Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 25 (5) September 2015
www.eubios.info ISSN 1173-2571
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2015 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page

Editorial: End of Life issues- Darryl Macer

169

End-of-life care in the adult intensive care unit: Attitudes
and practices of critical care physicians and nurses 170- Shahanaz Chowdhury
Fortune Telling as Mental Health Support
188- Ananya Tritipthumrongchok
A bioethical interpretation of Buddha’s enlightenment- Nader Ghotbi
204
ABA Renewal and EJAIB Subscription

208

EJAIB Editor: Darryl Macer
Associate Editors
Jayapaul Azariah (All India Bioethics Association, India),
Masahiro Morioka (Osaka Prefectural University, Japan).
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez Alanis (Mexico), Angeles
Tan Alora (Philippines), Atsushi Asai (Japan), Alireza Bagheri(Iran), Gerhold Becker (Germany), Shamima Lasker(Bangladesh), Minakshi Bhardwaj (UK), Christian Byk (IALES;
France), Ken Daniels (New Zealand), Leonardo de Castro(The Philippines), Ole Doering (Germany), Amarbayasgalan
Dorjderem (Mongolia), Thomas Gionis (USA), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Margaret Lock (Canada), Umar Jenie (Indonesia), Nobuko
Yasuhara Macer (Japan), Anwar Nasim (Pakistan), Jing-Bao
Nie (China, New Zealand), Pinit Ratanakul (Thailand), Qiu
Ren Zong (China), Hyakudai Sakamoto (Japan), Sang-yong
Song (Republic of Korea); Noritoshi Tanida (Japan), Ananya
Tritipthumrongchok (Thailand), Yanguang Wang (China),
Daniel Wikler (USA), Jeong Ro Yoon (Republic of Korea).

Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
Provost, American University of Sovereign Nations(AUSN), 8840 East Chaparral Road, Suite 285,
Scottsdale, Arizona, 85250 USA
Email: darryl@eubios.info
http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: End of life issues
This issue includes two papers that are based on
Masters thesis research for AUSN that break new
ground. The first is a study of end-of-life care in adultintensive care units in Bangladesh which describes theattitudes and practices of critical care physicians andnurses, by Shahanaz Chowdhury. It found humane
attitudes being expressed beyond what is in the law,and the results are useful for policy formation.
The second paper is on fortune telling as mental
health support by Ananya Tritipthumrongchok, whichfound that people in Thailand are three times more
likely to visit fortune tellers for mental health support
compared to psychologists. The roles of fortune telling
and types are discussed from a bioethical perspective.
Perhaps greater promotion of the counseling roles of
fortune telling, and having easily accessible mental
health support may alleviate the burden of suicides thatafflict some communities and countries.
The third paper is by Nader Ghotbi on bioethicalinterpretation of Buddha’s enlightenment, which hassome background for the previous paper as well.
Interestingly in the paper on fortune telling almost all
respondents, from any religion believed in karma.
- Darryl Macer

American University of Sovereign Nations(http://www.ausn.info) is accepting applications tostart every week for the MPH, Masters in Bioethics
and Global Public Health (MBGPH), andPostgraduate Certificate in Community and Health.
Email: provost@au-sn.com

ABA Renewals and Membership
The annual membership of Asian Bioethics
Association (ABA), for the 2016 issues of
Eubios Journal of Asian and International
Bioethics (EJAIB) (The Official Journal) are
due, please see the back page.

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

End-of-life care in the adultintensive care unit:
Attitudes and practices ofcritical care physicians andnurses- Shahanaz Chowdhury, M.D., MBGPH
Dhaka, Bangladesh
Email: jesmin_70@yahoo.com
AbstractEnd-of-life care in ICUs is often inadequate becauseof factors such as lack of communication between
patients and health care providers, lack of patient- andfamily-centered care and lack of emotional andpsychosocial support. The objective of this study was todetermine the attitudes and practices of physicians andnurses attending patients and providing critical care on
end-of-life care. This was a cross-sectional study
comprising of45 respondents including Physicians(N=24) and Nurses (N=21). Subjects were collectedpurposively and data was collected by face-to-faceinterviews through a semi-structured pretested
questionnaire and data were collected in the ICU of 3
hospitals in Dhaka, Bangladesh (Holy Family Red
Crescent Medical College, NICVD and National Heart
Foundation Hospital and Research Institute). Signed
consent was obtained from the participants and theresults were shared among the participants. Data wasanalyzed using statistical software namely SPSS
version 20 for Windows and both descriptive andinferential analysis was used, as appropriate. There
was one more male (51%) than female respondent(49%), more than half (58%) of the doctors had a
Bachelor degree and more than two thirds (71%) of thenurses had a Diploma. More than half (56%) of thedoctors and nearly half (44%) of the nurses had formal
education or training in critical care. Among the doctors,
37% had 1-5 years and 62% of nurses had 6-10 years
of ICU experience. Overall, 80% reported that theywanted to be involved in decision making of end of life
care, and 76% were satisfied with decision making in
end of life care. Most (71%) respondents said theirability was sufficient to make decisions about end of life
treatment. Most (69%) said it was time consuming
discussing end of life decisions with the patients andfamily members. Two thirds (69%) did not thinkdecisions for end of life care were usually taken quickly.
More than half (53%) thought that ‘do not resuscitate'orders should be present. Nearly half (40%) agreed thatwithholding or withdrawing life support is unethical and(56%) disagreed that withholding and withdrawing are
ethically the same. Sixty percent thought financial costs
to society are an important factor in influencing
decisions on the extent of life support therapy toprovide to a patient. Most (87%) let the family attend
the meetings with the medical team. Moreover, most(80%) respondents fully informed the family about all
aspects of the plan of care of the patient. More thanhalf (56%) permitted the family to visit outside of regular
visiting hours. Half (49%) asked the family how they arecoping. The association between feeling that it is sex,difficult to approach a dying patient and to ask thefamily how they are coping with occupation of the
respondent, was found statistically significant (pvalue<0.05). There was no significant association
between experience in ICU, involved in decision making
of end of life care, satisfaction with involvement indecision making, attitudes to the presence of ‘do notresuscitate' orders, beliefs that withholding andwithdrawing life support are ethically the same, belief
that the ICU bed availability should influence decisions,providing the family with options about the care of thepatient, reassuring the family that they are notresponsible, explaining all interventions to the family
about the dying process, permitting the family to visit
outside of regular visiting hours, asking the family about
their feelings, with occupation of respondent (pvalue>0.05).The results of this thesis may help plan
strategies to promote and emphasis on competent andcompassionate end-of-life care of among the physician
and nurses of adult intensive care units (ICUs).

1. Introduction
1.1. Background Information
The primary goals of intensive care medicine are tohelp patients survive acute threats to their lives while
preserving and restoring the quality of those lives.
These
goals
are
frequently
achieved,
withapproximately 75% to 90% of patients admitted to an
intensive care unit (ICU) surviving to discharge (Luceand Prendergast, 2001). Even so, the ICU has become
a common place to die; studies show that 22% of alldeaths in the United States now occur in or after
admission to an ICU(Angus et al., 2004). Admission to
the ICU is therefore often a therapeutic trial. Only when
the trial fails do patients and families consider a change
in goals, from restorative care to palliative care. Thischange, which has been called the transition from cure
to comfort, is one of the most difficult and important
aspects of medical and nursing practice in the.
ICU(Curtis, 2000). Two truths ensure that this transition
will remain difficult, despite our best efforts. “First is thewidespread and deeply held desire not to be dead.
Second is medicine’s inability to predict the future, andto give patients a precise, reliable prognosis about
when death will come. If death is the alternative, many
patients who have only a small amount of hope will pay
a high price to continue the struggle”(Finucane, 1999).
Many intensive care unit (ICU) patients do notsurvive the ICU experience(Prendergast et al.,1998)more die before leaving the hospital. Those who
eventually die in the ICU consume a disproportionate
amount of ICU resources (Esserman et al., 1995). In
the period before death, these patients may endure
physical and emotional consequences of aggressive
supportive technologies for longer than necessary,
when comfort-care measures would have been more

Eubios Journal of Asian and International Bioethics 25 (September 2015)
appropriate and more humane(Lilly et al., 2000, Nelson,
2002).
Only recently have a few investigators begun to
explore how interdisciplinary collaboration may improvethe care experience of ICU patients who eventually diein this setting. These researchers have demonstrated
improvement in care(Baggs et al., 2004).The key
activity of teams is collaboration, which has been
defined in the ICU context as ‘‘nurses and physicianscooperatively working together, sharing responsibility
for solving problems, and making decisions to formulate
and carry out plans for patient care’’ (Baggs andSchmitt, 1988). In a grounded theory study the processof collaboration between ICU nurses and resident
physicians was found to entail ‘‘working together’’ as
the core process, which incorporated a focus on thepatient, recognition of the importance of the team, andsharing. Antecedent conditions were ‘‘being available’’and ‘‘being receptive,’’ processes of mutual respect andtrust between the nurses and physicians, and their
willingness to discuss patient care. The outcomes ofcollaboration included ‘‘improving patient care, feeling
better in the job, and controlling costs’’ (Baggs andSchmitt, 1997).
End-of-life care was hardly a consideration whenintensive care units (ICUs) were developed in the mid20th century to provide invasive monitoring and medical
interventions to the critically ill (Luce and White, 2009).
Intensive care medicine was full of promise in thosedays, and ICU clinicians, especially physicians, seemed
more interested in saving lives with new technologies
than in comforting dying patients and their families.
Nevertheless, as ICUs proliferated, the limitations of thetherapies they provided were appreciated, along withthe realization that some 20% of patients in countries
like the United States die in ICUs or shortly after
discharge from them, usually after decisions to forego
life-sustaining therapy have been made(Angus et al.,2004). As a result, end-of-life care in the ICU has
become a clinical, educational, and research imperative(White and Luce, 2004). End-of-life care and decisionmaking are frequent issues for critically ill patients in
intensive care units(Curtis, 2005).Good end-of-life careis based on the understanding that death is inevitable,
and a natural part of life. As the final stage in a person’slife it is a uniquely important time for the dying person
and their family and close friends. The goals of end-oflife care are: to maintain the comfort, choices, andquality of life of a person who is recognized to be dying(in the terminal phase); to support their individuality;
and to care for the psychosocial and spiritual needs ofthemselves and their families. Support for families, if
needed, continues after death as bereavement care.
End-of-life care also aims to reduce inappropriate andburdensome healthcare interventions and to offer achoice of place of care when possible(Steinhauser etal., 2001).
During the last 15 yrs, there has been a dramaticincrease in decisions to withhold or withdraw lifesustaining treatment in critically ill patients (Prendergast
and Luce, 1997). All recent observational studies reveal

171

that more patients die in the intensive care unit after thelimitation of some form of life sustaining treatment than
the number who die after a failed but unrestricted
resuscitation attempt (Prendergast et al., 1998, BalfourLynn and Tasker, 1996, Ryan et al., 1993, Vernon et.
al., 1993) How clinicians should reason about end-oflife decisions has also received more scrutiny in recent
years. Recommendations for ethical decision-making
regarding limitations of life-sustaining treatments, aswell as the appropriate care of these patients once a
decision has been made, were put forth as early as
1983 by the U.S. President’s Commission for the Studyof Ethical Problems in Medicine and Biomedical and
Behavioral Research (United, 1983). Since then,consensus guidelines and recommendations forclinicians on the care of critically ill patients have been
put forth by most medical and nursing organizations(Panel, 1990, Society, 1991, 1994a, 1996, Hafemeister,
1992, States, 1998, Cassel et al., 1999). Thesestatements advise clinicians, among other things, that
there is “no ethically significant distinction between
withholdingorwithdrawaloflifesustaining
treatment”(United, 1983, Panel, 1990, Society, 1991,
1994a)and
that
healthprofessionals
should“aggressively treat pain with analgesic drugs and, whenneeded, with heavy sedation, even if these treatments
hasten death”(States, 1998, Cassel et al., 1999).
Despitethese
consensus
guidelines
andrecommendations, accumulating data in the literature
document wide variation in how clinicians makedecisions about life-sustaining treatments. Somestudies suggest that variables independent of patients’preferences, such as physicians’ attitudes and practicespecialty, are better predictors of end-of-life decisionmaking (Cook et al., 1995, Christakis and Asch, 1993,
Hakim et al., 1996, Randolph et al., 1997, Randolph etal., 1999). Other research in this field has demonstrated
that practitioners of critical care often hold views
dissimilar to consensus guidelines, and that significant
differences exist between physicians and nurses on
end-of-life decision-making as well as with theirsatisfaction with the actual care provided in thisarea(Solomon et al., 1993, Eliasson et al., 1997,
1994b). Decisions about end-of-life care were mostoften reported as being made too late or too
infrequently, and nurses as well as physicians weregreatly distressed by the perception of inappropriatecare(Nelson et al., 2010a, Cox et al., 2009).
Death in an ICU is often described as a devastating
experience for patients and their families, with patientsremaining dependent on intensive life support care,neither dying nor recovering. Expectations are still
unrealistically high among patients and their families
and also among physicians (Nelson et al., 2010a, Cox
et al., 2009). Continuing life-sustaining treatments
without clinical improvement causes suffering topatients and deprives them and their families ofpalliative care, deprives them and their families ofhonest prognostic information, and reduces patients¿
time to prepare for dying and their families¿ time toprepare for bereavement (Nelson et al., 2010a, Nelson

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

et al., 2010b). End-of-life care in ICUs is often
inadequate because of factors such as lack ofcommunication between patients and health careproviders, lack of patient- and family-centred care andlack of emotional and psychosocial support. It isapparent that some of these factors are due tophysician-related barriers, many of which have beenreported in the scientific literature(Nelson et al., 2010b,
Organization, 2014). ICU physicians are unable toprovide treatment according to a patient’s wishes when
the goals of care and the treatment preferences of thepatient are not clear and treatment decisions are notshared with the patient and the patient’s family. As aresult, the patient’s quality of life may be harmed. This
is why patients and families are currently expressing
their wishes for better communication and a larger rolein the treatment decision-making process and asking
ICU clinicians to respond to their palliative careneeds(Davidson et al., 2007).
1.2 Justification of the study
Admission to the ICU is therefore often a therapeutic
trial. Only when the trial fails do patients and families
consider a change in goals, from restorative care to
palliative care. This change, which has been called thetransition from cure to comfort, is one of the mostdifficult and important aspects of medical and nursing.
practice in the ICU (Curtis, 2000) Many intensive careunit (ICU) patients do not survive the ICU experience,(Prendergast et al., 1998) more die before leaving the
hospital. Those who eventually die in the ICU consume
a disproportionate amount of ICU resources (Esserman
et al., 1995). In the period before death, these patients
may endure physical and emotional consequences ofaggressive supportive technologies for longer thannecessary, when comfort-care measures would havebeen more appropriate and more humane (Lilly et al.,2000, Nelson, 2002).
Intensive care medicine was full of promise in the
mid-20th century, and ICU clinicians, especially
physicians, seemed more interested in saving lives withnew technologies than in comforting dying patients andtheir families. Nevertheless, as ICUs proliferated, thelimitations of the therapies they provided wereappreciated, along with the realization that some 20%of patients in countries like the United States die in
ICUs or shortly after discharge from them, usually after
decisions to forego life-sustaining therapy have been
made (Angus et al., 2004). As a result, end-of-life carein the ICU has become a clinical, educational, andresearch imperative (White and Luce, 2004). End-of-lifecare and decision-making are frequent issues forcritically ill patients in intensive care units(Curtis, 2005).
Good end-of-life care is based on the understandingthat death is inevitable, and a natural part of life. As the
final stage in a person’s life it is a uniquely importanttime for the dying person and their family and closefriends. The goals of end-of-life care are: to maintainthe comfort, choices, and quality of life of a person who
is recognized to be dying (in the terminal phase); tosupport their individuality; and to care for thepsychosocial and spiritual needs of themselves andtheir families. Support for families, if needed, continues
after death as bereavement care. End-of-life care also
aims to reduce inappropriate and burdensome
healthcare interventions and to offer a choice of placeof care when possible (Steinhauser et al., 2001).
Despitethese
consensus
guidelines
andrecommendations, accumulating data in the literature
document wide variation in how clinicians makedecisions about life-sustaining treatments. Thesestudies suggest that variables independent of patients’preferences, such as physicians’ attitudes and practicespecialty, are better predictors of end-of-life decisionmaking(Cook et al., 1995, Christakis and Asch, 1993,
Hakim et al., 1996, Randolph et al., 1997, Randolph etal., 1999). Other research in this field has demonstrated
that practitioners of critical care often hold views
dissimilar to consensus guidelines, and that significant
differences exist between physicians and nurses on
end-of-life decision-making as well as with theirsatisfaction with the actual care provided in this area
(Solomon et al., 1993, Eliasson et al., 1997, 1994b).
A majority of physicians surveyed throughout Asia
reported almost always or often withholding lifesustaining treatment in end-of-life care for patients in
hospital intensive care units when there is little chanceof meaningful recovery, although attitudes and practiceof end-of-life care varied widely across countries andregions on the continent(Younsuckm and Mervyn)
Recognizing the dying patient seems to be moredifficult than physicians care to admit. Knowing when tolet go as a provider and helping the family let go of their
loved
one
can
be
onerous.
Furthermore,communication with the family and among medical,
nursing, and ancillary health teams is not only
challenging and necessary, but it must also be
successful (Papadimos et al., 2011).
Limited research has investigated the actual attitude
and practices of critical care nurses and physicians in
the provision of end-of-life care, or the factors
influencing these practices. To improve that patients at
the end of life and their families receive, and to support
nurses and physicians in the provision of this care,further research is needed. Interesting and important
findings has been found in several published articles on
the attitude and practices of critical care of physicians
and nurses regarding end of life care in Intensive careunit in different countries of the world but no study could
be found in Bangladesh on this regards. The purpose ofthis study is to determine the attitudes and practices ofphysicians and nurses attending patients and providing
critical care on end-of-life care. The results of thisthesis will be used to help plan strategies to promoteand emphasis on competent and compassionate endof-life care of among the physician and nurses of adultintensive care unit.
This paper is based on a dissertation from the
Masters in Bioethics and Global Public Health(MBGPH) Program of American University of Sovereign
Nations (AUSN), United States of America (USA).

