Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 25 (1) January 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: Wisdom for our Future1- Darryl Macer
Quality of life and palliative care needs of patients with
Niigata Minamata disease: A complete survey after
50 years since the disaster2- S. Sakai, N. Seki, H. Yamanouchi, M. Miyasaka
Pandemic Influenza Planning and Response in India,
1949-20097-Rhyddhi Chakraborty and Chhanda Chakraborti
Animal rights and the need for a universal ethics
13- Georges Chapouthier
Implications of African Conception of Personhoodfor Bioethics: Reply To Godfrey Tangwa
15- Ademola Kazeem Fayemi
Compassionate Care by Clinicians: Insights from the
Judeo-Christian and Buddhist Traditions
21- Neil Pembroke
Ethical Issues of Wireless Sensor Network in HealthCare Applications
24- J. Thresa Jeniffer and J. Joannes Sam Mertens
Sinking of ethics with MV Sewol
26- Bang-Ook Jun
Bioscience Ethics Education Challenges Learning Acrossthe Generations
27- Irina Pollard
ABA Renewal and EJAIB Subscription
32
Editorial address (and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
Provost, American University of Sovereign Nations (AUSN),
8800 East Chaparral Road, Suite 250,
Scottsdale, Arizona, 85250 USA
Email: dmacer@au-sn.com
darryl@eubios.info
http://au-sn.com
http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329, Hornby,
Christchurch 8441, New Zealand

Editorial: New ABA Board
This issue includes 8 excellent papers, thanks to theauthors, with some original data from public health studies,and bioethical reflection from disasters to compassion.
thDuring the 15 Asian Bioethics Conference in Japan, 1-9
November 2014, we saw the election of the new Board of the
Asian Bioethics Association, and also expressed thanks toth
the ABA Board members whose terms have ceased. The 16
Asian Bioethics Conference will be held in Boracay, thePhilippines, 3-8 November 2015.

The new ABA Board is:
President: Prof. (Ms.) Miyako Takagi (Japan)
Immediate Past-President: Dr. Aamir Jafarey (Pakistan)Vice President for Asian Ethnic and Religious Minorities:
Dr. Jasdev Rai Singh (UK)
Vice President for China: Prof. (Ms.) Yanguang Wang
Vice President for India: Dr. M. Selvanayagam
Vice President for Indonesia: Prof. Umar Anggara JenieVice President for Japan: Prof. Tsuyoshi Awaya
Vice President for Korea: Dr. Young-mo Koo
VP for the Pacific: Prof. (Ms.) Irina Pollard (Australia)
VP for South Asia: Prof. (Ms.) Shamina Lasker (Bangladesh)
VP for South East Asia: Prof. Ravichandran Moorthy
Vice President for Pakistan: Dr. Shahid Shamim
Vice President for Taiwan: Prof. Shui Chuen Lee
VP for West Asia: Dr. (Ms.) Bakhyt Sarymsakova (Kazakstan)
Secretary: Prof. Darryl Macer (Thailand/New Zealand/Japan)
Country representatives include:
Iran: Alireza Bagheri
Mexico: Prof. Martha Marcela Alanis Rodriguez
Mongolia: Mr. Amarbayasgalan Dorjderem
Myanmar: Ms Yamin Thu
Nepal: Mr. Rimesh Khanal
Philippines: Prof. Marlon Lofredo
Sri Lanka: Prof. Anoja Fernando
Turkey: Dr. Hasan Erbay
Thailand: Prof. Soraj Hongladarom
Vietnam: Dr Ngu Thi Tuyen
Other key positions:Publicity Committee Chair: Prof. Latifah Amin (Malaysia)
Fund Raising Committee Chair: Prof. Nader Ghotbi(Japan/Iran)
ABA Logo Development Committee Chair: Ms. Ananya
Tritipthumrongchok (Thailand)2015 ABC16 Scientific Committee: Prof. Marlon Lofredo (thePhilippines)
On this page there is the Asian Bioethics Association logo,
which was chosen from over a dozen candidate logos, in aprocess that saw several rounds of voting and improvements.
In appreciation of the logo design and as a reward for thecompetition – Mr. Faidh Hussein, Sr. Daphne Furtado, Mr.
Muhammad Ziaul Huq and Prof. Marlon Lofredo – have been
provided lifetime membership in the Asian Bioethics
Association (ABA). We appreciate the efforts of Ms. Ananya
Tritipthumrongchok for arranging the logo process, and Mr.
Hasan Erbay, and others for their submissions andsuggestions. We look forward to seeing many persons at
ABC16 in 2015, and express appreciation to Prof. Nader
Ghotbi, Prof. Takao Takahashi and Dr. Kayo Uejima for theirefforts in holding a successful ABC15 in Japan.
- Darryl Macer

2

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

Quality of life and palliative
care needs of patients with
Niigata Minamata disease:
A complete survey after 50
years since the disaster
1

2

1

2

- Sayuri Sakai , Nao Seki , Haruo Yamanouchi , Michio Miyasaka
1
Graduate School of Medical and Dental Science, Niigata University
2
Graduate School of Health Sciences, Niigata University, Asahimachidori, Chuo-ku 2-746, Niigata City 951-8518, Japan
Email: miyasaka@clg.niigata-u.ac.jp (corresponding author)

Abstract
Background: Minamata disease (MD) is caused by theingestion of a large amount of fish or shellfish contaminatedwith MeHg included in industrial wastewater. In 1965, anumber of cases were found along the Agano River in Niigata
Prefecture in northern central Japan, which were collectively
designated as “Niigata Minamata disease.” Patients with MD
suffer from a set of complicated pains accompanied byvarious signs and symptoms. They also have mental andsocial pains, including loss of identity, stigmatization that
leads to the refusal of friendship and marriage, and isolationin the local community. However, few studies haveinvestigated the care and prevention measures required torelieve the symptoms of patients with MD.
Aim: The objective of this survey was to investigate thesymptoms, pain, and suffering experienced by patients with
Niigata Minamata disease as well as their QOL and coping
strategies.
Design and setting: The survey was designed as a complete
study of patients with MD accessible to the local governmentof Niigata Prefecture and that of Niigata City.
Results: The average score of the study subjects in theWorld Health Organization Quality of Life 26 (WHO/QOL-26)
was considerably lower than that of the general population,
while being female and having an occupation correlated withhigher scores for some domains and/or overall QOL scores.
The symptoms perceived by the subjects as distressing intheir daily lives included numbness in the limbs, physical pain,
disturbed sensory systems, limb dysfunctions, and fatigability.
The measures commonly taken to relieve these symptoms
included using medicines, taking a bath/going to springs, andmaintaining warmth. The common emotional support included
interpersonal relationships, emotional fulfillment, selfdiscipline in daily life, and bodily health. Those certified ashaving MD showed no significant difference in any domains
and overall QOL.
Conclusions: Palliative care providers should extend theirtargets for non-cancer palliative care and develop approaches
for MD-specific total pain.
Key words: Quality of life, palliative care, Niigata Minamata
disease, bioethics, complete survey
Introduction
Minamata disease (MD) was identified in the coast of
Minamata Bay in Kumamoto Prefecture in southern Japan in
1
1956. MD is caused by the ingestion of a large amount offish or shellfish contaminated with MeHg included in industrial
wastewater. In 1965, similar but relatively milder cases were
found along the Agano River in Niigata Prefecture in northern
central Japan, which were collectively designated as the2“Second Minamata Disease” or “Niigata Minamata Disease.”
Patients with MD suffer from a set of complicated pains
accompanied by various signs and symptoms, including

sensory disturbance in the distal parts of the extremities,
ataxia, disequilibrium, bilateral concentric constriction of thevisual fields, impaired gait and speech, muscle weakness,
tremor, abnormal eye movement, and hearing impairment.
Mental disorders and disturbed taste and smell also occur
occasionally. Patients also have mental and social problems,
including loss of identity as a worker or a fisherman,
stigmatization that leads to the refusal of friendship andmarriage, and isolation in the local community caused by a3
diffused prejudice that the disease is contagious.
As of May 2013, 702 patients in the aggregate were
officially certified as having MD in Niigata, whereas for 1,376,
4
the application was turned down. The strict criterion that
requires the full set of symptoms to be present for certification
as a patient with MD has generated a sense of unfairness
5
among patients and caused divisions. It has also been
criticized by the Supreme Court, which ruled in 2004 that aperson with a single symptom should also be recognized as a6patient with MD. The central government enacted a law (theAct on Special Measures for Compensation for Minamata
Disease and Solutions to the Problems of Minamata Disease)in 2009, which aimed to “let those who should be given relief
7
be given as much relief as possible.” The stigmatization ofpatients also caused them to receive insufficient access to8healthcare resources. Patients who undergo discrimination
are reluctant to visit medical or welfare facilities, whereas
healthcare providers in their communities, including publichealth nurses and visiting nurses, have difficulties in treating
patients because they have limited knowledge andexperience regarding their complicated ailments. The marked
characteristic of patients with MD in Niigata is that most of
their neurological symptoms are not observed in their outward
appearance. In addition, mental and social pains need to beassessed and managed carefully. However, few studies haveinvestigated the care and prevention measures required torelieve the symptoms of patients with MD. Because noeffective cure has been developed for MeHg poisoning andpatients are inflicted with multifaceted symptoms or “total
9pain,” the applicability of various palliative care approaches
developed for other diseases should be considered toalleviate some of the patients’ widespread pain and distressas well as to improve their QOL.
The objective of this survey was to investigate thesymptoms, pains, and sufferings experienced by patients with
Niigata Minamata disease as well as their QOL and coping
strategies.
Methods
1011
We adopted the QOL model and the total pain model for
palliative care described previously as well as theInternational Classification of Functioning, Disability, and
12
Health (ICF) as a theoretical model. Patients with MD areprevented from living a healthy life because they havemultiple chronic symptoms, age-related physical/mental
hypofunction, and the agony of having the disease. Therefore,
in the present study, we clarified the well-being of affectedpatients from the aspects of physical/mental function, society,spirituality, activities, social participation, as well as
environmental and personal factors and examined the carenecessary to improve their QOL.
Recruitment of participants
The survey was designed as a complete study of patientswith MD who were accessible to the local governments ofNiigata Prefecture and Niigata City. This means that the
subjects included those who had been officially recognized as
patients with MD by Niigata-ken Niigata-shi Kogai Kenko
Higaisha Nintei Shinsa-kai (Pollution Victim Certification
Committee of Niigata Prefecture and Niigata City) and thoseEubios Journal of Asian and International Bioethics 25 (January 2015)
who had not been recognized by the Committee but had been
issued a techo (health record book for medical and welfare
records) by the governments to compensate for all or part oftheir medical and welfare fees. Techo was issued to those
who were considered to have ingested a significant amountfish and other foods polluted with MeMg in the Agano river
before the end of 196 and who had some degree of sensory
13
disturbance.
Table 1: Patient demographics and clinical characteristics
GenderN (%)
FemaleMale
Not stated272 (58.6%)
187 (40.3%)
5 (1.1%)

Age
40's
50's
60's
70's
80's
90's
Not stated

6 (1.3%)25 (5.4%)
66 (14.2%)
214 (46.1%)
129 (27.8%)
15 (3.2%)
9 (1.9%)Residential area
Niigata City
Gosen City
Agano CityAga Town
Other
Not stated239 (51.5%)
14 (3.0%)176 (37.9%)
26 (5.6%)
8 (1.7%)1 (0.2%)

Living arrangements
Lives alone
Co-habits with spouse only
Co-habits with a non-spouseCo-habits with two persons
Co-habits with three persons
Co-habits with four persons
Co-habits with five or more persons
Not stated

31 (6.7%)
92 (19.8%)
18 (3.9%)65 (14.0%)
66 (14.2%)
55 (11.9%)
112 (24.1%)25(5.4%)

Employed
YesNo
Not stated

59 (12.7%)385 (83.0%)
20 (4.3%)

Certified as a patient with MD
YesNo
Not stated

128 (27.6%)
322 (69.4%)
14 (3.0%)

Authorized to require support or nursing care
Yes
Require support level 1
Require support level 2
Require nursing care I
Require nursing care II
Require nursing care III
Require nursing care VI
Require nursing care V
Not specifiedNo
Not stated

69 (14.9%)
7 (2.2%)10 (3.1%)
11 (3.4%)
12 (3.7%)
11 (3.4%)
7 (2.2%)5 (1.6%)6 (0.9%)368 (79.3%)
27 (5.8%)

Currently treated diseases (multiple answers)
Hypertension
Heart diseases
Diabetes
Malignant tumors
StrokeOthers
Not stated

216 (46.6%)
81 (17.5%)
67 (14.4%)
32 (6.9%)28 (6.0%)202 (43.5%)
77 (16.6%)

The subjects were informed of the protocols used for datacollection and analyses and then consented to inclusion in the
study. A self-rating questionnaire was mailed to participants
between November 2008 and March 2009. The questions

3

included items regarding the catchment areas, types ofcertification,
demographic
characteristics,
symptoms
perceived by the subjects as “distressing” rather than merely“experienced” in their daily lives and measures taken toprevent such symptoms, emotional support, and the World
14
Health Organization Quality of Life 26 (WHO/QOL-26). The
WHO/QOL26 is a 26-item, self-reported measure designed toassess QOL. Twenty-four items measure four domains of
QOL (physical, psychological, social, and environmental), andthe other two items measure overall QOL and general health.
The score for each question ranges from 1 to 5, and a higherscore reflects a higher QOL. The present study used theJapanese version of the WHO/QOL26, which was created by
15
Tasaki and Nakane in 1997. We obtained permission to use
this measure in our questionnaire from its publisher,
Kanekoshobo. The data obtained from the survey wereanalyzed using IBM Statistical Package for the Social
Sciences (SPSS) version 22.
Ethical considerations
The study was conducted in careful consideration of the factthat the subjects were suffering from discrimination andprejudice in their communities that caused them considerable
distress. The cover letter described the study objectives,
methods, and duration as well as ethical considerations
regarding the publication of the study results. Specifically, it
stated the following: 1) participation in the study was notmandatory, 2) personal information and privacy would beprotected, 3) the study would be conducted anonymously, 4)
there were no advantages or disadvantages of participation or
non-participation, and 5) the obtained data would not be used
for purposes other than those described in the study
objectives. The study was approved in advance by the Ethics
Committee of the School of Medicine, Niigata University.
Results
The questionnaire was distributed to 681 subjects, 464 ofwhich responded (a 68% response rate). Of the study
respondents 187 (40%) were male and 272 (59%) werefemale (Table 1). Most patients (77%) were aged ≥70 years,
and a considerable proportion was aged ≥80 years (31%).
More than half of the subjects (n = 239; 52%) lived in Niigata
City (an area downstream of the Agano River). In addition, 14(3%) and 176 (38%) lived in Gosen City and Agano City
(midstream areas of the river), respectively, and 26 (6%) lived
in Aga Town (an area upstream of the river), in which the
responsible companies were located. Most subjects (n = 408;
88%) lived with one or more family members, and a small
proportion (n = 31; 7%) lived alone. Although most
respondents (83%) were unemployed, 59 (13%) had jobs.
Just over one quarter (n = 128, 28%) were certified as
patients with MD. A smaller proportion of respondents (15%)
were authorized to receive support or nursing care. The
currently treated diseases of the study subjects were
hypertension (47%), heart disease (18%), diabetes (14%),malignant tumors (7%), and stroke (6%).
The differences in the total and average scores in the
WHO/QOL-26 were analyzed using t-tests to compare twogroups (Table 2). The overall average score was 2.62 points,
and the average scores of questions related to physical,
psychological, environmental, and social relationship domains
were 2.56, 2.59, 2.68, and 2.95 points, respectively. An
approximately normal distribution was observed for all thescores. When comparisons were made between genders, nodifferences were noted in the scores for most domains or
overall QOL, except that the social relationship domain scores
were significantly higher in females than in males (3.08 vs.
2.81, P<0.001). Although there were no significant differences
between age groups in overall QOL scores, the physical4

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

domain scores were significantly higher in patients aged ≤69
years than in those aged ≥70 years (2.76 vs. 2.52, p = 0.001).
Employed individuals reported higher scores for the physicaland psychological domains than unemployed ones (2.89 vs.
2.52, P<0.001 and 2.86 vs. 2.55, p = 0.001, respectively).
This was also observed with regard to overall QOL (2.80 vs.
2.60, p = 0.006). In contrast, there were no significant
differences between individuals with and without emotional
support in any scores. Individuals with an officially recognized
requirement for nursing care had significantly lower scores in

the physical and psychological domains (2.12 vs. 2.66,
P<0.001 and 2.22 vs. 2.67, P<0.001, respectively) and overall
QOL (2.37 vs. 2.67, P<0.001) than those without it. However,there were no significant differences in any score between
individuals with and without certified MD. When comparisonswere made between subjects with and without currently
treated diseases (hypertension, diabetes, stroke, heartdiseases, and malignant tumors), there were no significant
differences between groups in any score.

Table 2: Mean scores in the WHO/QOL-26

Table 3 summarizes the “distressing symptoms” felt by the
respondents in their daily lives. Of the 440 respondents, themost common sites of physical numbness and physical pain
were the limbs (75%) and the knees and/or lower back (61%),
respectively. A small proportion of respondents reported thatthey experienced numbness in their perioral area, back, andone side of the body, whereas some reported pain in theirneck, shoulders, head, and back. More than one-third of
respondents reported some sensory system disorders,
including having difficulty with sight because of narrowing of
the visual field (37%), ringing in the ears, dizziness,dysgeusia, and dysosmia. Fatigability (38%) and anincreased likelihood of falling (33%) were similarly prevalent,and some patients experienced cramps in their limbs andcalves, trembling in the limbs, weakness in the upper arms,
forgetfulness, anxiety, depression, and poor concentration.
These symptoms worsened more frequently when patients

moved their bodies, worked, did household chores, weretired, or the climate was cold or humid (Table 4). The
symptoms commonly continued all day or occurredintermittently (particularly when getting up and at night). The
effects of these symptoms on the patients’ lives were divided
into eight categories: hindered activities, mental distress,
physical distress, having difficulty working and performing
household chores, hindered activities and social participation,hindered safety, require support or nursing care, and financial
worries. The measures and efforts taken to relieve thesymptoms were separated into five categories: physicaltherapy, pharmacotherapy, making lifestyle changes,
recreation, and developing care resources in daily settings(Table 5). The use of medications, particularly poultices, wasthe most common measure. Exercising, rehabilitation, taking
a bath, going to springs, massages, acupuncture,Eubios Journal of Asian and International Bioethics 25 (January 2015)
moxibustion, outpatient visits, and hospitalizations were also
common measures taken.
Of all the study subjects, 211 (46%) had some emotional
support, while 163 (35%) did not; 90 (19%) did not answer
this question. Details regarding the subjects’ emotional
support were categorized into four groups (Table 6):interpersonal relationships (e.g., the presence of andinteraction with people), emotional fulfillment (e.g., pleasure
and the desire to live), autonomy in daily life (e.g., roles,
responsibilities, and manufacturing), and bodily health (e.g.,going to the springs, taking a bath, using medicines, andexercising). The most common emotional support was thepresence of family; interactions with other people for
emotional support were also common. Overall, various typesof emotional support existed among the subjects: a desire tolive (e.g., the growth of children, the well-being of the family,
and praying), pleasure, kindness from family, learning about
live, roles and responsibilities, manufacturing, support
systems, going to springs, and exercising.
Table 3: "Distressing" symptoms felt by the subjects in their
daily lives (n = 440, multiple answers)
Physical numbness (337)
Limbs
Perioral areaBack
One side of the body
Physical pain (279)
Knees/lower backNeck/shoulders/headBack
Sensory-system disorders (222)
Difficulty seeing
Ringing in the ears
Dizziness
Dysgeusia
Dysosmia
Limb dysfunctions (169)
Likelihood to fall
Cramp/tension/trembling in the limbs
Difficulties in stoma management
Weakness in the upper arms
Fatigability (167)
Mental/cognitive dysfunction (13)Forgetfulness
Anxiety/depression
Poor concentration
Stammering
Sleep disorder (6)Cardiovascular symptoms (2)Excretory disorder (1)Incontinence
Others (1)Stomatitis

N
329
4
2
2

%
(74.8%)(0.9%)(0.5%)(0.5%)

266
36
7(60.5%)(8.2%)(1.6%)

161
29
26
4
2

(36.6%)(6.7%)(5.9%)(0.9%)(0.5%)

143
24
1
1
167

(32.5%)(5.5%)(0.2%)(0.2%)(38.0%)

6
5
1
1
6
2

(1.4%)(1.1%)(0.2%)(0.2%)(1.4%)(0.5%)

1(0.2%)

1(0.2%)

