Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 27 (1) January 2017www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106(Online)Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2017 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page
Bioethics and Socio-Economic Conditions ofRagpickers’ in Tiruppur City, Tamil Nadu, India 1- A. Sebastian Mahimairaj and Darryl Macer
Sex Selection In Indonesia: An Ethical and Legal
Perspective
19
1- Rani Tiyas Budiyanti , Adi Sulistiyono, Pujiyono
Letter to the Editor: The challenges of medical ethics
educators at a research university
22- Atsushi Asai, Taketoshi Okita, Aya Enzo
Informed Consent: Substantive v. Formalistic
Approach and the Law
22- Chung-Lin Chen
Nurses’ Awareness of Biomedical Ethics and Their
Attitudes Toward Withdrawal of Life-Sustaining
Treatment
28- Eunsuk Choi, Kyung Suk Sung, Gil Hee Seo,
Geun MyunKim
ABA Renewal and EJAIB Subscription
36
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
Provost, American University of Sovereign Nations(AUSN), Arizona, USA
Email: darryl@eubios.info
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Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand
Eubios Ethics Institute is a nonprofit group that aims
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Institute was founded by Darryl Macer in 1990 in
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City, Japan. In 2005 we added Bangkok, Thailand to
the network. For 25 years Eubios Ethics Institute has
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Association, youth networks, and seeks to empower
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motivating youth to be leaders, and homing the skills ofprofessionals.

Bioethics
andSocioEconomic Conditions ofRagpickers in Tiruppur City,
Tamil Nadu, India- A. Sebastian Mahimairaj,
Arul Anandar College, Karumathur, India
Email: asmrajaocd2002@gmail.com- M. Jothi Rajan
Department of Physics, Arul Anandar College,
Karumathur, India- M. Michel John Peter
Department of Economics, Arul Anandar College,
Karumathur, India- Darryl Macer
President, AUSN, USA and Diretcor, Eubios Ethics
Institute, New Zealand
Abstract
Ragpickers are people who salvage usable items
from other person’s rubbish, and they are spread overdifferent localities all around the world. This raises
numerous issues related to the dignity of human life,
and the right to education. In addition to discussion ofthese issues, this paper includes an interview study on
bioethics of 150 ragpickers engaged in collection of
papers, bottles, waste plastic materials, scrap ironmaterials and so on in Tiruppur city, Tamil Nadu, India.
Ragpickers are mostly children below 14 years of age.
The objectives of the study were to find out the socioeconomic conditions of ragpickers, to examine theeffect of environment on their health conditions and to
identify their problems at work.
Society as a whole regards rag picking children as
anti-social elements, an embarrassment to thecommunity and unfit to live. However their usefulcontribution to society and ecology is little understoodand generally ignored. The waste collected by thesechildren is recycled and produces 25% of writing
paper, the packing materials, egg trays, economic
plastic and metal house hold items, and so on, used in
our homes. Society and ecology benefit from theproduction of cheaper household goods, and the2

Eubios Journal of Asian and International Bioethics 27 (January 2017)

slowing down of the destruction of the alreadythreatened rain forests. It also helps to prevent themountains of putrifying waste materials from building
up in city centres. The ragpickers valuable contribution
to society should not be ignored and taken for granted.
There are a number of ethical and human rights issues
raised by this practice, which should not be condoned
as ethically acceptable social attitudes to a child’s life.
1. Introduction
1.1. The Indian Context
In India rural society is inevitably characterized bysmall and marginal economic units. Growing
communities had to look beyond personal cultivation
for subsistence. A class of landless laborers came into
existence, often bonded to the large landowners.
These laborers used their children to help in theireconomic activities. Child labour is a global
phenomenon (Tripathy, 1989). Child labour exists bothin the developing and the developed countries of theworld, though with a difference in cause andmagnitude. The prevalence is more in the developing
counties as compared to the developed ones, because
the families to which the working children belong are inan urgent need of income of child labour for theirsubsistence whereas children in the developed
countries are often working for pocket money. As
Suresh (2015) wrote, “The informal sector of the ruraland urban economies of the developing countries is an
important source of employment for a major proportionof the labour force, particularly child and womenlabour.”Although the sectoral distribution of working children
differs from country to country, child labour is
predominantly confined to the agricultural sector
followed by services and industry. The working
children themselves may not be productive but arecapable of relieving the adults for productive
employment by engaging themselves to domestic
chores and looking after younger children in the home.
Thus, they allow their parents to spend more time on
income generating activities. They also free adults fortheir migration to the areas of high employment.
In the urban areas, child labour exists both in theformal as well as informal sector enterprises, though
its presence in the latter is more frequent in small
manufacturing enterprises, which are spread over widelocations and can ignore legal restrictions, the children
often work along with their elder relatives and friends.
They are possibly not paid directly but indirectly
through a supplementary wage paid to the main
worker. The main occupations where the children are
employed in the urban sector are those that don’t
require heavy labour. The packing pasting, labeling,
wrapping, etc. are the main activities of the children
working in small industries. Domestic works, hostels
and restaurants, canteens wayside shops andestablishments or street vendors or helpers in repair
shops are the main occupations of the working
children in the urban areas. Construction work is
another activity that attracts children. In this context,
child labour is considered a major source of cheap

labour and means of quick profits to the employers.
Normally the supply of child labour always exceeds thedemand. Consequently, child labourers do not haveany bargaining power and they are easily exploited bytheir masters. Hence they are working at much lower
wages than adults and made to work for longer hours.
Amongst the various causes of child labour,
unemployment, poverty and indebtedness of thehouseholds are the most important. Many parents
secure advances from the landlords or the employers
against which the children are forced to work till
repayment. In some cases the children are compelled
to migrate temporarily to the nearest cities, or theurban areas of adjoining states to earn the necessary
subsistence.
In most developing counties, parents depend upon
their children to assist them in performing importantwork at home or outside. In the absence of any social
security measures to the poor the dependence onchildren increases and in many cases the working
children are the main or the only support for theirparents. In this way, the children of the poor are
economically valuable to their parents as a source oflabour contributing to household income and social
security.
1.2. The International Context
In India the extent of child labour in not as large as inTurkey, Thailand, Bangladesh, Brazil, Pakistan,
Indonesia, Mexico, and Egypt, (Kumar, 2001). It isestimated at around 5.2% of the total labour force inIndia, as against 27.3% in Turkey, 20.7% in Thailand,
19.5% in Bangladesh, 18.8% Brazil, 16.6% inPakistan, 12.4% in Indonesia, 11.5% Mexico and 8.2%
1
in Egypt. However, in Sri Lanka child labourers
accounts for only 4.4% of the total labour force(Kumar, 2001). The workforce participation rate ofchildren in the age group 10 – 14 years of India(10.4%) is less than Bangladesh (33.3%), Nepal (22%)
and Pakistan (11.6%) but greater than Indonesia (6%)
and the Sri Lanka (1.8%).
However, according to the ILO, India contributes toabout a third of Asia’s child labour and a fourth ofWorld’s working children in terms of numbers.
According to various social scientists with estimatesvarying between 60 to 115 million, Indian has thelargest number of working children in the world. An
important feature of child labour in India is that nearly
eleven to eighteen million working children are street
children and approximately fifteen million children work
as bonded labourers (UNICEF, 1984).
In Ancient India, it was the duty of the kind toeducate every girl and boy and parents could bepunished for not sending their children to school called
Ashrams, which were really residential schools under a
Guru (a learned sage). Child labour existed only in theform of child salves. Children sometime even less that
8 years of age were purchased to do so called “lowthand dishonourable” work. Kautilya (4 century B.C)
conserved it degrading to make children work on such1

http://www.pibaizawl.nic.in/feature/archives/july05/july5.htm

Eubios Journal of Asian and International Bioethics 27 (January 2017)
jobs and hence prohibited purchase and sale of slavechildren below 8 years of age (Kautilya Arthshastra).
The rural artisan rarely worked alone. In fact, the entire
family is a work unit with the “pater familia” being themaster craftsman, occupations is determined largelyon the basis of heredity, and children are introduced totheir traditional craft at a young age.
th
In the late 17 century the most significant change
was the growth of organizations involving theemployment of large number of artisans. The Dutch
silk factory at Kasimbazar in Bengal employed 700800 weavers. But the characteristic unit of production
was still the small unit. “The persistent dominance offamily based work units indicated that any disciplinedorganization of an industrial society was not seen.
th
In the Middle of the 19 century there was anenormous growth of European industry in India
especially during 1860-70 as seen by the growth thetea, coffee, indigo and jute industry. At this time, thefactory industry taking the place of handicrafts. It wasin the 1950s that the cotton and industry and coalmining were started in an organized way. However, in1980 the number of people employed in theseindustries was rather high even though people werequickly being driven out form their old crafts.
th
It was after the industrial revolution in the early 19
century that industrially developed countries like
Germany and France started taking place. Factory
type units started spinning up. Agriculture became
more mechanized and small land holdings were nolonger economically viable. Small land owners left theirlands and started working as farm labourers on bigger
farms. Factories required cheap and in factories
because they provided a cheap, uncomplaining labour
force as against adults who could be more demanding
and hence more difficult to handle. In the course of thethth
19 and early 20 century.
People especially in the European countries became
conscious of the evils of the exploitation of children
and the International Labour Organisation (ILO) was
setup in 1919 to formulate guidelines to improve theworking conditions of children and ban theiremployment before the age of fourteen. In thepreamble to the constitution of the ILO, it is stated thatin many regions the conditions of labour are such as toresult in untold misery which disturbs the peace andharmony of the world. Children and young persons
especially must be protected. At the very first sessionof the International Labour Conference a convention
was adopted fixing the minimum age as 14 years forchildren in industrial employment. Between 1919 and
1965, there were 10 conventions on the minimum age.
Finally in 1973, the convention concerning minimum
age for admission to Employment (No 138) and the
Recommendation (No.146) were adopted and these
replaced all the previous conventions. However muchneeds to be done through national legislation in thevarious in the countries where exploitation of children
still exists. Today, child labour is almost non-existent in
the developed countries of the world. However, it still
persists in alarming proportions in the developing
countries. According to the ILO, the number of working

3children the world over increased from 43 million to 52
million between 1970 and 1979 of these approximately
29 million were from South Asia, 10 million from Africa,
9 million from East Africa, 3 million from SouthAmerica and about 1 million from the developed
countries.
1.3. Previous Research on Rag-picking in India
Rag picking is probably one of the most dangerous
and dehumanizing activities in India. Child ragpickers
are working in filthy environments, surrounded bycrows or dogs under any weather conditions and haveto search through hazardous waste without gloves or
shoes. They often eat the filthy food remnants they findin the garbage bins or in the dumping ground. Using
the dumping ground as a playing field the children run
the risk to come upon needles, syringes, usedcondoms, saline bottles, soiled gloves and otherhospital wastes as well as ample of plastic and ironitems. They suffer from many diseases, such as
respiratory problems, worms, anaemia, fever and otherproblems which include cuts, rashes, dog bites(Shrestha, 2000).
Ragpicking is the profession mostly dominated bychildren aged 6 to 15 years who do not have any otherskill and thus by way of refuse collection contribute tohousehold income or own survival. These are mainly
children of slum dwellers and poor people. Some ofthem are abandoned or runway children. A sustained
effort of national and international organizations in the
recent past to combat child labour has thrown light on
the issue leading to large scale debate and interest in
the problem. This has resulted in research anddevelopment of literature on the subject.
Few research studies have been done on thesituation of child ragpickers in India. There are,however a number of studies on child labour indifferent countries, as well as, in India. The studies,though not directly connected with the child ragpickers
have a special bearing on the problem underinvestigation in this thesis.
1.4. Socio-economic conditions of Ragpickers in
India
Balkumar et.al. (2001) in their study of “Nepal –Situation of Child Ragpickers: A Rapid Assessment”,
mentions about the family of child ragpickers of Nepal.
The authors conducted a survey of 300 children aged
5-17 years working currently as ragpickers in six major
municipalities. The average family size of child
ragpickers is 5.4 members, which is slightly higher
than the national average of 5.1. The girl ragpickers
usually come from larger families (6.3) than boys do(5.2). This assessment shows that 60% of childreninterviewed have both parents (own or biological father
or mother), only few are belonging to families with astep parent or single parent or no parents. In thisassessment, three indicators were chosen to
determine the economic background of child
ragpickers. Over two thirds of respondents (68%)
indicated that their family owned home. The majority ofchild ragpickers families (55%) do not own farmland.

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Eubios Journal of Asian and International Bioethics 27 (January 2017)

The main occupation among families of ragpickers isof a nonagricultural nature, which may include small
business, mechanical work, low paid services andother activities. For a few families, their main activity iseither in junkyard shops or ragpicking.
Tripathy and Pradhan (2003) in their work “Girl Childin India,” explains the problem of child labour bothmale and females, and their condition in a hazardous
occupation of ragpicking in Berhampur town (Orissa).
In this work they mentions about the family size of girlchild ragpickers. The girl child ragpickers family size ismore than 6 persons.
The work, Ragpickers: Scavengers at a Different
Graveyard A Documentary on The Ragpickers of
Mumbai (2005) explores the life of ragpickers thatmajority of them are below the poverty line and socioeconomic strata and live a difficult life. Singh (2006) inhis book “Child Labour” broadly categorized,
ragpickers into 3 groups, based on the contact with
their families:i) Children who will be living with their families.
Whether it be on the street, in slums, or waste land or
abandoned/derelict building and so on, but would be
spending a lot of time working or hanging about on thestreets. It has been estimated that this will be thelargest of the three categories; ii) Children who would
be living and working on the street with occasionalfamily contacts. These children, sometimes, sendmoney to their families. They consider the streets astheir homes; iii) Children who would be having nofamily contact what so ever. These children will beeither orphaned abandoned or neglected by, or
estranged from their families. Psychologically, they are
deprived of love, affection and sympathy of a family.
Thilagaraj and Prasanna Poornachandra (2001)
conducted a study of 706 street children of Chnnai. Of
the total they explain about family victimization. The
survey reveals that most of ragpickers are deprived ofbasic facilities of food, shelter and clothing. A
significant number of children do not live with theirfamilies and there are children who have to undergone
a great deal of hardship to secure basic needs.
Ashoka (2006) made an attempt to explore the social
status of street children in his work “Child and theLaw”. According to him, street children are thosewandering on streets, begging for alms, vending
goods, smoking besides sitting at corner places,
indulging in quarrels and participating in major street
brawls. These are the common features in most partsof urban areas. It is true that many children are pushed
out of the home due to various factors. Among themany, poverty is the main contributing factor to giverise number of street children. Poverty and sociopolitical insatiability are the potent reasons that makechildren leave their homes and take to the streets.
1.5. Education Level of Ragpickers
Tripathy and Pradhan (2003) made an attempt toanalyse the problem of child labour and their condition
for those engaged in hazardous occupations like
ragpicking in Berhampur town (Orissa). Analyzing thedata the authors revealed most of child labourers are

illiterate who do not know even how to read and write,
and almost all the female child labourers are illiterate.
Shishir Srivastava (2008) in his article “Ragpickers inModern Day India” studied the child ragpickers, in thecapital city of Delhi. According to him there are morethan 100,000 ragpickers in India with most of them
being young children. Young children’s education has
been promised from time to time, but this promise isnever kept. Forget education, these children have towork in the harshest of environments and yet find it
difficult to make ends meet. The government has tried
to do a lot for the young children. The Sarva Shiksha
Abhiyana, the Free Mid-Day Meal Programme are
initiatives taken by the Government to improve theirstatus.
Rai (2002) has conducted several case studies ofchild ragpickers.. Deepak Saxena in his research
report analyzing educational status of ragpickers foundthat most (94%) ragpickers are illiterate. The remaining
6% of them are having only 1 to 5 standards ofeducation.
2. Contemporary Scenario of Ragpickers
2.1. Forces to lead people to become ragpickers
The important factors include economic compulsion,
which continues to raise the size of children in thelabour market. Their life has become full of risks andtheir hash poverty compels them to do any type ofwork irrespective of their age and sex. Undoubtedly,
poverty alleviation programmes have been introducedby the government in these areas with help of
voluntary organization. However, because of thelimited coverage of the programme and defective
service delivery policy, benefits don’t reach thedeserving section of the society in the sense theirbackwardness deserves and they perceive toovercome the poverty they are experiencing.
Ultimately, the poor, needy, weak and fearful children
who cannot go against their parents are ready to faceneglect, abuse and exploitation, when they deserve tohave extra protection, and care because they don’t
have the physical and mental maturity to face.
The Ministry of Programme Implementation (PTI) in
its annual report of 1990-1991 pointed out there were
30% of population in 1987-1988 below the poverty line
and it was estimated that the percentage will go down
to 26% by 1989-1990. But unofficially, we know thatstill there are more than 50% of the population below
the poverty line, but of this, the percentage of children,
as stated earlier to be below poverty line, is very high.
A study conducted by the Singh (1990) reveals that as
high as 39% of child workers acted as labour becauseof poverty and 20% of increase their family income.
The motivation for 19% employers to prefer thechildren is that they are cheaper. Another study(George, 1977) conducted in Madras says that threefourth of children joined labour to supplement theirfamily income. In the matchbox industry (CRSR, 1989),
95% children took up jobs because of poor economic
conditions of their parents.
Increasing economic compulsion has been noted asa pull factor for migratory rural children. A studyEubios Journal of Asian and International Bioethics 27 (January 2017)
conducted in Bombay (Singh, 1979) reveals that
63.2% of children migrated to Bombay in search of
employment due to lack of family income. Inadequate
income of the adult earner is another factor whichleads to child labour practices. A study conducted in
Varanasi, Badhoni and Mirzapur belt (Singh, 1990,
p.114) reveals that one of the major compulsions forthe majority of children to take up jobs has been theinadequate income of the family earners. In fact,economic compulsion is also increasing due tounemployment, under employment, large number of
dependents, little or no skills and lack of productive
assets due to which children have to work.
A developing country like India needs to havesystematic planning to ensure a risk-free and secured
future. Undoubtedly, some effective attempts havebeen made from time to time by the government andvoluntary agencies to change the feeling of those who
believe in large family size. In fact, the problem needs
in depth education of population, implications of
population’s growth, complications which people(women and children) are likely to face in the absenceof resources of different kinds which they deserve andthe country feels to promote for the better quality oflife. However, the limited size of population control
programmes and its implementation at different levelsin the way people don’t perceive, it is not achieved its
acceptance; therefore, rural and urban and tribal
people still continue to believe in large family size. For
these poor, unexposed and backward families,
children are not a liability on them. Moreover, they
understand that more children means more income forthe family. In fact, to check the problem, it needs
overall planning at every level in the way people
perceive to accept it. As pointed out earlier, larger
family size in a poverty ridden society puts the parents
in a different situation where they fail to carry on their
responsibilities towards family and force their children
to take up jobs even at a tender age. Their ignorance
encourages them to children the view that children are
God gifted and we have no control on it.
2.2. Child labour
Child labour is a universal phenomenon, butestimates of the number of persons that are generated
by different national and international organizations
differ significantly. While it is impossible to quote asingle figure for the extent of child labour in the world,
it is clear that the number of children working
worldwide runs into hundreds of millions.
The percentage of economically active population ofchildren is very high in developing countries and it isestimated that 95% of the working children of the world
are in these countries. It is also know that on anaverage 25% of the total child population is
economically active in developing countries. The
extent of child labour varies from country and country.
For example, in Ethiopia, Senegal, Bangladesh,Pakistan and Nepal the percentage of economically
active population of children ranges between 21 and
57% (UNICEF, 1984).

