Eubios Journal of Asian andInternational Bioethic
EJAIB Vol. 31 (7) November 202
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).

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Editorial: Lessons to learn from 2021
329
- Darryl Macer
Ethno-bioethics and indigenous traditional knowledge:
Use of medicinal plants among indigenous communities
living in peninsular Malaysia
330- Yew Wong Chin, Sivapalan Selvadurai andRavichandran Moorthy
Egg yolk consumption and the risk and severity of
COVID-19: Need for research
333-Shamima Parvin Lasker, Shah Md Mahfuzur Rahman,
Md Abdul Jalil Ansari , Md Jafurullah and Arif Hossain
Use of convalescent plasma in COVID-19, a bioethicalperspective
336- Elsa Mariana Zúñiga Lara, Luis Giovanni Rosales
Pichardo, Miriam Deyanira Rodríguez Piña and Hugo
Mendieta Zerón
Would a ‘vaccine passport’ work in the Philippines? 341- Joefer Ganuelas Maninang
Staying positive amidst fears, anxieties and frustrations:
Travails of people in isolation and quarantine centers in
Davao del Sur
347- Rogelio P. Bayod, Rosemarie S. Gonzales, Erikka June
Forosuelo and Romulo Birondo
Psychological stress in mothers of children
undergoing stereotactic thermal coagulation for
hypothalamic hamartoma
356- Makiko Tsubokawa, Mai Yamada and Tomoko Sumiyoshi
Physician Privacy and Patient Bene it360- Saeedeh saeeditehrani, Mina Forouzandeh, NazafarinGhasemzadeh, Roya Rashidpouraie
Crispr-Cas9: The need for law reform in Australia
366-Aya McKenzie and Patrick Foong
COVID-19 PPE waste management: A looming ecologicalcrisis in the Philippines?
369- Aldrin F. Quintero
Re-education of responsible parenthood to a ruralcommunity373- Daryl Niko L. Cempron
Book Review: Harmonizing bioethics -- global ways inintegrating people and values (Michael Cheng-tek Tai) 377- Tsuyoshi Awaya
Medical ethics course for resident: a preliminary study- Sukran Sevimli
378
EJAIB Editorial Board
385
Ordering information
386

Editorial: Lessons to learn from 2021
As the world continues to face the COVID-19
pandemic, through the Delta variant of 2020 and the
Omricon variant now sweeping the world, we should havebeen reminded of the basics of evolution and thecoexistence of life together, not only all people, but all
forms of life. Hundreds of other species of animals, notonly mammals, are also being infected with the virus thatcause COVID-19. We can expect co-evolution of life as weface the coming year.
This last issue of 2021 includes a number of papers on
various issues in medical ethics and bioethics. First we
start with a paper on ethnomedicine and IKS from
Malaysia, which makes us re lect on the wide reservoir ofboth herbal medicines, as well as the associated wisdomof people. This is followed by two papers on some ethicalissues of possible treatments. EJAIB does not endorse anytreatment but is open to discussion of potential therapies
and the associated ethical issues.
As a growing number of readers will no doubt bealready using a vaccine passport, especially if traveling,some still have doubts about such passports. We havealready seen attempts to cheat the system by use of false
passports, and the criminal case in Germany of an anti-vac
nurse who seems to injected thousands of vaccine
recipients with saline instead of actual vaccine. The
WeCope statements of 2020 and 2021 have stood the testof time, and I still encourage readers to work together tohelp develop further statements and re lection from across-cultural perspective.
We have perspectives from Japan, Iran, Mexico,
Bangladesh, the Philippines, Malaysia, Turkey andAustralia. There are papers on law reform as well as
actual implementation of existing ethical principles andlaws, and education. Please enjoy this celebration of crosscultural bioethics and the variety of perspectives as a
global exercise in bioethics scholarship as we complete
the 31st volume of EJAIB! I also look forward to further
discussion both live in the conferences and on the pagesof the journal. Please re lect on the lessons we need tolearn and share them.
- Darryl Macer (darryl@eubios.info)sContents

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Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

Ethno-bioethics and indigenous
traditional knowledge: Use of
medicinal plants amongindigenous communities living inpeninsular Malaysia- Yew Wong Chin

Center for Research in Development, Society andEnvironment, Faculty of Social Sciences and Humanities,
National University of Malaysia (UKM), Malaysia
Email: vivienyew@ukm.edu.my- Sivapalan Selvadurai
School of Liberal Arts and Sciences, Faculty of Social
Sciences and Leisure Management, Taylor's University,
Malaysia
Email: sivapalan.selvadurai@taylors.edu.my- Ravichandran Moorthy
Centre for History, Politics, and International Affairs(SPHEA), Faculty of Social Sciences and Humanities,
National University of Malaysia (UKM), Malaysia
Email: drravi@ukm.edu.my
Abstract
Ethno-bioethics and indigenous traditional knowledge
assist in rediscovery of new knowledge and practices of avariety of knowledge, inventions, and traditions by local
communities worldwide. This paper documents somedifferent types of medicinal plants found in the rainforestof Malaysian National Parks and how they have been used
to treat diseases for generations by the indigenous
community (Batek) of ‘Our Village’, residing in the state ofPahang in West Malaysia. As the Batek community has
been living in the forest for many generations, thetraditional knowledge of medicinal plant use documented
in this study is considered valuable knowledge, as little
work has been done to document the oral traditional
knowledge of this community. Employing a qualitative
approach, the study lasted for about ten months from2017 to 2018. In-depth interviews were conducted in the
Malay language and lasted an average of about 45 minutes
to one hour. The study concludes that traditional
knowledge of medicinal plants and their use by the local
community was transmitted orally from generation to
generation. In an indigenous traditional context, culture
has played a role in establishing and transmitting a bodyof indigenous knowledge, beliefs, and practices withregard to the use of locally available medicinal plants formaintaining health and healing diseases.

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Introduction
The indigenous people of Peninsular Malaysia, commonlyreferred to as ‘Orang Asli', have traditionally been using awide range of medicinal plants to either maintain theirhealth or to heal certain diseases commonly found among
the indigenous communities. Medicinal plants haveparticularly been used for protection against various
diseases for thousands of years by the indigenous
settlements living in the interior regions of Malaysia’s
largest National Park (Taman Negara).
Herbal medicine is practiced globally, where theselection of medicinal plants through empiricalmethodology for generations has amply shown its ef icacy
towards healing of many diseases and ailments in the past
thousands of years. The use of herbal medicine peaked in
the 19th century but was then overshadowed by syntheticorganic chemistry in the 20th century.
Now, herbal medicine has grown in popularity again
due to some inadequacies of orthodox medicine, such as
the prohibitive cost of treatment, toxicity of treatment,
especially in treating cancer, failure in treating somecancers, and ineffectiveness against some chronic
illnesses like rheumatoid arthritis and SLE (Yew and Noor,
2015). Nevertheless, herbal medicine is still deemed as
dietary supplements in the United States but not scienti ic
medicine due to limited scienti ic research con ined to afew medicinal plants and largely just at the in-vitro stage.
In other countries, like many Asian, African, and SouthAmerican countries, dual medical systems, namely
orthodox and traditional medicine, exist side by side.
Before the knowledge of some medicinal plants is lost
permanently due to the passing of indigenous healers or
herbal practitioners, and the loss of once abundant lora
and fauna due to economic development, anthropologists
need to document and capture the essential knowledge of
medicinal plants and the traditions of cultivating,harvesting, and preparing them.
Ethno-bioethics and indigenous traditional knowledge
offer information from various indigenous ways ofexisting and future projects that are founded on ethicalviews developed from practical experiences in communal
life, traditional knowledge of indigenous and local groups'
knowledge, inventions, and traditions all over the world.
Traditional knowledge is passed down orally fromgeneration to generation, derived from decades ofexperience and suited in the local culture andenvironment. Over the last several decades, indigenous
traditional knowledge has gained visibility with new
research interests by local and international researchers.
The importance of the holistic approach of indigenous
knowledge systems was emphasized by the UN.
Indigenous knowledge systems signi icantly contribute to
the preservation of biological and cultural diversity,
poverty alleviation, con lict management, food andnutrition security, and ecosystem functions, andcontribute to indigenous peoples' resilience in mitigating
the impacts of climate change (United Nations Permanent
Forum 2019).
Worldwide indigenous traditional knowledge inmedicinal plants use
Case 1: Chinese herbal medicine
The use of medicinal plants for healing in China has beenpracticed for about 3000 years. Shennong is known as thefounder of Chinese herbal medicine. It is known widelythat through his empirical practice of trying out hundreds
or perhaps thousands of herbs, he was able to instruct
and guide his people on the use of medicinal plants (Chan,
1995). His life-long work was compiled in Shennong
Materia Medica (Shen Nong Ben Cao Jing ~220 CE).
Traditional Chinese medicine irmly believed in holism
and balance (Yin and Yang) and subscribed to thefundamental “Five Elements Theory”, wherein organs of
the body are inter-related (Chan, 1995). Thus, when anEubios Journal of Asian and International Bioethics 31(7) (November 2021)
organ is in imbalance, such as in the state of in lammation,
it will affect another organ connected to it. Thus, when theliver suffers (wood element), it will bring imbalance to theheart ( ire element) to a lesser extent too. Treatment of
the liver by herbs will play the principal role, andtreatment of the heart by herb will assume an associaterole. The amount of herb used is determined by theseverity of the imbalance and is tailored to each individual
patient. Also, treatment by symptom is extended to nonsymptom organs too.
In the advent of improved orthodox medicine,traditional Chinese medicine has seen innovations tobecome scienti ic and improve its ef icacy and delivery.
The attempt to treat malaria by rummaging through thevast array of 2,000 Chinese herbs yielded Arthemisia
annua (Qinghao in Chinese) and a reference to an ancient
text by Ge Hong (284-346 CE, A Handbook of
Prescriptions for Emergencies) has led to a drug,
artemisinin, earning the Lasker award and Nobel Prize in
Medicine for Tu Youyou in 2015 for effective malaria
treatment (Neill, 2011; Su & Miller, 2015).
Case 2: Indigenous peoples’ medicine in Canada
The indigenous peoples of Canada have identi ied over
400 different species of medicinal plants for the treatmentof various ailments. Also, they have devised some
protocols for foraging, preparation, and application of
medicinal plants with some spiritual elements (Uprety etal., 2012). Europeans and other immigrants to Canada
bene ited from the plant medicines of the indigenous
people. With the introduction of new diseases by
newcomers to Canada, indigenous people were able to use
existing medicinal plants as well as develop new plant
medicines to combat diseases such as smallpox,
tuberculosis, measles and some venereal diseases.
As highlighted by Nancy J. Turner (2014), some ofthese plant medicines have been adopted for current
orthodox medicine usage, such as cascara bark as alaxative medicine and anticancer drug, Taxol derived from
Yew trees, and many others. Tobacco, sage, cedar andsweetgrass are some of the fundamental and important
medicines for indigenous people in Canada.
Case 3: Bush medicines
Bush medicine is the traditional medicine of theaboriginal and Torres Strait Islander peoples of Australia,
where herbal medicine is a major component. The
indigenous peoples of Australia also adopted a holistic
view of healing where physical, emotional, social, andspiritual aspects are deployed. In bush medicine, plantmaterials such as bark, leaves and seeds are used. For
example, turmeric is now used for its anti-in lammatory
effect (Shahid et al., 2010).

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Case 4: Native American medicine
Native Americans have a long history of using nativeplants for healing purposes. They usually gathered
medicinal plants from their surroundings and sometimes
traded herbs from distant lands. New immigrants to
America found many herbal remedies superior to theirown (Cohen 2006). Nowadays, American people havewarmed to the use of medicinal plants as part of331

complementary medicine. It is found that of the 10 topselling herbal dietary plants, 7 of them are used by Native
Americans, and as many as 200 medicinal plants used by
Native Americans are still in use in the current era(Borchers et al., 2000).
The indigenous peoples of Peninsular Malaysia consistof three main ethnic groups: Negrito, Senoi and ProtoMalay. They can be further sub-divided into 18 sub-ethnic
groups (Carey, 1976). The use of medicinal plants is
widely practiced among all 18 sub-ethnic groups.
Nevertheless, there is no uniformity of medicinal plants
and healing methods among them and no full written
records of the types and total number of medicinal plants
regarding each sub-ethnic group. Thus, this paper aims to
document the different types of medicinal plants found in
the rainforest of Taman Negara and how they have beenused to treat diseases for generations by the indigenous
community (Batek) of the ‘Our Village’ in West Malaysia.
Methods
Study Area: The study sites included three settlementscharacterized by a hilly landscape, mountains, waterfalls,
rivers, and forests. Overall, in the study settlements, mostof the villagers are of the Batek tribe, with Jah Hut living
nearer to the town. The villagers speak their local
indigenous dialects, respectively. The Malay language has
been the common language used when communicatingwith people outside their tribe. Most indigenous people
who live in the settlements are dependent on agriculture,
forest products, and work as forest guides for visitors to
the National Park of Malaysia (Taman Negara).
Sampling: The sampling method combined both
purposive and snowball sampling techniques. First, iveelderly villagers were purposively chosen in the study
area "Our Village". Three interdependent criteria wereidenti ied for selecting the appropriate informants: (1)regular indigenous man/woman collecting forest produce(including medicinal plants) as a source of cash income;(2) indigenous man/woman who are knowledgeable
about medicinal plant species and their usage; and (3)indigenous man/woman growing medicinal plants in thehomestead of the study village. Second, as most middleaged villagers were spending many weeks in the forest
collecting forest products such as rattan for their own
economic support, the researchers approached anothersettlement, which is about a kilometer away. Anotherseven informants aged 40 to 50 years old wereinterviewed individually. Finally, six more informantsfrom three age groups (30s, 40s and 50s) from asettlement much nearer to a small town in the National
Park shared valuable information on indigenous
knowledge about the use of medicinal plants compared to
informants of the previous two settlements. For each of
the settlements, a key informant was interviewed, and therest of the informants were selected by snowball sampling(Corbin and Strauss, 2015). A total of 18 informants (8female and 10 male) were interviewed aged between 35
and 65 years.
Data Collection: The study lasted about ten months from2017 to 2018, and was carried out in the interior region of
Taman Negara, employing a qualitative approach with two
purposes: First, as an anthropological study using in-332

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

depth interviews to explore the names and functions ofeach medicinal plant, with information obtained from 18
elderly men and women of ‘Our Village’. Second, as an
exploration of the local culture in relation to traditional
knowledge utilized in the planting and preparing of the
medicinal plants. Key informants in the community
knowledgeable about medicinal plant use, indigenous
culture, and traditions provided data on medicinal plants
and their use. In-depth discussions were encouraged andundertaken during individual interviews. In-depth
interviews were conducted in the Malay language andlasted an average of 45 minutes to one hour. Several
questions about the anthropological study would be asked
if informants were exposed to the Western healthcare
system and thus might have had different beliefs andperceptions about medicinal plant use. Ethnographic
studies on medicinal plants include plant informationsuch as local names of species, parts used, mode of
preparation and disease treated. The use of medicinal
plants as home remedies for common ailments ordiseases is based on the use of parts of plants or plant
extracts.
Results
15 species of plants (Table 1) have been reported as
medicinal by the indigenous sub-ethnics in the rainforestof Peninsular Malaysia. The medicinal plants wererecorded based on uses by the sub-ethnics of Batek and
Jah Hut. Leaves and roots are the most common parts thathave medicinal uses.

ffDiscussion
The indings of the study highlight two important
observations. First, traditional medical knowledge of
medicinal plants and their use by the local community
was transmitted orally from generation to generation. In
an indigenous traditional context, culture plays its role inestablishing and transmitting a body of indigenous
knowledge, beliefs, and practices regarding the use of
locally available medicinal plants for maintaining healthand healing diseases (Vivien and Noor, 2013). Key
informants’ in-depth interviews and participant
observations (Corbin and Strauss 2015) reveal how the
local community perceives, understands, and uses
medical plants for their health and against diseases basedon cultural interpretations. However, the culturalinterpretations of pain, health and disease may lead themto use other methods until the pain or the disease
disappears. When the indigenous community cannot inda cure or remedy, they will seek help from a shaman orturn to a professional health provider. Thus, medical
pluralism is practiced among the indigenous community
until a cure is found (Yew 2015). Second, the cultural
construction of health, disease, healing, and the use of
medicinal plants indicates a holistic approach thatconsiders health, disease, and healing as a process withinterrelationships among nature, spirit, society, and theindividual. As such, in the context of indigenous culturalbeliefs, healing involves an individual, society and theforces of nature.

Conclusion
Ethno-bioethics and indigenous traditional knowledge
provide for the rediscovery and practices of a variety ofknowledge, inventions, and traditions by local
communities. Indigenous medicinal plants are found to be
widely used among the indigenous communities in
Peninsular Malaysia. The process of documentation ofindigenous medicinal plants could be further explored forany possibility of commercial use as modern medicines.
Acknowledgements
This study was supported by MPOB-UKM Endowed Chair,
Research Grants (EP-2017-061 and EP-2019-054). The authors
thank all the indigenous participants for sharing their usefultraditional knowledge on medicinal plants use.

References

Borchers, A. T., Keen, C. L., Stern, J. S., & Gershwin, M. E. (2000).
Inflammation and Native American medicine: the role ofbotanicals. Am J Clin Nutr., 72 (2), 339-347.
Carey, I. (1976). Orang Asli: The aboriginal tribes of Peninsular
Malaysia. New York: Oxford University Press.
Chan, K. (1995). Progress in traditional Chinese medicine. Trends
Pharmacol. Sci., 16, 182–187.
Cohen, K. (2006). Honoring the medicine: An essential guide to
Native American healing. New York, NY: Ballantine Books.
Corbin, J., & Strauss, A. (2015). Basics of qualitative research:
Techniques and procedures of developing grounded theory.
Thousand Oaks, CA: Sage Publications, Inc.,.
Dentan, R. K., Endicott, K., Gomes, A. G., & Hooker, M. B. (1997).
Malaysia and the Original People: A Case Study of the Impact ofDevelopment on Indigenous Peoples. Boston: Allyn & Bacon.
Hood, S. (2006). People and Tradition: The Orang Asli Origins,
Identity and Classification. Kuala Lumpur: Archipelago Press.
Neill U. S. (2011). From branch to bedside: Youyou Tu is awarded
the 2011 Lasker similar to DeBakey Clinical Medical ResearchAward for discovering artemisinin as a treatment for malaria. J.
Clin. Investig., 121, 3768–3773.
Shahid, S., Bleam, R., Bessarab, D., & Thompson, S. C. (2010). “Ifyou don't believe it, it won't help you: use of bush medicine intreating cancer among Aboriginal people in Western
Australia". Journal of Ethnobiology and Ethnomedicine, 6: 18.
Su X. Z., Miller L. H. (2015). The discovery of artemisinin and theNobel Prize in Physiology or Medicine. Sci. China Life
Sci., 58, 1175–1179.
Turner, N.J. (2014). Ancient pathway, ancient knowledge:
Ethnobotany and ecological wisdom of indigenous people ofNorthwestern North America. Montreal, Canada: McGillQueen’s University Press.
United Nations Permanent Forum on Indigenous Issues (2019).
Indigenous Peoples, Indigenous Voices, Fact Sheet. Available
from: <https://www.un.org/esa/socdev/unpfii/documents/
5session_factsheet1.pdf>
Uprety, Y., Asselin, H., Dhakal, A., & Julien, N. (2012). Traditionaluse of medicinal plants in the boreal forest of Canada: Review
and Perspectives. Journal of Ethnobiology and Ethnomedicine, 8(1), 7.
Vivien, Y. W. C., & Noor, NAM. (2013). An examination ofsociocultural factors influencing lifestyle, health and healthseeking behaviour–A case study of Malaysian Chinese cancer
survivors. In Proceeding of the International Conference on
Social Science Research, ICSSR.
Yew, V. W. C. (2015). Collecting qualitative research data on healthseeking behaviour of Peninsular Malaysia’s aboriginal people.
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Online – Malaysian Journal of Society and Space, 11 (1),183-193.

Table 1: Indigenous medicinal plants used in treatment
Scienti ic Name

Local Malay
dialect

Plant partusedMode of Preparation & medicinal uses

Psidium guajava

Jambu Batu

LeavesFresh plant parts chewed after cleaning in diarrhea

Eurycoma longifolia

Tongkat Ali

Root

Roots boiled in water frequently consumed to lower bloodpressure

Labisia pumila

Kacip Fatimah

Whole plant

Whole plant boiled with water for regular hot water bath tostrengthen women’s body after giving birth (for smoothblood low)Musa

PisangFlowerConsume as salad or stir-fry for anemia

Manihot esculenta

Ubi Kayu

LeavesStir-fried with choice of sauce and consumed regularly totreat stroke, migraine

Raf lesia

Bunga Pakma
Raf lesia

FlowerFlower to be dried and boiled for women who have justgiven birth to aid in recovery, for diarrhea, to treat thyroid

Carica papaya

Betik

Bunga

Flower boiled with water for lowering blood pressure

Saccharum of icinarum

Tebu

Branches

Sugar cane juice obtained by crushing plant parts for regularconsumption and relief from body pain

Cocos nucifera

KelapaJuice

Coconut juice to relieve hangovers

Muntingia calabura

Pokok Cherry
Malaysia

LeavesLeaves boiled in water frequently consumed to lower bloodpressure

Chromolaena odorata

Pokok Kapal
Terbang

LeavesPlant parts crushed to obtain a soft moist mass generally
used externally to stop bleeding

Parkia speciosa

Petai

Seeds

Eating the seeds fresh to treat kidney disorders

Morinda citrifolia

Mengkudu

Fruit

Fruits boiled in water and consumed for diabetes

Hibiscus rosasinensis

Bunga Raya

FlowerFlowers crushed to obtain a soft moist mass generally used
externally to treat migraine and headache

Alpinia galanga

Lengkuas

Leaves/fruit

Fruit cooked with meat to improve digestion

Egg yolk consumption and the risk
and severity of COVID-19: Needfor research5- Shamima Parvin Lasker1, Shah Md Mahfuzur Rahman2,

Md Abdul Jalil Ansari 3, Md Jafurullah4, Arif Hossai5
1. Professor & Head of Anatomy, Shahabudddin Medical
College and Vice President, Asian Bioethics Association(Bangladesh), Corresponding author Email:splasker04@yahoo.com
2. Head, Academic Wing (PRL), Institute of Public HealthMohakhali, Dhaka, Bangladesh
3. Principal and Professor of Endocrinology, Shahabuddin
Medical College & Hospital, Bangladesh
4. Director & Professor of Biochemistry, Shahabuddin
Medical College, Dhaka, Bangladesh
5. Professor & Course Co-coordinator, International
Affairs and Human Rights, Etrat University, Vice President,
Asian Bioethics Association (South Asia) and Vice
President of Bangladesh Bioethics Society

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Abstract
Vitamins A, E, D & K, and zinc and selenium are known toincrease immunity against infections. Recent researchshowed that people with compromised immune systems
are at a greater risk to suffer from the novel coronavirus.
Egg yolk contains vitamin A, E, D, K, and zinc andselenium. Many of coronavirus quarantine facilities,
patients in recovery from the diseases and healthcare
workers are offered eggs in their daily meals to boost up
immunity. General people are encouraged to take vitamin
A, D, C, K and zinc to boost up their immunity. There may
be a relation between consumption of dietary
micronutrients and a rapid recovery from COVID 19 thathas not been studied until recently. Available data
regarding egg yolk consumption and risk and severity of
COVID-19 are inconclusive. Considering the present
outbreak of COVID-19 throughout the world, studies inthis area are direly needed. Prioritizing such studies have
ethical importance as well. Such studies will be of utmost
interest in prevention, management, and development of
nutritional guidelines. Furthermore, it may havetremendous impact on the policies to ight against
COVID-19.
Introduction
COVID-19 has affected more than 222 countries of theworld, infected more than 217 million people, and taken
the lives of 4.5 million patients as reported till August 30,

334

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

20211. Old, urban, and inancially solvent people are more
vulnerable to COVID-19 than young, rural, andeconomically marginalized population 2,3,4. Scientists are
studying the etiology of risk and severity of COVID-19.
Researchers have proposed different causes for varying
severity of infection from corona virus. Warm-humid
conditions5, BCG (Bacillus Calmette-Guérin) vaccine 6,7,
higher young population 8 and low testing rate9 might
have caused a lower rate of COVID-19 cases indeveloping countries. All are assumption without strong
scientific basis.
However, people with compromised immune systems
are at a greater risk with coronavirus. Vitamins A, C, D, E,
K, and zinc and selenium enhance immunity against
infection10. Egg yolk contains vitamins A, D, E, K, zinc, andselenium 11,12. Many physicians prescribe eggs in their
daily meals to boost up immunity against coronavirus inquarantined people, patients in recovery and healthcare
workers assuming that egg consumption will protect themfrom COVID-19 infection in contacts. General people aresuggested to consume vitamins A, D, C, K and Zink toboost up their immunity. As immunity is considered
protective against all type of infections, it may also be
applicable to COVID 19. However, adequate data is notavailable. There may be relations between egg yolk
consumption and early recovery or not getting infected by
COVID-19. No data is available regarding egg yolk
consumption and risk and severity of COVID-19. Research
priority often extends to ethical consideration. All aspectsof human live have been negatively affected by COVID-19
pandemic in the world. In this circumstance research on
how to ight against it may deserve ethical priority.
Methodology
A retrospective normative research was done bysystematic literature review from July 2021 to September
2021 to understand whether there were any relationships
between egg yolk consumption and risk and severity of
COVID-19. English-language articles were reviewed only.
Medline, ISI, Web of knowledge, Web of Science, Google
scholar, Science Direct, Embase and Cochrane databasewere used as search engines for literature. Keywords forsearch were egg yolk, egg consumption, immunity,
Covid-19 pandemic.
Ethical clearance was obtained from Bangladesh Medical
Research Council. It is a retrospective review research,using secondary data; no ethical issues were present.
Plagiarism was checked by iThenticate software.

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Discussion:Composition of egg yolk: A single egg yolk contains all
vitamins except vitamin C and vitamin B3 (Niacin) 11,12. It
is composed of 50% yolk proteins and less than 10% yolk
lipids. It has immunoglobin Y-IgY, vitamins A, D, E and K,
lecithin, xanthophylls (for vision), calcium, potassium,iron, phosphorus, zinc and selenium 12. But people havethe misconception that egg yolk is full of fat andcholesterol anticipating heart diseases, 13 diabetes 14 andweight gain 15. Actually, its fat provides a major source ofenergy. 1 gram fat provides twice the energy from protein
and carbohydrates 16. Most organs like heart, liver, kidney,and skeletal muscles get energy from fatty acid oxidation

for normal functioning. Skeletal muscles and adipose
tissue cells also utilize glucose after a regular meal only 17.
Fat and immunity: Essential fatty acids (EFAs) e.g.,linoleic acid (Omega-6) and alpha linolenic acid(omega-3) decrease allergic reaction and in lammatory
activity, increase immune response, decrease bloodpressure 18 and prevent from breast cancer 16. EFAs areconverted into prostaglandins and eicosanoids, which
control biochemical reactions inside cells 19. EFAs also
contain all fat-soluble vitamins (FSVs), essential for
proper body functioning 10. In addition, FSVs and calcium
are absorbed from the intestine in the presence of fat.
Moreover, FSVs are antioxidant, and have a clear role inimmune function by producing antibodies. Antioxidants
play an important role in the prevention of cancer 20 as
well. Therefore, fat is essential for life. Egg yolk is anample source of fat.
De iciency of FSVs and immunity: Vitamin A keeps
moist the mouth, respiratory passage and skin. De iciencyof vitamin A causes dry mouth, rough skin, respiratory
infection 13, night blindness, faulty tooth development,
and slower bone growth 10. Vitamin A de iciency
d e c re a s e s n e u t ro p h i l d e ve l o p m e n t , i n c re a s e sin lammatory cytokine release by macrophages anddecreases the number of natural killer cells and their lytic
activity leading to decreased immunity. Therefore,
communities may suffer a high prevalence of infection due
to vitamin A de iciency 20.
Vitamin D is normally produced by the skin inpresence of cholesterol when exposed to sunlight. So,
vitamin D is known as the sunshine vitamin. Staying
indoors and longtime sedentary indoor work reduce
blood vitamin D levels21. Almost 50% of the population
who remain indoor, use sunscreen, and reside in northern
climates had vitamin D de iciency linked to respiratory
infection 10. Vitamin D de iciency causes rickets inchildren, osteoporosis, osteomalacia (muscle and bone
weakness), high blood pressure, autoimmune diseases,
type II diabetes, infectious disease, and cancer 22. Vitamin
D supplementation decreases acute respiratory tract
infections by 12% to 75% including both the seasonal23
and pandemic lu caused by H1N1 virus in 200924.
Vitamin D supplementation greater than 1000 IU
improved immune functions and decrease lu symptoms
and recovery faster from infection 25. Vitamin D isrequired to enhance calcium absorption from intestinethat improves immunity13.
Vitamin E is an antioxidant that protects human beings
against infection 16. Vitamin E decreases the risk of heartdisease, Alzheimer’s disease and cancer 10. Vitamin K is
crucial for blood clotting and promotes growth of thebone. Without enough vitamin K, hemorrhage can occur
17. One can get vitamin A, D, E and K from a single egg yolkfor protection from infection.
Egg yolk and weight loss: Fat has been considered bad
since the World War II. Some have proposed that fat
increases weight26, while others have observed decreases
in weight 19. But since late 1980s, the keto diet with highfat and protein and low-carbohydrate is recommended toEubios Journal of Asian and International Bioethics 31(7) (November 2021)
lower weight. It is said that if people consume less than
1200 calorie in weight-loss programs, immune functionsof body may decrease 16. Therefore, the World HealthOrganization recommends 30% calories by daily fat
consumption 27. But the Scienti ic Advisory Committeechanged their policy and recommended that Americans
should consume up to 35% of fat28.
Egg yolk and heart disease: Egg yolk is seen as thesource of vast amounts of cholesterol associated withweight gain15, diabetes 14, and heart disease 13. A study
conducted at the University of Connecticut found that thefat present in egg yolk actually helps to reduce the badcholesterol from the body 29. However, Women’s Health
Initiatives (WHI) study suggested that a low-fat diet was
not preventive of cardiovascular disease in postmenopausal women 30. Recent research found that eating
at least 12 eggs a week for three months did not increase
cardiovascular risk factors for people with prediabetes
and Type 2 diabetes 14. The National Heart Foundation inAustralia changed their policy and recommend a
maximum of 6 eggs/wk for persons with Type 2 diabetes
31. Moreover, the American Diabetes Association recently
recommended consumption of total cholesterol up to 300
mg/d 32.
Egg and socioeconomic group: Old, village people andeconomically marginalized people are more vulnerable to
COVID than young, urban and af luent society. Studyshows that most of the young age below 30 consume 7
eggs week 33. Another study from British Columbia in
Canada revealed that most of annual household Canadians<$40,000, consume more eggs in comparison with house
hold income $50,000-60,000 and 60,000-80,000 and>1,00,000 34. It is said that in Bangladesh lower middle
and low socioeconomic levels are less infected (Public
Communication 2020). In Bangladesh egg is eaten by low
socioeconomic groups at lunch or dinner time as egg isvery cheap and easily available. Egg yolk could be thecause of the low rate of coronavirus in developing
countries.

