Eubios Journal of Asian andInternational Bioethic
EJAIB Vol. 31 (4) May 2021
www.eubios.info

ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2021 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Editorial address, and all correspondence to:Prof. Darryl Macer
Email: darryl@eubios.info:

Editorial: Ethics and COVID-19 Vaccines

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One of the most hotly discussed issues of 2020 and
2021 is the development and access to vaccines to help
protect people against COCID-19. At the time of writing
two billion people in the world have received at least one
dose of the vaccine, still leaving six billion to be vaccinated- and more to be fully vaccinated, should they wish to do

so. Although there are a minority in most countries whoare hesitant to receive a vaccine, many more people faceissues of access to receive a vaccine. It is a signi icant
ethical issue of our time to provide vaccines to people
who will continue to live under direct threat of being
infected with COVID-19 and of suffering serious healthand other impacts. This disparity and delay also provides
further opportunity for new variants to evolve over time.
No country is safe, whether it is India, Brazil or others.
This statement took more time than most othersttaements of the World Emergency COVID19 Pandemic
Ethics (WeCope) Committee, and during the multiple
discussions of the different drafts we could see theemergence of a number of recommendations relating tojustice and access. In this issue the statement is also
folowed by an independent paper by Nuniala et al.
exploring the possibility that there might be compulsory
vaccines in the Philippines. It is also of signifciant interest
that the European Comission has announced theintroduction of vaccine passports from 1 June 2021, which
will provide more rapid entry for persons into Europe forthose who have undertaken a vaccination with a vaccine
approved in Europe.
Although it has come to the attention of the journal thatsome people have diied after receiving a vaccine, we havelearned of far more persons who have died fromCOVID-19 disease itself. Whether the COVID-19 pandemic
has made people better able to calculate the risks to theirhealth of their choices, and infectious diseases, could be apositive outcome from the tragedy.
The committee
reccomends that the vaccine is a public good, though we
do not mention the issue of whether patents should be
waived as this is a clear public emergency. Many havestated that the real delay in providing vacciens is in thesafe supply chain.
There are also papers on regular topics of bioethics
from different countries, including a case study ofcomplications of illegal abortion in Iran, and challenges oforgan transplantation in Bangladesh.
The paper by
Arambala takes us to a theoretical analysis of Heidegger.,whereas that of Quidet et al. focuses on issues ofadministrators facing
the economic challenges ofmeasures taken to decrease the spread of COVID-19.
Please enjoy reading, and join the monthly conferences.
- Darryl Macers

Contents
page
Editorial: Ethics and COVID-19 Vaccines - D. Macer 205
Ethical considerations on COVID-19 immunizationand vaccines
206- Statement of the World Emergency COVID19
Pandemic Ethics (WeCope) Committee (10 May 2021)
Exploring the ethics of a possible mandatory COVID-19
vaccination program in the Philippines
217- Louiejabe Nuniala, Alpha Kassadra Acain, Nicole
Blain Bonifacio, Dennis Jambalos Jr., Veronica Julia Tizon,
Angela May Vergara, Maria Angela Villamora, Bernardo
Caslib, Jr.
A short essay on pandemics and the nature of humanbeings as depicted in three Japanese ilms
produced in the past 60 years
224- Atsushi Asai and Taketoshi Okita
Martin Heidegger: The art of living in the midstof the global COVID-19 pandemic
228- Gerry Arambala
Ethico-legal aspects of complications of an illegal
abortion with trisomy 21 in Iran
234
- Roya Rashidpouraie, Saeedeh Saeeditehrani,
Mohamadnader Shari i- Mina Rashidpouraei
Ethical issues and challenges of organ transplantationin Bangladesh
237- Tanvir Ahmed
Caring in the midst of suffering: Views of administrators,
faculty and staff of Cor Jesu College of the school’s
mission and core value of compassion
242- Br. Ernesto Quidet, Jr. Rogelio P. Bayod, Erikka June
Forosuelo
Ordering information, Editorial Boad and policy
248

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Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

Ethical considerations on
COVID-19 immunization andvaccines
Statement of the World Emergency COVID19 Pandemic
Ethics (WeCope) Committee (10 May 2021)
a. Preamble
As an independent, multidisciplinary, and cross-culturalcommittee comprised of ethicists from cultures andnations across the world, we offer the following statement
and recommendations on ethical issues associated with
COVID-19 vaccines and immunization.1
The COVID-19 pandemic has raised several ethicalchallenges. It is therefore unsurprising that public healthauthorities have turned to ethicists for advice whendeveloping and implementing policies and measures intheir pandemic response. This has created many
opportunities for ethicists to enhance the moral quality of
public health decision-making. The statement includes
re lections on the moral responsibility of getting
vaccinated, sharing information on the side effects andef icacy of vaccines, and the rights and responsibilities ofeach person in decision making. The discussion includes
considerations over the economic, political, commercial,and inancial implications related to the distribution of
the vaccines. There are recommendations on the
distribution of vaccines, immunization, immunity, justice,and ethical procedures related to public healthinformation.
b. Immunization, immunity, and justice
We write this during one of the most dreadful pandemics
in modern human history caused by the coronavirus-19(SARS-CoV-2) disease (COVID-19), which continues tohave international, national, and local impacts. The moral
and ethical responsibilities, obligations and abilities of all
persons, communities, and nations of the international
community, to cooperate are especially signi icant insituations of emergency2 (WeCope. 2020a).
A vaccine is a substance used to stimulate theproduction of antibodies and provide immunity against
one or several diseases, prepared from the causative agentof a disease, its products, or a synthetic substitute, treatedto act as an antigen without inducing the disease. Vaccines
are scienti ically proven tools for controlling lifethreatening infectious diseases by the active
immunization. They are among the most cost-effective
healthcare investments for public health services in world
history. Vaccination has not only provided healthprotection, but also contributed to the development andmaintenance of education, economy, and preventing
impoverishment (Dubé et al., 2013).

The approval of COVID-19 vaccines has added one
further disease to the list of 26 diseases that have avaccine approved as a preventive therapy (Gravagna et al.,2020). We note that there is an expanding list of vaccines
against COVID-19 that have been granted emergency use
authorization in many countries, and we do not discuss
the technical aspects of clinical trials assessed byappropriate regulatory authorities in many sovereign
nations. The global focus has shifted to vaccines as asigni icant means to bring the pandemic under control.
The timeliness of scienti ic research initiatives will be oneof the main "hallmarks" of the COVID-19 pandemic. The
U.S. National Library of Medicine and U.S. National
Institutes of Health (NIH) lists around ten thousandstudies related to COVID-19. From a medical andpharmaceutical point of view, the main issue is the quality,
which is being assessed through the results of ongoing
research in the global immunization drive. Quality isdependent on the safety and ef iciency of the vaccines.
The more effective the vaccine is, the more impact it will
have to control the pandemic.
There are certain key technical issues that will not be
addressed further in this report. First even though a
growing number of vaccines have been approved for
emergency use in different countries, there is less datawith respect to the potential side effects of the vaccines tosome vulnerable groups e.g., pregnant women, children,and persons with disabilities such as autism, and whether
there are risks of blood clots to certain subpopulations,and so on. Governments must exercise caution, while also
gathering data and monitoring the evolution ofrecommendations for various groups. Especially while
there are safety doubts, governments should not makevaccinations for anyone, particularly children withintellectual disabilities, compulsory. Children were
underrepresented during the vaccine trials (Branswell,2020). However, after suf icient information andknowledge becomes available regarding the safetyconcerns, then any state or government may evaluate thesituation and prescribe a morally acceptable approach.
Pregnant healthcare workers were provided options
to take the experimentally approved vaccines in late 2020
because they face a high risk from infection, but thegeneral recommendation for pregnant women was given
after just six months of collecting safety data. In mostcountries the vaccine immunization programs are being
conducted as extensive clinical trials. Some countries withhigh immunization rates such as Israel, were provided
access to a high number of vaccine doses in return forthorough clinical trial reporting.
Another technical issue is the scienti ic and medical
understanding of “herd immunity”. The percentage of
population immunity needed to suppress community
transmission has been estimated at 25%-70% (Peiris and

1

The authorship of this statement reads as Mireille D'Astous, Darryl R.J. Macer, Shahanaz Chowdhury, Christopher Ryan Maboloc,
Atanasio Fabrino, Richard Nellas, Sukran Sevimli, Puroshottam Panday, Sibel Inan, Osama Rajhkan, Suma Parahakaran, Thalia Arawi,
Nader Ghotbi and other members of the WeCope Committee (listed at the end of this Statement. This Statement draws on ideas andliterature from many sources and bene ited through comments from the full Committee members and other persons as well.
https://www.eubios.info/world_emergency_covid19_pandemic_ethics_committee

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2 These were explored in our earlier Statement on Autonomy and Responsbility (WeCope, 2020a).

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)
Leung, 2020). Vaccination and immunization have impacts
on healthcare systems including reducing deaths,
hospitalizations, and the severity of the disease. However,vaccines may not eliminate community transmission of
SARS-CoV-2 until a very high proportion of the population
is immunized. Vaccine ef icacy can be de ined as “percent
reduction in disease incidence in a vaccinated groupcompared to an unvaccinated group under optimal
conditions” (McNeill, 2006). It shouldn’t be confoundedwith vaccine effectiveness: “ability of vaccine to prevent
outcomes of interest in the “real world””. In terms of
public health strategy, vaccination is a proven means toprotect a population, without being suf icient in itself:" irst-generation vaccines are only one tool in the overallpublic health response to COVID-19 and are unlikely to be
the ultimate solution that many expect” (Peiris and Leung,2020). The other strategy to “ ind-test-isolate-tracesupport” remains until the risks are de initively controlled(Rajan et al., 2020) while vaccine distribution began in a
few countries at the very end of 2020 and is steadily
growing.
An unavoidable question in resource allocation in
health systems is that who should bear the cost? Different
countries have different standards: public healthinsurance schemes, private insurances, and so on. It seems
that countries that have invested more will have more
vaccines rapidly. Countries that have manufacturing
capacities have advantages. The need for universal
coverage and universal vaccination to control the
pandemic is a moral and ethical question, challenging
conceptions of justice and the effectiveness of just actions
at the political, inancial, corporate, and democratic scales.
This raises a few questions. Should the vaccine beprovided on a non-for-pro it basis during the pandemic?
Or only in 2021? Like the lu vaccine, it is probable that a
new vaccine will be needed every year, with the virus
strains mutating. Already there are signi icant variants
that have been detected that are expected to require athird dose for some of the two dose regimes being
adopted. The cost of producing the vaccine is estimated at
USD 5-10 a dose (Kollewe, 2020), although some arecostlier. Analysts estimate the revenue generated,assuming an annual jab at an average unit price of USD20[$3-37] at between USD 10B to 25B per year globally. Free
universal coverage remains an objective of some national
health policies. It seems, however, that in the current
paradigm these costs will be absorbed, and vaccine
expenditures are still affordable. Many governments
provide the vaccines free of charge, especially thosemandated for their own citizens. Serbia has offeredvaccines to persons from neighboring countries as a
strategy for economic recovery, and for regional solidarity.
In most cases around the world tourists and applicants for
immigrant visas need to pay for their vaccines as requiredby each country (See the section on “travel immunizations
and immigration immunizations”).

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c. The global need for a COVID-19 vaccine, as a global
public good
Oxfam (2020) has reported that “the wealthiest nations in
the world comprising of 13% of the global population haveplaced 51% of the orders for Covid-19 vaccines.” This is207

expected given the uneven structures in the global
economic order (Maboloc, 2019). Oxfam (2020) also notesthat 61% of the world population will not have access tothe vaccine until 2022. The question of vaccination is a
global justice issue. It is necessary to evaluate the matterof prioritization when it comes to making the vaccines
available on a global scale and the prioritization plan isoften agreed upon by experts in different countries. The
World Health Organization (WHO) has taken a strong
stand when it comes to the low of vaccine distribution,and this is increasingly being recognized by different
countries. However, we can see vaccine nationalism
continues, as evidenced by the European Union’s
implementation of laws requiring export licenses for
COVID-19 vaccines from manufacturers in Europe. India,
as the world’s major manufacturer of COVID-19 vaccine in
2021 also imposed some restrictions on the exports ofvaccine in March 2021 as it encountered higher COVID-19
rates domestically.
A public good is de ined as one meant to bene it
everyone. However, how this public good is viewed anddistributed is often a matter of politics. The states decide
who gets to receive the vaccine and who does not. Since
the sovereign rights of nations determine their conceptionof a just entitlement, there is a gap in terms of how tode ine the public good on a global scale. There may becases where refuges or persons living in foreign lands may
not be treated fairly. While it is true that every humanbeing on earth must have access to the vaccines, it is thepolitics that actually decides what may happen. For thisreason, the less powerful nations have no option but towait (Oxfam, 2020). This is counter to the principles ofjustice. The issue of which population is offered what
vaccine may be seen as discriminatory. Societies canappeal to the principle of the equality of persons, not justthe equality of citizens, in pursuing a more equitableglobal norm in terms of vaccines distribution.
The utilitarian principle helps in justifying a more
equitable distribution of vaccines. For instance,
globalization was put to a stop because of theinterconnectedness of transport systems around theworld (Mansueto, 2020). It is bene icial, in this respect, forwealthy societies to also deliver to poor countries,
speci ically to frontline healthcare workers in poor
nations, to protect them in the same way that wealthy
nations initially prioritized health professionals and themost vulnerable (e.g., the elderly). The vaccines weregenerally not made based on economic pro it but fromemergency public funds from many countries, but theconsequence of their discovery and subsequent
distribution undeniably has some utilitarian intent interms of the desire to go back to normal or even to a postnormal scenario when it comes to global trade, travel, andmigration. The overarching goal is for COVID-19 vaccines
to contribute signi icantly to the protection andpromotion of human wellbeing among all people of theworld.
d. Global solidarity and global structural barriers toequity approach
The principle of solidarity is accepted globally on paper, as
written in the Universal Declaration on Bioethics andEubios Journal of Asian and International Bioethics 31(4) (May 2021)

Human Rights, Article 13: “Solidarity among human beingsand international cooperation towards that end are to be
encouraged.”, as is the principle of equity in Article 10:“The fundamental equality of all human beings in dignity
and rights is to be respected so that they are treated justly
and equitably.” (UNESCO, 2005). There are a number ofstructural barriers to implementation of global solidarity
such as discriminatory social arrangements that, when
encoded into laws, policies and norms, unduly privileges
some social groups while harming others (Farmer et al.,2006; Büyüm et al., 2020). Power imbalances andstructural violence can lead to disproportionate sufferingand premature death.
Pogge (2007) has proposed that rich countries must
recognize their negative duties toward justice. A negative
duty not to harm implies a positive right on another party.
For instance, global poverty is a result of unjust trade
policies and global economic structures that bene it therich countries at the expense of poor nations.
Globalization and the perverted nature of capitalism haveresulted in an unjust global economic order (Stiglitz2015). This reality has an impact with respect to theacquisition and distribution of vaccines since poorer
nations may not have the suf icient funds to purchase thevaccines from pharmaceutical irms that are usually basedin the West. The acquisition of vaccines must not betainted with any politics but must be grounded solely in
the interest of global health and the solidarity of nations.
One proposal is that global inancial institutions
should help inancing the purchase of the vaccines.
Incidentally, this has already been started by the WorldBank and the Asian Development Bank. The World Bank
has approved the allocation of USD 12 billion. Meanwhile,
the ADB has allocated 9 billion US dollars for theacquisition and allocation of vaccines (adb.org). The next
step is to be able to identify those countries who need theinancing facility. An important aspect is to make the loan
available to poor nations at zero interest rate. The reason
for this is that many developing countries are saddledwith long-term and short-term loans that haveundermined their ability to attain any real economic
progress and well-being for their people. The pandemic
has only exacerbated this situation. From a moral end, it isincumbent upon rich countries as part of recti icatory
justice, to help governments with no real access to funds
for the vaccines to be able to avail of such aid all for thesake of global health and public safety.

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Recommendation 1:
COVID-19 vaccines are global public goods andtherefore efforts should be made to make themavailable to any human in need of vaccines,
irrespective of their socio-economic status. Global
vaccine manufacturing capacity should be enhanced.

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e. Public participation vis-à-vis COVID-19 vaccines
What is said to be crucial in the government’s
procurement of vaccines to contain Covid-19 istransparency. The role of the government is to inform andupdate the public regularly about the planned total
number of doses to be acquired, the current contracted
quantity, the plans for obtaining the remaining balance
and the period of the expected deliveries (Punongbayan,2020). In the global scale, governments should have clear,transparent, and objective criteria for bene iciaries andthose who will be prioritized and communicate thiswidely to the population. (UNODC Policy Paper, p.8)
It is incumbent upon every government to inform
citizens about its plans to procure whatever total quantity
it believes is necessary, and the expected dates of delivery.
The government must also inform everyone about what toexpect regarding the movement of people in terms ofplans for any continued restriction in public movement(Galvez, 2020). This is especially important as somepeople are questioning the vaccines' safety, particularly
what side effects do they really bring. Transparency isimportant, wherein all results are released and discussed
in scienti ic journals (Tamesis, 2020). In lieu of informed
consent, which many countries have waived because it isan emergency use approval, a fact sheet explaining
everything should be given to potential recipients prior to
obtaining the vaccine in question.
Public institutions should identify and address any
potential gaps and barriers, such as the risk of corruption
in distribution and allocation processes, to ensure that
populations have equitable access to vaccines. Addressing
corruption is a priority in times of crisis, and the
pandemic is creating new opportunities for corruption(UNODC Policy Paper, p.2). Civil society participation in
the formulation of policies, a system of checks andbalances, and monitoring of the overall health system is anecessary element in efforts to curb corruption in thehealth sector at every level. During the COVID-19
pandemic, civil society, non-governmental organizations,and community-based organizations can support
government efforts to counter corruption. Promoting theactive participation of civil society should include
enabling and encouraging civil society participation in
relevant decision-making processes related to theallocation and distribution of COVID-19 vaccines,
including those related to the prioritization of recipients,
the procurement of vaccines, and the low of emergency
funds for vaccine programs (UNODC Policy Paper, p.9).
There may be con licts of interest related to thefunding of the research and development of a COVID-19
vaccine prevents risk of corruption. An example of this
could be when a high-level of icer of a government’s
COVID-19 vaccine research and development program,
who used to work for a private vaccine company that is
bidding for a large contract under the government
program to manufacture a vaccine candidate, participatesin a decision-making process on that contract. Somecountries have created special commissions to negotiate
the purchase of COVID-19 vaccines with the laboratories
and universities conducting research and development on
potential vaccine candidates. There can be a lack oftransparency, and thus a potential risk of corruption inEubios Journal of Asian and International Bioethics 31(4) (May 2021)
what these agreements entail. These laboratories anduniversities have frequently had to sign con identiality
declarations as part of their agreements with the special
commissions to secure a vaccine for the populations ofh i gh - i n c o m e c o u n t r i e s . S u c h a g re e m e n t s r i s kundercutting fair global access of low-income countries toa COVID-19 vaccine (UNODC Policy Paper, p.3).
Recommendation 2:
Public participation in overseeing an equitable accessto vaccines is a desirable approach to public healthand this may reduce the risks of corruption.

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f. Just allocation, distribution, and prioritization of
COVID-19 vaccines
As the number of cases rise, and the longer the duration of
the pandemic, questions on just allocation anddistribution of the vaccines are intensi ied.
Everysovereign state needs to decide who will be the irst ones
to get the vaccine. Although multidisciplinary teams andhealth authorities in different countries are working inprioritization of vaccines, as long as there is a shortage ofthe vaccine and a capacity gap in immunization, problems
may arise. High success of an immunization program isonly possible if distribution and allocation is wellorganized and planned with a clear preparation andadministration plan, and an ef icient immunization
service. Occasionally there will be issues, such as thefailure of a freezer, that have resulted in the immediateneed to attempt to distribute doses before they expire,
and there is consensus that all efforts should be made to
avoid wastage of the vaccine. In addition, sometimes
additional doses could be recovered from vials of vaccine.
All countries have prioritized healthcare workers andhospital staff. Most countries have then prioritized older
people and critically ill and medically compromised
patients. Most countries have also elevated persons in
occupations that involve direct contact with people likedental professionals, ophthalmologists, and workers inessential services such as municipal garbage collectors to
get the vaccine because they are more at risk to get thecoronavirus. Allocation criteria should be determinedaccording to occupation, and people at high risk oftransmitting SARS-CoV-2, e.g., health workers, people
most essential to maintaining core societal, and economic
functions, and groups of people unable to physicallydistance such as disabled persons and their caregivers,
people living in dense neighborhoods, multigenerational
households, nursing homes and prisons. In addition, age
and health situation should be considered, e.g., older
adults, people with certain comorbid conditions, sociodemographic groups at disproportionately higher risks.
For example, Indonesia is prioritizing working adults, who
are at higher risk of contracting the virus, over someelderly persons who stay at home.
Although there are uncertainties about the fair
distribution of the Covid 19 vaccine among countries,
many national leaders, international organizations, andvaccine manufacturers recognize that one of the central
factors in this decision-making process is ethical values(AstraZeneca, 2020; Trudeau et al., 2020). Fair
distribution of the COVID 19 vaccine across countries is

209

an important ethical issue. Prioritizing disadvantaged
people is highlighted as a core value in ethics and global
health (Ottersen et al., 2008; Sharp and Millum, 2018).
National governments also have cross-border
responsibilities to help provide basic needs such as basic
healthcare, especially in global health emergencies(Sangiovanni, 2007).
The vaccines pillar of the ACT-Accelerator, convened
by CEPI GAVI and WHO, were speeding up the search for
an effective vaccine for all countries. At the same time, it
has supported the building of manufacturing capabilities,
and buying supply, ahead of time so that 2 billion doses
can be fairly distributed by the end of 2021 (WHO,
2020b). COVAX is an association formed by the World
Health Organization and non-governmental organizationsGAVI (Global Alliance for Vaccines and Immunization) and
CEPI (Coalition for Epidemic Preparedness Innovations).
It has also considered the fair and effective distribution of
Covid 19 vaccine to the world.
COVAX is one of three pillars of the Access to
COVID-19 Tools (ACT) Accelerator, which was launched in
April by the World Health Organization (WHO), theEuropean Commission and France in response to thispandemic, bringing together governments, global healthorganizations, manufacturers, scientists, private sector,
civil society, and philanthropy, with the aim of providing
innovative and equitable access to COVID-19 diagnostics,
treatments, and vaccines. The COVAX pillar is focused on
the latter. It is a global solution to this pandemic because
it is the only effort to ensure that people in all corners of
the world will get access to COVID-19 vaccines once they
are available, regardless of their wealth.
For lower-income funded nations, who would
otherwise be unable to afford these vaccines, as well as
several higher-income self- inancing countries that haveno bilateral deals with manufacturers, COVAX is quite
literally a lifeline and the only viable way in which theircitizens will get access to COVID-19 vaccines. For thewealthiest self- inancing countries, some of which may
also be negotiating bilateral deals with vaccine
manufacturers, it serves as an invaluable insurance policy
to protect their citizens, both directly and indirectly. On
the one hand it will provide direct protection byincreasing their chances of securing vaccine doses. Yet, atthe same time by procuring COVID-19 vaccines through
COVAX, these nations will also indirectly protect theircitizens by reducing the chances of resurgence byensuring that the rest of the world gets access to doses
too.
COVAX is necessary because without it there is a realrisk that most people in the world will go unprotectedagainst SARS-CoV-2, and this would allow the virus and its
impact to continue unabated. COVAX has been created tomaximize our chances of successfully developing
COVID-19 vaccines and manufacture them in thequantities needed to end this crisis, and in doing so
ensure that ability to pay does not become a barrier toaccessing them. There are currently more than 170
candidate vaccines in development, but most of these
efforts are likely to fail. To increase the chances of success,
COVAX has created the world’s largest and most diverse
portfolio of these vaccines, with nine candidate vaccines

