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Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 26 (4) July 2016www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2016 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page
129

Editorial: Dignity, Respect and Love
- Darryl Macer
Should a Brain-dead pregnant woman be provided
somatic support to save the life of the fetus?
130- Sakiko Masaki, Hiroko Ishimoto, Yasuhiro
Kadooka, Atsushi Asai
Compassion in medical ethics of traditional Mongolian
medicine
137-Dashjamts Shagdarsuren and Battogtokh
Gerelmaa
Framing Assumptions in Teaching Ethics Using Case
Studies140- Ann Boyd
Internal Evaluation of Subject Ethics in Health Care:My Experience of MS Nursing Students at a
Pakistani Nursing Institute144- Zoheb Rafique
The Patterns of Social Stigma among the Rural
Women in Bangladesh: A Sociological Study
146- Sumana Akter, Wardatul Akmam, Md. Nazmul Hoque
Would we leave our ageing parent or grandparent in
the care of a robot? – A perspective from Islam 153- Sibtain Panjwani
HESC to IPSC: Prohibition to Controlled Permissiveness to ethical panacea
155- Intekhab Islam, Vinicius Rosa, Raymond Wong
ABA Renewal and EJAIB Subscription
159
Editorial address
Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations(AUSN), P.O. Box 530, San Carlos, Arizona, USA
Address all correspondence to:
Email: darryl@eubios.info
http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: Dignity, Respect & Love
This issue includes 7 papers that could be grouped
as commentaries on different aspects of promotion of
dignity, respect, compassion and love. These are all
critical in our treatment of others, and our ourselves,and successful societies and institutions must promotethese. We could add honesty and not bearing false
witness as additional requirements. There are
numerous discussions of these over history and they
are very relevant to bioethics.
The first article by Masaki et al. reviews thearguments over the continuation of life sustaining
support for pregnant women when they have entered
the phase of brain death – which is the widely
accepted end of life. How do we balance the life of the
fetus, and her mother? Does this balance change
when the mother dies leaving the fetus a passenger ina living corpse? Her mother is clearly not a corpse toa vital fetus, and often not to the bereaved partner,
parents and surviving children. While many may
rejoice in the options presented by modern “life”sustaining technology, as will likely any baby born after
such gestation, others attempt to limit its use.
Compassion can assist us in medical decisions, asDashjamts Shagdarsuren and Battogtokh Gerelmaa
argue from a Mongolian perspective. Sibtain Panjwani
argues that there may be limits on the use of a robot in
elderly care. Aging societies face dilemmas ofshortage of care, and robotic surgery is becoming
routine. Robots may shake less and do a better job indelicate treatments, or through telemedicine.
Social stigma in Bangladesh is reported in an
extensive article by Sumana Akter, Wardatul Akmam,
and Md. Nazmul Hoque. There are clearly someurban-rural gaps in many countries, but stigma iscommon. Two papers on teaching ethics, by Ann Boydand by Zoheb Rafique, offer some clues to explore
how we can assist in formation of social values. Finally
there is paper from Intekhab Islam, Vinicius Rosa, andRaymond Wong exploring the use of HESC and IPSC
stem cells, and whether these can be an ethicalpanacea. At least love, dignity and respect, universally
can help us.
- Darryl Macer

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

Should a Brain-deadpregnant woman beprovided somatic support tosave the life of the fetus?
- Sakiko Masaki (corresponding author),
Department of Bioethics, Kumamoto University Graduate
School of Medical Science, 1-1-1 Honjyo, Chuo-ku,
Kumamoto, 860-8556, Japan.
E-mail:sakikomaki@hotmail.co.jp- Hiroko Ishimoto
Department of Bioethics, Kumamoto University Hospital, 1-11 Honjyo, Chuo-ku, Kumamoto, 860-8556, Japan
Email: heaven272005@yahoo.co.jp- Yasuhiro Kadooka
Department of Bioethics, Kumamoto University Faculty ofLife Sciences 1-1-1 Honjyo, Chuo-ku, Kumamoto, 860-8556,
Japan
Email: y-kad@kumamoto-u.ac.jp- Atsushi Asai, M.D., Ph.D.
Department of Medical Ethics, Tohoku University Graduate
School of Medicine 2-1 Seiryo, Aoba-ku, Sendai, Miyagi,
980-8575, Japan
Email: aasai@med.tohoku.ac.jp

Abstract
In recent years, a number of news stories werereported worldwide involving brain-dead pregnant
women. Debates over providing life support to braindead pregnant women and delivery of their children
have been around for some decades. Maintaining awoman’s life solely for fetal viability has become amajor controversial social issue. Opposing opinions
exist where one side supports the woman and herchild should be left to die in dignity and the other sideclaims to protect the unborn child’s right to live. Eachgroup has strong beliefs. This paper addresses main
aspects when considering the continuation of somatic
support to the brain-dead pregnant woman for the
purpose of fetus delivery including; human death,dignity of the woman, rights of the fetus, proportionalityof acts, and the woman’s donor status, andindependence of mother and fetus. Then, the authors
present several diverse opinions and positions
concerning the legitimacy of life support for brain-deadwomen based on them and critically evaluate them.
We show that each and every claim can be ethicallyrefuted. This paper also approaches to those claims
from three different points of views, which are that of
the brain-dead woman, her fetus and her family. We
believe that the brain-dead woman’s wish and dignity,
the child’s predicted wellbeing after birth, and thefamily’s beliefs and welfare should all be counted
equally when making the final decision. In conclusion,
we argue that the decision can be ethically justified
only when the interests of all parties are appropriately
taken into consideration and protected.
1. Introduction
A number of news related to delivery of a baby
born from brain-dead pregnant women were presented

worldwide between 2013 to 2014. In Japan, threebrain-dead pregnant women’s cases were reported in2014 (1, 2). These women were brought to a university
hospital and became brain-dead. Two of the three
women had delivered their babies. One family wanted
to save the fetus, the other remained uncertain until
the contraction of the woman began, and the third had
no desire for the baby in the first place (1, 2). Similarcases were reported from Canada, Hungary and theUnited States, too. A Canadian woman was just 22
weeks pregnant when she was declared brain dead.
Doctors in charge kept her alive at her husband’srequest so that their unborn baby would have a betterchance of survival. She was on life support for six
weeks before she gave birth to her child (3). The
Hungarian was 15 weeks pregnant and she was on life
support for 3 months before she delivered a healthy
baby boy (4). In the USA, a pregnant woman who
lapsed into a brain-dead state was removed from life
support after a hospital complied with a judge's order
to disconnect her from the machines keeping her alive.
Her husband wanted to have his wife die with dignity.
The fetus, which was at 23 weeks' gestation, was notdelivered (5, 6).
Debates over a brain-dead pregnant women’s life
support and their child birth have been around forsome decades. Esmaeilzadeh et al found 30 cases
reported between 1982 and 2010. Twelve viableinfants were born and survived the neonatal period (7).
Various countries, including Japan have reported
different cases (2, 8-16). For example, a woman’sorgans were donated to others post-delivery and, inanother case the mother’s life support was maintainedeven after the child-birth (4, 9, 10, 11). It is claimed
that an especially significant ethical problem arises if apregnant woman is declared “brain dead” before theage of fetal viability. Should she be maintained on life
support for the sole purpose of allowing fetal
maturation to occur before delivery? (14)Both pros and cons towards maintaining woman’slife when it is done only for the fetal viability became amajor controversial social issue although aninternational specialist group in Obstetrics andGynecology has already published comprehensive
recommendations concerning brain death andpregnancy (17). In the Canadian case, contributions
were gathered for the husband’s solicit donation. In the
US case, anti-abortion groups insisted that the infant
should have given a chance to live, whereas proabortion parties supported that the woman’s desire fordying with dignity should be kept (18-22). In 1993, thesimilar case was reported in Germany. The situation
became a public question that split the nation in two.
One side demanded that the young woman and herchild be left to die in dignity. The other side referred tothe unborn child's right to live and therefore wanted the
body of the woman maintained until the fetus could beborn (12). Gostin questioned that how should society
reconcile these two interests that stand in such stark
tension. He argued that there are no clear answers,
but only questions: when does life begin, how should it
be valued, and whose choice should prevail between

Eubios Journal of Asian and International Bioethics 21 (July 2016)
the woman’s and state’s. The answers to thesequestions have seriously divided the medical andpolitical communities and the public (23).
Given the conflicting claims about the justifiabilityof somatic support of brain-dead pregnant woman tosave the fetus, in this paper, we would consider
whether a brain-dead woman should be provided
somatic support to save the life of the fetus. We would
present several diverse opinions and positions
concerning the legitimacy of the life support for braindead women and give them our critical evaluations. It
will be shown that each and every claim, regardless of
its side, can be ethically refuted. Finally, we would
suggest that the brain-dead woman’s wish and dignity,
the child’s wellbeing after the birth, and the family’sbelief and welfare should all be counted equally when
making the final decision. In conclusions, we would
argue that the decision can be ethically justified only
when the interests of all parties are appropriately taken
into consideration and protected. We would alsopresent unresolved issues that require further
consideration.
2. Critical considerations towards main views
about the continuation of somatic support to thebrain-dead pregnant woman for the purpose of
fetus delivery.
2-1 Opinions based on the death of pregnant women
One opinion stands that the brain-dead woman is
no longer alive, likewise, the deceased body is nolonger for medical objectives, either. Hence it ismeaningless to use any life-supports for sustaining her
physical ability (24.25). However, not all the countries
have laws or regulations for brain-death as a man’s
death. A certain number of laws in different countries
state that brain-death is the definition of the death. In
Japan, on the other hand, under the organ transplantlaw, someone would be pronounced dead by brain
death criteria only when it directly relates to organtransplantation. For the rest, normally cardiac death isa definition of death in Japan (26). Besides legal deathdoes not necessarily correspond to biological death.
Sometimes, even if the brain is actually dead, otherbody parts are still normally functioning. Some
Japanese Shinto adherents insist that cardiac death isdesirable even when transplants are performed
because cardiac death is perceived as the time of asoul’s separation from a body and a natural death, but
a warm death, or an unseen death, is consideredunnatural（27, 28).
2-2 Opinions based on necessity of dignity towards thedeceased
When brain-death is considered as one’s death, it
becomes important how to handle the body withcertain dignity. The body must be carefully treated withgreat respect. Therefore when treating the body, we
should always be honorable to it and should not fail tolose its integrity at any time (29). Generally these arecommon attitudes for handling deceased bodies.
Hence if we were forced to maintain physical capacity

131of the brain-dead pregnant woman, it could have spoilt
her dignity. However, we could refute this opposition
based on her dignity by arguing that the position lacks
due consideration for the existence of the fetus in the
woman’s body. It can be dangerous to treat pregnant
woman’s body equal to a usual deceased body,
because even if she is dead, a fetus is still surviving in
her womb. Additionally we should take the pregnant
woman’s wish about child birth into consideration aslatter mentioned.
Conversely, some argue that the claim that use of
the pregnant mother as an incubator would violate her
right to autonomy and bodily integrity is irrelevant
because the patient is already dead. In ethicaldeliberations of obstetric interventions on behalf of the
fetus, one has to consider the risks to the mother andthere is no maternal risk in this case (12, 15).
Nonetheless, we should suggest that it would be quite
narrow minded medical remarks if they do not countone’s interest only because she is no longer alive.
Even if keeping the maternal womb is the only lifesaving method to the fetus, continuing life support tothe pregnant woman against to her and her family’s
wishes would be totally unacceptable, because it
would be adverse to both family and social interests.
Using a dead woman’s body as an incubator against
her wishes, as interpreted by her family, should be ofgrave concern to everyone who cares for and aboutboth women and our nation’s moral health (24). The
psychological grief of the family will get stronger when
the loved-one’s dead body gets hurt.
2-3 Opinions based on significance of dying with
dignity
It is argued that where brain-death is regarded asa terminal stage, the priority should be focused on
making one’s death be one with as much dignity as
possible. In the same token, when a brain-deadpregnant woman clearly voiced her wish to have deathwith dignity, her will should be protected and conveyed
as it is. Also for the brain-dead patients, continuous
life-support would have no meaning to themselves. In
another words, exposure to medically futile
interventions leads to take a contrary position fromhaving a dignified death. Moreover, some suggest that
it is unacceptable to keep the brain-dead mother’sbody only for the childbirth, since that practice reaches
to the sexual discrimination by demeaning anddegrading women, because it is treating her body as a‘delivery machine’, ‘container for fetus’ or ‘incubator’ (7,12).
Nevertheless, there are the arguments against
those who oppose somatic support of brain-deadpregnant women on the grounds that they had
advance directive indicating their wishes for dignified
death. We would argue that there must be someconditions for their argument to be accepted. In our
opinions, the woman should have been refusing to givea birth to her baby, or she had written an advancedirective expressing her wish to have dignified death at
the cost of her fetus’s life. What matters most is thather previous statement clearly specifies what she

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

would want to do when she lapsed into brain death
during her pregnancy. Advance directives which justmention about her wishes for delivery or death with
dignity are not good enough as guiding evidence.
Conversely, when it is known that the pregnant woman
was eager to sacrifice herself for the purpose ofchildbirth, then her dignified attitudes and actions
would be worth giving for. That is one of the forms oftransferring her love. Thus when the woman is clearing
craving for her baby to be alive, helping out alongsidewith her wishes is protecting her dignity. Therefore,
continuous somatic support of the brain dead pregnant
woman for childbirth in this situation would notconstitute exploiting her as a mere delivery-machine.
However, disagreement could exist over how tohandle the brain-dead woman’s wish to become amother, to raise a child, or to have a new family. Thisis because the fulfillment of these wishes is completely
impossible due to the fact that she is brain-dead andhas no chance of recovery. The authors have no idea
about what the woman would want concerning
childbirth in the situation where she became braindead and had no chance to live with her baby. It is also
anticipated that there must be very few women who
express their desires about child and family inadvance, after assuming that they become brain-deadduring their pregnancy. It may be especially true when
they are young and full of hope of the future and about
to start a new family and new life with a baby. For
them, picturing themselves in such situation is highly
unrealistic and bizarre. Moreover, it would be
unacceptable to make the final decision unconditionallyand automatically by using the brain-dead woman’s
advance directive because there are also otherconditions to take into account including the interestsof the fetus and the family as described later. Finally,
we should also consider the possibility that, for some
women, their affections to their own babies havealready started developing during pregnancy and it
may lead a strong desire to the baby to be born and bealive even without their existence. In such a case, theagenda regarding how to deal with the mother’s decent
affection would emerge for the bereaved family.
2-4 Opinions based on the rights of the fetus
When both the interests of a brain-dead pregnant
woman and that of a fetus are taken into consideration,some argues that the latter is given priority. If themother is to be considered a “cadaveric incubator” with
no autonomous rights, the rights of the fetus should
legally prevail (7). It is also claimed that, from the
medical point of view, the preponderance of argument
is that it is acceptable to strive to resuscitate the fetus
by maintaining life support if there is a reasonablechance the pregnancy will continue at least until fetallung maturity is achieved (13). There also exist theclaims that physicians must primarily focus on saving
the life of the fetus, and that therefore the treatment
protocol should give special recommendations on how
to support the mother in a way that she can deliver a
viable and healthy child (7).

However those who prioritize the birth of fetus
seem to have a firm premise to their argument. That isthat being born is better and more beneficial for thebaby itself than being unborn and non-existent. It is
possible that we recognize the right to be born and theright to live for the fetus in order not to deprive it ofsomething valuable such as life. From a secular
viewpoint, since life itself is worthwhile, a life-to-becertainly has essential values in it in order to lead a
personal life. The authors believe, however, that life
merely exists each moment as value-neutral position
where we cannot judge whether life is good or bad. At
the end of life, we believe it comes out even after all
ups and downs. Therefore, no harm would be inflicted
in an unborn child by remaining non-existent. Yet to beborn is value-neutral position and consciously nothing.
Nobody receives any disadvantages by not being born.
Fear of death and sadness of separation come fromlife experiences, thus it is extremely awful when aliving human-being including the authors dies. We belt
our personalities, self-consciousness and relations
with others through our life, which all together cause
fear of death because we were born. A fetus has
nothing.
In Christianity, abortion is strictly forbidden
because they believe the same right to live is equally
given to all human-beings including a life just begun
after a moment of fertilization. On the other hand, inJapanese folk religion, Shinto suggests that our soul
gradually grows over time and the growth of each soulclosely relates to his/her social roles thus the soul is
not stable or unchangeable from the moment of
fertilization. From that belief, under seven-year-old
children’s immature souls had been treatedexceptionally for a long time (30). Before the age ofseven, those children are not included in the humansociety, therefore even if the life was taken it regarded
as returning to the original world where they came fromrather than a murder (31, 32). As seen above different
religious thoughts can be opposed to each other andeach claim can be conflicting. The authors suggestthat the belief of the value of life which based on a
specific religion does not have huge influence in the
ethical judgment of the person who does not believe init. Hence we should not ignore any advance directivefrom a pregnant woman, refusal of life-support byfamily members or when handling the deceased bodywith dignity, just because there is a fetus
2-5 Opinions based on proportionality of somatic life
supportSome argue that it is proportional to perform
medical interventions for continuing life-support on abrain-dead pregnant woman in order to save a fetus(33). This opinion based on the proportionality of act
emphasizes that spoiling the woman’s dignity, integrity
and/or privacy by keeping brain-dead pregnant woman
alive can be justified because the life of the fetus isextremely important. However, judgmental criterion forproportionality varies among people. Both medical
professionals whose mission are saving lives andantiabortionists stand their position as it is acceptableEubios Journal of Asian and International Bioethics 21 (July 2016)
to sacrifice most for the fetus life. On the other hand,death-with-dignity supporters differ in their opinionsfrom above. They put high values on dignity, integrityand privacy of a brain-dead pregnant woman andwould be willing to sacrifice other thing they think lessimportant. Also, even for a fetus delivery promotion
group the question may arise whether to aim a goal for
fetus delivery when the cost for both maintaining lifesupport for a brain-dead woman and for post-delivery
child care will be excessively high. As just described,
the concept of proportionality is quite arbitrary andunstable. This argument can be used to support bothpros and cons.
2-6 Opinion based on the fact that the brain-deadpregnant woman is an organ donor
One of the determinant factors in this decisionmaking process is a prior statement by the mother withrespect to organ donation. If the deceased mother isan organ donor, then prolongation of her vital function
is more easily justified from an ethical point of view,
since the fetus would be the first to benefit fromreceiving the donation of the mother's organic function(14, 15). However, continuing somatic support fororgan donation is one thing and the support forchildbirth is completely other. First, this somatic
support for fetal delivery would possibly continue forweeks or more. Thus both the psychological andfinancial strain for the family would grow stronger.
Secondly we should pay attention to the differences
between continuing somatic support for existing people
and for a new life to be born. As mentioned previously,
there are big differences between someone who has
already existed will continue to live and someone who
is not yet to be born will become part of the world.
Thirdly, the consent for organ donation has to be
separated from the consent for giving a birth to theworld where the mother herself will not exist.
Additionally, we have to review the point whether abrain-dead pregnant woman’s intention for the organ
donation remain unchanged when the fetus is in her
uterus. Moreover when thinking about the family’s
following life without the brain-dead pregnant woman,
implementing of organ donation may have little
influence on it whereas delivering a baby gives directly
the opposite effects on the family’s future.
2-7 Opinion based on independency of the mother andthe fetus
It is argued that both the mother and the fetus are
two distinctive organisms, and, hence the fetus should
be saved. If the mother and the fetus are regarded as
two distinct organisms, maintaining the vital functionsof a brain-dead pregnant patient may be ethicallyjustifiable to support both the birth of a child andpossible organ donation (7). However, this claim is notplausible because, in order a fetus to survive, it must
be dependent upon its brain-dead mother. It is
impossible for the fetus to survive without the mother’sbody functions and the concurrent death of the fetus
would ensue as soon as the deterioration of its
mother’s condition would happen. This total