Eubios Journal of Asian and International Bioethics 25 (September 2015)
1.3. Operational Definitions
Withholding treatment means that a treatment,
which might be beneficial in a different scenario or
patient, is not initiated, e.g. in a patient weaned fromventilation, a decision not to recommence mechanicalventilation if respiration became inadequate. Other
forms of withholding include “Do not attempt
cardiopulmonary resuscitation” orders; not initiating
haemodialysis or treatments such as antibiotic therapy
or vasopressors.
Withdrawal of treatment means a treatment, whichmight be beneficial in a different scenario or patient, isreduced and stopped. Most treatments which may be
withheld can, in other situations in which they werecommenced, be withdrawn. Most ethicists view
withdrawing or withholding treatment as equivalent.
1.4 Research Question
What are the attitudes and practices of physicians
and nurses attending patients and providing criticalcare on end-of-life care?
2. Literature Review
2.1. ICU environment
Every member in the care team has the same
fiduciary obligation that is to protect and promotepatients’ health-related interests and implement
patients’ preferences in pursuit of health. However, theconflicting interests of end-of-life (EOL) care result instress for health care professionals involved inintensive care in clinical practice. The urgent need fortreatment and complexity of the diseases being cared
for in an intensive care unit (ICU) make the situationeven more complicated (Lee et al., 2009). ICUs areenvironments where patients have illnesses of highmorbidity and mortality. The ICU is a specialized
medical environment where critically ill patients arecared for. Patients in ICU have their own uniquecharacteristics. Their mortality rates are high, varying
from 10% to 20% in different ICUs (Knaus et al., 1986).
Avoidance of futile care is an essential task in ICU,
since the ward is supposed to resuscitate dying
patients(Lynn et al., 1997).These conflicts come fromnot only the dilemma of human dignity between therights of life and death, but also the dilemma of differing
attitudes toward EOL care between the medical staff
and family members (Chiu et al., 2000).
2.2. Attitudes and practices surrounding end of life
care in ICUs
A majority of physicians surveyed throughout Asia
reported almost always or often withholding lifesustaining treatment in end-of-life care for patients in
hospital intensive care units (ICUs) when there is little
chance of meaningful recovery, although attitudes andpractice of end-of-life care varied widely acrosscountries and regions on the continent, according to areportpublishedonlineby
JAMAInternal
Medicine(Younsuckm and Mervyn).Asia accounts for atleast half of all patients with critical illness, mechanicalventilation and ICU deaths internationally but data on

173

end-of-life care in ICUs in countries in Asia are sparse,
according to this background information.
Jason Phua, F.R.C.P., of the National University
Hospital, Singapore, and coauthors used survey data to
describe physicians’ attitudes toward withholding andwithdrawal of life-sustaining treatments in end-of-lifecare and evaluate the factors tied to those attitudes.
The survey was conducted among 1,465 physicians(physician response rate of 60% percent) who manage
patients in 466 ICUs (ICU response rate of 59%
percent) in 16 Asian countries and regions, including
Bangladesh, China, Hong Kong, Iran and Thailand. The
majority of respondents (70% percent) reported theyalmost always or often withhold life-sustaining
treatments for patients with no real chance ofrecovering a meaningful life, 20.7 percent almost
always or often withdraw life-sustaining treatments, and
2.5 percent almost always or often deliberately givelarge doses of drugs, such as barbiturates or morphine,
until the patient dies, according to survey results(Younsuckm and Mervyn). Survey results also indicatethat 75% of respondents believe that withholding andwithdrawing treatments were ethically different, a viewsupported by the majority of respondents in all
countries and regions, except Hong Kong andSingapore. Of all the respondents, 84%and 78%,
respectively, reported that patients’ wishes andrequests from family or surrogates were importantfactors when considering limiting life-sustaining
treatment. However, only 44% of respondents werecomfortable discussing limitation of care with families orsurrogates and 36% of respondents said patients,
families or surrogates almost always or often requested
inappropriate life-sustaining treatments.
“Multiple factors related to country or region,
including economic, cultural, religious and legal
differences, as well as personal attitudes, wereassociated with these variations. Initiatives to improve
end-of-life care in Asia must begin with a thoroughunderstanding of these factors,” the study concludes(Younsuckm and Mervyn).

2.3. The Value and Risk of Informed Assent
In the critical care setting, there are specificcircumstances when some standard therapies, such as
cardiopulmonary resuscitation, may not provide any
benefit to the patient. In these circumstances, areclinicians always obliged to obtain informed consent
from patients or family membzers to withhold or
withdraw such therapies? Because the process ofobtaining informed consent may cause considerable
distress for some patients and family members, theresearcher contend that obtaining informed assent—
when the patient or family is explicitly invited to defer toclinicians’ judgment in favor of withholding orwithdrawing life-sustaining therapy—is an appropriate,ethical alternative(Curtis and Burt, 2007).

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

2.4. End-of-life communication among medical
teams
Communication between patients (where possible),families, and caregivers of patients in ICU is vital andbecomes even more important when considering endof-life
decisions(Cohenetal.,2005).These
recommendations, therefore, do not deal primarily withthe process that leads to the decision to forego life
prolonging treatments but rather focus on theimplementation of that decision, with particularemphasis on the ICU environment. As the decision toforego further use of life-sustaining treatments is being
made, the family and clinical team must be prepared forwhat is to follow. As familiar as many clinicians may bewith the process of withdrawing life support, it is asingular event in the life of the patient and often isunprecedented for family members. Therefore, they
may suffer great anxiety during the experience. Clearand explicit explanations on the part of the clinicianmayalleviateanxietyandrefocusfamilial
expectations(Truog et al., 2001).
Although the needs of the patient must be theprimary focus of caregivers, there is growing consensus
that a family-centered approach is particularly importantin end-of-life care(Curley and Meyer, 1999). Families ofthe dying need to be kept informed about what toexpect and about what is happening during the dying
process. Communication between clinicians andgrieving families may be difficult in the absence of aprior relationship, as is frequently the case in the ICU.
Primary care providers and other more familiar
clinicians may be able to provide a helpful interface with
the ICU team(Hampe, 1975).Families vary in theirtolerance for uncertainty and ambiguity, but clinicians,from the primary intensivist to the subspecialists to thenursing staff, should strive to deliver a consistentmessage. This may be facilitated by having allcommunication occur through the same person, as one
model. Families should clearly know the identity of theattending physician, understand that this person is
ultimately responsible for the patient’s care, and beassured of his or her involvement. Clinicians should
avoid making firm predictions about the patient’s clinicalcourse, because these are notoriously difficult to make,are often inaccurate, and may result in a substantial
loss of credibility when they are in error. Althoughclinicians should be sensitive and compassionate intheir communication, it is important that they explain thephysiologic process of dying and describe in concreteterms how the patient will die and what it will look like.
At times it will be necessary for the clinicians toanticipate, ask, and answer questions that the family
appears to be afraid or unable to verbalize. Families
may benefit from reassurance that the clinicians arefocused on the patient’s comfort. Clinicians should earn
the patient’s and family’s confidence by continuallyassessing the patient’s suffering and demonstratingthat pain-relieving medications and treatments areconstantly available.
Families should know that the caregivers arecommitted to having a presence at the bedside, evenwhen the family members themselves are not able tobe there. Finally, families often need to be reassured
about the decisions they have already reached,emphasizing that the responsibility for these decisions
is shared between the family and care team. This canhelp to dispel lingering doubts and potential feelings of
guilt. Families should have the opportunity to be helpful.
They may be invited to participate in activities to relieve
discomfort, such as mouth care, bathing, andrepositioning. They should be encouraged to participate
in assessment of the patient’s pain and suffering. Thisis especially important in pediatrics and provides
parents with an opportunity to express their nurturing
role (Fleischman et al., 1994).
2.5. Good EOL Care—Commitment
The early years of critical care medicine were
defined by remarkable discoveries and innovations that
dramatically reduced the morbidity and mortality of
disease. In recent years, critical care practitioners
increasingly have recognized that our obligations topatients extend beyond our attempts to treat disease
and include a commitment to providing patients with adignified and tolerable death.
Practical aspects of end-of-life care are inseparably
wed to many intensely controversial ethical issues.
Recommendations such as these can only attempt toarticulate practices that are based on sound ethicalreasoning and that are consonant with current culturaland legal norms. These norms are not static andundoubtedly will change over the years. What is
unlikely to change, however, is a basic commitment tothe comfort and well-being of the patient, regardless ofwhether the hopes for cure are high or nonexistent. As
Albert Schweitzer noted several decades ago, “We allmust die. But that I can save him from days of torturethat is what I feel as my great and ever new privilege.
Pain is a more terrible lord of mankind than even death
itself”(Schweitzer, 1931).
3.2 Objectives of the Study
3.2.1. General objective
General objectives: To determine the attitudes andpractices of physicians and nurses attending patientsand providing critical care on end-of-life care.
3.2.2. Specific objectives• To assess the attitude of physicians and nurses
attending patients and providing critical care on end-oflife care.
• To identify the practice of physicians and nurses
attending patients and providing critical care on end-oflife care.
• To find out the factors influencing the provision of
end-of-life care by the critical care physicians andnurses.
• To find out the relationship between the attitude
and practice with selected socio-demographic
variables.
3.3. Data collection instrument
The tools were prepared by keeping the objectives

Eubios Journal of Asian and International Bioethics 25 (September 2015)of the study as the framework that reflect the study
variables. All variables were listed and appropriate
scales of measurements were determined. In the study
for maximum output, a semi-structured questionnaire
was developed and applied for data collection. The
questionnaire was pre-tested among a similar group ofpeople. Pretesting of the research instrument for the
purpose of validation was done before finalization. The
questionnaire was pretested on 10 critical careclinicians, who was not part of the final sample.
Permission for collection of data was taken from the
Director/Principal of the three hospitals.
3.4. Study details
The study was done within the time period of May to
October 2015. The respondents of the study weredoctors and nurses working in adult Intensive care units(ICU). All the physicians and nurses who were involved
with critical care on end-of-life care at the time of datacollection were enrolled.
The study area was selected purposively. These are
3 Intensive care Units (ICU).
a) National Heart Foundation Hospital and ResearchInstitute, Dhakab) National Institute of Cardiovascular Diseases,
Dhaka.
C) Holy Family Red Crescent Medical College an
Hospital, Dhaka.
Participants who meet the criteria will be included in
the study:• Doctors and nurses who worked in ICUs.
• Those who were willing to participate in the study.
Participants that will be excluded from the study:• Doctors and nurses who worked did not work in
ICU.
• Those who were not willing to participate in the
study.
The researcher observed the doctors and nurses
working in critical care in adult ICUs that meet theinclusion criteria. The purpose of the study was
explained to the selected respondents. Then data werecollected by face to face interview by me (researcher)and the responses were written in the questionnaire
accordingly. One questionnaire was used for each
respondent. Nine to ten respondents were interviewed
each day within 5 days and each interview requiredaround 30-40 minutes including rapport building withthe respondents.
The researcher individually approached them andinvited them to participate in the study. The workers,
volunteering to participate in this study, were assured
that their confidentiality and anonymity would bemaintained. A convenient sample of 45 workers wasinterviewed considering the time frame given by the
University. The study was conducted for learning
purposes only. A convenient sample was used because
this method of sampling is to organize and includes
subjects who agree to participate in the study. The
convenient sampling technique also allows theresearcher to target particular subjects who may be in175

the best position to provide the information required inanswering the research question.
3.5 Data management and analysis plan
All possible measures have been taken to maintain
good quality of the data. At the end of the datacollection through a semi-structured interview
questionnaire they were edited and coded. Bothdescriptive and inferential statistics was used and it
was presented in the form of tables, graphs anddiagrams. Both descriptive and inferential statistics wasdone as it appropriate. Demographic Variables wasanalyzed by frequency and percentage distribution. A
5-point Likert scale was used to measure the attitudelevel of respondents.
For the better quality of the research I followed thestandard proposal format provided by the University.
Pre test of the questionnaire that was taken in thesimilar situation in other places.
3.6. Ethical considerations
Ethical clearance was taken from the appropriate
authority and ethics were maintained strictly throughout
the study. Ethical clearance was obtained from Ethics
Review Committee of Bangladesh Bioethics Society,and the AUSN Institutional Review Board. A letter ofcooperation written from the Bangladesh Bioethics
Society to the hospitals was taken that were involved inthis study prior to the data collection period. All theparticipants’ were given an explanation about theobjective of the study and their right to participate or not
to participate in the study. An Information sheet forparticipants in Bengali was given to each participant toread and it was also explained by the investigator. Allquestionnaire and ethical documents was translated
into Bengali before interview. The prospective
participants were given free opportunities to receive
summary information of the study in writing before
giving consent and taking part in the interviews of theresearch. All participants who provided written consent
to take part in the study were included in the sample.
Personal information of the participants was keep
confidential.
The limitations while conducting the research work
include:1. As the study place is purposively selected in Dhaka
city so the result might be area specific.
2. To conduct research work on the topic, longer timeshould be utilized.
3. To conduct such a study resources are very
important factors. The researchers was a student
without financial support.
4. The sample size was of the study is small torepresent the situation prevailing nationally, so there isa high margin of error when we extrapolate nationally.
5. Lastly, the information of the respondents was
subjective.

176

Eubios Journal of Asian and International Bioethics 25 (September 2015)

Table 4.1: Distribution of respondents according to
the Demographic status (n=45)
Variable
Number
Percentage
Mean(SD)
Sex
Male
23
51.1
Female22
48.9
Age group (years)
Doctors
25-34
7
43.8
35-44
11
55
45-54
2
40
38.1±9.2
55-64
4
100
Nurses
25-34
9
56.3
35-44
9
45
45-54
3
60
55-64
0
0
Education
Doctors
Masters4
16.7
Bachelor
14
58.3
Diploma6
25
NursesMaster00Bachelor
6
28.6
Diploma15
71.4
Occupation
Doctor
24
53.3
Nurse
21
46.7
Experience in ICU
Doctor
1-5 years
9
37.5
6-10
8
33.3
11-15
7
29.2
Nurse
1-5 years
5
23.8
6-10
13
61.9
11-15
3
14.3
Formal education/training in critical care
Doctor
Yes
15
55.6
No
9
50
Nurse
Yes
12
44.4
No
9
50
Religion
Muslim
42
93.3
Hindu
1
2.2
Christian2
4.4
4. Results
4.1. Demographics of sample
Table 4.1 shows the demographic characteristics ofthe 45 doctors and nurses. Among 45 respondents, 23(51%) were male and 22 (49%) were female. The mean(±SD) of the respondents’ age was 38.1+9.2 years
whereas more than half 11 (55%) doctors aged from35-44 years and more than half 9 (60%) nurses aged
from 25-34 years. Regarding occupation among the 45

respondents 24 (53%) were doctors and 21 (47%) were
nurses. Regarding education among the doctors morethan half of the doctors 14 (58%) had a Bachelor’s
degree, 6 (25%) had Diploma and 4 (17%) had a
Master degree and among the nurses more than twothirds 15 (71%) had a Diploma and 6 (29%) had a
Bachelor’s degree. Regarding experience in ICU
among the doctors one-third, 9 (38%) had 1-5 years
experience, 8 (33%) had 6-10 years experience and 7(29%) had 11-15 years experience and among thenurses more than one fifth 5 (24%) had 1-5 years
experience, 13 (62%) had 6-10 years experience and 3(14%) had 11-15 years experience. Regarding formal
education/training in critical care among doctors morethan half 15 (56%) had formal education/training in
critical care and 9 (50%) had no formal
education/training in critical care and among nurses 12(44%) had formal education/training in critical care and9 (50%) had no formal education/training in criticalcare. Regarding religion 42 (93%) were Muslim, 2 (4%)
were Christian and 1 (2%) were Hindu.
4.2. Attitudes related to decision of end of life care
Table 4.2 shows attitudes related to involvement indecision of life support of the respondents. It shows thatout of 45 respondents 36 (80%) wanted to be involved,
8 (18%) did not want to be involved and 1 (2%)
sometimes want to involved in decision making of endof life care. More than two third 34 (76%) said they
were satisfied, 8 (18%) said they were not satisfied andonly 3 (7%) said sometimes satisfied with theirinvolvement in decision making of end of life care todate. Regarding their ability to make decisions about
end of life treatment, 32 (71%) of respondents said theirability was sufficient, 8 (18%) said that their ability was
not sufficient and only 5 (11%) said their ability wassometimes sufficient to make decisions about end oflife treatment. Out of 45 respondents 33 (73%) said it
was difficult to approach a dying patient, 10 (22%) said
they had no difficulty and only 2 (4%) said sometimes it
was difficult to approach a dying patient. The majority of
the respondents 36 (80%) said that giving dying
patients their prognosis provoked some anxiety, 5(11%) said sometimes it provoked some anxiety andonly 5 (11%) said it did not provoke anxiety. Nearly two
thirds 31 (69%) did not think that decisions for end oflife care were usually taken quickly and 14 (31%)
thought the decision was usually taken quickly. Amongthe 14 respondents who stated that the decision for endof life care is usually taken quickly, 9 (20%) said lack of
hospital beds was the reason and 5 (11%) said thematter of cost was the reason behind the decisions forend of life care usually being taken quickly.
Out of 45 respondents, more than half 24 (53%)
thought that ‘do not resuscitate' orders should bepresent and 21 (47%) thought that ‘do not resuscitate'orders should not be present.

Eubios Journal of Asian and International Bioethics 25 (September 2015)
Table 4.2: Distribution of respondents according to
the attitude related to decision of life care (n=45)
Variable
Number
Percentage
Want to be involved in decision making of end oflife care
Yes
36
80
No
8
17.8
Sometimes
1
2.2
Satisfied with involvement in decision making of
end of life care
Yes
34
75.6
No
8
17.8
Sometimes
3
6.7
Have the ability to make decisions about end of life
treatment was sufficient
Yes
32
71.1
No
8
17.8
Sometimes
5
11.1
Difficult to approach a dying patient
Yes
33
73.3
No
10
22.2
Sometimes
2
4.4
Giving dying patients
their prognosis
provoked some anxiety
Yes
36
80
No
4
8.9
Sometimes5
11.1
Thought decision for end of life care usually taken
quickly
Yes
14
31.1
No
31
68.9
Reasons for taking decision quickly for end of life
care
Lack of hospital beds
920
Matter of cost5
11.1

Yes 69%No 29%
Sometimes
2%

Figure 1: Distribution of respondents according totime consuming discussing end of life decisions
with the patients and family members (n=45)
Figure 1 shows that regarding discussing end of life
decisions, out of 45 respondents, 31 (69%) said it wastime consuming, 13 (29%) not time consuming, andonly 1 (2%) said it was time consuming to discuss theend of life decisions with the patients and family
members.