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Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

already in development and a further nine underevaluation. Gavi has created the COVAX Facility throughwhich self- inancing economies and funded economies
can participate. Within this also sits an entirely separate
funding mechanism, the Gavi COVAX Advance Market
Commitment (AMC), which will support access to
COVID-19 vaccines for lower-income economies.
Combined, these make possible the participation of all
countries, regardless of ability to pay. The fact that the
global community has come so far so quickly and built
such a comprehensive and effective global solution to thispandemic is a remarkable accomplishment. Now we needto implement it, and this hinges on countries buying into
the COVAX Facility so that it can make urgent investments
now.3
The ACIP (Vaccination Practices Advisory Committee)
highlighted the ethical principles and approved somerecommendations for the use of the COVID-19 vaccine in
September 2020. These principles express equity andjustice, maximizing bene its and minimizing harm. In
principle, they emphasized the importance oftransparency in vaccination practices and ethicaldecisions. Transparency ensures that allocation decisions
are open and open to scrutiny as well as public
participation. Transparency is also required to increase
public con idence (Bell et al., 2019).
One of the most striking conceptual initiatives
proposed in the global distribution of the Covid-19
vaccine is a fair priority model. The fair priority model
refers to three core values. These values encompass theconcepts of maximizing utility and minimizing harm,prioritizing the disadvantaged, and equal moral concern.
The WHO (2020a) approach recommends that countries
receive vaccine doses in proportion to the size of their
population. The WHO's initial dose allocation expectationfor each country varies between 3-20% of the population.
However, this rate may vary depending on the countries'
position in pandemic struggle. This creates a distinct
ethical challenge. As a matter of fact, the problem of
allocating more vaccines to countries that do not manage
the epidemic well, compared to strong countries that
implement health measures well, comes to the fore. Thissituation poses a particular dif iculty in ethical decision
making (Emanuel et al., 2020).
The issue of the distribution of vaccines is a serious
problem, so there is a need for guidelines based on ethicalvalues and human rights in order to improve world healthand ensure immunization and to reduce the problems thatpublic health professionals will face in this context(National Academies of Sciences, 2020). SARS-CoV-2
pandemic has led to an increase in basic social, economic,
education and health needs, and the existing imbalances
and inequalities both between countries and people livingin the same country. For these reasons, the distribution of
vaccines must be transparent and inclusive, and all
information on this issue must be made available to the
public in a clear and understandable way, withjusti ications provided on the legality of such decisions.
Failing to do so will reduce public trust in healthcare
providers and systems, as well as government leadership,

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3 https://www.gavi.org/vaccineswork/covax-explained

and may lead to chaos. Therefore, the common bene itshould be determined as a goal and encouraged, andpeople should be treated equally and fairly, that is, every
individual should have access to vaccines, and societies'
legitimacy, trust, and sense of ownership should be
encouraged (Toner et al., 2020). As stated in a report of
the World Health Organization (WHO), international
vaccine distribution should be carried out in accordancewith the equality value of ethics, and each country should
follow immunization by determining priority groups inorder to control the pandemic (WHO Working Group on
Ethics and COVID-19, WHO 2020a). The following
principles are among the most important ones regarding
vaccine allocation during the pandemic:
Human-wellbeing: The aim of getting vaccinated is toprotect and promote human well-being, including
physical, psycho-social, and social health, economic
security, human rights and civil liberties, and theprotection of all vulnerable groups (National Academiesof Sciences, 2020).
Equal respect: Acknowledge and vaccinate all people
without prejudice, as having equal moral and rights status
and interests, and worthy of equal ethical/legal
consideration (National Academies of Sciences, 2020).
Global equity should aspire to achieve equality in vaccine
access by ensuring that people living in all countries,
especially people living in low and middle-income
countries have access to vaccines.
National equity: Ensure equality in vaccine access in the
distribution and priority of the vaccine in accordance withbasic ethical and scienti ic criteria, avoiding biological andsocial discrimination such as over political, religious, andethnic af iliation, socioeconomic status, and gender(National Academies of Sciences, 2020).
Legitimacy: It involves transparency, trust, andnonprejudice in the process of making evidence-based
allocation decisions (National Academies of Sciences,
2020).
Communication-media ethics: Media plays a vital role
during pandemic and disasters. Therefore, they should
use impartial and reliable sources, clear language, andexplain all terms, report the numbers, explain side effects,
using appropriate visuals, and reminding the bene its ofthe vaccine.
Recommendation 3:
The pandemic is a global challenge, therefore
international and national ethical values andprinciples must overlap in vaccine distribution andsetting priorities that can help contain the pandemic,
even if the virus cannot be eliminated. All countries
should be called upon in this regard. These principles
should be applied in the framework of human wellbeing, equal respect, global equity, national equity,
legitimacy and ethical communication.
Recommendation 4:
Ethical values should be taken into consideration in
vaccine distribution programs, and in the case oflimited resources, priorities should be determinedEubios Journal of Asian and International Bioethics 31(4) (May 2021)
according to explicit ethical criteria. These criteria
should take priority to protect and improve the healthof society, according to vulnerability, occupation, age,
health situation, population density and factors suchas people living in multigenerational households.
Especially, healthcare workers who face the mostserious risks and burdens in the pandemic, providing
material and moral support to alleviate their burden
and risks should be considered on a world scale.
Prioritization should be adjusted according to risk
groups and be considered in other professions too.
Recommendation 5:
Governments have a moral obligation to betransparent about any vaccine they are providing andthe reasons for choosing the vaccine, and about theright of people to choose another vaccine if available.
The public should be informed about the vaccinationand the technique of the vaccine, the tests performed
and the results of each phase, and the questions anddiscussions of independent scientists, journalists,
broadcasters, students, and other community leaders
should be encouraged, as part of a meaningful processthat can be trusted. Thus, the community should
clearly understand the criteria for vaccines, different
techniques of vaccines, autonomous approach torecipient selection, the priority reasons of vaccine
distribution, to be able to trust the authorities invaccine distribution.

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g. Vaccination as a moral responsibility
Vaccination remains one of the most economical andeffective interventions for preventing an array of
infectious diseases and the associated disabilities anddeaths, thus fostering public health (Afolabi, 2016).
However, it is very important to highlight that vaccination
should be voluntary unless it becomes critical to “preventa concrete and serious harm” and if so; visual aids andother media can be used to convey accurate and important
information to the public in a time-ef icient manner”(Moodley et al., 2013).
One of the reasonable means for ensuring individualautonomy is to provide people accurate information
related to positive and negative impacts regarding any
vaccination program that is expected to be implemented
in the society as a moral responsibility, in order tofacilitate the individual decision-making process. The lackof accurate information about a given vaccination
program can raise mistrust, weaken autonomy and theprocess of individual decision making. The current
strategies used can be improved by giving the citizens therights to make their own decisions with transparent andclear information from the government or the community
leadership.
From an ethical perspective, decisions made by anindividual’s moral consciousness should be open to
dialogue, and the procedures should be fair (Lenhardt andNicholsen, 1999). Considering a broader perspective, thevalue of every individual life is signi icant, with particularcare for vulnerable communities (e.g., people with special
needs, those living in poverty, indigenous communities,

211

and so on) should be protected by the government andthat should become the priority of every government.
To ensure the respect to autonomy, the need ofproviding accurate information on the risks and bene itsof vaccination to target populations should be regarded asvital, and it should done adequately to allow individuals to
make informed decisions, while bearing in mind thatmany will lack a basic understanding of germ theory andimmunology (Moodley et al., 2013). As it is well known“Vaccines produce bene its but can also cause individual orsocial harm. Side-effects are an example of individual harm.
These range from mild, common reactions, such as
in lammation and pain at the injection site, to more severe
but extremely rare events.” Thus, providing accurate
information related to the risks and bene its ofvaccination to target populations should always be
regarded as fundamental for ensuring the respect forautonomy and allowing individuals to make informed
decisions.
Philosophical views in many parts of Asia and Africa
emphasize the idea of ‘relational autonomy’ which, is as
an alternative conception of what it means for one to be afree and self-governing person, in that a person is sociallyconstituted and embedded in a social environment,
culture, or tradition that indicates value commitments,social obligations, interpersonal relationships, and mutual
dependencies (Ikuenobe, 2015). For example, Ubuntu
ethics is relational ethics, that prizes relationships ofinterdependence, fellowship, reconciliation, relationality,community friendliness, harmonious relationships andother-regarding actions such as compassion and actions
that are likely to be good for others, in which actions aremorally right to the extent that they honour the capacity torelate communally, reduce discord or promote friendly
relationships with others, and in which the physical world
and the spiritual world are fundamentally united” (Ewuoso
and Hall, 2019).
Recommendation 6:
Receiving the immunization during a public healthemergency can be a moral responsibility.
h. Compulsory vaccination by government authorities
There are circumstances in which governments havemade immunization legally compulsory, and we can
expect some of these policies to apply to COVID-19
vaccination regulations. The World Health Organization(WHO) has no of icial policy on mandatory vaccinations.
Discussion of the ethical issues of voluntary versus
compulsory immunization (Salmon et al., 2006) ared i s c u s s e d a b ove i n t h e s e c t i o n o n vo l u n t a r yimmunization.
Gravagna et al. (2020) surveyed 195 countries andfound that 105 countries had a national mandate for
vaccines as of December 2018. 62 countries de ined apenalty for non-compliance and 43 limited entry to school
based on immunization. Among these 62 countries, 12countries included the penalty of jail time for noncompliance, and 2 of these had immediate jail time morethan 6 months in duration. Even though some nations
have a compulsory immunization policy in law, they may
decide not to enforce that policy; for example, local

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authorities may decide not to ine or imprison violators(Walkinshaw, 2011).
If a nation mandates immunization, they usually havea national no-fault compensation program for those whohave medical problems because of these. Among G7
countries, Canada was the last country to introduce a nofault compensation plan for immunization, as recently as
December 2020.4 The province of Quebec had a no-fault
compensation scheme for 30 years, like many other OECD
countries. In the case of a pandemic there are additional
justi ications for compulsory vaccination that apply insome legal circumstances, consistent with national law.
Countries such as Australia and USA which have semimandatory programs argue on utilitarian grounds that the
public bene it from higher immunization rates justi ies
the mandate (Salmon et al., 2006).
Some national and local governments requirecompulsory immunization for employees that havecontact with certain populations (See Employee Mandated
Immunization). Given that to date COVID-19 vaccines have
only been granted emergency authorization, it is too early
yet to mandate compulsory immunization, even if thatshould ever be implemented.

Immigration mandated immunizations: Generally,
there are stricter requirements for immigrants as opposed
to short-term business travelers and tourists. Simply put,no immunization may mean no immigration! In the lightof the CDC guidance “Any future vaccines recommended by
ACIP for the general U.S. public will be subject to the new
vaccination criteria. If the recommended vaccines it the
new criteria, they will be added to the list of required
vaccines for immigrant applicants.”7, thus a SARS-CoV-2
vaccine is expected to be added soon. However, theEuropean Union does not have a uni ied policy as
surveyed by Bica and Clemens (2017): “With some notable
exceptions immunization policies to contain spread of
infectious diseases through migration are either nonexistent or vary widely between countries in the EU/EEA.
With freedom of movement within the EU/EEA there ought
to be harmonization and a common EU/EEA vaccination
strategy to replace national policies for immigrant
populations.”
Some countries do not require immunizations for
immigration, such as Japan. The COVID-19 pandemic may
lead to pressure on some countries to introduce such
regulations on the grounds of public health emergency
laws that exist in many more countries than those which
require immunization for immigration.

Travel mandated immunizations: Countries have legal
authority to impose compulsory vaccination on
immigrants and tourists. Immigrants to many countries
around the world are required to have a set of
immunizations and it has been announced by theEuropean Commission and some other countries that a
COVID-19 vaccine will be added to this list by mid-2021(Murphy, 2021; Stevis-Gridneff, 2021). There are existing
rules on international immunizations, and several
immunizations are legally required for tourists.5 The
existing certi ication scheme can be adapted to include
SARS-CoV-2 Virus and several countries have announced
that they are considering whether to make it mandatory
for tourists. The requirements for travel vary by eachcountry.6

Immunization policies for schools: In some countries
compulsory vaccination policies apply to teachers andstudents attending public school or private school. In the
United States students attending school are required tohave immunization against several diseases. The state ofMississippi and West Virginia only allow medical
exemptions for students attending school, but other states
also allow religious and philosophical exemptions.8 In
March 2020 Germany passed a law that requires all
children to be vaccinated against measles before they can
go to kindergarten or school. Since attending school is
obligatory in Germany, that means the country alreadyhas a de facto mandatory measles vaccination.9
Some countries such as Australia offer inancial
incentives for students who attend school who have met

4 https://www.cbc.ca/news/health/vaccine-compensation-1.5837406
5 An International Certi icate of Vaccination Against Yellow Fever is an of icial record and a legal requirement for entry into somecountries. There is an of icial list on the World Health Organization's International Travel and Health website of countries as requiring
proof of vaccination for yellow fever for all travelers entering the country (currently: Angola, Burundi, Cameroon, Central African
Republic, Congo, Republic of Cote d'Ivoire (Ivory Coast), Democratic Republic of Congo, French Guiana, Gabon, Ghana, Guinea-Bissau,
Liberia, Mali, Niger, Sierra Leone, Togo, Uganda). In addition, many other countries require certi ication when travelling from a country
with endemic Yellow Fever only, for example a traveller from Brazil to Columbia may require certi ication. The requirements also varyover time depending on the status of outbreaks of the disease. https://www.iamat.org/world-immunization-chart
6 A searchable country list for clinicians and for travelers is available at: https://wwwnc.cdc.gov/travel/destinations/list/

https://www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-immigrationfaq.html#whatvaccines For example, to apply for an immigrant visa to the United States the following immunizations are required(Mumps, Measles, Rubella, Polio, Tetanus and diphtheria, Pertussis, Haemophilus in luenzae type B (Hib), Hepatitis A, Hepatitis B,
Rotavirus, Meningococcal disease, Varicella, Pneumococcal disease, Seasonal in luenza).
7

8 State Vaccination Requirements. Centers for disease control and prevention. Available at: https://www.cdc.gov/vaccines/imz-

managers/laws/state-reqs.html

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9 https://www.dw.com/en/germany-makes-measles-vaccination-compulsory/a-51243094

the immunization requirements as an incentive toencourage vaccination under the Maternity Immunization
Allowance and Childcare Bene it Act. Ethically it is more
acceptable to offer inancial incentives than to impose
penalties such as jail time or loss of parental custody ofchildren, as discussed in the Section on voluntary
immunization.
For most children, in-person instruction is better thanon-line teaching. A return to physical schools is expected,
at the latest with the availability of immunization. Private
universities with enough inancial resources can take theinitiative to vaccinate university students. Governments
can provide funding to ensure that students from public
colleges and universities can have access to the vaccines.
Immunization, however, should not be compulsory. The
parents will have to make the decisions for students who
are not yet of legal age. Risk assessment should also be
conducted scienti ically. For instance, the government
should select schools where the Covid infection is highest.
In some cases, these are metropolitan cities where there
are millions of people who interact on a daily basis.
Employer mandated immunization: In some countries
compulsory vaccination policies apply to members of themilitary, or certain other occupations. In effect if you live
in a country with universal military conscription, and themilitary requires immunization, in effect immunization iscompulsory unless someone has an exemption against
military service. In the United States case, it has beenannounced that COVID-19 vaccine will not be compulsory
for all employees until it receives general FDA approval,
because currently it is approved on an emergency basis.10
Some other employers mandate vaccination for theiremployees, and there is no legal question when this comesto recruitment of new employees, if it is made clear to
applicants and new employees that is the policy. There are
more complex legal questions whether current employees
are required to have a vaccination in order to continue
employment, although if employment is based on
renewable contracts, then such additional requirements
could be added to the new contracts.
Generally compulsory employee immunizations will
be an attractive policy among consumers and customers
of service industries, especially healthcare providers, staff
of long-term care facilities, domestic help, and travelcompanies, for example. In the private marketplace, we
can expect such marketing by companies. In a recent
survey of medical students in Austria, 80% of medical
students supported compulsory immunizations for
medical doctors (Kunze and Schweinzer, 2020).
Because some consumers are expected to haveprivileged access to businesses with a vaccination
passport, those businesses are also expected to require
employees to be vaccinated.
Dr. Frank Ulrich
Montgomery, president of the World Medical Association,
and Dr. Thomas Mertens, virologist and head of Germany's
Standing Commission on Vaccination (STIKO), have213

suggested that “people who have been immunized against
COVID-19 could use a vaccine "passport" to get access tolights, restaurants, concerts, and cinemas.”11 Many
Germans, like persons in some other countries, alreadyhave an "immunization passport" that records all
immunizations they have had.
Compulsory immunizations for employees of travelcompanies: Employees of travel companies that crossinternational borders, such as light crews, are alreadysubject to meeting international law on travel healthrestrictions. Some airline companies, starting with the
CEO of Qantas, have announced that they will make
COVID-19 immunization compulsory for all passengers to
all destinations, as well as all their cabin crew.
The International Air Transport Association (IATA)(2020) is considering a consistent international policy
and has recommended: “Governments should put
procedures in place to ensure that travelers who havebeen vaccinated should not need to undergo COVID
testing.” Some countries are considering mandatory
immunization as an entry requirement, but in December
2020 IATA stated, “While IATA expects that a signi icant
majority of international travelers will be willing to get
vaccinated, COVID vaccination should not be a mandatory
government requirement for international travel.”
However, as the IATA acknowledges, some countries will
waive requirements for COVID-19 testing and mandatory
quarantine periods for those with vaccination
certi ication. We can expect some countries will add
COVID-19 immunization to other required immunizations
that exist as entry requirements. In the case of paper
certi ication for COVID-19 vaccines, there are already anumber of cases of reported forgeries and fraud in 2021.
Recommendation 7:
Experience from existing immunization programs,
both mandatory and voluntary, should be assessed toconsider whether vaccines against SARS-CoV-2 should
be added to the list of mandated or elective
immunizations, while considering the cultural andlegal milieu, and the situation of the pandemic.
Recommendation 8:
Existing international travel certi ication systems
should be extended to ensure just and transparent
requirements for COVID-19 immunizations. Researchshould be conducted to determine whether digital
vaccine certi ication is effective.
Recommendation 9:
When applying mandatory immunization policies,
employers and travel companies should apply existing
legal requirements fairly for their employees andcustomers. There is an urgent need to further
elaborate ethical procedures, based on the

10https://www.militarytimes.com/news/your-military/2020/12/09/troops-could-begin-getting-covid-19-vaccines-as-early-as-next-

week-and-they-wont-be-mandatory/

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11 https://www.dw.com/en/covid-special-privileges-for-the-vaccinated/a-56077470

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Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

experiences that global society is gathering during
2021.
i. Global funding and initiatives: affordable andavailable COVID-19 vaccines
As well as reducing the tragic loss of life and helping to get
the pandemic under control, introduction of a vaccine will
prevent the loss of US$ 375 billion to the global economy
every month (WHO, 2020b). Equitable access to Covid-19
tests, treatments and vaccines in all countries will lead tothe pandemic ending sooner, many lives saved, a return ofinternational mobility and trade, and a start to economic
recovery. The $28.1 billion investment still needed todevelop these lifesaving tools could be recouped in 36
hours once international mobility and trade are restored.
This investment is less than 1% of what G20 countries
have already unlocked to support businesses and national
economies.12
There is an extraordinary need to manufacture anddistribute safe and effective vaccines to protect the entire
global community from the ongoing threat of SARS-Cov 2
coronavirus infection, morbidity, and mortality (Corey etal., 2020). Cold chain requirements, cost and providing
wide coverage are understood as potential restriction
points in the delivery of vaccines to individuals andcommunities. Because of these problems, global
cooperation between healthcare delivery and economic
organizations is vital.
As an example, the Asian Development Bank (ADB)
said it will only fund vaccines that have satis ied any of thefollowing criteria: selected for procurement via COVAX on
behalf of participating countries, prequali ied by theWorld Health Organization, authorized by a Stringent
Regulatory Authority (SRA) for manufacture in an SRA
country or the SRA has authorized its manufacture in a
non-SRA country. The funds will be available for ADB
developing members to support vaccine-related healthsystem assessments and the development of country
readiness plans to strengthen the capacity to access,introduce, monitor vaccines, safely and effectively. Funds
will help members assess and strengthen vaccine cold
chain and logistics, infection control, supply and skills of
health workers, risk communications, and real-time data
capturing and monitoring (ADB,2020b).
The principle of solidarity and social responsibility isadopted, and countries with the ability to produce
vaccines are expected to irst provide vaccines to theirown citizens, but also to allocate part of the supply toother countries (National Academies of Sciences, 2020).
Recommendation 10:
Investments should be made immediately tostrengthen supply chains, allocating sustainable andadequate financing, and empowering community andfrontline health workers to ensure no one is left
behind. Investment is needed to enhance the Accessto COVID-19 Tools (ACT) Accelerator. By investing in
the ACT-Accelerator, governments will have a betterchance of accessing the successful tools

j. Prioritization of persons with special vulnerability
In addition to the vulnerabilities discuss above, a double
disaster occurs when a natural disaster happens in anarea affected by the COVID-19 pandemic. During natural
disasters including earthquakes, fire, flooding, severe
storms such as a typhoon or a cyclone, evacuation ofpeople in disaster prone ares and sheltering them inlarger public buildings have been common strategies tosave the lives of communities. However, such shelters
may face serious issues related to the risk of infection
spread especially in the urgency and panic of a natural
disaster. Authorities have to prepare methods to deal
with such situations (Shahul et al., 2020), andvaccination of communities living in areas at risks ofsuch disasters, especially in flood prone areas should bea priority.
Recommendation 11:
Communities living in disaster prone areas, such as
low-lying coastal areas that have been hit before
with severe natural disasters requiring evacuation
would benefit from having received
COVID-19 vaccines in case evacuation is required
during another disaster.
j. Hope for a better and healthier future should not behinged only on vaccines
While vaccines are a critical tool to save lives, the immune
system is dependent upon all aspects of health – physical,
mental, and social. Food sustains our life, and we need to
pay more attention to making nutritious food available toas many people as possible around the world. Exposurelevels are critical for social groups who run a high risk of
associated complications, as in settings whereenvironmental protections are loose, healthcare spending
is low, there is poor access to running water, and where ispoor nutrition.
Evidence shows that a better life can be secured
through higher physical and mental health standards,
which in turn can reduce the risk of infection, and the bestand easiest way toward this public goal is to help all
people adopt conscious thoughts and behaviors that
foster their wellness. Moreover, as social norms andvalues shift selection pressures to wider groups, clarity
about the determinants of morbidity and mortality
through lifestyles can help restore individual andcommunity immune systems and vitality so people adapt
and continue contributing to glocal communities inharmonious and ethical ways.
While it is encouraging to see so many vaccines
proving successful scientists from across the world arealso collaborating and innovating to develop better tests,
treatments and vaccines that will collectively save lives,
especially when combined with holistic approaches toenhance our immune systems. At the same time, still
simple hygiene, wearing masks and physically distancing
when close to other persons who might be infected, canprotect ourselves and others.

12 Wellcome.org, Equitable access to vaccines, tests and treatments for Covid-19, https://wellcome.org/what-we-do/our-work/

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Recommendation 12:
Vaccines are only one part of the global responses to
COVID-19 that are necessary. The lessons that we candraw for improving equity and justice can be appliedin all aspects of public health promotion.
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Signed by Members, World Emergency COVID19 Pandemic
Ethics (WeCope) Committee
h t t p s : / / w w w . e u b i o s . i n f o /world_emergency_covid19_pandemic_ethics_committee
Dr. Thalia Arawi (Lebanon)
Dr. Lian Bighorse (San Carlos Apache Nation, USA)
Dr. Rhyddhi Chakraborty (India, UK)
Dr. Shahanaz Chowdhury (Bangladesh)
Mr. Anthony Mark Cutter (U.K.)
Dr. Mireille D'Astous (Canada)
Dr. Ayoub Abu Dayyeh (Jordan)
Dr. Nilza Maria Diniz (Brazil)
Dr. Hasan Erbay (Turkey)
Prof. Nader Ghotbi (Japan)
Prof. Abhik Gupta (India)
Prof. Soraj Hongladarom (Thailand)Prof. Miwako Hosoda (Japan)
Prof. Dena Hsin-Chen Hsin (Taiwan)
Dr. Anower Hussain (Bangladesh)
Prof. Bang-Ook Jun (Republic of Korea)
Prof. Hassan Kaya (South Africa)
Dr. Sumaira Khowaja-Punjwani (Pakistan)
Prof. Julian Kinderlerer (South Africa)
Dr. Lana Al-Shareeda Le Blanc (Iraq)
Prof. Marlon Lofredo (the Philippines)
Prof. Manuel Lozano Rodríguez (Spain)
Prof. Christopher Ryan Maboloc (the Philippines)
Prof. Darryl Macer (New Zealand)Prof. Raffaele Mantegazza (Italy)
Dr. Aziza Menouni (Morocco)
Dr. Endreya Marie McCabe (Delaware Nation, USA)
Dr. Ravichandran Moorthy (Malaysia)
Prof. Firuza Nasyrova (Tajikistan)Eubios Journal of Asian and International Bioethics 31(4) (May 2021)
Dr. Suma Parahakaran (Malaysia)
Prof. Maria do Céu Patrão Neves (Portugal)
Prof. Deborah Kala Perkins (USA)Dr. Laura Victoria Puentes (Colombia)
Prof. Osama Rajkhan (Saudi Arabia)
Ms. Carmela Roybal (Tewa Nation, USA)
Prof. Hans-Martin Sass (Germany)
Prof. Mariodoss Selvanayagam (India)
Dr. Sukran Sevimli (Turkey)
Dr. Dhastagir Sultan Sheriff (Mauritius)
Dr. Jasdev Rai Singh (England)
Dr. Raquel R. Smith (USA)Prof. Ananya Tritipthumrongchok (Thailand)
Dr. Kayo Uejima (Japan)
Prof. Erick Valdés Meza (Chile)
Dr. Lakshmi Vyas (UK)Prof. Yanguang Wang (China)
Prof. John Weckert (Australia)
Dr. Anke Weisheit (Uganda)

Inquiries to:Prof. Darryl Macer, Chair, WeCope
C o m m i t t e e ; E m a i l : d a r r y l @ e u b i o s . i n f o Te l .
+1-949-439-9307.