133

dependency state of the fetus makes the forementioned argument based on the fetus as anindependent organism quite strange and weak. The
fetus is not self-independent until at least it acquires
viability outside of the mother’s body. On the other
hand, even legal abortion is accepted in somesocieties including Japan now, so all abortions would
be forbidden once the total independency of fetus is
accepted.
3. The diversity of the brain-dead pregnant woman
family’s hopes and their situations
So far, we have reviewed many important
conflicting opinions concerning maintaining the life
support on a brain-dead pregnant woman in order todeliver a fetus and we have found a way to refute eachand every argument. In this section, we are going todiscuss about the third important party, the bereaved
family. We have to learn about the family’s situationand carefully consider their intentions as a substitutedecision maker. A family judgment would widely vary
due to the love from a husband to his wife, his love forthe fetus, affordability and positive attitudes towards
child-rearing, and attitude towards the fetus’s
handicap. For instance, if the family has no financial
capacity for the childcare, they may have to give up on
the childbirth. On the other hand, even the fetus has
some handicaps the bereaved family may wish thebrain-dead mother to deliver a baby. Also the decision
making may be influenced by the husband’s age,whether he has the opportunity of redo his life or not,the level of anxiety towards child-bearing, the relative’s
intentions and how much support the husband can getfrom them. Sometimes parents cannot accept thebrain-dead daughter’s baby simply because she is notmarried (1). The decision may differ from the first andmultipara pregnancy. Sometimes the national attitude
towards abortion can be an influence factor. The
gestation stage may affect the family’s preparation forthe baby. Some family may wish to keep the baby alive
as a keepsake of a wife/daughter. A husband and/or
his relatives may wish to save the baby for the sake of
keeping the blood line of their own family root. There
may also be different attitudes of the pre-existingchildreninthefamily.
Circumstancesandpsychological status of the family vary in each case,thus the final decisions naturally differ from eachindividual situation.
4. The authors’ positions: Love, happiness,
responsibility, privacy, and tolerance
There are a great number of variables to consider
in the judgment of the right or wrong about keeping
brain-dead pregnant woman alive for the purpose of a
fetus delivery. Significant medical uncertainty also
exists. Additionally, the family’s psychological status
and circumstances are multifarious. All of them would
make the judgment of this matter extremely difficult.
The authors would argue that it would be nearly
impossible to determine right or wrong of maintaining
life support for brain-dead pregnant patients just for the134

Eubios Journal of Asian and International Bioethics 21 (July 2016)

childbirth, because any pros and cons do not havedecisive strength to it as mentioned previously.
Using the diagram of the benefits of brain-deadpregnant woman vs. fetus is too simple in deliberatingon this issue since the family circumstances andintentions are important and deserve being taken into
account as well. Of course, it would be insufficient tofocus only on the family’s intention, either. The reason
for this includes that some family’s decisions would be
unacceptable from the ethical point of view. Somefamily’s intentions may focus on their own benefit byusing the brain-dead pregnant patient as a mere
means. Then, what do we have to do? The authors
would argue that our decision regarding this dilemma
should always cover all three parties’ benefits including
the woman, her fetus, and her family. The only
judgment will be ethically justified when those threeparties’ circumstances are equally considered; thebrain-dead pregnant woman’s dignity and wishes, thechild’s welfare after birth and the family’s belief andhappiness. Specifically, some important points aredescribed as below.
At first, the situation should include the brain-deadpatient to have strong love and desire to deliver herbaby into this world even without her existence as amother, and her family to have strong beliefs in thepatient’s wishes. The most important point is thefamily’s genuine beliefs in her wishes based
longstanding communication between the patient andher family and mutual understanding among them.
There should not be any mistrust about the brain-deadpatient’s intention and desire concerning delivery ofher baby. Secondly, at least, either the father or thepatient’s parents has firm intention to nurture the childand develop a new family. That is; the bereaved family
expresses a strong urge for the childbirth, they havesense of love to the baby and they are willing to takeall responsibilities for bringing-up her baby. The
childbirth should be the expression of their pure love.
Thirdly, a child-to-be-born should be able to findhappiness with secure enough possibility in its life.
When the baby’s life is full of love, dedication andvarious pleasant experiences from the family, even
without the mother, it may be good to be born. Of
course nobody knows what the future is like, but itwould be far better to have fewer disturbing factors tofind happiness. The child needs to have positive
prospect that the life will be decent enough to enjoy
even if it would not be the best. Fourthly, both society
and health professionals should not force any specificjudgment for a bereaved family. Both extremes - “Thepatient must deliver the baby” or “The patient should
give up the childbirth” should be prohibited. The main
focus should be on the patient and the family side; “I
do want to give a birth” and/or “We want the babe to
be born”. Because having a baby and making new
family is an extremely private issue.
5. Conclusions
In summary, it would be acceptable to maintainbrain-dead pregnant woman’s somatic function inorder to deliver her baby only when the bereaved-

family-to-be will care for the baby with decent love andhave responsibility to that child and when the family
firmly believed that their choices would fulfill thepatient’s wish. What are crucial are to love, not tocoerce, to aim for happiness and to have long-term
responsibility for our own acts to the others including
the child and its mother. Otherwise, maintaining life
support to the brain-dead pregnant woman should not
be performed. Patients should be free from any
medical procedures unless there are good therapeutic
reasons for them (34). We are aware that both love
between the couple or among family members andhappiness of the child could be temporary and fragile
and they might be too unstable to be a legitimate
reason for serious life and death decisions.
Nevertheless, we argue that only love and prospect ofhappiness can justify such interventions.
The authors would argue that it is not be justifiable
to maintain the brain-dead pregnant woman’s somaticfunction for the child delivery in the following situations:A state compels the family to continue the pregnancy
of brain-dead woman to increase the state population;
the radical pro-life individuals physically threaten either
the family or the hospital to force it based on their own
beliefs against abortion;. a pro-choice group puts
pressures on the family or the hospital to discontinue
the woman’s life-support in the name of protecting her
right and dignity; the family or physician maintains thewoman’s somatic support to develop and deliver the
fetus who has serious congenital disorders and is likely
to lead only a short and painful life after birth; and thephysician would conduct experimental somatic
supports for the purpose of making the new record of
the longest physical maintenance of brain-deadwoman and/or the minimum weight delivery.
Furthermore, in the majority of cases, the braindead pregnant women had actually delivered theirbabies (16). However, there are also some cases inwhich the fetus reportedly died along with the mother(5, 12). It is possible that cases involving somaticallysupported brain-dead women who had failed to deliver
their babies alive were not reported. In the same vein,cases involving the families of brain-dead women who
had refused to have their babies delivered might nothave been reported either. In Japan, the following
reports have been published between 2012 and 2013:a case in which the family of a brain-dead pregnant
woman did not want her baby delivered, even though
the fetus was at 34 weeks’ gestation (1); a case inwhich the family did not want the baby to be delivered
initially, after the declaration of brain-death of themother, but finally gave the medical team their consent
to have the mother undergo cesarean section after
consultations with the medical team. (2); and a case inwhich the family wished to continue the mother’s life
support, but without delivering the baby (35).
Only one report published by Kinoshita et al.
describes the details of decision-making processes
concerning the delivery of brain-dead pregnant
women’s babies in Japan. Thus, detailed interactions
and communications among those concerned in theirdecision-making processes, and how the decision toEubios Journal of Asian and International Bioethics 21 (July 2016)
maintain the brain-dead pregnant woman’s somaticfunction for the sake of child delivery has beenreached, remain uncovered.
However, it would certainly be unacceptable for a
responsible physician to coerce or demand the family
to maintain the brain-dead pregnant woman’s somaticfunction. Such action would clearly disregard thewoman’s dignity, her family’s emotion, and theirfinancial concerns. In the Kinoshita’s case, the medical
team in charge of the care of the brain-dead pregnant
woman convened an ethics conference involving
various healthcare professionals to discuss relevant
moral issues. The team had consultations with thewoman’s family members and provided them withnecessary information, but without giving a specificrecommendation. Finally, her family gave the medical
team their consent to have the mother undergo acesarean section.
The above-mentioned cases are unacceptablebecause these cases lack in respect for the woman’s
decision, protection of her dignity, the love in personal
relations, the responsibility for the happiness of thechild, the consideration to her physical privacy or thegenerosity for others. Of course, timely interventions
by ethical committee would be beneficial in order toavoid these clear abuses. However, decisions
concerning somatic support of brain-dead pregnant
woman and subsequent delivery of the fetus are an
extremely private and delicate matter. The tasks of the
ethical committee should, therefore, focus on providing
sufficient objective information to the patient’s family
as a third party and preventing the abuses fromhappening. For anyone it is extremely difficult to makeany decision in a cool-headed way under one’s family
member’s life and death situation. Therefore it isnecessary for both medical professionals and theethical committee to provide enough support to thefamily so that they can realistically imagine their futurewith the child and avoid being confronted by thesituation that the family regrets their choices
afterwards. The patient family should be the final
decision-maker to choose a course of action because
they are the very persons who would have to live withthe consequences of their own choices. Theirdetermination should be given a top priority unlessthere are any irrefutable reasons to repel it.
6. Unanswered questions
Finally, we would consider the following two
scenarios and issues concerning just resource
allocation. The first scenario is that the brain-deadpregnant woman’s husband and/or parents are eager
to request maintaining the patient’s somatic support
due to the desire for keeping their blood-stream or
having their heir, even if the patient’s intention is
unclear. The family may claim that the expectant
mother would rejoice her genes being left. It is in asense a common sense in society, and it is also
understandable for some extent that they argue thatthe continuation of a family-tree has great meaning forthem. However the authors would conclude that thefamily’s intention expressed in the above-mentioned

135

scenario is unacceptable. This is because the family’s
motive lacks affections to the patient or the baby andconsiderations to the patient’s dignity do not exist. It is
doubtful that the family intends to use the patient as amere means for their own contentment.
The second scenario is that the husband wishes tohave their baby as a keepsake of his wife yet thepatient’s intention remains unsure. His desire of having
their baby as his wife’s memento may be consideredas the pure expression of his love to his wife. This isbecause his love to his wife is the foundation of his
wish to want his wife to give a birth and he wants ababy on the ground that the baby is her baby. In thiscase, it might be acceptable to maintain the patient’s
somatic support until the delivery if there was thehusband and the parents’ affections to the patient; if
the baby had a sufficient chance of happy life; and if
the family has firm commitments to child rearing.
However, as mentioned in the conclusion, love andhappiness may be too unstable to be a legitimate
reason for serious life and death decisions. Moreover
the opinion has validity that the decision to maintainthe pregnant woman’s somatic support to have a baby
cannot be justified when the wife’s intention is unclear.
Thus, in this case, the authors cannot determine theappropriate course of action for the present.
Finally, it is necessary to discuss whether
maintaining the brain-dead pregnant woman’s somaticfunction for the purpose of child delivery is justifiable ornot, from the perspective of healthcare resource
allocation alone. Worldwide, when a patient is declared
brain-dead, one is legally declared dead, andtherefore, public or private health insurances do
not usually cover services after death is declared(17). Moreover, some people doubt that allocating
scarce medical resources to maintain the “dead body”
is justifiable (36). On the other hand, current situationsin Japan are quite different, for example, the cost of
medical care for brain-dead patients is completely
covered by the national healthcare insurance.
Furthermore, as previously mentioned, Japanesepublic opinions predominantly support continuation oflife support immediately after brain-death diagnosis,
because brain death has yet to be sociallyacknowledged as human death (26). A nationwide
survey of physicians specialized in emergency
medicine and intensive care revealed that only 2% of
these physicians would discontinue life support forbrain-dead patients; in fact, many were afraid thatwithdrawal of life support from brain-dead patientsmight constitute homicide, and that they would be sued
as a murderer (37). Thus, there have been no social
discussions on the appropriateness of use or complete
public coverage of medical resources for thesepatients, regardless of whether the patient is pregnant
or not.
Nonetheless, issues concerning the allocation oflimited healthcare resources and national healthcare
costs are becoming more and more serious in Japan,
which has entered the era of “super-aged” society
earlier than any other countries. In addition,
advancements of medical technology would make it136

Eubios Journal of Asian and International Bioethics 21 (July 2016)

possible to sustain the somatic function of brain-deadpregnant women for a prolonged period, and toincrease the chance of their babies being delivered.
Healthcare costs required for somatic support of suchpatients would simultaneously increase, and thissituation would attract public attention, possibly
initiating a social debate on this matter in near future.
However, we would argue that, for the time being, thecriticism towards maintaining the brain-dead pregnant
woman’s somatic function to deliver her child will likely
remain suppressed, because, as mentioned above,
sustaining the somatic function of brain-dead patient
who is not pregnant has not even led to a heatedsocial debate from the viewpoint of medical cost andjustice. Furthermore, it can be argued that an attempt
to save and deliver the baby would be regarded as aworthy goal to pursue, or a good enough reason tojustify the use of public funds and precious medical
resources for the brain-dead patient. Even if the family
wishes to maintain the brain-dead pregnant woman’slife support without wishing the fetus delivery, it would
not be different from other ordinary life support forbrain-dead patients and would not bring about a major
dubious issue. Therefore, in Japan at least for the time
being, we would argue that it is unacceptable forhealthcare professionals to unilaterally limit or
discontinue somatic support of a brain-dead pregnant
woman by declaring that such use of medical
resources is not justifiable from the viewpoint of fairresource allocation.
For future consideration, we believe that an urgent
discussion should be carried out from the macro level
regarding whether or not it is appropriate to use
healthcare resources to maintain a brain-deadpregnant woman’s somatic function for child delivery.
There is a need to clarify if “together all, let’s save thefetus” is a social consensus or not. Of course, in thisdebate, serious deliberation should also be given to
consider the appropriateness to use healthcare
resources for the woman and her fetus itself, no matter
who pays the bill. Finally, discussions concerning thepriority of use of limited health resources between
brain-dead pregnant woman and other patientsrequiring intensive care would also be necessary. We
need to make explicit policies regarding this matter ineach institution urgently.
References
1 Noushi-no- ninpu syussann-2rei…Kumamoto University
Hospital-de-2nennkannni(inJapanese)(Brain-DeadPregnant Woman, 2 Delivered Cases…at Kumamoto
University Hospital in 2 years). The Yomiuri 19 April
2014.
2 Y. Kinosita, H. Kamohara, K. Kuramoto, et al. A Healthy
Baby Delivered From a Woman with Irreversible Brain
Damage due to Multiple Trauma, Journal of Japanese
Association for the Surgery of Trauma;2014, 28(4):323326.
3 Brain-Dead Canadian Woman Taken off Life Support after
Giving Birth to Baby Boy. CBS/REUTERS 11 Feb 2014,
6:34 PM, http://www.misterbenson.com [Accessed 11
Feb 2016]
4 Anonymous. Hungarian Woman Gave a Birth to a BabyBoy, 3 Months after Declaration of Brain-Death. Hungary

Debrecen 14 Nov 2013.
5 Brain-Dead Pregnant Woman to Be Laid to Rest after
Being Disconnected from Life Support by U.S. Court.
News Sunday 26 Jan 2014 10:42 AMBy HasaniGittens,
NBC News.
6 Brain-Dead Canadian Woman Dies after Son’s Birth by
Paula Newton Published. 17 February 2014, 6:52 pm.CNN's.
7 M. Esmaeilzadeh, C Dictus, E Kayvanpour, et al. A
Unterberg, AMehrabi & R Ahmadi. One Life Ends,
Another Begins: Management of a Brain-Dead Pregnant
Mother-A Systematic Review-BMC Medicine. Availableat:
http://bmcmedicine.biomedcentral.com/articles/10.1186/1
741-7015-8-74 [Accessed 11Feb 2016].
8 British Mother Gives Birth Two Days after Brain Death.
th
10:41 January 14 2009 JST (London Reuter 13 ).
9 T. Fukuda, A Case of Delivering a Baby by Cesarean
Section when the Mother is Brain-Death Post Cerebral
Hemorrhage. Japan: A journal of Tokyo Jikeikai Uniersity
hospital 2004; 119(2):201.
10 S. Someya, Two Cases of Putaminal Hemorrhage during
Pregnancy. Japan: Journal of Japanese Association for
Acute Medical 2002;13:619.
11 K. Takeuchi, Thinking about Brain-Dead Delivery. Japan:
Japanese Journal of Fertility and Sterility 2001;46(4):269.
12 C. Anstötz, Should a Brain-Dead Pregnant Woman Carryher Child to Full Term? The Case of the “Erlanger Baby”
Bioethics1993;7(4):340-50.
13 H. E. Fadel. Postmortem and Perimortem Cesarean
Section: Historical, Religious, and Ethical Considerations.
JIMA 2001;43:194-200.
14 J.P. Souza, A Oliveira-Neto, F GSurita, J G Cecatti*2, E
Amaral and J L Pinto e Silva. The Prolongation ofSomatic Support in a Pregnant Woman with Brain-Death:a Case Report BMC Reproductive Health 2006; 3:3.
15 S. Abuhasna, A Jundi, M Rahman, et al. A Brain-DeadPregnant Woman with Prolonged Somatic Support andSuccessful Neonatal Outcome: A Grand Rounds Casewith a Detailed Review of Literature and Ethical
Considerations. Int J Crit IllN Inj Sci 2013; 3: 220-224.
16 J. Wawrzyniak. Continuation of Pregnancy in a Woman with
Critical Brain Injury. Anaesthesiology Intensive Therapy 2015;
47(1): 40–44.
17 FIGO Committee for the Ethical Aspects of Human
Reproduction and Women's Health. FIGO Committee
Report Brain Death and Pregnancy. International
Journal of Gynecology and Obstetrics 2011; 115: 845.
18 P. Newton. Brain-dead Canadian Woman Dies After
Son’s
Birth.
CNN,
February122014.
http://edition.cnn.com/2014/02/11/health/canada-braindead-pregnant-woman [Accessed 11 Feb 2014].
19 Asked about…A Brain-Dead Pregnant Woman Suit isArgued at the United States -Choice of Death with
Dignity, the Life of the Fetus and the Life Modal
Interpretation. Sankei Express, 27 Jan 2014.
20 United States; Argument for Protection of Fetus when
Abundant of Life Support for Brain Dead Pregnant
Woman. The Mainichi 29 Jan 2014.
21 Huge Arguments at the Court in the United States; BrainDead Pregnant Woman- Death with Dignity or Life of
Fetus. Mainichi News Paper 27 Jan 2014.
22 Brain-Dead Pregnant Woman to be Laid to Rest after
Being Disconnected from Life Support. News Sunday 26
Jan 2014.
23 O.G. Lawrence. Legal and Ethical Responsibilities
Following Brain Death. The McMath and Munoz Cases.
JAMA. 24 Jan 2014, online.

