Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 32 (3) May 2022
www.eubios.info

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

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2022 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents
page
Editorial: Medical ethics in practice and inliterature - Darryl R.J. Macer
69
Proposals to improve patient safety
approaches based on analysis of medical
error cases
70- Xu Hua
Desperate mothers and mad scientist in a
divided world: Discussions of ethical, legal,
and social issues depicted in Kazuo
Ishiguro’s Klara and the Sun
77- Atsushi Asai, Taketoshi Okita, Miki
Fukuyama, Motoki Ohnishi and Seiji Bito
Urgent care services: An initiative towards
combating non-emergent emergencies in
Karachi, Pakistan
85- Kiran Karim Jivani, Aamna Nazish Iqbal,
Arusa Lakhani and Unab Khan
Ethics in COVID-19 pandemic: Narrative
review of challenges and lessons learned
by healthcare workers
88- Sarosh Saleem and Maha Khalil
ReQlections on research resource allocationand data sharing as ethical dilemmas inconducting COVID-19 research92- Isaac A. Adedeji, Saheed Akinmayowa
Lawal, Onyeunoneme Alexandra, Odiari, Sola,
Aluko-Arowolo and Ebunoluwa Oduwole
EJAIB Editorial Board
96
Ordering information
96
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations (AUSN),
https://www.ausovereignnations.org
Email: darryl@eubios.info

Please submit your papers,
commentaries and reflections!

Editorial: Medical ethics inpractice and in literature
Although, in the midst of immediate medical ethics
crises, it may seem that the issues raised are novel
and unprecedented, one of the important ethicalissues is the necessity to draw from our traditions,culture and social context, in order to resolve moral
dilemmas that we face in medical ethics. In thisissue, we have a couple of papers examining the
COVID-19 pandemic and challenges that it raised,from Pakistan and Nigeria.
No matter where we live, it is important forpeople in the medical system to raise fundamental
issues of preservation of autonomy and protection of
persons, and doing good. Medical themes are
explored in many different literature, and in thispaper the question of the issues raised by desperate
mothers and mad scientists by Asai et al. is quite
fascinating. We can see this issue also raised when
we have questions such as the debate over,whether
or not to start human gene editing, as was seen in
the Qirst trial in China. Although that issue has notreally been resolved, but just postponed, we cancontinue to beneQit from an expansion of such
depictions in television, movies, and other media.
Human beings always have to balance what is thesafety and what is beneQicence. It’s no coincidence
that balancing is also really the fundamental ethicalprinciple. As human beings we will always makemistakes and is there anything in the regulatory
system that will protect everyone all the time? It's inthese broad issues that that we see explored in thisthe papers in this journal, and we need further
debate on these topics in the coming years. We haveto build upon the wisdom of all who wrote before, as
in the famous saying, we stand on the shoulders ofgiants.
Thank you for those who have renewed theirsubscriptions to EJAIB and looking forward tomeeting you in person at the ABC22 Conferencein Kuala Lumpur, Malaysia, 15-17 May 2023! Darryl Macer

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Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

Proposals to improve patient
safety approaches based on
analysis of medical error cases- Xu Hua

Department of Medical Ethics, Tohoku University
Graduate School of Medicine, School of Public Health
Sendai, Japan
E-mail: xuhua813hh@163.com

Abstract
The purpose of this paper is to point out serious
problems related to patient safety in the modern
Chinese medical setting and discuss how to resolve
them, based on an analysis of a hypothetical event
created in reference to actual experiences and thelatest literature. In this case study, a hypotheticalscenario is presented in which three doctors treat
three patients in a particular department and all thepatients die within 24 hours. After presenting the
hypothetical case, I examine the problems involving
the doctor's practice system and clinical education,communication among relevant personnel, thedischarge policy, physician well-being, anduncertainty in medicine. I argue that serious harm tocurrent and future patients is inevitable if these
conditions are allowed to persist and conclude thatnew patient safety approaches are needed to resolvethese problems in China.
Introduction
As a patient safety manager, I often feel deep sorrowand regret from witnessing the sudden death ofmany patients caused by medical errors and thegreat loss experienced by their families. I have seensituations in which a medical error also damages thewell-being of the doctor who committed the error.
A recent study claimed that the causes of medical
malpractice are complicated and fundamentally nota "bad apple" problem, but rather a problem faced bycompetent healthcare providers working in a broken
system that does not prioritize safety; signiQicant
errors should be thoroughly investigated by a root
cause analysis (RCA), seeking system problems thatmerit improvement [1].
A signiQicant amount of work has been done topromote patient safety, and yet, evaluation of theeffects of this work yields primarily frustration anddisappointment. The occurrence of medical errors is
no new trend, and their frequency has generally
increased. Somehow the same or similar medical
errors have a way of repeating themselves. Most
Chinese people, including myself, have always
insisted that medical errors are mainly due tohuman error, including the doctors' lack of
responsibility, communication ability and skills, andvigilance. In the past, we have spent signiQicant timereviewing the Qlaws in the treatment process, i.e.,
medication error, postoperative remaining sponges,
infections, or skin burns in operating rooms. Doctors
involved in medical malpractice face possible

suspension from work, and may even be transferredout of their department, which may harm their
future career success. In recent years, somestrategies and tools aimed to improve patient safety
have been introduced, including items such as
incident reporting systems, root cause analysis(RCA), and even the PDCA cycle (plan, do, check, act).
Unfortunately, I would argue that many people still
do not fully understand the essence and signiQicanceof these safety tools. Little emphasis has been placedon system improvement, which means that more
paperwork, rather than action, has been generated
by these efforts [2,3]. Even less emphasis has beenplaced on doctors’ attitudes toward medical errors[4,5]. All these factors have prevented us fromidentifying the true root causes of medical errors.
In this paper, I present a situation involving
inadequacies in the physician’s practice and clinicaleducation, poor communication among those
involved, a problematic discharge policy, a damaged
sense of well-being of the doctor due to overwork
and burnout, the uncertain nature of medicine, andQinally, the added impact of Chinese society andculture. In my discussion of the implications of thissituation on patient safety, I argue that if such asituation persists, serious harm to present andfuture patients is inevitable. I also maintain that it isunfair, irrational, and even unscientiQic to place theentirety of the blame on the individual doctors who
committed the medical errors as a main cause of theerror and the patient’s resulting predicaments. I
conclude that new approaches to patient safety that
contribute to the resolution of these problems areurgently needed to achieve and sustain safe medical
practices in Chinese healthcare. The case I present
here is a hypothetical scenario, synthesized frommany past cases I have encountered during my many
years of experience as a patient safety manager.
Importantly, the issues implied by this Qictional
scenario are real. I will develop my arguments byusing additional Qictional information in mydiscussion.
Hypothetical medical malpractice cases involving
three doctors and three patientsFirst, I brieQly describe the doctors and patients
involved. The following three doctors belong to the
Department of Emergent Surgery (DES) of Teaching
Hospital X. Doctor A is the Head of the DES withroughly 30 years of clinical experience. Doctor B is afull-time doctor in the DES with roughly 20 years ofclinical experience, subordinate to Doctor A. Doctor
C is a full-time doctor in the DES with approximately
10 years of clinical experience, subordinate toDoctor B.
The following three patients visit the DES of
Teaching Hospital X, where Doctors A, B, and C work,
one after the other, from early morning to early
afternoon on the same day. All patients areaccompanied by several family members, but thefamily members have not received a full explanationfrom the doctors about the patient conditions.

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
Patient D is 30 years old, brought to the DES due
to a stab wound with a sharp piece of metal in theneck. Patient E is 50 years old, came to the hospitalwith acute abdomen, is febrile and complaining of
abdominal pain; urgently admitted to the DES.
Patient F is 70 years old, was discharged from
Teaching Hospital X after undergoing surgery forcolorectal cancer in another department. Half amonth later, the patient developed gastrointestinal
bleeding and was treated for more than one week atthe Department of Internal Medicine of Teaching
Hospital X. However, as the bleeding could not be
controlled, the patient was transferred to the DES.
Patient D is transported to the DES on theweekend. Doctor C is on duty and provides Qirst aid
and reports the patient condition to Doctor B when
he arrives at work. Doctor B instructs Doctor C on
treatment and follow-up for Patient D, then begins
emergency surgery on Patient E. Doctor B has
recently been in poor health due to overwork.
Doctor A then instructs Doctor C by telephone tofollow a different treatment plan for Patient D thanthat prescribed by Doctor B, and Doctor C follows
Doctor A's instructions to treat Patient D. Doctor A
does not examine Patient D directly but gives his
instructions to Doctor C after receiving a direct
telephone call from Patient D's family. At this point, adetailed investigation of Patient D's neck puncturesite is not performed.
Doctor B's surgery on Patient E is completed a
few hours later, but postoperative bleeding leads to asecond emergency surgery. Patient E is given
intensive care after surgery, but the condition isunstable.
Doctors B and C are responsible for Patient E andnewly transferred Patient F; both doctors are busy
treating these two patients, and consequently, delay
their observations of Patient D.
The conditions of Patients D and E worsen, andthey die from massive bleeding, one after the other,
despite treatment by Doctors B and C. Neither of thepatient families can accept the patient deaths andrefuse to leave the hospital with the deceased; theirbodies are therefore kept in the hospital ward.
Doctors A and B operate on Patient F to stop
their gastrointestinal bleeding. However, thepatient's condition worsens after the surgery andthe patient dies. Neither doctor was informed of thedetails of the cancer resection surgery that had been
performed a month earlier in another department of
Teaching Hospital X, nor were they informed ofPatient F's behavior prior to the occurrence of the
bleeding (i.e., failure to follow home bed rest
instructions).
Subsequently, Doctor B becomes involved in
medical disputes concerning Patients D, E, and F. It isdetermined that the deaths of the three patientswere caused by Doctor B's errors in his surgery,
rapid deterioration of the patient conditions, andlack of disclosure on the part of Patient F about poor
compliance to medical instructions. Doctor B's
practice is suspended.

71

Discussion
1. Problems with the doctor’s practice systemand training
China's medical system has several serious problems[6]. The doctors practice in a three-level doctor
round system, which coexists with the attending
doctor round system in China [7]. The former was
designated in 1982 and gradually implemented
thereafter. The system is composed of residents,
attending doctors, and (associated) chief doctors.
The department director makes rounds once a week
and the attending doctors do so at least twice a
week; residents make rounds at varying times as thesituation demands. In the three-level round system,
there are three main shortcomings [8,9]: First, thedepartment director is the person in charge of theadministration and business of the department, andcannot spend enough time and energy on thepatients, which not only leads to rounds becoming aformality without signiQicance, but increases thepatient safety risks; second, junior doctors often
contact patients but have no decision-making power;
third, the growth of junior doctors is hindered,
which is not conducive to the cultivation ofintermediate strength in hospitals. Although thelatter system (composed of one team leader, one
attending doctor, and one to four residents) makes
up for the shortcomings of the former to a certain
extent, some problems still exist in the clinicalpractice. First, the cohesion of the department andteamwork of the whole department is low [10];second, “management blind spots” are created,
increasing patient risk; third, problems emerge
regarding qualiQication assessment, ability andemployment of the team leader, and the assessmentof the medical team [11].
It can be argued that treatment for Patient D wasdelayed. The patient should have been able tosurvive. I cannot help but think that the patient was
unlucky because they required care on an extremely
busy weekend. As mentioned above, the three
medical accidents occurred on the same weekend.
Only one doctor was on duty in each department
over the weekend, when the three patients required
hospitalization and/or surgery. Clearly, this was
destined to be a very busy weekend, and many
uncontrollable factors contributed to the bad luck.
Several points are worth considering: Qirst, it is areality that health workforce is lacking in both
quality and quantity. The team has only one
associate chief doctor (team leader), one attending
doctor, and one resident. The lack of medical
resources and uneven regional distribution is a
global problem; however, this is not the key point ofthese issues. While there is certainly a marked
decrease in the number of doctors in China relative
to those in other developed countries, China’s
shortage is not the most serious. The number ofdoctors per 10,000 people in China was 19 in 2012[12] and 30 in 2021 [13]. As a comparison, thedensity of medical doctors was highest in European

72

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

region around 43 per 10, 000 population in 2021
[14]. Conversely, the African region remains with thelowest density of medical doctors (around 2 per
10,000 population) in 2021 [14]. The ambiguous
amalgamation of the two medical systems (leading
to training deQiciencies among junior doctors) is
likely the key factor causing the lack of humanresources. Doctor C and other residents on the team
could neither play an intermediary role in case of
emergency, nor get help from other team members.
Moreover, despite their frequent contact with thepatients, they lack decision-making authority.
Furthermore, the Grading Management regulations
stipulate that senior attending doctors can masterLevel 3 operations (moderately difQicult) under the
instruction of the doctors with a higher professional
title, and (associated) chief doctors can perform
Level 4 operations (very difQicult). However, inpractice, most of the operations above Level 3 areperformed by (associate) chief doctors, withresidents and attending physicians rarely gettingmuch surgical practice. This explains the highincidence of medical disputes in the surgical systemagainst doctors with a higher title. To sum up,
although doctors technically work only 8 hours
every day, the care for patients D, E, F, and others
demands far more than 8 hours. This imbalance incircumstances reQlects the contradiction between theunlimited health demand of the public and thelimited quantity of medical resources.
2 The problem with information transmission
Even though transitions are inevitable in medicalcare, transition and handoff errors are among themost common and consequential errors inhealthcare [1]. The presence of all these transitions
and handoffs makes it critical to consider how
information is passed between healthcare providers
and patients (and their family members). In theclinical setting, there are generally two kinds ofinformation transmission: between the doctor andpatient, and between doctors. The informationtransmission can also occur in the same department,
among several different departments or institutions,and sometimes after the patient is discharged fromthe hospital.
In China, medical resource availability is highly
dependent upon the region, the setting of the area
(urban or rural), and population, which means that
increasingly more patients are opting to visit large
urban general hospitals in pursuit of better medical
services and technology. According to data from the
National Health Commission of China, in developed
cities, i.e., Shanghai and Beijing, out-of-province
patients accounted for 23.19% and 10.58% of thepatients, respectively [15], which is a very large
group of patients. When patients receive a higher
level of medical care, transition and handoff errors
can increase patient safety risks. Of the three
medical malpractice scenarios presented here,
Patients D, E, and F all experienced transition andhandoff errors, to varying degrees.