Exploring the ethics of a possible
mandatory COVID-19 vaccination
program in the Philippines- Louiejabe Nuniala- Alpha Kassadra Acain- Nicole Blain Bonifacio- Dennis Jambalos Jr.
- Veronica Julia Tizon- Angela May Vergara- Maria Angela Villamora- Bernardo Caslib, Jr.
University of the Philippines Manila, the Philippines
Email: bncaslib@up.edu.ph

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Abstract
In an effort to mitigate the impacts of the ongoing
COVID-19 pandemic and acquire herd immunity against it,
the Philippine government aims to procure vaccines anddeliver them to 80% of the population. However, most
Filipinos are hesitant to be inoculated due to vaccine
skepticism reinforced by the Dengvaxia controversy in thePhilippines. Given this, the researchers aim to uncover the
ethics of a possible mandatory COVID-19 vaccination
program in the Philippines through the lens of different
moral and ethical theories in public health. In line withthe principle of Least Restrictive Alternative andprinciplism, the researchers suggest an intervention thatis considerate of both the advocacy for mass vaccination
and respect for individual autonomy. Factoring in theFilipino values of bayanihan (cooperation) and damayan(compassion), the researchers, in the end, do not suggest
a mandatory vaccination plan, but a more ethically viable
voluntary COVID-19 vaccination in the Philippines with acommitted effort of the government to educate andpersuade the people to get vaccinated without infringing
upon their autonomy.

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Introduction
As of March 1, 2021, the Philippines placed third amongten Southeast Asian countries with the highest active
coronavirus disease 2019 (COVID-19) cases based on thenumber of cases per million people (Bueva, 2020).
Although the number of new con irmed cases continues todrop, the country still remains second in terms of most
COVID-19 cases in the region with more than 578,000
total cases (Center for Strategic and International Studies[CSIS], 2021). However, with respect to the case fatality
rate, the country places third with 2.1% (Bueva, 2020).
The Philippines has gotten out of the top 30 with thehighest number of con irmed COVID-19 cases worldwide(World Health Organization, 2021). This downward trend
should not serve as an indication to be complacent(Gonzales, 2021) but to practice the health protocols
mandated by the Department of Health (DOH) even morewhile arrangement for vaccine procurement is in process.
Before the end of 2020, the government started
communicating with the pharmaceutical companies that
could supply vaccines for about 60 to 70 million Filipinos
representing the percentage of the population needed toachieve herd immunity (Ranada, 2020). At the onset of thepandemic, epidemiologists estimated that herd-immunity
can be achieved with 60 to 70 percent of the population
getting vaccinated. Recently, this approximation increased
to 75 to 80-plus percent (McNeil, 2020). Corollary to this,the Philippine government plans to vaccinate 80% of theFilipino population in three to ive years (Gonzales, 2020).
In this regard, the government is currently in talks withseven companies: P izer, AstraZeneca, Moderna, Novavax,
Sinovac, Gamaleya, and Johnson & Johnson (Janssen
Pharmaceutica) (Philippine News Agency [PNA], 2021).
The irst rollout was scheduled in mid-February with
117,000 doses of P izer and BioNTech’s vaccine forfrontline health workers (Tomacruz, 2021). In midFebruary, it was announced that there would be slightdelays since the national government was still processing
some needed documents (Aspinwall, 2021). Healthcare
workers, front-liners, senior citizens, indigents, anduniformed personnel are on the priority list for vaccine
recipients. The most affected areas will be given utmost
priority for the administration of vaccines. As of the
moment, the government plans for a voluntary
vaccination program (Gulla, 2020). However, with several
factors involved such as vaccine hesitancy intensi ied byrecent reports on vaccine side effects, the implementationof a mandatory vaccination plan in the country is possible.
In developing COVID-19 vaccines, the US Food andDrug Administration issued guidelines on thedevelopment and licensure of vaccines. The document
requires the manufactured vaccine to be at least 50%
effective. Most of the COVID-19 vaccines authorized for
emergency use are not yet studied for their long-term
adverse effects but companies are obligated to follow up
with their participants in the clinical trials and reportback the outcomes to the FDA (Karron, 2020). As such,
vaccine side effects may be described as inevitablebecause they may come along in the process. Some knownside effects include pain and/or swelling at the injection
site, tiredness or fatigue, headache, muscle and joint pain,

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Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

chills, fever, nausea, and swollen lymph nodes (Radcliffe,2020). Experiencing temporary side effects means the
body is developing an immune response toward theweakened pathogen. It does not necessarily mean that thevaccine recipient will have COVID-19; instead, the vaccine
helps the body recognize and become familiar with thepathogen in a safe way (Woodruff, 2020). Recently, from areport of Taiwan News, Chinese vaccine expert Tao Lina
named China’s Sinopharm vaccine as the most unsafe
vaccine in the world (Everington, 2021). Although this
vaccine claims to be 79% effective, it is accompanied with73 side effects as posted from Tao Lina’s Weibo account.
Some of the severe side effects indicated in the vaccine
manual were high blood pressure, loss of vision and lossof taste, which are among the symptoms of COVID-19.
However, Tao Lina retracted his statement saying that his
post was misunderstood, as well as clarifying that thevaccine is safe and he himself was inoculated with this
vaccine (Global Times, 2021). Because of this news report,
people became more skeptical and more reluctant tosupport the vaccination program.
Tracing back the effects of the Dengvaxia controversy,
vaccine hesitancy has been heightened among Filipinos.
This controversy, in addition to reports of COVID-19
vaccine side effects, results in vaccine skepticism causing
people to doubt the safety and effectiveness of theavailable vaccines. This is not limited to the Philippines
but is observed globally. Social media plays a big role inin luencing and dispensing information about these two
phenomena. The Philippine FDA reported thatapproximately 30% of the population are reluctant to takethe COVID-19 vaccine shot (Rita, 2020). If vaccine
hesitancy continues to heighten, it will impose negative
consequences to everyone’s health security from thevirus. Possible consequences may include the failure toacquire herd immunity, increased burden to humanresources for health, worse economic decline, andinsuf icient support for the immunocompromised andgeriatric populations.
In line with these, researchers are interested in
exploring the possibility of imposing a mandatory
COVID-19 vaccination plan. Generally, this paper aims todiscuss the ethics behind the current situation of
COVID-19 vaccination in the Philippines. Speci ically, thispaper aims to:
1. explain the reasoning behind the con licting valuesof different groups of people with regard to mandatory
COVID-19 vaccination; and2. make a decision and propose recommendations to
identify whether mandatory COVID-19 vaccination is an
ethically plausible intervention in the country based on
ethical and moral frameworks in public health andrelevant Filipino values.

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Perspectives on vaccination
Vaccines aid the body in developing immunity bysimulating an infection (Center for Disease Control andPrevention [CDC], 2020). Vaccines contain weakened orinactive parts of pathogens called antigens (WHO, 2020).
By simulating an infection, vaccines induce the immune
system to produce T-lymphocytes and antibodies to attack
the antigen. After the infection, "memory" T-lymphocytes

and B-lymphocytes remember how to combat the antigen
thereby building immunity (CDC, 2020). Herd immunity
refers to indirect protection from disease when asuf icient number of individuals are vaccinated andbecome immune to the infection, which reduces thepossibility of infection being transmitted to otherindividuals who lack immunity (WHO, 2020).
Despite the fact that immunization is one of the mostremarkable developments in the 20th century, the ef icacy
and safety of vaccines are still issues in the contemporary
world. As vaccines mitigate disease spread, some may
seem unnecessary due to reduced disease occurrence,
thereby fostering a nature of complacency (Jacobson et al.,2015). The dread of diseases has shifted to the fear of
possible vaccine reactions and side effects. This led to theemergence of the term "vaccine-hesitancy" and thecategorization of individuals into pro-vaccine and antivaccine.
Perspectives on vaccination lie within a spectrum
ranging from total acceptance to total refusal. Keane et al.
(2005) categorized individuals, particularly parents, into
four groups according to their attitudes towards
vaccination: vaccine believers who believe in the bene itsof vaccines, cautious individuals who are skeptical andseek information about vaccines, relaxed individuals whoare passive and have relaxed parenting approaches, andunconvinced individuals who have the most negative
views and attitudes towards vaccination.
The primary argument against mandatory vaccinationis the violation of individual autonomy and parents' rights
to make choices for their children. Although the antivaccine movement originated in the mid-19th century, its
resurgence occurred after the publication of Wake ield'spaper in 1998. Wake ield (1998) reported a correlation
between measles, mumps, rubella (MMR) vaccination, andgastrointestinal and developmental regression, including
autism, disintegrative psychosis, and post-vaccinal
encephalitis in children. Although the paper was later
retracted, the damage had already been made and news
about the research spread worldwide. The impact wasmost profound in the United Kingdom where thevaccination rate dropped from 92% in 1996 to 84% in2002 and 61% in 2003. National immunization levels also
dropped to 80% in Ireland and 60% in North Dublin(Hussain et al., 2018).
The psychology of risk perception leads to vaccination
being perceived with a higher risk than it actually has.
Surveys reveal that meningitis is perceived to be the mosthazardous and measles as the least when it should be theopposite (Spier, 2011). Furthermore, humans are
inherently inclined to reject changes and stick to thestatus quo. The emergence of new developments such as
vaccines can be perceived as threats to this equilibrium,
thereby encouraging resistance.
Religious reservations also contribute to reluctanceregarding vaccination as some religions have speci ic
restrictions regarding vaccines. Wombwell et al. (2014)
reported that vaccine refusals associated with religion are
primarily due to the use of aborted human fetal tissue invaccine products and animal-derived gelatins, including
porcine and bovine components. While Hinduism does
not prohibit vaccination, most followers are hesitant due

to its fetal cell and bovine components. Roman
Catholicism deems abortion as immoral, thus,
discouraging the use of vaccines derived from fetal
tissues. As aforementioned, the Islamic faith prohibits theconsumption of porcine products, including those used in
vaccines. Thus, for some individuals, religious
reservations outweigh the risk of diseases and vaccination
is not worth offending or abandoning their religious
beliefs.
Underlying moral foundations also in luence people’s
attitudes on vaccination. Amin et al. (2017) found that
respondents who strongly believe in the moral foundationof purity perceive vaccines as "unnatural" and"contaminants". They believe that instead of receiving
vaccines, children should build immunity naturally
through exposure to disease. Moreover, individuals whostrongly believe in individual liberty were associated withmedium and high hesitancy on vaccination. They believethat mandatory vaccines violate individual liberty andimpose excessive government control (Amin et al., 2017).

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Evaluation of arguments through epistemic
responsibility
Perhaps one of the most popular arguments for people’s
reluctance to vaccination is the claim that it leads to thedevelopment of autism, especially for children. As
previously discussed, this particular belief originatedfrom the work of Wake ield (1998). However, the study’s
results and indings have not been replicated by any major
and recent research up to this point. In fact, the journal
where Wake ield’s study was originally published, The
Lancet, has since retracted the paper stating that “several
elements are incorrect” (Eggerston, 2010). A conspicuous
law of Wake ield’s conclusion that environmental factors,
such as the MMR vaccine, cause regressive developmental
disorder is the small sample size of only twelve children.
Furthermore, it was later unearthed that Wake ield
actually acted unethically by receiving research funding
from a group of lawyers representing parents who weresuing vaccine manufacturers at the time, and he was later
stripped of his medical license (Mayor, 2004).
Moreover, there is a clear break in the logic of the claimthat MMR vaccines contribute to the onset of autism: thebasic principle that correlation does not equate causation.
In a compelling argument by Davidson (2017), MMR
vaccines are usually administered 12-18 months after
birth, which coincides with the time frame where the irst
symptoms of an impending developmental disorder suchas autism start to become observable. There is also arecurring argument which states that while an exhaustive
list of scienti ic studies conclude that there is no evidence
that vaccines cause autism, these studies also fail todisprove the relationship between the two. This argument
is simply illogical as it shifts the burden of proof to those
who advocate for vaccines instead of those who areagainst it due to their unfounded claims. People who claimthat a particular relationship between entities exists
should have the responsibility to provide scienti ic
evidence. Without logical, observable, and replicableevidence, the claim is worthless and knowledge of no
falsifying evidence is irrelevant.

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219

Another popular argument against vaccines is due toreligious objections. In fact, the World HealthOrganization (2014) reported that religious beliefs are
one of the most common reasons for vaccine hesitancy.
Mainly, the objection comes from the methods of vaccine
development which involve aborted human fetuses or any
form of life. However, it is important to emphasize that
only two human fetal cell lines are currently used indeveloping vaccines against viruses and both wereaborted therapeutically (Giublini, 2018). Moreover, only
four vaccines that are commonly mandated (hepatitis A,
rubella, chickenpox, and zoster) are derived from animal
cell lines (Giublini, 2018). Most religions believe in theinherent value of life but if vaccines aim to protect andsave more lives, they ought to be permitted. In this regard,
theological perspectives are not in direct contradiction to
immunization and public health. Rather, questionableinterpretation of religious texts and practices by certain
individuals cast the shadow of doubt that ultimately leads
to vaccine hesitancy (Pelčić et al., 2016).
Aside from the natural side effects brought about by
the immune system's response to vaccine exposure, there
is also a small proportion of the population which, forvalid medical reasons such as genetic predisposition andhypersensitivity reactions, may not be able to bene it fromvaccination. These objections, albeit currently lacking
scienti ic consensus, could be grounds for vaccine
hesitancy for the argument of individual safety andpersonalized medicine. However, using the same reasons
to instill skepticism for the overall safety of vaccines
would be misguided and irresponsible. In fact, it could beargued that since certain members of the population may
not be vaccinated, the attained herd immunity by massvaccination of other individuals would be essential inprotecting them from diseases which they would besusceptible to otherwise.
All the counter-arguments presented above ultimately
lead to one simple truth: responsible actions are
grounded in epistemic conditions. Levy and Savulescu(2020) argued that moral agents are more likely to
exercise control if they understand the nature of theiractions and its consequences to society in general. The
notion of epistemic responsibility, as de ined by one of its
earliest proponents Clifford (1877), simply is that “It is
wrong, always, everywhere, and for anyone, to believe
anything upon insuf icient evidence”. This philosophicalframework is applicable in the conversations surrounding
the safety and ef icacy of vaccines in the midst of a deadly
pandemic. Moral agents must be held accountable to theirmoral and ethical duties to only hold and share opinions
that are backed by reason and supporting evidence inorder to prevent the spread of conspiracy theories andmisleading information that could potentially cost lives.
Overall, immunization remains as one of the mosteffective public health interventions to protect
populations from preventable diseases (Shen & Dubey,2019). Every member of society has an individual
responsibility to contribute to the attainment of herd
immunity to protect the population. People may holdindividual beliefs but no one is entitled to their own set off a c t s . A ny e f f o r t t o c a s t s k e p t i c i s m , s p r e a dmisinformation, and jeopardize public trust regarding

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Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

vaccine safety without factual evidence is morally
irresponsible and may be considered a public healthconcern as vaccine hesitancy leads to avoidable andunnecessary deaths.

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Nuf ield bioethics intervention ladder
Aside from the spread of misinformation, attaining thebalance between civil liberty and autonomy with thegovernment's responsibilities in upholding population
health and welfare is a fundamental ethical dilemma in
public health (Fleetwood, 2017). While public healthexperts and legislators act as the primary body in
implementing health-related policies, the participation of
the community is also deemed vital in achieving theobjectives of the protocols imposed to resolve prevailing
public health concerns (Kongats, McGetrick, Raine, &Nykiforuk, 2020). However, institutionalizing regulations
requires comprehensive deliberations as it can pose
con licts due to varying perspectives among the public.
This decision-making, therefore, requires ethicalconsideration (McClung et al., 2020), among other factors
such as the state's economic status and healthcare system
capacity (Krishnaswamy, Lambach & Giles, 2019). Hence,
it is crucial for public health legislators to be able toassess and yield the most ef icient intervention thatmaximizes public welfare while minimizing infringement
on individual rights.
According to Hillier-Brown et al. (2017), one way toeffectively encompass every aspect of decision-making inpublic health is by enumerating potential interventions,which range from reactive to proactive protocols,depending on the degree of the measures imposed by the
public health and governing body per se. The Nuf ield
bioethics intervention ladder serves as a framework
which systematically ranks probable public healthmeasures by assigning hierarchies in terms of theircoerciveness or nature to intrude on individual liberty andautonomy (Dawson, 2016). Consequently, in cases ofurgency to implement a more coercive measure, thisframework provides the logical justi ications on thenecessity to implement such restrictive protocols. Thissection will discuss the spectrum of possible interventions
that each stakeholder holds, especially the public healthlegislators, in the ever-existing public health concern on
vaccination brought about by varying beliefs andreactions among the public.
Generally, the Nuf ield bioethics intervention ladderpresents eight intervention levels, which are ranked withan increasing degree of restriction from bottom to top(Clark, Crandall & O’Bryan, 2018). The irst and least
restrictive intervention is characterized by an absence ofauthoritative regulation, which solely involves modest
surveillance of the public health crisis and omits
government responsibility. The second level seeks toprovide knowledge about the health crisis wherein thegovernment opts to campaign the importance ofvaccination during a pandemic, allowing individuals topractice autonomy and, at the same time, be informed
about the need for immunization. The third intervention
is enabled choice wherein the government provides freeaccess to vaccination for those who participate in the
program voluntarily. Fourth is a choice guided by altering

the default policy wherein public health of icials are lessrestrictive in implementing quarantine protocols for those
who volunteer to be vaccinated. In a way, this can further
stimulate public interest and engagement in thevaccination. The ifth level is a choice guided by incentives
in which the citizens who participate voluntarily in the
program receive incentives such as cash transfers. The
sixth intervention is more restrictive as it leaves thecitizens with an illusion of choice. The individual's
decision of vaccine acquisition is guided and manipulatedby disincentives, such as increased taxation or prolonged
house lockdown in this public health context. The seventhintervention is a restricted choice wherein imposed
vaccination is implemented to certain social groups which
prohibits them from practicing autonomy. Lastly, theeighth and most restrictive intervention eliminates choiceby implementing absolute public health measures. In thislevel, the of icials require vaccination for all, whether
voluntary or by coercive authority, which infringes on
individual liberty and autonomy.
The aforementioned interventions on vaccination weregrounded on the hierarchy-based Nuf ield bioethics
intervention ladder and, therefore, present varying
degrees of intrusiveness. Although this framework is
considered as an ef icient tool in public healthmanagement, it is limited to exploring and evaluating
implementation alternatives. Thus, further considerations
for the intervention ladder are necessary for the listed
alternatives to be legislated. Incorporating this frameworkwith other public health concepts, such as the least
restrictive alternative principle and stewardship model,
directs public health authorities towards precise healthpolicy-making. Hence, amidst global health crises anddilemmas faced like the COVID-19 vaccination, which
requires urgency and a comprehensive course of action,
the Nuf ield bioethics intervention ladder provides anopportunity for critical and ethical decision-making.
The principle of least restrictive alternative
In the case of infectious diseases which can be prevented
by vaccines, public health measures such as mandatory
disease testing and even mandatory vaccinations are
implemented to prevent from the spread of infection andeventually achieve herd immunity. The problem withthese mandatory policies is that they often interfere withthe autonomous freedom of the individuals affected(Byskov, 2019).
In public health decision making, principles areapplied to clarify ethical concerns and justify public healthactions (Upshur, 2002). These are used in deciding among
the potential policies which can all realize the same goal.
In this paper, the principle of least restrictive alternative(PLRA) will be focused on, with the goal of achieving herd
immunity.
There are ive conditions needed to justify publichealth policies and the PLRA exempli ies the conditions ofleast infringement and proportionality. According to thecondition of least infringement, in choosing among publichealth policies, which all move toward the same goal, thepolicy shall be selected which interferes the least withmoral considerations. The moral considerations include
the right to autonomy, to bodily integrity, to individualEubios Journal of Asian and International Bioethics 31(4) (May 2021)
liberty, to safety, and to receive bene icial medical
interventions. The principle of least restrictive alternative
evolved from the condition of least infringement on therights of autonomy and bodily integrity in particular. The
condition of proportionality on the other hand shows thatwhen a bene icial public health policy is shown to haveinfringed on any of the moral considerations, the policy
may be justi ied by showing that the bene its given by thepolicy are greater than the infringement of moral
considerations (Childress, et al., 2002).
According to the PLRA, between two alternatives
which can both effectively deal with public health orhealth issues, the intervention which is the least intruding
to individual liberties and autonomy shall be opted. PLRA
is committed to protecting the autonomy of individuals
capable of self determination (Giubilini, 2019).
Qualitatively, the least restrictive alternative is the policythat restricts established and valued freedoms in thesociety while quantitatively, it is the policy which restricts
the range of choices or freedom an individual has to theleast extent. The qualitative interpretation focuses moreon the extent of restriction a policy causes (Byskov, 2019).
The PLRA is not frequently discussed in the ield of
public health. This principle is often discussed in the ieldof mental health ethics and laws wherein it addresses
issues on con inement and enforcement of behaviorchanging methods to protect individuals who have mental
illness and the community in general. Public health andmental health may be distinct disciplines on their own but
certain arguments and discussions may be applied to theconcerns of both ields. As an example, before employing
an alternative which is more restrictive, it has to be madesure that the previously implemented less restrictive
alternative is incapable of achieving the set goal (Giubilini,2019).
With these said, in applying the PLRA into the context
of vaccination, alternatives should be implemented inorder of restrictiveness, from the least to the most. The
restrictiveness of public health policies are dependent on
contexts such as the socio-economic status and mental
attitudes of the people. In connection with this, thesuccess of the implemented policies in achieving the set
goal would also be context-dependent since the involved
individuals and groups of people all have different status
and ways of thinking and are then affected differently bydifferent policies. Taking this into consideration isimportant for policy makers to be able to follow the
principle of least restrictive alternative by tailoring andimplementing the least restrictive and most effective
policy for a certain goal, which for this case is herd
immunity (Giubilini, 2019).
With respect to the principle of least restrictive
alternative, this paper leans on the idea of a voluntary
vaccination policy with the maximum effort to educate
and persuade people to vaccinate against COVID-19,
preserving liberty and autonomy in pursuit of herd
immunity.

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Voluntary vaccination with maximum effort toeducate and persuade
As previously discussed, following PLRA, a voluntary
vaccination plan with the maximum effort to educate and221

persuade is the most recommended. This follows theutilitarian principle with the aim to offer both protection
from diseases and liberty thus, maximizing overall wellbeing for the greatest number (Giubilini, 2020). The moral
framework of Principlism will then prove that thisalternative is the best balance between individual,
collective, and institutional ethical considerations.
According to Rossi & Yudell (2012), persuasion isde ined in public health ethics as an “in luence that is
noncoercive and nonmanipulative”. Thus, in terms ofindividual ethical considerations, this is in accordancewith the Kantian categorical imperative of respecting eachhuman person’s autonomy, and the PLRA.
However, some argue that this voluntary intervention
would not be as effective as expected in more restrictive
policies. Notwithstanding, a recent study by Masic & Gerc
(2020) shows that even with respect to autonomy amongindividuals, the phenomenon of fear plays a large role.
Additionally, due to a reaction of anger, according to theexperimental study of Betsch & Böhm (2016), mandatory
vaccination led to a 39% decrease in vaccination uptake.
This further proves the utilitarian or consequentialist
aspect that mandating vaccination may not ultimately
yield the most bene it for the greatest number of people.
In terms of collective ethical considerations, the valuesof bene icence and non-male icence are present.
Bene icence is de ined with doing good to others while
non-male icence is preventing harm and both are
expected of medical professional experts (Kinsinger,
2009; Omonzejele, 2005). These are in line with the moral
theory of consequentialism. In the Philippine context, theFilipino values of bayanihan and damayan, anchored
towards the common good, are more exhibited in thevoluntary plan. Bayanihan is the Filipino value ofcooperation which refers to “any communal voluntary
effort to achieve a common goal” while damayan is thevalue of compassion in the practice of “community’ssolidarity through compassion”. These Filipino values are
more felt and observed in the presence of extreme
situations resulting in collective survival and recovery(Barrameda & Barrameda, 2011). So, given the voluntaryand seemingly uncertain nature of a proposed vaccination
plan, these values will be felt and applied more by
Filipinos, thereby increasing vaccination uptake.
On the other hand, some may argue that the religious
context of the country is a signi icant barrier in voluntary
vaccination. According to a recent study by Whitehead &Perry (2020), certain religious ideologies can delay herd
immunity worldwide as shown with the current
disinclination to follow physical distancing and maskwearing in countries like the United States. However, thisis not true in the Philippines. According to a global survey,
90% and 91% of Filipinos are willing to wear face masks,
and accept international organizations’ advice on facemasks respectively (Institute of Global Health Innovation,
2020b). Moreover, the Philippines ranked 1st in being
more likely to avoid going to shops and working outside
their homes among eight Asian countries surveyed(Institute of Global Health Innovation, 2020a). Thus, datasuggest strict compliance of Filipinos on expert
recommendations. This entails positive implications on
COVID-19 vaccination in the country.