5

The highest workforce participation rates of children
were reported from Asia, Africa and Latin America. But
half of the child labour are located in Asia alone. In
Africa one out of every three children is actively
engaged in an economic activity. However, inLatin
America one out of every ten child works. According toestimates of World Health Organisation (WHO) one
out of every four children works in India, Thailand andTurkey, and about one in every three in Mali andTanzania. In Mali about 45% of the children in the agegroup of 10-14 years were part of the labour force. In
Bhutan, Bangladesh and India, the proportions ofworking children were 44% 32% and 20%,
respectively.
The International Labour Organisation (ILO)
estimated 52 million working children in the world
during 1979. An overwhelming majority of the working
children (50.7 million) was from the developing
countries with Asia having a learning share(36.1million). In Asia, however, the South East Asia
alone was having a major chunk of child labour force(29 million). In 1990, the ILO again estimated theeconomically active children under the age of 15 years
as 75.5 million in many as 124 countries. Anothersignificant finding was that 70.9 million of them were inage group of 10-14 years. In another estimates (1996)
the ILO put the number of child labourers between theage of 10 and 14 years at 73 million in some 100
countries.
In a report entitled “Child Labour Targeting theIntolerable” the ILO doubles its previous estimates ofchild labour saying 250 million children between theages of 5 to 14 years work in developing countries withsome 120 million working of full time and 130 million
as part time workers. The report has also highlighted
that in the total child labour force the share of Asia was
61%, Africa, 32% and Latin America, 7%.
Whatsoever, the case one infers emerging from thefigures given above, is that child labour iscomparatively more in Asia than Africa and Latin
America and also its magnitude is very high. The ILO
in an experimental survey has also found that in
Ghana, India and Indonesia the average percentage of
economically active children aged between 5 to
14years is 24%. In Senegal it is as high as 40%.
These estimates are based on a sample survey of4000 households and 200 businesses in each country.
Another significant feature of child labour is that in
the developing countries 56% of the children in the agegroup of 10-14 years are boys. However, if it waspossible to measure the number of girls doing
unregistered work as domestic help or working at
home to enable other family members to take-up paid
employment, the figures so arrived may show more
female child labourers than male.
Developing countries of the world being agrarian innature seen to employ child mainly in agriculturalactivities. Two thirds of the working children of thedeveloping countries live in the rural areas and nearly
three quarters of them are engaged in agriculture andrelated activities. Most of these workers are unpaid
family workers (70%) and the proportion being higher

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Eubios Journal of Asian and International Bioethics 27 (January 2017)

in rural areas (81%). The International Labour
Organization has further reported that “in somedeveloping countries nearly a third of the agriculture
labour force is comprised of children. In India nearly
as% of the working children work in the agriculture
sector. In Bangladesh, most of the economically active
children (82%) are in agriculture and in Kenya 25% of
the agriculture labour force are children.
In India the extent of child labour in not as large as inTurkey, Thailand, Bangladesh, Brazil, Pakistan,
Indonesia, Mexico and Egypt. It is estimated around
5.2% of the total labour force in India as against 27.3%
in Turkey, 20.7% in Thailand, 19.5% in Bangladesh,
18.8% in Brazil, 16.6% in Pakistan, 12.4% inIndonesia, 11.5% in Mexico and 8.2% in Egypt.
However, in Sri Lanka child labour accounts for only
4.4% of the total labour force. Even the workforce
participation rate of children in the age group 10-14
years of India (10.4%) is less than Bangladesh(33.3%). Nepal (22%) and Pakistan (11.6%) but
greater than Indonesia (8%) and Sri Lanka (1.8%).
In India, as elsewhere, no proper estimates of childlabour are available. Various social scientists and nongovernmental organization have estimated their own
figures depending upon their methodology anddefinition of child labour. Thus, the estimates of childlabour are not exact and vary from source to source.
However, according to the ILO India contributes toabout a third of Asia’s child labour and a fourth ofWorlds working children. According to various social
scientists, with estimates varying between 60 to 115
million. India has the largest number of working
children in the world. An important feature of childlabour in India is that nearly eleven to eighteen million
working children are street children and approximately
fifteen million children work as bonded labourers.
In India if all the children under 15 years of age whoare not attending schools are considered as childlabourers then the figures of child labour run into one
hundred million. More recently, in 1997 UNICEF
estimated –child labourers in India at 73 million ofwhom 15 million are said to be bonded and stated thecondition of 70.6 million in the age group of 5-14 years
who had not gone to school was not known.
A Baroda base operational Research Group placed
the estimates of child labour in India for 1985 at 44
million. The study further reported that one –sixth of
the working children are of tender age. Every third
household has a working child and every fourth child in
the age group of 5-15 years is employed. Even the
Ministry of Education (1985) reported that no exact
figure of child labour in India is available but the
number of working children here may be nearly 4
crore. The Ministry of Labour has estimated the childworking population in the country as 15 million.
The Planning Commission of India has pointed outthat the extent of child labour in India is on theincrease overtime. In 1985, the child labourers under
the age of 14 years was 17.5 million, in 1990, 18
million and in 1995, 20 million. Even the commission
on Labour standards has reported 25 million working
children in the country with a growth rate of 4%annum. A plan outlay, it is estimated of 1.500 billion
USD is required to abolish child labour totally.
According to 1971 census 10.7 million children were
working in India for their living. The national sample
survey organization estimated the child labour force as
16.25 million on 1 March 1978 (14.68 million rural and1.57 million urban) and 17.58 in 1985. The survey has
shown that the extent of child labour among malechildren is higher than among female children. Also its
magnitude is higher in the rural areas than in the urban
areas. According to census estimates the number ofchildren labourers (5-14 years) was 13.6 million in1981 and reduced to 11.2 million in 1991.
Thus, the census estimates though show a
progressive decline in the number of child labourers
over the years yet several other surveys by NonGovernmental Organisations have shown that the
problem of child labour has been on an increase overdecades. Various estimates of child labour generated
by a variety of sources make it difficult to draw
inference. Whether child labour in India has increased
or decreased over time. However, it is obvious that thecountry accommodates one third of the world childlabour force, which contributes sustainability (nearly20%) of the country’s Gross Domestic Product. On an
average, in India children’s contribution to householdincome is between 20 and 30%.
While child labour is continuously being employed,
not much is known about the contribution of childlabour to the household income. Moreover, not many
empirical studies exist on the subject in the state of
Punjab, which is one of the most developed states ofIndia in terms of its per capita income. The present
study is a modest attempt in this direction.
2.3. Employer’s preferences for child labour
One of the main objectives of the employer is to get
more profit from limited expenditure. Moreover, they
are aware of the economic compulsions of the families
having extreme poverty. They watch out for exploiting
the parental economic compulsions when they knowthat children of backward families are more tolerant,
can be put on difficult jobs for longs hours, even on
lower wages, secondly, they have understood the
productive quality of children who do not raisegrievances pertaining to their working conditions. A
study conducted Singh, (1990), in Varanasi finds that
33.5% employers prefer children as they work hard.
For 18.5%, child labour is cheaper; for 15% they canbe put on put on any job, for 15% child workers create
less trouble; for 15% they can work for long hours,
these establish the importance of employers
willingness to employ children which further becomes
an important reason for increasing child labour in the
country.
Overall literacy percentage in the country continues
to be unsatisfactory. In the areas where the rate ofchild labour is higher, illiteracy is also longer andencouragement of child labour practices. It is a wellestablished fact that educated, enlightened andexposed parents plan the future of their children andmake every possible effort to ensure all roundEubios Journal of Asian and International Bioethics 27 (January 2017)
development and protection to their children from
insecurity and risks of life.
It is observed that the parents who are illiterate keepbusy with their present happy life of the family andnever think of the future. They believe in employing
children rather than planning their future rather thanplanning their future. The study conducted (Singh,
1990, p.98) on child labour indicates that 84% of thechild workers’ fathers were illiterate, 13% were justprimary school graduates and 3% were middle andhigh school graduates. Similarly, another study(George, 1997) reveals that most of the children whocame to the labour force belonged to the lower literacy
group. About 44% of children workers parents were
illiterate.
There are some more factors like rapid urbanization,home environment, and broken homes, which havebeen found responsible for child employment which
will be discussed in the following chapters. However,
the employment of children holds both positive andnegative aspects. Positive aspects motivate theparents and employers to employ children whereas
negative aspects retard children’s development,
motivate them to develop evil practices which becomeareas of interest for the researchers, social thinkers,
government and society in general to feel concerned
about the problem.
The proper physical, mental, social and spiritualdevelopment of children is linked to the availability ofeducation, nutrition, love and affection. Physicalexercises keep their own place. These need priority
work in the interest of children’s physical fitness when
they become capable to do work, should be
encouraged with the care that its interests remain fordeveloping people. Compulsion of work and excess
load, as said earlier, retards the growth anddevelopment of the children and is not an economic
gain of the family. The following points can be noted:i.
The child has vision to observe and learn tothink without taking much of the time. If it is madeinteresting to him/her. He/she has more flexibility ofarms, fingers and body as compared to adults whichhelps them learn and pickup work skills easily, anddevelop a sense of responsibility and confidence.
ii.
By and large, a child takes more interest in
knowing and learning a thing. In this way, a curious
child by nature gradually becomes trained in different
skills provided it is made more purposeful withavailability of all possible development services
iii.
Children who assist in the family occupation orwork with their relatives do not have the same kind of
the problem and treatment, which employed children
are getting with their employers and adult co-workers.
Therefore, these self-employed children have freedom
to express their grievances and difficulties they face
while working. Therefore, work is not much burden onthem as employed children feel and experience.
iv.
The aim of education and training institution isto help the people to become more responsible andindependent. Work environment, if developmental
provides a king of climate which makes children
sincere, punctual and disciplined.

7

2.4. Negative Aspects of Child Work
Being young and the future architect of the nation,
the children deserve to have overall protective,
primitive and development opportunities in the areas of
their interests. Compulsion of work, when they areyoung, deprives them of their right stand is unjustified
to humanity and the future of the nation. in theabsence of these, there will be problems in proper
human resource development. The future of a large
chunk of young population will be full of risks and it willfurther raise the rate of dependency in the country.
Long hours of work place along with morning andevening hours at home is injurious to their growth anddevelopment. Night work, continuous standing or
sitting or use of single set of muscles in poor working
environment where they carry heavy loads, pressure of
speed of work, contact with the industrial poisons andso on, provide harmful conditions for the future of childlabourers. Compulsion of work performance in a given
time with controlled supervision leads furthermore to
problems relating to the physical fitness and mental
alertness of working children.
Children while working get liberty from the parents
and are given importance when they supplement thefamily income or give or helping hand to their family.
This kind of parental freedom motivates these children
to take up independent decisions which further leadthem to spend more of their earnings on their own andstart smoking, gambling and join gangs which canaffect their future development.
Employers attitude to have more and more
protection on lower expenditure encourages them to
put the children in exploitative and abusive conditions
and mature them in a watchful night administration
which results in the form of occupation diseases,
physical deformity and handicap. A study conducted
on working children (Singh, 1990, p.145) reveals thatafter working 57 parents, 65 child workers themselves
accept that child workers have the problem ofheadache. Eye ache has been seen in 54 cases,
which has been confirmed by 30 parents stomach andjoin pain has found in 160 cases. Chest pain isreported by 25 child respondents. Other problems
reported by child workers are finger pain, skindiseases and so on, they study further reveals the kingof bad habits which children develop after working.
This show that as high as 51% children develop thepractice of playing cards, 45% smoking and 5%
gambling.
It is felt by some of the employers who employ
children that output of the child worker is comparatively
less profitable as compared to the adults. According tothem, child needs more supervision and care andchances of damaging raw material are higher
especially when they learn to work.
Children, while working, decrease the value of adults
in the labour market and raise the risk of adult
employment. It further moves with a lot of
psychological, social and moral implications forchildren, economic implications for adults and a social
stigma to the society at large. These deserve in-depth

8Eubios Journal of Asian and International Bioethics 27 (January 2017)

study of the problem reality of their situation,
responsible reasons motivating them to continue thepractices and to have desirable and perceived
corrective strategies, which will be discussed in the
coming chapters.
Research of any kind needs proper, systematic andin depth understanding of the subject one is going toselect for study. Therefore, or selection of the problem,
which is new and need based picking up the pattern ofstudies in the field introduced by the researches and tohave an all dimensional understanding of the problem,
one has to go through the studies conducted in thefield. Consultation of related literature helps theresearcher to have an adequate, comprehensive
understanding and up today knowledge of the subject.
More so, it brings enough explanation of doubts one
finds in the process of study and also generates
sufficient guidelines, which enable the researcher to
conduct his study without experiencing complications,which could come in the absence of its consultation.
As per the 1981 census, India is the second largest
country in the world and has the largest chunk of thechild population. The estimate of the Director- General,
ILO shows that about one-eighth of the children in theage group 10-14 years are at work, and further one –third of rural children are seen working. According to
the census reports of 1961, 1971 and 1981, thenumber of working children are 14.6, 10.8 and 13.6
million respectively. The Operation Research Group(ORG), Baroda, on the basis of an all India survey
estimates that there are 44 million children at work.
Further, labour force projection estimates that the
number of child workers is to go up to about 33.38
million by 1990 and 37.95 million by 1995. It means athreefold rise of child labour population between 1981
and 1990. This demands the concern of academics,
bureaucrats and those who are in national planningand development.
Undoubtedly there has been a regular increase in
the work participation rate of child worker in the years
for which we have census data. Moreover, projections
made and studies conducted thereafter also reveal thenon-stop increase of child labour population in different
forms. During 1971-81, available data show that over
90% of child workers come from rural areas. In total,
there has been 3.91% increase of child workers from1971 to 1981. Of the total increase, 25.64% are inurban areas whereas in rural areas, this increase isjust 2.12%. The rate of increase has been noticed
higher in case of girl child workers in both rural as wellas urban areas. That is, 30.48% and 47.06%
respectively. In case of male child workers, there has
been increase of 19.67% in urban areas i.e., 30.48%
and 47.06% respectively. In case of male childworkers, there has been increase of 19.67% in urban
areas whereas their rate of participation in rural areas
goes down to 8.24%. The data available further
indicates that in 1981, 63% male and 77% female childworkers were illiterate in urban areas, whereas in rural
areas, the percentage of illiteracy had been 80% formale workers and 89% for girl child workers. Sectorwise participation on percentage basis shows that in