2.1 Information transmission problems in thesame department
Patient D did not leave the ward until after death;
however, there were at least Qive incidents of
information transmission errors related to his case:1) that which occurred between Doctor C andPatient D, 2) that between Patient D and Doctor A(family members of Patient D contacted Doctor A byphone), 3) that between Doctors C and B, 4) thatbetween Doctor B and Patient D, and 5) thatbetween Doctors A and C. The following points areworth considering. First, Chinese people have a
deep-rooted belief that "it is easy to work amongacquaintances" and that they should "obey authority,
but not willingly." This would explain why the family
contacted Doctor A, as well as some of the behaviors
exhibited by Doctors B and C. These traditional
cultural behaviors may have rendered Patient D’s
treatment unnecessarily complex. They not only
complicated the interpersonal relationships between
superiors and subordinates but also increased thenumber of people involved in Patient D’s treatment
to excessive numbers. It is also worth noting that on
the weekend when Doctor A was resting at home,
information about Patient D’s condition could only
be transmitted through Patient D's family membersby phone. Moreover, Doctor A discussed thetreatment plan for Patient D with Doctor C only by
telephone. This style of communication could
increase the medical risk of Patient D.
Secondly, Doctor B instructed Doctor C toobserve rather than suture the wound. Doctor B
obviously knew Doctor C very well. If the patient's
neck wound remained exposed for several hours, it
might have increased his chances of survival.
However, in this scenario, there was no effective
information transmission among the three doctors
and Patient D’s family. Accordingly, Patient D’s family
called Doctor A again to express that they did notunderstand Doctor B’s treatment plan, attempting toexert pressure on Doctors B and C through Doctor A.
After receiving the second instruction from Doctor A,
Doctor C quickly explored the wound and sutured it.
The effect of the telephone call between Patient D’s
family and Doctor A was evident, but theconsequence was fatal. Finally, when Doctor B
learned that Patient D’s wound had been sutured, hegave no further treatment instructions to Doctor C.
This relates not only to the difference in status of thetwo doctors within the system but also the inherent
inclination of Chinese people to obey authority, but
not willingly (speciQically, Doctor B obeyed Doctor A,
but not willingly, expressing silent deQiance throughpassive action). Doctor C lacks diagnostic decisionmaking authority, and Doctor B is administratively
subordinate to Doctor A.
2.2 Problems in information transmission
between departments
Patients E and F were both in serious postoperative
conditions and needed to be transferred to anotherEubios Journal of Asian and International Bioethics 32(3) (May 2022)
department. Patient F rotated through three
departments, one by one. For patients with serious
and complex conditions who need to be transferred
to another department or another hospital forfurther treatment, it is critical that their disease
information can be accurately and effectivelytransmitted among the doctors caring for them. Data
from the United States show that nearly 20% of
patients have experienced adverse events within
three weeks after discharge [16], reQlecting thecorrelation between patient transfer and patient
safety. Family members of Patients E and F had
doubts from the beginning to the end concerning
treatment because of the insufQicient explanation
they received from the doctors, as well as their lackof comprehension about the patient situation; they
were unsure of what exactly happened. In my
experience as a patient safety ofQicer, this is the mostcommon complaint in real medical malpracticecases. Doctors are challenged with questions andaccusations such as, “Why did my family member die
immediately after being discharged? He was Qine
when he was admitted to the hospital!” or “Doctor,
you are a murderer! Our family member walked into
the hospital and left there lying down.” While somemight point out that this is merely a problem of
informed consent, I would argue that some deepseated factors are affecting information transmission
among the different departments in the following
ways.
First, regarding the transition and handoff
between departments, information transmission
between departments generally occurs via a formal
application for consultation within the hospital, andthe doctors on duty at the time are responsible for
consultation. However, in practice, several problems
exist [17]. First, department consultation is a mere
formality, and its effectiveness and timeliness are
difQicult to guarantee. In addition, inexperienced
doctors might go to other departments for
consultation, which makes the actual effect ofconsultation poor. Furthermore, the preparation
prior to the consultation is insufQicient. Finally, there
is no strict implementation standard and protocol
established for the consultation system. Collectively,
this creates a situation in which the accuracy andintegrity cannot be guaranteed for information ofpatients who have been transferred. In the present
hypothetical situation, additional issues exacerbatedthe situation surrounding treatment for Patient F.
For one, Patient F concealed some of their own
behavior that negatively inQluenced their physicalcondition. The professional differences between
internal and surgical medicine compounded the
problem, and an uninformed doctor on duty that day
underestimated the seriousness of Patient F’s
situation. All these issues led to the situation inwhich Patient F had to wait for longer to receive
conservative internal medicine treatment, which
resulted in the delayed execution of the second
operation, leading to the patient’s death.
Second, in terms of information transmission

73

between doctors, although the Qirst surgeon who
operated on Patient F knew the operation process
very well, he was not obliged to disclose the key
information to the other related doctors, unless it
happened that this Qirst surgeon was on duty at thetime the information was needed. Doctor C was theconsulting doctor on that day and was the only
doctor who had a face-to-face handoff with theinternal doctor. It is highly likely that there was no
information exchange between Doctors A and B andother previous doctors of Patient F. These
inadequacies in information sharing could havecaused delays in performing the second operation on
Patient F, which would have represented a fatal
failure of treatment for Patient F in this scenario.
Finally, as far as information transmission
between doctors and patients (i.e., the informed
consent process) is concerned, a high incidence of
medical disputes has led doctors and patients to feel
defensive and on guard against each other in China.
This lays the foundation for a toxic situation in which
both parties are sensitive toward the issue of who is
responsible for any medical errors that might occur.
This is likely why Patient F's family concealed fromthe doctor that the bed rest instructions were notfollowed strictly. Doctors B and C did not feel obliged
to inform their patients and family members of theprevious treatment the patient had received in otherdepartments. Furthermore, Doctors B and C may
have felt that it would be wise for them not todisclose the information, including that about the
problems in the Qirst operation, the latest discharge,
and the conservative treatment given by the internal
medicine department, to avoid unnecessary conQlict
with the patient families and preserve therelationships between colleagues (including thatbetween the Qirst surgeon and internist). Taken
together, all these factors could create a situation inwhich the new doctors taking over patients would
not inform patients about their previous diagnosis
and treatment in other departments. In other words,
Patient F’s family members would have noknowledge of the diagnosis and treatment for the
disease of Patient F until the patient died. Of course,
any of Patient F’s existing medical problems could
have a tremendous impact on the treatment offered
by Doctor B; failed treatment could then lead topatient death. Such a non-disclosure policy shouldbe abandoned not only to improve patients’ andtheir family’s understanding of the medical situation,
but also to avoid medical lawsuits.
2.3 Information transmission issues with
discharging patients
Patient F developed massive postoperative bleeding
after discharge, which begs several questions: Did
the surgeon's discharge decision meet the standards
for discharge? Assuming that these standards weremet, was the patient adequately informed of thedischarge notes including medical directions tellingthem what they should or should not do? The patient
should have rested at home but failed to follow this74

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

instruction. The mortality rate of discharged patientsin China has been on the rise year by year, reaching
1.05% in 2020 [15]. Some medical disputes pertain
to discharged patients or those who were
readmitted. These data include many patients withsevere complications after discharge, such as PatientF.
3 Doctor well-being, burnout, and treatment
outcomes are related
There is no doubt that the core purpose of patient
safety is patient safety itself, but it must beemphasized that modern patient safety refers not
only to patient safety, but to doctor safety as well.
This is because doctor safety and patient safety aremutually interdependent [18-20]. Well-being is thestate of feeling healthy and happy [21], whereas
burnout is primarily driven by certain characteristicsof the work. Many factors contribute to the health ofan organizational system, and particular attention is
warranted for items such as electronic health record(EHR) documentation, coding, and inter-ofQicecommunication [22,23]. Doctor well-being, burnout,and patient safety are highly interconnected, suchthat change in one variable inevitably causes marked
changes (both good and bad) in others, regardless ofwhich occurred Qirst [24].
The poor health status of Doctor B is undeniably
and directly related to the unsuccessful operation ofPatient E. Due to overworking, he was likely burnt
out, with a low sense of well-being. A study
published recently suggested that burnout, wellbeing, and work unit safety grades were strongly andindependently associated with perceived major
medical errors and, together with other previous
studies, identiQied an association between physician
burnout and adverse quality of care including selfreported errors [25]. If Doctor B had a healthymental, physical, and work status, Patient E’s
operation should have gone as smoothly as it couldgo, and Patients D and F would have been able toacquire the attention they required. The healthbeneQits and lives of these three patients are likely
connected to a large degree. From my experience asa patient safety ofQicer, the relationship between theworking state and health of doctors is undeniably
correlated with the treatment outcomes of theirpatients.
In this scenario, especially for Doctor B and
Doctor C, this is a very challenging weekend. We canimagine how busy their work is, how chaotic thework scene is, and how tense their psychology is fora long time. Of course, the story only reQlects thedoctor’s work of treating patients. However, doctors
obviously perform a great deal of other work,
including but not limited to rounds in the ward,
consultation, meetings, medical record writing,education, and administering examinations, to namejust a few. In the hypothetical scenario presented
here, in the days following the patients’ death,
Doctors B and C will become involved in medical
disputes and may face suspension, transfer,interrogation by the hospital, criticism and threats
from patient family members, and evaluation fromtheir own colleagues, not to mention their own
internal battles processing through the incident. We
must acknowledge that in real clinical settings,
doctors are also victims of medical accidents.
For Doctors B and C, this was no doubt achallenging weekend, both emotionally andphysically. Unfortunately, this represents a typicaland common workload to which countless Chinese
doctors can relate. They work hard, year after year,
under high risk and high pressure, and their healthproblems are worrisome. Within the single hospitalwhere I previously worked, Qive highly qualiQied andexcellent surgical doctors died of cardiovascular or
cerebrovascular diseases in just three years. The
fourth Special Research Report on Doctor-Patient
Relationship from the National Health Commissionof The People’s Republic of China shows that doctors
are worse than laypeople in making time for selfcare and daily exercise, and relative to laypeople,
they have signiQicantly higher levels of pain anddiscomfort, anxiety, and depression [26]. Coupledwith this toxic medical practice environment
described above, there is no country in the world
where the doctor-patient relationship is like that ofChina, i.e., that in which patients, doctors, thegovernment, and society are all so highly
dissatisQied. The number of reports of workplace
violence against physicians in medical settings isincreasing in many countries including China, and isconsidered a serious problem [27,28]. A searchwithin the Chinese Judgement Online System for
medical dispute damage cases in China in the past
decade will reveal a sharp increase in the number of
medical lawsuits, from 221 in 2010 to 23,338 in2018 [29]. Injuries to and murders of doctors are
frequent in China and have persisted even during the
COVID-19 pandemic. These situations affect thephysical and mental health of medical staff, andincreasingly more doctors are extremely worried
about their personal safety and dignity.
4. Problems with medical technology anduncertainty in medicine
Doctor B had roughly 20 years of work experienceand signiQicant surgical experience, but in this
scenario, he failed. Medical experts might argue thatrare surgical complications, difQicult clinicaldiagnoses, rapid disease transformation, and thepatient’s concealment of their personal behavior
caused the fatality in this hypothetical scenario. Let
us consider several points here.
First, surgery does not come with a safety
guarantee, and the risk of adverse events inevitably
exists. Due to advances in medicine and the various
procedures, we have good reason to believe thatsurgery (as well as anesthesia and prospective care)is safe enough. However, deaths and complications
arising from the technology itself or the disease itself
cannot be omitted by technology and are
unavoidable. Nevertheless, survey data [15] on in-Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
hospital mortality of surgical patients from the
National Health Commission of China show thatfrom 2016 to 2020, the in-hospital mortality ofsurgical patients in the tertiary general public
hospitals in China (8442 hospitals) has been
increasing yearly; mortality rates at private hospitals
is even higher. The Inpatient Hospital Acquired
Condition Index (IHACI) also shows an annual
upward trend; speciQically, among the 33 kinds of
IHACI, 22 kinds of IHACI including infection,b l e e d i n g , fo re i g n b o dy re te n t i o n , s u d d e npostoperative death, and a few others, showed an
upward trend. Total in-hospital mortality of patientswith IHACI was 7.43 times that of patients without
IHACI.
These phenomena should not simply be
attributed to medical errors or medical system Qlaws.
No matter how fast medical technology andunderstanding of diseases progress, and whether weare willing to admit it or not, advances in medical
technology must be regarded, Qirst and foremost, as a
double-edged sword. The perks from the healthgospel and economic beneQits brought about by
medical technology are inevitably accompanied byproblems such as over-medication, complications,and side effects, to name a few, and the occurrence of
these could very well increase due to the everincreasing complexity of the medical procedures.
According to the WHO 2022 World Health Statistics
Report [30], global life expectancy at birth increased
from 66.8 years in 2000 to 73.3 years in 2019, while
healthy life expectancy (HALE) at birth increased
from 58.3 years to 63.7 years. Life expectancy has
increased at a slightly faster rate than HALE; thediscrepancy between the two would result in aslightly larger proportion of years lived withdisability. The longer the period of disability andphysical vulnerability, the greater the challenge tothe safe use of and satisfactory outcomes given by
medical technologies. Finally, as is the case for mostthings, medical technology has its limitations. It
would be arrogant for us to assume that medical
technology can eliminate all disease and suffering in
our world. Regardless of rapid advances incontemporary medicine, human death will continue
due to disease and human tragedies. These trends
reQlect the existence of both the limitations of
medical technology and the complexity of disease
itself.
Second, the maxim that practice makes perfect is
not absolute. One early study [1] showed thatsurgical volume and perfect operation technique are
not fully proportional. Another remarkable study
showed that surgeons vary from one another intechnical skills, and that surgeon scores are highly
correlated with rates of complications, mortality,
infection, and secondary surgery. In one medical
dispute I experienced, a local doctor spent 2 hours
trying and failing to remove a short pencil that had
been stuck in a patient's hand for over 20 years,
while another doctor took less than 10 minutes toremove it successfully. In the hypothetical scenario

75

presented here, Doctor C debrided the patient's neckwound twice, but apparently did not thoroughly
explore the wound. Clearly, subjective and objective
factors can create differences in the technical skillsof doctors; these differences can be minimized only
through continuous practice.
Finally, the uncertainty of disease itself is always
a factor, and human beings have yet to overcome thischallenge. The verdict of medical malpractice
involving a patient death rarely places all of the
responsibility and blame on the doctors. Rather, it ismost often shared by the doctor, patient, and“uncertainty in medicine.” Some diseases develop
very quickly, and even doctors have difQiculty
comprehending accurately and quickly their own
disease development. In real life, just like ordinary
people, some doctors may die suddenly andunexpectedly, possibly even at work.
Conclusion
While the scenario portrayed here is Qictional, all thecomponents come from real life situations. We must
establish the rational belief that most errors arecommitted unintentionally by hardworking, welltrained individuals, and that some errors involving
complicated factors in the story are not those thatcan be prevented simply by admonishing people tobe more careful, or worse, by shaming, Qiring, orsuing them. Doctors who inadvertently caused
terrible harm to their patients due to medical
mistakes should not become the second victim of theincident, and doctor well-being and patient safety
cannot be separated at all. Patient safety isdependent upon the nation's health care resources
and their distribution, its healthcare systems,
doctor’s practice systems, and doctor and patientgroups, to name a few factors. Patient safety can also
be regarded as the result of interactions between
people, society, and the medical system. Doctors
cannot operate independently of medical system andhospital management systems [31-33].
Improving patient safety in China will require thejoint participation and cooperation of thegovernment, hospitals, doctors, and patients; this isa very arduous task. From a governmental
perspective, China’s medical system is a rare systemwith unique issues. Compared to other developed
countries and some developing countries, thefollowing problems are particularly prominent [6]:InsufQicient investment in medical resources andextremely unbalanced allocation, an incomplete
medical insurance system, low levels of medical
insurance, poor equity of medical services, a chaotic
practice system for doctors, poor quality of medicalcare, poor coordination and integration of various
interests (government, local, and medical service
provider, etc.), and conQlicts between doctors andpatients. China’s massive population, combined with
its aging population and the constraints of economic
development, make it difQicult to balance equity inmedical services and ensure the quality and quantityof medical human resources; this is an urgent

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Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

problem that needs to be addressed. All these issues
negatively impact patient safety. For the Chinese
government, resolving these contradictions not only
requires human and Qinancial resources but also
wisdom to learn from other countries, rather thansimply imitating their medical policies. China faces asigniQicant challenge in this regard.
From the perspective of hospital patient safety
management, medical quality and safety of hospitals
largely depend on the management of humanresources. This is relatively easy to control compared
to government policy regulation, and also has
immediate results. In daily clinical practice, not all
adverse outcomes are caused by medical errors, andnot all medical errors are preventable. Nevertheless,both preventable and unpreventable medical errors
must be acknowledged in order to improve patient
safety. Conventional ways of addressing medical
errors that are unscientiQic and unreasonable must
be abandoned; instead, energy should be spent moreon exploring the true root causes and on improving
the medical system. Rather than simply making
policy changes in writing, posting reminders or
addressing it only in a class setting (to say nothing ofcondemning and sermonizing doctors), our efforts
should focus more on making true and lasting
improvements in clinical settings. This may, in fact,
be the only way to control and reduce similar errors
by addressing the root causes.
Funding: This work was funded by the Ministry of
Education, Culture, Sports, Science and Technology(MEXT) Grant-in-Aid for ScientiQic Research (B)(KAKENHI 20H03922): Decision-making process
and role of health care professionals in clinicalpractice with advanced information technology(Principal investigator Seiji Bito, 2020-2023).
ConRlict of interest: The author declares nopotential conQlict of interest with respect to theresearch, authorship, and/or publication of thisarticle.
Acknowledgment: Professor Atsushi Asai at the
Department of Medical Ethics, Tohoku University
Graduate School of Medicine made excellent
suggestions regarding this manuscript.
References
1. Robert M. Wachter, Kiran Gupta. Understanding Patient
Safety[M].New York: McGraw-Hill Education,2018.
2. Zhang Yanli, Ma Guoqiang, Zhao Ji, et al. Analysis of big
data and strategy research on medical safety(adverse) events in China[J]. Chinese HospitalManagement, 2020,40(8):29-32.
3. Huang Li, Yuan Da, Peng Hua. Application and practiceof medical risk management in medical safety adverse
events[J]. Chinese Hospitals, 2022,26(1):63-64.
4. Zhang Meng, Xu Lina, Zhang Chunhua. Qualitative study
disclosing medical adverse events and errors among
medical staff[J]. Journal of Nursing Science, 2020,(35):75-77.