Eubios Journal of Asian and International Bioethics 21 (July 2016)
24 L.E. Jeffrey. Death in Pregnancy – An American Tragedy.
NEJM. 17 Feb 2014, online.
25 D.C. Magnus, B.S. Wilfond & A.L. Caplan. Accepting
Brain Death. The New England Journal of Medicine. 17
Feb 2014. Online.
26 A. Asai, Y. Kadooka & K. Aizawa. Arguments Against
Promoting Organ Transplants from Brain-Dead Donors,
and Views on Life and Death of Contemporary Japanese.
Bioethics 2012;26:215-223.
27 M. Izawa.2008. Issues in Brain Death Debate. In Shinto
and Bioethics. Shintobunka Kenkyukai, ed. Tokyo:
Kobunsha,:177–203 (in Japanese).
28 K. Tanemura. Brain Death and Japanese Ideas of Body.
Kagoshima University Kyoikugakubu-kiyo 2009; 60: 43–
63 (in Japanese).
29 A. Asai, M. Fukuyama & Y. Kobayashi. Contemporary
Japanese View of Life and Death as Depicted in the Film
Departures (Okuribito), Journal of Medical Ethics; Medical
Humanities 2010:36;31-35.
30 K. Ueda. 2008. Shinto and Bioethics. Tokyo: Kobun-do(in Japanese).
31 T. Shinmura, 1996. History of Childbirth and View ofReproduction. Tokyo: University of Hosei Print.
32 T. Chiba & T. Ootsu. 1983. Mabiki to Mizuko (Cull andAborted Fetus). Tokyo: Rural Culture Association Japan(in Japanese).
33 TAZ 1992, 17 Nov
34 British Medical Association Ethics Department Medical
Ethics Today The BMA’s Handbook of Ethics and Law
Second Edition, BMJ Books, 2004:100.
35 M. Imaya, T. Narayama, Y. Mori, et al. A Brain-DeadPregnant woman Post Cardiac Arrest due to Hanging,
was Maintained Her Brain-Dead Status in order to Give aBirth to a Baby who had no Obvious Neurological
Damages even after Premature Birth. Journal of Japan
Society for Premature and Newborn Medicine 2014;26(3):620(in Japanese).
36 P. Horn. Clinical ethics casebook. Second Edition,
Wadsworth, Belmont, 2003-121.
37 2% --Doctors concern the criminal liability on “Removal of
Respiratory in Brain-death” The Nikkei 25 Oct 2009.

Compassion in medical
ethics of traditional
Mongolian medicine-Dashjamts Shagdarsuren-Battogtokh Gerelmaa
Health Sciences University of Mongolia, Mongolia
Email: shagdarsuren_11@yahoo.com

Abstract
In traditional medicine of Tibet and Mongolia
where Mahayana buddhism prevails, a physician isseen as an enlightened person who had been trained
throughfully in Buddhist phylosophy. In order tobecome a physician one should develop compassion
which is considered as a path to enlightenment.
Compassion is not a characteristic, but it is a skill used
for therapetic purpose which should be masteredthrough training and meditation stage by stage.

This research puts forward hypothesis thatquantum physics can explain the therapeutic137

effect of physician’s compassion toward thepatient. Meditating on compassion can resultin stimulated photon emmission. Theseemmitted
photons
throughquantum
entanglement
serve
as
an
invisible
connection between physician and patient,improving the treatment results significantly.
Introduction
Medical ethics in present day Mongolia is shapedby Western medicine developed since the socialist era
under influence of Soviet Union, and traditional
Mongolian medicine which has roots in Buddhist
philosophy. Compassion is considered as a main
determinant in both Eastern and Western medical
ethics. In Western medical ethics compassion is seen
as a conduct of the physician and emphasized
significantly in rules, regulations, codices, and oaths.
In this context, compassion in developed westerncountries defines the responsibilities and duties of
medical professionals [Ngandajina Silva, 2007]. In
contrast, medical ethics of Mongolian traditional
medicine based on Mahayana Tibetan Buddhism
consider compassion as prerequisite to become aphysician. Compassion is a womb of enlightenmentand should be developed by physician to comprehend
fully the nature and causality of the illness.
Importance of compassion in treatment
In the famous traditional medicine scripture ofMongolia “Four principles of medicine” physician’scompassion is equaled to “bodhicitta” (Figure 1).

Figure 1. The first page of 31st chapter of “Fourprinciples of medicine“ (from author’s personal archive)
The famous Mongolian physician and scholar of
Traditional medicine Lunregdandar, who wrote aninterpretation to the “bible” of Mongolian traditional
medicine, “Four principles of medicine” emphasizedthat enlightenment and compassion are in the essenseof the treatment. In his book “Introduction to Tajod andfundamentals of secret theory of eight collars of holyelixir”, Lunregdandar wrote “Bodhisatvas should learn
how to cure same as one who learning to become aphysician should learn the bodhisatva way.” According
to teachings of Traditional medicine, anger, ignorance
and lust are the main causes of all illnesses and are
named as “three poisons”. To treat illnesses thephysician should get rid off himself of these “threepoisons” through practicing and meditation of Medicine
buddha Manla and then pepare the medication
mastering the professional knowledge and talent[Lunregdandar, 2005]. Here the logic is same to the

138

Eubios Journal of Asian and International Bioethics 21 (July 2016)

example of smoking physician who may not be able tohelp the smoking patient to quit the bad habit.
Through history physicians were Buddhist monks
that had been trained in medicine. By mastering
Buddhist philosophy at first physician learns to see hispatient’s illness not only as a physical sickness but inwhole picture of cause and effect. His goal is not
limited to treatment the particular ill organ of thehuman body but in liquidating the seed of cause ofillness. In a Buddhist view all living beings should betreated and loved as someone’s own mother[Shantidewa, 1997]. This comes from belief inincarnation of the soul and life after death. Each soul isborn and dies limitless times and through thesecountless lives every being had been mother or child ofother’s. Therefore, a physician should be able to loveevery living being as his own mother and this achived
through developing compassion. In this way thesincere desire to cure “his own mother” boosts thetreatment effect.
The 9th Jebtsundamba Khutugtu (1932-2012), thespiritual leader of Mongolia taught, “Physician is aperson who serves others with compassion... Heshould be someone with compassion and should betrained professionally upon it. In such way thephysician treats people not only with professional
knowledge and skills but also with compassionate
soul... Inside, he should follow buddha footsteps, while
outside he should master his medical profession.
Compassion as weel as medication helps the living
1
beings to get through illness suffering” .
In “Four principles of medicine”, the causes of allillnesses are summarized into 404 types from which
101 can be cured by medicine, 101 can be cured byrituals and tantras, 101 can be cured by itself without
any intervention, 101 are incurable due to karma andcausality effect. Such classification indicates that
illnesses traditionally were treated not only by
medicine but also by physician’s desire and wish for
wellbeing of his patient coming from hiscompassionate soul.
Dr. Adrian Feldmann, an Australian doctor wholater become a Buddhist monk, describes his
encounter with a Tibetan doctor which medical practice
he finds completely different from his Western
experience “I was deeply impressed by the emphasison compassion as being the main therapeutic power ofa doctor; this had not been mentioned at my medical
school. A doctor only became fully qualified when heor she was well advanced on the bodhisattva’s path of
wisdom and compassion based upon perfectconcentration and renunciation – subjects also missing
from the syllabus at medical school. A Tibetan doctor’s
day begins while asleep: dreams are observed andcertain signs of success or failure of treatments arerecognised. Then, before breakfast, meditation on the
Medicine Buddha practice is performed, and medicines
are blessed through the power of compassion andmantra.” [Feldmann, 2005]
Stages of developing compassion
The famous script of Mongolian

traditional

medicine “Four principles of medicine” equals
compassion to bodhicitta or enlightened mind. It canbe achieved throughfollowing four stages[Lunregdandar, 2005]
1. Equal mind
2. Joyfull mind
3. Caring mind
4. Compassionate mind
At first a physician should understand that all
sentient beings are the same and treat them equally as
his own mother. He should not make distinction
between his own and others’. This stage comes uponunderstanding the karma and causality. As soulincarnates numerous times every being is born as one
other’s mother and has been other’s child. So one
should see all beings as his own mother. However,seeing every being as equal is not enough forcompassion because equality can be easily turned toneglect and ignorance. Therefore after treating every
being equally a physician should have emotional
sharing with his patients. She should feel the joy when
the patient is joyful and feel the pain when the patient
is in pain. Like a radio-receiver the physician must
adapt his soul mode to emotional wave frequency
coming from his patient or other’s being. However,feeling the emotions of the others does not always
translate into action. A person can be overwhelmed byhis emotions but still can be passive and refrain fromproviding needed care. Thus the emotional sharing
should be translated into genuine care. Treating
equally, feeling the patient’s pain, caring for him in thisand next lifetime translates into compassion.
Compassion in the sense of bodhicitta should betrained, mastered and reached by attentive meditation.
Buddha Manla is meditated on for this purpose. The
medicine Buddha turned blue as it treats the sufferringof the patient through compassionate mind.
The common depiction of Compassion Buddha
Avalokitesvara (the Dalai Lama is regarded as amanifestation of Compassion Buddha) is thousand
armed and mutliple headed buddha. Meditation on thisBuddha helps to unleash the soul stuck inside one’s
physical body, a fragile temporary shell but hardenough for soul to be shaped by and strained within it
in this lifetime [Thurman, 2007].
Compassion and quantum physics
Albert Einstein insisted that fundamental quantum
theory is incomplete since its fails to describe thequantum entanglement of photons, which they referred
as “spooky action at a distance” (Einstein, Podolsky, &Rosen, Can Quantum-Mechanical Description of
Physical Reality be Considered Complete?, 1935).
Quantum entanglement of photons is observed whenphotons obtained from a particle can instantly affecteach other even separated by long distances andsince referred as EPR paradox. When movement of
one photon found to be clockwise spin on a certain
axis, the polarization spin of the other’s is measured tobe complete an opposite. Einstein disagreed N.Bohr
who maintained that these photons immediatelytransfer the information and share single quantum

Eubios Journal of Asian and International Bioethics 21 (July 2016)
state even if they separated physically (Bohr, 1935).
According to Einstein such instant communication is
impossible because it will exceed the speed of light.
Measurement
Quantum entangled photons

Crystal139

Conclusions
The traditional medicine of Mongolia is based on
Mahayana buddhism transmitted from Tibet. In a
Buddhist view compassion equals to enlightened mind
and is regarded as the main therapeutic power of aphysician which should be achieved throughmeticulous training and meditation stage by stage.
Accordingly, illnesses are classified by their causes
into several groups, with some of them being treatedby compassion as well as by medicine. Our hypothesisis that the therapeutic effect of compassion can be
explained by recent breakthrough in quantum physics.
Photon emission of human bodies might be stimulated
by compassion meditation. The space-time shortcut
tunnel established by physician’s compassion toward
his patient might have significantly boosting the effectof the therapy.

Figure 1. Quantum entanglement of photons
References
Since then numerous tests (Bell, 1964) (Hensen, et al.,2015) indeed proved exsistence of “spooky action at a
distance” rejecting possibility of predeterminedentanglement. The recent explanation for EPR
paradox came from L. Susskind and J. Maldacena who
proposed that entangled particles are connected bywormhole or Einstein-Rosen bridge (Maldacena &Susskind, 2013). Einstein-Rosen bridge is a tunnel
with two ends in two different places of universe which
was used to explain the black holes (Einstein & Rosen,
The Particle Problem in the General Theory ofRelativity, 1935). According to L. Susskind and J.
Maldacena instant communication of entangled
particles can be made possible by shortcut tunnel
created by spacetime curvature (Figure 2)

Figure 2. Einstein-Rosen bridge created by spacetime
curvature
It is known that human bodies emits biophotons.
Research has been done on detection andmeasurement of these biophotons (Cohen & Popp,
2003). Physician’s meditation on compassion can
result in stimulated emission of biophotons. Stimulated
emission of photons which is contrast to spontaneousemission was theoretically discovered by A.Einstein(Einstein, Strahlungs-emission und -absorption nach
der Quantentheorie, 1916 ). These emitted biophotons
through quantum entanglement can enhance thetherapy by creating spacetime curvature or shortcut
between the doctor and his patient. In this way
compassion entangles the doctor and his patient andcan have significant therapeutic power.

Bell, J. (1964). On the Einstein-Podolsky-Rosen Paradox.
Physics (1) , 195-200.
Bohr, N. (1935). Can Quantum-Mechanical Description of
Physical Reality be Consdered Complete? PhysicalReview (48) , 696-702.
Cohen, S., & Popp, F. (2003). Biophoton Emission of Human
Body. Indian Journal of Experimental Biology , 440-445.
Einstein, A. (1916 ). Strahlungs-emission und -absorption
nach der Quantentheorie. Verhandlungen der Deutschen
Physikalischen Gesellschaft (18) , 318-323.
Einstein, A., & Rosen, N. (1935). The Particle Problem in the
General Theory of Relativity. Physical Review (48) , 73-77.
Einstein, A., Podolsky, B., & Rosen, N. (1935). Can
Quantum-Mechanical Description of Physical Reality be
Considered Complete? Physical Review (47) , 777-780.
Ethical Principles of psychologists and code of conduct.
(n.d.).
Retrieved
2011
йил
March
from
http://www.apa.org/ethics/code/index.aspx
Feldmann, A. (2005). A Leaf in the Wind. Melbourne: LothianBooks.
Frey, R. (1998). The Fear of a Slippery Slope. In G. Dworkin,
R. Frey, & S. Bok, Euthanasia and Physician-Assisted
Suicide (pp. 43-63). United States of America: Cambridge
University Press.
Gensler, H. (2009). Singer's Unsanctity of Human Life: A
Critique. In J. Schaler, Peter Singer Under Fire (pp. 163184). United States of America: Carus Publishing
Company.
Hensen, B., Bernien, H., Dreau, E., Reiserer, A., Kalb, N.,
Blok, M., et al. (2015). Loophole-free Bell inequality
violation using electron spins separated by 1.3 kilometres.
Nature (526) , 682-686.
Jambalnamdolchoijijantsan, I. J. (2009). Teachings.
Ulaanbaatar: Gandantegchinlen Temple.
Kitchener, B., & Jorm, F. (1999). Conditions Required for a
Law on Active Voluntary Euthanasia:A Survey of Nurses'
Opinions in the Australian Capital Territory. Journal of
Medical Ethics , 25-30.
Lunregdandar. (2005). Analysis of Script Four Principles ofMedicine. translated by Oyunbaatar P. and Boldsaikhan B.
. Ulaanbaatar.
Maldacena, J., & Susskind, L. (2013). Cool horizons forentangled black holes. Fortsch. Phys. (61) , 781-811.
Ngandajina , J., & Silva, B. (2007). Nanotechnologies andEthics. Paris: United Nations Educational, Scientific andCultural Organization.

140

Eubios Journal of Asian and International Bioethics 21 (July 2016)

Orlando, S. (2010 йил 4-January). An Argument for the
Legalisation of Active Euthanasia. Annual Celebration ofStudent Scholarship and Creativity , pp. 1-27.
Rachel, J. (1975). Active and Passive Euthanasia.
Satyanarayana, Y. (2010). Ethics:Theory and Practice. New
Delhi: Dorting Kindersley.
Shantidewa. (1997). Way of the Bodhisattva. Padmakara
Translation group, trans. . Boston: Sera je library.
Shukla, R. (2011 йил 30-April). Is the 'Next Friend' the Best
Friend. Economic and Political Weekly .
(1994). In P. Singer, A Companion to Ethics. Oxford:
Blackwell.
Singer, P. (2003 йил 2003-Dec). Social Science Research
Network .
Singer, P. (1993). Practical Ethics. United Kingdom:
Cambridge University Press.
Supreme Court's Judgment on Aruna Shanbaug Euthanasia,
115 (The Supreme Court Of India 2009 йил 7-March).
Thurman, R. (2007). We can be buddhas. Retrieved 6 25,
2016,
from
https://www.ted.com/talks/bob_thurman_says_we_can_be_buddhas/transcript?language=en
Young Minds Debate Euthanasia. (2011 йил 30-September).
The Times of India .

