Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 26 (1) January 2016www.eubios.info ISSN 1173-2571
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2016 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contentspage1

Editorial: Reflection of Life Ethics- Darryl Macer
Reflection on the bone marrow donation toSung-Duk Bauman
2- Bang-Ook Jun
The Present State of Regulations Concerning
Reproductive Medicine, Particularly Surrogacy, in both
India and Thailand
4- Masayuki Kodama
Issues of Research Ethics in Developing World 8- Sumaira Khowaja-Punjwani
Responsible Innovation and Ethics: A need for
Globalization
11- Hannah Holitzki & Gregor WolbringConsideration of Health Capability Paradigm to Ensure
Equitable Protection through Indian National
Tuberculosis (TB) Prevention Program18- Rhyddhi Chakraborty
Differences in gender and educational stage in theemotional skills during teacher training
26- Lara López-Hernáez & Carmen Sabater Fernández
Analyzing Bioethics Curriculum in Korea
32-Manjae Kim & Kyung-Suk Sung
ABA Renewal and EJAIB Subscription
36
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations (AUSN);
Editorial Address: 13 Carlina, Irvine, CA 92620-1826, USA

Email: darryl@eubios.info
http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: Reflection on Life Ethics
The theme of life ethics is explored through the 7
papers in this issue of EJAIB. Bang-ook Jun revisits abone marrow donation that occurred two decades ago
in Korea, and questions the ethics of the thenCommander in Chief of the Military, insisting on all
soldiers having a test for compatibility as a bonemarrow donor. It is claimed that there was a lack of
freedom of choice, with implications for high level
campaigns for donors that are sometimes made.
Masayuki Kodama reports on the recent legislative
moves in India and Thailand, two havens forcommercial surrogacy trade, that have developed laws
to restrict access to surrogacy services in thosecountries to those who are nationals, or in a real
relationship with a national.
Sumaira Khowaja-Punjwani explores some issues
including vulnerability in Pakistan and in the developingworld in general, that researchers and ethics
committees should read. Rhyddhi Chakraborty
examines equity in the Indian National Tuberculosis(TB) Prevention Program, which has implications forthe policies in other countries as well. More attention
should be placed on TB prevention, which is often
neglected. Hannah Holitzki and Gregor Wolbring use aliterature analysis to examine the frequency of key
words in papers published in responsible innovation.
There are two papers on bioethics/moral education,
Lara López-Hernáez and Carmen Sabater Fernández
found gender differences in emotional skills in Spanish
teacher trainees, with implications for the reform ofteacher training. They used the AURE instrument toexamine moral reasoning of teachers and views of life.
Manjae Kim and Kyung-Suk Sung review bioethics
curriculum in Korea at junior and senior high school andtwo universities, calling for increased attention tobioethics. They recommend including bioethics and life
ethics education, and also the UNESCO Bioethics
Curriculum.
th
The 17 Asian Bioethics Conference of the Asian
Bioethics Association (ABA), ABC17, will be held in
UGM, Jogyakarta, Indonesia, 14-17 November,preceded by a National Bioethics Meeting which also
welcomes all participants.
- Darryl Macer

2

Eubios Journal of Asian and International Bioethics 26 (January 2016)

Reflection on the bonemarrow donation to SungDuk Bauman

their ranks that a match was found and the transplant
was successfully done.
Twenty years on, upon close examination of the
supposed altruistic donation, several ethical issues
now emerge.

- Bang-Ook Jun, Ph.D.
Professor, Department of Biology, Gangneung-Wonju
National University, Gangneung 25457 KOREA
Email: bojun@gwnu.ac.kr

To volunteer or to be volunteered?
First, the donation was mandatory and notvoluntary on the part of the army donor. The donor
was in military service, where soldiers are situated2
within ranks. Soldiers are often coerced “to be
volunteered" to sacrifice even their lives for thecommon good. Though he might not have sufficient
intention to give his bone marrow to others, it wasprobably difficult for him to decline to be tested for
initial compatibility against the order of the
Commander-in-Chief. No one knows for sure whether
he joined the registry voluntarily or not.
Cheyette (2000) categorically divided donors into
the donor who is altruistic, remained anonymous andthe donor who decides to donate in response tointernal or external pressure. And the donor decides to3
donate can be divided into two groups.

1

Abstract
Sung-Duk Bauman was born in Korea and adopted
to an American family. Later, he was diagnosed withchronic myelogenous leukemia. His family began tosearch for potential donors having compatible bonemarrow that exactly matched to his bone-marrow type.
After broadcasting a touching documentary on thistissue search, a national campaign to look for donors
swept Korea. The Commander-in-Chief ordered themilitary to find the match in an army donor and thetransplant was successfully done.
Twenty years on, upon close examination of the
supposed altruistic donation, several ethical issues
now emerged. First, the donation was mandatory andnot voluntary on the part of the army donor. Second,
the Ministry of National Defense disclosed the identityof the donor before the family consent for transplant
was given. Third, the information consent process forthe donor or his family was also improper. Fourth, themedical staff failed to prepare a safeguard for thedonor. This paper insists on free and voluntary
donation of human tissue and/or organ, and not forced,
commanded or mandated donation.
Key words: Transplantation, tissue/organ donation,
informed consent, donor’s right
Introduction
Sung-Duk Bauman was a U.S. Air Force Cadet,born in Korea and adopted at the age of 3 to an
American family. Before graduation, he was diagnosed
with chronic myelogenous leukemia. He could nothave survived five years if someone had not donatedcompatible bone-marrow to cure his disease. His
family began to search for potential donors including
his biological parents and siblings. There was anarrow chance to find the compatible bone marrowthat exactly matched to his bone-marrow type. After
failing to get information on Bauman's biologicalparents and siblings, the Korean media made this atouching tissue donation documentary, with one
producer saying: "His country abandoned him once.
We must not do it again." A national campaign to look
for a donor soon ensued with 20 civic and religiousorganizations participating and 7,000 bone-marrow
registry entries. The Commander-in-Chief ordered themilitary to register as potential donors and it was from1thPart of this paper was presented in 16 Asian Bioethics
Conference held at St. Paul University Quezon City,
Philippines on November 8, 2015.

2

See Goodwin (2007) (defending children donors rightagainst compelled donation, “Children are uniquely situatedwithin families, where the power relationships are vertical andtheir status resides at the bottom” and “youth are coerced into
"volunteering" for the sake of "saving" their tribes,
governments, or communities; and such sacrifices for thecommon good can demand an enormous social price. The
moral value of those types sacrifice does not pale in the faceof individualism. There are some sacrifices that should notcome with applause, lest we encourage unsound behaviors
for which the costs may be socially and legally incalculable or
morally unjustifiable. Rather, we must be guided by criticalthinking as it relates to altruism, There are some sacrificesthat should not come with applause, lest we encourage
unsound behaviors for which the costs may be socially andlegally incalculable or morally unjustifiable. Rather, we mustbe guided by critical thinking as it relates to altruism.
Individuals who decide to donate organs fall into two primarygroups: those who donate in response to a sense of moral
obligation and those who donate in response to pressure fromthe society. Generally, when adults decide to donate in
response to a sense of moral obligation-that is, on the basisof an internal motivation-they experience their participation as
voluntary and generally feel good about their decision. While
the society member's need for the organ triggers the donor's
feeling of moral obligation, the donation itself is driven by theneed to satisfy the feeling of obligation”).
3
See Cheyette (2000) (“Individuals who decide to donate
organs fall into two primary groups: those who donate in
response to a sense of moral obligation and those who
donate in response to pressure from the society. Generally,
when adult decide to donate in response to a sense of moral
obligation-that is, on the basis of an internal motivation-theyexperience their participation as voluntary and generally feel
good about their decision. While the society member's needfor the organ triggers the donor's feeling of moral obligation,
the donation itself is driven by the need to satisfy the feelingof obligation. The second group of adults decides to donate in
response to pressure from the society. This pressure canrange from subtle situational pressure, to messages as
blatant as: "if you don't donate, s/he will die." Whereas moral

Eubios Journal of Asian and International Bioethics 26 (January 2016)
In this case, the bone-marrow tissue was harvested
4rather than donated.
Urgency and disclosure of the situation results inthe adult donor being pressured to make an immediate
decision, while for the vulnerable donor, the situation
results in a rushed proceeding in which the donor's
interests go unprotected (Cheyette, 2000).
The donor who is volunteered may be more likely toexperience psychological or physical trauma than thedonor who steps forward as a mature and competentvolunteer (Cheyette, 2000). One of the Korean media
reported that the potential donor was in a
psychiatrically unstable condition before the surgery,and the medical team had to postpone the wholeschedule (Jang, 1996).
Donor's identity disclosed without consent
Second, the Ministry of National Defense disclosed
the identity of the donor before the family consent fortransplant was given. The participants in bone marrow
registries usually remain anonymous, though thedonor and recipient's identities may be disclosed withboth parties' consent (Cheyette, 2000). Soon after
finding the compatible bone-marrow, the Ministry of
National Defense spokesman announced that "Thecompatible donor is a 23-year-old army sergeantsurnamed Soh. The consent of his family has yet to beascertained."
While the donor's identity was disclosed, he had tobe volunteered in response to pressure from thesociety. With directed donation by a nation-wide
campaign to save Sung-duk Bauman, worries could
arise about the intense pressure put on sergeant Soh
to donate, leading someone who might be reluctant todo so, to feel coerced (Truog, 2005).
Directed donation to a stranger (in this case, a5celebrity) raises more additional ethical questions(Truog, 2005).
obligation can be properly called an internal motivation, thesepressures are external and can be quite intense. Even when
the pressure is not overt, the treat of society sanctions may
be coercive to the point where society members feel that they
truly have no choice. More than half of the kidney donors in
one study group were subjected to pressure that researchers
felt had a "compulsory quality"”).
4
See Cheyette (2000) (“Organs are "donated" by competent
adults who voluntarily and altruistically consent to give what issometimes called "the greatest gift." Competent adults areunder no compulsion to submit to organ harvests for the
benefit of third parties. Notwithstanding the internal andexternal pressures on society members to volunteer;competent adult may decide that for whatever reason, they
are unwilling to step forward. Besides, organs are "harvested"from living individual who are unable to give a full competent,
valid consent because of their age, mental illness or weaksocietal position. It is this latter methods of obtaining organs
that poses the ethical dilemma”).
5
See Troug (2005) (“This type of donation usually occurs
when a patient's appeal for an organ publicly, on television orover social network services. Such appeal is not illegal, but it
has been strongly discouraged by the transplantation
community. Two central objections are that the practice3

Improper consent process
Third, the consent process for the donor or his
family was also improper. As the identity of potential
donor was disclosed, the surgery should be done in ahurry on the part of the Ministry of National Defense
whether donor and/or his family gave proper consent
or not. It was reported that his family once refused togive the consent, but finally they surrendered. It seems
not an informed consent process but persuasion that6enabled them to give their agreement.
Also before the consent, the donor should be fully
provided with the information that (1) the risk thatdeath or serious injury will result from the harvest; (2)the temporary or permanent physical changes that theharvest will cause; and (3) the overall level of surgicalcomplication or invasiveness of the procedure
7(Cheyette, 2000).
Failure to prepare a safeguard
Fourth, the medical staff failed to prepare asafeguard for the donor. It is possible that any
vulnerable individual, including a soldier, could becoerced into donating a tissue or an organ. When thedonor is under an extremely coerced condition, thetransplantation centers are typically willing to identify aplausible medical excuse, so that the person can
8escape the situation gracefully (Truog, 2005).
ignores waitlist and patient who have the most compellingstories and the means to advertise their plight tend to be theones who get the organs - rather than those most in need.
This strikes some ethicists as unfair”).
6
See Korea Times (1996) (“[Sgt.] Soh said during aninterview “I thank my parents for allowing me to donate mybone marrow.”…… Soh’s parents were reluctant at first toallow their son to donate part of his body but readily agreed
after being told about Bauman’s plight”).
7
See Cheyette (2000) (“After undergoing tissue typing, abone marrow harvest must be done under general anesthesia
so the marrow can be extracted via multiple punctures in thepelvic area with a rigid needle screwed through the bone. It
takes approximately half an hour and upwards of 200 taps toextract one liter of bone marrow fluid from an adult”). And see
also Goodwin (2007) (“Such invasive procedures poses
health risks, including the potential for complications with
anesthesia, difficulties during the operation, the need forpossible post-operative blood transfusion, and other problems
unique to the particular type of harvesting”).
8
See Israni et al. (2004) (“Such coercion has been describedwhen vulnerable society members are chosen based on blood
type and cross matching. Therefore donors should be'competent, medically and psychologically stable, and fully
informed of risks and benefits to themselves and to thepotential recipient.' At many transplant centers both therecipient and the potential donors are informed that results ofthe donor's evaluation will only be revealed to the donor. In
such a situation, the donor has an easy 'out' by claiming thatthe blood type or the cross-match did not allow for donation.
Transplant centers should provide committed donors withevery opportunity to change their mind up until the time of thesurgery itself. When donors choose to opt out, the medical
directors should provide the potential donor with the option of
being declared 'inappropriate for medical reason' so that the4

Eubios Journal of Asian and International Bioethics 26 (January 2016)

One year after the surgery, the donor was reported
to have a herniated spinal disk, which was later denied
to be related to the donation itself (Yoon, 1998; Confer
et al, 2004). Thus it seems that after the harvest wasdone, the donor was not physically andpsychologically protected at all.
Conclusion
Chasing bone marrow compatible for Sung-duk
Bauman was documented in the media as a touchingstory, and the donor had to be volunteered to donate
his bone marrow under intense social pressure. Unlike
other transplantation stories, the stories focused on
the recipient who became a hero who endured his
unfavorable circumstances, not the donor to be
altruistic to keep his brother. So, the right of the donor
could be easily ignored. Former researchers studiedcompelled donation by children and incompetent
adults (Cheyette, 2000; Confer et al, 2004; Goodwin,
2007; Goodwin 2009; Israni et al, 2004; Peters, 1991;
Scheper-Hughes, 2007; Truog, 2005), but none paid
attention to compelled donation by the individuals who
are uniquely situated in a weak position such as
mandatory army soldier or prisoner in custody. It canbe argued that tissues and/or organ harvests fromvulnerable persons or in a questionable situation
should be strictly prohibited. The donations fromvulnerable persons cannot easily fall into the categoryof altruism (Goodwin, 2007). This paper insists on freeand voluntary donation of human tissue and/or organ,
and not forced, commanded or mandated.
References
Cheyette, C. 2000. organ harvests from the legally
incompetent: An argument against compelled altruism.
Boston College Law Review 41:465-515.
Confer, D. L., Leitman, S. F., Papadopoulos, E. B., Price, T.
H., Stronncek, D. F., Robinett, P., Braem, B. and Gandham,
S. 2004. Serious complications following unrelated donor
marrow collection: experiences of the national marrowdonor program . Biology of Blood and Marrow
Transplantation 10(S1): 13-14.
Goodwin, M. 2007. My sister's keeper?: Law, children, andcompelled donation. Western New England Law Review 29:
357-404.
Goodwin, M. 2009. Saint Louis School of Law. Confronting
the limits of altruism: a response to Jake Linford. SaintLouis University Journal of Health Law & Policy 2: 327-346.
Israni, A. K., Halpern, S. D., Zink, S., Sidhwani S. A. andCaplan, A. 2004. Incentive models to increase living kidney
donation: encouraging without coercing. American Journalof Transplantation 5: 15-20.
Jang, H. M. 1996. Sung-duk Surgery to be postponed next
week: Donor Soh psychiatrically unstable, Hankookilbo,
June 29, 1996. (in Korean)Peters, T. G. 1991. Life or death. The issue of payment incadaveric organ donation. Journal of American Medical
Association 265: 1302-1305.
Scheper-Hughes, N. 2007. The tyranny of the gift: sacrificial
violence in living donor transplant. American Journal ofTransplantation 7: 507-511.
relationship between potential donor and recipient is notadversely affected”).

Truog, R. D. 2005. The ethics of organ donation by living
donors. New England Journal of Medicine 353: 441-447.
Yoon, J. G. 1998. several media gave false reports"herniated spinal disk after bone marrow donation",
Dongailbo, November 30, 1998. (in Korean)
1996. Sgt. Soh willing to help Bauman. Korea Times,
February 3, 1996.

The Present State ofRegulations Concerning
Reproductive Medicine,
Particularly Surrogacy, inboth India and Thailand- Masayuki Kodama, Ph.D.
Professor Emeritus at National Institute of Fitness and Sports
in Kanoya, Kagoshima, Japan
Correspondence: 13-237-6 Honmachi, Higashiyama-ku,
Kyoto, Japan, 605-0981
Email: kodama@nifs-k.ac.jp

Abstract
If the Assisted Reproductive Technology (ART)(Regulation) Bill, 2013 (not yet officially disclosed, withthe objectives of assisting infertile Indian couples andlimiting commercial surrogacy), is passed as per thewishes of the Indian Ministry of Internal Affairs, then it
is expected that the use of Indian surrogate mothers
will be limited to infertile couples who are Indian
nationals. As Thailand’s law regulating reproductive
medicine (surrogacy) was successfully enacted withthe approval of the cabinet and King Bhumibol
Adulyadej in July 2015, the developed world’s
reproductive medicine refugees will likely shift theirattentions from India and Thailand to alternative
countries, such as United States, Georgia, Cambodia
and so on.
Keywords: Surrogacy, Medical Tourism, ART, Ethics,
2013 ART (Regulation) Bill
1. Introduction
By making medical tourism a national policy at theststart of the 21 century, India and Thailand havebecome hubs for reproductive medicine (particularly
surrogacy) within Asia, and achieved rapid economic
development. However, since 2012, both countries
have begun to experience major adverse changes inthe support for foreign use of their reproductive
medicine (surrogacy) services. This report provides
updated information on this issue for the benefit of theresearchers and patients of reproductive medicine.

