Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 30 (1) January 2020
www.eubios.info

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

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2020 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents
page
Editorial: COVID19 and Health 1
Darryl Macer
Patients without borders: medical tourism
2Ann Boyd, Brianna Higgins & Katelyn Millison
Experiences of a Japanese couple following fertilization
with a donated egg: the husband’s narrative
7- H arumi Hayashi and Michio Miyasaka
Historical and modern aspects of Islamic
philosophical, religious and ethical traditions inmedicine in Uzbekistan
12 - Mukhamedova Zamira Mukhamedzhanovna &Umirzakova Nargiza Akmalovna
An ethical proposal for Universalism versus relativism
in research
20- Al O. Giwa
Fostering integrity in scientiWic research: understanding
conWlict of interests (COI) through responsible
conduct of research (RCR)
25- Angelina Patrick, Olesen , Latifah Amin, Zurina Mahadi& Maznah Ibrahim
Ordering Renewal
32
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President,
American University of Sovereign Nations (AUSN),
https://www.ausovereignnations.org
Email: darryl@eubios.info
EJAIB adopts and complies with the Committee on
Publication Ethics (COPE) Publication ethics andmalpractice policy. All potential authors should haveread these guidelines and by submission of an article forpublication you acknowledge that you have complied withthis policy. Violations will be handled in proportion to theintention and seriousness of the violation.
Registered address of EJAIB: P.O. Box 16 329, Hornby,
Christchurch 8441, New Zealand

Editorial: COVID19 and Health

Although we are at the beginning of the new
decade, and the new year 2020, already we canpredict that the dominant health issue of the year isthe emergence of a novel coronavirus, named
COVID-19. Although this started in Wuhan, China,
the net around the city was closed too late and thevirus has spread globally. Each country attempts tolimit the spread of the virus through a variety ofmeasures, and quarantine and social distancing have
led to dramatic impacts of the global economy andon the ethics of people as they panic. Please be calm!
American University of Sovereign Nations(AUSN) has just launched a new Postgraduate
CertiWicate Program in Thailand to prepare people
and communities to respond to COVID-19.: https://www.ausovereignnations.org
One of the most signiWicant trends of the past
decade has been the increasing accessibility tointernational travel, where many persons see theworld as a place withut borders. Medical tourism is
discussed by Ann Boyd et al., in this inaugural issueof 2020.
Ironically, with the travel restrictions
imposed by many governments as a response to
COVID19, a pandemic disease, medical tourism isbeing affected negatively.
Still humanitarian
exceptions are permitted by most countries.
The next two papers in this issue look at casesof how culture affects treatment, with Hayashi andMiyasaka documenting a husband’s experiences of aJapanese couple following fertilization with adonated egg. Mukhamedzhanovna and Akmalovna
describe Islamic philosophical, religious and ethicaltraditions in medicine in Uzbekistan.
An ethical proposal for Universalism versus
relativism in research is proposed by Al O. Giwa. A
Malaysian study with broader generailizability on
fosterin g in teg rit y in scien t iWic resea rch:understanding conWlict of interests (COI) throughresponsible conduct of research , is presented byOlesen et al. We welcome further papers to explore
cross cultural bioethics.
- Darryl Macer

2

Eubios Journal of Asian and International Bioethics 30 (January 2020)

Patients without borders: medical
tourism- Ann Boyd, Brianna Higgins, and Katelyn Millison
Hood College, Frederick, MD, USA
Email: boyda@hood.edu

Abstract

Medical tourism is a form of medical travel whereinpatients move across borders from their homecountry to another for the purpose of seeking
medical treatment that is unavailable orunaffordable at home, for the privacy of atransnational location, or for the tourist destination
attractions. Medical tourist may seek procedures
not approved at home, such as stem cell treatments,or physician assisted suicide. International travel forprocedures legal at home and in the destinationc o u n t r y a re p re d o m i n a t e ly m o t iva t e d byaffordability and shorter wait-time. In the U.S. someinsurance agencies offer reimbursement if a patientgoes abroad and has a procedure that is drasticallycheaper. Globalization of health care is becoming afact of life and medical tourism is only one facet ofthe picture. This paper will examine what we know
about medical tourism from a literature survey andevaluate ethical concerns including welfare ofp a t i e n t s ( q u a l i t y o f c a re , p a t i e n t s a fe t y,communication), impact on healthcare systems indestination countries, and effect of medical travel on
public health.

Introduction

Medical tourism is a form of travel wherein patientsmove across borders from their home country toanother to seek medical treatment that isunavailable or unaffordable at home, or for theprivacy of a transnational location or the tourist
destination attractions. However, medical tourists
may seek procedures not approved at home, such asstem cell treatments or physician assisted suicide.
International travel for procedures legal at home andin the destination are predominately motivated byaffordability and shorter wait-time. In the USA, someinsurance agencies offer reimbursement if a patientgoes abroad and has a procedure that is drasticallycheaper. Globalization of healthcare is becoming afact of life and medical tourism is only one facet ofthe picture. This paper reviews medical tourism
through a literature survey and evaluates ethicalconcerns including welfare of patients (quality ofcare, patient safety, communication), impact on
healthcare systems in destination countries, and theeffect of medical travel on public health.
How do people in the US decide to use a
foreign provider for a medical procedure?
Do they investigate the international Winancial
complexity or the impact of healthcare investmentsin the destination countries on the poor? It is likelythat persons facing a healthcare need and difWiculties
to have it performed at home, regardless of thecountry in which they live, may in the age of Internet
simply investigate possibilities to obtain thetreatment they need. Some private hospitals
advertise internationally their high-tech procedures,
Western-trained physicians and comfortableaccommodations.
Motivation for medical tourism
Patients paying out of pocket for elective medical
procedures can shop through websites of hospitals
and medical tourism companies for the procedurethey want. Some medical tourism companies alsooffer to make the needed arrangements. including
travel, visa application, hotel accommodation, andholiday excursion. Patients choose from among
healthcare packages and travel to their selected
destination. Whereas the term “medical travel”
indicates the only purpose is the treatment, “medical
tourism” may imply other factors, such as more
comfort and privacy.
As of 2013, 47 million Americans lacked full
health insurance: some are uninsured, others
underinsured. For these individuals, the dilemma iswhether to go into debt to have a medical procedurein the US, travel to obtain care at a more affordable
price, or go without the medical care they need
(Turner, 2013). Lacking a systematic comprehensive
global database to document how many patients
leave home to receive care at international sites, it is
difWicult to know who is traveling where and why.
Hanefeld (2014) analyzed 100 publications forpatterns motivating medical travel and medical
tourism. Destination countries are known for special
types of medical care. Thailand is known for cardiac,orthopedic and gender reassignment surgery.
Singapore specializes in high-end procedures such asstem cell therapies. Spain is favored for fertility
treatment and Eastern Europe for dental work.
Motivation includes cost savings, waiting time for aprocedure, and availability. Travelers seeking morecosmetic elective procedures cite privacy, comfort
with type of care, and cost.
In a 2016 report released by VISA and Oxford
Economics, the medical tourism industry was valued
at US $439 billion with a projected growth rate of up
to 25% year-to-year for the next decade. The Medical
Tourism Index (MTI) lists 41 destinations for thoseseeking value-added services and high-quality
healthcare (http://www.medicaltourismassociation.
com , accessed 6/23/18).
Cost savings case
Howard Staab, a 53 year old resident of the US
needed heart surgery to replace a failing mitral valve
but he had no health insurance. The local hospital
cost of the surgery was $200,000 with $50,000 down
payment and arranged payments after surgery forthe remainder of the bill. His wife began to search foralternatives. A sympathetic Texas doctor offered to
do the procedure for $45,000. The couple turned toEubios Journal of Asian and International Bioethics 30 (January 2020)
the internet for alternatives. The valve replacement
was performed at Escorts Heart Institute andResearch Center in New Delhi. Treating a
postoperative complication with a second operation,and remaining in India for a month for the total
rehabilitation, the couple paid $10,000 including air
fare (Turner, 2007).
The $190,000 differential
between local US hospital-based valve replacement
and the procedure in India helps explain why someuninsured and underinsured US citizens are willingto travel to access affordable care.
Medical brokerages
Medical brokerages promote travel, cost-effective
healthcare, quality care, and good accommodations.
The companies showcase comparative prices
between countries for the same procedure.
Singapore, Thailand, Mexico and India are ten-times
cheaper for a coronary bypass or knee or hip
replacement than the US. To assure quality of caremany of the brokerages feature international
partnerships. Duke University is in partnership with
the National University of Singapore for graduate
medical school education. Harvard Medical
International and Mayo Clinic are partners in Dubai
Healthcare City.
Many countries depend on tourism for revenue
but medical tourists spend $362/day compared with
$144/day by an average tourist. Revenue promotes
jobs and reduces brain drain because doctors are notas tempted to migrate to developed countries if they
can practice at home. What is less well documented
is how or if the increased revenue improves local
access to healthcare. Turner (2007) suggests thatinternational patient revenue may actually crowdout local patients. “Already in India there are elite,
high-quality medical facilities offering healthcarethat is unaffordable to all but a tiny segment of local
individuals” (Turner, 2007).
In the past, the US was one of the major
destinations for cosmetic surgery, but now better
opportunities are available in developing nations at
more reasonable costs. From 2005-2018 there was a
6-8% reduction in the number of cosmetic surgeries
in the US. The Asia PaciWic region dominates theglobal medical tourism market as of 2018. India,
Thailand and Singapore are advertising aggressively
and effectively.
The Bumrungrad International
Hospital in Thailand and Apollo Hospitals Enterprise
Ltd. in India are top hospitals, accredited by Joint
Commission International (JCI). In 2017, anestimated 2.4 million individuals visited Thailand
seeking affordable and quality medical care (Global
Medical Tourism Market Forecast up to 2025 @https://www.infoholicresearch.com/report/
medical-tourism-market).
Patterns of travel
Historically, people have traveled to sacred springs,
holy sites, and consulted with holy persons in hopesof a cure for an illness. In 20th-21st century medical
travel began with patients crossing borders to obtain3

healthcare unavailable at home and most of thedirection was from developing to developed
countries, what may be labeled South to North. At
the cusp of the 21st century the tide turned andmedical travel shifted to North to South and South toSouth. In 2008, South Americans and Middle
Easterners traveled to North America for treatment(Kelley, 2013). Medical travelers from Asian and
African countries traveled primarily to AsianCountries, especially Singapore, India, Thailand andMalaysia. The pattern in 2018 is shifting from Westto East.
China’s massive investment (US $7.4 trillion) for
the Belt and Road Initiative (BRI) is shifting
economic growth from West to East and may
facilitate a similar change in medical tourism. The
BRI connects Asia with Africa and Europe by landand sea, involving over 70 countries. BRI has
implications in medical tourism based on expanded
transport infrastructure, new high-tech hospitals,
and China has signed a memorandum of
understanding on medical and health cooperation
with the World Health Organization (WHO)expanding cooperation to Belt and Road countries.
Consider the reach of BRI covering 70 countries
containing 70% of the world’s population with 30%
of world’s GDP and 75% of world energy reserves(Youngman, Ian, 2019, Get on Board China’s belt &road initiative” International Medical Travel Journal@ https://www.imtj.com).
Dynamic pattern of medical tourism
Medical tourism is currently characterized by twopatterns: North-South and South-South. Patientsfrom the Global North accessing treatment in private
healthcare centers in the Global South is the NorthSouth group. The more populous pattern is intraregional: 85% of patients traveling to India for
medical care are from other southeastern Asian
countries (Crush and Chikanda, 2015).
South-South medical tourism, including wealthyclients from neighboring countries going to higher
quality private healthcare institutions, mirror thehigh-end tourism from North to South. The
differentiating factor is motivation, distance, andtypes of procedures sought. In contrast, South-South
medical travel is populated primarily by poorer
people desperately seeking life-saving interventions
that they cannot get at home.
South Africa serves both population trends. For
those traveling from the North (UK and Germany) toSouth Africa, the target market is cosmetic
procedures, kidney and stem cell transplantationand fertility treatments. However, South-South travel
for medical procedures in S. Africa is growing andincludes those who come from a growing middleclass of western and eastern African nations, thosesent by government-sponsored medical advisers for
specialized treatment unavailable at home, andmedically disenfranchised individuals fromneighboring countries, such as Mozambique,Lesotho, Swaziland, Botswana, Zimbabwe and4Eubios Journal of Asian and International Bioethics 30 (January 2020)

Malawi. South Africa has a better doctor-patient
ratio than surrounding countries and is a suitable
destination for treatments unavailable at home. The
number of medical tourists in this category is
growing: from 8,000 in 2003 to 180,000 in 2012
(Crush and Chikanda, 2015). Rapid growth andinWlux of patients have consequences to equality ofhealthcare access in South Africa. Denial oftreatment is unconstitutional. The regional medicallyneedy population is putting pressure on the South
African healthcare system.
Neoliberalism influence
Neoliberalism arose after WWII fueled in economic
and philosophical applications leading to
privatization, deregulation and commodiWication of
goods. Neoliberalism expects the state (nation) tocreate circumstances wherein private businesses
Wlourish through low taxes and public funded
incentives. Further it relies on market forces tocontrol distribution of goods. Internationally,
neoliberalism favors free trade, no tariffs, andcompetitive business. World Trade Organization(WTO) and structural adjustment programs (SAPs)
are shaped by neoliberalism philosophy among theG8 countries who dominate Winancial and tradeorganizations. Medical tourism represents acontemporary iteration of the neoliberal philosophy
in global healthcare.
Individuals needing a hip or knee replacement or
cardiac surgery may not be able to afford thetreatment and it is difWicult to blame the needy
patient for seeking more affordable care. One could
suggest that using medical tourism to Wind a more
affordable treatment is wrong because it augments
inequality. The greater moral wrong is the systemic
inequality of healthcare provision within the US (andsuch inequality in healthcare access is not unique tothe US). The US has a patchwork of employer based
private and government-sponsored insurance. Costs
are rising and out of pocket expenses are impacting
access to care. The rising cost of health insurance
premiums is attributable in no small part to the US
decision to allow health insurance companies todetermine premium rates, including allowing
businesses to charge exorbitant rates for covering
persons with pre-existing conditions; and the US
fails to make caring and just rationing decisions
about the use of very expensive ‘last chance’ medical
therapies that offer only marginal beneWits, andrefuses to control medical care costs. The conWluenceof these factors, along with a political system marredby partisanship and a culture of patronage thatfavors special interest groups, such as the healthinsurance lobby, is responsible for the fact thatmillions of Americans do not have health insurance
in 2010 (Meghani, 2011). Comparing the cost of aprocedure between the US and India make theappeal evident: hip replacement in the US averages$43,000 whereas in India it is $9,000; heart bypass
surgery in the US is $130,000 vs $10,000 in India.

India has made medical tourism an export, so tax
breaks are given to facilities and their patients.
Prices in the public sector have increased while
government subsidies to public hospitals havedecreased. Meghani (2011) argues that it is not
ethically right for a citizen of the US to go to India forsurgery to save money because it makes the gap ofaccess to medical care for the rich and poor of India
worse. “One should see the harm and not contributet o i t ; re f u s e t o b e n e W i t f ro m d a m a g e t oothers” (Meghani, 2011). She supports this ethicalposition through a social connection model of
responsibility which argues that there is no clear
direct link between those harmed and those who
beneWit. The social connection model of
responsibility helps evaluate structural processes
that may exploit the marginal or deprive a speciWic
class of people.
Supporting a free market ideology may condone
India’s decision to invest in medical tourism withprivate hospitals, owned or in partnership withcompanies from Australia and Canada and the US,such as the Sir Edward Dunlop Hospital, a US$ 40
million cardiac care facility in Faridabad. Apollo
Hospitals are also Winanced by international
investments.
Government investment in medical tourism
Recognizing the economic value of medical tourism,
countries have chosen to become medical tourism
destinations. Moghavvemi et al. (2017) analyzed
medical tourism facility (MTF) websites for
information about hospital accreditation, cost perprocedure, visa assistance, accommodations,medical record handling, translation services, postoperative care, patient testimonials and virtual tours.
Information varies in content between locations.
There is no regulation on what can be posted.
Consumers should be aware that this information isadvertising-info commercials.
What are the policy implications of MT?
The impact of healthcare access in medical tourism
destination countries relative to just access tohealthcare within the country is a concern (Pocock
and Phua, 2011). With a growing demand for
healthcare access, aging populations, increases inchronic diseases and cost of care escalating, the time
is ripe for countries to position as medical tourist
destinations. Thailand, Singapore and Malaysia werecompared using an inductive theory approach. The
policy used to frame medical tourism in thesecountries overlaps policies about trade and healtht h ro u g h i n te r n a t i o n a l m o b i l i t y, a dva n c e dinformation technology, and expanding the private
healthcare sector. However, trade policies and healthpolicies tend to have conWlicting objectives.
Regulation of trade under WTO and health under
WHO along with regional associations challenge us
to reconcile aims of economic growth with equitable
health services in countries seeking to grow the
medical tourism market (Pocock and Phua, 2011).