Conclusions
The traditional medicine of Mongolia is based on
Mahayana buddhism transmitted from Tibet. In a
Buddhist view compassion equals to enlightened mind
and is regarded as the main therapeutic power of aphysician and should be achieved through meticulous
training and meditation stage by stage. Accordingly,
illnesses are classified by their causes into several
groups, with some of them being treated bycompassion as well as by medicine.

Framing Assumptions in
Teaching Ethics Using Case
Studies- Ann Boyd, Ph.D.
Professor of Biology, Hood College, 401 Rosemont Ave,
Frederick, MD, 21701, U.S.A.
Email: boyda@hood.edu

Introduction
Teaching ethics is both challenging andintellectually fulfilling when the students and instructor
are engaged in open mutually respectful dialogue.
Over the past twenty years the shape of the bioethics
course has changed both in content and pedagogy.
The constant has been the centrality of case studies
and moral deliberation. Seeking to help students
identify ethical issues within a case and understandseveral philosophical claims of what is good, four
moral theories were introduced for case analysis:
utilitarian, respect for persons, egoism and natural law.
Students worked each case within the framework of amoral theory and rotated through all four theories infour separate case studies. Groups representing
students within the same moral theory discussed themoral rule and moral judgment of the case. The

instructor facilitated feedback from each groupcomparing and contrasting wherein there wasagreement and disagreement within and between
moral theories. Over time, it became clear that somestudents were forming an intuitive response to thecase study and cleverly framing the analysis using theguidelines of the moral theory, to support his/her
judgment, rather than allowing the normative claims ofthe theory to guide ethical analysis. Intuition supported
by moral theory was not one of the objective of thecourse. In evaluating the course at the end of thesemester individual students claimed to prefer one
theory for a particular type of case and another for adifferent ethical issue because utilitarian or egoism
would allow them to make a good justification forsomething they approved personally and natural law
and respect for persons would prohibit an issue they
opposed. This outcome was disappointing and led torevisions. By adding virtue ethics and removing bothegoism and natural law, and increasing the number ofcase studies used, students dig deeper into literaturein support of their ethical analysis. Choosing andpresenting the case for ethical deliberation is not acompletely objective process. Cases are chosenbecause they invite examination of values in a specificcontext. Each case has within it particular facts anddetails, abstract issues and concepts. When and why aparticular case is chosen helps frame ethical questions
for deliberative dialogue.
Framing assumptions of cases
Teaching ethics with the aid of cases helps focus
discussion, highlight particular issues and concepts
and test various normative values. Most cases have afactual foundation: the situation happened and was
repeated by someone involved. Why that case wasmemorable or shared in order to make its way into acourse suggests it offers an opportunity to evaluate
ethical values through critical thinking. In selecting acase, several questions are considered. Whatcommunity is represented? What values does the casesuggest? Is the story intuitively or emotionally stirring?
Is the case presented as normal, abnormal, ordinary,or unusual?
Students are aware of making ethical choices.
They have decided to tell the truth or not. They knowthat taking what does not belong to them is wrong.
They have over time developed a code of conduct thatreflects their culture and tradition. Why they tell thetruth, or refrain from taking what is another person’s
property may be less well developed. Why one action
is good and an alternative bad may rest on a belief thatto obey rules helps avoid trouble or punishment.
Explaining why telling the truth is good is more difficult
because most students can think of times when notdisclosing all information was protective. Students
may lack philosophical language to articulate why
specific values are good.
A historical summary is given for each theory usedwith an outline for ethical analysis modified from C.E.
Harris, Applying Moral Theories (Harris, 2007).
Students diligently applied the testing rules andEubios Journal of Asian and International Bioethics 21 (July 2016)
evaluative process, but struggled with creating a moral
rule that was specific enough to direct action andgeneral enough to apply to a variety of similar
situations. Interestingly, after each student had
prepared his/her analysis, they discovered divergent
views from other class members within the same moral
theory, a good outcome because it encourages
deliberative dialogue. Asking for a consensus in group
discussion stimulates a search for common groundand illustrates that the theory is a guiding normative
framework but not a prescription for a “right answer.”Students often disagreed about which issues andconcepts were most important, why one action or rule
was good and why leading to compromise andsynthesis. They discovered that the views of others
often strengthened their own position, and occasionallyinspired a change of mind. Diversity of values
discussed within the platform was beneficial.
After introducing moral theories and someexamples of cases analyzed by each theory, theremainder of the course in bioethics moves through aseries of conceptual issues: health professional-patient
relationships, health policy, life-sustaining treatment
and end of life choice, life and death, reproduction,
genetic medicine, each of which is covered with avariety of ethics articles on the concepts and issues(Steinbock, et al., 2013) supplemented with otherjournal articles.
Choosing a case generally reflects the unit focus,
for example in the Doctor-Patient relationship unit,
autonomy of doctor and patient is stressed along withthe presumed intent of health care professionals to
help a patient achieve better health. The Steinbock text
offers cases within each unit. Some are discussed inclass as a prelude to their first written case assignment
such as, “Beneficence Today, or Autonomy (maybe)
Tomorrow, Antihypertensives and the risk of temporary
impotence: A case study in Informed Consent”(Steinbook, 2013, p 68). Whereas the principles ofautonomy, beneficence, non-maleficence, and justice
are conceptually important they are used to support
the ethical analysis within the moral theory rather thanas an independent framework. Agreeing with Callahan,principles should be considered but not used as “moral
trump cards” (Callahan, 2012).
Conceptual
developmentofautonomy,paternalism, Hippocratic tradition, is developed withmaterial from the text and other journal articles. The
first case to be written, discussed in discussion groups,
and evaluated by various theories is an opportunity totest each student’s ability to apply moral theory, extract
issues and concepts from the case that require
analysis, and deliberate within small groups. Prompt
grading with liberal annotation is necessary forstudents to get feedback on their effort and to informthe instructor of what is understood and where
additional explanation may be needed. The
philosophical understanding of autonomy within the
doctor-patient relationship is critical because it is much
more than an individual wish.
Patients may be
influenced by family relationships that are contrary to141their individual wishes. Patients may hold religious
views about what can and cannot be done.
The first case assigned for analysis and groupdeliberation to be graded brings out all of thesevariables that affect how a person exercises
autonomy: “Devotion or Disease?” (Hastings Center
Report, March-April 2011). In summary, the caseinvolves MV a fifty-year-old woman who called 911 forhelp. Her husband would not admit emergency
responders but police gained entrance. She wasminimally communicative. A packed suitcase was onher bed. When asked if she was trying to leave herhusband she would not answer. She was transported
to the emergency room because she was emaciatedand intermittently mute. MV’s medical records reveal
MV has schizophrenia. She is admitted but the only
treatment she and her husband will accept arevitamins because they believe in Scientology. MV isadmitted to the psychiatry unit as an involuntary
patient. While a patient, her health improved but shedenies any psychiatric problem and will not takeantipsychotics. Should the health care team accept
her treatment refusal?
Some of the framing assumptions of this case are
the concepts of competency and vulnerability inpatient’s exercise of autonomy, the doctor-patient
relationship, and the role of the physician to act in thebest interest of the patient. Students discuss thecompetency and vulnerability of MV, and the duty ofthe physicians to do what they can to improve herhealth. Should she be declared incompetent in order totreat? Should they allow her to return to the family
physician who was willing to accept her beliefs? Is MV
competent to decide? If the doctors treat her based onher incompetence and she is mentally stable, is she atthat point competent to reject further treatment?
Should they ignore her Scientology beliefs? If her
husband is abusive should he be a surrogate decision
maker? What is in the best interest of MV? One of thecomplications of this case is whether or not it ispossible to separate MV’s capacity to make decisions
because of her psychiatric disease is causing her todeny her schizophrenia or if the Scientology beliefs areprompting her to deny treatment. The challenge toseparate these is vital to analysis of the case. If shecannot understand her illness due to delusional phaseof her schizophrenia, paternalistic treatment may bejustified. If she will not accept the diagnosis or accept
treatment because of her religious convictions, treating
her against her will is a violation of her autonomy anda lack of tolerance for her religious convictions. Giving
MV the right of self-determination involves some risks.
The second unit deals with allocation, social justiceand health policy, and uses articles about ethicalframework for access to health care and the cost ofcare in relationship to social justice. Students read avariety of articles about the cost of care especiallyregarding technological interventions. The text includes
a few cases alongside articles selected from theliterature to explore the complexities of social justiceand health. One example is “Bone Marrow Transplantsfor Advanced Breast Cancer: the story of Christine

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

Demeurers”(Steinbock,2013,
pp223-239).
Discussion includes an expanded understanding that
health care in the US has been subject to market
forces for a long time. The Affordable Care Act seeks
to make insurance coverage available to everyone.
While the law has increased coverage there are
significant numbers of residents lacking insurance
either by personal choice or their status as
undocumented resident aliens.
Is it a social orindividual obligation to ensure health care coverage?
How much care is enough? Are the costs and benefits
proportional? Is health care a right? Should all types oftreatment be covered? Are there limits and if so what
are the guiding parameters? What rationing system isfair if rationing is necessary? Who decides?
The case assigned for student analysis is“Undocumented Patients” (Hastings Center Report,2012). Briefly, Mr. A was admitted to the emergency
department at a Catholic hospital complaining of
fatigue. He is a thirty-five-year-old African male from
Tanzania. He complains of headache, no appetite andnausea, and has swelling in feet and hands. After
testing, the physician informs Mr. A that he has endstage renal disease and he needs dialysis or a kidneytransplant to live. The physician recommends dialysis
but the man is living in the US illegally, and has no job
or family in the area. The Emergency Medical
Treatment and Labor Act (EMTALA) requires the
hospital to examine and stabilize the patient. To
stabilize Mr. A, the physician admits him and starts
dialysis. Administratively, the hospital is concernedthat a non-paying patient could compromise quality ofcare for other patients and that his long term dialysis
required to prevent Mr. A’s death would involve
substantial costs. Should Mr. A be discharged once
stable? If you were a member of the hospital ethics
committee what would you recommend?
Complexities in this case include the legal
requirements of EMTALA: is this an emergency
medical condition? If so, it is not only this current
treatment that is at issue but the continuing legal duty
after he is stabilized. Furthermore, this is a Catholic
hospital with religious normative guidelines for healthcare. “In accord with its mission, Catholic health careshould distinguish itself by service to and advocacy for
those people whose social condition puts them at themargins of our society and makes them particularly
vulnerable to discrimination” (p16 HCR, Jan-Feb
2012). The hospital needs a policy to deal with cases
like this so that the mission of the hospital does not put
the facility in financial jeopardy while being responsive
to patients.
Framing assumptions for this case are theinfluence of law and institutional mission on healthcare access. Finance and legal concerns are obvious
but how either should impact access to health care is abroader and deeper question. What ethical values
guide health care availability? Is the current system
just? Does it provide equality of opportunity? Must
there be limits for the system to be sustainable? Whatis the responsibility of each stakeholder? The overall

objective is to get students to read and think deeply
about health care as a justice issue.
Selecting the case should reflect the teaching
objective within the spectrum of ethical thinking,deliberation, and analysis. It is difficult to present thecase in a completely neutral way. Often a case isrecorded because it is emotionally stirring, unusual, orpresents an opportunity to uncover multiple ethicalnorms. Using a case such as “A Case of Dwarfism”
first recorded by Science News in 1994 could be used
to explore reproductive freedom.
The case is included in the “Genetics, Birth andthe Biological Revolution” (Veatch, 2010, pp 233-236).
The obstetrician requests a bioethics consultation toconsider the request from a pregnant woman and herhusband wanting genetic testing for achondroplasia(dwarfism). The woman is three months into thepregnancy. She and her husband are achondroplastic
dwarfs. The condition is caused by a mutation in one
gene, the FGFR3 (fibrobast growth factor 3) genewhich is recessive. If both parents are dwarfs each isheterozygous for the gene (+/-) since the homozygous(-/-) genotype is lethal, and homozygous wild type(+/+) will produce normal stature individual. The
chance the child will be dwarf is 2 in 4, and one in four
for a normal stature child. It would be reasonable totest for the -/- genotype and abort since the fetus is not
likely to survive. But it is their intent to abort if the fetus
is +/+ and not a dwarf.
“If the fetus was notachondroplastic, they would have the pregnancy
aborted because they did not want to rear a childobviously different from themselves” (Veatch et al.,2010, p 236).
It is clear that this case could be inflammatory, orpresented in such a way that the community of Little
People could take offense. The thought that a “normal”
child is not desirable could be surprising to student
hearing the case, thus, inviting a discussion of theperspectives of “normal” intelligence, height, eye color,hair and where the line between trait and disease
might be drawn. Is abortion restricted to disease based
justification or is the full range of reproductive choices
dependent on the will of the parent(s)?
Holly Gooding and coauthors warn that this caserisks stigmatizing one group of people (Gooding, et al.,2002). Interestingly a survey of the “Little People ofAmerica” revealed that they “value the opportunity tocontribute a unique perspective to the diversity ofsociety” (Rinker, 1995). The value of the case is that it
draws attention to deeper questions and fuels
discussions about reproductive autonomy, genetic
determinism, environmental influences, social values,
genetic testing, in so far as the introduction of it ismade clear, that it is an unusual request because only
2% of persons with achondroplasia would consider
terminating a fetus because it would be average instature.
Framing questions help to avoid a biased reading
and analysis of cases. What will future technology
allow in selection of embryos? Will the “best” embryo
be an individual free choice or will a more equality
based policy limit such decisions? When it is possible

Eubios Journal of Asian and International Bioethics 21 (July 2016)
to reliably edit embryos to correct genes will there be
agreement on a liberal ideal of respecting any and all
individual choices or will there be a more egalitarianconservative norm of editing to correct conditions forwhich a consensus exists that such conditions areharmful or deleterious to the future child? Will the ideal
embryo be the same for everyone? While it is not
helpful to try to suppress the intuitive or emotional
response to a case. It does require overcoming thoseinitial reactions in order to engage in reasonable,
critical dialogue for why something is moral and how it
can be explained in a reasonable and logical way. The
goal is why something that is called good can beshown to be so (Giubilini, 2015).
Objectivity: Kathryn Montgomery warns against
the idea that cases can be presented neutrally. “Thereis no pure, objective presentation of a case, and,
although there may be a cultural or national or
professional consensus on the values engaged by acase and the principles that apply to it, consensus
never forecloses further examination, reinterpretation,and retelling. The medical ethicist’s case, far frombeing a piece of reality isolated for the testing ofassumptions and hypotheses, has been constructedfrom the very materials it purports to test”(Montgomery, 2001).
Recognizing the limitations,using cases does help to focus discussion and help
students learn to engage in deliberation and criticalthinking. To science majors who want the one and only
right answer to a problem, it is a surprise that
deductive reasoning is not critical thinking. The
temptation for many students is trying to solve thedilemma posed by the case, rather than evaluating thevarious normative guidelines: what is this case about?
What values and issues are relevant? What concept(s)is/are involved?
Narrow framing of issues undercuts criticalanalysis. What assumptions do we have, individually,
as members of one culture, and collectively as humans
sharing a planet? What do we know that is empiricallyrooted about a subject? Are we biased for one theory
over others? Do we challenge a theory from within?
Are we reflexive as teachers always looking for new
ways to shape questions to produce the most open
deliberative and dialogical exchange of ideas? Narrowframes emerge from uncritical belief in one tradition
over another or putting a higher value on one or a few
norms. How questions emerge and are discussed
should produce reasons all can accept or at least
understand as reasonable. The direction of the field ofbioethics seems to be driven at times by thebeneficence of therapeutic medicine rather than the
deeper generative question of what is good healthcare.
Framing Effect
There is a “framing effect” in the way a case isdescribed that influences how it is evaluated. Criticalbioethics calls for a polite informed skepticism,
informed dialogue, civil disagreement because truth isoften more complex than people claim (Arnason,2015). The course moves deliberately from individual143

choice to communal impacting policies. An end of life
choice highlights autonomy. To the extent that thetechniques are available and affordable, these
individual choices within the “market of medicine”
should be respected. However, when the community
collectively pays for health care, limits may be imposed
for how allocations are made in end of life caresituations.
Public health includes the setting ofpriorities, equal, fair, and just contours of health carefinancing, aims at the conceptual understanding ofjustice. What is fair? How broad must the defining
community be to encompass the fair distribution of
resources? When a new technology emerges
anywhere in the world, how does it become the“standard of care” in particular locations? Pursuingsocial justice in public health should expand thehorizon to global dimensions. Few issues in publichealth are restricted to a particular time and place.
Certainly for infectious diseases the ability of people totravel is the open avenue for distribution of infectious
agent. Larger issues of justice emerge from expensive
treatments available in one geographical location but
absent in another and the idea that people with equal
needs being treated equally. Because of the absenceof a universal system of financing health care globally,
the issues get parsed into individual goals each under
its own banner of appeal as is evident in both theMillennium Development Goals and its successor, theSustainable Development Goals.
Appeal of Socratic Debate
Reading the dialogues of Plato introduces thereader to Socrates, a person who never wrote a book,in part because he was never sure he had reached a
final conclusion. Socrates did not indoctrinate his
students and neither should professors seek to do sotoday. The good dialogue partners of Socrates
engaged in deliberative dialogue circling around andaround the subject of virtue.
Refuting negative
examples of character only confirms what virtue is not,and stops short of defining what virtue is. The Socratic
Method examines questions and answers, without
assuming any answers will be or should be the samefor everyone. The goal is to evaluate how reasonable
and rational a position may be.
Teaching students the art of deliberation requires
having certain virtues: the ability to think the “other”
may be right, that another person’s views can help
move me in a direction that is more wise and prudent.
Without the ability to listen to diverse views thedeliberative approach cannot succeed. Each person
should be able and free to articular his/her position
without fear (Gracia, 2016).
Professional Modeling
If an instructor exposes a preference for values or
methods early in a course, students may seek to alignthemselves seeking to please which defeats the
purpose of the opportunity to exercise and develop
moral analytical thinking. If the instructor is overly
neutral on all issues and methods, students may
conclude prematurely that all moral reasoning is simply