177

4.3. Attitudes related to withholding or withdrawingof life support
Table 4.3 shows the attitudes related to withholding
or withdrawing of life support. Over half, 25 (56%)
agreed that withholding or withdrawing life support isunethical. Two thirds, 32 (71%) agreed that withholding
is more ethical than withdrawing. Only7 (16%) agreed
that withdrawing is more ethical than withholding.
Regarding whether withholding and withdrawing are
ethically the same, 25 (56%) disagreed and 13 (29%)
agreed.
Table 4.3: Distribution of respondents according to
the attitude related to withholding or withdrawingof life support (n=45)
Variable
Number
Percentage
Withholding or withdrawing life support isunethical
Strongly4
8.9
disagreeDisagree14
31.1
Neutral
2
4.4
Agree
18
40
Strongly agree
7
15.6
Withholding is more ethical than withdrawing
Strongly4
8.9
disagreeDisagree5
11.1
Neutral
4
8.9
Agree
29
64.4
Strongly agree
3
6.7
Withdrawing is more ethical than withholding
Strongly
1
2.2
disagreeDisagree35
77.8
Neutral
2
4.4
Agree
4
8.9
Strongly agree
3
6.7
Withholding and withdrawing are ethically thesameStrongly00disagreeDisagree25
55.6
Neutral
7
15.6
Agree
11
24.4
Strongly agree
2
4.4
4.4. Attitudes related to factors in influencing
decisions on the extent of life support therapy toprovide a patient
Table 4.4 shows attitudes related to factors in
influencing decisions on the extent of life support
therapy to provide to a patient. Out of 45 respondents
35(78%) viewed it important that the quality of life as
viewed by the patient was a factor in influencing
decision on the extent of life support therapy to provide
a patient. Regarding quality of life as viewed by thefamily as factor in influencing decision 33(73%) of the
respondents viewed it to be important. Over half

178

Eubios Journal of Asian and International Bioethics 25 (September 2015)26(58%) of the respondents said it was important and12(27%) say it as less important that the patient was
unlikely to survive as a factor in influencing decisions
on the extent of life support therapy to provide a patient.
Fear of litigation or breaking the law was thought to beimportant by 27(60%) respondents and less importantby 11(5%) thought it was not important as a factor in
influencing decisions on the extent of life support
therapy to provide a patient. Out of 45 respondents,
financial costs to society was thought to be a factor in
influencing decision on the extent of life support therapy
to provide a patient as important by 35(78%) and 4(9%)
a less important factor. Regarding ICU bed availability,
33(73%) thought it was important as a factor in
influencing decision on the extent of life support therapy
to provide a patient.
Table 4.4: Distribution of respondents according to
the attitudes related to factors in influencing
decision on the extent of life support therapy toprovide a patient (n=45)
Variable
Number
Percentage
Quality of life as viewed by the patient
Less important7
15.6
Neutral3
6.7
Important22
48.9
Very important13
28.9
Quality of life as viewed by the familyLess important
10
22.2
Neutral2
4.4
Important
19
42.2
Very important
14
31.1
Patient unlikely to survive
Not important2
4.4
Less important
12
26.7
Neutral5
11.1
Important20
44.4
Very important
6
13.3
Fear of litigation or breaking the law
Not important2
4.4
Less important
11
24.4
Neutral5
11.1
Important
19
42.2
Very important8
17.8
Financial costs to society
Not important2
4.4
Less important4
8.9
Neutral4
8.9
Important
27
60
Very important8
17.8
ICU bed availability
Not important3
6.7
Less important6
13.3
Neutral3
6.7
Important22
48.9
Very important
11
24.4

4.5. Attitudes related to medications
Table 4.5 shows that attitudes related to medications
should be added or increased in the patient’s regimen
as life support is discontinued. Regarding narcotics
29(65%) said that they had not prescribed them in endof life care, while 7(16%) said that they should be
added or increased in the patient’s regimen as life
support is discontinued. More than half 26(58%) said
never and 9(20%) said sometimes regarding adding
Benzodiazepines or increased in the patient’s regimen
as life support is discontinued. Three fifth of the
respondents 27(60%) said never, while 11(24%) said
sometimes Barbiturates should be added or increasedin the patient’s regimen as life support is discontinued.
Regarding neuromuscular blocking agents 32(71%)
said never and 6(13%) said sometimes that it should be
added or increased in the patient’s regimen as life
support is discontinued.
Table 4.5: Distribution of respondents according to
the attitude related to medications should be added
or increased in the patient’s regimen as life
support is discontinued (n=45)
Variable
Number
Percentage
Narcotics
Never
29
64.4
Infrequently1
2.2
Sometimes
5
11.1
Frequently
7
15.6
Always3
6.7
Benzodiazepines
Never
26
57.8
Infrequently
3
6.7
Sometimes
920Frequently
3
6.7
Always4
8.9
Barbiturates
Never
27
60
Infrequently
4
8.9
Sometimes
11
24.4
Frequently
1
2.2
Always2
4.4
Neuromuscular blocking agents
Never
32
71.1
Infrequently
2
4.4
Sometimes
6
13.3
Frequently
4
8.9
Always1
2.2
4.6. Practice related to patient and family centereddecision making
Table 4.6 shows practices related to patient andfamily centered decision making. It shows that threequarters of the respondents, 34 (76%) provided thefamily with options about the care of the patient. The
majority, 33 (73%) asked and 12(27%) did not ask thefamily if they would like to be involved in the care ofpatient. Most, 39 (87%) said that they asked the family
their preferences for the patient’s care. More than four
fifth 39(87%) let the family to attend the meetings with

Eubios Journal of Asian and International Bioethics 25 (September 2015)
the medical team. Regarding reassuring the family thatthey are not responsible for any end of life caredecisions made nearly to two third 29 (64%) said theyreassured. More than two third 33 (73%) asked thefamily about knowledge of the patients’ wishes for endof life care.
Table 4.6: Distribution of respondents according to
the practice related to patient and family centereddecision making (n=45)
Variable
Number
Percentage
Provide the family with options about the care of
the patient
Yes
34
75.5
No
9
20
Sometimes2
4.4
Ask the family if they would like to be involved in
the care of patient
Yes
33
73.3
No
12
26.7
Sometimes
00
Ask the family if their preferences for the patient’s
care
Yes
39
86.7
No
6
13.3
Sometimes
00
Let the family to attend the meetings with the
medical team
Yes
39
86.7
No
5
11.1
Sometimes
1
2.2
Reassure the family that they are not responsible
for any end of life care decisions made
Yes
29
64.4
No
15
33.3
Sometimes1
2.2
Ask the family about knowledge of the patients’wishes for end of life care
Yes
33
73.3
No
9
20
Sometimes
3
6.7
4.7: Practice related to explaining and providing
information of the patient:
Table 4.7 shows practices related to explaining andproviding information to the patient. It shows that most(89%) answered the family’s questions about thepatients’ condition and nearly four fifths, 36(80%)
respondents fully informed the family about all aspectsof the plan of care of the patient. Regarding explaining
all interventions to the family about the dying process,the majority of respondents (73%) explained and 87%
explained to the family what is happening to the patient.
The table also shows that 82% listened to the family
reminisces about the patient.

179

Table 4.7: Distribution of respondents according to
the practice related to explaining and providing
information of the patient (n=45)
Variable
Number
Percentage
Answer the family’s questions about the patients’condition
Yes
40
88.9
No
1
2.2
Sometimes
4
8.9
Fully inform the family about all aspects of the planof care
Yes
36
80
No
3
6.7
Sometimes
6
13.3
Explain all interventions to the family about thedying process
Yes
33
73.3
No
9
20
Sometimes
3
6.7
Explain to the family what is happening to thepatient
Yes
39
86.7
No
5
11.1
Sometimes
1
2.2
Listen to the family reminisce about the patient
Yes
37
82.2
No
5
11.1
Sometimes
3
6.7
Table 4.8: Distribution of respondents according to
the practice related to continuity of care of thepatient (n=45)
Variable
Number
Percentage
Arrange for transfer of the patient out of the ICU
after a decision to withdraw treatment
Yes
36
80
No
9
20
Sometimes
00Document the family’s preference for the care of
their relative
Yes
33
73.3
No
11
24.4
Sometimes
1
2.2
Introduce the next care staff on the oncoming shift
to the patient and family
Yes
25
55.6
No
16
35.6
Sometimes
4
8.9
4.8. Practice related practice related to continuityof care of the patient
Table 4.8 shows practices related to the practicerelated to continuity of care of the patient. The tableshows that majority (80%) arranged for transfer of thepatient out of the ICU after a decision to withdraw
treatment. More than two thirds (73%) documented thefamily’s preference for the care of their relative. Half180

Eubios Journal of Asian and International Bioethics 25 (September 2015)(56%) introduced next care staff on the oncoming shift
to the patient and family.
Table 4.9: Distribution of respondents according to
the practice related to emotional and practicalsupport for patient and families (n=45)
Variable
Number
Percentage
Permit the family to visit outside of regular visiting
hours
Yes
25
55.6
No
17
37.8
Sometimes
3
6.7
Encourage the family to talk to the patient
Yes
32
71.1
No
12
26.7
Sometimes
1
2.2
Encourage the family to touch the patient
Yes
22
48.9
No
21
46.7
Sometimes2
4.4
Ask the family how they are coping
Yes
22
48.9
No
20
44.4
Sometimes
3
6.7
Ask the family about their feelings
Yes
30
66.7
No
12
26.7
Sometimes
3
6.7
Table 4.10: Distribution of respondents according
to practices related to symptom management andcomfort care (n=45)
Variable
Number
Percentage
Administer fluids to the patient
Yes
39
86.7
No
5
11.1
Sometimes
1
2.2
Keep the patient sedated
Yes
39
86.7
No
6
13.3
Sometimes
00Provide adequate pain management
Yes
41
91.1
No
4
8.9
Sometimes
00Provide care to maintain patient hygiene
Yes
39
86.7
No
4
8.9
Sometimes
2
4.4
Maintain the patient’s airway using
oro/endotracheal suction
Yes
41
91.1
No
3
6.7
Sometimes
1
2.2
4.9. Practices related to emotional and practicalsupport for patient and families
Table 4.9 shows some practices related to emotional
and practical support for patient and families. Morethan half (56%) permitted the family to visit outside ofregular visiting hours respectively. A majority (71%)
encouraged the family to talk to the patient. Almost half(49%) encouraged the family to touch the patient also
almost half 22(49%) asked the family how they arecoping. More than two third 30(67%) asked the family
about their feelings.
4.10. Practices related to symptom management
and comfort care
Table 4.10 shows practices related to symptom
management and comfort care. Most (87%)
administered fluids to the patient. A majority 39(87%)
kept the patient sedated and 91% of the respondents
said that they provided adequate pain management. A
majority (87%) provided care to maintain patienthygiene. Moreover nearly all (91%), maintained
patient’s airway using oro/endotracheal suction
respectively.
Table 4.11 shows the association between
occupation and different attitudes related to end of life
care.
Desire to be involved in decision making about
end of life care and occupation
Almost half of the doctors (49%) wanted to be
involved while only 4% did not want to be involved, butless nurses (31%) wanted to be involved and 1 (2%)
sometimes wanting to be involved in decision making of
end of life care. The association between desire to be
involved in decision making at end of life care andoccupation is not statistically significant (p value>0.05).
Satisfaction with involvement in decision
making of end of life and occupation
More than one third (38%) of doctors said they weresatisfied with involvement in decision making of end oflife care, the same proportion as nurses (38%) who
said they were satisfied. There is no statisticaldifference with involvement in decision-making at theend of life and occupation (p value>0.05).
Have the ability to make decisions about end oflife treatment was sufficientMore than one third (40%) nurses and 31%
doctors said they had the ability to make decisions
about end of life treatment was sufficient. There is no
statistical difference with ability to make decisions
about end of life treatment was sufficient andoccupation (p value>0.05).
Difficulty to approach a dying patient andoccupation
Almost half (44%) of doctors said it was difficult toapproach a dying patient and very few (4%) said they
had no difficulty to approach a dying patient. However,
only one fourth (29%) of nurses said it was difficult toapproach a dying patient, and nearly one fifth (18%)
nurses said they had no difficulty to approach a dying
patient. The association between difficulty to approacha dying patient and occupation is statistically significant(p value<0.05).

Eubios Journal of Asian and International Bioethics 25 (September 2015)
Table 4.11: Association between occupation anddifferent attitudes related to end of life care (n=45)
Variable
Occupation
χ2
pvalueDoctor Nurse
Want to be involved in decision making of end oflife careYes
22
14 4.598 0.100(48.8%)(31.1%)No
2 (4.4%)6 (13.3%)
Sometimes
01(2.2)
Satisfied with involvement in decision making of
end of lifeYes
17
17 2.813
0.245(37.7%)(37.7%)No
4 (8.8%)4 (8.8%)
Sometimes
3 (6.6%)0
The ability to make decisions about end of life
treatment was sufficientYes
14
18 (40%)(31.1%)
5.82
0.054
No
5
3 (6.6%)(11.1%)
Sometimes
50(11.1%)
Difficult to approach a dying patientYes
20
13 6.916 0.031*(44.4%)(28.8%)No
2 (4.4%)8 (17.7%)
Sometimes
2 (4.4%)0Thought ‘do not resuscitate' orders should bepresent
Yes
14
10 0.517 0.472(31.1%)(22.2%)
No
10
11(22.2%)(24.4%)
Withholding and withdrawing life support are
ethically the same
Disagree15
10 1.038 0.792(33.3%)(22.2%)
Neutral
3 (6.6%)4 (8.8%)Agree
5 6 (13.3%)(11.1%)
Strongly
1 (2.2%)1 (2.2%)Agree
ICU bed availability influencing decision on theextent of life support therapy to provide a patientNot
0
3 (6.6%) 4.821
0.306
importantLess
4 (8.8%)2 (4.4%)
important
Neutral
1 (2.2%)2 (4.4%)
Important
1210(26.6%)(22.2%)Very7
4 (8.8%)important(15.5%)

181

Belief that ‘do not resuscitate' orders should bepresent and occupation
One third (31%) of doctors thought that ‘do notresuscitate' orders should be present and 22% doctors
thought that ‘do not resuscitate' orders should not bepresent. One quarter (22%) of nurses thought that ‘do
not resuscitate' orders should be present and 24%
nurses thought that ‘do not resuscitate' orders should
not be present. The association between those who
thought that ‘do not resuscitate' orders should bepresent and occupation is not statistically significant (pvalue>0.05).
Beliefs that withholding and withdrawing life
support are ethically the same and occupation
Regarding the idea that withholding and withdrawing
are ethically the same among the doctors 33%
disagreed and among the nurses, 22% disagree. The
association between the idea that withholding andwithdrawing life support are ethically the same andoccupation is not statistically significant (p value>0.05).
Beliefs that ICU bed availability influencing
decision on the extent of life support therapy toprovide a patient & occupation
Regarding ICU bed availability as a factor
influencing decisions on the extent of life support
therapy to provide a patient, 27% of doctors and 22% ofnurses thought it was important. The association
between ICU bed availability influencing decision on theextent of life support therapy to provide a patient andoccupation is not statistically significant (p value>0.05).
Table 4.12 shows association between occupationand different practices related to end of life care
Provide the family with options about the care of
the patient and occupation
It shows that 42% of the doctors and 33% of thenurses provided the family with options about the careof the patient. The association between providing thefamily with options about the care of the patient andoccupation is not statistically significant (p value>0.05).
Reassure the family that they are notresponsible for any end of life care decisions madeand occupation
Regarding reassuring the family that they are notresponsible for any end of life care decisions, 29%doctors reassured and 36% nurses reassured thefamily that they are not responsible for any end of life
care decisions. The association between reassuring thefamily that they are not responsible for any end of life
care decisions made and occupation is not statisticallysignificant (p value>0.05).
Explain all interventions to the family about thedying process and occupation
Regarding explaining all interventions to the family
about the dying process 40% of doctors explained andamong the nurses one third (33%) explained allinterventions to the family about the dying process. The
association between explain all interventions to thefamily about the dying process and occupation is notstatistically significant (p value>0.05).

182

Eubios Journal of Asian and International Bioethics 25 (September 2015)

Permit the family to visit outside of regular visiting
hours and occupation
One third (31%) of doctors and one quarter (24%)
nurses permitted the family to visit outside of regular
visiting hours respectively. The association between
permit the family to visit outside of regular visiting hours& occupation is not statistically significant (pvalue>0.05).
Table 4.12: Association between occupation anddifferent practices related to end of life care (n=45)
Variable
Occupation
χ2
p-value
Doctor
Nurse
Provide the family with options about the care of
the patient
Yes
19
15
0.383
(42%)
(33%)
0.826
No
4 (9%)
5 (11%)
Sometimes
1 (2.2%)
1 (2%)
Reassure the family that they are not responsible
for any end of life care decisions made
Yes
13
16
2.789
0.248
(29%)
(36%)
No
10
5 (11%)(22%)
Sometimes
1 (2%)
0
Explain all interventions to the family about thedying process
Yes
18
15
4.091
0.129
(40%)
(33%)
No
3 (7%)
6 (7%)
Sometimes
3 (7%)
0
Permit the family to visit outside of regular visiting
hours
Yes
14
11
0.555
0.758
(31%)
(24%)
No
9 (20%) 8 (18%)
Sometimes
1 (2%)
2(4.4%)
Ask the family how they are copingYes
8 (18%)
14
6.264
0.044*(31%)
No13
7 (16%)(29%)
Sometimes
3 (7%)
0
Ask the family about their feelings
Yes
14
16
3.281
0.194
(31%)
(36%)
No
9 (20%)
3 (7%)
Sometimes
1 (2%)
2 (4%)
Ask the family how they are coping and occupation
One fifth (18%) doctors and one third (31%) nurses‘permitted the family to visit outside of regular visiting
hours respectively. There is significant relationshipbetween ask the family how they are coping &occupation (p value<0.05).

Ask the family about their feelings and occupation
Regarding asking the family about their feelings 31%
doctors asked the family about their feelings and 36%
of nurses asked the family about their feelings. The
association between asking the family about their
feelings and occupation is not statistically significant (pvalue>0.05).
Table 4.13: Association between sex andoccupation related to end of life care (n=45)
Variable
Occupation
χ2
p-value
Sex
Male
FemaleDoctorNurse

22 (49%)2 (4%)

1 (2%)
20
(44%)

3.852

0.000*

Table 4.13 shows that half (49%) doctors are maleand nearly half (44%) nurses’ were female. There is asignificant relationship between asking the family how
they are coping and occupation (p value<0.05).
Table 4.14: Association between experience in ICU
and occupation related to end of life care
Variable
1-5
years

Experience in ICU
6-10
11-15
years
years

Occupation
Doctor9 (38%)
Nurses5 (24%)

8 (33%)
13 (62%)7(29%)
3((14%)

χ2

pvalue

3.75

0.15
3

Table 4.14 shows that one third (38%) doctors had
1-5 years experience and three fifths (62%) nurses’ had
6-10 years experience. There is no significant
relationship between experience in ICU and occupation(p value>0.05).
Table 4.15. Association between age have theability to make decisions about end of life
treatment was sufficient and age
Variab
le
Age
25-34
35-44
45-54
55-64

Have the ability to make decisions
about end of life treatment was
sufficient
Yes
No
Sometimes
14 (31%)0
2 (4%)
10 (22%)8v(18%)
2 (4%)
5 (11%)00
3 (7%)0
1 (2%)

χ2

pvalue

13.7
53

0.03
3

Table 4.15 shows that almost one third (31%)
respondents aged 25-34 said that their ability to makedecisions about end of life treatment was sufficient andmore than one fifth (18%) said that their ability to makedecisions about end of life treatment was not sufficient.
There is a significant relationship between having theability to make decisions about end of life treatment
was sufficient and age (p value<0.05).