Eubios Journal of Asian and International Bioethics 30 (January 2020)
WTO requires legally binding obligations formember nations, including no tariff barriers to tradeof goods and services and have a mechanism toresolve disputes. In contrast, WHO lacks legal
obligations by member nations and has nocompulsory dispute resolution mechanism.
Medical tourism is organized under the General
Agreement on Trade in Services (GATS) allowing forcross border supply of services, consumption ofservices abroad, foreign direct investment in healthfacilities and movement of health professionals.
Malaysia, Cambodia and Vietnam have made GATs in
the health sector, while other countries trade outsideof formal agreements. One advantage of a GAT isthat foreign direct investment can be constrained
protecting health systems from monopolization. All
public hospitals in Singapore are Joint Commission
International (JCI) accredited and publicly owned,
but in some cases, physicians may operate in a
private wing to treat medical tourists. JCI is the mostestablished medical tourist industry accreditor
worldwide. It is used to assure quality, but it is also
voluntary.
Policy recommendation by Pocock and Phua(2011) constitutes an interactive systemic approach(Figure 1) that deals with governance (policymaking
at international, regional and national levels),delivery (private sector growth, foreign investment
in healthcare), Winancing (OPPs organized medical
tourism insurance), human Resources (distributionof specialists between private and public sector
hospitals, future capacity building), and regulation(public and private sphere quality control through
JCI accreditation).
Governance
Delivery

Regula5on

Human
Resources

Financing

Figure 1: Policy creation for medical tourism should
involve an interaction of Wive components in order toprovide safety of patients, uniform standard of care,and promote global healthcare.

Why regulation is a bioethical issue
The medical tourism phenomenon has attracted
academic attention as the Wield expands and policies
are crafted to oversee patient safety, global publichealth, and mechanisms to deal with regulatory
issues. Regulatory considerations should consider
whether the procedure is legal in home anddestination countries, or legal in destination but not
at home (such as euthanasia or stem cell tourism).
Some destination countries (44 nations as of 2001)
include healthcare services of medical tourism under
General Agreement on Trade in Services (GATS) as

5an extension of the WTO, which has legal obligations
among member states with dispute resolution
mechanisms (Cohen, 2012). It would be preferable
to have more multilateral regulation, through what
Gostin (2008) has proposed: a framework
convention on global health. Theoretically, WHO has
the authority to address epidemic spread of
infectious agents. If WHO worked in collaboration
with the Council for International Organization of
Medical Sciences (CIOMS), they could form aworking group like the current focus on vaccine
safety and pharmacovigilance, in order to oversee
medical tourism. It will take considerable political
will to achieve multilateral regulation of medical
tourism (Cohen, 2012).
Healthcare as a commodity
Consumer driven healthcare could lead tocompetitive pricing to the beneWit of patients, but
proWit driven markets may more likely contribute toinequality of access. Out of pocket expenses are
increasing in many countries which is a larger
burden for the poor than for the wealthy. In medical
tourism, providers compete for patients based on
price. US insurers may offer reimbursement ofelective procedures done in foreign countries where
differential pricing is favorable. Faced with paying
for a needed operation, individuals who cannot
afford treatment at home will beneWit from lower
priced care abroad.
The US, Mexico and Turkey are the only countries
among 30 industrialized nations that do not offer
universal healthcare. Organization of Economic Cooperation and Development (OCED) reports thatspending in the US in 2007 for healthcare averaged$7,290 per person per year compared to an averageof $3,000/per person per year among otherindustrialized countries and is projected to reach$13,000 per capita in 2019. OECD health statistics
for 2019 were released July 2, 2019 (www.oecd.org/
els/health-systems/health-data.htm). In 2017, theUS spent 8.8% of GDP on health. According to theCenters for Medicare and Medicaid Services (CMS)“the average American spent $9,596 on healthcare in
2012, “more than twice the per capita average ofother developed nations.” It averaged $10,345 in2016 and is expected to go up annually. UnitedStates Department of Health and Human Services(USDHHS) estimates health spending will reach 4.5
trillion dollars by 2019 (29% GDP). Drivers forincreased cost include technology, drugs,
independent proWit motives, aging population andincrease in chronic disease.
Kumar et al. (2012), addressing the impact of
medical tourism on the supply chain of healthcare in
the US, framed three questions intended to guide an
ethical discussion of medical tourism and to shapepublic policy. What are the inefWiciencies in thevarious US healthcare systems that are leading toincreasing costs? The answer is new technology,
high administrative costs, increased pricing ofpharmaceuticals, and an escalation in the number of6

Eubios Journal of Asian and International Bioethics 30 (January 2020)

residents with chronic illnesses. The second
question is: What are the factors that potentiallyinWluence US citizens who are considering medical
travel? In an age of the internet and global access to
information, individuals seeking a speciWic procedureor treatment for a medical condition can consult theWe b . M e d i c a l t o u r i s m a s s o c i a t i o n . c o m ;healthbase.com; health-tourism.com each offer
advice about where to go for speciWic types of care.
The third question by Kumar et al. (2012) is:
What are the overt and hidden supply chain beneWits
and costs of exporting medical procedures overseas?
And what are the long term ramiWications ofpromoting a global healthcare supply chain? The
cost savings per procedure and the number ofprocedures done for US citizens reveal signiWicant
savings for the medical cost of care for both patientand insurance company and a large increase inrevenue for the destination country. Kumar
compared cost of three procedures (knee and hip
replacement and heart bypass surgery) in India,
Thailand and the US.
Using information from
Medical Tourism Association to estimate the numberof US residents traveling for medical procedures, andcost comparison based on Monte Carlo simulation
with variability encapsulated by triangular
distributions, Kumar et al. (2012) estimate that inthese two destination countries, US citizens will
spend 20-30 billion US dollars.
Twenty billion dollars of cost savings or lost
revenue is a wakeup call to medical stakeholders
including hospital administrators, insurance
industry executives, members of US Congress,
Medical School Deans, and Pharmaceutical industry
ofWicials. The implications for US healthcare is thatunless ways are found to eliminate waste and other
inefWiciencies and curb rising costs, the nation willcontinue to lose revenue to foreign health providers.
This means the domestic healthcare supply chain
must improve or patients will seek competent andless expensive medical care overseas. It is difWicult topredict what the longterm ramiWications of a global
healthcare supply chain may be (Kumar, et al., 2012).
Global impact on public health
Global documentation of medical tourism isfragmented and incomplete. Countries seeking to be
medical tourism destinations record incoming
patients whereas their home countries may have norecords of their going abroad for a medical
procedure. Insurance or other co-payers may knowof medical tourists for purposes of reimbursement
or treatment of complications after returning home.
Data for quantitative analysis of effectiveness forpatients’ wellbeing is incomplete, making it more
difWicult to measure risks and beneWits (Turner,2013).
A robust ethical assessment of medical tourism at
the individual patient level should focus on
beneWicence to patients but as regards to publichealth, global medical tourism needs to evaluate theimpact on destination country citizens’ access tohealthcare. Qualitative assessment of care and public
safety is an ethical concern among and withincountries. Post-surgical complications occur, and it isunclear if more occur in medical tourism than in
traditional contexts. Concerns about skill level andinternational standards of care should be addressed
through JCI and WHO. Lacking a regulatory
framework within WHO, the World Medical
Association (WMA) does have inWluence through
CIOMS and this could be expanded to address quality
controls for medical tourism.
Travel has inherent risks, such as pulmonary
embolism and thrombosis which occur post
surgically and have an increased risk with air travel.
It should be clear to medical tourists what
preventative measures to use to reduce the risk.
Individual case reports highlight the risk, but
quantitative analysis has not been done to document
if medical tourists as patients have a higher risk thanordinary travelers or post-operative patients(Snyder et al., 2013). Medical tourists rarely travelalone for a medical procedure. Caregivercompanions are another stakeholder in this industry(Casey et al., 2013). Risk to companions deserve
further scrutiny.
Infectious diseases are a public health concern as
they spread quickly by international travel. One
patient who had a kidney transplant in India
returned home with Hepatitis B and infected eight
others locally (Turner, 2013). Multi-drug resistantbacteria (MDR) and pathogenic viruses are easilytransmitted in crowded conditions, such as plane
travel and in hospital environments. Medical travel
could increase transmission of MDR bacteria, but
again more quantitative data is needed to document
the frequency and sites for more informed consumer
choice and for action by public health ofWicials.
Conclusion
Overall, medical tourism is a growing market
industry fueled by technology. It has the potential to
improve global health by offsetting inequalities of
medical care access and standardizing quality ofcare. To become a positive rather than a negative
force in healthcare, several concerns should bemonitored quantitatively and addressed in new
ethical guidelines: safety and quality of care forpatients, more just access to standard treatments,
public health monitoring for spread of infectious
diseases, data capture of all medical tourism forquantitative analysis, and assessment of impact on
the gap of inequality in price of treatment within andamong countries (Casey et al., 2014; Adams, et al.,2017; Connell, 2011).
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Kumar, S., R. Breuing, and R. Chahal, 2012, “Globalizationof Health Care Delivery in the United States throughMedical Tourism,” Journal of Health Communication
17:177-198.
Casey, V., V. Crooks, J. Snyder, and L. Turner, 2014,“Knowledge Brokers, Companions and Navigators: A
Qualitative Examination of Informal Caregivers’ Rolesin Medical Tourism. International Journal for Equity in
Healthcare 12:94Adams, K., J. Snyder, V.A. Crooks, and R. Johnson, 2017,“Developing an Informative Tool for EthicalEngagement in Medical Tourism,” Philosophy, Ethics

7and Humanities in Medicine 12doi:10.1186/
s13010-017-0045-9Agnihotri, HC.
Connell, J.
2011. Medical Tourism @ https://
wbookcentral.proquest.com.
Snyder, J., V. Crooks, R. Johnston, and P. Kingsbury, 2013,“Beyond Sun, Sand, and Stitches: Assigning
Responsibility for the Harms of Medical Tourism,”
Bioethics 27(5): 233-242.

Experiences of a Japanese couple
following fertilization with adonated egg: the husband’s
narrative- Harumi Hayashi
School of Nursing, Gunma Prefectural College of Health
Sciences, Japan
Email: harumih98@gmail.com- Michio Miyasaka
School of Health Sciences, Niigata University,
Asahimachi-dori, Chuo-ku 2-746, Niigata City
951-8518, Japan
Email: miyasaka@clg.niigata-u.ac.jp

Abstract

The objective of this study is to understand theexperiences of husbands whose wives haveconceived via donor eggs, before the birth of theirchild. Participants of this study were recruited
through newspaper advertisements, through queries
for Japanese husbands who would volunteer for thisstudy. Data were analyzed through a qualitative
method. A semi-structured interview was conductedwith a Japanese man married to a woman who
became pregnant with a donor egg. The narratives
were “the decision to receive treatment with donor
eggs,” “a genetically unrelated child,” “the struggle
with the ethical question of receiving a socially
unacceptable treatment,” and “informing a childabout the truth of his conception.” When Mrs. X
became pregnant, Mr. X had worries and anxieties
over whether or not his wife would be able to lovethe genetically unrelated child. This is considered anissue of the family norms in modern Japan.

Introduction

Japan leads the world in the use of assisted
reproductive technologies (ART). Women who
receive these treatments are older, peaking at theage of 40.1 According to a national survey, the mean
age of egg recipients is 45.2, with some recipients
being over the age of 55. The number of children
conceived via donated eggs is estimated to be 300 to
400 annually.2 The International Fertility Center(IFC) reported that more than 1,500 Japanese
couples have given birth to a child through egg
donation, and the rate of pregnancy for those whohave received these donations is 75 percent3.
However, the use of ART through third-party

8

Eubios Journal of Asian and International Bioethics 30 (January 2020)

donation is prohibited by Japanese Society of
Obstetrics and Gynecology.4 For this reason, theJapanese Institute for Standardizing Assisted
Reproductive Technology (JISART),5 which consistsof 30 ART clinics, developed its guideline forprescribing ART to women who cannot have theireggs extracted for medical reasons. Fifty-six children
have been born through this procedure through2018. However, since JISART has excluded women
who are infertile because of their age, women who
are around 50 years of age or older and cannot
conceive on their own must travel abroad to receive
treatment using donor eggs.
Popular travel destinations for Japanese couples
seeking treatment include the United States,
Malaysia, Taiwan and Thailand. Since medical costs
for this treatment in the United States are high,couples are increasingly receiving treatment incountries where medical expenses are more
affordable.6,7 Dozens of agencies have emerged thattarget Japanese couples, some of which have poor
reputations after receiving negative reports;6 The
majority of Japanese women who become pregnant
with donor eggs have given birth in Japan. It has
been pointed out, however, that some are unawarethat their pregnancy could be a high-risk pregnancy,8and the number of such cases will only increase
unless perinatal outcomes for older women areinvestigated and feedback is gathered.9 Furthermore,
there are complex issues to be resolved, including
the physical burdens of donors (such as the side
effects of egg extraction), the legal status ofnewborns, and children’s right to learn the identityof their genetic parents.9
The majority of Japanese couples who are
considering ART or who have previous experience
with this treatment do not get introduced tooverseas agencies from the facilities where they arereceiving fertility treatments; instead, they collectinformation by consulting websites and social
networking services to determine the country inwhich to receive treatment.6 Those who haveexperienced treatment using donor eggs haveidentiWied a range of issues, including medical costs,
problems arising from differences in language andculture, the absence of facilities for delivery, and thelack of follow-up care after pregnancy.2
In Japan, research into ART with donor eggs has
consisted almost entirely of surveys of trends inreproductive tourism or analyses from legal, ethical,
and medical perspectives. There are only a few
studies of families that have formed as a result of
this treatment. Moreover, all of these have focusedon women; no studies have been conducted on men.
Study objective
The objective of this study is to understand what it islike for a husband to form a family by means oftransnational egg donation, through the experienceof a husband (Mr. X) whose wife (Mrs. X) has
conceived via donor eggs.

Study methods
Participants for this study were recruited throughnewspaper advertisements; Japanese husbands who
volunteered for this study were queried. Data wereanalyzed through a qualitative method, after theauthor conducted 60-minute semi-structured
interviews in 2014. Interviews were recorded on an
IC recorder with the approval of the participants andtranscribed verbatim. The transcriptions were read
carefully, with a focus on the events and the thoughts
and feelings of the husbands, beginning with thereception of donor eggs and continuing until thebirth of their child. Condensed meaning units wereabstracted and labeled with a code. The codes werecompared, and those that conveyed similar
meanings were categorized together in order todevelop themes that were related to theirexperiences. In the course of analysis, advice fromexperts in qualitative research was received. The
present study was conducted with the approval of
the research ethics committee of the Niigata
University Graduate School of Health Sciences.