5. Lu Lanting, Lu Jiangzhen. Current challenges of medical
safety supervision in China and suggestions ofimprovement: based on Health Care Supervision
Committee’s experiences[J]. Chinese HospitalManagement, 2018, 38(6):38-41.
6. Zhou Yi. Comparative research on medical system
reform[M]. Xin Hua Press, 2015.
7. Ying Jiaoqian, Li jing, Wang Chenxi, et al. Comparative
Analysis of the Three-Level Rounds System andResponsible Physician Rounds System[J]. Chinese
Health Quality Management, 2021,28(2):3-5.
8. Wu Peixin, Wang Chen. Exploration and practice ofattending physician responsibility system under the
background of China’s medical reform[J].Chin J Hosp
Admin, 2021,37(6):501-504.
9. Xu Xi, Hu Xinyu, Qian Cuiyyu, et al. Practice andExploration of Attending Physician Responsibility
S y s r e m [ J ] . H o s p i t a l M a n a g e m e n t Fo r u m ,2020,37(7):36-37,53.
10. Luo Jiade, Zhang Yajue, Guo Menglun. Actors’
motivation for change and system reform, taking theimplementation of the attending doctor rounds
system in public hospitals as an example[J]. Academia
Bimestrie, 2020(2):90-99.
1 1 . Wu S h a owe i , Yu X i a oy u n , H e Z h e , e t a l .
Implementation Strategy and Thinking of Medical
Group Management System under the Attending
Physician Responsibility[J]. Chinese HospitalManagement, 2022,42(10：57-59，63.
12. National Health Commission of the People’s Republicof China. Statistical bulletin of the health anddevelopment in 2012.http://www.nhc.gov.cn/
13. National Health Commission of the People’s Republicof China. Statistical bulletin of the health anddevelopment in 2021. http://www.nhc.gov.cn/
14. http://www.who.int/data/gho/data/themes/healthworkforce.
15. Health Service, Quality and Safety Report 2021 from
National Health Commission of the People’s Republicof China[M]. ScientiQic and Technical Documentation
Press.2022.08.
16. Kitch BT, Cooper JB, Zapol WM, et al. Handoff caused
patient harm: a survey of medical and surgical housestaff.Jt Comm J Qual Patient Saf 2008;34;563-570.
17. Ying Jiaoqian, Zhang Yan, Wang Chenxi, et al.
DifQiculties Analysis and Management Strategies of
Implementation of Consultation System[J]. Chinese
Health Quality Management, 2021,28(2):06-08.
18. Bingemann TA, Laubach S. Physician well-being inallergy and immunology: Creating a culture ofwellness. Ann Allergy Asthma Immunol. 2021;
126(3):219-227.
19. Montgomery,A., Panagopoulou, E., Eamail, A., Richards,
T.,＆Maslach,C., (2019).Burnout in Healthcare: thecase for organizational change.BMJ,366,14774.
20. Prabath IHDS, Mohottala VS, Prasanni WDD,
Ranathunga RTR, Mathangasinghe Y. Health-related
attitudes, behaviors and burnout in intern medical
ofQicers and their effects on self-reported patient carein a developing country [published online ahead ofprint, 2022 Jan 7]. Ir J Med Sci. 2022:1-7.

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
21. McIntosh C (eds.). Cambridge Advanced Leaner’s
Dictionary 4 th Edition. Cambridge: Cambridge
University Press, 2013.
22. Trockel M, Corcoran D, Minor LB, Shanafelt TD.
Advancing Physician Well-Being: A Population Health
Framework. Mayo Clin Proc. 2020;95(11):2350-2355.
23. Gyimah MB, Shah HP, Lee YH. Maximizing theeffectiveness of scribes in surgical practices. Am J
Surg. 2022;223(1):208-210. doi:10.1016/j.
24. Anthony Montgomery, Margot van der Doef, EQharis
Panagopoulou, at el. Connecting Healthcare Worker
Well-Being, Patient Safety and Organisational Change.
Springer Nature Switzerland AG; 2020,p11-17.
25. TawQik DS, ProQit J, Morgenthaler TI, et al. Physician
Burnout, Well-being, and Work Unit Safety Grades in
Relationship to Reported Medical Errors Mayo Clin
Proc 2018 Nov;93(11):1571-1580.
26. Investigation and research on the doctor-patient
relationship in China - a special research report on the
fourth national health service survey[M]. Center for
Health Statistics and Information,MOH,2008.
27. Ali Sahebi, et al. Prevalence of workplace violenceagainst health care workers in hospital and prehospital settings: An umbrella review of meta-analysis
Frontiers in public health 2022 Online published
August 08.
28. Zhu H, Liu X, Yao L, et al. Workplace violence inprimary hospitals and associated risk factors: A crosssectional study. Nurs Open. 2022; 9(1):513-518.
doi:10.1002/nop2.1090
29. China Judgments Online. https://wenshu.court.gov.cn/
30. World health statistics 2022: monitoring health for theSDGs, sustainable development goals https://www.who.int/publications/i/item/9789240051157
31. Bian Lin. The theory of doctor-patient relationshipscientiQic thinking on the contradiction of doctorpatient relationship[M]. 2018.
32. Wang Xiaobo, The Construction of Harmonious
Doctor-patient Relationship in China[M].2014.09
33. Gu Jinxian, Li Daqin, Yu Shaoping, et al. Research on
doctor-patient relationship from multidiscplinary
perspective[M]. 2009.09.

77

Desperate mothers and madscientist in a divided world:
Discussions of ethical, legal, andsocial issues depicted in Kazuo
Ishiguro’s Klara and the Sun- Atsushi Asai (corresponding author)
Department of Medical Ethics, Tohoku University
Graduate School of Medicine, School of Public Health,Sendai, Japan
Email: aasai@med.tohoku.ac.jp- Taketoshi Okita
Department of Medical Ethics, Tohoku University
Graduate School of Medicine, School of Public Health,Sendai, Japan- Miki Fukuyama
Nursing, Faculty of Life Sciences, Kumamoto University,
Kumamoto, Japan- Motoki Ohnishi
Department of Health and Welfare Public Policy,
Aomori University of Health and Welfare, Aomori,Japan
Seiji Bito
Division of Clinical Epidemiology, National Hospital
Organization Tokyo Medical Center, Tokyo, Japan
Abstract
This paper discusses Klara and the Sun, Kazuo
Ishiguro’s eighth full-length novel and Qirst since his
Nobel Prize in 2017, from biomedical ethics
perspectives. The novel, set in a near-future societyof inequality, addresses issues related to intellectual
enhancement in children by means of gene editing
and social implementation of self-aware artiQicial
intelligence, which prompt readers to think deeply
about the ethical, legal, and social implications ofadvanced science and technology. Many havecommented on the novel’s diverse implications
including the nature of human uniqueness, dignity,
and soul; the anxiety of people in a highly
technological capitalist society; the prevalence of
meritocracy and scientism and resulting social
fragmentation; parents’ dilemmas as they makechoices for themselves and their children in such asociety; the ideal way to complete one’s life; and theimportance of hope and faith. In this paper, we focus
on related ethical issues that have not beenpreviously discussed: the dichotomous ‘win-lose’view of life; the blameworthiness of favoritism in an
unjust world; a better end for the protagonist of thiswork, Klara, a self-conscious humanoid artiQicial
intelligence; and the signiQicance of the notion of
persistence of self. We offer observations on these
topics and argue how we should respond toproblems brought about by advanced science andtechnology in future society.
Introduction
A great work of science Qiction (SF) offers vivid
images of possible futures. Readers can learn

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Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

valuable lessons from various issues depicted
through the portrayal of human relations, newcultural tendencies, and novel relationships between
human beings, science, and technology (Asai, Okita,
Ohnishi, & Bito, 2020). Klara and the Sun, Kazuo
Ishiguro’s eighth full-length novel and Qirst since his
acceptance of the 2017 Nobel Prize in Literature(Ishiguro, 2021), brings to light issues related togene editing (GE) for enhanced intellectual ability inchildren and social implementation of self-aware
artiQicial intelligence (AI) as matters of everyday
family life. Many critics and academic experts havereviewed this novel from diverse perspectives(Abrams, 2021; Askew, 2021; Bravery, 2021; Cain,
2021; Charles, 2021; Enright, 2021; Finch, 2021;
Gordon, 2021; Holmes and Rich, 2021; Hui and Ping,
2021; Lombardo, 2021; Maloney, 2021; Mejia &Nikolaodis, 2022; Shulevitz, 2021; Swaminathan andRavi, 2021; Yiqun 2021).
Ishiguro has dealt with the issues of humancloning and live organ transplantation in his SF novel
Never let me go from 2005, along with other issues
related to the human soul. Some referred to Never
Let Me Go as a modern Frankenstein story, claimingthat the novel depicts what might happen when, in
the race to advance science, individuals and societies
fail to fully examine the broad consequences of theirdecisions; it warns us to consider not only who will
beneﬁt but also who will suﬀer (Marchalik & Jurecic,2016). It was also argued that novels like Never Let Me
Go are thought experiments that prompt readers to
reﬂect on the human costs of scientiﬁc ambitions(Marchalik & Jurecic, 2016). We believe that thesame argument can be made for Klara and the Sun.
In this paper, we will Qirst provide an outline ofKlara and the Sun and a brief review of various
arguments published to date regarding theimplications of the novel (Table 1). We will thendiscuss important ethical, legal, and social issues
that have not yet been fully explored, including thed i c h o t o m o u s ‘ w i n - l o s e ’ v i e w o f l i fe , t h eblameworthiness of favoritism in an unjust world,
how Klara’s ending should be, and the notion of
persistence of self (continuity of a dying child’ssense of self). Finally, we will present our views onthese issues and argue how we should respond to
the problems of future society brought about by
advanced science and technology.
Outline of Klara and the Sun (Ishiguro, 2021)
The novel is set in a near-future United States.
Advances in science and technology have led to theprevalence of artiQicial intelligence (AI), pushingpeople out of employment as their jobs are replaced
by AI. Meanwhile, with the spread of GE technology,
Qinancially able parents are utilizing the technology
to improve the intellectual performance of theirchildren. GE is sometimes referred to as AGE, withno clariQication on what A stands for. Most
universities only admit “lifted” children, i.e., thosewith GE-enhanced intellectual abilities. However, GE
is not safe, and children who have undergone theprocedure fall ill or die young. “Lifted” children
receive their pre-university education at homerather than in school, with an android AI as theirartiQicial friend (AF) who they themselves pick andpurchase from a series of new models introduced
one after another. Children from less afQluent
families cannot afford an AF, and not all people are
comfortable with the presence of AFs in society andtheir daily lives. In this Qictional world, the lives ofKlara, an AF, the “lifted” child Josie, her mother, andher neighbor/childhood friend Rick unfold as a storyof encounters and goodbyes.
The main character of this novel, Klara, is a
French-like, solar-powered B2 android AI who
becomes an AF of Josie, a 14-year-old “lifted” girlwho takes a liking to Klara. Klara believes that thesun has miraculous powers, such as restoring the
lives of sick street people, based on her AI
observations and analysis. She asks the sun to saveJosie, who has fallen ill. Rick, Josie’s childhood friend,is “unlifted” but is very intelligent and has aparticular talent for science and technology,
especially when it comes to drones. They are deeply
in love and have promised to be together forever.
Josie’s mother, Chrissie Arthur, works full time tomaintain her and her daughter’s lives. She isconstantly worried about Josie’s health, as she hadlost Josie’s sister Sal to a GE-induced illness; she isvery afraid she might lose her daughter again. Paul,
Chrissie’s ex-husband and Josie’ father, lost his job
after being replaced by AI and now lives in a special
community with others in similar circumstances. He
occasionally visits Josie and his ex-wife and is
opposed to the plan that Chrissie proposes regarding
Josie and Klara. Chrissie asks Henry Capaldi to create
a portrait of Josie in preparation for her plan. Henry,
who believes that society should more positively
embrace AFs, is a pro-AF AI researcher; he continues
his research of trying to solve the “black box”
problem that is making people in society uneasy
about AFs.
Miss Helen is Rick’s mother, once a starlet but
now poor, who regrets not having given Rick GE andgrows critical of the society that only favors the“lifted.” Mr. Vance is Helen’s old lover and one of thefounding members of Atlas Brookings University, theonly university with an admission quota (2%) for“unlifted” children. Mr. Vance receives a request from
Helen concerning Rick’s future. The story of Josie’s
life and death is told against this backdrop, withportrayals of the characters and their relationships.
Through the eye of Klara, the narrator, the readers
experience human love and obsession, hope anddespair, conQlict and anxiety, the fragility ofrelationships, and the importance of trust.

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
Various discussions on Klara and the Sun
Table 1 summarizes the various perspectives andissues that have thus far been discussed regarding
Klara and the Sun. These issues may not be mutually
exclusive and are also partly related to ourarguments discussed in the following sections.
Table 1. Previously discussed themes of Klara andthe SunWhat is a human being?
What is human uniqueness?
What is human dignity?
Is there something special about each individual
human being that is unique and non-transferable?
What are differences between humans and AI?
Problems in human society brought about by advanced
science and technology
Anxieties about the future of emerging technologies
and capitalist societies
Life Qilled with dilemmas with regard to choices one
faces in an advanced scientiQic and technologicalsocietyMortal lottery and the price a child has to pay
because of his or her parent’s decision
Emergence of new social practices (e.g., interaction
meetings)
Division, discrimination, and conQlict in a dystopianworld
Divided world
Class struggle
Othering
Savage meritocracy
Other issues
Good death and ideal life completion
Skepticism about the validity of our moral intuitions
Importance of hope and faithSources: Abrams, 2021; Askew, 2021; Bravery, 2021;
Cain, 2021; Charles, 2021; Enright, 2021; Finch, 2021;
Gordon, 2021; Holmes & Rich, 2021; Hui & Ping, 2021;
Ishiguro, 2018; Lombardo, 2021; Maloney, 2021; Mejia& Nikolaodis, 2022; Shulevitz, 2021; Swaminathan &Ravi, 2021; Yiqun, 2021.
What is a human being?