the year 1981, male child workers participation inprimary sector was 84.63 for male and 86.39 for girlworkers, and in the secondary sector, the participation
percentage of male workers was 9.18, girl workers
participation percentage was 9.7 in the tertiary sector,
it was 3.91 whereas male workers participation was
6.19 percentage points.
The priority of employees to employ children for
profit has raised the extent of child workers because ofwhich they now found to be seen in almost all states
and by and large, in the fields where adult workers areworking. A comparative rate of child workers
participation between 1971 -81 given here reveals theincreasing rate of their participation of both rural aswell as urban areas and in both the years, theparticipation rate of employed worker is higher ascompared to those working in household.
As evident from above, over 90% child work force
comes from rural area. The participation rate of childworkers varies from state to state and from one
organization to another. For example, according to a
1978 survey male child workers participation rate insame area varies from 0.3% in Punjap to 10.5% in
Andhra Pradesh. However, the appearance of childlabour is organized sector is reported to be eliminated.
Statistics of the Ministry of Labour show a decline in
the average daily employment in the registeredfactories from 7784 in 1950 to 3592 in 1986. It is also
reported that children constituted only 0.07% of total
employment in factories in 1976. However, thesefigures don’t underestimate the incidence of childlabour in the organized sector, even so, there is hardly
any doubt that child employment is mainly
concentrated in the unorganized and semi organizedsector and small scale establishments. One example(UNICEF, 1984) in Mirzapur carpet weaving belt, foundchild workers are reported to be more than 40%, in
Sivakashi, 60% of the workers were girls. Similarly outof 800,000 were children from 0-14 years. Of total
workers in mica and shllac factories, the percentage ofchildren is 30% and ,10% respectively. An ILO study
says that about 35% of workers in the Firozabad glass
bangles industry are children. A study (NIPCCD, 1977)
reveals that 18.7% of children start working before
they complete an age of 12 years. In urban areas,significant number of children are found to be seen
working in small establishments like shops, way side
restaurants, domestic help, brick industry, stone
breaking, garage, metal workshops, handloom andhandicraft industries. Thus their area of operation isscattered across various work establishments.
Child labour is a heinous social economic problem.
Countries all over the world have denounced childlabour regarding it as a social evil that destroys thepotentially of the future generation in any society. Mostof the developed and some of the developing countries
have passed probably legislations to curb the practiceof child labour.
To a large extent, the entrepreneurs who runworkshops employing orphans have a free hand where
their access to child labour was concerned. However,
the attempts to develop workshops for orphans intoEubios Journal of Asian and International Bioethics 27 (January 2017)
dependent enterprises failed due to inadequate profits.
A system of “renting out” cheap child labour developed
next, with the entrepreneurs working in conjunction
with feudal political authorities (Kings) here. As a resultof this, the spheres of life and work of the children
were duly separated from each other.
The Napoleonic system has led to the liberalizationof the economics in the western territories (Rapport
and McPhee, 2013).
Prussia followed suit bypromulgating the Hardenberg Legislation in 1810.
There remained only a few small territories in which
efforts were being made to restore the economic
system of the Ancient Regime. The first measures
towards child protection were initiated in England 1802
(Kumar, 2006), sparking off a controversy in Germany
about the pedagogic value. Child labour hasdeleterious effects on health and its economic effects.
The protective clauses for labour embodied in thestatues of guilds dating back to the Middle Ages were
either no longer in keeping with changes in reality or
were forgotten. It was not altruistic but rather sociopolitical considerations which led to Legislation forchild Protection. Here, the statement made by General
Von Horn in 1818 as a result of child employment fornight work in factories the army was being deprived of
sufficient stand – by recruits induced suitablelegislation. Industrial pedagogy proceeded on theassumption that the disciplining of child factory
workers could be combined with the development ofcreative skills. However, no specific line of teaching
was developed for this purpose.
In the “Communist Manifesto” Marx and Engel
already defend the parents of working children against
these accusations. But they seized on a realization
which was to surface later when they formulated thefollowing questions addressed to the bourgeoisis. “Areyou accusing us of wanting to put an end to this
exploitation of children by the parents?”. To which they
replied. “We admit this crime” lashed out at the“Pharisacainess” behind these accusations in 1863 in
his “Das Capital”. In 1827, the world renowned“Bourgeois” pedagogue F.A.W. Diesterweg criticized
the utilization of children as factory workers – a view
from the Pedagogic Angle, “However he did not at thesame time question the phenomenon of capitalist
exploitation”. In Diesterweg’s opinion, children under
10 should not be allowed to enter a factory and should
only work for a maximum of 4 to 6 hours there. He
pleads for socially corrective state intervention ineconomic life through the education system.
The emergence of the proletarian movement in the“Fraternity of Workers” (Arbeiterverbruenderun) official
protest against child labour was articulated for the firsttime by the workers themselves. According thecongress of workers convened in Berlin between 23
March 1848 and 3 September 1848 resolved that nochild should be engaged in industrial work of any sortwhich prevents regular and full attendance of school
before completing 14 years of age, however, therecruitment of children infantries and for paddling is not
permitted on any grounds whatsoever before the childcompletes 14 years of age.

9

In opposition to the representatives of the bourgeois
parties the social democratic members of parliamentthattacked child labour during the last quarter of 19
century and questioned their ideological justificationthat child labour has educational value. They also
voiced strong criticism on “the transformation of
mature human beings into mere machines” (Karl Marx)and pointed out the harm this was causing to themental, physical and moral development of these.
Child Labour – “Social Assassination” as Engels
termed it – was an expression of the prevalentbourgeois form of society. Despite legislation againstchild labour, the number of children working infactories doubled between 1880-86.
The Social Democratic education movement of the“Friends of Children” (Kinderfreunde). Since 1908 in
Austria and 1923 in Germany became the largest nonprofessional pedagogical and child movement of its coeducational, a religious, child education and selfmanaged children’s groups formed an alternative tobourgeois and clerical institutions of education andfollowed the thoughts of August Bebel. The
suppression by the state of the proletariats emerged
under social democracy, with its Marxian Eisenachprogramme was simultaneously or soon after
supplemented by the positive role played by the statethrough social legislation in shaping social conditions.
India has the largest number of child labourer in theworld and withdrawing them from work and ensuring
their rehabilitation is a major challenge facing thecountry. The country has the largest child labourthpopulation in the world. The 50 round of the National
Sample Survey conducted in 1993-94 estimated thechild labour population as 13.5 million and according to
1991 census it is 11.28 million.
However, child labour is not peculiar to India alone –it is global phenomenon. Recent estimates (1998) by
ILO point out that developing countries alone accountfor 120 million full-time working children (between 5-14
years of age). Of these 61% are found in Asia.
As a country, India has the largest child labour
population in the world in terms of absolute numbers.
But the proportion of working children to the total
labour force is lower in India that in many otherdeveloping countries. In 1991, the total working
population in the country was 314 million, out of which
the number of working children was 11.28 million,
which works out be only 3.59%.
Another important source of data to estimate thenumber of working children is the data on children out
of school. As per the estimates for 1995 -96 there were
173 million children in the age group of 6-14. O these
110 million children are estimated to be out of school.
Of the 110 million children 60 million are girl children.
(Source: Government of India 1995-96 estimates
MHRD, NCERT, SAIES provisional statistics).
Another aspect of child labour in India is that it ismuch more of a rural phenomenon than urban. Morethan 91% of the working children are in the rural areas
and employed in agriculture and allied activities.
Cultivation, agriculture labour, livestock, forestry andfisheries account for 85% of child labour. In the urban

10

Eubios Journal of Asian and International Bioethics 27 (January 2017)

areas, child labour account for 8.74% in the
manufacturing servicing and repairs. Out of this only,
0.8% of the children work in factories.
The unorganized and informal sector both in urban
and rural areas account for almost all the child labour
force. The distribution of child labour in various states
appears to indicate certain correlations. States having
a longer population living below the poverty line have ahigher incidence of child labour. Similarly, higher
incidence of child labour is accompanied by highdropout rates in schools. The incidence of childlabours partly linked to the level of socio-economic
development of an area and partly to the attitude andapproach of parents of the children and employers andsocio-cultural compulsions.
3. Field survey of Rag-picking
3.1. Objectives of the study
1. To assess the age of the ragpickers
2. To find out socio-economic condition of ragpickers
3. To examine the effect of environment on theirhealth condition
4. To identify the factors responsible for poor
conditions of the ragpickers.
5. To identify their problems with respect to bio-ethics
and to suggest remedial measures to enable themlead a dignified life.
3.2. Methodology and Sampling
The district of Triuppur is one of the industriallydeveloped districts in Tamil Nadu, India. 150
ragpickers were selected randomly from different partsof Triuppur city in Tamil Nadu for purpose of collecting
data. A structured questionnaire / interview guide has
been used in which questions and items regarding thesocio-economic background and other problems of thechild ragpickers are included. Efforts have been madeto elicit their free and frank views, and the research
was approved by the Institutional Review Board of
AUSN.
3.3. Research Design
A simple descriptive research design was used
when data were collected by using a survey
methodology in order to examine the effect ofenvironment on their health condition. Since, one ofthe objectives of the study was to determine the socioeconomic conditions of ragpickers, earning patterns
and to identify their problem at work, thus, theresearchers have adopted a descriptive design. This
study has thus used a descriptive design based on
survey methodology.
3.4. Profile of the study area
Tiruppur is one of the emerging industrial cities
in Tamil Nadu, India, formed in February 2009. The
district is well-developed and industrialized. The
Tiruppurbanian industry, the cotton market, and thefamous Uthukklui butter, among other things, provide
for a vibrant economy. The city of Tiruppur is theadministrative headquarters for the district. As of 2011,
the district had a population of 2,479,052 with a sex-

ratio of 989 females for every 1,000 males. Being an
industrialized city, ragpickers are found around the city,so the researcher decided to select the district ofTriuppur in Tamil Nadu for the present study.
3.5. Collection of Data
The required primary data were collected from thesame respondents through the questionnaire and bymeeting them in the railway station and bus stand. The
information was gathered during the working hours.
The data were collected during the month of July andAugust 2015.
3.6. Limitations
There are a few problems encountered by the
researcher. The respondents were located in different
parts of the city. Hence, contacting them directly forasking questions was time consuming. The researcher
was often travelling from one place to another place forcollecting the data.
4. Analysis and Interpretation of the Field Data
4.1 Socio-economic Characteristics
The tables present the distribution of the ragpickers
of various socio-economic characteristics.
Table 1: Distribution of Respondents based on theAge GroupAge groupNSD%(standard
deviation)
Below 10 years
40
6.6
26
11 – 20 years
105
17.5
70
21 – 30 years
5
0.8
3.4
It is evident from Table 1, that a majority of the
respondents (70%) belong to the age group of 11 to20, and one quarter (26%) of the respondents belong
to the age group of below 10 years. The age groupbetween 21 to 30 years represents just 3%. The
majority of them (70%) are boys (N=106/150). Twothirds (N=99) were illiterate.
Table 2: Distribution of Respondents based on
Past Residence
Locality
N
SD
%
Rural
Urban
Semi-urban

103
42
05

17.16
7.0
0.8

69
28
3.4

It is seen from Table 2 that 69% of the respondents
are from the rural areas of the Triuppur district itself.
Only 28% of respondents came from urban areas ofdifferent districts in different towns of Tamil Nadu andAndhra Pradesh. The remaining 3% of the
respondents are from semi urban areas.
Most, 76% of the rag pickers belong to a nuclear andthe remaining 24% belongs to joint families. It indicatesthat family which keeps less number of helping hands
is producing the higher number of child ragpickers. It
may be to supplement the income of the family.

Eubios Journal of Asian and International Bioethics 27 (January 2017)
Table 3: Distribution of Respondents Based on
Place of Living
Place of staying
NSD%
As a tenant
Small HutBus station
Railway station
Total

17
16
07
110
150

2.8
2.6
1.1
18.3
25

11.40
10.70
4.10
73.40
100

It is seen from Table 6, that 73% of the
respondents are staying at the railway station, and 4%of the respondents are staying at Bus Station (sevenpersons). Only 11% of the respondents are staying asa tenant and the same number in a small hut.
The respondents are divided into two groups
based on the experience. 58% of the respondents areworking in the field of picking 1 to 5 years and theremaining 42% of respondents have worked in thefield of picking for 6 to 10 years!
One third of respondents self-reported annual
savings (47 out of 150 respondents), whereas 107 outof 150 sample respondents said that their savings arenil. Most, 80% of respondents are in debt, while therest, 20%, of the respondents are not. Hence, there isa clear trend of indebtedness found among the
ragpickers.
Table 4 Distribution of Respondents Based on
Means of Transportation for Collection of
Garbages
SourceBicycleFour wheeler cycle
On Foot
Total

N

SD

%

15
05
130
150

2.5
0.8
21.6
25

10.0
3.40
86.70
100

It is clear from Table 4, that 87% of the
respondents go on foot for rag picking, 10% of the
respondents are going by bicycle and remaining 3.4%
by four wheeled cycle. This indicates that the majorityof children are collecting garbages on foot.
4.3 Problems facing Ragpickers
Almost all, 91% of the respondents confirmed thestatement regarding the bad effect of this work on theirhealth and only 9% of respondents expressed in thenegative. Most, 82% of the respondents are affectedprimarily by health issues as their most importantconcern amongst the list presented to them. 13% of
respondents faced problems by Gang leader andgoondas while collecting garbage, and remaining 5%of the respondents aid that their largest issue wasbeing disturbed by the local police.

11

Table 5: Nature of Problems Faced by the
Ragpickers
Type of Problem
N
SD%
HealthPoliceGangleaderGoondas

and

111
07
18

18.5
1.1
3.0

82
5
13

Almost all, 97%, of the respondents expressed thatthey don’t want any welfare schemes from thegovernment and remaining 3% of respondents want
the government welfare schemes.
5. Bioethical concerns of Ragpickers
5.1. Age Group
Even the poorest of the poor will keep the children athome even in their total poverty. That is why from
infant to the age of ten years there are major incidents
of ragpicking. Poverty makes some parents helpless.
This throws the children into the streets. This starts at
the early age of ten years and continues for a decadein the life of children. The major reason for this long
period of ten years could be the non-availability ofsafety jobs. Since, there is no substitute available tothe children; they are forced to continue as ragpickers.
There mental makeup is turned to such occupation.
But this has to change according to age because ofvarious factors. By this time their mind will be matured
to some extent which make them to realize thesituation. The other reason could be to attainmarriageable age, which brings a lot of changes in
one’s mental makeup. The other reason could be thatthey become physically fit to carry out difficult tasks.
This physical labour can be escaped from thehumiliating occupation like ragpicking.
5.2. Sex
Males have more freedom in doing the lower tasks
like ragpicking. The pattern shows that this occupation
also has no exemption from the male dominatedsociety. There is no inter-gender justice. The otherreason could be the influence of the patriarchic
community in which the male has shouldered the
responsibility of the families. The male has more
responsibility to the family needs of the female. Of
course the female also comes to the streets to attend
the family needs.
5.3 Education
Illiteracy causes ignorance. The ignorance is themother of all evils. That is why there is fifty percent
difference between the literate and illiterate children in
the occupation of ragpicking. Literacy throws many
windows of knowledge to the children like reading,access to newspapers, reacting to the contemporary
incidents in the society, and so on. Naturally theawareness makes one to be ashamed of theoccupation. The awareness makes a lot of difference
in determining the consciousness of human beings.
The existing social condition of the awareness of social

12Eubios Journal of Asian and International Bioethics 27 (January 2017)

conditions will contribute a lot in making one’s own
personality.
Another reason could be the parents themselves.
The parents deliberately or inevitably keep the children
out of the educational atmosphere even though
education is free. The reason is that the income fromchildren makes a difference in their living conditions
positively. Some parents themselves degrade thedignity of their own children. Of course the parents
may feel constrained by the forces around them, thewhole social issue needs to be resolved.
5.4 Migration
The majority of ragpickers in this study migrated
children from the rural areas. They have come to this
occupation because their parents themselves are inneed of such a condition so that the children arethrown into the streets and they will be forced to takeup any small work to contribute something to besuffering families. The autonomy of their children isdenied.
This scenario is reduced to half when we come tothe urban situation. The reason is that the parents are
already habituated to the city conditions. They are little
bit better though they may be living in the slums or insuch bad conditions. Since they have a little financial
capacity they try to educate their children by sending
to schools. This income is slightly better because of
the nature of work available to them. The income level
will be higher to a maid servant than to a agriculturallabour in the village. This small change in the income
naturally affects the growth of the children and theiroccupation.
5.5 Family TypeThe impact of industrialization and urbanization isclearly indicated. The families which are migrated fromrural areas are bound to be a family in its economic
structure. The individual revolutions make people for
not only to migrate, from the villages but also to realize
the strict financial limitations. The families which
migrated from the village are in search of theiremployment. They are in constant
struggle andsearch for their own livelihood.
5.6. Place of Living
There are more ragpickers in and around railway
stations. This is largely due to the convenience. The
railway stations provide not only a good shelter but
also a good source of livelihood. As the railway station
size is large when compared to other places, thisprovides them ample opportunity to take shelter in sun
and rain. It also gives an opportunity to occasional
begging on the platform. The major reason could besource of income which is fetched through the garbage
thrown by the passengers on the platform, on the track
and in the railway compartments. The proximate ofwork place and shelter is a strong reason for shelteringin the railway station. The state has failed to givereasonable justice for livelihood.
5.7 Duration of Rag picking/ Years of Experience