Results

Both the husband and wife were in their 40s (theywere married in their 20s). For medical reasons, Mr.
and Mrs. X had no choice but to receive eggs from athird party abroad in order to have a child. The
husband and his parents wanted a child, and theparents covered all expenses for travel and medical
treatment. The data analysis resulted in four main
themes: “the decision to receive treatment withdonor eggs,” “a genetically unrelated child, “thestruggle with the ethical question of receiving asocially unacceptable treatment,” and “informing achild about the truth of his conception.” A
description of Mr. X’s experience follows; his words
are in quotes.
The decision to receive donor eggs
Because Mrs. X was infertile, Mr. X had been
considering what problems might arise after
receiving eggs from a donor. He searched for
information on egg donation on the Internet andread the blogs of people who had received suchtreatments, without telling his wife. He perceived
that social changes had occurred because domestic
media had started to feature stories of surrogatedelivery and pregnancy via donor eggs in the UnitedStates. Since travel and medical expenses werecostly, Mr. and Mrs. X did not think they could afford
the procedure based on their income. However, Mr.
X’s parents offered to cover the medical expenses;
thus, treatment with donor eggs became an option
for them. Mr. X was familiar with various problems
that might occur after pregnancy using donor eggs
because of his research online, and he believed it
was important that both parents should be awarethat the pregnancy would be the result of egg
donation. When Mrs. X consulted her parents andexpressed her desire to receive the treatment, theyEubios Journal of Asian and International Bioethics 30 (January 2020)
immediately approved. Since most overseas facilities
offering fertility treatments do not have agencies inJapan, Mr. and Mrs. X searched for agencies online.
Mr. and Mrs. X decided on an agency and asked them,without much hope, to explain whether they
legitimately provided treatment with donor eggs.
Hearing their explanation, Mrs. X was assured of
their reliability and became suddenly enthusiastic
about the treatment. Mr. X thought, “I wanted to
seize this opportunity to proceed with treatment.”
Mr. X said he was eager to travel abroad immediately
to have a child. However, he considered the feelingsof Mrs. X, who was going to give birth to a child towhom she was not genetically related; he gave due
regard to Mrs. X, allowing her to decide whether she
would receive the treatment.
He said, “When I considered my wife’s feelings, I
couldn’t get in gear with egg donor treatment via athird party. Though it may sound cowardly, I
arranged things so that it was ultimately up to her
whether or not to receive treatment. That’s what I
prioritized over everything else.”
A genetically unrelated child
Mr. X was more anxious than delighted when his wife
became pregnant. He continued to be concerned,
until the birth of the child, whether his wife would
care for the genetically unrelated child and whether
she would develop maternal instincts without
guidance from an experienced parent. Mr. X said he
had acted cautiously so as not to hurt Mrs. X’s
feelings, especially because the child would be
genetically related to him but not her. Through thepregnancy, Mr. X completely refrained from touching
her belly or talking to the child until the child wasborn. Mr. X was prepared to live with the child even if
Mrs. X was incapable of loving the child. Mr. X
continued to reWlect on these concerns but did notcommunicate them with Mrs. X.
He noted, “I was very concerned whether my wife
would work with me to raise a child who was
genetically unrelated to her and behaved cautiously(treating her with kid gloves), thinking of how I
might interact with her without being offensive.”
The struggle with the ethical question ofreceiving a socially unacceptable treatment
In Japan, there are no legal restrictions on the use ofART. However, Japanese Society of Obstetrics andGynecology prohibits ART that uses donor gametes.
Mr. X continued to struggle with the ethical questionof whether it was right or wrong to create life via atreatment that was not socially acceptable in Japan.
He stated, “I was unable to proceed with thetreatment. Though I had heard of egg donation
treatment, I was not sure how to answer the ethicalquestions surrounding this treatment or how I
would treat my child if he were to Wind out about it in
the future.”I n f o rmin g th e c h ild o f th e tru th o fconception

9

Mr. X decided to keep the egg donation a secret andthought it unnecessary to inform the child, as thechild resembled him. However, he said that if theneed to inform the child arose in the future, hewould leave it to Mrs. X’s judgement.
He said, “I am not going to tell him the truth. I willtake the secret to the grave. After my parents die andthen we die, no one will know the secret.”

Discussion

Leaving the decision to receive treatment to
the wife’s judgment
Mr. X was eager to begin treatment without missing
any opportunity to receive a donor’s eggs. However,he left the decision to proceed to Mrs. X’s judgement.
This may be understood as Mr. X’s respect for Mrs.
X’s feelings being greater than his desire to have achild of his own. In the case of donor egg treatment,
the mother must make a major decision regardingwhether or not she will be able to deliver and rear agenetically unrelated child. Furthermore, because
donor egg treatment has not been accepted by
Japanese society, it is essential for the prospective
mother to make this decision from the perspective ofreproductive health and rights. Although anincreasing number of couples in Japan travel abroad
to receive treatment, there have not been sufWicientsocial discussions about issues such as the risks
associated with pregnancy at an advanced age(≥45),10 physical burdens on the donor, children’s
right to know or to refusal to know their biologicalparents,11 what information the child should begiven about the donor, and the counseling needed
before parents decide to travel abroad fortreatment.9 Moreover, the difWiculties parents with achild from a donor egg will face in the future areunknown; they may encounter unexpected eventsand emotions. These situations suggest that the
information necessary for deciding whether or not
to receive donor egg treatment is not readily
available. Thus, couples who are considering donor
egg treatment must have the determination topersevere together through potential hardships in
the future.
A family not dependent on genetic
relatedness
Mr. X received approval from Mrs. X’s parents as wellas his own to proceed with donor egg treatment.
Receiving donor egg treatment after couples have
Wirst obtained approval from their respective parents
has some beneWits for couples. First, if no one otherthan a couple knows that they are having a childusing a donor egg, they may worry that their parents
will point out that the child’s appearance does notresemble the mother’s.12 If the couple’s parents
know in advance that the child was born from adonor egg, this problem does not arise. Second, if thechild becomes skeptical about his origin or his
parents are worried about how to raise their child,they will be able to consult their parents. Third, since10

Eubios Journal of Asian and International Bioethics 30 (January 2020)

the child will not inherit Mrs. X’s genes, knowing
about the donor egg in advance will give a couple’s
parents a period during which they may prepare
psychologically to accept the child, as seen with theparents of the couple in this study. This will facilitate
support for the new family that might not arise
naturally because it does not adhere to traditional
Japanese notions of biological parenthood.12
With the advances in ART, combined with medical
technologies, various family structures haveemerged: heterosexual couples, single parents, andgay and lesbian couples, all of whom are able to havechildren and start a family.13 Although Japan has
witnessed a rise in new families that do not adhere
to traditional notions of biological parenthood,12such cases are limited in number. In the case of
couples with a child born from a donor egg, Japanese
civil law recognizes the woman who gives birth to achild, genetically related or not, as the legal motherand the couple as the legal parents of the child.
However, as many couples have been raised in a
family with biological connections, they may
occasionally feel embarrassed by the fact that thechild was born from a donor egg or experience
unexpected events related to this in the course ofrearing the child.
Genetically unrelated mothers and children
Mr. X continued to be anxious about whether Mrs. X
would love a child genetically unrelated to her. In thecase of conception from egg donation, while theprospective father is genetically connected to the
expected child, the mother who gives birth to thechild is not. It is the norm of modern Japanese family
to more highly regard and give priority to geneticallyrelated parents over foster parents.13 This may leadto anxiety over the relationship between the donor
recipient mother and the child. Studies of a few
Japanese mothers who started a family from a donor
egg reported that pregnant women do have worries
and anxieties over the prospect of being able to lovea genetically unrelated child.12,14 This is the Wirst
study in Japan to reveal that prospective fathers have
similar anxieties as mothers.
During the modernization of Japanese society in
the Meiji period, it was determined that an ie (familyhome) can be established only through genetic
connections, and a notion developed that the only
unrelated individuals who could be included in a
family were a “bride” (a son’s wife) or a “groom” (adaughter’s husband); adopted children were the only
exception.15 For husbands and wives who grow up ina culture in which it is desirable for matrimonial loveto produce children, it may be natural for the couple
to worry whether they will be able to love a
genetically unrelated child. However, reports basedon the experiences of those who have started
families through donor sperm or adoption claim thatparent–child relationships are not necessarily
dependent on genetics; time spent together as afamily establishes psychological intimacy.16
In contrast, Mr. X absolutely refrained fromtalking about the coming child with Mrs. X during

her pregnancy. This kind of situation has notpreviously been observed during pregnancy among
couples undergoing ART treatments;17 it can beinterpreted either as an embodiment of the care thehusband took to prevent his pregnant wife fromfeeling alienated or as his unwillingness to remind
her of his genetic connection to the child, a
connection she did not share. Little is known about
the emotions that prospective fathers feel in theprocess of starting a family via egg donation.
Informing the child of the truth
Advances in ART have promoted the formation offamilies of various types. Mr. X was determined not
to inform his child of the truth from the beginning.
His child resembled him, which led Mr. X to believethat both his acquaintances and the child would not
doubt that they were biologically related, conWirming
his strategy of not telling the child the truth. Thisline of thinking is indicative of the signiWicant effectof social conventions on families, to expect genetic
connections. If the baby does not resemble either thehusband or the wife, the family may worry that theiracquaintances as well as the child may suspect thatthey are not genetically related.
In Japan, there has been a call to recognize the legal
right of children conceived via donor insemination(DI) to learn the truth of how they were conceived.
Children’s rights to know or to refuse to know havenot been legislated yet. In Japan, more than 60 years
have passed since DI was Wirst carried out with donor
sperm, and more than 15,000 children are born
annually through this procedure.18 Since sperm
donors are anonymous in principle in Japan, mostchildren are not informed that they were conceived
using DI. However, some children, who have learned
that they were conceived via DI, have expressed
concerns that arose subsequently in criticalsituations such as the death of a parent or divorce, as
well as concerns over no longer trusting theirparents after reaching adulthood and learning thetruth.19 Furusawa et al.20 argue that behind thehesitation of the parent to tell a child the truth lies astigma attached to families that use DI, arising fromsocial conventions that expect parents and children
to have genetic connections. On the other hand,children conceived via DI are hurt because theirparents wish to keep the use of the medical
technique a secret from those around them.19
Treatment using donor sperm and treatment using
donor eggs are similar in that, in both cases, themother delivers a child. However, in the case ofdonor eggs, the conWlict the couple faces whenendeavoring to inform the child of the truth is more
difWicult in Japan where a mother who becomes
pregnant with and gives birth to a geneticallyunrelated child is nevertheless treated as the legal
mother of the child even though the father isgenetically related and the mother is not. Somecouples who became parents via donor eggs arereported to have the intention of informing theirchildren of the truth.12 An increasing number ofEubios Journal of Asian and International Bioethics 30 (January 2020)
couples are starting a family with donor eggs, yetlittle is known about their experience. It is therefore
necessary to conduct additional studies in order todiscover their views and identify medical and social
challenges.

Conclusion

Mr. X left the Winal decision of whether or not toproceed with egg donor treatment up to his wife. It is
important from the perspectives of reproductive
health and rights for a prospective mother to decide
for herself. However, the information needed tomake such a decision is not readily available inJapan. Thus, couples receiving treatment must havethe determination to persevere together throughpotential hardships.
Mr. X obtained approval for donor egg treatment
from both his parents and his wife’s parents. Thisnot only gave the couple’s parents time to prepare
psychologically to accept the child, but it also
facilitated support for the new family who did notadhere to the traditional Japanese model ofbiological parenthood.
When Mrs. X became pregnant, Mr. X had
worries and anxieties over whether or not his wife
would be able to love the genetically unrelated child.
This is considered an effect of the family norms inmodern Japan. Moreover, as many couples withchildren from egg donation treatment have beenraised in a family consisting of biologically related
members, they may occasionally feel embarrassed
that the child was conceived via a donor egg orexperience unexpected events in the course ofrearing the child.
Acknowledgements
We would like to express our cordial gratitude to thecouple who participated in this study. This study ispart of a project supported by the 2012–2015
Grants-in-Aid for ScientiWic Research (C) under the
Ministry of Education, Culture, Sports, Science, andTechnology (Grant number 24593358). Part of thisstudy was presented at the 15th Asian Bioethics
Conference.

References
1. Ishihara, O., Jwa, S. C., Kuwahara, A., et al. (2019).
Assisted Reproductive Technology in Japan: Asummary Report for 2016 by the Ethics Committee of
the Japan Society of Obstetrics and Gynecology.
Reproductive Medicine and Biology. 18(1): 7-16.
2. Ministry of Health, Labour and Welfare. Seishi ranshi
hai no teikyou ni yoru seishoku hojo iryou seido no seibi
ni kansuru houkokusho. https://www.mhlw.go.jp/
shingi/2003/04/s0428-5.html (Accessed June 1,2019). (in Japanese)
3. Kawada, Y. Ranshi teikyou puroguramu. https://www.ifcbaby.net/program/egg-donation/ (Accessed
October 7, 2019). (in Japanese)
4. Japan Association of Obstetricians and Gynecologists.
Hai teikyou ni yoru seishoku hojo iryou ni kansuru
kenkai, http://www.jsog.or.jp/modules/statement/
index.php?content_id=35 (Accessed October 7 , 2019).

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5. Japanese Institution for Standardizing Assisted
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June 6, 2019). (in Japanese)
6. Shirai, C. Ranshi teikyou / dairi shussan wo kangaeru
purojekuto. https://www.babycom.gr.jp/ ranshi/
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3292/1.html (Accessed April 1, 2019). (in Japanese)
8. Nakayama, S. and Adachi, T. (2011). Perinatal
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Achieved by Donor Egg In Vitro Fertilization.
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(in Japanese)
9. Okagaki, R., Ishihara, O., and Deguchi, A. (2007).
Oocyte Donation. Journal of Mammalian Ova Research,l24: 142-152. (in Japanese)
10. Nakayama, S. (2015). Egg Donation Risk. JapaneseSociety of Psychosomatic Internal Medicine, 19(4):223-229. (in Japanese)
11. Mizuno, N., Yuzawa, Y., and Utsuki, S. (2004). Jinkou
seishoku ni okeru minpou to kodomo no kenri: Hito no
hou to i no rinri. Tokyo, Shinzansya: 201-231. (inJapanese)
12. Shirai, C. (2017). Experience of Reproductive HealthCare and Medical Care Treatment. The Japanese
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(in Japanese)
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suru: Jisshi shugi to haiburiddo na oyakokankei. in
Nobe, Y., Matsuki, H. eds. Haiburiddo na oyako no
shakaigaku. Tokyo, Seikyuusya: 17-20. (in Japanese).
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Adopted Children in Nonbiological Families about
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12

Eubios Journal of Asian and International Bioethics 30 (January 2020)

Historical and modern aspects ofIslamic philosophical, religious andethical traditions in medicine in
Uzbekistan- Mukhamedova Zamira Mukhamedzhanovna
Department of Social and Humanities, Tashkent State
Dental Institute, Tashkent, Uzbekistan
Еmail: muhamedova_zamir@mail.ru- Umirzakova Nargiza Akmalovna
Department of Social Sciences and Humanities,
Tashkent State Dental Institute, Tashkent, Uzbekistan
Email: n.a.umirzakova@mail.ru

Abstract

This article provides a brief presentation of the
traditional sources of Islamic bioethics, the spiritualbasis of the Muslim medical code, the role offundamental methodological sources in the Uzbek
model of bioethics, a study of key bioethicalproblems in the context of the teachings in Koran,
Sharia, and Hadith and their transformation in thelate twentieth century in relation to sensitive andcomplex medical and biological problems in Islamic
medical ethics and bioethics.

Introduction

The addressing this subject is due to the tasks set ina presidential decree in the Republic of Uzbekistan
on 20 April 2017, over "measures for further
development of the system of higher education" andother decrees that have a wide impact on the
educational process in the curriculum and teachingmaterials based on international educational
standards related to the course of bioethics. The
main concerns in the course of bioethics are topics
related to the presentation of modern philosophicalorientations and humane cultural values associatedwith delicate issues that emerged after
breakthroughs in biomedical technologies: issues oflife and death, biomedical research involving humansubjects, medical genetics, genomic medicine, etc.
The subject "bioethics" refers to a social andhumanities course which requires knowledge in the
Wield of philosophy, history of medicine, religious
studies, history of Uzbekistan, law, public health andhealthcare, clinical genetics, and others. Modern
biomedical ethics is based on a rich tradition ofsystematic moral thought, both philosophical andreligious. Nowadays, in the 21st century, thei n te ra c t i o n a n d sy n t h e s i s o f n a t u ra l a n dhumanitarian disciplines is of paramountimportance in the system of medical education. Oneof the ways to solve this problem for futurespecialists is to learn the basics of biomedical ethics.
The Wirst bioethics research Institute, the Hastings
Center, was established in June 1969 in New York. In
1971, Georgetown University in Washington
established the Joseph and Rose Kennedy Institute of
Ethics, which in turn opened the Bioethics Centerand published the Wirst "Encyclopedia of bioethics" in
4 volumes in 1978 (the last edition was published in2005). These were the Wirst steps towards theinstitutionalization of bioethics, which can becompared to the current number of bioethicalorganizations around the world. The total number
has long exceeded one hundred; the largest centersof bioethical research are located in Australia, theUK, Canada and the USA. As an academic subject,bioethics has become a standard part ofinternational educational in philosophy andmedicine. The priority of philosophical training for
medical students is to help form their creative
thinking and scientiWic outlook to become free andresponsible persons able to work constructively inproblematic situations, combining professional
competence with civil responsibility.
Currently, Uzbekistan pays special attention tocreating conditions for further improving the qualityof medical services in all regions of the country. To
implement this task, it is important to build abioethical culture with future doctors. The
development and study of bioethics will help toformulate new ethical postulates, push them to the
medical and scientiWic community, and understandbetter the moral dilemmas faced by doctors, medical
staff and researchers not only in their daily work,
but also in the development of the latest biomedical
technologies. It is physicians who Wirst of all face theproblems of biomedical technologies and theirconsequences. The presence of these problems andsolving them is directly linked to the physical,
mental, social and spiritual health of people. The
solution of these problems is envisaged in the futurein the priority areas of the strategy for 2017-2021.
The search for new value foundations of biomedical
ethics, such as compassion, charity, harmony, andsolidarity continue the ancient spiritual traditions
which were Wirst introduced by Arab-speaking
scholars of the West and Central Asia.
Modern biomedical ethics is based on richphilosophical and religious traditions and maintains
historical continuity with traditional professional
medical ethics (Mukhamedova, 2015). The rapid
growth of problems related to the progress of
biomedical technologies in the West led to theemergence of medical ethics. The origins of thebioethical teachings of Western philosophy are
undoubtedly of great importance in the formationand development of Islamic bioethics and many of its
concepts. However, in a period of 35 years during
which Islamic bioethics has been developing in
Uzbekistan, its features and priorities have appearedin not only religious consciousness, but also sociocultural, philosophical, legal and other aspects.
The role of Islamic bioethics in the developmentof global bioethics should be noted; the signiWicanceof the great scientiWic, medical and philosophical
heritage left by Arab-speaking scientists in West andCentral Asia. A clear recognition of this historicalfact is the establishment of the Avicenna prize forresearch in the Wield of ethics by the UNESCO

Eubios Journal of Asian and International Bioethics 30 (January 2020)
Executive Council in 2004, as well as the
proclamation of the city of Tashkent as one of thethree capitals of Islamic culture in 2007 by theInternational Islamic Organization for Education,
Science and Culture (ISESCO).
The program
honoring the capitals of Islamic culture wasapproved by ISESCO in 2001 and involves the annual
election of three capitals representing three Islamic
regions – the Arab world, Africa and Asia. Bukhara
has been recognized as the capital of Islamic culture
in 2020. This decision was made at the ninth
conference of ministers of culture of the state
members of the Organization of Islamic Cooperation(OIC). In addition to Bukhara, Cairo (Egypt) andBamako (Mali) were approved as the capitals ofIslamic culture in 2020. In fact, Bukhara has been thecapital of Islamic culture for several centuries. In the
Muslim world, Bukhara has Wirmly established theepithets "Kubbatul Islam" and "Gunbadi Islam",which mean "Dome of Islam" in Arabic and Farsi. The
fact that the city was recognized as the capital ofIslamic culture once again conWirms the outstanding
contribution of this city and its scientists to thedevelopment of Islamic civilization.