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relative. Disclosure of why a particular case or article isassigned helps to avoid either entrapment. Sadly,some students care more about making a good grade
than taking the opportunity for moral development.
Persuading students to enter into dialogue with anopen mind is best achieved by modeling. When astudent expresses an opinion, asks a question
designed to pontificate a particular value the instructor
has an opportunity to take the statement seriously,
calmly counter with questions or alternative
considerations. Remaining neutral means respectfultreatment of students with divergent views and values.
It is helpful to explain why particular cases or articles
are being used to explore specific ideas, concepts, andvalues. The classroom is then a microcosm of thelarger social context and the exercises in deliberation
within the small group prepares students for criticalthinking, and engagement in the world. The one
critique that remains to be addressed in futurerevisions is a move from an almost exclusive Greek
Philosophical ethics to a more global approach.
References
Harris, C.E. 2007. Applying Moral Theories, Thompson,
Wadsworth, Belmont CA.
Steinbock, Bonnie. Alex John London, John D. Arras, 2013.
Ethical Issues in Modern Medicine: Contemporary
Readings in Bioethics, 8th ed, McGraw Hill, New York,NY.
Callahan, Daniel. 2012. The Hastings center and the earlyyears of bioethics. Theor. Med. Bioeth. 33:11-20.
Devotion or Disease? 2011. Hastings Center Report 42 (2):18-19.
Undocumented patients, 2012. Hastings Center Report 43:
doi 10.1002/hast.8., p16
Veatch, Robert M, Amy M Haddad, Dan C. English, 2010.
“Genetics, Birth and the Biological Revolution” pp 233-236
IN Case Studies in Biomedical Ethics: Decision-making,principles and cases, NY, Oxford University Press, 2010.
Gooding, Holly, Benjamin Wilfond, Karina Boehm, andBarbara Bowles Biesecker, 2002. Unintended Messages:
The Ethics of teaching Genetic Dilemmas, Hasting Center
Report, 32 no 2: 37-39.
Ricker, Ruth E. 1995. “Genetic Testing – Do We Really
Want
THIS?”@
http://www.dwarfism.org/library/genetics.php.
Giubilini, Alberto, 2015. Don’t Mind the Gap: Intuitions,emotions and reasons in the enhancement debate, HCR
45: 1-9.
Montgomery, Kathryn, 2001. Literature, Literary Studies,and Medical Ethics: The Interdisciplinary Question,
Hastings Center Report 31, no3: 36-43.
Arnason,Vilhjalmur, 2015. Toward Critical Bioethics,
Cambridge Quarterly of Healthcare Ethics, 24: 154-164.
Gracia, Diego, 2016. The Mission of Ethics Teaching for the
Future, International Journal of Ethics Education 1:7-13.

Internal Evaluation of
Subject Ethics in Health
Care: My Experience of MS
Nursing Students at a
Pakistani Nursing Institute- Zoheb Rafique
Department of Community Medicine,
Liaquat University of Medical & Health Sciences (LUMHS),
Jamshoro, Pakistan
Email: dr_zohaib@hotmail.com

Abstract
This article shares my experience of internal
evaluation of bioethics at postgraduate level at anursing institute of Pakistan. Bioethics is included in
the MS Nursing student’s curriculum as a subject“Ethics in Health Care”. In this article I will focus oninternal evaluation and also put some light oncurriculum design of MS Nursing students.
Introduction
The MS Nursing program at the public school of
Nursing LUMHS (Liaquat Uuniversity of Medical and
Health sciences) Jamshoro started in 2016 and thesubject Ethics in Health Care is also included in thestcurriculum. This subject is being taught in the 1semester of MS Nursing and the degree comprises of
two years. Like other specialties related to health care,nursing discipline also needs Ethics because Nurses
are experiencing ethical and moral issues as a resultof contemporary global developments and newchanges in health care (1). In the past few years,
nurses were expected to behave obediently without
question and they did not participate in decision
making of ethical issues (2), but now the nursing
students are given training in ethics to recognize andresolve ethical dilemmas in the field of nursing andalso to face the situations where ethical analysis is acompulsion (3). The Ethics in Health Care curriculum isrecognized by the Pakistan Nursing Council denoted
as PNC and also by the Higher Education Commission
Pakistan denoted by HEC.
This master’s degree program of MS Nursing
students is designed like any other modern program
and the students are assigned various tasks during
their semester. The teaching of ethics is included fromst
start to finish in 1 semester and it includes various
units and students are given home assignments, grouppresentations, debates, summaries of various units towrite up and also internal evaluation class test and allthese assignments comprises internal evaluation
which includes 20% marks and semester exam will
cover 80% marks. In this paper I will share myexperience of internal evaluation of master’s students
and also their Course contents and how students
performed in internal evaluation before final exam
which is scheduled in August 2016 as semester wasststarted in 1 week of March 2016.

Eubios Journal of Asian and International Bioethics 21 (July 2016)
The students are taught for 16 weeks (2hour/week) and the subject holds a weightage of 2
credit hours. The students are given preparation timeof 2 weeks before their final exam and in between they
are given 5 weeks summer holidays and this period
covers our Holy Month of Ramadan and Eid festival. I
thcompleted the Internal Evaluation of students on 25th
May 2016 (13 week of Teaching) before the summer
vacation.
Discussion
The MS Nursing program at LUMHS is a modern
program and its curriculum includes the essential
ingredients of contemporary bioethics. This course has
philosophical ethics as its major component which ispracticed in the health care setting. It develops
philosophicalandethicalknowledge,
ethicalawareness and skills. Patient care is a compulsory
aspect and component of nursing education thatstudents have to master in to graduate (4).
The course has different units and it comprises ofunit 1 which focuses on social, philosophical, and otherhistorical forces which has influence on thedevelopment of nursing. Ethical theories are covered inunit 2 and they include Utilitarianism, Kantianism,
LiberalIndividualism(Rights
basedtheory),Communitarianism(Community
based
theory),Character ethics (virtue based theory), Ethics of care
(Relationship based theory), and Casuistry (casebased reasoning). Unit 3 includes Ethical principles
which include all fundamental principles and they are
elaborated, discussed and analyzed. This unit also
includes Professional Patient Relationship anddemonstration of Professional behavior.
Unit 4 focuses on value clarification anddevelopment i.e. what is value process and how
values are acquired. Values conflict and its
implications in nursing care are also highlighted.
Ethical Dilemmas are taught in unit 5 and includes
various examples of ethical dilemmas and ways ofthinking to solve them. Professional Ethics andInstitutional Constraints in Nursing Practice are
discussed in unit 6 and multiple ethical obligations andresponsibilities of nurses are elaborated, the nurse
doctor relationship is also discussed and importance ofnursing is also highlighted. Rights, obligations andhealth care are taught in unit 7 and it includes theconcepts of rights. The last unit 8 includes Policy,
Ethics, and Health Care. In this unit ethical dimensionsof health policy are discussed, health care policy inrecent decades is analyzed and its historical,
legislative and political background is discussed. Now
coming to internal evaluation and as per our university
policy 20% marks are assigned for internal evaluation
before the final semester exam.
As discussed earlier students are obliged to givepresentations, debates, write summaries and makehome assignments and also have to appear in classtest, so therefore it was not possible to mark every
assignment in internal evaluation. To solve thisproblem I assigned marks to 4 of the components andmade other assignments unmarked. The first145

assignment that I assigned to students was to makesummary of unit 1 which comprises of social,philosophical, and other historical forces influences on
the development of nursing. The students have to write
summary of minimum 500 words and one week wasgiven for each and every assignment except the classtest, which was announced 2 weeks before to give
ample time to students to prepare. The firstassignment was not marked in internal evaluation. The
second assignment was given as group presentations
on the topic fundamental principles of bioethics. There
are 15 students in our class and I made 4 groups (3group each having 4 members and one group having 3
members). Each group was assigned one fundamental
principle and all four principles i.e. Autonomy,
Beneficence, Justice and Non-maleficence were
presented. 5% marks of internal evaluation wereadded through this presentation. This happened in 3rd
week after teaching those principles. The students
performed better and majority got 80% marks in that.
The third assignment was given as “To develop
thinformed consent form” and it was given in the 5week after teaching the concept. This assignment also
comprises of 5% marks in internal evaluation and thestudents took marks in the range of 60 to 90 percent.
th
The 4 assignment was again a write up summaryof the topic values clarification and development fromunit 4. This summary of 500 words was also unmarked
and not included in internal evaluation. The summary
assignment was a group activity from each of 5
members and the consent form assignment wasth
individual work. This was done in 6 week. The
students were informed 2 weeks before of the classthtest and as per rule it was taken in 9 week (mid term).
The class test was also given 5% marks in internal
evaluation. It comprised of SBQS (single bestquestions) and SEQS (short essay questions). The test
was of 1 hour duration and having 13 SBQS (26 marks
and 20 minutes) and 4 SEQS (24 marks and 40
minutes duration). The students performed in therange of 40% to 78%. Out of a total 15 students, one
was absent and one failed (less than 50% marks)
while the highest marks were obtained 39/50 (78 %marks). The other 13 students passed the test. The
5% of internal evaluation was taken accordingly fromthe total of 50 score. The next assignment was also
one of group presentations and the group comprised
each of 3 students. This assignment was unmarked
and the students had to present ethical theories andthe 5 groups were assigned 5 main ethical theories(one each). The presentations were good and students
presented better arguments. The groups wereassigned topics by small slip as one member fromeach group has to take one piece of paper (folded slip
having the name of topic written) to choose his/her
topic through luck. All the slips were folded and put on
the table). The last assignment was marked and itthhappened in 13 week of semester. This was a debate
on various contemporary bioethics issues. This debate
was also a group activity and 6 groups were made tohandle 6 topics. This was included as 5% marks ininternal evaluation and each group had either 2 or 3

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

members. The topic was included after they had beentaught in the course, and included issues: Organ
donation (pro and con groups), Euthanasia (congroup), In Vitro Fertilization (IVF) or assisted
reproduction (Pro and Con group) and Abortion. The
students performed well in the debate and the majority
got 80% marks (4/5). This last assignment concluded
the 20% percent marks of internal evaluation and they
are finalized before the final exam which has
weightage of 80% marks. The final exam will be on thepattern of class test and having both SBQS and SEQS.
The students performed in the range of 70 to 85% ininternal evaluation (20 marks). One student left the MS
program. The performance of students was verysatisfactory for me as a facilitator and they worked
very hard throughout the semester and for almost
every week they got home assignment in the form ofsummaries, presentations and other such as debates,class test. The students were provided articles, notes,
presentation material and the book (Beauchamp andChildress, Principles of Biomedical Ethics) for
reference and preparation.
Conclusion
In conclusion I want to state that the experience ofteaching at masters level (MS Nursing) was very goodand it was first time for me to teach at the
postgraduate level. I already had experience ofteaching bioethics at undergraduate level at many
institutes and programs, but this exposure was far
more satisfactory because the students were moremature and qualified (Maters level). Because of theirfield and expertise (Nursing care), they are always
active members of the health care team as they haveto provide critical care, face ethical dilemmas, resolve
the critical ethical conflicts and now they are also
involved in more formal ethical decision making. I tried
my best to achieve my target of completing the ethics
course in one semester and to put all my efforts toteach those things in one semester which I learned in
two years in my master of bioethics. In my opinion andas per the feedback given to me by nursing instituteadministration I have achieved my target and it was
not possible without constant hard work of MS
Students.
References

1.

Li-Ling Hsu. Blended learning in ethics education: A
survey of nursing students. Nursing Ethics 2011, 18(3)418–430.

2.

Leyla Dinç and Refia Selma Görgülü. Teaching
Ethics In Nursing. Nursing Ethics 2002, 9(3).

3.

Zoheb
Rafique.
Bioethics
Teaching
andAssessment: My Experience of Three Institutes.
Bangladesh Journal of Bioethics 2014; 5(2):44-48.

4.

Parvan Kobra, Zamanzadeh Vahid, Hosseini
Fahimeh Alsadat. Nursing students’ perspectives on
professional values in the universities of medical sciencesin Iran. International Research Journal of Applied andBasic Sciences 2012, Vol., 3 (6), 1183-1191.

The Patterns of Social
Stigma among the Rural
Women in Bangladesh:
A Sociological Study- Sumana Akter, PhD
Lecturer, Department of Sociology, Varendra University,
Rajshahi, Bangladesh
Email: sumanasoc@gmail.com- Wardatul Akmam, PhD
Professor, Department of Sociology, University of Rajshahi,
Rajshahi-6205, Bangladesh
Email: akmamw@hotmail.co.jp- Md. Nazmul Hoque
Assistant Professor, Department of Sociology, University of
Rajshahi, Rajshahi-6205, Bangladesh
Email: nazmulru@gmail.com

Abstract
A pattern of social behavior usually refers to therelatively permanent, recurrent and objective social
behavior of human beings that emerge as a reality ininteracting with one another as members of society.
However, it is not possible for all human beings to be
the same regarding age, gender, taste, physicalstructure, face and appearance, personality, skin color,
intellectual and social characteristics, etc. Althoughpeople in general realize their situation and characters,some characteristics become justified by them as
undesirable and social stigmas appear. This study was
conducted in Gopalpur village of Natore district. The
objective of this study was to explore the patterns ofsocial stigma among rural women in Bangladesh.
Several methods such as social survey method
through scheduled interview, focus group discussions(FGD), informal meetings, spot observations havebeen used to explore and gain a critical view of overall
aspects of social stigma in the study area. The study
found that all of the women were stigmatized on thebasis of one issue or another. Social stigma may occur
in many different forms. The most common forms that
occur are related to socio-cultural identity, family,
poverty, ignorance, physical structure, gender, skincolor, disease etc. In this study women who had been
stigmatized felt as if they had been transformed from awhole person into a tainted one. They felt themselves
as different and devalued by others. Social policies
should promote inclusion of all people in socioeconomic activities and prevent the processes ofstigmatization and social exclusion.
1. Introduction
A pattern, originating from the French word
“patron”, is a type of theme referring to recurring
events or objects, sometimes taken as elements of a1
set of objects. It denotes a social construction ofordered social behavior in a social milieu. Social1

http://en.wikipedia.org/wiki/Geometric_patterns Accessedon 22/02/2011

Eubios Journal of Asian and International Bioethics 21 (July 2016)
stigma is also a social construct. Expected andunexpected attributes are always dependent on social
atmosphere. Such atmosphere emphasizes wealth,materialprosperity,sociability,
educational
qualification, health status and physical beauty, youth,
competence,
independence,
productivity,
andachievement. Deficiency in exposition of such values
2
can import social stigma.
The totality of beliefs and sentiments common to
the average members of a society forms a determinate
system with a life of its own. It can be termed
3“collective” or “common” conscience.
According to the model prescribed by Bruce Link
and Jo Phelan, stigma exists when—(a) social groups differentiate and label humanvariations,(b) prevailing cultural beliefs tie those labeled toadverse attributes,(c) labeled individuals are placed in distinguishedcategories that establish a sense of separationwall between “us” and “them” and finally(d) labeled individuals experience “status loss anddiscrimination”
that
lead
to
unequal4
circumstances.
2. Methods
The study is exploratory in nature. Blending ofseveral methods such as social survey method
through scheduled interview, informal meeting, spot
observation, and non-participant observation havebeen and were used to explore and to gain critical
overview of overall aspects of social stigma in the
study area.
Sampling and Sample Size: Gopalpur village under
Baraigram thana (a local administrative unit) of Natore
district was selected purposively as the locale of thisstudy. After conducting a preliminary baseline survey,
it was found that the total number of households in the
study locale was 1309 and the total number of married
women was 1519. For this study, 218 married womenfrom 218 households have been selected throughsimple random sampling.
Unit of Analysis: The household was considered theunit of analysis in this study.
Sources and Techniques of Data: Both qualitativeand quantitative data were gathered for the study.
Primary data were collected from the respondents inrelation to the objectives of the study. Techniques suchas face-to-face interview using a schedule, spot
observation,
andnon-participant
observation,compilation of personal and family profiles throughinformal meetings were used. Both open-ended andclosed-ended questions were incorporated in theschedule. In addition, focus group discussions using a

147

checklist were carried out with people belonging todifferentsocialstrata.
Moreover,secondaryinformation from books, journals, documents were also
put to use.
Data Analysis and Presentation: Data wereanalyzed through simple statistical tools andtechniques using inductive logic to draw inference.
Analyses were presented in a narrative form along withtables and graphs.
3. Patterns of Social Stigma
Goffman has categorized social stigma into three
categories- a) overt or external deformities as can be
exemplified by leprosy, polio etc. b) known deviations
in personal traits as can be exemplified by ill motivatedpersons, drug addicts, those with suicidal tendency,
dementia, etc. c) tribal stigma as can be exemplified by
the Afghan madrasa students (known as Taliban), or
Pakistan as a place of religious extremism, race such5
as Bantu, as examples.
Falk classified stigma into two classes, namely a)
existential stigma- deriving from a condition which thetarget of the stigma either did not cause or over whichshe/he has little control and b) achieved stigma –6
stigma that is achieved through behavior. Social
stigma may occur in many different forms. The mostcommon forms occur with socio-cultural identity,
family, poverty, ignorance, physical structure, gender,
skin color, and disease etc. In this study, women who
had been stigmatized felt as if they had beentransformed from a whole person into a tainted one.
They felt themselves as different and devalued byothers. These things took place in their workplaces,
educational settings, and mostly in their own families,
neighborhoods and community as well.
4. Results
4.1 Age distribution of the respondents
Social perception of age is important in shaping
and coping with social stigma in society. Fig. 1
showing age distribution of the respondents reveals
that most of the stigmatized women (69%) were aged
between 21 and 50 years. Only 20% of them wereaged above 50 years. It is also notable that 11% of the
respondents were aged below 20 years. Thus it isclear that more than 80% of the stigmatized women
were in their working age.
4.2 Religious identity and stigmatization
Religious identity can mould social stigma at various
levels. Originally, the study village was dominated byHindu people, but since 1947 the number of Muslims in
the area increased and it became Muslim dominated.
In the present study, 86% (n=188) of the respondents
were Muslims, 4.6% (n=10) were Hindus and 9.2%
(n=20) of the respondents were Christians (Fig. 2).