This data indicates that ragpicking is a source of
livelihood and the only job they got easily. This
occupation just fills their stomach. But at the sametime it does not allow the children to die. In thisinevitable conditions the children continue this job but
in course of time they gradually search for anotheralternatives because the present job cannot give themproper food and clothing. The growing children willrealize the insult in the job. The sample clearly
indicates a decrease in the percentage of ragpicking
as the time goes on. Even the ragpickers who arecontinuing in the same job due to the non-availability ofother alternatives, strive to seek for alternatives.
5.8 Annual Family Savings
With regard to the savings in the family, most thesavings are used for either purchasing cycles orconstructing new houses. Some of the savings are
utilized for purchasing four wheeler cycles. The
respondents are saving though chits, relatives andother agencies. Majority of the respondents do nothave the habit of saving because the monthly used foralcohol, seeing films and drugs, which gives themsolace.
5.9 Debt Particulars
The economic compulsion of the parents of child
ragpickers leads them to borrow money from one
source or the other. The majority of parents who are
illiterate neither understand the situation they live nor
do they feel concerned enough about proper planningand management of the family. Therefore, whatevermoney they earn during the day is spent on alcoholand drugs without thinking of insecurity of income in
the next day and most of the consumption on
unproductive things like celebrating birth, death andmarriages yet they are happy. This is surely
exploitation of the rich people towards the poor.
5.10. Means of Transportation for Collection of
Garbage
The poverty of ragpickers is severe. They cannot
even afford to buy a bicycle. Since their income cannot
allow them to make arrangements for transport, that isusing a majority of ragpickers have no other means oftransportation that their own feet. Making a means oftransportation is a sign of organized system. Since theragpickers are themselves, they continue this job ondaily basis knowing nothing about their tomorrow. One
view is that some NGOs can help them form anorganized sector and get them their insurance
benefits. Non-maleficience is found to a larger extend
in the affluent society.
5.11 Problems Faced by Ragpickers at theCollection Spot
The problem of ragpicking is not an old
phenomenon. It is relatively new which is prevailing inurban and industrial cities only. In fact that, therecycling of the waste material has emerged due toincreases in the cost of raw materials for producing
paper, plastic, glass, bottles etc., however theEubios Journal of Asian and International Bioethics 27 (January 2017)
materials which child ragpickers collect include waste
and unused paper, paper boxes and cartons, water
clothes, sackings, plastic containers, bags, tins, boxes,
discarded utensils, glass bottles, jars, broken glasses,
used medical syringes, medical waste, likecontaminated plastic bottle screws, bandages, tablet
containers from garbage roadside bins and such otherplaces.
By and large, as stated earlier these materials
produce chemical poison including pesticides, skininfections, gastric infections etc., which hamper thegrowth and development of children engaged in thecollection and sale of all these material. Besides these
problems, children in this work usually experience
injuries, cuts and bruises, which further leads to ulcers
and tetanus. Biting by dogs and other animals who
feed on refuse is quite common in their occupation.
In the area of the study, 82% of the child ragpickers
feel that this work affects the health. While interviewing
the parents of the child ragpickers, not only healthproblems, but also some times they are facing
problems with gundas, gang leaders, street leadersand police people, to make them get involved in antisocial activities. Non-maleficience is ignored to a larger
extend in the affluent society.
5.12 Nature of Problems Faced by the Ragpickers
With regards to the health, this job is linked with dirt
and other unhygienic conditions. The fall prey to illhealth. They cannot avoid this, because this originatesfrom dirt. The other considerable problem is fromgundas and gang leaders. These anti-social elements
depend on small earners because it is very easy tothreaten them, since they lack proper support either
from parents or from society. Their problem also
includes the harassment of police since their job in andaround the residential areas; there is every suspicionof theft. The data indicates that, there are many
problems in the ragpickers at the collection centres.
When asked about the problems the respondents
reveals some of them this shows that almost the
ragpickers are facing problems. Thus we canunderstand that the problem of these respondents
areunbearable.
5.13 Assistance by the Government
The respondents are of the opinion that the
government is almost unknown to them. The presenceof the government cannot make any difference in theirlives in the form of suitable assistance. The
government alsocan not extend any scheme to the
respondents since they are in unorganized sector. A
negligible part of the respondents feel that they are thehelp extended to other schemes like street children orother similar schemes.
5.14 JusticeStreet children, aged between five and eighteen
years of age, earn their livelihood by polishing shoes,
washing care, finding park spaces, ragpicking(recycling garbages), selling lottery tickets and news
papers, and so on, so they also work as coolies and13

helpers in automobile repair shops, construction sites,
and hotels. Their average earnings vary between Rs.
25 and Rs.30/- per day, while the more experienced
ones earn Rs.30 to 50/-Rupees. However, these are
the lucky ones. The girls are forced into prostitution at
an early age. Arising at dawn, the ragpickers children
start their work. With bare feet and backs aching they
carry the heavy gunny bags that contain the day’s
pickings. Sometimes on foot they travel even 20
kilometers each day for the best pickings. Theirclothing is filthy, tattered, ill fitting, and wholly
inadequate for protection especially, when the weather
is wet and cold. Therefore, life is very hard as theyrummage (competing and fighting with stray bugs andcattle) through filthy garbage heaps in the city andrailway station.
However, the issue of greater concern is related totheir pattern of spending where a major part of theirincome is spent on drugs, alcohol, solvent abuse(sniffing solvents) and gambling. They frequently
become involved in street fights. With little money andtoo much freedom, they are vulnerable and fall prey toa great number of situations that threaten life and soul.
Late in the afternoon they resume their second
round of collection. Then after sorting and selling theirloot, they spend their nights on the streets or ingraveyards, where they are exploited and abused.
Older ragpickers and perverted people give themdrugs or threaten them for sexual purposes. Thus, thisexposes them to HIV and AIDS, and many moresexual and life threatening diseases.
From the study, it is implicit that ragpickers arefacing so many problems physically, psychologicallyand socially. Therefore, justice must be provided tothem by the State Government.
5.15. Autonomy
More autonomy must be given in making decisions
independently, going to school regularly, doing noharm at the work place and doing good for ragpickers.
Human dignity must be respected at every level of
their growth, and sustainability. All principles of thebioethics are violated when this society encourages
ragpicking even in this modern era of nanotechnology
and enabling technologies.
6. Discussion
6.1. An unethical social trap
Basing on the data interpretation and analysis, we
make the following specific suggestions on theprofession of ragpickers in Trippur city. Society as awhole, regards ragpicking children as an antisocial
element, an embarrassment to the community and thechildren are even considered unfit to live by some.
However, their useful contribution to society andecology is little understood and generally ignored. The
waste collected by these children is recycled andproduces 25% of the writing paper, the packing
materials, egg trays, economical plastic and metalhousehold items, and so on, used in our homes. This
benefits society and world ecology enormously by the
production of cheaper household goods and by14

Eubios Journal of Asian and International Bioethics 27 (January 2017)

slowing down of the destruction of the alreadythreatened rain forests. It also helps to prevent themountains of purifying waste materials from building
up in city centres. The ragpickers valuable contribution
to society should not be ignored and taken for granted.
As a street child, between five and eighteen years ofage, these children earn their livelihood by polishingshoes, washing cars, finding parking spaces,
ragpicking (recycling garbage), selling lottery tickets
and newspapers. They also work as coolies andhelpers in automobile repair shops, construction sites
and hotels. Their average earnings vary between Rs
20/- per day, while the more experienced ones earn
Rs. 30 to Rs.60/- Rupees. However these are the lucky
ones. Some girls are forced into prostitution at an earlyage. Arising at dawn, the ragpicker children start theirrounds. With bare feet and backs aching they carry theheavy bags that contain the day’s picking sometimes
on foot they travel over 20 kilometers each day for thebest pickings. Their clothing is filthy, tattered, ill fitting
and wholly inadequate for protection especially when
the weather is wet and cold.
Life is very hard as they rummage (competing andfighting with stray dogs and cattle) through every filthy
garbage heap in the city and railway stations. All
recyclable garbage is collected and sorted, paper,
plastic, bottles, bones, metals and rotting discarded
food thrown out by households and railway
passengers, with this they fill their bags and often they
have starving bellies. If the day’s collection is bad, they
resort to stealing for survival. If good, they rush to thenearest way side shop to ease their hunger. All haveregular scrap dealers to buy their loot. They recover ameager pittance and sometimes this pittance iswithheld to repay a previous enforced loan. Some days
they starve if another dealer negotiates a better price,
the child is frequently beaten and tied up.
However, perhaps the issue of great concern is theirpattern of spending, where a major part of their income
is spent on drugs, alcohol solvent abuse (sniffing
solvents) and gambling. They frequently become
involved in street fights. With little money and too
much freedom, they are vulnerable and fall prey to any
number of situations that threaten life and soul.
A ragpicker is not a beggar. He/she works hard andconsiders ragpicking a profession of choice. It enables
them to earn money, daily and offers him ample
amounts of free time. They are very loyal andprotective of eachother, sharing food and money. The
ragpicker is proud and feels that she/he is master ofher/his own life.
However, they are physically vulnerable and sufferfrom infectious skin diseases, and they are victimizedsocially through poverty, illiteracy and rejection. Street
children and ragpickers suffer from diseases likescabies; lice; chronic dysentery; lung, ear, nose andthroat infections; cuts and abrasions. These arecaused by poverty, malnutrition and the unhygienic
surroundings in which the children are forced live. Withno facilities available for bathing or laundry, they areforced to live in filth and squalor (they have no
education in personal hygiene) since they live incorrupt gangs for security and survival, they facesociety as gangs it is very difficult to isolate one
member, since group pressure is so strong that they
are soon threatened, forced and blackmailed to returnto their old habits.
They soon become dependents, both physically andmentally on their readily available addictions, enablingthem to forget for a while their pitiful existence. This isa huge problem and expert help is needed to treat their
physical and psychological dependence and addiction.
They are many disappointments for the worker as
relapses are very common. Integration into society isdifficult, as the public has preconceived ideas about
the ragpickers and neither accepts nor encourages thevision to transform such street children who became
ragpickers.
Most importantly, the children on the streets remain
deprived of their basic needs of food, shelter, clothing
and the security of family love and a home. With noadult to care for them, these children have to fend forthemselves and cope with the problems of the world,
before they have developed the emotional maturity.
6.2. What solution?
Counseling, and through informal talks andbefriending allow some children to start to trust us andbe less defensive. Non-formal education is being
provided on weekdays. To set up training centers,
teaching marketable and useful skills which will
provide self-sufficiency and independence are goals
that emerge. We encourage them to save money. We
discourage borrowing money.
Street children represent the end point of a complex
set of factors which require a multitude of resourcesand efforts to address the problem. A situation that has
been created due to the existing social, political andeconomic pressures in society, which need to beaddressed at the root of the problem through an
attitudinal change. However, change is not any easy
process. A change that demands a modification in
attitudes, as well as change in the social, economic
and political situation is a slower process. Policy
makers, government and society need to view thestreet children with compassion and sensitivity.
This is the only way forward towards ensuring abetter future for the children, and it is strongly believedthat this is only possible through commitment andperseverance. The term “child labour” is commonly
understand in the contrast of exploitation when a childis gainfully employed and works in such conditions
which deny him the opportunities of growth anddevelopment both physically and mentally. It may also
be defined and activity done by children which either
contributed to production gives adults free time,
facilities the work of other or substitutes for theemployment of others.
6.3. Education of children
The term “child labour” is at times used as asynonym for an employed child or working child. In thissense it is co-extensive with any work done by a childfor gain. The practice of children working isEubios Journal of Asian and International Bioethics 27 (January 2017)
economically unsound, psychologically disastrous,
physically and morally dangerous and harmful for any
society and even for the individual child, as it involves
the use of labour as its point of lowest productivity andis as inefficient utilization of labour power. It deprives
people of education, training and skills with are thenecessary pre-requisites for earning capability andeconomic development. The child labour in a restrictedsense means the employment of children in gainful
occupations, which are dangerous to their health anddenies them the opportunities of development.
The vital aspect of provision of education to the childlabourers did not receive proper attention during thefive year plans of India. The central and state
governments are concerned and concentrated on
primary education, secondary education, higher
education, technical, medical, adult education, and soon, but did not throw light on the ever increasingproblem of child labour education and child healthaspects. The illiteracy rates are unsatisfactory,
unhygienic and unhealthy conditions rampant among
the lives of the child labourers of our country as awhole.
The Government of India and the different state
Governments are undertaking a number of measuresfor provision of education to the people of our country
from time to time. But the rate of illiteracy is higher andprevailing among the children and adults of ourcountry. Millions of child labourers are increasing day
by day in the rural and urban and tribal areas of ourcountry. It is estimated that the prevalence of morechild labourers ratio is very high in the state of Tamil
Nadu, Bihar, Orissa, Delhi and Andhra Pradesh, whencompared to the other states of our country.
A healthy happy educated child is an asset to a
country, while an illiterate ignorant child is liability tonation. The Government of India has launched anational child labour project in the year 1987 to free
the child labourers and to provide education. In 1995
some states of our country have launched similar
project such as kakatiya Balam Karmika Vidya
Vikasatakam has been undertaken in Tiruppur districtof Tamil Nadu state, from the month of November
1995.
Since independence, the Government of India has
appointed a number of committees and commissions
on different aspects of education from time to time forthe solution of illiteracy problems and further
development of the educational status of our country.
A survey on the appointment of committees andcommissions by the Government of India from 1947 to1980 reveals that, committees have been appointed on
the aspects of technical education, education
technology, adult education, co-operative education,
working groups on education of child labour, labour
study groups for the construction industries, study
groups on tribal labour, and so on, and the survey also
reveals that no single committee or commission has
not been appointed on the aspects of child labour
education in India. It is an unfortunate and sorry stateof affairs, that the ever increasing problem of childlabour educational aspect has been ignored, neglected15

and rejected by the various state and central
governments of our country.
Child labour education has been a major problem inour country since 1947, which has not paid any serious
attention by Government to improve the educational
status of children of our country. But unfortunately until
1986 a National Commission on Labour Policy has notbeen formulated it was carried on as a part of National
Five year plans. The expression child labour is used assynopsis for employed child working child. Child labour
according to the United Nations is any work by childrenthat according with their full physical development, theopportunities for minimum of education.With theintention of protecting and promoting childhood. Article
45 of the constitution of India requires the state toendeavor to provide free and compulsory education for
all the children until they complete the age of 14 years.
6.4. Abolition of Child Labour
The Supreme Court of India in 1996 delivered asignificant judgment aimed at abolition of child labour
and implementation of free and compulsory education
for all children until they attain the age of 14 years andgave a series of directions to all state governments.
1987 is the landmark in the milestone of education
development of India, because the Government ofIndia has formulated a specific National Child Labour
Policy. The National Child Labour policy was approvedby the cabinet in August 1987, during the seventh plan
period under the policy a project –based plan of action
was envisaged.
The National Child Labour Policy was formulatedwith the basic objective of suitably rehabilitating thechildren withdrawn from employment and to reduce theincidence of child labour in areas where there is aknown concentration of child labour. Under that
National Labour Policy Project based plan of action,that is, a National child labour project envisaged eighty
thousand working children in the selected areas of ourcountry as a result of National Child Labour Policy
1987. Ten Child Labour Projects were sanctioned forthe benefit of child labourers engaged in industries.
The Ministry of Labour, Government of India hastaken an initiative to withdraw the children in the agegroup of 6-14 years from the child work force in Tamil
Nadu. Working in the hazardous occupations was tobe stopped and to prepare them for their education
and rehabilitation. For the purpose of achieving theabove objective special schools for the child labourers
have been started in month of November 1995 indifferent places of rural and urban areas of the Trippur
districts with the help of some of the Non-Government
Organizations (NGOs) of the district for the purpose of
implementation of child labour educational program in
the district. The district collector appoints the field
officers. They work under the control of the project
director in the district. The district collector is
responsible for the implementation of the project. He is
assisted by two field officers and a clerk cum
accountant at the district level.
Every child labour school administered by the NGO
has one vocational teacher, two non-vocational

16

Eubios Journal of Asian and International Bioethics 27 (January 2017)educational teachers, one accountant and one
attendee for imparting education to the children whoare enrolled in special schools will be provided. Every
parent of child labourers enrolled in each special
school will be paid Rs.150 as stipend every month by
the respective NGO. Every child labour student will begiven nutritious food during such period andsupplementary diet like egg, bread, milk, upma andfruits. One variety and each day will be followed
regularly. The children of special school will be
provided a free medical checkup every month by theNGO. There are a few tribal community students
studying in the labour school. The percentage of malechild labour students is more when compared to thefemale child labour students. The occupational
background of the parents of the child labour students
are agricultural labourers, rickshaw pullers, stone
cutters, metal cutters and hotel servants.
A key priority for action in the short term implication
is in the area of prevention. States along with national
and international organizations should promote antipoverty strategies, improved flow of information,
universal
primary
education,community
consciousness raising, mobilization, the satisfaction ofbasic needs, occupational opportunities and alternative
forms of employment for families.
Protection of children from child labour exploitation
depends upon adequate and effective laws andpolicies together with their implementation at thenational and local levels. All countries already havelaws, which can be used to protect children, forinstance the criminal law. These should be
implemented in a more committed manner. The qualityof the law enforcement authorities, namely police
force, immigration authorities, judges, inspectors
others, needs also to be improved.
A key priority for action is in the area of protection.
States should promote anti-poverty and universal
primary education, universal primary education,community consciousness and satisfaction of basic
needs, occupational opportunity forms of employment
for families. Protection of children from child labour
exploitation depends upon adequate and effective laws
and policies together with their implementation at thenational and local levels. All countries already havelaws, which can be used to protect children, forinstance the criminal law. These should be
implemented in a more committed manner. The qualityof the law enforcement authorities, namely policy
force, immigration authorities, judges, inspectors andothers needs also to be improved.
7. Conclusions
7.1. Summary of the Results of the Empirical Study
The socio-economic background of the sample
respondents shows that a majority of the child
ragpickers are male; belonging to those under 20
years of age. Out of 150 child ragpickers, 102 (65%)
belong to scheduled castes, 19% belong to scheduled
tribes, and 13% belong to backward classes.
The majority of the ragpickers are from rural areas of
the Triuppur district. Other ragpickers came from theurban areas of different districts and towns of the Tamil
Nadu. The majority of the child ragpickers family typeis nuclear (76%) and size of the family is identified as
one of the important reasons for child rag picking. 110(73%) are staying in railway stations, among manyrisks. Nearly 58% of them, 87 out of 150, have taken to
ragpicking for the last five years.
Illiteracy and other economic factors were importantreasons for their ragpicking. Nearly 80% of thesampled child ragpickers families are still having debt.
Debt is also identified as one of the reasons for child
ragpicking and the source of debt is rich money
lenders. The majority of sample child ragpickers went
for collection of garbage on foot. All the sample child
ragpickers responded positively that they would notcontinue this field more than five years.
Nearly 90% of the respondents were facing different
problems at the time of ragpicking, and 82% of the
ragpickers are suffering from health hazards. 70% of
the ragpickers thought that they were not getting
reasonable prices for they have collected garbage.
The majority of child ragpickers have bad habits suchas underage homosexuality, tobacco and alcoholism. It
is observed that majority of child ragpickers are
unproductive as they spend the hard earned money forseeing movies and drinking alcohol. It is observed thatmajority of the sample ragpickers did not purchase any
significant consumer articles.
7.2. Specific suggestions
1.
Sufficient publicity has not given regarding theawareness of child labour education and the facilities
provided by the government for education of illiteracyof the child labour students, therefore, wide publicity
should be given through mass media regarding thegravity of the child labour problem. Their situation
should be more widely known, and we should makeuse of the facilities provided by the government fromtime to time2.
The unrelated departmental supervision for
visits with Director for the purpose of supervising thechild labour educational program in the district.
3.
The present study reveals that in many
schools, un-trained teachers were appointed in special
schools by the voluntary organizations for educating
the unorganized freed child laborers. It is very
important to note that the permanent teachers andtrained staff are very essential for the effective andsuccessful implementation of the child labour
education program and inculcating discipline and formolding the future of the child labour students.
4.
There is a need for proper supply of first Aid
Services at the school, and every child labourer should
be given proper medical and health check up.
5.
Periodical counseling should be given to bothparents and their children.
6.
The Indian government has recognized
ragpickers and the informal recycling sector throughpolicies and law, some of them are like E-waste(management and handling) of 2011, Plastic waste(management and handling) of 2011, National action
plan on climate change of 2009, and the National