Eubios Journal of Asian and International Bioethics 25 (September 2015)
5. Discussion
The 45 respondents included 24 doctors and 21
nurses working in adult Intensive care units (ICU), andprovide useful information to determine the attitudes
and practices of physicians and nurses attending
patients and providing critical care on end-of-life care.
This study showed that out of 45 respondents 80%
wanted to be involved, 18% did not want to be involved
and 2% sometimes want to be involved in decision
making of end of life care. In another study done in
Italian urban setting it was found that direct involvementof family and treating physician was limited (Giannini etal., 2003). Most (76%) said they were satisfied, 18%
said they were not satisfied and only 7% said
sometimes satisfied with in involvement in decision
making of end of life care. No study could be foundregarding this matter. Regarding the ability to makedecisions about end of life treatment was sufficient 32(71%) respondents said their ability was sufficient, 8(18%) said that their ability was not sufficient and only
11% said their ability was sometimes sufficient to make.
decisions about end of life treatment Comparable study
was found that 81% of respondents said ethicalconsultation on end-of-life decisions was never sought
and only few physicians sought external ethical advice
and decisions were entirely taken by the medicalteam(Giannini et al., 2003).Fewer respondents in the
United States and Canada replied that they would makethe decision alone or just with other physicians (27%
and 29%, respectively) than in the otherregions(Yaguchi et al., 2005).It seems that majority of
the respondents in this study were confident enough tostate that their ability was sufficient to make decisions
about end of life treatment.
Regarding discussing end of life decisions, 69% said
it was time consuming, 29% said not time consuming
and only 2% said it was time consuming discussing endof life decisions with the patients and family members.
Almost similar findings were seen in case of otherstudies, some respondents also mentioned that
discussing end of life decisions with patients and family
members was very time consuming in that it had to berepeated over and over again in spite of a tightschedule. Even then, some patients never accepted thepoor prognosis of their disease and that they could not
be cured: some denied its existence. The physiciansbelieved that the media supported the illusion that allills could be cured, and they thought the expectations offamily members, in particular, were often too high.
Judicial claims of malpractice were also feared(Hilden
et al., 2004). Regarding this matter no such finding
could be in Bangladesh context. Two thirds (69%) did
not think of decisions for end of life care usually taken
quickly and 31% thought the decision usually is taken
quickly. In one study it is stated that high-quality
communication about withholding and withdrawing life
support in the ICU must not assume “one size fits all.”An important aspect of this communication is todetermine the role an individual patient or family wants
to play in such decisions (Council on Ethical and
Judicial Affairs, 1999). In other studies, it was found

183

that
observational
studies
have
found
that
communication issues with clinicians are the number
one source of complaints among families of deceased
patients, with as many as 30% of family members
feeling dissatisfied with communication in the ICU(Hanson et al., 1997). Poor communications can affectfamily satisfaction, clinical decision-making, and thepsychological outcomes of family members. One fifth(20%) said lack of hospital ICU beds was the reason
behind decision for end of life care usually taken
quickly. No study was found regarding this finding. It
could be suggested that in this study there is hugepressure in our hospital settings due more patient flow
but limited but limited ICU settings in hospitals. Morethan half (53%) thought that ‘do not resuscitate' orders
should be present and nearly half (47%) thought that
‘do not resuscitate' orders should not be present. It
might be possible that the less experienced physicians
and nurses are aware of recommendations andconsensus
statements
regardinglife-sustaining
treatments and simply disagree with them; it seems
more likely that they are unfamiliar or uncomfortablewith these issues. Recent evidence indicates thatneither physicians nor nurses are well trained in end-oflife patient management. For example, one-third of 115
medical residents at three teaching hospitals reported
that they had never been supervised in “do notresuscitate” discussions with patients(Tulsky et al.,1996).A study of all accredited general surgery
residency programs in the United States found that
76% had one or no sessions devoted to teaching ethics
in their curriculum (Downing et al., 1997). Similar
problems have been noted in the education of nurses.
More than half of 300 nurses at an acute care teaching
hospital for adult patients reported that they did nothave a good understanding of advance directives(Crego and Lipp, 1998).
Regarding the question of whether withholding orwithdrawing life support is unethical, 18 (40%) agreed,
7 (16%) strongly agreed, 14 (31%) disagreed, 4 (9%)
strongly disagreed and only 2 (4%) were neutral
regarding whether withholding or withdrawing life
support is unethical. Critical care physicians and nurses
in this study held views about end-of-life decisionmaking and patient management in strong agreementwith the ethical and legal consensus that has evolved inthese areas. Here in this study physicians and nurses
agreed or strongly agreed with the statement that“withholding or withdrawing life support is unethical,”
whereas the vast majority of respondents disagreed(56%) that withholding and withdrawing are ethically thesame. Similar reasoning has been advanced bynumerous ethical and legal positions on this commonly
cited distinction that is 47% considered withholding andwithdrawing life support were not ethically equivalent(Giannini et al., 2003).
Indeed no valid moral or legal distinction exists
between the two, a willingness to withdraw life
sustaining treatment may be preferable because it
allows for a time-limited trial of treatment in situations
where the prognosis is uncertain or there is conflict in184

Eubios Journal of Asian and International Bioethics 25 (September 2015)

decision-making(Panel, 1990, Society, 1991, 1994a,
Briarcliff, 1987, 1990). It was also found that over 60%
of physicians and nurses cited financial costs to society
variables as the most important determinants ofdecision-making about life-sustaining treatments, it isdifferent from the study (Sprung et al., 2007) thatphysicians (88%) and nurses (87%) found quality of life
more important and value of life less important in theirdecisions for themselves than patients (51%) andfamilies (63%).According to published consensus
recommendations, especially when considered as afactor in the decision to forego life-sustaining treatment,
should only be judged from the patient’s perspective,
and not by health care workers’ personal assessments(United, 1983, 1996, Briarcliff, 1987).
The difference in this study may be because
Bangladesh is a developing country and most people
are living in poverty and cannot afford the cost burdenof the health care. Over three fifths of physicians andnurses were not willing to add or increase analgesia
and sedation to a patient’s regimen as life-sustaining
treatment is discontinued, a position also consistent
with other studies. This is not surprising as manystudies from different regions have shown thatphysicians and nurses have issues regarding the use ofmorphine in oncology patients(Sapir et al., 1999).
Maximizing pain relief at the end of life is critical, but
can sometimes cause unintended morbidity and evenhasten death itself (Paris et al., 1997, Beauchamp andChildress, 2001, Jonsen et al., 2010).Also other studies(Brody et al., 1997, Committee, 1997, Truog et al.,2000) stated that a large majority of physicians andnurses did not agree with the addition of neuromuscular
blocking agents, medications devoid of any sedative or
analgesic properties, as life-sustaining treatment is
discontinued. There has been more discussion of thisissue recently, with most commentary strongly
discouraging the initiation of neuromuscular blockade
as life-sustaining treatment is withdrawn. In this study
two thirds of the respondents provided the family with
options about the care of the patient and moreover four
fifths let the family to attend the meetings with the
medical team. Another study shows that patients andfamily members vary in their interest in being involved
in medical decision making about end-of-life care.
There are some who want to be centrally involved in alldecisions, while others want to defer such decisions tothe clinicians (Heyland et al., 2003).
Nevertheless, the results of this study highlightseveral areas of concern around the provision of endof-life care in the adult intensive care unit. Finally, more
intensive interdisciplinary collaboration, possibly
through ongoing case review, is needed to reduce
uncertainty at the bedside and to promote an emphasison competent and compassionate end-of-life care as
strongly as other aspects of critical care medicine.
6. Conclusions
End-of-life issues in the ICU are of paramountthimportance. In the mid-20 century it was obvious only
for the health care professionals in ICUs to provide lifesaving care rather than looking into matter ofcomforting dying patients and their families. However
this understanding of the health care professionals
started to undergo some significant change latter on.
This global understanding has influenced the national
health care professionals in some aspect of end of lifecare. The study has highlighted some important issues
which show the changes. It was found that among 24
doctors and 21 nurses, one more male than female
were the respondents. The mean (SD) was 38.1±9.2.
More than half of the doctors had a Bachelor degreeand more than two thirds of the nurses had a Diploma
degree. In addition, more than half of the doctors andnearly half of the nurses had formal education ortraining in critical care. Most of the doctors had 1-5
years and majority of the nurses had 6-10 years of ICU
experience. Thus not only the formal education andtraining but also adequate experience are the major
factors in strengthening the positive attitude andpractices of doctors and nurses regarding to the patient
who are under the critical care in ICU.
Though this study focuses that more doctors had
expressed their desire for their involvement in decision
making of end of life care but when it came to
discussing end of life care nearly same number of both
respondents agreed that it was time consuming.. An
explicit attitude is seen among the respondents for thepatient and family centered decision making process of
end of life care. It might be due to the fact that majorityof the respondents thought might be influenced thatdying is a normal process of life, doctors and nurses
who give care for patients should not hasten their
death.
More than one third nurses and one fourth doctors
said they had the ability to make decisions about end oflife treatment was sufficient. Even though there was no
statistical difference with ability to make decisions
about end of life treatment was sufficient andoccupation it could stated that the nurses in this study
seems to be more confident about being able to makethe decisions as the nurses were more experienced
working in the ICU than the doctors.
More than half thought that ‘do not resuscitate'orders should be present. Here it demonstrates that the
respondents understood the fact that interventions in
the ICU can cause more discomfort to the patient andpatient may have quality life reduced. So it focuses thatthe respondents had a good understanding of advancedirectives as most of the respondents had undergone
training in critical care. Having such instruments inplace helps health professionals manage the end-of-life
process, which is increasingly fraught with ethicaldifficulties.
Almost half of doctors and only one fourth of nurses
said it was difficult to approach a dying patient andsignificant association was found between difficulty toapproach a dying patient and occupation. As data
revealed that nurses were more experienced in working
in ICU so they may be more accustomed to handle themedical uncertainties in dealing with end of life care.
However, recognizing the situation that the doctors andEubios Journal of Asian and International Bioethics 25 (September 2015)
nurses are involved in is the best way to overcome
these challenges.
This study also focuses that the half of the
respondents were agreeing that withholding orwithdrawing life support is unethical whereas morethan half disagreed that withholding and withdrawing
are ethically the same. It focuses that withdrawal ofcare or withholding decision has an important point ofdivision ICU so to provide the patients proper end of life
care from the above finding it focuses the necessity tounderstand that while therapies may be withheld or
withdrawn, care continues until the very end.
Sixty percent thought financial costs to society are
an important factor in influencing decisions on theextent of life support therapy to provide to a patient.
Bangladesh is a developing country and it is alreadyoverburden with outpocket expenditure in health carematter. So in this perspective it might be the reason the
respondents financial costs to society are an importantfactor in influencing decisions on the extent of life
support therapy to provide to a patient.
Most of the respondents let the family attend themeetings with the medical team and also fully informed
the family about all aspects of the plan of care of thepatient. In this study it focuses that precise andinclusive communication has been demonstrated toincrease the understanding of patient care plans in the
ICU by the respondents.
More than half permitted the family to visit outside ofregular visiting hours. Fifty percent asked the family
how they were coping. It shows that the respondentactually gives emotional and practical supports for thepatient and family.
It also showed significant association between havethe ability to make decisions about end of life treatment
was sufficient and age. It was found that almost one
third respondents aged 25-34 years said that theirability to make decisions about end of was sufficient. Itemphasized that more younger aged group were more
confident about their ability to make decisions about
end of life treatment.
In summary, this was the first study in Bangladesh
to evaluate physicians’ and nurses views about end oflife care. Its weakness was the small number of
respondents, and its strength was the high number of
responding physicians and nurses. Another limitation is
the fact that responses to a questionnaire may give a
too positive picture of attitudes and practice. In real life,
haste, stress, uncertainty, and demands from different
parties may seriously compromise the issue inquestion. In addition physicians and nurses responding
to a questionnaire on ethical decision making probably
also tend to pay more attention to the ethical aspects of
their work. Furthermore, the respondents were
specialist physicians. Thus the results of the study
cannot be generalized to physicians and nurses withless experience. I have no information on the attitudes
and practices made by senior versus junior physicians
and nurses with respect to end of life treatment. .

185

7. Recommendations
End-of-life care is emerging as a comprehensive
area of expertise in the ICU and demands the samehigh level of knowledge and competence as all otherareas of ICU practice. With a view to improve more thepresent situation, this study finding suggests thefollowing recommendations:
Research:
A broad based longitudinal study can be undertakenon end-of-life care, it would reveal better findings. It
could be form for the improve end-of-life care:
1. Defining the problems,
2. Identifying solutions
3. Evaluating solutions, and4. Overcoming barriers.
Education:
1. Development of training programs such as
Education for Doctors on End- of-Life Care and End-ofLife Nursing Education.
2. The results of this thesis may help plan strategies
to promote and emphasis on competent andcompassionate end-of-life care of among the physician
and nurses of adult intensive care units (ICUs).
3. Educational programs that offer the opportunity totalk about their experiences caring for dying critically illpatients and their families and the effect of providing
this care on their own emotions and work attitudes canbe valuable
Quality Improvement focused on end-of-life care in
the ICU
1) Patient- and family-centered decision making;2) Communication;3) Continuity of care;4) Emotional and practical support;
5) Symptom management and comfort care;6) Spiritual support; and
7) Emotional and organizational support for ICU
clinicians.
Acknowledgements
It will not be sufficient in words to flourish my deepest
regards and admiration to my respected supervisor Darryl
Macer, Provost, American University of Sovereign Nations forhis meritorious guidance, valuable suggestions, generous andliberal supervision, and also sympathetic help in preparationand completion of my academic research work. I am also
grateful to my respected Prof. Shamima Parveen Lasker forher endless effort and kind support. I also deeply appreciate
the thorough analysis and positive comments of my thesis
examiners, Prof. Dyah Woro Dwi and Prof. Duujian Tsai.
I am in debt and grateful to Professor Dr. Fazila-Tun-Nesa
Malik, Director, Academic Affairs, National Heart Foundation
Hospital and Research Institute, Prof. Md. Maniruzzaman
Bhuiyan, Principal, Holy Family Red Crescent Medical
College & Prof. Dr. Abu Azam, Director and Professor,
National Institute of Cardiovascular Diseases for granting
permission for data collection and their continuous support.
My heartiest thanks go to all the staffs of different hospitals
ICU for their kind co-operation during data collection.
Finally, I express my sincere thanks, gratefulness andrespect to Prof. Liaquat Ali, Vice Chancellor, Bangladesh
University of Health Sciences (BUHS) who has kindly186

Eubios Journal of Asian and International Bioethics 25 (September 2015)

contributed his guidance and encouragement and sincere cooperation.

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Fortune Telling as Mental
Health Support- Ananya Tritipthumrongchok, MBGPHManager, Eubios Ethics Institute; President, AUSN Alumni
Association, Thailand
Email: ananya@eubios.info

Abstract
Fortune-telling is the practice of predicting
information about a person’s life. People will go to see
a fortune teller for advice on just about any issue, butmany questions they have are related to mental health.
One of the objectives of fortune telling as a practice isto seek counseling support, rather than simply belief in
the accuracy of the predictions that are made. This
thesis examines different types of fortune-telling, withand presents the results of interviews and a written
survey of persons conducted in 2015 on 57 persons,
mainly in Thailand. The attitudes that persons, whohave consulted a fortune teller, and those who havenot, is compared. More Thai persons stated that they
prefer to see a fortune teller compared to those
respondents from other countries. There were various
types of fortune telling that were sought, with the mostcommon being Tarot card reading, palm reading andbirthday predictions. The reasons and questions are
examined, with comparisons to attitudes people have toseeking a counselor or psychologist, who were muchless commonly used. Two thirds of respondents went tosee fortune tellers with a friend. Almost all believed inkarma. The roles of fortune-telling in mental publichealth, and the ethics of the practice will be analyzed.
1. NoteThis paper is based on a dissertation from the
Masters in Bioethics and Global Public Health(MBGPH) Program of American University of Sovereign
Nations (AUSN), United States of America (USA).
2. Fortune-telling
2.1. Fortune telling in Asia today
Throughout Asia, fortune telling – or what some calldivination – is still widely practiced. Tarot cards, palm
readers, and numerologists can be seen everywhere.
Some of the best known diviners work out of temples.

For many Western people, divination is something thathas been somewhat watered down by popular culture
over the past 100 years or so, and it’s generally taken
less seriously than it is in Asia. It may be consideredsimply as a novelty or a fun thing you do with friends orat a carnival, although there are certainly those whoplace great importance on a good reading. I propose
however that for people from Japan to China to
Thailand to India, divination is very much a part of daily
life, and is often taken into consideration when making
important decisions. The survey in this research should
help answer that question.
2.2. Types of fortune-telling2.2.1. Zodiac Signs and Astrology Signs Meanings
and Characteristics
Certainly the oldest known method of divination islooking to the stars. It’s hard to say exactly where thepractice originated, but certainly as early as 4,000
years ago, the Babylonians (in present day Iraq) had anorganized system of predicting events based on thestars. Soon after, Chinese, Indian, and Mayan systems
had emerged, and the practice spread to Greece when
the armies of Alexander the Great conquered what wasthen the known world.
If you want to find out what is your zodiac sign andwhich are your compatible zodiac signs, you are on theright place. Here you will find out all about zodiac sign
astrology, zodiac sign compatibility and zodiac sign1
dates. We can see some of these practices still amongindigenous cultures today, although many were
suppressed because there was religious prejudiceagainst these spiritual matters among modern
Christians and Muslims.
There are 12 zodiac signs, and each sign has its
own strengths and weaknesses, its own specific traits,
desires and attitude towards life and people. On thebasis of analysis of images of the sky, or the position of
the planets at the moment of birth, astrology can give
us a glimpse of a person's basic characteristics,
preferences, flaws and fears. We can really get to know
people much better, if we know the basic
characteristics of the zodiac signs.
2.2.2. Tarot cards
Many people think this practice has a mystical Asianbackground, but in fact they are European playing
cards. The first documented tarot deck was made in
Milan, Italy in the mid-1400s and even then they were
simply for playing games. The divination aspect,however, didn’t enter into practice until the 1780s, andclever marketing cemented the mystical divining
properties just as the spiritualism movement swept
through Europe in the mid-1800s. There will be further
discussion of Tarot cards in the Discussion section 6.5.

1

http://www.astrology-zodiac-signs.com/

Eubios Journal of Asian and International Bioethics 25 (September 2015)
2.2.3. Palm reading
More properly called palmistry, its origins are notwell documented, but likely date back to Hindu
astrologers in India thousands of years ago, where it
spread to China, the rest of Asia, and then Europe.
However, in the middle ages palmistry was suppressedby the Catholic Church, until it rose in popularity in themid 1800’s, again in the wave of interest generated
from the spiritualism movement.
2.2.4. Numerology
A belief that the numbers that pertain to your life –birthday, age, time of birth, number of letters in yourname, etc. – can predict certain traits or events.
Numerology is based on several ancient traditions froma variety of cultures, including Chinese, Hebrew, Hindu,
Egyptian and even Pythagoras, the famous
mathematician who lived in ancient Greece.
2.2.5. Pulse Reading2
This is important in Chinese medicine. Part of being
an acupuncturist involves reading pulses. In both
Chinese and Japanese systems, the pulse is read – inthree positions and at three depths. Each of these six
positions is used to gather information about one of thesix yin (and corresponding yang) organ systems. There
are also qualities of the pulse as a whole that are used
to diagnose more general conditions within the bodymind.
I have experienced pulse reading in Bangkok. I met
a Chinese medicine practitioner by my Mom’s friend’s
recommendation. Because she had a health condition,
her sister had suggested her to see him. The Chinese
medicine man put his finger on the pulse and read it.
Then he could let my Mom’s friend know which part ofthe body has a problem so they can correct her
symptoms and giving her some Chinese medicine.
There is something similar in indigenous people I met in
Phoenix, Arizona, USA. I can report that in the case of
my mother’s friend it seemed to work because someweeks later, her symptoms were getting better. For myvisit to this practitioner, after checking me, he reported
that my organ systems are fine, but my friend has someproblem, as she known. Some cases will use
acupuncture to treat (See Chapter 3 on Chinese
medicine).
2.2.6. Gene tests
Fortune telling with genetic testing, and diagnostic
tests, and medical tests is part of the technological fix
paradigm that we see after the Human Genome
Project’s completion. The origins go back a century
though. In the 1900 that an Austrian scientist
discovered the existence of different blood types, a
discovery that earned Dr. Karl Landsteiner a Nobel
3
Prize. Since that discovery, scientists have gone on to
figure out that different types of blood have different

types of antibodies and antigens. What does thismeans in medical or scientific terms, but the mostimportant thing is that immune systems react differently
to different kinds of blood types.
Epigenetics is the understanding of how gene
imprinting, methylation of DNA, affects gene
expression. It is possible that during gestation the
nutritional and environmental conditions that a pregnant
mother has will affect the epigenetic imprinting of the
fetus, which may have seasonal variations. This could
provide a linkage to birthday and birth month fortune
telling, that future research could explore.
In Japan, a person’s blood type is a popularly used
to determine a person’s temperament, personality andcompatibility with others, in much the way that someAmericans use astrological signs. This is similar to how
astrological signs are perceived as influencing factors
in a person's life within other countries throughout theworld. However, blood type plays a much more
prominent role in Japanese and other East Asian
countries than astrology does in other countries.
The obsession with blood types began in Japan in
1927, when a psychology professor by the name of
Furukawa Takeji who worked as a high school
administrator began observing the differences intemperament of the students who applied to his
4school. Recently, manufacturers even market a wide
variety of blood-type specific products, including
calendars, chewing gum, colas, and condoms.
In the 1970s, this blood type craze got greater when
Masahiko Nomi published a book called Understanding
Affinity by Blood Type. The book was an instant bestseller and led to lots more books on the subject.
2.2.7. Parrot astrology
Parrot fortune-telling is a type of astrology popularamong the Tamils of Tamil Nadu, Telugus in Andhra
Pradesh, India and Singapore. It involves using green
parakeets which are trained to pick out Tarot likefortune cards. A parrot astrologer/fortune teller typicallysits beneath a tree or by the side of the road where
people congregate in numbers. He has a cage whichcontains one or two trained parrots. The tarot like cards
are either spread out or stacked in front of him. Theyare 27 in number representing the Indian cosmic
system. Each card contains the image of a Hindu deity
and some cards contain images of Buddha or Virgin
Mary with Infant Jesus. When a patron sits before thefortune teller, the latter opens the cage and lets theparrot out. He instructs the parrot to pick a card for thepatron. The parrot walks over to the cards, picks one
from the stack or the spread with its beak and gives it to
the astrologer. It then walks back inside its cage. The
astrologer opens the card and based on the image tells
5
the fortune of the patron.