Eubios Journal of Asian and International Bioethics 26 (January 2016)
2. India
2.1 Rapid changes in the state of reproductive
medicine (surrogacy) in India
The Indian government, which authorized for-profit
surrogacy in 2002, is now being challenged to alter the
stance that it has maintained for over 10 years. As of
May 2015, as a measure in response to numerous
incidents involving surrogacy in recent years, theIndian government is hard at work preparing to enact
the Assisted Reproductive Technology (ART)(Regulation) Bill, 2013. The bill, which follows theintroduction of the obligation for foreign persons to
obtain a medical visa when entering the country to use
surrogacy facilities, tightens policies governing
surrogacy and limits Indian surrogacy to infertile Indian
couples.
What is the background to this strengthening of
regulations?
2.2 Surrogacy incidents in India
Medical tourism is the national policy in India. In
2002, the government voiced its support for medical
tourism, and in the same year the Supreme Court ofIndia ruled that compensated surrogacy is lawful.
Since then, India’s surrogacy market has thrived year
after year. However, beginning with the Manji Yamada
9
incident (July 2008), numerous serious ethical-legal
10
issues have arisen, forcing the Indian government toregulate for-profit reproductive medical tourism. With
the Manji Yamada incident, India’s Ministry of Healthand Family Welfare (MHFW) hastily enacted the ART(Regulation) Bill, 2008, which is based on the ART(Regulation) Bill, 2006, and established the legal
status of surrogate children. Furthermore, with the aimof properly ensuring the welfare of surrogate children,
the Indian government revised the ART (Regulation)
Bill, 2008, to enact the ART (Regulation) Bill, 2010.
Despite this, there has been no ebb in the flow ofsurrogacy hopefuls toward India, such as singles andsame-sex couples, particularly from Australia.
2.3 Directives from the Indian Ministry of Home
Affairs to the Ministry of External Affairs, July 9,2012 and March 7, 2013
Concerned over the situation, the Indian Ministry ofHome Affairs issued directives to the Ministry ofExternal Affairs on July 9, 2012 and March 7, 2013.
9

Manji Yamada was born to a Japanese obstetrician with thehelp of an Indian surrogate mother. However, as the couple
who had commissioned the surrogacy divorced before Manji
was born, by Japanese and Indian law, the female child (bornof unmarried parents) was temporarily stateless. Afterwards,
extra-legal measures were used to take Manji to Japan (BabyManji Yamada Vs. Union of India & ANR. [2008] INSC 1656
(September 29, 2008)).
10
Since the Manji Yamada case of 2008, as of December
2014, there have been 21 such incidents surrounding exit andentry. Since 7 cases among these involved homosexuals, and4 cases among these involved singles, one can estimate that
half of those commissioning Indian surrogate mothers aregay, lesbian, or single.

5

Following the announcement of the July 9, 2012
directive, the orders of the supervisory authority
overseeing reproductive clinics were constantly
violated. This was dangerous, and the lack of thoroughmeasures to support ministerial orders regarding
reproductive clinics prompted the subsequent
toughening of surrogacy regulations by the Indian
government. The Ministry of Home Affairs again sent astrict order on March 7, 2013 to the Ministry ofExternal
Affairs,
demandingthethoroughimplementation of the intentions of the July 9, 2012
directive. With the announcement of this new directive
strictly regulating surrogacy, foreign nationals visiting
India for the purpose of commissioning surrogacy
must now apply to the Foreign Regional Registration
Office for a medical visa and exit visa.
The medical visa requires fulfillment of the following
five conditions:
1. The couple is legally married and has been for
at least two years, and consists of members of the
opposite sex.
2. The applicants must provide a letter issued by
the embassy of the home country in India or by theforeign ministry of the home country, stating clearly
that (a) the home country permits surrogacy, and (b)the child to be born will be granted citizenship andpermitted entry into the home country.
3. The applicants will take custody of thesurrogate child.
4. The surrogacy treatment can only be carriedout at one of the registered clinics recognized by the
Indian Council of Medical Research (ICMR).
5. The surrogacy contract must be signed by theapplicants and the prospective Indian surrogate
mother, and notarized.
The exit visa requires fulfillment of the following two
conditions:
1. Verified certificate clearly specifying that theapplicants have taken due custody of the child.
2. Verified certificate clearly specifying that the
Indian surrogate mother has relinguished custody ofthe child.
The result of the above directive is that clinics inIndia are now forced to refuse admission to foreign
nationals wishing to commission surrogacy who do nothold a medical visa.
2.4 Can Japanesenationals wishing tocommission
surrogacy
receivesurrogacytreatment in India in the wake of these two
directives?
As one of the conditions for issuing a medical visa,
the Indian government requires “a letter from theforeign ministry or embassy of the applicant’s homecountry” that authenticates that “surrogacy is permitted
by the home country” and that “entry will be permitted
and citizenship granted to the surrogate child by thehome country.” In Japan, given the lack of legislation
related to surrogacy from which to make a decision, it
is impossible for the Ministry of Foreign Affairs to issue
such letters. At this point in time, Japanese nationals

6

Eubios Journal of Asian and International Bioethics 26 (January 2016)

are unable to prepare the required documentation andtherefore cannot apply for a medical visa from theIndian Embassy in Japan. As such, since 2013, India
has ceased to be a host country for Japanesenationals wishing to commission surrogacy. Since
2013, the world’s wandering ‘reproductive medicine
11
refugees’ have flocked to Thailand as a haven.
3. Thailand
3.1 Rapid changes in the state of reproductive
medicine (surrogacy) in Thailand
In Thailand, since 2013, a rapid increase insurrogacy applicants has led to the occurrence of anumber of reproductive medicine (surrogacy)-related
incidents. In the backdrop of these problematic
incidents, a major political change has taken place.
After Yingluck Shinawatra, the 36th (and first female)
Prime Minister of Thailand, was removed from officeon May 7, 2014 over government corruption charges,
the Commander in Chief of the Royal Thai Army,
Prayuth Chan-ocha, declared martial law on May 20,
and then launched a military coup and appointed
himself the temporary head of state on May 22. With
the acceptance by King Bhumibol Adulyadej onthAugust 25, Chan-ocha became the 37 Prime Ministerof Thailand. Accompanying the birth of thisconservative government, Thailand, which had once
been known far and wide as a haven for reproductive
medicine (surrogacy) by patients from the developed
world, underwent a drastic change in this industry. It
was reported in 2013 that, for homosexual surrogacy
hopefuls, “hundreds of agencies advertise theirservices online. While India used to be the hotspot –11

The two major home countries of gay surrogacy tourists
who have flocked to Thailand since 2013 are Australia andIsrael. In Australia, neither surrogacy nor adoption for gay
couples is recognized. For example, according to theAustralian Department of Foreign Affairs and Trade
documentation (More parents defy law with overseas
surrogacy [The Sydney Morning Herald, September 14,
2013]), the number of Indian-born children applying for
citizenship rose rapidly from 126 in the 2008 financial year
(2007-2008) to 519 in the 2012 financial year (2011-2012)(among these, the number of Australians born in India
averaged around 50 per year); similarly, Thai-born children
applying for Australian citizenship jumped from 294 to 459. In
the 2013 financial year, the number of Thai-born Australian
citizenship applications increased even further. The
proportion of gay and straight parents in these figures is
estimated to be half and half. As a result, an increasing
number of incidents, in which couples commissioning
surrogacy encounter difficulty in bringing the surrogate child
home, have occurred. In Thailand, this has usually been
resolved through the following administrative procedure. The
surrogate mother and the sperm donor are written down as
mother and father on the surrogate child’s birth certificate,
and the surrogate mother then signs a release relinquishingparental rights. Finally, the surrogate child obtains citizenshipbased on a DNA test with the commissioning father. However,with the passing of the 2015 bill banning surrogacy, all formsof surrogacy for foreign nationals was banned, whether they
are for business or non-profit treatment purposes.

12

now it’s Thailand.” However, as the government had
been distressed by this state of affairs, it began acrackdown on surrogacy businesses immediately after
inauguration, and the long-debated proposed ban oncommercial surrogacy was approved by the temporary
National Assembly in February 2015. Thus, as of2015, Thailand is no longer a haven for gay surrogacy
tourism. What triggered this crackdown?
3.2 Surrogacy incidents in Thailand
Of the numerous reproductive medicine (surrogacy)related incidents that have occurred in Thailand, thetwo major incidents that have drawn the disfavor of the
Chan-ocha military government are the August 2014case of an Australian couple commissioning surrogacy
who had returned home refusing to accept one of theirtwins with Down Syndrome, and the case of multiple
surrogacies
involvingtheyoungJapanese
entrepreneur, Mitsutoki Shigeta, which had been
uncovered soon thereafter.
In reality, before the 2014 multiple-surrogacy
incident involving Shigeta, there had already been aforeigner surrogacy case in 2011 that had shocked
Thai society. Babe-101, a Taiwanese surrogacy
agency that had signed commercial surrogacy
contracts with 15 Vietnamese women, was raided by
13
Thai police on suspicion of human trafficking.
After the May 22 declaration of the military coup,Prime Minister Chan-ocha, who had received reports
from his subordinates of “the Thai homeland being a
Mecca for both commercial surrogacy and sex
preselection using preimplantation genetic diagnosis,”ordered Thai police to conduct raids of 12 reproductive
clinics in Bangkok on July 24. As a result, the Chanocha military administration, which views “paid egg
donation, commercial surrogacy, and sex preselection
using preimplantation genetic diagnosis” as “human14
trafficking,” was promised by these clinics that theywould no longer practice advanced reproductive
15
medicine.
Then, on July 31, the Chan-ocha administration met
to officially decide on the “shut-down of Thailand’scommercial surrogacy market.” This was directly
followed by the revelation of the multiple-surrogacybaby incident at Shigeta’s condominium. On August 5,
2014, Thai police stormed into the Bangkok
12

Wombs for hire: Aussie couples flock to Thailand to findsurrogates [SBS The Feed, Oct 29, 2013].
13
Surrogate moms to give birth in Thailand [Thanh Nien,
3/11/2011].
14
Thai generals had surrogacy in their sights [Sydney
Morning Herald, August 9, 2014].
Chan-ocha is not alone; Director Saowanee Khomepatr of the
Ministry of Social Development and Human Security also
shares his view, stating: “The government and the Preventionof Human Trafficking Act view commercial surrogacy as aform of human trafficking.” (Wombs for hire: Aussie couples
flock to Thailand to find surrogates [SBS The Feed, Oct 29,
2013]).
15
Sex-selection reports trigger investigation of fertility clinics[THE NATION, March 25, 2014].

Eubios Journal of Asian and International Bioethics 26 (January 2016)
condominium of the 24-year-old Japanese man,
Mitsutoki Shigeta, and seized nine infants. The raid byThai police was prompted by reports by neighbors in
the condominium complex, who were concerned about
the sound of many crying babies. However, long
before these reports, Dr. Mariam Kukunashvili, thedirector of the Thailand-based reproductive medicine
intermediary organization, the New Life Global
16
Network (whose headquarters is in Georgia), had
submitted reports to the International Criminal Police
Organization (ICPO) and the Japanese Embassy inThailand. Dr. Kukunashvili had suspected humantrafficking when she personally received a new
application from Shigeta for regular surrogacy (10-15
17children per year ) after the New Life Global Network
had already introduced him to two Thai surrogate
mothers, and thus strong suspicions had been held
regarding Shigeta a year before the Thai police acted.
The condominium searched by the Thai police wasalready registered as the residential address for 21
infants (12 males and 9 females) born from eggs
provided by women from various countries within
Europe and Asia. Whether or not Shigeta had intended
to distribute his assets to his children in Thailand,
where inheritance tax is not required, and pass on his
18business (based on statements by the Thai doctor
who had dealt with the surrogacy requests of Shigeta
and the Thai lawyer of the agency involved), thepreviously unheard-of plans to create masses ofchildren by a 24-year-old Japanese man are not only
inconsistent with accepted morals in Japanesesociety, but also greatly divergent from generalinternational moral standards. Moreover, he has also
been accused of contravening the United Nations
Convention on the Rights of the Child, to which both
Japan and Thailand are signatories.
16

This reproductive medicine agency, headquartered in
Georgia, also has offices in India, South Africa, Poland,
Armenia, and the Ukraine, and is a commercial organization
dealing with egg provision and surrogacy services (The brave
new world of the international egg trade [Mail & Guardian,
May 17, 2013]).
17
Jiji Press, August 14, 2014.
18
Asahi Shimbun Digital, August 8, 2014 / Global News Asia,
August 11, 2014. As of 2014, foreign nationals are limited tothe purchasing of condominiums. However, looking towards
the Association of Southeast Asian Nations (ASEAN)
Integration 2015, Thailand is making moves to deregulate
investments into Thai real estate, the prices of which continue
to rise. If Thailand’s real estate market is deregulated,
expatriates who have gained Thai citizenship will also be able
to buy Thai land. In other words, the agency’s lawyer likely
meant that Shigeta had planned to buy property in Thailand,
where there is no inheritance tax, under the names of hischildren (the surrogate children) after distributing his assets tothem. Rather than appear before the Thai police, Shigeta has
submitted via his lawyer documents proving the reason forcommissioning the surrogacies and his financial competency
for raising the children. As of January 2015, he is in theprocess of filing a civil suit against the Nonthaburi Province inthe suburbs of Bangkok for the return of the surrogate
children, who are currently in government care.

7

While investigations continue into this case, themotivations for which remain unclear, Thailand’s
19largest surrogacy service, the All IVF Clinic (owned
by Dr. Pisit), was revealed as one of those contracted
by Shigeta, after it was searched on July 24. The
Chan-ocha military administration ordered a second
search on August 8, which led to the forced closure of20
the offices of the clinic on grounds that the business21
in one of them was unauthorized and unregistered.
3.3 Passing of Thailand’s first law regulating
reproductive medicine (surrogacy)Theoccurrenceof
reproductive
medicine(surrogacy)-related incidents in such rapid succession
triggered the Chan-ocha military administration to label“paid egg donation, commercial surrogacy, and sex
preselection using preimplantation genetic diagnosis”
as “human trafficking,” and the temporary National
Assembly passed the Bill to Protect Children Born
Through Assisted Reproductive Technologies, 2015,
which is the first of its kind, when it met on February
19, 2015.
When passing the surrogacy ban of February 19,
2015, the Chan-ocha administration considered two
major issues – the prohibition of commercial surrogacy
and the regulation of altruistic surrogacy – and based
the ban on the abandoned Bill to Protect Children Born
Through Assisted Reproductive Technologies, 2010.
3.4 Can Japanesenationals wishing tocommission
surrogacy
receivesurrogacytreatment in Thailand in the wake of theestablishment of this regulatory legislation?
The bill was approved by the cabinet and King
Bhumibol Adulyadej and came into effect in August
2015. As well as banning for-profit surrogacy, the billlimits commission of non-profit surrogacy to “legallymarried couples of Thai nationality” and “couples
legally married for a period of at least 3 years, one
party of which holds Thai nationality.” It also limits thesurrogate mother to “a blood relative of at least 25
years of age who has already given birth.” This
language completely eliminates the opportunity forforeign couples, including the Japanese, to receive
surrogacy treatment in Thailand.
4. Conclusion
If the ART (Regulation) Bill, 2013 (not yet officiallydisclosed, with the objectives of assisting infertile
Indian couples and limiting commercial surrogacy), ispassed as per the wishes of the Indian Ministry ofInternal Affairs, then it is expected that the use ofIndian surrogate mothers will be limited to infertile
22
couples who are Indian nationals.
19

In Vitro Fertilization
Sivatel Bangkok hotel 12F&15F.
21[Bangkok Post, 8/8/2014] The All IVF Clinic, shut down on
August 8, had 165 surrogate mothers.
22
However, there is inconsistency in the stances of India’s
Ministry of Home Affairs and Ministry of Health and Family
20

8

Eubios Journal of Asian and International Bioethics 26 (January 2016)

As Thailand’s law regulating reproductive medicine(surrogacy) was enacted from August 2015, thedeveloped world’s reproductive medicine refugees will
likely shift their attentions from India and Thailand toalternative countries, such as Mexico and the UnitedStates.