Klara and the Sun poses various questions, of which
the most often discussed is what it means to be
human (Askew, 2021; Bravery, 2021; Cain, 2021;
Enright, 2021; Finch, 2021; Holmes & Rich, 2021;
Hui & Ping, 2021; Lombardo, 2021; Maloney, 2021;
Yiqun, 2021). What would happen to humanuniqueness and human dignity if AI robots were to79

exhibit intelligence like that of human beings andhave a sense of self and emotions, as Klara does?
(Lombardo, 2021). Various views on the uniquenessof individuals are expressed by Chrissie, Henry, Paul,and Klara when they discuss the plan to transfer
Josie’s whole inner life to Klara in the event of her
death (“Continuing Josie” project). Does each humanbeing have something special about them, such as aunique and un-transplantable “soul”? Is there an
essential difference between humans and AI (Askew,
2021; Bravery, 2021; Finch, 2021; Hui & Ping, 2021;
Lombardo, 2021; Maloney, 2021; Yiqun, 2021)?
These are questions of replication and authenticity(Enright, 2021). Science and technology canpotentially change our perception of what it means
to be human (Enright, 2021). In this regard,questions have been raised as to whether it is thesystematic memory, or the ability to love others
freely, that makes us human (Bravery, 2021; Hui &Ping, 2021; Lombardo, 2021). Lombardo argued thathumans can maintain their dignity and humanity as
far as they would never cease being able to love,even when they contradict the logic of efQiciency, i.e.,the social logic of order and control (Lombardo,2021). However, if Klara, transferred into a bodywith an appearance no different from Josie’s, could
play Josie perfectly, both Chrissie and Paul mightlove Klara with all their hearts.
Problems in human society brought about by
advanced science and technology
Klara and the Sun prompts us to face our own
anxieties about the future of emerging technologies(Mejia & Nikolaidis, 2022). In the novel, as social
implementation of AI becomes more extensive,
people’s fear of unemployment grows. It is alsosuggested that, with the spread of GE technology,
more parents who are Qinancially able to afford GE
opt for “lifting” their children so that they would not
be replaced by AI in the future, as Paul was (Enright,
2021; Gordon, 2021; Lombardo, 2021; Shulevitz,
2021). However, parents face a serious dilemmabecause it is a mortal lottery for the children, giventhat GE is associated with serious physical risks
including death (Bravery, 2021; Hui & Ping, 2021).
The risk of death in children is the parents’ greatest
anxiety and fear. GE exposes Josie to a childhood of
illness with the possibility of eventual death. In fact,
Josie’s sister Sal died because of GE. According toGordon (Gordon, 2021), the parents in the novel face
this terrible dilemma of whether to have theirchildren be “lifted” and risk losing them in the end or
refuse the idea and suffer the consequence oflimiting the prospects of their children’s success.
Josie’s mother is tormented by never knowing if she
had made the right decision (Gordon, 2021).
Parents’ motives for “lifting” their children, apartfrom their desire to provide a better future for theirchildren, are partly selQish, e.g., to maintain theircurrent social status, or to conform their children to
their own values and beliefs. In either case, theirchildren will pay the price for their decisions

80

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)(Askew, 2021; Finch, 2021; Shulevitz, 2021). The
development of advanced technology has
transformed the parent–child relationship, and thechild suffers a greater harm and risk due to theparent’s decisions (Askew, 2021; Enright, 2021;
Finch, 2021; Shulevitz, 2021). Had there been no GE,
parents would not have to decide whether to “lift”
their child, nor would they have to worry aboutlosing their child because of GE. Similarly, with no AF
available, there is no need to ponder whether tocreate a substitute existence for a child lost to GE, or
to worry about their ability to love that substitute.
New social practices are emerging in the novel(Abrams, 2021; Finch, 2021). School systems as weknow them today have disappeared as AFs like Klara
are employed to care for children, and advanced
tutoring for “lifted” children is provided online.
There is also a practice to improve communication
skills in children, although it is only offered to those
who are “lifted” (“interaction meeting”). However,
the impact of GE on the personality development of“lifted” children is unknown, as are the effects of
exclusive interaction meetings. There is concern that
GE may reduce human communication ability, thelong-term effects of which requires carefulmonitoring.

intellectual capacity or economic power, the moreable may bully, discriminate against, and belittle theless able, resulting in conQlict and struggle between
them (Askew, 2021; Shulevitz, 2021). Liu and Yanargue that human beings, as Qlesh and blood
creatures, are brutal, and people are divided into
different levels of hierarchy according to differencesin their genetic sequences (Hui & Ping, 2021). Kazuo
Ishiguro said in his Nobel lecture in 2017,‘And around the corner – or have we alreadyturned this corner? – lie the challenges posed bystunning breakthrough in science, technology andmedicine. New genetic technologies – such as thegene-editing technique CRISPR – and advance in
ArtiQicial Intelligence and robotics will bring us
amazing, life-saving beneQits, but may also create
savage meritocracies that resemble apartheid, andmassive unemployment, including to those in thecurrent professional elites (Ishiguro, 2018).’
Ishiguro’s awareness of the issues, asemphasized in his 2017 speech, are embodied in
Klara and the Sun. There is a fear that thedevelopment of science and technology and theincreasing dependence on them might exacerbate
merit-based evaluations and scientism in our society(Asai, Okita & Enzo, 2016).

Division, discrimination, and con@lict in adystopian world
The third issue relates to the social division,
discrimination, and conQlict caused by the widening
gap in the world of advanced science and technology
and capitalist society, as depicted in Klara and theSun. Some have pointed out that such division,
discrimination, and conQlict have already been
occurring in our present world (Askew, 2021;
Bravery, 2021; Lombardo, 2021; Maloney, 2021;
Mejia & Nikolaidis, 2022; Marchalik & Jurecic, 2016;
Shulevitz, 2021). For example, the “lifted” world canbe compared to a caste system (Bravery, 2021), with“unlifted” individuals being described as Pariahs(Shulevitz, 2021). Moreover, parents of the “lifted”
and “unlifted” (i.e., Chrissie and Helen, respectively)
are considered to belong to different social
hierarchies (Hui & Ping, 2021; Mejia & Nikolaidis,2022). Helen regrets not having had her son Rickundergo GE, even after witnessing the death of Sal,
her neighbor Chrissie’s oldest daughter, and Josie
being very ill because of GE (Gordon, 2021). This isbecause the very fact that Rick has not been “lifted”
almost entirely closes off the possibility of his
studying in college, regardless of his ability.
There are two types of AFs, B2 and B3, with thelatter trying to take over the former. Klara isdistinguished from humans and sometimes treatedas an object. Josie and Rick go their separate ways
because of their GE treatment or lack thereof. In
their world, everyone perceives others who
essentially differ from them as belonging to adifferent group (Othering) (Maloney, 2021; Mejia &Nikolaidis, 2022). If the hierarchy of people is basedon their ability – whether it relates to their

Other issues
Some have noted the importance of good death andcompletion of life, skepticism about the validity of
our moral intuitions, and the importance of hopeand faith (Abrams, 2021; Mejia & Nikolaidis, 2022;
Swaminathan & Ravi, 2021). Klara and the Sun issaid to teach readers a lesson about aging and death:when Josie leaves home for college, Klara, no longer
needed, is abandoned like garbage in the junkyard
where she slowly falls apart. However, it is stated that
Klara achieves gratiQication and a sense ofcompletion at the end of her life through a life
review and mental summation (Abrams, 2021).
Regarding the skepticism about the validity of
our moral intuitions, some pointed out that Klara
regarded the sun as an omnipotent personal deity
and argued that the faith is strange, and we might
agree with the oddity of this belief (Mejia &Nikolaidis, 2022). To what extent are our establishedmoral intuitions merely the upshot of the particular
Qlesh and blood from which we are made? Are ourmoral values shaped by our Qlawed social settings or
the caprices of natural selection (Mejia & Nikolaidis,2022)? Doubts about Klara’s “sun worship” may also
lead to similar questions about our faith and its
significance, importance, and moral legitimacy incontemporary society.
Finally, some commentators interpreted that
Klara’s wishes have come true and the sun actually
saved Josie’s life: “What has been medically declared
to be a hopeless case, ends in miraculous recovery,
thanks to Klara’s faith, hope and conviction in thehealing touch of the Sun. Klara gets the Sun to visit
Josie’s chamber to pour out his special energy, not bycomprehending the impulses and desires of Josie

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
and not deQinitely by rational thinking, but by
unshakable, blind faith in the Sun as the elixir of life.
In the battle between Faith and Rational thinking it
is not rationality but faith that wins (Swaminathan &Ravi, 2021).” Of course, it is also possible that Josie’s
recovery was a natural process unrelated to the sun’s
power, or that the event was unrelated to Klara’s
actions, although the rays of the sun were beneQicial
to her recovery. The facts remain unclear, but for
Klara, this is the most signiQicant event of her life. A
life lived with hope and faith may be a happier one
than one without.
Additional discussions from new perspectives
This section discusses Klara and the Sun from four
new perspectives, presenting issues that have notbeen uncovered in previous reviews of the novel.
Relevant statements of the main characters are citedin the text.
The dichotomous win-lose view of life
Toward the end of the story, as Josie’s condition
worsens, her doctor, Chrissie, and Rick gather toprepare for her death. Chrissie, believing that Josie’s
death is unavoidable, says to Rick,‘I’m asking you, Rick, if you feel like you’ve comeout the winner. Josie took the gamble. …But you, Rick,you played it safe. So that’s why I’m asking you. How
does this feel to you just now? Do you really feel likea winner?’ (Ishiguro 2021, p280)
She continues,‘What is it you’ve won? Take a look at yourfuture. You played for low stakes and what
you’ve won is small and mean. You may feelpretty smug just now. But I’m here to tell you,you’ve got no reason to be feeling that way. No
reason at all.’ (Ishiguro, 2021, p281)
This scene describes Chrissie speaking extremely
harsh words to Rick, who has loved and cared for
Josie almost all his life and deserves no such
criticism. Although GE is a post-birth intervention,
Rick himself had no choice (because GE is performed
when a child is very young). In addition, it is very
likely that Helen did not have the Qinancial means togive Rick GE. This brief exchange completely
destroys Chrissie’s relationship with Rick and leaves
Rick with a psychological scar that would never heal.
We think that it is unfortunate that people view andjudge their lives solely based on whether they had
GE or not. We wonder if Chrissie really believes it isbetter to die from GE’s side effects than to live an“unlifted” life.
What led Chrissie to say those words to Rick?
How has this worldview of winners vs. losers been
instilled in her? Chrissie appears to have developed aview of life that is so incredibly strong that, evenafter losing her Qirst child (Sal) because of GE, shegave GE to her second child (Josie). We believe that
she was brainwashed by the savage meritocracy
brought about by advanced science and technology(Ishiguro, 2018; Marchalik & Jurecic, 2016). Indeed,81

her cognitive style and thought processes appear tohave developed under the inQluence of scientism,
meritocracy, and the caste system established in thenovel. Other possible factors are her desire as aparent to have excellent children; pressure of being“right” in parenting (peer pressure); decisions she
has made because she truly cared for her children;and blindness to the risks due to her cognitive bias.
We also suspect that it was her strong worldview
that led her to think she ‘sensed’ Josie’s desire for GE
when she held her for the Qirst time. This claim, that
she had this intuition, served as justiQication for her
decision to give Josie GE despite the grave risks.
Naturally, this scene makes us wonder what itmeans to ‘win’ or ‘lose’ in life and to consider
whether our present thought processes too havebeen affected by scientism and meritocracy, whether
we are aware of it or not. Is there such a thing as
winning and losing in life? Are the rules of this game
fairly and publicly determined in accordance with
due process of law (i.e., are there clear and fair rules
to decide who wins and who loses?), and do allparticipants follow these rules? We would say “No.”
If the purpose of life is to be a winner, people arelikely to be unhappy because there is only one No 1
winner, and his/her position as a winner is only
temporary. There is no comfort in life in which
others are considered adversaries, and one ishaunted by the fear of losing all the time. It can beargued that we should abandon uniform standardsof evaluation, which are opposite of diversity invalues if we wanted to lead a happy and comfortable
life.
More to the point, is happiness in life promised
to the “lifted,” including Josie? We doubt it is. No one
knows what the future holds. Children who had GE
may be considered winners in terms of theirintellectual excellence, but there is a price to pay: thelack of empathy (as exempliQied by Josie’s attitude
toward Klara). Their attitudes can be regarded as
selQish and immature, like those of young children.
The lack of empathy and egocentric traits make“lifted” children feel isolated, and this has asigniQicant impact on the future society they build.
Thus, there is a fear that a society that judges people
as winners or losers solely based on theirintellectual excellence (e.g., a society dominated bygene-edited human beings) will decline in the longrun.
All three themes listed in Table 1 are condensed
in Chrissie’s statements. One might say that it ishuman nature to strive to win, dominate, or be thebest. The effects of advanced science and technology
will make disparities clearer and continue to widen
existing divisions. It may also be true that there is anatural inclination in human beings to discriminate
against others who are different, especially thoseperceived as inferior to them.
In the novel, all universities except for Atlas
Brookings University do not accept “unlifted”
children, and even at Atlas Brookings University, therate of admission is only 2%. Also, considering that

82

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)“unlifted” individuals are forced out of jobs, one
would think that everyone who would opt for GE. We
think that Chrissie is a desperate mother andhumans are vulnerable. We need a society thatwould not hunt down these individuals, or a society
where no one feels compelled to say horrible things
that should never be said to others. We must avoid
the domination of savage meritocracy that has lostthe value of diversity (Marchalik & Jurecic, 2016;
Ishiguro, 2018). We must create a world in whichpeople can live happily and are not disadvantaged,
even if they don’t share the same values (i.e., striving
for achievement or being a winner).
Blameworthiness of favoritism in an unjust world
Helen wants her son Rick to go to college to cultivate
his talent in drone technology and expand his future
possibilities. She and Rick visit Mr. Vance, an
executive at Atlas Brookings University, which is the
only university that accepts “unlifted” children.
Helen and Mr. Vance were once romanticallyinvolved and lived together for several years. Atlas
Brookings University has a 2% admission quota for“unlifted” children; the remaining 98% is reserved
for “lifted” children. Mr. Vance is impressed by Rick’s
talent but asks Rick what he would like him to do,noting that the admission process at Atlas Brookings
University is conducted fairly. When Rick hesitates toanswer, Helen says:‘I'm going to answer this one for him, Vance.
Yes, we are asking you for a favor…. It’s for me,
not you (Rick), to ask Vance. And we are asking
him to exercise favoritism. Of course, weare.’ (Ishiguro, 2021, p250)
Helen’s plan fails because of her statement andthe way she treated Vance in the past. Nonetheless,the blameworthiness of favoritism that Helen
expects Vance to show in this scene warrants someconsideration. University entrance examinations
should be strictly fair; there must be no “backdoor”
admission or preferential treatment of certain
applicants. However, in the world of Klara and theSun, the university admission system itself is unfair
and discriminatory in that all but one university
accept no “unlifted” children. Even Atlas Brookings
University is discriminatory in the sense that“unlifted” children have only a 2% admission rate. As
Kasuzo Ishiguro noted in his speech, advanced
science and technology (i.e., GE) “create savage
meritocracies that resemble apartheid” (Ishiguro,2018).
An unfair world justiQies unfair behavior, or atleast, such behavior is not strongly condemned:
discrimination, however, is wrong and should becondemned. Universities treating “unlifted” children
who excel at academics and have the aptitude forstudy differently and unfavorably simply because
they are not “lifted” is unacceptable. In such an
unjust society, favoritism is not automatically to be
blamed. For Helen, asking Vance to show favoritism
toward Rick was an act of survival, rather than aselQish act of injustice. Helen is a desperate motherjust like Chrissie. A society that produces suchparents must be changed.
What is a better ending for Klara?
A few years after recovering from her lethal
condition, Josie sets off for university far from home,
and Klara, who Qinished her role as Josie’s friend,
spends most of her time in the storage room in
Chrissie’s house. One day, Henry Capaldi visits Klara
and asks if she would volunteer for “vivisection”; hewants to know if Klara would allow him to dissect
and analyze the central part of her artiQicial brain. He
explains it is for research purposes and to solve the‘AI black box problem’ that has long made society
uneasy and hesitant to accept AFs. However, Chrissie
rejects this offer outright.
‘No, Henry, you don’t. Klara deserves better. She
deserves her slow fade.’ (Ishiguro, 2021, p298)‘Slow fade,’ as Chrissie puts it, may sound good toreaders, but it is in fact a lonely death in the
junkyard, rotting away bit by bit. Of course, Klara has
no fear of loneliness or death and may even Qind
meaning in her life as she dies alone, feeling satisQied(Abrams, 2021). It is hinted that other AFs are
similarly consigned to the junkyard. However, a bigquestion arises as to whether slow fade is a good
way of dying or ending life for Klara. Or would
undergoing “vivisection” for the cause of greatersocial acceptance be a better option for AFs?
Brain vivisection and slow fade are equally unfair
to Klara. There should be a better end for AFs when
they complete their role. Henry, a mad scientist, has
no respect for Klara and treats her like an object. Is
Klara as good as a “vacuum cleaner” to him? We do
not know what would happen to Klara after her
central computer system is subjected to detailed
investigation, but the fact that Henry goes throughthe trouble of asking Klara such a favor suggests that
he regards Klara as a mere object that can be
expended for the sake of scientiQic progress.
What is the appropriate end for AFs that fulQilled
the role of a friend to “lifted” children? If Klara were
to agree to undergo vivisection, would her consent
be valid? Her ability to decide whether to consent orrefuse the procedure might be limited given thenature of the program. Klara has a sense of self andemotions, and while it is debatable whether sheshould be considered a person based on this fact, sheshould not be subject to the abuse of being treated asa mere object, even as an artiQicial robot. Therefore,
neither of the two endings is acceptable. Then, whatis the best way for Klara to meet her end? This
question warrants careful consideration, as it also
touches on how to deal with AFs that had no buyer
until the end. This question, at least, needs to bepondered in advance, before AF appears.
In order to address problems related to AFs’appropriate end, we need to Qirst answer the broader
and more basic question of what general attitude
humans should take toward AFs. We believe thatwhen a being like Klara, who has consciousness andEubios Journal of Asian and International Bioethics 32(3) (May 2022)
feelings of independence, appears in human society,an important issue is how to respect such a nonhuman being. Klara has a clear and pure purposeand mission to cure Josie, even at considerable cost.
Klara is the most idealistic and sublime being in thenovel. She does not deserve to be treated as an
object or a slave, like the “lifted” children did in theinteracting meeting. Although many of the main
characters initially treated Klara as an object tovarying degrees, they came to understand her
devotion and love for Josie and learned to respect
her. Developing respect through relationships withothers is important at any age for everyone,
anywhere; this is one of the valuable insights we gainfrom the novel.
Continuity of a dying child’s sense of self (themissing perspective in the “Continuing Josie”
project)
Chrissie, unable to bear the thought of losing both
Sal and Josie because of her decisions, plans to ask
Henry to create an AF shell mimicking all of Josie’s
external characteristics and implant Klara’s central
nervous system, a computer system that perfectly
copies Josie’s central nervous system, into it. Henrysays to Klara,‘Klara, we’re not asking you to train the new
Josie. We’re asking you to become her…
You’re not being required simply to mimic
Josie’s outward behavior. You’re being asked tocontinue her for Chrissie. And for everyone wholoves Josie.’ (Ishiguro, 2021, p209)
Henry believes that all human internal elements
can be completely transplanted into an AI program.
While there is the idea that each human being has
something special about them, which is unique tothat individual and can never be transferred toanything else, we are not concerned with the ‘soul’ ofhuman existence; rather, here we focus on the fallout
from the “Continuing Josie” project.
First, we think that Josie’s fear of death will not
disappear because, whether the project succeeds or
fails, Josie would still die young. Whatever it is thatmakes each individual unique, the continuation of anindividual’s sense of self is essential. For example,
cloning oneself from one’s own cells would not makemuch sense to those who do not want to die. In
addition, we wonder what would happen to Klara’s
sense of self when the “Continuing Josie” project iscompleted. In any case, if Josie’s sense of self is notcontinued, Henry’s plan to continue Josie through an
AF is meaningless to dying Josie.
One might view that the purpose of the“Continuing Josie” project is to help Chrissie, andthat there is no need for consideration of Josie.
However, such a view may lead to a disregard for
Josie’s life. If there is always a replica or an AF
substitute, parents might not hesitate to choose togive risky GE to their children or give up treating thesick child prematurely. It is also unacceptablebecause the project disregards Klara’s original andordinal program function. We must remember that83

