%
0

MABOGINI>10 years
1.70%
24.60%
21.30%
52.46%

6-10 years

66.60%

0.00%
16.70%
16.70%

34.40%
21.90%
43.80%

0.00%

KAHE

1-5 years

ARUSHA
CHINI

TOTAL

Figure 3: The Period of years of smoking among thestudy participants
Out of 61 smokers, Most of them smoked 1 to 5 sticks
per day (39.3%) and more than 10 sticks per day (41%).
While the least of the smokers (19.7%), smoked six toten sticks of cigarettes per day.
6-10 stiks>10 stiks

KAHE

MABOGINI

ARUSHA
CHINI

41%
20%

20%

39%

37.50%

25%

37.50%

46.40%

80%

1-5 stiks

0.00%

Table 9: Bivariate association between smoking andsocio-demographic characteristics among adults inlower Moshi, Kilimanjaro (N=61)
VariableN%
p-value
Male
44
72.13
<0.001
Female1727.87
Age
18-45yrs
27
44.26<0.00146-59yrs
30
49.18
60 and above 4
6.56
Marital status
Single13
21.31
Married34
55.74
Separated
8
13.11
0.006
Divorced2
3.28
Widowed4
6.56
Education level
Never
6
9.84
attendedprimary
41
67.21
0.038
Secondary10
16.39
Tertiary4
37.04
Occupation
Employed
14
22.95
Peasant33
54.1<0.001
Self
employed
11
18.03
Unemployed 3
4.92
Monthly income (TZS)<5000029
47.54
50-100,000
0.061
17
27.87
>100000
15
24.59

less than a year

34.80%

Table 8: Knowledge of genetics as a risk factor foresophageal cancer among adults in lower Moshi,
Kilimanjaro (N=419)
Variables
Yes % No %Total N(%)
p-value
Name of the ward
Kahe
48.58
31.40
168 (40)
Mabogini
33.02
46.38
166 (40)
0.001
Arusha Chini
18.40
22.22
85 (20)
Sex
Male
51.42
49.28
211 (50)
Female48.58
50.72
208 (50)
0.661
Education levelNot attended
2.36
7.25
20 (5)
Primary
58.02
59.42
246 (59)
0.059
Secondary
28.77
26.57
116 (28)
Tertiary
10.85
6.76
37 (9)
Family history of esophageal cancer
yes
28.77
17.39
97 (23)
No
68.87
80.68
313 (75)
0.019
I don’t know
2.36
1.93
9 (2)
Marital status
Single32.55
26.09
123 (29)
Married57.08
63.29
252 (60)
Separated
3.77
7.25
23 (6)
0.15
Divorced
1.42
0.48
4 (1)
Widowed
5.19
2.90
17 (4)
Monthly income (TZS)< 50000
59.91
57.97
247 (59)
5000075 (18)
100000
16.04
19.81
0.592
>100000
24.06
22.22
97 (23)Out of the 61 smokers, about half of them (52%)
reported to have been smoking for a period of more than
10 years while 2% reported to have smoked for less than
one year preceding the study.

18.80%

smoking (Never attended school 10% vs primary 67% vssecondary 16% vs Tertiary 37%) (p=0.038)

91

TOTAL

Figure 4: Number of cigarette sticks smoked per day
Logistic regression was conducted to identify sociodemographic determinants of smoking among adults
living in lower Moshi Kilimanjaro region. Males
respondent were almost three times more likely to besmokers as compared to female respondents (OR=2.696;
95%CI: 1.372, 5.299; p=0.004). Moreover, people who
were self- employed were about five times more likely tobe smokers as compared to those who were unemployed.
(OR= 4.847; 95%CI: 1.019, 23.05; p=0.047)
4.4. Extent of Alcohol consumption among adults in lower
Moshi, Kilimanjaro region
4.4.1. Bivariate association between alcohol drinking andsocio-demographic characteristics among adults inlower Moshi, Kilimanjaro
The overall prevalence of reported alcohol
consumption was 23%. Reported prevalence of alcohol
consumption was 68% among male and 32% amongfemale (p<0.001) .Out of 97 Alcohol drinkers, majority(60%) reported to have been drinking for a period of
more than 10 years while 5% reported to have drinking
for less than one year preceding the study. Majority(71%) of the Alcohol drinkers took 1 to 5 bottles per daycompared to the while a relatively small proportion(9%) took 6 to 10 bottles per day. The alcohol drinking
prevalence significantly increased with age where 53%
for those who were 18-45 years compared to 30% (46-Eubios Journal of Asian and International Bioethics 28 (May 2018)
separated 7% vs widowed 4%) (p=0.254)

Kahe

3.02

0.92

9.91

0.068

Mabogini

2.53

0.82

7.81

0.106

Arusha Chini

9.40%

Ward

1

KAHE

Sex
Male

2.70

Female

1

1.37

5.30

0.004

MABOGINI

71.40%

pvalue>10 bottles

ARUSHA
CHINI

9.20%
19.40%

Upper

6-10 bottles

68.00%

Lower

37.50%

Odds
Ratio

53.10%

Variable

1-5 bottles

90%

Table 10: Socio-demographic determinants of smoking
among adults living in lower Moshi, Kilimanjaro region
Logistic
95% CI
regression

0%
10%

59 years) and 16% (60 and above years).

14.00%
18%

92

TOTAL

Figure 5: Number of bottles of Alcohol drank per day

Never attended

1.00

0.17

5.78

0.999

Table 11: Bivariate association between alcohol drinking
and socio-demographic characteristics among adults inlower Moshi, Kilimanjaro (N=97)
VariableN%
p-valuePrimary

0.81

0.22

3.00

0.752

Sex

Secondary

0.46

0.11

1.86

0.275

Male

66

68

Tertiary

1

Female31

32

Education level

Monthly income (TZS)

Age< 50000

1.46

0.62

3.441

0.387

18-45 yrs

51

53

50000-100000

2.28

0.906

5.738

0.08

46-59 yrs

29

30

60 and above

16

17> 100000<0.0011Age<0.001

Marital status

18-45yrs

0.45

0.092

2.20

0.323

Single212246-59yrs

2.84

0.59

13.59

0.192

Married63

65

60 and above

0.18

0.014

2.21

0.179

Separated

7

7

Divorced

2

2

4

4

Occupation
Employed

6.01

1.46

24.84

0.13

WidowedPeasant

4.75

1.23

18.40

0.24

Education level

Self employed

4.85

1.02

23.05

0.047

Never attended88Unemployed1

Primary

67

69

Marital Status

Secondary17

18

Single

2.60

0.74

9.17

0.136

Tertiary

5

5

Married

1.97

0.61

6.40

0.258

Occupation

Separated

0.58

0.14

2.37

0.445

Employed

22

23

Divorced

0.31

0.032

2.94

0.306

Peasant

49

51

Widowed1

Self employed13

13

Unemployed13

13

There was significant difference between level of
education and prevalence of alcohol drinking (Neverattended school 8% vs primary 69% vs secondary 18%
vs Tertiary 5%) (p=0.007). There was significant
difference between occupation and prevalence of alcohol
drinking (p=0.001). There was no significant difference
between marital status and prevalence of alcohol
drinking (Divorced 2% vs Single 22% vs married 65% vs

0.254

0.007

0.001

Monthly income (TZS)<50000434750000-100000

16

17>100000

38

39<0.001Eubios Journal of Asian and International Bioethics 28 (May 2018)

Kahe

1.486

0.584

3.784

0.406

Mabogini

4.116

1.832

9.247

0.001

Arusha Chini

1

Sex
Male
Female

1.918

1.097

3.351

0.022

1

Education levelNot attended

3.242

0.672

15.65

0.143

Primary

2.431

0.809

7.3

0.113

Secondary

0.978

0.302

3.171

0.971

Tertiary

1Monthly income< 50000

0.457

0.232

0.898

0.023

50-100,000

0.483

0.219

1.065

0.071

1

.

.

18-45yrs

0.156

0.036

0.671

0.013

46-59yrs

0.399

0.091

1.747

0.223

> 100000Age

60 and above

1

Occupation
Employed

1.645

0.653

4.144

0.291

Peasant

1.488

0.651

3.401

0.346

Self employed

1.747

0.575

5.304

0.325

Unemployed1

Marital Status
Single1Married

1.495

0.443

5.037

0.517

Separated

0.923

0.29

2.934

0.892

Divorced

0.703

0.168

2.939

0.629

Widowed

0.308

0.032

2.942

0.306

4.4.2. Independent determinants of alcohol consumption
Logistic regression was conducted to identify sociodemographic determinants of smoking among adults
living in rural Moshi Kilimanjaro region. Males
respondent were almost two times more likely to be
drinkers as compared to female respondents (OR=1.918;
95%CI: 1.097, 3.351; p=0.022). The results are in Table
12.

KAHE

MABOGINI

59.80%

50%
ARUSHA
CHINI

5.20%
20.60%
16.50%

Ward30%

pvalue

10%
10%

Upper

more than 10 years
59.70%

Lower

6-10 years

3.50%
22.80%
14%

Odds
Ratio

1-5 years

6.30%
18.80%
15.60%

Variableless than a year
59.40%

Table 12: Socio-demographic determinants of alcohol
consumption among adults living in lower Moshi,
Kilimanjaro region
Logistic
95% CI
regression

93

TOTAL

Figure 6: The Period of years of alcohol drinking among
the study participants
4.5. Level of awareness on cancer health related services
When participants were assessed about theirawareness with regards to cancer treatment, 51%
indicated to be aware of various cancer treatment
modalities which included Surgery, chemotherapy andradiotherapy. Female were just as aware of cancer
treatment modalities as male (both 51%, p=0.036).
Participants from Arusha Chini ward (62%) were moreaware of cancer treatment modalities than those fromthe other study wards (p<0.001). Additionally,
awareness was found to significantly increase withincrease in education level (p<0.001) and differed bymonthly income (0.013), occupation (<0.001) andfamilial history of the disease (0.027). The results are in
Table 13.
Out of 419 participants, 89% considered hospital as aplace to seek for treatment of esophageal cancer. The
proportion was the same in female and males. A
significantly larger proportion of participants from Kahe(92%) and Mabogini ward (94%) mentioned hospital asa place for cancer care as compared to those from
Arusha Chini ward (75 %), (p=0.001). The proportion ofparticipants reporting hospital as a place for cancer care
did not differ by education level, age or family history ofesophageal cancer.
5. Discussion
5.1 Knowledge on EC risk factors
More than 71% among adult aged 18 years and above
were aware that smoking and drinking alcohol are risk
factors for esophageal cancer at the Rural District inKilimanjaro Region. These proportions of participants
who were knowledgeable about smoking (84%) andalcohol (61%) as risk factors for esophageal cancer werehigher than the study done in Bomet in Kenya (Smoking
71% and alcohol 52%, Duron 2013). This observed
difference could be attributed by difference in location(Kahe 42% vs Mabogini 39% vs Arusha Chini 19%). Sex(male 53% and female 47%) showed that males in all thethree areas where this study was conducted were more
knowledgeable on the risk factors of esophageal cancer.

Eubios Journal of Asian and International Bioethics 28 (May 2018)94

Table 13: Awareness of cancer treatment modalities
among adults in lower Moshi, Kilimanjaro region
Variables
Yes (%)
No (%) Total
pvalueWard
Kahe

76 (45)92(55)

168

Mabogini

85(51)

81(49)

166

Arusha Chini

53(62)

32(38)

85

Male

107(51)104(49)211

Female107(51)101(50)

208

6(30)

14(70)

20

Primary103(42)143(58)

246

Secondary

76(66)

40(34)

116

Tertiary

29(78)

8(22)

37

Yes

47(48)

50(52)

97

No

163(52)150(48)

313

4(44)

5(56)

9

<0.001

Sex
0.036

Education levelNot attended<0.001

Family history

Don’t know

Table 14: Participants awareness on where to seekhome

155(49)161(51)316

46-59yrs

44(60)

29(40)

73

60 plus15(50)

15(50)

30

113(46)134(54)247

50-100,00040(53)

35(47)

75>100000

61(63)

36(37)

97

Unemployed80(66)

41(34)

121

Peasant

66(40)

97(60)

163

Self employed17(32)

36(68)

53

Employed

41(57)

31(43)

72

hosp
ital

tradition
al healer

totalN

pvalueName of the ward

0.763

Kahe

0

1

91

8

168

Mabogini

1

1

93

5

166

Arusha
Chini

2

1

75

21

85

Male

0.5

1

89

10

211

Female

1

0.5

89

9

208

None

0

0

85

15%

20

Primary

1

1

89

9

246

Secondary

0

0

91

9

116

Tertiary

0

0

89

11

37

Yes

0

1

92

7

97

No

1

0.6

88

10

313

Don’tknow

0

0

89

11

9

18-45yrs

0.6

1

88

10

316

46-59yrs

1

0

92

7

73

60 +

3

0

97

0

29

.001

Sex

Monthly income (TZS)< 50000

church0.027

Age18-45yrs

due to low education level. But also alcohol intake
prevalence was higher in our study compared to thatfound in Kenya (15%) (Duron 2013). This difference
could be due to the Chagga tribal culture that supports
drinking alcohol. Furthermore, there were some women
who were smokers (28%) and alcohol drinkers (32%)
despite the African cultural norms against smoking andalcohol drinking among females. This could be due tomodern life styles adapted in the society. This study also
went into more details to show the amount andperiodicity of smoking and alcohol intake. Most of themwere males aged 60 and above who smoked cigarettes ordrank alcohol for more than ten years with an average 15 bottles of alcohol and sticks of cigarettes. This was
associated with low levels of literacy, and the ability topurchase alcohol and cigarettes since employment was
the source of income. The study focused on smoking andalcohol intake because they were the most behavioral
practices scene in most studies (Pelucchi, 2011) (WHO,2014) (Jon, 2013). A study in China was done and about
15% of esophageal cancer deaths in men and 1.3% in
women were caused by alcohol drinking.