Materials and methods

The purpose of this study is to examine the ancient
sources of bioethics of Islam, which may include thepractical ethics by Dr. al-Ruhawi (Ishaq ibn Ali AlRuhawi), the "Canon" of medical science byAvicenna, "Adab Al-Tabib", "Spiritual medicine" by
Ar-Razi, and many others that have become theclassics in the annals of medical ethics. Thisknowledge continues to form the spiritual basis ofIslamic medical code, bioethics, environmental andbiomedical ethics. Here, special attention is given to
the role and signiWicance of the Eastern tradition ofphilosophy based on Islam, and its syncretism(indivisibility) with the doctrine of proper behaviorof a well-raised person, "adabnoma". The
methodological basis is general scientiWic methods,
historical and comparative analysis. The works by B.
A. Zikria, Hassan Chamsi-Pasha, Aksoy S. Karaman H.
Abu Bakr Al Razi, Omar Hasan Kasule, Ben Hamidaf,
Mohammed Ghaly, Abul Fadl Mohsin Ebrahim andothers are used in this article. This study
demonstrates the fundamental methodologicalsources of the Uzbek model of bioethics.

Results and Discussion

The syncretism of the Eastern tradition ofphilosophy has created a term that has no analogues
in European culture - "adab", the doctrine of proper
behavior of a well-raised person - "adabnoma". It
combines general education, the theory of morality
and rules of behavior, which can be simpliWied toeducation, with the formation of an ideal person of
the East, "Komil Inson". The fundamental
methodological sources of the Uzbek model ofbioethics include the Central Asian codes of behavior"Kobusnoma" by Kaikovus, the treatise "on Ethics"
by Ibn Sina, "Four conversations" by Aruzi

13

Samarqandi, "Code of decency in the East" by Sadiq
Kashgari, and many others.
The distinctive feature of Muslim medicine wasits ethics. Muslim hospitals served people regardlessof religion, color, or origin. The hospital staff treated
all believers equally, whether they were Christians,
Jews, or other confession. The Muslim doctor wascalled "Hakim", which means "wise" in Arabic.
Muslim doctors were deeply religious and practiced
in the name of God.
Classical sources and examples of medical
ethics that make up the spiritual basis ofIslamic medical code
Inspired by the ancient heritage of Hippocrates in
the Wield of medical ethics, Ishaq Ibn al-Ruhawi, ArRazi, Ibn Sina, Maimonides created an open system
of moral values, Adab al-Tabib. In contrast toEuropean neo-Hippocrates, the Adab al-Tabib value
system is Wlexible and multifunctional. It can also
adapt to the knowledge of bioethics in the twentyWirst century.
Back in the 9th century, the physician Ishaq bin
al-Ruhawi wrote the Wirst treatise on medical ethics,
Adab al-Tabib. In this treatise, Ruhavi refers to
doctors as "guardians of the soul and body", andobserves and analyzes the behavior and deeds of aMuslim doctor (Zikria, 1967, translated by Martin
Levey). Al-Ruhavi accomplished a lot in his work inorder to "humanize" medicine, considering the
problems of relationships with patients. He believes
that the purpose of the doctor is to bring good andwell-being to the human race in general, not only tofriends, but also to enemies. God made doctors
swear not to invent poisons (Chamsi-Pasha, Albar,
2013; Aksoy 2004;3:9-11). Al-Ruhawi quotes
Aristotle, Socrates, Galen, and Hippocrates andsupports their ideals, but Adab al-Tabib is primarily atext based on Muslim traditions and beliefs. Adab alTabib is not only a guide to professional ethics, butalso contains important information about personal
hygiene, a patient doctor, and provides an
explanation of the relationship between theprofession and society.
(Chamsi-Pasha, Albar, 2013; Aksoy 2004;3:9-11).
Adab al-Tabib consists of 20 chapters, which are
divided into 3 categories: 1) the behavior of thedoctor, 2) the behavior of the patient, 3) the attitudeof the society to the medical profession and topatients. The content of Adab al-Tabib considers thedoctor’s personal beliefs and practices, attaches
great importance to his faith in God, personal healthand hygiene, as well as his manner of dealing withcolleagues and patients. Al-Ruhawi emphasizes theimportance and role of patient authority andrespect, even though the doctor has to ignore
patients’ wishes when it is necessary for their health.
He says that doctors should occupy a high position in
the social hierarchy; their work should be well paid,so that the doctor does not look for some other job,
but doctors should not Wlaunt their wealth. AlRuhawi says that the costs charged to rich patients

14

Eubios Journal of Asian and International Bioethics 30 (January 2020)should be sufWicient to cover the costs of poor
patients who cannot pay for themselves, and medicalcare should be equally good for both rich and poor.
In Adab al-Tabib, al-Ruhawi talks about legislative
practices and punishments for lying andincompetence of doctors. Inspired by Galen's work,
he advocates the practice of medical exams andlicenses. He encourages doctors to keep a record of
the patient's symptoms, treatment, and recovery. AlRuhawi recognizes that the recovery of patients is
not always manageable, and if the patient is doomed,
he must die under the care of a doctor. Al-Ruhawi
suggests extreme punishments even the death
penalty for doctors who allow patients to die
because of their negligence and incompetence.
Another great physician, philosopher, and scholarof Islamic civilization, Abu Bakr Muhammad Ibn
Zakaria al Razi (865-925), wrote more than 200
books on various subjects (Karaman 2011; 30:
77-87). In the history of Islam, Razi is considered
the only doctor who can be compared to Abu Ali Ibn
Sina. Razi was a therapist, but also had a lot ofexperience in surgery. Razi wrote the book "Hawass
ut-Tallis", which explained the objectives for medical
students. The most famous book in the history ofIslam on medicine is "al Hawi", which includes
various experiments and clinical observations ofRazi in Baghdad and Rhea. Many authorities in the
Wield of medicine consider Razi's works "Al Hawi"
and "Al-Mansuri" to be the biggest and oldest
textbook. Razi wrote the book "For those who can't
get a doctor" ("Man lajuzarukh ut-Tabib")forgeneral use; this is general medicine. The basis of thephilosophical concept of Ar-Razi is the doctrine of
the Wive eternal principles: "creator", "soul", "matter","time", and "space". The atomism of Ar-Razi is close
to the atomism of Democritus. He wrote the book
"Measles and smallpox", on signs and symptoms, andexplained the necessary prevention from these
diseases. In this book, for the Wirst time, he spoke
about infectious diseases and described chicken
blindness. Razi has been known as a friendly andgenerous doctor. He did not let the patients go until
he identiWied the disease, he was very friendly to thepoor and provided them with free medicines andfood. He could amass a huge fortune, but did not
strive for it, and was always absorbed in the study ofscience.
Razi's most famous book is al-Hawi, which
includes a complete course of medicine from theancient times up to his time. He expresses his pointof view on each issue. This book has become famousas the most famous book on medicine in the history
of Islam, which includes various experiments andclinical observations. The book by Ar-Razi Ahlak alTabib, presents a model of Muslim medical ethics(Karaman 2011; 30: 77-87). For a doctor, it isimportant not only to be a professional, but also to
be an example in all respects. His ideas in medical
ethics were divided into the following concepts:
doctor's responsibility to the patient, patients’
responsibility to themselves, and patients’

responsibility to the doctor. According to Ar-Razi, adoctor, while practicing, should continue to improve
his education and strive to obtain new knowledge.
He recommends that doctors be virtuous, humble,
and strive to earn the respect of their patients. A
doctor has obligations to patients. First of all, inshowing compassion, a doctor must be attentive andkind.
Following the Hippocratic Oath, Ar-Razi believedthat the second duty of a doctor is to keep the secretthat he learned during the treatment of his patients.
Another duty of the doctor is to support the patientin every possible way morally and psychologically, toinspire him with hope for recovery, even if there is
no hope. The doctor must, according to Ar-Razi, treat
all patients equally, regardless of their wealth. The
goal of the doctor should not be money, but thetreatment itself and the patient's health. Doctors
should pay attention to the treatment of the poorand homeless. On the other hand, the patient also
has responsibilities to the doctor. So, the work of alRuhavi Adab al Tabib is a great illustration of the
problems of professional responsibility and ethicaldilemmas that are still relevant in medicine today.
Ahlak al Tabib Abu Bakr Muhammad Ibn Zakariya
Ar Razi, who received the title of Galen of the Arabs,
is undoubtedly one of the most outstandingachievements in medicine. A work written during
the Eastern Renaissance, it provides guidelines not
only for enriching the theory of bioethics, but also
serves as a guide to action, and functions as amechanism for humanizing modern medicine andhealthcare. The bioethical basis laid down in it, inwhich medicine and a decent way of life form asingle philosophy of health has not lost its relevance
today; moreover, it is in many ways ahead of ourideas about the ethics of the physician.
By equipping the doctor with knowledge of thelaws and principles for spiritual transformation, ArRazi and Ibn Sina create a philosophical basis for the
behavioral standards of both the doctor and the
dying patient. Islam regulates all spheres of life,
determines not only cultural, social, and legal issues,
but also penetrates into the interpersonal
relationships of members of the Muslim community.
The social, legal, and economic aspects of ethicalissues and key issues of bioethics in the Wield ofhealth, medicine, and biomedical technologies in thecontext of Islam continue to be studied. Bioethicalresearch is actively continuing in Iran, where Sharia
law is the law of the state. At the beginning of the XXI
century, Iran adopted a package of documents
related to transplantation, criteria for brain death (in2000), and therapeutic abortion (in 2005).
Modern Muslim medicine and bioethics havedeveloped within the framework of enlightened
Islam and medical ethics. However, despite thecurrent practice of Muslim bioethics, there areproblems and contradictions, starting with therecognition or non-recognition of its status(Mukhamedova, 2006, 2009).

Eubios Journal of Asian and International Bioethics 30 (January 2020)
The world religion of Islam has common sources:
the Koran, Sharia, and Hadith. Islamic medical ethics
both in the past and present rely on the tradition andthe law of Islam. At the same time, it is necessary toconsider some existing internal differences in thephilosophy and theory of Islam and its legal schools.
Therefore, there are not only external differenceswith the main Western philosophical theories andperspectives on medical ethics, but also internalones, due to different trends in Islam itself.
Therefore, before considering the main principles ofMuslim morality in the Wield of biomedical ethics, it isnecessary to point out the various sources of the lawof Islam.
Sharia is a set of canonical laws of Islam covering
all aspects. At the core of Sharia there is the Koran as
the Holy book of Muslims; Hadith- stories about thedeeds and statements of prophet Muhammad. In
addition, lawyers use other sources of Muslim law,
including "Istislah" - common interests; "Rie" - yourown opinion; "Kiyas" - judgment by analogy; and"Ijtihad" - ability and right of interpretation.
The biological revolution of the last decades has
posed new and serious challenges to humanity. Whatis the attitude of Muslims to these problems? The
absence of the institution of clerics in Islam makes it
difWicult to Wind an answer to this question: thebeliever is responsible for the decision. "Ijtihad"
allows a Muslim believer to comprehend the
problem and change the attitude to it, considering
the new circumstances that arise in connection withnew achievements in medicine, biology andbiotechnology.
The key elements of biomedical ethics in Islam
are the concepts of human personality and death.
The idea of the human person determines theattitude of the believer to abortion or childbirth withthe help of medicine. Organ transplantation isassociated with the determination of death,especially in cases where the vital organs of thedeceased donor are involved. The same deWinition isassociated with the choice of intensive care andeuthanasia.
Research on key issues of Islamic bioethics:
modernity
Research on the key problems of bioethics in thecontext of the teachings of the Koran, Sharia andHadith, including a large historical experience in the
Wield of medicine in the Renaissance era of Arab andCentral Asian scholars, began to transform in the latetwentieth century in response to sensitive andcomplex biomedical problems. In the development ofIslamic bioethics as a new form of scientiWic
k n owl e d g e i n t h e t we n t i e t h c e n t u r y, t h eestablishment of the Islamic medical scienceorganization IOMS and the holding of the Wirst (1981,
Kuwait) and second conference of the Islamic
medical science organization in Kuwait (1982),
where the code of Islamic medical ethics was
adopted, are of great importance. The adoption of
the code at the second international conference of15

the Islamic organization of medical science in 1982
was a starting point in the development of Islamic
bioethics. The code consists of thirteen parts thatcombine ancient and modern ethical teachings,
traditions of Eastern medicine, Islam, andphilosophy. The code deWines the medical profession,
the doctor's oath, regulates doctor-doctor relations,doctor-patient relations, doctor-society relations,biotechnological progress, medical secrecy, anddoctor's duties and responsibilities in wartime.
Special attention is paid to the sanctity of human life,
medical education, and issues of Islamic medicine.
Here are some excerpts of the doctor's oath: a doctor
has certain obligations to society, patients, andcolleagues; a doctor must honor the medical
profession; a doctor must have qualities such as
sincerity, compassion and empathy, patience andmodesty; a doctor must obtain the patient's
informed consent and female consent; practicalactivity should be accompanied by continuous
medical education.
In comparison with Western bioethics whichplaces a strong emphasis on human rights, Islamic
bioethics is based on the duty to preserve life, toseek all possible ways of treatment; and the rights(of God, society, and the individual) are reWlected inbioethics as human dignity (Ihsan). Islam is open toscientiWic knowledge, as evidenced by the Quranicverses and traditions of the Prophet:• "It is necessary to study, to seek knowledge nomatter how far it may be, even as far as China»;• "The ink of a scientist is more sacred than the
blood of a martyr. The acquisition of knowledge ismandatory for every Muslim, regardless of whether
they are male or female.”* Say, “My Lord, increase my knowledge." (Taaha
20:114)Islam requires the patient to behave rationallyand seek appropriate treatment, and requires
medical personnel to strictly fulWill their mission toprotect and save lives:• "And the one who saves this soul, as it were, willsave all people from death (Quran 5: 32; translation
by Valeria Porokhova).
Islamic medical ethics has become an importantcomponent in international ethical discussions andat the third world Congress in 1996 in San Francisco
there was a section on "Islamic Bioethics", where
Muslim scientists spoke. One of the well-known
researchers in the Wield of Islamic bioethics whose
works have received international recognition, is theAvicenna Prize winner in 2005, Professor Abdallah
Daar. He made a signiWicant contribution to the studyof the complex issues of bioethics in Islam.
Among important events in the development ofIslamic bioethics, there is the publication of a guideto international ethical principles, including
biomedical research of human beings in theperspective of Islam, Geneva, 2004. The guide wasprepared and published by the Council ofInternational organizations of Medical Sciences(CIOMS) in collaboration with WHO and the Islamic