Issues of Research Ethics in
Developing World- Sumaira Khowaja-Punjwani, MBeth** & BScN***Manager Nursing Education, Afzaal Memorial Thalassemia
Foundation, ST-1C, Shahrah-e-Jhangir, Block 10, Ayshea
Manzil, F.B Area, Karachi-75950, Pakistan
Email: sumaira.khowaja@yahoo.com* Pediatric Bioethics Certificate Student, Children Mercy
Hospital, Kansas, MO, USA** The Aga Khan University Medical College & Fogarty
International Centre, NIH-USA*** The Aga Khan University School of Nursing, Karachi,
Pakistan

Introduction
In this world of today, one can easily see thedramatic inequalities among developing and developed
countries. From the availability of safe water supply tohealth care i.e. from social needs to health care needs,
there is a great demarcation and discrimination
amongst these both. Particularly, health care isdemarcated significantly in these regions because indeveloped countries disease burden is equivalent toallocation, availability and access to health careresources. However, the situation of developing
countries is opposite i.e. there is increased disease
burden and decreased health care resources. These
inequalities have resulted in more disease burden andshorter lives in developing countries. As a result of
these inequalities and absence of the essential
safeguards and protection of human rights, theresearch in health care in developing countries is also
in debate. The status quo of research in developing
countries is such that some research that is being donein developing countries are purely altruistic whereas,others are driven for economic or academic interest. It
is important here to state that there is intense need forresearch in developing countries because of thedisease burden and the 10/90 gap in research between
Welfare (MHFW) regarding the granting of permission forsurrogacy commissioning by singles. In 2013, a Sudanesesurrogacy hopeful raised a statement of protest at the High
Court of Punjab and Haryana against the Ministry of Home
Affairs directive “to limit Indian surrogacy to infertile Indian
couples.” While the Ministry of Home Affairs responded bysubmitting the July 9, 2012 and March 7, 2013 directives(which called for strict regulation) to the High Court, the IndianCouncil of Medical Research (ICMR), which is run by the
MHFW, submitted the ART (Regulation) Bill, 2013, which
recognizes the commissioning of surrogacy by singles.
Ministries differ on single surrogacy [The Times of India, Nov
2, 2013].

developing and developed countries (WHO). In thispaper an attempt will be made to highlight some of the
ethical issues related to research in developing
countries and an effort will be made to provide
recommendations for ethical clinical research indeveloping countries especially in Pakistan.
The ethical framework that is being followed isbasically based on the four principles approach, i.e.
duty to alleviate suffering, duty to show respect for
persons, duty to be sensitive to cultural differences andduty not to exploit the vulnerable. In addition to this, it isimportant to take local social, cultural and economic
contexts into account. If this framework is being kept inmind then the key ethical issues those are very evident
while conducting research in developing countries are:the vulnerable population, the issue of genuine consent,
the debate standard of care, socio-cultural as well as
economic factors, assessment of risks and benefits,
post research benefits, issue of privacy andconfidentiality.
Developing Countries Population as Vulnerable
It is important to realize while conducting research indeveloping countries that the population or the group ofpeople whom researchers are inducting in researchstudies are vulnerable for various reasons. The
research population of developing countries is avulnerable group because they are economically andeducationally disadvantaged. The population indeveloping countries is striving for their basic
necessities i.e. food, shelter and water. More than halfof the population is living below poverty line and does
not have access to basic necessities of living, forexample, safe water. This group of people does not hasaccess to basic resources related to health care andmost of the population residing in developing countries
is illiterate, they are unaware about their rights therefore
they are unable to take a strong position. All thesefactors make this population vulnerable, and in thissituation the responsibility of researcher while doing
research that involves such population seems difficultand a challenging task. It becomes increasingly
important to take careful measures in order to prevent
developing country population from exploitation that
could be result of induction in research study. The
recruitment process should therefore be of special
consideration for researcher to maintain integrity ofvulnerable population and to prevent exploitation.
Genuine Informed Consent
According to Beauchamp and Childress, the concept
of informed consent revolves around five basic domainsi.e.
competenceandcapacity,
disclosure,understanding, voluntariness and consent or refusal.
Overall the population in most developing countries is
educationally disadvantaged, the level of education of
the people living in developing country covers a wide
range and most of the population is illiterate. In
addition, varieties of local languages are spoken indifferent parts of the country, especially referring toPakistan. Though these individuals are competent andhave capacity to make rational decisions for themEubios Journal of Asian and International Bioethics 26 (January 2016)
however, above mentioned factors present inordinate
challenges to researchers in the process of obtaining
informed consent as comprehension and understandingof informed consent is extremely indeterminate in theexistence of the element of language barrier.
Furthermore, coercion in any form makes informed
consent invalid and referring to developing country
research participant’s conditions, it becomes vital to
exclude the component of therapeutic misconception
and ensure that participation is absolutely voluntary.
However, it is recommended that individual genuine
consent should be obtained from the research
participant so that their autonomy is being respected
but in some cultures that are prevalent in developing
countries it may also be appropriate to obtainagreement of a community leader or head of the family
but it should be kept in consideration that taking
consent from community leader or head of the family
doesn’t eliminate the requirement of taking consent
from individual who is actually research participant andindividual consent should be a primary goal in eachresearch. It is important to take appropriate measures
to obtain genuine informed consent so that theindividual’s autonomy is not being violated by anymeans and valid attempts should be made for thispurpose in order to ensure that their decision toparticipate in research study is truly autonomous.
Standard of Care
It is a significant subject to discuss standard of carehere because of the international debate aboutstandard of care is about the question of what shouldbe the standard of care while doing research indeveloping countries? Should it be local or global? If
local then, would provision of locally available best
current treatment is considered as violation of theprinciple of justice? Many of the international guidelines
have also addressed this issue but are unclear andinsufficient to answer question completely; for example,
CIOMS guide line 11 clearly states that a control arm
should receive the established effective intervention but
it doesn’t say local or global because both could be
different especially if we are referring to developing
countries versus developed ones, paragraph 29 of the
Declaration of Helsinki states that: “The benefits, risks,burdens, and effectiveness of a new method should betested against those of the best current prophylactic,
diagnostic, and therapeutic methods.”
The concept of distributive justice places all
individuals at an equal place regardless of any
confounding factors and if developing countries aretreated differently by researcher then the principle of
distributive justice is being violated. A few of theimportant questions related to research ethics standardof care debate are: is it ethical to lower down ethicalstandards just for the purpose of generating well provenscientific knowledge? Are we considering humans living
in developing countries and participating in research as
merely means to generate scientific knowledge? Thenthe concept of human dignity is lost.

9

Socio-cultural and Economic Factors
The socio-cultural factors mainly concerned withresearch in developing countries refer to the social
value of the research that must be determined during
the initial phase of research study and subsequently,
should also be deliberated to the population. The areaof concern here is that most of the time it is theresearcher that defines the research subject according
to his need and select the locality from his level ofunderstanding so the research area that the researcher
is interested into can be different from the need of that
locality. In this way the question is how one candetermine the social value of the research if somebody
else is taking decisions on their behalf that is not thepart of that culture and society? However, the economic
factors mainly include the problem of inducement thatcan direct the participant’s decision to participate as
their economic condition is also not up to the mark. Thiscan make the decision of participation to be the result of
coercion, which is unethical.
Power Dynamics
The issue of power dynamics i.e. the relationshipamongst the research subjects and researchcommunity, and research subject and researcher is avery apparent concern in the area of research ethics indeveloping countries. As discussed earlier that the
population of developing country is educationallydisadvantaged therefore it is often believed that the
purpose of research whether observational or placebo
controlled trial is to provide benefit to study participants
and if anyone denies participation in research they will
be harming themselves, as they will not be getting
benefits out of research intervention or study. The
element of therapeutic misconception in either way may
also there because most of the time the participant’s
perception is that they are getting benefit out of
research as it is being conducted here for their goodand intervention is beneficial for them. The second
staged power dynamics is also present, if thecommunity leader or elder family member has provided
the consent then it is difficult for an individual so say no
against it. Their decision not to participate may
sometimes also lead to rejection by the community ortribe in which they are living. Beside this, anotheremerging issue is of privacy and confidentiality of thecommunities where the research is being conducted indeveloping countries. It is important to maintain privacy
and confidentiality of these communities so that they
can be prevented from stigmatization.
Post Research Benefits
The concept of post-research trial responsibilities
raises many questions especially the questions that are
related to ethics. The first important thought is that is it
ethically acceptable to conduct a research in a country
that in future may not be able to afford to provide thetreatment that is effective? The second thing is that if
the trial is successful and the intervention is beneficial
then should that intervention be provided after the trial
is over? And if we say yes, then the question arises of10

Eubios Journal of Asian and International Bioethics 26 (January 2016)

who should be responsible for making that effective
intervention available? Is this the responsibility of theresearcher, institution or the sponsor?
In order to have a broader perspective, let us viewthe issue of post-research trial responsibilities in thelight of international guidelines, so that it can be
determined that what does guidelines says about
research enterprise post-research responsibilities. It will
not be wrong to say that up till now it has been
accepted that the ethical responsibilities of researcher
as well as of sponsor, towards the participants of trial
do not come to an end on the completion of research
trial. In other words, determination and provision of
post-research trial benefits is becoming an integral
component of research. Many guidelines are developedthat address these guidelines include WHO, Helsinki
and CIOMS. According to WHO guidelines“investigators have a responsibility to trial subjects once
the trial is over” (WHO, 1995) but this guideline is justpointing out the issue and is not defining it in detail.
Referring to the guidelines developed by World Medical
Association’s declaration of Helsinki regarding postresearch trial responsibilities, it states that "at theconclusion of the study, every patient entered into thestudy should be assured of access to the best provenprophylactic, diagnostic and therapeutic methods
identified by the study", but this does not specify whatassured of access means when it comes in practicalterms, or who has the responsibility to assure it?
According to CIOMS guideline that is referring to postresearch trial benefits and responsibilities, "before
undertaking research in a population or community withlimited resources, the sponsor and the investigatormust make every effort to ensure that … any
intervention or product developed, or knowledge
generated, will be made reasonably available for the
benefit of that population or community". In thisguideline, although the direction towards placing the
responsibility is shown i.e. on sponsor and investigator,
however, the term reasonable availability is vague andopen to interpretation. Thus, by reviewing theseguidelines it can be concluded that although it has been
identified that there is essential to provide postresearch trial benefits but this thing is still in doubt that
who’s responsibility it is? From whom should and are
we expecting to provide post-research trial benefits?
What are the responsibility of research enterprise, e.g.
researcher, institution and sponsor with respect to postresearch trial benefits provision especially in developing
countries. This is a complex issue because to answer
these questions is abstract because beside thesequestions there are other areas of concern as well for
example, what should be provided to the control group,
all participants and to the community once research isover? These types of decisions should be made andnegotiated before the study has actually begun. This
problem can only be overcome if the gate keepers of
the community start negotiating prior to the study
having been initiated in that area so that their needs arealso being fulfilled and that community is not being
used as merely means to conduct research. There is anintense need that developing countries should set theirown priorities for research into health care.
Role of Ethical Review Committees (ERCs)
ERCs can play a vital role with regard to research
conducted in developing countries because effective
ethical review of research provides crucial safeguards
and determines scientific validity as well as ethicalacceptability. The condition of developing countries
ERC is likely to be vulnerable because of their level of
independent working, competency, quality ethicalreview, conflict of interest and minimal monitoring.
There is an intense need to build expertise because theexpertise to undertake research at local level isseverely limited, there is not enough training and these
are too limited for local researchers. Genuine attempts
should be made to strengthen expertise in researchand to develop institutions. Maximum opportunities
should be provided for transfer of skills and knowledge.
Besides building of expertise, capacity building should
also be the focus of developing countries’ ERCs andmoreover, an infrastructure should be developed thatmust have officially recognized regulations andguidelines. However, there are also related challenges.
These challenges includes which guideline to use?
Who should monitor research, and how? How can we
ensure that adequate ethical review is being done for a
research proposal? And most importantly, what sort ofethics training is appropriate and adequate? Along withthese challenges developing countries also lack laws
and regulations governing ethics in research andinternational guidelines are increasing in number but
these are not harmonized and are conflicting to eachother. In developing countries, such as Pakistan ERC
should be established but with the following
considerations i.e. it should have members withexpertise in scientific and methodological aspects ofresearch that is under review, it should clearly indicate
the regulations or ethical guidelines they use, it musthave rules of procedure, record keeping and should be
accountable. By doing this, the research that is being
done in developing countries could be made more
ethical. It should also be kept under consideration that
any international research and externally sponsoredresearch must go through local ERC approval so thatthe developing countries population can be protectedfrom the issues discussed above extensively.
Conclusions
To conclude this discussion, we have to realize thatthe developing countries are vulnerable and if researchis being done on communities residing in developing
countries then special consideration and attention
should be given so that they can be protected fromfurther exploitation.
The following considerations
should be kept under contemplation. These countries
should set national priorities that are related toprovision of health care so that their capacity can beenhanced to conduct relevant research according totheir needs. Research relevance should be justified toappropriate ERCs especially when the research is

Eubios Journal of Asian and International Bioethics 26 (January 2016)
externally sponsored. Measures should be taken tobuild and strengthen effective ethical review of researchthat should be independent of government andsponsors. Sponsors of national and international
research should ensure that adequate provision ismade for training in ethics of research for professionals
involved in research related to health care. And finally,
development of local expertise in provision of healthcare research should be an integral component of any
proposed research.
References
Beauchamp, T.L., & Childress, J.F. (2001). Principles ofbiomedical Ethics. Fifth edition, Oxford University press.
Council for International Organizations of Medical Science(CIOMS). (2002) International ethical guidelines forbiomedical research involving human subjects, guideline
10.
Elsayed, E.M. (2006). Publication and dissemination of
Health Research Findings: Strengthening post-trial benefit.
Sudanese Journal of Public health, 1 (4), 298-303.
Jafarey, A.M., & Farooqui, A. (2005). Informed consent in
the Pakistani milieu: the physician’s perspective. Journalof Medical Ethics, 31, 93-96.
Jafarey, A.M., Iqbal, S.P., & Hassan, M. (2012). Ethical
Review in Pakistan: The Credibility Gap. Journal of
Pakistan Medical Association, 62 (12), 1354-1357.
Moazam, F., & Jafarey, A.M. (2005). Pakistan andBiomedical Ethics: Report from a Muslim Country.
Cambridge Quarterly of Healthcare Ethics, 14, 249-255..
Cambridge University Press.
Moazam, F. (2006). Research and developing countries:
hopes and hype. Eastern Mediteraneam Health Journal, 1,
1-7.
World Health Organization. (1995). Guidelines for goodclinical practice on pharmaceutical products.
World Medical Association. (2000). Declaration of Helsinki:
ethical principles for medical research involving humansubjects. Paragraph 30.

Responsible Innovation andEthics: A need for
Globalization
1

2 ,- Hannah Holitzki and Gregor Wolbring *1
Cumming School of Medicine, University of Calgary,
Calgary T2N4N1, Alberta, Canada
2
Department of Community Health Sciences, Cumming
School of Medicine, Stream of Community Rehabilitation
and Disability Studies, University of Calgary, 3330 Hospital
Drive NW, Calgary T2N4N1, Alberta, Canada*Correspondence Email: gwolbrin@ucalgary.ca

Abstract
Background: Innovations ranging from science andtechnology to the social continue to shape humandevelopment.
Innovations
appearinginone
geographical area influence other geographical areas,in a shorter timespan than ever before. How to regulateinnovation processes and products has been discussed
for some time. Ethics theories and reasoning are used11

to give members of society guidance on how to act andrelate to each other. Responsible innovation (RI) is aframework initially proposed to integrate social andethical considerations with the practice of innovation.
Objective: To investigate a) how ethics is covered
within the RI literature covered; b) the geography of theauthors contributing to the RI academic literature and c)within which geographical context RI and innovation is
discussed.
Methods: To obtain quantitative and qualitative data
we searched four academic databases (EBSCO All –an umbrella database that consists of over 70 otherdatabases, Scopus, Science Direct and Web of
Science) for the phrase “responsible innovation” either
in the article title, article abstract, article keyword, under“topic” in the case of Web of Science, or in the title ofthe journal. We furthermore searched for the phrase“responsible
innovation”
ontheEuropeanCommission’s web site. All together 326 relevant
articles were downloaded for content analysis
Results: We found a geographical imbalance of a)
authorship, b) coverage of innovations, c) engagementwith RI and d) ethics reasoning and ethics theories
employed.
Conclusion: The RI discourse in general and theethics coverage within the RI discourse needs to be
globalized in order for it to reach its full potential.
1. Introduction
Innovations ranging from science and technology(S&T) to the social change continue to shape humandevelopment.
Innovations
appearinginone
geographical area influence other geographical areas,in a shorter timespan than ever before [1-11]. For
example Chinese innovations such as cast iron, chain
suspension bridge, wheel barrow, silk textile,
gunpowder, porcelain, paper, printing, compass andsailboat are part of the daily life of most humans
globally [12]. Innovation agendas differ between
geographical areas and countries as do the ways how
innovation procedures are embedded within a country
or geographical area [13-20]. As a political agenda,
government bodies of countries in the Global North[e.g. 21,22,23] and Global South [24-29], havedeveloped strategies and infrastructures around S&T
with the aim to benefit their countries. For example theOrganization of American States (OAS), composed of
35 independent states of the Americas, has identified
S&T as ‘the primary driving forces of today’s global
economy’ [30]. The OAS regards S&T as an integral
development for the Americas in generating
employment and well-being through innovation and thecommercialization of new products and services,
reducing poverty, improve education, health, nutrition,and trade; and building new capacities required in the
21st century’ [31]. Member states of the Association ofSouth East Asian Nations (ASEAN) (Brunei
Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia,
Myanmar, Philippines, Singapore, Thailand, and VietNam), reflecting on the influence of S&T on member
states, perceive S&T as “a key factor in sustaining12