0.013

Occupation<0.001

Also a history of having esophageal cancer among afamily member showed that 25% of those who
considered smoking as a risk factor for esophageal
cancer had a family history of esophageal cancer
compared to 75% of those who reported to have nofamily history of esophageal. Furthermore, this study
was able to show low levels of knowledge of additionalrisk factors which the study done in Bomet did not
address. These risk factors were obesity, pesticide
exposures, consumptions of hot beverages and red meat.
These low proportions were due to low education level.
5.2 Practices associated with risk factors of EC
The prevalence of smoking in this study was 15%
which was higher compared to 11% in the Bomet study,.878

Education level.814

Family history.926

Age group.87

5.3 Determinants for risk factors associated with EC
The study was able to identify the determinants ofpractice of smoking and alcohol drinking as esophageal
cancer risk factors which the study done in Kenya did
not show (Duron 2013). Male respondents were threetimes more likely to be smokers and drinkers asEubios Journal of Asian and International Bioethics 28 (May 2018)
compared to female respondents. Moreover, people who
were self- employed were five times more likely to besmokers as compared to those who were unemployed.
This could be attributed to the social norms andresponsibilities of male adults of making a monthly
income and provide to the family. Thus most of the maleadults were working class compared to female who
mostly were housewives or unemployed.
Also this study showed a higher prevalence of family
history of the disease (23%) compared to 9% in Bomet.
This could be due to the higher practices of risk factors.
5.4 Awareness of cancer related health services
The level of awareness of modalities of treatment was
low as that of Bomet, Kenya (49%) and almost similarlevel of awareness on a place to attain cancer related
health services (hospital) to that in Bomet (88%,)(Duron 2013). Thus awareness on types of treatments ofesophageal cancer is still low in the rural Kilimanjaro
may be due to low level of education.
Furthermore, this study also showed lower levels ofawareness on prevention 47% and early diagnosis(screening) 70% compared to the study done in Bomet(prevention 62% and screening 86%). This due to lowlevels of literacy and traditional beliefs like witchcraft
and evil spirits. This study also showed a lower
proportion of adults who considered difficulty inswallowing as a main symptom of the disease compared
to 79% in Bomet (Duron et al 2013). This may lead todelayed health seeking behaviors.
The study also showed that media (radios) was themain source of information, of which the study in Bomet
didn’t address. This could be due to high level ofilliteracy.
5.5. Discrimination and stigma
This study also showed a lower portion of adults (9%)
who thought the disease to be contagious compared to
Bomet (35%). Such a belief may contribute to ethicalissues of discrimination and stigma towards the people
with the disease thinking that it will spread. Thisdifference could be due to higher prevalence of family
history of the disease, where most of the people got
information through having a family member with thedisease5.6. Autonomy
With a diagnosis of EC, as many concerns areconcerned, ethical issues are of concern because mostpatients feel that their right to autonomy is not attained.
This is due to very limited options of treatment
especially upon a late stage diagnosis, and limited pain
control for end of life care due to the phobia of using
opioid analgesics, especially in a setting like ours.
Moreover, due to the deficiency of information on cancer
treatments, pathophysiology and distribution, mostpatients and relatives feel as though there is too muchprobing and treatment undertaken is focused on
answering said questions than on patient management
and concerns.
5.7. Economic Issues
In a resource limited population such as ours,
distribution of resources especially to the older

95

population is of concern. While medical care for patientsolder than 60 years is free as per the national healthpolicy, most of the investigations and treatment
modalities for cancer related services are expensive andneed to be paid out of pocket. This causes neglect tocancer patients (most of whom are in said age group) ora sense of guilt and inconvenience that the patient feels
towards the family. Ethical factors are ignored especiallyin private health providing centers due to economic
restraints.
5.8. Truth telling
Truth telling and honesty in cancer condition isanother ethical dilemma with respect to preserving apatient’s hope and religious beliefs, when the patient is
not willing to accept the prognosis. The invasive natureof respective procedures are related to a high morbidity
and mortality and this makes decision making difficult.
In addition to this, the chemotherapy and radiotherapy
procedures are not common modalities and thus special
considerations should be taken in such cases.
5.9. Study Limitations
There are several potential limitations in this research.
Social desirability bias could mean people do not reportcorrectly sensitive information such as those related tosmoking and alcohol. This was reduced by ensuring
privacy, confidentiality and establishing rapport witheach individual during the interview in aprivate space.
The results of the research may not be generalized forthe whole country. The literacy level was low.
5.10. Public health implications
The main step towards tackling prevalence ofesophageal cancer is through knowledge, awareness andpractice of esophageal cancer risk factors and related
health services. Hence there is need to improve low levelof knowledge and high level of practice of esophageal
cancer risk factors and low level of awareness of cancer
related health services among adults.
6. Conclusions
The study findings conducted in three wards confirms
that, despite a good level of knowledge about risk factors
for esophageal cancer, their practice of such risk factors
is high. Awareness of where to seek for cancer related
health services was high with hospitals been mentioned
by majority though there was low understanding on
modalities of treatment among adults in Rural
Kilimanjaro. There is still a high challenge on ethicalmatters such as end of life and palliative care, autonomy
and truth telling and economic restrains facing cancer
management and patients affected with the illness.
7. Recommendations
1. Behavioural intervention aiming at addressing risk
factors for esophageal cancer should be given priority.
The intervention should target important risk
behavioural risk factors such as smoking and alcohol
consumption.
2. Promotion of healthy life style is vital in prevention ofesophageal cancer through common ways such as media,
health facilities and education institutions.

96

Eubios Journal of Asian and International Bioethics 28 (May 2018)

3. Ethical matters such as truth telling, ageism, end of life
care and autonomy need to be addressed to improve theperception of cancer related health issues and healthseeking behaviour among the members of thecommunity.
References
Ahmedin Jemal et al., Global cancer statistics. CA: A Cancer Journal for
Clinicians 2011; 61(2):69–90.
Ahmedin Jemal et al., Cancer burden in Africa and opportunities forprevention. Cancer 2012; 118(18):4372–84.
Amanda J Cross et al., Meat consumption and risk of esophageal andgastric cancer in a large prospective study. The American Journal of
Gastroenterology 2011:106, 432-42.
Arjun Pennathur et al., Esophageal carcinoma.TheLancet 2013;
381(9864): 400-12.
Claudio Pelucchi et al., Alcohol Consumption and Cancer Risk. Nutrition
and Cancer 2011; 63(7) : 983-90 DalvinderMandair et al., Prostatecancer and the influence of dietary factors and supplements.
Nutrition & Metabolism 2014;11:30.
Ferlay J et al; International Agency for Research on Cancer. GLOBOCAN
2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer
Base No. 11. globocan.iarc.fr. Accessed June 20, 2016.
Hemantha K et al., Public awareness of oral cancer, of oral potentiallymalignant disorders and of their risk factors in some rural
populations in Sri Lanka. Community Dentistry and Oral
Epidemiology 2010; 38(6):540–48.
Jaime V Gabel et al., Clinical and epidemiologic variations of esophageal
cancer in Tanzania. World Journal of Gastointestinal oncology, 2016;
8(3):314–20.
Jessie Steevens et al., Vegetables and fruits consumption and risk ofesophageal and gastric cancer subtypes in the Netherlands Cohort
Study. International Journal of Cancer; 2011, 129(11):2681–93.
Ju-Sheng Zheng et al.; Effects of Green Tea, Black Tea, and Coffee
Consumption on the Risk of Esophageal Cancer: A Systematic
Review and Meta-Analysis of Observational Studies. Nutrition andCancer 2013; 65(1) : 1-16.
L. M. Morton et al., Risk of treatment-related esophageal cancer among
breast cancer survivors, Annals of Oncology 2012; 10:1093.
Linwei Li et al., The candidate tumour suppressor gene ECRG4 inhibits
cancer cells migration and invasion in esophageal carcinoma.
Journal of Experimental & Clinical Cancer Research2010;29: 133.
Lundell L.R: Aetiology and Risk Factors for Esophageal Carcinoma.
I.
Digestive Diseases 2010; 28: 641–44.
M Stahl et al., Esophageal cancer: ESMO Clinical Practice Guidelines fordiagnosis, treatment and follow-up. Annals of Oncology
2013;24(6):51-56.
Mamsau: Short term Clinical outcome of treatment among patientswith esophageal cancer treated at Ocean Road Cancer Institute,
Dissertation 2013.
MB Mwandri, JC Mwita, MGMD Magafu, KG Kilonzo, and SJUrasa: Risks,
precipitants and clinical presentation of gastro-esophageal reflux
disease at the Kilimanjaro Christian Medical Centre in Tanzania. Pan
African Medical Journal 2014; 19: 119.
Michael C. R. Alavanja and Matthew R. Bonner: Occupational pesticide
exposures and cancer risk. Journal of Toxicology and Environmental
Health 2012) : 238-63 Ming Wu et al., Does family history of cancer
modify the effects of lifestyle risk factors on esophageal cancer? A
population-based case–control study in China. International Journalof Cancer, 2011; 128(9):2147– 57.
National Cancer Institute’s Surveillance (NCSI), Epidemiology, and End
Results program, 2015.
RPacella-Norman, et al., Risk factors for esophageal, lung, oral andlaryngeal cancers in black South Africans. British Journal of CancerII.
2002;86:1751–56.
Rebecca et al., Cancer statistics. CA: A Cancer Journal for Clinicians
2015; 65(1):5-29.
Roger Jones, Wolfson professor of general practice, Radoslav Latinovic,
database manager, Judith Charlton, research assistant, Martin C
Gulliford, senior lecturer in public health: Alarm symptoms in early
diagnosis of cancer in primary care: cohort study using General
Practice Research Database. The British Medical Journal 2007; 334:
1040.
Rustgi AK, El-Serag HB: Esophageal Carcinoma. The New England
Journal of Medicine 2014;371(26): 2499- 509.
S. C. FitzGerald et al., Lack of Awareness of Esophageal carcinoma
among the public in Ireland. Irish Journal of Medical Science
2008:151-54.

Salehi M and M Moradi. Meat, fish, and esophageal cancer risk: asystematic review and dose-response meta-analysis. InternationalLife Sciences Institute 2013:257-267
Sarah B Umar & David E Fleischer: Esophageal cancer: epidemiology,
pathogenesis
andprevention.
Natureclinical
Practice
Gastroenterology and Hepatology2008;5:517-26.
Stephanie A. Navarro Silvera et al., Principal Component Analysis of
Dietary and Lifestyle Patterns in Relation to Risk of Subtypes of
Esophageal and Gastric Cancer. Annals of epidemiology 2011; 21(7);543-50.
Stewart, B. and Wild, C.P. (eds.), International Agency for Research on
Cancer, WHO. World Cancer Report 2014.
Stuart Jon Spechler, MD, Discussant: Barrett Esophagus and Risk of
Esophageal Cancer. The Journal of the Medical Association 2013;
310(6): 627-36.
TorinSchaafsma, et al. Africa's Esophageal Cancer Corridor: Geographic
Variations in Incidence Correlate with Certain Micronutrient
Deficiencies, PLoS ONE 2015; 10(10).
TwalibNgoma, John Mandeli and James F. Holland: Downstaging cancer
in rural Africa. International Journal of Cancer, 2015;136(12):2875–
79.
Twalib Ngoma: World Health Organization cancer priorities indeveloping countries. Annals of Oncology 2006; 17(8): 9-14.
United Nations Population Division: World Population prospects, the2012 revision.
V Duron et al., Esophageal cancer awareness in Bomet district, Kenya.
2013; 13(1): 122-28.
Wikipedia. (05/04/2017(10.36am)). Esophageal Cancer. Wikipedia.
Zhang, Y. Epidemiology of esophageal cancer. World Journal of
Gastroenterology, 2013; 19(34): 5598- 5606.

Jahr’s Bioethical Imperative &Euthanasia- Michael Cheng-tek Tai. Ph.D.
Chair professor, Chungshan Medical University, Taichung,Taiwan Email: tai@csmu.edu.tw- Phyllis Hsu. M.A.
Research Associate, Lee’s Attorney at Law, Yuanlin, Taiwan

Introduction
A famous journalist in Taiwan has recently flown to
Switzerland to register in a physician-assisted suicide
program (known as euthanasia by some [1]) and died
there. Prior to his trip, he had feverishly appealed to
Taiwan’s authority to legalize euthanasia without any
result thus decided to set himself as an example to provethat each person can possesses the right to end his own
life when suffering from incurable diseases.
This incident provoked much debate in Taiwan. A
major newspaper named Apple Daily reported the wholeincident for weeks. When the incident ended, the news
paper carried a whole page discussion inviting different
scholars and experts to express their point of views fromboth pro and con perspectives [2]. The debate on theissue is still going on even today.
Autonomy and Euthanasia"Patients’ autonomy" has been regarded as one of themost important principles of modern medical ethics. No
medical procedures can be performed without theconsent of the patients or their surrogates whereby thepatient is incapacitated. In research, either biomedicalor social behavioral, the "Informed Consent" of thehuman subjects is also absolutely necessary unless theInstitute Ethic Review Board known as IRB approves towaive it. From this emphasis of the importance ofautonomy, the younger generation has come up with aEubios Journal of Asian and International Bioethics 28 (May 2018)
new slogan, “ if it feels good, do it “. In Taiwan, this new
slogan is known as "as long as I like it, nothing isunallowable. " With the rise of this new living attitude,
the boundary of the good and the bad, or the right andthe wrong has been blurred because the judgment
depends on one’s own choice. Applying this newunderstanding to the issue of euthanasia, autonomous
decision-making seems to be justifiable and should bepermitted because it is an individual’s will and desirethat must be respected.
Fritz Jahr and Bioethical Imperative
Fritz Jahr was the first scholar who spoke of bioethics
in 1926. He can be known as the father of modern
bioethics. His profound writings have been discoveredby a former Georgetown scholar, Dr. Han Martin Sass
who in his research found that Dr.Jahr had discussed theissue of bioethics even before WWII and proposed anIII.
important view for all to reflect upon that is known as“ Bioethical Imperative” -- “ respect every living being on
principle as an end in itself and treat it, if possible, as
such.” [3]In Jahr’s writings, he repeatedly stated thepreciousness and sanctity of life, not only human life but
all forms of life. His view is similar to a religion such as
Hinduism that perceives life as one and for that sake alllife must be cherished. Jahr however, assumed that life
has different functions according to its kind fromcreation and humankind has been given with the duty to
manage the earth to carefully look after and equally treat
all creatures including animals and plants. He urged thatlife must be preserved due to the nature of life as morallysacred including one’s own life [4]. He quoted
Schopenhauer, “Neminem laede, imo omnes, quantum
potes juval“ (translated in English as “don’t hurt anyone
but help everyone as far as you possibly can”). Jahr also
illustrated on Moses’ Ten Commandments of “you shallnot kill “ [5] and provided a broader insight that besides
avoiding doing harm, we must also treat all creatures
respectfully and equally from the perspectives ofsanctity of life and life’s manifestations, therefore thecommand of “you shall not kill” is deepened as abioethical imperative to “respect every living being on
principle as an end in itself and treat it, if possible, as such.”[3]
The Duty to preserve life
Jahr discussed further that each person must observe
the duty to preserve one’s own life. According to him,
there are three stages of life, to begin with, life existing in
the earthly house of the mother’s body in flesh. It is apreparation for the second and also the third. Once weare born we live in this life-body which is mortal. The
third stage is like everyday dress is changed into aholiday dress, the hut becomes a palace, the natural bodythat is spiritual and transfigured.
He called the passage from the first stage to thesecond as death as the baby at birth cries at leaving themother’s protective womb. . In his words, “ for leaving
your quarters even if it is only a hut, is an inconvenience
as anyone knows who has to move”. He called thepassage from the second to the third is resurrection. Hisargument was theological and philosophical but heindicated that the three stages of life are what we have.