2

L M Coleman, “Stigma: An Enigma Demystified” in The
Dilemma of Differences, eds. S C Ainlay, G Becker, and L M
Coleman (New York: Plenum Press, 1986), pp. 211-232.
3
Emile Durkheim, The Division of Labor in Society (NewYork: The Free Press, 1984), pp. 31-149.
4
B G Link & Jo C Phelan, “Conceptualizing Stigma”, Annu.
Rev. Sociol., vol. 27, (2001), p.363.

5

Erving Goffman, Stigma: Notes on the Management of
Spoiled Identity (New York: Simon & Schuster, Inc., 1963),
pp. 32-123.
6
Gerhard Falk, Stigma: How We Treat Outsiders (New York:
Prometheus Press, 2001), p.11.

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Eubios Journal of Asian and International Bioethics 21 (July 2016)
stigmatized just like the Muslims who could not readthe Quran written in Arabic.

Figure 1: Age distribution of the respondents
Figure 4: Stigmatization status for not being able toread the Quran

Figure 2: Distribution of religious identity of the
respondents
Religious identity can stigmatize people. In the study
area, were Hindus. But they had lower caste status in
their own religion, and lived in the khas (land owned by
the government) land in the study area. For theirdrinking habits, they were always stigmatized.
Converted Santal Christians were habituated todrinking locally made alcohol from the palm trees. For
their drinking habits and food consumption patternsuch as eating meat of pigs, tortoises, snakes, frogs
etc., they were highly stigmatized.

Figure 5: Stigmatization status due to education

Figure 6: Association between stigma and levels of
education

Figure 3: Stigma for religious identity
Religion played an important role in rural social
life. Everything related to religion carried deep emotion
7
and a sense of sacredness. Arabic is seen as verysacred for among the Muslims as it is the language of
their holy book, ‘the Quran’. Hindus and Christians
who could not read the Gita and the Bible were
7

Emile Durkheim, The Elementary Forms of the ReligiousLife (London: George Allen & Unwin Ltd., 1915), pp. 219230.

4.3. Education and stigmatization
Women in the study village were expected to work only
as housewives and they were not allowed to pursue
formal education. It is seen from this study that 88% of
the respondents were socially stigmatized for either
both, acquisition of education and for not being able to
do so (Fig. 5). All the levels of education brought about
stigma for them at the same time though the generalpublic assumption is was that illiteracy is was relatively
more stigma prone.

Eubios Journal of Asian and International Bioethics 21 (July 2016)
4.4. Physiological factors of women and social
stigmatization
Traditionally, people in rural areas in Bangladesh
like a fat body and educated people in urban areas try
to be slim. Again, people of the developed world preferto be slim whereas people of the poverty ridden world
favor fattening of the body. It has been observed
among the respondents that 13.3% were fat and only
about 1% women were unusually thin.

149

Africa, members of which were very short), Gattu/
Bamun (very short/ dwarf) etc. If women were very tall,then they were called Hati (elephant), Talgach (palmtree), etc.

Figure 10: Stigma due to height

Figure 7: Physical structure of the respondents

Skin color is a vital factor in stigmatizing. In
Bangladesh, white skin is always appreciable albeit
European whites are always under fire. In the present
study, 33% of the respondents were fair skinned
whereas 44% were blackish and 24% of them weredark skinned (Fig. 11).

Figure 8: Stigmatization status due to physicalstructures
In this situation, fat, thin and a portion of physically“normal” women were stigmatized in the study area.
Even slimming efforts are stigmatized by traditional
rural society of Bangladesh.

Figure 11: Skin color of the respondents

Figure 12: Stigmatization status due to skin color

Figure 9: Height of the respondents
Too tall and too short women have always been
stigmatized. In the current study, 15% of the women
were ‘very tall’ and about 32% of them were ‘very
short’. Figure 10 portrays that 66% of the respondents
were stigmatized for their height. However, this caused
serious obstacles in women’s social life, especiallyregarding marriage. Women were stigmatized bycalling names, such as Bantu (referring to a tribe in

It is seen in Figure 12 that 58% of the respondent
women were stigmatized and often they were
stigmatized by the name Kalti, which meantabominably black or Ma Kali (a deity of the Hindus who
is black), petni (female ghost). Black skinned girls are
considered burdens to their parents, as it is an
impediment in being selected as a bride for marriage.
This often leads to a greater amount of dowry
dowry being needed, and low quality groom if parents
are poor.

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Eubios Journal of Asian and International Bioethics 21 (July 2016)
comparison to those who rarely become ill for a few
days.
4.5. Family and stigmatization
Women were stigmatized for the behavior of theirfamily members. The present study shows that 60% of
the respondent women were stigmatized for theirhusbands’ activities as an induction rule. An example
is a proverb that says “A man is best known by thecompany he keeps”. A number of open ended
responses have been collected from the respondents
in this study. These are given in Table 1.

Figure13:
respondents

PhysicalconditionoftheFigure 14: Burdened by illness

Figure 16: Stigmatization status due to husband’s
activity

Physical condition of the respondents shows that
61% of the women were in good health condition, 18%
fluctuated, 17% were in poor health and 4% were very
sick in this study (Fig. 13). Male dominant society
looks at women as dependent members as women’s
8contribution to household works are unpaid. When
women are in a physically vulnerable situation, it canfoster stigmatization to the apex.

Figure 17: Causes of stigmatization by the children
Table 1: Activities of husbands for which wives are
stigmatized (%)
Husband doesn't want to work
Husband is not clever enough
Quarrels with neighbor
Husband bought necessary commodities for wife

Figure 15: Stigma for sickness
Among those whose health conditions fluctuated,or were in bad or very bad condition respondents inthe study, 70% felt that they were a burden to theirfamilies for illness where as 30% of them did not think
so. Among those respondents who thought they wereburdens for their illness, 63% felt stigmatized for theirpoor health. Respondents spontaneously said that if awoman remains ill for long days or plunges into
illness very often, she is highly stigmatized in
8

ibid, p.39.

Drug addicted husband
Illegal relation with other women
Stolen caseFighting
Husband got married to another woman
Husband is a mental patient
Husband is a member of Bangladesh Rifles

Business problem
For playing cards

1.4
1.4
11
1.4
12
19
18
23
4.1
1.4
1.4
4.1
1.4

People generally relate children’s behavior with
their parents, especially with their mother. Among thecauses of such stigma, an ‘affair’ case alone

Eubios Journal of Asian and International Bioethics 21 (July 2016)
represented 69% of the respondents, who said that adaughter’s affair is much more disastrous than a son’s
affair and that rural people often blamed her mother-as “she the daughter is like that because of her
mother” and even husbands also blamed their wives,often ordering, “Control your daughter!” etc.

151

Prevalence of stigma emanating from negligenceand gender identity was alarmingly high in the study
area. Among the respondents, 67% informed that they
were victims of negligence and stigmatized for theirrole in family and society at large. Male members of
their families and community at large regarded
women’s role in family and community as trivial.

4.6. Personality traits and social stigma
Ideally, extramarital attraction for other males isstrictly forbidden in Bangladesh. From time
immemorial, extramarital relations are consideredstrong sources for stigmatizing. 5 Five (2.3%) of the
respondents confessed that they were stigmatized forbeing attracted to other males (Fig. 18). Respondents
also said that if male members are were involved insuch activities community people does did not
stigmatize them as harshly as they stigmatized
women.
Figure 19: Society’s view on gender identity

Figure 18: Stigmatization status due to attraction toanother male
4.7.
Social, political, cultural and economic
conditions in stigmatizing women
Sex refers to physical differences of the body but
gender is concerned with the psychological, social andcultural differences between the male and female in9society. Every society has different views on gender
identity. Gender and gender relations are the social
norms in societies and stigmatization mechanism liesin the gender expectations of society. These norms set
up appropriate behavior of the male and female and10
crystallize them. In the study area, 15% of the
respondents thought that society looked at their gender
identity negatively. Again, 45% of the respondents
thought that society’s judgment on the gender identity
was a situational one. Situational categories were
exemplified easily by the respondents in from theinformal discussions. They said that if gender identity
favors someone, then it was justified as right by that
person. If it did not favor their her/his interest, people
he/she justified that gender identity as a wrong one.
‘Positive attitude’ of community denotes that genderroles as fixed by the society are justified and ‘negative
attitude’ denotes that the roles are not justified.

9ndAnthony Giddens, Sociology 2 edition (Oxford: Polity
Press, 1993), p.162.
10
Ranna Haider, A Perspective in Development: Gender
Focus (Dhaka: UPL, 2000), p.35.

Figure 20: Negligence for gender identity
Widowed and divorced women, and those who
were married more than once, were stigmatized in the
study area. Society generally has a negative attitude
towards them. Data show that 5.3% of the respondentsof this category did not get proper treatment, 87% of
the respondents said that society took them negatively
and only 7.9% were viewed normally. When a husband
passes away, it is said that the wife has taken him
away. Divorced and remarried women were
stigmatized by the community. They consideredwomen of bad character. If they were not, such
calamities would not have happened in their lives.

Figure 21: Society’s outlook about widow,
divorced and married more than once
Poverty is a fundamental cause of social stigma inthe study area. Financially weak persons can be easily

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

stigmatized by the powerful ones. This, of course,
requires a discussion on power and economic
11
dimension in social stigma. Data show that 83.43%of the respondents among the poor realized that they
were stigmatized for their poverty (Fig. 22).
Sterile women are stigmatized highly in
Bangladesh society. Women who had failed to givebirth to child even after five years of their marriage
were severely criticized. Respondents of the present
study have shared that it was always women who were
stigmatized for this. Among the childless women, 35%
were stigmatized and blamed for not issuing a child.
Women who never became a mother were stigmatizedby formidable words such as apaya’ (bearing bearer ofa bad omen), ‘alaxmi’ (a woman with bad luck), ‘banja’(sterile womb) etc. Besides, many women are were
physically tortured by their husbands for this reason. In
many cases, people avoided meeting them when they
started their journey on a fishing endeavor, a business,or to attend an inauguration ceremony etc. If
unconsciously or accidentally met, people think
negatively about their lot.

Figure 24: Stigma for having only son/daughter
The importance of son in all religions and rituals
can be an important source fertile land for stigma. In
Hinduism, a son is needed to burn cremate his father’sdead body. In Islam, a daughter cannot take part in thefuneral of her parents. Sons are income earners anddecision makers in family and resultantly they are verymuch desired in families. Owing to all these facts
mentioned above, most of the respondents who had
no sons were stigmatized in the rural areas like in thearea of the current study. Women who had only sons(and no daughters) were stigmatized but less incomparison to those who had no sons. Data show that
58% of the women having sons only or daughters only
were stigmatized in the study locality.

Figure 25: Stigma caused for not putting on nose
pin/wedding ring

Figure 22: Stigmatization for poverty

Figure 23: Stigma for having no children

Ornament norms are maintained by the rural
people of Bangladesh irrespective of religion. Nakful(ornament for nose) is such an ornament. Normally,
women are expected to wear it after their marriage in
Muslim and Hindu communities. If the married womenof these two major religions did not wear the nakful, it
is thought that either they desire to do harm to theirhusbands’ or their husbands were dead. The study
shows that 88% of the respondents who did not wear
nakfuls/wedding rings were stigmatized (Fig. 25).
5. Conclusion
Social stigma among the rural women in
Bangladesh is almost entirely molded by longcherished socio-cultural patterns. Patterns of social
stigma in the study area embrace physical and sociocultural domains. Women are stigmatized nearly in all
spheres of their lives. It is understood from therespondents that patriarchy is the root of all suchstigma. Once women are socialized in patriarchy, theirviews become the same those of the male members ofsociety. Women are stigmatized by their husbands andby other family members including female members.
Full participation in all social domains to unfold theirpotential is still a far cry. This leads to their social
exclusion. Further research endeavor is needed to
explore the complicated nexus of social stigma in
Bangladesh.
Bibliography

11

BG Link & Jo C Phelan, “Conceptualizing Stigma”, Annu.
Rev. Sociol., vol. 27, (2001), p.363.

Books:
Ainlay, SC., and F. Crosby. “Stigma, justice and the dilemmaof difference.” In The Dilemma of Difference, eds. S. C.

Eubios Journal of Asian and International Bioethics 21 (July 2016)
Ainlay, G. Becker, and L. M. Coleman, New York: Plenum
Press, 1986.
Ainlay, SC., G. Becker and LM. Coleman. The Dilemma ofDifference: A Multidisciplinary View of Stigma. New York:
Plenum, 1986.
Allport, GW. The Nature of Prejudice. Boston, MA: AddisonWesley, 1954.
Becker, G., and Arnold, R. “Stigma as a social and cultural
construct.” In The Dilemma of Difference, eds. S. C.
Ainlay, G. Becker, and L. M. Coleman, New York: Plenum
Press, 1986.
Coleman, L. M. “Stigma: An enigma demystified.” In The
Dilemma of Difference, eds.
Crocker, J., B. Major,and C. Steele. “Social stigma.” In
Handbook of Social Psychology, eds. S. Fiske, D. Gilbert,
and G. Lindzey, vol. 2. Boston, MA: McGraw-Hill, 1998.
Durkheim, Emile. The Elementary Forms of the Religious
Life. London: George Allen & Unwin Ltd., 1915.
Falk, Gerhard. Stigma: How We Treat Outsiders. New York:
Prometheus Press, 2001.
nd
Giddens, Anthonny. Sociology 2 Edition. Oxford: Polity
Press, 1993.
Goffman, E. Stigma: Notes on the Management of Spoiled
Identity. New York: Prentice Hall, 1963.
Goffman, E. Asylums: Essays on the social situation ofmental patients and other, inmates. Garden City, NY:
Anchor, 1961.
Haider, Ranna. A Perspective in Development: Gender
Focus. Dhaka: UPL, 1995.
Link, BG., and JC. Phelan. “Labeling and stigma.” In The
Handbook of the Sociology of Mental Health, eds. CS.
Aneshensel, JC. Phelan, New York: Plenum,1999.
S. C. Ainlay, G. Becker, and L. M. Coleman, New York:
Plenum Press, 1986.
Journal Articles:
Avery, J. “Discrimination, thy name is stigma.” Addict
Profess. vol.1 (2003): 8–10.
Coleman, M., L. Ganong,and S. Cable. “Perceptions of
stepparents: an examination of the incomplete
institutionalization and social stigma hypotheses.” J.
Divorce Remarriage.vol. 26(1996):25–48.
Corrigan, and Penn. “Lessons from social psychology on
discrediting psychiatric stigma.” Am. Psychol. vol.54(1999):765–76.
Corrigan, Patrick W., and David L. Penn. “Lessons From
Social Psychology on Discrediting Psychiatric Stigma”
American Psychologist Vol. 54, No. 9 (September1999):pp. 765-776.
Crandall, CS. “Do parents discriminate against theirheavyweight daughters?” Personal. Soc. Psychol. Bull.
vol.21 (1995):724–35.
Crandall, CS. “Prejudice against fat people: ideology andself-interest.” J. Personal. Soc. Psychol. vol.66(1994):882–94.
Crandall, CS., and A. Eshleman. “A justification- suppression
model of the expression and experience of prejudice.”Psychol. Bull. no.129 (2003):414–46.
Crocker, J. “Social stigma and self-esteem: situational
construction of self worth.” J. Exp. Soc. Psychol. vol.35(1999):89–107.
Crocker, J., and B. Major. “Social stigma and self-esteem:
the self-protective properties of stigma.” Psychol. Rev.
Vol.96 (1989):608–30.
Crocker, J., B. Cornwell, and B.Major. “The stigma ofoverweight: the affective consequences of attributional
ambiguity.” J. Personal. Soc. Psychol. vol. 64(1993):60–
70.

153

Farina, A., JG. Allen, and B. Saul. “The role of thestigmatized in affecting social relationships.” J.
Personality vol.36 (1968):169–82.
Gerstel, Naomi. “Divorce and Stigma.” Social Problems Vol.
34, Issue. 2 (April, 1987): pp. 172 -186.
Link, B. G., and J. C. Phelan. “Conceptualizing Stigma.”
Annual Review of Sociology. vol.27 (2001): 363-385.
Link, B. G., J. Mirotznik, and F.T. Cullen.”The effectivenessof
stigmacopingorientations:Can
negative
consequences of mental illness labeling be avoided?”
Journal of Health and Social Behavior. vol.32 (1991):
302-320.
Link, BG., EL. Struening, M. Rahav, JC. Phelan, and L.
Nuttbrock. “On stigma and its consequences: evidence
from a longitudinal study of men with dual diagnoses ofmental illness and substance abuse.” J. Health Soc.
Behav. vol.38 (1997):177–90.
Major, Brenda and Laurie T. O’Brien. “The Social Psychologyof Stigma.” Annu. Rev. Psychol. 56 (2005.): pp. 393–421.
Miller, Carol T., Diane Felicio, and Pamela Brand.
“Compensating for Stigma: Obese and Nonobese
Women's Reactions to Being Visible.” Society for
Personality and Social Psychology Vol. 21, No. 10(1995): pp. 1093-1106.
Phelan, Jo C., Bruce G. Link, and John F. Dovidio “Stigma
and prejudice: One animal or two”. Social Science &Medicine Vol. 67 (2008):pp. 358–367.
Smith, Michael. “ Stigma”. Adv. Psychiatr. Treat. 8 (2002):
pp. 317-323.