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ReferencesfConclusions
There is an alarming occurrence of vaccine hesitancy insome Filipinos due to varying perspectives in the safety
and ef icacy of vaccines. In particular, misinformation,
fear, and anger have an in luence on the perspectives of
the citizens regarding vaccination. However, it has beenargued that continuously casting skepticism on vaccine
safety without presenting valid evidence corresponds tothe violation of an individual’s moral and ethical duty
under epistemic responsibility. Unfounded opinions on
vaccine safety remain a public health concern as it leads tounnecessary and avoidable deaths. It is important toclarify, however, that precautions regarding vaccine safety
should still be observed. Speci ically, proper storage, safe
dosages, and reviews of all features of its development,such as where and how it was processed, by health safety
and regulatory agencies like WHO, CDC, DOH, and FDA,
should be followed prior to deployment and distribution
to the public.
In relation to Filipino values such as bayanihan(cooperation) and damayan (compassion), communal
voluntary effort and solidarity through compassion arevital in designing a public health intervention involving
COVID-19 vaccination in the country. To decide an urgent
and comprehensive course of action, the Nuf ield
bioethics intervention ladder was utilized in discussing
the spectrum of possible interventions that would
consider each stakeholder amidst varying beliefs andfreactions to vaccination. Choosing a voluntary vaccination
plan, instead of a mandatory intervention, would be more
accepted by Filipinos due to the values geared towards theattainment of common good. With the proper mindset andindividual responsibility to contribute to attaining herd
immunity, an increase in vaccination rates will beobserved.
It is therefore recommended to conduct a voluntary
vaccination drive with a committed effort to educate andpersuade since it has the right balance between
vaccinating many people and respecting people’s
individual rights. This alternative also re lects theprinciples of autonomy, bene icence, non-male icence, andjustice, in line with the moral framework of Principlism.
Moreover, it also follows the principle of the least
restrictive alternative to choose the alternative with theleast intrusion to individual liberties and autonomy.
It is further suggested to implement this alternative
through information drives on why vaccination isnecessary for the betterment of public health. Using social
media and mass media as channels to empower, educate,and persuade people to consider getting the vaccine for
COVID-19 could be an effective way of attaining herd
immunity. Patient education is another avenue for all
patients that are already in medical centers or to those
who are handling their cases. Furthermore, having
community involvement in this plan can enhancecooperation in vaccinations in the country. Communitywide programs that aim to properly inform and educate
regarding the safety and importance of vaccines could
increase public trust and con idence which can then serve
as a irst step in combating vaccine hesitancy, not only for
COVID-19, but for other preventable diseases.

fFinally, in terms of institutional ethical considerations,the value of justice by the government is depicted. The
government has the responsibility of promoting justicethrough their constant commitment to promote andprovide equitable access to vaccination (Verweij &Houweling, 2014). It should then be noted that thechallenges of the government are constantly changing andincreasing in dif iculty (Nalbandian et al., 2013). Thus,
with this proposed voluntary plan, justice will beobserved easier by the government given that this plan
does not involve the more polarizing and laborious
mandatory vaccination plan.
In light of all these, the previously discussed values are
all weighed and considered using the moral framework of
Principlism or the four-principles approach to biomedical
ethics by Beauchamp & Childress (2013). This includes
the values or moral principles of autonomy, bene icence,
non-male icence, and justice. Considering this approach,bene icence dictates that vaccination be recommended
and promoted in the country. This can be applied throughpersuasion, or effective health communication andeducation. Autonomy then suggests that the vaccination
plan in the country should not be mandatory due to nonmale icence concerns. Finally, justice indicates that itshould be administered across all populations observing
equity following certain ethical frameworks such as The
Fair Priority Model by Emanuel et al. (2020). This threephased model aims to practically and fairly distribute
vaccines through limiting harms, bene iting thedisadvantaged, and recognizing equal concern. Hence,with all these considerations combined, our work points
towards the implementation of a voluntary vaccination
plan with maximum effort to educate and persuade.

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A short essay on pandemics andthe nature of human beings as
depicted in three Japanese films
produced in the past 60 years- Atsushi Asai
- Taketoshi Okita
Department of Medical Ethics,
Tohoku University Graduate School of Medicine
2-1 Seiryo, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
E-mail: aasai@med.tohoku.ac.jp
Abstract
The COVID-19 pandemic brought the value of theAmerican ilm Contagion (2011; director, Steven
Soderbergh) to the attention of a world-wide audience.
There are also several notable Japanese ilms that depict
pandemic/epidemic situations and provide realistic
descriptions of human reactions to deadly infections. We
composed a short essay on the nature of human beings inpandemic situations, focusing on three ilms produced inJapan in the past 60 years. The irst ilm Pandemic(2009; director, Takahisa Zeze), depicts nationwide
pandemic in a novel about a lethal virus and unwise
human behaviors during a ictional pandemic. We analyze
this ilm together with two Japanese ilms, Virus(1980; director, Kingi Fukasaku) and A doctor with aloincloth (1960; director, Hiroshi Inagaki, Japan). Virus is astory of human extinction triggered by a biologicalweapon, and A doctor with a loincloth portraits a local
epidemic of typhus about 150 years ago in a small town.
We will then touch on actual events that occurred in Japan
during the COVID-19 pandemic. By analyzing humanbehaviors depicted in the three ilms, we deliberate what
human beings are like and argue that they need to be wise
to lead a good life (Eubios).
Introduction
Recent volumes of the EJAIB contain many research
articles, reports, essays, and patient narratives on
COVID-19, all of which are important contributions to the
ethics literature relating to the pandemic. To add to thisbody of literature, we composed a short essay on thenature of human beings in pandemic situations, focusing
on three relevant commercial ilms produced in Japan in
the past 60 years. Great ilms not only entertain theaudience but also provide opportunities to consider
fundamental issues and life itself. Given the impact thatsuch ilms can have on viewers’ way of thinking, we
consider it worthwhile to bring these works into focus
and analyze them from the perspectives of medical
humanities and biomedical ethics (1-5). While a lie andiction both deal with the unreal, a lie is intentionallyopposed to some truth, whereas iction intends to provide
an illustration – albeit through implicit meanings andconclusions – of reality (6).
The COVID-19 pandemic brought the value of theAmerican ilm Contagion (2011; director, Steven
Soderbergh) to the attention of a world-wide audience.
This ilm is worth watching as it aligns with events
happening in the world today, and provides insight into
what could happen in the near future. There are also
several notable Japanese ilms that depict pandemic/
epidemic situations and provide realistic descriptions ofhuman reactions to deadly infections. These ilms,
produced and released in Japan long before Contagion,
provide a glimpse into the future of the post-COVID-19
world, and help one understand the nature of humanbeings in preparation for future challenges.
Brief summaries of the three ilms
Pandemic: In 2011, an Avian in luenza-like virus infection
with high pathogenicity and infectivity suddenly appears
in Izumino City, Tokyo, Japan. Individuals infected with thevirus suffer from massive hemoptysis, severe respiratory
failure, and irreversible multi-organ failure, dying withinseveral days. None of the anti-in luenza drugs are
effective. Dr. Matsuoka, an emergent care physician at
Izumino Municipal Hospital, and the visiting WHO
medical of icer Kobayashi, initiate virus containment
measures involving the isolation of infected persons andblocking entry into the hospital. Despite strict
interventions by the Japanese government, including thelock-down of Izumino City, the infection quickly spreadst h ro u g h o u t J a p a n , re s u l t i n g i n a n a t i o nw i d epandemic. The new virus is named Blame, meaning, ‘thepunishment of gods.’ Japanese society falls into chaos andbegins to collapse. A state of emergency is declared
throughout Japan, and the authorities forcibly isolate
infected individuals. Everything, including hospital beds,
medical staff, and ventilators, run low as ill people rush to
the hospitals. Medical staff members perform triage,
allowing only a few patients to be admitted. By the time
the causative virus is discovered and isolated, roughly 40
million people become infected, with 10 million dead (8,9). The original Japanese title, Kansen Rettou, translates to“an infected archipelago.”

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Virus: In 1982, humanity almost goes extinct due toan extremely toxic virus called MM-88, which is generated
in the process of biological weapon development. The 863
survivors in Antarctica live in several bases owned by
Japan, the United States, the Soviet Union, or othernations. The virus is named “Italian lu,” because the irst
outbreak occurred in Italy. The survivors establish a new
government and implement drastic measures to prevent
infected persons from entering the continent. However, alarge earthquake hits North America, and all nuclear
missiles in the United States and Soviet Union arelaunched automatically, destroying all parts of the world,
including Antarctica, eradicating almost all of humanity.
At the end of the ilm, only a few people survive. The
Japanese title, Fukkatsu no hi, translates to “the dayof resurrection.” This ilm was based on a novel with thesame title published in 1964 by Sakyo Komatsu, a

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225

Japanese best-selling sci- i novelist. In a paper publishedin 2003, a commentator praised the ilm for its excellent
depiction of the potential aftermath of a bio-terrorist
attack (10).
A doctor with a loincloth: This ilm depicts the life of
Keisai Koyama, a physician who devotes his entire life to
the healthcare of people in a small rural town in Shizuoka
prefecture. The ilm touches on Koyama’s emotionalturmoil. He regrets his life choices and is iercely jealousof his famous friend and young apprentice, Itoh, whopossesses progressive knowledge and superior skills. The
ilm also focuses on Koyama’s maturation, as he discovers
a newfound appreciation for his life with his wife. The
latter half of the ilm focuses on a local epidemic of
typhus, affecting mainly small children in the community
where Koyama belongs in 1872. The infected patientsdevelop abdominal pain, fever, rash on the trunk,
dehydration, and disturbed consciousness. Koyama andItoh isolate all infected children in their medical
institution and begin to treat them. However, unable tounderstand the importance of complete patient isolation,
parents of the patients break into the institution, assault
Koyama, and take their children back to their homes. The
Japanese title is Fundoshi isha, meaning, “a physician who
is naked but for a loincloth.”
Unwise human reactions in the face of pandemics
depicted in the three ilms
1. People blame people: Viral pandemics are not anyone’s
fault. Excluding cases of bioterrorism, there are no
criminals responsible for starting a pandemic. Yet, people
cannot help but blame others. In Pandemic, the pathogen
could not be identi ied initially, but is eventually revealed
to be a virus in bats living in the forests of Minas Island in
Avon. An outbreak had occurred on the island before theBlame infection spread to Japan, where it was explainedas ‘the haunting of the forest witch.’ In Japan, the infection
is mistakenly identi ied as bird in luenza, and the
manager of the poultry farm where the infection occurs
and his junior high school daughter take the blame andare harassed harshly. As a result, the poultry farmmanager commits suicide, leaving behind his young
daughter.
The irst infected person in Japan dies in a municipal
hospital in Izumino City, but the patient’s wife accuses
Matsuoka, the doctor who treated the patient, of murder.
Many people who were infected with Blame are rushed tothe city hospital for treatment. Triage is performed, andpatients who cannot be hospitalized, and their families,
accuse the triage staff, saying “Do you want to kill him?”
Later in the ilm, the Japanese doctor who devotedly
provided medical care to Avon residents brought Blame to
Japan. He came to Japan to see his family without theknowledge that he himself was infected. Should he beblamed for the pandemic? We don’t think so. After all, it’s
nobody’s fault.
In Virus, MM-88 is named the Italian lu because theirst outbreak occurred in Italy. However, it turns out thevirus emerged from a different region. Even in A doctorwith a loincloth, which is set in the beginning of the Meiji
era (produced in 1960), there is a scene in which a doctor

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working hard to treat patients who suffers from typhusinduced disturbed consciousness, is called a murderer by
the patient’s parents. In the present pandemic, it is freshin our memory that former President Trump referred to
COVID-19 as the “Wuhan virus,” accusing China of being
the cause of the pandemic (11). In Japan, residents ofTokyo are often accused of spreading COVID-19 to rural
areas, despite the lack of supporting evidence. We thinkthat we need to be familiar with the idea that something
can happen without de inite causes or reasons.
2. People deceive people: In Pandemic, Blame is identi iedin bats living in the forests of Minas Island in Avon. Mostof the islanders engaged in shrimp farming become
infected with the virus and die. However, a shrimp
farming company conceals the outbreak. An infectedislander girl says to a Japanese doctor, “I was told I
shouldn’t talk about what is going on in the island toanyone outside.” A woman, who learns that the source ofBlame is likely her father, is hospitalized with theinfection, but leaves the hospital without permission or
notice while in recovery, attempting to hide that
information.
In Virus, the cause of the lethal pandemic is MM-88, abiological warfare agent developed by the United States in
the military operation “Phoenix.” The President of theUnited States, who is fully aware of the fact, dies, hiding
the truth about MM-88 in order to avoid blame. A
researcher who tries to unveil the truth is diagnosed withschizophrenia and detained in a mental hospital by
military of icials.
In addition to the above example of deception, Virus
has another deception which, we believe, is likely to occur
or has already occurred in our world today. In the ilm, theUnited States government is one of the irst to provide its
citizens with the “Italian lu” vaccine. This vaccine,
however, is simply a combination of multiple vaccines
against conventional in luenza strains and is entirely
ineffective. A riot breaks out among American people forthe vaccine, and many people are killed. A senior
government of icial calmly tells other of icials that thevaccine is just a placebo. In A doctor with a loincloth, Dr.
Ito does not tell his patient’s parents that their child isunconscious, saying “it’s okay, he is all right.” Various
reasons can justify the doctor’s decision not to tell thetruth, including the fear of being blamed by the parents.
U n d e r t h e C OV I D - 1 9 p a n d e m i c , o n e c i t y ’ sadministrative authority in Japan announced that severalof ice workers had been infected with COVID-19, when infact the infected were nurses and medical clerks working
at a medical clinic. Even after discussions between theclinic and the city, the clinic did not consent to reveal thisinformation (12). The impact of this concealment seemed
to be ignored by those concerned. Overall, people appear
to live in mutual distrust, and there are still suspicionsthat COVID-19 was accidentally leaked from a virus
laboratory.

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3. People exclude people: In Pandemic, Izumino City
(where the irst outbreak occurs) is locked down, and theCity Municipal Hospital, designated as the “Blame
specialty hospital,” is closed in order to isolate Blame

patients. Even the medical staff cannot leave the hospital.
A female nurse is kept from seeing her young daughter,and her cell phone is the only connection to her family –far from a true and meaningful connection. She develops a
nosocomial infection with Blame and dies. During the eraof the plague in the 1600s, infected individual, as well as
their families, were subject to compulsory isolation (13).
This isolation resulted in the death of both patients andtheir families. Isolation, or constructing a barrier between
the inside and outside of infected areas, houses, or
facilities, is meant to protect the outside ‘non-infected’world.
In Virus, people in Antarctica take action to protect
their bases from infected ‘outsiders,’ who desperately
need help. A Soviet submarine leeing the global pandemic
reaches Antarctica, and the captain asks for landing
clearance. Many of its crew members are infected with
MM-88 and are in need of medical care. However, theAntarctica Government Commission does not allow themto land. As the Soviet submarine attempts a forced
landing, of icials unanimously agree to attack thesubmarine. The submarine is sunk by a nearby British
submarine, killing all crew members.
Those who are uninfected, asymptomatic, or mildly ill
may not readily accept isolation and/or quarantine. In
Pandemic, there is a scene early in the ilm where a young
boy in the Philippines becomes infected with birdin luenza and is taken to an isolation facility. The child’s
mother clings to his body and pleads, “Don’t take him.”
Meanwhile, in Japan, families in their cars break throughthe barrier blocking Izumino City, while patients, who areagainst involuntary isolation, hide in an abandonedbuilding but are forcibly taken away.
A doctor with a loincloth depicts a scene in which
patients’ families break into the inpatient facility after
doctors Koyama and Ito forcibly isolate infected patients,
mainly children, without their consent in order to preventthe spread of typhus. The parents of the hospitalized
children, shouting “Do you not allow parents to see theirchildren?” rush into the sanatorium. The parents are toldthat their children suffer from a terrible illness and need
to be kept there, and they unwillingly accept the
explanation and leave the facility. However, excitedparents once again rush to the clinic, saying, “I'll just takemy child,” “If my child will die anyway, I’ll take care ofthem,” and “You don’t want me to see my child die.” They
scream and smash the clinic and take the children away.
They also assault Koyama. Their actions could beunderstood as those of parents who love their children,and this love overrides the understanding that isolation/
quarantine is essential to protect society.
Currently in Japan, many medical institutions andelderly facilities prohibit the families of patients/residents
from visiting their loved ones (14, 15), and people are
discouraged from moving across prefectural borders.
Some medical facilities refuse to treat patients who havegone to other prefectures within a certain period of time,or whose families have traveled outside the prefecture.
However, we cannot understand why they are sticking toprefectural borders as boundaries that divide infection
and non-infection, or divide “ ilthy area” and “clean area.”
A mildly ill male COVID-19 patient broke the rules ofEubios Journal of Asian and International Bioethics 31(4) (May 2021)
home isolation and visited bars, with the intention to“spread the virus” around him. The employees became
infected with COVID-19, and this male patient, whoreportedly had liver cancer, subsequently died of
COVID-19 (16).
While an inside/outside barrier can result in
discrimination, discrimination against infected individuals
is not depicted in the three ilms. This may be because themain characters of these ilms are doctors and scientists,or because the infection itself is indiscriminate. Yet, in thereal world, the COVID-19 pandemic brought to light many
instances of discrimination against infected people,
against facilities where outbreaks occurred, against
medical professionals and their families, and against
drivers in vehicles with number plates showing otherprefectures (17).

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Living well in the world with COVID-19
A virus appears out of nowhere without warning – where
and when it emerges is unpredictable. By the time its
existence becomes known, it may have already spread toan endemic level (18). This is exactly what happened withthe current COVID-19 pandemic. COVID-19 is caused by avirus whose occurrence was unpredictable; however,human reactions to pandemics do not seem to havechanged much since Defoe reported on the British plaguein the 1700s (13, 19). It is perhaps rather natural that thethree ilms discussed here, which were released between
1960 and 2009, do not signi icantly differ in their
depictions of unwise human behavior.
People blame, deceive, and exclude. Sometimes they
break the cordon sanitaire dividing the epidemic area andsafe zone due to a lack of public spirit, or because of deep
affection, putting others at risk. Even if the consequencesof their unwise actions are perceived as unfavorable in thelong run, it may be the nature of human beings to do so. In
both Contagion (2011) and The Black Death (2001;
director, Niki Stein, Germany), the protagonists, both
medical doctors in charge of infection control, leakinformation that the city will be locked down, urging their
loved ones to leave the city before the cordon sanitaire isestablished.
Many people have died, and more will die, fromCOVID-19. Nonetheless, political and territorial disputes,
fraud and murder, and discriminatory remarks andactions still happen. In ilms and the real world, many
people commit suicide (20). Although sad, we cannot justdespair over human behavior and life. We must makeefforts to stop acting unwise, or, be wiser, in order to havea good life (Eubios) even during the COVID-19 pandemic.
Wisdom is a practical virtue cultivated from life
experiences (21-25). It can be de ined as the competency
to ponder and understand oneself and others, doing what
is important in life by distinguishing it from what is not,recognizing the limits of one’s knowledge while having
suf icient knowledge, enduring the uncertainty andinstability of life, thinking lexibly with suf icientconsideration of various viewpoints, and anticipating theconsequences of one’s actions and using imagination
about the reaction of others to materialize what ismeaningful to oneself (21-25). With the current COVID-19
pandemic still ongoing, we must be wiser than ever.

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Hopefully, watching the ilms discussed here will help
people (including ourselves) realize the importance of
wisdom.
Let’s learn wisdom by the follies of others. That way,
we might avoid situations where people succumb to theirurges to blame, deceive, exclude, discriminate, and put
others at risk. Moreover, even if Edgar. A. Poe's Masque of
the Red Death appears in front of us all of a sudden, some
may be able to calmly respond to a dreadful existence(26). However, how we can become wise, virtuous, andethical is a very dif icult question to answer. We will needto keep thinking about it, as thinking about these issues is
one of the roles of biomedical ethicists.
References
1 Atsushi Asai, Yuka Sato, Miki Fukuyama. An ethical and social
examination of dementia as depicted in Japanese ilm. Medical
Humanities 2009;35:39–42.
2 Atsushi Asai, Miki Fukuyama, Yasunori Kobayashi.
Contemporary Japanese view of life and death as depicted in
the ilm Departures (Okuribito), Medical Humanities,
2010:36;31-35.
3 Atsushi Asai, Sakiko Maki. An ethical and social examination of
the death penalty as depicted in two current ilms made in a“pro-death penalty society.” Eubios Journals of Asian andInternational Bioethics 2011;21:95-99.
4 Atsushi Asai, Sakiko Maki, Yasuhiro Kadooka. Ethicalre lections on the thoughts and lives of Kurosawa’s Doctors.
Journal of Medical Ethics Medical Humanities 2012;28:38-43.
5 Atsushi Asai. Cinema no nakano ningen to iryo (People andmedicine in cinema), Tokyo, Iryo bunka-sha, p1-4.
6 Jane Doherty and James Giordano What we may learn – andneed – from pandemic iction Philosophy, Ethics, andHumanities in Medicine (2020) 15:4.
https://doi.org/10.1186/s13010-020-00089-0
7 Tatsuya Mima Infection Society-Biopolitics after Corona.
Jinbun shoin 2020, Kyoto, p223-245.
8 Atsushi Asai. Pandemic Nursing Education 2019; 60: 958-9．
9 Atsushi Asai. An introduction to Cinema. Pandemic JIM 2013;
23:98910 Georgios Pappas, Savvas Seitaridis, Nikolaos Akritidis, andEpaminondas Tsianos Infectious Diseases in Cinema: Virus
Hunters and Killer Microbes CID 2003:37 (1 October) • 939-42.
11 Yasunari Ueno. What is President Trump’s aim to strengthen“Bashing against China” using Covid-19 Pndemic? Nikkei
Business May 12, 2020.
12 Yomiuri Newspaper August 13, 2020.
13 Daniel Defoe. The journal of plaque 1722, translated by
Masao Hirai, Chuokoronsha, 2009, Tokyo.
14 Nippon Keizai Newspaper June 22, 2020.
15 Yomiuri Newspaper August 10, 2020.
16 Nippon Keizai Newspaper March 18.
17 Mainichi Newspaper October 7, 2020.
18 Fred Guterl. The fate of the species: Why the human race may
causes its own extinction and how we can stop it. Translated by
Natsume Dai. Kawade Shobo, 2017, Tokyo, p42-3.
19 MIchifumi Isoda
Japanese history of infection.
Bunshunshinsho, 2020, Tokyo.
20 Suicide in COVID-19 Pandemic Weekly Igakukai Newspaper,
April 5, 2021. Number 3415, p1-2.
21 Michael Dunn, Tony Hope Medical Ethics: A very short
introduction, 2nd edition. 2018. Oxford University Press,
Oxford, p41.
22 Steve Paulson, Lisa Feldman Barrett, Philip Kitcher, andValerie Tiberius Cultivating character: the art of living. Ann. N.Y.
Acad. Sci. 1384 (2016) 97–112, 2016. doi: 10.1111/nyas.13208

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23 Staudinger, U. M., & Gluck, J. (2011). Psychological wisdom
research: Commonalities and differences in a growing ield.
Annual Review of Psychology, 62, 215–241. https://doi.org/10.
1146/annurev.psych.121208.131659
24 Katherine J. Bangen, Thomas W. Meeks, Dilip V. Jeste De ining
and Assessing Wisdom: A Review of the Literature. Am J
Geriatr Psychiatry 21:12, December 2013, 1254-1266.
25 Ricca Edmondson and Jane Pearce The practice of healthcare: Wisdom as a model. Medicine, Health Care andPhilosophy (2007) 10:233–244.
26 Edgar Allen Poe The Masque of the Red Death 1842 Available
at: http://xroads.virginia.edu/~hyper/poe/masque.html.