16

Eubios Journal of Asian and International Bioethics 30 (January 2020)

organization of Medical Sciences (IOMS) in Geneva in
2004.
The principles of professional ethics of a Muslim
doctor stipulate that all human research should be
conducted in accordance with three basic ethicalprinciples: respect for the autonomy of theindividual, generosity and legality. Each ethicalprinciple is accompanied by comments from theKo ra n o r p r i n c i p l e s a n d l aws o f I s l a m i cjurisprudence, which conWirm this principle. If
representatives of vulnerable groups (minors,
persons with impaired mental capabilities, thedisabled, terminally ill, comatose patients, etc.) areinvited to participate in the study, they should also
be given the opportunity to choose whether toparticipate or not (to the possible extent). Theirobjections should not be ignored, and their rights
should be carefully protected. Each group of these
persons should be considered separately.
Respect for individuals includes obtaining
informed consent to participate in the research froma third party (for example, a witness) in order tostrengthen the protection of the rights of subjects.
Consent to participate must be voluntary. It is
unacceptable to use violence or undue pressure toobtain consent to participate in the research,especially for members of vulnerable populations.
Here are a few comments from the Quran given in
the Guide.The law of Islam calls for recognizing,
preventing, and reducing harm.
"Any action that causes harm or hinders thebeneWit must be prohibited.""Mandatory prevention of a greater evil when thelesser of two evils is chosen."
Ethical requirements are a prerequisite forresearch; they are part of the research management
and the criterion of research quality, which should
not become an obstacle. This condition requires new
and additional qualities on the part of theresearcher; it requires special education (bioethics,
biomedicine) and training of researchers. Not
everything that can be implemented in terms ofscientiWic and technical capabilities can be resolved
ethically. Currently, the social, legal, and economic
aspects of key bioethical issues in the Wield of health,
medicine, and biomedical technologies continue tobe studied in the context of the Islamic faith.
Islamic bioethics is developing dynamically. It is
not conWined exclusively to the aspect of the creed,but integrates and transforms the most importantinternational documents (the Nuremberg code, theHelsinki Declaration, the Universal Declaration on
bioethics and human rights, etc.). Over the past 35
years, such issues of bioethics in Islam as organ and/or tissue transplantation, criteria for brain death,principles of care and technology in the intensive
care unit, problems of reproductive technologies,
cloning, genetic engineering biotechnologies, AIDS,
psychiatric care, and etc. were put on the agenda andreviewed. International conferences were held by
the Islamic Organization of Medicine (IOMS) in
Kuwait, Istanbul, Karachi, Cairo, etc. Various key

issues of bioethics were considered; special
attention was paid to children's rights, spiritualdevelopment and the moral component of medical
educational programs in order to train a Muslim
doctor.
Muslim legislators regularly meet to discuss
ethical issues related to the progress of biomedical
technologies: problems of organ and /or tissuetransplantation were discussed at the third
symposium on medical law (1987), at the Wifth
international conference of Islamic medicine in Cairo(1988), etc. Modern Muslim medicine and bioethics
are developing within the framework of enlightened
Islam and medical ethics. However, despite thecurrent practice of Islamic bioethics, there areproblems and contradictions, starting with therecognition or non-recognition of its status.
The position of a conservative part of Muslim
scholars (for example, Omar Hasan Kasule) (Kasule.
2005. P 2-4) is that they justify the appearance of
bioethics in the West, its concepts, theories, andprinciples not by the rapid development of
biomedical technologies, but solely by secularization.
Therefore, they believe that bioethics is neither a lawthat would represent a force for the government nor
a moral force/conscience; it does not have the statusof science. According to Omar Hasan Kasule, Islam
views the problems of human research as purely
legal issues; Sharia law provides adequate principles
and guarantees because Islamic law (Sharia), unlike
Western law, includes both law and morality in its
essence. In Islam, actions are divided into
mandatory, recommended, permitted, condemned,
and forbidden. Under special circumstances,
especially when it comes to life and death, evenforbidden things can be allowed.
Islam's medicine is eclectic, choosing the best,modern, affordable medical technologies that arecompatible with the spirit of Sharia and Islamic
society. Lawyers search and Wind answers to solve
the problems posed by modern life. Supporting
concepts are intended to be combined with the
Sharia guidelines so that Muslim patients can use
modern medical methods and technologies for the
beneWit of their health without violating theprinciples of Islam.
The syncretism of Eastern
tradition is also expressed in the fact that many
Muslims, including those who live in the secularstates of Central Asia, seek to adhere to their religion
in almost all spheres of life. They mention the nameof Allah on a daily basis, live according to the
instructions of the Koran, the instructions of theProphet, and believe that their actions are counted,
that they will be judged at the Last Judgment.
Despite the fact that concessions are made forpatients, many try to adhere to the Muslim lifestyle.
Hence, deep understanding of Islamic bioethics bydoctors can improve the quality of treatment for thissigniWicant population group, and is crucial.
Central Asian States are secular states, but they
are home to believers of various faiths. Therefore, it
is important to consider the socio-cultural realities

Eubios Journal of Asian and International Bioethics 30 (January 2020)of national traditions, and to study their experiencein making decisions on key issues of bioethics in thecontext of not only Muslims, but also other creeds.
Bioethics today is a socially signiWicant Wield ofknowledge that develops standards of ethical andlegal security for human well-being in the Wield ofhealthcare, medical science, and education.
The concept of brain death. In Muslim countries,
the deWinition of brain death is strictly deWined. Brain
death means a complete and irreversible stop ofbrain activity (hemispheres and brain stem) withcomplete destruction of its cells. In case of brain
death, artiWicial ventilation can support the life/
activity of other organs.
Ethical problems of reproductive technologies.
The main ethical issue related to reproductive
technologies is the status of the embryo; from which
point of its development is it considered a person
who has the right to protect his life and humandignity? The use of "extra embryos" in IVF selection,and in general the production of excess embryos thatcannot be transferred to the uterine cavity, devalues
the very concept of "life" and lowers the moral bar of
our society. In Islam, it is considered necessary not
to use donor sperm or eggs. Otherwise, there is aviolation of both the pedigree and the genetic codeof a particular family. Islamic theologians and legal
scholars compare this problem with the issue of
adoption. The Holy Quran prohibits adoption when
adopted children take the surname of a foster father.
"Address them by their fathers. This is fair to God.
And if you do not know their fathers, call them yourbrothers in faith." (Qur'an, 33:5). The use of donor
sperm and eggs is considered an unusual form ofadultery, since it is unclear who is the true father ormother of the unborn child, and pedigrees are mixed.
What is the ontological and moral status of theembryo? From what stage of the embryo's
development should it be considered a humanbeing? To what extent does it have human rights? In
the bioethics literature, various answers are given to
the question: from the moment of conception, when
the uniqueness of the future human being in thegenetic plan arose; from the 14th day, when theembryo is implanted in the uterus and when thegerm cells themselves are allocated (the "primarystrip"); after the 30th day, when the differentiationof the central nervous system begins; from 7-8
weeks, when the embryo begins to respond to
stimuli; after 7 months, when the sucking reWlex isformed and the fetus acquires the ability to live
outside the mother's body.
The general view of the Muslim tradition on thestatus of the embryo is expressed in the fact that afull human life with its rights begins only after thecompletion of the "ensoulment", although there issome form of life before the soul enters the embryo.
Based on the interpretation of approaches in the
Quran and the Prophet's hadith, Muslim scholars
agree that ensoulment occurs approximately about

17

120 days (4 lunar months plus 10 days) afterconception. Quran (verse 2, 228) states that a
divorced woman cannot remarry for 90 days, thus
avoiding doubts about paternity. A widowed woman
should wait for the same reason, 130 days, or 4months and 10 days before getting married again. By
setting the time frame from 90 to 130 days (from 3
months to 4 months and 10 days), Quran indirectly
determines the period during which the embryotakes the form of a human. Based on theseprovisions of the Quran and based on the legend of
the prophet Muhammad, according to which God
breathed the soul into the fetus at 3 months and one
week, Muslims conclude that "the fetus as a humanperson can actually be spoken of starting from the
Wirst week of the fourth month, i.e. on the hundredth
day of pregnancy" (Ben Hamida 1992, P. 50).
Other scientists, perhaps a minority, believe that
this happens after about 40 days. Muslim legal
scholars have slightly different views on abortion.
Abortion is allowed after implantation and before
embryo ensoulment occurs, in cases that relate tolegal or medical reasons. Acceptable reasons include
rape. However, many Shiites and some Sunnis
usually prohibit abortion at any stage after
implantation, even before ensoulment, if themother's life is in danger. Abortion after ensoulment
is strictly prohibited by all reputable specialists, but
the vast majority make an exception to preserve
mother’s life. In a dilemma where a choice must be
made between preserving the life of the mother orthe embryo, then the mother's life is preferred; it istreated as a root, and the embryo as a twig.
Professor of theology Abul Fadl Mohsin Ebrahim, ,notes in his study "Abortion, birth control andsurrogacy in an Islamic perspective", presents thediverse views on the issue of abortion and the statusof the embryo in various schools of Islam. He points
out that the most Wlexible position regarding
abortion among various legal schools of Islam is in
the HanaWi school. Here, before the fourth month of
pregnancy, an abortion can be performed if thepregnancy threatens the mother's life. The Maliki
position prohibits an abortion after implantation has
occurred. ShaWi'is support the ban, calling abortion acrime if the fertilized zygote is violated. The schoolof Hanbali, specifying the cause of abortion,
considers abortion to be a sin. After ensoulment, inwhich the embryo is considered to have equal rights
with the mother, the dilemma is solved by thegeneral principle of Sharia: choosing the lesser of
two evils. Without losing both lives, it is life thatshould be preferred - that is, the mother's life.
Referring to the Quranic tradition (5:32) to protect
the sanctity of life, Mohsin Ebrahim concludes thateveryone has the right to be born, and the right tolive as long as Allah allows. The right to live in Islamis absolute.
Childbearing with the participation of medicine.
There are various methods of artiWicial childbirth.
ArtiWicial insemination is inserting sperm directly18

Eubios Journal of Asian and International Bioethics 30 (January 2020)

into the uterus. It is used when one of the spouses issterile. According to Muslim law the use of thismethod is allowed only in the case that the sperm
donor is the legal spouse.
In vitro fertilization and embryo transfer (forwomen with tubal obstruction), is fertilization
performed outside the body; 48 hours after
fertilization, an egg is formed and this embryo is
implanted in the mother's uterus. Then the
pregnancy proceeds as usual. According to Islam, in
vitro fertilization is considered legal only if the
sperm of a woman's husband is used.
What is said about artiWicial insemination, which
method is allowed, and which is considered
forbidden? To answer these questions, the head of
the fatwa Department of the Department of Muslimsof Uzbekistan, Homijon Ishmatbekov, took part in
the second meeting of the fatwa Council of theEurasian Islamic Union, held in Istanbul on
December 16-17, 2017. The agenda of the meeting
included issues related to artiWicial insemination andartiWicial insemination. The Department of Muslimsof Uzbekistan published a fatwa "on artiWicial
insemination".
The practice of artiWicial insemination leads tosome moral, social and religious problems. In
particular, opportunities are opening up for women
who want to have a child without getting married;
the number of children born out of wedlock will
increase; there may be situations of mixing ancestry(origin), ignorance of who the child's mother is;trade in fertilized eggs or non-fertilized eggs andseed cells can become a source of income. Given theabove, the ofWice of Muslims of Uzbekistan
announced this fatwa:
1. The use of artiWicial insemination is allowed
only in extremely necessary cases for married
couples in accordance with the Muslim traditionnikoh.
2. During artiWicial insemination, when storing thesemen of men and women who have been married in
Sharia, all precautions must be taken to prevent
mixing the semen of other people. This operationmust be performed by a qualiWied doctor.
3. ArtiWicial insemination is prohibited for couples
who are not married in Sharia.
4. Muslims who care about maintaining the purityof their ancestry should not use prohibited methodsof artiWicial insemination.
Carrying someone else's child. If a woman's
ovaries are functioning normally, but she cannot
bear a child, she can take one or more eggs to
fertilize them in vitro with her husband's sperm. The
resulting embryo is placed in the uterus of another
woman after 48 hours, who gives birth to a childafter 9 months. Since Islam recognizes polygamy, thegestating mother may be the second wife of thehusband, who will give his sperm to fertilize the Wirst
wife's egg. However, Islam forbids this method of
procreation if the egg does not belong to the wife ofher husband or if the child is carried by an outside

woman. Thus, the Muslim religion allows only legal
spouses to resort to artiWicial childbirth with theintervention of medicine and subject to the following
conditions:- it is necessary to know the donor of the germ
cells in order to exclude incest and ensure legal
kinship in accordance with Muslim law;
- mutual voluntary and conscious consent of thelegal spouses is required.
Prenatal diagnosis. Great progress has been madein this area, which raises a number of legal andeconomic ethical issues. There is a question whether
such diagnostics should be performed before in vitro
fertilization in order to make sure that the embryo isof good quality. In this case, it is easy to slip into
eugenics, which is condemned by the morals of all
religions. The traditional method of prenatal
diagnosis is cytogenetic analysis with theestablishment of the embryo karyotype, carried out
on cells taken during amniocentesis (at 14 or 15
weeks). Another method is biopsy of trophoblastic
tissue of the chorionic villus through vagina that has
the same genetic material as the embryo. It allows
for prenatal diagnosis at 5 or 6 weeks. If the fetus isfound to have a genetic abnormality, then one canconsider a voluntary termination of pregnancy at 9
or 10 weeks, that is, in more favorable conditions.
Organ and/or tissue transplantation. From thepoint of view of the Muslim public, it is pointless tointerfere with the actions of nature in relation toimminent death. If active medical intervention in thecase of a patient with a severely damaged brain leads
to further suffering of the patient and those
associated with him in society (relatives or friends),
the subsequent harm cannot be ignored. However,there is no reason in Islam to put an end to humanlife just because of the suffering of the family and thepatient.
In Muslim culture, until recently, when modern
medical technologies did not recognize thedifference between the termination of brain andcardiorespiratory functions, the announcement ofdeath was based on the criteria provided for theviability of the interconnected systems of the humanbody. The concepts of cerebral death and brain death
are neologisms in Muslim society that perceive deathas the termination of vital functions in a particularorgan system, rather than a part of the body.
Complete cessation of the heartbeat was considereda sufWicient criterion to declare a person legally dead.
The problem arose when modern medical
technology acquired the ability to preserve life
functions through respiratory support in thepatient's brain stem. The patients were alive
according to the traditional deWinition of death. Thus,
another important issue of organ transplantation
was raised.
A long discussion in the Muslim community
continues to this day. In Iran, the current criteria forbrain death based on the principle of non-harm wereEubios Journal of Asian and International Bioethics 30 (January 2020)
rejected in 1995, but theologians who adhere to
enlightened Islam believe that brain death is a
sufWicient criterion for recognizing a person as dead.
This is also stated in the fatwa of the Muslim law
Council of Great Britain, which moves from the
problem of brain death to the issues oftransplantation:"The Council concluded that if reliable doctors
certify that the brain stem is dead, it means that theperson is dead from the point of view of Islam andthus the organs needed to save the lives of others
can be extracted and the life support system can beturned off." (Mohammed Ghaly, 2012).
The Islamic organization of medical Sciences(IOMS) discussed this issue at two symposia held in1985 and 1996, respectively, and concluded thatbrain death is an acceptable criterion for death. The
same view was adopted by the international Islamic
Fiqh Academy (IIFA) at its third session, held in
1986. However, the Islamic Fiqh Academy (IFA), at
its tenth session in 1987, did not recognize brain
death as an adequate criterion for death in Islam.
Over the past 35 years, issues such as organ andtissue transplantation, brain death, the principle ofcare, and technologies in the intensive care unit havebeen put on the agenda of Islamic bioethics. The
problems of organ and tissue transplantation werediscussed by Islamic lawyers at the third symposium
on medical law (April 1987). In Iran, theInternational Congress of Bioethics (March 2005)
stated that decisions on key issues of bioethics
should be made with a consideration of existing
religious norms, morals, and cultural traditions.
Organ transplantation, such as corneal
transplantation of a deceased person, is permitted
under the following conditions: death must be
determined by three doctors, including one
neurologist (the surgeon who will perform thetransplant must not be part of this group); thedeceased should not have objected to such an
operation during his lifetime, or must have theconsent of relatives; transplantation is performed incenters ofWicially recognized by the Ministry of
Health of the country concerned.
1) Live donors. Organs that can regenerate(kidney, bone marrow, liver) can be transplanted
from a living donor. In these cases, Islam does not
impose any restrictions. 2) Dead donor. In deadfetuses, only cases where organs are used fortherapeutic purposes are recognized as legal. In deadadults, the main condition for stopping artiWicial
respiration and blood circulation and then taking theorgan for transplantation is a statement of brain
death. The Council of Health Ministers of the ArabIslamic countries adopted a draft law on humanorgan transplantation consisting of 11 articles.
Transplantation of organs of the deceased person
was allowed with the consent of the relatives of thedeceased and provided that: the death was
determined by three specialist doctors, including aneurologist, and the surgeon who will perform theoperation should not be part of this group; the19deceased did not object to the removal of any organof his body during his lifetime. It is forbidden to sellor buy any organ or make it an object of donation for
any remuneration. Organ transplantation may be
performed in medical centers ofWicially recognizedby the Ministry of Health (Ben Hamida,1992. - P. 53).