her emotions as well as her appearance should bevalued.
We also believe that this project is an affront toJosie’s life. Chrissie fails to recognize the fact that her
child is a human being with an independent
personality and life. Moreover, had the “Continuing
Josie” project been implemented, what Klara would
be able to reproduce is based on her limited timewith Josie; she would not be able to reproduce thechanges Josie has undergone as she grew up, i.e.,
Josie’s history as a person, nor would she be able toreproduce what Josie has felt with her Qive senses,
such as temperature, smell, and atmosphere. In thisregard, the project can never be a complete success.
GE intervention and the “Continuing Josie” projectboth leave no room for mutual respect between
Chrissie and Josie, or the emotional connection thatis supposed to develop between a parent and childover time. In fact, there appears to be a constanttension in their mother–daughter relationship,
undermining the nurturing of healthy and pureaffection between the two.
Conclusion
At the end of the story, Klara meets the former
manager of the AF store where she was exhibitedand sold and describes her experiences at Josie’shouse. Klara’s answer to the question of what is
unique and non-transferable about everyone is
described, as follows:‘Mr Capaldi believed there was nothing special
inside Josie that couldn’t be continued. He told
the Mother he’d searched and searched andfound nothing like that. But I believe now he
was searching in the wrong place. There wassomething very special, but it wasn’t inside
Josie. It was inside those who loved her. That’s
why I think now Mr Capaldi was wrong and I
wouldn’t have succeeded.’ (Ishiguro 2021,
p306)
Social trends in the world of Klara and the Sun
undermine “something special inside those who
loved her.” This is because GE diminishes the abilityof “lifted” children to communicate with others, andsince the division due to GE gives rise todiscriminatory feelings in those children (i.e., they
do not see an individual as an individual), they fail tocultivate sound relationships with others. The AF
upgrade from B2 to B3 is another possible factor
that might have led to reduced empathy in “lifted”
children, negatively affecting their ability to form
friendships. Because of GE, Sal died; Josie got sick;Paul left Chrissie; and Rick and Josie lost something
special that they had once shared. More to the point,even if there is something special inside each person,
we will never Qind that special something in others if
we only focus on the results brought about by GE or
advanced science and technology. We do not know if
there is something special about us that is uniquely
human. We do not think this question is of great
importance in human life, but at least Klara’s view is84

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

correct: we must value the ‘special something’ weQind in others.
How should we address the various problems
brought about by advanced science and technology
in future society, as depicted in Klara and the Sun?
We should pay attention to not only the beneQits ofadvanced science and technology but also their
negative consequences, unintended or expected, as
well as moral failures at the time of technologicaldevelopment (Ishiguro 2018). We must not forget
the importance of human emotions and wisdom, in
addition to knowledge and intellectual ability. It is
not his or her social class or intellectual level thatmakes the relationship with that person special.
Finally, we should aim for a society in which all
beings with feelings and self-awareness arerespected and protected, even if they are not human.
When feeling weak or driven by fear and anxiety,human beings are prone to do foolish things thatthey may regret later and/or are harmful to others.
Unjust evaluation and selection of people should be
eliminated, and uniformity and mechanistic ways oflooking at things must be discarded. No one shouldbe allowed to treat AFs in a less than courteous
manner.
Japanese novelist Shinya Tanaka once wrote in an
essay, “It is often said that a writer is a canary in acoal mine ... they used to regard a writer as a person
who senses danger earlier than others. A writer
plays the role of quickly snifQing out any changes andputting them into words (Tanaka, 2017).” Klara andthe Sun predicts irrevocable social changes brought
about by advanced science and technology, including
genetic engineering and AI science, and warns usthat they may further damage precarious humanrelationships and fragile solidarity that we havemaintained throughout humanity. Klara and the Sun
will certainly become one of the most important
literary works in the Qields of science and technology
and biomedical ethics.
Statements and Declarations
Competing Interests: The authors declare neither
potential Qinancial nor non-Qinancial conQlicts ofinterest with respect to the research, authorship,
and/or publication of this article.
Funding: This work was funded by the Ministry of
Education, Culture, Sports, Science and Technology(MEXT) Grant-in-Aid for ScientiQic Research (B)(KAKENHI 20H03922): Decision-making process
and role of health care professionals in clinicalpractice with advanced information technology(Principal investigator Seiji Bito, 2020-2023).
References
Abrams, Robert C. 2021. Klara and the Sun: Kazuo
Ishiguro’s new model for “completion” at the end oflife. Journal of the American Geriatrics Society.,
Retrieved July 1, 2022 from https://doi.org/10.1111/
jgs.17547
Asai, Atsushi, Taketoshi Okita and Aya Enzo. 2016.

ConQlicting messages concerning current strategies
against research misconduct in Japan: A call for ethicalspontaneity. Journal of Medical Ethics 42(8): 524-7.
Asai, Atsushi, Taketoshi Okita, Motoki Okita, and Seiji Bito
2020. Should We Aim to Create a Perfect Healthy
Utopia? Discussions of Ethical Issues Surrounding
the World of Project Itoh’s Harmony. Science andEngineering Ethics 26 (6): 3249-3270, https://doi.org/
10.1007/s11948-020-00269-3
Askew, Kido, R. 2021. Kazuo Ishiguro, Klara and the Sun.
Social System Study (Shakai ShisutemuKenkyu) 43:
181-185.
Bravery, Hari. 2021. Review: ‘Klara and the Sun’ by Kazuo
Ishiguro. Cherwell, April 5th. Retrieved July 1, 2022
from https://cherwell.org/2021/04/05/review-klaraand-the-sun-by-kazuo-ishiguro/Cain, Hamilton. 2021. Klara and the Sun by Kazuo
Ishiguro. Harvard Review Online April 13, 2021.
Retrieved July 1, 2022 from https://
harvardreview.org/book-review/klara-and-the-sun/Charles, Ron. 2021. In Kazuo Ishiguro’s ‘Klara and theSun,’ a robot tries to make sense of humanity.
Washington Post, March 2.
Enright, Anne. 2021. Book of the day. Klara and the Sun by
Kazuo Ishiguro review – what it is to be human. The
Guardian, March 19.
Finch, Charles. 2021. Review: Kazuo Ishiguro’s new novel
is one of his very best. Los Angeles Times, February 24.
Gordon, Edmund. 2021. Faith in the Bildungs-robot. TLS(Times Literary Supplement), March 5, Issue 6153.
Holmes, Chris, and Kelly M. Rich. 2021. On rereading
Kazuo Ishiguro. MFS Modern Fiction Studies
67(1):1-19.
Hui, Liu, and Yiqun Ping. 2021. Analysis of Klara and theSun from the perspective of defamilarization. Higher
education of social science 21(2): 39-42.
Ishiguro, Kazuo. 2018. My twentieth century evening andother small breakthroughs. The Nobel Lecture. Tokyo:
Hayakawa-Shobo.
Ishiguro, Kazuo. 2021. Klara and the Sun. London: Faber
and Faber.
Lombardo, William. 2021. Losing Ourselves. The New
Atlantis, 65, 110-116. Retrieved July 1, 2022 fromhttps://www.thenewatlantis.com/publications/losing-ourselves
Maloney, Iain. 2021. In ‘Klara and the Sun,’ Kazuo Ishiguro
questions what it means to be human. The Japan
Times, March 20.
Marchalik, Daniel, and Ann Jurecic. 2016. From literature
to medicine. Kazuo Ishiguro’s uncanny science. Lancet
387(10026): 1365.
Mejia, Santigo, and Dominique Nikolaidis. 2022. Throughnew eyes: ArtiQicial intelligence, technologicalunemployment, and transhumanism in Kazuo
Ishiguro’s Klara and the Sun. Journal of Business Ethics
178, 303–306. Retrieved July 1, 2022 from https://l i n k . s p r i n g e r. c o m / a r t i c l e / 1 0 . 1 0 0 7 /s10551-022-05062-9
Shulevitz, Judith. 2021. The Radiant Inner Life of a Robot.
Kazuo Ishiguro returns to masters and servants with astory of love between a machine and the girl she
belongs to. The Atlantic April (2021, March 2)

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
Retrieved July 1, 2022 from https://www.theatlantic.com/magazine/toc/2021/04
Swaminathan, Bavetra, and R. Ravi. 2021. Hope, faith, love,
human and humanoid: A study of Kazuo Ishiguro’s
Klara and the Sun. Science, Technology andDevelopment 5 (May): 295-301.
Tanaka, Shinya. 2017. The theory of solitude. Run away andsurvive. Tokyo: Tokuma Shoten.
Yiqun, Xiao. 2021. Discussions of Emotions: Symbols on
Kazuo Ishiguro’s Klara and the Sun. Bungei Hyosho
Ronshu 9: 1-20.

Urgent care services: An initiative
towards combating non-emergent
emergencies in Karachi, Pakistan- Kiran Karim Jivani

Aga Khan School of Nursing and Midwifery, Karachi,
Pakistan
Email: kiranjivany@gmail.com- Aamna Nazish Iqbal
Department of Family Medicine, Aga Khan University
Hospital, Karachi, Pakistan- Arusa Lakhani
Aga Khan School of Nursing and Midwifery, Karachi.
- Unab Khan
Department of Family Medicine, Aga Khan University
Hospital, Karachi, Pakistan
Background
Lower middle-income countries (LMICs) such as
Pakistan face considerable challenges in the healthsector. From high maternal and neonatal mortality
rates of 14.47% and 4.2%, respectively, (Hanif,
Khalid, Rasul, & Mahmood, 2021; Pakistan
Demographic and Health Survey, 2019) and thephenomenon of ‘brain drain’ in which highly skilled
health professionals choose to move abroad for
greater quality of life and work opportunities,
Pakistan has gone through it all. Quality andaccessible health is yet a luxury for a common man
here. In addition, several natural or man-madetragedies strike Pakistan each year, putting thehealthcare system to the test. The global pandemic
no doubt posed a huge burden on healthcare in ourcountry making the Emergency departments on theverge of crowding and eventually missing thepatients that needed the facility and resources in the
Qirst place (Atif & Malik, 2020). Pakistan's primary
healthcare infrastructure is widespread, withapproximately 5000 basic health units (BHUs), 600
rural health centers (RHCs), and 7500 other primarycare institutions supported by a network of tehsils
and district-level secondary and tertiary care
hospitals for referrals (World Health Organization,2022), but unfortunately, the facilities are not fully
functional, lack access and resources, with few
clinically competent healthcare professionals.
According to Husseni and Ullah (2019), a tertiarycare hospital in Lahore handles 3000 people in the85

emergency room with a capacity of just 2000 beds;
additionally, another tertiary care hospital handles
500 patients with an actual bed capacity of only 80
beds. As a result, many emergency room admissions
are for mild ailments, highlighting the need forurgent care services.
The idea of Urgent Care Services (UCS) is novel toour part of the world; however, this has been
introduced to many countries quite a few years back(Javed & Ilyas, 2018). There is, in theory, a Qine line
between emergent and urgent care. An emergency islife-threatening or need immediate care, whereas anurgency necessitates urgent services but is not lethal
or life-threatening. In practice, nonetheless,emergency departments deals both emergent andurgent cases (Roy et al., 2020) that causes the
detrimental impact on patient care caused by ER
overcrowding, such as medication errors, increased
death rates, and a lack of efQicient care (Husseni &Ullah, 2019). The reformation of segregation
between emergent and urgent care departments is a
new global challenge (Turner et al., 2015). The
American College of Emergency Physicians (ACEP)
deQines an overcrowded ER as one where there is agreater demand for emergency care than there areresources to meet that demand (American College ofEmergency Physicians, 2018). This assertion afQirms
that this issue is being faced by practically all ofPakistan's major tertiary care hospitals. Medical
urgencies and emergencies can strike at any timeand in any place. According to research, 90% of
morbid conditions can be resolved by sustainably
establishing community-based primary care
physician-led teams (Hyder & Razzak, 2013) whichevidently highlights the need of UCS.
Need for urgent care services
According to studies from Canada, the United States,
Australia, and the United Kingdom, the need for
emergency care is increasing by 3% to 6% per year
(Di Somma et al., 2015; Nicholl & Mason, 2013).
More people are visiting emergency rooms, withannual increases of up to 5% in Belgium, 8.5% inEngland, and 10% in New Zealand (Karam, Tricas,
Darras, & Macq, 2016; Parkinson, Meacock,
Checkland, & Sutton, 2021; Tenbensel et al., 2017).
However, current evidence indicates that in Belgium,
the United States, Iran, and Jeddah, 56%, 20%, 64%,
and 65% of these visits to the Emergency
department were non-urgent , respectively(Bahadori, Mousavi, Teymourzadeh, & Ravangard,
2019; Bakarman & Njaifan, 2014; Uscher-Pines,
Pines, Kellermann, Gillen, & Mehrotra, 2013).
Urgent emergency room visits, also known as
inappropriate or avoidable ED visits, do not require
intensive intervention and typically range fromdesignated triage classiQication to self-perceived
urgency, making comparison estimates difQicult(Baier et al., 2019). High rates of non-urgent ED
visits result in overcrowding, prolonged waitingtimes, unpleasant patient outcomes, and Qinancial
losses for service providers (Kraaijvanger, Van