Martin Heidegger: The art of livingin the midst of the global
COVID-19 pandemic- Gerry Arambala
La Salle University Ozamiz, the Philippines
gerryarambala33@Yahoo.com
Abstract
The paper is a critical exposition of Martin Heidegger’s
fundamental ontology. In particular, the current endeavor
is aimed at elucidating Heidegger’s conception of thehermeneutics of factical life in response to the question oflife’s meaning amidst a global pandemic. The necessity ofrevisiting Heidegger’s philosophy is brought about by thecurrent global phenomenon that has reduced man’s world
into a pandemonium. The reduction of man’s existence
into a kind of fear-driven existence posits a serious
philosophical theme, that philosophy in its mostfundamental sense can illuminate and provide meaningful
determinations. The pandemic COVID-19 is not only athreat to the socio-economic and political structures ofhuman existence, but it necessarily posits a threat to thevery meaning of man’s existence. Ultimately, the paper
hopes to provide a philosophical underpinning of thecurrent global pandemic and how such phenomenon has
affected the lives of every individual human being in theworld.

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Introduction
The world has dramatically changed. We are looking at a
new world whereupon humanity is forced to stand against
a formidable enemy that has caused the loss of millions ofpeople’s lives and has disrupted the low of developmentof the past century. We are living in a world where fear
and uncertainty over our life and the security of thewelfare of our beloved is prevalent. Such state ofrestlessness immanent in the world today is brought
about by the advent of the COVID-19 pandemic. Since the
COVID-19 virus was announced as a global health crisis,
the world is still in its de ining stage of battle against thisformidable force of nature. The COVID-19 pandemic has
become a global nightmare. Despite the relief that theworld may have experienced over production of vaccinesthat give some people the opportunity to be vaccinated.
However, the truth remains that even in this trying
moment, unjust social-political structures possess theveto over the lives of the poor. Christopher Ryan Maboloc

emphatically argues that: “However, what is not seen is
the reality that unjust structures and unequal situations ofindividuals in human society have resulted in more
hardship on the part of the poor, thereby diminishing
their sense of self-worth (Maboloc, 2021, p.29).”
What the current global health crisis aggravates, aside
from the possibility of death, is the problem of global
inequality and poverty. The entrenchment of unjust global
structures and institutions are the ones that further
extend the extent of the actual effects of COVID-19 to theimpoverished societies and nations all over the world. The
truth remains that rich countries hold the future and livesof the poor even during this global health crisis. Suchinequality and power over the poor are further
manifested in the latent imbalance of global distributionof COVID-19 vaccines. The World Health Organization
reported that while there have been 700 million vaccine
doses administered across the world, the vast majority of
COVID-19 vaccines were administered in most of the richcountries in the world (Brago, 2021). Accordingly, 87
percent of the 700 million doses administered have goneto wealthy countries while only 0.2 percent wereadministered in poor societies. What that means is in
average 1 in 4 people in high income societies receives the
COVID-19 vaccine compared to just 1 in 500 people inimpoverished societies (Miao, 2021). While the rich in theworld are beginning to lourish during this pandemic, theworld’s poorest of the poor remain to suffer from thedevastating effects of the COVID-19 virus.
In the past the world was closely approaching the lightof development. However, with the advent of COVID-19
the lickering light of human prosperity has inally
retreated into oblivion. Humanity has seen chaos anddeath far worse than the two most devastating wars inhistory combined. The dread of social inequality andinjustice is laid bare by the pandemic. The injustices thathave persisted for centuries, that were covered byhumanity’s claims of development are now forced toreveal the deplorable states of the poorest of the poor. The
world has revealed itself in a manner that is truly
terrifying. The pandemic COVID-19 is not only a threat tothe socio-economic and political structures of humanexistence, but it necessarily posits a threat to the very
meaning of man’s existence. One can only hope with
Martin Heidegger when he writes: “May world in its
worldling be the nearest of all nearing, that nears, as it
brings the truth of being near to man’s essence, and sogives man to belong to the disclosing bringing-to-pass thatis a bringing into its own (Heidegger, 1977,p.49).”As the world continues to disclose itself, amidst thestruggle and the unnecessary sufferings brought about by
COVID-19, may man never lose sight of his very own
existence. This does not mean that man must simply
accept and live with the injustices and the inevitable
deaths the current world order has imposed to humanity.
Man may not possess the power to subdue andmanipulate his fate, being simply thrown in the situations
he inds himself in, nevertheless he can always challenge
it. For despite the prevalent danger of the possibility ofman losing his own sense of meaning of life, Heidegger
provides us with the assurance that where the danger
resides salvation is likewise present. “Where the danger isas the danger, there, the saving power is thriving also
(Heidegger, 1977, p.42).” The imminent danger of man
falling out of his being, in the attempt of inding meaning
to his life amidst the seeming meaninglessness of his
current existence is itself a saving power. It is when we arein our darkest moment of our existence that we begin tothink of the most fundamental questions in life. It is in our
most deplorable state of existence that we begin to ask theright questions, questions that bring us to our ultimate
realizations. “The danger is the saving power, inasmuch as
it brings the saving power out of its -the dangerconcealed essence that is ever susceptible of turning.
(Heidegger, 1977, p.42).”

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The being and time
Martin Heidegger was a German philosopher whose
manner of philosophizing is often associated withexistentialism and phenomenology, despite Heidegger’s
insistence that his method of philosophy is not to beconstrued as a philosophy of life and the sheer extensionof the phenomenology that Husserl developed.
Contemporary texts in philosophy, however, often identify
him as a leading exponent of the aforementioned
philosophical school of thoughts. To this Hans-Georg
Gadamer provides an illuminating response departingfrom Heidegger’s fundamental tenet on the ontologicalpriority of human in the question of the meaning of being.
He argues that Heidegger in taking the task of realizing
the destruction of metaphysics started by positing thequestion “What is being?” And that in order to properly
ask the question Heidegger posited the ontologicalpriority of the being of human against the transcendental
groundings posited by Western metaphysic. For Gadamer,
Heidegger’s presupposition of the ontological priority ofthe being of man in the question of being is what makes
his entire philosophy a “fundamental ontology.” Gadamer
thus explains that in recovering the lost sense of being,“Heidegger proceeded to de ine the being of human in an
ontologically positive way, instead of understanding it as“merely inite”, that is, in terms of an in inite and always
existing being, as previous metaphysics had done. The
ontological priority that the being of human acquired for
Heidegger de ined his philosophy as ‘fundamental
ontology’ (Gadamer, 2008, p. 215).”
Despite claims of existential postures, methods,
in luence and themes in Heidegger’s magnus opus “Being
and Time”, it must be clari ied that his greatest work’s
concern is the recovery of the lost sense of being that theprevious tradition of philosophy has forgotten being
engrossed with the determinations of beings in general. It
is for this reason that Heidegger’s Being and Time isreferred to as “fundamental ontology”. Furthermore,
although Heidegger in the Being and Time departed fromHusserl’s phenomenology, it cannot be denied that
Heidegger utilized some of Husserl’s fundamental ideas inrealizing his goal of saving the essence of being fromabsolute oblivion. Gadamer further explains that after
Heidegger referred to the human Dasein the ontologicalpriority in questioning the essence of being, he further
quali ied the ontological determination of Dasein as
determinations of existence: “existentials”. The reason
behind such quali ication will later reveal the necessity offf

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229

grounding his entire project in the Being and Time within
the con inement of self-understanding. Heidegger inmethodologically contrasting the categories of Dasein’s“existential” determinations with the categories of“present-at-hand” which dominated in metaphysics, hasprovided a clear exposition of the human Dasein’s mode ofbeing. That is: “when Heidegger raised once again theancient question of the meaning of being, he did not want
to lose sight of the fact that human Dasein does not haveits real being in determinable present-at-hand, but rather
in the dynamic of the care with which it is concerned
about its own future and its own being (Gadamer, 2008,
p.215).”
What that means is that man is distinguished in so far
as he is not just a thing in the world that is determined bymetaphysics as a substance or a rational suppositum thatis perfectly self-suf icient and complete, neither man issimply a mode of being “present-at-hand” that is subject
to scienti ic observations and calculations. Rather “Dasein
is distinguished by the fact that it understands itself interms of its being (Gadamer, 2008, p.215).” Such is
Heidegger’s new way of approaching the question of
being. With the presupposition of the ontological priorityof human Dasein, whose mode of being is determinable byhis self-understanding, Heidegger’s philosophy can rightly
be referred as “hermeneutical phenomenology”.
Heidegger’s philosophy is identi ied as hermeneuticalphenomenology “primarily because self-understanding
still represented the real foundation of the inquiry(Gadamer, 2008, p.215). The whole inquiry of the Being
and Time revolves around what is identi ied as“Hermeneutics of Dasein”, whereupon, hermeneutics isremoved from its conventional de inition as a science ofinterpretation, but rather to the process of understanding
and interpretation immanent in the essence of humanDasein (Gadamer, 2008, xlvi).
The question of the meaning of being
Heidegger in the irst part of the Being and Time took thetask of explicitly restating the question of being. The taskof reformulating the question of being is rooted in his
presupposition that western philosophy, in particular,
traditional metaphysics has forgotten the meaning of thequestion “What is being?”. This transpired when Plato
reduced the question of being to the duality of worlds; theworld of form and the material world. The reduction of
Plato’s philosophy to the necessary distinction between
the world of ideas and the world of contingent realities
has led to the neglect of the ontological priority of theessence of being as such. In like manner, Aristotle
immortalized the dogma of western metaphysics with his
de inition of being to sheer substances composite ofmatter and form whose grounding reason is the absolute
being (God). Aristotle’s reduction of the nature of being as
such to mere categories of substance, God, things,
substratum and rational suppositum, has led to thecorruption of the primordial meaning of being which wasirst presupposed by the pre-Socratics. Heidegger writes
that: “This question has today been forgotten … Not only
that. On the basis of the Greek’s initial contributions
towards an interpretation of being, a dogma has beendeveloped which not only declares the question about theEubios Journal of Asian and International Bioethics 31(4) (May 2021)

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meaning of being to be super luous, but sanctions its
complete neglect (Heidegger, 2008, p.2).”
What Heidegger means by this is that the history ofwestern metaphysics has failed to heed the ontologicaldifference of the primordial meaning of the question of
being, and so has construed being to mere categories ofultimate being, idea, substance, monad, and so on. This
has led to the complete neglect of being as such andconsequently led to its being forgotten. The task therefore
is to recover the lost primordial meaning of being throughthe being who is capable of asking the correct question. In
this context, Heidegger draws the necessary difference
between the “ontical” and “ontological” inquiry of being.
The former presupposes the facts of entities in the world,
while the latter is concerned with the meaning of being,that is, as to the very nature and essence of entities(Wheeler, 2011). Heidegger thus writes:“The question of being aims therefore at ascertaining
the a priori conditions not only for the possibility of thesciences which examine entities as entities of such andsuch a type, and, in so doing, already operate with anunderstanding of being, but also for the possibility of
those ontologies themselves which are prior to the onticalsciences and which provide their foundations. Basically,
all ontology, no matter how rich and irmly compacted asystem of categories it has its disposal, remains blind andperverted from its ownmost aim, if it has not irst
adequately clari ied the meaning of being, and conceived
this clari ication as its fundamental task” (Heidegger,
2008, 31).
Ultimately the aim of restating the question of being is
to establish the ontological difference between
conceptions of entities that are derived fromcategorizations of ontical sciences and from Michael
Wheeler’s distinction of “regional ontology” and“fundamental ontology”. Whereupon “the former isconcerned with ontologies in particular domains, saybiology or banking, and the latter is concerned with the apriori, transcendental conditions that makes possible
particular modes of being, that is, particular regional
ontologies (Wheeler, 2008).” And that unless all regional
ontologies, no matter how systematic and calculated andprecise their methods, take for their aim to primordiallyclarify the meaning of being as such and embrace it as
their most fundamental task, they remain futile and blindto the essence of being.
However, in as much as all the previous sciences andontologies have failed to clarify the meaning of thequestion of being, the question arises then, how are wethen to carry out the ontological distinction of
fundamental ontology from other ontologies? To thisHeidegger replies that “Fundamental ontology, fromwhich alone all other ontologies can take their rise, must
be sought in the existential analytic of Dasein (Heidegger,
2008, 34.)” The ontological priority of human Dasein in
the task of recovering the meaning of being lies in the factthat man is not simply a being that occurs in the world as
simply part of the world. Human beings are onticallydistinguished for the reason that Dasein can actively
create himself from his own actions and is able to re lect
on the very meaning of his existence. Dasein alone iscapable of self-understanding and in so doing re lects on

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the meaning of what it means to be. Thus, Gadamer argues
that it is from this foundation that “the understanding of
being that held sway in traditional metaphysics turns out
to be a corrupted form of the primordial understanding of
being that is manifested in human Dasein. Being is not
simply pure presence or actual … It is inite, historical
Dasein that “is” in the real sense (Gadamer, 2008, 216).”
Existential analysis of human Dasein
Heidegger’s new approach in Being and Time certainly
departs from the traditional metaphysics’ way of dealing
with the question of being. Instead of Heidegger dealing
the immediacy of the question to what is asked, he rather
redirected the questioning to the being whose mode ofexistence is understanding that being. To this Heidegger
explains that in so far as the subject of our inquiry is
being, it presupposes then that what is interrogated is the
being of entities. And that since there is no other being
who is capable of knowing the essences of things andwhose mode of being is self-understanding. “Thus, towork out the question of being adequately, we must makean entity -the inquirer- transparent in his own being …
This entity which each of us is himself and which includes
inquiring as one of the possibilities of its being, we shalldenote by the term ‘Dasein’ (Heidegger, 2008, p.27).”
The ontological priority of human Dasein in therecovery of the meaning of being lies in the fact thatamong the entities Dasein is the only being who isconcerned about his own existence. The world isconstituted with entities that exist; things “are” in so far
as they can be determined by human sciences. However,human Dasein does not just simply occur in the world, aspart of the world, rather man is capable of self-projection
and self-choosing. The manner in which man engages
himself in the world is determined by his capacity to
project for himself the kind of future and life that he inds
itting for him. Heidegger elaborates this point in saying
that, “Dasein is an entity which does not just occur among
other entities. Rather it ontically is distinguished by thefact that, in its very being, that being is an issue for it(Heidegger, 2008, p. 32).” The human Dasein’s concern ofhimself expressed in the mode of self-understanding andself-projection entails that man knows that he is nottotally the master of himself. That his projections, being in
the world, are directed towards ful illing the task ofrealizing his own being amidst the myriads of things that
may hinder him from achieving this noble task. Gadamer
writes:“Human Dasein’s understanding of itself out of its own
being is not a … self-projection. Rather it knows that it is
not master of itself and its own Dasein, but comes uponitself in the midst of beings and has to take itself over as itinds itself. It is a thrown-projection” (Gadamer, 2008, p.
218).
The existential analytic of the human Dasein’s
engagement with the things in the world, whereupon theknowledge of being becomes transparent, is expressed in
Heidegger’s tripartite modes of encounter in the world:“readiness-to-hand”, “present-at-hand”, and “unreadinessto-hand”. The “readiness-to-hand” encounter ispresupposed in man’s primordial experience of things as
equipment. Whereupon the engagement of Dasein with

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)
other beings is characterized with skilful manipulation ofequipmental entities. Thus, a hammer’s essence isdetermined not on the basis of its presupposed inherent
quiddity, rather on how man uses it in the process ofskilful and trouble-free hammering. In this primordial
encounter with entities, the being of the human Dasein
reveals itself as a mere part of the entire equipmental
structure. “Phenomenologically speaking, then, there areno subjects and objects; there is only the experience of theongoing task, that is, hammering (Wheeler, 2011).”
While, the “present-at-hand” encounter is concernedwith the removal of the equipmental aspect of entities tothe understanding of things as independent objects. The
revealing that is immanent in the “present-at-hand”
encounter of man with the things in the world is Dasein’s
realization of its subjectivity. With the ontologicalfoundation of “things” in the world in the “presence-athand” encounter comes the phenomenological rebirth of
the human Dasein as the subject whose mode of being is
to understand, explain and predict the behaviour ofobjective, independent realities. “Encounters with the“present-at-hand” are thus fundamentally subject-object
in structure (Wheeler, 2011).”
Lastly, the “un-readiness-to-hand” encounter
presupposes the disruption of man’s skilled practicalactivity caused primarily by the equipment being broken.
Hence the reality of what it means to be a hammer iswithdrawn from the object -hammer-when in the processof its being an equipment for hammering the nails and thewoods together is disrupted because it sudden snapped
and broke. In the “un-readiness-to-hand” encounter theentities lose their transparency as beings in the world.
Heidegger explains the point is saying that “The presenceat-hand of something that cannot be used is still not
devoid of all readiness-to-hand whatsoever; equipment
which is present-at-hand in this way is still not just a
Thing which occurs somewhere. The damage to theequipment is still not a mere alteration of a Thing-not achange of properties which occurs in something presentat-hand (Heidegger, 2008, p. 103).”

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Human Dasein as being-in-the-world
The above speci ication of the tripartite modes of Dasein’s
encounter with entities necessary implies the humanDasein’s fundamental mode of “being-in-the-world”. For
Heidegger Dasein’s constitutive state of being is “being-inthe-world”. What that means is that “human existence ismost tangibly immersed in the world of actually existing
concrete individuals (Kelechi Iwuagwu, 2011, p.32).” It ison this being situated in the world that human Dasein
further de ines himself and eventually inds the very
meaning of his existence. Being-in-the-world entails thatman is a being whose mode of existence, projections andconscious knowing are determined by the kind ofenvironment that he inds himself in. For Heidegger theworld,” being the referential totality of Dasein’s projection(Gadamer, 2008, 217)” and the horizon upon which man
eventually realizes his possibilities of being, cannot belimited to sheer material constitutions of the external
world. Rather, the world entails the totality of everythingthat grounds all of man’s concern for himself and theenvironment that provides the realm upon which human231

life is to be lived. Heidegger thus writes, “Ontologically,world is not a way of characterizing those entities which
Dasein essentially is not, it is rather a characteristic ofDasein itself (Heidegger, 2008, 92).”
Furthermore, in describing the nature of Dasein’s
comportment with the world, Heidegger argues thathuman Dasein engages himself in the world in a mannerthat is concern and solicitous. For Heidegger man’s“being-in” the world entails that he is not just a stationary
entity that exist together with other worldly realities,
whose relationship is limited to mere “spatial relation”.
Like when coffee is poured in my mug which is on top of
my table. The “in-ness” of Dasein’s relation with theworld presupposes an existential comportment wherein
Dasein inds itself dwelling and becoming familiar withthe world. “To dwell in a house is not merely to be inside it
spatially… Rather, it is to belong there, to have familiar
place there. It is in this sense that Dasein is (essentially) in
the world (Wheeler, 2011).” That is, if a thing is insidesomething, like when water is in a glass, the relationshipis spatial. However, if Dasein is considered to be in a
relationship with other entities, that means Dasein is indwelling, resting in a manner of being familiar withhimself. “Being-in reveals man’s state of mind, like when I
say, “I am “in” trouble.” This in turn help to disclose man tohis being. Disclosing his situatedness (Kelechi Iwuagwu,
2011, p.32).”
The human Dasein’s being-in-the-world constitution,
whereupon, man’s self-situatedness is revealed in his
everyday engagement with the things in the world asready-to hand, has paved the way for Dasein’s temporality
and facticity. Man’s existence is necessarily con ined
within the structure of time and facticity. What this meansis that man’s knowledge and projections are necessarily
restricted within the boundaries of its epoch andhistoricity. This necessarily re lects the embodied
existence of Dasein. That is Dasein’s projections in theworld are necessarily re lections of its being in a certain
period of history, culture and tradition. This necessarily
implies that when Dasein realizes its situatedness in theworld, he already carries within himself the existential
endowments of sex, race, culture, tradition, emotional
dispositions, capacities and so on. Such mode of existenceis what Heidegger refers as “thrownness” or “facticity”.
For Heidegger, “the concept of “facticity” implies that one
entity “within-the-world” has Being-in-the-world, in sucha way that it can understand itself, as bound up in its
destiny with the Being of those entities which it
encounters within the world (Heidegger, 2008, p. 82).”
Authentic and inauthentic Dasein
It is from the mode of being simply thrown in existencethat the human Dasein eventually projects either for its
authenticity or its fallenness or inauthentic existence. For
Heidegger, man begins to fall out from his authentic
existence the moment he loses track of his being. That iswhen Dasein is absorbed into the objectless existence of
the “they” and has fallen captive to the world. “As a basic
structure of man’s existence, fallenness designates man’s
tendency to disown himself in the world. In his selfprojection and self-transcendence, man understands hisworld and becomes himself (Kelechi Iwuagwu, 2011,

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p.35).” This happens when man is so engrossed with his
everyday encounter of things based on their serviceability.
And from such practical engagement of the things in theworld, the human Dasein creates a relationship with thethings it made and in the process is absorbed to them andloses its being. Like in the reduction of man to theobjectless existence of a standing-reserve in his
engagement with modern technology. Heidegger writes:“This term does not express any negative evaluation, but
is used to signify that Dasein is proximally and for the mostpart alongside the world of its concern. This absorption inhas mostly the character of Being-lost in the publicness of
the “They”. Dasein has, in the irst instance, fallen awayfrom itself as an authentic potentiality for Being its Self,
and has fallen into the world” (Heidegger, 2008, 220).
The Dasein who has fallen into the everyday life of the“they” is referred to by Heidegger as the “Das Man”. The“Das Man” is the mode of being of the fallen Dasein. It is
the individual who has failed to realize his possibilities ofbeing by choosing to live his life under the banality andthe shadow of the “neuter they”. He is the individual who
has refused to take responsibility over his life’s
projections and choices. The “Das Man” is the inauthentic
man who in his state of everydayness has totally
obliterated his individuality. “Mired deep in a levelling
mediocrity and shirking his personal responsibility,
Dasein leads a numbed type of existence. His everyday
action is controlled and determined by the all-pervasive
impersonality of Das Man (Lescoe, 1974, 211-212).”Moreover, Heidegger’s discussion on the nature of theauthentic Dasein revolves around the elucidations of thethree fundamental dispositions that renders man
susceptible to the call of Being. For Heidegger the threephenomena that dispose man to an authentic existence
are anxiety, death and conscience. Anxiety, for Heidegger,is that unique mood of the being of Dasein which enables
him to re lect over his position in the world. It is thedriving force which carries man out from his everyday
fallenness.
Anxiety is that mood of Dasein that
individuates man and isolates him from the temptation of
the living in the banality and mediocrity of the neuter
they. Heidegger explains that “The entire phenomenon ofanxiety shows Dasein as actually existing being-in-theworld. The fundamental ontological characteristics of thisbeing are, existentiality, facticity, and being fallen(Heidegger, 2008, 235). Anxiety, therefore, necessarily
brings man to his ontological reality by disclosing to man
his unique position in the world. The revealing of his
position in the world necessarily leads Dasein to embraceits primordial responsibilities of self-knowledge and selfrealization. Heidegger writes that, “Anxiety makes
manifest in Dasein its Being towards its ownmost
potentiality-for-Being -that is, its Being-free for the
freedom of choosing itself and taking hold of itself.
Anxiety brings Dasein face to face with its Being-free forthe authenticity of its Being, and for this authenticity as apossibility which it always is (Heidegger, 2008, p.232).”
From this realization springs the understanding that thehuman Dasein alone is capable of positing meaning in theworld. And that no other man is deemed worthy to givemeaning for one’s own life but oneself. “It is at this point,

at the threshold of authentic self-discovery that thehuman being experiences anxiety (Warnock, 1977, p. 57).
The full realization of the authentic self-discovery thatthe human Dasein experiences in anxiety is further
expressed in man’s knowledge of death. For Heidegger,
death is another mood of the being of Dasein that
disposes man for achieving an authentic existence. Man isa being-towards-death. What this means is that, theexistential structure of man’s mode of being in the worldnecessarily reveals the initude of human existence. Man’s
thrownness in time and his being-in-the-worldpresupposes that there will be a time in the history of
mankind that he will cease to be. As Heidegger rightly
states that “as a potentiality for Being, Dasein cannot
outstrip the possibility of death. Death is the possibility of
the absolute impossibility of Dasein (Heidegger, 2008,294).” The necessity of understanding the ontologicalinterrelation of death with Dasein’s authentic self isrooted from the fact that it is only when man truly
understand and embrace the possibility of his death that
he begins to truly live his life. At the sight of this dreadfulphenomenon of loosing one’s life, the human Dasein takes
every moment of his existence for himself and will nottake anything for granted knowing that in any moment in
time, the possibility of his death is nearest and most real.
Heidegger asserts “Death is the way to be, which Daseintakes over as soon as it is. As soon as man comes to life, heis once old enough to die (Heidegger, 2008, p.289).”
Another phenomenon that is rooted in the mode ofbeing of Dasein as care which helps Dasein achieve his
authentic self is the ontological possibility of conscience.
For Heidegger, “The call of conscience -that is, conscience
itself- has its ontological possibility in the fact that Dasein,in the very basis of its being is care (Heidegger, 2008,323).” He refers to two contrasting phenomena ofconscience as inner and public conscience. The former is
identi ied with that voice from within that recalls Dasein
from self-betrayal to self-understanding. While the latter
is identi ied with the voice of the everyday “Das Man”. “Butthis public conscience -what else is it than the voice of the“they” (Heidegger, 2008, 323).” The power of conscience
rests in its enabling capacity to reawaken Dasein from its
enchantment and mediocrity in living the life of the “DasMan”. Hence the call of conscience brings back man to his
senses of “being-in-the-world”, and renders him guilty ofthe sins he has committed against himself in allowing
himself to be intoxicated by the objectless and anonymous
existence in the “they”. Conscience calls Dasein from hisstate of fallenness -of being lost- to render it capable ofaccepting the opening of the possibility of its being. “Thiscall is not planned nor prepared nor voluntarily carriedout by ourselves. “It” calls against one’s own expectationand even one’s own wishes. Yet the call comes not fromanyone else, but from myself and upon myself (Blackham,
1965, p. 271).”
Dasein in the midst of a global pandemic
Heidegger in taking the task of restating the mostfundamental question of Being brought to light the realityof the being whose mode of existence is needed in orderto bring into clarity the essence of Being. Heidegger refers
to this being whose own existence is an issue to it as the