Eubios Journal of Asian and International Bioethics 26 (January 2016)

economic growth, enhancing community well-being andpromoting integration in ASEAN” [32].
1.1 Responsible Innovation
How to regulate innovation processes and products
has been discussed for some time [33-39]. In recent
times the European Commission has focused on
developing a framework for innovation that incorporates
the consideration of the societal impact of innovationsin the design process [40]. As part of the policy
movement toward Responsible Research andInnovation (RRI) in Europe, the European Commission
identified six key dimensions in the “Science in Society”
initiative framework under the Horizon 2020 programme[41]. RRI consists of designing and implementing R&I
policy that will a) engage society more broadly in its
research and innovation activities, b) increase theaccess to scientific results, c) ensure gender equality inboth the research process and research content, d)take account of the ethics dimension, and e) promoteformal and informal science education all of which are
under the umbrella of the sixth dimension of
governance [42,43]. As the concept of RI continued todevelop and evolve within the academic literature, theEC added the dimensions of “sustainability” and “social
justice/inclusion” to RI [44].
The framework of
responsible innovation (RI), as proposed by the UK
Research Council, is based on four dimensions:anticipation, reflexivity, inclusion, and responsiveness[45]. RI is seen as a “a transparent, interactive process
by which societal actors and innovators become
mutually responsive with regard to the (ethical)
acceptability, sustainability and societal desirability of
an innovation and its marketable products” [46]. It isseen to take “care of the future through collective
stewardship of science and innovation in the present”[45]. Finally, “[Responsible innovation is a] broader
reconfiguration, one that creates opportunity forinnovation toward socially desirable ends, as well as
opportunities for timely management, is needed. A
reconfiguration that is values- and not rules-based, thatis flexible in the face of uncertainty, and that allows us
to take collective responsibility for a future whichscience and innovation play such critical roles inshaping” [47].
1.2. Global regulation
Ethics theories and reasoning are used to givemembers of society guidance on how to act and relate
to each other [48]. Ethical reasoning is a global
endeavor [49-59,48,60-66]. UNESCO (United Nations
Educational, Scientific, and Cultural Organization), a
UN agency responsible for science and technology,
culture and education is since the 1970’s involved in the
ethics of science and technology [67] and has abioethics
capacity-building
programme,
theIntergovernmental
Bioethics
Committee
andInternational Bioethics Committee.
A resolution adopted by the General Assembly on
27 July 2012 called The future we want stated underpoint 275: “We recognize the importance ofstrengthening international, regional and national
capacities in research and technology assessment,
especially in view of the rapid development andpossible deployment of new technologies that may also
have unintended negative impacts, in particular on
biodiversity and health, or other unforeseen
consequences” [68]. The outcome document of theThird International Conference on Financing forDevelopment: Addis Ababa Action Agenda that took
place in 2015 states under point 5: “We recognize thatappropriate incentives, strengthening national andinternational policy environments and regulatory
frameworks and their coherence, harnessing thepotential of science, technology and innovation, closing
technology gaps and scaling up capacity-building at alllevels are essential for the shift towards sustainable
development and poverty eradication” [69]. Under point
9 the document states: “9 Processes to develop andfacilitate the availability of appropriate knowledge andtechnologies globally, as well as capacity - building, arealso critical” [69]. Under point 123 the document
mentions the establishment of a technology facilitation
mechanism in order to support the sustainable
development goals and which will be “based on a multistakeholder collaboration between Member States, civilsociety, the private sector, the scientific community,
United Nations entities and other stakeholders and will
be composed of a United Nations inter-agency task
team on science, technology and innovation for thesustainable development goals, a collaborative multistakeholder forum on science, technology andinnovation for the sustainable development goals andan online platform” [69]. The document outlines that“the online platform will be used to establish acomprehensive mapping of, and serve as a gateway
for, information on existing science, technology andinnovation initiatives, mechanisms and programmes,within and beyond the United Nations. The online
platform will facilitate access to information, knowledge
and experience, as well as best practices and lessons
learned, on science, technology and innovation
facilitation initiatives and policies. The online platform
will also facilitate the dissemination of relevant open
access scientific publications generated worldwide”[69].
The purpose of our study was threefold; toinvestigate a) how and to what extent the RI academic
literature engaged with ethics principles, theories,
approaches, and reasoning; b) the geography of theauthors contributing to the RI academic literature and c)within which geographical context RI and innovation is
discussed in the RI literature.
2. Methods
2.1 Data sources
To obtain quantitative and qualitative data wesearched four academic databases (EBSCO All – anumbrella database that consists of over 70 otherdatabases, Scopus, Science Direct and Web of
Science) for the phrase “responsible innovation” either
in the article title, article abstract, article keyword, underEubios Journal of Asian and International Bioethics 26 (January 2016)“topic” in the case of Web of Science, or in the title ofthe journal. N=185 articles were downloaded for use. In
addition, we downloaded all articles (n=61) published in
the Journal of Responsible Innovation by Taylor Francis
since its beginning in 2014 till the month of April 2015.
We chose this journal as it is the first journal focusing
solely on RI. This journal did not show up in the four
databases we covered. We furthermore searched forthe phrase “responsible innovation” on the European
Commission’s web site (at http://ec.europa.eu/
index_en.htm) as the European Commission is very
visible in the discourse of RI and n=80 documents were
downloaded,
which included press releases andspeeches in addition to policy documents.
2.2 Data collection and analysis
N=246 articles from the academic sources were
sorted into two general categories, those articles
published in the Journal for Responsible Innovation(“JRI”) and those published elsewhere (“Non-JRI”). The
articles taken from the Journal of Responsible
Innovation were published in January of 2014 or later.
The articles in the “Non-JRI” category had publishingdates ranging from 1979 to 2015. These were codedalongside the n=80 documents downloaded from theEC website (“EC Documents”).
All downloaded documents were imported intoatlas.ti 7™ software for both quantitative and qualitative
analysis. We used the auto-coding function of atlas.ti
7™ software to determine hit counts of keywords ofinterest such as ethical principles and approaches andto flag areas that covered RI. The articles were read togain qualitative data related to a) coverage of RI, b)
how ethics was used, c) which countries and regions
were covered in which way within the context of RI and
Innovation and d) the geographical origin of the authorsof the articles.
2.3 Limitations
We only searched four academic databases and assuch our findings cannot be generalized to the wholeacademic literature. We only analysed English
language articles and as such our conclusions cannot
be extended to non-English language literature.
However, we posit that our data can be used to guide
future research in this area. The EC documents werelimited to those that were available in the .pdf fileformat, and to those documents that were available
online through the EC website in English.
3. Results
3.1 Ethics
As to the first research question of how ethicalprinciples theories, concepts and approaches arecovered within the RI literature we found the following(Tables 1 and 2).
Table 1 reveals that many ethics terms and theterm ethic itself have been used frequently in theliterature covered. It is in particular striking that 93.4%of the articles in the Journal for responsible innovation
contained the term “ethic”. If we look at the four13

bioethics principle influential for example in North
America[70],
two of the principles are used
substantially, namely autonomy is covered in 26.2-40%of the articles covered and justice is covered in 14.136.1% of the articles. Harm as a concept is also
covered in 32.8-71.2% of the articles covered. Finallycare as a concept was mentioned in 56.2-78.8% of thearticles covered.
Table 1: Hit counts for and percentage of articles thatmention ethical principles and keywords
Term

Ethic
Value
Care
Moral
Justice
Harm
Autonomy /autonomousSocietal value
VirtueUtility
Beneficence
Maleficence

JRI(n = 61
articles =100%)

Non-JRI(n = 185
articles =100%)

Count (%)
93.4
86.9
59
55.7
36.1
32.8

Count (%)
44.9
89.2
56.2
26.5
14.1
50.3

EC
Documents(n=80
articles=100%)
Count (%)
63.8
81.3
78.8
18.8
22.5
71.2

26.2

23.8

40

9.8
9.8
9.8
0
0

8.1
10.3
41.6
1.1
0

5
2.5
15
0
1.3

Table 2: Hit counts for and percentage of articles thatmention ethical approaches by data source
TermPrecautionary
Principle
Institutionalism
Consequentialism
Feminism|feminist
Utilitarianism
Constructivism
Virtue Ethics /Virtue Theory
DeontologicaltheoryEgoismLibertarianism
Relativism

JRI (n =61
articles =100%)

Non-JRI(n = 185
articles =
100%)

EC
Documents(n = 80
articles =100%)
Count (%)

Count
(%)

Count
(%)

9.2

11.5

16.3

6.6
4.9

5.9
3.8

3.8
0

3.3

2.2

1.3

3.3
3.3

2.7
5.9

0
0

1.6

3.2

0

1.6

3.2

0

1.6
1.6
0

1.6
0
1.6

0
0
1.3

Table 2 reveals that specific ethics theories andapproaches are much less engaged than general ethics
concepts. Despite the use of ethical theories to build
ones’ case through ethical reasoning, they are rarely
mentioned explicitly in the literature we explored. We

14

Eubios Journal of Asian and International Bioethics 26 (January 2016)

found within the 4331 quotations generated for the code
“ethic*” from our 246 articles that some debate the useof a certain ethical theory as a basis for RI over another[45,71-77]. Some papers discuss the consequences ofadhering to specific ethical theories when developing
the framework of RI, and critique the current
approaches [78,72,75]. Most hits however only reveal areiteration of the importance of ethical considerations in
the practice of RI [45,72-77] without engaging with itconceptually.
Table 3: Origin of authors
Code

EuropeAustria
Belgium
Denmark
FinlandFranceGermany
GreeceItaly
Lithuania
NorwayPortugal
PolandRomania
Slovenia
Spain
SwedenSwitzerland
The
Netherlands
TurkeyUK
North America
Canada
USA
Asia
China
India
Japan
Korea
Malaysia
ThailandTaiwan
Other
Argentina
Australia
BrazilIsraelMexicoPakistanSouth Africa
Syria

JRI (n = articles
of authors froma given country)

Non-JRI (n = articles
of authors from agiven country)

0
2
1
0
1
3
0
1
0
1
0
0
0
0
0
0
0
12

3
2
2
8
17
23
2
26
1
5
1
1
1
1
8
2
4
25

0
9

4
18

4
29

6
18

0
0
0
0
0
0
0

4
1
6
3
2
1
1

0
1
1
0
0
0
0
0

1
2
2
4
1
1
2
1

Furthermore Table 2 reveals that many ethics
theories and approaches in existence are not applied

yet or seen as useful or a threat to RI in the RI
literature. One reason why certain ethics approaches
and theories are not mentioned might be due to thegeographical origin of authors and geographies
covered.
3.2 Geographical coverage
As to the question of the geographical coverage of
RI we investigated a) from where authors of the RI
articles originate from (Table 3) and b) which
geographical regions were mentioned in the articles(Table 4).
Table 3 reveals that most authorships originate
from a few European countries and the USA with very
few from Asia and South America and many othercountries missing. This may also represent the generalacademic literature.
Table 4 reveals that Europe and the US are
mentioned in over 60% of the articles in the JRI and
non-JRI articles whereby Asia is mentioned much less.
Canada is also covered much less.
Table 4: Geographical regions mentioned in the JRI
and non-JRI articles
JRI (n = 61 Non-JRI (n =Codearticles= 185 articles =
100%)
100%)
America* / United
86.9
91.4
States / US
Europe*63.9
75.1
Canada
14.8
15.7
Asia
9.8
18.9
Near East
1.6
4.9
Middle America
00South America
0
2.1
Reading the articles to obtain data on whichcountries where specifically linked to RI we found thatthe countries covered were mostly from Europe andNorth America. One article [79] covered a workshop
between UK and Brazilian scientists looking at RI
suggesting that the RI discourse is linked too closely toEuropean and North American thinking and realities.
Many countries that have shaped innovation processes
and generate innovative products in recent times suchas China and South Korea have not been mentioned inrelation to RI although articles mentioned that China
and South Korea are innovators. One 2008 article
covered RI of nanotechnology in Japan coveringsocietal impacts of nanotechnology from 2004 which
was the launch of the Nanotechnology and Society
open forum till 2007 with the ‘‘Nanotechnology Debate’’discussion forum
and outlines the policy
recommendations from a project called Research on
Facilitation of Public Acceptance of Nanotechnology[80]. India was mentioned in regards to personalized
medicine in the age of pharmacoproteomics [81] andagribiotechnology and agrinanotechnology [82]. Pandey
outlined the problem he sees in the existing RI
discourse. He states that power dynamics are aEubios Journal of Asian and International Bioethics 26 (January 2016)
neglected aspect in the “overall debates on responsible
innovation”. Pandey argues that the RI discourse isbased on the “interplay of the relationship between two
broader categories” namely a) The creation of an
innovation environment, and b) the Governance of theinnovation environment. Pandey proposes a ‘beambalance’ metaphor to engage with the idea of‘Responsible Innovation’ in order to take the inequalities
and alternative perspectives into account” [82]. Pandey
argues further “that the criteria of technological choice
which rely only on cost and returns, commercial
viability, export potential and contribution to GDP are
insufficient. The socio-technical imaginary needs to beenvisioned on a premise of sensitivity to broader
understandings of risks, uncertainty, ethics and social
structure and accommodative of alternatives” [82].
Pandey cites [83] when he states that “Responsible
innovation thus needs to be constantly self-reflexive by
having greater awareness of the histories, cultures, andnormative frameworks that have led and regularly leadto the ethical conundrums of an ‘irresponsible’
innovation” [82]. However Pandey did not employ
ethics theories as such to make his case.
4. Discussion
We found a geographical imbalance of authorshipin the RI literature we explored geographical imbalanceof context within which RI and innovation is discussed
and an uneven use of ethics theories, concepts andapproaches. The articles that discuss ethical principles
in the Non-JRI category discuss mostly business ethics
and financial responsibility in the sense of what types of
behaviour and guidelines constitute responsible
business practice. Most of the discussion in the RI
literature is around consequentialism, deontologicalethicsandvirtueethicsapproaches[78,72,75,74,84,85]. Some articles weigh the pros andcons of the adherence of one ethical principle overanother in the practice of RI [78,72,75,47]. An article[79] asks whether a feminist concepts of care that they
see to frame Northern conceptions of RI translate into
non-Western and Global South context. If thegeographical authorship of the English language RI
literature including the literature covering businessethics would be more diverse it is reasonable to expectthat more ethical principles and ethics theories would
be covered and the pros and cons of a given approach
would be discussed more. This is of particularimportance given the global impact of innovation
processes and products.
An article by [79] states: “It was also recognizedthat although RI has developed in the context of, andas a policy response to, controversial or questionable
forms of technological innovation, an enormous variety
of social innovation occurs in the global South, directed
specifically at social and/or environmental goals andsometimes as a means of adjustment-response toinadequately designed or badly chosen technologicalinnovations. RI needs to consider its role, if any, inaccommodating and encouraging such innovation too,15

generating recommendations for a more socially
focused, and less high-tech focused, innovation policy.”
Indeed if we look at the group of disabled people(people labeled as impaired) it is well reported that thefocus on high tech solutions is often a problematic one
especially for the Global South [86]. It is thematized bymany as a problem that technological solutions are put
forward often to rectify social problems [87-93]. A morediverse authorship might have thematized that issue
more.
The need for a more geographically diverse
coverage of RI in general and the ethics reasoning inparticular is also evident if we look at the 2015 outcome
document of the Third International Conference on
Financing for Development: Addis Ababa Action
Agenda [69]. This document gives voice to the opinion
that a harmonization of national and international policy
environments and regulatory frameworks is needed inorder to harness “the potential of science, technology
and innovation, closing technology gaps and scaling up
capacity-building at all levels” which are seen as“essential for the shift towards sustainable development
and poverty eradication” [69]. The outcome document
states that “processes to develop and facilitate theavailability of appropriate knowledge and technologies
globally, as well as capacity - building, are also critical”[69]. The RI discourse could play an important role if it
finds a way to be more global in its scope ofcontributions. The question is how the RI literature adds
to the capacity to evaluate technologies and to
generate appropriate knowledge? Some academic
literature on RI thus far has been focused on themethods through which the ties between society andinnovators can be forged in the practice of RI [9496,77,97,98]. However, the coverage is culturally too
homogenous and therefore missing certain problems oropportunities that could exist in linking society with
innovators and how to regulate innovation.
The outcome document [69] proposes thedevelopment of an online platform to facilitate “accessto information, knowledge and experience, as well as
best practices and lessons learned, on science,technology and innovation facilitation initiatives andpolicies” and “to facilitate the dissemination of relevant
open access scientific publications generated
worldwide” [69]. Furthermore, open access is one
dimension of RI outlined by the European Commission(EC) documents (see for example [42,43]). We positthat the open access is a challenge for the RI academic
discourse. Nearly every one of our 246 articles was notfrom open access sources. If open access is to becomea reality and if technology governance scholars andother stakeholders want to make use of the global open
access online platform outlined by the Addis Ababa
Action Agenda [69] to have their academic work madeavailable to multi-stakeholder groups worldwide, thescholar might indeed have to think hard where to
publish. What open access options do exist? What isthe cost of publishing open access? We posit open
access might be beneficial for a more geographicaldiverse engagement with what RI is and should be16