Discussion
The average score in the WHO/QOL-26 of the study
subjects was 2.62, which is considerably lower than that of
the general Japanese population (3.29) and comparable withthat of patients with schizophrenia (2.69) and individuals with
16
depression (2.81). When comparisons were made withsimilarly aged populations, the scores of the subjects aged
60–79 years in the physical, psychological, social
relationship, and environmental domains, which were 2.56,
2.58, 2.91, and 2.61, respectively, were much lower thanwere those of the general Japanese population in the same17
age range (3.53, 3.38, 3.25, and 3.27, respectively). In
addition, although the current subjects aged ≤69 years
reported significantly higher scores for the physical domain
than those aged ≥70 years, they did not report higher scoresin the psychological, environmental, or social relationship5domain or overall QOL. These data suggest that the negative
impact on patient QOL could not be completely explained bytheir age. The complexity of the factors that influence patient
QOL is reflected in comparisons made according to gender,
occupation, currently treated diseases, and emotional
support. In particular, being female correlated with a higherscore in the social relationship domain, being employedcorrelated with a higher score in overall QOL and physicaland psychological domains, and having currently treateddiseases or emotional support had no effect in any domain or
overall QOL. The fact that 43.5% of the responders answered“others” when they were asked about currently treateddiseases suggests that the subjects suffered from a wide
variety of diseases; therefore, a more detailed survey would
clarify this aspect.
Table 4: Factors that worsen symptoms and their influence on
patients’ lives
N
Predictors for symptom worsening (multiple answers)
Activities (199)
Moving bodies
Working/doing household chores
Being tired
Staying in a similar position (sitting, driving)
Going out
Doing work with their hands (eating, taking medicine, putting
on and taking off clothes)
No predictors (137)Continued all day
Occurred intermittently
Time (95)
In the morning (when getting up)
At night
In the evening
Seasonal conditions (temperature, humidity) (52)
In autumn/winter (coldness)
On rainy days (humidity)
Mental conditions (1)Haunted by future anxiety

83
39
29
19
19
10
120
17
49
35
11
46
6
1

Influences on patients’ lives (multiple answers)
Hindered activities (196)
Difficulty in walking
Impaired mobility
Difficulty in the activities of daily living
Mental distress (63)Feel stressed, low morale, poor concentration, distress
Sleep disorder
Future anxiety
Family relations distress (concerns related to family burden or
feeling alienated from family)
Poor concentration
Physical distress (56)Symptom-related distress
Having difficulty working and doing household chores (55)Having difficulty working and doing household chores
Hindered activities and social participation (43)Difficulty in activities/going out
Difficulty in communications
Difficulty in expecting others to understandHindered safety (24)Probability of accidents/incidents (burns and falls)
Require support or nursing care (8)Require support or nursing careFinancial worries (3)Financial worries
No influence (5)Worried about nothing

55
48
50
22
16
15
7
3
56
55
29
12
2
24
8
3
5

6

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

Table 5: Measures and efforts taken to relieve symptoms (n =353, multiple answers)
Physical therapy (211)
Exercising/rehabilitation
Taking a bath/going to springs
Massage/acupuncture/moxibustion
Keep warm (using a kairo warmer)
Assistive technology and equipment
Foot bath
Pharmacotherapy (168)
Using medicines
Outpatient visits/hospitalizations
Making changes in the lifestyle (60)
Taking a rest
Balancing activity and rest
Acting slowly
Living cautiously
Using public care resources
Recreation (27)
Refreshment of the spirit
Peace of mind
Meeting friends
Developing care resources in daily settings (6)Using daily equipment for care
Asking family members for care

N
61
57
49
28
15
1
110
58
26
12
9
8
5
13
8
6
5
1

The current study focused on the symptoms that the
subjects perceived as distressing in their daily lives andsuggested that some palliative care needs had been reported
insufficiently. Numbness in the limbs and disturbances in thesensory systems such as vision, audition, and olfaction are
well known symptoms in patients with MD; however, in thepresent study, physical pain (particularly knee and lower backpain), an increased likelihood of falls, and fatigability werealso observed. These symptoms affected the patients’
activities and social participation continuously in their daily
lives and potentially accelerated their physical and mental
dysfunction. In addition, difficulty walking, working, andperforming household chores affected the fundamental daily
life and interpersonal relationships of affected individuals.
Although some symptoms were common in the general aged
population, the prevalence of physical numbness suggeststhat these were associated with factors other than aging.
The measures commonly used to relieve these symptoms
included taking medications, taking a bath or going to thesprings, and staying warm. Many subjects made an effort toperform exercise and rehabilitation despite their bodily pain.
One subject described the reason for his or her effort as “I’msore and having a rough time, but I don’t want to be unable tomove.” This suggests that symptoms can be eased by thedeliberate provision of palliative care, including physicaltherapy and pharmacotherapy.
Approximately half of the subjects had emotional support,
which was mostly derived from interpersonal relationships.
Some of these subjects, both with and without certified MD,
described their experiences of discrimination and prejudicebecause of their disease, and their spiritual distress wasrooted in a sense of meaninglessness. Examples of patient
quotes include “I can’t express myself,” “I can’t make myself
known as an MD patient,” “why do I have to have this?,” and“I can’t find any meaning to live on with this body.” Japanese
18
individuals often have a firm sense of group identification.
MD impairs the interpersonal relationships between patients
19and their family, kinship, and local community. Althoughmany of the current subjects reported that they received
emotional support from the people surrounding them,including family members, friends, and physicians, only asmall number reported that they were estranged from family
members and friends. This could be explained by the fact thatthe focus of this survey was the distress caused by thesymptoms of MD and not the distress caused by being apatient with MD. Because the present study was performed ina questionnaire format, it is necessary to hold thoroughinterviews to clarify specific details regarding the spiritual
distress of patients.
Table 6: Emotional support (n = 211, multiple answers)
Interpersonal relationships (122)
Presence of people (75)
Family members
Friends
Physicians
Interactions with people (47)Interactions with family members
Interactions with friends
Interactions with people at a day center
Making friends
Visits from home care staff
Visits from volunteers
Emotional fulfilment (43)Desire to live (13)Growth of children/well-being of the family
Praying
Pleasures (11)
Enjoying TV/radio
Going out with friends
Singing
Reading
Going out alone
Kindness from the family (10)Love from family members
Understanding/support from family members
Learning about life (9)Pursuit of the way of life
Presence of people (75)
Family members
Friends
Autonomy in daily life (32)Roles/responsibilities (13)Taking care of family members
Doing jobs
Roles and obligations in society
Club/volunteer activities
Manufacturing (11)Manufacturing
Compensation system (8)For officially disclaimed victims
For officially recognized MD patients
Bodily health (27)
Taking a bath/using medicines (18)
Taking a bath/going to springs
Using medicines
Exercising (9)Exercise/rehabilitation
Preserving health

61
8
6
23
13
6
2
2
1

8
5
4
2
2
2
1
7
3
9
61
8

4
6
2
1
11
5
3

12
6
8
1

The present study clarified that one of the two official
authorization criteria for health conditions predicts victims’
QOL, while the other does not. Although individuals with arequirement for nursing care had significantly lower scores
related to physical/psychological domains and overall QOL,
there were no significant differences in the scores of any
domains or QOL between subjects with and without certified
MD. It is reasonable that subjects who required a higher levelof support or nursing care had a lower evaluation of their QOL
for the physical domain. However, evaluations related to thepsychological domain and overall QOL were also lower
among patients who required a higher level of support ornursing care. These results are important for devising
appropriate care services and providing support to victims ofthe disaster, regardless of whether they are certified patientswith MD.

Eubios Journal of Asian and International Bioethics 25 (January 2015)
While the palliative care needs of patients with Niigata
Minamata disease revealed by our study had only been
insufficiently known to healthcare providers, who are capableof intervening to sophisticate the measures taken by patients.
Healthcare providers could extend their targets for non-cancer
palliative care and develop MD-specific approaches, including
symptom management for physical numbness and physicalpain, psychosocial approaches for anxiety and depression,
nursing service for hindered activities, and care for spiritual
distress.
Conclusions
The average score in the WHO/QOL-26 was considerably
lower in the study subjects than in the general Japanese
population. In addition, being female and employed correlatedwith higher scores for some domains and/or overall QOL.
The symptoms perceived by the subjects as distressing intheir daily lives included numbness in the limbs, physical pain,
disturbances in their sensory systems, limb dysfunctions, andfatigability.
The commonly taken measures to relieve these symptoms
included the use of medications, taking a bath or going to thesprings, and maintaining warmth.
The common emotional support included interpersonal
relationships, emotional fulfillment, self-discipline in daily life,and bodily health.
Individuals with a requirement for nursing care reported
significantly lower scores in the physical and psychologicaldomains and overall QOL, whereas there was no significant
difference in the scores reported by individuals with andwithout certified MD in any domains or overall QOL.
Palliative care providers could extend their targets for noncancer palliative care and develop approaches for MDspecific total pain.
References
1. Kumamoto University Study Group for Minimata Disease. Historicalperspective of the study on Minamata disease. In: Kutsuna M (ed.)
Minamata Disease. Kumamoto: Shuhan Publishing, 1968, pp.1-4.
2. Tsubaki T, Sato T, Kondo K, et al. Outbreak of intoxication byorganic compounds in Niigata Prefecture: An epidemiological andclinical study. Japanese Journal of Medical Science & Biology
1967; 6:132-133.
3. Funabashi H. Minamata disease and environmental governance.
International Journal of Japanese Sociology 2006; 15: 7-25.
4. Niigata Prefecture. Minamata-byo nintei shinsei ni kakaru shobun
nitsuite,
http://www.pref.niigata.lg.jp/seikatueisei/1356753415812.html(2013, accessed 10 December 2014). (in Japanese)
5. Ushijima K, Sung W, Kawakita M, et al. Effect of Minamata diseasestatus and the perception of unfairness on ill health andinequalities in health amongst residents of Shiranui Sea
communities. Stress and Health 2010; 26: 394-403.
6. Songai baishou, kari shikkou no genjou kaifuku tou seikyu joukoku,
dou futai joukoku jiken (2004) Saikou Saibansho Minji Hanreishu(Supreme Court reports: civil cases) 58, 1802. (in Japanese)
7. Minamata-byo higaisha no kyusai oyobi minamata-byo mondai no
kaiketsu ni kansuru tokubetsu sochi ho (the Act on Special
Measures for Compensation for Minamata Disease and Solutions
to the Problems of Minamata Disease) 2009 (Japan). Availablefrom
http://law.e-gov.go.jp/htmldata/H21/H21HO081.html(inJapanese)
8. Seki R. Niigata minamata-byo wo meguru seido, hyoushou, chiiki.
Tokyo:
Toshindo,
2003.
Niigata Prefecture. Niigata minamata-byo no aramashi. Niigata:
Niigata Prefecture, 2013, p.46-48.
9. Saunders C. The philosophy of terminal care. In: Saunders C (ed)The management of terminal malignant disease. 2nd revised ed.
London: Hodder Arnold, 1984, pp.232-241.
10. Ferrell BR. The quality of lives: 1,525 voices of cancer. Oncology
Nursing Forum 1996; 23: 909-916.
11. Twycross RG and Wilcock A. Symptom Management inAdvanced Cancer. London: Radcliffe, 2002.

7

12. World Health Organization (ed). International classification offunctioning, disability, and health: children & youth version: ICFCY. World Health Organization, 2007.
13. Niigata Prefecture. Niigata minamata-byo ni kansuru techo toseidonogaiyo,
http://www.pref.niigata.lg.jp/HTML_Article/773/83/niigataminamata
byou%20tetyo&seido.pdf (2013, accessed 10 December 2014). (inJapanese)
14. Skevington SM, Lotfy M, and O'Connell KA. The World HealthOrganization's WHOQOL-BREF quality of life assessment:
psychometric properties and results of the international field trial. A
report from the WHOQOL group. Quality of Life Research 2004;
13: 299-310.
15. Tasaki M and Nakane M. WHO-QOL26: Division of Mental Healthand Protection of Substance Abuse, World Health Organization.
Tokyo: Kanekoshobou, Tokyo, 1997. (in Japanese)
16. Ibid: p.23-33.
17. Ibid: p.24.
18. Abrams D, Ando K, and Hinkle S. Psychological attachment to thegroup: cross-cultural differences in organizational identification andsubjective norms as predictors of workers' turnover intentions.
Personality and Social Psychology Bulletin 1998; 24: 1027-1039.
19. Seki R. Op Cit: 221-256.

Pandemic Influenza
Planning and Response in
India, 1949-2009-Rhyddhi Chakraborty, Doctoral Student, Department of Humanities
and Social Sciences, Indian Institute of Technology Kharagpur, West
Bengal 721 302, India, E-mail:rhyddhi_414@yahoo.co.in-Chhanda Chakraborti, Professor, Department of Humanities andSocial Sciences, Indian Institute of Technology Kharagpur, West
Bengal 721 302, India

Abstract
For last couple of years, the subcontinent of India has
witnessed a number of influenza epidemic outbreaks. History
reveals influenza epidemic to be a constant but neglectedcompanion of India. Considering the repeated occurrences ofthe event on Indian soil, including influenza A H1N1 (2012-13)
after 2009-10 pandemic event, a check to the planningmeasures has been done at national level. A literature survey
on the initiative measures, planning accomplishments etc.
reveals that it is only after the emergence of A H5N1 (2005),
national health authorities have began planning efforts tomitigate and respond to influenza outbreaks. This paper
outlines the evolution of Indian pandemic planning that can betraced in the research literature, summarize theaccomplishments, and explain the importance of pandemicplanning in India. Pandemic influenza (or influenza
pandemic), as it is commonly known, emerges, evolves,attacks, and sways a large part of world declaring publichealth emergency in a short span. Several outbreak events
such as SARS (2003), Avian influenza A H5N1 (2005), andH1N1 (2009) have demonstrated the need of international
concern for public health emergency and had established thevalue of planning in advance. Preparedness planning in India
is found to be at its nascent stage and it needs further
improvement at multiple aspects to tackle the future publichealth crises, to rectify ethical failures.
Key Words: Pandemic Influenza, Planning, India
Introduction‘Grip,’ ‘grippe,’ or ‘flu’ as it is commonly known was firstdescribed by Hippocrates (412 BC)(1) but was nicknamed as‘influenza’ in 1357(2). From 1650 onwards, mention ofpandemic influenza can be found in literature (3). Since the8Eubios Journal of Asian and International Bioethics 25 (January 2015)

1890s, the pathogen of flu was mistakenly considered to bebacillu till 1933s, when the actual pathogen, the virus behind
flu was identified (4). By then it has been recognized as aviral disease of mammals, specifically of humans, pigs,
horses, as well as of a number of bird species (5). Among
humans, it is a contagious lower respiratory tract diseasecharacterized by some unique features; suddenness ofarising, ease of spreading, short incubation period, highproportion of susceptible population, short duration of
immunity etc.(6).
Its changing pattern and virulence has made it difficult todefine and therefore continuous attempts have been made to
define and redefine it through virological, epidemiologicalcharacteristics and also as public health disaster (7)(8)(9). As
the effort to grasp its true nature continues all over the world,
pandemic influenza also continued to have its recurring
appearances in one or other part of the globe. The
subcontinent of India is one such place, which had witnessed
the repeated occurrences of pandemic and epidemic
influenza through centuries. Even from January 2013 till 24
February 2013, India has witnessed 2267 positive cases, 254
deaths out of influenza A (H1N1)(10). In a month, such huge
number of people falling ill, succumbing to the strain, alongwith the fact of circulation of strain A (H1N1) in epidemic form
after pandemic A H1N1 (2009), implies that it is high time tocontemplate
about
its
planning
initiatives
andaccomplishments. Therefore, an attempt has been made tocheck chronologically the planning efforts, measures,
initiatives in India for a span of 60 years; 1949-2009, that issince its independence till 2009, when India got affected by A
(H1N1) but first, a look into the pandemic and epidemic
experiences of India.
India and Its Experiences Out of Influenza
Before the twenty-first century, India suffered from influenza
pandemics in 1781, 1830-3, 1889, 1918, 1957, 1968, of which
the pandemics of 1830-3 and 1918 were ranked of the same
status in terms of severity(11)(12). Of all these incidences,
the first event of pandemic which attracted a pool of research
literature is that of 1918 ‘Spanish Influenza’. Virulence wassevere in young adults all over the world, India alone
witnessed about 70 million deaths and the mortality rate washighest among adults between 20-40 years (13). It coincidedwith famine and caused extreme excess mortality in Centraland United Indian provinces (for example, in Bombay
Presidency, the urban death rate was 9.5% of population incomparison to rural death rate of 6.9%). Excess mortality was
also found to be in females than in males in many provinces(such as in Bombay Presidency 7.4% women in the 15–40
age range died as compared to 5.7% men). In Bombay again,
low caste Hindus had a death rate of 16.7% in contrast toEuropeans (2.9%), Parsis (2.9%), Anglo-Indians (4.2%),
Indian Christians (5.4%), high caste Hindus (5.3%), andMuslims (6.1%). Among the British Army in India, casemortality for white troops was 9.6%, while for Indian troops it
was 21.9% (14, 15). The millworkers were also badly affected
and outside the cities, indigenous people of hill and mountainregion, the Adivasis, suffered in such a disproportionate
proportion that their population in India as a whole fell from9,593,695 to 9,072,024 (5.4%) between 1911 to 1921, while
the overall population of India increased during the same
period by 11.3% (16-20). The impact of the pandemic was sosevere that it is mentioned ‘…in Bengal in December …
“rivers became clogged with corpses because firewood
available was insufficient for the cremation of Hindus”’ (21). In
another description of this medical holocaust in India, it isdescribed, “In Punjab trains were packed with dead and dying
passengers, and streets and cemeteries were strewn withcorpses. Altogether more people died in India during thisepidemic than during 20 years of cholera or during the four
years of World War I.” (22)After this, pandemic influenza had its hold of Indian
subcontinent again in 1957. Though it was mild in nature,
India was worst hit (23). From 19 May 1957 to 8 February
1958, there were 445,178 reported cases with 1098 deaths.
Bengal, with 7.2% of total population of the country at thattime had lowest mortality rate (8.5/1000) during 1918 but
highest in 1957, with 6.4% of all influenza cases and 40.5% of
all influenza mortality. Along with the pandemic origin of type
A virus, type B virus had simultaneously caused infection inseveral other states during this time. This influenza outbreak
had affected mainly infants, children between 6-10 years(20.0%), young in between 21-25 years (20.8%). In someareas, specific occupational groups (medical and nursing
personnel), and closed communities (European Residential
School in Coonoor over three successive years of 1956(62%), 1957 (39.2%), 1958 (57%)) were worst affected. As awhole, out of this influenza outbreak, mortality rate had
increased by 19% in parts of India. As a precautionary
measure, for the target production of 100,000 doses, thePasteur Institute, Coonoor had managed to manufacture
35000 doses by 31 January 1958 but by the time the vaccine
was in market, influenza had left the subcontinent.
After a long gap of 52 years, life in India was again
disrupted by a highly transmissible but a low virulent
pandemic influenza A (H1N1) in 2009. By 3 July 2011, it
caused 2762 deaths with highest case-fatality in the agegroup of 20-39 years and next highest in under 5 years of age(24). Once it was even claimed that India topped the mortality
chart (25). As a preventive measure, vaccines were imported
initially but later on, indigenously developed vaccines were inmarket from mid 2010 for different groups of people (26).
Table 1: Circulation of Influenza Strains in India through theCenturies (28-37)
Year

Strain/s

1950-57

A (H1N1), A (H2N2),
A (H3N2)
A (H3N2)

1972-73

1976-2003
1981-1993
1990-2000
1993
2004(September)–
2008(December)
2007

A (H1N1) and/or A(H3N2) and Type B
A (H3N2), A (H1N1),
A (H2N2)
A (H3N2)
A (H3N2)
A (H1N1), A(H3N2),Type B

Geographical
Location
Coonoor(SouthIndia)
Dhoki and Thikoltaluks (Ahmednagar
District,
Maharashtra),Hyderabad(Andhra
Pradesh)Pune (Maharashtra)
Calcutta(Kolkata,
West Bengal)
Pune (Maharashtra)
Delhi
Different parts ofIndia
In and around Delhi

2008
2009(First Half)2009(SecondHalf)2010(First Half)
2010(AugustSeptember)

A (H1N1) and Type
B
Type BA (H3N2)
Pandemic A(H1N1)
and Type B
Type B
Type B subtype,
pandemic A (H1N1)

2010(JanuaryMarch)

A (H1N1) (2009), A(H3N2), Type B

Sri Nagar (Jammu
and Kashmir)

2010

Seasonal A (H1N1),
pandemic A (H1N1)

Eastern
India,
Greater
Kolkata
Metropolitan Area

In and around Delhi
In and around Delhi
In and around Delhi
In and around Delhi
In and around Delhi

Eubios Journal of Asian and International Bioethics 25 (January 2015)
Besides these major human influenza outbreaks, India
regularly suffers from frequent occurrences of humanseasonal influenza and Avian Influenza (2005-2011) (27).
Table 1 above highlights the circulation of seasonal influenza
strains in India through the centuries in chronological order.
The above mentioned influenza strains are found to be
circulated among the human population in India. However, it
is to be borne in mind that pandemics of influenza occur when
an animal or bird influenza virus, to which humans have no or
limited immunity acquires the ability, through genetic
reassortment or mutation, to cause sustained human-tohuman transmission leading to community-wide outbreaks.
The recent outbreak of influenza A (H7N9) in China in 20132014, and past outbreaks of 1918, 1976, 1997, evidentiallyproved this direct transmission from animals or birds tohumans. Keeping in mind this zoonotic nature of influenza
virus and interspecies transmission capability of the influenza
virus, a literature survey was also carried on the circulating
bird flu strains in India. Bird or avian flu was first noticed inIndia in 2006. From then on, it continues to resurface indifferent parts of the country. Literature brings to notice thatsince 2006 to December 2012, A (H5N1), Avian flu strain has
been found to be circulated in different states of the country(however, in West Bengal, different strains A (H9N2), A(H4N6) were also found to be circulated).
Table 2summarizes such incidences.
Table 2. Avian Influenza Outbreaks in Different Parts ofIndia, 2006-2012 (Source: DAHDR, Annual Report 20122013)(27)
States of India
Maharashtra, Gujarat,and Madhya Pradesh
ManipurWest Bengal