97

Since we are given the life-body, he appealed that wemust preserve it attentively until the time we are called
to enter into the third stage. [6] Taking care of one’s own
physical body of the second stage of life is not to abuse it“ by not taking one’s life, not shortening it, not harming
or endangering it, not weakening one’s health ….. [7].
From Jahr’s point of view, life is to be valued therefore
any action of taking it away by human effort is immoral.
If we trace back to the original tradition of medical
ethics, the Father of Medicine, Hippocrates has strongly
suggested in his oath – “ I will use treatment to help thesick according to my ability and judgment but never witha view to injury and wrongdoing . Neither will I
administer a poison to anybody when asked to do so, norwill I suggest such a course. Similarly, I will not give to a
woman a peccary to cause abortion. But I will keep pureand holy both my life and my art ” .[8] (Hippractic Oath).
Who holds the key to the formation of life?
With the rise of consumerism that emphasizes
individual’s rights to choose, to safety, to be informed
and to be heard [9], the world has changed. The
emphasis of modern medical ethics on autonomy isnothing wrong but it propelled many different
interpretations. Saying each person owns the right todecide his life or death is implausible subjected to debate.
J Savulescu has an interesting discussion on “ Is there aright of not to be born? Reproductive decision making
and the right o information” in Journal of Medical Ethics[10] in which he discussed a case in India that wrongly
gave birth to a baby whose gender is not desired and theparents thus sued the physician for wrongly predictedbaby’s gender. The right to life and death has nothing to
do with autonomy because we cannot choose to be bornor not. The naturally endowed right only begins when
the life is formed that some interpret as at the time ofconception while others view it as the moment of
spontaneously breathing at birth. From this view we findalthough we do have autonomous rights in life, the rightto have a life is always in nature’s hand.
To use a simple illustration, have we ever been asked
before our birth by our parents that they are going tobring us to life? No, absolutely not. Autonomous choice is
not applied here. Although family planning is available
now, our parents even cannot predict the baby who will
come to them is you or me. In other words, we practiceno informed consent to our life when we are born.
Likewise, the time of death is also in the hand of nature
or God. The Taoists have this famous teaching: “humanfollows heaven, heaven follows Tao and Tao follows
nature.“ Fung Yu-lan, the most important Chinese
philosopher of the 20th century has said: according toLao-tze and Chuang-tze, life followed by death is thecourse of nature and man should follow this natural
course calmly [11]Those who insist autonomy as inviolable right suchas John Harris who said “ the point of autonomy, thepoint of choosing and having freedom to choose between
comparing conception of how and indeed why, to live, issimply that it is only thus that our lives become in any
real sense our own. The value of our value is the valuethat we give to our lives [12], this right, however is only
relative . There are also many bioethical scholars who
argued from different perspective to uphold the value of

98

Eubios Journal of Asian and International Bioethics 28 (May 2018)

life itself such as Robert Orr, John Wyatt, Andrew
Fergusson, and so on [13].
Euthanasia is a controversial issue in medical ethics
today. The umbrella of medical ethics is the sacrednessof life. Without this premise, the discussion of ethics ismeaningless. The main argument of favoring euthanasia,
in addition to the principle of autonomy is the questionthat isn’t ending the suffering of a patient who enduresfrom unbearable pain, a good act? Thus euthanasia
should be justified.
In fact, euthanasia implies four different forms
depending on individual’s emphasis, namely positive andnegative, active and passive. The main controversy goingon in bioethical discussion focuses on active euthanasia,
that is to apply an artificial means either taking medicine
or injection or else to terminate a life prior to its natural
death. Since the procedures are quick and painless, it iscalled a good death or mercy killing to end all sufferings.
Indeed, this argument can somehow be seen as abeneficial act but the procedures are not completely freefrom psychological struggle and physical distress. The
question is not how we apply a method to ensure apainless ending, rather, do we possess a right to end alife?
The right to life and death has nothing to do withautonomy, we cannot even choose our own life as we
discussed earlier therefore although we do haveautonomous rights in life, the right of life and death isstill in nature’s hand.
Instincts to life and death
Freud in his book Beyond the pleasure principles in
1920, concluded all instincts fall into two categories,
namely, instinct to live and instinct to die. The life
instincts are those which deal with basic survival,
pleasure, and reproduction. The concept of the deathIV.
instincts was initially described in the book in whichV.
Freud proposed that “the goal of all life is death.” [14]Indeed, that is, the life instinct motivates people’s
desire to live and enjoy life to try their best to live, work
hard , endure sickness and seek medical treatment whensick. When people's physical and mental pain exceeds
the load, they sometimes seek liberation to end theirsufferings. This is death instinct. But life is always
stronger than death. Sun Su-miao, the father of Chinese
medical ethics, has a clear statement: "The human life isso important and valuable that is worth more than athousand pounds of gold..." [15] and Chinese Book of Filial
Piety also stated that "our bodies- to every hair and bit ofskin – are received by us from our parents, and we must
not presume to injure or wound them. This is the
beginning of filial piety". [16]Is it not a good thing to give euthanasia to patients
suffering from terminal cancer or patients whose
physical pain can no longer be managed?
Toaccommodate this need, many countries have regulated
new legislation such as a “Patients’ self-determination
Act “ to allow those patients to decide either to continue
treatment or to withhold and withdraw from medical
procedures and be admitted to palliative care unit toease their physical pain and die a dignified death.
Such an act will also be implemented and taken effectin Taiwan in January 2019. This bill that gives patientsright to decide whether to continue or suspend medicalVI.

treatment, is a manifestation of patient autonomy andrespect for individual wishes. Some people refer thispalliative care as passive euthanasia because no more
active medical treatments will be given except pain
control so that patients can live their last phase of life
with dignity. The difference between it and active
euthanasia is that it respects nature and does not require
artificial methods to end life early.
In this care, controlling pain medically is given toease the discomfort so that the patients do not need toendure excessive pain to maintain the quality of life. Thishospice care includes four dimensions that are to care
the whole person with whole medical team, wholejourney and the whole family is also involved.
Does the patient who has reached the terminal stageof life lose the meaning of life? No, absolutely not.
Regardless the physical condition or the senile age, aperson does not need to seek an early ending of life.
Imagining a young mother who is infected with anincurable disease, by the life instinct, she wants to live onfor the sake of her young baby because she as mother isneeded.
Jahr called this instinct as altruistic, the sense forcompassion, justice, pity and love [17]. If a motherprefers to die and leave her baby along, it become
egoistic, only interest in herself. Surely, human beings
have no say in either a person can continue to live or not,but a person out of compassion will not give up easily toseek medical help in order to live for others. In Paul’swords, to die is to gain as the end of earthly suffering but
to live is for Christ and to serve others. When a person isneeded, there is a responsibility to live on. When anelderly person is seriously ill, but his survival will makeanother person feel comforted and strengthened, his
continuous existence becomes meaningful.
Make Today Count
Orville Kelly had suffered an incurable disease when
he was 42 years old. He was disheartened and frustrated,
but later he thought time would elapse the same way
either he worried about his illness or if he cheered up. So
he started the "Make Today Count" movement for
instance, as long as I did something meaningful in a dayeither reading a book that inspired me or hearing a wordthat encouraged me or if I prayed for another person. . . .
I lived a worthwhile life. Thus every individual should
strive to make every day meaningful, to live bravely evenwith some physical pain because enduring a pain itself
has its own value as learning from pain is a living growthtoo.
In 1993, a farmer in Canada could not bear to see thesuffering of his 12 years old congenitally defecteddaughter when seizure stroke. He decided to end her life
by putting her in his car with exhausted carbon dioxides.
This incident provoked great controversy in the UnitedStates and Canada. A child with the same disease heard
the story and wrote a letter to his father that he indeed
suffered a great deal when the seizure stroke but every
time he survived and requested his father would never
use the same measure to end his suffering. He said: life
has many hardships but to be alive is precious. Each day
is a new day, a new possibility and a new hope.[18]Concluding words

Eubios Journal of Asian and International Bioethics 28 (May 2018)
Do people have the right to artificially terminate theirlives ? Life always bears meaning either in sickness or in
health. In Jahr’s own words: “ ….every human life as suchis morally ‘sacred’ – including one’s own life. Preservationof life—and one’s own life not excluded—is a duty. And
destruction and harm – again including one’s own life – isa moral sin.” [19].
References
1. Arakawa M: Moral Reflection on How to Improve End-of-Life
Decision Facing Patients and Care-givers in Japan :Confusions andDilemmas of Dying with Dignity in Journal of Philosophy and Ethics
in Health Care and Medicine. Japan. No.10. Dec, 2016:44
2. https:tw.news.appledaily.com/forum/realtime/20180614/137272
1/
3. Jahr.F: Essays in Bioethics 1924-1948, ed & trans by Irene M.Miller
and Hans Martin Sass. Berlin: Lit Verlag, 2013:28
4. ibid: 78
5. ibid:77
6. ibid:107-111
7. ibid:79
8. Hippocratic Oath
9. President Kennedy issued his Special Message to the Congress on
Protecting the Consumer Interest on March 15, 1962 in which heidentified four consumer rights.
10. Editorial, Journal of Medical Ethics Vol 28, Issue 2, 2002.
http://dx.doi.org/10.1136/jme.28.2.65
11. Fung YL: A Short History of Chinese Philosophy. New York: The
Free Press, 1966:3
12. HarrisJ: Euthansia and the Value of Life. In Keown J (ed) Euthansia
Examained. Cambridge: Cambridge University Press. 1995:11( Quoted from Watt J: Matters of Life and Death. Leicester: InterVarsity Press 1998:178
13. Ibid. 169ff
14. Mitchell S. and Black. M. Freud and Beyond: A History of Modern
Psychoanalytic Thought (Updated Edition).
New York: Basic
Books/Hachette Books; ISBN-13: 978-0465098811. 2016
15. Tai MCT: Medical Ethics and Humanities. Taipei: Gau-lih,2006:144
16. Xiao Jing ( Book of Filial Piety), The Scope and Meaning of Its
Treatise. Trans by James Leggs.
https://ctext.org/xiao-jing/scope-and-meaning of the treaties
17. Op.cit. Jahr, 2013:51
18. Tai MCT: The Medical Ethics of Life and Death. Taipei: HealthWorld Press, 2014:239
19. Op.cit. Jahr 2013:78

HIV/AIDS Health Promotion:
Coverage of disabled people
within academic literature
and Canadian newspapers- Syeda Farwa Naqvi,
Cumming School of Medicine, Department Community Health
Sciences, Community Rehabilitation and Disability Studies,
University of Calgary, 3330 Hospital Drive NW, Calgary,Alberta, Canada T2N 4N1
Email: sfnaqvi@ucalgary.ca- Gregor Wolbring, Ph.D.
Cumming School of Medicine, Department of Community
Health Sciences, Community Rehabilitation and Disability
Studies, University of Calgary, 3330 Hospital Drive NW,
Calgary, Alberta, Canada T2N 4N1
Email: gwolbrin@ucalgary.ca

Abstract
HIV/AIDS has been a public health issue and continues
to be epidemic. Eradicating HIV/AIDS is part of goal 3.3of the 2030 sustainability goals. HIV/AIDS is one focus of99

health promotion. Disabled people are one vulnerable
group at equal or increased risk than other groups for
HIV/AIDS. The purpose of our study was to analyze towhat extent and how the academic literature andCanadian newspapers engage with disabled people inrelation to HIV/AIDS health promotion. We performed ascoping review of academic articles and newspaper
articles covering databases to generate descriptive
quantitative and qualitative data on how and to what
extent the academic literature and newspapers engage
with disabled people in relation to HIV/AIDS healthpromotion. We identified n=621 newspaper and n=7896
academic articles that include the terms “HIV” and“health promotion”. Searching these articles using thesearch terms “disabled people”, “people withdisabilities”, “deaf”, “physical disability”, “impairment”,“intellectual disability”, “disabled” and “handicap” only
one newspaper article and eleven academic articles were
found that had relevant content. Our findings suggestthat public education through newspapers and evidence
published in academic journals is lacking on the topic of
HIV/AIDS health promotion in relation to the socialgroup of disabled people, which hinders a positivechange in the HIV/AIDS situation for disabled people andachieving target 3.3 of the sustainable development
goals.
Keywords: disabled people; people with disabilities;
HIV/AIDS; HIV; AIDS; health promotion; health;sustainable development goals
1. Introduction
Since the early 1980s, HIV/AIDS has been a publichealth issue and continues to be epidemic [1] withongoing efforts to prevent, treat and eradicate HIV/AIDS.
The UN Sustainable Development Goals have targeted to
end the AIDS epidemic by 2030 under Target 3.3 [2].
According to Groce, “one hallmark of HIV/AIDS epidemic
has been its impact on vulnerable populations”[3]. Groceand others have noted that disabled people, one
vulnerable group, are often overlooked in HIV/AIDS
discourses and actions [3,4] although they are at equal
or increased risk for HIV [3-7]. Disabled people are often
erroneously perceived as a low risk group as they areoften assumed to be “sexually inactive, unlikely to use
drugs or alcohol, and at less risk of violence or rape thantheir non-disabled peers” [3] (see also [4,8-10]). Data on
the prevalence of HIV/AIDS within the disability
community are rare [4,11] or non-existent [12,13].
Disabled people have problems accessing HIV related
information [14-18] and the level of knowledge of
HIV/AIDS is low among disabled people [17,19].
HIV/AIDS is one focus of health promotion [20,21].
Two key elements of health promotion are good
governance for health and health literacy [22]. The ideaof health promotion is to move beyond the individual
and recognize the impact that wider social andenvironmental factors have on an individual’s well-being.
It seeks to promote programs and other interventions
that enable people to take greater control over, andimprove, their own health and well-being [22].
According to the Ottawa Charter of Health Promotion,
Health Promotion Action includes the generation ofhealthy public policy, creation of supportive