Eubios Journal of Asian and International Bioethics 26 (January 2016)globally. However the cost factor has to be dealt withgiven that many journals charge author fees to makeones article open access. Or is one to give not thelatest version of a published document to the online
platform [69], one that one is also allowed to put into
ones University online repository?
5. Conclusion
In conclusion, there is a marked geographicalimbalance of authorship and countries/regions engaged
with in the content of the English language RI literature.
Additionally, although ethics as a concept has been
engaged with substantially in the RI literature we
explored, our findings suggest that certain ethicalconcepts, views and reasoning are not present which
could be due to the geographical imbalance ofauthorship a regions engaged with. Our findings
indicate that so far the RI literature does not have a
global reach and as such many places of innovation are
not visible in the RI literature as aren’t ways how RI
would be conceptualized and instrumentalized. Not
being open access might be another problem for a
global reach. Given that innovation products seem toreach global market at an ever increasing speed andgive the establishment of a technology facilitation
mechanism that is to support the sustainable
development goals and which will be “based on a multistakeholder collaboration between Member States, civilsociety, the private sector, the scientific community,
United Nations entities and other stakeholders” [69] weposit our findings to be problematic. There are many
opportunities for the RI discourse to be globally relevant
and for interested parties to get involved especially if
the establishment of a technology facilitation
mechanism is established in the way outlines in theoutcome document [69].
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doi:10.1007/s11948-011-9317-8

Consideration of HealthCapability Paradigm toEnsure Equitable Protection
through Indian National
Tuberculosis (TB)
Prevention Program23- Rhyddhi Chakraborty, Ph.D.
School of Health Sciences, American University of Sovereign
Nations (AUSN), Scottsdale, Arizona, USA
Email: rhyddhi_414@yahoo.co.in

Abstract
Tuberculosis(TB),
causedbybacteria(Mycobacterium tuberculosis), usually affects the lung.
Being airborne, TB has been one of the world’s
deadliest communicable diseases. In spite of being
curable and preventable, the disease has always beena continuous threat to human population. Moreover,there are cases of multidrug resistant (MDR), extremely
drug resistant (XDR) as well as HIV associated forms.
Recognizing this grave threat, the World HealthOrganization (WHO) urged every country to have anational program for tuberculosis prevention andcontrol. After incidences of involuntary detentions ofpeople with suspected TB in some places, WHO (2010)
also recommended that national TB prevention
programs should incorporate ethical considerations inthem. Specifically, it prescribed that human rights andsocial justice issues should be given due
considerations. Studies suggest that India, following theinternational recommendations, has rolled down anational program to prevent and control TB cases in the
country. However, neither is there much considerationof ethics in it, nor there is any pronounced effort to23

The earlier version of the paper entitled “Ethics in Indian
National Tuberculosis Prevention Program and Strategy: A
thSocial Justice Perspective” was presented in 16 Asian
Bioethics Conference held at St. Paul University Quezon City,
Philippines on and from 3-8 November 2015.

Eubios Journal of Asian and International Bioethics 26 (January 2016)
include social justice issues. The present paper
investigates how the inclusion of elements from social
justice theory can actually help India’s TB program toaddress the issue of equitable protection. Specifically, itshows how insights from JP Ruger’s ‘Health Capability
Paradigm’ can help India’s TB strategies to render
equitable protection by addressing health inequities(218 words).
Key Words: Ethics, Health Capability, India,
Tuberculosis
Introduction
This paper considers the fair provision of equitable
protection to the socio-economically vulnerable as oneof the foremost and crucial reasons for need of ethics inTuberculosis (TB) prevention program and strategy.
The paper argues that insights from the social justiceethical framework, more specifically, Jennifer Prah
Ruger’s theory of ‘Health Capability Paradigm’ (2009)
can actually help TB prevention program and strategy
to address the issue of equitable protection. Keeping
Indian TB prevention programs and strategy in focus,
the paper argues that TB prevention and strategies
need to adhere to ethical guidance to address healthinequity at the level of health capability.
To argue this, the paper is summarized in three
sections; Section I briefly explains the biologicalfeatures of TB and introduces global TB prevention
strategies. It also deals with the ethical considerations
in TB prevention and sets the argument to consider thefair provision of equitable protection to the socioeconomically vulnerable as one of the foremost andcrucial reasons for need of ethics in Tuberculosis (TB)
prevention program and strategy. Section II describes
the TB prevention policies and strategies in India,
points out the gaps and loopholes, highlights the ethicallapses in the existing strategies to ensure fair provisionof equitable protection. Section III explains the social
justice theoretical framework of Health Capability
Paradigm (HCP) and grounding in such theoreticalframework puts forth the necessary recommendations
to address the issue of equitable protection at the levelof health capability. It proposes and argues that
adopting a guiding vision of ‘health as a capability’, andincorporation of measures grounded in social justicecan bring the desirable changes in the TB prevention
program and strategy of India. Finally, the paper
concludes with the note that from 2016 onwards when
the whole world is moving towards making TB
prevention and eradication as one of the sustainable
development goals (SDGs), addressing the issue ofequitable protection by attending the underlying risk
factors of TB related health capabilities become ethicalimperatives. For, as part of public health obligation,complete eradication of TB from the world populationnecessitates addressing the deep rooted barriers of TB
related health capability but not just the barriers of TB
related health outcomes.

socioeconomic ramifications of an infectious disease
spread, and the preventive responses from a publichealth system, have always been important elements inshaping national public health policies. However, thepossibility of sustainable TB control and eradication
presents the need to reexamine the same elementsfrom a different angle altogether. It forces us toreinvestigate the nature and extent of governmental
level of preparedness to address the uncertainty andthe risk, and to probe into the vision underlying it.
Unlike many other emerging infectious diseases,
TB has been ever present in the human population (1)with oldest molecular evidence dating back to over
17,000 years (2). TB is caused by the bacillus
Mycobacterium tuberculosis and typically affects thelungs (causing pulmonary TB) but can affect otherphysical sites such as lymph, bone, and spine giving
24
rise to extrapulmonary TB . Being airborne, thedisease is spread when people, sick with pulmonary TB
expel bacteria by coughing, sneezing, spitting, etc. (3).
In 2014, there were an estimated 9.6 million new TB
cases, including 5.4 million men, 3.2 million women,
and 1.0 million children. Also, there were 1.5 million TB
deaths (with 1.1 million among HIV-negative people,
0.4 million among HIV-positive people) of whichapproximately there were 890,000 men, 480,000
women, and 140,000 children. Noticeably, of all theinfectious diseases, the morbidity and mortality out of
TB deaths are unacceptably high, though TB is curable,
treatable, and preventable by timely diagnosis andappropriate treatment (Ibid.).
TB, which was once considered to be the diseaseof the poor (5), gradually, due to its pervasive
potentialities and evolution of new strains, has beenreconsidered as an endemic disease of the whole world
as well as the disease potential enough to explode in
epidemic proportions in some parts of the world (2), (3).
Consequently, the global biorisk that TB poses has
been recognized as a serious public health threat by
the World Health Organization (WHO) and otherinternational agencies e.g. United Nations (UN).
Nonetheless, three greatest challenges have beenrecognized to be associated with TB; to deal with drug
resistant TB microbes, association of TB with HIV/AIDS
epidemic, and the ardent need of innovations both inhealth system processes and in the tools to combat thedisease (3).
The framing of an infectious disease as a global
and national health threat indicates the insistence on a
structured governmental response, the allocation of
resources, and an overall plan to place the right kind of
mechanisms to effectively prevent and control thedisease transmission. In 1991, global targets for TB
eradication were set. It was followed by declaration of
TB as a global public health emergency in 1993 andendorsement of setting of global strategies and targets
in 1995 (3), (6). In 2006, WHO came up with Global
24

Section I
Risks of outbreaks from infectious diseases, the19Besides, Mycobacterium tuberculosis,
Mycobacterium
africanum, and Mycobacterium bovis are known pathogenic
species capable to cause tubercular disease in humans (4).

20

Eubios Journal of Asian and International Bioethics 26 (January 2016)

Plan 2006−2015 to Stop TB and updated it in 2010. It
even identified the desirable components of such aplan, e.g. ensuring testing for drug susceptibility of all
previously treated patients and all new patients withknown risk factors for MDR-TB by 2015; enrollment of
all reported TB patients with MDR-TB (projected at
approximately 300,000) on second-line treatment; HIVtesting of all TB patients; prompt initiation of Anti
Retroviral Therapy (ART) in all HIV-positive TB patients
etc. (2). In spite of these initiatives, burden of TB looms
large on some countries such as India (Ibid.).This
disproportionate burden consequently prompted WHO
to include TB prevention and eradication into
Sustainable Development Goals (SDGs) from 2016
onwards (Ibid.).
WHO (2010) (7) also recommended that a TB
prevention program must include certain ethicalconsiderations to avoid violations of human rights andsocial justice issues. For, during the TB incidencessuch as lethal XDR TB emergence in South Africa in
2006, “the Speaker incident” in United States in 2007,
health officials were found to adopt drastic public healthmeasures such as forced detention, hospitalizations,
isolations, quarantine, short-to-long term detention
violating rights and civil liberties (6), (8). The incidences
also highlighted that TB patients are more likely to facea detention if they belong to the disadvantaged strata of
the society (8), (9). Consequently, for an effective
guidance to each member states, WHO recommended
that TB prevention should be based upon human-rights
approach and should have following considerations;putting individual at the centre of any health policy;
identifying, supporting the most marginalized andvulnerable
populations;addressing
relatedsocioeconomic determinants, their implications forhuman rights; overcoming institutional constraints andcapacity gaps preventing individuals and groups from
fulfilling their rights; supporting an integrated response
to TB; providing accountability mechanisms; andcreating a platform for documenting and sharing bestpractices (7), (10). WHO has also urged that specifichuman rights that need to have special considerationsin the management of TB, especially MDR-TB are: theright to life; the right to liberty and security of person;
the right not to be subjected to torture or to cruel,inhumane or degrading treatment; the right to respect
for private and family life; and the right to health (10).
Through these recommendations, the four broad ethicalconsiderations that WHO advised to focus are: (a)responsibility and obligation of government to provide
free, universal access to TB treatment and diagnosis, tomake patients informed about the treatments, as wellas to respect the voluntary, informed decisions ofpatients; (b) duty of health care workers (HCWs) toprovide care, support patients’ ability to complete
therapy, and not to abandon patients. In addition, it also
recommended reciprocal obligation towards HCWs toprotect their rights of not be infected with TB; (c)implementation of proportional public health measures;and (d) to have evidenced based TB research forenhanced TB prevention, treatment, and quality of25
care.
Over and above these criteria, the need forinclusion of ethics in TB prevention and strategy has
also been argued to address TB related healthinequities, which is caused when the threat of TB posesadisproportionate
burdenonthealreadysocioeconomically deprived groups (7). To thesegroups, vulnerability from TB gets worsened by theexisting social determinants of health (SDH) such as
poverty, malnourished status, lack of access tohealthcare, homelessness, gender, indoor pollution,
overcrowding, which cause not only differential
exposure to TB but also cause unequal TB infection,disease incidence, and clinical outcome (11). In
general, SDHs are known to cause health disparities,i.e., a type of difference in the health status. Healthdisparities adversely affect the health of populationgroups who have systematically experienced social or
economic deprivations; and positively influences thehealth status of those who are socio-economicallyprivileged (12), and therefore, are unwarranted, unjust,and to an extent avoidable. The health inequities borneby the SDH are also confirmed by TB experiences (13).
For example, during 1990s TB outbreak in the UnitedStates, it has been acknowledged that homeless,recent immigrants, injection drug users, and HIV
infected persons were more susceptible to TB thanothers (8). It was also highlighted by a 1991 study that
89% of TB patients at New York’s Harlem Hospital did
not complete their prescribed course of TB antibiotics
either due to personal issues or obstacles in the system(Ibid.). This implies that SDHs, manipulating the healthof some groups of people (socioeconomicallydisadvantaged) play a crucial role in TB outcomes andcontrol. In addition, it implies that they should be
essentially considered in TB prevention strategy andpolicy because they are unwarranted, avoidable, andunjust. However, in many national TB programs andpolicies such as that of India, neither is there muchconsideration of ethics in it, nor there is any
pronounced effort to render an equitable protection byaddressing the TB related health inequities manipulated
by SDH.
This paper especially focuses on India and its TB
prevention program and strategy. For, though the TB
prevention program was initiated during the colonial
period, India continues to experience the highest
burden of TB in the world even in 2015. Considering it
as a failure of public health obligation, the paper
reinvestigates the governmental responses to deal with
the TB burden in India and puts forward insights toovercome this failure.
Section II
25

Besides these recommendations, Selgelid (2008) brings tonotice that ethics is required for individual obligations to avoid
infecting others, third-party notification, and international
distributive justice encircling improving access to existing
medication, increased R&D for drugs and diagnostics fromlocal to global level.

Eubios Journal of Asian and International Bioethics 26 (January 2016)
In 2015, India alone accounts to 24% of global TB
cases (3). Annually, it has been estimated that there
are 2 million new cases and 300,000 people die from
TB in India (14). In 2009, it was observed that in every
three minutes, two deaths occur due to tuberculosis in
the country (15). In 2002, the number of people
succumbed to TB in India was 14 times higher than all
the tropical diseases combined (16). In addition, thecountry witnesses the rising problem of drug resistanttuberculosis (3), (2), (15). With India’s TB prevention
program and policy being initiated during the colonial
period, these issues question the efficacy of TB related
public health obligation of the country. Historically, TB
prevention in India can be seen to have evolved
through three phases: pre-independence phase, before
the discoveries of x-ray and chemotherapy; postindependence phase, during which nationwide TB
control programs were initiated and implemented; andthe phase with the ongoing implementation of WHOassisted TB control programs (2), (5).
Pre Independence period: This period is marked
by the influence of the European sanatorium
movement. In India, a Christian voluntary organization
founded the first open air sanatorium for treatment andisolation of TB patients at Tiluania, near Ajmer city ofRajasthan in 1906. This was followed by the first TB
dispensary in Bombay in 1917. Disease control
initiatives in India, including TB, started gaining
importance from 1929 through the concerted effort of
Red Cross with King George V thanksgiving fund. It
gained momentum in 1939, when the TB Association ofIndia was established and a health survey headed by
Joseph Bhore prescribed focus on TB and its
associated health problems in 1946. In 1948, withsupport from WHO and UNICEF, a BCG vaccine
production center in Guindy, Madras (now Chennai),
was set up and in 1951, India started a mass BCG
campaign to control TB, which was the first nationwide
campaign against TB. This period then ends with theestablishment of the chemotherapy center in the
country in 1956 (2), (17).
Post Independence Period: This period is
initiated with the establishment of a first tuberculosis
center of the country and with the roll down of thenational tuberculosis control program (NTCP) in thesubcontinent. In 1956 with the concerted efforts of the
Indian Council of Medical Research (ICMR),
government of Chennai, WHO, and the British Medical
Research Council (BMRC), Tuberculosis ResearchCenter (TRC) was established in Chennai. It wasestablished with the aim to provide information on themass domiciliary application of chemotherapy for
pulmonary TB treatment in the country. A National
Tuberculosis Institute (NTI) was also established in
Bangalore in 1959 to evolve a practicable TB program
and to make it applicable in all parts of the country,
both rural and urban. However, the first comprehensive
TB program was started in 1961, when the District
Tuberculosis Program was prepared by the government
and Anantapur district, Andhra Pradesh was first toreceive a model district TB center (DTC). Using this21

district TB center model Indian government finallylaunched the National TB Control Program (NTCP) in
1962 (18).
Current WHO-assisted ongoing TB control
program: This period is marked by the identification oflapses of NTCP and a revision of such program. In
1992, Government of India, together with WHO and
Swedish International Development Agency (SIDA),
reviewed the national program and concluded that itsuffered from managerial weaknesses, inadequate
funding, over-reliance on x-ray, non-standard treatment
regimens, low rates of treatment compliance andcompletion, and lack of systematic information on
treatment outcomes. Around the same time, in 1993,
when WHO devised the DOTS strategy andrecommended all countries to adopt this strategy, theWorld Bank agreed to provide credit assistance to
NTCP, initially for the coverage of a population of 271
million persons, which was later revised to cover a
population of 730 million. At present, other bilateral andmultilateral agencies, Danish International Development
Agency (DANIDA), Department for International
Development (DFID), US Agency for International
Development (USAID), Global Fund to Fight HIV/AIDS,
Tuberculosis and Malaria (GFATM), Global Drug
Facility (GDF), and WHO are providing invaluable
support to India’s TB prevention and control program.
To give a new thrust and to revitalize the NTCP, withassistance from the above-mentioned international
agencies, the Revised National TB Control Program
26(RNTCP) was launched in 1997 . It formulated andadopted the internationally recommended DOTS
strategy, as the most systematic and cost-effective
approach to revitalize the TB control program in the
country. It emphasized political and administrative
commitment to ensure the provision of organized andcomprehensive TB control services, reliable and early
diagnosis through smear microscopy, an uninterrupted
supply of good-quality anti-TB drugs, effective andpatient-friendly
treatmentwithshort-course
chemotherapy (SCC) given under direct observation,
and accountability through proper reporting andrecording, and thorough and effective supervision.
RNTCP was then rolled down to its second phase from2005 onwards. From 2006, with the aim “to achieve
universal access to quality and patient-centeredtreatment” and to “reduce human suffering andsocioeconomic burden associated with TB” RNTCP
was in its third phase by adopting the Stop TB strategy.
Along with RNTCP, the third phase of TB control in
India is also marked by the adoption of the following
programs: Programmatic Management of Drug

26

More recently, RNTCP, since April 2010, to improve TB
case detection, along with World Vision India (WVI) and its 6
civil society partners such as GLRA, ADRA India, CARE
India, SHIS, TB Alert and LEPRA India have been
implementing Project Axshya in selected problematic
areas in West Bengal, Bihar, Jharkhand, Chhattisgarh,
Orissa, Madhya Pradesh and Andhra Pradesh, with theassistance of Global Fund Round 9 TB Grant (20).