TripuraManipur
SikkimAssam
OrissaMeghalaya
KarnatakaYear
February–April 2006
July 2007
January- May 2008, December
2008- May 2009, January 2010,
September 2011
April 2008, February-March 2011,
January, March, April 2012
July 2007
January 2009
November-December
2008,
September 2011
January-February 2012
January 2012
October 2012

The above mentioned events of influenza outbreaks, bothin humans and bird population establishes that an influenza
outbreak is not an event to be listed in the forgotten pages ofIndian history. Rather it is a constant companion of India,
visiting the country with pandemic potential at certain
intervals. This implies a need of advanced awareness andbetter preparedness with the consideration of the experiential
lessons from past events. Therefore, the primary purpose ofthis paper is to describe the evolution of Indian pandemicplanning, starting from 1949 till 2009 when India got affectedby pandemic influenza A (H1N1). For, the historical and policy
context within which pandemic occurs help in assessing theimplications of pandemic planning for responses to future
pandemics and for ongoing infectious disease preparedness
efforts. The next following section is an attempt to look intosuch awareness, initiatives, and planning measures of India.
Sources
For the purpose of this article, searches have been
conducted of the key websites of Ministries of health, animal
welfare etc. (e.g., www.mohfw.co.in), peer-reviewed
manuscripts, research articles, published governmental plans,

9

working group reports, reports of health committees, annual
reports of the ministries, and other supporting documents
relevant to pandemic planning in India.
Chronology of Indian Pandemic Planning Measures andInitiatives
Acknowledging the devastating impact of pandemic
influenza of 1918-19 in India, the first health committee reportof the country, Bhore Committee report (1946) recommended
including influenza as a compulsory topic in the course of
Public Health Engineering. Soon after independence, in
response to the invitation from World Health Organization, anational influenza centre was set up in the Pasteur Institute,
Coonoor, India under the guidance of late Dr. I.G.K. Menon(38). While the centre continued to isolate and identify virus
and extended its support for international collaboration, in
1956-58, the country was shook by the deadly blow ofanother pandemic influenza, popularly known as “Asian Flu”.
The devastating impact of the influenza in the country
provoked the then health committee members to give aserious thought on the pandemic mitigation measures. So, thenext following health committee report, Mudaliar Committee
report (1962) considered influenza pandemic as a global
health problem and recommended the nation to initiate anddeal with vaccine production strategies, public healthimplementation measures; especially quarantine, isolation,and supporting World Health Organization in its world
influenza program through Pasteaur Institute, Coonoor. It had
also tried to draw attention to the need of research on
influenza in India.
The next major events leading to the rethinking of
pandemic influenza response measures in the country were
“Avian flu” (A H5N1 2005), “Swine flu” (A H1N1 2009).
th
Therefore, the working group’s report on 12 Five year Plan
(2011) and Annual Health Report 2010-11 (2011)(39) of
Ministry of Health and Family Welfare (MoHFW), haveacknowledged the burden of these two incidences of the thenrecent past and proposed implementing proper mitigation
strategies to avert future pandemics. These outbreaks havealso reminded that there is a need to have a comprehensive
pandemic preparedness with a focus on institutionalframework with proper planning and coordination, commandand control, regulatory framework, surveillance and laboratory
support, communication, public health measures, hospitalsystem, and also planning for logistical distribution. Therefore,
national pandemic planning committee was formed with thefollowing members; Secretary (Ministry of Health and Family
Welfare (MoHFW), Chairman), Secretaries of Department
Animal Husbandry & Dairying, Director General of HealthServices, Director General of Indian Council of Medical
Research, Director of National Institute of Communicable
Diseases, Animal Husbandry Commissioner, Department of
Animal Husbandry, Dairy & Fishery, Joint Secretary (DM),Ministry of Home Affairs as members, and Additional
Secretary (DG), MoHFW as Convener (40). Task Force andJoint Monitoring Group were also formed to check theoutbreak at its source, to delay the entry of the infection in the
country, and also to reduce the spread of the infection in the
country. Pandemic plans (41) with focus on the country not
being affected and affected and with an awareness andconcern for all these mentioned components were also cameinto formation. However, the plans were either in draft form or
disclosed as contingency plan. Moreover, they were found to
give more attention to the scientific and logistic aspects ofmitigation without revealing and acknowledging the impacts ofpast pandemics, epidemics as well as endemic influenza
strains. Apart from these, some initiatives and measures werealso undertaken through the centuries. An overview of the
major initiatives of management of influenza outbreaks in10

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

India is outlined in Table 3.
Table 3: Timeline of India’s Major Initiatives to Manage
Influenza Outbreaks in Birds and Humans (40, 42-48)
Year
1950

1957

1959
onwa
rds
197677

1986

1998

1999

2000

20012003
2004

2005

2006

Initiatives, Measures
Undertaken
India Influenza Centre,
Connoor established incollaboration with World
Health Organization
A committee under thechairmanship of the
Director General of HealthServices, New Delhi, wasset up to consider thevarious problems
concerned in the vaccine
production and use
Isolations of virus carriedout throughout the year by
Pasteur Centre
National Institute ofVirology initiated influenza
surveillance in Pune,
Maharashtra
Centre for Animal Disease
Research And Diagnosis
established in Indian
Veterinary ResearchInstitute (IVRI), Izatnagar
High Security Animal
Disease Laboratory at
BhopalThe disease investigation
wing of the Institute ofAnimal Health andVeterinary Biologicals (IAH
&VB), Hebbal, Bangalore,
Karnataka has beenrecognized as Southern
Regional Disease
Diagnostic Laboratory(SRDDL), identified as a
BSL III laboratory
Fully functional biocontainment laboratory

Action Followed
Virus was isolated for the
first time in the country

Production of vaccine
initiated
2008
2009

Study the prevalence of
influenza viruses in thesurrounding area continued
Surveillance extended

Made provision ofhealthcare and diagnosis ofanimal diseases in thewhole country
Made provision for research,
diagnosis and control of
exotic and emerging animal
diseases according to theneed of the nation
Made provision for promptand effective diagnostic
services for identification of
disease problems with an
aim to eradicate them in thesouthern part of the country

Established awareness ofcontainment, continuation of
precautionary measures(Same reference)

No documents foundMultisite influenza
surveillance, funded by
ICMR-CDC, IDSP
initiated, planning
activities started
Random collection ofsamples from poultry
farms as per sero
surveillance
recommended
A joint action group has
been formed between
the departments ofhealth and animalhusbandry.
Action Plan (Draft) in
respect of Avian Flu,
Contingency Plan by
DGHS, Department of
Animal Husbandry,
Dairying & Fisheries(DADF) MoHFW
Action Plan updated

2007

Continuation of precautionary
measures

Acknowledgement of the threatof global outbreak of Avian
Influenza, apprehensions of ahuman pandemic
Extension of testinglaboratories of the animalhusbandry department
capable of H5N1 diagnosis
to Bangalore, Pune, Kolkata,
Jalandhar, Bareilly andBhopalFormation of National
Pandemic Planning Committee
Enhanced biosecurity

measures, specified
requirements and protocol for
vaccination in poultry
Initiated production of vaccine
to strengthen capacity and to
fill global shortage

Serum Institute of India
received grants of US$
2-2.7 million to develop
processes for
production of inactivatedor live attenuatedseasonal and/or H5N1
influenza vaccines or forestablishing filling
facilities using imported
antigens/ India
No documents found
World’s apex body for animal
health (OIE) recognized HSADL
as OIE reference laboratory foravian influenza in May 2009
Draft plan for A H1N1 or any
novel sub type focusing onphase 5 and 6 by DGHS,
MoHFW

Led to the extension ofservices to neighboring
countries
Led to action steps tomitigate humaninfection spread

Evolution of the Pillars of Pandemic Preparedness
Table 3 clearly designates that, in India, the pandemicplanning initiatives have always been restricted mainly tosurveillance and vaccine development. However, more
recently, with the advent of influenza A H5N1 (2005), A H1N1
(2009), communication and emergency service provision
have been added as the foundation of disease mitigation
strategies. The evolution of these components of pandemicplanning is summarized below.
Surveillance, including isolation of virus, rapid detection of
the disease has always been the foundation of Indian
pandemic response strategy. With the outbreak of AH5N1(2005), the concern to provide referral diagnostic services
over and above the disease diagnostic laboratories mainly
arose. As a result of that five Regional Diseases Diagnostic
Laboratories and one central laboratory started working;Institute of Animal Health and Veterinary Biologicals, Kolkata(Eastern), Disease Investigation Laboratory, Pune (Western),
Animal Health Institute, Jallandhar (Northern), Institute ofAnimal Health and Veterinary Biologicals, Bangalore(Southern) and Institute of Veterinary Biologicals, Khanapara,
Guwahati (North-eastern) and the Centre for Animal Disease
Research and Diagnosis (CADRAD) of IVRI, Izatnagar has
been operational as the Central Disease Diagnostic
Laboratory (49).
With the concern of human pandemic influenza,
surveillance in India gained momentum soon after the
emergence of novel pandemic strain of influenza virus A(H1N1) in Mexico and USA in 2009. The main objectives ofthe surveillance programme had been establishment of
epidemiological and virological influenza surveillance network
in different geographical areas of India, development of
human resources through training and strengthening of
infrastructure, expansion and strengthening of thesurveillance in a phased manner, timely dissemination of
information generated and improvement of awareness andcontribution of the influenza strains and information generated
to the global influenza surveillance. Department of Health andHuman Services (DHHS)-CDC in collaboration with IndianCouncil of Medical Research (ICMR) had been involved in theintensive influenza surveillance programme and National
Institute of Virology (NIV), Pune was identified as the referral
center for the influenza surveillance programme in the country
and its task remained to control all the regional centers. The
regional centres were increased from 5 (in 2005-6) to 9 withthe onset of AH1N1 (2009) in the country. These nine
surveillance centers, funded by the Center for DiseaseEubios Journal of Asian and International Bioethics 25 (January 2015)
Control and Prevention, USA and Indian Council for Medical
Research (ICMR), across the country were operational to
study the epidemiology and disease burden due to influenza.
The centers were distributed at different geographical sites;
All India Institute of Medical Sciences, New Delhi; Vallabhbhai
Patel Chest Institute, Delhi; National Institute for Cholera andEnteric Diseases, Kolkata; King Institute of Preventive
Medicine, Chennai; Regional Medical Research Center,
Dibrugarh; Indira Gandhi Medical College, Nagpur; Christian
Medical College and Hospitals, Vellore and Haffkine Institute,
Mumbai (50). The expansion and extension of surveillance
networks had improved the detection, identification facilities
but whether they were sufficient to serve the need of thewhole of country had remained an unanswered question.
Communication, another core component of planning were
found to be very much disease outbreak oriented in India.
With the global outbreak of A H1N1 (2009), the Governmentof India initiated a series of preventive actions approved by
the Inter-Ministerial Task Force (IMTF). All health-carefacilities in states under the country’s Integrated Disease
Surveillance Project (IDSP) and medical colleges wereactivated to report on influenza-like illnesses and pneumonia
cases. The Government took the responsibility tocommunicate risks, personal protective measures andpreventive guidelines through the mass media to the public.
The Ministry of Health and Family Welfare had rolled out astructured media campaign on the prevention of flu infection(51). In spite of this development, timely dissemination of
information to the citizens of the country was disputed during
the A H1N1 (2009) incidence (52).
In order to meet the global shortage of pandemic AH1N1(2009) vaccines and to strengthen the local capacity, threepharmaceutical companies; Serum Institute of India, Bharat
Biotech, Hyderabad and Panacea Biotec, New Delhi worked
on vaccine development (53). Indian Council of Agricultural
Research (ICAR) had also developed bird flu vaccine tocontrol the spread of the virus and also for vaccination in
anticipation of an outbreak (54). However, no separate
prioritization plan was recommended for the distribution of thevaccines and antiviral drugs with the recognition of theshortage of the supplies.
After the onset of influenza A H5N1 (2005), a special task
force, rapid response team, and monitoring team were formed
in India. After the incidence of A H1N1 (2009), special task
forces were reset under the supervision of the Chief Medical
Officers at each district to spread information about thedisease and to monitor all suspicious cases of influenza.
However, as pandemic influenza mitigation involves an all
sector approach, a coordination strategy also needs to bebuild with emergency response staff such as water, fire,
telephone, etc.
These steps, taken as the measure to mitigate thepandemic AH1N1 (2009), reflect the planning process andinitiatives that had been continued through the years in the
country. And it highlights some noticeable considerations as
stated below.
Conclusion
Pandemic and epidemic influenza outbreak planning
initiatives and measures undertaken through the centuries
had a direct impact on the mitigation and response measuresduring 2009 pandemic event in the country. The response
and mitigation measures of human pandemic preparation aspart of public health obligation, in India, has been found to beat very nascent stage, outbreak oriented, and reactive innature with a lack of constant and continuous efforts to plan in
a complete and adequate manner.
The subsequent absence of pandemic influenza innational health policy documents and a lack of experiential

11

learning from past events, not only weaken national influenza
control and mitigation measures but also highlight moral
lapses in providing due protection from sudden invasive,
acute communicable infectious diseases such as pandemic
influenza. It also reflects overlooking the facts of foreseen andavoidable consequences and highlights the acts of omission
and commission. To prevent such happenings, this paper
suggests; (a) to ascribe a constant public health importanceto influenza pandemic and epidemic by giving them a due
place in national health policy and program documents, (b) toacknowledge past pandemic, epidemic as well as endemic
influenza events with facts and figures in pandemic
preparedness and response plan, (c) to commit to continuousand proactive planning, exercising, refining, and improving themeasures. For by doing that, (a) country can show its
responsibility, accountability to be a part of global influenza
pandemic preparedness program following International
Health Regulations (2005)(55), and also that of World HealthOrganization (2005, 2007, 2009)(56), (b) At national level,such acknowledgement can strengthen influenza prevention
and preparedness programs, (c) can at least lead tocontinuous commitment and effort to develop and revise thestrategies, (d) will also reflect a greater concern of protecting
a large number of lives which come to stake with a single
blow of pandemic, and last but not least, (e) can also help in
identifying the challenges, the barriers to preparation andresponse measures.
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Animal rights and the needfor a universal ethics- Georges Chapouthier, Ph.D.
UMR CNRS 8590, Institut d’Histoire et de Philosophie des Sciences
et des Techniques, and, USR CNRS 3246 “Centre Emotion”, Hôpital
Pitié-Salpêtrière, Paris, France
Email: georges.chapouthier@upmc.fr

As human beings, could we be happy if we are aware that
others are suffering or in pain? Many philosophers would givea firm negative answer to this question.
In this article, we try to discuss the same moral question forother living beings, namely animals. So, could we be equally
happy if we inflict suffering on animals? Consequently, thequestion is one that deals with the moral behavior of humanbeings. However, no serious thinker would expect that humanbeings could suppress suffering in the whole living world. So
what remains ethically legitimate is the question on sufferingthat is caused by us on animals.
For a start, I will consider the traditional ethics, be it
deontological (Kantian), utilitarian or based on virtues. In mostcases, all involve mainly human beings. For them, moral
principles are set by human beings for human beings. I would
like to suggest here that it is not exactly relevant. First of all,animals are able to develop cultural traits, including what
could be called “proto-morals”. Secondly, it is not true thathuman beings can attribute moral rights only to their fellow
human beings.
Animals and (proto)cultures
Many animals demonstrate evidence of behavioral traits
which can be considered as “cultural”. A cultural trait can be
defined as a behavioral trait which can be transmitted, usually
within a family or a society, by channels not involving thebiological (genetic) transmission (Marler and Hamilton, 1968).
These channels can be learning from the parents or justspontaneous learning by imitation from other members of thesame species. The more efficient the brain is, the more likely,
cultural traits will be more complex. Animal cultures areespecially developed among mammals and birds. To
distinguish these cultures from human cultures, which often
reach a level of language that has a much higher degree ofcomplexity, I classify these animal cultures as “protocultures”, though the “purists” would prefer to refer to them as“cultures”. It is implied here that, in many instances, animals
have less complex cultures than human beings, but this does
not of course contradict the Darwinian belief that any living
being is equivalent in its aptitude to live: bacteria and plants
are, at least, as adapted as we are. Referring to “protocultures” simply suggests that, in the field in which mankind
highly performs (that is complexity of thought, linked to a
powerful cerebral cortex), and only in this field, animals show,
to a certain extend, less complex behavior than us.

13

Animals use tools, cognitive rules, communication
processes (referring to stimuli present in their environment),(rarely) languages (referring to stimuli no more present in theirenvironment) and manifest occasional aesthetic choices forsome colors, some shapes or some rhythms during theirsongs (Chapouthier, 2009; Lestel, 2001). As far as ethicalchoice is concerned, some traits observed in animals can beconsidered as “proto-ethics, as defined earlier.
Human ethics provide several examples of “roots”
originated in these animal proto-ethical choices. We dislike
torture and condemn it, but we are usually more emotionallyshocked by the torture of a young child than by the torture ofan adult. This is the consequence of a deep Darwinian rulethat animals rearing their offspring must emphasize their
specific protection. Another example can be given in thetaboo of incest. Human beings behave as monkeys or apes
do. All of them have a tendency to avoid incest. If we would
be like mice or cats, then, for us, incest would not be a taboo.
This shows the existence of animal roots in our ethicalbehavior, even if we, humans, develop from these roots,
specific abstract and discursive moral systems.
The most extensive study of proto-ethics was made byFrans de Waal in chimpanzees (De Waal, 1989). Observing
troops of chimpanzees, Frans de Waal found in them may
behavioral traits that we, human beings, would consider as“moral”, such as: sympathy, attachment, care for the young,help to disabled subjects, punishments, negotiations,cooperations, reconciliations… For example, forgiving is not…
a mysterious and sublime idea that we owe to several
millenniums of judeo-christianity, noticed De Waal. The merefact that monkeys, apes and men all show reconciliation
behavior means that the ability to forgive is probably morethan thirty millions years old.
If ethical choices find their roots in animal behavior andproto-cultures, human beings could however be defined anddistinguished as “moral rulers “.
Human beings as moral rulers
If we accept the existence or proto-ethical processes inanimals, we should however consider that human beings arestill the only ethical rulers. By “ethical rulers”, I mean that only
humans would use the exceptional language ability to create
abstract and discursive systems, which belong to the threemain kinds of moral we mentioned earlier: deontological,
utilitarian or based on virtues.
Human beings owe to their powerful brain the ability totransfer the biological roots of morals into these complex
systems based on language. Human beings are ahead of(other) animals in their understanding of nature (science), in
their imaginary world (art) as well as in their sense of
duration, although all these abilities also find also their roots
in animal behavior. Higher animals have knowledge of theirenvironment, dream as we do at night and can anticipate
certain events, such as a migration or a coming winter. But it
is clear that these traits when developed by human beings are
more complex in science, art or duration, to the point thathuman beings can be considered as “obsessed” by durationand future.
However, despite this powerful brain, human ethicalbehavior is practically a disaster, taking into account thecrimes, tortures, wars or atrocities committed by mankind
throughout history.
The question that ensued is how can the human species
improve morals (ethics), which, despite the traditional ethicalstances, has remained so low? My view point is that humanmorals could be improved by establishing a more global
universal ethical stance that includes care for animals and forthe environment. This ethical stance would indeed be14