100

Eubios Journal of Asian and International Bioethics 28 (May 2018)environment, strengthening of community actions anddevelopment of personal skills [23].
Mass media, including newspapers are a major sourceof health information for the public [24]. Newspapers
have the ability to shape beliefs and public perceptions
and are vital in directing the discussion around social
issues [25].
Given the situation of disabled people in relation to
HIV/AIDS and given the mandate of health promotion
and the impact of newspapers, our study aimed toanswer the question: how often and in which way are
disabled people covered in academic and newspaper
articles that cover HIV/AIDS and health promotion?
2. Materials and Methods
2.1. Study Design
The objective of our study was to ascertain whether
and to what extent disabled people were engaged with inacademic literature and Canadian newspaper articles
that covered HIV/AIDS and “health promotion”. To
achieve the objective we searched first for the presenceof the terms “disabled people” and “people withdisabilities” the two major terms used in discourses
targeting the social group of disabled people [26-28]. We
then used a few other terms related to disabled people
namely deaf”, “physical disability”, “impairment”,“intellectual disability”, “disabled” and “handicap”. Grant
et al outlined the characteristics of 14 review types [29].
A modified scoping review drawing from [30] waschosen as most the appropriate method for the study
given our research question. Scoping studies allow for
identifying the extent of research present on a given
topic [29] and the current understanding of a given topic[31]. Our study followed in a modified way the stages
outlined by [30] namely: identifying the review’s
research question, identifying databases to search;recording the descriptive quantitative results, selecting
literature based on descriptive quantitative results for
qualitative analysis, qualitative analysis of data, andsummarizing and reporting findings.
2.2 Data Source
Approach 1: Three academic databases were accessed(EBSCO - an umbrella database that consists of over 70
other databases; Scopus and PubMed). The databases
contain journals that cover a wide range of topics andareas of relevance to our study. We limited our searches
to all articles (PubMed), article, conference paper,
editorial, book chapter, editorial (Scopus), and scholarly
peer reviewed journals (EBSCO) for any year.
Approach 2: We accessed the ProQuest CanadianNewsstream database which houses a collection ofnearly 300 Canadian English language newspapers
covering the years 1980-2017.
2.3 Data Collection (quantitative data)
Eligible papers were identiﬁed using explicit searchstrategies across a range of data sources [32].
Approach 1: First we searched the three academic
databases on May 1, 2017 (not reported) and again
August 1, 2017 (reported) with the keyword
combination of “HIV” AND “health promotion” (datareported), “HIV/AIDS” AND “health promotion” (data notshown) and “AIDS” AND “health promotion” (data notshown). We limited our searches to title/abstract(PubMed), title, abstract, keyword (Scopus) and abstract(EBSCO ALL). The obtained articles were then searched
for the presence of the terms “disabled people” OR“people with disabilities” in the title/abstract (PubMed),
title, abstract, keyword (Scopus) and abstract (EBSCO
ALL) or in the full text (all three databases). The
obtained articles were furthermore searched in the
abstract (Scopus, EBSCO ALL) or title/abstract (PubMed)
for the presence of the terms “deaf” OR “physicaldisability” OR “impairment” OR “intellectual disability”
OR “disabled” OR “handicap”.
We only report the results for “HIV” AND “Healthpromotion” in relation to terms related to disabled
people because when we conducted our search using theterm “HIV/AIDS” fewer articles appeared, but thearticles that did come up were no different than thearticles found using only the term “HIV”. When we
conducted our search using the term “AIDS”, the results
contained false positives and the articles that satisfied
our inclusion criteria matched the articles that resulted
from our search using the term “HIV”.
Approach 2: We accessed the ProQuest CanadianNewsstream database on May 1, 2017 (not reported)
and August 1, 2017 (reported). The search was limited tonewspaper articles from 1980-2017 with the same key
words used in Approach 1 appearing in the full text of
the articles.
2.4 Data Collection for Qualitative data:
Duplicates of academic articles due to articles being
listed in more than one academic database or listed
under abstract and full text were eliminated. The
remaining n=17 academic articles and n=6 newspaper
articles were downloaded in PDF format to the computer
and the articles were uploaded into Atlas.ti8©, aqualitative data analysis software, in order to conduct athematic content analysis of how disabled people werementioned in relation to HIV and health promotion. The
August search generated one more academic article fordownload in addition to the articles obtained in the May
search. No additional newspaper articles resulted in theAugust search.
.
2.5 Data Analysis
We employed a descriptive quantitative and aqualitative thematic content approach to answer the
research question of this study. The hit counts of theterms and phrases searched for in the three academic
databases and the Canadian newspaper databasegenerated our descriptive quantitative data for analysis.
Qualitative data was generated from the n=17
academic and n=6 newspaper articles downloaded as
aforementioned. The coding was deductive in the sensethat the top level themes we were looking for werepredefined by the research question [33,34]. However,the sub-themes that emerged were not pre-set and assuch could be seen as an inductive approach [33,34].
Credibility/dependability and confirmability arethree trustworthiness measures [35-37]. Both authors
performed the quantitative and qualitative analysis. To
enhance credibility/ dependability the authors engaged
in peer debriefing on the generation of the quantitativeand qualitative data. Differences in hit counts did notEubios Journal of Asian and International Bioethics 28 (May 2018)
occur. Differences in codes and theme suggestions of thequalitative data were few and discussed between
authors and revised as needed. Confirmability is evident
in the audit trail logged using Memo and coding
functions within ATLASti-8®. As to transferability [3537], our methods provide all the information needed forothers to decide whether they want to apply our
keyword searches on other data sources such as grey
literature or other English language newspapers or
newspapers and academic literature of other languages.
Given that we focused on some specific terms used inrelation to disabled people others could decide to see
whether using other terms covering disabled people
might lead to different results. We also used the explicit
phrase “health promotion” as this is a specific area andfield of engagement with certain narratives. Others could
use terms such as “HIV prevention” to look at thecoverage of disabled people within HIV/AIDS narratives.
2.6 Limitations
The database searches were limited to English
language academic articles and English language
Canadian newspapers present in the CanadianNewsstream database. Furthermore we only used a few
terms covering “disabled people” whereby others exist
to describe for example subgroups of disabled people.
However we submit that our findings based on the terms
used indicates that there is a problem.
3. Results
3.1. Quantitative Results
The terms “HIV” AND “health promotion” were
present in n=621 newspaper articles and n=7896
academic articles. Within the n=621 newspaper articles
n=6 articles mentioned “People with Disabilities” andn=1 article mentioned “disabled people”. Within the
n=7896 academic articles n=22 articles mentioned“people with disabilities” in the full text and n=10 in the
abstract. The term “disabled people” was mentioned
n=10 times in the full text and n=3 times in the abstract.
Within the 621 newspaper articles the term “disabled”
was mentioned in eleven articles “deaf” in 5 articles,“physical disability” in three articles “impairment” in two
articles, “intellectual disability” in one article and“handicap” in none.
Within the 7896 academic articles the term “disabled”
was mentioned in the abstract in n=17 articles,“impairment” in ten articles, “intellectual disability” in
six articles, “physical disability” in two articles, “deaf” in
one article and “handicap” in none.
However, all the articles obtained with the terms
disabled, “impairment”, “intellectual disability”, “physicaldisability”, “deaf” and “handicap” only two new articles(one containing “disabled” and one containing“impairment” were obtained not already found using theterms “disabled people OR “people with disabilities”. The
other hits reflect already found articles such as all
articles that contained the term “intellectual disability”
also contained the terms “disabled people” OR “people
with disabilities” or as in the case of the newspapers
none of the found articles were relevant.
3.2. Qualitative Data Newspaper

101

As to our newspaper related searches mentioned
only one article mentioned disabled people in relation to
HIV/AIDS or HIV/AIDS and “health promotion” whereby
all the other article did not contain relevant content suchas mentioning HIV as a disability which was not thefocus of our study or no linkage at all. This one
newspaper article was titled “Everyone has the right tolearn about safe sex” published by the Toronto Star in
1992 (Henderson, 1992). The author introduced thecontext of the article by stating “AIDS doesn’t
discriminate”. The article highlighted efforts in British
Columbia and Ontario to create networks andworkshops to inform people with disabilities as well as
caregivers and attendants on safe sex practices inregards to HIV/AIDS. According to the article, the efforts
were funded by the “health promotion directorate”.
3.3. Qualitative Data academic articles
As to our searches of academic articles n=19
academic articles were downloaded for analysis after theelimination of duplicate articles. Having read the n=19
articles, n=8 articles made no mention of disabled people
in relation to health promotion and HIV.
Of the remaining n=11 articles, all n=11 articles
stated that HIV health promotion as it relates to disabled
people needs improvement. The subgroups of disabled
people mentioned in these articles were: children withdisabilities (deaf and hard of hearing, motor disorder,
mentally retarded, blind and partially sighted,
leprosy)[38], physically disabled adolescents [39],women with disabilities [40], deaf people [41], speechand hearing impaired [42], visual disability [39,43,44],
physical disability [39,42,44], Attention Deficit
Hyperactivity Disorder[45] and intellectual disability[42,46,47].
Of these n=11 articles, n=8 articles argued orprovided evidence that disabled people have low
HIV/AIDS literacy and have problems accessing
HIV/AIDS information. N=7 articles made the point that
disabled people exhibit the same sexual and other risky
behaviors as their non-disabled peers. Kumar et alprovided empirical data that made them to conclude that
“ADHD may contribute to high risk sexual behavior andthereby also the risk of contracting HIV[45].
The n=11 articles [38-48] covered the countries of:
Uganda n=2 [40,42], South Africa n=2 [39,44], Zambia[43], Swaziland [41], Ethiopia [38], Australia [48],India[45] and Britain [46]. One article did not focus on a
specific country[47].
The article focusing on Britain covered the role of andcompetence of HIV prevention programs related topeople with intellectual disabilities. The authors
identified
recognizing
HIV
risk,
representing
homosexuality, sexual identity and behavior, complexityof message, the reality and explicitness of image as key
challenges for specialist residential support, sex
education services and mainstream health promotion
services. The authors argued that people withintellectual disabilities should be supported in theirrights to “information and support for sexuality andsexual health” [46].
The article that focused on the country of Ethiopia
argued that it is problematic that disability is dealt withas a medical issue whereas “social inequity, poverty, and102

Eubios Journal of Asian and International Bioethics 28 (May 2018)

lack of human rights protection” problems that are“reflected in their health status” are ignored [38]. Sorsa’s
study revealed that children with disabilities lack accessto HIV/AIDS information despite the fact that children
with disabilities practice unsafe sex and are exposed tosexual and substance abuse which put them at risk of
HIV infection. Sorsa called “for appropriate healthpromotion and disease prevention education for[children with disabilities] CWDs ” [38].
Groce et al found that the deaf participants from
Swaziland believed more in incorrect modes of HIV
transmission and HIV prevention than the non-deaf
participants. This study identified that 99% of deaf
participants reported communication problems withhealthcare facility staff [41]. Groce at al concluded that
there is “the need for targeted HIV/AIDS education
campaigns and improved accessibility in healthcare
facilities for deaf sign language users in countries such as
Swaziland” [41].
Kumar et al provided empirical data that made them toconclude that “ADHD may contribute to high risk sexual
behavior and thereby also the risk of contracting
HIV[45].
As to the two studies from Uganda the first study
asked people with disabilities how they felt about
HIV/AIDS educational programs and found thataccessibility to educational information was a problem
and that the participants felt discriminated as people
with disabilities [42]. The second article focused on
young women with disabilities and access to HIV/AIDS
and argued that “widespread misperceptions about thesexual behaviors of women with disabilities, exposure toviolence and exclusion from health promotion activities
and health services” [40] renders “women withdisabilities, particularly young women with disabilities,
disproportionately vulnerable to HIV” [40].
The study from Zambia concluded that “most visually
impaired people lacked knowledge on the cause,transmission and treatment of HIV and AIDS resulting in
misconceptions” and that discrimination, stigma, lack of
employment opportunities, funding and poverty wereseen as some of the causes visually impaired persons
faced which influenced negatively their ability to access
HIV and AIDS information. The study found also that“health promoters and people working with the visually
impaired did not have specific HIV and AIDS information
programs” [43]. The study found that the media were
one channel through which the visually impaired
accessed HIV and AIDS information [43].
As to the two studies from South Africa, Chappell’s
study focused on how peoples aged 15-20 with physicaland visual disabilities in South Africa communicatedwith their parents and caregivers on the topic of
HIV/AIDS based on the premise that health promotion
strategies have been implemented in South Africa that
aimed to encourage young people to talk about issues ofsexuality and HIV with their parents/caregivers. The
study found that young people resisted the efforts ofparental and caregiver control. The author concluded
that “young people with disabilities’ perceptions of sex,
sexuality and relationships are critical to efforts to more
adequately educate parents/caregivers about message
content and communication to help disabled youth makesense of love, sex, relationships and HIV” [44]. The

author argued further that “educational programs areneeded for parents/caregivers of youth with disabilities
that recognize young people with disabilities as ‘capablesocial agents’ and not just innocent vessels when it
comes to sexuality and HIV” [44].
Maart and Jelsma made the point that disabled people
are routinely excluded from mainstream healthpromotion activities in South Africa giving the example
that the national policy of the Department of Education
on HIV/AIDS in schools does not include learners inspecial schools. The study concluded that disabledadolescents are just as engaged in risky sexual
behaviours, and are at equal risk of developing HIV than
the non-disabled and therefore must be included inmainstream research and in health promotion activities
especially to sex education [39].
Wells et al showed in their study that computer-based
interactive multimedia programs are an efficacious
means to provide behavioral health content,
compensating for the dearth of available healthpromotion materials for people with intellectual
disability[47].
The Australian paper concluded that “masscommunication can maximize the impact of legislationby promoting awareness of new laws and, more
importantly, lead changes in the attitudes of the polity
and the wider public” [48]4. Discussion
HIV/AIDS is still an epidemic [1] and the prevention of
acquiring HIV is seen as the only path to an AIDS-freegeneration [49]. The UN Sustainable Development Goals
have targeted to end the AIDS epidemic by 2030 underTarget 3.3 [2]. Greenall et al reported that achieving
target 3.3 is hindered by “services failing to reachvulnerable and excluded populations”[50]. Our findings
suggest that Target 3.3 as it relates to AIDS is also
hindered by how HIV/AIDS health promotion academic
and newspaper literature engages with disabled people
and that changes in the coverage is needed if theacademic and newspaper discourses are to contribute ina positive way to target 3.3.
4.1. The issue of academic invisibility
Policies are to be informed by evidence generated
through research [51]. Disabled people are highly
impacted by policies and by the choice of evidence
generated to inform policies [52]. Our findings from ouranalysis of the coverage of HIV/AIDS and healthpromotion for disabled people in academic literaturesuggests that health promotion linked actions andstudies did not lead to published academic evidence that
could inform policies such as how to design healthpromotion actions so that they increase the HIV/AIDS
literacy of disabled people and the literacy of nondisabled people of HIV/AIDS vulnerability of disabled
people. The concept of health literacy is crucial for
individuals to attain education about HIV/AIDS and thiscan be implemented through academic literaturetransitioning into community outreach efforts for HIV
literacy [53]. Given that HIV/AIDS is still a public healthissue and disabled people still face risks and problems
related to HIV/AIDS we conclude from our study thatstudies are needed that provide data on HIV/AIDS