Eubios Journal of Asian and International Bioethics 27 (January 2017)environment policy of 2008. Apart from thegovernment efforts, many NGOs such as ARD,
VidiVelli, and child help line are working for the
betterment of ragpickers.
7.
Governments should really look after these
deprived people and must provide them with social
status, job opportunity, reduction andlook after theirhealth and shelter related problems.
7.3. Financial suggestions
1.
Proper sanction and release of grants from the
Ministry of Labour, and proper running of special
schools is essential. A delay in release of funds
hinders implementation of the schemes.
2.
The researcher has observed and found thatthe students’ performance and academic development
was not satisfactory. Most of the students werestudying in the same class from year together,because of the defective method of teaching
curriculum, syllabus and lack of trained teachers, thechild labour education policy has ignored. About the
co-operation and the role of parents of the child labour
students effective in utilization of the facilities provided
for the child labourer is found.
3.
Permission and the establishment contact of achild labour schools generally will be given to NGO
which will have about Rs.50000/-of annual income, but
in Trippur district the contract and permission forrunning of a child labour school were given to many
NGOs which have less income than Rs.50000/- perannum. Wherever the allocation and sanctioning the
grants for the maintenance of child labour schools
were given then there will be a scope for closing of thechild labourer school. Some schools were closed forsometime not only due delay in allocation of the funds
to the schools but also the self sufficiency of respective
voluntary organization.
7.4. Conclusion
This study on ragpickers is one of the researchareas of deep concernin the society today. However,limited research has been done in this area. Moreover,this area has been unprobed by social scientists orsocial work professionals. This research is an attempt
to study bioethical principles violated and socioeconomic conditions of ragpickers at Triuppur District.
It is an attempt by a researcher to venture into thestudy, which will be an eye opener to future
researchers.
A rag picker is not a beggar. He/she works hard andconsiders ragpicking a profession of choice. It enables
him to earn money daily and offers him ample amountsof free time. They are very loyal and protective of eachother sharing food and money. The rag picker is proud
and feels that he is a master of his own life. He/she
also helps the family and sharing the responsibilities ofthe family. In spite of difficulties and poverty, they arealso being exploited by the antisocial elements. While
involvement in ragpicking causes diseases likescabies, lice chronic dysentery; lung, ear, nose andthroat infections, cuts and abrations which are causedby poverty, malnutrition and the unhygienic

17

surroundings in which the children are forced to live.
Therefore, a solid awareness must be given to
ragpicker families on health, education and othersocial status, so that ragpicking is banned from theIndian society and hence these ragpickers maintaindignity by doing alternative jobs which are safe to theirhealth and the society in which they live.
8. Acknowledgements
Thanks are due to all the respondents, and theCarmel family, and many friends around the world.
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Eubios Journal of Asian and International Bioethics 27 (January 2017)

Sex Selection In Indonesia:
An Ethical and Legal
Perspective
12

2- Rani Tiyas Budiyanti , Adi Sulistiyono , Pujiyono
1
Master Student of Health Law, Sebelas Maret University,
Surakarta, Indonesia
2
Faculty of Law, Sebelas Maret University, Surakarta,
Indonesia
Email: ranitiyasbudiyanti@gmail.com

Abstract
The development of Assisted Reproductive
Technology(ART) may provide some beneficial
effects. However, some ethical and legal issues havebeen associated with ART, particularly sex selection.
Indonesia allows sex selection in ART for the second
child without mentioning medical or non-medical
reasons. Sex selection based on medical reason is
ethically acceptable. However, sex selection for nonmedical reasons remains controversial. Sex selectionin ART contradicts to the ethics that includes naturallaw, religion, human rights, eugenics, and designer
babies. Sex selection may also generate gender
discrimination. Some countries in the world haveaccepted sex selection for medical reasons which is
not limited by the order of child. Indonesia needs toreview the sex selection policy in ART throughconsideration of the medical or non-medical reasons
either in sperm separation technique or PGD.
Key words: sex selection, assisted reproductive
technologies, ethics, legal
Introduction
The development of technology affects all aspects oflife, including health. Technology that is created byhumans may increase the quality of human life, one ofwhich is in the field of reproduction [Basic, et al, 2010].
Assisted reproductive technology (ART) has been
identified as a result of the medical technology
development which may help couples who are trying toconceive.
In its development, ART not only provides theopportunity to obtain offspring but also allows a couple
to get a child the desired sex. Sex selection using ART
can be achieved by separation of X and Y
chromosomes in the sperm (sperm separation) or
using preimplantation genetic diagnosis(PGD).
[Dondorp, et al, 2013].
Sex Selection Using ART
Attempted sex selection has occurred for somedecades with changes in timing and positioning during
coitus and also with food intake. Along with thedevelopment of technology, sex selection has been
attempted through prenatal procedures such as
ultrasonography (USG), amniocentesis, and maternal
blood tests [Lipman, 1991]. Sex selection in that way isconsidered unethical because it may cause selective
abortion which against the law in some countries. Sex
selection using ART through pre-implantation

19

procedures has been developed either by separationof X and Y chromosome containing sperm or preimplantation genetic diagnosis (PGD). Nevertheless,sex selection using ART raises several controversies
whether for medical or non-medical reasons.
Medical and Non-Medical Reasons
In general, sex selection is attempted for either
medical or non-medical reasons [ACOG, 2013]. Nonmedical reasons refer to social reasons such as socialand economic factors, the tendency towards aparticular gender, religion, personal reasons and familybalance.
Sex selection for medical reasons is linked to sexlinked genetic diseases and uses genetic screening
technology. Pre implantation Genetic Screening(PGS) or Pre implantation Genetic Diagnosis (PGD)
may help a healthy fetus to be implanted into theuterus during in vitro fertilization process [Bumgarner,
2007]. This process provides an alternative solution toprenatal diagnosis and selective abortion for some
types of genetic diseases related to the sex such as
Thalassemia which tends to affect girls and Duchene
Muscular Dystrophy which tends to affect boys [Daar,2005].
In various international discussions, sex selection
for medical reasons is acceptable and in line withethics. A study by Marcy Darnovsky of The Center for
Genetics and Society in April 2009 demonstrated that36 countries include 25 countries from Europe, 8countries from Asia, two countries from Australia, andone country from North America refused to use IVF forsex selection for non-medical reasons [Darnovsky,
2009]. Austria, New Zealand, South Korea,
Switzerland, and Vietnam refuse sex selection using
IVF both for medical or non-medical reasons. In theUK, the Human Fertilization Embryology Act (HFEA)
allows sex selection only for medical reasons. The
underlying diseases that may affect sex selection aresevere diseases that are associated with sex such as
Thalassemia and Duchene Muscular Dystrophy.
Serious illnesses that may cause genetic defects andsevere mental illness are also allowed to be treated sothat they prevent the occurrence of eugenics (geneconversion) in humans [HFEA, 2003].
In some countries sex selection with ART are also
allowed for trans-generational reasons which may
prevent inherited diseases. Although, the inherited
diseases remain unknown in the embryos that are
obtained, but sex selection to prevent inherited
diseases is acceptable [Brenoord, 2012].
The use of ART for non-medical reasons such associal reasons, particular gender desired or familybalanced, is controversial in the international
community. Rejection of sex selection for non-medical
reasons is considered to violate the natural process.
The undesired gender or balancing gender in family is
not an anomaly and should not be used as a reason tochange the sex. In contrast to medical reasons, sex
selection is expected to improve the quality and extend
life expectancy [Daar 2005].

20

Eubios Journal of Asian and International Bioethics 27 (January 2017)

For those who agree with sex selection due to nonmedical reasons said that sex selection is a right thesame as the right to reproduce. They said that thedesire to obtain the particular sex of a future child is
one of the autonomous rights of parents to becherished and respected. However, that statement isrejected by many. For those who disagree argue thatthe autonomy rights of parents should not deprive therights and freedoms of children.
On the other hand, there is an idea that if thegender of children in line with parent expectation thenit will reduce the rate of abortions, child neglect andabuse because the child of the desired gender will be
cared for and loved by their parents. But if thiscondition was denied and questioned parents might beless loving and accepting if they have too many
demands and expectations of what their child shouldbe, including what gender the child should be.
The legalization of sex selection for social reasons
may cause potential gender discrimination. In somesocieties, males are preferred compared to females. In
China and India, males are preferred by a majority of
citizens for religious, economic, and social reasons.
ART may provide great opportunities for sex selection.
Therefore, ART is interesting in medical business.
Selective abortion rate is also growing quite rapidly
due to the emergence of assistive technologies suchas ultrasound that may detect the baby's gender
before birth. The tendency toward the male gender inthe country leads to abortion and birth sex ratio (SBR)
which may increases the ratio of males compared tofemales (115: 100). Baldauf reported that in India in
2006, there were 874 girls for 1000 boys born. Thissituation leads to gender inequality. The Indian
government has tried to overcome this problem bygiving money of 2500 rupees for every birth of adaughter, and 25,000 rupees at their 18 year oldbirthday [Baldauf, 2006].
Sex selection due to non-medical reasons is
triggered by the desire of parents to have a child withparticular gender. In some families, having both maleand female children gives pride for themselvesbecause they can feel how to care for children ofdifferent gender. This reason is so-called familybalance. For those who agree with the family balance
argument suggest that the desire of parents to haveboth male and female children indicated an ideal family
and should be encouraged by ART. However, thisargument should be re-examined. If this argument iscorrect, then for family who do not have both male andfemale children is a non-ideal family. In fact, having
either male or female children is a natural random
process.
Other non-medical reasons for sex selection are theemergence of eugenics and designing a baby as theparent desire. Each couple would like to have a child
who healthy and perfect either physically or mentally. If
sex selection based on non-medical reasons is
granted, then another reason for designing baby suchas smart, beautiful and handsome will be unstoppable.
Manipulation of genes and reproduction will develop

and further problems will arise, if there is no policy toovercome these consequences.
Sex Selection in Indonesia
Indonesia legalizes sex selection using ART.
However, the implementation was not based on
medical or non-medical reasons but based on thesequence of children. ART is permitted for the second
children. This policy is regulated by Government
Regulation No. 61, Article 44, 2014 on Reproductive
Health. Further questions have arisen, if sex selectionin ART is performed on the first child for medical
reasons. ART could be implemented for a second
child.
Legalization of sex selection in ART without
differentiating medical or non-medical reasons may
cause several issues in ethics, law, and religion. The
Indonesian Society of Obstetrics and Genealogical(POGI) consists of professional obstetricians suggeststhat sex selection in ART should be implemented only
for medical reasons. This statement is contained in the
Guideline of Ethics and Professionals for Indonesian
Obstetrics and Genealogiy, article 28. Sex selection
based on medical reason is used to avoid further
consequences such as abortion. This argument isencouraged due to poor acceptance of parents
regarding the gender of their children. Whereas, inIndonesia abortion is allowed for medical indications
and emergencies such as rape victims.
Sex selection for non-medical reasons are also
against religious rules. Sex selection in ART should bedone in accordance with the development of scienceand technology when it does not conflict with religious
norms. According to Islam, the majority religion inIndonesia, sex selection for non-medical reasons iscontrary to the holy Qur’an: "He created man with thewill and his power solely in the form of what he wants"[QS. Al.Infithar (82): 8]. According to the fatwa of theIslamic World League in November 2007, sex
selection is only allowed for medical reasons [Islamic
World League, 2007].
Some argue that sex selection for non-medical
reasons should be taken into account in Indonesia toprevent gender discrimination. In Indonesia, there aresome ethnicities that prefer children of a particulargender. For example, Batak people in North Sumatra
prefer male gender because the descendant of thefamily is determined by the male line. This tradition is
the so-called patrilineal system [Baiduri, 2014].
Conversely, Minang people in West Sumatra preferfemale gender because the descendant of the family isdetermined by the female line. This tradition is the socalled matrilineal system [Stark, 2013]. Although there
are no reports of gender discrimination in Indonesia
but sex selection for non-medical reasons increases
the risk of gender discrimination among people ofparticular traditions. Sex selection may cause an
imbalanced gender ratio.
Although sex selection should be done for medical
reasons, Indonesia still faces many challenges. Lackof resources and instruments for screening anddiagnosis of genetic diseases through PGS or PGD

Eubios Journal of Asian and International Bioethics 27 (January 2017)
may underlie the challenges. There is no regulation for
PGD implementation so it may cause a gap or
potential violations of ethics and other laws. Informed
consent and counseling between parents and service
providers of ART are required to prevent theconsequences of sex selection such as selective
abortion. Parents are expected to accept the final
result of this process, assume the child is not a productthat should be perfect, but as a party that should be
accepted and cherished whatever the conditions.
The use of ART for sex selection should be
addressed wisely. ART should be used for medical
reasons rather than non-medical reasons. Therefore,technology should not be used to deprive the rights
and nature of human beings.
Conclusion
Regulation of sex selection using ART should
allow ART to be used for medical reasons rather thannon-medical reasons. Indonesia should review therules regarding sex selection using ART on the orderof a child, to just those based on medical and nonmedical reasons. Advanced regulations concerning
sex selection are needed to prevent the negative
effects that may not conflict with ethics, law, andreligion in Indonesia.
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City Sex Selection Meeting.
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Kitchener, B., & Jorm, F. (1999). Conditions Required
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Orlando, S. (2010 йил 4-January). An Argument for
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Rachel, J. (1975). Active and Passive Euthanasia.
Satyanarayana, Y.
(2010). Ethics:Theory andPractice. New Delhi: Dorting Kindersley.
Shukla, R. (2011 йил 30-April). Is the 'Next Friend' theBest Friend. Economic and Political Weekly .
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Stark, A. (2013). The Matrilineal System of the
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Eubios Journal of Asian and International Bioethics 27 (January 2017)

Letter to the Editor: The
challenges
of
medicalethics educators at a
research university- Atsushi Asai, Taketoshi Okita, Aya Enzo
Department of Medical Ethics, Tohoku University Graduate
School of Medicine, Sendai, Japan
Email: aasai@med.tohoku.ac.jp

As medical ethics educators at a research facility,
we are in charge of ethics reviews and research
misconduct prevention education and come in contact
with many researchers. In this letter to the Editor, we
would like to briefly discuss conflicts of interest andethics education concerning research activities inpresent Japan. First, we are critical of the assumptionthat a researcher’s conflicts of interest can be wellmanaged through the current self-reporting system.
Self-declaration of the researcher’s conflict of interest
to one’s institution, academic society, and journal is
expected to prevent one from both interpreting andpresenting study results in a biased manner according
to self-interest. However, we feel that undesirable
influences of researchers’ conflicts of interest are likely
never going to be eliminated at the basic level. This isbecause self-advancement, self-actualization, selfpreservation, and family life of researchers all dependon the amount of research funds they have obtained
and the number of papers they publish. Regardless of
self-declaration,
substantial
conflicts
betweenfundamental self-interests and public and professional
interests never dissolve.
Second, ethics education for researchers is not
likely to be effective enough to prevent research
misconduct. In Japan, the Ethical Guidelines for
Medical and Health Research Involving Human
Subjects(December, 2014) state that the chief
executive of the research implementing entity as wellas investigators shall receive education and training on
the ethics of research and on knowledge and skills
necessary to carry out the research prior to its
implementation and that they shall also receive
education and training during the research period on aregular basis as necessary. At Japanese research
institutions, one cannot receive an ethics review of a
research proposal without undergoing research ethics
education. A “certificate” of having received theeducation is necessary. Nowadays, many researchers
do not participate in the education to learn about
ethics, but rather to obtain proof that they attended theclasses. There is a feeling that they are undergoingeducation merely to expedite the process of ethics
review. In other words, they are akin to students whoshow up to class merely for attendance purposes.
Current research misconduct prevention policies
in Japan could be summarized as “plowing the field
and forgetting the seeds.” Many researchers adopt the“shortest distance principle,” making it their motto toachieve maximal results with the least amount of timeand effort. There is no room to consider ethics withsuch a mindset. We ourselves have no bright ideas forplanting the seeds of ethics in people’s minds, andwelcome any suggestions from the readers.