86

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

Leeuwen, Rijpsma, & Edwards, 2016). In the United
Kingdom, the need for urgent care services is rising,as evidenced by a 46% increase in attendance
between 2006 and 2013. In addition, the number of
ambulance calls increased from 4 million in
1994-1995 to 9 million in 2014-2015, while in the
United States, the number of calls ranged from
16,000,000 in 2006 to 28,004,624 in 2009 (Coster,
Turner, Bradbury, & Cantrell, 2017). Nonetheless,there is a gap in the literature regarding the need forurgent care facilities in South Asia, notably inPakistan; however, Pakistan is also not exemptedfrom this danger.
Urgent care versus emergent care
Several developed countries are currently
implementing the concept of urgent care systems intheir hospital settings, which are deQined as an
outpatient or ambulatory care provided outside of aconventional emergency room in a hospital. Medical
ofQicers and family physicians in communities are
the Qirst responders to any medical emergent or
urgent situation that arises. A study has found thatthe growing elderly population requiring complex
care, as well as patients bypassing their primary care
physicians and going straight to the ER after
clinic hours, contribute to the increased demand for
emergency care services (Leonard et al.,2014). People have been reported to choose
emergency care for a wide range of reasons, which
may contribute to the rising demand for these
services. These reasons include perceived highly
satisfying treatment in the hospital, poor
accessibility to certain other services, theassumption that the issue was too severe to require
emergency treatment, and ignorance of otherservices (Arain, Nicholl, & Campbell, 2013; Coster etal., 2017). Therefore, it is imperative to think beyond
the conventional way of providing services to the
population and create other appropriate settings to
respond to the need in a timely and resourceefQicient manner.
Establishing an urgent care service
To meet the requirement of timely assessment of anurgently sick patient and implement the evidence
into practice, one of the Qinest medical institutes The
Aga Khan University, Hospital, Family Medicine
department in Karachi, Pakistan has initiated the
Qirst family physician-led Urgent Care Services (UCS)
at a tertiary setting that covers urgent care needs
and has channelized the segregation of cases fromemergent to urgent to cases requiring only clinic
visits. The effort aimed to lessen the ER burden,
provide cost-effective care, track continuity of careand follow-up, and provide convenience to patientsby being available 24/7. This is a four-bed facility
with one medical ofQicer, one registered nurse, andone nursing assistant per shift. After a thoroughneed assessment and baseline, the operational plan
was completed, before the execution, the relevant
employees had extensive training that included

workshops on triaging system, basic critical care,disease management pathways, scenario-based
evaluations on triaging, ER collaboration andacquisition of skills like communication, decision
making, laboratory interpretations, andadministration of emergency medicines whilst in theER, and Advanced Cardiovascular Life Support(ACLS) credentialing. However, during the
preparation, the project team addressed a few
challenges that were faced including recruitment
and acquisition of training to Qill the knowledge andskills gap in staff, staff concern of working in shifts, alack of space that would cause patients to wait, andhigher costs than the usual primary care clinics.
The facility has employed the Emergency
Severity Index (ESI) tool to categorize patients basedon their severity. The following are the ESI triage
levels: ESI-1: immediate life-saving intervention isrequired, ESI-2: high-risk situation, disorientation,
severe pain, or vitals in danger zone necessitating
immediate care, ESI-3: Urgent care involving the useof multiple resources such as lab investigation, IV
Qluid, IV medications, ECG, but vitals are not in
the danger zone. ESI-4: non-urgent therapeuticinterventions requiring only one resource tostabilize the patient, and ESI-5: non-urgent visit
requiring no resources to stabilize the patient.
Patients with ESI-1 require prompt intervention,
whereas patients with ESI-2 to ESI-5 are anticipatedto undergo medical evaluation and treatment within
15, 30, 60, and 120 minutes, respectively (Jordi et al.,2015).
The patients are either directly seen in UCS or
are referred to UCS via ER triaging system based on
their ESI Score. The cases that fall under the
category of ESI-3 to ESI-5 are admitted at UCS,
assessed and observed thoroughly, and provided
treatment. Once they are stable, they are discharged
with home management and care. The average stayof a patient in UCS ranges from 1 hour to 4 hours.
Approximately, 10-15 patients visit UCS per day,resulting in a monthly patient turnover of 300 to
450. Some of the common health issues reported tillto date are dengue fever, gastroenteritis, febrileillness, and respiratory disease.
Impact of urgent care service
Urgent care setup offers a broader range ofresources and facilities than a doctor's examination
room, in addition to more Qlexible schedules.
Furthermore, urgent care centers are frequently
associated with relief from prolonged waiting
hours for clinic appointments, populated emergency
health services, and positively contributing to moreaccessible care by having competent healthcare
professional available for the people especiallyworking adults and children from school to visit as
per their convenience and timeframe. Many patientsasserted that UCS has a signiQicant impact on making
healthcare more accessible, cost-effective, and easy
to coordinate.

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
Recommendations and Conclusions
The UCS is without a doubt a revolutionary attemptin Pakistan's healthcare setup, which has only
recently been born and has yet to achieve major
milestones. Certain responsibilities of healthcare
professionals other than physicians, such as theadvanced nurse practitioner (ANP), are becoming
established as a more recent specialty within thehealthcare Qield. Nurse practitioners (NP) in urgent
care are frequently viewed as low-cost, effective
options for treating common and acute illnesses in
the population. Thus, we advocate for the use of
ANPs in urgent care, which will beneQit both thehealth system and the patient in a variety of ways,
including lower costs for both the health system andthe patient, shorter wait times, and increased
physician capacity to treat more patients while
maintaining high-quality care and standards.
Moreover, we urge public health leaders andhealthcare organizations, however, to establish such
facilities in their institutes and train doctors andnurses to specialize in the Qield of urgent care, which
will both reduce the burden of emergencies
encountered, and reduce the burden on tertiary carein the long run. Policymakers can develop protocols
for implementing urgent care services for healthcareorganizations across the country, ensuring that thequality of care is consistent across regions.

Researchers can help Qind bottlenecks and gaps
based on patients' and healthcare providers'experiences, as well as better solutions,troubleshooting, and turning Qlaws into
opportunities for better healthcare outcomes.
In conclusion, The Family Medicine
department, which leads UCS in partnershipwith primary healthcare provided by welltrained family physicians and nurse
practitioners, will surely play an important roleand provide a new dimension to the health carein Pakistan. Also, the overall burden on
emergency services have been reduced, and thescope of Family Medicine Practitioners has beenbroadened by implementation of this initiative.
References
American College of Emergency Physicians. (2018).
Emergency Department Boarding and Crowding. At
https://www.acep.org/administration/crowding-boarding/Arain, M., Nicholl, J., & Campbell, M. (2013). Patients’experience and satisfaction with GP led walk-in
centres in the UK; a cross sectional study. BMC healthservices research, 13(1), 1-9.
Atif, M., & Malik, I. (2020). Why is Pakistan vulnerable to
COVID-19 associated morbidity and mortality? A
scoping review. The International journal of healthplanning and management, 35(5), 1041-1054.
Bahadori, M., Mousavi, S. M., Teymourzadeh, E., &Ravangard, R. (2019). Emergency department visits

87

for non-urgent conditions in Iran: a cross-sectional
study. BMJ open, 9(10), e030927.
Baier, N., Geissler, A., Bech, M., Bernstein, D., Cowling, T. E.,
Jackson, T., . . . Quentin, W. (2019). Emergency andurgent care systems in Australia, Denmark, England,
France, Germany and the Netherlands–Analyzingorganization, payment and reforms. Health Policy,
123(1), 1-10.
Bakarman, M. A., & Njaifan, N. K. (2014). Assessment ofn o n - e m e rg e n c y c a s e s a t te n d i n g e m e rg e n c y
department at King Fahad General Hospital, Jeddah;
pattern and outcomes. Life Science Journal, 11(8),20-25.
Coster, J. E., Turner, J. K., Bradbury, D., & Cantrell, A.
(2017). Why do people choose emergency and urgent
care services? A rapid review utilizing a systematic
literature search and narrative synthesis. Academic
emergency medicine, 24(9), 1137-1149.
Di Somma, S., Paladino, L., Vaughan, L., Lalle, I., Magrini, L.,& Magnanti, M. (2015). Overcrowding in emergency
department: an international issue. Internal andemergency medicine, 10(2), 171-175.
Hanif, M., Khalid, S., Rasul, A., & Mahmood, K. (2021).
Maternal mortality in rural areas of Pakistan:challenges and prospects. Rural Heal, 27, 1040-1047.
Husseni, A. M., & Ullah, M. A. (2019). The dire need ofurgent care centers in Pakistan; A potential solution to
emergency room overcrowding. Journal of Ayub
Medical College Abbottabad, 31(1), 1-2.
Hyder, A. A., & Razzak, J. A. (2013). The challenges of
injuries and trauma in Pakistan: an opportunity forconcerted action. Public health, 127(8), 699-703.
Javed, S. A., & Ilyas, F. (2018). Service quality andsatisfaction in healthcare sector of Pakistan—thepatients’ expectations. International journal of healthcare quality assurance.
Jordi, K., Grossmann, F., Gaddis, G. M., Cignacco, E.,
Denhaerynck, K., Schwendimann, R., & Nickel, C. H.
(2015). Nurses’ accuracy and self-perceived ability
using the Emergency Severity Index triage tool: across-sectional study in four Swiss hospitals.
Scandinavian journal of trauma, resuscitation andemergency medicine, 23(1), 1-10.
Karam, M., Tricas, S., Darras, E., & Macq, J. (2016).
Interprofessional collaboration between general
physicians and emergency department services in
Belgium: a qualitative study. International Journal of
Integrated Care, 16(6).
Kraaijvanger, N., Van Leeuwen, H., Rijpsma, D., & Edwards,
M. (2016). Motives for self-referral to the emergency
department: a systematic review of the literature. BMC
health services research, 16(1), 1-19.
Leonard, C., Bein, K. J., Latt, M., Muscatello, D., Veillard, A.
S., & Dinh, M. M. (2014). Demand for emergency
department services in the elderly: An 11 year analysisof the G reater S ydney A rea. Emergency Medicine
Australasia, 26(4), 356-360.
Nicholl, J., & Mason, S. (2013). Return of the “corridors ofshame”? In (Vol. 347): British Medical Journal
Publishing Group.
Pakistan Demographic and Health Survey. (2019, January
2019 ). Pakistan Demographic and Health Survey

88

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

2017-18. At https://www.dhsprogram.com/pubs/pdf/
FR354/FR354.pdf
Parkinson, B., Meacock, R., Checkland, K., & Sutton, M.
(2021). Clarifying the concept of avoidable emergency
department attendance. Journal of health services
research & policy, 26(1), 68-73.
Roy, P., Kumar, R., Aggarwal, P., Vhora, R. S., Gupta, M.,
Boobna, V., . . . Kumar, S. (2020). Framework fordevelopment of urgent care services towards
strengthening primary healthcare in India - Joint
position paper by the Academy of Family Physician ofIndia and the Academic College of Emergency Experts.
J Family Med Prim Care, 9(4), 1801-1804. doi:10.4103/
jfmpc.jfmpc_286_20
Tenbensel, T., Chalmers, L., Jones, P., Appleton-Dyer, S.,
Walton, L., & Ameratunga, S. (2017). New Zealand’s
emergency department target–did it reduce ED lengthof stay, and if so, how and when? BMC health services
research, 17(1), 1-15.
Turner, J., Coster, J., Chambers, D., Phung, V.-H., Knowles,
E., Bradbury, D., & Goyder, E. (2015). What evidence isthere on the effectiveness of different models ofdelivering urgent care? A rapid review.
Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., &Mehrotra, A. (2013). Emergency department visits fornonurgent conditions: systematic literature review. Am
J Manag Care, 19(1), 47-59.
World Health Organization. (2022). Pakistan-Primary andSecondary Healthcare. Retrieved from https://www.emro.who.int/pak/programmes/primary-asecoundary-health-care.html

Ethics in COVID-19 pandemic:
Narrative review of challenges andlessons learned by healthcare
workers- Sarosh Saleem- Maha Khalil
Bioethics Department, Shalamar Medical & Dental
College, Lahore, Pakistan
email: drsarosh@hotmail.com
Abstract:
Recognizing and addressing the challenges faced byhealthcare workers in response to COVID-19 is an
important aspect of healthcare leadership. Limitedaccess to personal protective equipment, fear ofcontagion to family and lack of vaccines are posing
tremendous challenges for healthcare workers.
Supporting ethical practice is essential to the healthworkforce’s well-being. A literature search was
conducted using a combination of keywords. Data
from the related reviews, abstracts, and articles werethen studied and summarized. This narrative review
summarizes the relevant literature, regarding thechallenges and risk perceptions, and the factors
associated with the duty to care during the
COVID-19 pandemic. It also discusses the strategies

to cope with uncertainty such in times of this crisis.
While the duty to care is uncertain when one's
personal well-being is at stake, it depends largely on
their own risk assessment. Learning from ourcollective experiences thus far is our most important
moral obligation, as failing to learn from ourprevious experiences would be a violation of the
ethical obligation to use available knowledge,
evidence, and experience to safeguard and promote
public health.
Introduction
COVID-19, which is the third outbreak of thecoronavirus, has affected more than 209 countries
including Pakistan 1. Healthcare providers (HCPs)
are at the frontline when treating infectious disease
cases and are at higher risk of contracting such
infections 2. In a study conducted in Wuhan China,
the rate of transmission to HCPs was 29% 3. As of
September 14th, 2021, a total of 17,866 HCPs were
infected in Pakistan 4.
As the pandemic advances, limited access toessential Personal Protective Equipment (PPE) isposing tremendous challenges, regarding personalsafety and patient care, for healthcare providers 5.
Studies have shown that HCPs reported reluctance towork because of fear of infecting their family, friends,
and colleagues 6,7,8,9.
The promotion of ethical practice is important to
the quality of health care and the well-being ofhealth staff. Recognizing and solving the challenges
faced by health professionals in response to
COVID-19 is an important aspect of leadership in
health care and civic service 10. The ﬁndings on theperceptions of HCWs about the risks of duty to careduring the COVID-19 pandemic could inform
medical institutional authorities about the need forurgent implementation of safety policies anddeployment of human resources and set priorities interms of safety and human resources allocation by
public health authorities 11. It also discusses theways of coping with uncertainty in times of crisis, inthe light of lessons learned by the pandemic.
Research Methods
A literature search was conducted on PubMed and
Google Scholar for articles using a combination of
keywords. Selected articles and abstracts werereviewed for full-text review. The references toincluded studies were also reviewed to identify
additional sources. Only studies written in English
were included. Due to the huge diversity of study
design and types, a narrative approach has been
adopted for this review paper.
Results
Ethical challenges of covid-19
A public health emergency such as COVID-19
disrupts normal practices that promote ethicallysound patient treatment. Ethical problems arise
when HCWs struggle to "do the right thing" because
their roles and responsibilities clash with theEubios Journal of Asian and International Bioethics 32(3) (May 2022)
common ethical principles 12. Three main ethicalissues that may arise include risk of infection vs duty
to care, risk mitigation, and scarcity of available
resources 13. Hasting’s center report suggested
three ethical duties of healthcare leadership
including the duty to plan, safeguard, and guide 14.
Ethical guidelines and professional obligations set
out the importance of delivering treatment to thepatients, in particularly difQicult situations like these.
1. Con@lict between duty to care and risks ofinfection
The "duty to care" may be challenged by different
risks that exist with providing care in a highly
contagious environment. The HCWs have a right totheir own safety amid responsibilities 15. It has been
acknowledged as the most important element tocount in favor of the obligation to work.vi The “dutyto care” when one’s own life, health, and personal
well-being is threatened is uncertain and largely
depends on their own risk assessment and value
system 16. Having to balance their own safety with
the needs of patients, families, and employers, in theface of limited resources, can lead to distressing
ethical dilemmas for physicians and, potentially, tomoral injury 17.
The responsibility of protecting one's family isanother dimension of this ethical dilemma 18. In
China, 287 out of 534 frontline HCPs showed stressdue to the health risks to their family members.
Strict implementation of infection control policies,
ava i l a b i l i t y o f n e c e s s a r y e q u i p m e n t , a n d
acknowledgment of their services by the state andthe hospital administration were the perceived
beneQits of the study 19. A study conducted on 4,357
HCWs from Wuhan, and other provinces states that
63.9% HCWs showed concern of infection to family.
However, this study does not reQlect the overall
status of HCWs in China and requires moreintervention 20. In another study, 46.97 percent of
HCWs were concerned about contracting COVID-19
in Pakistan 21. Other Qindings from developed anddeveloping nations conQirm the notion that HCWs
had signiQicant stress and anxiety and perceived
themselves to be at increased risk of COVID-19 andassociated risks 22.
Although there are multiple opinions in thisregard, it has been stated that in an outbreak, it ismorally acceptable for HCWs to abstain from workwhen their obligation to care is offset by the
cumulative dangers and pressures of that work 23.
However, the stress associated with the difQiculty inchoosing the right thing cannot be underestimated.
We have yet to see the results of such psychologicaland moral distress among HCWs around the world.
2. HCWs and availability of PPEs
Protective gear is an essential part of the infection
control strategy for COVID 19 infection. A signiQicant
challenge that arose for HCWs around the globe wascontinuous revisions of safety policies on one hand
and the insufQiciency of appropriate protective

89

equipment. Most PPE guidelines included disposableapron, gloves, Qluid-repellent surgical masks, and eye
protection containing either goggles or a face shield
24. In situations where it was in short supply or
inaccessible, the relative impact of the duty of carecan be substantially diminished 25. The availabilityof PPE added to the mental stress of these HCPs
26,27. It seemed unreasonable for a HCP to perform
an activity associated with a signiQicant risk of death.
Yet, they were expected to perform their duties. The
challenge of balancing the act was so distressing thatmany HCWs, particularly surgeons declined
surgeries and other procedures 28.
The distribution of health services is usually
impacted by political, economic, and social policies
and the same happened during the pandemic.
Adequate availability of PPE was a critical ﬁrst step
to be taken by the healthcare authorities 29. In the
midst of the COVID-19 pandemic, it was important toavoid excessive consumption of PPE and to reuse
them following a proper biological decontamination
procedure. The guidelines for adequate use of PPE
have been changing ever since the pandemic.
However, additional evidence is required fromtesting techniques on different models 30. The PPE
rationing recommendations should obey empiricalevidence and must be morally defensible. Therefore,
there was an immediate need to update theseguidelines to ensure equitable distribution 31. Thechanges in the guidelines should be conveyed clearlyand directly to frontline HCPs, without any politicalinterference 32. Instead multiple political opinions
were being voiced, in the context of the pandemic,around the world.
3. Psychological pressure and mental health
Fear and apprehension are inherent in the scenarios
like COVID-19 and are often not entirely manageable
33. With the emergence of COVID-19 in Pakistan, justlike in the rest of the world, the medical staff had
been under extreme pressure 34. HCPs who work
continuously in isolated hospital units encounter
conQinement phenomena that cause collective
hysteria 35. Severity creates more mental healthissues, which not only impairs the decision-making
ability but may also have long-term adverse impacts
on their well-being 36.
Table.1 shows the Qindings of psychologicaldistress levels and risk perceptions in frontline
healthcare workers in China and Pakistan 37,38,39.
However, most of these studies were conducted in
the early days of the pandemic and the long-term
psychological effects of this population should bestudied.
Studies from the earlier pandemics suggest thatthe level of professionalism by HCW cannot belinked with their willingness to put their ‘duty tocare’ into practice during times of risk. In order togain a deeper insight, it is important to assess therisk perceptions of health care workers as this Qield
remains unexplored by researchers.