Eubios Journal of Asian and International Bioethics 28 (May 2018)prevalence among disabled people and best practice dataon how to perform HIV/AIDS health promotion in
relation to disabled people.
4.2. The issue of newspaper invisibility
From our analysis of Canadian newspapers, one candraw three possible conclusions from the lack of reportsby the newspapers on HIV/AIDS health promotion anddisabled people in Canada: a) there were no HIV/AIDS
health promotion activities related to disabled people in
Canada that the newspapers could have report on; b)there were HIV/AIDS health promotion activities related
to disabled people in Canada but the newspapers were
never aware of them, or c) the newspapers were awareof HIV/AIDS health promotion activities related todisabled people in Canada but did not view thisinformation as important to report. All three possible
conclusions suggest a failure of HIV/AIDS healthpromotion activities within Canada.
One of the main goals of health promotion is toincrease health literacy [22]. At the same time,newspapers are a major source of health information forthe public [24] and have the ability to shape publicbeliefs and perceptions [25]. If conclusions (a) and (b)are true, there is a need for people involved in HIV/AIDS
health promotion activities in Canada to provide
newspapers with data on HIV/AIDS and disabled people
to ensure that data on HIV/AIDS and disabled people
reaches the public reader. If conclusion (c) is true, apossibility that would fit with prior studies thathighlighted the problematic coverage of disabled people
in newspapers [54,55], that is a problem more difficult tofix but efforts have to be undertaken to fix the lack ofinterest of the newspapers if conclusion 3 is the problem.
Although there are an increasing number of outlets
available for young people especially, to be informed
about HIV/AIDS (i.e. Facebook), many of these sources
will likely be used only after the person has been
impacted by HIV/AIDS. As such, these outlets do notwork for preventative measures, they do not increase
the HIV/AIDS literacy of the general community ofdisabled people, and they do not increase HIV/AIDS
literacy of the general public in relation to disabled
people.
5. Conclusion
Given our findings there is a need for more studies thatprovide evidence on best practices to fix the HIV/AIDS
literacy problems exhibited on and by disabled people.
The study from Wells et al provided some thoughts [47]but more studies are needed that provide evidence on
working strategies for improving HIV/AIDS literacy.
More efforts are also needed by health promotion
strategies to ensure that the public education mandate
performed by newspapers is eliminating the invisibilityof disabled people in relation to the coverage of HIV
health promotion. We submit that ethics theories andprinciples can be used to question the invisibility ofsocial groups such as disabled people in the coverage ofa topic that impacts them. It might be useful to havemore literature that uses explicitly the phrase ”ethics ofinvisibility” a phrase that appeared eleven times in our
Google Scholar search. Without thematizing the
problematic situation of disabled people within health103

promotion with the intent to rectify the problems suchas the low literacy around HIV and disabled people
present within and outside the disability community, candecrease the autonomy of disabled people. Without
literacy and knowledge on the topic for example,
disabled people cannot really make informed decisions
whereby informed decisions are part of being
autonomous. The lack of autonomy is further
jeopardized when this information comes from sourcesthat may be biased or have stereotypical views of
disability and disabled people. Given our findings it
might be useful to extent the study towards other media
types and to other geographical settings and to obtainviews of members of the HIV/AIDS health promotion
community and disabled people involved in HIV/AIDS
discourses to understand better the findings of our study
and how to fix it.
6. References
1. Medlock, J.; Pandey, A.; Parpia, A.S.; Tang, A.; Skrip, L.A.; Galvani, A.P.
Effectiveness of unaids targets and hiv vaccination across 127
countries. Proceedings of the National Academy of Sciences 2017, 114,
4017-4022.
2. United Nations. Transforming our world: The 2030 agenda forsustainable
development.
Available
online:https://sustainabledevelopment.un.org/post2015/transformingour
world (accessed on 15 September 2017).
3. Groce, N.E. Hiv/aids and individuals with disability. Health andHuman Rights 2005, 8, 215-224.
4. World Health Organization. Disability and hiv policy brief. Available
online:http://www.who.int/disabilities/jc1632_policy_brief_disability_en.pdf (accessed on 15 September 2017).
5. Rohleder, P.; Eide, A.H.; Swartz, L.; Ranchod, C.; Schneider, M.; Schür,C. Gender differences in hiv knowledge and unsafe sexual
behaviours among disabled people in south africa. Disability andRehabilitation 2012, 34, 605-610.
6. Godziek, S. Mdg 6-what about disabled people? Journal of HealthManagement 2009, 11, 109-126.
7. Mboua, C.P.; Touko, A. Psychosocial vulnerability and hiv/aids
epidemiological situation among people with hearing disabilities infour towns in cameroon. Medecine et Sante Tropicales 2016, 26, 391395.
8. Interagency coalition on AIDS and development. Hiv, aids anddisability.
Available
online:http://www.icadcisd.com/pdf/HIV_AIDS_Disability_EN.pdf(accessedon15
September 2017).
9. United Nations DESA. Disability and hiv/aids. Available online:
https://www.un.org/development/desa/disabilities/issues/disabili
ty-and-hivaids.html (accessed on 15 September 2017).
10. Groce, N.E.; Rohleder, P.; Eide, A.H.; MacLachlan, M.; Mall, S.; Swartz,
L. Hiv issues and people with disabilities: A review and agenda forresearch. Social Science & Medicine 2013, 77, 31-40.
11. TBfacts.org. Hiv south africa – antiretrovirals, prevalence &provincial statistics. Available online: https://www.tbfacts.org/hivstatistics-south-africa/ (accessed on 15 September 2017).
12. Davidson, L. Hiv and aids, and disability. CBR as Part of Community
Development: A Poverty Reduction Strategy. London, UK: University
College Centre for International Child Health 2006, 91-95.
13. The International Bank for Reconstruction and Development WorldBank ACTafrica—AIDS Campaign Team for Africa. Hiv/aids &disability: Three country studies south africa, uganda, and zambia.
Available
online:http://www.unaids.org/sites/default/files/media_asset/20091111_
hiv_and_disability_en_0.pdf (accessed on 15 September 2017).
14. Saulo, B.; Walakira, E.; Darj, E. Access to healthcare for disabled
persons. How are blind people reached by hiv services? Sexual andReproductive Healthcare 2012, 3, 49-53.
15. Eide, A.H.; Schür, C.; Ranchod, C.; Rohleder, P.; Swartz, L.; Schneider,
M. Disabled persons' knowledge of hiv prevention and access tohealth care prevention services in south africa. AIDS Care Psychological and Socio-Medical Aspects of AIDS/HIV 2011, 23, 15951601.
16. Yousafzai, A.K.; Edwards, K.; D'Allesandro, C.; Lindström, L. Hiv/aids
information and services: The situation experienced by adolescents

104

Eubios Journal of Asian and International Bioethics 28 (May 2018)with disabilities in rwanda and uganda. Disability and rehabilitation
2005, 27, 1357-1363.
17. Hanass-Hancock, J. Disability and hiv/aids-a systematic review ofliterature on africa. Journal of the International AIDS Society 2009,12, 34.
18. Porch, W. Hiv and disability: Intersections of access. Available
online: https://www.acyr.org/hiv-and-disability-intersections-ofaccess/ (accessed on 15 September 2017).
19. Lefèvre-Chaponnière, C. Knowledge, attitudes and practices
regarding hiv/aids amongst disabled youth in maputo(mozambique). Sante Publique 2010, 22, 517-528.
20. Chopra, M.; Ford, N. Scaling up health promotion interventions in
the era of hiv/aids: Challenges for a rights based approach. Health
Promotion International 2005, 20, 383-390.
21. Broring, G.; Van Duifhuizen, R. Mobility and the spread of hiv/aids:
A challenge to health promotion. AIDS health promotion exchange
1993, 1-3.
22. World Health Organization (WHO). What is health promotion?
Available
online:http://www.who.int/features/qa/healthpromotion/en/ (accessed on 15 September 2017).
23. Participants of the First International Health Promotion Conference,
O., Canada,. Ottawa charter for health promotion. Available online:
https://www.canada.ca/en/public-health/services/healthpromotion/population-health/ottawa-charter-health-promotioninternational-conference-on-health-promotion.html (accessed on 15
September 2017).
24. Chapman, S.; Lupton, D. The fight for public health: Principles andpractice of media advocacy. British Med. Assoc.: 1996.
25. Nord, D.P. A republican literature: A study of magazine reading andreaders in late eighteenth-century new york. American Quarterly
1988, 40, 42-64.
26. Barnes, C. Disability studies: New or not so new directions?
Disability & Society 1999, 14, 577-580.
27. Miles, S.; Singal, N. The education for all and inclusive education
debate: Conflict, contradiction or opportunity? International Journalof Inclusive Education 2010, 14, 1-15.
28. Chataika, T.; Mckenzie, J.A.; Swart, E.; Lyner-Cleophas, M. Access to
education in africa: Responding to the united nations convention on
the rights of persons with disabilities. Disability & Society 2012, 27,
385-398.
29. Grant, M.J.; Booth, A. A typology of reviews: An analysis of 14 review
types and associated methodologies. Health Information & Libraries
Journal 2009, 26, 91-108.
30. Arksey, H.; O'Malley, L. Scoping studies: Towards a methodologicalframework. International journal of social research methodology
2005, 8, 19-32.
31. Anderson, S.; Allen, P.; Peckham, S.; Goodwin, N. Asking the rightquestions: Scoping studies in the commissioning of research on theorganisation and delivery of health services. Health research policy
and systems 2008, 6, 7.
32. Davis, K.; Drey, N.; Gould, D. What are scoping studies? A review of
the nursing literature. International journal of nursing studies 2009,
46, 1386-1400.
33. Daly, K.J. Qualitative methods for family studies and humandevelopment. Sage: Thousand Oaks, California, United States, 2007.
34. Mayring, P. Qualitative content analysis. Forum: Qualitative Social
Research 2000, 1, Article 20.
35. Baxter, P.; Jack, S. Qualitative case study methodology: Study design
and implementation for novice researchers. The Qualitative Report
2008, 13, 544-559.
36. Lincoln, Y.S.; Guba, E.G. Naturalistic inquiry. SAGE Publications:
Beverly Hills, CA, 1985.
37. Shenton, A.K. Strategies for ensuring trustworthiness in qualitative
research projects. Education for Information 2004, 22, 63-75.
38. Sorsa, S. Health problems of children with disabilities with specialreference to hiv/aids in southern ethiopia. Ethiopian Journal of
Health Development 2013, 27, 94-103.
39. Maart, S.; Jelsma, J. The sexual behaviour of physically disabledadolescents. Disability and Rehabilitation 2010, 32, 438-443.
40. Nampewo, Z. Young women with disabilities and access to hiv/aids
interventions in uganda. Reproductive Health Matters 2017, 25, 121127.
41. Groce, N.; Yousafzai, A.; Dlamini, P.; Zalud, S.; Wirz, S. Hiv/aids anddisability: A pilot survey of hiv/aids knowledge among a deaf
population in swaziland. International journal of rehabilitation
research 2006, 29, 319-324.
42. Chireshe, R.; Rutondoki, E.N.; Ojwang, P. Perceptions of theavailability and effectiveness of hiv/aids awareness and intervention
programmes by people with disabilities in uganda. SAHARA: Journalof Social Aspects of HIV/AIDS Research Alliance 2010, 7, 17-23.