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

proposed by human beings who are ‘ethical rulers”, but itshould grant rights to other, non human entities.
This is already evident. Already abstract and legal entities,
such as “corporate bodies”, have rights without being humanbeings. Take the port of Pireaus, near Athens in Greece, as
an example. As a corporate body, the port of Pireaus has
rights, but it cannot claim to be a human being! I advocatethat similar rights should be granted by mankind to animals as“sentient beings”.
The Universal Declaration of Animal Rights
Respect for animals can be considered in two different
ways. Schopenhauer (2000) proposed to base it on“compassion” and this position is quite similar to religious
oriental stances, such as the ones derived from Hinduism,
Buddhism or Jainism. Since the occidental tradition is moreformal and expresses itself in “rights”, it is this notion of rights
which I will expound. Other authors have alreadyemphasized, in several ways, the idea to grant rights toanimals (Regan, 1983). But the position I will defend here is
the one expressed by the Universal Declaration of Animal
Rights, proclaimed at UNESCO in Paris (but not by UNESCO)in 1978, and usefully revised in 1989 (Chapouthier and Nouët,1998). My arguments broach the text of 1989.
This declaration is similar in project with the « Declarations
on Human Rights ». Its basis is that animals being sentient
beings should, as formerly suggested by Bentham (Bentham,1970) be protected against suffering. As a set of formal
principles, this declaration is basically Kantian. However,though this idea of rights for animals is clearly modern, it canalso be interpreted as an extension towards universalism in
the Aristotelian tradition, thus adhering to the ideas of modern
Aristotelian views (Chapouthier, 2008; Khroutski, 2010).
Rights here are not conceived in the philosophical stance as“natural rights”, but clearly as rights granted to animals byhuman beings in their role as ethical rulers. Such granted
philosophical rights could then be transformed into laws.
The declaration comprises a preamble based on «unity oflife», possession of a «nervous system», that allows theoccurrence of suffering, and finally a « unity of ethics ». The
first article states that: «All animals have equal right to exists
within the context of biological equilibrium – This equality ofrights does not overshadow the diversity of species and of
individuals» Thus this first article clearly includes an
ecological perspective and an opening on biodiversity. The
following articles relate to general respect for animals,
treatment of wild animals, domestic animals and animal
species, to experiments on animals, to necessary
modification of the laws, and to the important need for
education of the young. Additions to the text deal with “Thespirit of the Universal Declaration of Animal Rights” and with
“The biological foundation of the Universal Declaration ofAnimal Rights”.
The important facts are that rights for the animals do not
exclude however the specific characteristics of each animal
species (a spider cannot have the same rights as a dog) andthat human beings cannot rule nature (human beings should
respect conflicts in nature and not take sides, for example,
between a predator and a prey). Another important feature ofthis declaration is that, when there is a conflict involving ahuman being, Human Rights should be considered first. As
any other animal species, human beings should not be
deprived of the privilege of defending their own survival first.
By “Human Rights”, it should be understood that they are thefundamental rights to live, to eat, to improve medicine, andnot, of course, the rights to hunt for fun or to see bullfights.
Usually Human rights are in accordance with Animal rights.
Several examples of it can be given. When inspectors visit

families where there is suspicion of ill treatments of children,
they often discover ill treatment to animals as well. In Europe,
many owners of dogs or cats abandon their pets at theapproach of vacation time. At the same time, there is anincrease in the abandonment of elderly parents at hospitals.
In Europe also, the geographic areas where bulls are tortured
in bullfights are the same as those where fights of gladiators
once took place. The major punishment during the French
revolution was decapitation. But before the use of theguillotine, manual decapitations were practiced following thework… of a butcher, who knew how to cut easily the head ofanimals. A last example could be given in the wars of the lastcenturies, where animals such as horses, were injured or
killed in the same way as soldiers.
If Human rights and Animal rights are usually in accordancewith each other, there are still some exceptions. Obvious
ones are, for example, when a human being is attacked by a
predator. In this case the fundamental (human) rights of our
fellow man to live should be preserved first. The same
argument is valid for animal experiments, where animal rights
should come after the (human) rights to biological andmedical knowledge. But these are exceptional cases.
Conflicts between Human and Animal Rights, are relatively
rare.
Better care for animals could also greatly contribute to themoral behavior of human beings among themselves. This iswhat is mentioned in the preamble of the declaration:“Considering that the respect of animals by humans is
inseparable from the respect of men for each other”. The final
request of the declaration is not far away from oriental
stances such as the ones of Hinduism, Jainism or
Buddhism…But, in the declaration, the emphasis is nonreligious, as it is merely based on rational (scientific) grounds.
Thus the declaration could be adapted to (or adopted by)human beings, regardless of their religious convictions.
Finally, a universal ethics, extended to animals should also
take care of the environment. Indeed the declaration includes
the care for “species” and “natural equilibrium”, which implies
an ecological point of view. But a further extension to plants
or to “natural beauties” or “scenic environment” should follow.
Conclusion
An extended or universal ethics, including care for animals
and also, to a certain extent, care for other environmental
entities, would probably lead to an improvement in thecommunity life and this will finally foster a better and more
harmonious way of life for humankind as well as for animals.
Thus animal rights, not conceived in the philosophicalstance as “natural rights”, but clearly as rights granted toanimals by human beings as ethical rulers, could then betransferred into law and eventually extended to environmental
values, and so open the way to universal ethics. This will
possibly allow humankind to adopt a more ethical behavior, abehavior in better adequacy with human’s powerful brain than
the succession of atrocities we committed during history. And
this could be a proper way to happiness.
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Implications of African
Conception of Personhoodfor Bioethics: Reply To
Godfrey Tangwa- Ademola Kazeem Fayemi, Ph.D.
Department of Philosophy, Lagos State University, Ojo, Lagos,
Nigeria
Email: kcaristotle@yahoo.com

Abstract
The question of what constitutes personhood iscontroversial in Western bioethical literature especially in
relation to its implications for healthcare. Godfrey Tangwa
explores the traditional African perspective of a person andmaintains that it is different totally from the Westernperception(s) as there is no dichotomy between a person anda human being in the African context. He defends a
conception of personhood as a moral agent rather than amoral patient, which the Western view focuses on. The basic
justification he offers in support of his position is the eco-biocommunitarian worldview. This paper seeks to respond to
Tangwa by arguing that his positions on person are not only
metaphysically superfluous; they are also ethically incoherent.
This paper argues that Tangwa’s theses on “the traditional
African perception of a person” are inaccurate representations
and misapprehension of the common notion of personhood in
sub-Saharan Africa. In reconstructing an African concept of
personhood, this paper explores its plausible (but limited)
implications for global clinical bioethics relevance.
Introduction
The concept of personhood is one of the most contested
concepts with diverse interpretations in Western bioethicaldiscourse. The debate on personhood is important for twobasic related reasons. One is its connection with
understanding the value of life. For instance, theunprecedented advancements in biomedical technologies
have continued to challenge traditional understanding of lifeand death. According to Thomasma, Weisstub and Herve(2001: 3), “The concept of personhood has become intimately
connected with fundamental ethical questions about the valueof life…. [and] has come to be a means by which medicalcare is excluded from some (e.g., human embryos, fetuses,
anencephalic infants)”. In consonance with them, the conceptof personhood has become a central concern in the emerging
dilemmas posed by the biotechnological advances in today’s
world. In consequence, such advances have continued toquestion traditional definitions of personhood as inadequate
for coping with today’s reality not only in biomedical context,
but also in social human existence.
Related to the above reason on why the debate on
personhood is important is that it is pivotal to the resolution ofsome moral problems such as those concerning “the15

beginning and end of life; abortion and withholding or
terminating life support in a range of cases involving
neurological damage, dementing illness and comatose states”(Macklin 1983: 36-7). Given the growing importance of
personhood conception in health care, it deserves mentioningin consonance with Thomasma et al. (2001: 3) that “bioethics
ought to be enlarged to incorporate into its framework ananthropological understanding of person.” As Corrado Viafora(2014) observes, anthropological presuppositions do precede
every ethical theory, and philosophical anthropology ofrespect of person and human dignity should serve as thefoundations for any system of principles and rules inbioethics. As a consequence of the importance of concept of
personhood generally, and in particular, in biomedical
decisions in healthcare, it is therefore pertinent having cogent
understanding of personhood irrespective of the provenanceof the idea.
Perhaps it is in the light of the foregoing that Godfrey
Tangwa, a foremost African bioethicist, attempted providing a
discussion of the notion of personhood from the African
viewpoint. While the bioethical discussions on personhood
started in, and have mainly been conducted within Westerncontext, Tangwa’s article, “The Traditional African Perceptionof a Person: Some Implications for Bioethics,” is a pioneering
attempt to contribute to the discourse on personhood from theAfrican viewpoint. His central theses in the paper are: (i) “theAfrican concept of personhood is totally different from what isfound in the West” (Tangwa, 2000: 42); (ii) in traditional
African thought, there is no dichotomy between a person anda human being (Tangwa, 2000: 39); (iii) eco-biocommunitarianism is the justification of the African perceptionof the person (Tangwa, 2000: 42); and (iv) “it is ideal to
combine the efficacy of Western science and technology withthe moral sensibilities of traditional Africa” (Tangwa, 2000:
43).
This paper is a critique of Tangwa’s thesis on what heclaims as “the traditional African” notion of person and its
supposed implications for bioethics. This attempt becomes
pertinent, at least, because there seems to be no evidence inthe literature of a critical evaluation of Tangwa’s position on
personhood. Moreover, it is essential in order to avoid aputative spurious branding of “the traditional African
perception of person” when indeed, there is no such genericconception of person in Africa. There are many different
views, as there are in Asia, for example. The first part of thisarticle provides a conspectus of Tangwa’s positions. The
second part of this paper challenges Tangwa’s four-prongtheses as inaccurate representations of the African
understanding of personhood. In avoiding the conceptual
error, which his article is fraught with, this paper provides
rigorous analysis of an African concept of personhood bydrawing on the common understanding of it in sub-Saharan
ethical literature. Beyond the culturally sensitive notion of
personhood, which for the most part, has little significanceand implications for bioethics, the third part of this paper
attempts a reconstruction of an African conception of
personhood that is contributory to the existing bioethicaldiscourse on the theme. The critical inquisition here botherson understanding the extent to which the anthropologicalpresuppositions that implicitly or explicitly shape sub-SaharanAfrican understanding of moral principles may offer
reasonable insights on the extensively researched themes of
personhood and dignity in international bioethics discourse.
The concluding part of the paper indicates some suggestions
for future research.
On the Traditional African Perception of Personhood
Tangwa describes the perception, attitudes andunderstanding of the Nso-African on personhood. The Nso’

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

are an ethnic group that speak Lamnso language andsubstantially occupy the Bamenda Grassfields, Northwest
province, Cameroon. As Nso’ native, Tangwa discusses the
Nso’s understanding of personhood, which he contrasted witha popular notion of personhood in the West. According to him,in Nso traditional culture, personhood is generally captured in
the saying “Wir dze wir,” literally translated as a “human being
is a human being is a human being simply by being a human”(Tangwa, 2000: 39). Quick to disprove any objection of
tautology in the translation of wir dze wir, Tangwa said within
the Lamnso language, the supposed tautology is absent as
the phrase connotes “the reverential respect with whichanything human is approached” (Tangwa, 2000: 39). In thesaying “wir dze wir,” the keyword – wir, “stands
indiscriminately for both human being and human person”(Tangwa, 2000: 39). In the same vein, the word – wan, isused for neonate, infant, child and baby without discriminationof individuating features. Wan (baby human being), therefore,
biologically leads to wir (adult human being).
Though the Nso’ view recognizes differences indevelopmental stages of a being as well as variation in social
stratification typified by age, experiences and hierarchy insociety; yet, as Tangwa (2000: 39) notes, “suchcategorizations do not carry any moral significance.” This isbecause moral worth is indiscriminately due to all humanbeings, and remains constant and unchanging throughout
developmental stages and lifetime, regardless of any
individuating characteristics, possible health conditions, or
social rank. Therefore, for Tangwa (2000: 39), the African(Nso) traditional perception of personhood does notparticipate in the dichotomy between human beings andhuman persons, which is apparent in the West.
One basic justification for the linguistic and descriptive
perception of personhood in the Nso’ view identified by
Tangwa is the eco-bio-communitarian thesis. As he writes:“the actual justification for how the African perception of theperson is applied has to do with the African worldview”(Tangwa,
2000:
42),
which
he
calls
eco-biocommunitarianism. The idea of eco-bio-communitarianism isthat there is strong ontological interdependence and interrelations not only among human beings, but also among
human beings, nonhuman animals, superhuman spirits,
plants and inanimate things. The implication of this idea
highly held among Africans is that things are generally andreverentially respected because “a human being canconceivably transform or ne transformed (with or without
knowledge or consent) into any other ontological entities inthis life or in the life after death…” (Tangwa, 2000: 42).
On the above premise, Tangwa argues that the Nso’ view of
person is different from Western moral philosophy on the
ground that while the latter is driven by the attempt to sharply
distinguish persons from the rest of the cosmos, and then to
identify the ways in which persons must be treated, the former
does not draw such distinction. Critical to Tangwa’s sketch of
the differences between African views and Western views on
person, he cited Tristram Englehardt as exemplifying theWestern viewpoint. Englehardt defines persons as "entities
who are self-conscious, rational, free to choose, and inpossession of a sense of moral concern" (Engelhardt 1996:
136) and concludes that human "fetuses, infants, theprofoundly mentally retarded, and the hopelessly comatose"
are nonpersons, having no "standing in the secular moral
community" and falling "outside of the inner sanctum ofsecular morality" (Engelhardt 1996: 139). According toTangwa, the reverence to person in Nso’ African thought ishowever different from Englehardt.
Besides Englehardt, philosophers such as Peter Singer,
Joseph Fletcher, Mary Warren among others have also put
forward different criteria for the identification of personhood.

While our interest in the main is not to delve into details of
their views, it is important to state that their criteria of
personhood range from rationality, freedom of choice,recollection of the past, future awareness, minimum
intelligence,
sentiencetocapacityforautonomy.
Consequently, the emphasis on these criteria in the discourseof personhood exempts the neonate, children, irrational,
severely physically or mentally challenged from moral
consideration. By contrast, the African (Nso’) traditional
perception of personhood applies to humans in all thedevelopmental stages and to all possible conditions.
Implicitly, the Nso’ do not acknowledge wealth, power,
rationality, autonomy, rights and responsibilities etc., ascriteria for moral consideration in their understanding of
personhood. It is on this account that Tangwa makes this
distinction between the African and Western notions of
personhood thus:“If the African perception of a person differs from theWestern perception, this is not because it does not recognize
the various developmental stages of a human being or
qualitative differences based on the degree of attainment of
positive human attributes or capacities, but rather because it
does not draw from these facts the same conclusions as are
drawn in Western ethical theory. In particular, the differences
between, say, a mentally retarded individual or an infant anda fully self-conscious, mature, rational and free individual do
not entail, in the African perception, that such a being falls
outside the "inner sanctum of secular morality" and can orshould thus be treated with less moral consideration. But
since the Western preoccupation with personhood would
seem to be dictated precisely by the need to draw such a
consequence, it ought also to be said that the African conceptof personhood is totally different from what is found in theWest” (Tangwa, 2000: 42).
Pushing this comparative thought further, Tangwa argues
that: “The Western conception of a human person, as acategory or subset of human being, is appropriate only for the
ascription of moral responsibility, liability, and culpability
rather than for the ascription of moral worth, desert, eligibility,or acceptability into the moral community made up, as it
necessarily is, of both moral agents and patients. By contrast,
the African or Nso' perception of a human being, whichapplies to the elusive entity underlying all categories, stages,
and modalities of a human being, although conceptually lessneat and analytically less firm, seems to accord better with
our ordinary moral intuitions and sensibilities and is thus more
appropriate for nondiscriminatory morality in general.”(Tangwa, 2000: 42-43)
Besides the distinction between personhood as a moral
patient (in the West) and personhood as a moral agent (inAfrican thought), Tangwa warns against following the
motivations behind the constant rethinking of moral categories
of person in the Western world, which he identified to bescience, technology and commerce. The Nso-African view of
person, though reverentially respectful and ritualistic, it isdriven by the “deep-seated attitude of live and let live, be andlet be” (Tangwa 2000: 42). He suggests therefore that “itwould be ideal to combine the efficiency of Western scienceand technology with the moral sensibilities of traditional
Africa” (Tangwa 2000: 43) in order for Western technologicalculture to be humanized by African culture. In achieving this,he recommends alienating Western technology from “itsentire value system, assumptions, expectations, propaganda,
and evangelical spirit surrounding it” (Tangwa, 2000: 43).
Given the foregoing general textual overview of what
Tangwa considered to be “the traditional African perception of
personhood” what then are the strengths and flaws in his
discourse?

Eubios Journal of Asian and International Bioethics 25 (January 2015)
A Critique of Tangwa’s account of Personhood
The title of Tangwa’s article, “The Traditional African
Perception of a Person: Some Implications for Bioethics,”
presupposes that there is a generic “African perception of aperson” that is generally agreeable to among Africans.
However, in reality, there is none. Africa is heterogeneously
diverse in worldviews, ideals and perceptions of a person. At
best, there can be found a commonly dominant view on what
constitute personhood; but Tangwa seems not inclined to this.
Rather, he prefers advancing the Nso’ perception andproceeding from a particular instance to representatively
generalize as the traditional African perception of a person.
On this assumption, Tangwa is quick in judging the African
perception as better over the divergent conceptions inWestern discourse. Where there is dichotomy between
human being and human person in Western bioethicaldiscourse, there is no such dichotomy in “the African or Nso’
perception of a human being” as the latter is applicable to allstages and categories of human being in any possible
condition. On this supposedly difference, Tangwa rated theAfrican view as more cogent because it accords “better with
our ordinary moral intuitions and sensibilities and is thus more
appropriate for nondiscriminatory morality in general”(Tangwa, 2000:43).
While it is unconvincing that there is hardly such a
consensus about our ordinary moral intuitions, Tangwa’s
central thesis is questionable on many fronts. He premised
his claim that there is no distinction between a person and ahuman being among the Nso’ on linguistic fact. The word- wir,
is a referent without apparent differences between humanbeing and human person. Critically, this claim is suspect. The
absence of the ‘word’ person in Nso’ language is perhaps asituation indicative of some linguistic non-fecundity anddefects requiring no semantic celebration as Tangwa does.
He has mistakenly taken language as a necessitating basis
for drawing inferences about understanding of moral status.
While language may be an inclining cultural resource, it
should not necessitate reasoning at a fundamental moral
level, such as on what qualifies one to have moral status.
A central claim in Tangwa’s account of the African notion of
personhood holds that for the Africans, personhood isconstrued in terms of moral agent (one who is expected togive others the moral recognition they are owed) and not a
moral patient (one owed moral recognition, independently on
her own accord), which is Western oriented. While theconcern of the former is to attribute “moral worth, desert,
eligibility or acceptability into the moral community,” the latter
concern is that of assigning “moral responsibility, liability andculpability” (Tangwa, 2000: 42-3) to some humans than toothers. This position means that personhood should beunderstood simply as biological beings of intrinsic moral
agency without any different moral status. There are some
implications of this position. For one, it may be thought that it“would have the effect of making the bioethical conception of
personhood far less contentious” (Behrens, 2011: 113-4). But
this perhaps is not the case as the view itself is entangled in
more questionable assumptions.
One of the difficulties of such a view defended by Tangwa isthe eco-communitarian metaphysical foundation on which hebased the argument of the African concept of personhood. A
second difficulty is the normative inability of such a
conception to command higher moral priority to the mostvulnerable. A third difficulty that has no clear explanation in
Tangwa’s discourse is accounting for why human beings andanimals have different moral status when they both share thesame internal life force that allows for transmigration of one
being into the other. It is pertinent discussing each of these
possible critiques of Tangwa’s African account of person.