22

Eubios Journal of Asian and International Bioethics 26 (January 2016)

Resistant TB (PMDT) to combat the rising challenge ofthe drug resistance in the country; National Strategic
Plan (2012-2017) to reach out to those patients who
were earlier found to have been missed out by thesystem; and Social Action Plan (2013) (19) to identify
the gaps and barriers in program and system (20), (21).
In spite of its revisions and reconsiderations,Indian national TB control and prevention program has
been criticized. It has been blamed to have overlooked
and undermined several aspects of TB impacts and isalso held responsible to be less sensitive to several
issues that require ethical reflections. Some of suchaspects are stated below:(1)
RNTCP’s expectation was that at least half ofthe cases should be smear positive, however, many of
those diagnosed on x-ray (sputum negatives) revealed
not to be TB cases. And RNTCP has been blamed toprovide inadequate care to such cases, thereby
violating the right to health.
(2)
At one point, it was estimated that grossly there
was unethical treatment of at least 66% to 74% of thecases as identified by RNTCP, which then violated theobligation to provide the adequate treatment and also
hindered the right to life of the affected.
(3)
In spite of RNTCP’s expansion in the country“to achieve universal access to quality and patientcentered treatment”, there are reported delays inprocuring drugs, identification, diagnosis, and treatment
which thereby questions the duty to provide adequate
care. In addition, there are serious lapses in reporting,findings, and analysis of data (22), which affected theevidenced based TB research in the country.
(4)
In spite of the global recommendation to protect
health care workers from TB (10), on and from 2012 till
July 2015, at least 40 doctors in Mumbai, Maharashtra,
a western state of India, have reportedly contracted
tuberculosis; 20% of them were also diagnosed withdrug resistant tuberculosis (23). While, such recurring
incidences imply the lack of proactiveness fromgovernmental side, it also questions the onus of
RNTCP to have a reciprocal obligation towards HCWs
to protect their rights of not to be infected with TB.
(5)
Globally, India features with the highest burdenof multidrug-resistant tuberculosis (MDR-TB) (20). In
addition, there are rising cases of extreme drug
resistance and total drug resistance cases. Many times
it has been noticed that despite having received
treatment under the Revised National Tuberculosis
Control Program (RNTCP) for a long period (24), thepatient developed extensive drug-resistant tuberculosis(XDR-TB). This rising problem of drug resistant casesin the country is considered as “man-made problem
and system failure” (25), (26), (27). This then questions
the effectiveness of the program, responsibilities of thegovernment and the public health system of thecountry.
(6)
RNTCP is also found to have been blamed tostigmatize patients. For, the patients, who exclude
themselves from the system after adhering to treatment
for some time, are often marked as “Treatment
defaulter" or “noncompliant". While these incidences

make it noteworthy that TB involves stigmatization,
ongoing revised TB control program in India is found tohave been less sensitive to this issue, thereby, violating
the right to health and right to life of the stigmatized.
Over and above these issues, TB infection,
control, and prevention in India highlight another issue.
Certain groups and individuals in India are found to be
more prone to TB disease and these specific groups
and individuals are found to be people of lower SES,
those living in poor housing, facing poor environmental
conditions, food insecurity, indoor air pollution, having
less access to health care services, have less or no
education, experiencing tobacco or alcohol abuse andscheduled tribe women, and people with co-morbid
conditions such as diabetes, HIV/AIDS (28). TB, in
India, is also found to affect unevenly the social andeconomic status of individuals and groups and cast its
shadow disproportionately across genders. The
socioeconomic impacts of TB in India can besummarized as follows; more than $100 million debt isincurred by patients and their families out of TB in India.
More than 100 million productive workdays are lostannually and while more than 3,00,000 children haveleft school permanently for their parents being infectedwith TB, more than 1,00,000 TB infected women were
rejected by their families (28), (29). According to the
National Family Health Survey (NFHS)-3, though TB
cases are found to be located more in urban areas, theprevalence of TB is higher in rural areas in India. Thisregional disparity is sometimes attributed to the lack of
TB clinical facilities and health personnel in rural areas.
In addition to this, it has been observed that while twothirds of TB cases are male, TB takes adisproportionately larger toll among young females,with more than 50% of cases occurring amongst
females less than 34 years of age in India (29).
These groups and individuals being affected more thanothers, it implies that there is a significant relation
between SDH and TB related health disparities in India.
Well known SDH in India, manipulating TB disease, arefound to be poverty, caste, gender, geographicalregion, literacy, nutrition, water and sanitation, healthexpenditure, and inadequate health care services (30),(31).
With these known facts and figures out of TB in
India, India’s TB prevention program and strategy were
expected to be sensitive to these issues. However, on
the contrary the national TB prevention program andstrategy in India have undermined these issues.
Rather, the program has focused more on theimplementation of DOTS as a core strategy (with 46%
domestic share, 54% donor share), in sorting out theinadequacies in the treatment regimen, supply, drug
intake, by being influenced by the international
agencies and disregarded the indigenous healthinequities based on differing health needs of thecitizens of the country. To address these inadequacies,
national level initiatives have been taken to strengthen,improve, expand, and deploy the resources through theimplementation of the strategy of mandatory notificationof TB cases. And a normative, entitlement-basedEubios Journal of Asian and International Bioethics 26 (January 2016)
grants, outcome-based budgeting, testing services in all
PHCs have also been introduced (32). However, it has
been done as part of legal obligation, but not withethical insights. Under this RNTCP, the aim to end TB
in India or the ‘Zero TB’ concept, though, has been
introduced, its focus has been always on the funding
side. There has been no acknowledgement and scopeof the potent role of SDH that they may play in theonset and spread of TB exposure, infection, anddisease on groups and individuals, though the aim wasadopted to “reduce human suffering and socioeconomic
burden associated with TB”. The Social Action Plan
(SAP) though have been introduced in 2013, its aim
has been ensuring universally accessible service
delivery (19), that is, to provide opportunities but not
focusing on enabling such opportunities. It also
overlooks the utilization abilities of individuals andgroups to access and afford these opportunities
provided. This paper argues that through these gaps
and loopholes of RNTCP, TB related inequities may
pass through to cause greater health inequities, if thisissue remains unacknowledged and unaddressed in
RNTCP and its allied programs. And to address theseinequities, this paper claims that RNTCP requires theguidance of a theoretical-ethical framework. For, being
grounded in such theoretical-ethical framework, RNTCP
can address inequities by addressing TB related SDH,
can ensure and enable equitable provisions of TB
related health care services, can have a proper
underlying vision, can avoid violation of the right tohealth and life, and can also address several otherissues arising out of RNTCP.
The need for an ethical guidance to TB control andprevention program in India has been recommended bysome literature as well. For example, while somesuggested adhering to Due Care (22) framework,
others suggested Reciprocal Obligation (33) orRelational Autonomy (34) to render the public healthobligation. Some others have suggested following WHO
Ethical values (35), the principle of Primum non nocere(24) or the public health framework of Principlism (36),(37). However, gaps remain in the literature for having
less or no causal link between increased vulnerability ina population and the existence of SDH in relation to TB
incidence and prevalence. Moreover, though the above
mentioned literature highlighted the ethical aspects of
TB outbreak and control program in India, the concernof equity is relatively under discussed in them. It is also
noteworthy that in these literary sources, there is a lackof recommendation of underlying vision and that of acomprehensive framework. This paper claims that thesocial justice theoretical framework of Health Capability
Paradigm (HCP) can guide RNTCP in this regard. Next
section, with explanation of HCP delineates how acomprehensive HCP can help RNTCP to address thisissue.
Section III
Rooted in human flourishing, the social justicetheoretical framework of HCP values health intrinsically.
It gives special moral importance to health capability,

23

that is, a person’s ability to be healthy, which
recognizes two proxies; health functioning, or healthperformances, and health agency, or the ability to leada life one values. As a theoretical framework, it values“central” health capabilities that is, the capabilities toavoid premature mortality and escapable morbidity.
This view of central health capability employs “shortfall
equality” to judge public policies affecting health.
Shortfall equality compares shortfalls of actual
achievement from the optimal average (such as typicallongevity or physical performance) (38).
As a social justice framework, HCP focuses onvulnerability and insecurity. It is concerned with“individuals’ exposure to risk and their ability toadequately manage it…” (39). According to HCP,
people become vulnerable and insecure when they lackaccess to necessary health care services and several
socioeconomic,
individual
factors
affecttheaccessibility, availability, quality, and utilization ofhealth care services (40), (41). As some groups andindividuals are more affected by these, as aconsequence, inequities are caused, but theseinequities are caused at the level of health capabilities,
specifically, in central health capabilities (40). These
health inequities, according to HCP, prevent people
from achieving good health. As they arbitrarily,
unnecessarily reduce the capability for healthfunctioning and especially affect central healthcapabilities, they are social justice failures and are to
be considered as unjust, unwarranted, and avoidable(42).
HCP values human diversity and favors thosebelow the maximum average over those above it. In
favoring that, HCP requires, shared health governance,
a construct which promotes voluntary ethicalcommitment and shared responsibility by all, thosemore fortunate and those in need, to ensure and enable
health capability for everyone (Ibid.). In other words, it
is a construct in which individuals, providers, andinstitutions work together to create an environment
enabling all to be healthy, by ensuring and enabling
access to high quality care through “medical
appropriateness” and “medical necessity” (Ibid.). HCP
proposes that quality of health care can be judged by
its ability to address functional impairments arising frominjury or illness. And the impact of health care on
individuals’ health capability is assessed by examining
health needs, health agency, and health norms (Ibid.).
While health needs are directly observed through healthfunctionings; a health agency is judged through theshortfall of actual achievements from an agreed-upon
optimum. And health norms are “societal norms about
health that govern the environment in which individuals
navigate choices for healthier life” (43). To address
inequities in health capabilities, to help people totransform healthcare resources into optimal healthfunctionings, these norms, according to HCP, need to
be closely scrutinized, because norms can be either
positive or negative.
This paper argues that this social justicetheoretical framework of HCP and its insights can be24

Eubios Journal of Asian and International Bioethics 26 (January 2016)

extended to TB prevention and mitigation strategies. TB
negatively affects an individual’s perception of his/her
own health in various domains, including physical,
mental, psycho-social, and economic well-being. Froman HCP perspective, TB thus affects the health norms
and health agency. One’s susceptibility to TB is
increased with poverty, characterized by poor health,compromised immunity, exposure to unhygienic
conditions, and inadequate nutritional intake. And once
acquired, the physical effects of tuberculosis cause
debilitating impacts on the lungs, appetite loss,
weakness, weight-loss, and even cause death (28). In
terms of HCP, being unable to avoid these conditions,
TB affects health functioning and central healthcapability of individuals. And when the manifestation of
TB significantly hinders an individual’s physical capacity
to engage in routine activities, including those related tolivelihood and income generation, TB sabotages one’s
ability to work and it deprives one’s health capability(44). With disproportionate impacts of TB on healthfunctionings,
healthagencies,
centralhealthcapabilities, and health capabilities of some groups andindividuals, TB causes inequity at the levels of central
health capability and consequently, at the level ofhealth capability. And to address that, this paper argues
that RNTCP requires the insights of the social justicetheoretical framework of HCP. For, addressing
inequities in central health capability as the foremost
goal of HCP, it brings with it the need for attention to
the SDH-caused TB related inequities at the level ofcentral health capabilities and disparities in healthcapabilities. By focusing on these, TB prevention andprogram can better achieve its goal of fair provision ofequitable protection and can also address several otherissues as a comprehensive framework.
Recommendations
With insights from the social justice theoreticalframework of HCP, this paper recommends somemeasures for RNTCP.
• RNTCP should reconsider the underlying vision ofhealth to ensure and enable conditions to avoid
escapable TB. With a foundation on HCP, RNTCP
should consider health as a capability to avoid TB
related escapable morbidities and mortalities. Such avision can guide RNTCP to address the inequities atthe levels of TB related central health capabilities aswell as in health capabilities, and can also makeprovisions to avoid violation of the right to health andlife.
• Grounding in HCP, RNTCP should consider focusing
on both TB related health outcome and health agency,
but not just on TB related health outcomes. Focusing
on both would make a scope in RNTCP to equitably
assess the TB related health performances andutilization of TB related health care services by
individuals and groups.
• With the foundation on HCP, RNTCP needs toensure and enable vertical as well as horizontal equity,
by identifying the pockets of the shortfall at the groups
and individual levels. This can also lead RNTCP toaddress the barriers at the level of TB related healthcapability. And for this, the concept of shortfall equalityof HCP can guide RNTCP. Strategically, this implies
collaboration of RNTCP with other sectors and other
health care programs, risk estimation and assessment,
and improved surveillance of service delivery andutilization from national to block levels.
• HCP also suggests SAP/TAP (2013), a subsidiary
program under RNTCP, to undergo some changes. It
suggests ensuring and enabling a bottom up approach,rather than focusing solely on ensuring accessibility tosome selective groups. This implies, addressing theindigenous health needs, rather than being influenced
by the international agencies exclusively. It also implies
ensuring and enabling a provision of high quality
diagnostic and treatment services at the primary levelof health care service delivery.
• As mentioned earlier, TB in India involves
stigmatization and discrimination. In this matter, HCP
recommends RNTCP to modulate TB related social
norms and, thereby, health norms in cooperation withvaried stakeholders.
• Grounding on HCP, RNTCP should also exercise acollective responsibility. The HCP concept of shared
health governance can help RNTCP in this matter. At
the practical level, this implies collaboration withdifferent stakeholders of RNTCP such as TB infectedpatients, doctors, health care workers of different
levels, marginalized groups, including tribal women,
different research institutes to have a collaborativedecision making, to develop a shared consensus, andto ensure and enable the highest quality of TB
treatment from block to national level.
Conclusions
Tuberculosis infection is an airborne infection. The
risk, thus, depends on the concentration of tuberculosis
bacilli in the inhaled air and the duration of exposure.
Early case detection and effective treatment not onlycures patients, but interrupt the transmission of
tuberculosis in the community as well (5). While anyone
can contract TB, it predominately affects those who aresituated in the lower stairs of the socioeconomic ladder.
It is most prevalent among marginalized, discriminatedpopulations and people living in poverty, however, it
can also exacerbate poverty.
The foundation of this paper is on the social justicetheoretical framework of HCP. Grounding in that andwith a focus on India’s RNTCP, it argues that: (i) thevision of health needs to be changed to health as acapability in the RNTCP, and (ii) to equitably consider
the socioeconomically disadvantaged people in TB
control and prevention program, there is a need ofreconsideration of RNTCP. With such reconsiderations,the paper claims that RNTCP can have a greater
concern of preventing escapable TB disease andpremature TB deaths and can also deliver equity in TB
detection, diagnosis, treatment, and at the level of TB
related health capability.
As a concluding remark, the paper comments thatfrom 2016 onwards, when the Millennium Development

Eubios Journal of Asian and International Bioethics 26 (January 2016)
Goals (MDGs) are transforming to the Sustainable
Development Goals (SDGs) (2), complete eradicationof TB from the world population, necessitates
addressing the deep rooted barriers of TB outbreak,incidence, and prevalence. And this implies addressing
the barriers at the level of TB related central healthcapability and health capability as part of the publichealth obligation. For, addressing the underlying risk
factors of TB related health capabilities become ethicalimperatives to render an equitable protection to all.
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Differences in gender andeducational stage in theemotional skills during
teacher training- Lara López-Hernáez, PhD. in Educational Psychology
International University of La Rioja, Education Faculty, La
Rioja, Spain; Visiting Professor in Mindfulness andEducational Psychology, American University of Sovereign
Nations, 8840 East Chaparral Rd, Ste 285, Scottsdale, AZ 82520
Email: Llopez.lara@gmail.com/ lara.lopez@unir.net- Carmen Sabater Fernández, University of La Rioja
Email: carmen.sabater@unirioja.es