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human Dasein. For him, Dasein does not just simply occur
in the world, as merely existing present-at-hand, butrather dwells in the world as an entity who has familiarity
to it and engages with it on the basis of its own
projections and self-understanding. Dasein is
ontologically needed in order for the world to shed its
signi icance and in order for the meaning of life to reveal
itself in every individual human being. However, Dasein,
whose primordial mode of being is being-in-the-worldfacticity, is in constant possibility of becoming. It is on thisexistential possibility of becoming that Dasein may either
realize its authentic being as the one who takes
responsibility of bringing Being to itself, or to lee from its
existential struggles and embrace the anonymous
existence in the “neuter they”, thereby realizing his
inauthentic existence. It is in Dasein’s state of fallenness
and in man’s objectless existence in the “they” that the callfor the need to recover Being is manifested. Life’s meaningis all the more manifested in man’s falling from his
authentic existence.
However, the world at the present is confronted with adisclosure that challenges the fundamental structures ofhuman existence. The kind of disclosure prevalent in theworld today is a revealing that deems the light of being
and reduces everything into darkness. Man is forced tolook for the meaning of his existence amidst the darkness
and melancholy of COVID-19. More so, as the COVID-19
pandemic continues to cover the world in darkness; theworld simultaneously reveals the happenings of man’s lifeand struggles brought about by the inherent injustices of
the world’s social-political structures. The global healthcrisis has caused millions of lives and has disrupted thelow of development all over the world. It has changed thelives of people, the young and the old alike. The pandemic
posts itself as an ontological threat to the very meaning ofman’s existence. When man is forced to battle on his own
against a formidable enemy, like the COVID-19, fear andhopelessness sink in to his being that cause a disruptionof his ordinary and familiar existence. The being of Dasein
retreats itself into oblivion in his state of absolute fear andpreoccupation for his survival. This does not mean
however that to fear for one’s life and the security of thepeople you love during the pandemic are a kind of
inauthentic Being. Rather, they are the precise modes ofDasein’s “care-being” being-in-the-world. What thepreceding statement means is that, in his state of absoluteforgetting of his responsibilities of realizing his
projections for himself, man simply allows himself to bedrowned with fear and preoccupations that he no longer
strives to change his state of mind. The human Dasein inthis respect is absorb in the world.
For Heidegger, Dasein is a being that is for the mostpart always ahead of itself being-in-the-world. Such
constant projectivity of the human Dasein’s existence isdue to the fact that man is always concern for his future
and wellbeing. However, the mode of projection of Dasein
when confronted by the fear for his survival in the midstof the global health crisis is a revealing that does not open
him to the possibility of Being but closes himself. Life forhim is no longer conceived as the fountain of all
possibilities that he can readily embrace and dwell as in
the sense of “living-in” and being familiar to. Life as

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233

experienced under the veil of the global pandemic is a life
lived in absolute fear for death and the possibility of nonexistence. Such is expressed when man loses grip of what
is real and cling to things that are mythical and imaginary
in order to look for a place to inhabit. This mode ofdwelling that is empty of any relation is the anonymous
existence in the “they”.
A few weeks ago, the province of Misamis Occidental,
where I and my family live, experienced an unusual
phenomenon that has caused havoc and unreasonable
fear among the communities and members therein. It
started when certain people claimed that there were men,
who during the night, knocked at the doors of houses with
the intention of harming. Since then, people from all cities
and municipalities in the province claimed that they haveexperienced this knocking and this was followed by aseries of social media claims of the whereabouts and thepersonality of these men. Such has caused fear fromamong the people despite of having no actual evidence ofbeing harassed and harmed. And even the knocking itself
and the supposed supernatural abilities of these men are
absolutely baseless and unreasonable. What basicallytranspired in the place is the danger that Heidegger refers
to as the falling away of Dasein, being so much engrossedwith its everyday existence. The tendency to create a newworld apart from what is currently being experienced is
the result of man’s betrayal of himself. Such phenomenonof self-betrayal is manifested in his preoccupation of ade inite life that is devoid of any struggle and pain. With
the kind of life, that is seemingly meaningless, that man isforced to live during this hard time. One can presume thateverybody just wants their previous lives back. However,as Dasein is moving always ahead of itself and in time,
man can only look back at his previous existence.
Amidst the darkness of the world’s disclosure in the
pandemic, Heidegger offers a saving light imbedded in thevery nature of Dasein. That is when the human Dasein
inally comes again into his senses and recovers from his
self-betrayal to self-understanding. This phenomenon
Heidegger calls the “in-turning” of Being. That is when
Dasein rises itself from its objectless existence andrecovers from his absorption of the banality of his
everyday existence. Like when at the present, despite how
everyone is struggling to survive, there are people who
manage to extend a helping hand which paved the way foran endless possibility of helping the poor. The current
phenomenon of “community pantry” is thematerialization of man’s awakening from his deep
slumber of being cautiously preoccupied of securing his
own existence. Care, for Heidegger, is an ontologicaldisposition that is dwelling in the essence of Dasein’s
being-in-the-world and being-alongside-with-others. The
human Dasein receives its ful illment in not just ful illing
its responsibility towards himself, but in realizing its
responsibility towards other Dasein in a solicitous
relation. Man’s concern for himself, necessarily leads him
to be concerned with other beings in the world. Suchtranscendental care which goes beyond the limit ofeveryday Dasein is the lightning that breaks the silence
and the darkness of Death.
Conclusion

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The current phenomenon of the global pandemic
COVID-19 must not be conceived as a happening that is far
away from the human Dasein’s existential structures.
Neither it should be conceived as simply an object that is
distant from the world of man. For what COVID-19 brings
to Dasein is a revealing that is not alien to it but re lectiveof the kind of life that each Dasein is living. The sheer
objecti ication of the global pandemic is its alienation to
man’s very own existence. That is, when man steps backfrom his “equipmental” engagement with the things in theworld. And looks at the world from a far as the Subject
that observes the realities of things outside of him. The
beings in the world are then posited as present-at-handentities that are “things” observable by the huma Dasein.
And whose meaning of existence may not have signi icant
value to the task at hand of recovering the lost sense of
Being. The COVID-19 pandemic, nonetheless, is not ahappening in the world that is understood outside ofevery human reality. For the truth of the matter is that, theglobal pandemic is man’s own affair. It is for this reason
that the COVID-19 pandemic posits an existential threat tothe being of the human Dasein.
References

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Blackham, H. J. 1965. Reality, Man and Existence: Essential Worksof Existentialism. New York: Benton Books Inc.
Brago, Pia Lee. 2021. “Richer nations received 87% of vaccines –WHO.”[Article Online] https://www.philstar.com/headlines/
2021/04/12/2090526/richer-nations-received-87-vaccineswho.
Gadamer, Hans-Georg. 2008. Philosophical Hermenuetics. Los
Angeles: University of California Press.
Heidegger, Martin. 2008. Being and Time. New York: Harper
Perennial Modern Thought.
Kelechi Iwuagwu, Emmanuel. 2017. “Martin Heidegger and theQuestion of Being”. In Journal of Integrative Humanism (JIH)
vol.8 no.1: 25-48
Maboloc, Christopher Ryan. 2021. “Overcoming Death: The Stateof Man in the Midst of a Pandemic.” In Eubios Journal ofInternational and Asian Bioethics 31 (1): 29-31.
Miao, Hannah. 2021. “WHO says more than 87% of the world’s
Covid vaccine supply has gone to higher-income countries.”[Article Online] https://www.cnbc.com/2021/04/09/whosays-poor-countries-have-received-just-0point2percent-ofworlds-vaccine-supply.html
UN News. 2021. “Low-income countries have received just 0.2
per cent of all COVID-19 shots given.” [Article Online] https://
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Warnock, Mary. 1977. Existentialism. London: Oxford University
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Weaver, Stephanie. “Shocking imbalance’: WHO says 87% of
COVID-19 vaccines have gone to wealthy countries.” [Article
Online] https://www.fox13news.com/news/shockingimbalance-who-says-87-of-covid-19-vaccines-have-gone-towealthy-countries

Ethico-legal aspects ofcomplications of an illegal abortion
with trisomy 21 in Iran
- Roya Rashidpouraie, MD
Medical Ethics and History of Medicine Research Center,
Tehran University of Medical Sciences;
Department of Medical Ethics, School of Medicine,
University of Medical Sciences, Tehran, IranEmail: dr.roya9@gmail.com- Saeedeh Saeeditehrani MD,PhD
Assistant Professor, Medical Ethics Department,
Iran University of Medical Science, Tehran, Iran- Mohammadnader Shari i MD
Medical Ethics and History of Medicine Research Center,
Tehran University of Medical Sciences; Department ofMedical Ethics, School of Medicine, University of Medical
Sciences, Tehran, Iran- Seyedehsaba Mostaghim, Department of Science,
McMaster University, On, Canada- Mina Rashidpouraei,, MD-PhD
Researcher, Obstetrics and Gynecologist,
the Burwin Institute of Diagnostic Medical Ultrasound,
Toronto, Canada
Abstract
Illegal abortion is a common way to terminate unintended
pregnancies. A 38 year old pregnant woman decided toterminate her pregnancy illegally. This was complicatedby uterine perforation and bowel injuries. Illegal abortion
can be associated with serious complications. Ethically,
the patient must be provided with complete information
at the appropriate time in legally-prescribed treatment
centers through informed consent. The occurrence of
critical and threatening conditions to the patient withethical decision-making problems should be prevented.
Familiarity with abortion laws in each region is essential.
Introduction
Trisomy is a common chromosomal disorder, the mostcommon of which is trisomy 21, also called Down’s
syndrome [1, 2]. The prevalence rate of this syndrome in
Iran is one in every 814 births [3]. This syndrome isusually diagnosed through chromosomal examination [4].
The risk factor for increasing DS is increasing maternal
age and the history of another trisomic child in the family[5].
Case presentation
A 38 year old female who had a 12 years history ofprimary infertility, became pregnant at the third attempt
at intrauterine insemination (IUI). Her screening test
showed a high risk of trisomy 21 (1/45). A perinatologist
explained the entire procedure she needed to take forapproving or ruling out Down’s syndrome throughchorionic villous sampling (CVS) but she didn’t accept theadvice at that time. Then the perinatologist advised her to
do a Quadri test at the 16th week of her pregnancy. The
risk of T21 in her quadri test was 1/9 and theperinatologist strongly recommended amniocentesis but
she didn’t accept and asked for an alternative noninvasive
method. The perinatologist recommended cell free DNA

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)
test and by making explicit reference to the Iranianabortion law stipulating that therapeutic abortion isavailable till 19 weeks of gestational age. If a fetus is
known to have Down’s syndrome beyond that time it is
not possible to abort the fetus legally. She said: “I needmore time for making a inal decision and she left thehospital”. She came back to hospital with a positive cell
free DNA test at the 22nd week of gestational age and she
insisted to undergo legal abortion, but the perinatologist
stated that it was not possible to do legal abortion basedon her gestational age.
She went to a midwife clinic and requested an illegal
abortion. A midwife prescribed lingual and vaginal
misoprostol (400 μg of misoprostol lingual followed byhome administration of 800 μg vaginal misoprostol in 48
hours) and then she did curettage for retained placental
tissue but unfortunately because of the midwife’s
inadequate experience the curettage was complicated byuterus rupture and bowel injury, then immediately she
sent her to hospital and surgeons repaired her uterus andgut. She then sued in court for her injuries.

reasonable that the physician has extensive power overde ining the terms of the patient’s choice and the care andtreatment of the patient. Therefore, the physician is notallowed to take harmful actions but she should prevent
harming the patient by informing her of the risks
associated with such actions. Also, a midwife should not
do things that are not in their ield of specialty. According
to their professional commitments, health service
providers are allowed only to carry out actions they havethe expertise needed to do, and they should avoid taking
such actions whenever there is the risk of harming thepatent because of the lack of experience and skill. [9]Ethical approach
Bioethics theorists have sought to provide a list of
primary ethical duties that help physicians to solve theirethical dilemma. These principles have been tailored to
the norms of the medical profession [6]. One of the most
famous theories is the Beauchamp and Childress theory,
which has proposed four principles as the basis for ethicaldecision-making in medicine. These four principles are:autonomy, bene icence, non-male icence, and justice. In
relation to the challenges raised about the issue at hand,
this issue is examined in terms of each of these four
principles.

Non-male icence
The main task of the therapist is not to harm the patient
while providing the best possible services. The principleof non-male icence is not absolute, and when balanced
against the principle of bene icence often creates a dual
effect. If an action taken by a midwife who does not have
suf icient competence and quali ication is to thedetriment of the patient, and the risk of injury to theuterus and intestines is high, it will be considered as acase of male icence which is illegal during pregnancy.
Therefore, when faced with the request for abortion, themidwife’s professional duty is to refuse to act because thepriority is with non-male icence.

Autonomy
In a medical case, various actors may be involved in
making a decision, each of which may have anautonomous right to a degree. We examine the principle ofautonomy from each person’s perspective individually.
Patient’s autonomy
Today, patient autonomy is one of the most importantprinciples accepted in modern medicine but experts agree
that autonomy should be limited in some cases. There aremany differences between the cultures and schools of
ethics in relation to the autonomy limits. In Westerncountries, autonomy has been largely accepted, but in the
Middle East, sometimes the role of physician or the
in luence of relatives impose much restriction on thepatient’s autonomy and power [7]. After autonomy wasconsidered seriously as a principle in the irst perspective,
three moral dilemmas became apparent in practice. First,
autonomy occasionally causes a patient to lose a bene it in
his treatment. Second, sometimes autonomy con licts withthe ethical obligations of physicians, and they theninevitably defy the action. Third, in some cases, autonomy
itself becomes a serious threat to the patient [8].

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Health service providers (physician) autonomy
The physician is an expert in the treatment of diseases
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Bene icence
Physicians and practitioners should consider the mostbene it for patients according to this principle [10]. Basedon professional obligations, physicians are required to dotheir best to bene it their patients. Therefore, those who
do not have the necessary quali ications and expertise are
not allowed to take actions that have no bene it for thepatient.

Legal issues
To investigate the legal considerations of illegal abortionin Iran, we will examine it from two perspectives: 1) law
enforcement and 2) criminal aspect.
From the perspective of law enforcement: Pursuant to
Article 6 of the law on the investigation of union andprofessional violations of medical practitioners andassociates, medical and af iliated medical professionals
are not allowed to perform medical offenses and theyshould refrain from committing acts that would threaten
the dignity of the medical community and the practice ofthe mentioned midwife is one of the examples of medical
violations.
From a criminal perspective: Based on the de inition ofan unintentional harm, a fault occurs when a person does
not intend to harm another, but he/she does harm toanother person as a result of negligence and carelessness.
Accordingly, the action taken by the midwife is an example
of fault and in accordance with Article 2 of the Islamic
Penal Code (Article 2: Every action or omission of anaction for which there is a punishment in law, will be
regarded as an offense), and Article 145 of the Islamic
Penal Code, and its Note (Article 145- The commission of
unintentional offenses shall be subject to proving the faultof the perpetrator).

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Discussion
In Iran, until the 19th week, abortion is a therapeutic
option for a fetus with Trisomy 21 [11]. After the 19th
week, pregnant women will be permitted to taketherapeutic abortion only if it is established that themother may lose her life with this delivery. [12,13]. This is
one of the reported cases of illegal abortion in Iran,resulting in uterine and intestinal rupture at the sametime. However, various studies in Iran show that 60 to 70
percent of cases of legal abortion in Iran are related tofetal disease and abnormalities [14]. In various studies inother countries, uterine rupture has been proven to be acomplication of illegal abortion [15,16]. Also, illegal
abortion has been shown to be one of the main causes ofmaternal death in the world and the regulations must bereconsidered [17,18]. The results of a study by Sama et al.
(2016) in Cameroon con irm the rupture of the uterus andthe intestine through illegal abortion [19]. However,considering that maternal age is an important risk factor
for the fetus’ af liction with trisomy 21 [5], high-precision
low-risk tests such as cell free fetal DNA testing should betaken for mothers at older ages in the early stages ofpregnancy. [20]Conclusion
To reduce the complications of abortion with ananomalous embryo, pregnancy must be terminated legallyby quali ied specialists in equipped healthcare centers. It
should be aborted in a legal manner and therapeutic
abortion must be carried out in accordance with the lawsof each country. Due to respect to the patient's autonomy
in order to serve their interest and prevent any possible
harm, it must be provided with complete information at
the appropriate time in the legally-prescribed treatment
centers through informed consent. Besides, theoccurrence of critical and life-threatening conditions
which create ethical decision-making problems for thephysician and the patient should be prevented.
Ethics approval and consent to participate: This reportis part of a dissertation that was approved by the ethicalcommittee of Tehran University of medical science. The
approval number is: IR.TUMS.MEDICINE.REC.1397.836.
The consent of participant was verbal because we
promise to publish it anonymous.
Availability of data and informed consent of patient:
The dataset analyzed during the current study andinformed consent of the patient exist in the Shahriar
medical court repository.
References

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1. Bryan H, King-Karen E, Toth-Robert M. Intellectual disability.
In: Textbook of psychiatry. 9th ed. New York: Lippincott; 2009:3446.
2. Malt EA, Dahl RC, Haugsand TM, et al. Health and disease in
adults with Down syndrome. Tidsskr
NorLaegeforen2013;133:290-4.
3. Tayebi N, Yazdani K, Naghshin N. The prevalence of congenital
malformations and its correlation with consanguineous
marriages. Oman Med J. 2010;25:37-40.

4.Saito H, Sekizawa A, Morimoto T, Suzuki M, Yanaihara T.
Prenatal DNA diagnosis of a singlegene disorder from maternal
plasma. Lancet 2000; 356: 1170.
5. Asma K, Pranav P. Screening for Down syndrome. J Obstet
Gynecol India 2006; 56(3): 205-11.
6.Graber, Glenn C., Basic theories in medical ethics, In: Healthcare ethic: Critical issues for the 21st century, by John F.
Monagle & David C. Thomasma; 2005, chapter 48, p. 522-525.
7. Rachels, J. Ethical theory and bioethics. In Helga Kuhse & Peter
Singer: A companion to
8. Pellegrino, E. Patient and physician autonomy: Con licting
rights and obligations in the physician-patient relationship.
Contemp. Health L. & Pol'y, (1994). p. 47.
9. Saeedi Tehrani S., & Madani, M. Bioethical principles andmedical futility. IJME, (2015). 7(6), 1-14.
10. Beauchamp, T. L, Childress, J. F. Principles of bio-medical
ethics (5th ed). (2001). New York, NY: Oxford University Press.
11. Samadirad B, Khamnian Z, Bager Hosseini M, et al. Congenital
anomalies and termination of pregnancy in Iran. J Pregnancy
2012 (2012): Article ID 574513, 4 pages.
12. Erfani A. Tehran Survey of Fertility. Population Studies andResearch Center on Asia and the Paci ic. 2010; 4: 150-167.
13. Abbasi H, Hemati N. Abortion Prevalence and SocioDemographic Differentials. Biomedica. 2005;21-24
14. Masumi S.Z, Kazemi F, MotaghiZ , ShayanA , Khalili A, Khani S.
Attitude of Women in Fertility Ages to Relationship between
Fertility Status, Health and Socio-Economic with Induced andOverall Abortion. International Journal of Advanced
Biotechnology and Research (IJBR). 2016; 542-547.
15. Sonkhya P, Mittal P. Intestinal injury in illegal abortion. Int
Multispec J Health. 2015;1(4):1-4.
16. Subbappa K, Patil P, Gopal N. Uterus in illegal hands: a casereport. Int J Sci Stud. 2014;2(8):211–
17. Sekiguchi A, Ikeda T, Okamura K, Nakai A. Safety of induced
abortions at less than 12 weeks of pregnancy in Japan. Int J
Gynaecol Obstet. 2015;129(1):54-57.
18. Rashidpouraie R,Shari i MN.Covid19 and abortion right,
Obstet Gynecol Sci. 2020;63(6):743-744. https://doi.org/
10.5468/ogs.20185
19. Sama CB, Aminde LN, Angwafo FF. Clandestine abortion
causing uterine perforation and bowel infarction in a ruralarea: a case report and brief review. BMC Res Notes. 2016;9:98.
20.Radoi VE, Bohiltea CL, Bohiltea RE, et al. Cell free fetal DNA
testing in maternal blood of Romanian pregnant women. Iran J
Reprod Med 2015;13:623-6.

Ethical issues and challenges oforgan transplantation in
Bangladesh- Tanvir Ahmed
Jahangirnagar University, Dhaka, Bangladesh
Email: tanvir92ju@gmail.com
Abstract
Organ transplantation is one of the most remarkable
medical achievements of the century because it provides away to give life to patients with serious organ failure. In
the medical sector of Bangladesh, recent progress in theield of organ donation and transplantation has
introduced new hope. However, a signi icant issue raised
is ethical implications. But in a developing country and amulti-religious community like Bangladesh, additional
concerns arise relating to religious issues, different
medical policies, and the insuf iciency of healthcare
resources. These concerns are not addressed as attitudes
toward the medical policy of Bangladesh. But this culturaland religious diversity as well as healthcare policies
relating to organ donation may hamper its acceptability
and cause discouragement to donate organs. The objectiveof this article is to explore the ethical issues, different
religious opinions involved in organ transplantation in
Bangladesh and consider its importance. Additionally, in
Bangladesh, the appropriateness of costly services such asorgan transplantation will be discussed where thegovernment cannot guarantee medical services as thebasic needs for the people.
Introduction
Organ transplantation is a lifesaving therapy for organ
failure wherein an organ is removed from one body andset in the body of a receiver to reduce disability. The
success of organ transplantation is increasing due tomodern medical technologies and the advancement of
medical therapy. Organ transplantation was irst started
in the 1930s (DuBray & Busuttil, 2017, p. 3). This concept
gave new hope and new life to the moribund patients
when several kidney transplants were successfully
performed. In 1954, the irst successful kidney transplant
was accomplished where a kidney was taken from one
identical brother and transplanted in another and it
worked for approximately 9 years (DuBray et al., 2017, p.
4). Then, physicians discovered the way to successfully
replace other organs. Conversely, despite the tremendous
advancement of medical science in the case of organtransplantation, some ethical issues like the methods oforgan acquiring and allocation, suf icient medical
resources, social and religious obstructions have become
important. This article will focus on these ethical issues
within the context of Bangladesh.