43. Chintende, G.N.; Sitali, D.; Michelo, C.; Mweemba, O. Situational
analysis of communication of hiv and aids information to persons
with visual impairment: A case of kang’onga production centre inndola, zambia. BMC research notes 2017, 10, article 150.
44. Chappell, P. Secret languages of sex: Disabled youth’s experiences ofsexual and hiv communication with their parents/caregivers in
kwazulu-natal, south africa. Sex Education 2016, 16, 405-417.
45. Shankar, K.; Aashik, S.; Kasthuri, P.; Gopal, D.; Abhinav, N.;
Raveendra, K.; Chandrashekar, H. Prevalence of adult attention
deficit hyperactivity disorder and its correlates among recently
diagnosed young adult males with hiv. Journal of AIDS and ClinicalResearch 2014, 5.
46. Cambridge, P. Challenges for safer sex education and hiv prevention
in services for people with intellectual disabilities in britain. Health
Promotion International 1998, 13, 67-74.
47. Wells, J.; Clark, K.; Sarno, K. A computer-based interactive
multimedia program to reduce hiv transmission for women withintellectual disability. Journal of Intellectual Disability Research 2012,
56, 371-381.
48. Neilsen, G.A.; Young, F. Hiv/aids, advocacy and anti-discrimination
legislation—the australian response. International journal of STD &AIDS 1994, 5, 13-17.
49. Corey, L.; Gray, G.E. Preventing acquisition of hiv is the only path toan aids-free generation. Proceedings of the National Academy of
Sciences 2017, 114, 3798-3800.
50. Greenall, M.; Kunii, O.; Thomson, K.; Bangert, R.; Nathan, O. Reachingvulnerable populations: Lessons from the global fund to fight aids,
tuberculosis and malaria. Bulletin of the World Health Organization
2017, 95, 159.
51. Bowen, S.; Zwi, A.B. Pathways to “evidence-informed” policy andpractice: A framework for action. PLoS Med 2005, 2, e166.
52. Wolbring, G.; Diep, L.; Djebrouni, M.; Guzman, G.; Johnson, M.
Utilities of, and barriers to,'community scholar'as an identity.
Interdisciplinary Perspectives on Equality and Diversity 2016, 2, nopage numbers.
53. Nutbeam, D. Health literacy as a public health goal: A challenge forcontemporary health education and communication strategies into
the 21st century. Health Promotion International 2000, 15, 259-267.
54. Wolbring, G.; Mackay, R. Analysis of newspaper coverage of foodsecurity through a disability studies lens. Journal of Sustainable
Development 2014, 7, 1-27.
55. Wolbring, G.; Abdullah, B. Coverage of aging well of individuals
aging with a disability in canadian newspapers: A content analysis.
Review of Disability Studies: An International Journal 2016, 12, 1-19.

Is Organ Farming a Panacea to
Organ Crisis? Ethical Implications- Osebor Ikechukwu Monday
General Studies (Arts and Humanities), Delta State Polytechnic
Ogwashi-Ukwu, PMB 1030. Nigeria
Email; osebordarry@yahoo.com; osebormonday1@gmail.com

Abstract
Organ transplantation is one of the greatest
achievements of science in the 20th century. This
medical breakthrough is challenge with non-availabilityof organs for candidates on the waiting list, for organ
recovery and transplant. Organ farming is the scientificmethod of using animals, such as pig, as an incubator inwhich to cultivate healthy genetically human organs.
Such farming could to close the widening gap between
the supply and demand for organs. This subject, however,entails ethical debate over the moral justification and thepermissibility of organ farming. This paper will argue
from a consequentiality standpoint that, if organ farming
should turn out to be good for the greatest number of
persons, then it should permitted to avert organ crisisand help to reduce the high death rate among candidates
on the waiting list for organ recovery.

Eubios Journal of Asian and International Bioethics 28 (May 2018)

105

Key words; organic farming, organ transplant, organ
recovery, organic crisis, DNA, Xenotransplant, organ
allocation.

citizens, i.e., a pervasive scheme of values are announced
and promoted by institutional means to control and direct
all aspects of life State” (Aparna, 2015:p.3).

Introduction
Joseph Edward Murray (April 1, 1919 – November 26,2012) was an American, philosopher and a plastic
surgeon, who performed the first successful kidneytransplant (Tullius, 2013 p. 6). Before his death, Dr.
Murray trained and inspired surgeons who are today
achieving great exploits in the business of organtransplant.
Since the first organ transplant, scientists had been
relying on human-to-human organ donations, forcandidates on the waiting list for organ recovery. Thismethod of organ harvesting has been unable to keep up
with the high level of demand for viable organs.
To close the gap between the demand and supply oforgans, there is a need for organ farming which could,
ideally, eliminate the black market for organ trafficking,as well as the need for organ harvesting among prisoners(Antonio, 2017: p.3).
For instance, the cadaveric organ donation which
represents 80% of organ donation around the world, isbased in many countries on a presumed consent (StelaŽivčić-Ćosić,
et al,
2013). The World HealthOrganization (WHO) defines; “presumed consent” as asystem that permits ‘material’ to be remove from thebody of a deceased person for transplantation. However
if objection is filed, the informed party reports ispresented, in this sense the deceased definitely voiced an
objection to donation. (Aparna, 2015:p.3).
For some moral philosophers, the idea of presumed
consent is illogical because it aids conscription. The
default position is that anybody who wishes to donate anorgan, acted altruistically for the good of the society, andthis requires explicit consent of the donor, in some casehis family (Aparna, 2015: p.3). Additionally, supportersof presumed consent argue “the campaigned for one
such change – the move to "presumed consent.” Insteadof relying on people to volunteer, registration would be
automatic, but with an easy opt-out” (Guardian, 2009;p.8). In this sense, families of the deceased would still beentitled to prior consultation, and have a right to refuse.
Furthermore, a presumed consent occurs when adeceased person did not make any written statement
against donation; hence, organ harvesting against thedonor’s wills could be tyrannical or constrictive organ
donation. Constrictive organ donation is a philosophy
that affirms forceful and compulsory organ donation,
because the individual’s body and organs are, owned by
the State (Aparna, 2015: p.3). This approach is illogicaland it is not compatible with individual freedom, dignity
and a betrayer of the tenets of democracy.
In my opinion, conscription form of organ donation isa recipe for totalitarianism, if the family of the deceased
is not consulted before any ‘material’ could be removed
from the body of the deceased. In this sense, it istotalitarianism; the absence of the rule of law; the use offorce to implement government decisions on the citizens,
therebysuppressing
individuals’
freedom.
Totalitarianism denounces democracy and usually
portrays forms ofauthoritarianism. “state decisionmaking and ideology are not framed by the ordinary

Explicit Consent
Segen (2012) argues thus: “Explicit consent is a clear
and voluntary indication of preference or choice, usually
oral or written, and freely given in circumstances where
the available options and their consequences have been
made clear (informed consent). As defined in the UK,
express consent constitutes formal permission to undergoa diagnostic or therapeutic procedure, or to allow use of
personally identifiable information for research,epidemiology, financial audit or administration,
publication and/or to release into the public domain.
Without express consent, use of such materials is limited toteaching and training” (n.p.)
The World Health Organization (WHO) defines
explicit consent, as a system in which “cells, tissues, ororgans may be removed from a deceased person if theperson had expressly consented to such removal during his
or her lifetime” (Aparna, 2015: p.3). However, it is nolonger news that many people do not record theirdecision to be an organ donor.
Unfortunately, many 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 (Aparna, 2015: p.3).
Additionally, philosophical analysis of organ crisis in
American and Israel 1999-2010, would suggest that theefforts of these governments to increase organ donationin their states has persisted.
Father (2011) argues thus, “In 1999, some 40,000
Americans were on the waiting list for kidneytransplantation. By 2009, the list had grown to nearly
83,000 people, whereas only 16,500 people received atransplant. In Israel, the number on the waiting list forkidney donors has increased from 490 in 2006 to 690 in
2010, while the number of kidney transplants fromdeceased donors decreased from 87 to 65. At the sametime, there was an increase in live kidney donations from54 to 78. Thus, taking into account transplants from bothdeceased and living donors, there is only about one donor
for every five potential recipients, both in Israel and in theUSA, 2010”. (p.3).
A critical question arises at this juncture how long
would the world continue to depend on organ donations
from human to human donations, yet disappointing!
Must we continue to experience organ crisis, while many
candidates continue to die on the waiting list for organ
recovery and allocation. We think the scientificcommunity thinks outside the box to providing analternative source of organs donation, instead of relying
solely on human donors.
In my view, the panacea for organ crisis is genetic‘organ farming human-pig-chimeras’ not the “mythicalchimera.” Organ farming has the ultimate goal togenerate surplus organs that would be genetically
identical, human organ-matches from different species,
and would encourages human/animal interrelation in
anatomy, DNA, physiology etc. These will moreover, go a

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Eubios Journal of Asian and International Bioethics 28 (May 2018)

long way to averting the death of candidates on thewaiting list for organ recovery and allocation. In addition,organ farming will make organs available and sufficientfor human transplant.
Philosophical Foundations of Xeno transplantation
and Organ Farming.
Hetero transplantation also referenced as Xeno
transplantation. Xenon is a Greek word meaning"foreign." Xeno transplantation is the transplantation, or
infusion into a human lives cells or organs from anonhumanspecies(Kress,1998p.32).
Xenotransplantation has been instrumental in thetreatment of human organ failure. The rationale behindxenotransplantation research is, motivated by the factthat the demand for human organs for clinicaltransplantation far exceeds the supply, this has led toorgan crisis. For the purpose of understanding andillumination the concept of organ farming, let us review
literature on xenotransplatation.
Hindu mythology and religion, introduce its own
version of xeno transplantation. Hindu literature affirms
a cross-species in organ transplantation (human-animal
Chimera). Perhaps, the pre- historical mythologies of the
Hindu people on xeno transplantation were madewithout any knowledge of the species barrier. Cooper(2012) argues thus, “Xeno transplantation was theattempt by Daedalus and his son, Icarus, to fly across thesea from Crete to mainland Greece with the help of bird
wings attached to their arms. Icarus failed in the attempt,
and Reemtsma put this forward as a possible case of
hyperacute rejection (very rapid rejection of the graft),though he thought it was more likely to be related to
failure of a thermolabile adhesive. However, Daedalusy
successfully made the journey, providing this pair with anenviable 50% success rate” (p.2).
In 17th century, xeno blood transfusion was
temporary banned in France, reason been that adisinterested experiment was performed by Jean Baptist.
Jean Baptist experiments, the transfusion of animals’
blood into human body. Indeed, the result of theexperiment was unaccepted. Currently, with the
improvement on xeno transfusion researcher, animal
blood such as pig, could be successfully transfuse into
the human body with a proper scientific monitor to
avoid the transmission of infectious diseases to therecipient (Cooper, 2012. p.3).
Additionally, in 19th century, a scientific literaturereports that the salice of rabbit transplanted into a childwith renal diseases. However, the child did not live
because of the immunological basis of the organ
rejection. However, today, with the improvement inxenotransplant research including immunosuppressive
drugs, organ transplant from animals to human will beachieve without hindrances (Bailey, L.; Nehlsen et al,
1985: p.3323).
Without missing words, Organ farming is an offshootof the scientific innovation in xenotransplantation. Xeno
transplant researchers are currently making a giant
stride to address the problem of organ scarcity becauseof Human-to-human organ donations and transplant.
The cross species transplantation of organs has been
impracticable to sustain the fore seeable future, because
human immune system built to rejecting external organs.

Organ farming through genetically modified pigs isinvoked as a panacea to the organ crisis. Heather (2015)
argues thus, “A farm in Virginia, a company called
Revivicor is breeding pigs that have some genetic
similarities to humans. The scientists call them “GalSafe
pigs” and they have added five human genes to the pigs’
livers, kidneys, and hearts. The hope is that the organs canbe harvested and used for transplants, and that humanbodies won’t reject them” (p.3)
Lastly, surgeons at the National Heart, Lung, andBlood Institute, in Bethesda, Maryland are currently
investigating Revivicor's pig breeding centre. In a
unanimous decision, the “surgeons managed to keep oneof Revivicor’s genetically modified pig hearts alive insidea baboon’s stomach for 945 days” because there is apossibility of its organs matching with human DNA(Heather, 2015:p.3). However, with the transplanting ofa pig organ into the primate, is a great scientificbreakthrough in xeno transplantation and this presents agreat future for the cross species and organtransplantation.
Organ Farming Human-Pig-Chimeras
A group of scientists from the department of
Biological Science at the University of California in the
United States reported in “ the journal Cell” and “MITTechnology Review” they have successfully implanted
human stem cell into the embryonic stage of a pig
blastocyst. This scientific attempt is to create a hybrid, achimera that could be pig pancreas, kidney, liver, heartetc., for human transplant (Robby 2017: p1) (Antonio,
2017).
The scientific breakthrough in genetic organ farming,in my view is a wise exploration of inter-species sources
for organ donation; because it presents a great
opportunity for scientists judiciously use nature for the
benefit of man.
Robby (2017) posits thus, “The UC scientists had used
CRISPR gene editing to remove from a newly fertilized pig
embryo the DNA responsible for growing a pancreas,
creating a ”niche,” or a gap, into which human cells could
be inserted. Next, they took human induced pluripotent(iPS) stem cells — adults stem cells regressed so that they
can once again grow into any kind of human tissue — andslotted them into the niche” (p.1).
The experimental of organ farming however, involves
the fusing of human stem cells into a pig embryo, andthen allows these cell to gestate for up to four weeks insurrogate sows, the scientists are trying to grow organs
from different genetic make ups called “chimeras" inorder produce tissue which is sufficiently human forgenetic match (Antonio 2017:p.1).
The scientific breakthrough in organ farming will
provide a foundation, and a shine of hope, to reduceorgan crisis and it encourages human interspecies
chimeric’ relationship. Rita (1999) cites Wolfensohn &Lloyd thus; "All use of animals in scientific research forhuman benefit creates a dilemma the justification forusing the animal depends on it being different from thehuman, while the validity of the results obtained depends
on the similarity of the animals and their responses tothose of the human” (p.1). Organ farming will help to
explore further the humans and animals relationship,
their anatomic compatibility, and physiology, DNA etc.