Informed Consent:
Substantive v. Formalistic
Approach and the Law- Chung-Lin Chen, S.J.D.
Professor, Institute of Law for Science and Technology,
National Tsing Hua University, No. 101, Section 2, Kuang-Fu
Road, Hsinchu, Taiwan 30013
Email: clchen@mx.nthu.edu.tw

Abstract
The rule of informed consent is universally
regarded as a cornerstone in governing patientphysician relationships. The key element of “informed”
stresses that only the consent given after
consideration of sufficient information constitutes valid
consent. However, various studies in many countries
have shown inadequate information can often takeplace resulting in lack of understanding of medical
procedures. What role does the legal system play inpromoting substantive informing and respecting the willof the patients? And how does it realize the true ideaof informed consent?
Taking Taiwan as an example, this paper reveals
the dynamic and interactive relationships between law
and practices on this issue. First, the law may
incorporate the idea of informed consent into specificmandates to prompt its implementation. Second,
however, the need of evidence in court may sustain oreven reinforce undesirable formalistic practices thatlargely focus on written consent forms rather thansubstantive explanation. Third, to respond to theseformalistic practices, courts could reconstruct theshape of the legal requirement and guide institutions
and physicians to the new direction. The assertion ofthis paper is that formalistic practices are inconsistent
with the legal nature of informed consent, regardless ofwhether they appear to have complied with the law ornot. If courts can acknowledge the problem offormalism and are willing to actively investigate orrequest institutions for alternative evidence todetermine whether a meaningful dialogue existed ornot, the practices may be directed further towards
fulfilling the spirit of informing.
Introduction
The rule of informed consent is universally
regarded as a cornerstone in governing patientphysician relationships. The key element of “informed”
stresses that only the consent given after
consideration of sufficient information constitutes valid
consent. It follows that the purpose of requiring
physicians to provide this information is so as to allow
patients to gain sufficient enough understanding toEubios Journal of Asian and International Bioethics 27 (January 2017)
make a sound decision. Hence, imparting a large
amount of medical or technical terminology onto apatient without reasonable explanation would beconsidered inadequate. In reality though, medical
institutions may comply with the rule of informed
consent formalistically by merely asking patients tosign consent forms that contain too much complex
medical terminology for patients to digest and not
giving the patients the necessary time to reflect on thesituation based on their own values.
When the law absorbs the idea of informed
consent into its system, does it intrinsically promote
substantive informing and the respect of the patient’s
will? Legalizing the rule of informed consent does
impel physicians and medical institutions todemonstrate compliance. However, when physicians
and medical institutions do not sincerely embrace thecore value of the rule, practices may be directed tosolely avoid legal liability rather than to pursue true
respect for patients’ autonomy. Physicians andmedical institutions may place much emphasis on
signed forms of consent, as a means to be supporting
evidence in case of litigation, rather than truly helping
the patient to make a sound decision.
The assertion of this paper is that the factor of
legal liability may to some extent contribute to theoccurrence or at least fail to address the continuing
existence of the formalistic practices, which actually
are inconsistent with the legal nature of informed
consent; if courts can acknowledge the problem offormalism and are willing to actively investigate orrequest institutions for alternative evidence todetermine whether a meaningful dialogue existed ornot, the practices may be directed further towards
fulfilling the spirit of informing. The argument ispresented in three parts: Part I clarifies the legal
foundation of informed consent and comments on theformalistic practices from a perspective based on thespirit of law. Part II explores the informed consent law
2in literature and its formalistic operation in action.
Lastly, Part III seeks to respond to the issue offormalistic practices through judicial actions, while also
acknowledging the limits of this approach.
Since observations and analysis of laws andpractices require the context of jurisdiction, Taiwan is3
used as an example. Yet, the thesis in this paper can
improve general understanding with respect to theinteractions of the law and practices of informed
consent anywhere. The insufficient or even formalistic
informed consent process appears to be a problem
worldwide. Many studies conducted in different
countries similarly report doctors’ inadequate informing
and patients’ poor understanding of certain medical

2

The law and society movement has provided an important
insight that not only the written law but also the law
functioning in reality deserves careful attention. See
generally, e.g., Macaulay, Steward, et al., Law in Action, pp.
15-141; Pound, Roscoe, “Law in Books and Law in Action,”pp. 12-36.
3
For a brief legal history of Taiwan, see Lo, Chang-Fa, The
Legal Culture and System of Taiwan, pp. 1-4.

23

4

procedures. Hence, it is the author’s hope that thispaper could provide valuable insight to people in many
countries, especially in where the practices of informed
consent remain in the developing stage.
I. The Foundation of Informed Consent from a
Legal Perspective
Although the idea of informed consent in the viewof many doctors is originated from bioethics rather
than law, this rule actually has strong legal backgroundthat precedes bioethics. The most influential approachof bioethics establishes its analysis through specific“principles,” such as respect for persons, beneficence,5
and justice. From this perspective, informed consent
is primarily rooted in the principle of respect for
6
persons/autonomy. In comparison, law constructs its
framework by “rights,” which have surfaced inconstitutions, civil codes, and other laws in mostcountries. Therefore, finding a foundation for informed
consent in legal systems should begin with protectionof the rights that are involved in medical intervention.
Medical intervention impacts patients’ rights ofbodily integrity and health, which are legally protected.
Taiwan’s Constitution does not explicitly list the rights
of bodily integrity and health. However, recognizingthem as constitutional rights has been supported by
7
scholarly opinions and judicial decisions. Taiwan’s
Constitution contains a provision of unenumerated
8
rights, and in one case the Constitutional Court has
interpreted the Constitution to include the right of
9bodily integrity through that provision. Additionally, inmany other cases, the Constitutional Court has
4E.g., Jawaid, M. et al., “Preoperative Informed Consent: Is
It Truly Informed?,” pp. 25-30; Falagas, Matthew E. et al.,“Informed Consent: How Much and What Do Patients
Understand?,” pp. 420-435; Kušec, Sanja et al., “Improving
Comprehension of Informed Consent.” pp. 294-300; Amir,
Mohammed et al., “Informed Consent in Elective Surgical
Procedures: ‘What Do the Patients Think’?,” pp. 679-82.
5The National Commission for the Protection of Human
Subjects of Biomedical Behavioral Research (1979). The
Belmont
Report,Part
B.
http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.ht
ml (Retrieved: December 21, 2016); Beauchamp, T.L. & J.F.
Childress, Principles of Biomedical Ethics, pp. 12-13.
6
The National Commission for the Protection of Human
Subjects of Biomedical and Behavioral Research, supra note
5, at Part C.1.; Beauchamp & Childress, supra note 5, p.
117.
7
For scholarly opinions supporting the recognition of theconstitutional rights of bodily integrity and/or health, see e.g.,
Li, Chen-Shan, “On the Right to Be Free from Bodily Harmfrom the Perspective of Constitutional Law,” In Human
Dignity and the Protection of Human Rights, p. 159 (inChinese); Li, Chen-Shan, Plurality, Tolerance, and theProtection of Human Rights, pp. 121-128 (in Chinese);
Chen, Tsung-Fu, “The Realization of Patients’ Medical
Human Rights,” p. 33 (in Chinese); Chen, Chung-Lin, “TheRight to Bodily Integrity as a Constitutional Right,” p. 113 (inChinese).
8
Article 22 of the Constitution (“All other freedoms andrights of the people that are not detrimental to social order or
public welfare shall be guaranteed under the Constitution.”)9
Interpretation No. 689.

24

Eubios Journal of Asian and International Bioethics 27 (January 2017)

stressed the importance of protecting the interests of
10
people with respects to health and bodily integrity.
In the level of statutory law, civil and criminal laws
establish rules to embody the protection of the rights ofbodily integrity and health. The Civil Code specificallymentions the interests of bodily integrity and health as
11
protected personal interests.
Infringing those
12interests triggers delictual liability. At the same time,intentionally or negligently harming the body or healthof a person constitutes a crime under the Criminal
13
Code. Similarly to the delict, the purpose of theprovisions of the Criminal Code is to realize theprotection of the rights of bodily integrity and health.
Here it is worth mentioning that this paper intentionallyuses the term delict rather than tort. Although delict (aconcept in the civil law) and tort (a concept in thecommon law) share many of the same ideas and14
characteristics, they do develop into different forms.
For example, delict manifests itself in a general fashionof expression, while tort constructs the whole picture
15
through formulating particular causes of action.
Because of the high visibility of the U.S. developmentof informed consent, legal discussions in Taiwan often
begin with the U.S. laws and proceeds under thenotion of tort. However, because of the restriction fromthe statute language as well as established civil law
principles in Taiwan, the informed consent laws
developed through individual tort cases in the United
16
States might not necessarily fit squarely into the legal
context in Taiwan. On the other hand, despite theemphasis above on the differences in name andsubstance between delict and tort, both systems are17
established and designed to protect rights.
The very notion of the rights of bodily integrity andhealth entitles an individual the control over her/his
body and health. An individual may authorize
intervention or otherwise prevent it, depending on how
she/he views her/his best interests. These two sides ofpower constitute complete control. It naturally follows
that medical intervention must have the individual’s
authorization, that is, consent; otherwise, the patient’s
rights are violated. In addition, consent must be madefully voluntarily, and cannot be considered as suchwhen an individual made it based on insufficient
information. To illustrate, an ill-informed patient who
consented to a certain medical intervention could havedeclined that intervention or have chosen an
alternative treatment, consequently avoiding the harm
resulting from the intervention. Therefore, valid

10E.g., Interpretations No. 414, 472, 476, 531, 547, 550,
551, 577, 612.
11
Articles 195 of the Civil Code.
12
Article 184 of the Civil Code.
13
Articles 277, 284 of the Criminal Code.
14
Lee, R. W., “Torts and Delicts,” pp. 721-730.
15Ibid., pp. 727-29.
16
For an introduction to the evolution of the informed
consent case law in the United States, see King, J. S. & B.
W. Moulton, “Rethinking Informed Consent: The Case for
Shared Medical Decision-making,” pp. 429-501.
17
Ibid., pp. 727-729.

consent must be made after the individual has beenadequately informed.
Based on this perspective of patients’ rights,
deeming informed consent as merely a legal obligationof physicians, with view to avoiding liability as its
purpose, oversimplifies its legal meaning. Since legal
liability constitutes an imminent threat to physicians,
physicians may tend to focus attention on the
obligation of informed consent. However, it is the
person’s rights that represent the ultimate purpose
behind legal rules, and legal obligations are merely themeans to advance rights. Similarly, non-liability does
not necessarily mean full compliance with the rule ofinformed
consent.
Law,
underadequate
understanding, requires physicians to act underrespect for patients’ rights. Sincerely informing patientsand helping them to make sound decisions fulfills that
requirement whereas devoting effort to escape liability
does not.
The discussion above demonstrates that the ruleof informed consent has solid justification in legal
systems and that the constitutive elements of the rule
exist independently from bioethical theories on
informed consent. Properly understanding patients’rights protected by law would naturally lead to
acknowledging the rule. In turn, this right-based
understanding grants us the adequate perception of
informed consent, indicating that placing muchemphasis on obtaining a signed consent form, rather
than being committed to constructive dialogue withpatients with view toward making sound medical
decisions, does not truly satisfy the expectation of law.
II. The Informed Consent Law and Formalistic
Practices
After describing the legal nature of informed
consent from a perspective of jurisprudence, thediscussion in this section is turned to specific laws thatprovide the rule. In Taiwan, the rule of informed
consent has clearly become a legal mandate. The
legislature incorporates it into the Medical Care Act
and the Patient Autonomy Rights Act, and scholars
and courts include it into civil law and criminal law
through interpretation. Still, it should be noted that
although the informed consent law implicates medical
practices, it does not necessarily ensure ideal ordesired results.
According to the Medical Care Act, in principle,
medical institutions are obliged to provide information
to the patient and to obtain his/her consent in writing
before commnecing surgery, invasive examination or18
treatment. The provisions specifically stipulate that
institutions must obtain not only consent but also
19
signed consent forms. Violation of the law leads to afine of between TWD50,000 and TWD250,000
20(USD1,500 to USD7,500). The competent agency
can fine not only the medical institution but also the18

Articles 63, 64 of the Medical Care Act.
Ibid.
20
Article 103 of the Medical Care Act.
19

Eubios Journal of Asian and International Bioethics 27 (January 2017)21

acting persons. Moreover, if the acting persons are
medical professionals, they could be subject to22
professional sanctions.
To stress the idea of patient autonomy and further
embody the rule of informed consent, the Legislative
Yuan enacted the Patient Autonomy Rights Act inDecember, 2015. The Act, repeating the Medical Care
Act, mandates medical institutions to obtain signed
consent forms from patients before commnecing
23
surgery, invasive examination or treatment. More
importantly, it clearly establishes that “a patient has theright to be informed about his/her condition, treatment
options and their potential effects, and prognosis andhas the right to choose from treatment options
24
provided by physicians and make related decisions.”
Nevertheless, it is worth noting that the Act does notcontain any sanction provision. It should also be notedthat this new law provides a three-year grace period
25
and will not come into effect until January 6, 2019.
In addition to administrative fines and professionalsanctions mentioned previously, civil liability andcriminal penalty may be triggered by a violation of
informed consent. The Civil Code establishes that aperson is liable for wrongfully infringing, with intent or26
negligence, the rights of another person. Medical
institutions or professionals that implement invasive
procedures without obtaining legally valid consent may
be held liable for the harm that they cause. By thesame token, these medical professionals may also
violate criminal law, which imposes the penalty of
imprisonment or a fine for intentionally or negligently
27
harming the body or health of a person. These
potential liabilities place significant pressure on
institutions and physicians, and impels them to adhere
to the rule of informed consent.
The meaning of informed consent under contract
law is also worth noting. Although the implication of
informed consent in contract law draws much lessattention, some have indicated that the informing that aphysician delivers and the consent that the patient
gives may well constitute an offer and an acceptance28
and together form a contract. To illustrate, imagine
someone buying food from a night market stand, or
looking for a massage from a massage parlor. In bothcases, it is easy to assume that in order to make apractical decision, this person would require certain
information about the food he is buying or the service
he is soliciting. Otherwise there would not be a valid
contract. Making such choices based on sufficient
information is an everyday activity. This also applies in21

Article 107, Section 1 of the Medical Care Act.
Article 107, Section 2 of the Medical Care Act.
23
Article 6 of the Patient Autonomy Rights Act.
24
Article 4 of the Patient Autonomy Rights Act.
25
Article 19 of the Patient Autonomy Rights Act.
26
Article 184 of the Civil Code.
27
Articles 277, 284 of the Criminal Code.
28
Chen, Chung-Lin, “The Legal Meaning of Informed
Consent in Human Tissue Research and the Application of
the Biobank Act,” pp. 499-500 (in Chinese); Hung, Min-Yu,“The Legal Meaning of Informed Consent in Medical
Research,” pp. 65-67 (in Chinese).
2225

the patient-physician relationship. Undergoing medical
intervention at a medical institution naturally involves acontract, which provides the subject matter, quality,
quantity and so on of the service. It follows that when
the physician does not fulfill the promises outlined in
the contract, the patient may rescind the contract orsue for enforcement or damages, depending on what29
kind of obligations had been violated.
Despite the clear mandate of informed consent
empowered by administrative fines, professionalsanctions, civil liability, and criminal penalty, somehave indicated that medical institutions andprofessionals often carry out informed consent byformalistically asking patients to sign consent forms
and do not pay sufficient attention on offering30
reasonable explanations.
When the liability is aweighty concern for medical communities, preparing
evidence that can later be presented in court if
required becomes an important task. Naturally, awritten consent form with required information and thepatient’s signature on it constitutes a convenient pieceof evidence of informed consent. Moreover, in order toavoid a stalemate of one person’s word against
another, the Medical Care Act has explicitly required
written consent forms and patients’ signatures. With
this clear mandate, the focus becomes even further
directed towards the formalistical implementation of
informed consent. In one study a doctor reported that
this requirement leads to a misguided focus of clinicalpractices, placing more emphasis on written consent
31
forms than on providing adequate information.
Such observation indicates that the law does notnecessarily bring the sound embodiment of the idea of
informed consent and that the overhanging threat oflegal liability may misguide physicians. Obviously, thisis not the intention behind the legislation, nor is it
consistent with the spirit of law. Some have indeed
criticized this situation and have argued in favor of
establishing the patient-physician relationship on morepositive and firmer ground than that of the fear of
32
litigation. In that light, guiding practices toward therealization of the ideal, recognizing the true legal
meaning of informed consent is a key step.
III. The Judicial Response to the Formalism and Its
Limits29

See Hung, supra note 28, pp. 69-70; Chen, supra note 28,
pp. 500.
30
Yang, Hsiu-I, “Warm Paternalism vs. Empty Autonomy:
Exactly What Physician-Patient Relationships Does Law
Want?,” p. 23(in Chinese); Wang, Huang-Yu, “TheObligations of Physicians for Informing and Examining:
Comments on the Court Decision No. 2005-Taishang-2676,”
p. 267 (in Chinese); Yang, Hsiao-Yu et al., “Clinical Ethics
Case Discussion (7): Informed Consent,” p. 30 (in Chinese);
Guo, Suh-Er et al., “Informed Consent: What Patients Want
to Know Before the Surgical Operation,” p. 146 (in Chinese).
31
Wang, Chih-Chia, Patient Autonomy and Related Criminal
Issues: Case Study, p. 212 (in Chinese).
32
Sprumont, Dominique, “Informed Consent: Do Not Be
afraid,” published on line on 28 September 2015,
http://dx.doi.org/10.1016/j.jfma.2015.08.013(Retrieved:
December 21, 2016).