Conclusion

Currently, the social, legal, and economic aspects ofkey bioethics issues in the Wield of health, medicine,and biomedical technologies in the context of theIslamic faith continue to be studied. Islamic bioethics
is developing dynamically. It is not conWined
exclusively to the aspect of the creed, but integrates
and transforms the most important international
documents (the Nuremberg code, the Helsinki
Declaration, the Universal Declaration on bioethics
and human rights, etc.).
Over the past 35 years, emerging issues ofbioethics in Islam as organ and tissuetransplantation, criteria for brain death, principles ofcare and technology in the intensive care unit,
problems of reproductive technologies, cloning,
genetic engineering biotechnologies, AIDS,
psychiatric care, and etc. were considered ininternational conferences held by the Islamic
Organization of Medicine (IOMS), and attention was
paid to spiritual development and the moral
component of medical educational programs inorder to train a Muslim doctor. Modern Islamic
medicine and bioethics are developing within theframework of enlightened Islam and medical ethics.
Competing interests
All authors declare that they have no competinginterests.

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Levi.

An ethical proposal for
Universalism versus relativism
in research- Al O. Giwa
Department of Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, USA
Email: al@bema.nyc

Abstract

This paper seeks to advocate for the adoption ofuniversalism as the ethical basis for researchprinciples versus relativism, which would allow fordifferent rules for different cultures. I will argue that
although borne in, and out of, Western ideologies, it

is in the best interest of all humans to adopt humanrights based universal ethical principles.

Introduction

We live in an era where what is researched in
Pretoria will be later studied in Boise. Long gone isresearch focused on just a national or regional
audience that is free from world scrutiny. We are
now in an information age whereby mere seconds
separate the exchange of information around theworld. Research that previously concentrated on asegment of the population in one nation, can expect
to have its Windings and study methodologies
analyzed across the globe, especially if it is felt to notconform with “international standards”. Gone is theera where certain views depicting some humans as
being subhuman allowed research to be conductedin the same manner than that conducted on animals(which has further spurred a debate on animal rights
as well, but I digress). History has shown that if
allowed, some humans will view certain members of
their society as “less than” the other members,
whether it be due to their religion, their race, thecolor of their skin, their status as prisoners, or their
physical or mental handicaps. It is this relative
mistreatment of individuals that the principle ofuniversalism speaks against, and to which I will
dedicate this paper.
To distinguish this work from the many others
debating the virtues of one philosophy over theother, I would like to take a slightly different
approach advocated by a handful of scholars in the
research community. It seems that the debate
between advocates of universalism and relativism inresearch have generally taken to extremes to defend
one view and criticize the opposing (Tangwa, 2004).
The pursuit of truth between opposing points ofviews or accounts, typically lies somewhere between
both extremes. As it is commonly deWined,
universalism holds that morality is the same
everywhere and that established ethical rules apply
cross-culturally.
Relativism holds that different
cultures and customs give rise to divergent values
and thus differing ethical principles.
The accepted principles of research include
respect for persons, beneWicence, and justice, which
are equally universal in their scope of protection;
however, it is my view that the principles of justiceand respect for persons are most instructive to theneed for universalism in research.
Justice in research
The role of the principle of justice was most
famously raised in clinical ethics by Beauchamp andChildress (2013) with their four principles: respect
for autonomy, beneWicence, nonmaleWicence, andjustice. Justice is speciWically deWined by them as“fairness in the distribution of beneWits andrisks” (Beauchamp and Childress, 2013), andgenerally as a principle of fair and equitable
treatment of persons. Research ethics has similarly
attempted to adopt the principles of justice as part ofEubios Journal of Asian and International Bioethics 30 (January 2020)
its tenets. The Belmont Report, created by the
National Commission for the Protection of Human
Subjects of Biomedical and Behavioral Research by
the US Congress in April 1979, “articulated respect
for persons, beneWicence, and justice as the broader
ethical principles to provide a basis on which
speciWic rules may be formulated, criticized, andinterpreted” (Emanuel et al., 2008). Historically,justice “was considered largely in terms of ensuringthat burdens of research were not unfairly carried by
the vulnerable of society” (Killen, 2008), and“requires fairness in the distribution of both theburdens and the beneWits of research” (Beauchamp,2008). Additionally, “justice, addresses who ought toreceive the beneWits of research and bear its burdens.
The principle of justice requires that there be fair
procedures and outcomes in the selection ofresearch subjects” (Porter and Koski, 2008). It
seems that fairness, as I will equate justice to mean,
does not follow the relativist argument. To be fair inselection (and treatment) is the very underpinningof what human rights-based universalists advocate
for all peoples around the world irrespective of
individual differing cultures.
Emanuel et al elucidated certain guidelines forresearch scientiWic validity, which I will surmise havea universal applicability and are not to be taken as
solely an American or Western world rulebook, orconversely one which only applies to “X” culture but
not to “Y” culture. Congruent to the point of
universalism, the authors state “Unless research
generates reliable and valid data that can beinterpreted and used by the speciWied beneWiciariesof the research, it will have no social value andparticipants may be exposed to risks for no
beneWits” (Emanuel et al., 2008).
It is hard to
imagine a morally intact researcher arguing against
this point and/or suggesting that there is a relativist
sentiment attached to this statement.
In
continuation of their position on scientiWic validity of
research, they explicate the following fourbenchmarks:
1. The scientiWic and statistical design and methodsof research must plausibly realize the objectivesof the research and must also satisfy the generally
accepted norms of research.
2. A research study must be designed to generate
results that will be interpretable and useful in thecontext of the health problem
3. The study design must realize the research
objectives while neither denying healthcare
services that participants are otherwise entitled
to nor requiring services that are not feasible todeliver in the context
4. Finally, the study must be designed in a way thatis practically feasible given the social, political,
and cultural environment in which it is being
conducted.

I believe most researchers, academics, andethicists will agree with the Wirst two benchmarks
with little fanfare or argument and I will withhold
further analyses of these principles. However, thethird benchmark requires some further analysis, as
it is the subject of frequent criticism by those who
feel researchers have certain obligations to researchsubjects who do not have access to certain levels of
healthcare services available in wealthier areas. The
fourth benchmark will be addressed in the‘universalism vs relativism’ section.
It should come as no surprise, and it does not
require extensive analysis and argument to accept
that there are resource rich and resource poor areasin the world. I also would like to argue that there isbeneWit of research on healthcare issues affecting all
populations whether they be rich and poor. I further
argue that it is not necessarily the role of researchers
to provide the resources for the poor areas in order
to conduct responsible research in those areas.
Nonetheless, researchers can (and should) follow
universal rules of conduct for responsible research,
despite a relative lack in resource entitlements fromthe host to the sponsoring nations. Clearly, thecomplete exposition of this argument goes beyond
the scope of this paper but sufWice it to say that thearguments from both sides of this debate arewidespread and sometimes contentious. Emanuel etal. highlight the issue of healthcare service
entitlements that research participants are afforded.
They maintain that “studies can be ethicallydesigned yet not provide a service or intervention
individuals are entitled to under certain, restrictive
conditions” for example placebos in treatments and/or diagnostics under certain acceptable rules of theiruse1 (Emanuel et al., 2008).
Their argument
continues stating that the issue of healthcare service
entitlements is complicated not only on a global
scale (comparing resource rich vs resource poor
nations), but even within wealthy nations. They
state: “Even in wealthy countries, participants are
not entitled to every available or effective medical
service, because justice necessitates establishingpriorities for the distribution of scarce
resources” (Emanuel et al., 2008). To point out theobvious; justice is fairness and equity, but it is notequality. As reality mandates, no matter how rich asociety may be, there is limited availability of scarce
resources, of which healthcare services is amongst.
Hence, the entitlement of healthcare services issubject to the just distribution of such scarce
resources, which I maintain is a universal principle,
i.e. it applies to all cultures and all peoples, and any
system that attempts to put relative weight orpreference on some peoples over the other is bydeWinition unjust.
These arguments are presented to suggest that
although there might be cultural variabilities

1 There is a methodologically compelling reason to do so, and there is only minimal chance of serious harm, such as suffering

irreversible morbidity or disability, or reversible but serious injury.

21

22

Eubios Journal of Asian and International Bioethics 30 (January 2020)

between different nations where research is
conducted and sponsored, an adherence to the same
principles of responsible conduct of research need
not obviate universal rules of research. Conversely, a
relativist principle would suggest that rules incertain nations could be limited to the local
guidelines, which may not align with internationallyrecognized rules of research. This has been
repeatedly shown historically to be fraught with
opportunities to take advantage of vulnerable
populations and violate the principle of justice in fair
selection and equitable distribution as previously
described.
International research events and guidelines(respect for persons)
I believe it will be instructive to present some of thefoundations of research ethics and the principles put
forth by the world’s largest research sponsoring andregulating agencies. Although many authors haveargued that international research guidelines aremostly in response to past (mostly developed world)
atrocities, they are still the guide through which
responsible research is viewed (Emanuel et al.,2008). Beauchamp (2008) states that the respect for
persons “demands that the choices of autonomous
p e r s o n s n o t b e ove r r i d d e n o r o t h e r w i s edisrespected and that persons who are notadequately autonomous be protected by the consent
of an authorized third party likely to appreciate theircircumstances and who will look after their bestinterests”. Within this principle is the need forvoluntariness and informed consent.
In the United States, the National Institute of
Health (NIH) put forth seven principles to guide theconduct of responsible research. Namely,•
Social and clinical value•
ScientiWic validity•
Fair subject selection•
Favorable risk-beneWit ratio•
Independent review•
Informed consent•
Respect for potential and enrolled subjects.
(NIH, 2016)
Arguably, these principles themselves are derived (atleast in part) from recommendations from theNuremberg Trials and the resultant 10 principles
that comprise the Nuremberg Code (Annas and
Grodin, 2008).
The trials were conducted in
response to the Nazi atrocities of World War II(WWII), and provided guidance on the responsible
conduct of research for the world stage. Other
globally recognized research guidelines, such as the
Belmont report was a response to the Tuskegee
Syphilis Study, whereas the ethical guidelines of theAdvisory Committee on Human Radiation
Experiments were a response to radiation
experiments conducted in the US (Emanuel et al.,2008). The World Medical Association (WMA)
adopted the Declaration of Helsinki (DoH), andrecently updated it in response to the “controversy
surrounding placebo-controlled trials in developing

countries” (Emanuel et al., 2008). Interestingly, thepower and international reach of the DoH was
succinctly described by Capron (2008) as follows:“The evolution of the Declaration—which has
become much longer and more detailed, and which
now takes into account interests beyond those ofpracticing physicians—reRlects the reality that inmany parts of the world, this document, produced by aprofessional association, provides the de facto legal
criteria for consent and other ethical requirements inresearch. Indeed, the U.S. Food and Drug Administration (FDA), which in 1975 Rirst incorporated
the original Declaration into its regulations forforeign clinical trials conducted without an
investigational new drug application (IND), still relieson the Declaration’s 1989 version as the standard towhich investigators are held.”
Although it is far from a perfect document, theDoH has as its greatest strength its universality andclarity for researchers around the world “wishing to
avoid unethical practice and by ethical committees
wishing to enforce ethical standards” (Aschcroft,2008).
Given the Western/American origins of many
international research guidelines and regulations,these rules for research have been viewed by someas an “imperialistic” and Western attempt at
globalizing their views and mores on developingworld nations and eliminating (or at least
jeopardizing) the local cultures. There may be sometruth to that; however, I believe the internet has amuch further reach and effect than international
research guidelines. This notwithstanding, the“common rules” for research, “focused primarily on
the processes of review, approval, and oversight ofresearch with humans generally” (Porter and Koski,2008), are supported by most agencies within the US
federal government as well as the research
regulations of the US FDA.
And as previously
mentioned, it Winds in its origins many of theprinciples of the earlier versions of the DoH. As aresult, international studies sponsored or conductedby American biotech and pharmaceutical companies
can further extend the global inWluence of theCommon Rules due to the need to submit theirresearch Windings to the FDA for Winal approval andlicensing (Emanuel et al., 2008).
Given the international scope of scientiWic
research, and its impact on all humans, its moral
code must succinctly address and protect the moral
code and interests of all humans. Merton (1973)
stated, scientiWic research must be universal, andshould not depend on who or from where it comesfrom. Merton (1973) further exempliWies scientiWic
research based on relativist principles that have led
to a “moral strain” and have even “hindered theadvancement of society”. Clearly, the atrocities ofNazi Germany, among many other regional crimes ofresearch, come to mind regarding some of thepitfalls of a relativist scientiWic ethic. An argument
frequently levied against relativists in theirculturally based ethics principles is the Nazi

Eubios Journal of Asian and International Bioethics 30 (January 2020)
Germany era. Many of these experiments wereconducted under and even scrutinized by the
research ethics of the Third Reich. They were said tobe conducted under the strictest conditions of“proper scientiWic research” (Annas and Grodin,2008). Similarly during the early 1900s, research
was conducted by the Japanese under a similar viewthat the Chinese (and other imprisoned nonJapanese) were subhuman and did not violate theirestablished local rules and ethical researchguidelines for (Japanese) humans (Tsuchiya, 2008).
These are just some of the many human rights
abuses that have been committed in the name ofresearch, with a common theme of them all being
approved under local cultural guidelines. Ironically,
this is why an international declaration of humanrights was adopted (coinciding with the creation of
the United Nations) after WWII to address theinconsistent treatment of all humans all over theworld via the Universal Declaration of Human Rights(UDHR), which was accepted across nations globally(Johnson and Symonides, 1998).
Another case that highlights the need foruniversalism in clinical research, was the 1996 PWizer
clinical trial of the antibiotic TrovaWloxacin during ameningitis outbreak in Kano, Nigeria. The outbreak,which affected primarily children, attracted theattention of local, national, and regional
governments, as well as several international nongovernmental organizations (NGOs) such as
Medecins San Frontiere (MSF). Many have argued
that the study violated many universal research
ethics, namely respect for persons, need for
informed consent, fair selection of subjects, andmaintaining of a favorable risk-beneWit ratio in thetreatment modalities.(Okonta, 2014; Marchat et al.,
2002; Wise, 2001). The principle argument behindthese claims is that a Western corporation took
advantage of a society that insulated itself frominternational rules, and conducted locally acceptable
research on a vulnerable and marginalized segmentof society similar to experiments conducted during
the Nazi atrocities of WWII, which similarly violated
the DoH and other internationally accepted researchguidelines.
For the above stated reasons which have detailed
the importance of the scientiWic method and theworldwide implications of its Windings, it should not
matter in what subdiscipline the scientiWic researchoccurs (i.e. basic research versus research involving
animals, basic research versus research involving
human participants). It is the need to respect all
humans, regardless of where they reside, that
supports my argument for universalist-based
research. It is only through the respect andadherence to universalist principles that research
conducted around the world can be ensured to be
responsible. However, there are clearly some culturaldifferences around the world regarding theparticular use of certain animals that should be
respected. Nonetheless, the use of animals forscientiWic research should follow universalism.