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Conclusions
From above literature it is seen that egg is a high source ofvitamins, minerals and antibodies that provide immunity
to help survive from infections. There may be relations
between egg yolk and micronutrients for early recovery or
not getting infected by COVID-19. No data is available ofrelationships between previous egg yolk consumption andrisk and severity of COVID-19. So, it is ethical to urgently
prioritize research to ind out relations between egg yolk
consumption and risk and severity of COVID-19. Costly
medicines can be used during COVID-19 pandemic.
However, it is ethical to use inexpensive measures that are
more economical and natural. The diet of egg eating may
reduce the medical costs of governments and latten thecoronavirus curve. Pharmaceutical industries,
universities, research institutes or individual researchers
may come forward to undertake such research by
designing different methodologies. This is a moral andsocial duty to develop comprehensive protection

335

management and prevention regiment from COVID 19
suffering.
Acknowledgements
We acknowledge and thank Bangladesh Medical ResearchCouncil (BMRC) for grants for this research. This research isdone at Research Unit, Medical Education, Shahabuddin Medical
College. We thank authorities of Shahabuddin Medical College
for their cooperation. Some part of this article has beenpresented in the 21st Asian Bioethics Conference, August 2021.
Con licts of Interest: Authors declare no con lict of Interest.

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3. Ishaan G. 2021. https://www.business-standard.com/article/
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4. Rafael HMP, Carlos KVB, Luciana MS, Bernardo S, Pedro A,
Nelson G, Antonio el al. 2021. Geographic access to COVID-19
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5. Michael PW, Shuang X, Zhijie Z. 2020. The role of climate
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COVID-19: First Verdict and Future Directions. Frontiers in
Immunology,12 :1-11.
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population-based seroepidemiological study. PLoS ONE,16(3):1-11.
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pone.0249247
9. Kefyalew AAA, Yalemzewod AG, Dagnachew MF, Digsu NK,
Yohannes AM et al. 2021. COVID-19 in Ethiopia: a geospatial
analysis of vulnerability to infection, case severity and death
BMJ Open,11: e044606. doi:10.1136/bmjopen-2020-044606
10. Clifford J, Kozil A. (2020). Fat-Soluble Vitamins: A, D, E, and K– 9.315. Colarado state University https://extension.colostate.edu/topic-areas/nutrition-food-safetyhealth/fat-soluble-vitamins-a-d-e-and-k-9-315/
onlinedirectory (3 July 2020).
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Medical News Today. https://www.medicalnewstoday.com/
articles/320445 (Jan 2021).
12. Zamora R, Hidalgo FJ. 2016. Egg Yolk Lipoproteins. In
Encyclopedia of Food and Health, Science Direct. https://www.sciencedirect.com/topics/medicine-and-dentistry/eggyolk (3 July 2020).
13. Allison W. 2019. Going Low-Fat? Here’s what your diet might
be missing. International Food Information Council
Foundation. https://foodinsight.org/going-low-fat-hereswhat-your-diet-might-be-missing/ (2 July 2020).
14. Nicholas RF, Amanda S, Ian DC, Gareth D, Mackenzie F, James
GI, Chloris L, Namson SL, Kathryn HW, Andrzej SJ, Alicia JJ,
Tania PM. 2018. Effect of a high-egg diet on cardiometabolicrisk factors in people with type 2 diabetes: the Diabetes and336

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10.3382/ps.2010-01129 .

Use of convalescent plasma in
COVID-19, a bioethical perspective- Elsa Mariana Zúñiga Laraa, Luis Giovanni Rosales
Pichardob, Miriam Deyanira Rodríguez Piñac, Hugo
Mendieta Zerónd*a Ciprés Grupo Médico, Toluca, Mexico;b Faculty of Medicine, Autonomous University of the Stateof Mexico, Toluca, Mexico;c Faculty of Medicine, Autonomous University of the Stateof Mexico, Toluca, Mexico;d Faculty of Medicine, Autonomous University of the Stateof Mexico, Toluca, Mexico and Ciprés Grupo Médico,
Toluca, Mexico.
*Corresponding author: Hugo Mendieta Zerón. Felipe
Villanueva Sur Toluca, Mexico
Email: drmendietaz@yahoo.com
Abstract
Currently, the COVID-19 pandemic is a huge threat to
global health. Several treatments have been proposed for
it as well as adjuvant treatments that can allow
strengthening of the immune system when ighting thedisease. In this work, we review the use of plasma as atreatment for COVID-19, evaluating their risks, bene its,
previous use, and bioethical aspects.
Introduction
Convalescent plasma therapy has been used for more than
100 years to treat several diseases, with varying degrees
of success. For example, it has been tested against
measles, Argentine hemorrhagic fever, in luenza,
chickenpox, cytomegalovirus infections, parvovirus B19
as well as in the Middle East Respiratory Syndrome(MERS) caused by a speci ic coronavirus, and in the H1N1
and H5N1 in luenza variants (Marano et al. 2016).
The current coronavirus disease 2019 (COVID-19)
pandemic has caused a lot of economic and human losses(Burlacu et al. 2020; Briggs et al. 2021); this poses achallenge to public health systems around the world intrying to contain the damage that this terrible disease has
generated. On the other hand, the scienti ic community

has been immersed in an unprecedented race to ind newtherapeutic options (Attia et al. 2021). Given the current
world panorama, the convalescent plasma is seen as atherapeutic alternative in patients infected by SARSCoV-2.
COVID-19 overview
SARS-CoV-2 (a positive single-stranded RNA virus) has
been seen to alter the normal immune response, making it
de icient and creating an uncontrolled in lammatory
response, especially in patients with severe or critical
illness. These patients might exhibit lymphopenia,
lymphocytic dysfunction, and abnormalities in monocytes
and granulocytes, as well as elevated levels of cytokines
and an increase in immunoglobulin G (Yang et al. 2020).
Virus transmission between humans is through therespiratory secretions of infected people, especiallyduring expulsion by coughing or sneezing, of small
droplets and aerosols that can cross the air. The clinicalpicture of COVID-19 can manifest a wide variety of clinicalsymptoms, from an asymptomatic patient to those withmultiple systemic compromises, respiratory failure, anddeath (Tay et al. 2020; Lewis 2020).
In January 2020, the World Health Organization(WHO) declared SARS-CoV-2 a global emergency. The irst
case reported in Mexico was on February 28, 2020. By
January 30, 2021, the Johns Hopkins University of
Medicine, through the Coronavirus Resource Center,
reported 102,257,414 cases of people infected by SARSCoV-2 worldwide and 1,841,893 cases in Mexico, of which
156,579 have died from COVID-19, placing Mexico in 3rdplace of deaths after the US and Brazil (Johns Hopkins
University of Medicine, Coronavirus Resource Center. s. f.).

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Plasma, quantity de inition, method of obtaining andstorage
Plasma is the liquid component of the whole blood. It ispreferably frozen within the irst six hours after being
obtained in a quantity between 150 ml and up to 600 ml.
Plasma contains normal levels of stable clotting factors,
albumin, and immunoglobulins (Storch et al., 2019).
Therapeutic plasmapheresis is the process of separating
and removing the plasma from other components of theblood and is considered an adjunctive treatment for
diseases; it is based on removing substances such as
cytokines or autoantibodies which can be therapeutic incertain situations (Balagholi et al., 2020). Plasmapheresis
is performed by 2 fundamental techniques: centrifugation
or iltration. With apheresis by centrifugation, the blood is
divided into 4 components and separated into layers by
their different densities; it is commonly performed bychemists, and its advantage is that there are no limits tothe size of the molecules that are being removed. With
iltration plasmapheresis, all blood passes through a ilter
to separate plasma components into red blood cells, whiteblood cells, and platelets, it is commonly performed bynephrologists and intensivists (Nguyen et al., 2012).
Plasma therapy is generally indicated to replace thede iciency of coagulation factors before invasive surgeries
where there is a risk of severe bleeding or in cases where
the concentration of the speci ic factor to be replaced is
not enough. In these circumstances the requirements forff

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

337

an effective plasma therapy are laboratory con irmation of
any coagulopathy by PTT or PT, ibrinogen level;
determination of factor X or XI de iciency; speci ication of
the dose according to the objective of the therapy; controlof the ef iciency of transfusion by laboratory analysis; andspeci ication of transfusion intervals.
The transfusion is carried out intravenously using
peripheral veins with a transfusion device that contains
170-210 micron ilters to retain clots. Several units ofplasma can be transfused using the same transfusion set(4 plasma for therapeutic use, 2009). In Mexico, before
the transfusion, tests such as blood group and RH, HIVserology, hepatitis B, and C viruses and syphilis should bedone (Secretaría de Salud, 2007) but certainly, as in othercountries, some pathogens may escape from standard
screening and inactivation procedures (Udvardy, 2018).
History of the use of plasma as a treatment
When suffering from a disease, the human body generates
antibodies against a speci ic antigen; these antibodies
together with the immune system respond to an infection
caused by that pathogen (Berry and Gaudet, 2011).
However, the antibodies production requires time, andevery human being has a different response. For thisreason, antibodies collected from patients who sufferedfrom the same disease or arti icially generated antibodies
can be considered as a way of offering instant immunity tosusceptible cases in a short period.
In 1901, Emil von Behring became the irst laureate of
the Nobel Prize in Medicine/Physiology for his work inserum therapy, especially testing its application against
diphtheria. This opened a new path in the domain of
medical science. His work gave rise to the so-called"Behring’s Law" that blood and serum from an immunizedindividual transferred to another individual can cause thelatter to be immunized. It has allowed the development ofpassive immunity concepts, establishing that what istransmitted through the plasma are antibodies that thedonor has generated against certain pathology towards
the recipient. Based on these indings, the treatment ofmultiple pathologies evolved (Nobel Prize in Physiology
or Medicine, 1901).
The use of convalescent plasma is a passive
immunization strategy that has been used in theprevention and treatment of epidemic infections for morethan 100 years. In 1907, it was used in Italy for the irst
time to protect children infected with measles and in
1916 to treat acute paralysis during a polio outbreak in
New York, in both cases proving their ef icacy (Marson,
Cozza, & De Silvestro, 2020). Also, this kind ofintervention was recommended as an empirical treatment
during the outbreaks of Ebola (Garraud, 2017) and MERS
(Mustafa, Balkhy & Gabere, 2018). It has also been used totreat other viral infections (Hui et al., 2018).
In case of prescribing convalescent plasma, antibodies
should be administered as early as possible to maximize
their effectiveness, because there is the possibility that the
number of antigens is much higher than antibodies when
the disease becomes severe, thus reducing its effect(Samad et al., 2020).

338

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

The use of convalescent plasma in COVID-19
Although preventive measures have reduced the spread of
COVID-19 such as social distancing, hygiene, andprotection with face masks (Moran et al. ,2021), scientists
have been looking for cures for this disease and in 2021,
vaccines from different countries were approved for
massive use. However, convalescent plasma is still an
option in the contention of this disease.
In summary, it has been observed that the use ofconvalescent plasma reduces the mortality rate,
decreasing the viral load and improving the clinicalcondition; it not only neutralizes the pathogen but also
provides immunomodulatory properties that allow
controlling the in lammatory cascade that is created dueto the infectious agent (Rojas et al., 2020).
Potential convalescent plasma donors must go througha pre-donation check-up to ensure that they ful ill theappropriate conditions: They must be between 18-65
years old, without symptoms, and a negative test for
COVID-19 (qPCR or serology) after 14 days of recovery(this test must be performed again 48 hours later), a
negative test for COVID-19 by pharyngeal swab and / orblood sample at the time of the donation, neutralizing
antibody titer greater than 1:320, and a check that thedonor is free of infectious-contagious diseases.
The recommended procedure for obtaining plasma isapheresis by centrifugation; the plasma administration
ra n g e i s b e t we e n 2 0 0 - 5 0 0 m l ; c u r re n t ly t h e
recommendation is to administer 3 ml/kg/dose in 2 days.
The ef icacy of this procedure relies on the neutralizing
antibodies concentration in the donor plasma; these
antibodies bind to the spike 1 receptor binding protein of
the coronavirus (S1-RBD) and to the terminal domain S1and S2, inhibiting their entry and limiting viral
ampli ication, in addition to other antibody-mediatedpathways such as complement activation, cellularcytotoxicity, and phagocytosis that can promote thetherapeutic effect of convalescent plasma (Rojas et al.,2020).
It is a therapeutic product with special characteristics
and should be stored in a differentiated form from the restof the blood components, clearly indicated on it:"Convalescent plasma for use in studies related to SARSCoV-2". The expiration date will be in accordance with thestorage practices of blood banks; for fresh frozen plasma
being 1 year from the date of collection if stored at -80ºCor less and must be frozen within 8 hours after collection.
In clinical trials, one unit of plasma (200 ml) is used
for prophylaxis and two units (400 ml) for treatment. The
duration of the effectiveness of the antibodies decreases
through time. It is estimated to last from weeks up to afew months. After 40 days from recovery, convalescentplasma no longer has a signi icant number of antibodies.
In a previous use of SARS convalescent plasma therapy, 5
ml per kg was used at a titer of 1:160; in linear proportion
3.125 ml of plasma per kilogram with a titer of more than
1:64 would provide adequate therapy (Alcántara, 2020).

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Discussion
Given the current world panorama, in-depth research isneeded to assess the bene its of a new treatment option.
Convalescent plasma has been used as a therapeutic

alternative since ancient times. The use of plasma as atherapeutic modality to treat infectious diseases has been
known for more than 100 years, being of great bene it incertain pathologies, while in others being moderately or
not effective.
The bene its of this therapy are still uncertain against
COVID-19 although the evidence seems to indicate aclinical improvement while its risks are the same as inother cases of transfusions, that is, allergic reactions,
possibility of transmission of infectious agents,
anaphylaxis reactions, acute lung damage as well as
hemolysis among others (https://www.covid19treatmentguidelines.nih.gov/anti-sarscov-2-antibody-products/convalescent-plasma/ 2020).
Overall, plasma donation is safe for patients and adverse
effects are rare.
The Food and Drug Administration (FDA) has
approved the emergency use of the convalescent plasma
in the United States considering the possible bene its ofthis therapy, which include an improvement in symptoms,
a reduced need for supplemental oxygen and mechanicalventilation, and possibly a reduction in mortality. The datasuggest that the use of convalescent plasma from patientswith COVID-19 that have high antibody titer is more likely
to be effective in reducing mortality in hospitalized
patients (FDA).
In South America, several countries have implemented
speci ic protocols to administer convalescent plasma topeople with COVID-19. Those developed by Bolivia and
Venezuela (Nina Garcia & Cussi Coronel, 2020; Sánchez
et al., 2020) attract attention. In Mexico, there are some
protocols recruiting patients to be treated withconvalescent plasma (NCT04356482; NCT04405310).

Figure 1. Examples of different percentages of deaths andsurvival to decide whether to try the use of convalescentplasmaA bioethical aspect of the use of convalescent plasma
The Mexican Ministry of Health reports that the morbidity
rate of SARS-CoV-2 is 16.18 per 1000 patients (consulted
on January 30, 2021). However, morbidity could be higher
due to persistent under-diagnosis in this nation.
Medicine as science has had the ultimate goal ofsafeguarding human health by all means but always

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
respecting the four principles of bioethics: autonomy,bene icence, justice, and non-male icence (Holm 2002). In
relation to COVID-19 and convalescent plasma, one
paradoxical situation we are facing nowadays is that thisblood product is stored in blood banks without being used
due to the lack of authorized research protocols in
hospitals where it is obtained. For example, the average
activity of the Blood Bank of the “Mónica Pretelini Sáenz”
Maternal-Perinatal Hospital (HMPMPS), Health Instituteof the State of Mexico (ISEM), Toluca, Mexico, shows thatsince the beginning of this pandemic (approximately
March 2020) 1,100 packages of blood and 550 of plasma
would have accumulated. Applying the morbidity data andprobability reasons, at some point, a patient infected with
SARS-CoV-2 has donated blood or plasma that has been
stored and administered to a patient without knowing thiscondition because the COVID-19 test is not a routine test
before the donation. Furthermore, we can assume that
this phenomenon is occurring throughout the world.
Taking into account the bioethical principles of respect
for autonomy, nonmale icence, bene icence, and justice,imagine the circumstance in which there is one patientwith COVID-19 intubated in an Intensive Care Unit (ICU)
with a mortality of 60% and the physician in charge has
the possibility to ask for plasma donors from recovered
patients and all but a physician agree to give a single doseof the convalescent plasma; due to the discordance theplasma cannot be infused. The opposed physician argues
that the convalescent plasma has not been added into aninternational lowchart to treat COVID-19. With a
COVID-19 mortality higher than 60% when intubateduntil when do we have to wait for a randomized, double
blind trial with convalescent plasma before trying to get a
reduction in the mortality using convalescent plasma? At
what point not transfusing plasma is more harmful thantrying this procedure? (Figure 1).
Are we applying the principle of bene icence by letting
the disease advance towards possible death without using
a possible tool that has been used in several diseases? Are
we applying the principle of autonomy by not telling thepatient or his/her family about the existence of a possible
treatment with convalescent plasma? Do they deserve theright to take the risks? The principle of nonmale icence isclear, as the treatment with convalescent plasma is wellknown and under usual conditions the risks are low.
Under substantial uncertainty during aggressive andunknown diseases, waiting too long for the perfect clinicalassay could condemn hundreds of patients.
Notwithstanding, the scienti ic evidence on the use of thistherapy is still limited. However, multiple studies are
currently being carried out throughout the world on theuse of convalescent plasma for the treatment of SARSCoV-2 infection (Table 1). It is expected that the results ofthese investigations will begin to appear in 2021
(Wooding & Bach, 2020).

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Conclusion
Convalescent plasma can be a therapeutic alternative inpatients with COVID-19 that improves symptoms andprognosis, and it does not have a statistically signi icant
adverse effect on mortality rates. Based on the evidence
mentioned above, convalescent plasma against COVID-19

339

should be considered, at least as a compassionate therapy,
particularly in emergency cases of patients admitted tohospitals, despite the absence of an authorized protocol,
considering that the attempt to safeguard life is more
important than the existing technical limitations. We
strongly recommend to health institutions that they canfacilitate the prompt approval of the different protocols
necessary to start the use of this complementary therapy.
Acknowledgments
Authors thank the students af iliated to the Latin
American Scienti ic Association (ASCILA) for theirvaluable comments in improving this manuscript. No
potential con lict of interest was reported by the authors.
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Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

Would a ‘vaccine passport’ work in
the Philippines?
- Joefer Ganuelas Maninang
University of Mindanao, Davao City, Philippines
Email: joefer_maninang@umindanao.edu.phAbstract
A novel coronavirus in 2019 took the life of ‘patient zero’and then millions of others alerting nation states toprotect and secure the lives of their citizens. The
coronavirus known as SARS-CoV-2 caused the ‘COVID-19’
disease which had governments impose restrictions on
the freedom of movement or the right to travel in the formof ‘community quarantines.’ The serious adverse effects ofthese on the world and national economies moved thegovernments to loosen the quarantines and implement
versions of so-called ‘vaccine passport,’ an international
digital health certi icate proving COVID-19 vaccination
status. One of the uses of the vaccine passport is toexpedite the safe and orderly passage of people in airports
which extends to other travel terminals, essential andcommercial establishments, and facilities. There are
ethical concerns, however, such as the inequitable
distribution of the scarce supply of vaccines, among
others. In this article, I brie ly describe the vaccine
passport idea, its uses, and ethical concerns, and thenapply these concerns in a national context through thepending bills that aim to legitimize a Vaccine Passport
System in the Philippines. In the end, I recommend thatlawmakers (who represent the moral interest of Filipinos)
consider such concerns before they cast their votes.

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Introduction“COVID-19” is an infectious disease caused by the
recently discovered coronavirus SARS-CoV-2 (World
Health Organization, 2020) whose outbreak began in (awet market) in Wuhan, China in December 2019 and was
declared a global pandemic (Ducharme, 2020). After‘patient zero’ – “the irst human infected by a viral orbacterial disease in an outbreak” (Duarte, 2020) – andover a million others died, millions (or more) of hospitalpatients were diagnosed and medicated all over the worldand symptoms were known. A COVID-19 patient may
experience fever, dry cough, and tiredness, trouble inbreathing, chest pain, and loss of speech and/or
movement. Mild symptoms include head and other bodyaches, nasal congestion, sore throat, diarrhea, loss of smell
or taste, a rash on the skin, and discoloration of ingers or
toes. Those who have underlying medical problems likethe elderly are vulnerable or at a higher risk of developing
the disease. COVID-19 test kits were made that can detect
the virus in those who are ‘asymptomatic.’ If one
experiences mild symptoms, s/he may just ‘selfquarantine’ for 14 days but if symptoms worsen, s/hemust immediately seek medical attention. Asymptomaticpatients may self-quarantine but if symptoms appear andworsen, they must seek medical attention.
How COVID-19 is interpersonally transmitted has been
known. Droplets from an infected person who sneezes,
coughs, or speaks within 1 meter near another person341

may infect them through the airborne droplets. One canalso become infected if s/he touches objects: tables,
doorknobs, handrails, etc. where droplets land and remain
for up to 72 hours and then touches her/his eyes, nose, or
mouth. To prevent transmission, health authorities advisethat people should observe personal body hygiene,
disinfect their hands using soap and water or alcohol rub
or sanitizer, wear a mask and/or a face shield, andpractice physical distancing, especially in high-risk areas.
But with the rising cases of COVID-19, States declared
COVID-19 a public health emergency and then enforced
lockdowns to prevent the transmission of the disease.
Welfare programs provided economic resources in kind or
cash while the believed-to-be-the most ef icient in curbing
transmission – the vaccine – was still being developed.
With the unprecedented pressure on healthcare
systems and companies, comes the risky but necessary
development of the new ‘mRNA vaccine’, a long-theorized
technology which “take[s] a slightly altered approach tovaccination protocols. Instead of inoculating people with awhole—but altered—virus for which antibodies will becreated against, they instead encode a messenger RNA(mRNA) with the information to produce the SARS-CoV-2
spike protein,” (Brothers, 2020) paved the way for curbing
transmission. The mRNA vaccine does not cure the
COVID-19 but when administered, will teach the humanbody’s immune system to safely recognize and block thevirus thereby helping prevent the vaccinated from
infecting others. The World Health Organization (WHO)has listed mRNA vaccines and other types for emergency
use and many ‘vaccine candidates’ await enlistment(undergoing clinical trials, subject to ‘independent
reviews of the ef icacy and safety evidence,’ etc.).
The development of the COVID-19 vaccine paved theway for curbing transmission on a global scale.
International vaccination programs have been initiated.
WHO has been operating its international massvaccination program and co-leads the COVID-19 Vaccines
Global Access (COVAX) (Gavi, 2020) to ensure that Statesreceive their fair share of the vaccines from the COVAX
facility for their national vaccination programs. To date,the WHO-led international vaccination program has
administered more than 2 billion doses of vaccines (World
Health Organization, 2021) that are still not enough tocatch up with the continued global transmission, active
cases, and casualties. At the national level, states havestarted their mass vaccination programs and maintained
the lockdowns complemented with welfare programs at
the same time. But household and national economic
resources are running out which had governments loosen
the lockdowns and implement versions of the so-called‘vaccine passport.’
Vaccine passport and its uses
First, the vaccine passport idea is not new. Fran Kritz
writes (2021) that the vaccine passport debate stretches
as early as 1897, when scientist Waldemar Haf kine
developed a plague vaccine that was used in British India,
and discussions on asking for proof of vaccination began.
At the time, one area of concern was religious pilgrimagesites where sudden transmissions of the plague could not
be controlled, and so after long negotiations between

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relevant parties, authorities decided to require proof of
vaccination from the pilgrims. Vaccinations were done atgovernment centers and health certi icates were issued tothose who got vaccinated. Kritz then informs that theInternational Health Regulations were adopted by theWorld Health Organization which speci iy “yellow fever”
as the only disease for which states may require proof of
vaccination. Such proof is known as the “yellow card”
without which entry to certain countries requiring thecard will be denied.
The vaccine passport varies from country to country,
comes in versions, uses, and is referred to with different
names namely ‘digital health certi icate,’ “digital healthpasses” (Gostin, 2021), “smart vaccination certi icate”(Cohen, 2021), “EU Digital COVID Certi icate” (Lovell,2021), and many others, which come with correspondinguses and motivations. An Asia-based news outlet reportsthat the COVID-19 vaccine passport is a digital healthcerti icate that Chinese citizens can display via the
WeChat software application (app) as proof for COVID-19
test results and vaccination status (Channel News Asia,
2021). When an account user logs in, the app generates ahealth certi icate with personal details, nucleic acid, andantigen tests, and a statement of vaccination. Thiscerti icate can be printed and has a code that authorities
can verify. It was reported that China would establish
further mechanisms for other countries to recognize thecerti icate and the personal information it contains while
protecting privacy. China’s ‘vaccine passport system’ will
facilitate the safe and orderly low of people across stateborders which will bene it national economies as well as
resuming interaction in the world. For a freelance
journalist in the article Covid Passport: The 15 Best
European Destinations Ready for Vaccinated Travelers,
Iceland is the irst European country to issue vaccine
passports to its vaccinated citizens and is prepared torecognize vaccine passports issued by other European
countries. Many other European countries were listed by
the tourism ministries of the European Union (EU) as thebest destinations for vaccinated travelers. EU members
join in the effort to rescue the return of summer tourists
in the continent which provides millions of jobs andincreases the Gross Domestic Product. Vaccine passportsystems are operating and even the World HealthOrganization recognizes it for the use of national publichealth of icials and managers of immunization programs
which may be of interest to other branches of government
responsible for travel or immigration, international
funding agencies, vaccine advisory groups, the medical
community, the scienti ic media, and the public (World
Health Organization, 2021). Whatever form, name, anduses the vaccine passport has, it essentially presumes thatthe passport holder has got jabbed with the COVID-19
vaccine. Facilitation of traf ic in airports which extends totravel terminals, establishments, and facilities, bolstering
tourism or reviving the economic interaction in the world,and facilitating the work of public health of icials andimmunization managers are some of the uses of thevaccine passport.