17

On the first point, Tangwa claims that “the line separating
human beings from the other ontological entities that populate
the world, in the African world view, is neither hard nor
straight.” This is because of the African belief intransmigration of the soul and reincarnation. The idea of soultransmigration makes it difficult to make sharp distinctions
between human beings and the rest of the cosmos as all
nature’s constituents are interdependent and interrelated.
Besides the point that the idea of transmigration of the soul inAfrican thought is a controversial issue and largely disputed inmany quarters as a myth without any evidential merit,
Tangwa’s (2000: 42) justification of it is more problematic. He
argues that the “the actual justification for how the African
perception of the person is applied has to do with the African
world
view,”
thatiseco-bio-communitarianism.
Epistemologically, to justify a belief as such, an internalreferent to eco-bio-communitarian African worldview cannot
suffice. It is only an external justification that can allow for an
unsympathetic appraisal of the deficiency, flaws and possible
strengths of the African view of person.
We now turn to the normative ground of objecting toTangwa’s claim on every being, irrespective of state ofvulnerability such as infant, dementia, the aged, and otherphysically challenged, has the same moral status as humanbeings with capacities. Contra Tangwa, the problem with thisposition is that the most vulnerable ought to be treateddifferently with greater compassion and care consideration,and doing this requires the recognition that such beings havedifferent moral status (Behrens, 2011). Tangwa’s (2000: 39)
claim on Wir dze wir,” (a human being is a human being is ahuman being simply by being a human) does not sufficiently
warrant such special moral protection. A position as this does
not allow for degrees of moral status, which sometimes isjustifiable on equitable grounds to promote the best interestsof the most vulnerable.
Related to the above is the question of divergence between
the moral status and agency of human beings and animals,
when they share the same internal property of life force,
which makes possible the idea of transmigration from one
being to the other. Nso’ morality, writes Tangwa (2000: 39),“is human-centered in the sense that only human beings are
deemed to be moral agents, with moral obligations andresponsibilities, but not in the sense that moral considerationand concern are limited to human beings.” In this sense,human beings only have asymmetrical obligations and duties
towards nonhuman animals and other things in nature while
they do not have same in return towards human beings. Yet,
Tangwa insistence on the possibility of “transmigration,transformation, and transmutation within and across species”
is premised on the supposition of common life force that bothliving species and inanimate things in nature share. The truthof this claim lies in providing clear explanation of what is
ontologically responsible for difference in moral status andagency. Alternatively, the truth of the claim would require
normative explanations detailing why human beings in
general are directly owed duties as opposed to the indirect
duties reverentially owed other animate and inanimate things
in nature.
Though without a concrete outline or exploration of theimplications of the traditional African perception of a person
for bioethics, Tangwa’s optimism of using the African notion of
moral agency to humanize what he called the “morally blind”
economic driven proclivity of Western science and technology
is unwavering. A way of achieving this synthesis is his
recommendation that “the kernel of Western science andtechnology” should be separated from its “Western package”
by which he meant the Western “entire value system”(Tangwa 2000: 43). Neither is this conceptually andpractically possible and desirable because technology is

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

intractably linked to culture. Nor is his recommendation that
“Western science and technology be put to different and morehumane uses in other cultures [when received] without thesocio-politico-economic and metaphysico-religious conceptual
structures that accompany them in the West” (Tangwa 2000:43) feasible in my opinion. It is more rational to encourage
local cultures in the non-Western world to develop their own
technologies in realization of the interconnectedness anddiversities of the human race than the divisive strategies
being reinforced by Tangwa.
From the foregoing, a critical view of Tangwa’s perception of
the African-Nso idea of personhood shows that it is not only
metaphysically superfluous; it is also ethically incoherent.
Such a view is a misapprehension and a reductionist
conflation of person with human being and not in any way
representative of the common notion of personhood in subSaharan Africa. His purported African notion of personhood,as Behrens (2011: 116) unambiguously notes, “does not leadto highly contentious moral conclusions in quite the same waythat the bioethical notion does.” Importantly, it is limited in its
possible contributions towards understanding and illuminating
many bioethical problems plaguing our contemporary world.
If ideas from Africa are to be substantially useful for global
bioethics, the original views latent in the people’s worldview
would have to be reconstructed and not left at the first-orderof latent worldview as surreptitiously done by Tangwa.
Reconstructing an African Concept of Personhood
Contra Tangwa, the concept of personhood whether inAfrican thought or Western is distinguished from humanbeings as biological species. While the question of what
exactly constitutes personhood has been central to many
philosophical debates in the Western world both at ontologicaland normative levels, especially in the field of bioethics; in the
African context, the controversies surrounding it haveremained purely in the area of African normative ethics,
descriptive sociology, anthropology and metaphysics (Menkiti
1984; Wiredu 1992b; Gyekye 1997; Ikuenobe 2006; Metz
2007, 2011a, 2011b; Fayemi 2009;Comaroff and Comaroff
2001; Behrens 2011; Iroegbu 2012).
As a moral philosophical construct, personhood, be it inWestern theorizing or African articulation, is “used to denote
some morally relevant status attributed to those who might beidentified as persons” (Behrens 2011: 107). A cross-section
analysis of personhood in African philosophical literaturesuggests that it is a constructive ensemble of virtues ofrelations of both potential and capable beings in thecommunity. The concept of personhood as a bioethicalcategory has not gained much attention in the African1
discourse. However, it is important to state that from theexisting African philosophical-anthropological scholarship,some differences can be delineated between the common
Western understanding and the prominent African view of
personhood.
Thadeaus Metz (2011a: 11), an American native of African
scholarly orientation, brilliantly articulates, broadly speaking,the core difference between the African and Western notionsof personhood: “In a sub-Saharan context, ‘personhood’ mostoften indicates virtue or human excellence, a quality thatvaries from individual to individual based on her attitudes anddecisions. In contrast, Anglo-American bioethicists use the1

An exception is the works of Metz (2012) who have engaged in aserious discussion of the bioethical implications of a constructed
African theory of moral status and dignity. Though the sub-title ofTangwa’s paper has the caption “some implications for bioethics,” acontent analysis of the article reveals no clearly cut-out intimation andimplication for bioethics.

same term to pick out moral status or standing, a feature thatis often thought to be invariant among individuals (or at mostto vary based on differential capacities, rather thanactualizations of them).”
It is in line with the above that D.A. Masolo (2010: 13),
writing on the African conception of personhood states that
we are “…born humans but [strive to] become persons … [as]the project of becoming a person is always incomplete.”
Understood in this sense, personhood is an unending processof becoming more of a humane person, acquiring virtuous
attributes “through associating with others with whom weshare a mutual dependence” (Behrens 2011: 110). By
implication, personhood in the words of Behrens is an ideal
we strive to “attain than a status we either possess or do notpossess.” It is a social process of self-construction in a
relational framework of diverse long-live daily activities. While
the process is inseparable from the product, the productremains an ideal. As an ideal, Wiredu (1992b: 104-5) notes, it“may or may not be realized and to which one may
approximate in varying degrees.” Menkiti, the renowned
Nigerian philosopher, is famous for writing that: “As far as
African societies are concerned, personhood is something at
which individuals could fail, at which they could be competentor ineffective, better or worse. Hence, the African emphasized
the rituals of incorporation and the overarching necessity oflearning the social rules by which the community lives, so thatwhat was initially biologically given can come to attain social
self-hood, i.e., become a person with all the inbuilt
excellences implied by the term” (Menkiti 1984: 173).
The above position is similar but not the same with that ofTangwa. For both Menkiti and Tangwa, personhood in African
thought focuses on status of persons as moral agents, andnot moral patients. While in Menkiti it is about normatively
developing virtues of the moral agent, in Tangwa it is about
ontological constituents or force that connects human beings,
superhuman spirits, nonhuman animals, plants and inanimate
objects in mutually reinforcing and interdependent
relationship. For Tangwa, personhood qua humanhood istherefore not a matter of degree and one cannot be a ‘lesser
person;’ personhood is simply a human being as a moral
agent.
Tangwa’s position is related but not the same with that ofKwame Gyekye (1992), the Ghanaian philosopher, who holds
that a person is endowed with certain attributes which areprior to community formation. Unlike Tangwa that uses
metaphysical category in bluffing the distinction between
human being and person, for Gyekye, he normatively argues
that while personhood is partly determined by communal
values, fundamentally, there are other things apart from thecommunity which make a human being enjoy the attribute ofpersonhood. Gyekye (1992: 111) identifies attributes such as,“rationality, the capacity for virtue, ability to make moral
judgments and to choose as those conferring personhood on
the individual.” However for both Tangwa and Gyekye,
personhood cannot be achieved or acquired because one
automatically becomes a person at birth.
Whether in Gyekye, Metz, Tangwa, Menkiti, Masolo,
Wiredu or Behrens, the normative conceptions of personhoodin many sub-Saharan thinking has to do with the moral statusof an agent with profound social significance. To quote Metz
(2012: 391), “in typical African reflection, talk of ‘personhood’… is inherently moralized, such that to be a person is to be
virtuous or to exhibit good character. That is, one can be
more or less of a person, self or human being, where themore one is, the better.” At the level of social significance, “aperson is social not only because he or she lives in acommunity (the only context in which full, humandevelopment is possible), but also because, by internal
constitution, a human being is part of a social whole” (Wiredu,

Eubios Journal of Asian and International Bioethics 25 (January 2015)
1992a: 84). The communal and social identity of a being isbelieved to be present even before birth in sub-SaharanAfrican culture. Every being is “essentially the center of a
thick set of concentric circles of obligations andresponsibilities matched by rights and privileges revolving
around levels of relationships” (Wiredu, 1992a: 87) startingfrom household kinship through lineage and clan to the larger
community.
Wiredu also shares the ‘becoming’ conception of
personhood in African thought, which has link with the social
relational constitution of a person. In consequence of thesocial characteristic of a person, Wiredu (1992a: 87) holds
that life is “a continual striving after personhood in everincreasing dimensions.” This view allows the possibility ofloss specter of personhood, especially, when there is habitualdefault in duties and responsibilities of a being. However,
becoming less of a person does not imply not being worthy ofbasic respect and sympathy as a human being. Every humanbeing is entitled of respect by the virtue of simply being
human but being respectable is associated with personhood.
As an ideal worth striving for, Wiredu (1992a: 87) defines
personhood as “the concept of an individual who throughmature reflection and steady motivation is able to carve out areasonably ample livelihood for self, ‘family,’ and a potentiallywide group of kin-dependents while also making substantial
contributions to the well-being of the larger society.”In the sub-Saharan anthropological conception of theperson, there is what Wiredu (1992a) calls “an acute sense ofan essential dependency of the human condition.” While theidea of self-determination is understood by the Africans, “itsvery possibility is predicated on the residue of humandependency. Human beings, therefore, at all times, in one
way or another, directly or indirectly, need the help of theirkind” (Wiredu 1992a: 89). The awareness that humandependency cannot be completely eliminated irrespective of
one’s abilities acquired overtime, makes pivotal, theconsensual approach in decision making among the Africans.
Just as Wiredu (1992a: 92) notes, “A communalisticorientation will naturally prize social harmony.” The greater abeing demonstrates capacity for being part of harmonious
relationship, the greater the being’s moral status. The level ofa being’s personhood is therefore associated with the degree
to which the person conforms to the ideal standard of humanactions. Actions are considered right in so far as they connect
people together and “what separates people is wrong”(Verhoef and Michel, 1997: 397). The African way of
pursuing such an ideal is through decision making byconsensus rather than individuated exclusion position or
majority opinion.
In striving for such an ideal, cultivation of virtues of
excellences such as wisdom, politeness, generosity, care,friendliness, harmony, fellowship and hard work is important.
In addition, values such as solidarity, consensus,
dependency, relationality, care, proper participation in therituals of bereavement are “contributory proof[s] of real
personhood” (Wiredu, 1992a: 92) in African culture. The
normative constituents and criteria of personhood among the
sub-Saharan Africans are therefore, largely, about selfregarding duties to others which among other things aim at
harmony of interests and caring for the ‘other-self.’
African Relational Conception of Personhood: Any
Global Bioethical Relevance?
From the foregoing, it might be asked whether the subSaharan African conception of personhood, by implication,necessarily excludes certain group of vulnerable beings fromthe ideal of personhood be it potentially or permanently andare the rationale of such exclusions different from thecommon explanations in the West. Put differently, what can

19

the sub-Saharan African anthropological understanding of
personhood as status of moral agent add to the subsisting
international bioethical debate? The sub-Saharan notion of
personhood can enrich global bioethical discourse with its
intimation towards developing moral sensitivities, virtues andobligations of the agent in relationship to others. It is useful,in a way, in the sense of fostering relationships either
between healthcare providers and care receivers or between
researchers and research participants.
In addition, in the light of the dominant sub-Saharanunderstanding of personhood as moral agents, such view
leads one to the conclusion that infants and some nonachieving adults fall short of personhood. This view isarticulated by Wiredu when he states that “Neonates, infants
are not persons because they are “still in preparation for thatstatus” (Wiredu, 1992b: 107). While adults who are notconsidered persons lack virtues of excellences and areconsidered with opprobrium, severely vulnerable beings, thedemented aged for example, are still respectable ofpersonhood based on their past outstanding contributions totheir lineage and community, respectively. Considerations ofpast actions are, therefore, relevant in partly determining how
people ought to be treated in the present (Metz 2011b). But inthe absence of such evidential moral uprightness, integrity,communal affection and good human fellowship, the elderly
demented remains just at the level of a human being. The
most fundamental problem with this relational and communal
conception of personhood is that “if one is not part of acommunity of the relevant sort, then one counter-intuitively
lacks a moral status” (Metz 2012: 393).
The above limitation notwithstanding, the conclusion to be
drawn from the common African conception of personhood isthat it is useful only in the sense of ‘moral agent’ and not‘moral patient’ to use Tangwa’s phraseology. However, it ispossible to argue that the African anthropologicalunderstanding of personhood can be revealing as well for the
moral status of moral patient. Metz’s construction of an
African relational theory of moral status is apt in this regard.
For him, the capacity of a being to be “part of a communal
relationship of a certain kind” determines personhood in
degrees. Communal relationship is understood here as“relationships in which people identify with each other [bysharing a way of life] and exhibit solidarity with on another [bycaring for one another’s quality of life]” (Metz 2007). In such a
relationship, a being can either be a subject or object. To
quote Metz at length on this point: “… a being that is capableof being both the subject and object of such a relationship has
full moral status, whereas a being that is capable of being
merely the object of such behaviour has partial moral status.
Being a subject involves identifying with others and exhibiting
solidarity with them oneself. A being can be a subject of therelevant communal relationship insofar as it can think ofhimself as a “we”, seek out shared ends, sympathize withothers and act for their sake. In contrast, a being can be theobject of a friendly relationship insofar as characteristic
human beings could think of it as part of a “we”, share its
goals, sympathize with it and harm or benefit it. Note thathaving the capacity to be an object of such a relationshipdoes not imply that a being would or even could respond toany friendly engagement by another” (Metz, 2012: 394).
The above construction of personhood is based on a modal
relational view that emphasizes in principle, capacity of being
part of a relationship either as a subject or an object. The
differences in degrees of ability to be either a subject or an
object of a communal relationship constitute differences inmoral status. The greater the capacity is the greater the
degree of personhood. This view has some direct implications
for grading the personhood of moral patients such as people
in vegetative state, the severely mentally incapacitated,20

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

psychopaths, infants, who are capable of objects ofcommunal
relationship.
Whether
thisconstructedinterpretation of personhood in African thought as consistingof both moral patients and agents is plausible than the
exclusive popular African understanding of personhood as
moral agent remains a controversial issue not of immediateconcern.
Irrespective of the African conception of personhood one
holds dearer, it has implications for bioethics, though at
different degrees. For instance, the idea that personhood
consists in virtuous activities of a moral agent such as
fellowship, caring for the ‘other-self,’ and sharing a way of life
through mutual aid are important for improving others’ qualityof life and well-being, especially in end-of-life discussions in
the health care setting. Such a conception of personhood thatrecognizes the dependency, vulnerability, relationality,
insufficiency of human beings, and “sharing a way of life withothers is an important relational ethical perspective” (Metz,2013: 89) that can complement the care ethics orientation inWestern bioethics.
The African notion of personhood as ‘other-regarding’ has
implications for clinical practice, especially as it concerns
consent, information disclosure and proxy-representation. The
element of family-determination (as opposed to selfdetermination) in African health care practice has
anthropological foundation in the African understandings ofthe nature of personhood and familyhood. Rather thandisclosing information and obtaining formal consent from theindividual patient directly, a patient’s family representative(s)takes charge. Without necessarily isolating the patient, theactive involvement of the family in the diagnosis, treatment
and reconciliatory trajectory is that “a sick person should notsustain the burden with directly signing a consent form” (Fan
1997: 195). In such process, there is a broader consultation
involving not only the family-representative, the patient (where
necessary) but also the other family members, maternal andpaternal.
The decisions usually made by family members are usuallyin harmony with the patient’s interest and wishes and notnecessarily patient’s consent. Given the sometimes
metaphysical conception of the source of an illness common
in African beliefs, the consent of a patient cannot be achieved
because of the supposed transcendental element or cause
obstructing the consciousness of the patient. In suchsituations, family members act in the best interest of thepatients even without consent. However, in situations of
natural etiology, decisions of family representatives areusually in consonance with the patient’s wishes and consent.
Where there are disagreements, either between the patientand he rest of the family or among the members of the family,
it is expected that the family head resolves that before suchconsent authorizes the physician’s course of action.
It is important to critically point that this family-embedded
autonomy in decision making may perhaps be imprudent inemergency situation, especially in cases of intra-family
conflicts, which sometimes creates some moral distress forphysicians. More fundamentally, it is epistemologicallyquestionable, the extent to which family-embedded autonomy
and representation are truly representative without
questionable interests.
Conclusion
This paper has attempted a critical evaluation of Tangwa’s
conception of personhood from an African perspective. As
problematic as his views are, this paper establishes that his
narration of Nso’s perception of personhood is not in tandemwith what common views in the African literature. However,the critical evaluation of Tangwa’s view attempted in this work
should not undermine his significant contribution to thediscourse on personhood from an African viewpoint. While
this paper provides some insights on the common strand ofthought on personhood in sub-Saharan African philosophicaldiscourse, it shows the possible inferences that can be drawn
from the emphasis on personhood as moral agency forbioethics. The paper establishes that the possible
contributions of the African notion of personhood, thoughdifferent from the emphasis on moral status in the Western
discourse, are however incapacitated for robust bioethics
discourse.
The limited contributions of the common African
understanding of personhood to bioethics is not unconnectedto the fact that theorizing on personhood itself is more of afirst-order activity relying heavily on the cultural worldview. A
second-order theory of personhood that would valuably
constitute a resonant anthropological frame for bioethics
anywhere at least, needs to “rest on the best scientific [andgenetic] data … available about human beings … along withthe [ontological, sociological and moral] values we associatewith persons” (Thomasma, Weisstub and Herve: 2001: 8).
Metz (2012) has attempted doing this with his constructed
African modal-relational theory of moral status. Though an
illuminating work both on moral agency and moral status froman African perspective with well-outlined implications forbioethics debates, it is apt to say, contra Metz, that theidentity label of ‘African’ in his theory, would by implication not
be claim of uniqueness of thought or commonality of subSaharan experiences. Rather, it will only be claim of point oforigin of the author. As an American, it perhaps remains to be
seen how his view qualifies as African despite his defense to
the contrary. While it is beyond the scope of this research toattempt constructing a theory of personhood in African
thought, or replying Metz in particular, the point is that the
moral agent conception of personhood in Africa cancomplement existing understanding of personhood as status
of moral patient in the Western tradition. This is important inserving as an integrative basis for justifying bioethicaljudgment in our pluralistic society.
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Compassionate Care by
Clinicians: Insights from the
Judeo-Christian andBuddhist Traditions- Neil Pembroke, Ph.D.
Associate Professor, Studies in Religion; Director of Teaching &Learning, School of Historical and Philosophical Inquiry, University of
Queensland, Brisbane, Australia
Email: n.pembroke@uq.edu.au

Hospitals in modern industrialized countries have a culturethat is significantly shaped—some would say dominated—by
rationality, the scientific paradigm, and the technology ofdiagnosis and treatment. Though it is widely acknowledgedthat both cure and care are important, there are a significant
number of healthcare practitioners who are competent inrelation to the technologies of cure but who have little facility
with the human dimension in medical practice. Others see thevalue in compassionate care, but in the midst of the pressuresand demands of their profession lose sight of the vision to an
extent. With this in mind, some writers in the field ofhealthcare have felt the need to highlight the vital importanceof care and compassion (Brien & Lewith 2001; Coulehan
1995; Dougherty & Purtilo 1995; Graber 2004; Pellegrino
1979; Pellegrino & Thomasa 1997; Pembroke 2007; Rhodes
1995; Stevenson 2002; Sulmasy 1997; Thomasa & Kushner
1995). There are slight variations in the way the termcompassion is understood in these texts. I take it to mean
opening oneself to the suffering of a person, being moved byit, and feeling a strong desire to do all in one’s power toalleviate it.
The aim in this essay is to make a contribution to theexisting body of work by focusing on certain insights that areprovided by the Judeo-Christian and Buddhist traditions. The
writing on compassion in these traditions is of course

21

extensive. In order to keep the task within manageablebounds and maintain a sharp focus, just three of the many
possible facets of the topic covered in the relevant spiritual
writings have been selected for attention. From the Jewish
and Christian traditions, the notion of receptivity to thesuffering of the other is highlighted. In the biblical perspective,
the compassionate person is viewed as someone who takes
the suffering of others into her womb or heart. It is suggested
that the tenderness and kindness expressed by these
metaphors presents an ideal in compassionate care byclinicians. Further, the insights of the Christian philosopher,
Gabriel Marcel, on overcoming a lack of compassion will be
employed. Marcel contends that breaking through hardness ofheart requires a sudden submersion in the inner reality of theother and being compelled to see things through her eyes.
In turning to Buddhism, use is made of the notion ofcompassion with equanimity. The Buddhist ideal is opening
oneself to the pain of the other while maintaining calmness or
stillness of mind. This is particularly appropriate in the context
of healthcare. The healthcare professional needs to be able toshare the suffering of her patients without becoming
overwhelmed by it.
In Conversation with the Judeo-Christian Tradition
Bergant (1996) observes that in the cluster of Hebrew
words for compassion, rhm is the most prominent. It has theprimary meaning of “cherishing,” “soothing,” or “a gentle
attitude of mind.” It refers to a tender parental love. The word
rehem, meaning womb, is also derived from this root. Hence,
Bergant (1996) concludes that this Hebrew word-groupindicates a bond like that between a mother and the child of
her womb.
Leon-Dufour (1988) describes the Hebrew notion ofcompassion, as one might expect, in a very similar way. He
suggests that rhm “expresses the instinctive attachment of
one person for another” (p. 351). Leon-Dufour (1988)
observes that this feeling has its seat in the maternal bosom
or in the bowels (or, as we would prefer to say, heart) of thefather. It is a tenderness which drives a person to action on
behalf of those in distress.
The New Testament writers often use éleos (mercy) when
speaking of compassion (Bergant 1996). A form of the verb
oiktiro (connoting sympathy) also appears. However, whenreference is made to the compassion of Jesus, splánchnon isalways used. Köster (1985) provides a convenient summaryof this Greek word’s derivation and its employment in thesacred texts. In early Greek usage, the word denotes the“inward parts” of a sacrifice. Later, it was used to refer to the“inward parts of the body,” and finally to the womb. We alsofind the noun form used in the Testaments of the Twelve
Patriarchs. There it denotes “the center of feelings” or “noble
feelings.” On one occasion the verb is used to indicate mere
emotion, but it generally refers to the inner disposition which
generates acts of mercy. The adjective, eúsplanchnos(tender-hearted), denotes human virtue and the disposition of“pity.”The noun appears in three of Jesus’ parables: the Good
Samaritan, the Prodigal Son and the Unmerciful Servant. Of
particular interest for our discussion is the way Paul describes
compassion. Only the noun occurs in his writings. He uses
splánchna not merely to express natural emotions but as “avery forceful term to signify an expression of the total
personality at the deepest level” (Köster 1985, p. 1068). It
occurs twice in Philemon (vv. 7, 20); reference is made to therefreshing of the splánchna. In v. 12 of that letter, Paul saysthat in Onesimus he is, in effect, coming in person with aclaim for Philemon’s love. Phil. 1:8 contains a unique phrase.
Paul declares that “God can testify how I long for all of you
with the affection (splánchna) of Jesus Christ.” The reference22