23

Universalism vs relativism
The previous examples of local cultures overriding
international laws and human rights abuses, might
be decried by relativists as imperialistic judging or
meddling in local affairs by Western agencies.
Relativists argue that individual cultures are better
apt at establishing the ethics of human behavior.
However, it is unfathomable that a relativist would
not see any commonality whatsoever in any peoples
of differing cultures. One could say, perhaps suchbasic commonalities between all humans is not
sufWicient to override the clear cultural differences,
but I would argue that the commonalities, albeit few,
are what is needed to be human. I would further
argue that within each culture there are certain sets
of guiding rules and principles that share things incommon even with their most ardent enemy
cultures.
As I alluded to in the beginning of this paper, thetruth (or best approach) lies usually in between the
opposing presented arguments. Msoroka andAmundsen (2018) similarly embrace “theapplication of universal ethical principles withdiversity that permits partial detour from universal
principles.” They further state that “Radical cultural
relativism would hold that culture is the sole sourceof the validity of a moral right or rule. Radical
universalism would hold that culture is irrelevant tothe validity of moral rights and rules, which areuniversally valid” (Msoroka and Amundsen, 2018;
Chandler and Munday, 2016). One of the concerns
raised about universalisms is that it neglects toacknowledge local cultural mores. I reject thisargument and join a chorus of other authors(ironically mostly Western educated with ties to thedeveloping world like myself) who state we must
distinguish relativism from absolutism. Tangwa(2004) likens our need for Wlexibility in moral rules
to those of universalism. On the former, he says
a l t h o u g h m o ra l n o r m s a n d r u l e s c a n b e
generalizable or “universalizable”, “Moral norms/
rules may, of course, be expressed in, mixed with, orreRlected in laws, societal customs, cultural practices,taboos, etiquette, and so on. But all these differ frommoral norms/rules proper in that they are—by theirvery nature and raison d’etre—context bound. A law,for instance, has no jurisdiction and no applicability
outside of its area of sovereignty. Moral precepts arenecessarily universal as well as abstract and, if theirdynamic and dialectical relation with concrete
particulars is not properly appreciated, they may
appear rather empty.”
It is my understanding of Tangwa that althoughmoral principles can be derived from a universal
source, they may require contextualization in thelocal culture to which they are being applied. This
does not in and of itself eliminate the universal ethicthat was originally applied, but only provides “local
Wlavor”, so to speak. He gives the classic Kantian
example regarding a deranged murderer seeking aparticular victim who runs by a 3rd party witness

24

Eubios Journal of Asian and International Bioethics 30 (January 2020)

asking if the intended victim has been seen. The
absoluteness to which the moral rule of never lying
would in most people’s opinions clearly beinappropriate under such circumstances. Hence, themoral rule, can have exceptions and contextual
variations. Again, this does not eliminate theuniversality of the underlying moral principle, in thiscase, lying is generally immoral. To insist on
universalism to the extreme is to embraceabsolutism. Tangwa (2004) continues his argumentwith the following:“The same point can be made by drawing a
distinction between universalism and absolutism.
Moral rules are universal but not absolute: they canadmit justiRiable exceptions. Such putative exceptions,however, do not justify the postmodernist relativistic
position that moral judgments are or ought to be
entirely culture bound or culture dependent. In otherwords, accepting the possibility of a justiRiable
exception to the applicability of a moral rule in noway implies moral relativity, let alone the absurd ideaof ‘‘geographical morality’’ or ethics which change atterritorial borders. Obeying or applying an ethicalrule, however, is necessarily done within theco n s t ra i n t s o f th e p a r t i c u l a r p l a ce , t i m e ,circumstances, and perspective. To say that there are
ethical universals—that is, norms and values having
cross cultural validity—is to make an understatement.
It would be more accurate to say that all ethicalnorms or rules are cultural universals, because a ruleor norm cannot properly be described as ‘‘ethical’’unless it is understood as having cross culturalvalidity, in the sense of being perceived as applying inall similar circumstances, irrespective of place andtime.”
Again, exceptions must exist for every rule inorder for them to be universal, and such exceptions
do not make them necessarily culturally relativistic.

Conclusion

In order to ethically conduct research, we as asociety should expect researchers to respect therights of the individuals who have volunteered
knowing the reasonable risks and consequences of
their participation. To do so is not just a Western
ideal, but an expectation all member states of the UN
have agreed to (Johnson and Symonides, 1998). To
allow cultural variances that do not conform with orrespect universal ethical principles is to open up adoor for potential human rights abuses that havedominated research (and humanity) since its
inception. Universalism with a degree of Wlexibility is
the appropriate manner in which to conduct
research in cultures with particular elements that
may require a different approach to the researchsubject.

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Annas GJ and Groodin MA. (2008) The Nuremberg Code.
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EJ, Grady C, Crouch RA, Lie RK, Miller FG, Wendler D(eds). New York, NY: Oxford University Press.
Ashcroft RE. (2008) The Declaration of Helsinki. Oxford
Textbook of Clinical Research Ethics. New York, NY:
Oxford University Press.
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Textbook of Clinical Research Ethics. New York, NY:
Oxford University Press.
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Capron AM. (2008) Legal and Regulatory Standards ofInformed Consent in Research. Oxford Textbook ofClinical Research Ethics. New York, NY: Oxford
University Press, pp. 613-32.
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and communication. Oxford: Oxford University Press.
Emanuel EJ, Wendler D, Grady C. (2008) An Ethical
Framework for Biomedical Research. Oxford Textbookof Clinical Research Ethics. New York, NY: Oxford
University Press.
Johnson MG and Symonides J (1998) The Universal
Declaration of Human Rights: A history of its creationand implementation 1948–1998. Paris: UNESCO.
Killen JY. (2008) HIV Research. Oxford Textbook of ClinicalResearch Ethics. New York, NY: Oxford University
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Porter JP and Koski G. (2008) Regulations for theProtection of Humans in Research in the United StatesThe Common Rule. Oxford Textbook of ClinicalResearch Ethics. New York, NY: Oxford University
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Disadvantaged Participants. Oxford Textbook ofClinical Research Ethics. New York, NY: Oxford
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Merton, Robert K. (1973) The Sociology of Science:
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Msoroka, SM and Amundsen, D. (2018) One size Wits notquite all: Universal research ethics with diversity.
Research Ethics, Vol. 14(3) 1–17
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Ethical Research. Available at: https://www.nih.gov/
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guiding-principles-ethical-research
Okonta, Patrick I. (2014) Niger Med J. Ethics of clinical
trials in Nigeria. May-Jun; 55(3):188–194.
Tangwa GB. (2004) Between universalism and relativism:
a conceptual exploration of problems in formulating
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China. An Ethical Framework for Biomedical Research.

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Oxford Textbook of Clinical Research Ethics. New York,
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Wise, J. (2001). "PWizer accused of testing new drug
without ethical approval". BMJ (Clinical researched.). 322 (7280): 194.

Fostering integrity in scientificresearch: understanding conflict ofinterests (COI) throughresponsible conduct of research(RCR)- Angelina Patrick, Olesen(Formerly) Pusat Citra UKM, Universiti Kebangsaan
Malaysia, Bangi, Malaysia.
Email: patrick.angelina@gmail.com- Latifah Amin (Corresponding author)
Pusat Citra UKM, Universiti Kebangsaan Malaysia,
Bangi, Malaysia.
Email: nilam@ukm.edu.my- Zurina Mahadi
Pusat Citra UKM, Universiti Kebangsaan Malaysia,
Bangi, Malaysia.
- Maznah Ibrahim
Pusat Citra UKM, Universiti Kebangsaan Malaysia,
Bangi, Malaysia.

Abstract

A conWlict of interest situation can potentially harm
the integrity of research and contribute to research
misconduct. This study highlights participants’
perception and knowledge on issues related toconWlict of interest. In response to mails to 40
participants in RCR training, 15 of them agreed tothe interview. The interviews demonstrated that theparticipants’ knowledge regarding conWlict ofinterest in research was rather limited andparticularly focused on the Winancial aspect ofconWlict of interest. Participants stated that thetraining program had increased their knowledge on
the different types of conWlict of interest and also
provided them the necessary knowledge on how tomanage conWlict of interest in their research.
However, since this is an incidental Winding, thenecessary method of handling different types ofconWlict of interest was not immediately instigatedduring this study as it was not the focus of theinterview at the time. Conclusively, there should be aneed to expose the researcher to issues related toconWlict of interest. Considering the variation of
conWlict of interest policies by research institution,
academic journals and funding agencies, they might
not be adequate to maintain a high level of research
integrity.

Introduction

The importance of responsible conduct of researchor RCR’s training program has been the focus of the25

scientiWic community for the past three decades. It isa phrase that is used to describe several concepts
associated with the discovery and discussion of
newfound knowledge including topics on research,
responsible science, scientiWic integrity andresponsible researchers (Horner & MiniWie, 2011).
The training in RCR has become necessary for someresearch institutions including the National
Institutes of Health (NIH) and National Science
Foundation (NSF) which made it compulsory for
their funded research trainees to have RCR training.
Since then, responsible conduct of research (RCR)
training has become one of the requirements for PhD
students as well as for postdoctoral training,particularly in biomedical sciences (McCormack &Garvan, 2014). Initially, there are nine core areas in
the RCR training program including data acquisition,
management, sharing and ownership; mentor/
trainee responsibilities; publication practices andresponsible authorship; peer review; collaborative
science; human subjects; research involving animals;
research misconduct; and conWlict of interest andcommitment (Schamling & Blume, 2009). However,there might be some variability in the training
program, depending on the trainees’ discipline.
Even though the deWinition, types and handling ofconWlicts of interest and commitment is speciWicallymentioned on the website of OfWice of ResearchIntegrity (ORI), there has been no consensus on thedeWinition of conWlict of interest. For some, conWlict ofinterest (COI) is a situation where an investigator is
tempted “to compromise professional judgment for
Winancial or personal gain” (Thompson, 1993;
Werhane & Doering, 1997). ConWlict of interest could
happen when an individual or an institution has a
primary allegiance that requires certain actions, andat the same time, has a secondary interest that could
jeopardize their primary allegiance (Cohen, 2001).
Therefore, this interest may result with theindividual or institution failing to perform theirprimary ethical or legal obligations to researchsubjects, colleagues, research institutions, or the
public (Thompson, 1993; Shamoo & Resnik, 2003).
However, according to most researchers or
institution, some conWlicts of interest are
unavoidable which can vary in term of signiWicance,as there is a natural tendency to create
preconceptions and biases as well as the possibility
to inWluence the investigator’s thinking and behavior;
this emphasizes the need to manage the conWlicts
appropriately and transparently (Coyne, 2005). On
the contrary, conWlict of commitment refers to any
conWlict between two sets of professional obligations
that could both be adequately fulWilled withoutcompromising one’s judgment in fulWilling either ofthem (Werhane & Doering, 1997).
Mentioning a conWlict of interest is normallyassociated with the Winancial aspect of research but
individuals may also have many other interests that
can affect their judgment, including personal,
professional, political, and intellectual interests. For
example, Sollitto et al (2003) highlighted that

26

Eubios Journal of Asian and International Bioethics 30 (January 2020)

although some investigators may not have any
Winancial conWlict of interest in a clinical trial, they
may have strong interest in conducting andpublishing the outcome of the research outcomes. At
the same time, the research institutes including
universities, medical schools, or hospitals can also
have a conWlict of interest, in which the institution
has a Winancial or other interest that tends to affectits decision-making. It may result in their inability to
fulWill their primary ethical or legal obligations to theresearch subjects, profession as well as the public(Shamoo & Resnik, 2003).
ConWlicts of interest are important ethicalproblems for scientiWic research for at least threereasons. The Wirst reason is that it can inWluence theoutcome of research as there is considerable
evidence showing a connection between the sourceof research funding and the outcome of biomedical
research studies (Krimsky, 2003). This connection
was found in studies by Friedberg (1999) and Stelfox
et al (1998) where they found that more than 90% of
publications sponsored by pharmaceuticalcompanies favor the company’s products. This isbecause pharmaceutical companies who funded theresearch can withhold research results that showednegative outcomes which caused biased
interpretations of the data (Krimsky, 2003).
Secondly, conWlicts of interest can harm patients
because investigators who have conWlict of interest
may be tempted to bend the rules and engage inunethical research practices while conducting
research in order to produce desirable outcomes.
Finally, for the third reason, conWlicts of interest canalso reduce the trust that public have in the researchenterprise because research subjects, politicians andlay people may view investigators with COIs as
biased or unethical (DeAngelis, 2000; Shamoo &Resnik, 2003).
An article by Horner & MiniWie (2011) provides
empirical support for the inWluence of outside
interests on investigators and authors. Several
articles have examined the relationship between
conWlicts of interest and research results (Friedmen& Ritcher, 2004; Kelly et al, 2006; Kjaergard & AlsNielsen, 2002; Perlis et al, 2005). While someliterature examined conWlicts of interest policies(McCrary et al, 2000; Studdert, mello & Brennan,
2004; DeAngelis, Fontanarosa & Flanagin, 2001;
Stossel, 2005; Sharp & Yarborough, 2006), others
examined the inWluence of industry on researchoutcomes from the perspective of potential research
participants (Kim, Millard, Nisbet, Cox & Caine,
2004; Wienfurt et al, 2008) and readers of thescientiWic literature (Schroter, Morris, Chaudhry,
Smith and Barrat, 2004).
An “uneasy alliances” was reported between
clinical investigators and the pharmaceuticalindustry, where the strong inWluence of thepharmaceutical industry over trial design, data
analysis, decisions about what to publish and when,
and the use of professional ghostwriters as authors
were highlighted (Bodenheimer, 2000). However, a

study by Buchkowsky and Jewesson (2004) on 500
pharmaceutical trials showed that the outcome fromthe studied drug is no different from publicly funded
trials. Whether the drug trials were funded by a
private pharmaceutical company or governmentalorganizations, the outcomes were still favorable tothe studied drug. This Winding contradicted with theforgoing studies that found a greater likelihood offavorable outcomes for industry funded trials(Lexchin, Beros, Djulbegovic & Clark, 2003).
In addition, there is variability in terms of policies
on conWlict of interest, including variability acrossdifferent institutions, vagueness of deWinitions,
lacking of procedures in terms of managing conWlictsof interest, and also lacking accountability for those
who breach ethical conduct. What makes the matterworst is that, despite the requirement to have policy
on conWlict of interest, there are still quite a numberof institutions that do not have one. In general,
conWlicts of interest or commitments do have thepotential to inWluence research outcomes andpublication practices. Thus, some suggest that
disclosing the conWlict of interest is sufWicient butothers suggest that both individuals and institutions
should be subject to tighter regulations to assure
uniformity in order to maintain researcher subjects’trust in the research ecosystem and subsequently, toassure scientiWic records are reported with highintegrity.
There has been an increase in research done by
Malaysian researchers in local research institutions
including public and private universities to support
the government’s aim to place the country
researchers on par with other high impact
researchers in developed countries (NST, 2018).
Some of these researches are collaborative research
between universities and industry players; therefore,
they create tendencies for conWlict of interests
between both parties. Most previous studies on COIs
are related to Winancial conWlicts between research
institutes or investigators and funders of research(McCrary et al, 2006; Bekelman, Li & Gross, 2003;
Friedman & Ritcher, 2004; Rockey & Collins, 2010;
Cooper, Gupta, Wilkes & Hoffman, 2005; Blumenthal,
2002; Dunn et al., 2016; Bero, 2017), particularly in
the Wield of biomedical sciences. However, there areother aspects of conWlict of interest that are seldom
discussed in the literature. Hence, it raises a question
regarding researchers’ knowledge on issues related
to conWlict of interest. Currently, most institutes ofhigher learning in Malaysia have conWlict of interest
procedures or policies but information on
researcher’s knowledge regarding the types ofconWlict of interest is still limited. Therefore, theobjective of this paper is to explore participant’s
knowledge and views on conWlict of interest and tohighlight the importance of RCR training with regard
to strengthening researcher’s awareness andknowledge about conWlicts of interest. Nevertheless,
it is important to caution that the Windings in thisstudy cannot be generalized as it is based on theviews of selected researchers.