26

Eubios Journal of Asian and International Bioethics 27 (January 2017)

In reality, the situation largely depends on theaction of institutional forces. The judiciary, the final
authority regarding law interpretation, has the potential
to change how the law is viewed. Since the analysis in
the previous chapter demonstrates that practices do
not completely realize the true legal nature of informed
consent, is it possible that courts could take the true
legal nature into account, reconstruct the application oflaw, thereby guiding institutions and physicians to a
new direction? The discussion below addresses thisinquiry by taking into account observations of current
opinions of the courts.
In some cases, written consent forms heavily
influenced the judicial determinations regarding theexistence of informed consent. The courts in thosecases based their findings on signed consent forms tofind that institutions or physicians have fulfilled their33
obligations of informing the patients. This way of fact
finding is not without legal grounds. As certain
declarations of the Supreme Court have previously
explained, institutions or physicians carry the burden of
proof to show that they have satisfied the rule ofinformed consent; however, when they submit thesigned consent forms as evidence, the burden of proof
may shift to the patient to show that adequate
34
informing did not exist.
In comparison, in several cases, the Supreme
Court has declared that merely relying on signed
consent forms is not sufficient enough to determine the35satisfaction of informed consent. After elaborating on
the spirit of informed consent and identifying theprotection of patient body autonomy as the purpose,the court made it clear that the obligation of informing
requires substantive explanation and merely asking
patients to sign a consent form with related information36
does not fulfill the obligation. Accordingly, the court
criticized the lower court in its failure to sufficiently
investigate whether the physician really fulfilled theobligation of informing and whether the patient37
understood the content of the consent form. In a
more recent case, although the court did not elaborate
as clearly, it seemed to follow the same train ofthought. The court questioned the sufficiency of theconsent form before the court as proof that thephysician had explained and helped the patientunderstand the risk and alternatives of the surgery, inlight of the fact that the consent form did not contain33

E.g., Supreme Court judgment No. 2013-Tai Shang-192;
Supreme Court judgment No. 2010-Tai Shang-588; Supreme
Court ruling No. 2009-Tai Shang-1877; Taiwan High Court
judgment No. 2011-Yi Shang Geng Er-1; Taiwan High Court
judgment No. 2012-Yi Shang-5.
34
Supreme Court judgment No. 2010-Tai Shang-2428;
Supreme Court judgment No. 2013-Tai Shang-192.
35
Supreme Court judgment No. 2005-Tai Shang-2676;
Supreme Court judgment No. 2006-Tai Shang-3476.
36
Supreme Court judgment No. 2005-Tai Shang-2676;
Supreme Court judgment No. 2006-Tai Shang-3476.
37
Supreme Court judgment No. 2005-Tai Shang-2676;
Supreme Court judgment No. 2006-Tai Shang-3476.

the signature of the physician as the form itself
38
required.
These two views lead to different realities.
Following the traditional rule of burden of proof, thefirst view protects institutions and physicians from theaccusation without a factual basis. However, it may
reinforce the practices that place a great deal of focus
on the written consent form. As the previous chapter
shows, the formalistic practice is actually not thedesired result of the law. To pursue a clearer
realization of the spirit of law, courts need to consider
changing the interpretation of law. The second viewhas indicated a possibility of this changing, although
the first view appears to remain more common.
Considering the severity of criminal sanctions, thetraditional view of assigning burden of proof could besustained in determining criminal liability. On the other
hand, in the context of civil liability, this paper argues
for a change to the second view. Courts should
actively investigate or request institutions for evidence
other than consent forms to determine whether any
meaningful dialogue existed. This should not be
deemed as particularly harsh, considering that
institutions are in a better position to find potential
witnesses – nurses, anesthetists, and other medical
professionals, and so on. This interpretation of law, if it
becomes a mainstream judicial view, would help urge
institutions and physicians to pay attention to not only
written information but also adequate informing.
That is not to say that this proposed judicial
response would fundamentally eliminate formalism.
Relying on judicial judgments on civil liability still
confines physicians to a perspective of legal obligationand liability. Only when physicians sincerely respectpatients’ rights, will they sincerely practice informed
consent and formalism will no longer be an issue. The
achievement of this ideal depends on to what extent
physicians absorb genuine understanding of informed
consent, rather than the threat of legal liability. To
promote a more appropriate practice of informed
consent, the proposed judicial response could be a key
step. But seeking a fundamental change may need toappeal to a scheme that plants the idea of respect forpatients’ rights deep into every physician’s heart when
they inquire what the law is truly concerned with.
Conclusion
This paper has revealed the dynamics and theinteractive relationship between law and practices.
First, the law may incorporate the idea of informed
consent into specific mandates and prompt theimplementation in reality. Second, however, the needof evidence in court may sustain or even reinforce theundesirable formalistic practices, which largely focus
on written consent forms rather than substantive
explanation. Third, to respond to formalistic practices,
courts may reconstruct the shape of the legal
requirement and guide institutions and physicians
toward the practices that further fulfill the spirit of
informing. This observation clearly shows the38

Supreme Court judgment No. 2014-Tai Shang-774.

Eubios Journal of Asian and International Bioethics 27 (January 2017)39

importance of attending to law in action and provides
valuable insights on the relationship between law andpractices regarding informed consent.
In terms of theoretical understanding, this paper
clarifies the legal foundation of informed consent andindicates the failure of the formalistic practices incomplying with the spirit of informed consent. The legal
requirements of informed consent is rooted in patients’rights, and only approaching the requirement throughthis right-based perspective provides adequate
understanding. Deeming informed consent as merely alegal obligation of physicians, with view to avoiding
liability as its purpose, is an oversimplification. Afteracknowledging that the expectation of law is actually
sincere respect for patients’ rights, physicians should
implement the rule of informed consent by promoting
substantive and meaningful dialogue with patients. In
that light, providing information only through written
forms fails the expectation of law.
Fulfilling the expectation of law largely depends
on institutional responses though. The judiciary, as anactor that possesses the final authority over law
interpretation, plays a key role. If courts are willing toactively investigate or request institutions for not only
consent forms but also more effective evidence todetermine whether a meaningful dialogue existed,institutions would be encouraged to focus more on theessence of substantive informing. However, theschemes that seek to transform physicians’
understanding of informed consent, other than
threatening physicians with legal liability and judicial
enforcement, are more important. As this paper has
clarified, the true expectation of law is to act out of
respect for patients’ rights. This sincere respect is thefundamental solution.
Acknowledgements
The author wants to express sincere appreciation
to Professor Dominique Sprumont. His input andencouragement made this paper possible. Thanks also
to Ai-Chen Sung for her valuable assistance.
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Eubios Journal of Asian and International Bioethics 27 (January 2017)

Yang, Hsiu-I (2002). Warm Paternalism vs. Empty
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Research of Applied Ethics (21): 23 (in Chinese).

Nurses’ Awareness ofBiomedical Ethics and Their
Attitudes Toward
Withdrawal of LifeSustaining Treatment- Eunsuk Choi, Kyung Suk Sung, Gil Hee Seo, Geun
MyunKim
Department of Nursing, Graduate School, Gangneung-Wonju
National University, Wonju, South Korea
Email: sungks@gwnu.ac.kr

I. Introduction
1. The need for research
The development of technologies in life scienceand medicine have enriched our lives by extending life
expectancy through the cure of various diseases. As
such, changes bring about abortions, euthanasia, organtransplants, the criteria of death, and stem cells, andthey are creating new ethical situation, which make theethical judgments and practices for them inevitable.
Especially, the development of life sciencetargeting human life and natural environment requires
careful ethical judgments and the right institutional
responses because of its influences on human lives
today and in the future. Accordingly, biomedical ethics
began coming to the fore in the sense of new ethicalchoices for humans in the age of life science since
1960s (1,2).
Since biomedical ethics is a field that concerns
human life and is an important issue for health careproviders working in areas related to life, a consensus
on the ethical standards of bioethics are needed (3).
While the development of modern medical technology
made a large contribution to curing human diseases
and saving lives, it also brought about the meaninglessextension of the painful lives of critically ill terminalpatients due to limitations of treatment (4).
Such a situation creates many conflicts andethical issues for health care providers between
continuing life-sustaining treatment to prolong the lifeof the patient and stopping it to relieve the pain andprotect the patient's right to die with dignity (5).
Especially, nurses who do not have clearly
established opinions on death or withdrawal of lifesustaining treatment face ethical conflicts and tend tobe passive in nursing (6). Therefore, nurses' firm
awareness of biomedical ethics can be an importantfactor when they face ethical issues, such as
withdrawal of life-sustaining treatment in health carefacilities.
Despite such importance, there is very limited
research on nursing related to biomedical ethics andwithdrawal of life-sustaining treatment. The majority ofnursing research related to biomedical ethics are on the
ethics of nurses (7), ethical values of nurses (8),health care professionals or nurses (3, 9,10), or
medical or nursing students (11-14). Previous studies
on the withdrawal of life-sustaining treatment are
mostly focused on the institutional, ethical, and,religious aspects (15) attitude of the general public
toward life-sustaining treatment; and medical staff andfamilies on euthanasia (5,16).
Accordingly, the present study was conducted tocreate the foundation of educational data on theestablishment of the desirable bioethical viewpoint ofnurses by identifying the level of consciousness ofbioethics among nurses and investigating their attitudes
toward the corresponding withdrawal of life-sustaining
treatment.
2. Research purpose
The purpose of the present study was to identify
the level of consciousness of biomedical ethics andattitudes toward withdrawal of life-sustaining treatment
among nurses, and the objectives are as follows:
1) To identify the general characteristics of thesubjects.
2) To identify the consciousness of biomedical ethics
among nurses.
3) To identify nurses' attitude toward withdrawal of lifesustaining treatment.
4) To identify nurses' consciousness of biomedical
ethics and the attitude toward withdrawal of lifesustaining treatment based on their generalcharacteristics.
5) To analyze the correlation between nurses'
consciousness of biomedical ethics and the attitude
toward withdrawal of life-sustaining treatment.
II. Research methods and procedures
1. Research design
The present study is a descriptive research toidentify the nurses' consciousness of biomedical ethics
and the attitude toward withdrawal of life-sustaining
treatment, and the relationship between these twovariables.
2. Subjects
The subjects were nurses working at Y hospitalin W city who understood the purpose of the present
study and consented to participate. The minimum
number of subjects needed to maintain thesignificance level of .05, effect size of 0.5, and powerof .95 was 210, based on the G*power program, andwith the consideration given to the dropout rate, 250
subjects were randomly sampled, and the data from
230 subjects excluding insincere responses were usedin the final analysis.
3. Research instruments
1) Consciousness of biomedical ethics
The Biomedical Ethics Scale by Gwon (2003), a
modified and supplemented version of the ethicalvalue scale developed by Lee (1990), was used forEubios Journal of Asian and International Bioethics 27 (January 2017)
measurements with the author's permission. The scale
comprises of 49 items, which include five items on theright to life of the fetus, six items on artificial
termination of pregnancy, seven items on artificial
insemination, five items on fetal diagnosis, five itemson the right to life of the newborn, five items on
euthanasia, four items on organ transplant, five itemson brain death, and seven items on humanbiotechnology. The responses are scored on a fourpoint Likert scale, with higher scores indicating higher
consciousness of biomedical ethics. The instrument
reliability measured using Cronbach's α was .76 in the
study by Gwon (2003), and Cronbach's α in thepresent study was .73.
2) Attitudes toward life-sustaining treatment
The measurement of the attitudes towardwithdrawal of life-sustaining treatment was made using
the instrument on the attitude toward withdrawal of lifesustaining treatment developed by Park
(2000),
modified and supplemented by Byeon et al. (2003),
with the authors’ permission. The instrument is scoredon a five-point Likert scale comprising of 19 items,
which include 15 items describing a positive positionon the withdrawal of life-sustaining treatment and four
items describing a negative position; a higher scoreindicates a positive attitude toward withdrawal of lifesustaining treatment. The reliability measured using
Cronbach's α was .88 in the study by Byeon et al.
(2003), and Cronbach's α in the present study was .81.
4.
Data collection method and ethicalconsideration
Permission was obtained for data collection forthe present study from the Institutional Review Board(IRB) (Permission number: GWNUIRB-2015-16). Data
was collected from subjects who consented toparticipate after the purpose and contents of theresearch were explained to them, and that were toldthat they could discontinue participation while theresearch was in progress, if they wished. Data
collection was conducted from 5-15 September 2015.
5. Data analysis
The general characteristics of the subjects wereanalyzed using frequencies and percentages, and theconsciousness of biomedical ethics and attitude
toward withdrawal of life-sustaining treatment wereanalyzed using averages and standard deviations. To
identify the consciousness of biomedical ethics andattitude toward withdrawal of life-sustaining treatment
according to the general characteristics, the t-test and
one-way ANOVA were performed, and the Scheffe
post-hoc test was conducted if the difference wassignificant. For the correlation between the
consciousness of biomedical ethics and attitude
toward withdrawal of life-sustaining treatment,
Pearson's correlation analysis was conducted.
III. Results
1. General characteristics of the subjects

29

Table 1: General characteristics (N=230)
Characte
ristics

Classification

N (%)

Age

29 years or younger

118 (51.3)

30 - 39 years
40 years or older

60 (26.1)
52 (22.6)

Single143 (62.2)

Married87 (37.8)

Graduated from a 3-year
nursing college

35 (15.2)

Graduated from a 4-year
nursing college

163 (70.9)

Attending graduate schoolor higher

32 (13.9)

Less than 1 year

43 (18.7)

1 year to less than 10 years
More than 10 years

104 (45.2)
83 (36.1)

Ward
Intensive Care Unit

137 (59.6)
47 (20.4)

Emergency room, operating
room, outpatient46 (20.0)

General nurse

211 (91.7)

Charge nurse

11 (4.8)

Head Nurse or higher

8 (3.5)

Maritalstatus
EducationWorkexperienceWork unit

Job
position

Religion

Yes
No

147 (63.9)
83 (36.1)

Religious
activities

Very active

12 (5.2)

Level ofparticipati
onGenerally active

56 (24.3)

Casual participation

25 (10.9)

Almost no participation

61 (26.5)

Very firm46 (20.0)

Sometimes confused
Changes by the situation

106 (46.1)
74 (32.2)

EthicalvaluesThink it is not realistic

4 (1.7)

Biomedic
al ethicsYes

57 (24.8)

training

No

173 (75.2)

The analysis of general characteristics of thesubjects showed that most subjects were aged 29
years or younger(51%), and there were more
unmarried than married subjects (62% unmarried).
The most prevalent highest level of education was
four-year nursing college graduation (71%); work
experience was between 1-10 years (45%); and ward
working as part of the work unit (60%). For job
positions, general nurses were the most prevalent(92%). Further, most subjects reported as “having a
religion” (64%), “sometimes confused” was the most30

Eubios Journal of Asian and International Bioethics 27 (January 2017)prevalent ethical value (46%), and for the experienceof receiving an education on biomedical ethics within
the last one year, ”no” was the most common
response (75%).
2. Characteristics of research variables
The characteristics of the research variables in
the present study are shown in Table 2.
Table 2: Consciousness of biomedical ethics (N=230)
Characteristics

M (SD)

Consciousness of biomedical
ethics (Overall average)

3.03 (0.22)

The right to life of the fetus

3.38 (0.49)

Organ transplant

3.31 (0.64)

The right to life of the newborn

3.27 (0.48)

Artificial insemination

3.14 (0.44)

Artificial termination of pregnancy

2.96 (0.35)

Human biotechnology

2.93 (0.36)

Fetal diagnosis

2.86 (0.33)

Euthanasia

2.85 (0.41)

Brain death2.58 (0.28)

Attitudes toward withdrawal of lifesustaining treatment

3.40 (0.46)

3. Characteristics of research variables according
to the general characteristics
Among the research variables according to thegeneral characteristics, age (F=4.67, p=.010), marital
status (t=-3.79, p<.001), work experience (F=5.23,
p=.006), and the level of religious participation (F=3.16,
p=.026) showed significant differences. According toage, over 40-year-old group was highest with 3.09
points followed by 30-39 years old group with 3.07
points, and 29 year old or younger group with 2.99
points, which showed significant differences; thebiggest difference was seen in the over 40 year oldgroup and the consciousness of biomedical ethics washighest in that group.
For work experience, more than 10 years washighest with 3.09 points, one year to under ten years
was 3.01 points, and under one year was 2.97 points,
which showed significant differences. Those who had
more than 10 years of work experience showed higher
consciousness of biomedical ethics than those who
had 1-10 years or under one year or experience.
For the level of religious participation, “veryactive” was the highest with 3.24 points, followed by“casual participation” with 3.07 points, “generally active”
with 3.06 points, and “almost no participation” with
3.02, and the differences were significant. The
consciousness of biomedical ethics was higher for'very active' than 'almost no participation'. For marital
status, the married group scored 3.10 points, which
was significantly higher than the unmarried group whoscored 2.99. The consciousness of biomedical ethics
was significantly higher for the married group than theunmarried group. Significant differences were found in
the subareas of the consciousness of biomedical

ethics, i.e., marital status (t=-3.45, p=.001) for the rightto life of the newborn; job position (F=3.76, p=.025) for
artificial termination of pregnancy; age (F=12.19,
p<.001), marital status (t=4.14, p<.001), education(F=6.86, p=.001), and work career (F=12.36, p<.001)
for artificial insemination; age (F=8.52, p<.001), marital
status (t=-4.37, p<.001), and work career (f=7.12,
p=.001) for fetal diagnosis; job position (F=4.81,
p=.009) for the right to life of the newborn; level ofreligious participation (F=3.16, p=.026) for euthanasia;
and age (F=8.02, p<.001), marital status (t=-3.76,
p<.001), and work career (F=9.36, p<.001) for humanbiotechnology.
The consciousness of the right to life of the fetus
was significantly higher for the married group thanunmarried group, and the consciousness of theartificial termination of pregnancy was significantly
higher for head nurses or higher ranking nurses thancharge nurses. The consciousness of artificial
insemination was significantly higher for the groupaged 30-39 years or 40 years and older compared to
29 years or younger group, married group thanunmarried group, and attending graduate school orhigher than three- and four-year nursing college, andthe work career was significantly higher for 10 years or
higher group than under one year and one to ten year
groups.
The consciousness was higher for the 40 years
or older group than 29 years or younger group, and for
married group than unmarried group in fetal diagnosis
and human biotechnology, and the 10 years or higher
group than under one year and one to ten year groups
in work career. The consciousness was higher forcharge nurses than general nurses with regards to theidea of the right to life of the newborn. Higher
consciousness was found for euthanasia for “veryactive” group than “almost no participation” in the levelof religious participation. The difference in the attitude
toward withdrawal of life-sustaining treatment
according to the general characteristics was nonsignificant (Table 3).
4. Correlation between the consciousness of
biomedical ethics and the attitude towardwithdrawal of life-sustaining treatment
The results of the correlational analysis between
the consciousness of biomedical ethics and theattitude toward withdrawal of life-sustaining treatment
showed significant correlation (r=-.200, p=.003).
Among the subareas of the consciousness of
biomedical ethics, artificial termination of pregnancy(r=-.179, p=.007), euthanasia (r=-.418, p<.001), andthe right to life of the newborn (r=-.383, p<.001)
showed significant correlations. No significant
correlations were found in the right to life of the fetus,
artificial insemination, fetal diagnosis, the brain death,organ transplants, and human biotechnology. It was
found that the higher the biomedical ethics score, theattitude toward withdrawal of life-sustaining treatment
was more negative (Table 5).