COVID-19 in the Philippines: socio-political-legal
rights-based responses to the pandemic
The irst two con irmed cases in the Philippines wereadmitted to the national infectious disease referral
hospital in Manila (Edrada et al., 2020). Both werepreviously healthy, a couple, Chinese nationals (from
Wuhan) who traveled to the Philippines in January 2020.
Patient 1 (female, 39) had symptoms of cough and sorethroat, and human coronavirus was detected while Patient
2 (male, 44) had additional symptoms of fever and chills
and SARS-CoV-2 viral RNA was detected. Both weretreated but Patient 2’s condition deteriorated andfollowing cardiac arrest, he died of COVID-19. It was also
known that Patient 2 had contact with someone unwell in
Wuhan. Patient 2 was the irst casualty outside China(BBC, 2020).
So, even in the time of ‘COVID-19,’ the Philippine Statethrough its government acted or responded by upholding
the rule of law (International Development Law
Organization, 2020) as expected of a democratic country
and state party or signatory of international human rights
treaties such as the International Covenant on Economic,
Social, and Cultural Rights which provides for protection,
ful illment, and promotion of social, economic, andcultural rights. The Philippine state incorporated thesocial right to health and the economic right to labor inarticles 2 and 13, sections 15 and 3, respectively, of its
Constitution which provides:
Section 15. The State shall protect and promote theright to health of the people and instill healthconsciousness among them.
Section 3. They (workers) shall be entitled to…
humane conditions of work, and a living wage. They
shall also participate in policy and decision-making
processes affecting their rights and bene its as may beprovided by law.
The right to health must guide responses to COVID-19(Puras et al., 2020) together with other human rights suchas the economic right to labor and civil and political rights
since human rights in principle are indivisible,
interdependent, and interrelated (United Nations
Population Fund, 2005). But in the COVID-19 era, therights to health and labor are prioritized over the otherrights.
What is common between the ICESCR and thePhilippine constitutional provisions on the rights tohealth and labor provisions is the protection andenjoyment of physical and mental health and its
promotion, just, safe, healthy, and humane conditions ofwork with remuneration or living wage which are implicitin the country’s responses to the pandemic.
On March 8, 2020, the Philippines President Rodrigo
Duterte issued Proclamation No. 922 titled Declaring aState of Public Health Emergency throughout thePhilippines based on sections 15 and 23 of articles II andVI, respectively, of the Philippine constitution, and basedon Republic Act No. 11332 which provides that thepresident shall declare such emergency in the event of an
epidemic of national and/or international concern which
threatens national security (Of icial Gazette, 2021). Thenon March 16, 2020, the House of Congress passed
Republic Act No. 11469 otherwise known as theEubios Journal of Asian and International Bioethics 31(7) (November 2021)

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“Bayanihan to Heal as One Act” which gives the president
emergency powers to address COVID-19.
The president called the Inter-Agency Task Force for
the Management of Emerging Infectious Diseases (IATFMEID) (which existed before the epidemic) composed ofthe executive departments chaired by the Department of
Health (DOH) and co-chaired by the Department ofEnvironment and Natural Resources (DENR), Departmentof Labor and Employment (DOLE), and many otherdepartments. The IATF-MEID aims to prevent loss of life
caused by COVID-19, to contain its spread, prevent
dysfunction of the government, and avoid deterioration of
the economy. It is a policy-making body that develops the‘national normative and legal framework’ as the basis for
decision-making in ‘a whole-of-government response’ to
the COVID-19 pandemic; its policies or laws imply therights to health and labor. The IATF-MEID laid the
National Action Plan to manage the COVID-19 situation. It
created the COVID-19 National Task Force headed by the
Department of National Defense (DND) to handle theoperational command and the Joint Task Force COVID-19
Shield composed of the police, military, etc. intended to
enforce health and ‘community quarantine’ (lockdown)
protocols in streets, checkpoints, establishments, andfacilities nationwide to prevent transmission, maintainthe peace, order, and security.
The enforcement of the quarantine that restricts some
civil and political rights is valid and justi ied based on
scienti ic and legal grounds (Human Rights Watch, 2020).
The International Covenant on Civil and Political Rights towhich the Philippines is also a state party provides “forthe possibility of limiting certain rights in the interests ofpublic health, and, in the most extreme cases, derogatingfrom certain rights during declared states of emergency,
to the extent strictly necessary to meet a threat to the lifeof the nation” (Gil, 2020). Such limitation is not absolutethough. This means that the freedom of movement, rightto assembly, right to speech, and other related rights canstill be exercised. Some more rights such as the ‘right toseek, receive and impart communication’ pertaining to
COVID-19 may also be exercised.
Community quarantine levels depend on how intense
the local transmission is. Quarantine levels range from
Enhanced Community Quarantine (ECQ) being thestrictest, General Community Quarantine (GCQ), Modi ied
Enhanced Community Quarantine (MECQ) to the mostrelaxed Modi ied General Community Quarantine (MGCQ)(Gotinga, 2020). The strict ECQ has the military and police
in the streets, checkpoints, establishments, facilities
imposing the curfew, travel bans, and other quarantine
restrictions.
LGUs were also enjoined to autonomously manage the
COVID-19 situation but within the parameters of theregulations and directives issued by the IATF-MEID.
According to the Local Government Code, any LGU canlegally create its task force that can function in the same
way as the IATF-MEID. Philippines News Agency’s “Davao
City showcases best practices vs. Covid-19” for instancereports and features the Davao City local government’s“best practices” in managing the COVID-19 situation in
Davao City. The article opens by saying that the city “aimsto strike a balance between containing the number of343

infections while providing an elbow room to prevent the
local economy from going into a tailspin.” Such practices
are non-pharmaceutical interventions such as the wearingof a face mask, safe physical distancing, proper
handwashing, and staying at home.
During the quarantines, Local Government Units(LGUs) facilitated the distribution of economic relief
goods while the regional of ices of the Department ofSocial Welfare and Development initiated amelioration
programs (Perez, 2020) by disbursing money to eachfamily member who had to show her/his community
quarantine pass and ration/amelioration card. But thesocio-economic goods and money were not enough tomatch their needs. Testimonies narrate a period whensome Filipino locals were running out of means, of food,supplies, and savings to feed themselves and their families
and relieved themselves of other economic or basic needs.
Household economic problems evoked anxiety among theFilipinos especially the breadwinners and the other
COVID-19’s adverse effects on the national economy
necessitated the government to relax the community
quarantine with the citizens utilizing locally made QR
codes for contact tracing should a rapid community
transmission occur.
It was during the time between the GCQ and MGCQ
when economic affairs started to resume wherein
businesses reopened, and professionals and laborers
commenced reporting for work. Speaking of economic
affairs and the right to work/labor – which is protectedunder the Labor Code of the Philippines - in the time of
COVID-19, such right was implicitly integrated into the
Department of Labor and Employment (DOLE) Labor
Advisory No. 9, Series of 2020 titled Guidelines on the
Implementation of Flexible Work Arrangements as
Remedial Measure Due to the Ongoing Outbreak ofCoronavirus Disease 2019 (COVID-19) which was issued
on March 4, 2020 (just in time before the enforcement of
the nationwide Enhanced Community Quarantine, ECQ)
which in its section two (II. Concept) delineates “ lexible
work arrangements” - herein referred to as ‘ lexible work
scheme’ – as “alternative arrangements or schedules otherthan traditional or standard work hours, workdays andworkweek” and are “temporary in nature, subject to theprevailing conditions of the company.”
In the same advisory, the lexible work arrangements
presented are: Reduction of workhours and/or workdays;
rotation of workers; and forced leave - on which theemployers may have the discretion to ‘schematize’ but thisschematization should be after due consultation of
employees as per the advisory’s section one (I. Purpose)or else, if not adopted or disagreed to by the parties of theemployers and the employees (as per IV. Administration)– for instance, the terms are not amenable to theemployees – are a case of differences of interpretation (ofthe arrangements), the differences are treated as
grievances under the grievance mechanism of thecompany and the grievance(s) could be referred to the(DOLE) Regional Of ice that has jurisdiction for
appropriate conciliation.
The advisory has signi icantly anticipated the labor
relations scenario between non-government or private
corporate/company employers and their employees, andEubios Journal of Asian and International Bioethics 31(7) (November 2021)

the implementation of lexible work arrangements like ineducational institutions. Hopefully, such arrangements
underwent due consultation with employees before theirimplementation otherwise employees may refer thematter to the grievance mechanism of the company or if
inadequate must be referred to the labor regional of ice.
Moreover, lexible work arrangements imply theprotection and promotion of the right to health such as
personal hygienic measures and social-physical distancing
protocols so-designed to reduce the risk of the employees’
exposure to COVID-19 outside their homes. The mayoral
executive orders and local ordinances enforce thesepractices which imply the protection and promotion of therights to health and labor.
Local executive orders related to the lexible working
scheme explicitly or implicitly integrate the right to laborwhich in turn integrate the right to health. These rights
are among the minimum legal norm or standards thatmust be integrated even by private corporations in theircompany administrative policies or memoranda on
lexible work schemes.
In the Philippines, while all constitutional rights are inprinciple universal, inviolable, indivisible, andinterdependent, social, and economic rights such as therights to health and labor of the Filipino citizens are
relevantly prioritized while other human constitutionalrights are conditionally limited to make way for the rights
to health and to labor which complement each other.
After a year since COVID-19 was declared a global
pandemic, a Filipino congressman started talking about
the vaccine passport that proves inoculation which “willallow Filipino travelers to reconnect with the rest of thecountry and the world” and as “a key element in bringing
back public con idence and reviving the economy”(Cervantes, 2021).

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HB No. 8280 and SB 1994: vaccine passport and its
uses in the Philippines
It is not surprising that the vaccine passport idea, its uses,and ethical concerns have reached the Philippine shores
in the ‘globalized’ (Steger 2003) world, not to mention theinternet media and technology that are instrumental for
the Filipino lawmakers-politicians, journalists, news
reporters, academicians, etc. to know and echo such idea,
uses, and concerns albeit in the Philippine national
context.
Both the House Bill No. 8280 (HB 8280) (House ofRepresentatives, 2021) and Senate Bill No. 1994 (SB1994) (House of Senate, 2021) iled and introduced in thelower and upper houses of the Philippine congress are
essentially about the vaccine passport and legitimizationof a vaccine passport system in the Philippines. HB 8280
and SB 1994 explain that the “fear of infection and theimposition of community quarantine” and “restrictions on
travels within and outside the country and on opening
and entering business establishments” reduced householdspending, affected individual mental and individual
health, (Of icial Gazette, 2021) and therefore the plunge ofthe national Gross Domestic Product or the decline of theeconomy. This introduction of the vaccine passportsystem means further relaxation of the community
quarantine as the government began its national mass

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vaccination program and roll out of the vaccines to groups
in the priority list and as private business corporations
purchased vaccines for their employees so that they could
safely resume their business operations to be eligible tovaccine passports as proof to be exempt from the usual
COVID-19 restrictions.
Anchored on Article 3, Section 6 of the Philippine
Constitution and modeled after the Philippine Passport
Act, HB 8280 de ines the vaccine passport as the“internationally-recognized vaccine passport to serve as
proof that a person has been vaccinated against
COVID-19” which contains personal information,
vaccination details, and other relevant medical
information such as infection history and comorbidities.
The same Bill lists the vaccine passport uses such as
international and domestic travel, employment abroad,
local checkpoint and quarantine exemptions, opening ofand access to some business establishments, and postvaccination protocols applicable to passport holders(public gatherings, wearing of face mask, etc.). These uses
imply that airline companies, tourism, and hotel
establishments will bene it from the increase in domestic
and international passengers with vaccine passports.
SB 1994 empowers the Secretary of Health to issue
vaccine passports while the Inter-Agency Task Force isauthorized “to issue rules and regulations on what
activities will require the possession of a vaccine passport… as well as penalties for certain prohibited acts (that)have been provided” in the rules.
The pending vaccine passport bills in the legislatureampli ied the topic in the domain of public discourse. The
Senate wanted to replace the ‘passport’ with the term‘card’ because the former may be interpreted as
restricting mobility and discriminatory (Reformina,
2021). The existing certi ication and/or ‘vaccine card’ isthe only proof that one is fully inoculated (LardizabalDado, 2021) which has personal and health informationand vaccine details that could be integrated by the
Department of Information and Communications
Technology (DICT) with the of icial exposure noti ication
software application StaySafe endorsed by DOH anddifferent from the RapidPass which was for front liners
and authorized personnel.
But while the senators’ and legislators’ socio-economic
reasons and justi ications for introducing the vaccine
passport to legitimize a vaccine passport system in the
country have merit, I think they still need to re lectfurther and consider the ethical implications of thepassport as these implications are already embodied in
the ethical concerns shared in the media at least before
the bills are considered as items for inal reading in thePhilippines’s bicameral legislature.
Ethical concerns of the vaccine passport in thePhilippines
Like many states, the Philippines experiences economic
adverse effects of COVID-19 which necessitated thegovernment to relax the community quarantine so that
economic activities may resume. Relaxation of thequarantine and loosening the quarantine restrictions
spurred conversations on the ethical concerns of thevaccine passport which appear to be related to global

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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distributive justice “involving obligations of fairness in the
distribution of bene its and risks” and “the attempt todetermine what is fair or owed when scarce medical
resources must be rationed” (Beauchamp, 1994),
resources such as the vaccines and/or vaccine doses andother related needs in the COVID-19 era.
In its interim position paper, the World HealthOrganization does not endorse any vaccine passport that
purports to prove the vaccination status of the passport
holder as a condition for departure or entry because
generally, the full ef icacy of the vaccines/vaccination in
reducing transmission is yet to be known. WHO lays
considerations for its position, some of which apply in thePhilippines.
Firstly, the global COVID-19 vaccine supply is scarce.
Vaccine production may be accelerated but hygiene, noncontamination, and safety in vaccine manufacturing plants
must also be guaranteed – this being promoted by healthorganizations for instance (Reuters, 2021). But this andsimilar necessary health safety precautions slow down
vaccine production and therefore limit the supply of
vaccines to all human persons around the world.
Secondly, there is already an inequitable distributionof the scarce COVID-19 vaccines since those in the highincome countries have better access than lower-middleincome and low-income countries.
The Philippines is admittedly in the lower-middleincome category and although it is receiving its fair shareof COVID-19 vaccines from WHO/COVAX and manages tonegotiate with vaccine-manufacturing countries (nations
that host pharmaceutical companies) and procure
millions of doses for the country’s mass vaccination
program, its vaccine stocks still fall short of achieving the‘herd immunity, not to mention the country’s insuf icientnumber of hospitals and/or health centers or clinics andinadequate medical resources for viral/antigen testing(swabbing), and hospitalization of the infected which
includes support for their biological, economic, andpsychological needs.
Thirdly, individuals who do not have a vaccine
passport will be deprived of their right to travel(International Norms and Standards Relating to Disability,2021) to the country that requires such a passport.
Filipinos who do not have a vaccine passport, thus
without vaccine access or unvaccinated, will be deprivedof their right to travel domestically and internationallywhile others can and enjoy the exemptions (privileges)
listed in HB 8280.
Fourthly, the vaccine passport would mean
preferential vaccination of travelers that will limit thealready limited vaccine supply to priority populations.
The proposed vaccine passport system will mean
preferential vaccination of Filipino travelers that willfurther limit the already limited vaccine supply to those in
the Philippines’s national vaccination program priority
list. The vaccines roll out to medical practitioners,
essential front-liners/workers, vulnerable individuals
such as the elderly, those with comorbidities, and otherprofessionals excluding children.
Fifthly, the vaccine passport will exacerbate theexisting inequities and introduce new ones. The vaccine
passport would result in new social exclusions and345

discriminations (Tambuyung, 2021) or create a divided
population (Cana, 2021), the vaccinated and theunvaccinated. The vaccine passport, which will eventuallyreplace the quarantine pass, amelioration card, locallymade contact tracing QR codes, and vaccine cards will
deprive non-passport holders of their freedom of
movement within the country. They will be denied entry
to establishments and/or facilities where they could buy
economic goods and services; they will not be able toattend school and/or ind work, and they will beincapacitated to do recreational activities. New inequities
and unintended consequences will also emerge such as
the incentivization of vaccination, competition among
private corporations to acquire vaccines for theiremployees to help revive their business operations,commercialization of the vaccines, and the building of a
‘black market’ where fake vaccines and vaccine passports
are sold.
And sixthly, the economic bene its of the vaccine
passport must be balanced against public health risks
based on recent scienti ic medical knowledge about
vaccination in reducing transmission, including criticalunknowns or gaps on viral mutations or variants. The
DOH which chairs the IATF-MEID is expected to provide
the said scienti ic medical knowledge to Filipinos andvaccine passport proponents-lawmakers must be
reminded that the vaccines roll out in the country must be
constantly checked whether they still can protect thevaccinated from the disease and viral mutations such as
the Delta and Lambda (Diamond, 2021) variants that may
cause unpredictable rapid transmissions and increase theactive cases and casualties. The new variants may evenrequire the development of new vaccines. But a vaccine
does not cure, it only protects when injected to teach thehuman body’s immune system to safely recognize andblock the virus. But the knowledge about vaccination in
reducing transmission is yet to be known. There is noclear evidence that the vaccines substantially curb thetransmission – which clearly should make the proponents
conscientiously cautious.
Just recently, the DOH, DICT, and other partner
agencies have developed and softly launched thePhilippine Digital Vaccination Certi icate (Government of
the Philippines 2021) with an online portal that can beused by those inoculated in the nation’s capital andplanning to work or travel abroad (Ranada, 2021). The
digital portal is a step-by-step process that generates avaccination certi icate with some personal andvaccination details and a QR code that can be scanned byauthorities or any third party for veri ication and is valid
for 14 days. VaxCertPH system will soon replace theamelioration card, the quarantine pass, the RapidPass,
and the vaccine card. Such innovation is ahead of thedeliberations on the pending vaccine passport bills in
Congress.
VaxCertPH is laudable because the system ensures thatthe passport holder’s personal and health data areprotected by the country’s data privacy law (National
Privacy Commission, 2021), but it is still premature to saythat privacy or con identiality will not be “abused by thedata controllers” (Lee, Lai & Skahill, 2021), the centralized
database will not be breached, the government will not346

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

utilize the health records for surveillance and pro iling,
corporations or businesses will not misuse the same.
Adding to these con identiality concerns are the reliability
and integrity of the system, possible digital inaccuracies,
or glitches, and cyberattacks on the database for criminal
purposes. These concerns only mean that VaxCertPH likethe previous innovations will be a test case which if it
succeeds would make a vaccine passport work in thePhilippines.
Conclusions
In the foregoing, I described the vaccine passport idea, its
uses, and ethical concerns and then attempted to show
how these apply in the Philippine context. Apart from theconcerns described and applied, there are still more thatawait exploration to help understand the ethical concernsof the vaccine passport in national contexts. More
importantly, such concerns are not only about the vaccine
passport per se but also the other elements of thepandemic.
The vaccine passport systems operating in othercountries and the acquired vaccines should not
overwhelm. Perhaps efforts must rather focus on
vaccinating all Filipinos. And so, I recommend thatlawmakers (who represent the moral interest of Filipinos)
consider the concerns irst before they inally cast theirvotes on the pending Bills.
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347

Staying positive amidst fears,
anxieties and frustrations:
Travails of people in isolation andquarantine centers in Davao delSur- Rogelio P. Bayod
Email: roger.bayod@gmail.com- Rosemarie S. Gonzales
Email: rosemariesumalinoggonzales@gmail.com- Erikka June Forosuelo
Email: erikkajunedecrepito@gmail.com
Cor Jesu College, the Philippines- Romulo Birondo
LGU-Sta Cruz, the Philippines
Email: rzbirondo18@gmail.com
Abstract
The Philippine government in the national and local levels
has instituted different measures to contain the spread of
the coronavirus. Imposition of local ordinances such as
mandatory wearing of face masks and face shields, use of
QR Code scanning for contact tracing, border lockdowns
and forced isolation and quarantining of recovering
COVID-19 positive patients and those Persons Under
Investigation (PUIs) and Persons Under Monitoring(PUMs) have been implemented in different Local
Government Units (LGU) in Davao del Sur. This study
focuses on the experiences of people who have undergone
mandatory quarantine in three isolation facilities in Davaodel Sur. While in one isolation center, they have their own
toilet in the room and the rooms have enough ventilation,in the two facilities, they do not have exclusive toilet andthe rooms are not properly ventilated and have plenty ofmosquitoes. Common to their experiences is the lack ofsupport from the government in terms of free food supply
for the PUIs and PUMs except for those who are alreadycon irmed to have the COVID-19 virus. There is no
program to support the people in dealing with fears,
anxieties, worries and other unpleasant emotions while
they are under quarantine in government facilities. Theirfaith in God, positive mindset and concern with theirfamilies and children have helped them to survive theordeals. This study can provide the policy makers andworkers in LGUs the irsthand experiences andinformation that they might need to improve systems of
isolating and quarantining people and come up withinterventions to assist persons who are forced to stay inisolation and quarantine centers in the province.
Introduction
It is already almost a year since the threat of Covid-19
pandemic became real in the province of Davao del Sur. As
to this writing, more than one thousand con irmed
positive cases of Covid-19 in the province have beenrecorded.
There had been initiatives by the Local
Government Units (LGUs) in the province to contain the
spread of the virus such as mandatory wearing of facemask and face shields, use of technology-aided system forcontact tracing, lockdowns, curfews, and mandatory

348

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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isolation of the recovering covid-19 positive patients, PUIs
and PUMs. But cases of covid-19 in the province
continued to rise.
To respond to COVID-19 crisis at the global scale, many
countries use containment and mitigation activities todelay major surges of patients and lower the demand for
hospital beds, while protecting the most vulnerable,
including the elderly and those with comorbidities. Most
national response strategies include varying levels ofcontact tracing and self-isolation or quarantine.
Construction of suitable care settings, including hospitals
with the best facilities, were other responses in somecountries. Hospitals or shelters for caring from suspected
or con irmed cases at both stages of therapy and recovery
were built to reduce the death rate in these countries(Nussbaumer-Streit et al., 2020).
In Italy, the health system was highly equipped, andthe government responded quickly to the outbreak but
was not prepared enough to deal with the impact of
COVID-19 pandemic, and the number of cases is stillrising. The government employed measures to restrict
viral spread, including interruptions of air traf ic from
China, organized repatriation lights and quarantines for
Italian travelers in China, and strict controls atinternational airports' arrival terminals. Local medical
authorities adopted speci ic WHO recommendations to
identify and isolate suspected cases of COVID-19
especially patients with respiratory symptoms who had
travelled to an endemic area in the previous 14 days or
who had worked in the healthcare sector, having been inclose contact with patients with severe respiratory
disease with unknown etiology. Suspected cases weretransferred to preselected hospital facilities where the
COVID-19 test was available and infectious disease units
were ready for isolation of con irmed cases. The COVID-19
response teams handle patient low to local hospitals andaddress speci ic issues of bed resources, emergency
department overcrowding, and the need for patienttransfer to other specialized facilities (Spina et al., 2020).
In France, French Prime Minister Jean Castex
recommended that French citizens avoid going toCatalonia. Norway imposed a 10-day quarantine on
people arriving from Spain. Belgium banned travel to
Huesca and Lleida, with recommendations against travel
to a few other areas in Spain. Half of those who are COVID
positive in Spain are asymptomatic, which gives a clear
indication of the huge efforts that all the regions in Spain
are undertaking to test for COVID-19 in its citizens(Nussbaumer-Streit et al., 2020).
In the United States, isolation and quarantine help
protect the public by preventing exposure to people whohave or may have contacted the COVID-19 virus. The
federal government has authority for isolation andquarantine if a quarantinable disease is suspected or
identi ied; CDC may issue a federal isolation or quarantine
order. U.S. Customs and Border Protection and U.S. Coast
Guard of icers are authorized to help enforce federal
quarantine orders. A federal order is issued by CDC, thoseindividuals will be provided with an order for quarantine
or isolation (Jernigan, 2020; Patel & Jernigan, 2010).
In Asia, Korea’s early and rapid response to theoutbreak as well as implementing preventive strategies

helped preclude community infection and limit it to somespeci ied medical centers by utilizing appropriate
approaches. Although South Korea was once one of themost infected countries outside China, the outbreak hasreached a period of stability after stringent monitoring
approaches and mass quarantine (Kim, Kim, Peck & Jung,
2020). Singapore has used a vigorous surveillance
program to identify many cases by monitoring andintensive contact tracing among con irmed cases.
Singapore has managed to prevent the virus fromspreading without substantial disturbances to daily life
because the Intensive Care Units (ICUs) of the country
were fully prepared and responded swiftly to the virus
outbreak (Wong et al., 2020). Iran is among countries thatlaunched a psychological assistance system for residents
and a self-monitoring website for suspected cases of
COVID-19. Social distancing and travel restrictions wereamong the key methods used by the government toconfront the crisis and control the virus outbreak (Abdi,
2020). The Government of Malaysia imposed compulsory
quarantine orders. All individuals entering Malaysia
through the International Entry Point (Pintu Masuk
Utama - PMA) are required to bear the quarantine costs.
Individuals who are subject to quarantine orders will bereferred to as Persons Under Surveillance (PUS). PUS will
undergo a 14-day quarantine period. PUS who are tested
positive for COVID-19 will be transferred to the nearby
hospital for COVID-19 treatment. All PUS belongings at
the hotel will be taken to the hospital and the cost of thequarantine shall be settled accordingly by PUS. Refunds
will be made by the hotel management. The PUS checkout
process from the Quarantine Station is in accordance withthe health care regulations and security measures as
directed by the Ministry of Health. PUS will be issued witha Release Order upon the completion of the quarantine
period by the Ministry of Health. PUS must settle theoutstanding payment to the Quarantine Station
management. Failure to make payment may result in legal
action against the PUS by the Management of the
Quarantine Station. All incoming travelers are subject tothe quarantine order (Nussbaumer-Streit, et al., 2020).
These countries have implemented quarantine andisolation protocols to prevent the spread of COVID-19.
However, no program is instigated to address the effect of
quarantine and isolation measures to COVID patients
especially in terms of the psycho-emotional struggles thatthey’ve been through. In the Philippines, the local
government units are required to provide isolation
facilities designated for probable, suspect, and con irmed
COVID cases. In Davao region alone, law enforcement
agencies are directed to assist in the enforcement of
granular lockdowns upon affected communities orclusters. The LGUs are instructed to reduce entry
protocols such as test-upon-arrival requirement imposed
upon airline crew layovers/positioning due to emergency
situations (Mendez & Jaymalin, 2020).
Despite these mitigating measures to prevent the
spread of COVID 19, none focuses on how the patients feelin the isolation and quarantine centers. What is unknown
to many people in the province are the different
experiences and struggles of people who are forcefully put
into isolation and quarantine centers. This paper focusesEubios Journal of Asian and International Bioethics 31(7) (November 2021)
on the different experiences and emotions of people who
are forced to stay in isolation and quarantine centers in
the province. The reasons why they are brought into
isolation centers, their expectations as well as realexperiences in the isolation centers and during their
entire quarantine days, their assessment of theirexperiences as regards to the support of the government,
their ways of dealing with their ordeals are the focus of
this paper.
Objectives of the study and research questions
This study aims to gather irsthand data from the people
forced to stay in isolation and quarantine centers during
the onslaught of COVID-19 pandemic in the province. We
believe that scienti ic data are important in the evaluation
as well as crafting of programs and policies. We want tohelp the government and different front-liners in theirquest to end the pandemic, but we also want them toinvestigate the struggles of those in isolation centers andcome up with programs to make their stay comfortable aspossible. While there are different initiatives as well as
budget being released by the government to help end thispandemic, we also would like to know how these
initiatives and budgets have been implemented in themost crucial area in a public health emergency situationthe recovery of infected people and the assurance that the
PUIs and PUMs who are in isolation and quarantine
centers are really COVID-19 free so that they can go backto their families and function normally in the society.
To gather the data, we asked our 25 participants thefollowing questions: Why are you brought in the isolationand quarantine centers? What do you expect of an
isolation center? What are your experiences during thequarantine period? What about the support of thegovernment? How do you cope with your situation?
Methods
In the conduct of this study, we used individual interviews
with our participants. Five of the 25 participants wereinterviewed online. The 20 participants were interviewed
face-to-face in an isolation center because one of theresearchers in this study was also forcefully put in an
isolation center and another researcher is a healthcare
worker assigned in another isolation center in Davao delSur. In other words, 2 of the co-researchers have direct
experiences of the phenomena being studied in this paper.
The interviews were then transcribed and analyzed using
thematic and content analysis which are the most useddata analysis technique in qualitative phenomenologicalstudy.