Eubios Journal of Asian and International Bioethics 30 (January 2020)
Methodology

A qualitative method was used for this study because
it is well suited to the needs of the study, that is to
explore participants’ views regarding conWlict ofinterest. In response to a mailing of 40 participantsof RCR training, 15 participants agreed for aninterview over a period of six months. In-depth
interview is an appropriate approach for a wide
range of topics, particularly when investigator
intends to explore, and highlight participant’sopinion and perceptions on the topic discussed.
Participants: Universiti Kebangsaan Malaysia
approved this study. Participants were recruitedfrom mid-April 2018 to end-October 2018. The
participants in the study were either those who hadparticipated in the jointly organized Young Scientist
Network-Academy of Science Malaysia (YSN-ASM)
and High Education Leadership Academy (AKEPT),or those who had attended RCR training organizedby trainer or RCR training by YSN-ASM and AKEPT.
Recruitment of participants for this study wasfrom a wide range of academic disciplines including
physical sciences (4), medicine and health sciences(6), engineering (3), pharmacy (1), and science andtechnology (1), and consisted of six male and nine
female participants. Most of the respondents were
early career researchers with less than Wive years
research experience, while some had more than 10
years’ experience in research. Eleven respondents
were from research universities (RUs), while four
were from non-RU. The answers to these questions
highlight their knowledge and view on conWlict ofinterest. It may also highlight some suggestions
raised by participants on improving researcher’s
knowledge regarding conWlict of interest.
Data collection: Data were collected via in-depth
interviews. The design of the open-ended semistructure questionnaires was adapted and adopted
from a previous study on plagiarism by Devlin andGray (2007). It was modiWied and pilot tested. Prior
to the interview, an email was sent to theparticipants including a brief introduction to theresearch and its purposes, why they were chosen toparticipate and an informed consent form. After
participants provided us with their consent to theinterview, time and venue was decided. Theinterview was conducted in English, and lasted
between 45 minutes to an hour. The interviews wererecorded and all of the interviews were transcribed.
Data analysis: Data was analyzed using thematic
analysis and the analysis was validated with anotherresearcher to compare and deWine the major Windings
to test their validity.

Results

Knowledge: Our Windings showed that participant’s
knowledge regarding conWlict of interest is still very
limited. Although they had heard and dealt with theterm all the time, they were not aware of the depth

27

of issues related to conWlict of interest. Most
participants’ knowledge on COIs were restricted toWinancial conWlict of interest and this is not surprisingbecause most of them are from the biomedical Wield,
where they are sometimes involved in collaborative
research with medical or pharmaceutical companies.
One participant said: “I realized how little I know
about COI. When I wrote the paper, you know that you
need to make declaration right. It’s like automatic you
write no conRlict of interest. For me being in the
medical science Rield, I would only think about theconRlict in term of Rinance or collaboration. But in thistraining program, they also talked about COI in termof publication, peer review or even grant proposal.
That is something new for me.”Issues related to COIs are seldom discussed in
ethics education so that some took it for granted anddid not view the issues as anything serious: “I seldom
really think seriously about conRlicts of interest. I
mean you thought that you know it good enough but
when we discussed it in detail and thoroughly, I
realized wow, there is so much detail on COIs that I do
not have knowledge about. It is only after the sessionthat I think about conRlict of interest thoroughly when
I do research and publication. So, yes it really is an eye
opener.”Another participant said: “Basically I heard about
COI and basically I know what it is but only after theworkshop when it was presented and discussed indetail that I get to learn more and in depth on issues
related to COIs.”
Personal relationship: According to Werhane andDoering (1997), conWlicting interests may involvecommercial or Winancial interests, reputational
interests, or simply conWlicting commitment of time,
expertise, energy or interest. However, someresearcher may not be aware of different types of
COI. For instance, one of the participants mentionedthat she didn’t know that certain actions are
considered to be a conWlicting interest: “I did not evenknow that when you are one of the reviewers for grant
proposal and you found out that the grant applicant issomeone you know personally, and yet you still forgo
with the review. And that actually is a conRlict ofinterest. That I am not aware of.” [P5]In addition, two participants shared theiropinions: “I am not aware that having both husband
and wife in a research team is considered as conRlict ofinterest. It never occurred to me that it can lead to
COI.”“You know, COI was the most debated topic during theworkshop, which is mostly based on the personal
experience of other participants. For example, in peer
review for publication, I just knew after the workshopthat it is a COI when you do review for someone whom
you know come from the same department or using
the same laboratory as you. It is like you have a‘personal’ relationship with them.”
Financial management: A participant believed thatlack of knowledge in Winancial management also canlead to conWlict of interest: “We normally learn about

28

Eubios Journal of Asian and International Bioethics 30 (January 2020)

Rinancial management through our own experience or
we learn from our supervisor. Yes, as student we did
apply for grant but the Rinancial part is normallyhandled by the supervisor. So, when you are now
researcher, I didn’t know that applying for grant canalso cause COI. I thought that COI can only happen
during collaboration or publication.”
Hierarchy: Holding a certain position within thefaculty or research team, or being appointed to that
position sometimes can lead to a situation where it
indirectly creates a conWlict of interest: “It opened myeye on the different types of conRlict of interest. You
know sometimes you are either appointed or got
certain position that you might have the ability toabuse. It’s like you have the opportunity to abuse it foryour own good. At the same time, I also learned how
to handle it.”Handling strategies of COI:
The training program also taught participant how tohandle different types of conWlict of interest. This was
agreed by a participant where he mentioned: “I think
I learned the most in term of COI. Not only have I
learned about the different types of COI but also how
to handle different types of COI.”
However, unfortunately further details on
different methods of handling COIs were not asked
during the interview. Therefore, it is suggested that
future studies on the topic of COI and RCR training
should include strategies of handling COIs. Overall,the Windings showed that the workshop managed toincrease participants’ knowledge and awarenessregarding different types of conWlict of interest andhow to handle different situation of COIs. Although
the data might be minimal in term of the number ofparticipants, it provided an insight on how we needto educate researchers with knowledge regarding
conWlict of interest as a lack of knowledge in COI canpotentially lead to research misconduct. At the sametime, it also highlighted the importance of research
institutes investing in RCR training program in orderto provide researchers with a platform fordiscussion on other ethical aspects of research
including COIs.

Discussion

We could not Wind any other study that explore
researcher understanding and knowledge regarding
issues of conWlict of interest in Malaysian university,
therefore, indicate the signiWicant of this study inorder to know how far do Malaysian researcher cum
lecturer know about conWlict of interest. Our Windings
showed that participants are very intrigued in the
topic related to conWlict of interest because thoroughdiscussion on the topic are rarely done in any ethics
classes or subject that they had attended previously.
The growing interest in COI is not new particularly
among biomedical research (McCrary et al, 2006)
due to the realization that commercial interests playa strong inWluence on the researchers, reviewers aswell as the editors, during the peer-review process.
Therefore, making COI a sensitive and of upmost

importance issues to the Wield of biomedical research(Friedman & Ritcher, 2004). In fact, the discussion
among other researchers during the RCR training,particularly regarding their own experience with
conWlict of interest has become an eye- opener forthem and they realized that there are other different
types of conWlicts of interest and different way ofhandling it. According to Weinfurt et al (2006),
discussions on COI has subsequently raised concerns
about both the integrity of clinical research andprotecting the right and welfare of research
participants (Weinfurt et al, 2006).
Our Windings highlighted the lack of awareness ofparticipants on the different types and situations
related to conWlict of interest. According to Horner &MiniWie (2011), there are generally three types ofconWlict in academic research: commercial or
Winancial competing or conWlicting interests, conWlictof commitment, and conWlict of guidelines. The
clearest and most often discussed example of aconWlict of interest in biomedical research involves
doing research on a speciWic intervention while
receiving research funding or personal
remuneration from the company producing theintervention. While there are many other forms of
Winancial and non-Winancial conWlicts of interest(Horton, 1997), this is the type that is most often
measured and discussed (Dunn, Coiera, Mandl &Bourgeois, 2016).
Previous researches on COI have focused
primarily on issues related to Winancial conWlicts ofauthors, which is also evident in our study. Yet, nonWinancial interests can be equally important, because
it can affect the whole process of publishing the
research Windings in academic journals (Bird & Spier,2005; Levinsky, 2002; WAME, 2006; Smith, 1998).
Non-Winancial conWlicts of interest can occur during
publication, particularly when the author has aprofessional or personal relationship that could
inWluence or bias his or her decisions,interpretations, conclusions or publications (Ancker& Flanagin, 2007). There is also a growing concern
on the inWluence of social context in which theresearch was conducted, on the outcome of theresearch results (Bero & Grundy, 2016).
ConWlict of interest is more common than most of
us realize and it is commonly unreported because
researchers are not aware of the different types of
COI. This was also found in our study where most of
the participants came to realize how common
conWlict of interest was in their daily conduct of work
once they knew the different types of conWlict ofinterest. When they did not realize that suchsituation was a conWlict of interest, they did notdisclose it or report it. This concurred with aprevious study by Bekelman et al (2003), where athird of biomedical researchers held conWlicts ofinterest that could potentially introduce a risk of
research or publication bias. Cross-sectional studies
across a heterogeneous set of conditions suggestthat in between 29% and 69% of published clinical
trial reports, there are still quite a number of conWlict

Eubios Journal of Asian and International Bioethics 30 (January 2020)of interests that go unreported including disclosuresof conWlict of interest (Roseman et al., 2011;
Roseman et al., 2012; Jagsi et al., 2009; Perlis et al.,2005; Matsen. Jette & Neradilek, 2013; Bosch et al.,2013; Bridoux et al., 2014).
A few other studies that measured undisclosed
conWlicts of interest, suggest that between 43% and
69% of studies fail to include disclosures of conWlictof interest (Kesselheim et al., 2012; Rasmussen et al.,2014; Norris et al., 2012; Chimonas, Frosch &Rothman, 2010). This concurred with a crosssectional study of published clinical practiceguidelines issued by medical organizations in the
USA and Canada, in which 48% of authors disclosed
a conWlict of interest, whereas approximately 25% ofauthors formally declared none; However, 11% outof the 25% were found to have an undisclosed
conWlict of interest (Neuman, KOrenstein, Ross &Keyhani, 2011). In a study on the Danish clinicalpractice guidelines, 96% of guidelines included atleast one author with a conWlict of interest, but only
2% of the guidelines disclosed those conWlicts ofinterest (Bindslev, Schroll, Gøtzsche & Lundh, 2013).
Most of these studies were conducted among
biomedical or medical researchers, and we foundvery limited survey conducted among researchers
from other Wields. One of the reasons given is that
medical science already has a well-established andwritten policy on conWlict of interest, and it issuggested that future studies regarding COI should
include researchers from other research Wields, forinstance, social sciences.
Researchers’ knowledge associated with conWlictof interest is rather limited. This was highlighted by
one of the participants in this study, where she
mentioned that her knowledge on the types of COI
and how to manage COI was very limited before she
attended the RCR training program. Thus, the needto provide researchers with more exposure anddiscussion on issues related to COI is highlighted sothat they can identify and manage COI. However,Bero and Grundy (2016) mentioned that confusing‘interests’ and lack of knowledge on ‘conWlict ofinterest’ makes conWlicts of interest appear so
pervasive that they cannot be avoided but only
disclosed. However, there are precedents fordisclosing and managing Winancial conWlicts ofinterest, which should be adopted and enforced
widely within biomedical research institutions aswell as other research Wields. In fact, disclosing
Winancial interests was highlighted as one of thestrategies to manage COI or complete prohibition
from research on a product in which one has anequity interest. This approach is often taken by
institutions and regulatory bodies and also wasrecommended by expert panels in term of managing
COI (Romain, 2015; AAMC, 2008; IOM, 2009; Drazen
et al., 2009).
Curzer & Santillanes (2012), have suggested
different approaches to manage COIs on different
levels: professional, institutional and personal. Oneof the approaches suggested is to restructure the29

profession in a way that it is able to eliminate or
reduce various sorts of perverse incentives. Anothersuggestion is to regulate the researchers where they
are urged to eliminate conWlict of interest wheneverpossible, to minimize, monitor and disclose conWlictof interest when necessary, and try to screen out
immoral applicants from graduate programs. It wasalso suggested that researchers should attend
compulsory courses or classes in research ethics
before conducting any research so that they could begood mentors to their junior researchers.
ConWlict of interest threatens all aspects ofresearch process, from the choice of research
problem, to research design, to recruitment andtreatment of research subjects, to datainterpretation, to peer-review of publication andgrant applications (Curzer & Santillanes, 2012).
Researchers with conWlicts of interests will most
likely prefer to choose comparators that would
produce results, which are favorable to them
(Lathyris, Patsopoulos, Salanti & Ioannidis, 2010),
selectively publish outcomes that are signiWicant(Mathieu et al, 2009), only publish conclusions thatare consistent with the study results (Als-Nielsen,
Chen, Gluud & Kjærgard, 2003; Yank, Rennie & Bero,2007), or complete a clinical trial but not publish theresult (Dunn, Coiera, Mandl & Bourgeois, 2016).
Based on these, it is concluded that conWlict ofinterest can pose three general risks. The Wirst risk isthat conWlict of interest can be a distraction to theresearchers’ observations and deductions ofresearch thus undermining their scientiWic
objectivity through bias. The second risk is that it
may compromise the ability of researchers to decide
what their duties are which can lead to the wrong
action through warped moral judgment. Finally, thethird risk is that researchers tend to engage inunethical action because of their weak will (Krimsky,
2003; Thompson, 1993; Resnik, 2006).
We would like to highlight that the lack ofknowledge and awareness of participants in thisstudy regarding issues related to conWlicts of interest
is an incidental Winding. This Winding, althoughincidental, shows that there is an urgent need toprovide researchers with necessary knowledge on
conWlict of interest in order for them to identify andmanage the issues at their institute. Therefore,emphasizing the importance of RCR training
program for researchers in research institutions in
Malaysia is highly recommended. Even though someresearchers may have attended ethics education,
discussion on topics related to conWlict of interest islimited to the most common aspects such as
Winancial matters. Mandatory education in research
ethics may provide only a small impact toresearchers’ behavior but such training or education
may improve and raise awareness on moral
reasoning including issues on conWlict of interest.

Conclusion

Based on our Windings, participants had limited
knowledge on issues related to conWlict of interest.

30

Eubios Journal of Asian and International Bioethics 30 (January 2020)

Most of them were aware of the Winancial aspect of
COI but unaware of COI that involved personal
relationship between researchers, which canpotentially become a threat to the integrity of
research. We also found that participants gained
knowledge regarding the different types of COI andhow to manage and handle it accordingly throughtheir participation in responsible conduct of
research (RCR) training program. Even though someof them might have attended ethics education before,
the focus on COI was quite limited. In conclusion, ourWindings highlight the need for further study toinvestigate and explore researchers’ knowledge andawareness regarding conWlicts of interest in academic
research, particularly on the different types ofconWlict and how to handle the situation
professionally.
There is a necessary need to also focus on the
topic of conWlict of interest in research ethics
education by providing researchers with different
scenarios or cases of conWlict of interest other thanjust the Winancial aspect of conWlict of interest.
Previous studies on COI are mostly conductedamong biomedical or medical researchers, thus it isalso important to conduct a study on researchers
from other Wields because it is feared that
researchers might take the issue for granted and thismay contribute to a higher incidence of research
misconduct.
Acknowledgment
We would like to thank all the participants for theirtime and views for this study.
Funding
This study was funded by Universiti Kebangsaan
Malaysia with the grant no. MI-2018-005.

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NEW: POSTGRADUATE CERTIFICATE IN
EPIDEMICS AND ETHICAL GLOBAL HEALTH
American University of Sovereign Nations(AUSN) has just launched a new Postgraduate
CertiWicate Program in Thailand - classes fromMarch 2020. Do not delay to join us to prepare
yourself and your community to respond to
COVID-19.
Email to: provost@ausn.info:
https://www.ausovereignnations.org

For forthcoming conferences see:www.eubios.info

20th Youth Peace Ambassadors
Training Workshop (YPA20) andIndigenous Leaders Global
Summit, Kitami, Hokkaido, Japan,

17-22 August 2020. https://www.eubios.info/
youth_peace_ambassadors_international/
ypa20_kitami_hokkaido

Followed by the Second AUSN-Tohoku
University Bioethics Roundtable: Cross
Cultural Bioethics Addressing Advanced
Technology: The `irst 20 years into the 21stCentury, 24-27 August 2020. Details and thedraft agenda of these two conferences are on thelinked website. Contact: darryl@eubios.info
The 21st Asian Bioethics Conference is
expected to be held in October 2020 in
Malaysia.
Email to Darryl@eubios.info.
EJAIB Editor:
Darryl Macer (Chair, Accredited Universi5es of Sovereign
Na5ons)
Associate Editor:
Nader Ghotbi (Ritsumeikan Asia Paciﬁc University, APU))
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany), Rhyddhi
Chakraborty (India/UK), Shamima Lasker (Bangladesh),
Minakshi Bhardwaj (UK), Chris5an Byk (IALES; France),
Ken Daniels (New Zealand), Ole Doering (Germany),
Amarbayasgalan Dorjderem (Mongolia), Hasan Erbay(Turkey), Soraj Hongladarom (Thailand), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Umar Jenie (Indonesia), Nobuko Yasuhara Macer (Japan),
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Noritoshi Tanida (Japan), Ananya Tri5pthumrongchok(Thailand), Yanguang Wang (China), Daniel Wikler (USA),
Jeong Ro Yoon (Republic of Korea).

Eubios Journal of Asian and International Bioethics 30 (January 2020)

33

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