32

Eubios Journal of Asian and International Bioethics 27 (January 2017)

Table 4: The consciousness of biomedical ethics according to the general characteristics (N=230)
The right to
The right toTermination
Fetal
Artificial
Char
life of thelife of theof pregnancy
diagnosis
insemination
acter Classifica
fetus
newborn
istic
tion
M
(SD)

t/
F

p

M
(SD)

t/
F

p

M
(SD)

t/
F

p

29 years or
younger

3.32(0.46)

2.3
6

.096

2.96 (0.35)

.03

.968

2.79 (.030)

8.5
230-39 years old

3.48(0.47)

2.96 (0.33)

2.87 (0.35)

40 years or older

3.42(0.56)

2.97 (0.40)

3.01 (.36)

s

Human
biotechnolog
y

(SD)

t/
F

p

M
(SD)

t/
F

p

<.001

3.01
(0.44)

12.1
9

<.001

3.30 (0.46)

.28

.755

a<c

3.20
(0.38)

a<b,c3.25 (0.47)

3.05(0.36)

3.25 (0.56)

2.99(0.36)M

M(SD)

Euthanasia

Organtransplant

Brain
death

t/F

p

M
(SD)

t/
F

P

M
(SD)

t/F

P

M
(SD)

t/F

P

8.02

<.001

2.84
(0.37)

.26

.770

3.26
(0.45)

1.55

.214

2.59
(0.29)

.13

.870

a<c

2.85
(0.42)

3.36(0.41)

2.58(0.31)

2.89(0.49)

3.38(0.53)

2.56(0.23)

.24

.803

.99

.372

.09

.907

.91

.402

Age

3.35
(0.44)

2.84(0.34)

Marital status
Single3.30(0.47)

Married

3.52(0.49)

3.4
5

.001

2.95 (0.34)

.80

.420

2.98 (0.38)

2.78 (.28)

4.3
7

<.001

3.05
(0.45)

4.14

<.001

3.28
(0.39)

2.99 (0.37)

3.26 (0.47)

-.34

.729

2.86
(0.34)

-3.76

<.001

3.04
(0.36)

3.29 (0.51)

2.85(0.37)

.25

.800

2.86
(0.47)

3.27(0.45)

1.89

.060

3.39
(0.47)

2.58(0.28)
2.57(0.28)

Education
3-year college

3.39(0.46)

4-year nursing
college

3.36(0.49)

2.97 (0.36)

2.86 (0.32)

3.11(0.42)

Attending
graduate schoolor higher

3.47(0.53)

2.99 (0.42)

2.95 (0.37)

3.39(0.46).69.500

2.89 (0.30)

.85

.428

2.81 (0.33)

1.5
5

.214

3.03
(0.46)

6.86

.74

.478

3.00
(0.30)

.81

.444

2.79
(0.37)

2.3
7

.096

3.24
(0.47)

.61

.541

2.64
(0.28).001

3.26 (0.39)

a,b<c3.29 (0.48)

2.92(0.38)

2.84(0.41)

3.33(0.46)

2.57(0.29)

3.18 (0.59)

2.89(0.29)

2.99(0.44)

3.34(0.49)

2.58(0.25)

Work Experience
Less than 1 year

3.29
(0.48)

2.4
3

1-10 yrs

3.35(0.44)

2.94 (0.35)

2.81 (0.32)

More than 10
years

3.47
(0.54)

2.98 (0.38)

2.97 (0.37).089

2.98 (0.31)

.43

.648

2.78 (0.24)

7.1
2

.001

2.99
(0.39)

a,b<c

3.05(0.45)

12.3
6

3.31 (0.49)

a,b<c3.27 (0.44)

2.92(0.32)

3.26 (0.55)

3.04(0.36)

3.32(0.40)

.15

.855

2.76
(0.38)

<.001

9.36

<.001

2.86
(0.38)

a<b,c2.86(0.36)

3.30(0.45)

2.57(0.30)

2.84(0.47)

3.39(0.50)

2.58(0.27)

.05

.944

3.20
(0.39)

2.47

.086

2.60
(0.27)

Work unit
Ward

3.42
(0.50)

Intensive Care
Unit

3.32
(0.48)

2.93 (0.31)

2.91 (0.34)

3.16(0.41)

3.26 (0.49)

2.90(0.37)

2.88(0.34)

3.33(0.47)

2.5(0.28)

Emergency room,
operating room,
outpatient

3.35(0.49)

2.88 (0.39)

2.75 (0.33)

3.09(0.47)

3.26 (0.48)

2.90(0.48)

2.80(0.39)

3.20(0.50)

2.54(0.26).83.439

3.00 (0.36)

2.2
4

.109

2.88 (0.33)

3.5
9

.029

3.15
(0.45)

0.34.712

3.28 (0.50)

.04

.963

2.95
(0.36)

.55

.577

2.96
(0.44)

.50

.607

3.35
(0.45)

1.78

.171

2.60
(0.29)

Eubios Journal of Asian and International Bioethics 27 (January 2017)
The right tolife of the
fetus

Terminationof pregnancy

M
(SD)

t/
F

p

M
(SD)

t/
F

p

M
(SD)

t/
F

p

General nurse

3.38(0.48).03.963

2.96 (0.35)

3.7
6

.025

2.85 (0.32)

1.0
6

.346

Charge nurse

3.36(0.60)

2.76 (0.30)

b<c3.00 (0.32)

3.22(0.36)

2.84 (0.53)

Head nurse

3.43(0.65)

3.21 (0.54)

2.90 (0.47)

3.43(0.59)

3.25 (0.72)

Char
acter
istic
s

Classifica
tion

Fetal
diagnosis

Artificial
insemination
M(SD)

The right tolife of thenewbornHumanbiotechnologyM

33
Euthanasia

Organtransplant

Brain
death

t/
F

p

M
(SD)

t/
F

p

2.03

.133

3.30 (0.47)

4.8
1

.009

2.93
(0.37)

a>b2.96(0.22)

2.75(0.37)

3.20(0.56)

2.53(0.26)

2.89(0.35)

3.10(0.39)

3.34(0.64)

2.45(0.20)

(SD)

t/F

p

M
(SD)

t/
F

P

M
(SD)

t/F

P

M
(SD)

t/F

P

.08

.921

2.85
(0.41)

1.8
4

.160

3.32
(0.45)

.33

.716

2.59
(0.29)

1.0
7

.344

.68

.498

.16

.921

1.2
0

.308

.13

.896

Job position
3.12(0.44)

ReligionYes

3.40(0.52)

No

3.36(0.44).60.547

2.98 (0.35)

1.1
6

.248

2.92 (0.37)

2.87 (0.33)

.54

.587

3.18
(0.43)

1.82

.069

3.07
(0.47)

2.85 (0.35)

3.29 (0.50)

.69

.490

2.95
(0.37)

.90

.368

2.90
(0.33)

3.24 (0.47)

2.87(0.44)

1.0
1

.313

2.82
(0.35)

3.35(0.46)

1.35

.178

3.26
(0.47)

2.57(0.26)
2.60(0.32)

Level of religious participation
Very active

3.60(0.49)

Generally active

3.39(0.53)

3.01(0.37)

2.90(0.33)

3.21(0.43)

3.26(0.49)

2.91(0.29)

2.89(0.46)

Casual participation

3.39(0.47)

2.96(0.29)

2.89(0.28)

3.13(0.47)

3.39(0.45)

2.99(0.40)

Almost no
participation

3.38(0.54)

2.93(0.36)

2.83(0.33)

3.16(0.39)

3.25(0.52)

2.96(0.43).62.599

3.21 (0.27)

2.3
9

.071

2.92 (0.28)

.60

.614

3.32
(0.47).69.559

3.63 (0.25)

2.5
1

.061

3.06
(0.32)

.63

.596

3.20
(0.32)

3.1
6

.026

3.42
(0.39)(a>d)

3.34(0.53)

2.59(0.28)

2.94(0.43)

3.37(0.39)

2.55(0.17)

2.78(0.41)

3.29(0.46)

2.59(0.28)

.33

.798

2.57
(0.25)

Ethical values
Very firm

3.50(0.50)

1.9
6

Sometimes
confused

3.31(0.50)

2.97(0.35)

2.85(0.33)

3.14(0.48)

3.29(0.49)

2.94(0.33)

2.88(0.40)

3.32(0.42)

2.58(0.28)

Changes by thesituation

3.40(0.47)

2.91(0.33)

2.87(0.34)

3.11(0.41)

3.20(0.46)

2.92(0.40)

2.80(0.37)

3.25(0.48)

2.58(0.30)

Think it isunrealistic

3.65(0.47)

2.83(0.38)

2.80(0.16)

3.00(0.48)

3.30(0.26)

3.00(0.26)

2.65(0.61)

3.25(0.67)

2.80(0.36).120

3.02(0.39)

1.1
5

.329

2.87(0.35)

.80

.967

3.20
(0.41).46.705

3.34(0.50)

.88

.452

2.93
(0.35)

.07

.974

2.89
(0.46)

1.0
2

.382

3.41
(0.48)

1.25

.291

2.5
(0.243)

Biomedical ethics training
Yes
No

3.40
(0.48)3.
38(0.49)

.21

.829

2.99
(0.32)2.95(0.37)

.86

.388

2.84
(0.32)2.87(0.33)

.63

.528

3.10
(0.40)
3.16(0.45)

-.81

.417

3.38
(0.39)3.24(0.51)

1.9
4

.56

2.91
(0.33)
2.94(0.37)

-.55

.582

2.88
(0.38)
2.84(0.42)

.61

.540

3.26
(0.44)
3.33(0.46)

1.07

.284

2.58
(0.24)
2.58(0.29)

34

Eubios Journal of Asian and International Bioethics 27 (January 2017)

Ⅳ. Discussion
Due to rapid development, issues on the
consciousness of biomedical ethics and withdrawal of
life-sustaining treatment have started to emerge.
Accordingly, the present study was attempted so that
nurses can be conscious of biomedical ethics, and tohelp to understand values on withdrawal of lifesustaining treatment without having conflicts, andethics related training by identifying the consciousnessof biomedical ethics among nurses and the attitude
toward withdrawal of life-sustaining treatment. The
subjects' average score on the consciousness of
biomedical ethics was 3.03 out of four points and theresult is similar to the results of a previous study (1).
The reason for the similar scores in the
consciousness of biomedical ethics between nurses
who deal with life in their clinical work and nursing
students is that consciousness does not change easily
and is influenced by ethics education in college.
Further, continuing education is considered necessary
for the nurses who face ethical conflicts in their clinicalwork.
Among the subareas of the consciousness of
biomedical ethics, the right to life of the fetus was thehighest with 3.38 points, and brain death was thelowest with 2.58 points. Such results partially agreewith previous study on nurses' consciousness of
biomedical ethics and the attitude toward withdrawal of
life-sustaining treatment (17). It also partially agrees
with the results of a previous study, which found thatthe highest area among nurses' consciousness of
biomedical ethics and attitude toward human tissue
donation and transplants was the right to life of thenewborn and the lowest area was brain death (11).
The reason for the right to life of the fetus obtaining thehighest score among the consciousness of biomedical
ethics is considered to be because nurses are
acknowledging the fetus as a human being that
already has life and perceive it as a weak life thatcannot assert its rights by itself or have its rights
recognized.
The reason for brain death to be the lowest
among the consciousness of biomedical ethics is thatthe issues of brain death are still actively discussed,and because the other person has to make thedecision for the patient, even if brain death isrecognized as legitimate.
When the consciousness of biomedical ethics
according to the general characteristics was examined,
it was higher for married and older subjects, and this
could be because of the influence of life experience on
the relatively stable and desirable ethical belief. In
addition, the consciousness of biomedical ethics washigher for nurses with more work experience, which isconsidered helpful in establishing ethical values.
In terms of the level of religious participation, theconsciousness of biomedical ethics was higher for“very active” than “almost no participation,” and it
appears that due to the nature of religion thatconsiders respect for life as important, “very active”
can positively influence the consciousness of18)
biomedical ethics.

Among the subareas of the consciousness of
biomedical ethics according to general characteristics,
marital status, religious participation, job position, age,education, and work experience were influencing
factors, and since detailed studies on the areas ofconsciousness of biomedical ethics according to thegeneral characteristics are lacking, further studies areneeded.
The average score of the attitude towardwithdrawal of life-sustaining treatment was 3.40 out offive points, which shows a somewhat positive positionon the withdrawal of life-sustaining treatment, and “thepatient has the right to decide his or her own death” on
the question of nurses' attitude toward withdrawal of
life-sustaining treatment scored the highest point, and“basic medication (fluid and antibiotics) should begiven even if the patient is terminally ill duringhospitalization” scored the lowest point. The reason forthe highest score on “the patient has the right todecide his or her own death” is perhaps that it puts thegreatest significance on the principle of autonomy
among the ethical principles of withdrawal of lifesustaining treatment.
A significant negative correlation was found in
the relationship between the consciousness of
biomedical ethics and withdrawal of life-sustaining
treatment. In the consciousness of biomedical ethics
area, artificial termination of pregnancy, euthanasia,
and the right to life of the newborn showed significant
negative correlation, and the results are similar to thefindings of a previous study, "Awareness of biomedical
ethics and attitudes to euthanasia of clinical nurse's"(17). It can be seen that the higher the consciousness
in the areas of artificial termination of pregnancy,
euthanasia and the right to life of the newborn, themore negative it is about withdrawal of life-sustaining
treatment; overall, the higher the consciousness of
biomedical ethics, the attitude toward withdrawal of
life-sustaining treatment is more negative.
In summary, the consciousness of biomedical
ethics and withdrawal of life-sustaining treatment are
related to each other, and there are many conflicts andethical issues between sustaining patient's life andwithdrawing life-sustaining treatment. As a means toresolve the issues, active and systematic education on
biomedical ethics and withdrawal of life-sustaining
treatment is necessary.
Ⅴ. Conclusion
The present study intended to help nurses firmly
have the consciousness of biomedical ethics, help
establish values on withdrawal of life-sustaining
treatment without having conflicts, and provide ethics
related training by identifying the consciousness of
biomedical ethics among nurses and the attitude
toward withdrawal of life-sustaining treatment.
Summarizing the results of the present study, theaverage score of nurses' consciousness of biomedical
ethics was 3.03 out of 4 points, which indicates
relatively high consciousness of biomedical ethics.

Eubios Journal of Asian and International Bioethics 27 (January 2017)
The attitude toward withdrawal of life-sustaining
treatment was 3.40 points out of 5 points, which shows
an overall positive attitude.
An inverse correlation was found between the
consciousness of biomedical ethics and attitude towardwithdrawal of life-sustaining treatment, which signifies
the higher the score of the consciousness of biomedical
ethics, the more negative the attitude towardwithdrawal of life-sustaining treatment.
Based on the results discussed above, a repeated
and detailed study on conflicts based on the subareasof consciousness of biomedical ethics is needed, sinceeasily accessible continuing education for nurses isrequired and there is a lack of research on this topic. In
addition, a qualitative and repeated study to generalize
the results of the present study is needed to conduct
proper intervention for nurses to understand their rolein the decision-making process on the withdrawal of
life-sustaining treatment.
Note: The present study is based on an excerpt fromthe thesis for the degree of Master of Science at theGraduate School of Gangneung-Wonju National
University in 2016.
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EJAIB Editor: Darryl Macer
Associate Editors
Jayapaul Azariah (All India Bioethics Association, India),
Masahiro Morioka (Osaka Prefectural University, Japan).
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany), Rhyddhi
Chakraborty (India/UK), Shamima Lasker (Bangladesh),
Minakshi Bhardwaj (UK), Christian Byk (IALES; France), Ken
Daniels (New Zealand), Ole Doering (Germany),
Amarbayasgalan Dorjderem (Mongolia), Hasan Erbay(Turkey), Soraj Hongladarom (Thailand), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Umar Jenie (Indonesia), Nobuko Yasuhara Macer (Japan),Anwar Nasim (Pakistan), Jing-Bao Nie (China, New
Zealand), Pinit Ratanakul (Thailand), Qiu Ren Zong (China),
Hyakudai Sakamoto (Japan), Sang-yong Song (Republic ofKorea), Takao Takahashi (Japan), Noritoshi Tanida (Japan),
Ananya Tritipthumrongchok (Thailand), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republic ofKorea).

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Future Conferences (see details on www.eubios.info and email to Darryl@eubios.info) include:
Joint AUSN, Center for Ethics of Science and Technology, and Eubios Ethics Institute Roundtable andConference: Bioethics, Development Ethics, and Global Policy into Action
Chulalongkorn University, Bangkok, Thailand, 25 January 2017
International Responses to Disasters of Nature and Human Behaviour: Bioethics, Indigenous People andJustice , Norwood Hall, Norwood Green Rd, Southall, England, 11-13 February 2017
International Bioethics Roundtable: Bioethics Across and Between Continents and Peoples
Betterment of All, AUSN, Arizona, late March 2017 (dates to be confirmed)

for the6th Joint IIB-AUSN Bioethics Intensive Course and Conference, Monterrey, Mexico, 4-8 July 2017.
Eighteenth Asian Bioethics Conference: The Future of Bioethics and Healthcare (ABC18), 25-28 October 2017
in Seoul, Republic of Korea, followed by a Joint AUSN-Gangneung-Wonju National University Intensive Bioethics
Workshop (ABA Satellite meeting) 29-30 October 2017 in Gangneung, Korea.