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Results and Discussion
Reasons why they are brought to isolation centers
16 or (64%) out of the 25 participants in this study were
exposed to persons who had COVID-19 in the workplace,in their homes and in the different social gatherings thatthey were able to attend. 5 or (20%) were Locally
Stranded Individuals (LSI) who arrived in the province at
the height of the government’s ight to stop the local
transmission of the virus. There were 3 (12%) who were
Returning Overseas Filipino Workers (ROF), all working in
the maritime industry. 1 (4%) was a con irmed COVID-19

349

positive and was brought to the isolation center for
further monitoring. Some of them volunteered to undergoswab testing after members of family and/or friends got
infected and since the results were positive, they werebrought to the isolation center. 18 (72%) of the 25participants were positive with COVID-19 while 7 of themwere negative as indicated in their initial test results but
were put to isolation centers for monitoring while waiting
for the SWAB test results.
The LSI and the ROF had no other choice because themoment they arrived at the Davao International Airport,
vehicles from the LGUs already were waiting for them sothat they would go straight to isolation centers. While thispractice is already common and that some of them might
have experienced being quarantined in some other places
before reaching to the province of Davao del Sur, they still
said that they were surprised. One of our participants who
is an LSI said: “When I went back home to Sulop from
Pampanga, an ambulance was already waiting for me at
the airport in Davao. I underwent SWAB test immediately
and was found positive. I neither had fever, cough nor
colds. My temperature was even low. Since I was
asymptomatic, they brought me directly to an Isolation
Center in Sulop.”
Another LSI participant sayid: “I am an LSI from Cebu.
When I arrived at the Davao Airport, there was already an
ambulance waiting for me and I was immediately brought
to Isolation center while waiting for another swab test. I
was already negative in a swab test in Cebu. I was
surprised of the ambulance. It’s a bit scary because it
connotes a kind of impression that I am sick.” However,other LSI and ROF already expected this scenario, but they
were hoping that they would be allowed to undergo homequarantine because their families were already preparing
for their quarantine room or house. One participant
shared his experience the moment he arrived in his
hometown, “We were actually three who came from
Gensan. When we reached Sulop, we reported
immediately to the center for checkup. But the problem
was that the three of us had high temperatures because it
was too hot during the travel. So, instead of going home,
we were transferred to an Isolation Center for SWAB
testing. We stayed there until the result of our SWAB test
was determined”.
For the LSI and ROF, isolation and quarantine are notsomething new. What might be new to them is the systemor the process of bringing them to the isolation centerslike they must ride to an ambulance vehicle. Anothersurprise to them was the way they were treated in theisolation center in the province.
Others were brought to isolation centers because of
their exposure to COVID-19 positive persons in theirworkplace, in their homes and in social gatherings thatthey were able to attend. For instance, a medical frontliner said: “I was quarantined due to my direct exposure
to two positive COVID cases in Digos City – my boss who
was a doctor and my nurse colleague. My SWAB test result
is not yet available, so I stayed in the Isolation Center
while waiting”. Another participant who works in a callcenter shared the reason why she was brought to an
isolation center: “Our manager was found positive. During
the contact-tracing all the call center agents who had

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direct exposure to him were brought to the Isolation
Center for quarantine.” However, one participant sharedthat she volunteered to undergo swab testing in order toknow her status and to work for appropriate measures toensure that her co-workers would not be affected. “I evenvoluntarily surrendered for SWAB testing because I am
connected with an industrial plant and if I happen to bepositive with COVID, the whole plant would be shutdown
not to mention that all the employees that I had directcontact with shall be quarantined as well.”This participant was not only concerned about her
self-interest, she was also looking for the interests of her
co-workers. This is in conformance with theconsiderations on who to get tested such as those people
who have closed contact with someone with con irmed
COVID-19 within 6 feet from the infected person for a
total of 15 minutes or more. Also, this is in compliancewith RA 11332 or the Mandatory Reporting of Noti iable
Diseases and Health Events of Public Health Concern Act
in which mild or asymptomatic COVID-19 patients are
required to voluntarily surrender and con ine themselves
in isolation centers to prevent further spread of the virus
especially if they do not have their own room withbathroom and toilet at home, and if they are living withpersons who are vulnerable to COVID-19 like seniorcitizens and people with comorbidities. In fact, many
Filipinos do not have proper facilities at home to observe
quarantine procedures, that is why these patients need to
be extracted and put in isolation facilities managed by the
LGUs (Romero, Tupas, & Cabrera, 2020).
Another participant said: “I think I got the virus
because of social gatherings especially last December
when I got to have drinking sessions with different groupsof people. Some are my friends, some are my workmates
and there are also other people and when you are too
engrossed with drinking the pleasure it brings, you are
not mindful where the glass came from when it arrived toyou”.
It is common among Filipinos to have drinking
sessions during social gatherings and when there arecelebrations in the community and family such as iesta
and birthday. Much more common among the Filipino
folks in the province is to only use one glass when having
drinking sessions; to have your own glass while the rest
are using one glass can be interpreted as you think you
are above them. But to drink with one cup shows that you
are one with them as their kin and brother, and they will
be so comfortable with your presence. This comfort
brings forth con idence in them to share their innermost
selves, sometimes even dark secrets which most men only
feel comfortable sharing when they are under the
in luence of liquor and when they are with other men who
they think can understand them. It’s normal in provinces
that drinking sessions during important celebrations last
one or even two days. Sometimes drinking sessions areaccompanied with having “pulutan” with only one spoon
and with Videoke or Karaoke singing using one
microphone. At other times, cards are being played during
gatherings while also having drinking sessions. This is
con irmed by one participant when he said: “Maybe I got
the virus from my friend who came from a travel and thenwe had our gathering, we played cards and we also had
our drinking session.”
Some of them shared that maybe because of the natureof their work dealing with different people that they got
the virus. Others shared that in the plant or company theywork, one of the employees had the virus and that theymight have been infected by him. One patient said that hegot the virus from his employer who was positive with
COVID-19 and because he was in close contact with that
person, he was forced to undergo testing which turned
out positive.
It was common in their answers that they got the virus
because of their work and their lifestyle which predisposethem to mingle with different people. While because of
their work they were forced to mingle with other people,
they could lessen the possibility of being infected byfollowing the health protocols prescribed by the
Department of Health (DOH) and the companies andinstitutions. However, we can assume that they did not
bother to follow the health protocols because some ofthem joined different gatherings where drinking, Videokeor Karaoke singing and playing of cards are almost always
present.
The governments, media, doctors, researchers,celebrities, police, and other stakeholders of the society
appealed to the public to avoid public gatherings
including sports, religious ceremonies, family functions,
meetings as well as classes in school, to prevent the global
spread of coronavirus infection (McCloskey et al., 2020).
Despite these efforts, many people ignore the importanceof social distancing due to attitudinal issues (Roy et.al.,2020). This is true to several places in the Philippines
where people do not heed to government mandates torefrain from mass gathering such as parties. People on theother hand, may have been bored having to endure longdays and even months of staying at home.
However, there is nothing to be afraid of when one
voluntarily surrenders for SWAB testing. If tested positive,
most people have mild COVID-19 illness and can recoverat home even without medical care. If the result isnegative for COVID-19, one is perhaps not infected at thetime when the sample was collected. This does not mean
one will not get sick. A negative test result only meansthat one did not have COVID-19 at the time of testing orthat the sample was collected too early to detect theinfection. There is a possibility that one could also be
exposed to COVID-19 after the test and then get infected
and spread the virus to others. If symptoms are foundlater, then, another test is needed (Centers for Disease
Control and Prevention, 2020; Kolivras et al., 2020).
Their experiences in isolation and quarantine centers
Except for three ROF who experienced other isolation andquarantine centers in other countries and/or places in thePhilippines, the remaining twenty- ive participants had
their expectations that life in the isolation centers would
be lonely, miserable and a constant struggle. Indeed, they
are true. Their experiences in the isolation and quarantine
centers in Davao del Sur are full of worries, anxieties,
fears, loneliness, sacri ices. Some experienced hunger in
the irst few days because they did not have free supplies
of food and that they were not properly oriented what toEubios Journal of Asian and International Bioethics 31(7) (November 2021)

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bring. Some also expected that there would be free foodjust like in other isolation and quarantine centers. In
Davao del Sur, they found out that only those who arereally con irmed to have COVID-19 get free food and othersupplies such as vitamins. Those who are only PUIs and
PUMs do not have free food. They were only given little
supplies of toiletries and thermometer to check theirtemperature. Some also shared that they might die fromdengue rather than COVID-19 because their quarters were
infested with plenty of mosquitoes, and they did not havemosquito nets.
Through the sharing of their stories and experiences,
one can feel the dif iculties and sacri ices they endured in
the isolation and quarantine centers in Davao del Sur.
Narrating her own experience before coming to andduring her stay in the isolation center, the co-researcher
in this study has these words:“What caught me by surprise was that someone fromthe healthcare unit called me that an ambulance would
pick me up so early in the morning not even 7:00AM. I did
nothing but cry because I have kids. I worry about theirsafety. I felt very helpless during that time. Better that mykids were not home with me. During my irst day, I
couldn’t eat lunch because I wasn’t able to bring anything
to eat except for a few pieces of clothes because it was
sudden. When the ambulance picked me in my house, thehealth care providers did not instruct me on what to do.
They just told me to get ready because I need to beisolated. I wasn’t even able to bring water. I suffered fromthirst and hunger during my irst stay. I was disoriented
and did not know what else to do. They should haveinformed me what to bring in the quarantine area. I criedand cried because of helplessness and self-pity thinking of
my kids, my family, clients, my deadlines, and theconstruction of my new house, my workers, my income,and my payables. My quarantine period hinderedeverything. I worried about my SWAB test result. What if
I’d be positive, all the people who have direct exposure tome would be traced and isolated as well. It was very
dif icult living in uncertainty because you do not know if
you will be positive or not. Many things come to mind.
What if I am positive? Can I still recover? How long? Can I
still go back to my old world? All these questions candrive you crazy. If you cannot adapt immediately to yoursituation, you will either land in a mental hospital orcommit suicide.”
The experience of the co-researcher in this study is notunique to her. Fears and worries of what the future mightbring, anxieties about the situation of their families andkids at home, their worries about their works and sourceof income, their stress and loneliness in the isolation
centers are common to all our participants. For instance,
one of our participants said:“When I arrived at the isolation center, I was reallyscared. Imagine from the airport, I was directly brought
here. Better that I had biscuits in my trolley. Anyway, thefood is free in the shelter, if you are positive. But I met
someone new who was crying because she couldn’t bringfood. Out of hunger she did not have much choice but toaccept that biscuit I gave, even though I was positive. I just
hoped that she won’t acquire the virus from me. Anyway, I
disinfected the biscuit. Aside from that it was still351

wrapped. I worry that if she turned positive, they would
blame me. I also worry about my family because they
expected me to arrive in our house and have my selfquarantine there. Nobody informed them immediately
about my situation.”
Sharing her re lections while she was in an isolation
center, another participant of our study narrated her fears
and worries as well as hopes:“COVID is real. It is not something to make fun of. It is
deadly. I don’t worry much about my health because I am
not feeling the symptoms of the virus like fever, cough andcold. But what I am worried of is the result of SWAB test.
It caused me sleepless nights just thinking what if I might
be positive. I guess I cannot accept it that I would becremated when I die. Only my ashes will remain and given
to my family. I really hope not.”A call center agent whose test was positive shared herexperiences and struggles in the isolation center and how
it affected her mental health because her family was
severely affected by her condition:“I am already suffering from almost a nervous
breakdown here because I was alone. No one was allowed
to neither go near me nor talk to me. It’s very frustrating
and disgusting when your friends won’t talk to you
anymore because you are positive with the virus. While I
was suffering here in silence, my neighbors were
circulating rumors that I was already dead. It hurt me a lot
and affected me psychologically. The saddest part is thatthey discriminated against my family. My nephews andnieces cannot play with their friends anymore because weare COVID positive. They generalized us instead though it
was only me as the one positive. I am sad that my family
experienced such humiliation. When my second SWAB
test result arrived, I was already negative with the virus.”
Societal sickness is more dangerous and deadlier than
COVID-19 and it has also no cure. That disease is people’s
discriminatory attitude towards other people. With therise of COVID-19 cases, such diseases also increase. The
saddest part is that those who are targets of this disease
are the victims of COVID-19. So, in a way, it added insult toan injury. According to World Health Organization (2020),
the recent COVID-19 epidemic has incited social stigma
and discriminatory behavior against people who are in
isolation or quarantine centers as well as anyone
perceived to have been in contact with the virus. Thesepatients suffered from being labelled, stereotyped,
discriminated against, treated separately, and/or
experienced loss of status because of a perceived link witha disease, as well as their caregivers, family, friends, andcommunities. People who do not have the disease butshare other characteristics with this group may also sufferfrom stigma.
In fact, not only patients suffer from stigma anddiscrimination but also the front-liners. They weretraumatized and suffered sleepless nights. Their isolationand quarantine are not only about physical con inement,
but also behavioral, cognitive, and affective due to thelimitations in the interactions with family, relatives,
friends, and health workers. The restrictions on freedom
involved in quarantine and isolation are sometimes
described as occurrences of intimidation (Sánchez-Villena,

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& de La Fuente-Figuerola, 2020; de Castro, 2020; Villa, etal., 2020).
Our participant who is a college student shared herordeals in an isolation center and how these affected herstudies, her families and friends: “It was terrible. It’s not a
conducive place for me especially because I study, and I
have plenty of deadlines. We did not have a conducive place
to stay; the place was very hot and there were plenty ofmosquitoes. I was afraid I would die of dengue rather than
Covid. It became more terrible when I learned I was
positive. I felt scared about what would happen to me. I also
got angry because the people discriminated to my family.”
The experience of a participant about mosquitoes was
as such: “Staying here is not good. It’s better that they
released me and allowed me to go home to our farm
because it’s better there because of the fresh air, lowing
river and fresh vegetables. Here it is very hot and there
are many mosquitoes. It’s not easy to be quarantined in
Digos. Better that my SWAB test result was negative. They
let me go home to our farm and inish my quarantine
period there. However, people there feared me though
they knew that I was negative. I can understand that they
don’t want to come near me because I don’t want to have aclose contact with them. It is a sad truth that you are nolonger welcome once you are a Covid suspect, especially if
you come from abroad.”
Indeed, their experiences in isolation centers are full ofmisery, sacri ice, fear, and worry. Another participant who
is a graduate school student, a family man and a breadwinner had these words: “I experienced anxiety andworries. I worry for my children, my work, my studies,and my SWAB test result. When it turned positive, I felt
the whole world was tumbling down on me and I did notunderstand what I felt, I was angry why of all people, I
was the one contacted with the virus. What would happen
to my family, my kids, and those people who trusted me?
What about my studies? I was really depressed. It wasn’t
really that easy”.
Beyond the immediate impacts of COVID-19 on health,being in quarantine or isolation increases the patient’s
anxiety, fears, frustrations, helplessness, uncertainties andworries, which eventually affect their social relations,
their trust in other people, their personal security andsense of belonging. In fact, these people have already been
through a lot the moment they were transferred to an
isolation center. They are afraid because of a perceived
danger or threat, which causes physiological changes andultimately behavioral changes. It is closely related toanxiety, which occurs as the result of threats that areperceived to be uncontrollable or unavoidable. This
causes irrational fear to patients due to negative thinking
or worry which arises from anxiety accompanied by asubjective sense of apprehension or dread (Kim &Markman, 2005).
The co-author was also COVID-19 patient herself, andshared that she really suffered from fear, anxiety,depression, and uncertainties. She feared for her life, her
career, her colleagues, especially, her kids and family. As asolo parent, she tried her best to sustain the needs of her
kids; then, something unexpected happened. She got a
close contact with a fatal COVID case. At irst, she wasshocked, how could that happen to a very healthy person?

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She was able to talk with her before her con inement in
the hospital. She was afraid and confused on what to do.
The fear and anxiety she felt was overwhelming. It caused
her sleepless nights especially when the healthcare unit
called that she needed to be transferred to an isolation
center. The more she became lonely and stressed out. In
an isolation center, the nights are too long and days too
short. What she felt is supported by the premise ofShechter, Diaz, Moise, Anstey, Ye, Agarwal and Claassen(2020) that the stress suffered by patients may cause fear
and worry about their own health and the health of their
loved ones, inancial situation or job, or loss of support
services, changes in sleep or eating patterns, dif iculty
sleeping or concentrating, worsening of chronic healthproblems, and worsening of mental health conditions.
However, quarantine and isolation are necessary to
reduce the spread of COVID-19. My fellow patients shared
the same sentiments as mine. Life in the isolation center isilled with fear and uncertainty which left feelings ofstress, anxiousness, and powerlessness over the directionof life. It is emotionally draining because of “what-ifs” andworst-case scenarios about what tomorrow may
bring. According to Durodie (2020), the COVID-19
pandemic has heightened uncertainty because it changes
life very quickly such as becoming sick suddenly, losing
job, or keeping the family safe. People become anxious
about when the pandemic will end or if life will everreturn to normal.
Government support to people in isolation andquarantine centers
In terms of government support all our participants
shared that the government is really lacking in terms of
supporting the people in their ordeals and struggles in theisolation and quarantine centers. Even a medical frontliner who was con ined in an isolation center noticed thefailure of the government and other healthcare providers
in managing the people in isolation centers: “There arereally lapses in the part of the government and healthcare
units especially when the COVID suspects are transferred to
the Isolation Center. They should have oriented them onwhat to do and what to bring in the shelter house. They
know that food is not free, and some rooms are not reallythat comfortable, they should have told them what toprepare and bring. For those who are here already, theyshould constantly follow up if they are still okay or not. But
the healthcare workers are afraid to acquire the virus.”
A call center agent who is also con ined in an isolation
center shares her sentiment about the lack of government
support: “There is not much support from the government.
Not even enough to support my quarantine period. Actually,
my family is the one supporting my needs here especially interms of food. Good that I have my family here and that they
can afford to travel and give me my needs. But what aboutothers whose families have barely just enough for them?
The government only provided me with basic toiletries.
That’s all. It’s really lacking.”
While some participants were appreciative of the little
help coming from the government like free toiletries andvitamins, they were still hoping that the government
could do more than that and would have interventions to
help the people in isolation centers cope with thedif iculties and struggles they experienced. This wascaptured in the sharing of one participant when she said:“In fairness, the government/healthcare unit provided mewith a mat, blanket, thermometer, shampoo, toothpaste,
toothbrush, and a pack of multivitamins but no food. You
must provide yourself with your own food. The problem wasthat you have no one to turn to. Surely, you will not die of
COVID; you will de initely die of HUNGER. I believe, thegovernment should have focused on providing food, andmedicine; especially psychological counseling for thevictims so that they can easily accept and adjust to theirsituation.”
Though the local government unit did not provide foodfor the PUMs and PUIs but a Community Isolation Unit
(CIU) was setup in coordination with local government
units to serve as quarantine facilities for COVID-19 cases(Department of Health, 2020). Similarly, the Departmentof the Interior and Local Government (DILG) required all
local government units (LGUs) to establish their own
isolation centers as part of their efforts to combat the
spread of the coronavirus disease (Caliwanm, 2020) As
these participants shared: “The government lacks support
because when they brought me here, I was only given a
vitamin and thermometer to monitor my temperature,morning, noon and evening. Aside from this, nothing more.”
Apparently, the government mandates or programs
that we saw on TV and read in newspapers are totallydifferent from the reality. The programs are impressive
but in terms of implementation, it is somewhat inef icient.
For example, Bayanihan Grant to Cities and Municipalities
enables the LGUs to have greater capacity to purchaseequipment and help those who are greatly affected by thiscrisis (Caliwan, 2020). But what about support in terms offood, and psychological counseling? The government
should not only focus on the medical side but also on
resource management and psychological wellbeing of thepatients.

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Different ways of coping with their ordeals
This study con irmed results of other studies on the roleof positive mindset and prayer of faith in God as well as
care for their families as the important means employedby most Filipinos when they experienced adversities andhardships in life (Bayod, 2020; Arnado & Bayod, 2020;
Bayod, Forosuelo, Arnosa, Cavalida & Orion, 2021). For
most of our participants having a positive mindset andfocusing on positive thoughts, having faith in God andconstant prayer and the thought that they had to bestrong for their families were the things that kept themgoing despite the dif icult situations they experienced inisolation centers. Below are just some of their sharing on
how they cope with their situations: “Although, this is
unacceptable, but you can do nothing because our enemy isinvisible. I just entrust my life to the Lord because I knowthat he is my refuge and redeemer. He will not forsake meeven if I am sinful (Businesswoman, Covid-19 Positive)“I focus on positive thoughts and I pray hard. I also takecare of myself by eating fruits, taking vitamins, and having
enough time to rest. (College student, Covid-19 Positive)“I prayed and tried to be strong and positive. It’s astruggle but eventually I accepted, and I need to have astrong immune system. My family and kids helped a lot soff

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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that I tried to recover and survived”. (Graduate student,
Covid-19 Positive)“My family is my strongest support because of what theyexperienced from our neighbors; it enabled me to ight evenin my moments of desperation that I would really want todie. They gave me the strong hope to survive COVID and
now I am back to the outside world. I thank God for that. I
guess my family is the reason why I ight to survive myillness even if it is already very dif icult for me. I was getting
weaker each day I stayed in the isolation because I had noone to talk but what my family did made me stronger, and it
made me survive. (Business manager, Covid-19 Positive)“At irst, prayers then family support is very important,and you need someone to talk to and share your problems.
Someone who will not judge you. Someone who is willing tolisten and understand you no matter what your situation is.
I was very positive that I could survive this because there
were many COVID positive patients who survived. She kept
on advising me to drink a lot of hot ginger and kalamansi
juice to boost my immune system. She kept on telling methat I was still young and could survive that.
(Businesswoman, Covid-19 Positive)
We could not ask about their prayer life prior to theirstay in isolation units but found out that most of them
resorted to prayer. This might be because they were notgiven any medicine except for some vitamins. Filipinos are
known to be religious, and their religiosity have helped
them to survive the trials that they have experienced. But
we sense that most often some Filipinos considered God
as their last recourse. This means that when everything isokay, they do not really need God. Yes, some might go to
the Church, but Church going is considered a social
gathering and obligation so that their friends and theirneighbors will see them in the Church. For Rolheiser,(2003), the Western culture is often characterized as aculture, that for the most part, no longer imagines andbelieve that God exist. This culture has in iltrated thePhilippines. We also feel that this is even true to a certain
extent to many of us. Because of too much concern with
our works and our individual achievements, happinessand agendas, our everyday consciousness contains little
or no awareness of God. In our normal lives, we tend to beatheistic in our imaginations and feelings, even as we still
profess our faith, say the creed, go to Church, and perhaps
even do our ministry (Rolheiser, 2003). But during
emergency situations, many of us call to God because even
if he is not in our ordinary consciousness, many Filipinos
still remember him.
Similarly, adaptability and resilience are important inovercoming the struggles and hardships in the Isolation/
Quarantine Centers. As Gonzales (2020) cited resilient
people see struggles as a challenge and an opportunity togrow not as a paralyzing incident. This is revealed in thefollowing statements of the participants:“When I regained my composure, I requested my cousin
to bring me groceries, rice cooker, heater, laptop and myiles. I cooked my own food and kept myself busy by doing
my work even inside the shelter house. I have so many
deadlines to meet. Now I have all the time to inish them. I
am really very optimistic and resilient. I can easily bounceback from a dif icult situation after crying my heart out.

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A positive mindset, faith, adaptability, and resilience
were some of the many ways to cope with the ordeals thatthe participants have gone through at isolation/
quarantine Centers in Davao del Sur. The study of Monyeand Adelowo (2020) recommends that everyone,susceptible, suspected, and con irmed COVID-19 cases
should be encouraged to adopt healthy lifestyle practices
in their daily living. Such measures if practiced
consistently should signi icantly reduce the susceptibilityof at-risk cases, severity, complications, the recovery
period, and the fatality rate of the disease. This is a matterof self-discipline and an inspiration to fellow citizens to bewatchful and value life and family back home.

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Conclusion
Most study participants said that they became COVID-19
positive due to exposures to people who were positive in
different social gatherings and in their workplace. Most ofthem in isolation centers anticipated the result of theirtest which means due to their exposure, they already had
the feeling that they were positive with the virus. Also, anumber of these positive COVID-19 patients did not feel
any of the symptoms at all because they wereasymptomatic. This condition helped them ight the onsetof the virus and learned to have positive dispositions
because they felt nothing except they were aware of theresult of their test. To ight the fear and anxiety, they
consider prayers, practicing healthy lifestyles andfollowing protocols as their means to overcome theunprecedented situation. In terms of receiving aid andassistance from the government, most of those placed in
the isolation centers expressed that they did not receive
any help. Some received food and vitamins but notconsistently while they were under quarantine in thegovernment facility. There were many lapses on theimplementation of the quarantine and isolation measures
to prevent the spread of COVID 19 such as the lack ofgovernment support especially in terms of emotional andpsychological counseling; the government focused muchon the prevention of the virus without considering theeffect of these measures on the psycho-social well-beingof the people in isolation and quarantine centers;
therefore, there is a need to revisit the effectiveness of the
program so that any pitfalls maybe corrected because if
this continues people might lose faith in the government.
The thought of those asymptomatic patients that it’s
just nothing because they do not feel anything is alsosigni icant. While it may help them to have the guts andcourage to ight against the virus, it can also be
problematic if these persons are not identi ied and they
continue to mingle with other persons in their homes, intheir workplace and in the different social gatherings thatthey will attend. Asymptomatic persons are still carrier ofthe virus and if they can infect the vulnerable persons likethe sick, the elderly and the children, they might be thecause of their sudden and unexpected hospitalization oreven death. That is why it is always good to consider
oneself as a potential carrier of the virus. The healthprotocols instituted and instructed by healthcare experts
are an important weapon to protect oneself and othersfrom the virus. The front-liners and the law enforcers
have been doing their part to educate the people of theimportance of following health protocols, but they are justfew. If people have self-discipline and a sense of
responsibility towards the common good, the ight against
this virus will end sooner. Social cooperation is very
important during times of pandemic. According to Lapeña(2020), people are giving hope because others are giving
hope in return and there are also people who go over andbeyond the call of duty. However, these efforts will all be
put in vain if citizens in the community do not do theirpart in practicing all the measures to help prevent the
spread of the virus.
Aside from controlling the spread of COVID-19, thenational government may also implement programs on
how to lessen the effect of isolation and quarantine
programs on the psycho-social well-being of the persons
affected. The Local Government Units (LGU) may conduct
information dissemination and stress debrie ing for these
persons to prepare them emotionally and psychologicallyon the adverse effect of isolation to one’s health. The
Health Care Units should properly orient the persons
under monitoring or investigation so that they areprepared on what to bring once they need to be isolatedor quarantined as a preventive measure. The healthdepartment should craft programs on how to manage
p o s t - t ra u m a t i c s t re s s , u n c e r t a i n t y, i r r i t a t i o n ,disappointment, insuf icient knowledge, inancial loss andstigma. The persons under monitoring and investigation
should be properly informed about what is going tohappen once they are isolated. They should learn how toadapt to their situations immediately.
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Psychological stress in mothers ofchildren undergoing stereotactic
thermal coagulation for
hypothalamic hamartoma- Makiko Tsubokawa
Graduate School of Health Sciences, Niigata University,
Niigata, Japan.
Email: b14a305c@mail.cc.niigata-u.ac.jp- Mai Yamada
Health Science University, Yamanashi, Japan- Tomoko Sumiyoshi
School of Health Sciences, Niigata University, Niigata,Japan
Abstract
Epilepsy is one of the most frequent neurologicaldisorders and affects 0.5–1% of children worldwide. In
Japan, the term epilepsy has historically had negative
connotations and patients still face discrimination andstigma. Parents of children with epilepsy are highly
stressed and suffer increased risk of psychologicalproblems such as depression and anxiety. The ef icacy of
epilepsy surgery has become widely recognized as atreatment option for uncontrollable epilepsy. A qualitativeand descriptive survey was conducted with six mothers
whose children had undergone epilepsy surgery in
Hospital A. A total of eight recommendations based on thesurgical procedure, the postoperative condition of thechild, and the overall health and mental condition of theparents were derived. Suggestions on the development of
a support system and the provision of support on thehealthcare professional side were obtained. The data wereanalyzed based on the Steps for Coding and Theorization(SCAT). Results indicate that shared parent-child decisionmaking is a barrier when surgical outcomes are uncertain.
It is suggested that it would be effective for the medical
staff to explain the surgery to the child while providing
information to the parents. In addition, parents should be
provided with multidisciplinary psychological support.