42

http://en.wikipedia.org/wiki/Pulse_diagnosis
3
http://www.tofugu.com/2011/09/21/true-blood-personalityand-blood-types-in-japan

189

Japanese Culture 101: Personality by Blood Type,http://thegreatgeekmanual.com/blog/japanese-culture-101personality-by-blood-type5
https://en.wikipedia.org/wiki/Parrot_astrology

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

2.2.8. Sole reading (Foot)
Foot reflexology charts show the location of reflex
points on your feet. You can easily learn to read a chartthat will show you where the reflex points on your feetcorrespond to specific areas of your body's anatomy.
Highly technical foot reflexology maps are more
complicated than most amateur reflexologists reallyneed. Below are some key points to look for when
6
reading a foot chart.
2.2.9. Signature reading
Signature is a unique style of writing one’s own
name. It is a snapshot of your personality and discloses
a lot about your character and general outlook in life.
Signature is also considered as an image that the writeris willing to show to the outer world.
It reveals about your nature and temperament basedon the way you write your letters, i.e, small or large,
dark or light, curved or angled. Personality traits likehonesty, communication abilities, creativity, emotional
stability etc. can easily be determined just by analyzing
a signature. Other traits like social skills, outgoingnature, confidence level and goal setting abilities canbe identified by analyzing the letters used while signing.
Therefore, the way you sign your name represents your7
personality traits enormously.
2.2.10. Horoscope
A horoscope is an astrological chart or diagram
representing the positions of the Sun, Moon, planets,
astrological aspects, and sensitive angles at the time ofan event, such as the moment of a person's birth. The
word horoscope is derived from Greek words hõra andscopos meaning "time" "observer" (horoskopos, pl.
horoskopoi, or "marker(s) of the hour.") Other
commonly used names for the horoscope in English
include "Natal Chart" astrological chart, astro-chart,celestial map, sky-map, star-chart, cosmogram,vitasphere, radical chart, radix, chart wheel, or simply
chart. It is used as a method of divination regarding
events relating to the point in time it represents, and it
forms the basis of the horoscopic traditions of
8
astrology.
2.2.11. Birthday prediction
Birthday prediction or birthday forecast can predict
about your personality and character, and also yourfuture. What will be happen or who you can be but justyour guideline to know as we can find many definition ofeach birthday one part is science that we can doresearch who born in each birthday their character will
be different or some people will be born in the same
day and some personality will be similar. Thais use
birthday prediction for some partners, they are matched6

http://www.wikihow.com/Read-a-Foot-Reflexology-Chart
http://handwritinglense.com/41Signature_Analysis__What_Does_Your_Signature_Say_Abo
ut_Your_Personality.html
8
https://en.wikipedia.org/wiki/Horoscope7

with each other or not when they want to marry or tocontinue relationships.
2.2.12. Life graphs
Life graph can predict a whole life since you wereborn until dead. Life graph is a method of calculating
the destiny of another person. The idea is that the fateof our people would be up and down like a curve and if
we can know in advance that during our life - down,
however, would be nice if we would be prepared tosolve or handle. to what might happen. Life graph isforecasting fortune with numbers, which split many
ways a mathematical principles which have provenstatistical accuracy is very high for a long time.
2.2.13. Communicate with spirits thought psychics
After somebody dies, if we would like to contact with
their spirit, they need to contact them thought a psychic
who is a person who claims to use extrasensory
perception (ESP) to identify information hidden from thenormal senses. The word "psychic" is also used as an
adjective to describe such abilities. Psychics may betheatrical performers, such as stage magicians, who
use techniques such as prestidigitation, cold reading,and hot reading to produce the appearance of such
9
abilities.
2.2.14. Number of Identity card
Another way to predict life by number of your identity
card, some fortune tellers will calculate a whole number
after you can get an outcome that can predict to yourfuture, personality, love or anything else that you wantto know, or some fortune will use only the 4 last
numbers to predict.
2.2.15. Egg reading
Some fortune tellers predict life by the egg after
break the egg, what it looks like can predict the future,find solutions, forecast about disease, physical health,financial, love, etc.
2.2.16. Tree leaf predictions
Tree leaf is a living organims like us so has thesame life cycle. Our life is like a tree, most likely
because there were a burgeoning growth of branches,
dividends, even breathing also needing oxygen. To thewater, the soil cares if he falls ill. But some people cut
trees felled by a storm, so they die prematurely. Unlike
some people who are born immediately before theaccident was fatal. There are predictions about life ineach moment depending by which leaf we get, andwhat it looks like.
2.2.17. Name forecasting
When we were born, our name is given which has ameaning for life. Some parents name their baby asangel or a god’s name to identify the baby and hopethat they will have bright future. A name forecasted by
calculating numeric can predict about life and how
9https://en.wikipedia.org/wiki/Psychic

Eubios Journal of Asian and International Bioethics 25 (September 2015)
much power a person will have. Does it alter the
success of our life? What’s our character? About yourcareer, love or people who come to your life.
2.2.18. Poker card readingThis is another method used by fortune tellers, as away to know your life and who you will meet. An
ordinary pack of cards is used and a familiar card
game, poker. The fortune may include questions likewhat the person is looking for, and what they propose
to come to your life. Also its predicts the overall aspectsof your life and identifies your life in each time. The
cards can predict about your character and find thesolution. Then you will be aware of your own life andthings happening to you
2.2.19. Monk fortune teller
Many people believe in fortune telling and rely on it
so much that they get themselves into difficulty. Believe
it or not, if we believe and rely on something too much,
we can easily get stuck; life cannot move on. Thais will
go to a monk fortune teller for advice on just about any
issue, such as setting the date for their wedding to be
an auspicious day, to consult on baby names, forpredictions about relationships, buying a house andbasically anything that is a major purchase decision inlife.
2.2.20. I Ching
The I Ching as a system of divination is based on 64
hexagrams. A hexagram is returned in response to ausers question or query. Traditionally the hexagram is
produced by tossing three identical coins six times orby a system using 49 yarrow stalks. Each hexagram is
10
a picture consisting of six horizontal lines.
Each line can be one of four types.
.

Yang

.

Yin

.

Changing Yang
Changing Yin

This method was not mentioned by anyone in thesurvey conducted here, but could have been morecommon if the survey was conducted in China or othercountries. This could be a matter for future research.
3. Fortune-telling as a Public Health Service
3.1. Love, Solidarity and HealthLove of life (Macer, 1998) is a philosophy ofbioethics. As said, “the gift that we receive when we areborn into this world is love. While it is a gift that few are
deprived of, a deprivation that is in itself and insult tothe humanity that our flesh embodies, it is a norm for all
forms of life for the new life to be given a good start.”(p.1) “Love for the Future” is why we have a desire forsurvival of our family, society and planet.

10

http://ichingfortune.com/iching_info.php

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Moral demands are a basis for trans-generational
ethics, and basic for our survival. We have to balance
our choices with those of counterparts. How do webalance the love of ourselves with love of others? This
represents the traditional fight between autonomy ofself and of the community, and justice for all.

Figure 1: Maslow’s pyramid
Figure 1 shows that the most fundamental and basic
four layers of the pyramid contain what Maslow (YEAR
in 1940-50s) called "deficiency needs" or "d-needs":
esteem, friendship and love, security, and physicalneeds. Recently, we are in a race against time to beatdeadlines and our need is increased, so we try to avoid
suffering. This only seems to create more suffering inthat one person’s positive work can be someone else’s
suffering, for instance medicine, politics and so on.
How do we judge? Shouldn’t we just accept a certain
amount of suffering and discomfort?
The World Health Organization (WHO) defines
health inclusively:“Health is a state of complete physical, mental andsocial well-being and not merely the absence ofdisease or infirmity.”, “The enjoyment of the highest
attainable standard of health is one of the fundamental
rights of every human being without distinction of race,
religion, political belief, economic or social condition.” ,“The health of all peoples is fundamental to theattainment of peace and security and is dependent
upon the fullest co-operation of individuals and States.”,“Unequal development in different countries in the
promotion of health and control of disease, especiallycommunicable disease, is a common danger.” (World
Health Organization, 1995).
3.2. Fortune telling and Psychology
In my work experience, when a colleague comes tosee me because they are unhappy about life andworrying about the future, if is often because someone
has conflicted with their supervisor or subordinate. It
might also be because someone needs to know about
their love life, or somebody wants to change to a newjob but is afraid to move on. How do we get success?
What is success? How to be rich? , How to make life
better? There are a lot of questions and demands, thisis the nature of human beings, and social health is a
critical component of any society.
Our experiences and feelings are mainly related toour bodies and our minds. We know from our daily

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

experience that mental happiness is beneficial. For
instance, though two people may face the same kind of
tragedy, one person may face it more easily than theothers due to his or her mental attitude. Perseverance
is important, as we can see in the story of Thomas
Edison who developed one of the first practical lightbulbs and never gave up “I have not failed. I have justfound 10,000 ways. That won’t work”.
We can define supernatural as “unnatural
phenomena; spirits and demons, magical, mystic,
occult, sacred, strange, bizarre, extreme, unexpected,
fairies, fairy or act of god.” (Longdo dictionary 2015).
LaMuth (2014) in The Spiritual / Universal Realm wrote
that, “In terms of the current spiritual/universal focus,
this would amount to the positive sequence of charity,
civility, faith, and providence; as well as the negative
reinforcement sequence of decency, austerity, hopeand liberty. Indeed, most common interactions are of agroup or personal nature, with the universal perspective
primarily restricted to those expressing strong religious
or universal viewpoints.”
Fortune tellers are comforted by the spirit ofPhilosophy, who tells him that the greatest gifts are notdue to Fortune, but to other forces, such as the laws of
God and nature (Wu, 2006). The difference is thatdivination (to be inspired by a god) by seeking guidancefrom what can be perceived as contact with asupernatural agent.
Counseling is a psychological specialty thatencompasses research and applied work in several
broad domains: counseling process and outcome;supervision and training; career development and11counseling; and prevention and health. There aremany professional degrees that people can gain toqualify them as counselors, and there are also fields
such as Social Work, which are recognized as Public
Health related professions.
In my opinion, “Fortune tellers” should have some
capability as a Counselor to talk with people. However,there are difference definitions of Fortune tellers andCounselors. But some professional skills we expectfrom them are similar, as ones I used to use forsupervising people in HRM such as interpersonal skills,
positive thinking, emotional intelligence, influence andnegotiation.
3.3 Culture in Thailand
Thailand has a population of over 60 million people
with an average per capita income of around US$1500
per annum. Most Thai people are aware andexperience the 'globalisation' of communication andtrading, and new sciences and technologies are known
to many of them. Thailand is a strongly Buddhist
country, with rising living standards and a rapidly
developing economy. The vitality of the Buddhist faithalso does much to bridge social gaps, such as prevail
between city and countryside. It is therefore ofparticular interest to see how attitudes bioethicaldilemmas have changed over the 1990s.
11

http://en.wikipedia.org/wiki/Counseling_psychology

In Buddhism there is a welcome attitude to fortune
telling, and this is also seen among most Thais whether
they be Hindu, Confucian, Christian or Muslim. Fortune
tellers are commonly seen around Buddhist temples inThailand. We will explore religions more in the next
chapter.
4. Religions and Life
4.1. Buddhism
Religion serves important roles in the life of people.
The Buddha’s teachings can be understood on two
12
distinct levels. One is logical and conceptual and isconcerned with an intellectual comprehension of man
and the external universe. It is on this level that thequestions asked in previous chapters are more easily
answered. The second level is empirical, experiential
and psychological. It concerns the ever-present andinescapable
phenomenaofeverydayhuman
experience, love and hate, fear and sorrow, pride andpassion, frustration and elation. And most important, it
explains the origins of such states of mind andprescribes the means for cultivating those states which
are rewarding and wholesome, and of diminishingthose which are unsatisfactory and unwholesome. It
was to this second level that the Buddha gave greater
emphasis and importance. All of us will pass away
eventually as a part in the natural process of birth, oldage and death. The impermanence of life should
always be kept in mind. We all cherish and wish to
hold on to life.
Karma is a word that almost everyone has heard of,13
but few people know the true meaning of. It's often
mistakenly thought of as a punishment and reward
system, and is used as a curse on those who do bad
things. "You'd better watch out for Karma!" as if it's avoodoo police force of the universe. Karma is mostimportantly, understanding. Neither good nor bad, justwhole, if a person does good deeds, helps others, andlives an honest life, they can still get whacked with "badkarma." If that person does all those things, but thenjudges others who they say are evil, then they will soon
find themselves on the opposite side of that fence. By
judging someone negatively, one is actually asking the
Universe for the understanding that made that person
behave that way. Common examples are in traits thatare misunderstood. If a person says another is too
controlling, then pretty soon, they will be accused of thesame. They may not even notice, because to them,
they were only being helpful, or looking out forsomeone, but most certainly not being controlling! Only
after the karmic shoe is on the other foot do they gain
the insight as to why the person they judged seemed tobe acting in a controlling way.
Rebirth in traditional Buddhist cosmology these lives
can be in any of a large number of states of being
including the human, any kind of animal and several
12

http://www.mahidol.ac.th/budsir/buddhism.htm
Quote about living-Doe Zatamata: Khama-Book review,
http://www.quotesaboutliving.com/2014/08/karma-bookpreview.html
13

Eubios Journal of Asian and International Bioethics 25 (September 2015)14

types of supernatural being. “Rebirth is conditioned by
the karmas (actions of body, speech and mind) ofprevious lives; good karmas will yield a happier rebirth,bad karmas will produce one which is more unhappy.
The basic cause for this is the abiding of consciousness
in ignorance, when ignorance is uprooted, rebirthceases.”4.2. Animism
Animistic beliefs are common all around the world.
We can see interesting mixes, for example, Islam inIndonesia, particularly Java, has developed a hybrid
culture, which has incorporated many Animistic rituals
such as sacrificing a goat and burying the remains in15
the foundations of new buildings. Wayang kulit or
shadow puppets are still very popular in Indonesia andSouthern Thailand where mythical stories ofsupernatural powers are the main themes of
performances.
4.3. Animism and Yin and Yang
Animism is also very heavily incorporated in
traditional Chinese religions, as well as Taoism, andBuddhism. Many Buddhist monks are consulted
because of the belief they possess the ability to see
into the future. Many Chinese make pilgrimages toparticular Wats or temples to get trinkets, or amulets forluck. Omens and numbers are still a part of everyday
life.
Feng Shui is an age old practice based upon cosmic
and geographic dimensions that is widely practiced
16
throughout the region. Literally wind, water - the art(or science if you prefer) of manipulating or judging theenvironment. Many will not purchase a new residence
without seeing if the location and features are suitableaccording to Feng Shui consultants. These concepts
also seem to be religiously upheld by other indigenous
cultures where for example, it is not considered lucky tolive at the top of a "T" intersection. In addition, many
people including politicians consult the calendar todetermine the best dates to do certain things.
Another science of Chinese Medicine is called Yin
17
and Yang. In Chinese medicine health is represented
as a balance of yin and yang. These two forces
represent the bipolar manifestation of all things innature. In terms of your personal health, if you think of
how you feel when you feel really well, you mightrealize you don’t think of wellness at all! Everything inyour life just flows and moves seamlessly—in harmony.
Your body, mind, emotions, and spirit can adjust andreadjust to the circumstances in your life. This isprecisely the state Traditional Chinese Medicine (TCM)
seeks to create; that of A Theory Fundamental to TCM
Practice.

14

http://en.wikipedia.org/wiki/Rebirth_%28Buddhism%29
http://english.pravda.ru/hotspots/disasters/24-032014/127152-animism-0/
1613
http://en.wikipedia.org/wiki/Feng_shui Chinese Medicine ;17
http://www.tcmworld.org/what-is-tcm/yin-yang-theory/
15