Eubios Journal of Asian and International Bioethics 28 (May 2018)
these remains the best for human and animal clinicalinvestigation. For this reasons, organ farming should be
accepted and allowed to flourish for the good of man.
Organ Farming Debate
In antiquity, most ancient Greeks, who used animals
for experiments, did not think about the moral relevanceof their actions, nor did they raises questions about the
moral justification and permissibility of animal research.
They believed thus, “Likeliness of humans to theiranthropomorphic deities granted them a higher ranking
in the scala naturae (“the chain of being”), a stricthierarchy where all living and non-living natural things—
from minerals to the gods—were ranked according totheir proximity to the divine” (Nuno, 2013:p.2).
The above postulation attributed to humankind therank of the highest and the most superior species in thehierarchy of beings. Additionally, the assertion also had
supported the teaching of most medieval Christian
thinkers. The Judeo-Christian teaching about humans
presumes dominion over all nature, as represented by
the texts of Augustine of Hippo, Thomas Aquinas andother influential Christian thinkers of the Middle Ages
(Nuno, 2013:p2).
For Saint Augustine a Christian theologian, “animals
were part of a natural world created to serve humans (asmuch as the “earth, water, and sky”) and humankind did
not have any obligations to them” (Nuno, 2013:p.2). The
above assertion disagree with Singer argument thatanimals share equal moral status with human beings( eating animals is wrong only if the animal suffers when
it is slaughtered. An animal who is killed without
suffering is acceptable as food; hence, all Kosher meat is(Steven, n-d:p.1).
Today, there is plethora of unsettled ethical issues
about organ farming; these have led to various criticalquestions, from biomedical animal right campaigners,
religious body etc. Apparently, there are questions about
the moral justification of breeding pigs in order togenerate human tissue. In some quarters, there are alsoquestions and worries about the handling of pigs’ tissues
and its compatibility with human DNA.
In my opinion, we must guard against yuk-factor
arguments in responding to reports of scientificbreakthroughs in organ farming. Scientists areattempting to insert human stem cells into pig embryosin order to produce organs for transplant at a muchhigher rate than donations have hitherto provided. In
considering the morality of inter-species organtransplants, we must weigh the cost of the human lives
that would otherwise be lost.
“For those, who views experimentation of animal as
inalienable right of the human being? The rightcorresponds increasingly to certain concomitant rights
for animals, since 'cruelty' should always be combated,
given that it is kind of behavior pertaining to the sphereof morality and based on evidence from the scientificdomain itself, animal well-being has a positive influenceon the results of experiments” ( Rita 1999:p.2).
Biomedical Argument
Organ Farming is a scientific process that facilitates
the creation and growth pigs’ stem cells, geneticallymodified for humans use. (Synopsis organic farm, 2014:
p1).
The‘chimeras-breakthrough’insurgical

107

implantation, antigens of the donor-animal is a serious
challenge, “Human body would immediately reject a pig
organ as foreign, the “transgenic" pigs are geneticallyaltered with human DNA in the hope that a humanrecipient's body will be fooled into thinking the organ ishuman” (Synopsis organic farm, 2014:p.1).
The biomedical argument also takes into cognizancethe likelihood of introduction/invasions of new diseases
in humans and pigs because of the difference in the DNA(Robby 2017: p.2).
Additionally, there is the possibility that human cells
might wind up in a pig’s brain. This could cause whoknows-what kind of problems (Robby 2017: p.2). Robby(2017) quotes Pablo Ross, a xeno transplant researcher
who told the British Broadcasting Corporation (BBC) lastyear; "We think there is very low potential for a humanbrain to grow, but this is something we will be
investigating”(p.2). The views of scientists on thisproject of organ farming seem positive for the future,
because the xeno transplant doctors, researchers andmedical ethicists, are working closely to provide
improved medications to suppress xeno transplantation
with cyclopropine to neutralize the antigens. It is
possible that improved treatments for various brain
injuries and diseases could be improve from the research
being carry out on pig brains (Synopsis organ farm,
2014:p.1).
A critical examination of organ farming, somescholars have argued that it will lead to human gene
editing and manipulation of the genome. For thesereasons, organ farming should not be permitted. In myview, the approval of organ farming does not me it
cannot be sufficiently regulated by the government toavoid harmful consequences, it is a hard, and sober a life
to manipulate the genome! It is an obnoxious pratices tomanipulalet the genome, we therefore argue thatgenome manipulation be regulated by law (Sprague et al
1956:p.522).
Animal Right Campaigners“Animal Liberation,” 1975, is a book written by anAustralian philosopher Dr. Peter Singer. The book has
aided in animal rights campaigns, although Singer
himself is not an advocate of “rights” for animals, butrather merely that animal suffering deservesconsideration in our moral reasoning, much like humansuffering, although animal suffering is always
outweighed by human suffering.”
It is noticeable that the key to the understanding ofSinger’s philosophy, especially on Animal liberation is
utilitarian sensibilities and assumptions, which form the
backbone of his work (Steven, n-d: p.1). Additionally,
Singer’s work has played a vital role in shaping thecontemporary animal rights debate, and has influenced
hundreds of thousands to become vegetarians andanimal rights activists.
In Animal Liberation, Singer raises questions about
the moral status of animals, eating animals is wrong only
if the animal suffers when it is slaughtered. An animal
who is killed without suffering is acceptable as food;hence, all Kosher meat is acceptable to Singer (Steven, nd:p.2). Singer would argue, “The ability of animals to feelpain and pleasure puts them on a plane with humans.

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Eubios Journal of Asian and International Bioethics 28 (May 2018)

Whether or not animals can author treatises onmathematics, they, like us, feel pain, and we therefore
have an obligation not to cause them needless suffering”(Steven, n-d:p.2).
Today, xeno transplantation is under attack byanimal rights' groups, why the experimentation ofanimals for organ farming. Nevertheless, a critical review
of organ farming, it does no ‘needles suffering’ to animals,
if I may borrow singer’s words from above.
Animal activists denounce the experimentation on
animals such, as pigs in the name of scientificadvancement (Synopsis organic farm, 2014: p.2).
However, it seems unreasonable to condemn in totality
the use of animals for biomedical research, in light of its
contributions and benefits to humankind. One must also
admit that animal subjects at times suffered serious
harm during the process of scientific research. Rita
(1999) cites Kant animals do not belong to the sphere ofhuman morality, (p.4). This argument might besubjective, but the question remains thus; can animaland humans have equal moral value?
The debate on organ farming precedes question on
moral status of an animal, scholars may agree thatanimals have a moral status; for this reason, it is wrong
to abuse, hurt or make them feel pain, but there must be
exploration for the benefit of humanity. We may not in
any way denying animals’ ability to feel pain just likehumans. For moral reasons; we argue that animal
research and experimentation should be well thoughtout and humans should never “use animals as theyplease, treating them in a way which best suits us; fortheir nature is not like ours” (Nuno, 2013:p.4).This
assertion posits that the human use of animals as ameans to an end is morally unjustifiable.
Considering the moral status of animals, common
sense would tell us to reduce animal suffering by
avoiding the repetition of experiments on single orparticular animals. According to Rita (1999), citing Hall’s
principles, the organ farming experiments should only
performed when simple observation cannot provide ananswer. In addition, unnecessary repetition ofexperiments should be avoided (p.4). The continued
repetition of the experiment on a particular animal willamount to animal cruelty because such a scientist has
subjected the animal to a continuous pain and terror.
Nuno (2013) cites Aquinas who says that cruelty toanimals ought to be condemned, because it can cause
humans to build up feelings and actions of cruelty
towards other humans (p.2).
Utilitarianism
The xeno transplant researchers do not completely
refute the charges made by an animal rights advocate.
"We have to be honest about this: We are exploitingthese pigs.” Says Dr. David White, director of research at‘Imutran’ in Cambridge, England, “but, I believe it's far
more justifiable to exploit these pigs in order to savepeople's lives than for the production of food” (Synopsis
organic farm, 2014: p.2). This is a consequential
worldview, the experimentationof pigs to produce
human organs. Common sense would tell us that thegood done to human beings outweighs the harm done toanimals, Thus; even when researchers had strong
misgivings about inflicting suffering on animals, benefit

to humans remains a valid justification for them topursue their scientific goals through organ farming(Nuno, 2013:p.4). While this might be too extreme
scientist must outweigh the consequences of theiractions, taking into consideration the xeno transplantresearchers experiments to ensure the least possible
suffering of animals during and after organ farming.
However, a critical examination of the organ farming
debate of shows that these arguments leave both sides
frustrated, particularly doctors, researchers and animal
rights campaigners frustrated because the more time
wasted on organ farming debate, and a without ascientificbreakthroughinorgan
farmingexperimentations, the more candidates die on thewaiting list.
Utilitarianism was first formulated by Jeremy
Bentham and developed by John Stuart Mill; according to
Steven (n-d), “utilitarianism” holds that the morally best
action is that which brings about the greatest amount ofpleasure or happiness to the greatest amount of people)(Steven, n-d:p.1). This view says that the most importantfeature of an action is the consequences, rather than theintention or motivation behind it.
Organ farming is for the benefit of man; for thisreason, utilitarianism has been a humanistic philosophy
that cannot be over rule in this research. Moral action isthat which results in the highest overall “wellbeing” forall stakeholders (Nuno, 2013:p.4). Here, Organ farming
should permitted and is morally justified, provided theresearch has “a determinate object, beneficial tohumankind, accompanied with a fair prospect of theaccomplishment of it,” thus admitting that humans haveprecedence over other animals, limited by the due
consideration for animal suffering, and is acted-upon for
the interest of large numbers of persons (Nuno,
2013:p.4).
Lastly, it is rational to maintain that human interests
take precedence over animals. Also, it will be a basis forphilosophical arguments to be used twenty-first century
xeno transplant researchers, as an ethical justification
for the use of pigs for the farming of human organs inorder to an avert organ crisis and reduce the risingnumber of deaths among candidates on the waiting listof organ recovery and allocations.
References
Aparna, R. (2015). Philosophy of Organ Donation: Review of EthicalFacts.World
Journal of Transplant, 2015 Jun 24; 5(2): 44–51.
Publishedonline2015
Jun
24.
AvailableatDui:
10.5500/watts.v5.i2.44 Retrieved 20/02/2018.
Antonio, R. (2017). Pig-Human Organ Farming Doesn’t Look PromisingYet.
MITof Technology Review. Available athttps://www.technologyreview.com/.../pig-human-organ-farming.
Retrieved 20/02/2018.
Bailey, L. et al (1985). Baboon-To-Human Cardiac Xenotransplantation
In A Neonate. The Journal of the American Medical Association. Vol.
254 (23). p. 3321–3329.
Available at http://www.
doi:10.1001/jama.1985.03360230053022. PMID 2933538
Carolyn, C. (1991). Animals Used for Medical Research. A Philosophical.
Available at Viewpoint http:// www.gargaro.com/experiment.Html.
Cooper, D. (2012). A Brief History of Cross-Species Organ
Transplantation. Processing Baylor University Medical Centre v.25(1).
Vol.
25(1):
p.49–57.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246856
Heather, H (2015) The Future of Animal-to-Human Organ Transplants.
Available
https://www.smithsonianmag.com/innovation/futureanimal-to-human-organ-transplants-

Eubios Journal of Asian and International Bioethics 28 (May 2018)
Kress, J. (1998). Xenotransplantation: Ethics And Economics". Food anddrug law journal. 53 (2). http://www. 353–384. PMID 10346691
n-d, (2014). Synopsis organ farm frontline educational foundations.
Retrievehttps://www.pbs.org/wgbh/pages/frontline/shows/organf
arm.
Nuno, H. (2013). Animal Experiments in Biomedical Research. A
Historical Perspective Institute for Molecular and Cell
Biology.University of Porto, Portugal. Animals ISSN 2076-2615.
Available at www.mdpi.com/journal/animals..
N-Stephanie L.(2010). The Ethics of Animal Experimentation.
Huntington's Outreach Project for Education at Stanford Animal
Research,ResearchandHD.
Availableathttps://web.stanford.edu/group/hopes/cgi-bin/hopes_test/animalresearch.
Organ Donation: Why We Should Move To 'Presumed Consent.’ The
Guardian Newspaper Editorial, Sunday 13 Sep 2009 00.05 United
Kingdom. Available athttps://www.theguardian.com/commentisfree/2009/sep/13/orga
n-donation-presumed-consent
Paul, V. (2016). Look beyond the Frankenscience - Church Times.
Availableathttps://www.churchtimes.co.uk/articles/2016/10.../look-beyondthefrankenscience.
Rita, L. (1999). Ethics and animal experimentation: what is debated.
Availableat
http://
www.Scale.Br/scielo.Pp?Script=scripture&cid=S0102311X19990005000. Retrieved 20/02/2018.
Robby B. (2017) Early Days Of Organ Farming Are A Bit Gnarly.
Available at http://www.bigthink.com/robby-berman/the-earlydays-of-organ-farming-are-a-bit-gnarly.
Rupert, W. (2014) Quest to grow human organs inside pigs in Japan
BBC. Available at http://Newswww.bbc.com/news/world-asia25550419.
Stela Živčić-Ćosić, et al, (2013). Development of the Croatian model oforgan donation and transplantation. Croat Med J. 2013 Feb; 54(1):65–70. Available at http:// doi: 10.3325/cmj.2013.54.65 PMCID:
PMC3610255
Segen, F. (2012). Medical Dictionary, Farlex, Inc.Available at
http://medical Dictionary.thefreedictionary.com/explicit consent
Sprague et al (1959) Knowledge and Value, New York. Harcorts Brace
World Inc
Steven, B. (n-d). Peter Singer Animal Liberation Front. Available at
http://www.animalliberationfront.com › Activists + › Authors ›Interviews
Tullius, S. (2013). "Dr. Joseph E. Murray (1919-2012): A Life of
Curiosity, Humanism, and Persistence". American Journal ofTransplantation, 13 (1): 5–6. Available at http://www.
doi:10.1111/ajt.12076. PMID 23279678.