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

is to “the love or affection which, gripping or moving the whole
personality, is possible only in Christ...” (Köster 1985, p.
1068).
In these various uses of the word compassion by the biblicalauthors, there are a number of key features. First, the idea oftenderness comes out in a number of places. Second,
compassion is associated with an instinctive, intimate
relationship: it is like the loving, soothing action of a mother orfather. Finally, it refers (most clearly in Paul’s usage) not justto an emotion, but to the deepest part of the personality. This
depth dimension is indicated by the cluster of inner parts
identifying the seat of the emotion—namely, the womb, thebowels, and the heart.
In the Bible, then, we have a picture of compassion
according to which a person is in such deep solidarity with thepain of another that she takes that pain into herself. She
receives the other in her suffering and distress in her
innermost space (the heart or the womb). This notion ofcompassion-as-receptivity is developed by the French
Christian philosopher, Gabriel Marcel.
Marcel (1964) establishes the link between receptivity anddisposability (disponibilité) using the metaphor of “incohesion.” To exist with others, he observes, is to be exposed
to influences. It is not possible to be human without to someextent being permeable to those influences. Permeability, inits broadest sense, is associated with a certain lack ofcohesion or density. Thus, the fact of being exposed toexternal influences is linked with a kind of in-cohesion. I am
“porous,” open to a reality which seeks to communicate withme. Marcel (1964) puts it this way: “I must somehow makeroom for the other in myself; if I am completely absorbed inmyself, concentrated on my sensations, feelings, anxieties, itwill obviously be impossible for me to receive, to incorporate
in myself, the message of the other. What I called incohesion
a moment ago here assumes the form of disposability…” (p.
88).
Disposability, then, is closely associated with receptivity. As
we saw above, receptivity involves a readiness to makeavailable your personal center, your innermost domain (recall
the metaphors of the womb and the heart). Marcel (1964)
uses a different metaphor to capture this phenomenon; herefers to inviting others to be chez soi (at home). He observes
that we receive others in a room, in a house, or in a garden,
but not on unknown ground or in the woods. Receptivity
means that I invite the other to “be at home” with me. A homereceives the imprint of an individual’s personality; somethingof myself is infused into the way my home-space isconstructed. Contrast this with “the nameless sadness”
associated with a hotel room; this is no-one’s home. To share
one’s home-space is disposability or availability because “[t]oprovide hospitality is truly to communicate something of
oneself to the other” (Marcel 1964, p. 91).
The meaning of hospitality can also be broadened toinclude receiving into the self the appeal of another forunderstanding and compassion. When I open myself to thecall of the other to be with her in her pain and confusion, I am
able to spontaneously feel with her. The intonation of mywords, my posture, and my facial expressions say to her that I
am with her in her suffering. Contrasted to this
responsiveness, however, there is an indisposability which
Marcel refers to as an “inner inertia” or “spiritual asthenia”(Marcel 1964, p. 50). The distress of the other is experienced
as something alien; I simply cannot receive it into myinnermost sphere. To illustrate this fundamental lack of
responsiveness, Marcel (1964) contrasts the mundane
scenario of a person asking for information which is not at
one’s disposal with the case of a person appealing to one’s
sympathy. In the first case, I must respond to a concrete
question such as: What is the population of Rome? I go

through my “file” of information and find that there is nothingavailable in relation to this question. Marcel (1964) thenmoves to the appeal from the other for understanding of her
personal distress. In response, I can “utter certain formulas”
from my repertory of sympathetic responses, but this is “onlyreading something out of a catalogue” (pp. 50-51); it is not
feeling-with her. The only way to break out of this “selfobsession,” according to Marcel (1964), is by “submerging
oneself suddenly in the life of another person and being
forced to see things through his eyes” (p. 51). A person
cannot break out of this “inner inertia” relying only on her own
personal resources; it is through the presence of anotherperson that this “miracle” is accomplished.
It is worth noting that what Marcel is talking about here is
sympathetic rather than empathetic engagement. Empathy
and sympathy are not interchangeable terms (Chismar 1988;
Wispé 1986). The form of the substitution in the two isdifferent. “In empathy, we substitute ourselves for others. In
sympathy, we substitute others for ourselves. To know what it
would be like if I were the other person is empathy. To knowwhat it would be like to be that other person is sympathy”(Wispé 1986, p. 318; emphasis in the original). Marcel issuggesting that to move from cohesion to in-cohesion, tobecome porous to the other’s suffering, requires imagining
what it would be like to be the other person. The clinician who
lacks compassion needs to substitute the other for him- or
herself. He or she needs to grasp what it is to be thisperson—someone who is suffering pain and discomfort,
disorientation, loss of independence, and anxiety.
In Conversation with the Buddhist Tradition
We saw above that in both the Hebrew Scriptures and the
New Testament compassion is viewed essentially as taking
the pain and distress of the other “to heart.” Buddhists have asimilar notion (Dalai Lama 1999; Salzberg 1995). The Paliand Sanskrit word karuņā, “compassion,” literally means“experiencing a trembling or quivering of the heart in
response to a being’s pain” (Salzberg 1995, p. 104).
In the texts of early Buddhism, the term often refers to amental state to be radiated out to all sentient beings (cf.
Aronson 1980; Harris 1997). This is usually taken to be its
primary reference. In the meditation on compassion, a phrase
such as “May you be free of your pain and sorrow” is used
(Salzberg 1995). The one meditating first directs the blessing
toward a person who is experiencing great physical or mental
suffering. He or she then directs the benevolent wish toward a
series of other select individuals. Included in the list is him- or
herself, a benefactor, a friend, a neutral person (someone
about whom the mediating person has neither positive nor
negative feelings) and a difficult person. Finally, the blessing
is radiated out to all sentient beings.
It is held that compassion and loving-kindness are(potentially at least) fundamental characteristics of all human2
beings (Dalai Lama 2002; Dreyfus 2002; Master Sheng-Yen
1998). But the compassion that exists naturally in humanbeings is not particularly strong and neither is it universal; itneeds to be developed. While persons naturally feelcompassion toward those that they like, the situation may bequite different in relation to strangers. Certainly, it is not often
the case that a person responds with compassion to thesuffering of an enemy. In contrast, the Buddha held up theideal of compassion for all sentient beings.
What is required of the person on the path to enlightenmentis a state of equanimity. Equanimity (upekkhā) is along withcompassion one of the four brahma-vihāras or sublime
attitudes (the other two are loving-kindness—mettā , and2

Actually, Buddhists believe that this is true of all sentient beings.

Eubios Journal of Asian and International Bioethics 25 (January 2015)
sympathetic joy—muditā). Upekkhā is even-mindedness or
impartiality. It should not be confused with feeling
equanimity—a stance that will become important for us below.
The former attitude refers to extending your compassion
impartially and therefore to all sentient beings; the latter
indicates “the experience of neither pain nor pleasure…and it
can arise in wholesome, unwholesome, and neutral states ofmind” (Aronson 1980, p. 81). Importantly, the stance of feeling
equanimity should not be equated with the absence of feelingor emotion.
In the Māhāyana tradition, the bodhisattva is one who has“the great compassion” (māhā karuņā ). Though the primaryreference to compassion is the meditative practice, it is also
closely linked to liberative action. Out of compassion for thesuffering of sentient beings, bodhisattvas commit themselves
to helping others on the path to enlightenment. They
postpone complete enlightenment and attainment of nirvana
in order to make themselves available for this service.
A distinction is made between bodhisattvas who are
beginners and those who are advanced. Both types areintensive and impartial in their expression of compassion, but
only the beginning bodhisattvas are overwhelmed bycompassion. They are deeply moved by the suffering of otherbeings and sometimes weep in their distress. Those who are
advanced, on the other hand, develop equanimity (i.e., feeling
equanimity). Their compassion is even stronger than that of
the beginners, and it is more balanced in the sense that it
does not result in emotional outbursts.
The cultivation of compassion with equanimity is considered
to be vitally important as it ensures that encounters withsuffering by those on the path will not lead to emotionalturmoil. The Buddhist ideal is calmness or stillness of mind
combined with a heart of loving-kindness and compassion.
“Equanimity allows one to feel compassion for the suffering ofothers without becoming overwhelmed by or neglecting it…
This completely open mental atmosphere depends onachieving a state of emotional nonattachment in whichperception is not directed by our self-ascribed interests”(Friedland 1999, p. 39).
The Buddha taught that associated with all experiences inlife are three feeling states—namely, pleasure, pain, andneutrality. The aim of those on the path is the cultivation of anonreactive stance in relation to the various states. In order todo this, they must counteract their natural tendencies. Whenexperiencing something that is pleasant, a person naturally
wants it to continue; she clings to it. Here she is encountering
a fundamental cause of dukkha—suffering or, better,
disquietude or unsatisfactoriness. That cause is attachment.
When a person suffers a painful experience, she views it as
negative and she instinctively wants to push it away. Anotherbasic cause of dukkha surfaces here—namely aversion. If theexperience is neutral in tonality, a person habitually falls into
inattention; the lack of stimulation means that she is unable tostay interested and focused. A third fundamental cause ofdukkha is unveiled here, and that is delusion. The way of the
Buddha is balanced response or non-reactivity to thedifferently toned experiences that make up our lives. It may
seem that equanimity indicates an unfeeling stance—andsome scholars of Buddhism have argued this (see, forexample, Spiro 1970)—but this is not the case. In the Pāli
scriptures, it is clearly indicated that the abandonment of thenegative emotions of attachment, hatred, and delusion does
not mean the destruction of all emotion (cf. Aronson 1980, p.
95). Those who have chosen the way of non-attachment may
experience a rich and fulfilling emotional life. Salzberg (1995)
expresses the situation well, “Meditation does not turn us into
gray, vegetative blobs with all feelings washed out. The
Buddha taught that we can feel pleasure fully, yet without
craving or clinging, without defining it as our ultimate

23

happiness. We can feel pain fully without condemning or
hating it. And we can experience neutral events by being fully
present…This non-reactivity is the state of equanimity, and it
leads us into freedom in each moment” (p. 144)
In sum, compassion in the Buddhist tradition is construed as
opening to the suffering of others while maintaining a stanceof non-attachment. Non-attachment should not be interpreted,however, as indicating a lack of emotion or feeling. It is heldthat it is possible to sorrow with those who are sorrowing,
while maintaining a calm, balanced state of mind.
One can easily see how this insight from the Buddhist
tradition can be profitably applied in the healthcare context.
The caring clinician needs to open herself to the suffering ofher patients without becoming overwhelmed by it. I hasten to
point out that this stance of compassion with equanimity isdifferent from the detached approach that has sometimes
been advocated in the past. In his Valedictory Address
delivered at the University of Pennsylvania in 1889, Sir
William Osler exhorted the Medical School graduates tocultivate equanimity or imperturbability. This essential quality“means coolness and presence of mind under all
circumstances, calmness amid storm, clearness of judgment
in moments of grave peril, immobility, impassiveness…”(Osler, 1963, p. 27). Osler (1963) recognizes the value insensitivity, but only on the condition that it does not interferewith calmness and control. In fact, in order to ensure that thephysician operates with an optimal level of composure, heshould cultivate “a judicious measure of obtuseness” (Osler,
1963, p. 28). Aring (1958) echoes the views of Osler. He
advocates a “reflective commitment” to the patient’s problem
while at the same time maintaining equanimity. In order tocarry out his or her clinical duties with maximum
effectiveness, the physician identifies to an extent with thepatient’s situation, while at the same time standing apart from“the enervating morass” (Aring, 1958, p. 440).
What the Buddhist tradition indicates vis-à-vis clinical work
is quite different. Buddhist masters would feel very
uncomfortable with expressions such as “a judicious measureof obtuseness” and standing apart from “the enervatingmorass.” These clinical approaches connote detachment
rather than the non-attachment or non-grasping advocated by
Buddhist teachers. These teachers claim that it is possible tomaintain inner calm and freedom of spirit while opening
oneself to the suffering of others.
Conclusion
The biblical view of compassion as receiving the suffering of
the other in one’s innermost space (the “womb,” the “heart”)
takes us to the center of what is involved in this vitally
important human quality. It establishes an ideal forcompassionate clinical work. The clinician who acts withcompassion opens herself to the suffering of her patients. To
use Marcel’s metaphor, she is porous in their presence. She
facilitates a humanized engagement in which connection withthe lived experience of the illness is accorded the sameattention as skilled diagnosis and treatment.
Of course not all clinicians have a capacity forcompassionate care; they suffer in their work from “spiritualasthenia.” The only way for them to move past this, according
to Marcel, is to break through the wall that has been erected
and enter into the experience of the patient. That is, theyneed to imagine what it is to be this person—to be someone
who is experiencing pain and discomfort, disorientation, fear,
and uncertainty. In the absence of any attempt to reachacross the interpersonal space, there is simply no possibilityof growing into compassion.
The danger in opening oneself to the suffering of others isthat one may be overwhelmed by it. The Buddhist ideal ismost helpful at this point. The Buddha taught opening oneself

24

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

to the distress of the other while maintaining calmness or
stillness of mind. This is particularly appropriate in the context
of healthcare. The healthcare professional needs to be able toadopt a compassionate stance to the suffering of her patients
without becoming burdened and distressed by it.
References
Aring, C.D. (1958). Sympathy and empathy. JAMA 167, 448-452.
Aronson, H.B. (1980). Love and sympathy in Theravāda Buddhism.
Delhi: Motilal Banarsidass.
Bergant, D. (1996). Compassion. In C. Stuhlmueller (Ed.), The
Collegeville pastoral dictionary of biblical theology (pp. 154-157).
Collegeville, MN: The Liturgical Press.
Brien, S. & Lewith, G. (2001). Why are you doctors? The importanceof care and compassion. Clinical Medicine 1, 223-226.
Chismar, D. (1988). Empathy and sympathy: The importantdifference. The Journal of Value Iquiry 22, 257-266.
Coulehan, J.L. (1995). Tenderness and steadiness: Emotions inmedical practice. Literature and Medicine 14, 2, 222-236.
Dalai Lama (1999). Ethics for the new millennium. New York:Riverhead Books.
Dalai Lama (2002). Understanding our fundamental nature. In R.J.
Davidson & A. Harrington (Eds.), Visions of compassion: Westernscientists and Tibetan Buddhists examine human nature (pp. 6680). Oxford: Oxford University Press.
Dougherty, C.J. & Purtilo, R. (1995). Physicians’ duty of compassion.
Cambridge Quarterly of Healthcare ethics 4, 426-433.
Dreyfus, G. (2002). Is compassion an emotion? A cross-cultural
exploration of mental typologies. In R.J. Davidson & A. Harrington(Eds.), Visions of compassion: Western scientists and Tibetan
Buddhists examine human nature (pp. 31-45). ). Oxford: Oxford
University Press.
Friedland, J. Compassion as a means to freedom. The Humanist 59,
35-39.
Graber, D.R. and Mitcham, M.D. (2004). Compassionate clinicianstake patient care beyond the ordinary. Holistic Nursing Practice 18,
2, 87-94.
Halpern, J. (1993). Empathy: Using resonance emotions in theservice of curiosity. In H.M. Spiro et al (Eds.). Empathy and thepractice of medicine: Beyond pills and the scalpel, pp. 160-173.
New Haven: Yale University Press.
Halpern, J. (2003). What is clinical empathy? Journal of General
Internal Medicine 18, 670-674.
Harris, E.J., (1997). Detachment and compassion in early Buddhism.
Bodhi Leaves Publication no. 141, 1-16. Kandy: Buddhist
Publication Society.
Hojat, M., Gonnella, J., Nasca, T., Mangione, S., Vergare, M. andMagee, M. (2002). Physician empathy: Definitions, components,
measurement, and relationships to gender and speciality. The
American Journal of Psychiatry 159, 9, 1563-1569.
Köster, H. (1985). Splánchnon. In G. Kittel & G. Friedrich (Eds.),
Theological dictionary of the New Testament, one vol. ed. (pp.
1067-1069). G. Bromiley (trans). Grand Rapids: Eerdmans.
Landau, R.L. (1993). …And the least of these is empathy. In H.M.
Spiro et al (Eds.). Empathy and the practice of medicine: Beyond
pills and the scalpel, pp. 103-109. New Haven: Yale University
Press.
Leon-Dufour, X. (1988). Mercy. In Dictionary of biblical theology 2nded., updated (pp. 351-354). P. Cahill & E. Stewart (trans.). London:
Geoffrey Chapman.
Marcel, G. (1964). Creative fidelity. R. Rosthal (trans.) New York: The
Noonday Press.
Master Sheng-yen (1999). Subtle wisdom: Understanding suffering,
cultivating compassion through Ch’an Buddhism. New York:
Doubleday.
Osler, W. (1963). Aequanimitas and other papers that have stood thetest of time. New York: W.W. Norton.
Pellegrino, E. D. (1979). Humanism and the physician. Knoxville: The
University of Tennessee Press.
Pellegrino, E.E. & Thomasa, D.C. (1997). Helping and healing:
Religious commitment in health care.
Washington, D.C.:
Georgetown University Press.
Pembroke, N. (2007). Empathy, emotion, and ekstasis in the patientphysician relationship. Journal of Religion and Health 46, 287-298.
Rhodes, R. (1995). Love thy patient: Justice, caring, and the doctorpatient relationship. Cambridge Quarterly of Healthcare ethics
4,434-447.

Salzberg, S. (1995). Lovingkindness: The revolutionary art ofhappiness. Boston: Shambhala.
Spiro, M. (1970). Buddhism and society: A great tradition and its
Burmese vicissitudes. New York: Harper & Row.
Spiro, H.M. (1993). What is empathy and can it be taught? In H.M.
Spiro et al (Eds.). Empathy and the practice of medicine: Beyond
pills and the scalpel, pp. 7-14. New Haven: Yale University Press.
Stevenson, A.C.T. (2002). Compassion and patient centred care.
Australian Family Physician 31, 12, 1103-1106.
Sulmasy, D.P. (1997). The healer’s calling: A spirituality forphysicians and other health care professionals. New
York/Mahwah, N.J.: Paulist Press.
Thomasa, D.C. & Kushner, T. (1995). A dialogue on compassion andsupererogation in medicine. Cambridge Quarterly of Healthcare
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Wispé, L. (1986). The distinction between sympathy and empathy: To
call forth a concept, a word is needed. Journal of personality andsocial psychology 50, 314-321.

Ethical Issues of WirelessSensor Network in Health Care
Applications- J. Thresa Jeniffer
Department of Computer Science Engineering,
St. Joseph’s College of Engineering, Jeppiar Nagar, OMR Road,
Chennai – 600 119, Tamil Nadu, India
Email: jjeniffer24@gmail.com- J. Joannes Sam Mertens
Department of Electronics and Communication Engineering, SSN
College of Engineering, Kalavakkam, OMR Road, Chennai, India

Introduction
Advances in medicine and reduction in morbidity rates arelending to an aging populations of human beings. Especiallyin developed countries there is a tendency towards
gentrification of the population. It is speculated that in 2060,
30% of the human population in EU countries will be at or
above 65 years old. Similar situation would be found inJapan, USA and Canada. Hence efficient and effective agedcare will become an important issue.
Hospitals, careproviders and nursing homes may not have enough facilities
to look after the aged people. When people become older
they feel a decline in their cognitive, sensory and motor
functions. Hence even simple tasks become difficult for themand they cannot look after them safely. Hence they have tobe shifted to institutional care facilities or retired homes. In
this context, Ambient Assisted living gains importance inwhich WSNs will assist and monitor the aged or patientsassuring a better quality of life.
Applications
The health care applications of WSNs include monitoring
temperature, respiration, heart rates, pulse, blood pressure
and blood glucose levels of the patient. The medical sensors
can closely monitor the patient’s physiological conditions.
After sensing the vital body signs, they can be transmitted
after returning home becomes feasible. WSNs are very
useful for people affected by Alzheimer’s disease as theyexperience progressive neurological disorder. They can behelped by WSNs in carrying and their routine activities.
Components of WSN
The key components of WSN include sensor coverage area,
sensor mode, sink node and WSN manager.
The
geographical region covered by the WSN is the sensor
coverage area and the sensor node is the actual sensor
device. The sink node is provided with the additional
networking capacity like WiFi, 3G or internet connection.