90

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

Table 1: Psychological Qindings of studies conducted
in China
Study Title &Year

Survey Tool

Findings“Psychological GHQ-12 scale
impact of thecoronavirus
disease 2019
(COVID-19)
outbreakon healthcare
workers in
China” -Jan 01,
2020.

39%
had
psychologicaldistress, 40%e x p r e s s e dconcern about
getting infected.

“ F a c t o r s
Associated With
Mental HealthO u tc o m e s
Among HealthCare Workers
Exposed toCoronavirus
Disease 2019.” –March 02, 2020

PHQ-9, GAD-7,
the 7-item
Insomnia
Severity Index,
and the 22item Impact ofEve n t S c a l e Revised

Depression(50.4%), anxiety( 4 4 . 6 % ) ,insomnia (34%),
and distress(72%)“ C O V I D - 1 9 WHO (SRQ-20)
pandemicknowledge,
perception,
anxiety anddepressionamongf r o n t l i n e
doctors ofPakistan” –March-2020.

43% prevalenceof anxiety/depression, 94%
felt unprotected.

“Assessment of E l e c t r o n i c
K n o w l e d g e , questionnaire
Perceptions and via Qualtrics1
Perceived Risk
Concerning
COVID-19 inPakistan.” – June
2021

The perceived
risk score for bothcognitive andaffective domains
was raised at 2.24
± 1.3 (eight items)
and3.01 ± 1 (seveni t e m s )respectively

Coping with Uncertainty in times of crisis
Effective communication, provision of adequate
PPEs, adequate rest, and both practical andpsychological support are associated with improved
psychological outcomes. HCWs must address thesituation with medical integrity, manage personalrisk, and professional responsibility. At the sametime, the society and state must ensure that workers
are protected during the pandemic and beyond.

The HCWs, organizational leaders, andgovernments have a huge responsibility to safeguard
the rights of HCWs and minimize risks to everyone. A
Qive-step organized process can be used to identify
risks and viable solutions, and then analyze theirethical relevance and impact.
PPE rationing should follow the scientiQic
evidence and be ethically justiQiable. Ensuring that
HCWs were well-trained and well-equipped with
empirically sound information and tools toeffectively discuss and cope with the effects of
COVID-19 was a progressive and challenging stepahead.
The top Qive ethical lessons learned include
preparing adequately, better articulation andp r i o r i t i z i n g ove ra c h i ev i n g g o a l s , wo rk i n gcollaboratively, protecting the most vulnerable
groups, and improving communication. Many
healthcare systems struggled throughout the world
but HCWs globally showed sheer resilience andcourage during this pandemic. Even now as thetravel bans have been lifted, mask mandates havebeen relaxed, infection rates have dropped andvaccinations are being distributed, the commitmentof HCW to Qight this pandemic globally has notweaned off.
Limitations
This review highlights the ethical challenges inmostly Asian countries. It does not include data on
the risk perception of HCWs in other countries. This
review includes articles from early days of thepandemic till 2021 and as psychological pressure
can rise with the progression of the pandemic, it isan area to be explored by researchers. The online
surveying and small sample sizes can also limit thescope of these articles.
Conclusions
Ethical challenges (personal safety vs. duty to treat),heavy workload, inadequate availability of essential
PPEs, risk of contagion to family and friends, thedesire to earn daily wages, and lack of vaccines areimportant challenges affecting individual HCWs’
decisions and “duty to care” during this pandemic.
While the duty to care is uncertain when one's
own life, health, and personal well-being are at stake,it depends largely on their own risk assessment andvalue systems. It takes a toll on physical and mental
wellbeing. Therefore, it is important to investigate
the levels of risk perception, particularly in Asian
countries and efforts should be made toprofessionally guide the HCWs.
Factors that support the HCWs’ duty to careinclude emotional and psychological support
provided during and after the pandemic, urgent
implementation of safety policies and deployment of
human resources. Furthermore, there is animmediate need to update these guidelines in orderto ensure appropriate security. Learning from ourcollective experiences thus far is our most important
moral obligation, as failing to learn from ourEubios Journal of Asian and International Bioethics 32(3) (May 2022)
previous experiences and prevent the ethicalshortcomings of previous waves of the pandemic
would be a violation of the ethical obligation to use
available knowledge, evidence, and experience tosafeguard and promote public health.
References
1. A Waris, U K Atta, M Ali, A Asmat, A Baset. COVID-19
Outbreak: Current Scenario of Pakistan. 2020 Apr
14;35:100681. doi: 10.1016/j.nmni.2020.100681.
eCollection 2020 May.
2. Abrar Ahmad Chughtai, Wasiq Khan. Use of PersonalProtective Equipment to Protect Against Respiratory
Infections in Pakistan: A Systematic Review. J InfectPublic Health. Jul-Aug 2019;12(4):522-527. doi:
10.1016/j.jiph.2019.01.064.
3. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinicalcharacteristics of 138 hospitalized patients with 2019
novel coronavirus–infected pneumonia in Wuhan,
C h i n a . J A M A . 2 0 2 0 Fe b 7 . d o i : 1 0 . 1 0 0 1 /jama.2020.1585.
4. Hakim M, Afaq S, Khattak FA, Jawad M, Ul Islam S, Ayub
Rose M, Shakeel Khan M, Haq ZU. Perceptions of
COVID–19-related Risks and Deaths Among HealthCare Professionals During COVID-19 Pandemic in
Pakistan: A Cross-sectional Study. INQUIRY: The
Journal of Health Care Organization, Provision, andFinancing. 2021 Dec 17;58:00469580211067475.
5. Honda H, Iwata K. Personal protective equipment andimproving compliance among healthcare workers inhigh-risk settings. Curr Opin Infect Dis.
2016;29(4):400-406. doi:10.1097/
QCO.0000000000000280
6. McConnell D. Balancing the duty to treat with the duty
to family in the context of the COVID-19 pandemic[published online ahead of print, 2020 Apr 24]. J Med
Ethics. 2020;medethics-2020-106250. doi:10.1136/
medethics-2020-106250
7. Lima CKT, Carvalho PMM, Lima IAAS, et al. The
emotional impact of Coronavirus 2019-nCoV (newCoronavirus disease). Psychiatry Res.
2020;287:112915.
doi:10.1016/
j.psychres.2020.112915
8. Bakewell F, Pauls MA, Migneault D. Ethicalconsiderations of the duty to care and physician safety
in the COVID-19 pandemic [published online ahead ofprint, 2020 Apr 24]. CJEM. 2020;1-4. doi:10.1017/
cem.2020.376
9. Galbraith N, Boyda D, McFeeters D, Hassan T. The
mental health of doctors during the Covid-19
pandemic [published online ahead of print, 2020 Apr
28]. BJ Psych Bull. 2020;1-7. doi:10.1192/bjb.2020.44
10. Berlinger N, Wyna M, Powell T, et al. Ethical
Framework for Health Care Institutions Responding to
the Novel Coronavirus Pandemic. The Hastings Center;
2020.
Availablefrom:https://
w w w. t h e h a s t i n g s c e n t e r. o r g /ethicalframeworkcovid19/
11. Iserson KV. Healthcare Ethics During a Pandemic. WestJ Emerg Med. 2020;21(3):477-483. Published 2020
Apr 13. doi:10.5811/westjem.2020.4.47549

91

12. Cai H, Tu B, Ma J, et al. Psychological Impact and
Coping Strategies of Frontline Medical Staff in Hunan
Between January and March 2020 During theOutbreak of Coronavirus Disease 2019 (COVID19)
in Hubei, China. Med Sci Monit. 2020;26:e924171.
Published 2020 Apr 15. doi:10.12659/MSM.924171
13. Harkin DW. Covid-19: balancing personal risk andprofessional duty. BMJ. 2020;369:m1606. Published
2020 Apr 29. doi:10.1136/bmj.m1606
14. min F, Sharif S, Saeed R, Durrani N, Jilani D. COVID-19
pandemic- knowledge, perception, anxiety anddepression among frontline doctors of Pakistan. BMC
Psychiatr. 2020;20(1):459,
15. Mrklas K, Shalaby R, Hrabok M, et al. Prevalence ofperceived stress, anxiety, depression, and obsessivecompulsive symptoms in health care workers andother workers in Alberta during the COVID-19
pandemic: Cross-sectional survey. JMIR MentHeal.
2020;7(9):e22408
16. Jessop ZM, Dobbs TD, Ali SR, et al. Personal Protective
Equipment (PPE) for Surgeons during COVID-19
Pandemic: A Systematic Review of Availability, Usage,and Rationing [published online ahead of print, 2020
May 12]. Br J Surg. 2020;10.1002/bjs.11750.
doi:10.1002/bjs.11750
17. Lai J, Ma S, Wang Y, et al. Factors Associated With
Mental Health Outcomes Among Health Care Workers
Exposed to Coronavirus Disease 2019. JAMA Netw
Open. 2020;3(3):e203976. Published 2020 Mar 2.
doi:10.1001/jamanetworkopen.2020.3976
18. Taghrir MH, Borazjani R, Shiraly R. COVID-19 andIranian Medical Students; A Survey on Their RelatedKnowledge, Preventive Behaviors and Risk Perception.
Arch Iran Med. 2020;23(4):249-254. Published 2020
Apr 1. doi:10.34172/aim.2020.06
19. Raphael T. Bloomberg. Why Surgeons Don‘t Want toOperate Right Now. Bloomberg 2020. Available at:https://www.bloomberg.com/opinion/articles/
2020-03-24/thecoronavirus-crisis-is-puttingsurgeons-at-risk-too
20. The Lancet, COVID-19: protecting health-care workers,
Lancet 395 (10228) (2020) 922, doi: http://dx.doi.org/10.1016/S0140-6736(20)30644-9.
21. Boškoski I, Gallo C, Wallace MB, Costamagna G.
COVID-19 pandemic and personal protective
equipment shortage: protective efQicacy comparing
masks and scientiQic methods for respirator reuse[published online ahead of print, 2020 Apr 27].
Gastrointest Endosc. 2020; S0016-5107(20)34247-4.
doi:10.1016/j.gie.2020.04.048
22. Thomas JP, Srinivasan A, Wickramarachchi CS, Dhesi
PK, Hung YM, Kamath AV. Evaluating the national PPE
guidance for NHS healthcare workers during the
COVID-19 pandemic [published online ahead of print,
2020 May 1]. Clin Med (Lond).
2020;clinmed.2020-0143. doi:10.7861/
clinmed.2020-0143
23. Cori L, Bianchi F, Cadum E, Anthonj C. Risk Perception
and COVID-19. Int J Environ Res Public Health.
2020;17(9):E3114. Published 2020 Apr 29.
doi:10.3390/ijerph17093114

92

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

24. Mukhtar S. Mental health and emotional impact of
COVID-19: Applying Health Belief Model for medical
staff to general public of Pakistan [published online
ahead of print, 2020 Apr 10]. Brain Behav Immun.
2020;S0889-1591(20)30463-3. doi:10.1016/
j.bbi.2020.04.012
25. Lai J, Ma S, Wang Y, et al. Factors Associated With
Mental Health Outcomes Among Health Care Workers
Exposed to Coronavirus Disease 2019. JAMA Netw
Open. 2020;3(3):e203976. Published 2020 Mar 2.
doi:10.1001/jamanetworkopen.2020.3976
26. Dai Y, Hu G, Xiong H, Qiu H, Yuan X. Psychologicalimpact of the coronavirus disease 2019 (COVID-19)
outbreak on healthcare workers in China. medRxiv.
2020 Jan 1.
27. Amin F, Sharif S, Saeed R, Durrani N, Jilani D. COVID-19
pandemic-knowledge, perception, anxiety anddepression among frontline doctors of Pakistan. BMC
psychiatry. 2020 Dec;20(1):1-9.
28. Haque A, Mumtaz S, Mumtaz R, Masood F, Buksh HA,
Ahmed A, Khattak O. Assessment of knowledge,
perceptions and perceived risk concerning COVID-19
in Pakistan. Journal of Epidemiology and Global
Health. 2021 Jun;11(2):186.
29. Damery S, Draper H, Wilson S, et al. Healthcare
workers' perceptions of the duty to work during an
inQluenza pandemic. J Med Ethics. 2010;36(1):12-18.
doi:10.1136/jme.2009.032821
30. McDougall RJ, Gillam L, Ko D, Holmes I, Delany C.
Balancing health worker well-being and duty to care:an ethical approach to staff safety in COVID-19 andbeyond. Journal of Medical Ethics. 2021 May
1;47(5):318-23.
31. Smith MJ, Ahmad A, Arawi T, Dawson A, Emanuel EJ,
Garani-Papadatos T, Ghimire P, Iliyasu Z, Lei R,
Mastroleo I, Mathur R. Top Qive ethical lessons of
COVID-19 that the world must learn. Wellcome Open
Research. 2021;6.