Sharp Safety Curriculum for
Health Workers- Guntur Heri Putranto, Winny Setyo Nugroho
Master of Hospital Management, Universitas Muhammadiyah
Yogyakarta, Indonesia
Email : gunturheriputranto@gmail.com

Abstract
Sharp injury is a sharp stabbing event that is veryrisky to health workers. The incidence of sharp injury is
still high in the world. This event can lead various
implications such as the spread of infection,
psychological and economic implications. This is
influenced by the understanding of health workers about
the importance of sharp safety.
Sharp safety curriculum consists of seven main topics,
i.e. safety device, safety procedures, safety disposal,
implications of sharp injury, prevention of infection by
vaccination, regulation relating to sharp safety,
reporting,monitoring, and evaluation of sharp injury.
Sharp safety curriculum is needed to increase knowledge
and understanding of health workers regarding sharp

109

safety so it is expected to reduce the incidence of sharp
injury.
Keywords: sharp safety, sharp injury, curriculum, healthworkerBackground
Work accidents due to sharp stabbing (sharp orneedlestick injuriy / NSI) is one of the many problems
that occur in health workers. On the safety evaluation
conducted by the National Audit Office at NHS Hospital
UK in 2003 found 17% of events related to needlesticks
or sharp injury (National Audit Office, 2003).
In a follow-up survey conducted on 4,000 nurses at
the Royal College of Nursing (RCN) in 2008 found that
48% of nurses had experienced NSI or sharp injury(RCN, 2008). In a study conducted in the United Statesfound that more than 8 million health workers in
hospitals exposed to blood or other bodily fluids,
including through contact types such as wounds withcontaminated sharp instruments (Askarian et al, 2011).
In Indonesia, in the study of 114 health workers in 10
health centers in Jakarta found approximately 84% ofofficers had been stuck needles used (Hudoyo, 2004).
The incidence of sharp injury in health workers may
increase the risk of spreading infection of blood-borne
pathogens such as hepatitis B, hepatitis C, and humanimmunodeficiency virus (HIV) (CDC, 2008). In 2003, theWorld Health Organization (WHO) recorded cases ofinfection due to contaminated needle puncture wasestimated to result in 21 million hepatitis B virus
infections (32% of all new infections), hepatitis C virus
infection of 2 million (40% of all new infections ), andHIV infection of 260,000 (5% of all new infections)(WHO, 2003). In a study conducted in Indonesia on
health workers at puskesmas in DKI Jakarta, theprevalence of HBsAg positive was 12.5% in the dentistgroup and 13.3% in laboratory workers, whereas
prevalence among health workers was generally around
4% (Hudoyo, 2004)
In addition to the increased risk of spreading theinfection, sharp injury may increase the costs incurredby healthcare providers. These costs include serologicalexamination for follow-up investigations, consultationand diagnosis to health personnel, as well as affecting
the work time of health workers. In addition, the costs
incurred for initial treatment of health workers affectedby Hepatitis B, Hepatitis C and HIV were also
considerable (Adams & Elliott, 2006).
Sharp safety is a safe procedure in the use andutilization of sharps in health services (Foley & Leyden,
2002). Such procedures include prevention in the formof safe use of sharps, personal protective equipment,
prudence, understanding of health personnel, removal of
sharps waste according to procedure, and vaccination. In
addition to prevention, also obtained follow-up
procedures are performed if the incidence of incident
sharp injury is recording and reporting, examination of
exposed health workers, and monitoring and evaluation.
A good regulation of sharp safety is also needed toreduce the incidence of sharp injury (Adams, 2012).
Given the magnitude of the effects and risks of sharp
injury to health personnel, a sharp safety curriculum isrequired to be implemented for health workers.

Eubios Journal of Asian and International Bioethics 28 (May 2018)110

Results
In the curriculum about sharp safety, there are twomain things that are important to note that is learning
objective and maping concept.
Learning Objective
Sharp safety is a safe procedure in the use andutilization of sharps in health services (Foley & Leyden,
2002). The sharp safety curriculum is needed with thegoal of health workers being able to identify tools thatcan cause sharp injury and safe means of use, be able toidentify actions that can cause sharp injury and how to
perform safe actions, be able to define the spread of
infections due to sharp injury, able to mention theimplications of sharp injury events, knowing the role ofvaccinations in sharp injury events, knowing the ways
and benefits of post sharp injury reporting, knowing theways and benefits of monitoring and evaluation post
sharp injury events, and knowing regulations related to
sharp safety.
Maping Concept
In sharp safety, there are 7 things that must be
considered so that health workers can avoid sharp injury
events, namely safety devices, safety disposal, safety
procedures, sharp injury implications, vaccination,
regulation, reporting, monitoring, and evaluation.
Safetydevices
Reporting,Monitoringdanevaluation

Safetydisposal

Sharp
safetyRegulation

Vaccination

Safetyprocedures

Sharp injury
implications

Figure 1. Components of sharp safety’s curriculum
Safety Devices
Jagger et al (1988) mentioned that there were 326
occurrences of NSI in one of the educational hospitals in
Virginia, USA. Some of the tools that can cause sharp
injury include disposable syringe and needle,
intravenous tubing and needle assemblies, pre-filled
syringe catridges, winged steel IV sets, vacuum tube
phlebotomy assemblies, iv styles, and other devices. In
the study mentioned that the highest cause of NSI is theuse of disposable syringes (35%). In the study has not
mentioned other tools that cause sharp injury such as aknife or scapel at the time of operation.
In the use of safe tools, there are two types of toolsthat can be used are active safety devices and passive
safety devices. Passive safety devices do not require theadditional safety required in use, while active safety
devices require additional safety (CDC 2008). There are
four major factors in evaluating the security of a device:

security, usability, suitability, and assurance that it does
not cause other problems (Adams & Elliott, 2003).
Safety Procedures
Cone (2000) identifies actions that often cause NSI to
be injection, venipuncture, suturing, manipulating
intravenous (IV) injection parts, inser- ting peripheral IV
catheters, other medical procedures. In the study
mentioned that the action of injection is a procedure that
often causes NSI. In another study conducted by McGeer
et al (1990) reported that 13-62% of NSI was due tovenaseksi. In addition, NSI events in doctors, healthworkers, and laboratory personnel are often caused byflebotomy procedures. Gaffney et al (1992) mentionedthat 72% of physicians had experienced NSI during
flebotomy within 6 months and less than 5% of reported
events. Cardo et al (1997) mentioned that the risk ofinfection transmission due to NSI caused by depth injury.
Safety disposal
In addition to the use of safe objects, removal of
sharps that have been used also has an important role.
Foley and Leyden (2002) have identified processes toreduce the risk of exposure to blood-borne pathogens
such as elimination of hazard, engineering control,
administrative control, work practice control, andpersonal protective equipment.
Sharp injury infection and implication
Blood-borne pathogene infections can occur in sharp
injury. Department of Health (DH) in 2006 advocated theearly treatment of wounds caused by sharp objects. DH
does not recommend mentioning that sucking the woundwith the mouth. If the splash of blood on the eyes or themouth should be immediately irrigated or rinsed withwater, If the contact lens in the eye then should bedrained water before and after it is released. Healthworkers should follow established procedures
established in the hospital.
Some infectious diseases such as humanimmunodeficiency virus (HIV) and hepatitis C virus(HCV) are potentially infectious to health workers. In
Italy, an organization incorporated in the Italian Study
Group for Occupational Risk of HIV Infection reported astudy in 1982-1992 that mentioned almost half theincidence of HIV and HCV transmission. In France, theInstitut de Veille Sanitaire, mentioned that 11 out of 13
HIV incidents and 22 of 63 HCV occurrences wererelated to blood retention. It was generally reported that106 out of 106 HIV positive cases and 238 suspected HIV
cases were identified as a result of transmission to
health personnel. Research conducted in December 2002
stated that as many as 128 (37.2%) occurred in nurses,
42 (12.2%) in physicians, and 39 (11.3%) in laboratory
personnel.
In addition to affecting the safety of health personnel,
the incidence of sharp injury also affect the cost or cost
incurred. Handling of sharp injury events often requires
a greater cost than the cost when prevention. These
costs include serological examination for follow-up
investigations, consultation and diagnosis to healthpersonnel, as well as affecting the work time of healthworkers. In addition, the costs incurred for initial
treatment of health workers affected by Hepatitis B,

Eubios Journal of Asian and International Bioethics 28 (May 2018)
Hepatitis C and HIV were also considerable (Adams &Elliott, 2006). The incidence of sharp injury can also
affect psychological health workers even significant.
Health workers who wait for post lab test results
exposed to sharp injury often experience pressure or
stress is high enough. Costigliola et al (2012) conducteda study of 634 nurses from Europe and Russia who had
experienced NSI due to injection of diabetic patients.
They point out that the incidence of sharp injury affects
their emotional state such as depression, sudden cry,tension in the family, problems with spouses andfamilies, panic attacks, anxiety and inability to work.
Vaccination
Vaccination is important in dealing with exposure to
infection of blood born pathogene. The sharp safety
guidelines published by the Centers for Disease Control
and Prevention mention that full hepatitis B vaccine isnecessary for health workers (CDC, 2008)
Regulation
On 11 May 2013 EU Member States implemented theCouncil Directive 2010/32 / EU regulations. The
implementation includes Framework Agreement on
factors related to NSI and sharp injury covering safe typeof device and procedure. In addition, the identification of
the principle of safe use of equipment and disposal anddiscussion of regulations to improve security and reduce
the NSI. EU member states agree to prevent sharp injury
and infection in the public and private sphere. Some of
the things that need to be done are risk assessment (arethere any risk of exposure to blood-borne pathogens
from NSI? Can these risks be minimized or eliminated?),Risk elimination and prevention, elimination of
unnecessary sharps, identify whether exposure risks canbe decreased by use of safe tools, improved educationand caution, and ensuring proper and safe sharps
disposal systems. Ensure that regulation or procedure isin place.
In Indonesia, Health and Safety (K3) is an effort toprotect workers and others entering the workplaceagainst the hazards of accidents. The purpose of Healthand Safety (K3) is to prevent, reduce and even eliminate
the risk of occupational diseases and accidents andimprove the health of workers so that work productivity
increases. Law No.36 of 2009 on Health article 165
states that workplace managers are obliged to undertake
all forms of health efforts through prevention,
improvement, treatment and recovery for workers.
Based on the above article, the workplace managers at
the Hospital have an obligation to nourish the workforce.
One of them is through work health efforts in addition tosafety work. Law no. 36 of 2014 on Health article 11
letter (d) also states that health workers in carrying out
their practice obtain protection for occupational safety
and health. One of them is through work health efforts inaddition to safety work. Hospitals must ensure healthand safety both to patients, service providers or workers
and the surrounding community from various potential
hazards, therefore the hospital is required to implement
Health and Safety (K3) efforts that are implemented in
an integrated and comprehensive so that the risk of
disease and Work Accident Accident in hospital can be
avoided (Ministry of Health RI, 2010).

111

Monitoring and Evaluation Sharp Injury
When health workers are exposed to sharp injury,
there are several important things to do namely
reporting and recording. It is necessary to monitor the
injury and identify the necessary next steps. This action
is often underestimated by health personnel and many
health workers who do not report the incidence of NSI or
sharp injury so it is not directly addressed. The processof reporting and recording should not only occur locat
but also done regionally to nationally. It is also useful asa means of evaluating the spread of infectious diseases ofblood borne pathogene. Post-reporting and recording of
NSI events should be performed immediately such aslaboratory tests or antiretroviral administration. It isalso related to the responsibility of health care providers
to their health workers. Further monitoring is also
required in this event and there should be a standard
procedure to be implemented. Risk assessment should
also be conducted primarily for HIV transmission, HBV
and HCV transmission. Blood in the body is a fluid that
often causes infections in health personnel, though otherbody fluids such as cerebrospinal fluid and pleural fluid
may also be at risk. Percutaneous exposures are more at
risk than contamination of the mucosa. In addition,
contamination may also occur through conjunctiva. The
average risk of HIV occurrence in NS incidence was<0.5%.
Conclusion
The curriculum concerning sharp safety needs to be
developed and implemented to health personnel
including learning objective, and maping concept
curriculum. The curriculum is needed to improve theunderstanding and awareness of health personnel so as
to reduce the incidence of sharp injury.
References
Adams D &Elliott TS. 2006. Financial costs associated with acontaminated needlestick injury. Journal of Hospital Infection; 64,
Suppl 1, S31-S32
Adams D. 2012. Needlestick and sharps injuries: implications for practice.
Nursing Standard; 26, 37, 49-57.
Adams, D & Elliott, TS. 2003. A comparative user evaluation of threeneedle-protective devices. British Journal of Nursing; 12, 8, 470-474.
Askarian, M., et al., 2011. Precautions For Health Care Workers To Avoid
Hepatitis B And C Virus Infection. Int J Occ And Enviro Med, 2 (4):191-198
Cardo, D.M ; Culver, D.H ; Ciesielski, C. A. et al .1997. A case-control
study of HIV seroconversion in health care workers after
percutaneous exposure. Centers for Disease Control and Prevention
Needlestick Surveillance Group. New England Journal of Medicine;
337, 21, 1485-1490.
Centers for Disease Control and Prevention (CDC). 2008. Workbook for
Designing, Implementing, and Evaluating a Sharps Injury Prevention
Program.
www.
cdc.gov/sharpssafety/pdf/
sharpsworkbook_2008.pdf
Cone, J. 2000. Needlestick Injury Surveillance in California, 1998-1999.
California
Morbidity.
September:
1-3.
http://tiny.cc/
needle_surveillance_Ca
Costigliola, V; Frid, A; Letondeur, C; Strauss, K. 2012. Needlestick
injuries in European nurses in diabetes. Diabetes and Metabolism; 38,
Suppl 1, S9-S14
Foley, M; Leyden, A.T. 2002. American Nurses Association: Independent
Study
ModuleNeedlestick
SafetyandPrevention.
www.who.int/occupational_health/ activities/1anaism.pdf
Gaffney, K; Murphy, M; Mulcahy. 1992. Phlebotomy practices/ needles
stick injuries/hepatitis B status/among interns in a Dublin hospital.
Irish Medical Journal; 85, 3, 102-104
Hudoyo Sri, Kuwat. 2004. Hubungan Kewaspadaan Universal dengan

112

Eubios Journal of Asian and International Bioethics 28 (May 2018)

Status HbsAg Petugas Kesehatan Puskesmas Kecamatan di Jakarta
Timur.
Jagger, J; Hunt, E.H; Brand-Elnaggar, J; Pearson, R.D .1988. Rates ofneedle-stick injury caused by various devices in a university hospital.
New England Journal of Medicine; 319, 5, 284-288.
McGeer, A.; Simor, A.E., Low, D.E. 1990. Epidemiology of needlestick
injuries in house officers. Journal of Infectious Diseases. 162, 4, 961964
Ministry of Health RI. Guidline for Patient Safety in Hospital. Third
Edition. Jakarta. 2015.
National Audit Office (NAO) . 2003. A Safer Place to Work: Improving
the Management of Health and Safety Risks to staff in NHS Trusts.
http://tinyurl.com/ bnd4zc9
Royal College of Nursing (RCN) . 2008. Needlestick Injury in 2008:
Results from A Survey of RCN Members. RCN, London.
World Health Organization (WHO). 2003. Sharp Injuries : Global burdenof disease from sharp injuries to health-care workers. World HealthOrganization Protection of the Human Enverionment Geneva.

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