193

The theory of Yin and Yang is fundamental to thepractice of TCM in terms of understanding, diagnosing,and treating health issues. At the most basic and deeplevel, TCM treatment seeks to balance Yin and Yang ineach person. One ancient TCM text expressed thepower and importance of Yin and Yang this way: “If you
can understand Yin and Yang you can hold theuniverse in your hands.”
Yin and Yang can apply to any mental or physicalhealth issues people face. Theories are interesting, but
unless they have some meaning to your own
experience, what’s the point? First, the theory of YinYang tells us that at the macro level—the largest scale
imaginable—all things are always balancing andrebalancing into a state of perfect harmony. Yes, there
is ceaseless change, yet this movement and flux, at its
deepest level, is creating harmony, is perfect harmony.
Yin and Yang are the two energies that embody
Universal law, which ensures that all things remain in18
harmony.
Fortune-telling is the practice of predicting
information about a person's life. People will go to see a
fortune teller for advice on just about any issue. In
Thailand, many Thais go for predictions about
relationships; the date for their wedding is an
auspicious day, consulted for baby names, Investment
advice, buying a house, basically anything that want to
get guideline to make decision. Also, many way of
Fortune telling able to predict people life, that why? I
would like to do research about Fortune telling as
mental health support. Let’s see how it works forpeople through the survey!
5. Survey Methodology and Results
5.1. Objectives
This thesis will look at the practice of fortune-tellingin several countries, with comparison to that in
Thailand. The primary target of the survey will be Thai
citizens living in Thailand and overseas, with acomparison group to persons from other countries.
5.2. Development of the questionnaire
Literature review and experience led to aquestionnaire being developed. Survey forms were
circulated among clients who sought fortune telling
advice from me, and participants who did not request
fortune telling also. Among the 70 forms circulated 82%
returned the survey form in either hard copy or byemail. The survey was estimated to take 20 minutes tocomplete.
The AUSN Institutional Review Board (IRB)
approved the consent form and questionnaire (SeeAppendix 1). The research was self funded, and there
are no conflicts of interest (except that the author isalso a fortune-teller). Counseling and fortune telling
require privacy protection, as normal operating practice.
The names of any persons mentioned in the responses
were protected, and changed in case quotations areincluded in the thesis or publications. The names of18

http://www.tcmworld.org/what-is-tcm/yin-yang-theory/

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

respondents were not recorded on the survey.
The survey was open to anyone who canspeak/write English or Thailand, who is at least 15
years of age. There was a mix of persons who sought
fortune-telling and those who did not and social
network members.
5.3. Respondent Characteristics
Three quarters, 76%, of the respondents are living in
Thailand, and 24% live overseas including from Dhaka,Bangladesh (1), Sydney, Australia (1), Purwokerto,
Indonesia (1), Taiwan (1), New Zealand (1), Italy (1),
Arizona, USA (3), Nepal (3), Cameroon (1). Most ofpeople live in urban settings (95%), just 3 people areliving in rural areas. The age of male respondents
ranged from 20 years old to 54 years old (total 23% of
respondents), and the 43 female (77%) were aged
between 23-53 years of age.
About race/ethnic origin, 43 respondents were Thaiand the rest had race/ethnic origin as Bangladesh (1),Cambodian (1), Chinese (2), European (2), Native
American(1),African(1),
Mexican/Spanish/Irish/English (1), Nepali (3), other
Asian (1). Most, 82%, of the 56 respondents are
Buddhist and 18% listed their religion as none (1),Christian (4), Moslem (3), Navajo (1), and Hindu (1).
The occupation of 56/57 respondents who answered
the form are indicated in Table 1, and the educational
level in Table 2.
Table 1: Occupation of respondents (Number andpercentage of the total)
Student
5 (9%)
Government employee
4 (7%)
Business employee
36 (64%)Self-employed
5 (9%)
Business Owner
4 (7%)Other
1 (2%)
Unemployed
1 (2%)
Regarding marital status 38 (68%) respondents
were single but among 2 persons had 1 child and 1
single person had 3 children. There were 14 (25%)
respondents who were married and half of them havechildren, 4 respondents were divorced and 3 of themhad 1 child.
Table 2: Educational level of respondents (Number andpercentage of the total)High School
7 (13%)
Two year college
9 (16%)
University graduate
22 (39%)Postgraduate degree
16 (29%)Other(Doctorof
Business
2 (3%)
Administration Program)No stated
1
Total
57
Among the respondents, 12 (21%) respondents lived
with their parents, 17 (30%) lived with their family andhad from 2-6 family members living together, 13 (23%)
live alone, 9 (16%) live with partners, 5 (9%) live withfriends and 1 did not state their situation (Q24). They
were also asked how many people they are responsiblefor (Q25). 23 persons said that they have no people tolook after, 29 respondents had 1-5 people under their
responsibility, one respondent needed to take care for5-10 people and another one had more than 10 people
he was responsible for.
5.4. What people think about Fortune-tellers? (Q1)
In response to Q1 which asked respondents, “Whatdo you think about Fortune-tellers?” there were 57
comments from the 57 respondents. There were 11(20%) who seemed to have total trust in what they say.
These comments included:“Fortune teller is somebody who can give an answer
for our problems, sometimes makes me feel good,sometimes not, and sometimes can give solution tosolve the problem.”“Feeling good.”“I like to see a fortune-teller when I get upset.”“Able to treat my mind”“Feeling good”“Sometimes, when we face the difficult circumstances,
Fortune-tellers can give good advice to solve it.”“For checking fortune in each year”“If have chance and good suggestion, I will go to see
them”“It's interesting and should try it”“Psychology about counselling”“Sometimes, fortune-tellers can make me feel goodwith their answer.”
Ten percent of questionnaires mentioned that they
believe / do not believe Fifty-fifty, and 3% believed
some parts but not all of what they say. These
comments included:“50% half of what they tell you”
“Some believe but not all”
“Half believe”“Half believe”“Fifty belief”“Fortune-tellers are the practicing of predicting
information about a personal life”
There were 7% who mentioned fortune telling as
mental health support for people, even though they did
not believe in it themselves. For example:“I don't believe in fortune-telling but this is helpful topeople's satisfaction and pleasure to know his/her
fortune”“Some are true and predict things, but some are not”
“I think that fortune-tellers are master observers that telltheir opinion based on what they have observed”“Fascinated and always wondered if it’s true”
Even if some people said they do not believe in
fortune tellers, they said that they went to see them forpersonal mental health support, for example:

Eubios Journal of Asian and International Bioethics 25 (September 2015)“I do not believe in fortune telling much but I usually go
to see them time by time when I feel unhappy.”“Some fortune tellers use statistics to predict andsomeone is expert and using psychology to talk tocustomer”
Some others said that they can help people, but did
not indicate if they themselves believed in fortune tellingor not. For example:“Can help person who have a problem.”“Fortune tellers give a suggestion but we can choose
the way to do it.”“A person who tells people's fortunes”“The person who can give advice for the problem”“Fortune-teller is a person who predicts the fortune ofother persons, maybe true or false.”
Some responses were simply descriptive, forexample:“Fortune telling is profession which gives a service of
telling other person’s fate and fortune”.
“I feel this is a good career, high income. Thai people
have some beliefs in it.”
“It's a good career to earn a lot of money”“There are good earnings”“It's an interesting idea”
One fifth 18% specifically mentioned “decisionmaking”, for example:“Strong advice can have an impact on decision
making.”“Fortune-tellers, who learnt all information from a text
and gives advice for us to judge again, sometimes
correct but sometimes just guessing.”“Sometimes, I need to consult a fortune teller to remindme about living if something is not good.”“Friendly and clearing problems to give answers”“They could be a "guider" when one's life reaches
problems, obstacles.”“Fortune-teller is guide for decision marking”“Fortune-teller is guide for many stories but need to use
judgment to make decisions”“To know or predict our future.”“They make me happy.”“They are OK. They can help a lot of people”
Among the respondents 10% of them did notthink anything about fortune-tellers, for example:“Don't know.”“Indifferent.”“Nothing special.”“Nothing special.”“Neutral”“Indifferent and sometimes get stress.”
Also some the respondents, 10% of them do
not trust about fortune-tellers, for example:“They are fetish people. I don't like fortune-tellers. It's
wrong to predict the world or one's life”“Rarely believe”“Do not believe”“Do not believe”

195“Fortune-teller comes with guessing.”“Just guessing”
5.5. Frequency of visiting Fortune-tellers? (Q2)
There were 50 respondents who made a comment
to Q2, as described in Table 3. 38% said that they
consulted a fortune teller once a year and 18% went
more often than that.
Table 3: How often do you consult a fortune-teller? (Q2)
Number ofPercent
Comment
respondents (%)
2
1

4
2

Visit once a month to see
fortune-tellers.
By internet and every 3months.

1

2

3-4 times per year

5

10

Twice a year

19

38

Once a year

12

It’s
not
specific,
anddepends on the situation(1); About 2 times in life (1);occasionally (1); Depends
on “fate” (1); When I havesuffering (1); When I’mworried (1)14Rarely4Long time ago (1), One
time since 5-8 years ago (1)

14

Never

100

[Only 50 of 57 answered
this question]

6

7
2
7
50

5.6. Types of Fortune-telling (Q3)
A list of five conditions was mentioned in Q4 alongwith a list of people who would be consulted (Table 5).
Few listed fortune tellers specifically, and parents,
relatives, spouses and close friends were mentioned.
The figure for spouse is relatively low because amajority of participants were single.
There were 49 from 57 respondents or about 86% ofrespondents to Q5 (Have you ever talked to acounselor or psychologist? How often do you visit?)
who did not say that they talked to a counselor or
psychologist. Only 7 people spontaneously mentionedthat they (12%) used to visit them, and 4 respondents
said that they visit them less than 5 times in their life
and one respondent did not state an answer.
Also, 11 respondents said they had talked to a
fortune teller or a psychologist by using social network(Have you ever talked to a fortune teller or a
psychologist using social network? (Q7)). Most, 79%, of
respondents (45 persons) said that they had nevertalked to them in that way.

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

Table 5: When you are mentally confused who do you talk to (Q4)
Who is the first one
you talk with?

Mentally confused topic
Family crisis

Financialstatus18

Studyproblem
8

Relationship withpeople12

Healthcondition
17

29
57%

40%

19%

25%

35%

20

15

31

30

10

39%

33%

72%

63%

21%

2

9

1

4

9

4%

20%

2%

8%

19%

Parent/Relatives%
Close friend%
Partner/spouse%

3

Psychologist

6%%
Fortune-teller%
Other (Teacher,
Doctor, Google)%
Total N

51

2

1

4%

2%

3

3

8

6%

7%

17%

45

43

48

48

Table 7: Ease of Talking with a Fortune Teller or Psychologist Separated by Religion
Types

Numberofrespondents

Buddhist%N

Fortune-teller

34

28

61%

Psychologist

11

9

20%

Not stated

4

3

6%

Don’t know

1

Neither

6

Same

1

Total

57

6

46

of

Muslim

%
N

2

67%

1

of

33%

Christian

%
N

1

25%

1

25%

1

25%

of

Other
None

&

% of N

3

75%

1

25%

4

100%

13%

100%

3

100%

1

25%

4

100%

Table 7: Do you think about science and technologies do more harm than good, more good than harm, or about thesame of each? (Q8)
P2000**
P1993**(%)(%)
DegreeMale% of N
Female% of N
Total N%
More harm

0

0

6

14%

6

11%

4.4

3

More good

7

54%

5

12%

12

21%

47.3

54

Same

4

31%

17

40%

22

39%

45.3

42

Don’t know

2

15%

15

35%

17

29%

2.9

1

Total

13

100%

43

100%

57

100%

Note: 1 person did not state their gender, select the same** Results for general Thai public in 1993 (Macer, 1994) and from 2000 (Kachonpadungkitti and Macer, 2004).

Eubios Journal of Asian and International Bioethics 25 (September 2015)
Q10 (What is the reason to meet a fortune teller?)drew 53 comments from 57 respondents, and about
68% use fortune-telling to be guides in life as following.
“Want them to inform me in the situation”“What to know the future, and what is going to happen
in my life”“It will help me when I face the problem”“Find ways of living”“When feeling anxiety, disappointed, uncomfortable”“To ask prediction of my future life”“Curious about something in the present and in the
future if something happens, even though good or bad
how to find the good solution to solve it?”“Asking for a soulmate, healthy, financial status”“Check my fortune”“Unsolvable problems, seeking advices”“Ask about the future”“Curious about future and present”“Finding the solution to solve the problem and make life
better”“For getting comfortable first and making decisions
later”“There are guidelines for living”“Curious about persons who used to connect
previously, Lucky, Fortune”“Finding solutions”“Curious about the future”“For decrease worrying in something that I wonder orbeing guidelines to live”“For guidelines”“Finding solutions”“Would like to know about life”“Need counseling for finding solutions”“Curious about fortune”“Check my fortune”“Curious about future”“To freely discuss about the problems and concerns”“To learn about the future”“Finding out the unknown”“Finding the solution to solve the problem and make life
better, also feeling good”“Many problems are the same time and difficult to findthe solution”“Needs consulting and find the solution”“Don't want to let some secret to somebody who I know
so a Fortune-teller is the one that I don't know before
that why I can talk to them immediately”“Career”“About my career”“It's true”
Among the respondents to Q10, 11 persons hoped
to get happiness or feeling well after talking with
fortune-teller. For example:“I think the reason most people meet a fortune teller isthat they want to be happy more or when they are
weak.”“For peace of mind”“Indecision, worrying”“Suffering”“Feeling upset”

197“Face serious problem”“I was scared when I set home and somebody isrunning in front of me.”Also, some people said that they had no reason tosee fortune-tellers (Q10). For example:“Friend’s invitation.”“No reason, because of I don't believe in them. They
merely increase one's problem in life"
Table 6: Summary of the most common topics to ask
fortune tellers (Respondents gave open answers in
response to Q11. Please rank the top 5 topics you ask
fortune tellers about?
Number of% of
Ranking
Topics
1
2
3=
3=
5
6
7
8
9=
9=
9=
9=
13=
13=
13=
13=
13=
13=
19=
19=
19=
19=
19=

Career / work / Job
Money / Financial /WealthLove
HealthFamily member orcrisisFuture / Fortune
Relationship withpeopleStudy
Accident
Success
Partner/Lover/spouse
Children
MarriedSomething gone
Livingtraveling
House/ Residential
area
Obstacle / Anyconcern
Happiness
Economic
Travel aboard
Death
Unlucky
No stated
Don’t know

Comment

Respondents(N=49)

32
30

65
61

26
26
24

53
53
49

23
6

47
12

5
3
3
3
3
2
2
2
2
2

10
6
6
6
6
4
4
4
4
4

2

4

1
1
1
1
1
6
2

2
2
2
2
2

The most commonly cited topics to ask fortune
tellers are illustrated in Table 6. Q11 (Please rank the
top 5 topics you ask fortune tellers about?). Six persons
did not state a comment and two said that they don’t
know.
5.8. More frequent to visit Fortune-tellers thanpsychologists (Q6)
As can be seen in the results above, there is apreference to talk with fortune tellers rather thanpsychologists among the respondents (Q6. Who iseasier to talk with, a fortune teller or a psychologist?)(Table 7).

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

5.9. General attitudes to science and technology
Overall most respondents saw science andtechnology as having more positive impacts thannegative impacts (Table 8).
5.10. Views of life
Will you please express freely, in sentences and/or
pictures, the images which come to mind when you
hear the word “Life” and/or ideas you have on “Life”(Q9). The categories of Macer (1994) were used. In thissurvey a high proportion of comments were placed in“Other”, including 8 comments (14%) who said life istough.

“When I hear the word life the first thing that comes tomind is smiling and happiness of people”“Flower, Sun, lively”“Baby born”“Baby born”“Future”“Living in the Future”

Some ideas of 27% thought “Life” is pragmatic andfunctional, as below:“Giving birth, Going sick, Going death”“I saw a picture of the body and mind is very highresponsibilities”“Life is a process from being young till getting old.
Table 9: Images of Life
During the process, one ought to fulfill the expectation,
Q22. Will you please express freely, in sentences
social and cultural norms of their own society. For
and/or pictures, the images that come to mind when
instance, one ought to go to school, get married, andyou hear the word "life", and/or any ideas you have on
have children and so on. However, life should not be"life". (Figures in % of total respondents, including
viewed in such way. One life shall be distinct; one canthose who did not state a comment.).
do anything as long as it doesn't harm anyone”
Reasons (%)
N 2015 % P2000 P1993 S2000 S1993 “Born, Older, Sickness and Death”
Not stated
10
17.5
20.1
16.2
13.8
11.6 “Physical”
Beauty
0
0
1.9
0.3
2.4
0.9 “A process”
Scenery
0
0
3.9
0.2
1.2
0.9 “Human being ex: baby born”
Harmony
3
5.3
12.4
4.7
16.2
3.0 “Cycle of life (Birth-Old-Sick-Death), Rich-Poor,
Ecology
1
1.8
1.0
0.2
2.4
1.3 Socialize”
Picture
3
5.3
33.9
21.2
36.2
24.1 “Cycle of life (Birth-Old-Sick-Death), HappinessEncounter
3
5.3
9.5
7.9
12.6
8.2 Suffering, Love-Greed-Anger-Lust”
God/spiritual
4
7.0
11.0
4.5
3.8
4.3 “Human in the earth and all sentient being”
Action
4
7.0
5.3
3.8
6.5
3.9 “Running, Pulse, Birth-Older-Sick-Death”
Enjoy
8
12.3
7.2
15.3
2.5
14.2 “Family, Friend, Social, Learn to live with community”
To be saved
2
3.5
7.2
6.7
3.8
6.0 “Myself”
Baby
6
10.5
3.8
5.0
5.0
5.2
Nine respondents mentioned a negative side. forLife & Death
13
22.8
13.0
22.6
13.8
26.3
example:Natural
1
1.8
6.7
5.0
11.3
3.9
Health
2
3.5
0.5
3.9
1.2
3.4 “Just make me feel so down”“Be troubled and tough”
Science/
0
0
5.3
3.5
11.3
5.6
“Confusing”
definition
Animals /living
1
1.8
7.6
4.7
3.8
5.2 “Struggle, working for living”“The struggle and patience”
thingsFamily &
2
3.5
3.4
12.8
5.0
9.9 “Life is a struggle and keeping going”“Everyone has problem”
Friends“The struggle and fighting”
Other
13
22.8
0
6.4
0
5.2
“Picture of previous life with mistaken, it’s a cause ofComparisons to Public (P) and Student (S) in in 1993 (Macer,present”
1994) and from 2000 (Kachonpadungkitti and Macer, 2004).
There were 47 comments from the 57 respondents.
They can see their images or ideas of Life in different
ways. One third (34%) have positive images ascomments:“My imagine seeing freedom and Happiness in my life. I
don't want a 'perfect life' but I want a 'Happy life' ”“Feeling good when see my dream picture”“High quality of life and secure future life”“Nice picture having Mom, Dad and children with happy
family”“Living a worthy life”“Living and quality of health”“Life is very valuable more than other things”“Value and responsibility”“Life is going on with lively”

Also 19% of respondents thought in various ideas,
which are mixed between good and bad sides,
sometimes seemingly confused, as below:“Life is fighting, facing in many circumstances,
sometimes good, sometimes bad”
“This time to survive, happiness, problem's family,society, good but experience all of that”“Life is full of surprises. It can be cruel, selfish,
wonderful, beautiful, and phenomenal, and life is an
opportunity to do everything”“Feeling about life for today and future what will happen
with me and people around me? Today is happy, so
how about tomorrow?”“Sometime good, sometimes confused”“Mixed between happiness and sadness”

Eubios Journal of Asian and International Bioethics 25 (September 2015)“Life is moving forward, good or bad depends bythinking and action”“Life is a struggle and a happy things if we take it in ourown ways”“Empty”
5.11. Predictions of Fortune Tellers and Follow-up
There were 46 comments from 57 respondents(Q12. Name an example of a topic where fortunetellers’ prediction came true). Most, 37 respondents(80%), mentioned that some stories were correct from
fortune-teller’s prediction as in the statement below:“All were common problems, and common positive
achievement of people came true.”“Having some problems in family.”“My lover has another woman.”“Romantic life.”“About work that one is real.”“Life is smooth and be calm.”“Should not move institute, if move may be cannot get
success or graduate. A missing thing will come backbut not be the same one and I needed time to wait.”“Love is really true.”“Getting older is better.”“Job.”“Case about education in aboard.”“Relationships.”“Having house from myself.”“In that period I cannot save money, more obstacles inwork.”“Personality, behavior.”“The stories in the part, behavior.”“The stories in the part.”“Changing a career.”“Having the seniority to support, makes good get well.”“There will be some lady who is chubby, tall and whiteskin, she will be a good support and helper.”“I have bad luck in love.”“Career”“There was bad luck which was correct.”“Health, illness.”“Accident.”“Obstacle, money, career.”“Changing a career.”“Health condition of a family member.”“Love”“Travel abroad or a long journey.”“Professional life and love affairs.”“Career promotion.”“Not been in a relationship, have a good job.”“My financial status.”“What happens to me? I do not get well. I get fine after
I’ve been to fortune tellers and I did worship to God
too.”“Changing a career.”“Go aboard.”
There were 7 respondents who said nothing cametrue from fortune-teller’s prediction.
“At this moment, still nothing”“None”

199“Never truth”“Couldn't remember”
There were 45 comments from 57 respondents toQ14. What do you feel after meeting a fortune-teller?
Please describe a few cases, with different fortunetellers. The comments:“All fortune tellers, they comment in a positive andbright future about my life and it made me happy.”“Surprising.”“Feeling relieve and chill.”“I feel quite surprised when fortune tellers known
exactly about my condition. I didn’t say anything when I
come to see her but by the time she finished she drawa tarot card. She could tell that I am in a complicatedrelationship with my spouse. I felt surprised at thatmoment and felt a bit of trust about her prediction when
I left her.”“I feel it is fair for some case that he told me. My belief
is 50:50 but I never refuse what he said from thepredictions. I always listen to him when making
decisions.”“Sometime feel good if positive prediction or I reach my
expectation but sometimes I feel more concerned if
there has been a different way or being negative that I
don't want it to happen.”“Nothing special”“Feeling good that moment but have to wait to see is it
possible or not?”“Love, fortune-teller said my partner is notmysoulmate but I don't mind.”“After I meet a fortune teller (tarot card, Sole reading) I
feel relaxed about the future”“Usually confused but I don't have too many questions
to ask. Sometimes, the fortune-tellers tell a lot ofstories, but I don't think I have something special.”“Wondering whether stories from fortune-tellers will
happen or not?”“Sometime great but sometime disappointed.”“Feeling comfortable when asking about what should
be done in the future.”“Feeling better and also find the solution for the futureplan.”“More suffering and something is impossible.”“It's not correct and sometime is guessing.”“Unbelievable.”“If positive prediction will be happy but will not besadness.”“Nothing true.”“Career”"This moment, changing job will get success andsupporters."“After I met fortune tellers about a birthday reading, hementioned that, "Life is not easy, please be patient foreverything." it's truth after proving about past life.”“Can't remember”“Some fortune-teller is reliable, someone is not”
“Feeling good when get a solution and advice from a
fortune-teller.”“Nothing special.”