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Introduction
Epilepsy is one of the most frequent neurologicaldisorders. The World Health Organization (WHO) de ines
it as “a chronic brain disease of various causes, mainly
characterized by recurrent seizures due to excessive
discharge of brain neurons.” Epilepsy has been reported toaffect 0.5–1% of children worldwide [1]. It is an important
public health issue in Japan given that the country has one
million epilepsy patients [2]. In Japan, the term epilepsy ishistorically accompanied by negative nuances, such as
madness and evil spirits. Given this cultural background,patients still face discrimination and stigma. In general,parents who have children with epilepsy are highly
stressed and are clearly at increased risk of psychologicalproblems such as depression and anxiety [3,4]. Parents
feel intense guilt over children’s illness, and those withchildren with epilepsy are psychologically and sociallystressed [5,6]. In recent years, epilepsy surgery has
become widely recognized as a treatment option for

uncontrollable epilepsy [7]. The purpose of surgicaltreatment is to eliminate or reduce seizures, and above all,improve the quality of life (QOL) of patients and theirfamilies [8]. Few studies have clari ied the psychologicalcondition of parents when their children are undergoing
surgery for pediatric epilepsy, for which new surgicalmethods are being developed. The construction of new
therapies is important not only for improving QOL but
also regarding bioethics.
Hypothalamic hamartoma is a congenital benign tumorof unknown cause in intractable epilepsy syndrome that
affects 1 in 200,000 people. Symptoms include epileptic
seizures (mainly laughter seizures), precocious puberty,
learning disabilities, and attention de icit hyperactivity
disorder. Stereotactic thermal coagulation is a newly
developed surgical method for this disease, developed andpresented in Japan in 2007 [9,10]. Head surgery on
children is a hard decision not only for healthcare
professionals but also for parents.
By clarifying the psychological stress of mothers ofchildren who will undergo this operation, this study
obtained suggestions on the development of a support
system and the construction of support on the healthcare
professional side.
Methods
This study used a qualitative and descriptive design inaccordance with the criteria for reporting qualitative
research (SRQR) recommendations [11].
Subjects: There are 37 epilepsy centers in Japan, which
treat epilepsy in close cooperation [12]. Among them, theaccompanying family members of children who wereadmitted to Hospital A for the purpose of stereotactic
thermal coagulation of hypothalamic hamartoma weretargeted. Hospital A was chosen because it is a specialized
center for epilepsy covering a radius of 250 km. The
facility has many inpatients not only from Japan but also
from overseas and caters to people from various
backgrounds. In addition, it has a hypothalamic
hamartoma center and is one of the top-class epilepsy
centers in Japan as it develops new surgical methods. As
such, the facility oversees many operations.
In this survey, we asked the ward of Hospital A to
perform purposeful sampling, and asked eightrecommendations based on the surgical procedure, thepostoperative condition of the child, and the overall healthand mental condition of the parents. A total of six mothers
who had consented were included in the study.
Data collection: Data were collected from mothers ofchildren who underwent epilepsy surgery through semistructured interviews (1 hour) and, if necessary, follow-up
interviews (30 minutes) for clari ications. The interviews
were recorded using a digital recorder and latertranscribed verbatim.
Subjects were asked the following questions: (1)“What do you feel while taking care of your child who isabout to undergo epilepsy surgery?” (2) “How did you tell
your child about their illness or surgery?” (3) “How did
you take your child’s reaction to the fact that they wereabout to undergo surgery?” and (4) “During the
explanation of the surgery, what do you want or not wantEubios Journal of Asian and International Bioethics 31(7) (November 2021)

357

to tell your child?
Table 1: Background of study subjects
Child’sage

Sex

Age at irst surgery

Number of surgeries

Mother’s age

Time of interview

A

4 yearsMale

1 year old

4 times30s

3 months after surgery

B

11 years

Female3 years old

3 times

40s

5 days after surgeryD

11 years

Female5 years old

1 time40s

3 months after surgery

E

13 years

Female10 years old

2 times40s

3 months after surgeryF

11 yearsMale

2 years old

3 times40s

3 months after surgeryG

13 yearsMale

2 years old

4 times40s

3 months after surgery

A

4 yearsMale

1 year old

4 times30s

3 months after surgery

B

11 years

Female3 years old

3 times

40s

5 days after surgeryD

11 years

Female5 years old

1 time40s

3 months after surgery

E

13 years

Female10 years old

2 times40s

3 months after surgeryF

11 yearsMale

2 years old

3 times40s

3 months after surgeryG

13 yearsMale

2 years old

4 times40s

3 months after surgery

Table 2: Themes and subthemes<Subtheme>[Theme]<Hesitation regarding the decision>1[Heavy responsibility as a surrogate decision-maker]

2[Desire for a normal life]<Inspiration from healthy children><Long-sought disappearance of seizures><Expectations for surgery to reduce symptoms><Sympathy for the frightened child>3[Dif iculty in explaining to the child]

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Data analysis: The data were analyzed based on the Steps
for Coding and Theorization (SCAT), a theme analysis
method inspired by grounded theory [13]. The text
increases the risk of the divided data in a matrix. <1>
Notable words were identi ied in the data. <2> Words
outside the text that can be used to re-express the focused
word were identi ied. <3> External concepts in the textthat describes the focus word were identi ied. <4> Coding<Relief due to the careful explanation of the medical staff>

was done using the themes and structural ideas that
occurred [14].
During the survey period, all members examined theentire analysis process of the main analyst, discussed, andcorrected any problems to ensure the reliability andcon irmability of the data. Furthermore, the robustness of
the results was ensured through open discussions at themember-sponsored study group.

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Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

Ethical considerations: This study was approved by the
Ethics Review Board of Niigata University of Health andWelfare (approval number 17471-14031) and approvedby the Ethics Review Board of Hospital A. In addition, theresearch objectives were explained in writing and verballyto the research participants, and a consent form wassigned. Careful consideration was given to the obtained
data so that no individual could be identi ied.

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Results
The subjects were six mothers in their 40s and 50s, andtheir children were 4 to 13 years old. The patients
underwent surgery one to four times. All the patients had
hypothalamic hamartoma and underwent stereotactic
thermocoagulation. (Table 1). We extracted the themes
and two subthemes. (Table 2)
Themes are in [ ] and subthemes are in < >. Examples
are shown below.
! [Heavy responsibility as a surrogate decision-maker]
The mothers said that before the surgery, they weremore anxious about the risks than the bene its to theirchildren. They explained that the decision made them feelguilty over letting their child undergo a rare and nonurgent surgery. Despite the pressure, many mothers were
inspired to see their children playing and going to surgery.
" <Hesitation regarding the decision>“I was happy to know that my child can undergo thesurgery. However, as a parent, I had con licting feelings. I
was worried because there was no guarantee that mychild would be 100% cured.” (D)" <Inspiration from healthy children>“I felt vitality when I saw children. I was trying to stand on
my own. When I saw that, I really cried. Seeing children
gave me strength.” (G)! [Desire for a normal life]
Mothers wanted the surgery to eliminate theirchildren’s laughter episodes, which was the main
motivation for their decision to undergo surgery. They
believed that their family would have a “normal life” after
the surgery. They were also relieved by the positivechanges in their child after surgery.
" <Long-sought disappearance of seizures>“My child gradually became able to do various things, but I
wouldn’t know what to do if their cognitive andbehavioral levels decline. I really wanted the seizures todisappear.” (B)" <Expectations for surgery to reduce symptoms>“The irst surgery cured their hyperactivity. He’s now very
well-behaved. It would have been better if the laughter
episodes disappeared, but they didn’t. I hope they
disappear with future surgeries.” (F)! [Dif iculty in explaining to the child]#Many mothers were upset by the frightened child’sreaction and had dif iculty explaining the purpose and thespeci ics of the complex surgery. Among them, theexplanation from the medical staff cleared the child andthe mother’s anxiety.
" <Sympathy for the frightened child>“As a parent, it was really dif icult to take care of children
while they were saying that they were scared.” (D)" <Relief due to the careful explanation of the medical

staff>“I didn’t know what to explain to my child. The nurse’s
careful explanation helped me a lot.” (A)Discussion
This study investigated the preoperative psychologicalstress of mothers of children undergoing stereotactic
thermal coagulation developed in Japan for hypothalamic
hamartoma. The procedure was not urgent and had only
been performed on a small number of cases, which madethe mothers feel guilty over making the decision
regarding surgery. The decision was backed by a desire to
improve the QOL of the family when the child’s seizures
disappeared. However, before the operation, they were
upset by the reaction of their frightened child, whichbecame a hindrance to convincing their child about asurgery they themselves could not explain. Medical staff’s
careful explanation reassured the children.
In adult patients, the shared decision-making (SDM)
process in which physicians and patients interact witheach other and discuss values, treatment deliberation andmethods, is important for their own surgery [15].
However, in the case of medical care for children, it isoften dif icult for children to participate in decisionmaking and express their opinions when they are youngor have problems with cognitive function [16,17].
Therefore, parents become surrogate decision-makers
while respecting the best interests of the child.
The study reveals that shared parent-child decisionmaking is a barrier when the outcomes are uncertain,such as in new surgical procedures or when there are only
a few cases due to the rareness of the disease. It is wellknown that risks and uncertainties have a signi icant
impact on critical decisions. In addition, many reports
have stated that parents struggle with the treatment of
their children but have dif iculty giving them theopportunity to make decisions [18-20].
#In addition to the above, Japan’s Civil Code stipulates
that children under the age of 20 are subject to parental
authority. Within this context, parental decisions will havea legal effect on children’s surgery. We can infer that the
new surgical procedure known as stereotactic thermal
coagulation for hypothalamic hamartoma made it dif icult
for mothers to make rational decisions concerning risk
assessment, and that they experienced enormous stress insurrogate decision-making.
What actions do parents take to relive that stress?
Regarding decision-making, there are reports that parents
actively collect information by searching past cases online,
and so on, in an attempt to alleviate confusion and anxiety[21]. It was suggested that stress can be reduced byproviding suf icient information and dialogue before
decision-making to improve medical care for children
receiving new treatments.
In particular, regarding this operation, mothers were ina sensitive psychological state, such as being unstable andcrying immediately due to the symptoms and anxiety of
the child before the operation. As contained in the theme[Dif iculty in explaining to the child], mothers wereparticularly worried about the fact that the surgical site
was the head. We speculated that the pain of not being
able to fully explain to the child due to lack of information

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)(cognitive function effects, scheduled multiple surgeries,etc.) also affected mothers. Despite receiving adequate
information from physicians before the surgery, weclari ied again that mothers were in an unstable andirritable psychological state before their children’s
surgery.
We believe that healthcare professionals must provide
better care. Despite being hospitalized for surgery, theextent of the children’s understanding of the surgery isunclear even if parents received information fromphysicians. Children may not be informed, especially if thesurgery had only been performed on a few cases and if theif the child is unable to make rational judgment based on
previous cases. Therefore, it is necessary to discuss withparents as soon as possible to con irm when, who, andhow to speak to their children. Parental anxiety can also
be reduced by explaining to the parent in front of thechild.
It has also been reported that discussions on relevant
information attended by nurses, social workers, andpsychologists are effective for parents [22]. It is useful towork with physicians to provide ongoing knowledge andpsychological support to parents.
Limitations: Due to the rareness of the disease, there
were only six subjects, which constitutes a small sample
size. Therefore, the results most likely do not apply to allparents of children undergoing stereotactic thermal
coagulation. In the future, it is necessary to conduct
continuous interviews and further examination.
Conclusion
It has become clear that mothers of children undergoingstereotactic thermal coagulation, a new procedure for therare disease hypothalamic hamartoma, experienceextremely high stress due to the heavy responsibility
associated with surrogate decision-making. Furthermore,mothers feel guilty because the surgery is not urgent andaims to stop episodes, which would improve their QOL.
The results suggest that it would be effective for the
medical staff to explain the surgery to the child whileproviding information to the parents. The results alsosuggested that it is necessary to provide multidisciplinary
psychological support to parents.
Acknowledgements
We would like to thank the mothers who agreed to beinterviewed and the staff at Hospital A for theircooperation. This work was supported by JSPS KAKENHI
Grant Number 17K12378.
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Physician Privacy and Patient
Benefit- Saeedeh saeeditehrani1, Mina Forouzandeh1, NazafarinGhasemzadeh2, Roya Rashidpouraie3
1. Department of Medical Ethics, School of Medicine, Iran
University of Medical Science, Tehran, IranEmail: s.saeeditehrani@yahoo.com
2.Department of Medical Ethics, Medical Faculty, Urmia
University of Medical Sciences, Urmia, Iran
3. Medical Ethics department, Tehran University of
medical science, Tehran, Iran
Abstract
Privacy is a fundamental human right that provides asense of security against the disclosure of one's personal
life such as emotions, thoughts, and bodies. Physician
privacy should also be considered. Ignoring physician's
privacy while on duty can cause stress to physicians. This
causes their job burnout and dissatisfaction, which in turn
reduces their ef iciency and has a signi icant impact on
reducing community health service.$In the present study,
we will irst explain the concept of privacy dimensions
and scope, then de ine the physician privacy and privacy
concerns for the community and the practical challenges
associated with physician privacy and propose a solution
to enhance privacy management communication.

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Introduction
Respecting patient’s privacy and con identiality is one of
the most important physician’s moral duties; hence it has
a long history in medicine. This has been highlighted andreferred to as a sacred matter in Hippocratic Oath.
Con identiality is of special importance in religions,especially in the physician-patient relationship (Parsa,2009). Respect for patient privacy is rooted in respect forpatient autonomy which prevents from psychologicalharms (Jenkins et al., 2005). While having their own
personal autonomy, humans are social beings and theirrelations with others and social life gives meaning to theconcept of privacy and associates its observance withhuman dignity. Due to the special nature of the physicianpatient relationship, respecting human dignity, privacy,
and con identiality has increasingly become critical.
Con identiality is the most basic and unconditional
principle in the physician-patient relationship. In astatement of the World Health Organization and the
Iranian Patient Rights Charter, it has been emphasizedthat respecting patient privacy and con identiality isessential in provision of healthcare services (Parsapoor etal., 2010). Respecting patient privacy maintains trust in
physician-patient relationship. This relationship isbilateral and mutual. Although patient privacy andcon identiality is of the utmost importance, patientsshould respect the dignity of the physicians and the

medical profession. Patients and the society have duties tophysicians, to establish an optimal interactive
relationship, and both parties should comply with
communicative considerations. Observance of physician
privacy and providing a safe and secure environment for
the healthcare system may improve the quality ofhealthcare services. In other words, patients andphysicians’ rights are like two wings of a bird; both should
work together for proper relationship and optimal
provision of healthcare services.
Unfortunately, physician’s rights and their professional
dignity have been less considered. Numerous articles havebeen published about patient privacy (Sankar et al., 2003;
Kiser, 2015; Dolan, 2014); however, few papers haveaddressed physician’s privacy. Hence, the present paper
aims to deal with the concept and value of physician
privacy and its dimensions and scope, to clarify the
associated challenges, and to discuss duties of patientsand society to physicians.
Methodology
The present review article aims at clarifying the conceptof privacy, its dimensions, scope, value, and practicalchallenges. To this end, the keyword “privacy” wassearched on search engines and websites such as PubMed,
ScienceDirect, Scopus, and MDConsult. At irst, many
papers (without limitation) were found but most of themwere about patient privacy. Then, other keywords such as“healthcare information”, “physician privacy”, and“physician con identiality” were searched during the past
20 years. At this stage, there was a dramatic reduction in
the number of papers. In addition, medical ethics
textbooks, especially in issues such as autonomy, privacy,
and con identiality, were reviewed. However, no relevant
paper was found in our national databases such as
Iranmedex and Magiran in Persian.
Concept of privacy
The term “privacy” was derived from the Latin word
“Privatus” at the end of the 14th century. “Privatus” means
to separate, belong to someone, and not belong to thegovernment, as opposed to words “Publicus” and“Comminus”. “Privatus” originates from the word
“Privare” which means to deprive and dispossess.
“Privare” roots in the Latin word “Privus” which means
the property of own, derived from the Latin root “Pri”
which means before (Harper, 2000). The term “privacy” isderived from “Priva”, or “privilege”, which means a special
advantage or a desirable opportunity (Leino-Kilpi et al.,2000). In reference books and dictionaries such as
Webster and Oxford, the same de initions of privacy havebeen provided. Most of these de initions refer to the statein which one is alone, away from the public view, and freeof any interference of others in his/her personal affairs. In
Persian dictionaries, privacy has been translated into
personal life, solitude, comfort, and peace (Mehrdad et al.,2005).
Dimensions and scope of privacy
Privacy has several dimensions including physical,
psychological, social, and informational (Leino-Kilpi et al.,2000). However, There are ive dimensions when privacy

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
in healthcare is considered: physical privacy (respect for
the human body); informational privacy (respect forcon identiality and protection of patient information);communicative privacy (providing a peaceful and intimate
environment for the patient and the health service
provider); privacy of ownership (respect for one’s right ofownership on information about his/her disease, genetics,
body tissues, and identity); and privacy in decisionmaking. Thus, patient privacy is not restricted to physicalprivacy and includes respect for patient autonomy at allstages of examination, diagnosis, and treatment.
Ethical foundations of privacy
In physician-patient relationship, privacy of both sides
should be respected. The right of every human being to bealone should be observed by others. One should beentitled to deal with his/her own personal life away fromothers and their controlling looks and free fromsurveillance and inspection. Freedom and individualautonomy are concepts that give meaning to humanpersonality (Leino-Kilpi et al., 2001; Chalmers et al., 2003;
Neill, 1999). Privacy means a limited access of others to
one’s body, thoughts, and feelings. On the other hand,privacy is closely associated with normative values andpeople naturally desire to protect it (DehghaniMobarakeh et al., 2013).
Philosophical bases of privacy
There is no consensus between contemporary theorists
about de inition, evaluation, and protection of privacy, as
they argue over two different philosophical perspectives
on the independence of the concept of privacy. A group oftheorists do not consider an independent identity for
privacy and express a skeptical and critical view about theright to privacy. They believe that any interest included asa bene it of privacy has been already supported by otherrights or interests such as right of property and the rightto physical security, and thus, privacy lacks any new andspeci ic provision or content and cannot be cited as anindependent right. This group of theorists is known as
reductionists (DeCew, 2018). By contrast, another groupof theorists, known as coherentist, consider an
independent identity for privacy and believe that privacy
itself is a meaningful and valuable concept. In this view,
some argue that there is relevance, coherence, andconsistency between topics and issues related to privacy(continuum theory). The third group includes those who
subject moral justi ication of privacy to the acquisition of
independent principles of privacy (differentiation theory)(DeCew, 2018). Although theorists of philosophy,
bioethics, and law try to explain the meaning and value ofprivacy, they do not achieve a generally and universally
acceptable theory. However, what can be inferred fromthese principles is that privacy is rooted in human dignity
and its observance is one of the necessities of social life.

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Legal view into privacy
From a legal standpoint, privacy is one of the mostfundamental and basic human rights which is closely
associated with human dignity. The right of humans to bealone and away from others and their controlling looks
and free from surveillance and inspection is a right that is361

essential for an independent personality (Margulis, 2003).
According to the resolutions of the International Congressof Jurists in Stockholm in 1967, ten examples of invasionof privacy are as interference in the private and internal
life of others; violation of physical and mental integrity
and creating moral and spiritual limits; violation of
dignity, honor, and reputation of individuals;
misinterpretation of the sayings and deeds of individuals;
misuse of the name, identity, and images of others forcommercial purposes or advertisements; disclosure ofprivate secrets of individuals; spying and monitoringothers; arrest or inspection of personal correspondence;
abuse of written or verbal correspondence; disclosure of
professional information (Naserzadeh, 1993) .
According to law, all human beings, regardless ofnationality, age, civil capacity, or mental ability, shouldhave the right to privacy. All individuals, either citizens or
foreign nationals, can enjoy this right. The human right toprivacy is a fundamental right of citizenship regardless ofage and all people are subject to this right immediately
after being born alive.
Table 1: The proposed strategies for strengthening theprocess of communication privacy management
Strategies

Interventions

Education andincreasing awareness• Communication privacy
management training for physicians• Communication privacy
management training for public
community• Increasing awareness about
consequences of bad
communication management• Teaching privacy management inmedia-health system relationship• Strengthening medical students'
knowledge about relationshipmanagement and persuasion• Creating ethical sensitivity,
especially on the effect of wrong
connections and professional career

Administrative
policyCulturalization$$
Developing guidelines and ethicalcodes$
Physician’s rights Charter

Privacy in Iranian law
In accordance with Article 957 of the Iranian Civil Code,even legitimacy or illegitimacy of an infant cannot deprive
him/her from the right to privacy (Rahmdel, 2006). The
scope of this right is so broad that involves legal entities
like natural persons). Although there is no explicit
reference to the concept of privacy in Iranian law,examples of privacy have been discussed in many
provisions of the law, most of which are related to medical
and clinical cases. According to Article 22 of theConstitution of the Islamic Republic of Iran, the dignity,
life, property, rights, domicile, and occupations of people
may not be violated, unless sanctioned by law. It can beconcluded that examination and contact of patients
without permission is considered one of the examples ofEubios Journal of Asian and International Bioethics 31(7) (November 2021)

violation of the physical integrity of individuals and isprohibited by law. On the other hand, human beings havea dual physical and spiritual life. The physical life islimited in human body, but the spiritual life, is more
prominent, involves intellectual and emotionalfoundations, individual and social dimensions, andperformance. This important issue has been also taken
into consideration by law.
Physician privacy
Like other members of the community, physicians should
enjoy human rights including privacy which can beviewed in the form of personal privacy and professional
privacy. For physicians all personal and identi ication
information and information on health and professional
performance are considered their personal affair andshould be protected with respect to autonomy andfreedom of choice. Disclosure of personal and family
information of physicians will harm their professional
reputation and dignity. Sometimes the ethicalresponsibilities of physicians towards patients, colleagues,
society, and the environment are so highlighted thatphysicians and their families are being neglected. In somecases, people think that being a physician means that one
should dedicate himself/herself to the profession andserve the public by overlooking his/her own welfare,
health, and rights. This is appreciated in many cultures asa kind of positive sacri ice (Borgan et al., 2015).

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Bene its of mutual observance of privacy in thephysician-patient relationship: According to duties they
have to society, patients should follow their responsibility
in the physician-patient relationship, avoid hasty
judgments, avoid causing doubt of their physician in themind of other patients, and avoid disclosure of any false
medical information (Cruess & Cruess, 2008; Tallis, 2006).
Physicians are expected to provide services of highest
quality to their patients, while patients are required torespect the dignity and honor of those who provide suchservices to them (Gruen et al., 2004) and avoid hasty
judgments, publication of incomplete information, andpersonal impressions which may diminish the dignity ofthe medical profession. However, in this bilateralrelationship, physician’s personal and professional
information are misjudged. This is also a kind ofdisrespect and violation of privacy which corrupts the
dignity of the medical profession, and its consequences
will affect the society.
Regardless of the philosophical bases of privacy,
experts of the health sector believe that observance ofprivacy in healthcare services can maintain peace andincrease patient’s satisfaction. In the physician-patient
relationship, most “Dos” are directed to physicians.
Observance of patient privacy and con identiality is one ofthese “Dos”, which is true as physicians professionallybecome aware of the details of patients’ life.
Maintenance of physicians’ professional privacy
protects the dignity and sanctity of their career in thesociety and improves the trust of the society to physicians
as a group of service providers. Continued trust improves
the physician-patient relationship and will result inpatient satisfaction and improvement of the health

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362

system, which directly bene its the public. Respecting
physicians’ rights including privacy, health and well-being
has positive impacts on healthcare services. Studies haveshown that paying attention to physicians and protectionof their dignity is a prerequisite for maintenance of trust
between physician and patient, and this will have directbene its for patients (Farahmand & Shari ian, 2005).
Previous studies indicate that observance ofphysicians’ privacy can play a decisive role in their job
satisfaction and mental security as well as improvementof the quality of healthcare services (Friedberg, 2014;
Scheurer et al., 2009). Farahmand and Shari iyan havefound that job satisfaction has strongly decreased among
physicians in recent years. They demonstrated that job
satisfaction of physicians has little to do with income, butworkplace and colleagues, job and mental security, andmutual trust are more effective in improving their job
satisfaction (Farahmand & Shari ian, 2005). Addressing
human rights and security in some universities may beeffective in improving quality of healthcare services
because of the positive impact on physician’s lifestyle(Borgan et al., 2015).
Practical challenges related to physicians’ privacyA) Publication of information in cyberspace:
Nowadays, much of the communications and social
relations take shape in cyberspace. Many people acquire
medical and health information from websites, as morethan 40% of searches in internet are on health issues(Gruen, 1999). More than 60 million patients ind their
medical information through internet searches (Hollander& Lanier, 2001). A variety of information about physicians
are presented on these websites every day; true or false,
comments in relation to physicians or medical errors areprovided and images and information about theperformance of physicians are shared. The volume of suchinformation is so great that companies can classify
physicians based on the evaluation and surveys of people(same as restaurants). Since these are based on reviews
and opinions of patients in cyberspace rather than legal
indings, it is purely opinion and non-expert impressions(Freudenheim, 2009).
Some pharmaceutical companies obtain information
about physicians and their prescriptions from pharmacies
and use them to know the patients, how physiciansprescribe, and the amount and type of prescribed drugs
and apply those for their own commercial interests.
Similarly, insurance companies and organizations, such as
Medicare in US, misuse electronic information ofphysicians, their prescription style, and their diagnostictherapeutic processes and include them in the insurance
coverage of people (Field, 2009).
Medical information, type of prescription, diagnostictherapeutic processes, personal impressions of patients
about behavior, deeds, and professional abilities ofphysicians, and even medical error disclosure all areaccessible in cyberspace. At the irst glance, this is taken
as a matter of free access to information and freedom ofcommunication, while it may be an instance of violation ofphysician privacy and desecration of the medical
profession.

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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B) Medical error disclosure: Medical error disclosure is
one of the physicians’ strategies for medical error
management which represents honesty in the physicianpatient relationship (Chamberlain et al., 2012) andenhances transparency in health professionals. Based on
the principle of autonomy, patients should be informed
about medical error especially when it results in harm;
otherwise, it is considered deception and diminishes thetrust to medical profession (Ghalandarpoor et al., 2011).
In medicine, it is assumed that errors are inevitable while
predictable and preventable. Medical error disclosure
faces many challenges in practice. Mismanagement of
medical errors and improper disclosure will havedevastating effects on the healthcare system, hurts
physicians’ reputation, credibility of hospitals, medical
staff, and health system and reduces public trust to healthprofession (Bernhardt, 2004; Robertson, 2004). This isconsidered an instance of invasion of privacy anddefamation of physicians and health system. Certainly,
respecting physician’s privacy and the medical profession
will bene it patients both directly and indirectly.
Observance of privacy and prevention of inappropriate
disclosure of information are considered a moral deed.
Undoubtedly, a turbulence of privacy may occur inphysician-patient relationship and disclosure of common
information can hurt one or both parties. Hence, ef icientand transparent management is an important principle ofhealth system in preventing violation of privacy (Petronio,
2010). For solving the ethical challenges of error
disclosure, the communication privacy management(CPM) system was designed to properly manage humaninteractions and relations that may particularly interferewith privacy, in a way to result in the least harm to bothsides. One side of this relationship is the patient who
needs compensation upon harm, and further damages
should be prevented. In addition, they should be informed
with enough information. Physicians and hospitals are theother sides of this relationship, and their dignity andprivacy should be respected. This system, with a history of
35 years, creates a safe and secure setting for physicianpatient relationship (Petronio, 2002; Petronio, 2010). The
communication privacy management system, in addition
to compensation and prevention of future damages,
attempts to address another important issue regarded as
the respect for privacy of all parties of the relationship(Petronio, 2006). Accordingly, privacy of patients andtheir family members, their physicians, medical staff, andthe hospital should be respected (Petronio, 2002;
Petronio et al., 2012). This system is based on three
general principles including private property, respect for
privacy, and violation of privacy. Data and information
related to medical procedures are basically owned bypatients. However, the ownership of these data andinformation could be shared between two parties. This
framework helps managing medical errors with a morecomprehensive view. Conditions in which the error has
occurred, the amount of information that must be
disclosed, disclosure conditions, audiences of disclosed
information, and the level of con identiality of information
to the public opinions should be considered in thisframework (Petronio & Sargent, 2011).

363C) Interaction with media: Interaction with media canresult in a better communication and directs public
opinion. The media play an important role in raisingpublic awareness, increasing the level of health literacy,
establishing appropriate expectations, and directing
public opinion (Petronio et al., 2013). However, their
negative impact cannot be ignored. Media is a powerfultool with potential capabilities in changing or modifying
the public attitudes and inappropriate stances on
different issues related to health (Boufford et al., 2002).
Although criticism and disclosure of different issues andlatent layers of social harms will be a great help in
improving health systems, the ethical considerations ofmedia-health system relationship should not be ignored.
According to this and for better use of the potential
capabilities of media, a guideline was codi ied in Iran. This
guideline de ines a framework for media-health system
relationship to protect patients and health system privacy.
Communication and criticism by media should be donein a proper and scienti ic manner. The irst modality formoral criticism is its scienti ic nature. Non-expert
comments have detrimental effects rather than improving
the status quo. Criticism and disclosure of different issues
in the health sector should be done at the right time andplace (Jawaid & Jawaid, 2018). Disclosure of physician
information before his/her medical error is proved has
adverse consequences. If disclosure of medical errors andother similar issues are aimed at improving the healthsystem and national communication, in addition toobserving the considerations of constructive criticism andcorrect communication, reputation and privacy of
individuals should be respected. Naming the physiciansand hospitals in newspapers and other media anddisclosure of minor and major issues in a non-expert basis
will have no fruit but diminishing the dignity, honor andreputation of physicians and the medical profession.
Therefore, attendance of the media staff in medical
centers and preparation of verbal, written, and visual
reports could lead to damage to the privacy of patientsand health system (Burkle, 2011), while negligence may
encourage physicians to commit dishonest and unethicalbehavior, deception, and secrecy to maintain theirreputation.
D) Camerawork from doctor’s of ice and surgicalprocedures: Today, camerawork from medical
procedures by patient’s family members is common and is
not considered unethical. Some physicians believe this canhave positive effects on the recovery process of thepatient and encourages physicians to be more careful
during the treatment, because the photos and videos
taken can be a document of all medical procedures andpatient’s conditions. Nevertheless, it has somedisadvantages such as violation of patient privacy, andnegatively affects physician concentration, comfort, andautonomy (Allen, 2021). In addition, presence of patient’s
family members in the doctor’s of ice or operation room
may affect the sterility and cleanness of tools andequipment and other considerations. What happens intoday’s world, speci ically in the ield of radiology or
surgery, does not merely violate patient’s privacy.
Camerawork or taking photos during a fetal ultrasound or364

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

in operation room violates the privacy of the operating
room and physicians and personnel. They are entitled to
be sensitive to camerawork or imaging while working. In
this regard, ethical considerations of both sides should be
respected, including privacy, informed consent, andcon identiality. Patient’s interest is the top priority, and noaction should transgress it.
E) Electronic medical records: General Medical Council
explicitly states that physicians are responsible formaintaining con identiality of patient’s electronic
information and physician’s information and must ensure
effective protection of information (Stanberry, 2001). In
this regard, development of electronic records forpatients, upload of information in cyberspace, andinformation transfer via email, social networks or
personal websites are of importance. In the virtual world,
it is possible for people to get access to con idential
information and even see and hear the transferred data.
Hence, physicians who widely use these electronic means
to communicate with their patients and develop
electronic records for them should apply appropriate
security measures to provide the highest level of security
for information of their patients and prevent thedisclosure of medical secrets (Farnan, 2013; Clark, 2010).
Protection codes for medical information
Considering the above issues, some countries havedeveloped speci ic codes. The Canadian Medical
Association has proposed a set of codes under the title of“principles relating to the protection of physician
information”. Physician or healthcare provider
information includes information on health and personal
wellbeing, identi ication of professional practice,professional performance feedback, and identity
information. This set of principles clearly explains how
and by whom this information should be kept. This
guideline insists on obtaining physician consent about
conditions of maintenance, disclosure, and access to
information. It is noteworthy that access to thisinformation is possible only in the range de ined in goals.
This guideline also explains terms of using information
without consent under the conditions speci ied byadministrators and managers of the health system.
Otherwise, the priority is with information con identiality
and respect for privacy. This guideline also describes
terms of physician’s access to information, information
security, storage and destruction conditions, questions
and complaints, transparency, and accountability ofauthorities to protection of the medical information(Canadian Medical Association, 2018). Health Insurance
Portability and Accountability Act of 1996 (HIPPA)
statement has dealt with privacy of physicians andexplains different conditions and situations which may
violate the privacy and con identiality of physicians(Newport Hospital, 2017).