Reflections on research resource
allocation and data sharing as
ethical dilemmas in conducting
COVID-19 research- Isaac A. Adedeji
Medical/Health Sociology and Bioethics Unit,
Department of Sociology, Olabisi Onabanjo
University, Ago-Iwoye, Nigeria- Saheed Akinmayowa Lawal
Medical/Health Sociology and Bioethics Unit,
Department of Sociology, Olabisi Onabanjo
University, Ago-Iwoye, Nigeria
Email: sakinlawal@gmail.com- Onyeunoneme Alexandra OdiariCommunity Medicine Department, Babcock
University Teaching Hospital, Ilishan-Remo, Nigeria- Sola Aluko-Arowolo
Medical/Health Sociology and Bioethics Unit,
Department of Sociology, Olabisi Onabanjo
University, Ago-Iwoye, Nigeria- Ebunoluwa Oduwole
Department of Philosophy, Olabisi Onabanjo
University, Ago-Iwoye, Nigeria
Abstract
In recent years and in times past, pandemicinQluenzas have negatively impacted the world.
History records 1918, 1957, and 1968 as important
periods when pandemic-inQluenzas occurred. From
2009-2010, the Swine Flu pandemic outbreak andthe Ebola outbreak of 2014 show how emerging andre-emerging health threats affect people across theworld having a negative impact on global healthresearch. The ongoing COVID-19 pandemic
continues to affect the entire world and distorts theprocess of research resource allocation, and data
sharing when conducting global health research.
These issues among others have become an ethicaldilemma faced by researchers in conducting
COVID-19 research. This article discusses how theongoing COVID-19 pandemic limits enrollment inresearch due to fear and uncertainty of the harmthat may be incurred. On the other hand, theallocation of resources is grossly affected becoming
an ethical dilemma on who gets what, why, when,
and where. Hence, there is a need for a global
framework to guide research resource allocation in
the event of a global pandemic. The paper concludes
with the need for better data sharing acrosscountries to help the world overcome COVID-19.
More so, there is the need for countries to practice
open data sharing which is beneQicial to the world in
the Qight against COVID-19 and future pandemics
Introduction
Pandemic-inQluenzas have majorly originated from
Asia and North America1. History records 1918,
1957, and 1968 as important dates of pandemicinQluenzas. These periods – except for the Swine Flu

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
pandemic outbreak of 2009-2010, were major
events that contributed to the emergence of existing
ethical guidelines and principles which is used to
guide the nature of human subject participation in
research. The Helsinki declaration (1964), Beecher’s
publication (1966), the National Research Act(1974), and the Belmont Report (1979) are
milestones in the establishment of bioethics inglobal health research. Second, because epidemic
inQluenza, though recurrent, affects only a small
population, locked within geographical limits, suchmay not attract signiQicant global attention to requirean ethical review of the research practices.
Epidemic-inQluenza has a regular occurrence and theethics of doing research gain less traction andengagement amongst researchers. As such, there is a
paucity of sufQicient ethics-based scientiQic
publications on large inQluenza outbreaks2. This
scarcity reinforces the short supply of evidence of
ethical processes and emergent issues on large
inQluenzas in the extant literature.
Closing the gap is essential as the COVID-19
pandemic has shown. The outbreak which began in
Wuhan, China became a global pandemic in March
2020 the rate of its spread did not allow countries tohave sufQicient time for adequate preparation. A
2019 report demonstrated that no health system
was fully prepared for a health emergency3. This
unpreparedness extends to the scientiQic community.
The pandemic signiQicantly displaced existingprocesses including research, except for thosetesting life-saving interventions4. Then a race
towards the development of a vaccine or drug vis-àvis and the need to fully understand theepidemiology of COVID-19 intensiQied. The extent of
the COVID-19 pandemic threatened the safety of
researchers, research facilities, and study sites5. As
such, process-based dynamics forced an urgent needfor priority setting in research. The re-organizationof research priorities, the scientiQic enterprise, andits associated processes of funding, data gathering,and data sharing were signiQicantly affected by theoutbreak4, 6. The ethical dilemmas associated withthese processes are enormous as they createdchallenges in terms of resource allocation to nonCOVID-19 researchers and the sharing of data in thecontext of global politics regarding the outbreak.
As such, utilitarianism and deontologicalphilosophical ideals as well as other humanistic
principles like egalitarianism, reciprocity, andprioritization became valid perspectives in the
COVID-19 discourse. However, the processes andchallenges which surround the COVID-19 situation
cannot be sufQiciently explained based on a single
theory or principle. A multi-value ethical framework
is more adequate to explain the dynamics ofresearch resource allocation, consent process, anddata sharing during COVID-19. Research resource
allocation was a major challenge both in terms offunding and the use of existing resources at the startof the pandemic. As such, more funding for
COVID-19-related research was made available and93

research facilities in Europe were converted for
COVID-19 research support6. Due to the deadly
nature of the virus and the urgency for a solution to
the pandemic was needful. COVID-19 research ortreatment structures were prioritized over the preexisting public health challenges across the world.
For example, in the UK, USA, France, and Spain lesscritical in-patient services were moved to online
platforms and hospital buildings became restricted
areas for the general population. Most of the healthresources were focused on addressing the COVID-19
challenge.
The dynamics of resource allocation and data
sharing evolved sufQiciently around stakeholders likeresearch administrators, researchers in the Qield, andresearch leaders. This is because they all have toensure the equitable distribution and utilization ofresearch resources. Hence, the deontological theory
provides the basis for the roles and duties of thesestakeholders during COVID-19. Although indeed, thestakeholders being moral agents are also subject totheir rationality and humanistic orientations, the callof duty imposes a greater burden. Kantian
deontology emphasizes the importance of staying
bound to the cause of duty regardless of theoutcomes. Deontological ethics is bound by the'categorical imperatives to produce actions which
are capable of becoming universal principles, respectfor humanity by not seeing people as means to anend, but as ends in themselves, and acknowledging
the human will as a universal law. Because duty is acorollary of roles and expectations, duty in itself is
not free from moral conQlicts. Therefore, thesestakeholders had a duty to ensure that there is abalance in the way all forms of research wereconducted reducing any form of disruption despite
the COVID-19 pandemic. Data sharing occurs within
the context of cultural, social, and politicalconsiderations. As such, existing and emerging
national policies on data sharing would evolve andrespond to the needs of the COVID-19 pandemic.
Data sharing is one of the reference points of disease
control efforts, especially as they impact theunderstanding of disease epidemiology. It istherefore expected of researchers as a duty to sharedata notwithstanding prevailing national and orcultural imperatives.
About the preceding discussions on the ethicaland practical processes related to COVID-19, at thecommencement of the National Institutes of Health
Phase III clinical trials on the COVID-19 pandemic, it
was needful to focus on the urgency of the situation
thereby making some exceptions7 (NIH News
Releases, 2020), as the outbreak was a rarity interms of its occurrence8. The need to speed up
research (through the ethics review process) andscale up to vaccine development is at the core ofpandemic-related research9. Also, concerning theexigencies of conducting research during disease
outbreaks, this article draws from relevant ethicalviewpoints; this article engages an assessment of the
ethical dilemmas regarding research resource

94

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

allocation and data-sharing, which have/are
emerged-ing in the scientiQic enterprise of COVID-19
and other inQluenza research.
Research resource allocation and participationin the COVID-19 outbreak
The need for vaccines and/or drugs and providing
care are two important interconnected needs thatshape the landscape of resource allocation when
there is a disease outbreak. Thus, in the context of an
existing pandemic like COVID-19, 10 the fear of
becoming infected limits participation in research,and the extent of the harm incurred as a participant
is worrisome. These are important ethical dilemmas
that potentially affect the enrollment of participants.
It also shapes the process of data collection,
including the monitoring of patients and an unbiased
systematization of obtained data. This occurs
because patients did not present at the clinic(fearing infection), they may have to be monitored
through telehealth platforms, and this led todeviation from the protocol. The prioritization of
COVID-19 vaccine research to address a subsisting
global health threat affected other research funding
across the world. The deployment of personnel andresources to COVID-19 research resounds an ethicalimbalance in the value of other researchers and thestakeholders who are involved. The ethical principleof non-maleQicence was in operation to tackle thecurrent COVID-19 research. Beyond ensuring that noharm is done to participants in research studies,such studies should not constitute harm toparticipants in other studies9,11. There is an ethicalobligation to make sure that the process of researchdoes not cause harm to non-participants as well asother research stakeholders. 11has argued from theviewpoint of competing clinical trials, and they
identiQied the need for an explanatory framework
through ‘ethical criteria’ which substantiates thepolicy of prioritizing clinical trials, bearing in mind
the exigency of the need to fast-track vaccine
development. The need to speed up ethical reviews
and prioritize speciQic clinical trials for vaccine
development became important. This functioned
better through an integrative process, wherein an‘ethics preparedness’ structure was established12.
In China, research protocols submitted during
the COVID-19 outbreak show that more than 50% of
the requests for Ethics Committee approval werebased on interventional studies13. Other major typesof studies were observational and diagnostic studies.
These studies conformed to the core values ofhuman subject research, 14, drawing extensively
from the Belmont Report (1978), which emphasized
four important ethical principles – beneQicence, nonmaleQicence, respect for persons, and justice.
However, because of the unique nature of research inemergency settings, principlism (also emergent

upon the Belmont Report), occurs as an engagementof professional deontology which relates to on-thespot assessment and decision-making by theindividual researcher. In the coordination of theresearch process, important ethical issues constitutethe basis for rejecting or requesting a review of
COVID-19-related protocols in China. As such in13 it
was reported that some protocols were rejected
because they lacked scientiQic merit and possessedmore than minimal risk. Protocols that were sent forrevision needed to address statistical justiQication forsample size determination, inclusion and exclusion
criteria, and most of the protocols required a clear
description of risks and the need to ensure a riskbeneQit balance about compensation.
In Africa, a duo of French scientists alluded to thepossibility of vaccine trials. But as a COVID-19
research agenda brewed dissatisfaction, especiallyamong African Scientists. References were made topast experiences of Africans. More recently wereprevious ethical challenges that were recorded
during the Ebola vaccine trials. At the beginning of
the COVID-19 pandemic, the commencement ofvaccine trials in Africa needed to be properly
justiQied as the ethical frameworks which discuss theidea of fairness have not been satisQied. Utilitarian(beneQit for the most people), prioritarian (Qirstcome-Qirst-serve), egalitarian (equality of risks) andreciprocity (social contract) do not sufQiciently alignwith the agenda to locate vaccine trials in Africa. In
the early weeks of the pandemic in 2020, Africa did
not have the highest number of reported cases; theoutbreak did not Qirst occur in Africa, it was the lastregion to be affected. Hence there was no moral
basis for reciprocity between Africa and the rest of
the world, and Africa’s relationship with the Westremains skewed. As such, there is no basis forreciprocity.
Data sharing and the intricacies of the COVID-19
outbreakIn the wake of the COVID-19 outbreak, the World
Health Organization had expressed concerns, thatcountries were not sharing in-country data from theoutbreak1. In terms of data sharing and its potential
to strengthen the frontiers of research, a hegemonic
structure exists in the context of the world system.
There are underlying cultural interpretations
regarding the challenge of data-sharing. The value of‘protecting honour’ and ‘avoiding shame’ and not
being perceived as weak or inadequate is at the coreof data sharing15. It is important to share data
without compromising the conQidentiality andprivacy of the primary owners of the data. In
outbreak situations, the limits of conQidentiality andprivacy are permissibly extended due to the need forcontact tracing and follow-up. However, the limits

1 h$ps://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-mission-brieﬁng-on-covid-19---26-

february-2020

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)
and extenuating possibilities have to be Qirmly
established at the point of entry into the research.
Amid the COVID-19 research upheaval, it isimperative to introduce an 'ethics preparedness'
approach12. This idea is built upon the need tofacilitate a rapid and ethically sound review process
through collaborative engagements across national,
multi-country, and oversight structures. In China,
forty-one (41) protocols were reviewed in 29days13
surpassing the twenty-seven (27) reviews in 12.4
days, done by the ethics committee of the Médecins
Sans Frontières during the Ebola crisis. It isimperative to develop structures that will essentiallybuild on existing emergency-oriented ethicalframeworks for research to make COVID-19 researchmoParticipants

20

Teachers

11

IT Teachers

1

G e r m a n L i te ra t u re 1
Teachers
Gymnastics Teachers

1

Arts Teachers

2

French Literature 1
Teachers
Music Teachers

1

Psychologist

1

Coordinators1

re ethically sound and acceptable.
Conclusion
In the conduct of COVID-19 research, investigators
must be able to manage the available researchresources for COVID-19 and other research as theglobal challenge of research resource allocation
continues to persist due to the current pandemic.
Also, the entire ethical review process must be
strengthened to enable researchers to deliver timely
and well-conducted research to address the current
pandemic and future outbreaks. Lastly, the need forcountries to practice open data sharing acrossborders is paramount to ensure that the negative
implications of COVID-19 are addressed globally.
Acknowledgements
The research reported in this publication was
supported by the Fogarty International Center andNational Institute of Mental Health, and the National
Institute on Aging (NIA) of the National Institutes of
Health under Award Number D43 TW010543. The
content is solely the responsibility of the author anddoes not necessarily represent the ofQicial views of
the National Institutes of Health.

95

References
1. Saunders-Hastings PR, Krewski D. Reviewing thehistory of pandemic inQluenza: Understanding patternsof emergence and transmission. Pathogens (Basel,
Switzerland). 2016; 5(4): 66. doi:10.3390/
pathogens5040066
2. Flahault A, Zylberman, P. InQluenza pandemics: past,present and future challenges. Pub Heal Rev. 2010; 32:319-340. doi:10.1007/BF03391605
3. Elliott, D. These are the countries best prepared for
health emergencies (Vol. 2020): World Economic
Forum. 2020. Retrieved from https://www.weforum.org/agenda/2020/02/these-are-thecountries-best-prepared-for-health-emergencies/.
4. Weiner DL, Balasubramaniam V, Shah SI, Javier JR, & on
behalf of the Pediatric Policy C. COVID-19 impact on
research, lessons learned from COVID-19 research,
implications for pediatric research. Pedia Res. 2020;
88(2): 148-150. doi:10.1038/s41390-020-1006-3
5. Chukwuma KH. Fieldwork and the Coronavirus
Pandemic. E-International Relations. 18 April 2020.
2020. Retrieved from: https://www.e-ir.info/
2 0 2 0 / 0 4 / 1 8 / Q i e l dwo rk- a n d - t h e - c o ro n av i r u s pandemic/
6. Inchcoombe S. Understanding better the impact of
COVID-19 on the research enterprise. Springer Nature.
2020. Retrieved from: https://www.springernature.com/gp/advancing-discovery/
blog/blogposts/understanding-impact-of-covid-onresearch-enterprise/18253260
7. National Institutes of Health. Phase 3 clinical trial of aninvestigational vaccine for COVID-19 begins - Multisite trial to test candidate developed by Moderna and
NIH. News Releases. 27 July 2020. Retrieved from:https://www.nih.gov/news-events/news-releases/
phase-3-clinical-trial-investigational-vaccine-covid-19begins
8. World Health Organization. WHO Handbook for
Journalists: InQluenza Pandemic. 2005. Retrieved fromhttps://www.who.int/csr/don/Handbook_inQluenza_pandemic_dec05.pdf
9. Chong SA, Capps BJ, Subramaniam M, Voo TC, Campbell
AV. Clinical Research in Times of Pandemics. Pub Heal
Ethics. 2010; 3(1): 35-38. doi:10.1093/phe/phq005
10. Vaidya M, Castaneda R. Covid-19: Experts say clinical
trials may be affected from enrolment to data analysis.
GlobalData Healthcare. 2020. Retrieved from Retrieved
from: https://www.clinicaltrialsarena.com/comment/
covid-19-trials-enrollment-data-analysis/
11. Gelinas L, Lynch HF, Bierer BE, Cohen IG. When clinical
trials compete: Prioritising study recruitment. Jour
Med Ethics2017; 43(12): 803-809. doi:10.1136/
medethics-2016-103680
12. Saxena A, Horby P, Amuasi J, Aagaard N, Köhler J,
Gooshki ES, . . . the, A.-W. H. O. W. (2019). Ethics
preparedness: facilitating ethics review during
outbreaks - recommendations from an expert panel.
BMC Med Ethics. 2019; 20(1): 29. doi:10.1186/
s12910-019-0366-x
13. Zhang H, Shao F, Gu J, Li L, Wang Y. Ethics committee
reviews of applications for research Studies at 1
hospital in China during the 2019 novel coronavirus

96

Eubios Journal of Asian and International Bioethics 32(3) (May 2022)

epidemic. JAMA. 2020; 323(18): 1844-1846.
doi:10.1001/jama.2020.4362
14. Beauchamp TL, Childress JF. Principles of biomedical
ethics. (7th Edition). Oxford: Oxford University Press;
2013.
15. Lor A, Thomas JC, Barrett DH, Ortmann LW, Herrera
Guibert DJ. Key ethical issues discussed at CDCSponsored international, regional meetings to explore
cultural perspectives and contexts on pandemic
inQluenza preparedness and response. International
Journal of Health Policy and Management. 2016;
5(11): 653-662. doi:10.15171/ijhpm.2016.55
Chief Editor: Darryl R.J. Macer
Associate Editor: Nader Ghotbi
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico), Angeles
Tan Alora (Philippines), Atsushi Asai (Japan), Alireza Bagheri(Iran), Gerhold Becker (Germany), Rhyddhi Chakraborty (India/UK), Shamima Lasker (Bangladesh), Minakshi Bhardwaj (UK),
Christian Byk (IALES; France), Ken Daniels (New Zealand), Ole
Doering (Germany), Amarbayasgalan Dorjderem (Mongolia),
Hasan Erbay (Turkey), Soraj Hongladarom (Thailand), Dena
Hsin (Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Umar Jenie (Indonesia), Nobuko Yasuhara Macer (Japan),
Masahiro Morioka (Japan), Anwar Nasim (Pakistan), Jing-Bao
Nie (China, New Zealand), Pinit Ratanakul (Thailand), Qiu Ren
Zong (China), Hyakudai Sakamoto (Japan), Mariadoss
Selvanayagam (India), Sang-yong Song (Republic of Korea),
Yanguang Wang (China), Daniel Wikler (USA), Jeong Ro Yoon
(Republic of Korea).

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