Would we leave our ageing
parent or grandparent in thecare of a robot? – A
perspective from Islam.
- Sibtain Panjwani BDS MA PhD
Email: sibtain@blueyonder.co.uk
Dr Sibtain Panjwani has a special interest in bioethics
and currently operates on a freelance basis in both Muslim
community life and the wider academic environment

You may think this question is far-fetched. It is not.
Just look at what the social/economic trends tell us. In
Western Europe and Japan, there is ageing populationand shrinking population size. In the long term, it isestimated that by 2050, all the continents except for
Africa will have increased ageing population andshrinkinggeneralpopulation.
Twoimportantchallenges among others, for the world in 2050, are:
1. Demands of the Ageing population
2. Limited human resources available from thedeclining general population.
In the UK, there are 11 million people aged 65 orover with 3 million people aged 80 or over. By 2050,
estimates predict that the elderly will account for 16
percent of the global population. Research suggeststhat about three in four of elderly people will develop asocial care need such as assistance getting up in themorning to all day support for physical, emotional andmental care. With declining population generally

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

throughout the world, there will be shortage of humanresource willing to take on the responsibility. Families
that traditionally look after the elderly will also comeunder pressure due to much social and economic
pressure.
In the last 500 years, technology has come to therescue of humanity to solve some of our challenges. It
is said that, in the last 100 years, more knowledge is
discovered than ever before. It is increasingly likelythat robots and artificial intelligence (AI) assisted
appliances will take on the part of the role of careproviders, including, meeting practical care needs,
providing round–the–clock support and even providing
a form of companionship. Over 22 per cent of Japan’s
population is currently aged 65 or older and many
companies are working on robots that can assist theelderly, ranging from those which offer therapeutic careto those which can help move and carry objects.
Within the next 20 years, it is increasingly likely that
(AI) robots will be used in the care of older adults
throughout the developed world. What are theimplications for human society as a whole of thisintervention in our social relationships? What ought tobe the Muslims perspective on Artificial Intelligence(AI) assisted appliances?
As part of larger global society, Muslim
communities are also undergoing increasing ageing
population. The community needs to deliberate upon
the key ethical and social implications on the use ofthis technology; implications it will have, on the family
life, social life as well as on individual identity. I am
expressing a reflection from an Islamic perspective on
this topic briefly, hopefully, to encourage deeper
deliberations on this topic among bioethics andreligious scholars:
Metaphysical perspective
Though there is little work, if any, done in the
aforementioned subject, there is one major issue whichruns
throughout
Islamic
metaphysicalandphilosophical literature – the soul (nafs). There is no
indication in the Qur’an or hadith that a being higher
than the human being would possess something likethe complexity of the human soul – both in terms of its
intellect, desires, capacity, emotion and transcendental
yearning. For this reason, a robot would not be able toreplace the human soul but only resemble it. We haveto ask, is this resemblance enough for communication
with an elderly person? It is possible that in cases
where an elderly person has no one at all, a highly
developed robot with some human-type personality
possessing self-awareness could be programmed tocommunicate with the elderly person. It is up to anelderly person to accept such an entity. However, fromthe Islamic viewpoint, this does not replace the soul
which is the basis for human identity, emotional
capacity and spiritual, ethical and transcendental
growth. This complexity allows for deeper intuitions
which the robot may not be aware of. Therefore, one
may argue that the use of robots in absolutely
replacing humans (from a metaphysical point of view)
is not only counter-human but dangerous as it reduces

human beings to nothing more than mechanical beings
who require mechanical communication. There would
no room for deep human communication or flourishing.
However, the use of robots in aiding human beings to
perform certain services like cleaning or the such
would be permissible as the role of human identity is
not threatened in a major way.
Scriptural perspective
There is nothing in the Qur’an and ahadith which
explicitly talks about A.I or robot. Even if so, it has to
be interpreted a great deal. From a purely textualist
angle, one may argue there is no prohibition on using
robots to communicate with the elderly but this is alimited angle requiring a greater ethical andmetaphysical framework which is not present in Islamic
theory.
Legal viewpoint
This depends on the judgment of a jurist with his
own ijtihad. Again, this is subjective as no overall
framework exists with regards to bioethical issues.
Usually ihtiyat or bara’ah (exemption) is used in theface of bioethical issues unless some verses andhadith is found which contain some sort of orderprohibiting or permitting the technology or action inquestion.
The Islamic viewpoint may, at present, utilize a
mixture of principles from metaphysics, philosophy andethics with a broad reference to scripture to argue forthe protection of human identity. This would position
the soul as the basis of human identity requires
cultivation rather than hindrance. If robots hinder thetranscendental and ethical cultivation of the elderly,
even at the time of death, this is against the spirit ofjourneying towards God. It is possible that robots
aiding human beings in their services to the elderly
would be allowed and as a last resort, to allow robots
to replace a human in the case of truly isolated andalone elderly persons (as some movies havesuggested). But the thumb-rule is one of prohibitionand caution as from a metaphysical viewpoint, it
renders human beings like machines which is not their
purpose in accordance with Islamic scripture andmetaphysics.
What do you think about this question?
EJAIB welcomes commentaries, viewpoints andresponses to all articles.

Eubios Journal of Asian and International Bioethics 21 (July 2016)

HESC to IPSC: Prohibition
to Controlled Permissiveness to ethical panacea- Intekhab Islam, Vinicius Rosa, Raymond Wong
Assistant Professors, Faculty of Dentistry,
University of Singapore
Email: denii@nus.edu.sg

National

Abstract
Human Embryonic stem cell (HESC) research wasreplete with controversies involving the origin of thesecells and the moral status of the embryo. The
emergence of Induced Pluripotent stem cells (IPSC)
was heralded by many as the solution to thecontroversy. It was believed by proponents of Induced
Pluripotent Stem cell research that finally the fruits ofthe technology could be cherished without the dilemmaof research involving human embryos. However,Induced Pluripotent stem cells are not the quick fix
solution to the ethical issues of Human Embryonic
Stem cells research as was made out to be. They
come with their own ethical implications and the mostglaring of them is the downstream applications ofthese cells. Regulations need to be formulated withthese downstream applications in mind. The problem
to define the moral status of IPS cells will become
unavoidable as will research involving zygotes andembryos. Urgent international regulation is required forharmonization and proper advancement of the field.
1. Introduction
It is widely recognized that stem cell research has
the potential to transform modern clinical medicine.
The potential ability of stem cells to drive
transplantation therapy as well as to serve as models
for drug discovery and testing drove stem cell researchin spite of wide spread controversy and opposition.
The array of Pluripotent stem cells now contains
embryonic stem cells, induced pluripotent stem cells
and amniotic fluid stem cells. Pluripotent cells arethose that are able to proliferate indefinitely, express
pluripotent cell markers and are able to differentiate
into all three germ layers [1].
Embryonic stem cells are isolated from the Inner
Cell Mass (ICM) of the blastocyst stage embryo. Thesecells demonstrate the unique property of pluripotency,
which is the ability to form any specialized
differentiated cell types of the organs from which they
are derived.
The derivation of pluripotent human stem cells
lines from oocytes and embryos is intertwined withdisputes regarding the onset of human personhoodand human reproduction. A major objection to thegeneration of Human Embryonic Stem Cells is that it
requires destruction of fertilized eggs which raises
ethical concerns. The alternative established methodsof deriving stem cells such as reprogramming of cells
to produce induced pluripotent stem cells (iPS) avoids
the ethical problems specific to embryonic stem cells.

155

The works of Takahashi and Yamanaka caused aparadigm shift in stem cell research as they
demonstrated the forced expression of fourtranscription factors was sufficient to convert mouse
fibroblast cells into embryonic stem cell like cells [2].
The resulting cells were called Induced Pluripotent
stem cells (IPSC) and these cells are regarded as
pluripotent as they display characteristics ofpluripotency, which include ability to express multiple
stem cell genes and the ability to differentiate into
tissues representative of all three germ layers. The
new method was revolutionary as it provided themeans of generating pluripotent cells without
embryonic tissue.
However, is it possible that IPSC cells will erase all
the ethical dilemmas that Human Embryonic Stem cellresearch raises? There are problems with Induced
Pluripotent Stem cell research that goes beyond theorigin of these cells. The downstream applications ofstem cells derived from both Human Embryonic stem
cells and Induced Pluripotent stem cells raise similar
concerns. This paper will address some of theseconcerns that the downstream applications of thesecells raise and how the existing regulatory frameworks
may be applied to guide such research.
2. HESC Research: Ethical Quandaries andObjections
A major ethical concern pertaining to research
involving Human Embryonic Stem cells was thecreation of human embryos for research anddestruction of embryos for such research. This ofcourse is based on the assumption that humanembryos have moral status.
Some consider the fertilized ovum to have full
moral status and that it should not be subject toresearch and or destruction. Others argue that theembryo is merely a ball of cells with no moral status.
Most however take a middle ground that the zygote
has a moral status but many only become deserving at
a later stage of development [3].
Some advocate full moral status of the embryo
from fertilization; that personhood begins atconception. They believe development from a fertilized
egg to a baby is a continuous process and any attempt
to pinpoint an arbitrary period when personhood
begins is wrong[4, 5] . They believe that the embryos
should not be viewed as means to an end and should
be valued as human beings with moral status andhuman rights. The embryo is thus supposed to havethe same set of basic moral rights, claims or interests
as an ordinary human being and should be afforded
the same dignity and respect as a person. Thus
creating and using embryos for research isimpermissible even if it saves lives[6] . Others however
advocate full moral status only from the fourteenth day
onwards. The Warnock Report [7]stated that no live
embryo derived from in vitro fertilization maybe kept
alive beyond fourteen days after fertilization nor may it
be used as a research subject beyond fourteen days
after fertilization. This formed the basis for the cut-off
point being fourteen days. Although the fourteen day

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Eubios Journal of Asian and International Bioethics 21 (July 2016)has been criticized as being quite arbitrary. Other
institutes such as the Royal College of Obstetricians
and Gynaecologists had suggested seventeen days as
a cut off period at which early neural development
begins. Many believe this to be a slippery slope whereembryos will be created to fuel such research. There
was a dilemma to choose between the duty to preventor alleviate suffering and the duty to respect the valueof human life for those who viewed the embryo as
human. In the case of Human Embryonic Stem Cell
research, it was impossible to respect both thesemoral principles for those viewing the embryo as
human life with moral standing. The early embryo had
to be destroyed to obtain embryonic stem cells. This
meant destroying a potential human life according to
opponents of this research. However, it was acceptedthat Embryonic Stem Cell Research would lead to thealleviation of suffering of a lot of peoples. One view
was that use of discarded IVF Embryos to obtain stem
cells was compatible with the respect due to embryos,
whereas the creation and used of cloned embryos wasnot. The argument was that cloned embryos are
created for instrumental use only as a mere means[8].The main issue was the moral status of the embryo.
There was also debate about the intentionality andwhether it was permissible to create embryos forresearch[9] .
From a human rights perspective, the key isrespect for individual human rights[10]. The theory
claims that humans have rights and these rights must
be taken seriously, but it is imperative to understand
who qualifies for such protection. It is debated whether
this protection applies and extends to unborn humanbeings. From the viewpoint of dignity based theories,
the dignitarian perspective condemns any practice,process or product which will compromise humandignity. Originating in Kantian principles, the actions oromissions that could compromise human dignity are to
be avoided.
3. The Ethical Panacea of IPSCThis possibility of creating pluripotent stem cells
without “destroying a human embryo” in the process
has been welcomed by scientists and bioethicists,
policy makers as well as the scientific community. The
words of Thomas Berg, Archdiocese of New York andProfessor of Moral Theology, that “The work of
Yamanaka has put Human Embryonic Stem cellresearch largely out of business” summarizes the viewthat Induced Pluripotent Stem cell are said to bypass
ethical problems with research on embryonic tissue.
The production of Induced Pluripotent Stem cell
eliminated the problem opponents of stem cellresearch had with the origin of the cells. It was
assumed that embryos were suddenly not needed forsuch research. The new method was potentiallyrevolutionary as it provided the means of generating
pluripotent cells without embryonic tissue and was
widely accepted as an end to the controversy
surrounding Human Embryonic Stem Cell research.
However, with any stem cell research there arequestions that go beyond the origin of the cells.

4. Ethical Issues raised by IPSC research
Stem cell research whether embryonic or induced
poses unique ethical and moral questions andchallenges. The rapidity with which research is
expanding has made the emerging issues even morechallenging. Induced Pluripotent Stem cell researchraises the question of complicity as it was derived fromtechnology based on Human Embryonic Stem Cell
research. There are also questions about the technicalissues concerning research involving Induced
Pluripotent Stem cells. There are issues pertaining toconsent, discrepancies in regulation, and conflicting
legal and ethical standards across nationalboundaries. There is also the matter of ownership ofthese cells as well as privacy infringements. The mostpressing of these issues is the downstream use of
these cells. This section will try to address some ofthese issues.
4.1 Complicity
When raised with two conflicting alternatives,
prudence
dictateschoosingthemorally
unobjectionable means and IPSC seems to be themorally less objectionable means.
However, theproblem of moral status of the embryo re-emerges as
moral complicity in the development and progress ofInduced Pluripotent Stem cell research. Complicity
refers to the collaboration or collusion with a morally
wrong act. Induced Pluripotent Stem cell researchtechnology originated in human embryonic stem cellresearch and subsequent advancements in the fielddepended directly or indirectly on human embryonicstem cell research. Some argued that participation andadvocacy of Induced Pluripotent Stem cell research
implicates proponents in being morally complicit incausing harm to embryos. Apart from complicity there
are other aspects of this research that raises uniquequestions and dilemmas.
4.2 Scientific and Technical Challenges
As with all research, there are existing scientificchallenges. It is well accepted that there are known
disagreements, knowledge gaps and uncertainties
pertaining to research involving Induced Pluripotent
stem cells. These include patient safety, treatment
efficacy, and suitability of these cells for drug testingand disease studied or their theoretical ability tocontribute to a human embryo under suitableconditions [11]. It is well accepted that advances in
reprogramming technology will require parallel Human
Embryonic stem cell research [12].
Both Human Embryonic Stem Cells and Induced
Pluripotent Stem cells have the potential to form
teratomas, and carry the risk of tumorigenesis. The
Induced Pluripotent Stem cell in addition are at risk ofalteration from age or toxins. There were also initial
objections to the use of viral vectors for creation ofthese cells but advancement and refinement inproduction methods have eliminated that issue.
Induced Pluripotent Stem cells also permit creation ofpatient specific histocompatible pluripotent stem cells

Eubios Journal of Asian and International Bioethics 21 (July 2016)
and can be directed towards production of tissue
specific progenitors.
4.3 Potentiality and Downstream applications
However, the similarities in the issues that Induced
Pluripotent Stem cell research and HESC researchraises go beyond moral complicity and donor andconsent issues. The major concern with Induced
Pluripotent Stem cell research is the potentiality of thisresearch. Stem cell research and treatment areentangled in ethical issues that now go beyond thequestions related to the destruction of the embryo.
Induced Pluripotent Stem cell and Human Embryonic
Stem Cell are very similar in potential. Thus thedownstream application of both groups of cells raisesimilar concerns. All the concerns regarding the
problems arising from the applications of Human
Embryonic Stem Cell were applicable to Induced
Pluripotent Stem cell as well.
Moreover, the field advanced very rapidly and withit the potential implications grew as well. In the words
of Peter Singer, the Australian philosopher andProfessor of Bioethics, “more often than not there is acompromise between ethics and expediency”. Thiswas very pertinent to the advancing field of Induced
Pluripotent Stem Cell research. There was an urgent
call to proclaim Induced Pluripotent stem cells as thesolution to all ethical issues raised by embryonic stem
cells by proponents of the technology. The ethicalissues that Induced Pluripotent stem cells themselves
raise were not considered and merely the origin of
these cells formed the basis of such an argument.
The ethical issues in Stem cell research starts
from informed and voluntary consent during donationof biological materials. The risk and benefits ofexperimental intervention and informed consent is arecurring issue when it comes to clinical trials involving
stem cells.
A study conducted in the Berman Institute of
Bioethics looked at patient’s perspectives and attitudes
towards donating materials for Induced Pluripotent
Stem cell research[13] . The most common reason forsupporting Induced Pluripotent Stem cell research was
altruism and the desire to help others. There was also
the question of personal benefit with people believingthat such research could benefit them in future.
Despite broad endorsements, there were also
concerns about privacy, immortalization and thecreation of gametes. There is great concern that
donation of materials could lead to invasion of privacy.
Some were worried whether genetic information
obtained from their tissues could preclude them fromobtaining insurance. There was also concerns about
the immortalization of the cell lines. The concerns not
only stemmed from the potential inappropriate use of
these cells but also about the profit that futuretechnologies will produce.
There are concerns with the process and control of
the original tissue donation and the purposes to which
it is applied. There is a major concern with privacy. If
these cells are to be used to study disease processes
or to treat diseases like Parkinson’s or Alzheimer’s, it157

will be important to know the donors history and it may
make it impossible to maintain donor privacy.
Moreover, can consent be modified to track every
new and potential use of the cells? If a person does
not consent to say use for chimera research, will they
have rights to withhold use for similar but undefined
research.
There is also the concern regarding patentability
and profitability. Will a donor be privy to the profits
arising from commercial products derived from theircells? There is also the question of distributive justice.
Will such treatment be available for all, or will it beavailable to only the privileged few in society? Thus it
was clear that not only with the scientific community
but also with donors and patients there are dilemmas
pertaining to consent for donation of materials for stem
cell research, early clinical trials for translational
therapy and oversight and progress of stem cellresearch.
The most disconcerting thought was the
production of gametes from Induced Pluripotent Stemcells. Derivation of male germ cells from induced
pluripotent stem cells in vitro and in reconstituted
seminiferous tubules were demonstrated in mice[14] .
Equizanal et al. showed complete differentiation ofhuman induced pluripotent stem cells to postmeiotic
cells. They also obtained haploid cells from human
IPSC of different origins and of both genetic sexes[15]. Panula et al. demonstrated that human iPSCs derived
from reprogramming of adult somatic cells can form
germline cells[16] . It was also shown that Human
IPSC’s could differentiate directly into male germ celllineages including postmeiotic spermatid like cells[17].
Easley in a review states that Spermatozoa with full
reproductive viability establishing multiple generationsof seemingly normal offspring have been reported inmice and, in humans, haploid spermatids with correctparent-of-origin imprints have been obtained[18]. The
production of oocytes is proving challenging atpresent.
Although a myriad of ethical issues surround
Induced Pluripotent Stem Cell research, there is none
as controversial as the generation of gametes andsubsequently life from this technology. There is auniversally accepted norm that entities with intrinsic
potential to become full grown humans should not be
used for research. However, there are proponents that
believe Ethical conduct is justifiable by reasons that go
beyond prudence to “something bigger than theindividual”. These cells can be used for cloning
purposes and have been proved to be able to generate
gametes for IVF in animal models. There is no
scientific difference between Human Embryonic Stemcells and Induced Pluripotent Stem cell based
therapies concerning the theoretical possibility of thesecells to contribute to a human embryo. The mostobvious ethical objection stems from the ability ofInduced Pluripotent Stem cell to form tetraploid
complementation, the ability to form a health and fertile
animal with no contribution from cells other than the
Induced Pluripotent Stem cells themselves [19].