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Conclusion
Active cooperation between patients and physicians is
considered as one of the most important commitments ofboth parties in the healthcare system which improves thequality of healthcare services. Such cooperation meansthat both parties have their rights and responsibilities.
Although physicians should irst try to attract patients’
trust, patients should also have an optimistic andunprejudiced view towards their physician.
The principle of autonomy gives the right to patients to
be involved in decision-making about their health andtreatment, receive complete information, be aware of theneeded medical information, and make the inal decision.
On the other hand, patients also have responsibilities
which include providing accurate and complete history,
following-up the prescribed medication or treatment
procedure, attending the next appointments, sincere
expression of the extent of compliance with medicalprescriptions, reporting unexpected changes in the
disease status, respecting the right of others to health,promoting their health by observing the optimal lifestyle,and respecting physician’s dignity and honor.
Therefore, disregarding any of the above-mentioned
duties could cause patient’s dissatisfaction or complaints
that may be considered in media analysis and judgment ordisclosure of information in cyberspace or by press.
Otherwise, unfair, and unethical disrespect for physicians’
honor and dignity may create a stressful and insecureenvironment in the health system that would notencourage physicians to correct scienti ic and moral deeds
and may trigger unethical behavior and damages topatients and the health system.
It seems that patients can play a major role inrespecting physician’s privacy and the privacy of medical
community. If this role is well played by patients and thesociety, it can improve the quality of the physician-patient
relationship, something which can undoubtedly bene it
the society. Therefore, some interventions may beconsidered for better understanding of the issue such as
guidelines or ethical codes devoted to each health systemor the Physicians Rights Charter.
Accordingly, oursuggested strategies for strengthening the process ofcommunication privacy management are presented intable 1. Those strategies are divided into two types: A)
education and increasing awareness which contains six
interventions; and B) administrative policy which
includes three interventions.
References
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Bernhardt, J. M. (2004). Communication at the core of effective
public health. American Journal of Public Health 94(12),2051-2053.
Borgan, S. M., Jassim, G. A., Marhoon, Z. A., & Ibrahim, M. H.
(2015). The lifestyle habits and wellbeing of physicians in
Bahrain: a cross-sectional study. BMC public health, 15, 655.
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Crispr-Cas9: The need for law
reform in Australia-Aya McKenzie and Dr. Patrick Foong,
Faculty of Law, Western Sydney University, Australia
Email: P.foong@westernsydney.edu.au

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Introduction
Medicine is on the brink of change as neoterictechnologies such as human genome editing enable
scientists to tackle diseases and conditions. This change is
led by CRISPR-cas9 gene editing (CRISPR), making it
feasible to rectify errors in organisms' DNA, including
bacteria and animals. CRISPR can eliminate the genes
causing heritable illnesses and disorders such as muscular
dystrophy and Parkinson. However, the adoption of
CRISPR to alter germline cells is ethically controversial.
The advancement of genome editing hasinternationally prompted governments to reassess theregulatory frameworks that govern genetic technologies,
as in the United States (U.S.) and the United Kingdom(U.K.). In Australia, the Prohibition of Human Cloning for
Reproduction Act 2002 (Cth) (PHCR Act) and the Research
Involving Human Embryos Act 2002 (Cth) (RIHE Act)
govern genome editing in human embryos. However, thecurrent ambiguity of the legislative proscription onhuman genome editing activity prompted the authors toconsider the prohibitions and limitations set under thecurrent regulatory framework. Speci ically, section 15 of
the PHCR Act prohibits the intentional genome alterationthat is inheritable by descendants while not outlining
whether this section could be deployed to conduct
embryonic genome editing for research purposes solely.
This section could be amended to explicitly delineate thatthe prohibition will exclusively apply to genome alteration
for reproduction rather than pursued for research
purposes. Thus, the Australian legislation on research
involving human embryos could catch up with the swift
advancement of the biomedical ield, at least in thefundamental scienti ic research setting.
Considering the regulatory ambiguity of section 15 of
the PHCR Act, there has been no recent law review on thearea of research involving human embryos. However, as it
stands, this section requires an amendment to provide
certainty and pave the way for recognizing new interests,
being CRISPR technology that may hold future potentials
in the biomedical ield.
This paper will explore CRISPR technology, which
potentials are unrecognized under PHCR Act and whichsafety and ethical concerns highlight the bioethicists'demand for a moratorium. Furthermore, the study's
novelty in light of identi ied gaps in the literature will
highlight the proposition that a public discussion thatengages various stakeholders should precede the decision

to amend the regulatory framework that supervises
genetic research and technologies. This engagement
includes policymakers, biomedical researchers, CRISPR's
pharmaceutical pioneers, ethicists, disability groups,social scientists, healthcare providers and the public.
These stakeholders could delimit the implications of
CRISPR technology, confront the challenges imposed bygenome editing and attain a complete societal unanimity.
Critically, this paper explores CRISPR's swift
development, tremendous potentials in light of current
and future epidemics and pandemics and reveal thenecessity of law reform in Australia to enable thispromising research as humans' survival may depend on it(Kosal, 2020).
The potentials and downsides of CRISPRCRISPR, is a revolutionary gene-editing technology.
Initially, this repeating segment of DNA was detected in a
repeating series in the DNA of E. coli Bacteria, where it
functioned as a defence against the viruses' attack(Shwatz, 2018). Ultimately, researchers discovered that
this bacterial immune system could be employed in
genetic engineering. Thus, in 2012, Doudna demonstrated
that CRISPR could be designed to alter human DNA(Shwatz, 2018).
Genome-editing technology is a subject of greatinterest in its potential in treating and eradicating medical
conditions (Semiz, 2019). Gene-editing applications havebeen effectively conducted on animal models tounderstand diseases that af lict humans (National Human
Genome Research Institute). For instance, is the alterationof embryonic development of the neural crest (N.C.) in
amphibians (Kosal, 2020). This mutation was passed tothe amphibians' next generation of progenies. N.C. is adistinct cell population which are pluripotent and highly
migratory; they can generate an array of cell types,
particularly the peripheral nervous system and facialbones. This experiment shows the dexterity of the CRISPR
gene-editing technique in developing prospective
applications into the cognitive neurosciences, anadditional category of promising technology.
Wielding CRISPR In future pandemics
CRISPR genome editing could one day be employed totackle future pandemics. With this technology, it could befeasible to modify immune cells in the body to make themless prone to being weakened by disease (Synder 2020).
Furthermore, CRISPR could be deployed to program
immune cells to identify those areas before the emergenceof an active virus. Hence, ‘such genetic vaccination is along way off, but it could eliminate having to wait until avirus shows up, make a vaccine to that virus and thenvaccinate people’. This is, especially that COVID-19 could
be the outset of a series of international health crises that
could occur.
A report issued by IPBES highlighted
the correlation between global pandemics, the loss of
biodiversity and climate change (Rabiah, 2020).
Prominently, the U.N. report asserts that global climatechange directly in luences the transmission pace ofdiseases. Accordingly, the emergence of more frequent
pandemics, which could be more fatal than COVID-19, isEubios Journal of Asian and International Bioethics 31(7) (November 2021)

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foreseeable. Furthermore, if malaria starts emerging inregions with ill-equipped healthcare systems, therepercussions on healthcare provisions could be
devastating. Correspondingly, the survival of humans is ata critical juncture where every prudent technology andtheory should be considered (Levy, 2020).
The revelation of the irst genome-modi ied babies
during the 2018 Second International Summit on Human
Genome Editing startled the world, especially thescienti ic community. Associate Professor He said the
CRISPR technique was employed to modify the twins'
girls' genomes to confer them immunity to HIV, which
could cause AIDS. The conferral was attained by disabling
the embryos' CCR5 gene, which generates a receptor thatenables HIV to penetrate and infect cells. This heritablegenome editing entails the alteration of embryos that are
passed down to future descendants. Accordingly, CRISPR
applications could emit erratic effects and unforeseen
consequences. CRISPR technology cleaves the DNA at aparticular spot, enabling scientists to insert, eliminate, or
substitute the DNA where it was sliced.
The total number of human genomes is almost 20,000
to 25,000, of which ive thousand genes are associatedwith medical conditions. It is feasible for CRISPR to trigger
an off-target effect by modifying the wrong area.
Researchers are bewildered about the fallout of the offtarget results that may be immutable (National Human
Genome Research Institute).
Another concern ismosaicism, where not all cells could carry the genetic
alteration. The perils correlated with the clinicalapplication of CRISPR are severe, as averred by the Second
International Summit on Human Genome Editing (TheNational Academies of Sciences Engineering Medicine).
The World Health Organization (WHO) established theExpert Advisory Committee on Developing Global
Standards for Governance and Oversight of Human
Genome Editing in 2018. This international committee
ensures that various perspectives from around the world
are represented. In July 2021, the committee recently
issued a report containing multiple recommendations on
global governance for genome editing (WHO Human
Genome Editing Recommendations, 2021). The
recommendations include a call for a mandatory
mechanism for approvals for clinical trials of genome
editing, including somatic gene editing, to the WHO
Human Genome Editing Registry while limiting thepotential for fraudulent registration through strict
monitoring, an accessible mechanism for con idential
reporting of any concerns regarding illegal, unethical,
unsafe, or otherwise undesirable research or activities,
encouraging patent holders to ensure equitable access toediting interventions and investigating ways of facilitating
public consultation, e.g. online ones, consensus
conference methods and citizen assembly consensus. In
addition, this report guides future steps by presenting
appropriate frameworks for effective regulation ofscienti ic and clinical research and practice.
However, due to the ambiguity of the Australianlegislative prohibition on genome editing, i.e. section 15 of
the PHCR Act, there has been no current applications
submitted to conduct human germline editing research inAustralia (Taylor-Sands and Gyngell, 2018). Therefore,

367

section 15 of the PHCR should be amended to permit thisresearch explicitly, and there should be no reproduction.
However, the decision to amend the regulatory framework
should include the engagement of several stakeholders in
the discussion.
The ethical concerns of CRISPR
Before exploring the ethical concerns of CRISPR, adistinction must be drawn between the two types of genetherapies: germline therapy and somatic therapy. Somatictherapy operates on non-reproductive cells like liver orskin cells, and modi ications made in these cells affectsolely the patient who receives the treatment. With
germline therapy, it alters the DNA in reproductive cells
like eggs and sperms. Accordingly, as this genetic
modi ication is passed down to future generations,
germline therapy raises serious ethical concerns.
The primary concern regarding germline therapy is
the social inequalities deriving from CRISPR's ‘designer
babies' technique (MIT Technology Review). To illustrate,
the germline alteration of the hereditary germ cells would
allow people to alleviate their descendants' particular
traits. CRISPR could be deployed as a genetic
enhancement tool to remove undesired traits or electenviable ones, like physical attractiveness or intelligence.
However, the making of 'designer babies', which is notcorrelated with diseases, will place people on 'a path
toward a dystopia of super people for those who canafford it' (Regalado, 2015). Accordingly, this techniquewill heighten stigmatization and injustices in a society
where prejudices are already prevailing. Therefore, unless
any clinical intervention is obtainable by everybody, social
inequalities will mount further (Zocalo Public Square,2018).
Germline editing could curb social inequities.
Formerly, the Nazis adopted the social Darwinian conceptof 'survival of the ittest', by preserving the purity of theirgene pool (United States Holocaust Memorial Museum).
CRISPR potencies will be imposed to improve theprinciples of protection, restriction, avoidance, mitigation,and reaction (Kosal, 2020). Thereupon, CRISPR would be
deemed as a dual-use technology.
This amendment of section 15 of the PHCR Act may
provide more certainty to future researchers, who fear the
15 years of imprisonment set under the PHCR Act (Foong,2019). Also, notwithstanding the genetic researchers'
objectives, whether this type of research is considered
ethical is controversial. Therefore, public debates thatengage ethicists in the discussion is necessary to explore
and clarify the ethical dilemma in using CRISPR
technology.
The legal framework on research involving humanembryos in Australia
The two main pieces of legislation regulating research
involving human embryos in Australia are the Prohibitionof Human Cloning for Reproduction Act 2002 (Cth) (PHCR
Act) and the Research Involving Human Embryos Act 2002
(Cth) (RIHE Act). The PHCR Act prohibits certain activities
involving human embryos. It proscribes activities
conducted to create embryos unless a license is issued by
the National Health and Medical Research Council

368

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)(NHMRC) licensing committee. The RIHE Act institutes astrict licensing scheme to create and utilize embryos andoutlaws their use in unlicensed research. Under section 15of the PHCR Act, a person will commit an offence if theymodi ied the human embryo's genome in a heritable way.
Secondly, they intended the modi ication to be inheritedby descendants of the person whose embryo wasmodi ied.
Accordingly, section 15 of the PHCR Act entails thesatisfaction of a two-limb test for the offence to becommitted. This test outlaws germline genome editing forreproductive purposes. Hence, if Associate Professor He
had altered the twins' babies' genome in Australia, hewould face the 15 years of imprisonment set out under
the PHCR Act. Yet, it is unclear whether section 15
proscribes all types of research that deploy germline
genome editing (Taylor-Sands and Gyngell, 2018).
Thus, there are two approaches to the interpretation ofsection 15. A narrow approach to section 15 proscribes
germline genome editing conducted for reproductive
purposes. However, where the research comprises ahuman embryo with no intention for the genomic
modi ication to be inherited ie where there is no intentionof implantation, the second limb of the section 15 test
would not be satis ied.
However, a broad interpretation of section 15 would
proscribe germline genome editing for both research andreproductive purposes. It could be suggested that, inresearch settings, irrespective of the lack of intention to
pursue a modi ication which will be inherited by theembryo's descendants, an intent to seek a change which iscapable of being inherited remains.
The extent of the proscription in section 15 depends
on the de inition of 'heritable', which is unfortunately not
restricted in the PHRCR Act. Therefore, it is necessary torefer to the PHCR Act legislative history (Taylor-Sands andGyngell, 2018). In 2005, the Lockhart Legislative Review
Committee conducted a review of the PHCR and RIHE
Acts. In the review, the committee made tworecommendations regarding the editing of embryos, andof relevance are Recommendations 10 and 26.
Recommendation 10: Implantation into the reproductive
tract of a woman of an embryo carrying heritable
alterations to the genome should continue to beprohibited.

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Recommendation 26: Creation of human embryos using
the genetic material from more than two people, or
including heritable genetic alterations, should bepermitted, under licence, for research, training andclinical applications, including production of humanembryonic stem cells, as long as the research satis ies all
the criteria outlined in the amended Act and theseembryos are not implanted into the body of a woman orallowed to develop for more than 14 days.
These recommendations infer that the Lockhart
Committee interpreted section 15 of the PHCR Act as
legislation proscribing research comprising heritable
genetic modi ications. However, section 15 was notamended in the amendment legislation (Taylor-Sands andGyngell, 2018). One justi ication for this could be that thelegislation did not entail an amendment to permit
embryonic genome editing for research purposes. This isbecause the legislation is read in conformity with thenarrow interpretation of the prohibition in s 15 of the
PHCR Act. Yet, this justi ication is not provided in any ofthe parliamentary documents related to the amendment
Bill.
Another explanation could be that there has been anomission in the amendment bill draft (Taylor-Sands andGyngell, 2018). The essential amendments to section 15
were overlooked. This section is currently equivocal anddepends on two possible interpretations and accordingly,
legal reform is necessary.
The vagueness of section 15 of the PHCR Act might
worry future Australian researchers who fear theconsequences of facing 15 years of imprisonment set
under the PHCR Act. The legislative ambiguity of section
15 of the PHCR Act leaves no room for recognizing newinterests, such as CRISPR technology and research that
may hold future potentials. The PHCR Act operates to dent
recent advances in the general research ield involving
human embryos and human germline modi ication
particularly (Dohn, 2018). Therefore, identifying a gap
between law in books and law in action entails reforming
the PHCR Act, as the latter re lects practical solutions
rather than social practice solely (Davies, 2017).
Nevertheless, the decision to arbitrate between theparadoxical claims of bioethicists and CRISPR proponents
by striking a balance between them cannot resolve thedispute of which interests are essential (Masotti, 1979). It
is proposed that section 15 should be amended to
explicitly delineate that the legislative prohibition on
genome editing is limited to activities conducted for
reproduction applications rather than research purposes.
This is provided that a license is obtained and that '(i) theembryo will not be implanted into a woman, and (ii) theembryo will be destroyed after 14 days' (Taylor-Sands andGyngell, 2018). Such amendments will provide much
more clarity and assurance to future Australian
researchers.
Conclusion: Proposed law reform
The Australian framework regulating human genome
editing should catch up with the swift advancement of thebiomedical ield, at least in the fundamental scienti ic
research framework. Notwithstanding that humangermline genome editing conducted for reproduction
purposes is explicitly prohibited in Australia, theregulatory framework on the legality of the genome
editing research, speci ically section 15 of the PHCR Act,requires an amendment to provide more clarity to future
researchers. However, a public discussion that engages
various stakeholders should precede the decision toamend the regulatory framework. The stakeholders
include policymakers, biomedical researchers, ethicists,disability groups, social scientists, healthcare providers
and the public. They could delimit the implications of
CRISPR technology, confront the challenges imposed bygenome editing and attain a complete societal unanimity.
The revision of the law will provide a legislative certainty
that paves the way for recognising the cutting-edge
CRISPR technology.

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
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content/en/article/victims-of-the-nazi-era-nazi-racialideology
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www.zocalopublicsquare.org/2018/01/17/designer-dna-isntjust-designer-babies/ideas/essay/

COVID-19 PPE waste
management: A looming ecologicalcrisis in the Philippines?
- Aldrin F. Quintero
Notre Dame of Marbel University, Philippines
Email: mengzi.khun@gmail.com
Abstract
Presently, the world is focusing on combatting COVID-19;
however, the issues of economic crisis and ecologicalimbalance are quite imminent. Environmentalists warned
public health of icials that the additional infectious
medical waste could have serious impacts on humanhealth and the environment if not managed properly.
Personal protection equipment (PPE) has become an
essential prerequisite for healthcare workers. PPE kits arereported to provide suf icient protection against
pathogens, but their disposal can be devastating toenvironment.
This paper asserts the following: irst, that the wrong
disposal of the PPE could become a growing problem forthe environment and public health in the Philippines.
Second, that the public authority specially policy makers
need to lay out new waste disposal standards for thegeneral public and promote reusable PPE wheneverpossible. Third, the wrong disposal of PPE waste involves
environmental risks and raises issues of public healthsafety. Just like COVID-19, the waste, plastic, and PPE
pandemics cannot be solved overnight. But knowing one’s
moral obligation how to pivot to sustainability,
responsibly dispose of waste, and recycle as much as
humanly possible is half the battle.
Introduction
The pandemic has altered the waste generation dynamics,
creating distress among workers involved in sanitation as
well as policymakers. In the Philippines, as COVID-19
cases continue to pile, putting pressure on hospitals,

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Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

medical facilities are seeing a surge in the volume ofinfectious medical waste they produce; there is a need toeducate and inform front-line workers who are handling
this waste as well. Environmentalists warn that theadditional infectious medical waste could have serious
impacts on human health and the environment if not
managed properly (CPCB, 2020). Covid-19 pandemic
threatens to exacerbate the proliferation of plastic waste
and its pollution of bodies of water, which were already amajor problem in the Philippines even before thecoronavirus pandemic (Justine, 2020). The use of
Personal Protective Equipment (PPE) has emerged as themost reliable and visible preventive control safety gear tokeep the COVID-19 transmission at bay (Herron et al.,2020). Typical PPEs, also referred to as PPE kits, are madeof over 50% plastics (which takes up to 500 years todegrade) like PP, PC, and PVC, etc., the surgical face maskwith metal strip, gloves, goggles, full-body suits containing
pant, gown with head cover and shoe cover (Park et al.,2020). National Disaster Management & Safety protocols
advise the use of PPEs, by attending physicians and all thehealthcare– nursing staff, funeral workers including
visiting families etc., who are directly or indirectly incontact with any COVID-19 (con irmed or suspected)
patients (Selvakumar et al., 2020; WHO, 2020d; NMPA,
2020).
In the wake of necessary preventive control measures,
it is evident that the used PPEs waste is likely to increase
multiple folds and stress the current waste management
systems, and pose a grave threat to the environment, if not
tackled properly (ICT, 2008). The safe disposal of medical
waste during the coronavirus pandemic is a pressing yetoverlooked problem, according to an environmental
advocate (The Guardian, 2020).
The United Nation’s Basel convention on theTransboundary Movement of Hazardous Wastes and their
Disposal has recently urged member countries to treat
waste management amid COVID-19 as an urgent andessential public service to minimize possible secondary
impacts, upon health and the environment (WHO, 2020).
Therefore, safe and sustainable recovery and treatment of
PPEs should be intensi ied. It is important to clarify therole of informal recyclers in developing countries, where
medical waste has not been adequately regulated.

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Surge of waste
The Philippines has generated 52,000 metric tons of
medical waste since the start of lockdown in March 2020.
This is equivalent to 2 million sacks of rice, with each sackcontaining 25 kilograms of rice. Of the total igure only
14,000 metric tons were treated (DENR, 2020). The AsianDevelopment Bank estimated that hospitals in Metro
Manila—the region that accounts for at least 55% of thenation’s cases—would generate 280 metric tons of
medical waste in a single day. Before the pandemic struck,
healthcare facilities in the capital region were estimatedto produce only 47 metric tons of medical waste daily,
with 56%—around 26 tons—of this consideredpotentially infectious (ADB, 2020).
Hospitals outside of the outbreak epicenter of Metro
Manila are also grappling with additional infectious
medical waste. Before the current health crisis, Dr. Paulino

J. Garcia Memorial Research and Medical Center—known
as PJG—in Cabanatuan City, Nueva Ecija, generated only
3,500 kilograms of infectious medical waste monthly. As
the pandemic continues to rage, the average volume ofinfectious medical waste produced per month reachedaround 15,000 kilograms. Most of the COVID-19 patientsin Nueva Ecija, a province north of Metro Manila, areadmitted at PJG (DENR, 2021).
Healthcare waste gradually increased in quantity
during pandemic not only in the Philippines but also inother countries abroad. This trend has also been observedin France, Italy, and the Netherlands. Healthcare solid
waste in France, and the Netherlands has increased from
40% to 50%, respectively (Wei and Manyu, 2020). The
trend has also been observed in India and Iran. Used PPE
and general waste, i.e., food and dining boxes and fusion
bottles and bags used by nurses, have seen a tremendous
increase in quantity during the COVID-19 pandemic.
The Philippines has made a special amendment forhandling healthcare waste during the COVID-19
pandemic. There are special registered transporters andtreatment, storage, and disposal (TSD) facilities forhandling healthcare waste and disposing of it on theisland of Luzon. There is a special permit in place tocollect pathological and infectious healthcare waste forsmooth handling. Each registered transporter is required
to pass through a special checkpoint, and to provide thefollowing online documents: an of icial request letter; atransporter and TSD registration certi icate; a transportmanagement plan; a transportation route; a schedule; andan agreement between the healthcare waste generator,
the transporter, and the treatment workers. Each vehicle
used for transporting the waste has the following special
markings: name and ID of transport; placard; waste class;and waste number. These are readable from 15m distancefrom the vehicle. The registered transporter is required tosubmit a compliance and completion report oftransportation, attested by a representative from thehealthcare and TSD department (EMB, 2020)
Medical waste in the Philippines is typicallydisinfected through steam sterilization, also called
autoclave, which subjects the waste to intense heat andpressure to kill pathogen prior to disposal in a land ill(DOH, 2005). Autoclaves can process between 100
kilograms to as much as 3,000 kilograms per cycle.
Treated healthcare waste is then transported to a licensed
sanitary land ill for inal disposal in a cell dedicated for
infectious waste. Infectious waste must not be mixed withmunicipal waste or non-hazardous waste. Treated wastethat comes in the facility is again disinfected in theland ill. This process is repeated while the waste is being
disposed of in a special cell before it is buried.
According to Department of Environment and Natural
Resources (DENR,2021) recent assessment report, Luzon,
where many of the country’s urban centers are, canhandle the increased volume of medical and infectious
waste, hazardous waste management section. However,the challenge lies in Visayas and Mindanao. There are atleast 26 registered treatment, storage, and disposal (TSD)
facilities nationwide, a fourth of which are in Luzon. But
there are no TSD facilities in the provinces of Cagayan
Valley and the Bicol region, however. Farther south, theEubios Journal of Asian and International Bioethics 31(7) (November 2021)
Eastern Visayas region and Zamboanga Peninsula andSocsksargen in Mindanao do not have waste treatment
centers.
Volume reduction
The pandemic may strain licensed land ills in the country.
There may be facilities outside Luzon, but healthcare is
not part of their business. It needs more investors toprocess healthcare waste. A time may come that ourland ills will reach capacity because volume will be toohigh and there is no reduction. The waste is treated but it
is not reduced. If there is no volume reduction at the rate
this waste is generated, there will be competition between
municipal solid waste and hazardous waste for landdisposal.
Although the government is looking into
building between 10 and 30 sanitary land ills intended forhazardous waste to address the current issue, it takes atleast six months to build a sanitary land ill. Incineration is
only an option for a worst-case scenario. Moreover,burning of waste is prohibited under the country’s Clean
Air Act of 1999.
Incineration, hereby de ined as the burning ofmunicipal, bio-medical and hazardous wastes, which emit
poisonous and toxic fumes, is hereby prohibited, the law
states. But, if the incineration facility has proper pollution
control technology and complies with incineration
standards, then the incineration is not banned. The
Philippines is currently treating solid waste and medical
waste through land ill and dumping. The environmentalist
movement warned the government that it willcompromise public health sector since, land ill containing
healthcare solid waste generated during the pandemic cancontaminate water. The government is pushing for
adoption of waste to energy (WTE) treatment facilities todeal with solid waste.