Abstract
The aim of this study is to assess the level of selfrealization and personal growth of teachers in training
in two Spanish Universities, one located in the north,
University of La Rioja, and other in the south,
University Catholic Murcia. The sample consists of
366 teachers who were in training, 183 future primaryteachers belonging to the University of La Rioja, and
183 future pre-school teachers at the Catholic
University of Murcia. The "Questionnaire Self-concept
and realization", AURE, (Aciego et al., 2005;
Dominguez, 2001) is used, and the results show that
future primary school teachers, which teach students
between 7 and 12 years old, show favorable levels in
self-realization and personal growth. However, thesemeasures are significantly lower compared to futureteachers of pre-school education, that teach students
between 3 and 6 years old-. Differences in variables
are also produced by gender, significantly higher in the
future women teachers of pre-school. These data
indicate a more urgent need to strengthen programs
based in emotional skills, in particular programs suchas Mindfulness among men, and among those whoteach the older students.
Keywords: Self-realization, Personal development,
Emotional skills, Teacher training, Mindfulness, Genderand Educational stage.
Introduction
The need for integrally training all the educational
community members in emotional skills and especiallyto teachers is a priority key in education (LópezHernáez et al., 2014). Bisquerra (2009) and LópezGoñi et al. (2012) describe the inclusion of emotional
competencies in initial teacher training as afundamental, although, in practice, they are secondary
in the set of teaching skills.
The development of emotional skills in a teacher
means an improvement in their interpersonal
relationships and their education efficacy (Bisquerra,2007). Emotional competencies are defined asnecessary to be a good teacher (Vaello, 2009),
because the most personal and emotional facet,based on the awareness and ability to manage andcontrol one's emotions and feelings, is directly related
to interpersonal relationships with others and it
represents a basic element in the motivation to face
the teaching-learning process (Soriano et al., 2008).
Gallego et al. (2004) note that the appropriate
emotional management and the harmonization
between the cognitive and emotional, should be fully
considered in the curriculum. Jennings et al. (2009)
and Sutton et al. (2003) show the close relationshipbetween social and emotional competencies ofteachers and the effectiveness and quality fordeveloping processes of teaching-learning in theclassroom and to promote prosocial behavior of
students in class. The university context is a privileged
space for the promotion and development of emotional
skills, contributing positively to the personal and social
welfare of students (Livia et al., 2015) and an ideal
study environment for identifying and evaluating them
(López-Goñi et al., 2012).
A study of Zuazua (2001) shows that most young
Basque Professional Training students claim to have afull life and have more luck in their life projects;
however, only those with higher levels of self-efficacy
generate higher expectations of themselves, they trust
their capabilities, they perceive the academic
environment as less threatening and are adapted
successfully to the demands, experiencing higher
levels of general welfare (Cabanach et al., 2010).
Pertegal et al. (2009) show that most of the students
are not prepared for successful employment
integration in terms of emotional competencies areconcerned.
According to Marchesi et al. (2007), 77% ofteachers are satisfied with their life and career,
although a 75% feel that the profession has worsenedin recent years, generating a growing discontent. Thismalaise affects the concept that the teacher has ofhimself, causing him insecurity and lack of self-esteem(Hue, 2008). In this sense, Pena et al. (2012) havefound a significant relationship between emotional
competence in primary-school teachers and thedifferent dimensions of burnout and engagement, thus,
greater emotional competence by teachers involves alower level of exhaustion, in addition to higher levels of
personal fulfillment. Peñalba et al. (2013) found that
one in two student teachers have a deficit in emotional
competencies, including personal and interpersonal
skills; although their skills in this area are higher
compared the University population in general (Bueno
et al., 2005).
Personal maturity allows teachers to be more selfaware, to perceive better and have a deeper
understanding of what they do and its effects (Ramírez
et al., 2012). The teacher who is emotionally morecompetent is better prepared to engage in a positive
and appropriate manner with the educational
community, which increases the efficiency of
education (Bisquerra, 2007), the learning process,Eubios Journal of Asian and International Bioethics 26 (January 2016)
mental and physical health, the quality of social
relationships and the academic and work performanceof the educational community (Brackett and Caruso,
2007; Extremera et al., 2004). Teachers withhighemotional skills experience higher levels ofgeneral welfare (Cabanach, et al., 2010) and they act
as agents of social change in their educational
experiences (Leguizamon, 2014).
Gender difference and emotions“Gender differences are not natural, but historicalcultural constructs that express power relationships
based on differences that distinguish the sexes”(Monzón, 2004, p.8). Children are born neutral
psychosexually and can be assigned to one or othergender during the first years of their lives, with only achange in the practice of learning (Money, 1988).
Gender is not a natural quality of people but rather
a complex set of cultural beliefs mutually related which
stipulate the social meaning of the masculine and thefeminine, concept that varies across cultures andacross time (Gaviria et al., 2013). Throughout history,
women have played a secondary role in society being
relegated to the family, or small circles of friends, sothey have learned to express their emotions in intimate
places, being more prepared phylogenetically to
express their emotions while men socialize to express
a greater extent physical force (Subirats, 1997).
The relationships of the girls are morecomprehensive and they have a different sense of life
project and self-realization to men (Zuazua, 2001).
Professionally, women opt for employment models
that represent greater harmony in the interaction
between work, family and community (Mojerón, 2010).
In this sense, the study of Pegalajar et al. (2015)shows that future female teachers have more positive
levels of self-realization and personal growth that maleteachers, and tend to get significantly higher scoresthan men on emotional intelligence measures (Bueno
et al., 2005; Extremera et al. 2007; Joseph et al.,2010; Valdez et al., 2010).
Recent studies on cyberbullying relate a greater
attitude toward violence and reduced capacity on
emotional skills on men. There is a higher prevalenceof men as large cyberbullies (Sabater et al., 2015,
Garaigordobil et al., 2013). This fact is transferred to
traditional bullying, where the prevalence is higher
among boys, which harass more physically than girls(López-Hernáez, 2013; Ortega, 2008). In general,boys are more interested in controlling external
events, being more aggressive physically and withgreater domain to their peers (Anastasi, 1982).
Professional choice and emotions
An effective personality is linked to a more mature
vocational decision making based on the best
knowledge of the person and the labor market(Bethencourt et al., 2011). A study by Mejia et al.
(2011) shows how some future teachers have notcovered their emotional needs and self-esteem. In thissense, Peñalba et al. (2013) also found how one in27

two student teachers shows a deficit on emotional
competencies, including personal and interpersonal
skills; although the skills in this area are higher
compared to the general student population (Bueno etal., 2005). According to Pertegal et al. (2009), most
students are not prepared for successful workplace
integration, because they do not have sufficient skills
to the relationship with others, nor to adapt tocontinuous change, nor to control their emotions.
The teaching profession has a low social andeconomic status in many countries, and it is difficult forthem to achieve a similar status to that of otherprofessionals with careers traditionally more dilated,as doctors or lawyers (Garcia-Garduño, 2010). Almost
half of the student teachers do not study because of astrong vocational interest, they have expectations toabandon the degree and make another (GarciaGarduño et al., 2006), with an unfavorable attitude
towards it. According to Mendías et al., (2004), themain reason why the future teachers of pre-school
education choose this degree is because they likeyoung children.
Moreover, according to Garcia-Garduño (2010) it
is the intrinsic interest, satisfaction for a job well done
and personal achievement, which leads most teachers
to choose this profession. The teaching vocation andfamily influence, especially having teacher’s relatives,
are the main reasons why the degree of education ischosen (Garcia-Garduño, 2010; Pegalajar et al.,2015). Family involvement is essential in the processof self-regulation and academic vocational choice of
their children, as it affects significantly and positively
on the perception of their competence as students(Gonzalez et al., 2002).
The study of Pegalajar et al., (2015) aims toassess the level of self-realization and personal
growth of student pre-school teachers at the Catholic
University of Murcia (n = 183). The questionnaire
results of -AURE- (Aciego et al., 2005; Dominguez,2011) show that future pre-school teachers show very
favorable levels of self-realization and personal
development, mainly in behaviors of sociability,
respect and collaboration. Participants are themselves
quite motivated and show efficiency in planning tasks,
and most of them express high levels of effort andpersistence, seeking alternatives, they are tolerant andautonomous, and they enjoy on the realization of theirprojects. These results are much more positive in thecase of the female students.
Therefore, the objective pursued in this research is
to know what results are obtained at the University of
La Rioja, compared to the study conducted on the
Catholic University of Murcia (Pegalajar et al., 2015)
using the same methodological framework (planningfieldwork techniques and instrument). It aims todetermine the level of self-realization of futureteachers of primary education, and whether genderaffects this self-realization. Finally, it is performed acomparison between both samples, to find out if there
are differences regarding to the educational stage

28

Eubios Journal of Asian and International Bioethics 26 (January 2016)(pre-school and primary education) and gender (menand women) between them.

relation to others, concern and communication withothers.

Methodology
SampleThe population is composed by student teachersof all courses with a primary education degree at the
University of La Rioja, and a total of 183 students
completed the questionnaire. The selection of subjects
was performed using a simple random probability
sampling (Tójar et al., 2009) by selecting all subjects
who were in the classroom at the time the survey was
conducted. For the calculation of the sample, it wasused the formula for communities with fewer than
100,000 subjects with a confidence level of 95%, anda maximum estimation error of 5%.
In relation to the composition of the sample,
gender is distributed with 68% being women,
compared with 32% of men. Their ages are between
18 and 39 years, predominantly from 18 to 21 years(76%), followed by the range from 22 and 25 (18%)
and the range from 26-39 years (6%). The majority
origin is the autonomous community of La Rioja (85%)
with a wider segment residing in the capital andsurrounding municipalities (71%). However, it should
be noted that 15% came from other regions. In the
distribution by courses, there were more in the firstyear (36%), followed by the third year (31%), second
year (22%) and fourth year (12%). Most have studiedin public schools (74%). In general, they live with theirfamily or with peers (92%), are interested in culture, toread and to travel (97%) and a significant percentageof them, do sports regularly (67%).

Procedures
For the application of the questionnaire to thesample, we contacted the faculty of the University of
La Rioja teaching different courses by email, indicating
to them the objectives of the investigation andrequesting the necessary authorizations to access thestudy sample.
To get a correct application of the instrument, thestudents were informed about the rules for completion,
the questionnaire characteristics and purpose of thetest. The questionnaire was administered individually,
during school hours within the Faculty of Letters andEducation, thanks to the collaboration of the
responsible teachers for compulsory subjects in eachgroup.

Instrument
The methodology is quantitative and it is based on
the technique of standardized statistical survey. The
data collection was performed through thequestionnaire AURE "Questionnaire Self-concept andrealization" -AURE- (Aciego et al. 2005, Domínguez,2001) which includes 55 items grouped into six
factors: Self-Concept, Projects, Attitude towards Work,
Friendship and Love, Social Concern and Ego
Strength. Each item is measured on a Likert scale,whose answers are between 1 and 5 (representing 1 =strongly agree, and 5 = strongly disagree). The
application time is short and the questions are simple,
which makes its application be an advantage.
The questionnaire meets high standards ofreliability, because the coefficient obtained through
Cronbach's alpha (.97) and Spearman Brown forunequal halves (.93) prove it. Besides analyzing thefactorial structure, it provides an understanding of thecontents able to reorganize its into three major factors,
such as: 1) Coping, operability and fulfillment in thework: includes aspects of planning, availability andself-control against the task and the norm; 2) Selfconcept and self-esteem, which compiles all aspects
related to the evaluation of himself, and 3) Empathy
and social fulfillment, that refers to the satisfaction in

Analysis of data
For the statistical processing of the data SPSS
was used, version 21 for Windows and it performed adescriptive and correlational analysis of the results
obtained from the various dimensions of thequestionnaire. We have implemented the Student t
test for comparison of means to demonstrate theexistence of significant statistically differences
between the scale factors and the variable "gender" ofthe participants, besides the Levéne test to know
equality of variances. All analyzes were calculatedwith a confidence level of 90%.
Results
Regarding the first objective, which aims todetermine the level of self-realization of futureteachers of primary education, the results are shownin Table 1. The mean scores and standard deviations
are reflected, for each of the dimensions of thequestionnaire, showing generally favorable levels of
self-realization and personal development.
Table 1. Analysis of mean (M) and standard deviation(SD) by factors at the University of La Rioja (n = 183).
Dimension
M
SD
Friendship and
1.89
.935
Love (FL)
Self-Concept (SC)
2.21
.902
Social Concern (SC) 2.22
.936
Attitude Towards
2.30
.994
Work (ATW)Ego Strength (ES)
2.38
.994
Projects (P)
2.38
.886
It is in the "Friendship and Love" dimension where
the best scores are obtained, which means a good
future teachers behavior towards others, in relation tovariables
sociability,communication,
respect,
cooperation and identification; as well as othertowards them, while they declare receive affection,
positive assessment, to feel respected and get support
and assistance.

Eubios Journal of Asian and International Bioethics 26 (January 2016)
It is also quite favorable for their valuation to thedimension "Self-Concept", at the level of personal
satisfaction, overall personal assessment, physical,
intellectual
ability,mood,socialinteraction,
confrontation with reality and regulatory adaptation.
Participants show at the same time, a high "Social
Concern" with active participation in social problems,
together with their high "Attitude towards Work",concerning
theiravailability,
motivationandachievement assessment, such as planning, andprecision of action and evaluation of work.
However, the dimensions "Ego Strength" and"Projects" are valued lowest by the participants. The
future teachers of primary education, show lower
values as to their availability to the effort,
perseverance and persistence on the task, tolerance
and patience with the difficulties, self-control andsearching for alternatives. It is the same with thedimension centered on the potential of enjoyment andthe adequacy of projects carried out, although it isfocus more towards agreement, since scores areplaced closest to the middle of the range.
Regarding the second objective, which seeks toascertain whether the gender variable affects the
personal development of the participants, statisticallysignificant differences are detected in some of thestudy variables, listed in the following tables.
Table 2. Means and standard deviation of variables"Self-Concept" by gender*
Self-Concept
GenderSig. tMen
Women
M (SD)
M (SD)
SC4. I feel very
2.00 (.90)
2.39 (.78).003*capableSC7. Physically I
2.52 (.84)
2.98 (.99).003*
am strongSC18. I am hard2.36
1.91 (.95).004*working(1.04)* Only statistically significant variables are shown, <=0.05 ((in each table)
In general, the self-concept of men is higher than
women, feeling more capable and stronger physically.
However, the girls claim to be more hard-workers.
Table 3. Means and standard deviation of variables"Friendship and Love" by Gender*
Friendship and Love
GenderSig. tMen
Women
M (SD)
M (SD)
FL2. I tell myproblems to friends
and familyFL3. I am interested inproblems andillusions of my friends
FL4. I do not like tomock others

2.22(1.01)

1.84
(1.0)

.017*

2.02
(.89)

1.58
(.99)

.005*

2.76
(1.07)

2.38(1.20).039*

29

Participating women report a higher level in thedimension "Friendship and Love" in relation to men,since they have more emotional empathy in yourrelationship with others. They care more about the
dreams and problems of others, communicate morewith their close people and do not like to make fun ofothers.
Table 4. Means and standard deviation of variables"Attitude towards the task" by gender*
Attitude towards the Gender
Sig. t
task
Men
Women
M
M (SD)(SD)
ATT2. Facing a new
2.14 2.49 (.99).024*task or job I think I am(.93)
able to do this and I act
with confidence
ATT3. I prefer tasks
2.24 2.66 (.97).006*that involve new(.87)
challenges anddifficulties
Generally men feel more capable and more
confident before a new task that involves newchallenges and difficulties than women.
Table 5. Means and standard deviation of variables"Projects" by gender*
Projets
GenderSig. tMen Women
M (SD)
M (SD)
PR4. I usually have funjust imagining things I
could do

2.36
(1.00)

2.01
(.91)

.019*

Table 6. Means and standard deviations by factors
at the Catholic University of Murcia (n=183)
Dimension
M
SD
Friendship and
1.77
.542
Love (FL)
Attitude to the
1.95
.608
task (ATT)
Self-Concept
2.04
.520
(SC)
Ego Strength
2.18
.690
(ES)
Projects (P)
2.20
.563
Social Concern
2.22
.826
(SC)
Source: Pegalajar, Mª.C. and López-Hernáez, L.
(2015)
Participating women have a higher level ofimagination than men. However, no statisticallysignificant differences were observed according togender in any of the variables belonging to thedimension "Social Concern" and "Ego Strength".
The third objective aims to determine whether
the educational stage and gender affect the personal
development of teachers. For this, we have made a30

Eubios Journal of Asian and International Bioethics 26 (January 2016)

comparison between the University of La Rioja (UR)and the Catholic University of Murcia (UCAM).
Relating to the educational stage, students of preschool education at the Catholic University of Murcia
obtained significantly higher scores to students ofprimary education at the University of La Rioja.
Comparing Table 7 and Table 1, the results
observed are closer with the dimension "Love andFriendship" appearing in both cases first. In thedimension "Social Concern", both samples share thesame mean. However, it reflects how future pre-school
education teachers (Catholic University of Murcia)
show much more favorable mean in every one of thefactors, with a lower deviation of the data with respect
to future primary education teachers at the Universityof La Rioja
Regarding to the gender variable, significant
differences are shown in most dimensions in both
samples. In Table 7, it is seen as the UCAM (preschool future teachers) women participating obtained
highest score, except in "Self-Concept" and "EgoStrength." However, at the UR (primary school futureteachers) the significant differences are present indimensions "Self Concept", "Friendship and Love","attitude towards the job" and "Projects" (but only insome variable and no in the overall dimension), andthere are no differences in any of the variables
referring to the dimensions "Social Concern" and "EgoStrength." These data demonstrate that the influenceof gender in personal fulfillment is greater in preschool future teachers than in primary education futureteachers.
Table 7. Means, standard deviations and global
significance in UR and the UCAM
Dimension UR
UCAM

SelfConcept
Friendship &LoveSocialConcern
Attitude
to thetask
Projects
Ego
Strength

Men
M

Women
M

Sig.
t

Men
M
(SD)

Women
M
(SD)

Sig.
t

(SD)

(SD)

2.12
(.86)
1.86
(.85)

1.98
(.86)
1.66
(.80)

.316

1.94
(1.00)
1.98(1.26)

2.04
(.50)
1.76
(.49)

.055

2.43
(.76)
2.36
(.87)

2.30
(.84)
2.16
(.77)

.297

3.23
(2.91)
2.08(1.02)

2.18
(.61)
1.95
(.58)

.000
*
.046
*

2.29
(.71)
2.28
(.87)

2.34
(.70)
2.33
(.80)

.675

2.22
(.97)
2.07
(.85)

2.20
(.54)
2.18
(.68)

.018
*
.656

.115

.114

.669

.001
*

Discussion and Conclusions
In conclusion, both future teachers of pre-school
education and primary education, have high levels of
self-realization; however this is significantly lower inthe primary education teachers, so they seem to needadditional support in their emotional skills acquisition.