Eubios Journal of Asian and International Bioethics 25 (January 2015)
WSN manager helps in managing WSN with the software
hosted on fixed workstation. The components of sensor node
are Transceiver, power, processing and sensing units. The
power unit comprises of several alkaline or lithium batteries or
solar power units. The processing unit has a microcontroller
and flash memory. The transceiver unit looks after thecommunication with the other nodes while the sensing unit
will generate an analogue signal, convert it to digital andtransfer it to the processing units.
Ethical issues
There are ethical issues related to the applications ofWireless Sensor Networks. Most of them involve privacy of
the users. There are also concerns about the security of
information. WSNs are vulnerable to security attacks.
Privacy issues
In health care applications, the medical data transmitted
should remain confidential. But WSNs are prone to attacks
and may be accessible to others. The threats can come frompassive attacks like listening into data or active attacks likemanipulation of the data. According to NCVHS (National
Committee for Vital and Health Statistics) of the United States
Department of Health and Human Services “Healthinformation privacy is an individual’s right to control theacquisition, uses or disclosures of his/her identifiable healthdata.” Individuals have to share their data with doctors,
sports team trainers, relatives, friends, family members or
insurance companies. Unauthorized collection of data or its
leakage may harm the patient. If an intruder alters the
medical data of a patient, it may pose life-threatening risks.
Misuse of medical information, leakage of prescriptions andeavesdropping on medical data are some of the privacy
issues on health care applications of WSNs. When thepatient’s data flows in the WSN, it is prone to wireless threats
like eavesdropping and snooping.
Leakage of medicalprescriptions can be a big source of privacy violations. Data
eavesdropping may cause damage to the patient as his data
can be used for illegal purposes, which will breach his
privacy. If the privacy issues are not addressed properly, it
may lead to public mistrust and the benefits of WSN
technology cannot be reaped. There are privacy issues like
who can have permission to own the data, what type of data,
how much and the place of collection of data and who caninspect the data. Normally the medical data of particularpatient has to be accessed by the physician, nurses andclinical staff. Hence there should be firm guidelines anddefined regulations about the uses of medical data for privacy
to be maintained. In emergency situations there can be
flexibility in other people having access to such data. At thesame time, the data should not be accessible to persons withmalicious intend. Hence to avoid such issues the information
sensual through WSNs can be encrypted and awarenessabout the importance of keeping privacy can be createdamong the public.
Security issues
Security involves the maintenance of protection that ensurea state of inviolability from hostile influences.
As thecommunications in WSNs are wireless in nature, there are
more possibilities of threats and attacks to security. They
may be of system security and information security. The
attackers may change the destination of packed data or steal
the data by eavesdropping. The sensor devices have little
external security measures and hence are prone to physicaldamage. During transmission of data through networks, vital
data may be stolen by eavesdropping. According to Kargl etal. (2008) the attacks include, eavesdropping and modificationof medical data, forging to alarms on medical data, denial of25

service, location and activity tracking of users, physicaltampering with devices and jamming attacks. Wireless media
are more vulnerable than wired media to attacks and threats.
In selective forwarding threat, malicious nodes can refuse to
forward certain messages like patient’s data and it may not be
broadcast further. In sinkhole threat, the attacker can attract
all neighbouring nodes to form routes through a malicious
node.
A compromised node may prevent multiple false identities
to other neighbouring nodes in the network resulting in Sybil
attack. As wireless rely nodes are unguarded, a rogue rely
node may provide unrestricted access to an attacker who cancause a masquerade. In certain cases false alarms can becreated which will result in the rescue operations of theemergency team futile.
Masquerading nodes are very
dangerous in health care applications as they can apply
denial of service attacks disrupting the application operation.
If such a node capture the medical data of a patient, thesecaptured messages can pose replay threats, when the
medical treatment relies on fresh messages from the medical
sensors, masquerade nodes replay the old messages which
may lead to mistreatment and over treatment.
WSNs help patient mobility and his location can be traced
with system based on radio frequency, ultrasound, or
received signal strength indicator or geopositioning. If suchsignals are intercepted by an adversary, it could directly
infringe a person’s privacy. If an athlete is monitored, theadversary can modify his health data which may lead tosuspicion in doping tests and spoiling of his sports career.
Denial-of-Service (DoS) attacks can be on physical, link,
network and routing, transport and application layers throughjamming, node tampering, collision, exhaustion, neglect andgreed, homing, misdirection, spoofing, replaying, routingcontrol traffic or clustering messages, flood and desynchronization, overwhelming sensors and reprogramming
attack. These attacks may cause damage to the WSNs andlend to the loss of the patient’s life in health care applications.
Ashraf et al. (2009) suggested that safety should
accompany the availability, scalability, efficiency and thequality parameters of inter-node communication. For having
system security safety measures have to undertaken atadministrative, physical and technical levels.
Keeping valuable and personal information in network
devices leaves the data at serious risk to theft, sabotage,
exploitation and manipulation.
Hence for achieving
information security, data encryption, data integrity,
authentication and freshness protection can be incorporated.
Security mechanisms
These mechanism help to detect, prevent and recover fromsecurity attacks. As sensitive information is handled by
WSNs, strong cryptographic functions like encryption,authentication and integrity can be adopted to prevent
malicious attacks. Key management protocols can be applied
to distribute different types of cryptographic keys. They
include trusted server, key pre-distribution and self enforcing
protocols. Secure routing protocols have to be designed to
avoid security vulnerabilities.
Conclusion
WSNs make the life of people more comfortable andprovide viable solutions for health care applications. As there
are several security and privacy issues in WSN application,
they need to be addressed at the starting point of design,
deployment and implementation of any application. Thus afool-proof security mechanism must be designed for the
successful deployment of WSN application. People will trustit, if the technology is safe.

26

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

Acknowledgements
The authors thank the authorities of their colleges forencouragement.
References
Ameen, M.A., J.Lieu and K.Kwak 2012. Security and privacy issues in
Wireless Sensor Networks for Health care Applications. Journal of
medical systems 36: 93-101.
Ashraf, A., A.Rajput, M.Mussadiq, B.S.Chowdhry and M.Hashmani.
SNR based digital estimation of security in wireless sensor
networks. In: Communications Infrastructure. Systems andApplications in Europe 16:35-45.
Corke, P., T.Wark, R.Jurdak, W.Hu, P.Valencia and D.Moore 2010.
Environmental wireless sensor networks. Proceedings of the IEEE.
98: 1903-1917.
Kargl, F., E.Lawrence, M.Fischer and Y.Y.Lim 2008. Security, privacy
thand legal issues in pervasive health monitoring systems. 7
International Conference on Mobile Business, ICMB, pp 296-304.
Kumar, P and H.Lee 2012. Security issues in Healthcare applications
using wireless medical sensor networks: A survey. Sensors 12: 5591.
Kumar, Y., R.Munjal and K.Kumar 2011. Wireless sensor networks
and security challenges. In: National Workshop cum conference on
Recent Trends in Mathematics and computing (RTMC 2011),
Proceedings published in International Journal of Computer
Applications, pp 17-21.
Liu, Y. 2012. Wireless Sensor Network applications in Smart Grid:
Recent trends and challenges. International Journal of Distributed
Sensor Networks. Doi 10.1155/2012/442819, 8p.
Mishra, R. and S.Bhatnaar. Wireless Sensor Network and theirgeneralissues.
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O’Hare, G.M.P., M.J.O’Grady, D.Marsh, A.G.Ruzzelli and R.Tynan.
Autonomic wireless sensor networks: Intelligent Ubiquitons
sensing. www.csserver.ucd.ie/~aruzzelli/ pubs/ANIPLA06.pdf.
Ramli, R., N.Zakaria and P.Sumari, 2010.
Privacy issues in
Pervasive Health care monitoring system: A review. World
Academy of Science and Engineering Technology 72: 741-747.
Spasova, V and I.Iliev. 2012. Computer vision and Wireless Sensor
Networks in Ambient Assisted Living: State of the Art andChallenges. Journal of Emerging Trends in Computing andInformation Sciences 3: 585-595.
Steele, R, C.Secombe and W.Brookes 2006. Using Wireless Sensor
Networks
for
Aged
care:
The
patient’s
perspective.
www.epress.lib.uts.edu.au

Sinking of ethics with MV
Sewol- Bang-Ook Jun, Ph.D.
President, Gangneung-Wonju National University, Gangneung 210702, Korea
Email: bojun@gwnu.ac.kr

Abstract
The 2014 sinking of Korean ferry MV Sewol leaves many
victims and social problems behind. It also raises many
ethical problems. This paper reviews its occurrence andethical dimensions in business and governmental ethics,
media reporting ethics and seafarers’ ethics. The ethical study
on this accident will clarify the problems surround the disasterand can prevent further tragedy from occurring.
Introduction
The tragic sinking of Korean ferry MV Sewol occurred on 16
April 2014. Two hundred and ninety five bodies were founddead and nine are still missing. Most of the victims were
Danwon high school students on a field trip to Jeju island. The
sinking was real-time and televised, without any proper

passenger rescue operation, and thus became a great shockto the Korean people.
The ferry that should have been discarded but Illegally
modified for overloading lost balance after the sharp turn by
novice crew members at maenggol channel notorious for its
strong underwater current. The improperly secured cargo fell
to one side of the ship and the Sewol lost restoring force. and
The ferry became tilt and began to take on water. While theauthorities The Sewol sank within two and a half hours. The
captain announced the passengers should stay calm and not
to leave the current position. Only the passengers who
disobeyed this announcement saved their lives. A few
passengers who reached the deck or jumped into the water
were rescued by fishing boats and other commercial vesselsthat arrived at the scene. More lives could have been saved if
Coast Guard and Navy carried out more proper rescue
operation. They did not get into the sinking ship to get any
passenger out. Coast Guard even prevented Navy divers
from participating while waiting for divers from Undine, aprivate underseas rescue operation company. Japan Coast
Guard offered support, but Korea Coast Guard declined thisoffer. The Navy disapproved of an American warship andhelicopters searching for missing passengers. The othergovernmental authorities such as Counter Disaster
Headquarters failed to control the whole emergency situation.
As the public began to condemn the government, thepresidential office even denied their responsibility as a control
tower.
It caused furious political reactions. Victims' families ask toinvestigate the reasons why 304 innocent passengers cameto death being televised by mobile phone messages andyoutube video clips. And they request the person in charge ofthis man-made disaster to be prosecuted.
Besides, there are many efforts to bring the truth of Sewol
into light. Musicians play the music “A thousand winds”,
writers wrote the book "Nation of the blind”, journalists madethe documentary film “The truth shall not sink with Sewol” andthe activists are on hunger strikes and advertise Sewol
tragedy in foreign newspapers.
It can also become an ethical issue. The behavior of many
actors involved can be judged ethically. This paper considers
bleaching of business and governmental ethics, media
reporting ethics and seafarers’ ethics surrounding thisdisaster.
Bleaching of business and governmental ethics
Chunghaejin marine bought the Japanese ship ferry
Naminoue over the average life span of 15 years and illegally
added a 240 passenger cabin under the patronage of Korea
Register of Shipping. on the last voyage They reduced theballast water to hide the overloaded cargo; these in a whole
resulted in a balance problem. Chunghaejin Marine andKorea Resister of Shipping bleached business ethics to makemore profit at the sacrifice of passengers’ safety.
They did not train the crew properly. The 25-year old thirdmate only had one year of experience in steering a ship andan additional five months of experience on the Sewol.
Helmsman had only 6 month of experience on the Sewol. At
the moment of accident, the captain (employed on a one year
contract) was absent from the bridge and they were in control
of steering the ship. There appears to have been a deficiency
in training relating to emergency planning. This is an ethicalissue since emergencies can happen at any time. Staff
training is essential and should always include emergency
training (1). And risk can be managed by following the
precautionary principle. There seems to be suspicious
connections among the ship owner, ship resister office, navy
and coast guard. These ethical bleaching and corruption
altogether make simple accident into horrible disaster.

Eubios Journal of Asian and International Bioethics 25 (January 2015)
Bleaching of media reporting ethics
The Korean media did not show enough level ofprofessional ethics violating a set ethical guidelines onreporting disasters and major accidents provided by
Journalist Association of Korea. Some reports were notcorrect; at first, MBC reported that all passengers have been
rescued. This news was re-reported by other news media. If it
were not any reports that almost all of the passengers were
saved in the first few hours, the rescue operation could be
more efficient. Other reports were blamed for theirsensationality; the reporters desperately in need of the news
materials contacted survivors and victims families and friends
from the sinking ship (2).
During the capsizing, it was thought that passengers madecalls and sent messages. But later some of the survivors'
messages inside the capsizing ship were found fake.
Some intentionally posted the malicious hoax messages
Other who believed these messages true shared thesemessages. The problem worsened immeasureably whenconventional media disseminated these messages to the
public. Intentional or unintentional spreading of thesemessages may have retarded the rescue. The problem
worsens immeasurably when trusted conventional media
streams are utilized (3).
Bleaching of Seafarers’ ethics
Above all, the ship crews, especially the captain should beblamed not to meet ethical standards. They abandoned thesinking ship first, left many passengers on board without
giving any proper information for evacuation.
It seems that we cannot blame the coast guard for notgetting into the sinking ship to risk their lives but at minimumon the rule of beneficence we can blame the captain andcrews members for abandoning the ship and not giving
passengers information for evacuation.
The captain’s ethical responsibility can be simply expressedin a phrase “the captain goes down with the ship.” Thecaptain did not make any efforts to rescue passengers undercondition of minimal risk. Rule of beneficence argue that aperson P has an obligation of beneficence to help anotherwhenever the other is at risk of significant loss of or damage
to some basic interest; P's action is necessary (singly or
collaboratively) to prevent this loss or damages; P's action(singly or collaboratively) is likely to prevent the loss ordamage; and P's action does not present significant risks,
costs, or burdens to P while the benefit that the other person
can be expected to gain outweigh any burden that P is likely
to incur. Some legal punishments for failure by the rule ofbeneficence may be justified (4).
At now there is no specific international regulation on
violating captain’s professional ethics. While United States
law does not require a captain to stay on the ship (5), Korean
Seafarer Act Article 10 says “The captain must checkpassenger’s safety and should remain on the ship during adisaster.” Article 11 also says that, “The captain should try
his/her best to save the passengers’ lives, ship and cargoes,”and Article 106 says, “Any captain who violates Article 11
shall be subjected to an imprisonment under 5 years.”
In other countries such as Taiwan, the law also requires it.
Taiwanese Seafarers Act Article 73 says “1. If a ship is in
imminent danger, the master shall endeavor to adopt any
measures to save the human lives, ship and cargoes. 2. No
matter what danger occurs during navigation, the master shallnot abandon the ship unless has consulted with otherseafarers. Nevertheless, the master has the right to makefinal decision. When the ship shall be abandoned, the mastershall endeavor to rescue the passengers, seamen, ship
documents, mails, moneys and precious articles. 3. The

27

master, if violate the regulation stipulated in Paragraph 1 and2 shall be responsible for the measures adopted by him/her.”
And Article 76 says, “any master who commits the provisionsof Paragraph 3 of Article 73, shall be subject to an
imprisonment under seven years, and subject toimprisonment from 3 to 10 years for causing death to another.”Conclusion
The tragic sinking of MV Sewol is yet to be solved. The
captain and other crews who abandoned MV Sewol are being
indicted on charges of murder and abandoning the ship, butlegal punishment alone is not sufficient. If we try our best to
clarify the issues in many dimensions including ethicaldimension, we can prevent further tragedy. If we fail, it canhappen again and it will cost many lives of innocent people. It
is one of ethicists’ duty to consider the ethical dimension of
the tragedy, mostly can be neglected.
References
1. Brian Keen. 2012. Ethics in Business: Disaster at Sea(http://www.canadaone.com/ezine/mar2012/ethics_costa_concordia.
html)
2. Kim Tong-hyung. 2014. Media coverage on ship sinking has been
pathetic.
Korea
Times,
18
Apr
2014.
(http://www.koreatimes.co.kr/www/news/nation/2014/04/316_155
641.html)
3. Eric Saferstein. 2014. Malicious hoax aboard the MV Sewol.
AGASF: staring down the stampedes, Blog Posted on April 24,
2014. (http://www.agsaf.org/malicious-hoax-aboard-the-mv-sewol)
4. Beauchamp, Tom L. and Childress, James F. 2013. Principles ofthBiomedical Ethics, 7 edition, New York: Oxford University Press,
Chapter 6.
5. Divya Yadav. 2014. Importance of compliance, regulations, andethics in the wake of Korean ferry accident.
(http://anniesearle.com/webservices/Documents/ResearchNotes/ASAResearchNote_201405_Yadav_KoreanFerryAccident.pdf)

Bioscience Ethics Education
Challenges Learning Acrossthe Generations- Irina Pollard, Ph.D.
Department of Biological Sciences, Faculty of Science & Engineering,
Macquarie University, Sydney, New South Wales 2109, Australia.
Email: irina.pollard@mq.edu.au

Abstract
There is an urgent need to reduce the gap in translating
newly acquired knowledge from the bench to the classroom.
With no secure, long-term solutions towards protecting our‘global’ natural and cultural heritages, we must empower
future generations to become sufficiently knowledgeable tobest provide them with a safety net for survival. This proposal
depicts a workable framework incorporating more fully ethicalelements into existing educational programs as taught inscience, medicine, law and economics. To facilitate reform, acommitment to update education and to expand the pool ofindividuals concerned about ‘Global’ ethics would, ofnecessity, facilitate path-breaking discoveries and creative
opportunities for social advancement. I am convinced that
newly created Education Department will enhance thepleasure of learning whilst increasing community accessibility
to much needed ethics education. By working together toimprove the available resources for learning, we will promote
understanding and further endorse relevant themes crucial tomodern bioethics. UNESCO can be a powerful and neutral
platform where stakeholders with diverse backgrounds from28

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

all over the world get together to incorporate updated
education materials and create adaptive change.

as future citizens, in making ethically informed choices aboutthe ‘doing’ of science.

Introduction
One of the activities undertaken to disseminate information
concerning the Universal Declaration on Bioethics andHuman Rights, adopted in 2005 by UNESCO, is the Ethics
Education Program. This program maps existing teachingmaterial in the area of ethics in the Member States of
UNESCO. Different programs are described, discussed inexpert meetings, and made available on the Global Ethics
Observatory website http://www.unesco.org/shs/ethics/geobs.
Experiences concerning the contents, passion, methods andmaterials of existing programs are therefore publicly
accessible and can be exchanged among experts. Teachers
who want to research and initiate ethics teaching can findsuggestions and ideas in the database.
The quality of ethics teaching programs, however, depends
substantially on the quality of the teachers. Ethics teaching
can be made much more influential and attractive for students
if it is presented by a highly qualified, stimulating and inspiring
teacher. The present proposal is an all-purpose guidehighlighting possible ethical dimensions of science and isdivided into two parts – general background and specifics
identifying skills where I may possibly be useful in facilitating
a flexible series of interconnected workshops and educational
tools in bioscience ethics. The specific themes, as identified
in Part 2, can readily be up-graded or adapted for teamteaching and integrated as required within the overall
curriculum of our fledgling UNESCO Education and Research
Departments. Bioscience ethics facilitates free and accurate
information transfer from applied science to applied bioethics.
Its major elements are increased understanding of biologicalsystems, responsible use of technology, and curtailment of
ethnocentric debates to be more in tune with new scientificinsights. Pioneered by me in 1990s, bioscience ethics has
become an internationally recognized discipline interfacing
science and bioethics within professional perspectives suchas medicine, law, bioengineering and economics. The
fundamental feature of the discipline is its breadth; thus,
facilitating streamlining of significant aspects across futurelearning/teaching requirements while, at the same time,
provide individual student/teacher choice of topic or field of
endeavour.
Validating science into the teaching and practice of ethics isimportant because science plays a crucial role in the learningof ethical behaviour. Overlooking such critical aspects oflearning must, inevitably, diminish a student’s comprehensionof the true natures of science and of ethics. Scientists and the
population at large are frequently forced to make difficult
value-laden ethical choices which may include choices
between pure and often more lucrative applied research
projects. Critical choices such as whether to work on militaryor non-military projects, whether to generate power fromdepleting energy sources or from renewable energy, by whatmeans should climate change be managed are crucial to our
future wellbeing. Increasingly, potential conflict between
industrial developments and the ecological health needs ofthe planet force us to select from a variety of possible
alternatives – especially since a sizable fraction of current
scientific research is funded by big business or the military
which, predictably, imposes restricted information access on
corporate, security or other grounds. Scientists, because of
their specialized training, have distinct social responsibilities
to ensure that society is sufficiently knowledgeable to assist
their communities make informed choices about the uses andpotential abuses of science. The introduction of biosciencebioethical themes in all education curricula should be adefinite requirement since all students will need to participate,Part 1: General Background: Active Approach to
Learning and Teaching
The delivery of effective education can be through face-toface delivery, multimedia, video and online conferencing
tools, podcasting lectures and 'online only' courses. Whendesigned effectively, e-Learning has been recognised for its
potential to enhance learning and to increase student
accessibility to higher education. Online-based teaching
programs, at their best, promote flexibility in which students
listen to their i-Lectures in private and do their 'homework' in
the classroom with their educators and colleagues. Typically,
the focus is on the topic's most difficult aspects or on
widening the concept through deliberating broader
implications – all promoting valuable learning interactions.
Active learning is about learning by doing – it involves astudent-focused approach and requires students to researchmeaningful learning activities and think about what they are
doing. Active learning demands that students became cocreators of their learning; that is, teaching and learning
activities and the assessment tasks require students toparticipate in their learning. This challenges the more passive
forms of direct instruction since active learning techniques are
far-reaching and may well require students to design theirown activities and assessments, team learn or use group
design. For example, students may choose to modify or upgrade a task, set new standards for the outcomes of the task,
or mark each other’s work, give feedback, and reflect on thelearning research that was developed. In essence, group
work provides a thought-provoking range of opportunities toengage in a wide variety of skills such as resourcefulness,critical thinking, group interaction and communication, time
management, logical and succinct delivery of outcomes,
leadership negotiation, conflict management and much more.
The main principle behind active learning is to directly
engage and to challenge students in activities that activate
both mental and physical skills and to question their own levelof understanding.
Traditional Teaching

Active Learning

Instructor is a knowledgetransmitter.
Students are passive learners.