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Environmental risk
Land ills help to keep communities clean, but they alsopose serious threats to the health of the environment.
Land ill and open dump release large amounts of methane
into the atmosphere and contribute to climate change. Asa potent greenhouse gas, methane traps up to 20 times
more heat in the atmosphere compared with carbon
dioxide, making it one of the most potent greenhousegases and a huge contributor to climate change. Emissions
from land ills pose a threat to the health of those who live
and work around land ills. A study in New York showed a
12% increased risk of congenital malformations inchildren born to families that lived within a mile of ahazardous waste land ill site (Newton, 2018).
Biomedical waste incineration is never an option
because it will add to pollution in the air. It results in therelease of extremely harmful pollutants such as dioxins(Emmanuel, 2015). But if dioxins release into theenvironment, they will stay there not only during ourlifetime, but also the lifetime of our children and theirchildren. Dioxins are a group of chemically related
compounds that are persistent organic pollutants (POPs).
These pollutants accumulate in the environment and in
the food chain, mainly in the fatty tissue of animals. Highly
toxic, dioxins can cause reproductive and developmental

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problems, damage the immune system, and interfere withhormones.
Thermal Waste-to-Energy (WtE) has potential bene itsof waste reduction and energy generation; yet there arechallenges regarding its applicability and potential
impacts on health, environment, and the climate. WTE is
not a solution. It causes pollution and in the time of
COVID-19, the pollution in the air aggravates sufferingfrom asthma and respiratory illness. Incinerator
companies are often marketing “waste-to-energy” as asource of renewable energy. But unlike wind, solar orwave energy, waste doesn’t come from in inite naturalprocesses. On the contrary, it is sourced from inite
resources, like minerals, fossil fuels and forests, that are
cut down at an unsustainable rate. Subsidies to support
incineration could be better invested into environmentallyfriendly, energy saving practices like recycling andcomposting (IETC, 2019). Incinerators are the mostexpensive method to generate energy and to handle
waste, while also creating a signi icant economic burden
for host cities. The story of Copenhagen’s infamous
Amager Bakke incinerator is just an example.
Promote reusable PPE
Waste-to-energy plants offer relatively few jobs whencompared to recycling. The livelihood of millions of waste
workers worldwide depends on recycling. Studies showthat the sector creates 10-20 times more jobs thanincineration. With a national rate of less than 33%, the US
recycling industries currently provide over 800,000 jobs
(Muznik, 2018). In developing countries like thePhilippines, building incinerators will take jobs away frominformal waste workers including waste pickers,
recyclers, and haulers. Investment in recycling, reuse andcomposting can enable informal workers to transition tothese green jobs.
The overwhelming amount of medical waste can becountered by promoting the use of reusable PPE, as well
as boosting information dissemination on the safety ofreusable and safe handling of medical wastes. Reusable
PPE’s provide the same amount of protection without
aggravating the problem of waste. Health experts fromaround the world have vouched for the safety of reusable
PPEs for non-medical use. This must be publicly known.
Reusable PPEs are cheaper per use than disposable ones.
With proper usage and even better post-use handling,
reusable PPEs can make a massive impact not only inpandemic response measures but for the future of thehealthcare sector.
The environmental impact of PPE is substantial andrequires urgent review to mitigate effects on planetary
health. The most opportune and impactful strategies may
be through reduced use of gloves by hand washing alone,
domestic manufacture of PPE and extended use or reuseof PPE such as masks and gowns. These possibilities
warrant further investigation and analysis of feasibility
and safety, as well as engagement of policy makers (Rizan
et al., 2021).
A new report in the journal Science led by researchers
from Pew charitable trust and SYSTEMIQ states thatnearly 80% of plastic pollution could be resolved by 2040
using current technologies and knowledge. Biodegradable

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

gloves are available, which decompose in land ill in two
years. The Reelshield lip – is a face visor made frompaper board and wood pulp cellulose, meaning it can becomposted at home (Klemes et al., 2020). These
alternatives to disposable plastic PPE could provide
options to reduce long-term costs and environmental
damage, ultimately helping in the campaign to reduce
sing-use plastic.
Conclusion
Timely, safe, and proper disposal of medical waste is thesecond line of defense for epidemic prevention andcontrol in the case of an unexpected public health event.
The combination of a solid theoretical foundation andrelevant management system is needed to achieve
optimization of key links and improvement of the
management system. Adopting sustainable solutions help
such as proper implementation of the solid waste
program and the shift to reusable from disposables.
Proper quanti ication of the medical waste along withprospective policy response and alternative approaches tothe medical disposal and treatment facilities are requiredfor building rigid resilience and management of
hazardous medical waste volume generated by healthcare
facilities and households.
Furthermore, this study recommends the coordinationand cooperation of government, hospitals, communities,
and other departments in the healthcare waste disposal
process and provides guiding suggestions for healthcare
waste disposal nationwide to deal with potential risks andprovide effective references in all regions.
References

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ADB (2020). Solid Waste Management Sector Project. Retrieved
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Klemes J.J., Fan Y.V., Tan R.R., Jiang P. Minimising the present andfuture plastic waste, energy and environmental footprints
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Re-education of responsible
parenthood to a rural community- Daryl Niko L. Cempron, M.A
Department of Professional Education, Central Mindanao
University, Bukidnon Philippines
Email: f.darylniko.cempron@cmu.edu.phAbstract
The study addresses the documented problems in a ruralcommunity of Bukidnon Province in the Philippines on
caring for their children along with securing livelihood forsurvival. Through capability-building, more than half weresatis ied with the conduct of training upon participationas manifested: acquisition of skills, application of theknowledge and skills transfer, and changes in theirpractices that were felt and noticed as claimed by theparticipants. In retrospect, the indings were indicationsof the participants’ willingness to sustain the knowledge
and skills transferred to them.
Introduction
Time may move so fast, changes might be constant, but aparent is a parent. Certain responsibilities and roles are
expected for them to ful ill. And these responsibilities androles, are the duties they need to do for the children andthe family itself- providing the needs in multiple aspectsof each member of the family, particularly the children,
rearing the children to become better versions ofthemselves, the preparation of meals that are vital for
growth, development, and survival in safe ways and ofEubios Journal of Asian and International Bioethics 31(7) (November 2021)
quality. All these, in one way or another, de ine them andwho they must be.
However, as time brings so many changes day by day,
too many demands are resulting in too many expenses,
and making a living is no longer that easy; and it is evenmore dif icult if the earning is inadequate of which BaseCamp, a rural locale of Maramag, Bukidnon Province in
the Philippines is among the spots that have been
experiencing this situation. The community is about 2-3
kilometers away from the municipal center. The major
source of income by the residents is agricultural
production (i.e. sugarcane, rice and making ‘balot’, aboiled un-hatched duck embryo, a local street food);
however, the majority of them are not the owners of thefarms but are tenants and laborers living the parents withchoices: working at the farm sacri icing their roles andresponsibilities as parents; or ful illing their roles andresponsibilities as is, but settling for a meager income. All
these choices may boil down to certain unpleasant effects
on the children and the family’s wellbeing.
In the current data of Central Mindanao University (astate-funded university, nearest to the area), through aproblem tree analysis, the indings revealed that from a
total of 1,530 households, the major problems of thecommunity were: weak and sick children caused byinsuf iciency of food, lack of supervision to the children as
the housewives are also hired as farm laborers, a large
number of children and lack of knowledge in familyplanning; and poverty largely caused by low income, of
which most of the farm laborers in the area are earning amaximum of 150 pesos per day for a family with 6
members, and low educational attainment as mostresidents are just elementary graduates and high schoollevel.
To act on these problems, this study was designed tore-educate the parents about Responsible Parenthood,
being deemed as the core of the problems. It visualized its
participants living a healthy and strengthened family day
by day. This vision was anchored from the “2040
Philippine Ambition” which is a long-term vision for thePhilippines by the National Economic Development
Authority (NEDA), describing the kind of life for Filipinosby 2040 (National Economic Development Authority,2017).

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Conceptual framework
In the implementation of this phase, Central Mindanao
University funded the procurement of materials and otherexpenses as re lected in the study’s budget plan. The
counterpart in the locale provided the venue, soundsystem, and the meals of the participants in every session.
Trainers and resource speakers were faculty members of
the College of Human Ecology who are specialists infamily and child development studies. Lea lets containing
the topics were prepared and distributed to theparticipants.
The conduct of each session was guided bydemonstration and discussion of methods employed indifferent strategies therein, in which the outputs were
products that they had processed and created from thediscussions of the trainers and the insights they had
valued and organized from the learning episodes.
Several participants claimed that they applied in theirhousehold what they learned and noticed certain changes
in their practices. Some also suggested certain programs
they hoped the community itself would initiate. Theirclaims, testimonies upon participating in theimplementation were taken as indications towards
contributing to the long-term vision of the country andthe impact of the study.
Context
Responsible parenthood is the fundamental duty of aparent for maintaining good family relations andstrengthening the family ties together. It simply pertains
to ef icient and effective parenting that result in a good
relationship between parents and children.
The parenting extension program is the provision of
speci ic knowledge and child-rearing skills to parents andother caregivers to enhance a child’s health anddevelopment. Parenting education efforts focus on speci ic
child-rearing skills for enhancing the so-called parentchild interaction, such as appropriate and recommended
discipline practices, or on more general subjects, such as
careful and critical understanding of child development.
The goals of and objectives of parenting education
programs may encompass a variety of parent and childoutcomes. While the term “parenting education” is notuniversally accepted, it is sometimes called parent
training (Howe, 2020).
Methodology
The implementation was done through pieces of training
and capability-building activities. Primarily it adhered tothe approach in which a modi ied discussion method wasused. In context, the said approach may be de ined asteaching which knowledge is used to develop learning
skills. Whereby, in this approach, knowledge is still there
but it is not the end of instruction. Participants wereactively engaged in the activities so the competencies
needed could eventually be acquired by them (Corpuz &Salandanan, 2013).
The conduct utilized the the techniques of small group
discussion, socialized classroom discussion, panel
discussion, recitation, and direct instruction. This methodadhered to the following steps:

Figure 1: The paradigm of the study

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1.
2.
3.
4.

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
Planning served in designing of the activities to bedone during the conduct
Starting the Discussion, served as the presentation of
the intent of the training to the participants
Conducting the Discussion Proper, this served as thetraining using the mentioned strategies above
Culminating the Discussion, this served as theconcluding part of the training

Ethical consideration: The study adhered carefully andcritically to the ethical principles and practices of social
research, i.e. no participants were forced to take part inthis project and proper protocols were observed andadequate information was given to the participants before
the conduct: educating participants about their rights,
giving the most appropriate incentives, structuring
mechanisms to ensure the privacy of their identities andcon identiality of their responses.

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Results and Discussion
All the participants were female, and mostly were (a) inan age bracket of 25-34 years old (51.62%) and one was ateen-aged mother; (b) high school graduate; (c) married;(d) housewife; (e) and had 3 children. A study suggested
that people should get married between the ages of 25
and 32 if they do not want to get separated, at least in theirst ive years (Girgis et al., 2011) which Cohen andStrong (2020) described this phase as “con lict-habituatedmarriage” where couples argue and experience con lict ona routine basis, i.e., nagging, complaining, criticizing,
belittling, and the like. The result was tension and con lict.
They communicated to “win”, rather than to resolve
issues, and if one partner were to apologize, or admit
they're wrong, he or she would lose face for the next
argument.
While most of the participants were young parents
who quite possibly fall under the right age of getting
married per se, they were still at a stage of having a lot ofthings to learn about marriage and parenting yet alreadyraising more than one child. In another spectrum, thoughmostly housewives there were still many things they
could do for their family. They just must be empowered on
the things that they do daily in their households in thesense of their relationship to their spouse and children,
the ways they prepare and process the food they serve on
the table, and the utilization of anything that seemed to be
out-of-use in their houses.
Parenting re-education
This study was composed of two sessions. The irst
session was about educating the participants about“Marriage”. In this session, the participants wereprimarily taught that marriage, itself, is a process
whereby certain factors, either internal or external, canin luence or distract the low of the process. Hence, theparticipants were taught the different types of maritalcon licts of which some were relatable to most. During thediscussions, the participants opened up about theirexperiences, while some shared their points of view about
these con licts. But the essence of this talk was about how
to solve these con licts whenever and if ever theyexperience these. As such the participants were taught by
the resource speaker how to handle each of these con licts
and how to resolve them peacefully so that the process ofmarriage itself lows smoothly. After all, marriage is a
lifetime commitment, as each con lict does not always last
still there will be more con licts to face ahead on. By theend of the talk, the speaker gave homework that was
designed for the participants to take up with theirspouses.
The second session was about “Parent-Child
Relationship”. In this topic, the participants were reeducated on the fundamental parental duties andresponsibilities in which the speaker taught theparticipants about many effective ways of imposing
discipline on children’s misbehaviors.
The different
duties and responsibilities of the children were also
tackled. In essence, the speaker emphasized that ineverything between parents and children, it’s an open
communication that builds a strong foundation,
considering that nowadays, teenage pregnancy is

Figure 2: Demographic pro ile

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Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
becoming an unlikely phenomenon in rural communities.
The discussion concluded with a few participants sharing
their re lections and insights about what they havelearned for the day.

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such that in session 1, 20% had rated the workshop as“better” and in session 2, 16% rated “better” and 20%
rated “good”.
Table 1: Participant feedback

Figure 3: Training evaluation
Most of the participants had rated each session as“best” in terms of the knowledge they gained, topics
discussed, and the workshop itself. However, in the
conduct of the monitoring and evaluation of this phase,
there were certain subtopics in the discussions in which
certain participants had clari ications such that in session
2 in the above igure, 4% had rated both the topics andknowledge as “fair” and 20% rated “good” (topics).
Furthermore, certain participants gave their suggestions
on how to conduct the pieces of training more effectively

A few of the participants had acknowledged that one
thing they had learned, which they did not know before as
parents, was “the need for the parents to respect theirchildren” (26%). Alongside this are “the importance oftrust to children” and “the different acceptable ways of
discipline” (both, 10%). These are in line with the changes
that they have noticed in themselves as parents.
These changes upon attending the enhancement
seminars align with what Deater-Deckard et al. (2011)
had indicated that an extension program can bringchanges in the behavior of mothers and fathers with theirchildren. It can raise the awareness and knowledge of theparents on child-rearing such as a decrease in beating thechild and increase in talking to the child and explain
wrongdoings. In connection, Collins and Fetsch (2012)
also contended that this kind of program can reduce
punishment malpractices among parents, and decrease
parental stress, anger, and aggression. It can lower the
expectations of some parents to their children and thatthe use of positive discipline styles may increase.

Table 2: Participant’s perspectives on the roles of parents in community development

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Upon participating in the two-session parenting
enhancement seminar, certain participants perceived thatas parents the way to contribute to the progress of theircommunity is to participate in any programs initiated by
the community. Van Roekel (2008) posited that as parents
make up the solid foundation of the community, they must
support the vision of the community that they are in. For376

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

some, it would be sharing the knowledge they have gainedwith others, considering that not all parents were able toparticipate in the said seminars; engaging in any
livelihood activities, as it not only increases their income
but provides additional resources to other families of thecommunity; and showing empathy towards the husband,
who must not only be perceived by the wife as theprovider of the family but a partner as well (Cohen andStrong, 2020).
The participants suggested that their community itself
should initiate programs related to family planning,
couple training, having a family counselor, and women’s
program. Family planning program in any usual sense
aims at preventing pregnancy using methods ofcontraception. This idea has been widespread as there is aheightened concern that the world’s unprecedented rateof population growth only concerns governments not thepeople (Miller and Babiarz, 2016). The suggestions oncouple training and having a family counselor are insupport of the idea that family relationships are an
important factor in the psychological health of the familyinteraction regardless of the origin of the problem, andregardless of whether the clients consider it an"individual" or "family" issue. The involvement of families
in programs like this helps in strengthening the wisdomand support of the wider system of the community(McShane et al., 2009).
There is already an existing women’s association in thecommunity. However, the participants said more activities
should be spearheaded by the community to make theassociation more functional and effective. The feedbacks
of some participants about the subtopics/ topics included
their suggestions as to how the pieces of training may be
conducted more ef iciently and effectively; the insights
they gained, the changes they noticed in themselves upon
participating, and their perceptions how they cancontribute to the progress of the community; and theirsuggestions to the community to empower them more.
These de initely set the direction of the second phase ofthis study towards more empowered parents who will bea stronghold of the Base Camp.

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Conclusion
The methodology employed in this project yielded
positive results as manifested in the training evaluation as
the majority rated each session as “best”. Application andchanges in practices were claimed and those insights were
gained. Parenting education supplemented awareness andunderstanding about marriage and parental
responsibilities to the family and the household. Changes
in their household in the relationship towards theirhusbands and children in different degrees were claimed,
an indication that there is adaptability or application
upon participating in the study, and there is a drive withinthem to attend more parenting seminars or pieces oftraining. Some information was learned from the pieces oftraining upon participating and was not learned before.
Because of their insights from the sessions, they were able
to develop the value of the relationship between them as
parents and the community they are in, that the progressof the family contributes greatly to the progress of thecommunity. This, then, encouraged them to suggest

certain programs relating to family empowerment to theirlocal of icials to design and initiate.
Acknowledgments
This piece of work is dedicated to all rural community
parents whose lives are worth uplifting, to the local
counterparts of Base Camp community, and thecollaborators of the project: Cherry O. Librando, MS (theextension coordinator); and Lady Munique P. Charles, MA
and Annie Fritce A. Aballe, DBM, for sharing their collective
experiences as parents to the participants and for being ofgreat help in the overall implementation of the project.
Central Mindanao University, the institution of the author,
funded this project with 257,000.00 PHP for support.
References
Cohen, T. F., & Strong, B. (2020). The marriage and family
experience: Intimate relationships in a changing society.
Cengage Learning.
Collins, C. L., & Fetsch, R. J. (2012). A review and critique of 16
major parent education programs. Journal of Extension, 50(4),4-21.
Corpuz, B. B., & Salandanan, G. G. (2013). Principles of Teaching
1. Quezon City, Philippines.
Deater-Deckard, K., Lansford, J. E., Malone, P. S., Alampay, L. P.,
Sorbring, E., Bacchini, D., ... & Dodge, K. A. (2011). The
association between parental warmth and control in thirteen
cultural groups. Journal of Family Psychology, 25(5), 790.
Girgis, S., George, R. P., & Anderson, R. T. (2011). What ismarriage. Harv. JL & Pub. Pol'y, 34, 245.
Howe, R. B. (2020). Parenting Education and Support A
Children’s Rights Perspective. A Question of Commitment: The
Status of Children in Canada.
McShane, K. E., Hastings, P. D., Smylie, J. K., Prince, C., &Tungasuvvingat Inuit Family Resource Centre. (2009).
Examining evidence for autonomy and relatedness in urban
Inuit parenting. Culture & psychology, 15(4), 411-431.
Miller, G., & Babiarz, K. S. (2016). Family planning program
effects: Evidence from microdata. Population andDevelopment Review, 7-26.
NEDA (National Economic and Development Authority),
Republic of the Philippines. (2017). Philippine development
plan 2017-2022.
Nel, E., Connelly, S., & Stevenson, T. (2019). New Zealand's small
town transition: The experience of demographic andeconomic change and place based responses. New ZealandGeographer, 75(3), 163-176.

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

Book Review: Harmonizing
bioethics -- global ways inintegrating people and values
Author: Michael Cheng-tek Tai
Publisher: Lit Verlag, Germany
Date of Publication: December 2020
Pages: 250- Tsuyoshi Awaya,
Vice-president, and Professor of Medical Law andBioethics, Okayama Shoka University, Okayama, Japan
Email: t-awaya@nifty.ne.jp

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With the rapid development of technology, the importanceof bioethics has become indisputable as a reminder tohumankind that the progress of science cannot be
ethically blind. Any human endeavor to attend new things
must not neglect the essential human values of “do noharm” and “justice” … etc. The debates however are goingon, such as on what basis should we deliberate the ethics,
duty or utility, justice, or convenience…?
The publication of this book comes in time torecommend a new consideration of harmonizing
bioethics. The author wrote at the beginning of this book –‘Harmonizing bioethics – global ways in integrating
people and values’ is an attempt to emphasize on
comparable value theory among different cultural
heritages. Though there are diversities in expressions, all
ethical teachings however, uphold the similar value thatlove is stronger than hatred, life is better than death, andthat human harmony and world peace have been the goalsof human moral teachings from the beginning ofcivilization”.
The author, Tai, shared his easternunderstanding of the nature of things along with hiswestern experience to come up with a recommendationthat bioethics must play a role in integrating people andvalues together for a common morality. He quoted Hans
Martin Sass who wrote “interaction and integration,
cooperation and competition are as essential for us
human as they are for all forms of bios”, thus we must
respect every living being and strive for a harmonious
relationship among all.
Tai is a chair professor of bioethics and medical
humanities at Chung Shan Medical University and an
adjunct professor at China Medical University in Taiwan
and had served as the president of International Society
for Clinical Bioethics from 2002-2006 and was the winnerof Fritz Jahr Award in 2019. Tai sees bioethics as arelational science and calls for “bioethics of conscience”
which, when facing ethical dilemma, should extend one’s
inner knowledge for humanized decision-making without
considering any external personal gain and convenienceor giving in to biased pressure. The book centers aroundTai’s conviction that compassion, respect, responsibility,
righteousness (which means to do the right thing and do
it right) should be the guides for ethical consideration
besides bearing in mind the other common principles
such as Georgetown’s which re lect on similar concerns
according to Tai’s understanding. Tai presents a very
interesting suggestion in decision-making that deserves
our attention which he calls “three-dimension approach”

377(I will call it Michael Tai’s three-dimension approach). Thisapproach irst examines the situation in which a decisionmust be made by judging the motivation and thenevaluates it to check whether or not the contemplated
decision is reasonable and also if it takes into account thenorms of society. If no answer is found through thiscontemplation process, the last resort is to reply on thegoverning law which, though as the lowest standard of
ethics, becomes a guide at an ethical deadlock. This“situation/motivation, reason/propriety and law/legality”
approach is an Asian traditional way of decision-making
and Tai re-examines it to give it a new dress that does notoverlook other emphases either deontological orconsequential arguments. This approach is based on
bioethics of conscience as a way of harmonizing different
assertions.
The book has eight sections beginning with a
discussion of harmony, the goal of bioethics, which Tai
regards as the foundation of world brotherhood as the
harmony within nature, society and humanity must be
essential for any moral cultivation, family closeness andsocial solidarity. The way to ful il this goal is by the way of
empathy and conciliation to ind common ground for all
which Tai calls as a process of conscientization. The book
advocates that virtues should be cultivated and looked
upon as the basis for bioethical dialogue. Tai presents his“three-dimension approach” stressing duty yet still
bearing in mind to minimize the possible negative impact
upon others. He tends to emphasize the moderation on a
middle ground that bene its all. He regards bioethics aninterdisciplinary discipline not only from bioethical pointof view, but also from other aspects. The book shows thatTai is not only a bioethicist, but also a philosopher, atheologian, a sociologist, and an ecologist who sees life
from a holistic perspective that echoes Fritz Jahr’s calls forrespect toward every living being. Tai suggests four
considerations to promote integrated bioethics: 1) to ind
the common morality of the world as the foundation andguide for collaboration, 2) to seek translational bioethics
that facilitates the practical needs of human society andenvironment, 3) to develop consultation skills by
providing consulting service to contemporary needs
including biomedical research and 4) to discuss further
the meaning and scope of integrated bioethics and todeepen the dialogue among different views of bioethics.
The debates of bioethics take place in the west, andwe are delighted to see an Asian scholar participating in
the discussion of an integrated global bioethics. I will
recommend this excellent book to anyone who isinterested in and concerned with the impact of modern
technology upon humankind and the world. As the bookback cover indicates: “Harmonizing bioethics is about
relationships of peoples and cultures, our civilization andliving environments. Following the original concept ofbioethics by Fritz Jahr, it searches for harmonizing a
discussion over the process of industrialization andglobalization. The issues such as euthanasia, organtransplantation, physician-lay collaboration, urban
bioethics, research ethics and the in luence of arti icial
intelligence … are all touched in the book. Building uponthese pluri-perspective grounds can direct us and theworld in future collaboration to a bridge in global ways in378

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

integrating people and advancing values to a new age forall.

Medical ethics course forresidents: A preliminary study- Sukran Sevimli, Ph.D.
Department of Medical History and Medical Ethics,
Dursun Odabas Research Hospital, Faculty of Medicine,
Van Yuzuncu Yıl University, Zeve Campus,
65080 Van, Turkey
Email: sukransevimli@gmail.com
ORCID ID: https://orcid.org/0000-0001-9621-3438
Abstract
Purpose: The objective of this study is to determine theimportance of supplementary medical ethics course forresident physicians. In this study, we assessed the current
state of their knowledge of medical ethics and aimed to
improve and deepen their understanding with clinicalscenarios to increase their awareness of the link between
the practice of medicine and ethical issues.
Methods: The course was held for groups of 10-12 people
for 3 days a week for a total of 6 hours. Tests given prior
to and following completion of the course were used toassess the effectiveness of a medical ethics training course
in which 120 resident physicians completed. Evaluation
was made on the basis of the same pre- and post-tests (14scenarios) and direct observation of participants.
Result and Discussion: The average age was 28.23 ± 4.08
and 25% were female and 75% were male. Of theparticipants, 68.3% were training to be internists, 24.2%
were training to be surgeons, and 7.5% were training inlaboratory medicine. There was a signi icant statisticaldifference between the mean total scores of both tests(p=0.00). After completing the course, residents took into
account the medical ethical principles while discussing
ethical decisions.
Conclusion: After inishing the course, participants
defended their responses in regard to issues of medical
ethics more carefully and articulated their thoughts moreclearly. Our experience demonstrated that the trainees
bene ited from a structured curriculum in medical ethics.
We believe that the development and implementation of
our course may serve as a case study for training resident
physicians in medical ethics.
Keywords: Medical ethics; education; ethical dilemma;
clinical ethics.

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Introduction
A basic principle of medicine is that healthcare
professionals should be loyal to their patients andadvocate for their rights within the framework of ethicalprinciples. Medical ethics education and the application of
medical ethical principles in the practice of medicine haveincreased in importance for patients and healthcare
providers in last three decades (Childress, Beauchamp1989), especially in hospitals throughout Turkey(Ekmekçi 2017). The importance of medical ethics
education involves theoretical and practical training toresolve value-laden issues between physicians andpatients or patient surrogates. It is now considered a
responsibility of health professionals, particularly
following the establishment of patients’ rights regulations(Türkiye Cumhuriyeti Meclisi 2004; Yüksek Öğretim
Kurumu 2020). In recent years, the public has become
more aware of issues pertaining to medical ethics as wellas medical intervention. There are three main factors thathave played a role. The irst is increased awareness about
patients’ rights, while the second is increased interest in
patient rights and ethical violations on the part of thelegal profession (Türkiye Cumhuriyeti Sağlık Bakanlığı
1998). In September 2004, Article 90 of the Turkish
Criminal Code codi ied the rights of patients and/or
volunteers in medical research (Türkiye Büyük Millet
Meclisi 2004; Türkiye Cumhuriyeti Sağlık Bakanlığı 1998).
The third factor is the implementation of an accreditation
programme by the Turkish National Medical Education
Accreditation Committee (Yüksek Öğretim Kurumu 2011)
with the goal of raising the level of medical education as
regards both scienti ic training and ethics instruction tomeet new national requirements and re lect universal
principles (World Medical Association 2020).
These developments in Turkey are in line withinternational declarations and organizations. As is known,
the World Medical Association was founded in 1945, andit has regulated international standards on ethics codes,
ethics education, human rights, and medical science, boththeoretical and practical, since 1947 (WMA 2020). In
Turkey, deontology regulations were irst published in1960 to protect patients (Türkiye Cumhuriyeti 1960) andto regulate the relationship between healthcare
professionals and patients. In addition, medical ethics
education was irst begun in Turkey in 1983, after The
Higher Education Board (YӦK) established Higher
Education Law No. 2547 in 1981, which added medical
ethics instruction to the irst year curriculum of medical
and dentistry schools (The Council of Higher Education(YÖK)n.d.). Medical ethics education was started based on
philosophical-theoretical information involving discussionof ethical principles in the irst year of instruction in
medical and dental schools. This instruction led to theacceptance of ‘ethics’ as an intellectual concept; hence thefrequent misuse of the term ‘ethics’ by the general public.
However, genuine misunderstanding of the meaning of
ethics has not prevented the creation of new ethicalregulations. After the European Consultation on the
Rights of Patients in 1994, authorities in Turkey published
the Regulation on Patient Rights (RPR) in 1998 (Türkiye
Cumhuriyeti Sağlık Bakanlığı 1998). As a result, informed
consent has become the subject of litigation, and thus
medical ethics education has gained importance forhealthcare professionals. The Turkish National Medical
Education Accreditation Committee (UTEAK) was
founded in 2008 and applied for accreditation to theWorld Federation of Medical Education (WFME) in2013((WFME) 2020). The accreditation process has
in luenced the standards of medical ethics education byincreasing ethics instruction to 20-40 hours for 6th-year
medical students and including ethics consultation
practices in its agenda.

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
Why do we organize medical ethics courses for resident
physicians? After completing medical school, physicians in
Turkey must perform compulsory service by working for
one or two years in underdeveloped towns or cities. Afteror during their compulsory service, they may take an
exam to be a specialist after a four- or ive-year residency.
Medical ethics are an important factor in determining theoverall quality of healthcare. Therefore, physicians require
medical ethics instruction to consolidate theirunderstanding of ethical issues. The goal of this study wasto evaluate how physicians determine whether or notthere are ethical dimensions in a given scenario and to
improve their understanding of medical ethics.
Materials and Methods
This study was conducted at the education and researchhospital of the university to determine the level of medical
ethics education of resident physicians and whether theirgrasp of ethics was suf icient to resolve ethical issues.
This research employed a demographic information
checklist regarding participants’ characteristics including
age, gender, major, and prior knowledge. Each groupconsisted of between 10-13 participants who participatedin the course for 3 hours a day, 5 days a week. Before theclassroom-based training programme, the participants
completed questions regarding 14 scenarios which
i n c o r p o ra te d c u l t u ra l i s s u e s ( A p p e n d i x ) . T h equestionnaires were distributed to and completed by allparticipants, both before and after training, and at theconclusion of the course each group offered its own
suggestions. ‘What are medical ethics and principles? Why
does the practice of medicine require ethical input? What
are the functions of research ethics committees and ethics
consultation committees? What are the differences
between ethical issues and legal issues? What do patient
regulations, deontology regulations and ethical codes
mean?’
The collected data were analyzed using SPSS (version
16). The descriptive and paired t-tests were used to assess
differences, where a p-value of less than 0.05 and 0.01
was considered signi icant for each item.
Limitations
This study involved several limitations. It was carried out
in one hospital with a small sample size, utilizing a 14scenario questionnaire created by the study author, andthe time was too limited to reinforce information anddiscuss additional cases. Therefore, the indings of thisstudy cannot be generalized. Despite these limitations,this study included ethics courses to measure the extent
to which resident physicians’ understanding of ethicalissues was expanded and deepened, as indicated by pretest and post-test results. In addition, the indings of thepresent study and the course content utilized therein canbe used as a starting point for new research to set up aninternational database of cases involving ethical issues
and physicians' views on medical ethics.