200

Eubios Journal of Asian and International Bioethics 25 (September 2015)“Too much apprehension, afraid some things will
happen, such as an accident.”“Birthday prediction: can predict previous stories, Tarot
card reading: can forecast future life and our
expectations.”“Nothing special, because life is simple.”“Some predictions make us feel good, prediction about
future just wait to see.”“Tarot card reading: if not good result we can be careful
by doing merit and anything else to make the feeling
better.”“Tarot card reading, card reading, talking with monk.”“Birthday prediction: in case fortune-teller said this year
is good, it's ok but if not they suggested to do merit canmake us feel good."“Feeling good when they predicted a positive side but
feeling bad if not.”“I feel a relief. I can only describe this feeling because I
have not been to other fortune-tellers.”“Usually, I feel better.”“Excited”“Don't know”“Normally I have beautiful ladies telling my future andeveryone loves my life.”“N/A”“I feel relief and happy after I get fine when I was sickand medicine doesn't work at that time but after I did
what the fortune teller told me it made me felt better.”“Tarot card: answer is neutral, Horoscopes: Related tomerit and sin, also take in the big picture.”“Feeling better, getting solution such as I had conflictwith colleague so a fortune-teller told me I should do
merit and dedicate to her then everything will be better.
After I did it everything is OK.”
5.12. Visiting Fortune Tellers with Friends
Fortune telling is often a social event as can beseen from Q13 (Do you like to go to a fortune-teller on
your own or with friends? Why?). There were 50
comments from 57 respondents. Two thirds, 66%, of
respondents go with friends because they canaccompany each other, prevent a dangerous thing thatmight happen, sharing opinions how much thepredictions of fortune teller will be correct, feeling safe
when having friend, and helping to remember all thedata. The comments were:“With friends coz we stay together there.”“Go with friends to be my company.”“Actually not, I only consult with my close friend who isreally like a fortune-teller.”“Go with friends to prevent dangerous.”“Mostly, going with a friend because I can share andprove how much the prediction of the fortune teller istrue.”“Going with friend who can help to remember.”“Going with friend, since I cannot analyze alone sofriend can help .”“Friend to share and consult.”“With friends to remember what the fortune tellermentions.”“I once went with a friend. Some other things, I justwent alone. Going with a friend so I could be happierand be accompanied.”“Friend”“With friend is better than going alone.”“Friend, she can help me.”“Friend who can invite the right fortune-teller.”“Friend to ask anything else.”“Friend to ask anything else.”“Friend”“Friend”“Friend I am comfortable with.”“Friend who can avoid some suggestions from Fortuneteller that has to pay more money for them.”“Close friend only, I don't want to tell anyone about mysecrets.”“Friend”“Friend who is safe.”“Friend because they can help to gather some missing
information.”“Friend”“Friend to ask anything else.”“Friend to ask anything else.”“Friend to consider how much is credible.”“Friend to ask anything else.”“Friend who made me feel warm and helps me.”“Going with friend who invited me.”“With friend.”
The rest thought they are comfortable to see a
fortune-teller alone due to their secrets, something isprivacy and they don’t want to reveal secret. For
example:“By myself, I need to be private when I go to see a
fortune teller.”“Alone because something is personal.”
5.13. Belief in Karma and Religion
Almost all, 96%, of people (51 respondents from53 respondents to this question) said that they believe
in karma (Q15). One person mentioned what goesaround comes around. Only 2 people who answered
did not believed in karma. There were 42 commentsfrom 56 respondents who believed in rebirth and 12
respondents who didn’t believe in rebirth.
Regarding the term “supernatural”, (Q17. What do
you think about the word “supernatural”?), there were
47 comments from 57 respondents, including:“Something is beyond our thought. I believe insupernatural is something that we are not yet able tocomprehend due to limitation of our brain capacity.”“A man tries to use science to explain 'supernatural' but
I never look down at it.”“Something that cannot be proved.”
A majority of respondents considered religion to beimportant (Q18. In your daily life, do you consider
religion to be...?), and it was answered with 56
responses from 57 respondents. About 60% or 34
people consider religion to be very important for their
daily life, and 16 (29%) respondents though religion toEubios Journal of Asian and International Bioethics 25 (September 2015)
be somewhat important, also 7% or 4 respondents do
not consider that religion is too important and just 2
persons consider religion is not important at all. For
example one of the comments was, “I am a Christian
but Christianity is not a religion.”
The religiosity was measured by asking Q19. How
often do you go to church / temple / mosque, etc.?
(times per month). Less than half, 43%, of them went tochurch/temple/mosque about twice per month, half of
respondents went about 2-3 times a month and 20%
went there more than 3 times per month. In response
to Q20. How often do you pray? (times per month),
about 57% (26 people) said that they pray less than 5times per month, 15% (7 people ) pray 5-10 times amonth, also another 7% pray 11-20 times per month,
the rest, about one third pray everyday.
6. Discussion
6.1. The sample
This paper has examined the practice of fortunetelling in Thailand. The primary target of the survey wasThai citizens living in Thailand and the sample numbers
are too small to draw conclusions about trends in othercountries. Three quarters of the respondents are livingin Thailand, and 24% live overseas. However, as a pilot
survey we can see some interesting comments fromthose in other countries, and further research could
address this. Among the 70 forms circulated 82%
returned the survey form, which is an acceptable
response rate.
Most respondents live in urban settings (95%),
and the age of male respondents ranged from 20 years
old to 54 years old (total 23% of respondents), and the
43 female (77%) were aged between 23-53 years ofage. The sample excludes older persons, which could
be targeted in future surveys. Generally we expect
older persons to be more religious. Two thirds of
respondents were working in the private sector (Table1), and two thirds were single. The sample were moreeducated than the general Thai population, with over
80% having a postsecondary educational qualification(Table 2). A different sampling method would beneeded to contact persons from less educated groups,
and possibly interview methodology would be better to
employ for seeking their views.
6.2. Frequency of Visiting Fortune Tellers
Although a majority of respondents visited fortune
tellers, but only 20% did so more than once a year, and
40% said about once a year. The views of visiting themwere not always utopic, for example, “Fortune teller issomebody who can give an answer for our problems,
sometimes makes me feel good, sometimes not, andsometimes can give solution to solve the problem.”This idea of fortune tellers as a problem solver wascommon, and is relevant to the concept of bioethics to
aid in decision making.
Usually people visit a fortune teller when they
have a problem, for example, “I like to see a fortuneteller when I get upset.”
There were 7% who
specifically mentioned fortune telling as mental health201

support for people, even though they did not believe init themselves. For example,“I don't believe in fortunetelling but this is helpful to people's satisfaction andpleasure to know his/her fortune”. Some people said
they do not believe in fortune tellers, but they said thatthey went to see them for personal mental healthsupport, for example,“I do not believe in fortune tellingmuch but I usually go to see them time by time when I
feel unhappy.” One fifth specifically mentioned“decision-making”, for example, “They could be a
"guider" when one's life reaches problems, obstacles.”,
and a “Fortune-teller is guide for decision marking”.
Only 10% of respondents said that they do not trust
fortune-tellers, for example, “They are fetish people. I
don't like fortune-tellers. It's wrong to predict the world
or one's life”.
Many people, about 68%, use fortune-telling to be
guides in life (Q10). Fortune telling is often a social
event as can be seen from Q13 (Do you like to go to a
fortune-teller on your own or with friends? Why?). Twothirds, 66%, of respondents go with friends because
they can accompany each other, prevent a dangerous
thing that might happen, sharing opinions how muchthe predictions of fortune teller will be correct, feelingsafe when having friend, and helping to remember all
the data.
The frequency of visiting was not so high as thegeneral history of visiting fortune tellers, and 38% said
that they consulted a fortune teller once a year, and
18% went more often than that (Table 3). In Q4 a list of
five conditions was given along with a list of people who
respondents would consult, and few listed fortune
tellers or psychologists specifically, rather parents,
relatives, spouses and close friends were more often
mentioned. The figure for spouse is relatively low
because a majority of participants were single. Most,
86%, of respondents to Q5 said that they had not talked
to a counselor or psychologist. Only 12% mentionedthat they used to visit them. One fifth of respondents
said they had talked to a fortune teller or a psychologist
by using social network (Q7).
As can be seen in the results to Q6, there is apreference for fortune tellers rather than psychologists
among the respondents (Table 6).
6.3. Types of Fortune-telling
There were a range of methods used for fortune
telling as discussed in Chapter 2. The survey foundmore than half the respondents who mentioned Tarot
cards and 40% mentioned palm reading. One third
also mentioned birthday prediction (Table 4). Some
respondents listed multiple options, and there wasdiversity of approaches. If the research is extended tomore foreign cultures and indigenous societies there
may be even more kinds that we can describe.
Most, (80%) mentioned that some stories werecorrect from fortune-teller’s predictions. There weremany comments to Q14. What do you feel after
meeting a fortune-teller? The comments included some
who appreciated a positive attitude, “All fortune tellers,
they comment in a positive and bright future about my202

Eubios Journal of Asian and International Bioethics 25 (September 2015)

life and it made me happy.” Some mentioned theirsurprise that the fortune tellers apparently knew about
their conditions and problems, “I feel quite surprised
when fortune tellers known exactly about my condition.
I didn’t say anything when I come to see her but by thetime she finished she draw a tarot card. She could tellthat I am in a complicated relationship with my spouse.
I felt surprised at that moment and felt a bit of trust
about her prediction when I left her.” The mostcommonly cited topics to ask fortune tellers (Table 6.
Q11) were career, followed by money, love and health.
One quarter mentioned when a family member has acrisis.
6.4. Common Belief in Karma
Almost all, 96%, of people said that they believe inkarma (Q15). One person mentioned what goes aroundcomes around. Only 2 people who answered did not
believed in karma. This is despite the different religionsthat people have. There were 42 comments from 56
respondents who believed in rebirth and 12
respondents who didn’t believe in rebirth, and most who
did not believe in rebirth were not Buddhists. About
60% consider religion to be very important for their daily
life, and 29% thought religion to be somewhat
important, while only 11% do not consider that religion
is too important or not important at all. Less than half,
43%, went to church/temple/mosque about twice permonth, half of respondents went about 2-3 times amonth and 20% went there more than 3 times permonth. About 57% said that they pray less than 5times per month, while 15% pray 5-10 times a month,while 7% pray 11-20 times per month, and about one
third pray everyday.
The views of life were overall similar to the results ofearlier surveys (Table 8) and saw a number ofinteresting comments. Many were brief with a few
longer comments, such as, “Life is a process frombeing young till getting old. During the process, one
ought to fulfill the expectation, social and cultural normsof their own society. For instance, one ought to go toschool, get married, and have children and so on.
However, life should not be viewed in such way. One
life shall be distinct; one can do anything as long as it
doesn't harm anyone”
6.5. Scientific knowledge and Belief in Fortunetelling
Overall most respondents saw science andtechnology as having more positive impacts thannegative impacts (Table 7). There were more
respondents in this sample that said that they “Don’t
Know” whether there is a positive or negative impact
from science and technology compared to the otherstudies conducted in Thailand in 1993 (Macer, 1994)
and from 2000 (Kachonpadungkitti and Macer, 2004).
A part of the Taiwan Social Change Survey, anation-wide longitudinal survey conducted every five
years since 1985, has investigated the beliefs andpractices of fortune-telling. The data showed a fairly
consistent pattern of about a third of the people having

sought fortune-telling services for the past 27 years ofsurvey research (Chiu, 2006; Fu and Tu, 2010), andabout a third of the people believing that fortune-tellingis accurate or predictive of the future (Chang, 2000). In
analyzing the data from 1985 to 1995, Chiu (2006)
found that education increased the likelihood of the useof fortune-telling services and suggested that “the kindof rationality cultivated by modern education, which
generally tended to counter [fortune-telling], might fallshort in countering deep, profound methods of fortunetelling.”
Kuo (2009) surveyed users of online fortune-tellingin China and found that the most common reason given
for seeking fortune telling was questions over personal
relationships. Shein et al. (2014) said that a relationaland situated perspective was needed to interpret theresults of their survey of 1863 adults in Taiwan tounderstand the relationship between scientificknowledge and fortune-telling. The findings showed thatknowledge of scientific methods was negatively
associated with fortune-telling beliefs. However,knowledge of scientific facts was, by and large,
positively associated with engagement in fortune-telling
practices, a phenomenon known as cognitive
polyphasia. This study does not imply that science
communication or education have no effect on
promoting scientific knowledge; rather, it hopes toencourage researchers and practitioners to use aculturally sensitive lens to rethink the role of science insociety and its relationship with other forms ofknowledge and belief.
Shein et al. (2014) found that highly educated andcity dwellers, in general, had a larger likelihood tobelieve in and practice fortune-telling. Higher
educational attainment and closer proximity to cities
indicate more social opportunities and a higher degreeof uncertainty, which may explain a stronger belief in
fortune-telling (Chiu, 2006; Giddens, 1991). More than
80% of the current survey respondents were urban
dwellers, with more than half from Bangkok, so theirstrong belief in fortune-telling may be consistent with
the Taiwanese studies. However, in the opinion of theauthor, rural Thais also belief in fortune telling, as seenin the small sample described for this study.
6.6. Tarots as a Journey through Life and BioethicalDilemmas
The Tarot originated in Europe in the late 14th
century, with a reference in 1371. The earliest known
Tarot deck is the Cary-Yale deck of 1441 in Milan, Italy.
The link to the occult and fortune-telling are due to 18thand 19th century trends. The Tarot are a game ofcards still played in some parts of Europe. The Catholic
church may have been promoting the use of thesecards with spiritual messages as a alternative to someother forms of gambling. Several British and Frenchoccultists claimed that the Tarot had alleged ancient
Egyptian origins. We see a reference to this in Court De
Gebelin (1781) in volume VIII of Monde Primitif (The
Ancient World), in which he included two essays
claiming that the Tarot was drawn out of Egypt, butEubios Journal of Asian and International Bioethics 25 (September 2015)
there was no evidence presented to back up his claim(Collingwood, 2011). The fortune-telling connection was
introduced by Jean-Baptiste Alliette (under his reversed
surname, Etteilla), 1785, How to Entertain Yourself with
the Deck of Cards called Tarot.
For those who follow the system of Tarot they referto the apparent timeless ideas of spiritual truths andhuman behavior. For example the Wheel of Fortune
Tarot trump warns of the cycle of fortune and hubris,that represents those people who have ultimate faith inpursuit of money or power, such as bankers oremperors.
The trap of secular humanism, a common
proposition in modern bioethics, has led to the collapseof many human civilisations, and is represented by theMoon trump. Collingwood (2011) argues that in order
to live intelligently we need to know and understandthese fatal archetypal scripts so that we are aware of
their presence, understand and master them and so
become creators of our lives according to reason rather
than be driven beings or victims. Some people blame
these drivers as demons but they predict
theconsequences of our often irrational behaviors.
Some Tarot cards are very positive, such as the Sun
and The Star, the trump of hope for a better future
which has been linked to evolution. The introduction of
Tarot cards as a tool for fortune telling is less than two
centuries old, but we can see that among the manymethods used by oracles (fortune tellers) that are seenin Table 5, Tarot cards are popular. Few users may beaware of the origins of the Tarot cards however. For
example the Tarot, Fool, is modeled on the work of
Dante, Divine Comedy, which traces an allegoricalprogression of Dante form Hell to Paradise through 22
trumps. The Fool is un-numbered allowing the “Fool” ortraveller, Dante, to progress through all stages of life.
There could be more written on the links between Tarot
and bioethics of the progress of life. This could be a
subject for further research in itself.
Sallie (1980) explored interpretation of the tarot interms of Jungian psychology. She argued that thesignificance of the cards is related to personal growthand individuation. The idea is to explore a map of life,
and the hero's journey becomes something that eachindividual can relate to the symbolism of the cards andtherefore to the personal life. In a pack of 78 Tarot
19
cards, much like the 64 hexagrams of the I Ching, anentire mutant mental universe is ciphered, which can beused to form predictions. “We can predict the future,”
Carl Jung stated, “when we know how the present
20
moment evolved from the past.” This evolution of thepresent is linked to the past, just as the conscious mind
is subjected to the unconscious: the Tarot card or the
hexagram is a visible manifestation of this connection,a type of synchronicity that forces itself to rise to thesurface, but requiring, just as an oracle does, anaccurate interpretation. In 1933, during a seminar, Jung19

http://ichingfortune.com
http://www.faena.com/aleph/articles/carl-jungs-tarotalchemy-and-archetypes/

20

203

spoke about Tarot (in his work Visions: Notes of the
Seminar given in 1930—1934), and he stated thatthese cards are the predecessors of the sets we use togamble, where red and black represent two opposites,
and the division of four —spades, hearts, diamonds
and clubs— also corresponds to the symbolism ofindividualization. They are psychological images,
symbols we play with, in the same manner that theunconscious seems to play with its contents. They are
combined in a certain way, and its different
combinations correspond to a playful development of
humankind’s history.
We can see here that when people put their trust in
Tarot cards, they are answering something that all
people may seek, some through a psychologist andsome through a fortune teller. In this research we cansee three times more people seek the opinions of afortune teller rather than a psychologist. I hope that thisthesis has raised the awareness of the linkage between
support for our decisions and counseling provided byfortune tellers.
7. Conclusions
Fortune-telling is the practice of counseling people
who have mental doubts about some issues, and notjust predicting information about a person’s life. People
seek guidance on their future attitudes and choices, tomake better decisions. This paper has briefly reviewed
different types of fortune telling including the meanings
and characteristics of Zodiac Signs and Astrology
Signs, Tarot cards, Palm reading, Numerology, Pulse
Reading, Gene tests, Parrot astrology, Sole reading(Foot), Signature reading, Horoscope, Birthday
prediction, Life graphs, Communication with spirits
through psychics, Number of Identity card, Egg reading,Tree leaf predictions, Name forecasting, Poker cardreading, Monk fortune teller, I Ching, and newtechnology.
We can consider fortune-telling as a Public HealthService. Health is a state of complete physical, mental
and social well-being and not merely the absence ofdisease or infirmity. Fortune telling can support people
from the fields of mental health, using knowledge,
statistics, consulting skills to talk with people in a teamof multiple religions and faiths. It also examines karma
as culture in Thailand.
The survey found that people more frequently visit
Fortune-tellers than they do psychologists. It also
explores general attitudes to science and technology
which were generally positive, and comments on thepredictions of fortune tellers by the respondents. Twothirds of the respondents visited fortune tellers withfriends. Almost all believed in karma and many had
religious faith.
There were various types of fortune telling that weresought. The reasons and questions were examined,with comparisons to attitudes people have to seeking acounselor or psychologist. We can conclude that
fortune-telling has an important role in mental health,and the ethics of the practice is fruitful grounds forfurther research.