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Eubios Journal of Asian and International Bioethics 21 (July 2016)

In July 2009, two independent research groups
reported the first successful generation of human micefrom induced pluripotent stem cells[19, 20]. They used
a technique called tetraploid complementation andinvolved creating tetraploid embryos by fusing theblastomeres of two cell stage embryos. They have
twice the number of chromosomes. They tetraploidembryos are grown to the blastocyst stage, injectedwith mouse ESC and injected into the uterus of asurrogate mouse. The resulting pups are derived solely
from the ESC with the tetraploid embryos contributing
to the tissues that form the placenta and membranes
that nourish and protect the growing organism.
Although these experiments have not been carriedout in humans, there is the inherent possibility thatthese cells may be used for creation of organisms or
the pursuit of reproductive technologies from cells
made into sperm and egg. Although the possibility is
distant, it is very real. Ethical and legal concerns exist
about ownership and about publishing and sequencing
the entire genome. At present human reproductive
cloning is banned in all countries and therapeuticcloning is banned in several. However ethicalenvironments may change or may differ acrossinternational borders. There would be serious concerns
over aspects of patentability.
The derivation of gametes is a distinct possibility.
While fraught with controversies it is accepted
universally that there is considerable scientific value
and potential for both understanding basic
mechanisms of gamete biology and for overcoming
clinical problems in translational research. While thedevelopment of a human gamete from a Pluripotent
stem cells may not be fully conceivable yet, thescientific community firmly believes that technology isadvancing rapidly and the fructification of this reality iscloser than it seems. The production of gametes andthe potential ability to create life has been frowned
upon in all circles. Once gametes are created,
determining the functional potential of these gametes
will require and necessitate production of an embryo toestablish their capacity for fertilization and early
embryogenesis. This will be morally objectionable tofactions who afford full moral status to humanembryos. It will also be against policies where it isillegal to create embryos exclusively for research
purposes.
Thus although we may have potentiallycircumvented the issue of status of the embryo byproducing induced pluripotent stem cells, these cells
themselves may bring the research to a full circle andpresent the same ethical quandaries.
If life were to be created via this technology, whatsort of dignity would that life form have? Would they betreated as a means to further research? There arefears that the identity and individuality of the createdlife form would be threatened thus reducing autonomy[21, 22].

4.4 Human Dignity
Human dignity is the value by virtue of which weare what we are. It is the very basis of all human rights
and interpersonal morality. Are we prepared to answer
questions about the dignity and rights of the createdlife forms? There are also concerns about prejudicesand respect for such life forms. Will there be fear forsuch created life forms or will there develop a newform of discrimination against such life forms.
UNESCO’s Universal Declaration on the Human
Genome and Human Rights (1997) was the firstinternational
instrument
tocondemnhumanreproductive cloning as a practice against humandignity. Article 11 of the declaration states that
“Practices which are contrary to human dignity such as
reproductive cloning of human beings shall not be
permitted”. This position was shared by the World
Health Organization and the European Parliament.
This stance can be extrapolated to life forms created
via IPSC technology. Allowing IPSC technology toproceed with production of gametes is also contrary tohuman dignity. Human dignity is related to Kant’s
categorical imperative that a person should not be
used as a means to an end and opponents of Human
Embryonic Stem cell research who believe that using
Embryos for research is contrary to Kant’s imperative
should be wary that downstream applications of IPSC
research are also contrary to Kant’s that a person
should not be used as means to an end.
Different societies will respond differently toregulate and oversee research with such potential. Asof now there are vast discrepancies in regulations andpolicies.
4.5 Discrepancies in Regulations
There is a lot of discrepancy between regulations
and guidelines for Induced Pluripotent stem cellresearch in Canada, UK, US, Japan and the ISSCR.
The US and Japan allows use of identifiable cells with
IRB approval or notification to a designated committee
but Canada requires anonymity and does not allow useof identifiable cells[23]. The emerging themes in theseregulations from different countries is that derivation ofgerm cells or transplantation into humans or grafting
into animals requires additional approval or review andmonitoring.
It is generally accepted that research should avoid
the creation of entities in which human sentience orconsciousness might be expected to occur andanimals into which human embryonic stem cells,
induced pluripotent stem cells, or any other kind ofpluripotent stem cells have been introduced should not
be allowed to breed.
The use of stem cells derived from other countries
or institutions places the user at crossroads ofconflicting legal and ethical standards. While medical
tourism remains a distinct possibility, it is imperative torecognize that there will be jurisdictions where
research with gametes is permitted or will bepermitted. Scientists and policy makers will have toconsider a variety of issues as the science progresses.

Eubios Journal of Asian and International Bioethics 21 (July 2016)
Though social issues should form a part of any
policy decision, scientific inquiry should not be
restricted simply because of divergent views in society.
Instead safeguards should be built to direct and guidesuch research.
4.6 Consent, Privacy, Patenting and Ownership
Some bioethicists have advocated that donor
consent processes should include the disclosure of thepossibility that their cells could be used inhuman/animal chimera research. They should also be
informed that the research was based on cells derived
from human embryos. Several iPSC lines have been
derived from commercial tissue banks presumably
without informing donors that they may be morally
complicit in research that derived its base from embryo
research.
There are also concerns about reidentification of the donor leading to privacy
infringements and potential for information to be usedin an unfair and discriminatory manner. The major
concern stems from the inability to control thedownstream use of cells and prevent their
inappropriate use. This includes concerns about thecommercial aspects of cell use and the question ofpatentability and ownership. The ownership could restwith universities or industries or IPSC banks andrepositories. There is also concern about cells derived
from stored specimens.
These future concerns can be addressed by
mitigating factors like proper consent, transparency
and trust. Informed consent is a means ofsafeguarding violations of autonomy. A robust
informed consent process along with transparency
about potential uses and commercialization and close
attention to policy.
While issues regarding the moral status of theembryo still remains relevant and is debated politicallyand scientifically, the field is constantly evolving andextending its consideration to current and emerging
policies and issues including procurement of embryos,
patenting, stem cell tourism and new sources of stem
cells among others[24] .
It has been argued that stem cell based produces
are considered somatic cellular therapies that do not
warrant a distinct regulatory approach[25] .
When it comes to translational stem cell research,autonomy and safety of research subjects as well as
patients are recognized as intrinsic value. Respect forindividuals, reciprocity, proportionality, justice andsustainability form the basis of the future of stem cellresearch.
From this stems debates and proposals
and resolutions on informed consent and voluntary
participation.
Most regulating authorities now reiterate that there
is a need to keep a keen eye on whether stem cellresearch is conducted in an ethically defensible way
with consistency and transparency. What is necessary
is regulation that promotes greater safety, efficacy, andgreater accessibility for larger number of patients.
Scientific advancement and query will necessitatecontinuity of HESC and IPSC research.

159

5. Conclusion
The problem of how to define the moral status of
IPS cells will become unavoidable. It is imperative torecognize that regulations should be formulated withthe future in mind.
Research should be regulated the same way as
research involving embryos and zygotes. International
regulation is required for harmonization and is required
urgently. IPSC is not the quick fix solution to ethicalcontroversies of HESC research. It carries its own
ethical quandaries. IPSC cells present with uniquepotentials and corresponding ethical concerns, policy
should come closer to reflect public opinion and should
involve researchers, regulators, patients andorganizations. Only then will the potential be fulfilled
and will allow society to reap benefits of research
progress. Lines and limits must be drawn to prevent
abuse and focal consideration is vital for efficient andethical development of the field.
When compared to HESC, the methods used tocreate IPSC’s may not be ethically problematic orsocially controversial, however the downstream uses
most certainly are and require immediate regulatory
responses.
Conflict of Interest:
The Authors declare no conflict of interest
6. References
1. de Wert G, Mummery C: Human embryonic stem cells:
research, ethics and policy. Hum Reprod 18:672, 2003
2. Takahashi K, Tanabe K, Ohnuki M, Narita M, Ichisaka T,
Tomoda K, Yamanaka S: Induction of pluripotent stem
cells from adult human fibroblasts by defined factors. Cell
131:861, 2007
3. Fadel HE: Developments in stem cell research andtherapeutic cloning: Islamic ethical positions, a review.
Bioethics 26:128, 2012
4. RM D: The ethic of funding embryonic stem cell research:
A Catholic viewpoint Kennedy Institute of Ethics Journal
9:137, 1999
5. G M: The point of a ban : OR , how to think about stem cellresearch Hastings Centre Report 31:9, 2001
6. Deckers J: Are those who subscribe to the view that early
embryos are persons irrational and inconsistent? A reply to
Brock. J Med Ethics 33:102, 2007
7. Mary W: Report of the committee of inquiry into human
fertilization and embryology. Department of Health andSocial Security London, 1984
8. National Bioethics Advisory Commission N: Ethical issues
in Human Stem Cell research. Rockville, MD:NBAC, 1999
9. W F: Surplus embryos, nonreproductive cloning and theintend/foresee distinction. Hastings Centre Report 33:29,
2003
10. Brownsword: Ethical Pluralism and the regulation ofmodern biotechnologies New Technologies and Human
Rights 19, 2009
11. Hug K: Do we still need Human Embryonic stem cells forcell-based therapies? Epistemic and Ethical Aspects. Stem
Cell Rev and Rep 7:761, 201112. Belamonte J: Induced Pluripotent Stem cells andreprogramming: Seeing the science through the hype.
Nature Reviews 878, 2009
13. Ishan D: Patients attitudes towards donation of biologicalmaterials for the derivation of Induced pluripotent stem
cells Cell Stem Cell 14:9, 2014

160

Eubios Journal of Asian and International Bioethics 21 (July 2016)

14. Yang S, Bo J, Hu H, Guo X, Tian R, Sun C, Zhu Y, Li P,
Liu P, Zou S, Huang Y, Li Z: Derivation of male germ cells
from induced pluripotent stem cells in vitro and inreconstituted seminiferous tubules. Cell Prolif 45:91, 2012
15. Eguizabal C, Montserrat N, Vassena R, Barragan M,
Garreta E, Garcia-Quevedo L, Vidal F, Giorgetti A, Veiga
A, Izpisua Belmonte JC: Complete meiosis from humaninduced pluripotent stem cells. Stem Cells 29:1186, 201116. Panula S, Medrano JV, Kee K, Bergstrom R, Nguyen HN,
Byers B, Wilson KD, Wu JC, Simon C, Hovatta O, Reijo
Pera RA: Human germ cell differentiation from fetal- andadult-derived induced pluripotent stem cells. Hum Mol
Genet 20:752, 201117. Easley CAt, Phillips BT, McGuire MM, Barringer JM, Valli
H, Hermann BP, Simerly CR, Rajkovic A, Miki T, Orwig
KE, Schatten GP: Direct differentiation of humanpluripotent stem cells into haploid spermatogenic cells.
Cell Rep 2:440, 2012
18. Easley CA, Simerly CR, Schatten G: Gamete derivationfrom embryonic stem cells, induced pluripotent stem cells
or somatic cell nuclear transfer-derived embryonic stem
cells: state of the art. Reprod Fertil Dev 27:89, 2014
19. Kang L, Wang J, Zhang Y, Kou Z, Gao S: iPS cells can
support full-term development of tetraploid blastocystcomplemented embryos. Cell Stem Cell 5:135, 2009
20. Zhao XY, Li W, Lv Z, Liu L, Tong M, Hai T, Hao J, Guo
CL, Ma QW, Wang L, Zeng F, Zhou Q: iPS cells produce
viable mice through tetraploid complementation. Nature
461:86, 2009
21. G A: The prospect of human cloning: an opportunity inhuman embryo research” Human Cloning. New Jersey
Humana Press, 1998
22. Kitcher P: Whose self is it, anyway? Sciences (New
York) 37:58, 1997
23. Caulfield T, Scott C, Hyun I, Lovell-Badge R, Kato K,
Zarzeczny A: Stem cell research policy and iPS cells. Nat
Methods 7:28, 2010
24. Zarzeczny A, Caulfield T: Emerging ethical, legal andsocial issues associated with stem cell research & and thecurrent role of the moral status of the embryo. Stem Cell
Rev 5:96, 200925.
Fink DW, Jr.: FDA regulation of stem cell-based
products. Science 324:1662, 2009EJAIB Editor: Darryl Macer
Associate Editors
Jayapaul Azariah (All India Bioethics Association, India),
Masahiro Morioka (Osaka Prefectural University, Japan).
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany), Shamima
Lasker (Bangladesh), Minakshi Bhardwaj (UK), Christian Byk(IALES; France), Ken Daniels (New Zealand), Ole Doering(Germany), Amarbayasgalan Dorjderem (Mongolia), Hasan
Erbay (Turkey), Soraj Hongladarom (Thailand), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Umar Jenie (Indonesia), Nobuko Yasuhara Macer (Japan),Anwar Nasim (Pakistan), Jing-Bao Nie (China, New
Zealand), Pinit Ratanakul (Thailand), Qiu Ren Zong (China),
Hyakudai Sakamoto (Japan), Sang-yong Song (Republic ofKorea), Takao Takahashi (Japan), Noritoshi Tanida (Japan),
Ananya Tritipthumrongchok (Thailand), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republic ofKorea).

ASIAN BIOETHICS ASSOCIATIONMEMBERSHIP 2016
and subscription to Eubios Journal of Asianand International Bioethics (EJAIB)
Web site: http://eubios.info/ABA.htm____ I wish to pay my annual membership fees ofAsian Bioethics Association (ABA), and receivethe 2016 issues of Eubios Journal of Asian andInternational Bioethics (EJAIB) (The Official
Journal).
____ Regular Price: US$70 Euro 50 NZ$80 ¥7000(=Credit card price NZ$90)____ I wish to make a reduced contribution of____ I wish to make a donation to Eubios Ethics
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Please indicate the publications you wish and provide credit card details - the prices are below andinclude postage.

Eubios Ethics Institute Publications(Books sent by SAL post, Journal by Airmail - Price included)
Eubios Journal of Asian and International Bioethics (Annual subscription)
NZ$80
Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture
by Darryl Macer, Oct. 1990, 421pp.
NZ$50
Equitable Patent Protection in the Developing World
by William Lesser, May 1991, 150pp.
NZ$40
Attitudes to Genetic Engineering: Japanese and International Comparisons (Bilingual)by Darryl Macer, May 1992 330pp.
NZ$40
Human Genome Research & Society
Eds: Norio Fujiki & Darryl R.J. Macer July 1992
ISBN 0-908897-03-0 (English), 230pp. ISBN 0-908897-04-9 (Japanese), 240pp.
NZ$40
Intractable Neurological Disorders, Human Genome Research and Society Eds: N. Fujiki & D. Macer
Feb. 1994 ISBN 0-908897-06-5 (English), 320pp. ISBN 0-908897-07-3 (Japanese), 340pp.
NZ$40
Bioethics for the People by the People by Darryl Macer,... May 1994 ISBN 0-908897-05-7, 460pp.
NZ$50
Bioethics in High Schools in Australia, Japan and New Zealand,
by D.Macer, Y.Asada, M.Tsuzuki, S.Akiyama, & N.Y.Macer March 1996, ISBN 0-908897-08-1, 200pp.(A4) NZ$50
Protection of the Human Genome and Scientific Responsibility (English and Japanese Bilingual)
Editors: Michio Okamoto, Norio Fujiki & D.R.J. Macer, April 1996, ISBN 0-908897-09-X, 210pp.
NZ$40
Bioethics in India Eds: Jayapaul Azariah, Hilda Azariah & Darryl R.J. Macer
June 1998 ISBN 0-908897-10-3, (includes 115 papers) 403 pp. (Printed in India)
NZ$60
Bioethics is Love of Life: An alternative textbook
by Darryl Macer, July 1998 ISBN 0-908897-13-8, 152pp.
NZ$40
Bioethics in Asia Eds: Norio Fujiki & Darryl R.J. Macer,(includes 118 papers from Nov.1997 conferences, ABC’97 Kobe and Fukui Satellite)
June 1998 ISBN 0-908897-12-X, 478 pp. October 1999 ISBN 0-908897-14-6 (Japanese), 320pp.
NZ$50
Ethical Challenges as we approach the end of the Human Genome Project
Editor: Darryl Macer, April 2000 ISBN 0-908897-15-4, 124pp.
NZ$40
Bioethics Education in Japanese High Schools (in Japanese only)
Editor: Darryl MacerApril 2000 ISBN 0-908897-16-2, 112pp.
NZ$40
st
Bioethics and the Impact of Human Genome Research in the 21 Century
Eds: Norio Fujiki, Masakatsu Sudo, & D.R.J. Macer March 2001 (English and Japanese bilingual, 350pp). NZ$50
st
Bioethics in Asia in the 21 Century
Eds: Song Sang-yong, Koo Young-Mo & Darryl R.J. Macer
August 2003 ISBN 0-908897-19-7, 450pp.
NZ$50
Challenges for Bioethics from Asia Ed: Darryl R.J. Macer November 2004 ISBN 0-908897-22-7 656 pp. NZ$70
A Cross Cultural Introduction to Bioethics, Editor: Darryl Macer 2006, 300pp. (A4)
NZ$50
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