Instructor is a problem
setter and coach.
Students actively
formulate their own learning.
Students develop cognitive
learning strategies.
Learning focus is on
problem solving.

Students apply acquired
knowledge in tests.
Learning is content-based,subject focused.

Active learning techniques are designed to harness thepower of collective intelligence and network effects.
Active Learning: Example Case Studies
1: Ask your students to choose one slide from a particularPowerPoint lecture presentation which piqued their interestand then expand on the content by providing a couple of extra
slides. In this way students are actively engaged in research
and acquire practical experience in delivering course
materials.
2: Ask your students to write a newsprint article, or produce avideo or audio news report, based on published bio-scientificresearch, or having the students re-write or edit a problematic
newspaper article to be more accurate, more ethicallybalanced. This could include reference to additional media
resources that clarify science-based and ethical perspectives
or clarify the original data where it is available to the public.
3: Group work is where the group is responsible for delivery ofa project outcome or analysis of real-world case studies andEubios Journal of Asian and International Bioethics 25 (January 2015)
dilemmas. Specifics might be to critically appraise the ethics
of a science-based article. Students gain experience in active
rather than passive reading and the critical evaluation of
possible biases, or prejudices, of scientific material aspresented to the general public. Another related technique isto directly engage students in the design and execution oforiginal research, in this case both as researchers andsubjects. This advanced scheme allows the educators to work
alongside the students as peers rather than sitting above
them as judges. A good idea is to ask each student to take ona rotating role of Presenter, Manager and Recorder in
addition to a Reflector role. Leadership roles are thenexperienced by all members of a particular group.
We may well remind ourselves that the word ‘assess’ isderived from the Latin word assidere which means ‘to sit
beside’ emphasizing that teachers and students sit besideeach other as partners with common educational objectives.
In this sense, assessment is not simply a testing and judging(ranking) instrument, but also a nurturing and mentoring toolin the learning and teaching processes.
4: Problem-based learning (PBL) is a popular technique inmedical schools where rather than presenting content as intraditional classroom teaching, the teacher poses a problem
for the students to solve, usually in groups. The main
characteristics of PBL are:
1. Students explore real world, open-ended problems.
2. Learning is largely self-directed, including planning,
implementation and evaluation.
3. The activities are usually conducted in small groups.
4. Teachers take the role of facilitators.
5. Learning outcomes emphasize not only content
knowledge but also process and learning attitudes.
5: Discovery-based learning (DBL) is similar in concept toproblem-based learning. The main difference is that DBL is
structured around practical learning environments such as
science labs. Students are required to design and constructtheir own investigations in order to discover fundamental
principles within a particular domain; i.e., putting theory into
practice.
6: Concept Maps are instructional rubrics that show students
how to make a map with clear routes to their destination –they provide information and direction within the whole picture(see selected example on page 7). Using concept rubrics ineducation is far beyond routine learning as it is aboutengaging students in collaborative, active learning within aframework of social evaluation.
Part 2: Existing Skills and Materials Available to
Education or Research Departments
During the last two decades there has been a considerable
increase in science information followed by rapid
development of new techniques and varied applications.
Applying new knowledge raises new challenges – not least
the challenge of interpreting the ethical significance of any
new scientific application. Despite this, and at a time when
student demand for ethics education is increasing, ethics is
not currently a significant part of the senior high school oruniversity curriculum. Thus it is clear that a greater focus on
science-ethics education is essential. We need to examine ingreater detail the ethical questions arising out of simple
everyday life events, discuss ethical dilemmas and interrogate
and explore new ways of being.
It must be emphasized that children begin to develop
enduring ethical standards at an early age and that thesestandards are realized through experiences of earlychildhood. The junior and senior high school years are crucialtransitional years where students are most susceptible to both29

negative and positive experiences. Consequently, there is aneed for targeted educational programs dealing with lifestylechoices, health and wellbeing ratings, sexual experience,
fertility and responsible reproduction. Long before young
adults consider parenthood a desirable option, they need theopportunity to acquire adaptive biological, technological andethical knowledge. Contemporary subjects dealing with issues
as identified above should be incorporated into the school
curriculum at an appropriate time that correlates with thestudents’ biological age rather than with their chronologicalage.
There are many reasons for my proposal to review existinghigh school curricula. For instance, statistics from differinginternational sources (Australia, Canada and the United
Kingdom, among others) have shown that girls reach puberty
at a younger age and undergo menarche (first menstruation)
years earlier than did girls in the middle of the last Century.
This accelerated development is thought to be predominantly
due to improvements in nutrition and socio-environmental
change while other theories range from rising rates of obesity
to endocrine-disrupting chemical ubiquitously present in ourenvironment. The onset of puberty signals, in both sexes, acomplex period of development experienced as a changing
kaleidoscope of physical, cognitive, emotional and social
capacities that climax in sexual maturity and full reproductive
potential. Indeed, adolescence ushers in profound changes inpatterns of risk taking relating to health.
Reports originating from many countries have establishedthat adolescent sexual experience and heightened substanceuse are significantly interrelated. Notably, high school
students are well acquainted with sexuality and have, on thewhole, had experience with one or more partners before age
17. They also have ready access to tobacco, alcohol and avariety of other recreational substances. Girls, who have gone
through puberty early, are twice as likely to have beenpregnant or aborted a pregnancy at the age of eighteen,
compared with their peers – a serious statistic impacting on
the health of the present and subsequent generations.
Whether the fall in the age of puberty is based on our
evolutionary response to improved health and nutrition or not,we still have an ethical obligation to see that communities
focus on preparing young kids for sexual maturity with all its
attendant vulnerabilities whenever it might arrive. Educationalguidelines for teaching sexuality should promote that all
children need to know about puberty before it happens but fora growing number of primary schoolers this is not the case.
In summary, the above demographics highlight thenecessity for the introduction of a coordinated course, orseries of team taught programs, made available andimplemented by UNESCO’s Education Program, aimed atincreasing reproductive understanding at a stage when theemotional ability to make serious, informed decisions is not
yet fully developed. Across Australian public schools, forinstance, education regarding safe sex practices is not taught
in the classroom until students reach the senior years and, forearly maturing girls, this may not be in time for their firstsexual experience. Even lessons on reproductive biology,
minus sexuality, are generally not taught until later years,
making holistic understanding fragmented and uncoordinated.
Conceiving and bringing up a child is the most important
responsibility any adult can have and there is much to learn
about interacting genetic and epigenetic variables affecting
biological systems and behavioural consequences. Learningneeds to be in tune with present-day reality and insights.
The present proposal aims to build a secular multifaceted
course, or series of programs, informing students and theireducators about important physiological changes that go on inyoung bodies and which may, depending on circumstance,
have positive or negative effects across societies and30

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

generations. The proposed programs (see ‘Lecture
Descriptions and Links’) do not follow or impose a particularmodel or specific view of ethics. Rather they articulate aseries of transdisciplinary topics that reflect and integratecurrent bioscience-bioethical theories and principles as they
relate to human reproduction.
Access to additional potential projects can be found in mystudent text book 'Bioscience Ethics' CUP, 2009 or from myeducation
webportalfreelyaccessibleathttp://www.bioscience-bioethics.org/ . However, in order toincorporate effective tools and innovative ideas into theclassroom teacher guidance has to be provided to ensure thatlearning sessions are culturally appropriate. A related issue
concerns assistance provided in the translation of workshop
subject matters and their realization within individual schools
i.e. ethics from workshop to classroom. Importantly,
educational realizations need to appropriately respect
adaptive local norms and diversity while also protecting
secular stewardship and international rights. Some
communities are also well covered by stewardship of secular
ethics as expressed in mission statements or statements
such as the UNESCO charter.
Figure 1: Emotional Intelligence & Ethics – facets

Emotional or Limbic Brain – interconnects with all outerrings and also connects exclusively with the subcompartments via Functional Compartments (i.e. connected
to = thalamus, hippocampus, amygdala, hypothalamus,
pituitary gland).
Functional Compartments – connected to = thalamus,
hippocampus, amygdala, hypothalamus, pituitary gland.
Emotional Compartments – connected to = perceiving
emotions, reasoning with emotions, understanding emotions,managing emotions.
Measuring Emotional Intelligence – connect to = selfawareness, assertiveness, independence.
Ethics – connected to = innate, self-taught, learned,
improved.

Ethical Behaviour – connected to = social awareness, selfmanagement, relationships management.
Observer’s Creative Space – connected to = newly built
construction.
Bioscience Ethics Education: Downloadable Notes andTeaching Materials
The following tools maybe used to initiate faculty
undergraduate/postgraduate discussion workshops relating topossible ways of incorporating within their institutions formal
bioscience-bioethics
programs
that
supplement
themandatory curriculum.
A: Concept Map
A concept map is a diagram, or graphical tool, showing
possible relationships and is useful in the organization ofparticular ideas and knowledge. For example, the concept
map depicted here refers to the plasticity of the human mind.
The central theme or focus of this diagram is education. To
this end the map provides a set of interconnecting
relationships, ideas, and terms where each layer (ranging
from the innermost to the outermost) can be readily linked
back to its original focus. Students are invited to respond in
three parts by providing links between EQ and ethics
according to individual choice:a)Consider the list of facets provided with each layer.
These are suggestions rather than exhaustive lists, and you
are welcome to use any of these in any combination in youressay, or devise your own (based on these examples).
b)State in your essay what you would title your outerring (where it currently says “Observer’s Creative Space”).
This should be at least referred to in the title of your essay or
it may even be used as your essay title. Make a number ofconnections between your new outer layer and the otherlayers, based on how you consider they interact.
c)
Write an essay on how your chosen topic (the newtitle of your outermost ring) interacts through theconnection(s) you have chosen from the Map (making sure tostate what the connections are in the introduction of youressay).
B: Downloadable i-Lecture and DVDs
Subjects covered in this lecture series promote increased
awareness of self within the environment. Modules 1-3
provide an overview of topics such as the treatment andcauses of infertility, growth and maturation, parental
behaviour and neonate biology and examines the effects ofprocreational biology on the foundation of human social
structure. Modules 4-6 deal with reproduction as it relates tohealth and social issues and reinforces the role ofbiotechnology in the rapid advancement of humanachievements in medicine and veterinary science. Topics
include stress physiology, fertility control, teratogens, human
dominated ecosystems and responsible global stewardship.
Other topics emphasize lifestyle and health, immune
regulation, and the state of wellbeing. To facilitate learning
each module is separated by a series of questions or
problems that the students are expected to discuss byparticipating on the discussion board. Discussion’s intention isto encourage thinking about what has been learned – thedeeper the engagement, studies show, the better theretention. The overall gain is the opportunity to flexibly
integrate and embed digital learning into the fabric of theentire curriculum.
Selected Lectures, DVDs & Links
Module 1: Introduction to Bioscience
Reproduction

Ethics

L1.1:

Reproduction

Bioscience

Ethics&&Eubios Journal of Asian and International Bioethics 25 (January 2015)
The role of ethics in science and technology are explored using
practical applications of reproductive functions in medicine.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=HIMFQAEKwbo
L1.2: Human Origins, Natural Selection & Evolution of Ethics
Traces the evolution of ethical consciousness and relates how ethics
impactsonmodernscienceanditsapplications.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=rSVqkVuGPJc

Module2:

Human

Reproduction

andDevelopment

L2.1:
Fertilization
andtheInitiationofDevelopment
Provides an overview of human reproduction taking particular note oflifestyles, fertility and the ethics of preconceptional care.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=TW1YGbjVC4Q
L2.2:
Development
andPlacentation:
Maternal-Fetal
Communication
Traces the evolution of bonding, the establishment of pregnancy,
placentation and epigenetic gene regulation heritable down thegenerations.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=MAlmCoVWh4s
L2.3:
Patternsof
Human
GrowthTraces life cycle as defined by biological characteristics such as
critical periods during development and factors contributing to
intrauterine
growthrestriction
andpreterm
births.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=D7b83ylZOdM
L2.4: Sex Determination, Brain Sex & Postnatal Personality
Development
Traces the foundation of adult sexuality in fetal life and explores thegeneticsofregularand‘hiddengenders’.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=hcAfMrBDF_U
L2.5: Assisted Reproduction: At the Intersection of Ethics andSocialDetermination
Experience a realistic simulation of routine medical assisted
treatments available to couples seeking fertility assistance at an IVF
clinic.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=bW0iFX7rTq0

Module3:

Gender,Sexuality

andSocialAspects

L3.1: GL1: Transgendered: A Personal Perspective – Katherine
Cummings
Introduces the evolution and wide-ranging bases of thetransgendered
as
lived
by
an
XY
woman.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=OPSdQRUNP6E
L3.2: GL2: Gender Diversity – Gina Wilson and Katherine
Cummings
Traces current political activism supporting Intersex Rights andacceptanceofsexualdiversity.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=AyWtTaZe0eo
L3.3:
Human
Sexuality:
Behaviour&
Pheromones
Describes the chemistry of attachment, desire, kinship laws andincest.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=sMSSHu9r7YI
L3.4:
Sociobiology
Describes the biological basis of social behaviour and fitness
enhancing strategies such as sexual triggers and body image.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=fpAou13S4c0

Module 4: Considerations of Effective and EthicalReproduction
L4.1:
Principles
of
Toxicology&
Teratology
Establishes a better understanding of the science of toxicology withspecialreferencetohuman
reproduction.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=lM268WpvA18
L4.2:
Substance
Abuse&
Parenthood
Describes the physiochemical characteristics of drugs, theneuroendocrinology of addiction and socio-political responsibilities.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=z8uUnEBOHYg

31

L4.3:
Fertility
Awareness
&
the
Aging
GameteCauses of human congenital anomalies at birth are investigated fromthebiological,
behaviouralandbioethicalperspectives.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=nsK2ySJBPms
L4.4:
Parental
Behaviour&the
NeonateEarly developmental patterns and physiological adaptation to
extrauterine
life
arediscussed.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=gDHY6zwnwbU
L4.5 Stress and Adaption: Neuroscience & Neuroethics
The biology of stress from the perspectives of sickness and health,happiness and depression, advances in neuroscience andneuroethics
areexamined.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=dbzzNl8ckw4Module5:

Sustainable

Ethics5.1: Social Discrimination and Health Disparity Across Generations
Challenges social discrimination and health disparity in general and incontemporary
Australia.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=LU1xMSp41LY
L5.2:
Population
GrowthandEconomic
Dynamics
Provides an overview of economic dynamics, sustainable population
growthandmodernapproachestofertility
regulation.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=4gpqXBDGFGo
L5.3:
Human
Dominated
Ecosystems
Environmental priorities are re-evaluated and the effectiveness ofmultiple-entry bookkeeping, stewardship of Earth and the Gaia theoryareassessed.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=uwkRu9mj7LA
L5.4:
Sustainable
Peace
for
a
Sustainable
FutureSelf-sustaining characteristics of the ecology of violence arechallenged and whether modern warfare is fitness enhancing or alosingevolutionary
strategyisquestioned.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=DJT4QDRSHAY

Module6:

EthicsIn

Society

L6.1: GL3: Policy Papers: The Politics & the Ethics – Jenny
Burchmore
Examines the ethical and political dimensions of policy developmentusing case studies in fisheries and water management policy.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=TIwjQq-b7mI
L6.2: GL4: Sustainability Indicators – Morgan Pollard
Reviews the bioethical basis of global limits, ecological economics
andUN
Millennium
development
Goals.
YouTubelink
isasfollows:
http://www.youtube.com/watch?v=f_7CzmohBmU
L6.3: GL5: Ethics of Doing Science – Roger Hiller
Provides an integrated view of academic science, industrial scienceand military science to promote a better understanding of the ethicalimplications of scientific and technological developments.
YouTubelink
isasfollows:
http://www.youtube.com/ watch?v=7iARfSPcTDI

Lecture Associated Movies and Other Resources
Below are two free-to-air public education movies ofinterest.
“Lifestyle, Fertility and the Assisted Reproductive
Technologies” describes
how our life choices andreproductive
healthinterrelate
acrossthegenerations. YouTube linkisasfollows:

32

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

http://www.youtube.com/
watch?v=PE69WMmw8nU“Marsupial
Reproduction and theConservationofEndangered Species”
challenges
humandominated ecosystems,
portrays kangaroos in
the wild and presents
examples of endangered
species and captive
breeding
programs.
YouTubelink
isas
http://www.youtube.com/watch?v=Bq0xxq49C6Q

follows:

The Bioscience – Bioethics Friendship Co-operative
Portalhttp://www.biosciencebioethics.org/ provides accessto educational materials andother useful links for thoseinterested in Bioscience andBioethics.

Student text ‘Bioscience
Ethics’ by Irina Pollard(Cambridge University Press,2009).

References
Cruess, S., Johnston, S. & Cuess, R. (2004). “Profession”: A working
definition for medical educators. Teaching and Learning in Medicine
16(1), 74-76.
Delport, T. & Pollard, I. (2010). Changing perspective on obesity:
Genetic and environmental health consequences in the offspring.
Eubios Journal of Asian and International Bioethics 20(6), 170-173.
Downie, R. & Clarkeburn, H. (2006). Approaches to the teaching of
bioethics and professional ethics in undergraduate courses.
Bioscience
Education
E-journal
5(2)(available
atwww.bioscience.heacademy.ac.uk/journal/vol5/Beej-5.2.pdf)
Eisen, A. & Beny, R. (2010). The absent professor: Why we don’t
teach research ethics and what to do about it. American Journal of
Bioethics 2(4), 38-49.
Healey, M. & Roberts, H. (2004). Introduction – Active learning andthe swap shop. In M. Healey & J. Roberts (Eds). Engaged students inactive learning: Case studies in geography (pp. 1-5). Gloucestershire
UK: Geography Discipline Network.
Kabenov, D., Muratkhan, R., Satybaldina, D. & Razahova, B. (2013).
Ontology-based testing system for evaluation of student’s knowledge.
International Journal of Philosophy Study 1(1), 1-8.
Lizzio, A, & Wilson, K. (2004). Action learning in higher education: An
investigation of its potential to develop professional capability.
Studies in Higher Education 29(4), 469-488.
Lysaght, T., Rosenberger, P. & Kerridge, I. (2006). Australian
undergraduate biotechnology student attitudes towards the teachingof ethics. International Journal of Science Education 28(10), 12251239.
Mackie, J., Taylor, A., Finegold, D., Daar, A. & Singer, A. (2006).
Lessons on ethical decision making from the bioscience industry.
PLoS Medicine 3(5), 605-610.
Pollard, I. (2009). Bioscience Ethics – Student Text. Cambridge UK:
Cambridge University Press.
Pollard, I. (2009). Establishing Institutional Ethics Committees inAustralia: Challenges and operational procedures with particularattention to the new reproductive technologies. Biomedical Law &Ethics 3(2), 197-216.

Pollard, I. (2013). Developmental programming of ethicalconsciousness: Impact on Bioscience ethics education and learning.
Philosophy
Study
3(6),
431-442.
Open
Access:http://www.davidpublishing.com/show.html?13335
Rickard, W. (2002). Work-based learning in health: Evaluating theexperience of learners, community agencies and teachers. Teachingin Higher Education 7(1), 47-63.
Tye, S., Van Rooy, W. & Pollard, I. (2013). Drug and alcohol use,
sexual intimacy and associated health status of senior high school
students: Implications for learning and schooling. Eubios Journal of
Asian and International Bioethics 23(1), 23-30.
Van Rooy, W. & Pollard, I. (2002). Teaching and learning aboutbioscience ethics with undergraduates. Education for Health 15(3),381-385.
Van Rooy, W. & Pollard, I. (2002). Stories from the bioscience ethics
classroom: Exploring undergraduate students’ perceptions of theirlearning. Eubios Journal of Asian and International Bioethics 12, 2630.
Willmot, C. & Willis, D. (2008). The increasing significance of ethics inthe bioscience curriculum. Journal of Biological Education 42(3), 99102.

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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 (ThePhilippines), 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 (Republicof Korea).

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