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

8. Acknowledgements
I appreciate my supervisor, Professor Darryl Macer andmy advisers Professor Soraj Hongladarom and Professor
Angelica Baylon. I also appreciate the support of my thesis
examiners, Professors Marlon Lofredo and Professor Miyako
Takagi. Thanks to all the respondents for spending time toanswer my questionnaires.

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Collingwood, Leigh, 2011, Deforestation: Why YOU Need toStop it NOW. Durban, South Africa.
Douglas, C. ed., C.G. Jung, Visions : Notes of the seminar
given in 1930-1934 (2 Volume Set) ( Bollingen). Claire
Douglas: Books.
Fu YC and Tu S-H (2010) Technical Report of the Social
Change Survey in Taiwan. Taipei, Taiwan: Institute ofSociology, Academia Sinica.
Goodman, David (2012) Making Early American
Broadcasting's Public Sphere: Radio Fortune Telling and
The Demarcation of Private and Public Speech, Historical
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10.1080/01439685.2012.669884.
Giddens A (1991) Modernity and Self-Identity: Self andSociety in the Late Modern Age. Stanford, CA: Stanford
University Press.
Kachonpadungkitti, Chalobon and Macer, Darryl (2004).
Attitudes to Bioethics and Biotechnology in Thailand(1993-2000), and Impacts on Employment, Eubios Journalof Asian and International Bioethics 14: 118-134.
Kuo, Cheng. 2009. A study of the consumption of Chinese
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10.1080/17544750903209010
Macer, Darryl R.J. Bioethics is Love of Life; An Alternative
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LaMuth, John E. The Spiritual / Universal Realm ; The
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uture.html

A bioethical interpretation of
Buddha’s enlightenment- Nader Ghotbi, Ph.D.
Ritsumeikan Asia Pacific University (APU), Beppu, Japan
Email: nader@apu.ac.jp

Abstract
Siddhārtha Gautama attained Buddhahood by‘awakening’ or ‘enlightenment’. Having spent many
years in the struggle to find the truth about suffering, he
was finally enlightened after spending days inmeditation under a tree in Bodh Gaya, India. Later hestarted on a journey to spread his teachings, what iscurrently known as Buddhism with about 360 million
practitioners worldwide. This paper examines theteachings of Buddhism in a bioethical perspective tohypothesize on what awakening or enlightenment
meant to the Buddha. The paper argues that theconcept of reincarnation, cycle of suffering, andcompassion are closely knitted in Buddha’s realizationof enlightenment; suffering follows a cyclic pattern
through life and unless the cycle is broken, it is inclined
to repetition. This cycle starts with birth which is thenafflicted with illness, aging and death. However, allliving things are connected through the unity of life, likea river that flows. The ‘truth’ is that we are all but one
living organism. Compassion can reduce suffering,
though suffering can only be stopped when one is sooverwhelmed with pure compassion that ‘oneness’ withall life is realized. This allows one to lose the illusion ofself so that the cycle of suffering may be brought to an
end. Therefore, compassion, altruism, giving andreceiving are only ‘natural’. Those who do not realize
the truth, stay within the cyclic pattern of suffering that
only changes form along the time. Purity and perfectionof compassion is the key to end suffering. It can beconcluded that the concept of enlightenment is basedon Buddha’s philosophical comprehension of the unityand connectedness of life as understood in biology
today.
Keywords:
Awakening,
Buddha,Buddhism,
Compassion, Cycle of suffering, Enlightenment.
Introduction
Buddhism started about 2500 years ago in northIndia through the teachings of Siddhārtha Gautama
who found the ultimate truth through enlightenment or
awakening; Buddha means the enlightened or theawakened one. Popular belief is that Siddhārtha
Gautama was a prince and lived a comfortable life but
after observing people affected with aging, illness,
ignorance and death realized that there was suffering in
the world; so he left the palace to find a meaning for alife that appeared to be destined to suffering and death.
For many years he tried different disciplines including
austerities that existed at the time but did not reachenlightenment until he sat under a tree and meditatedfor many days, and finally he found a complete insight
into the cause of suffering, and the steps necessary toEubios Journal of Asian and International Bioethics 25 (September 2015)
eliminate it, meaning the four noble truths; thatexistence leads to suffering because of desires, and bystopping desires suffering can be stopped. Buddhataught that all things are temporary, even the self
(Henslin, 2011) and suggested an eightfold path tocease
sufferingwhich
includesthe‘right’understanding, resolve, speech, action, livelihood,effort, mindfulness and concentration. In short,
existence involves suffering which results from desiresthat can be fought and may be stopped. The practice of
Buddhism involves exercises in meditation and spiritual
training (Bowker, 2006).
Buddha did not write down his teachings but his
disciples recorded them after he passed away. Pali
Canon is the name of such a collection in Pali
language. Later, Buddhist teachings were translated tomany other languages. Many such scriptures are in theform of a dialogue between Buddha and some of his
disciples. These debates are highly philosophical andexplore the nature of self, feelings, senses,
perceptions, formations and consciousness (Abel,
2004). Buddhism emphasizes on the concept that all
things are connected in chains and dependent on eachother. Also the moral law is based on karma whichrefers to the cause and effect bound with each other ina chain. Therefore freedom from any dependence,liberation from all suffering, or Nirvana, can be attainedby fighting one’s desires and attachments. The schoolof Buddhism called Mahayana or “Great Compassion”
spread to China, Korea and Japan. This school
believes that there is a Buddha nature in everything
and therefore Nirvana can be attained, even suddenly,
through awakening. Nirvana is the perfect peace ofmind free from ignorance, greed, hatred and othertroublesome states. Mahayana claims to havepreserved the teachings of Buddha in the form of texts
called sutra. These may be chanted in rituals that help
attain mindfulness in meditation (Bowker, 2006).
Buddhism entered Japan about 1400 years ago
and after about 500 years, a purely Japanese school
developed out of the lotus sutra. Zen is a well-known
form of Japanese Buddhism in the West. In Japanese,zazen refers to meditation in a sitting state which wasthought to result in enlightenment. On the other hand,tantric Buddhism uses the power of sacred sounds
known as mantras to help attain enlightenment in ashorter time. They use not only human voice in the formof chants but also the sound of bells in rituals that aredesigned for meditation (Bowker, 2006). Many new
forms of Buddhism have also emerged in Japan in thelast century, including Soka Gakkai and Shinnyoen.
This study is trying to find a less abstract meaning
for awakening or enlightenment known as satori inJapanese. The argument that a rather clear meaning
should exist for awakening is based on the following
observations: First, Buddha’s awakening did not
happen during years of austerity and struggle throughthe hardest trainings but after a few days of meditation
under a tree. Buddha himself referred to his path as thebalanced way in the middle that requires
understanding, not extreme austerity and physical205

training. Awakening can thus be about understanding
the ultimate truth through thoughtful deliberation on thenature of existence and life. Second, Buddha inherited
the knowledge of Hindu priests before him but
deliberately challenged some of them while providing
an alternative explanation for others. He accepted
rebirth through many lives but rejected the rebirth ofsouls (atman) and permanence in anything. He instead
believed in the sequence of new forms of appearance.
He also rejected the sacrificial system in Hindu andinstead asked his followers to seek their own salvation
through diligence (Bowker, 2006). We can thus
presume that his new insight was based on a wisdom
he gained during meditation. Is it possible that bioethics
as the discipline of life values can provide a scientificinterpretation for the mystical language of Buddha?
This is the main question that we attempt to answer inthis paper.
Methodology
The bioethical interpretation of enlightenment in thisstudy is based on the use of symbolic interactionism(Henslin, 2011) to decipher the meaning of awakening
by focusing on the symbolic meanings of the story
associated with Buddha’s awakening under the Bodhi
tree, the rituals associated with Buddhist meditation,and the beliefs and religious experiences of Buddhists.
Therefore I have tried to refer to the symbolic meanings
for these components that can associate them in acomprehensive structure. There was also extensive
literature review to look at the story of the life of Buddha
and his teachings until the last teaching about Nirvana.
Besides the literature review and exploration ofcontemporary Buddhist teachings, the author used an
ethnographic method to explore the religious practicesof a Buddhist sect in Japan known as “Shinnyoen”.
There were many reasons for selecting this special
sect. First and foremost, they believe in spreading theessence of Buddhism to the masses, that everyone
even lay and common people have a chance to reachenlightenment. Second, they routinely practice
meditation through sessions of supervised ritual‘chants’ called “sesshin”. This practice soon turned into
a mainstay of the findings of this study, as a relation
between the acoustic nature of the sounds in the
chants with the cyclic pattern of life and of suffering
could be speculated. The third reason was about thefeasibility of such research as Shinnyoen welcomes thepresence of foreigners (non-Japanese) and facilitates
their participation in religious ceremonies with modest
requirements which eased the ethnographic nature of
the study. The study was done in two centers, a formal
temple building in Oita city and a house in Beppu city,
Japan, and continued for two years in the form ofbiweekly visits to the temple plus daily visits to thehouse in Beppu during the annual period of intensive
meditation called “winter training”.
Also interviews were done with two of thededicated members of the sect for qualitative research.
The topics of discussion included the concepts ofcompassion and lovingkindness, the nature of

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

enlightenment, and the significance of sesshin
meditation as well as some other issues that will be
explained and also discussed further in the part ofdiscussion.
Findings & Discussion
Siddhārtha Gautama was meditating underneath a‘peepal’ fig tree known as Ficus religiosa. The tree isknown for its large heart shaped leaves that movecontinuously even with no wind, for uniquely releasing
oxygen in both day and night, and for a huge trunk the
diameter of which can be up to 3 meters. These
qualities provide for a special symbolic value for thistree. In life science today, it is common to speak of the“tree of life” in reference to the unity and connectednessof all diverse life forms (Campbell, 2005).
The Bodhi tree was located on the bank of a river(called Nairanjana); a drawing in a temple near Bodh
Gaya shows Buddha sitting calmly underneath a large
tree with water flowing in waves inside the nearby river(Figure 1). Buddha was offered a bowl of rice-milk
porridge prior to meditation by which he regained thelost physical strength (Sato, 2013). It is said thatthrough meditation he gained an insight first into the
future and then into the past whereby he realized thecauses of conditions that result in suffering. He also
realized that the root cause of suffering was ignorance
and illusions.

Figure 1: A drawing in a temple near Bodh Gaya(which literally means place of enlightenment) shows
Buddha sitting calmly underneath a large tree while
being offered a bowl of porridge, with water flowing inwaves inside the nearby river (Sato, 2013). There aremany symbolic meanings in this drawing: Buddha’s
calmness under the tree (of life), Buddha receiving
nourishment offerings from a woman, the flow ofvarious wave forms (reincarnation) that appear at thesurface of the river, with the background lightened upby the bright light of the sun, birds flying in the air,and flowers growing along the river. Symbolic
interactionism suggests that such representations ofevents and objects were commonly used forcommunication among humans especially on
religious and philosophical matters (Henslin, 2011).
By taking the components of this image as
symbolic units that refer to a less abstract knowledge
within the story, one may assume that Buddha realized
how he was on the receiving end of a relationshipamong all the living which is the fundamental reason oflife. All animals including humans depend on plants thatabsorb energy from the sun, water from the soil and thebreath in the air to produce food for all. In fact, there isa web of life that connects all life forms and is built on
the surplus produce of the plants, as described by themodern science of biology and ecology.
The flow of water can be a symbolic reference tothe flow of time which brings about different forms of life
like the waveform in the water; some waves are larger,
some are small, some drops are at the top, and someare down, but it is all just water in an ever-changing
form. On the one hand, Buddha realized that all life wasconnected and that all depended on one another; noone could live without the others. On the other hand, it
connects the past, present and future, as it is one
stream of life that flows over time into different forms
rising at different times.
With all life being connected and interdependent,
compassion would be nothing other than ‘natural’.
Buddha received the porridge offering as naturally as
he received support from the tree. Human compassion
can learn a lesson from the tree that naturally serves
and protects. The birds, the tree, the flowers, andBuddha are all taking and receiving what they neednaturally. Compassion becomes lovingkindness andtherefore altruism loses its contrast with it. We are allone!
Now let’s assume that on the ripples of waterflowing in the river, Buddha could see the periodic
cycles of suffering, the impermanence of formations,and the illusion of self and its permanence. After all, it isa wave progressing through the river and moving someof the water down and some other up at every moment,
moving the drops of water to different spots. One may
feel suffering when falling, and to desire to move up,
and feel pleasure when moving up; however, any
movement up is followed by falling down (suffering).
Nothing is permanent and one needs to be mindful torealize that. But compassion can help overcome
emotions such as anger, hatred, greed, selfishness,
etc. However, if desires are not subdued, they can takeover compassion and love.
Buddha would relate and connect information in
the nature of the world around him, similar to methods
in the study of complex systems in contemporary life
science. In a way, Buddha could have used aphilosophical insight into the nature of life, andsuffering, by relating his mindfulness of theEubios Journal of Asian and International Bioethics 25 (September 2015)environment around him into one complex system toexplain all life, at present, future and the past.
Furthermore, Siddhārtha Gautama lived at a place andtime when many violent conflicts between different
tribes happened periodically. He could see how theviolence persisted in disguise between the attacks, inthe form of tense emotions of hatred and enmity; thecycle of violence would be repeated as long as it was
not fully broken. However, enlightenment can only
happen when the cycle of violence can be stooped. The
Pali version of the Nirvana sutra asserts that the person
who offered food to Buddha was not responsible for his
death. In the Mahayana version, Buddha’s passing
away after accepting a food offering is paralleled withhis awakening/enlightenment after accepting the foodoffering under the Bodha tree (Ito, 2013). After all, inboth instances, before enlightenment and before
passing away, the receiving of an offer by Buddha wasfollowed by a peaceful Niravana state.
Findings of the qualitative interview with the two
Buddhist members of Shinnyoen in Oita, Japan include
interesting points that have been italicized in thefollowing paragraph in their original quotes: The two
followers were attracted to this particular school of
Buddhism for the “spiritual need” they felt in their lives.
Over the years, they had “accumulated merits” andtherefore felt “gratitude”. They had especially learned
the value of “altruism” and “compassion”; one
interviewee described it as intimate as “giving one’s
flesh to feed others”. To the question of why they chose
Shinnyoen among various schools of Buddhism inJapan, they answered: The founder appeared to be“spiritually connected”, was “willing to lead” others to
the truth, and was also willing to teach “ordinary”
people. Therefore the teachings of Buddha could reach“all people”. This school emphasized on Buddha’s “lastteaching, Nirvana sutra” which included “secrets” toachieve the “nirvana state”.
As for their beliefs
regarding the issue of suffering, the interviewees
believed that “doing good deeds can reduce suffering”
and such good deeds can also be “accumulated
through one’s offspring”. Being asked about theirbeliefs on reincarnation, they mentioned that people
may be “reincarnated in different levels based on theirdeeds in a previous life”, and “it is possible to gradually
move up through these levels”. Asked to describe‘awakening’, they stressed a “purified state” that one is“freed from greed, selfishness, and other negative
emotions” and thus can “in practice, act for the benefitof others” and “prioritize the happiness of others”. An
awakened person would “feel very peaceful” and would
be able to “interpret events in a spiritual manner”
without suffering from negative emotions because of
the “lack of wants” or any experienced “losses”. Finally,
asked about their main religious practice to achieve thatpeaceful state, they emphasized on “sesshin” as a formof meditation where a “medium” helps them to “receive
spiritual messages” that can help set them free. This isdone while they are reciting chants monitored by thehigher rank (in a spiritual sense) “medium”. However,
the majority of practitioners are ordinary people from all207

various sorts of livelihood. A common slogan among
the followers is that “we share one heart”.
Finally, Buddhist rituals commonly include thechanting of mantras which are believed to help with theempowerment needed for awakening. These chants
have a specific acoustic quality that may be describedas similar to the “Gregorian chants” in Christianity. In
September 2015, Japanese media reported that a CD
of Buddhist monks reciting sutras published in June2015 was already among the top 10 selling albums inJapan. The media report referred to the “many virtues
and even health benefits of listening to the soothingsounds of sutras (called “okyou” in Japanese) being
read aloud by groups of monks”. The CD contains thesounds of bells and the harmonious reading of sutras
by Buddhist monks; the accompanying book
recommends listening to it for “calming the nerves,
helping one sleep, and a soothing effect on the heartand body, relaxing tension in the body and maybe evenhelping one feel better when ill or heartbroken”.
Conclusion
Symbolic interactionism provides a methodologicaltool to explore the mystical concepts in Buddhism
especially the concept of awakening or enlightenment.
The texts, drawings and other art form that was madeafter Buddha’s death include symbolic meanings thatcan be explored in order to provide a less abstract
interpretation of the mystical vocabulary common in
Buddhist teachings. I have studied one of the newer
schools of Buddhism in Japan who aspire to present apath to enlightenment for all people from all groups.
Ordinary people are asked to participate in spiritualsessions where they recite harmonious chants, practice
meditation, control their negative emotions and conduct
practical lessons in altruism, compassion andlovingkindness. Using symbolic interactionism on thestories in the sutras, the beliefs, and the spiritual
practices of ordinary followers, and the rituals of theirreligious ceremonies helped with defining a more orless clear idea of what awakening/enlightenment
means.
It appears that the concept of reincarnation, thecycle of suffering, and compassion are closely knitted in
Buddha’s realization of enlightenment. Life starts withbirth which is accompanied by suffering because of
aging, illnesses and inevitable death. But this is notabout the life of one individual because all life isconnected; all living things, not just humans, but otheranimals, trees and the living environment are allinterconnected. Thus suffering of an individual may
continue in the life of another living thing. This is how
suffering also follows a cyclic pattern and unless thecycle is broken, it is inclined to repetition. Living things
are all connected even through time, and along themany generations, for the unity of life flows in changing
waveforms, just like a river.
The ‘truth’ is that we are all but one livingorganism. So to have compassion to others, and to be
altruistic, is only ‘natural’. Pure compassion can reduce

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Eubios Journal of Asian and International Bioethics 25 (September 2015)

suffering, but suffering can only be stopped when one isso overwhelmed with pure compassion that he practices
oneness with all life. To believe in self is thus an illusion,and awakening can open the eyes of the enlightened
ones to the illusion of self, of desires and of wants that anindividual follows for “him/herself”. They may remain
within the cycle of suffering that only changes form.
Compassion can save them but it needs to be perfectedby practice; the key to end suffering is the purity andperfection of compassion. Finally, it can be concluded
that the concept of awakening/enlightenment of the
Buddha is based on his philosophical comprehension of
the unity and connectedness of life as understood in
biology today. Such interpretation of enlightenment is very
close to the concept of “love of all life” in bioethics.

ReferencesndAbel, Donald C. Fifty readings in philosophy (2 edition).
Reading 25: The middle-length discourses of the Buddha.
pp: 243-257. Mc Graw Hill, New York, 2004.
Bowker, John. World religions, the great faiths explored &explained. DK Publishing, New York, 2003.
Campbell, N. and J. Reece, Biology (7th Edition),
Pearson/Benjamin Cummings, San Francisco, 2005.
Henslin, James M. 2011. The Sociological Perspective. Pp: 763 in “Essentials of Sociology, a down-to-earth approach”.
11th Edition. Boston: Pearson.
Ito, Shinjo. The importance of contemplation and the essenceof esoteric Buddhism (speech on April 24, 1968). Resonance(The Shinnyo-en Journal) No.3 April 2013: 1-4.
Ito, Shinso. Mahayana acts. Resonance (The Shinnyo-en
Journal) No.2 February 2013: 3-8.
Sato, Naomi. The Buddjha: ascetic training and enlightenment.
Resonance (The Shinnyo-en Journal) No.3 April 2013: 2629.

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