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Types of organ transplantation
Organ transplant mostly refers to transplanting solidorgans like heart, lungs, kidneys, liver, pancreas andintestines. Other organs such as eyes, ear, nose, skin,bladder, nerves, brain, spinal cord, skeleton, gallbladder,stomach, mouth, tongue, muscles etc. are also

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transplantable. The sources of organs for transplantation
are often divided into three categories: living donors,
cadaveric donors and brain-dead donors (Kamal, 2008, p.
99). Living donors are frequently associated with thepatient; spouses and close friends generally donate organs
to ailing loved ones.
Organ transplantation in Bangladesh
Organ transplantation is increasing in Bangladesh though
it is still in the initial stage of its development. Cornea
transplantation mainly started up in 1974 (Ali, 2012, p. i).
Then, the primary successful kidney transplantation was
accomplished at the Institute of Postgraduate Medicine &Research (presently Bangladesh Sheikh Mujib Medical
University) in 1982 and subsequently, regular kidneytransplantation from ‘living donor’ donations of close
relatives has been proceeding since 1988. Likewise, theirst successful liver transplantation of the country wasdone in 2010 at BIRDEM Hospital (Ali, p. i). Since then,this has been continuously increasing in this country.
Examples of organ transplants can be observed in various
government and private hospitals in Bangladesh. For
instance, the total number of living kidney transplants in
the BIRDEM was 111 from November 2004 toNovember 2014 (Siraj, 2016, p. 40). Public hospitals like
BSMMU have always played a leading role in kidneytransplants. By 2007, 306 kidney transplants had been
performed in BSMMU (Moniruzzaman, 2010, p. 104). The
rate of organ transplantations is practically higher in the
Kidney Foundation Hospital and Research Institute among
the other private hospitals. From September 2006 to
September 2017, this hospital successfully performed
408 transplantations with a 98% success rate (Kidney
Foundation Hospital and Research Institute, 2017). The
transplantation rate is limited as the interest for kidneys
surpasses the number of accessible organs. Only 130
patients with end-stage kidney failure can acquire organs
contrasted with an expected interest of 5,000 every year
(Siraj, 2016, p. 41). Besides, the kidney dialysis facilities in
Bangladesh are limited and these facilities are profoundly
costly as well. But, organ transplantation is not as
expensive as dialysis. Studies show that kidney dialysis isa wretched experience for transplant patients indeveloping countries (Radcliffe-Richards et al., 1998, p.
1950).
Organ transplantation could be a preferable inancial
alternative over dialysis in Bangladesh. This is because
kidney transplantation is less costly than dialysis andeffective kidney transplantation would effectively
diminish the general needs and brings about a better
nature of human existence that enables more noteworthy
wellbeing (WHO, 2011, p. S30). Regardless of society
having a moral responsibility and obligation to offer equal
healthcare for everyone, due to limited economic
resources, corruption in medical sectors, unequal
distribution of organs, social or religious restrictions,transplantation, still doesn’t rank as the main concern for
the Bangladeshi government (Moniruzzaman, p. 107). As
the constitution of the People’s Republic of Bangladesh
announces: “The State shall adopt effective measures toremove social and economic inequality between men andwomen and to ensure the equitable distribution of wealth

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among citizens, and of opportunities in order to attain auniform level of economic development throughout theRepublic” (GoB, 2011: article 19:2); thus, the government
utilizes the greater part of the health budget for primary
healthcare, giving priority to fundamental requirements
for the vast majority of people like vaccination, familyplanning, and the control of infectious diseases. So it canbe said that the Bangladesh government fails to offer
proper organ transplant services (Siraj, 2016, p. 43).
“Bangladesh Organ Transplant & Donation Act, 1999”
was passed in parliament, allowing two types of organ
donation – ‘living donor’ donation from close relatives and‘cadaveric’ donation (Ali, p. i). Then, in 2018, an updated
law of organ transplantation was approved in theparliament named “Transplantation of Human Organs(Amendment) Bill, 2018” (“Transplantation of Human
Organs”, 2018). The amendment added a number ofextended family relatives as potential donors to theexisting donor list.
Besides the laws, many important issues like ethical,
social, and religious considerations regarding organtransplantation as well as the allocation process of organs
have been viewed with less importance. If the medical
law concerning organ donation makes these factors clear,then the fear of organ donation will be reduced andpeople’s interest in organ donation will be increased.
Since organ transplantation is now popular in Bangladesh
and its requirements and availability are upgrading
gradually, it has become necessary to follow certain
ethical standards to implement it positively. The moral
issues that the government should keep in mind aredescribed below.

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a. Organ distribution policy
Some moral questions are: What will be the distribution
method of organs? Who will get the priority irst? Will
priority be based on the seriousness of a person’s illness
or her/his age or gender? Will money, social status
in luence this decision? These sorts of ethical dilemmas
and controversies associated with the procedure of organtransplantation may hamper the overall issue. Therefore,
it is essential to have clear answers and guidelines forsuch questions in the medical policy of Bangladesh.
Firstly, the question of allocation procedures of organs
and who will get the priority irst. In this context,
justi ication is very important. We can consider John
Rawls’s conception in this case. According to John Rawls
general conception of justice consists of one central idea:“All social values—liberty and opportunity, income andwealth, and the social bases of self-respect—are to be
distributed equally unless an unequal distribution of any, orall, of these values is to everyone’s advantage.” (Rawls,
1971, p. 54)
From this general conception, we can deduce one
distributive justice criteria that is equal access. According
to equal access criteria, organs are allocated to patients
based on objective factors. Equal access may consist ofsome standards such as (i) length of time waiting which
includes who comes irst, organs will be served irst to
her/him, (ii) the priority of age that includes organs will
be distributed from youngest to oldest (University of
Minnesota: Center for Bioethics, 2004, p. 15). Besides,

equal access theory promotes a distribution process thatis free of biases based on race, sex, income level andgeographic distance (Douglas, 2003, pp. 1883-1885). As
Bangladesh is a developing country, equal access theory ismore sustainable in the case of distributing organs. But
there are some arguments against equal accessdistribution which should be considered too. One
argument that opposes equal access distribution comesfrom a 1990s article in the Canadian Medical Association
Journal by E. Kluge. Kluge argues that equal accessdistribution of organs is not fair for the people whochoose their lifestyle taking tobacco and alcohol or otherdrugs and ruin their organs (Kluge, 1994, p. 746).
Another criterion of distributive justice is maximum
bene it. The objective of the maximum bene it criteria is
to maximize the number of transplants. The maximum
bene it consists of some points such as (i) medical needs
that consider the sickest person who will get the irst
opportunity for a transplantable organ, (ii) the probablesuccess of a transplant that considers the person who will
live the longest (University of Minnesota: Center for
Bioethics, 2004, p. 16). Most supporters of the maximum
bene it criterion consider organ transplantation as a
medically valuable method and wish to avoid the wastingof organs. To reduce waste, they examine how sick thepatient is and what is the probability of survival of thepatient after transplanting organs (Neuberger, 2003, pp.
1881-1883). Therefore, supporters of maximum bene it
distribution state that organs should be allocated so thatthe greatest bene it is derived from every available organ.
This concept is often similar to utilitarianism where themain motto is “maximization of pleasure and theminimization of pain”.
Likewise, we evaluate some arguments that oppose
maximum bene it distribution criteria. Firstly, medical
success is hardly predictable because a successful
outcome can vary. Medical science cannot ensure howlong the patient will survive after organ transplantation(Childress, 2001, pp. 365-376). Secondly, these criteria
can open the door for bias, lying, favoritism, and otherunfair practices which are considered as subjective rather
than objective (Childress, pp. 365-376). Thirdly,
considering age and maximizing life years as criteria for
distributing organs devalues the remaining life of an older
person. Additionally, in the organ distribution line, there
may be many important persons like doctors, scientists,
artists, presidents, researchers, etc. whose lives may be
given more importance than others.
From the above discussion, I could conclude that
following John Rawls’s distributive justice theory as acriterion for organ allocation and maintaining otherdiverse arguments may help form a viable organ
distribution policy for Bangladesh.
b. Considering religious values
Despite all the advantages of organ transplantation in
Bangladesh, people oppose donating and transplanting
organs. There are many reasons why certain populations
are not interested in donating organs. Among thesereasons, both social and religious issues play a role. Mostof the population is Muslim (88%) while a considerable
number of citizens are Hindus (10%), Christians (1%),

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and Buddhists (1%) including various ethnic entities.
Citizens from every religion have different rituals andbeliefs that may create some obstacles in organtransplantation. If the organ donation policy contradicts
people’s religious beliefs, it may violate their autonomy
and people will show less interest in donating organs.
Because sometimes heavenly salvation is more important
to a person than saving a life.
For instance, most of the Muslims in Bangladesh
believe that Islam prohibits organ donation. Muslims who
argue against organ donation believe that Islam forbids
organ donation as it was not mentioned in the Qur’an. In
Islamic culture, the deceased’s body must be buried assoon as possible after death. This belief promotes theopinion that the body is resurrected after death and it ismore desirable to remain whole after death (Robson,
Dublin & Razack, 2010, pp. 7-8). Muslims believe thatorgans will play an independent role as ‘witnesses’ to anindividual’s life on ‘Judgement Day’ (Al-Qur’an 41:20).
But, it is also mentioned that saving a life is a supreme
value in Islam as the following verse illustrates: “And if
anyone saved a life, it would be as if he saved the life of all
mankind” (Qur’an 5:32). From this statement, it can besaid that since saving lives is a sacred act, saving the life ofa person by donating organs cannot con lict with Islam.
The second major religious group in Bangladesh are
Hindus. Many sources support organ donation in Hindu
scriptures. Daan is the original word in Sanskrit thatstands for sel less donation. It is also the third componentof the ten Niyamas (virtuous acts) (“A Hindu perspectiveon organ donation”, 2020). Organ donation is supported in
the Hindu religion because it saves a person’s life.
However, a person should take care of her/his body whiles/he is alive because it is the house of God. Thus, organ
donation from the Hindu point of view is a spirituallyauspicious act for the donor. In Hindu mythology, sometraditions support the use of body parts to bene it others.
As for Christianity, both Catholics and Protestants
support and encourage organ transplantation. Jesus
instructed people to love one another and embrace theneeds of others. Christians assume that organ donation isan act of love and a way of following Jesus’ instructions.
They believe that whatever happens in their body before
or after death cannot impact their relationship with God.
Pope John Paul II had even repeatedly advocated organ
donation and organ transplantation as a ‘service of
life’ (Robson et al., 2010, p. 9).
There are a few Buddhist communities in Bangladesh.
Buddhist religious belief does not support organ donation
as they correlate an intact dead body with respect forancestors or nature. It would therefore be wrong to returna person’s body not intact by removing organs from it(Sugunasiri, 1990, pp. 947-949). But, there are differencesamong different Buddhist communities regarding organtransplantation. For example, organ donation is
acceptable in Theravada Buddhism. In Buddhism,
extending help to other sentient beings is a noble virtue
and this covers the case of organ donation too (“ABuddhist perspective on organ donation”, 2020). From
this viewpoint, organ donation would be praised as an act
of generosity.

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So, we ind a lot of varieties in the beliefs of Muslims,
Hindus, Christians and Buddhists. It is critical to maintainthese religious issues in the case of organ transplantationin Bangladesh. In this situation, the patients should makethe physicians informed about their religious beliefs.
When patients share their personal beliefs and religious
identities with the physicians and the physicians informthe patients about their treatment, it is called informed
consent. This informed consent will build the platform ofa patient’s autonomy and inspire people to donate andtransplant organs.
c. Suf iciency of clinical experts and medical
equipment
In Bangladesh, besides religious and social values, thesuf iciency of clinical experts and medical equipment
must be evaluated seriously to create an ethical platform
for organ transplantation. For instance, in the case of aliving donor, we need to check whether an individual isbeing compelled to give organs. Similarly, the hospitalauthority must have specialist physicians and proper
medical equipment for collecting organs securely from aliving donor, and they need to ensure the donor’s physicalitness after donating an organ.
The same factors are valuable in the case of collecting
organs from brain-dead donors. Cornea transplantationfrom brain-dead donors has just started in Bangladesh.
But, the government of Bangladesh recently attempted tolaunch a project of transplantation of vital organs likekidney, liver, heart and pancreas etc. from brain-deaddonors (Siraj, 2020, p. 1). To collect organs from a braindead person, the medical board should get permission
from the relatives of the brain-dead donor to allow the
body for organ donation. Besides, hospital authorities
must have proper clinical experts and medical technology
to verify that the brain-dead patient has no chance ofcoming back from a coma. Otherwise, that is considered acrime.
The above two facts are essential because if there is any
harm to the organ donor and organ client during organtransplantation, it will violate the principles of medical
ethics. The principles of medical ethics have strictly
forbidden harming the patients. There are speci ic
guidelines that offer general direction for practitioners
and healthcare professionals, one of which is the “fourprinciples” approach (autonomy, non-male icence,bene icence and justice) developed by Tom Beauchamp
and James Childress (Beauchamp & Childress, 2013). The
second principle named the principle of non-male icencerequires not to intentionally harm the patient.
Furthermore, the principle of bene icence states that
healthcare providers must bene it the patients and takepositive steps to remove their pain.
Keeping these points in mind, we should follow the four
principles of medical ethics in the case of organtransplantation in Bangladesh. Simultaneously, theseguidelines will protect the patient’s autonomy and justicewill be established ultimately. The Bangladeshi medical
policymakers should include these factors in this context.

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Challenges in organ transplantation
In Bangladesh, we face some obstacles to establish an
ethical platform for organ transplantation. For instance,some social and religious misconceptions may hamper theorgan donation policy. Many people believe that organ
donation is prohibited in their religion. In this regard,
people should be concerned about their own religion.
Besides, Organ traf icking and corruption in the medical
sector may frustrate the legal distribution of organs.
The biggest trouble, however, happens in collecting
organs from living donors and brain-dead donors, because
Bangladesh still does not have enough medical experts
and medical resources in every hospital. According to thereport of Bangladesh Statistics 2019, there are 85,633
registered physicians and 8,130 registered dental
surgeons in Bangladesh for the whole population of 164.6
Million (Ministry of Planning, 2019). As indicated by thesestatistics on physicians who were registered with BMDC
(Bangladesh Medical and Dental Council), there is only
one physician per 1,847 people (“Bangladesh has one
doctor”, 2018). These data show that the medical service
in Bangladesh is very poor where the government cannot
guarantee medical services for all citizens. In thiscircumstance, the ethical considerations of organtransplantation will be assumed as a ‘white elephantproject’ which refers to a concept that is useless andexpensive to maintain. So, establishing proper ethicalguidelines in the case of organ transplantation is quite
challenging for a developing country like Bangladesh.
Conclusion
In summing up, with a view to resolving organtransplantation issues in Bangladesh, everyone has to be
involved in this moral practice including physicians andhealthcare professionals. Society as well as the medical
authority should approach this case both positively andobjectively and treat ethical and religious issues asnavigable viewpoints and not impediments to organtransplantation. If we establish proper ethical guidelines
for organ allocation and clarify the religious opinions, thefear of donating organs will be curtailed. As a result,general people will inspire for organ transplantation andthe organ traf icking rate will be minimized.
References

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Ali, M. (2012). Organ Transplantation in Bangladesh - Challenges
and Opportunities. Ibrahim Medical College Journal, 6(1), i-ii.
https://doi.org/10.3329/imcj.v6i1.14709
A Hindu perspective on organ donation. (May 2020). Retrieved
August 28, 2020, from https://www.organdonation.nhs.uk/
helping-you-to-decide/your-faith-and-beliefs/hinduism/
A Buddhist perspective on organ donation.
(May 2020).
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Caring in the midst of suffering:Views of administrators, faculty
and staff of Cor Jesu College of theschool’s mission and core value ofcompassion- Br. Ernesto Quidet, Jr., SC
Vice President for Administration and Finance, Cor Jesu
College, the Philippines
Brjrsc.1821@gmail.com (Corresponding author)- Rogelio P. Bayod
Professor of Religious Studies and Ethics, Cor Jesu College
roger.bayod@gmail.com- Erikka June Forosuelo
Program Head, BSBA, Cor Jesu College
erikkajunedecrepito@gmail.com

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Abstract
The COVID-19 Pandemic has affected the normal
operations of schools all over the world. In thePhilippines, there are schools that experienced decreaseof the number of their enrollees because of the pandemic.
This has resulted in signi icant inancial setbacks to many
schools. Some schools decided to stop their operation andterminate their employees. Meanwhile, Cor Jesu College(CJC) has experienced not only the economic impact of
Covid-19 pandemic but also a series of earthquakes thatjolted the province in 2019 causing the collapse of theirthree big buildings. The school was still in the process ofrecovery when Covid-19 hit it hard again. But having theresolve to continue its mission of compassion, the school
has devised different strategies to ensure that its
employees will continue to work and get the income theyneed during this dif icult time. This paper presents the
viewpoints of CJC administrators, faculty and staff on how
the school continued its mission of education guided byits core value of compassion despite having experienced
suffering and several challenges to its operation. Results
show that administrators, faculty and staff experienced
the care and compassion of the school providing themwork to be able to sustain their needs and that of theirfamilies during the pandemic. They further said that theschool is true to its core value of compassion andcommunity building by treating their employees well.
However, many of them also said that it would be good if
the management treated them as important partners intheir mission by consulting them during policy making
and involving them in the different discussions on thedevelopment of the school. Lastly, they hope that theschool management will be more transparent as to the241real situations of the school so that they can understand,and help their co-employees to understand the situationand devise a strategy on how to help the school especiallyin its inancial struggle.
Introduction
The work of administrators, faculty and staff in an
academic institution in this time of crisis has been
multifaceted. During dif icult times, organizational
strategy, culture, relationships, administration, aspects ofdecision making and contradictory views of stakeholders
are commonly manifested in the environment as Covid19
pandemic started to take its toll. It is in this period where
schools and school systems are responding to constantly
evolving circumstances, including the increasing
complexities of the lives of those in the communities they
serve and its external environment (Netolicky, 2020).
The strength of character is tested not when all is well
but in the presence of pain and suffering; academic
institutions are ighting against setbacks by strategizing
and maximizing available resources to keep up with thepredicament. Schools have their own mission and vision
including core values that greatly de ine their brand as
learning institutions that help mold students to become
responsible citizens in the years ahead. In a time of crisis,
educational leaders must act swiftly and with foresight
and with careful consideration of options, consequences
and side effects of actions taken. They must communicate
with clarity and purpose but also with empathy andhumanity (Derksen, 2020).
Table 1: CJC Student population over the past 3 Years
Department

SY
2018-2019

SY
2019-2020

SY
2020-2021

Grade School

498

504

337

Junior High

957

1,034

843

Senior High

2,511

2,753

2,053

TOTAL BED

3,966

4,291

3,233

College

2,073

2,235

2210

Graduate School

387

459

381

Law School

190

279

271

TOTAL HEI

2,650

2,973

2,862

GRAND TOTAL

6,616

7,264

6,095

Source: Finance Of ice
Cor Jesu College, a private Catholic school in theprovince of Davao del Sur has faced two succeeding major
crises. The irst happened on October and December 2019
when the school experienced major economic loss when aseries of earthquakes jolted the province and caused the
major buildings of the school to collapse. Since there were
not enough rooms to accommodate students, the school wasforced to implement distance learning while working fast to
put up classrooms for the targeted increase of enrollees byschool year 2020-2021. The second, is the COVID-19
pandemic. The school is still in the process of healing and242

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

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recovery from the adverse effects of the earthquakes when
Covid-19 hit it hard towards the end of the school year
2019-2020 until present, forcing the school to continue
distance learning of its students. Unlike the earthquakes
which only caused great damage to school facilities, theCovid-19 has caused damage to the entire aspects of humanlife and this has a tremendous effect on the school.
As you can see in Table 1, the total population
decreased across departments for school year 2020-2021.
For the higher education (college, graduate school and law
school), there is a drop of its population by 16.09% forschool year 2020-2021 compared to school year
2019-2020. For the basic education department, thepopulation decreased much higher by 24.66% for school
year 2020-2021 compared to school year 2019-2020.
The decrease of the number of enrollees is basically
due to the fact that a lot of people lost their jobs andtherefore, they cannot really afford to send their children
to private schools. Since schools are not allowed to haveface-to-face classes, CJC continues to implement on-line
and/or modular classes at all levels. The decrease ofenrollment and the implementation of distant learning
had implications to the inances of the school. To help thestudents and their families cope with the economic
impact of the pandemic, CJC did not increase tuition fees
for two consecutive school years (SY 2019-2020 and SY
2020-2021). In addition, miscellaneous fees were cut
down. Furthermore, due to the pandemic, collection ofschool fees was affected; we have observed higher
receivables this time. This is due to the fact that we don’t
force our students to pay if they have dif iculty to pay
their school inancial obligation on time. We have become
more understanding with our students because a numberof the parents of these students lost their jobs due to thepandemic.
Despite above realities, the school did not opt for
retrenchment so that it can still continue its educational
mission in the province. This can be the school’s concrete
expression of its core value of compassion during therecent crises (earthquake and pandemic). The school
looked for other measures to retain all employees. One
measure was to adopt skeletal scheme among nonteaching personnel including administrators. This meansthat they only received half of their monthly salary. Thiswas implemented only for 2 months (July and August2020). Those who were under skeletal scheme, they
returned to their normal condition (meaning, they alreadyreceived their full monthly pay by September 2020) but
they were given built-in teaching loads for a maximum of
2 loads. Still, despite the pandemic, the school allocatedbudget for those who want to proceed to graduate andpost-graduate studies recognizing its commitment on its
pillar of excellence. School varsity scholars were retained
so that they could continue and inish their studies whilemost schools of the region removed their school varsity
scholarship due to the pandemic. Sports coaches wereretained but their allowances/honoraria were reduced to50%. So, sports coaches still have work and they are still
earning up to this time while most of the schools in theregion did not renew the contracts with their sports
coaches due to the pandemic. So, many of the sports
coaches from other schools lost their jobs.

But how long can the school sustain this scheme? Howlong can the employees endure such changes? It is a factthat in uncertainties, everyone is afraid of consequences.
Can schools remain compassionate amidst suffering? The
management must consider a range of impacts amongindividual workers, organization, well-being, learning,
service provision, performance, staf ing, inancial
implications, management of resources and sustainabilityof business, while keeping all of their individual people inmind. This is the best time to igure out if the school has
been steadfast to its core values and if the employees felt
the expression of the said values expressed throughunderstanding and responsiveness to the needs of its
employees especially in this hard time when a lot ofcolleges and universities ceased to operate because they
could no longer cope with the impediments brought about
by the Covid-19 pandemic.
The purpose of this study was to explore the different
viewpoints of faculty members, staff and middle
managers or administrators at Cor Jesu College on theschool’s mission and the core value of compassion
especially during this time of the pandemic.
Methods
To be able to gather the viewpoints, sentiments andfeelings of administrators, faculty and staff were asked thefollowing questions:
1. Do you experience the care and compassion of
Cor Jesu College during the pandemic? If yes, inwhat way? If not, why not? Please specify.
2. As an employee, how are you treated by Cor Jesu
College during this pandemic?
3. What are your insights/realizations as an
employee of Cor Jesu College during the
pandemic?
The participants of the study are the administrators
not on the higher up and not part of the management
council – the highest policy making body of the school,
aside from the board of trustees. Other participants of thestudy are members of the faculty both from the college aswell as the basic education departments and the nonteaching staff. The data that we gathered were subjected
to content analysis.
Result and Discussion
The members of the management council- the highest
policy making body of the school had crafted new policies
to ensure that everyone would have work and the income
they need during the pandemic. However, the policies had
affected some employees. By giving teaching loads to the
Non-Teaching Staff (NTS) and administrators so that theywould receive their usual or regular salary, the supposed
overloads of the faculty which they enjoyed for so many
years were reduced. Moreover, if the students in one
class/section cannot reach 22, it will not be considered
one load. Thus, many faculty members were forced to takeup many subjects which require many preparations just to
have the regular loads and the allowable overloads. In
addition, some of the staff and administrators who were
given the teaching loads as part of their regular work
might be affected because many of them are not trained in
the nuances of the teaching profession. Below are theEubios Journal of Asian and International Bioethics 31(4) (May 2021)
presentation and discussion of the results of ourinterviews with our study participants.