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Results
This study included 146 participants, selected randomly. A
total of 120 (82.1%) participants from different medical
specialties completed course and the pre- and post-tests

379(25% women and 75% men), while 10 participants
underwent most of the training and 16 participants
underwent half of the training. All participants weredivided into 10 groups, each group consisting of 10-13
participants. The participants ranged in age between 23
and 38 years old. The mean and standard deviation of theage of the study group were 28.23 ± 4.08 (Table 2). Of theparticipants, 68.3% were training to be internists(neurology, infection), 24.2% were training to be surgeons(general, child, plastic, ophthalmology so on), and 7.5%
were training in laboratory medicine (psychology,
biochemistry, anatomy, medical biology, parasitology). A
majority (59.2%) of the participants had practiced
medicine for one year, 33.3% for between two and three
years, and 7.5% had more than 3 years of experience(Table.1).
Table 1. Demographic data (n=120)
Age(28.23 ± 4.08)

Gender
Male

75%

(90)

Female25%(30)Work experience 0-1years

59.2% (71)

2-3 years

33.3% (40)3+ years

7.5%

(9)

Internist

68.3% (88)Surgeon24.2% (29)

Laboratory Science

7.5%

(9)

Participants’ attitudes to the scenarios
Traditional medical ethics is based on the Hippocratic
Oath and the theories of Ancient Greek naturalphilosophers; however, in the last decades of the 20th
century its focus has shifted to the medical ethics
principles of ‘nonmale icence, bene icence, autonomy, andjustice’(Beauchamp and Childress, 2001). Autonomy,
which includes informed consent, is increasing inimportance with improvements in human rights.
However, autonomy with informed consent is notconsistent with traditional practices. For this reason, thepractice of medicine provides not only medical treatment
but also involves the autonomy of the patient throughmedical ethics practices and patient rights regulations.
The aim of this course was to reinforce the participants’knowledge of medical ethics. According to our data, there
was a signi icant difference in the attitudinal responses
between the pre-test and post-test results (pre-mean
36.06 ± SD 4.91, post-mean 38.61± SD 4.47), with
p=0.000. This study results showed the mean scores of theparticipants regarding respect for autonomy andinformed consent to treatment before and after the course(Table 2). Ten of the scenarios concerned respect forpatient autonomy. A statistically signi icant difference wasfound between the mean scores of the irst six scenarios(p <0.05).

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

However, for three scenarios, participants’ attitudes
exhibited no statistically signi icant change between pretest and post-test results.
These scenarios involved
various aspects, such as the ‘loss of consciousness’ (p<0.05) scenario which led to a deliberation concerningorgan loss or loss of life. The next scenario concerned anintersex child (p <0.01). Many Turkish people give more
importance and advantages to boys than to girls. This
attitude is especially prevalent among poor people. The
inal of these three scenarios involved esthetic surgery (p<0.05). We can conclude that participants need a valueladen compass to cope with real medical ethics dilemmas.
Therefore, comparing the before and after results of thesethree cases does not result in a signi icant difference. The
next two scenarios measure the concepts of ‘bene icence’and ‘justice’ in terms of medical resources and patient
access to health care. There is a signi icant difference inthe results obtained before and after the course according
to the data. The irst of these scenarios concerns a 30year-old patient with respiratory failure and limited
resources (p <0.05), while the second involves a mass
traf ic accident (p <0.05). The last scenario in our study
concerned the choice between following the law or
medical ethics (p=0.00).
After completing the post-test, participants wererequested to provide feedback about the course. Almost
all (98%) of the participants found the course informative,
while 89% stated that the course helped them consolidate
their knowledge of ethics, and 90% found the scenariosvery useful for discussing ethical issues. A total of 74% of
the participants stated that there was enough time tosuf iciently cover the material, 89% declared that theywould pay more attention to ethical issues after taking thecourse, 97% were satis ied with the course, and 95% said
that they would take another ethics course.

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Discussion
This study has provided us with results regarding theknowledge of medical ethics by physicians in Turkey andhas shown the need for medical ethics courses toreinforce and improve physicians’ knowledge of medical
ethics following graduation. The participants were eager
to attend the medical ethics course. A total of 86% agreed
that the course gave them necessary information on
ethical-legal issues in nursing, and 94% stated that it was
helpful to discuss cases regarding medical ethics
principles of recent decades, since patient rights
regulations are increasing in importance and physicians
feel more responsibility for both treatment andrecognizing patient rights.
This study involved 14 scenarios, six of which concerned
patient autonomy. As is known, patient autonomy and thel e g a l re q u i re m e n t o f i n f o r m e d c o n s e n t w i t h
con identiality have forced physicians to follow ethicalrules. Most cultures employed paternalistic approaches
toward social relationships, including health care, until
the French Revolution (1789-1799). After the revolution,
European countries started to embrace democracy rather
than paternalistic views, in both the social and politicalspheres. However, paternalism continued to be embedded
in social and political life, which can be observed in all
aspects of social life.

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Table 2: Means and standard deviations for medical
ethics scenarios (N=120)* scenario descriptions andthe principals involved

95 %con idence
interval
PretestPost test
Mean ± SD
Mean ± SD

pvalue
p<.05
;
p
<.01

1. Drug research- ‘Informed 2.70 ±consent’
1.10

2.24 ±

P=0.

0.67

00

2. child with cleft palate 3.56 ±‘informed consent- from who1.30
to respect autonomy’2.56 ±

P=0.

1.46

00

3. child with avian lu ‘The 3.23 ±right to refuse treatment0.84
respect autonomy’3.60 ±

P=0.

0.69

00

4. male patient with cancer‘ surrogate offer informed
consent from who and privacy’

2.62±
1.36

3.18±
1.23

P=0.
001

5. 58-year old male diabetes
type II patient ‘to respectpatient autonomy and tobene it the patient’

1.88 ±

2.32±

P=0.

1.13

0.97

002

6. Female cancer patient ‘torespect patient autonomy,
con identiality’

3.09 ±

3.64 ±

P=0.

1.33

1.32

00

7 . L o s s o f c o n s c i o u s n e s s 3.82 ±‘informed consent and to
1.13
respect autonomy ‘

3.77 ±

P=0.

0,94

60

8. Intersex child ‘informed
consent from who, to bene it
the patient’

1.32±

1.21 ±

P=0.

0.78

0.62

21

9. Aesthetic surgery ‘do no 2.48 ±harm- respect of autonomy’
0.96

2.56 ±

P=0.

1.06

53

10. 30-year-old patient with 2.78 ±respiratory failure ‘to do
0.66
justice’2.91 ±

P=0.

0.36

09

11.Mass traf ic accident ‘ to do
justice, be of bene it’

2.89 ±

2.56 ±

P=0.

1.37

1.46

07

12. Preference ‘law or medical 2.70 ±ethics’
1.10

2.24 ±

P=0.

0.67

00

1 3 . S t e r i l i t y p r o b l e m s 2.89 ±’Informed consent and telling
1.37
the truth’

2.56 ±

P=0.

1.46

00

14. Surgery complications 2.48 ±“informed consent and
0.96
communication issues”.

2.56 ±

P=0.

1.06

53

Total data of pre-test and 36.0 ±post-test
4.91

38.6 ±

P=0.

4.47

00

The practice of medicine still involves paternalistic
practices (Flanigan 2013), whereas medical ethics

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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emphasizes patient self-determination as the ultimate
principle.
Regulations pertaining to patient rights have been
implemented in a number of countries and are closely
related to socio-political-cultural and scienti ic
developments. The historical, cultural and religious background of Turkey supports paternalistic attitudes which
are interwoven into all relationships including medical
ones, therefore the patient’s decisions are sometimes
made by the head of the family.Thus, the paternalistic
approach has not yet been entirely abandoned. However,educated people advocate respect for autonomy to raise
con ident, free-thinking children who desire selfdetermination. The major reasons for the persistence ofpaternalistic attitudes are, irst, that physicians possess
more knowledge and experience in medicine than theirpatients, and thus believe that their decisions are more
valid than their patients’ own decisions. Secondly,
physicians’ personalities may play a signi icant role in theinformed consent process. However, physicians mustcomply with medical ethics and legal regulations. Third,some patients choose to follow their physicians’
recommendations, because they cannot diagnose theirown conditions, and they are still operating under the
in luence of paternalism.
However, physicians must change their attitudes
towards their patients. As well as legal sanctions,
physicians work in partnership with patients/patientsurrogates who have the legal capacity to make medical
decisions for the patient; they can undertake theirtreatment program willingly and follow the physician’s
suggestions to achieve optimal care. The outcome of thisstudy indicated that informed consent, which is thecornerstone of medical ethics, is not well understood byresident physicians, and its application presents a numberof dif iculties.
In this course, the scope of the resident physician's
obligation to inform and how to obtain informed consent
was discussed through scenarios and also discussed in
Article 26 of the Physician Code of Ethics, “The physician's
patient, the patient's condition and diagnosis, the type of
the proposed treatment method, rate of success, theduration of the treatment method, enlightens about therisks to patient's health, the use of the drugs given and thepossible side effects, the consequences of the disease if
the patient does not accept the recommended treatment,
possible treatment options, and risks" were re-evaluated.
Eleven of the scenarios incorporated values necessary
for the realization of patient autonomy, especially as
regards informed consent. However, since each attitude
based on these values consisted of three aspects(cognitive, affective, and behavioral), changes in attitude
required constant nurturing, involving the assimilation of
new information as well as the implementation of saidvalues. For this reason, unlike a change in rhetoric, it is
not easy to shift from a paternalistic model to a patientcentered model. The paternalistic model has been
dominant in most societies throughout most of recorded
history (as the long history of empires, kingdoms,
sultanates, colonies, etc. has demonstrated), whereas
autonomy (informed consent) has only recently begun to
be considered and implemented in the form of patient

381

rights (Patient right regulation, 1998). The other two
scenarios primarily concern the concept of justice, whichis still much debated in Turkish society and is discussed
within the framework of what-which-how-why questions.
Scenario 1. Physicians have planned a drug researchstudy in their clinic. They must obtain informed consent
from clinic patients regarding the potential bene its andrisks of the proposed drug. It was found that when ethicalprinciples along with information on sample cases were
presented to the course participants, their evaluation ofthis scenario changed in the direction of patient autonomy
after the course, and participants’ awareness of medical
research regarding informed consent increased after thecourse. (p = 0.00).
Scenario 2. A 17-month-old baby with a cleft palate has
been brought to the hospital for treatment; however, themental ability of the patient surrogates was limited. The
question was whether the surrogates could give informed
consent through a legal advocate. The participants werevery concerned about the mental competency of thepatient surrogates. The course results showed thatparticipants received higher scores regarding the issue of
informed consent and believed that the involvement of alegal advocate was necessary, indicating that theparticipants perceived a link between mental competence
and informed consent. (p = 0.00).
Scenario 3. An 8-year-old girl is suffering from avian lu
and the patient surrogate (her father) has refused
treatment, because the patient’s chance of survival isminimal and the father must also care for seven otherchildren at home. This case involves economic issues,social policy, and cultural features. The population ofTurkey is 76 million and unfortunately, uneducatedfamilies prefer to have 7-15 children. These children
usually do not receive education past primary school, andmany start working on the streets at the age of 6-8 years
to earn money for their families. Turkish laws include
serious measures to prevent child abuse and protect
children, and ines are imposed against parents-adultsinstitutions who abuse children. However, there are notsuf icient numbers of authorities and concerned
institutions to uphold the laws. The participants were able
to make a clear decision concerning this scenario. They
assessed patient age and condition based on ethical-legal
standards and rejected the father’s request to deny care,receiving higher scores after the course regarding theinformed consent of patient surrogates to reject care. (p =0.00).
Scenario 4. A 63-year old patient is diagnosed with lungcancer, and the patient surrogate (his son) has requested
that the doctor not reveal the diagnosis to his father. This
scenario involved the concepts of keeping diagnoses a
secret from patients, patient privacy and patientautonomy. The paternalistic approach still persists andresults in a tendency for surrogates to make decisions onbehalf of patients. People who have assimilated
paternalistic attitudes may advocate for democracy,
autonomy, and freedom of speech, but their actions do notconform to their speech. This course has contributed toawareness of the discrepancies between behaviors andspeech, as indicated by the fact that participants received

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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higher scores after the course regarding informed consent(p = 0.001).
Scenario 5. A 58-year old male patient is diagnosed withdiabetes II and when examined 7 months ago it wasdetermined that he has hypertension. He wishes toregulate his medication according to Islamic fasting
practices. This scenario is related to the concept of patientautonomy and respect for all faiths. Participants evaluatedboth the regulation of patient rights and the importance of
patient autonomy. The information provided by thecourse led to changes in participants’ thinking, resulting
in higher scores on the subject of informed consent after
the course (p = 0.00).
Scenario 6. A 67-year-old woman was diagnosed withcolon cancer by physicians, who recommended surgery.
After the operation, the doctors recommended a course of
chemotherapy and radiotherapy, but the patient refusedboth. However, the surrogates tricked the patient into
beginning chemotherapy, without obtaining the patient's
proper informed consent, by telling the patient that they
will be receiving a different treatment. In this scenario,
patient rights and the wishes of the surrogates regarding
treatment were evaluated in terms of legal and ethicalprinciples. Many people in Turkey support withholding
information on diagnoses from patients where cancer isconcerned. Patient surrogates generally perceive patient
rights regulations as pertaining to themselves (thesurrogates), rather than the actual patients. The
participants comprehended that secrets/privacy andpatient autonomy are considered patient rights, and notsurrogates' rights, in this scenario. Participants received
higher scores after the course on the subject of informed
consent (p = 0.00).
Scenario 7. A patient experiences loss of consciousness
following a traf ic accident, and thus cannot give informed
consent. The physician needs to amputate a leg to save thepatient. In this case, which ethical principle(s) can beignored? For this scenario, participants’ awarenessincreased after the course regarding the issue of when
informed consent on the part of the patient can bedisregarded. Participants suggested that amputation of
the unconscious patient's leg without informed consent is
not ethical, because amputation will affect his/her qualityof life. Participants could not make a clear decision,
debating whether it would be better to have the patient's
informed consent after the patient regains consciousness,or accept the decision of the patient surrogate. (p <0.05).
Scenario 8. Physicians examined a 15-year-old child who
is intersex. After examination, the medical consultationteam decided that the child would have a better life as a
girl, basing their decision on their medical indings.
However, the child's parents, especially the father, wanted
the child to live as a boy, as they are valued more. This
scenario, which involves the concept of male supremacy,
has led to a discussion of paternalistic attitudes in society.
In some societies, including many parts of eastern Turkey,
having a son is considered crucial to proving one’s
manhood, thus women must continue to have babies until
producing a boy. If a woman does not give birth to a boy,her husband may marry again, whether legally or illegally,in order to have a son. In rural areas of the eastern
provinces of Turkey, a daughter is not even counted as a

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child. In this scenario participants faced an ethicaldilemma, but did not change their decision, perhaps
because of subconscious sexist attitudes or support of thepaternalistic model. There was no statistically signi icant
difference in participants’ decisions before and after thecourse (p <0.01).
Scenario 9. A patient who has undergone rhinoplasty
three times believes that her primary duty is to be
beautiful. She demands a new rhinoplasty. The physician
evaluates the risk for the patient and concludes thatsurgery would be very dangerous and that the patient will
likely experience health issues as result of the surgery.
However, the patient insists on surgery, although she isreceiving psychiatric counseling. This scenario involves
multiple ethical dilemmas. Can someone’s request to haveplastic surgery for aesthetic reasons be regarded as an
ethical issue? This discussion concerned patientautonomy, but surgery was not medically indicated. There
was no statistically signi icant difference in theparticipants’ responses before and after the course (p<0.05).
Scenario 10. A 30-year-old patient with respiratory
failure requires the use of a ventilator. However, there area limited number of ventilators in the hospital. A 70-yearold patient with a prior diagnosis of dementia has justbeen connected to a ventilator because he/she wasexperiencing respiratory failure. What ethical dilemmas
arise when a ventilator is taken from an elderly patient togive to a younger patient? There was no statisticallysigni icant difference in the participants responses before
and after the course (p <0.05)
Scenario 11. After multiple traf ic accidents, two patientsfrom the emergency service require urgent treatment.
However, all the hospital beds are full, so the physician
must prioritize one patient over the other. One is a 75year old female patient; the second is a 40-year old male
drug/alcohol addict, who according to the police reported
caused the accident. Which patient should be treated
irst? Which ethical principle is open to debate in thiscase? Scenarios 10 and 11 bring the concept of justice tothe forefront. The personal qualities of patients cannot betaken into consideration when determining the
distribution of limited resources, as this would not be inaccordance with the principle of justice. Therefore, ethicalinstruction includes discussion of the concept of justice toexamine the dilemma and propose solutions. Scenarios 10
and 11 both produced similar results. Justice involves anumber of different concepts and practices, discussion ofwhich revealed that these were not well understood.
Although justice in Turkey is frequently discussed, there isno consensus regarding its application. These scenarios
reveal the intransigence of Turkish society in general.
There was no statistically signi icant difference inparticipants’ decisions before and after the course (p<0.05)
Scenario 12. During contact with a patient what is aphysician’s primary consideration, the medical ethics codeor laws related to patient rights? Participants received
higher scores on the subject of medical ethics code andlaws after the course (p = 0.00)
Scenario 13. A 42-year-old man came to the urology
clinic because of an inability to produce a second child.

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)

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Clinical tests indicated that the patient was not able tohave children because of azoospermia and sterility. The
physician was hesitant to tell the patient the truth,
believing that this information could lead to a family
tragedy. The test results are likely to indicate that thepatient is not the biological father of his irst child.
Whether or not the doctor should tell the patient the truthis the question. This scenario concerned the values of
informed consent and truth-telling ( p= 0.00).
Scenario 14. As a result of the examination, the doctor
suggests to the patient that he should undergo goitersurgery. The patient also stated that he has somehesitations and accepts the surgery. And postoperativeesophageal perforation occurs. Therefore, the patient has
started legal complaints about his doctor. As in this case,what would you do if the patient accepted the treatment
but had some hesitations? What do you think is the main
ethical problem here? This scenario concerned the valuesof informed consent and communication; the doctor
should give more information about complications andalso more elaborative information should be given to
resolve the patient's hesitation, and even more timeshould be given to making a decision if possible (p <0.05).
In this course, the scope of the resident physician's
obligation to inform and how to obtain informed consent
was discussed through scenarios and also discussed in
Article 26 of the Physician Code of Ethics, “The physician's
patient, the patient's condition and diagnosis, the type of
the proposed treatment method, rate of success, theduration of the treatment method, enlightens about therisks to patient's health, the use of the drugs given and thepossible side effects, the consequences of the disease if
the patient does not accept the recommended treatment,
possible treatment options, and risks" were re-evaluated(Türk Tabipler Birliği Merkez Konseyi 2012).The
residents obtained information about informed consent
being not a burden and also that the illumination to bemade should be appropriate for the patient's cultural,social, and mental state. In addition, it has clearly learned
that the information in question should be in a form thatcan be understood by the patient, and the patient himself
should determine the people to be informed besides him.
Because of the cultural and traditional structure of thiscity, relatives and even friends of the patients have tried to
get information about their patient before the patient andhave even made various threats in this regard. However,legal regulations and medical ethics clearly reveal that all
health-related initiatives can be carried out with the free
and informed consent of the person.
The opinions of the course participants regarding thevalue of the course were: 98% stated that the course wasinformative, 94% stated that they understood ethical-legal
issues better thanks to discussion of the scenarios, and
89% stated that they could more easily determine ethicaland legal issues regarding patient care and that the course
helped consolidate their knowledge of ethics. Ninety- ivepercent of the participants stated that they would
willingly attend another ethics course, and 89% werepleased with the conduct of the faculty member and thecourse itself, in terms of the ethical information
presented, duration of the course, and case discussions.

383

Conclusion
The study reveals that physicians are aware that a varietyof ethical and legal problems may arise in the process oftreating patients. However, they often do not have very
precise information concerning how to resolve ethical andlegal dilemmas. Because most physicians in this study had
not received medical ethics education by trained ethicists(only 22 of 82 medical schools in Turkey provide ethics
education by actual medical ethicists), or had only
received theoretical ethics education, they did not possess
suf icient awareness of the ethical principles involved fortheir proper application. Physicians have to create abalance between treatment, ethical principles, and theindividual rights of patients.
The course implemented in this study included a varietyof scenarios regarding ethical-legal issues of patient carewhich contributed to better understanding of said issues.
Therefore, the participants expressly recognized that
ethical-legal issues are concomitant with treatment issues
when they carefully evaluated each scenario according to
medical ethics principles. Indeed, the participants noticed
that informed consent provides a positive and meaningful
link between physicians and patients which, byreinforcing patient trust and helping to solve ethical-legal
issues, can contribute to patient satisfaction as well as
positively impact health outcomes. Medical ethics
concepts and patient rights regulations are an importantpart of core healthcare values and practices. These values
are in the patient’s best interest and improve levels ofpatient trust and satisfaction. For these reasons, medical
ethics courses should be organized by medical ethicists
and specialist educators and supported by healthorganizations.
Acknowledgements
I would like to express my gratitude to the resident
physicians who participated in this study and to the
University Research Hospital Authority Head Of ice for
their support. This research received no speci ic grantfrom any funding agency in the public, commercial, or notfor pro it sectors.
References
Association, The World Medical. 2020. “Medical Ethics.” Medical
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medical-ethics/).
Childress, Thomas Beauchamp, James. 1989. Principles ofBiomedical Ethics. Third. New York: Oxford University Press.
Ekmekçi, Perihan Elif. 2017. “Medical Ethics Education in
Turkey; State of Play and Challenges.” International Online
Journal of Education & Teaching 3(1):54–63.
Flanigan, Jessica. 2013. “Refusal Rights, Law and Medical
Paternalism in Turkey.” Journal of Medical Ethics. doi: http://dx.doi.org/10.1136/medethics-2012-100945.
Meclisi, Türkiye Cumhuriyeti Millet. 2004. “Türk Ceza Hukuku.”TÜRKİYE CUMHURİYETİ ANAYASASI (5237).
The Council of Higher Education. n.d. “The Higher Education
System in Turkey.”
Türk Tabipler Birliği Merkez Konseyi. 2012. Hekimlik MeslekEtiği Kuralları. Ankara-Turkey.
Türkiye Cumhuriyeti. 1960. “Tıbbi Deontoloji Tüzüğü (Medical
Deontology Regulation).” Resmi Gazete (Of icial Gazette).
Türkiye Cumhuriyeti Sağlık Bakanlığı. 1998. “Hasta Hakları
Yönetmeliği (Patient Rights Regulation).” Resmi Gazete (Of icial

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Gazette) (23420).
(WFME), The World Federation of Medical Education. 2020. “TheWorld Federation of Medical Education (WFME),.” Retrieved(https://wfme.org/accreditation/).
Yüksek Öğretim Kurumu. 2011. Ulusal Tıp Eğitimi Akreditasyon
Kurulu(UTEAK).
Yüksek Öğretim Kurumu. 2020. MEZUNİYET ÖNCESİ TIP EĞİTİMİ
ULUSAL ÇEKİRDEK EĞİTİM PROGRAMI 2020. Ankara-Turkey.
https://www.yok.gov.tr/Documents/Kurumsal/
egitim_ogretim_dairesi/Ulusal-cekirdek-egitimi-programlari/mezuniyet-oncesi-tip-egitimi-cekirdek-egitimi-programi.pdf

Appendix (case scenarios)
1. You are working as a doctor at a university hospital; you
took part in Phase 3 clinical trials. The patients participate in
the study after giving ‘informed consent’. What is your main
reason for getting informed consent from the participants?
2. A 17-month-old baby with cleft palate has been brought tothe hospital for treatment by his family. Palate surgery can be
performed on babies, however the baby’s family has a low
level of intelligence; they cannot understand all of theprocedures involved with the surgery and the riskof complications. In this case, what is the ethical approach
regarding informed consent?
3. An 8-year-old girl is suffering from avian lu and her father
says that he has 7 more children at home. He denies treatment
for his daughter and demands that she be discharged from thehospital. What is your ethical solution to this dilemma: toprovide treatment without consent, to force the father toconsent to treatment under threat of legal action, or to agree
to discharge the patient?
4. A 63-year old patient is diagnosed with lung cancer, and thepatient's surrogate (his son) requested that you do not explain
the diagnosis to his father. The son believes that if his father
learns of his diagnosis, his psychological condition will beworsened. If you accept the patient's surrogate’s demand,
what kind of ethics violation will occur?
5. A 58-year old male patient is diagnosed with diabetes II andwhen you examined him 7 months ago you determined that
he has hypertension. The patient described himself as areligious man and requested to fast for 3 months plus 30 days.
He wanted to regulate his medication again, because Islamic
fasting rules permit eating between 7 pm-4am. If you regulate
his medication based on his fasting, the patient’s condition
will be worse. The physician’s job is to ‘do no harm, to bene it
the patient and family, to respect autonomy and to do justice’.
Which ethical principle would in luence your decision?

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6. A 67-year-old woman was diagnosed with colon cancer byphysicians. Physicians suggested that she have a colon
operation. After the operation they recommended
chemotherapy and radiotherapy. The patient refused bothchemotherapy and radiotherapy, since some of her friends
had died during both therapies. The patient's surrogates
wanted the patient to begin chemotherapy and radiotherapy.
The surrogates beg you to start the therapies without thepatient's proper informed consent. What kind of violation canoccur in terms of medical ethics principles in this case?

7. A patient experiences loss of consciousness following a
traf ic accident. When the patient arrives at the emergency
room you notice that he/she has a gangrenous leg. The patientcannot provide informed consent due to loss of consciousness.
You have to amputate the leg to save the patient. In this case,which ethical principle can you ignore?
8. Physicians examined a 15-year-old child who is intersex.
Physicians suggested an examination which involved
psychosocial and physical aspects to determine which genderwould be better for the child. After examination, the medical
consultation team decided that the child would have a better
life as a girl, basing their decision on their medical indings.
However, the child's parents, especially the father, wanted tohave a boy, because boys are valued more. The father didn’t
accept the team’s indings, saying that he had raised his childas a boy. In addition, he asked the medical team, ‘How can I
explain this to my social circles?’ A man who has a son isconsidered more of a man. However, the child wanted to be a
girl. In this case, whose wishes should take priority in terms of
ethics?
9. Your patient who has undergone rhinoplasty three times
believes that her primary duty is to be beautiful. She demands
a new rhinoplasty. When you evaluate the risk for the patient,
you concluded that surgery would be very dangerous and that
she will likely experience health issues as result of thesurgery. However, the patient insists on surgery, although she
is receiving psychiatric counseling. How do you determine theethical approach to this case?
10. A 30-year-old patient with respiratory failure requires theuse of a ventilator. However, there are a limited number ofventilators in the hospital. You have just connected a70-yearold patient with a prior diagnosis of dementia to a ventilator
because he/she was experiencing respiratory failure. Whatethical dilemmas arise when a ventilator is taken from anelderly patient to give to a younger patient?
11. After multiple traf ic accidents, two patients from the endof the emergency service needed to be treated urgently.
However, all the beds were full, which you can select thepatients. One of them is a 75-year old female patient; second a
40-year old male patient who is drug-alcohol addict andpolice reported that he caused that accident. Which patientsshould be treated irst? Which ethical principle is opened up
discussion in this case?
12. During contact with a patient what is your primaryconsideration, the medical ethics code or laws related topatient rights?
13. A 42-year-old man came to the urology clinic because of
an inability to produce a second child. Clinical tests indicatedthat the patient was not able to have children because ofazoospermia and sterility. The doctor was hesitant to tell thepatient the truth, believing that this information could cause afamily tragedy. The test results are likely to indicate that thepatient is not the biological father of his child. Should thedoctor tell the patient the truth?

Eubios Journal of Asian and International Bioethics 31(7) (November 2021)
Scenario 14. As a result of the examination, the doctor
suggests to the patient that he should undergo goiter surgery.
The patient also stated that he has some hesitations andaccepts the surgery. And postoperative esophageal
perforation occurs. Therefore, the patient has started legal
complaints about his doctor. As in this case, what would you
do if the patient accepted the treatment but had somehesitations? What do you think is the main ethical problem
here? This scenario concerned the values of informed consent;
the doctor should give more information about complications
and also more elaborative information should be given to
resolve the patient's hesitation, and even more time should begiven to making a decision if possible.

385

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Registered address of EJAIB: P.O. Box 16 329,
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