In this sense Mejia et al. (2011) propose emotional
teacher training, integrated into the mandatory content
of the curriculum, with the main responsibility tosupport future students in the development of theirpersonal autonomy.
The skills involved with emotional intelligence arefocused on the ability of the person to become awareof himself as well as in the management andrecognition of their own emotions and motivations andthose of others (Goleman, 1995). Salami (2010)
affirms the importance of designing programs topromote psychological well-being in university
students as a means of improving the quality ofteaching and the development of programs to improvetheir affective-motivational resources for a better selfacceptance and personal fulfillment.
Gender influences personal fulfillment of futureteachers, women show higher levels of personal
achievement than men, and even more future preschools women teachers. In this regard, Sanchez etal. (2008) show that women score better on issues
related to the relationship with the other. So, further
works is needed in emotional skills with men, and toreflect on the need to encourage the creation of new
education programs for equality at all levels, along thelines set by Díaz-Aguado (2009). These results
confirm the need for more female qualities to positionsof responsibility, thus affecting positively thedevelopment of social work organizations (RamosLópez, 2005).
The study shows that the choice of educational
stage is also determined by the emotional capacity ofteachers, future teachers with more favorable levels of
self-realization and personal growth, choose preschool education and they also have a higher vocation(Pegalajar et al., 2015). According to De León et al.
(2008), university students who reported higher levelsof personal growth, has more capacity for a correct
career choice. A greater capacity for professional
choice is consistent with the purposes of the degreechosen, related to a good academic performance anda more favorable attitude (García-Garduño, 2010).
Nelis et al. (2009) found that young adults who
participated in an intensive emotional training had
improved their levels of emotional intelligence,
maintaining this improvement six months later. In thissense, the implementation of programs that workemotions in schools, for example, mindfulness
techniques in the educational community, show very
positive results in personal development andacademic of their participants (López-Hernáez, 2015).
However, its implementation is not without its
limitations, so it is proposed to increase the duration ofthese programs and teacher training, among otherguidelines for improvement (López-Hernáez, 2015).
Studies of the practice for emotional and personal
development "Mindfulness" offers promising results,
encouraging educational institutions to integrate its inacademic training, for beneficial results in emotional
well-being, ability and learning potential and physicalhealth and mind of those who practice (Burnett, 2011).

Eubios Journal of Asian and International Bioethics 26 (January 2016)
In recent decades “Mindfulness” training has been
introduced in numerous health improvement programsand various psychological treatments (Miró, 2007).
Franco et al. (2011) have shown that these
programs are valid and appropriate to promotepersonal growth and self-realization of those who
perform it. Kuyken et al. (2013) showed theacceptability
andeffectivenessof
program
Mindfulness, reporting improving of mental health andwell-being factors such as coping tasks without fear
and with enjoyment, self-esteem and empathy. It
would therefore be advisable to implement programs
like Mindfulness in the curriculum of the Faculty of
Education, since the school landscape and current
professional requires the involvement of different
educational agents, beyond the mere transmission ofacademic content; teachers should be aware that their
participation has to contribute to the overall
development of students and their future professional
performance (Álvarez et al., 2011).
The main limitations of this study are the sample
size, however the strength is the diversity in the originof the participants, and it would be reasonable to try
out programs to lessen the observed gender gaps andgap between these two groups of teacher trainees inorder to improve the outcomes of the training
programs to provide enthusiastic and mature teachers.
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Analyzing Bioethics
Curriculum in Korea-Manjae Kim,
Professor, Department of Urban Planning and Real Estate,
Gangneung-Wonju National University, 7, Jukheon-gil,Gangneung, 210-702, Korea
Email: mjkim@gwnu.ac.kr-Kyung-Suk Sung,
Professor, Department of Nursing, Gangneung-Wonju
National University, 150, Namwon-ro, Heungeop-myeon,
Wonju, 220-711, Korea
Email: sungks@gwnu.ac.kr

1. Introduction
There is a global agreement that bioethics education
should be provided to citizens at all levels, which
explains why UNESCO has promoted the education of
ethical issues of science and technology (Macer, 2008).
In Korea, too, bioethics education has become popular
as the Ministry of Education required to include somebioethical issues as a part of the life science in juniorand senior high school education.
At the university level, however, the contents ofbioethics education tend to reflect lecturers’ personalviews because there is no mandated textbook. Until
now, most bioethics education is largely provided to
medical and nursing students. Without shared
philosophy and determined lecturers, therefore, it is noteasy to offer bioethics education related courses togeneral students.
As Kim (2006) claims, Hwang Woo-Suk scandal
has confirmed that ordinary citizens as well as
researchers and physicians need to have a certain levelof proficiency in ethics and bioethics in order not to be
distracted by sensationalism in mass media. To
achieve this goal, education is imperative. For a morevital educational system, it is necessary to understandpresent situations and problems.
Therefore, this study tries to find out current
conditions of bioethics education in Korea bypresenting bioethics curricula in junior and senior highschools, and two selected universities, which will beable to show the (dis)continuity of underlined
philosophy in bioethics education. And then it aims toprovide some suggestions as final remarks.
2. Bioethics education in high school
1) Junior high school
Bioethical considerations in Korean high school
education have been directly or indirectly addressed indiverse subjects such as science, Korean, Morals,
Social Studies, Technology and Home Economics(Park et al., 2005). Among others, however, it seems to
be clear that moral education is most closely relatedwith bioethical issues (Kim, 2006: 55).
Table 1 shows that contents of Morals in junior highschool are divided into four areas including personal life,thfamily·neighbor·school, social life and nation (the 7
Curriculum; in Han, 2007: 35-36) .

Eubios Journal of Asian and International Bioethics 26 (January 2016)
Table 1: Contents of “Morals” in junior high schoolstth
Major value
1 yr (7 grade)
Personal -Life respect-Meaning of life andlife-Faithfulness
morals-Honesty-Personality-Self-reliance-Human life
-Self-control-Adolescence
Family,-Love and respect-Happy family life
neighbor -Filial duty
-Manners among
and-Manners
relatives
school-Cooperation-Neighborhood-School spiritmanners-School manners
Social-Law-abiding
life-Consideration ofothers-Protection ofenvironment-Justice-Community spirit
Nation-National love
-National security-Peaceful reunification-Humanity

2

nd

th

yr (8 grade)

Respect for humanlife

Biomedical
ethicsLife respect for othercreatureLife respect forenvironment
Bioethics related withbirth and death

Treatment of disease

Ethics ofbiotechnology

Distribution of
medical resources
Recognition of
cutting edge
biotechnology

Recognition ofproblems inbiotechnology
research processrdth

3 yr (9 grade)-Life plan and pursuit of value-Human life and value conflict-Moral problems and moral
judgment-Future exploration-Family, relatives, neighbors
and moral problems-School life and moral
problems-Modern society andtraditional morals-Modern society andthe morality of
citizenship-Democratic life
-Economic ethics-National development
and culture-The importance ofnation-Proper attitude to lovea nation-The reunification of
North and South

Table 2: Han’s analysis (2007) on bioethical consideration in junior high school
Area
Category
Subject
Ethics oflife respect

33

Precious human life
SuicideSmoking, drinking, and drug abuse
Concern and love for animals and plants
Welfare of animals and plants
Destruction of animal and plant habitat
Emission of pollutants
Abortion
Test tube
Gene test
Criteria of death, brain death
Human vegetable, life-support machine,
euthanasia
organ, tissue transplantReleasing patient medical records
Fair social distribution of medical resource
Human genome project
Stem cell cultivation, human embryo cloning
Clone
Genetically manufacture organism, geneticallycodified foodExperiments involving human subjects
Validity of the process of bioethical research
Critical attitude of bioethical research outcome

1

st

th

(7 gr)
○

○
○
○

nd

2
th
(8 gr)
○
○
○
○
○
○
○

3

rd

th

(9 gr)

○
○
○

○
○
○

○
○
○
○
○

34

Eubios Journal of Asian and International Bioethics 26 (January 2016)

Most major values except life respect and protection ofenvironment are not concerned with bioethical issues.
Han (2007) more specifically analyze bioethicalconsiderations categorized into ethics of life respect,biomedical ethics, and ethics of bio-Technology.
According to her analysis, Korean textbooks in juniorhigh schools fail to provide constructive and balanced
education. For the first and the second graders, moral
textbooks hardly mention either biomedical ethics orbiotech ethics(Table 2). They also address bioethicalissues only as additional contents. Furthermore, byemphasizing on furnishing information to students, it ishard to encourage students’ operant participation.
2) Senior high school
Like Morals in junior high school, “Life and Ethics”
deals with bioethical issues in senior high school.
According to Table 3, two areas such as “Life, sex andfamily Ethics” and “Scientific technology, environment,
and information ethics” are most directly related withbioethics education among others (Lee, 2013: 29).
The emphasis on “ethics of life respect” is also
noticeable in senior high school education as of 65% in
total, compared with biomedical ethics (20%) and ethicsof biotechnology (15%) (Lee, 2013: 52). Lee (2013)
more specifically analyzes the frequency of subject
mentioned in the textbook (Table 4):

Table 3: Contents of “Life and Ethics” in senior highschoolArea
Subject
Modern life andapplied ethics

Life, sex, and family
ethicsScientific technology,
environment, andinformation ethics

Social ethics andoccupational ethics

Culture and ethics

Peace and ethics

Modern life and applied ethics
Inquiry and practice of ethicalproblems
Diverse approaches of ethicalproblems
Ethics of life and death
Life science and ethics
Ethics of sex and love
Ethics in family relation
Ethics among friends and neighbors
Scientific technology and ethics
The relation between man and nature
Ethical consideration on
environmental problems
Informational society and ethics
Social morality and ethics
Social justice and a just society
Respect of human right and a fairsociety
Importance of occupation and moral
responsibility of occupational life
Aesthetic value vs. ethical value
Religion and ethics
Ethical problems and the necessities
of life
Ethics in multicultural society
Ethical issues of national reunification
Ethical issues of global village

Table 4: Lee’s analysis (2013) on bioethical consideration in senior high school
Area
Category
Subject
Ethics of life
Respect for human life
School violence
respect
Sexual violence
SuicideHuman dignity
Death penalty system
Respect one’s own body
Recognition of scientific technology, scientists’ social
responsibilityLife respect for other creature
Protection of animals and plants, animal welfareLife respect for environment
Ethical consciousness and attitude towards nature
Biomedical ethics
Birth and death, sex
Test tube baby
determination
Surrogate mother
Gene test
Abortion
Criteria of death, brain death
Human vegetable, life-support machine, euthanasia
Treatment of disease
Releasing patient medical records
Organ, tissue transplantPatients’ right to know
Fair social distribution of medical resource
Ethics of
Recognition of cutting edge
Biological cloning, human cloning
biotechnology
biotechnology
Stem cell cultivation, human embryo cloning
Human genome project
Genetically manufacture organism, geneticallycodified food
Recognition of problems inExperiments involving human subjects
biotechnology research process

f
0
3
0
0
2
1
6
1
13
0
0
0
1
2
2
0
2
0
1
2
1
0
1
2

Table 5: Bioethics education at Gangnueng-Wonju National University and Daegu University
Area
Category
GWNU
Daegu University
Introduction
Basic theories
What is bioethics?
Definitions of bioethics
Bioethics and theories of ethics
Principles of bioethics
Ethics of life
respect

Biomedical
ethics

Ethics ofbiotechnology

Respect for human life
Life respect for othercreaturesLife respect forenvironment
Birth and death, sex
determination

SuicideEco life-style
Abortion

Abortion

Gene therapy
Euthanasia
Brain death

Euthanasia
Surrogate mother
Prenatal diagnosis
Trade of eggs and sperm
Organ transplantPatients’ rights

Treatment of disease

Organ transplant

Recognition of cuttingedge biotechnology

Reproduction, Life reproduction
Human cloning
Embryonic stem cell research
Stem cell research
Animal biotechnology
Agriculture biotechnology
Food biotechnology

Recognition ofproblems inbiotechnology
research process
Whereas “ethical consciousness and attitude
towards nature” and “recognition of scientifictechnology and scientists’ social responsibility” standout, school violence, suicide and human dignity are notmentioned in the area of ethics of life respect, whichraises issues of serious concern, considering that thesuicide rate among adolescents in Korea has
increased dramatically for the past 10 years; in thearea of biomedical ethics, “criteria of death and brain
death”, “human vegetable, life-support machine andeuthanasia”, and “organ and tissue transplant” areaddressed twice respectively; and in the area of ethicsof biotechnology, “biological cloning and humancloning” and “experiments involving human subjects”
are also equally referred twice.
3. Bioethics education at university
Curriculum of bioethics education at the university
level varies depending of lecturer’s purpose of course.
This study compares two cases, Gangnueong-Wonju
National University and Daugu University. Whereas
the former has offered Bioethics as a selective course
since 2007, the latter first provided Bioethics in theAge of Human Cloning in 2004, the title of which has
been changed into Bioethics and the Movie since 2006.
In spite of some differences between the two, Table
5 vividly presents that bioethical education at theuniversity level tends to stress “biomedical ethics” and“ethics of biotechnology” rather than “ethics of life
respect”, when contents of lecture are reorganizedbased on three major areas. Considering that “ethics

Reproductive technology
Human cloning

Animal experiment
Genetically modified organism
Human genome project
Experiment on a human bodyof life respect” is heavily emphasized in high school
education, the shift toward the other two at university
seems to provide a balanced perspective. As Yang
and Koo (2009) claim, however, Bioethics educationneeds to be a compulsory course rather than aselective one. Yoo and Park’s study (2010) also
supports the importance of bioethics education at theuniversity level by proving that the effects of a nursing
ethics education on bioethics awareness were
statistically significant.
4. Discussion
Concerns on bioethics were introduced in 1992 forth
the 6 Curricula of Junior and Senior High Schools in
Korea. However, it is criticized that contents ofbioethics education are insufficient not only
quantitatively, but also qualitatively. According to Kim(2006: 61)’s analysis, only 5 out of 100 subjects arethrelated with bioethics in the 7 grade Curriculum.
Moreover, controversial issues are not directly
addressed. For example, only illegal abortion based on
ascertaining the gender of fetus is mentioned, without
discussing the moral status of the embryo (Kim, 2006:
61). Considering all the details, it is hard to evaluate
the current status of the bioethics education system
highly.
For bioethics education at university, bioethics
should be a compulsory course rather than a selective
one and it is necessary to develop diverse educational
supplements to help students have a great curiosity(Yang and Koo, 2009). The UNESCO Bioethics Core

36

Eubios Journal of Asian and International Bioethics 26 (January 2016)

Curriculum which aims to introduce the bioethicalprinciples of the Universal Declaration on Bioethics
and Human Rights to university students cancontribute to providing an objective guideline ofbioethics education with various cases (UNESCO,
2008).
References
Han, Jin-A. 2007. Study about Realities of Bioethics Education in
Junior High School’s Moral Textbooks. MA thesis, Ewha Womans
University (in Korean)Kim, Sang Don. 2006. Critical reflections on moral education in the
middle and high school and bio-medical ethics education. Journalof Korean Bioethics Association 7(2): 53-72
Lee, Pil-yon. 2013. Bioethics Education in Moral Textbooks:
Focusing on “Life and Ethics”. MA thesis, Korea University (inKorean)Macer, Darryl. 2008. Preface. in Asia-Pacific Perspectives on
Bioethics Education. Bangkok: UNESCO Asia and PacificRegional Bureau for Education.
Park, In-Ok et als. 2005. Teachers’ Interest and Understanding of
Bioethics and Their Perception of Bioethics Teaching in
Secondary School Education. Biology Education 33,4: 491-504 (inKorean)UNESCO. 2008. Bioethics Core Curriculum. Paris: UNESCO
Yang, Jae Sub and Mi-Jung Koo. 2009. Bioethics Education in the
University: Centering to the Case of Daegu University. Journal of
Korean Bioethics Association 10, 1: 1-16 (in Korean)

Yoo, Myung-Sook and Hyun-Sook Park. 2010. Effects of Nursing
Ethics Education on Bioethics Awareness and Critical Thinking
Dispositions of Nurses. . Journal of Korean Bioethics Association
11, 1: 51-60 (in Korean).

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),
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