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Experiences of CJC employees on the care andcompassion of the school during the pandemic
There were 35 employees who participated in this study.
14 of them were members of the college faculty, 4 weremembers of the faculty of Basic Education Department, 4were program heads, 5 were of ice heads and 8 weremembers of the Non-Teaching Staff. Among the 35
employees, 31 of them or (88.57%) categorically said thatthey experienced the care and compassion of the school
during the pandemic. 3 out of 25 or (8.57%) categoricallysaid they did not experience the care and compassion of
the school during the pandemic. The remaining one
employee, a college teacher, gave a Yes and No answer. For
him, if he only thinks of himself as a faculty member, hewould rather say that during this pandemic, he did notexperience the care and compassion of the school but if hechooses to transcend from his own personal interest andconsider his co-employees, especially the non-teaching
staff, he would say that the school’s care and compassion
has been evident during this time of pandemic: “I’d like tosay that…on a personal note, I really feel that I am notreally receiving my fair compensation to the services I giveto the school. This is because of the salary decrease thatcurrently affects me and everyone due to the pandemic
situation affecting the school. Another one, I see that theschool through the Human Resource Of ice actually did nothave any intervention to check, support the emotional,
mental well-being of the employees. We work together withthe school. We work to achieve the mission and vision of theschool but it seems that the school is not taking care of me
in these aspects. On the positive note, knowing that theschool is doing it in order to keep all employees having
work and not lose their jobs is something that shows theyalso care for everyone. But I wish they could do more inorder to keep everyone longer.”
The sentiment of this faculty as regards to the decisionof the management to cut some teaching loads of thefaculty and to give them to the Non-Teaching Staff so thateveryone will continue to have jobs during this mosttrying time was supported by 31 employees who
categorically said that the school has been compassionate
and caring for each one. For instance, an of ice head said:“Yes, I still feel the care and compassion of the school
because despite the pandemic, the school tried their best
not to retrench their employees.” Another college faculty
said:“Yes, I still believe that the institution is really doing
their very best to care for their employees and reach out totheir employees as well as those outside the campus despite
the challenge they experienced.” This is echoed by anothermember of the college faculty when she said: “Yes, CJC
continued its operation and employees are fortunate tokeep their jobs despite the on-going struggles brought
about by the pandemic. Although new regulations werearranged, I am thankful for the institution as I was still
given the opportunity to teach and receive reasonableamount of pay.” A Non-Teaching Staff who felt insecure
about his job at the start of the pandemic because of thenature of his job which is much dependent on the physicalpresence of students in the campus had these words: “Yes,243

I experienced the care and compassion of CJC during thispandemic. During this pandemic, many employees fromdifferent companies had lost their jobs but we, at CJC, didnot. The nature of my job needs student interactions. Since
face to face learning is not allowed, my function is not thatneeded anymore. I thought, I will experience “No Work No
Pay” for many months or worse, lose my job just like others.
But, CJC just made adjustment in our workloads so no oneof us will lose our work. In this way, I felt that they truly
cared for us.”
These employees were so grateful that they still havetheir jobs during the pandemic which provided them themoney that they need to support their families. For them,the compassion and care for the school are evident. They
feel supported by the school during this dif icult time. In
the study of Lee, (2021) the employees' emotional
reactions were elicited from the perceived organizational
support, in how organization cares for their well-being
and work contributions and, in turn, in luence thepsychological safety. For example, the approach of theonline communication (as a form of organization support)
practiced by the managers has implications on the
different levels of psychological safety experienced by theemployee. In addition, emotional resources can beinterpreted as organization support. This holds true in thecase of Cor Jesu College in the effort and initiative of the
management to retain all the employees in the academic
institution, be it teaching and non-teaching staff.
Everybody needs inancial provision in this pandemic
when the majority of basic resources become scarce andall people in the community are experiencing the same
predicaments. During a crisis and major workplacechanges, demonstrating employee care through feedback,timely and speci ic information sharing and participatory
form of communication contribute to their positive
perception and would add up to work productivity andeffectivity.
Some employees said that the compassion and care of
the school is evident in its policies which are bene icial tothem like not requiring them to report to school every day,giving them academic freedom and enough time toaccomplish some tasks and deliverables. A program headsaid: “Yes, I experience the care and compassion of CJC
through these ways: a. we are allowed to work from homeand only required to physically report to school twice a
week, b. salaries are given on time, and c. we are given moretime to accomplish deadlines.” A college faculty said: “myauthority as a classroom instructor is still trusted and I am
not constantly monitored by the heads.” For these
employees the compassion of the school goes beyond thegiving of material bene its like salaries to its employees
but also in providing an atmosphere of trust, respect andcare. Wu et al. (2020) have set out three strategic
principles for good leadership during the COVID-19
pandemic: effective crisis management, planning andaction, communication that provides up-to-date
information and encourages individual empowerment,
and the provision of a ‘continuum of staff supports’ thatoffers a range of initiatives, normalizes feelings of distressand encourages their expression. Leaders and managers
need to be empathic, compassionate and understanding;they need to be aware of their employees’ personal

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

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circumstances and that they may change rapidly. This only
implies that compassion expressed in the companies andorganizations do not necessarily mean monetary aspect
but also the intangibles such as manifestations of trust,
respect and care from the higher authorities down to theemployees across all level.
However, 3 employees categorically said that they do
not experience the care and compassion of the school
during this time of pandemic. A college faculty sharedthese words: “I honestly do not feel so much the care of theinstitution during this time of pandemic. It seems like theschool has another priority that its employees were nottaken care of. One example is the salary. Though I
understand that the inances of the school are not thatstable during this time, I think it is the responsibility of theschool to make sure that it can provide the salary that theemployees deserve to have since they work for it. But itturned out that the employees need to ight for it for theschool to give full payment. Also, I can see that other schools
or companies give some support for their employees during
this time like free internet load, vitamins and others but CJC
did not even bother to give even one tablet of vitamins to its
employees whom they required to go to school. The salariesof the faculty are also cut because of the scheme that they
implemented like for the subject that does not reach 22
students, it will not be treated as one load even if it is amajor subject and is a regular offering of the school so thatthe school can save to pay its debt. So, it’s like the faculty is
the one who has to pay for the debt of the school.”
The sentiment of this faculty member was supported
by a program head when she said: “For me as an employee,
I did not experience the care and compassion of ourinstitution. Yes, everyone suffers. A lot of businesses
experienced inancial dif iculties but in the height of thispandemic, our institution did not even bother to hand evena small bag of relief goods like rice, canned goods or any
food that might help the employees survive the lockdown.
Our institution does not even extend a helping hand.
Instead, they cut duty hours which eventually cut thecompensation. I think it’s the opposite of the pillar set by
the institution, compassion was never felt and is not visible
to me as an employee.”
One employee said that the pandemic has revealed thetrue character of CJC. For her, she entered CJC thinking
that the school is really compassionate as what it proudly
preaches to the community. She even said that before thepandemic, she never thought of transferring to anotherschool. She thought of retiring in CJC but now she isentertaining the thought of transferring to another school.
“No, I did not experience the care and compassion of CJC
during this pandemic. As a matter of fact, this is my irst
time feeling insecure about my work being enough tosustain my needs and the needs of my family. It might bebecause of the newly implemented policies, which I didn’t
see coming, brought about by the pandemic, which alsobrought drastic changes to my salary which I very muchdepend on to put food on our table”, she said. She further
said: “for years I have put my con idence in Cor Jesu. I neverimagined myself working outside it, but this pandemic
made me realize that it might inally be the time for me tolook for security in my job.”

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While it is an acceptable fact that we cannot please
everybody, it is good to listen to voices of dissent anddissatisfaction from the people on the ground even if they
are just a few. In a utilitarian perspective, when thegreatest number of people are happy and satis ied, we canjudge that what we are doing is right. However, thesevoices of dissatisfaction need to be heard so that theadministration can re lect and learn something fromthem. They might be “a voice in the wilderness” thatbrings forth new way of looking at things, new direction of
the school. People feel anxious and dissatis ied either
when their workloads decrease or increase. A decrease inworkload during the pandemic may signal a higher job
insecurity and workers may fear losing their jobs. Higher
job insecurity due to COVID-19 is documented by Baert etal. (2020). In contrast, an increase in workload may relate
to higher work related stress due to the coronavirus
condition. Both circumstances lead to increases indissatisfaction and anxiety. Similarly, individuals with
reduced income due to COVID-19 report higher
dissatisfaction and anxiety. Income reduction affects
economic security and creates psychological problems.
With several changes in the work settings due to thepandemic, employees came to the point of looking forother means of income because there is drastic
modi ication in their salary which would also mean
cutting of bigger portions of family sustenance.
Employees assessment on how the school treats themduring the pandemic
Almost all of the 35 employees said that the school treats
them with dignity even during the pandemic and they arethankful for that. Some even said that school considers
them worthy employees because the school chooses torenew their employment. For the staff, they are very
thankful that the school has devised a strategy to help
them by giving them teaching load so that they can receive
their full salary instead of cutting their duty hours which
resulted in having a 50% cut of their salaries. This was
said by a staff of the school: “I appreciated how Cor Jesu
College made sure that all employees can still have theirwork despite this pandemic especially for all non-teaching
staff who were greatly affected by the situation by giving
them also teaching loads which somehow supported us
inancially.”
Most of the college faculty members, who somehow,
are affected negatively by the giving of loads to the nonteaching staff, understand the situation. They appreciate
the gesture of the school to treat each one equally. For
instance, two college faculty members shared their
sentiments: “Lately, for institutions like CJC, things havebecome quite challenging yet I must say that I am
particularly treated decently. I was able to keep my job
and I was able to arrange my schedule which I ind
advantageous since I have engaged in a new crafting
business.”“As a teaching personnel, although there are smallchanges in our salary, it is still acceptable given thecircumstances that CJC faced starting from earthquake tothe corona virus. Despite all these, the management
continues to look for means to address the concern of thepersonnel… the operation is affected yet they still continue

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

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to give job unlike other private institutions which imposed
retrenchment to their personnel… I am still tankful that I
have work to sustain my family. I appreciate how CJC madesure that employees can still have their work despite thispandemic especially for all non-teaching staff who weregreatly affected by the situation by giving them teachingloads.”
Another college faculty member said that she isthankful to CJC not only for the continuous job but also forthe opportunity to grow professionally. These are her
exact words: “As an employee of CJC, I felt the negative
impact of the Covid-19 pandemic, however, the institution
still managed to uplift employees by giving a continuous job
opportunity to its members even during this challenging
time where job security is crucial. Personally, as a college
faculty member, I am still very thankful that CJC gave me an
opportunity to teach students and still continue to enhancemyself professionally.”
Many college faculty members imbibe the value ofcompassion to their co-employees. That is why even if
they are affected by the cutting of loads, they were able totranscend from their personal interests and think about
the interest of others too. The school administration has
to be proud of their employees. The employees are also
considerate of the situation of the school. This kind of
attitude of its employees must be supported and nurturedby the school through an atmosphere of dialogue andconsultation. The clamor of some faculty members to be
involved and consulted in the crafting of important
policies and decisions should be viewed by the school
administration positively. By engaging the employees in a
regular basis, the school of icials will be acting like acompassionate father who welcomes and takes care ofeveryone (Bayod, 2020). By doing so, the employees will
feel that they are valued and important. The constantpractice of an ethics care during pandemic is very crucial
to lessen the antagonism of the employees and transformtheir antagonism to an agonism (Bayod, 2020) in which
they are willing to sacri ice for the school and its
employees. In such situation, we can expect to lessensome dissenting voices of the employees like what thesecollege faculty shared during our interview with them: “I
don’t know honestly. I cannot feel the compassion of theinstitution this time. To me, it seems like the employees need
to work and they will just be paid out from it. I could not
feel the compassion that this school is trying to brag to thecommunity.”“Instead of showing “compassion” they opted to makeme feel not secure. What they feed is that, we should bethankful that we still have work because a lot of schools
closed, like really? Faculty members and staff spend years
working to uplift the current status of the school thinking
that in hard times the school will give back, and what theadministration rubs to each and everyone’s face is that weshould be thankful that we still have jibs, really?
Unbelievable!”
While they are only few and can just be dismissed
easily, we also feel the need to highlight their negative
feelings and experiences because they are so important as
we move forward as a family. In a time of global crisis,
grief, trauma and instability, we need to consider Maslow
before Bloom (Doucet et al., 2020). We should foreground245

health, safety, well-being and belonging irst, before
curriculum, pedagogy and assessment. While this reality
is happening in various institutions, employees are left
with no choice than to thrive and re-create mechanisms tocope with the new normal. Solvason and Kington (2019)
found that cross-school groups could provide schoolleaders with a safety net of emotional support, enhancedby shared values, a lack of hierarchy and openness ofmembers to participate in the work of the group. There is
still hope because solidarity among school management
and the employees are revealed locally and even globally.
Perhaps, reciprocity between school management and theworkers depends on the kind of culture that theinstitution has imbedded to the constituents, so that in
dif icult situations, the core values become more apparent
and noticeable to both parties which results in generosityof sharing and of support.
Insights of employees
We asked our study participants about their insights orrealizations as CJC employees during this pandemic. Mostof them said that the CJC management needs to betransparent and practice participatory approach in thecrafting of policy and direction of the school. For instance,a college faculty said: “I think CJC Management must betransparent to their employees regarding policy that theywanted to implement.” She further said: “as one
community, we must be open to listen to different side sothat we understand and come up with a good solution of aproblem for the bene it of everybody.” This is supported byanother member of the college faculty by sharing thesewords: “My realization is that the pandemic posed a greatchallenge to all of us. As an employee of CJC, it was nodifferent. There are changes in schedule, the mode ofteaching, the delivery of tasks, salaries and others. althoughthese changes are dif icult to some if not all, it is importantthat we adapt. No institution is perfect but I would suggestthat the HR/Administration would be more transparent as
to which direction we are heading, initiative on teacher
assistance and more. Keeping my job is a great help to me
and my family but I am also thinking of my future…”
Another college faculty member shared herrealization: “I realized that I am blessed to be part of the
CJC family despite the matter about overload computationand the like. I am very happy to be in CJC because we areprovided with good health care insurance and we havesalaries on time. However, they could improve in policy
making where it should not be imposed directly but to havetransparent discussion and feedback coming from theconcerned persons.”
To some of the employees, the response of the school
during this pandemic has a signi icant impact on theloyalty and trust of the employees over how the schooltakes care of their employees in the future where similar
or worse situations happen. This is beautifully capturedby the sharing of a non-teaching staff in the following
words: “The institution’s response on dealing with thechallenge and uncertainties we are facing will have an
impact on how employees perform, even the loyalty of theworkers may be challenged, too. For us employees, job
security and inancial stability and support are top
priorities right now… the institution should help resolve

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Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

those concerns in substantive ways. I believe that for years
to come, like business, how you treat your employees will be
remembered even in good times and in bad times.”
Indeed, treating your employees well is important.
That is why for a college faculty, her realization is that CJC
is like a mother who welcomes and loves everyone. These
are her exact words: “CJC is likened to a very responsible
mother, she is like a woman of few words but having a very
big family with members of diverse cultures and principles.
She does not want any member to be lost and left behind.
She is also suffering and struggling so much during thispandemic yet sometimes she tries to set aside some of her
own problems just to cater irst to the different needs of herchildren. She really cares for all her children, yet some ofthem could not see all the things she does that they keep oncomplaining. The leaders are merely instruments to be herheart and hands to reach out to love and care for all.”It is very true that CJC is suffering so much not only
during this pandemic but even before the pandemic
because of the huge devastation from the earthquakes.
The leaders of the school are challenged to the same. They
should practice empathy to the plight of the employees
and prioritize their needs and concerns rather thanbuilding and developing many infrastructures whichmight not be the immediate need during this pandemic.
While they would like to position the school strategicallyin the future, that future is still far and maybe uncertain.
What is certain and immediate is the need of theemployees to be protected and secured. CJC has done that,
but they are challenged to do more – be transparent, apply
participatory approach in management instead of doing
micro-management, practice the ethics of care andcompassion by listening and welcoming everyone eventhose who might be categorized as “prodigal children”. Of
course, when everything has been done to prioritize theneeds of the employees and still some employees are notsatis ied, CJC can just smile and be secure as a faculty inthe Basic Education Department said: “gratitude is really amatter of attitude”.
Gratitude is de ined as a state of thankfulness after
receiving something valuable from others. Broadly, it may
encompass the feeling of thankfulness for those general
positive aspects of life which cannot be attributed to any
speci ic benefactor (Garg,2020). Underlying the critique of
the Epicurean position is a certain understanding ofgratitude as ‘the proper or called-for response in abene iciary to bene its or bene icence from abenefactor’ (Manela, 2015). Gratitude understood in thisway is only appropriate when the bene it we receive wasintended to bene it us. If we unintentionally or
coincidentally bene it from something, then it seems
strange to say that we owe that person a debt of gratitude(Wood, 2020). Whether or not there is an immense
mutuality or trade-off, our values will determine the kindof persons that we are. Some are accustomed withexpressing gratitude even on little favors and others only
manifest this act when they receive something at theiradvantage.

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Conclusions
The Covid-19 pandemic has affected Cor Jesu College
which is still in the process of recovery from thedevastation because of earthquake. But the crisis, indeed,
has revealed the attitudes of people in the organizations.
On the part of the management, they devised amechanism to ensure that no one will be left behind. Theyarranged a kind of system during the pandemic that nonteaching staff in the organization would bene it (Rawls,
1999). Taking something from the other person which heor she has been receiving and giving this to the others
might be a form of injustice against the former. But since
the bene it of unjust arrangement is for the other workers
to continue their work, it is fair according to Rawls (1999)
conception of justice. No doubt, the management had thenoblest intention in mind in doing this. However, theymight need to consider that there are collective decisions
to make and this entails consultation, dialogue andparticipation from the stakeholders so that there will begreater sense of ownership of the agreed schemes andmechanism to address the adverse effects of the pandemic
to the school operation. If they consider the employees as
members of the family, they must be consulted too. They
should be transparent in discussing the situation of theschool so that the employees will really understand. But
still, they are fortunate because almost all employees havethe heart to care for the suffering school. For sure, manyof them suffered. Many of the faculty members wereaffected by the sudden implementation of the policy to cut
the overload. But they have a compassionate heart too. In
spite of the pain and the frustration of not being
consulted, they tried to understand the situation of theschool. Indeed, they too, care for the school. Thus, it might
be good that when things will go back to its usual routine,
when enrollment will rise, the school will sit down andhave a heart-to-heart dialogue and crucial conversation
with the administration, faculty and staff. Together, they
have to evaluate some policies and programs. Maybe, it
might be the right time to revisit the policies as regards to
the giving of overload, and think of another program toensure that employees will feel protected and secured
emotionally, physically, intellectually and economically sothat they will retain the compassionate employees thatthey have. Certainly, satis ied and motivated employees
are the ones who energize, direct and sustain their
behavior which results in high morale and leads to
dedication, loyalty, and the desire to do the job well.
References
Baert, S., Moens, E., Sterkens, P., Weytjens, J., and Sterkens, P.
(2020) How Do We Think the COVID19 Crisis Will Affect Our
Careers (If Any Remain)? GLO Discussion Paper, No. 520, Global
Labor Organization (GLO), Essen
Bayod, R. (2020). Ethics of Care and Philippine Politics during
Covid-19 Outbreak, Eubios Journal of Asian and International
Bioethics, 30 (3) (April 2020), pp. 69-76.
Derksen, M. (2020), Michael Ryan (WHO Health Emergencies
Programme) at Daily Press Brie ing on COVID 19 March 13th
2 0 2 0 [ V i d e o ] , Yo u T u b e , a v a i l a b l e a t : h t t p s : / /www.youtube.com/ watch?v5AqRHH6e-y6I
Doucet, A., Netolicky, D., Timmers, K. and Tuscano, F.J. (2020),
Thinking about Pedagogy in an Unfolding Pandemic: An
Independent Report on Approaches to Distance Learning
during COVID19 School Closures, available at: https://
issuu.com/educationinternational/docs/2020_
research_covid-19_eng.

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Garg, N. (2020). Exploring role of gratitude in developing teacher
leadership in Indian universities. International Journal of
Educational Management, 34(5), 881–901. doi:10.1108/
ijem-07-2019-0253
Lee, H. (2021). Changes in workplace practices during the
COVID-19 pandemic: the roles of emotion, psychological safety
and organisation support. Journal of Organizational
Effectiveness: People and Performance.
Manela, T. 2015. ‘Gratitude’. In E.N. Zalta (ed.), Stanford
Encyclopedia of Philosophy (Spring 2015 Edition). https://
plato.stanford.edu/archives/spr2015/entries/ gratitude/
Netolicky, D. M. (2020). School leadership during a pandemic:
navigating tensions. Journal of Professional Capital andCommunity.
Rawls, J. (1999). “A Theory of Justice”, Revised Edition, Harvard
University Press.
Solvason, C. and Kington, A. (2019), “Collaborations: providing
emotional support to senior leaders”, Journal of Professional
Capital and Community, Vol. 5 No. 1, pp. 1-14.
Wood, N. (2020). Gratitude and Alterity in Environmental Virtue
Ethics. Environmental Values, 29(4), 481-498.
Wu, A. W., Connors, C., & Everly Jr, G. S. (2020). COVID-19: peer
support and crisis communication strategies to promote
institutional resilience.

Obituary for Dr. Frank Yeruham
Leavitt (1940-2019)f

It is with sadness that we have lost one of the founding
editorial board members of EJAIB, who passed away at theage of 79 years after a struggle with cancer. After having
written about the bioethics of palliative care for many
years, in the end we lost Frank. Frank was especially
active in EJAIB in the years 1990-2005, being a solid
source of support writing many commentaries on other
scholars’ papers, and stimulating others with a wide rangeof topics from the Rights of Rocks to martial arts, andspirituality and cross-cultural bioethics..
Frank served as the Chairman, Centre for Asian andInternational Bioethics, Faculty of Health Sciences, Ben
Gurion University of the Negev, Beer Sheva, Israel; andalso as the irst Vice President for Asian Ethnic Minorities
for the Asian Bioethics Association. He participated in thenine Tsukuba International Bioethcs Roundtables, andcontinued to come toTsukuba and Kushiro, and otherlocations in Japan. Frank was also active in theInternational Society for Clinical Ethics. I last met Frank in
Kushiro, Hokkaido, and he is also sorely missed byProfesor Tsuyoshi Awaya, the convener of that series ofbioethics actvities, as well as many person’s lives he has
touched over time.
I refer readers back to the obituary that Frank wrote
for two of our mentors that I had the pleasure to be
introduced to and meet thanks to Frank, Professor John
Goldsmith and Lord Rabbi Immanuel Jakobovitts. We will
miss Frank’s wisdom and informality.
Frank wasprepared to write original articles, and often enjoyed toplay the Devil’s advocate, but helped nurture many
students and scholars through discourse and teaching.
Thanks to the cross cultural approach but Frank had tolearning from many different cultures and different typesof people, we could develop a broader and more inclusive

247

approach to Bioethics across the world, both in theinternational Association of Bioethics and in the Asian
Bioethics Association. I had the pleasure to visit Ben
Gurion University of the Negev, and many otherinstitutions there,-4 times as part of the Japaneseinternational research grant project to develop a Bioethics
across Asia. We also travelled widely in India, with thelate Professor Jayapaul Azariah.
I visited many parts in the hotly contested areas ofIsrael and Palestine, before the Wall was build. It is still apart of a world where we really need to pray for peace sothat people will understand how we have to live together.
Thanks to Frank I also went to Gaza twice, and it is withpain that we continue to say these senseless acts ofviolence by both sides, in the framework of the need forbroad recognition of the state of Palestine, the so-called
two state solution.
All people have a right to live indignity, and people of different faiths need to live
togetherin this very special part of our world.
- Darryl Macer

Chief Editor: Darryl R.J. Macer
Associate Editor: Nader Ghotbi
Editorial Board: Akira Akabayashi (Japan), Sahin
Aksoy (Turkey), Martha Marcela Rodriguez-Alanis(Mexico), Angeles Tan Alora (Philippines), Atsushi Asai
(Japan), Alireza Bagheri (Iran), Gerhold Becker(Germany), Rhyddhi Chakraborty (India/UK), Shamima
Lasker (Bangladesh), Minakshi Bhardwaj (UK),
Christian Byk (IALES; France), Ken Daniels (New
Zealand), Ole Doering (Germany), Amarbayasgalan
Dorjderem (Mongolia), Hasan Erbay (Turkey), Soraj
Hongladarom (Thailand), Dena Hsin (Taiwan), Rihito
Kimura (Japan), Abby Lippman (Canada), Umar Jenie(Indonesia), Nobuko Yasuhara Macer (Japan), Masahiro
Morioka (Japan), Anwar Nasim (Pakistan), Jing-Bao Nie(China, New Zealand), Pinit Ratanakul (Thailand), Qiu
Ren Zong (China), Hyakudai Sakamoto (Japan), Sangyong Song (Republic of Korea), Takao Takahashi( J a p a n ) , N o r i t o s h i Ta n i d a ( J a p a n ) , A n a nya
Tritipthumrongchok (Thailand), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republicof Korea).
EJAIB adopts and complies with the Committee on
Publication Ethics (COPE) Publication ethics andmalpractice policy. Our policy is on the EJAIB website.
All potential authors should have read these guidelines
and by submission of an article for publication you
acknowledge that you have complied with this policy.
Violations will be handled in proportion to the intention
and seriousness of the violation. Registered address of
EJAIB: P.O. Box 16 329, Hornby, Christchurch 8441,
New Zealand
For forthcoming conferences see: www.eubios.info or
www.ausn.info Email to Darryl@eubios.info

International Public Health Ambassadors
https://www.ausovereignnations.org/
international_public_health_ambassadors
Email to: provost@ausn.info

248

Eubios Journal of Asian and International Bioethics 31(4) (May 2021)

EJAIB Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations(AUSN), https://www.ausovereignnations.org
Email: darryl@eubios.info

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